Document of The World Bank Report No: ICR1929 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-H1030) ON A GRANT IN THE AMOUNT OF SDR 4.0 MILLION (US$ 5.77 MILLION EQUIVALENT) TO THE KINGDOM OF BHUTAN FOR A HIV/AIDS AND STI PREVENTION AND CONTROL PROJECT December 29, 2011 Human Development Sector Unit Bhutan Country Management Unit South Asia Regional Office CURRENCY EQUIVALENTS (Exchange Rate Effective December 15, 2011) Currency Unit = Bhutanese Ngultrums (BTN) 1.00 US$ = 53.64 BTN 1.00 US$ = 0.65 SDR FISCAL YEAR July 1- June 30 ABBREVIATIONS AND ACRONYMS AFD Administration and Finance Department AIDS Acquired Immuno-Deficiency Syndrome ART Anti-retroviral therapy BAS Budget and Accounting System BCC Behavioral Change Communications BSS Behavioral Sentinel Surveillance CBOs Community Based Organizations CSW Commercial Sex Worker DADM Department of Aid and Debt Management DANIDA Danish International Development Agency DBA Department of Budget and Accounting DGA Development Grant Agreement DVED Drugs, Vaccines, and Equipment Division FMR Financial Monitoring & Reporting GBFA Government Budget Fund Account HCWM Health Care Waste Management HIDP Health Infrastructure Development Project HMIS Health Management Information System HIV Human Immunodeficiency Virus IA Implementing Agency IBRD International Bank for Reconstruction and Development ICB Information and Communication Bureau ICB International Competitive Bidding ICT Infection Control Team IDA International Development Association IEC Information, Education, and Communications IGA Innovative Grant Agreement IP Implementation Plan ISDS Integrated Safeguards Data Sheet LC Letter of Credit LIS Laboratory Information System M&E Monitoring & Evaluation MOF Ministry of Finance MOH Ministry of Health MSTF Multisectoral Task Force NACP National STD/AIDS Control Program NHAC National HIV/AIDS Commission NCB National Competitive Bidding NICC National Infection Control Committee NIFM National Institute of Financial Management NGO Non-Governmental Organization OI Opportunistic Infection OM Operational Manual PBM Planning and Budget Monitoring PHL Public Health Laboratory PIP Project Implementation Plan PLC Project Letter of Credit PLWHA People living with HIV/AIDS PMT Project Management Team PPD Policy and Planning Division RGOB Royal Government of Bhutan RIHS Royal Institute of Health Sciences RMA Royal Monetary Authority of Bhutan RBP Royal Bhutan Police SA Special Account SBD Standard Bidding Document SOE Statement of Expenses STI Sexually Transmitted Infections TA Technical Assistance UNAIDS Joint United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNFPA United Nations Population Fund UNICEF United Nations International Children‟s Fund VCT Voluntary Counseling and Testing WHO World Health Organization Vice President: Isabel Guerrero Country Director: Nicholas J. Krafft Sector Manager: Julie McLaughlin Project Team Leader: Sandra Rosenhouse ICR Team Leader: Phoebe M. Folger ICR Author: Son Nam Nguyen BHUTAN HIV/AIDS AND STI PREVENTION AND CONTROL PROJECT TABLE OF 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 .................................................. 5 3. Assessment of Outcomes .............................................................................................. 13 4. Assessment of Risk to Development Outcome ............................................................. 19 5. Assessment of Bank and Borrower Performance ......................................................... 20 6. Lessons Learned............................................................................................................ 22 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners............... 23 Annex 1. Project Costs and Financing .............................................................................. 24 Annex 2. Outputs by Component...................................................................................... 25 Annex 3. Economic and Financial Analysis ..................................................................... 29 Annex 4. Bank Lending and Implementation Support/Supervision Processes................. 30 Annex 5. Beneficiary Survey Results ............................................................................... 33 Annex 6. Stakeholder Workshop Report and Results ....................................................... 34 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR ......................... 35 Annex 7(b). Government's comments on the World Bank ICR ....................................... 48 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders ........................... 49 Annex 9. List of Supporting Documents .......................................................................... 50 MAP .................................................................................................................................. 52 A. Basic Information Bhutan - HIV/AIDS Country: Bhutan Project Name: and STI Prevention and Control Project Project ID: P083169 L/C/TF Number(s): IDA-H1030 ICR Date: 12/30/2011 ICR Type: Core ICR ROYAL Lending Instrument: SIL Borrower: GOVERNMENT OF BHUTAN Original Total XDR 4.00M Disbursed Amount: XDR 3.58M Commitment: Revised Amount: XDR 3.59M Environmental Category: B Implementing Agencies: Ministry of Health Cofinanciers and Other External Partners: B. Key Dates Revised / Actual Process Date Process Original Date Date(s) Concept Review: 08/21/2003 Effectiveness: 08/18/2004 08/18/2004 Appraisal: 04/02/2004 Restructuring(s): Approval: 06/17/2004 Mid-term Review: 03/31/2007 11/14/2006 Closing: 12/31/2009 06/30/2011 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Moderately Unsatisfactory Risk to Development Outcome: Substantial Bank Performance: Moderately Unsatisfactory Borrower Performance: Moderately Unsatisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Moderately Satisfactory Government: Satisfactory Moderately Implementing Moderately Quality of Supervision: Unsatisfactory Agency/Agencies: Unsatisfactory Overall Bank Moderately Overall Borrower Moderately Performance: Unsatisfactory Performance: Unsatisfactory i C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Indicators Rating Performance (if any) Potential Problem Project Quality at Entry Yes Satisfactory at any time (Yes/No): (QEA): Problem Project at any Quality of Yes None time (Yes/No): Supervision (QSA): DO rating before Moderately Closing/Inactive status: Unsatisfactory D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Central government administration 40 40 Health 45 45 Other social services 15 15 Theme Code (as % of total Bank financing) HIV/AIDS 40 40 Health system performance 20 20 Population and reproductive health 40 40 E. Bank Staff Positions At ICR At Approval Vice President: Isabel M. Guerrero Praful C. Patel Country Director: Lalita M. Moorty Alastair J. McKechnie Sector Manager: Julie McLaughlin Anabela Abreu Project Team Leader: Sandra Rosenhouse Hnin Hnin Pyne ICR Team Leader: Phoebe M. Folger ICR Primary Author: Son Nam Nguyen F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The proposed project aims to reduce the risk of HIV and STI transmission among the general population, in particular among groups with high risk sexual behaviors. Revised Project Development Objectives (as approved by original approving authority) ii (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 Indicator 1 : Percentage of persons reporting condom use with last non regular sex partner. Female bar workers 38-54%; IDUs 70%; non- Bhutanese migrant 60% among workers 35-71%; Value priority groups and police 61-82%; quantitative or <20% 30% among the military 85%; taxi Qualitative) general population drivers 91%; truckers 84-97% (BSS 2008). General population 74% (GPS 2006) Date achieved 12/01/2003 12/31/2009 09/01/2008 Comments '03 baseline not accurate estimate of indicator. Surveys implemented late and not (incl. % repeated, so difficult to interpret achievement. Target achieved for general pop. achievement) in '06, partially achieved for risk groups in '08. Percentage of patients with selected STIs (i.e. urethral discharge in men, and Indicator 2 : genital ulcers in men and women) at health care facilities who are appropriately treated accordingly to the updated national guidelines. Value 25 - 30% (Health quantitative or <20% 60% Facility Survey Qualitative) 2009) Date achieved 12/01/2003 06/18/2004 09/01/2009 Target not met in '09. 2nd HFS did not measure this indicator. However, 70%, Comments 28% and 23% of health workers knew how to treat urethral discharge, female and (incl. % male genital ulcers respectively in '11. It can be thus deduced that target was not achievement) met in '11. (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 Percentage of general population and selected priority groups reporting easy Indicator 1 : access to condom supply. Access by general pop (among those who have heard Value about condoms) (quantitative <20% 75% 75% (2006). or Qualitative) Access by risk groups (2008): IDUs 30%, female bar workers 30- iii 36%, migrant workers 2-14%; police 24-44%; military 32%, taxi drivers 62%, truckers 18%-47%. Date achieved 12/01/2003 12/31/2009 09/01/2008 Comments Baseline <20% in PAD and 30% in ISR, probably not an accurate estimate. (incl. % However, if assumed to be accurate, target was met for general population in '06, achievement) but not for high risk groups in '08. Indicator 2 : Percentage of persons reporting correct knowledge on STIs/HIV/AIDS. 50% among Value general population (quantitative <30% Not available and 75% among or Qualitative) priority groups. Date achieved 12/01/2003 12/31/2009 06/30/2011 Baseline was probably not an accurate estimate. Moreover, this indicator was not Comments well framed as it spans many different areas such as knowledge and (incl. % misconceptions about transmission, prevention, treatment, etc. Indicator not achievement) monitored by the project. Indicator 3 : Percentage of labs meeting basic quality assurance standards. Value (quantitative Not available 80% 78% or Qualitative) Date achieved 12/01/2003 12/31/2009 05/15/2011 The original indicator is for general lab standards, but project only monitored Comments quality of HIV testing. In the 8th round of HIV panel testing for 38 labs, 33 (incl. % submitted correct results, 5 did not have reagents or technicians. Target was achievement) almost achieved. Indicator 4 : National Policy on HIV/AIDS formulated and disseminated in Year 1 The first National National policy Strategic Plan for formulated and Value HIV/STI was disseminated by (quantitative developed and August 2005 (end or Qualitative) disseminated in of Year 1 of the 2008, well past project) MTR. Date achieved 08/30/2005 12/30/2008 Comments The project did not benefit from a NSP in its first 4 years of implementation. Due (incl. % to the significant delay in the development of NSP, the target for this indicator achievement) was therefore only partially achieved. Number of staff in MOH and other implementing agencies trained in Indicator 5 : management, procurement, and financial management. Value (quantitative 0 5 15 or Qualitative) Date achieved 06/18/2004 12/31/2009 05/16/2011 Comments (incl. % Target was exceeded achievement) Indicator 6 : Percentage of persons aware of where to access VCT services. iv 40% for general Value population and (quantitative <5% N/A 60% for priority or Qualitative) groups Date achieved 12/01/2003 12/31/2009 05/19/2011 Comments This indicator was not monitored by the project and no information was (incl. % available. achievement) 50% of known PLWHA receiving comprehensive care and treatment, including Indicator 7 : OIs, services (receiving CD4 count). 72% of known Value PLWHA receiving (quantitative 0 50% CD4 counts every 6 or Qualitative) months Date achieved 12/01/2003 12/31/2009 05/16/2011 NACP did not monitor the % of people receiving OI treatment. This indicator Comments was revised as "% of known PLWHA receiving CD4 counts every 6 months" (incl. % with a 100% target. However, target was partially met according to the original achievement) indicator and goal. Percentage of health care providers with accurate knowledge of AIDS and STI Indicator 8 : management as per national guidelines. 70%, 28% and 23% of health workers Value knew how to treat (quantitative <20% 70% urethral discharge, or Qualitative) female and male genital ulcers respectively Date achieved 12/01/2003 12/31/2009 05/16/2011 Comments The facility survey did not assess health workers' knowledge in AIDS (incl. % management. Target was met for management of urethral discharge, but not for achievement) male and female genital ulcers. 90% of health facilities and implementing agencies providing complete and Indicator 9 : timely reporting through HMIS and PBM tool. Value (quantitative Not available 90% not available or Qualitative) Date achieved 12/01/2003 12/31/2009 05/16/2011 Comments (incl. % This indicator was not monitored by the project and no information is available achievement) Second generation surveillance system established and implemented in Year 2 Indicator 10 : and Year 4. Implementatio n of two rounds of Value No second generation second One BSS for high (quantitative surveillance system in the generation risk groups was or Qualitative) country at baseline surveillance conducted in 2009 system (in 2006 and 2009) v Date achieved 12/01/2003 12/31/2009 05/16/2011 Comments (incl. % With one round of BSS implemented in 2009, this target was partially achieved. achievement) Additional Indicator: No. of condoms distributed through health centers (incl. Indicator 11 : supply of MSTFs, line ministries, cumulative) with project support. Value 28,000 gross (4 (quantitative 0 40,000 gross million) or Qualitative) Date achieved 08/18/2004 12/31/2009 05/16/2011 Comments Indicator was informally added during project implementation. Target was (incl. % exceeded achievement) Additional Indicator: No. of priority group interventions (peer networks) Indicator 12 : organized and operating (reporting monthly contacts). Value 1 in Phuntsholing (CSW) (quantitative 6 2 6/2004 or Qualitative) Date achieved 08/18/2004 12/31/2009 05/16/2011 Comments Indicator was informally added during project implementation. Target was not (incl. % met. achievement) Additional Indicator: No. of sexual hot spot interventions organized and Indicator 13 : operating (reporting monthly contacts). Value (quantitative 0 5 0 or Qualitative) Date achieved 08/18/2004 12/31/2009 05/16/2011 Comments Indicator was informally added during project implementation. Target was not (incl. % met. achievement) Additional Indicator: Percentage of women screened for syphilis amongst ANC Indicator 14 : attendees at hospitals. Value (quantitative 32% 60% 29% or Qualitative) Date achieved 12/01/2003 12/31/2009 05/19/2011 Comments Indicator was informally added during project implementation. Target was not (incl. % met. achievement) Additional Indicator: No. of laboratory technicians trained in HIV and STI Indicator 15 : diagnostic testing and NEQAS Value (quantitative 0 40 40 or Qualitative) Date achieved 08/18/2004 12/31/2009 05/19/2011 Comments (incl. % Indicator was informally added during project implementation. Target was met. achievement) Indicator 16 : Additional Indicator: Proportion of blood donations that are voluntary. Value 25% (Thimphu, 2004) 60% Thimphu 80% Thimphu vi (quantitative 45 % Nation-wide 46% Nation-wide or Qualitative) Date achieved 08/18/2004 12/31/2009 12/31/2010 Comments Indicator was informally added during project implementation. Target was (incl. % exceeded. achievement) Additional Indicator: No. of lab technicians trained to use the SOP manual for Indicator 17 : blood banks and clinical use of blood. 105 trained in SOPs Value for blood banking. (quantitative 0 50 240 trained in or Qualitative) clinical use of blood Date achieved 08/18/2004 12/31/2009 05/19/2011 Comments Indicator was informally added during project implementation. Target was (incl. % exceeded. achievement) Additional Indicator: Number of staff sent abroad for technical training for a Indicator 18 : minimum of one month Value (quantitative 0 50 33 or Qualitative) Date achieved 08/18/2004 12/31/2009 05/19/2011 Comments (incl. % Indicator was informally added during project implementation. Target not met. achievement) Additional Indicator: No. VCT sites operational (with rapid test results and Indicator 19 : pre/post-test counseling). Value 5 sites (2 free- 33 sites (2 free- (quantitative 0 standing) standing) or Qualitative) Date achieved 08/18/2004 12/31/2009 05/19/2011 Comments Indicator was informally added during project implementation. Target was (incl. % exceeded achievement) Additional Indicator: No. of people receiving pre-test counseling in HISC (VCT Indicator 20 : centers). Value (quantitative 0 2,500 7,209 or Qualitative) Date achieved 08/18/2004 12/31/2009 05/19/2011 Comments Indicator was informally added during project implementation. Target was (incl. % exceeded. achievement) Indicator 21 : Additional Indicator: No. of HIV tests conducted through VCT at HISC. Value (quantitative 0 2,500 7,015 or Qualitative) Date achieved 08/18/2004 12/31/2009 05/19/2011 Comments Indicator was informally added during project implementation. Target was (incl. % exceeded. vii achievement) Indicator 22 : Additional Indicator: No. of people receiving pre-test counseling in JDWNRH. Value (quantitative 0 5,000 11,760 or Qualitative) Date achieved 08/18/2004 12/31/2009 05/19/2011 Comments Indicator was informally added during project implementation. Target was (incl. % exceeded. achievement) Indicator 23 : Additional Indicator: No. of HIV tests conducted through VCT at JDWNRH. Value (quantitative 0 4,500 10,307 or Qualitative) Date achieved 08/18/2004 12/31/2009 05/19/2011 Comments Indicator was informally added during project implementation. Target was (incl. % exceeded. achievement) Additional Indicator: No. of dzongkhags covered by trained and fully staffed care Indicator 24 : and treatment team. Value Thimphu, 20 20 dzongkhags, 3 (quantitative 0 dzongkhags, 3 army army hospitals or Qualitative) hospitals Date achieved 08/18/2004 12/31/2009 05/19/2011 Comments (incl. % Indicator was informally added during project implementation. Target was met. achievement) Additional Indicator: No. of health care workers trained in revised national STI Indicator 25 : guidelines (WHO standard). - 555 health workers were trained by Feb 2007. Value - 611 received (quantitative 0 400 refresher training in or Qualitative) 2009 - 42 DHOs and DMOs were trained in 2010. Date achieved 08/18/2004 12/31/2009 12/31/2010 Comments Indicator was informally added during project implementation. Target was (incl. % exceeded achievement) Additional Indicator: % of staff trained on national infection control and hospital Indicator 26 : waste management guidelines. Value (quantitative 0% 80% 63% or Qualitative) Date achieved 08/18/2004 12/31/2009 05/19/2011 Comments Indicator was informally added during project implementation. Target was not (incl. % met achievement) viii Additional Indicator: Percentage of facilities complying with national policy on Indicator 27 : waste management. Value (quantitative 0% 80% 65% or Qualitative) Date achieved 08/18/2004 12/31/2009 09/01/2009 Comments Indicator was informally added during project implementation. Target was not (incl. % met in 2009. The Second Health Care Facility survey in 2011 did not assess achievement) health care waste management. Additional Indicator: No. of program officers and managers, DMO/DHSO Indicator 28 : trained on use of data for management (cumulative). Value (quantitative 0 50 641 or Qualitative) Date achieved 08/18/2004 12/31/2009 05/19/2011 Comments Indicator was informally added during project implementation. Target was (incl. % exceeded. achievement) G. Ratings of Project Performance in ISRs Actual Date ISR No. DO IP Disbursements Archived (USD millions) 1 11/07/2004 Satisfactory Satisfactory 0.50 2 01/27/2005 Satisfactory Satisfactory 0.51 3 07/26/2005 Moderately Satisfactory Moderately Satisfactory 0.88 4 01/25/2006 Satisfactory Satisfactory 1.61 5 07/14/2006 Satisfactory Moderately Satisfactory 1.95 6 01/16/2007 Satisfactory Satisfactory 2.54 7 07/19/2007 Satisfactory Satisfactory 2.97 Moderately 8 01/18/2008 Moderately Satisfactory 3.59 Unsatisfactory Moderately 9 07/16/2008 Moderately Satisfactory 3.94 Unsatisfactory 10 12/19/2008 Moderately Satisfactory Moderately Satisfactory 4.21 11 06/16/2009 Moderately Satisfactory Moderately Satisfactory 4.29 12 01/26/2010 Satisfactory Satisfactory 4.78 Moderately 13 01/15/2011 Moderately Satisfactory 5.32 Unsatisfactory Moderately Moderately 14 06/27/2011 5.39 Unsatisfactory Unsatisfactory H. Restructuring (if any) Not Applicable ix I. Disbursement Profile x 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal 1. Country and sector issues The HIV/AIDS situation in Bhutan: It has been recognized that increasing cross-border migration and international travel has made the Kingdom of Bhutan pervious to HIV/AIDS despite its geographical isolation. At the end of 2001, there were 100 Bhutanese living with HIV/AIDS (less than 0.01% adult prevalence rate), but the number of reported new infections was on the rise, and the majority of them were acquired through unprotected sex. The country had risk factors and conditions that could have fueled the spread of the virus: neighboring countries with generalized or concentrated epidemics, high mobility across borders and within the country, high levels of sexually transmitted infections (STIs), relaxed sexual norms, existence of sex work, limited access to condoms, and an emerging problem of substance abuse. While Bhutan was considered to be at the early stages of a low-grade HIV epidemic, it did not appear to conform to the typical pattern of the HIV epidemic in Asia where the spread of HIV is initially driven by commercial sex and injecting drug use (IDU). Commercial sex work in Bhutan appeared limited and was focused in border towns. Injecting drug use was also believed to be limited. However, non-paid casual sex was common among long distance drivers, armed forces, migrant workers and drug users. These behaviors tended to occur in specific locations (e.g. bars, restaurants, vegetable markets) and events (e.g. festivals). At the time of appraisal, information on the nature of casual sex behaviors in Bhutan remained limited and required more extensive investigation to inform HIV control efforts. National Response: In 1988, five years before the detection of the first HIV infection, the Royal Government of Bhutan (RGOB) established the National STD/AIDS Control Program (NACP) in the Ministry of Health (MOH), under the Department of Public Health with two full time staff members. The Information and Communications Bureau (ICB), which is responsible for IEC, and the Royal Institute of Health Sciences, which provides basic training to mid-level health workers, also provide input into the national program. In 2002, the multisectoral task forces (MSTFs), with members from key local government departments, private sector and civil society, were established in all dzongkhags with the mandate to carry out health promotion and HIV/AIDS awareness. They served as an important mechanism to ensure involvement of key sectors beyond health and the public sector in HIV/AIDS prevention efforts. The development partners, including DANIDA and UN agencies such as WHO, UNICEF, UNDP and UNFPA, had been working closely with the Royal Government in the health sector, including on HIV/AIDS prevention and control efforts. DANIDA had strengthened the health infrastructure and information systems, and WHO had provided both technical and financial assistance to the country's HIV/AIDS prevention program 1 that included short-term consultants in the areas of sentinel surveillance and health education as well as financing travel to conferences and to global and regional events. UNFPA supported development and distribution of national guidelines for contraceptive services to field staff, and condom procurement. UNDP provided US$200,000 to strengthen the capacity of the MSTFs in planning and managing dzongkhag-based HIV prevention and advocacy activities. RGOB recognized that at this epidemiological juncture, the country had a unique opportunity to act vigorously, tackling the abovementioned challenges, and effectively scaling up and accelerating the national response to ensure that the level of infection in the country remains low. Key challenges: According to the PAD, at the time of appraisal, Bhutan faced several issues and challenges in scaling up the HIV/AIDS response, which included (i) the lack of a national HIV/AIDS strategy; (ii) inadequate information on the nature of the epidemic and risk factors; (iii) NACP staffing shortages and weak capacity; and (iv) widespread stigma attached to HIV/AIDS, especially people living with HIV/AIDS (PLWHA); and (v) the response to HIV/AIDS limited to the health sector instead of a multi-sectoral approach. In that context, the following areas were identified as priorities: (i) Instituting a strategic response and focused prevention: The project was to support the development of a national HIV/AIDS policy, strengthening of existing institutions for sustainability, and interventions that will have the highest impact in reducing the spread of HIV. In a low prevalence setting, such as Bhutan, this would entail HIV/AIDS prevention interventions for subpopulations having higher rates of sexual partner exchange or needle sharing, in addition to targeting geographical hot spots. (ii) Gaining better understanding of the epidemic through improved strategic information systems: There were little or no systematic data to accurately describe risk behaviors in the Bhutanese population or assess the potential for HIV spread in the country. A strong behavioral and sero-surveillance system and monitoring and evaluation strategy would be financed by the proposed project. (iii) Strengthening institutions: The project would strengthen NACP in its technical capacity (a program manager has been recruited), and put in place a project management team to facilitate NACP and other implementing agencies, which include divisions and programs within MOH, NGOs/CBOs, dzongkhag authorities, and other line ministries. Considering human resource constraints in Bhutan, the project would institutionalize a well-planned and sustained technical assistance and training program. (iv) Reducing stigma: PLWHA in Bhutan reported a high degree of stigma associated with HIV/AIDS and fear of disclosure of their status. Care and support was limited with little or no medical treatment available for HIV/AIDS related diagnoses. The project would support efforts to reduce stigma and discrimination by: (i) advocacy by opinion 2 leaders to promote positive attitudes towards PLWHA; (ii) providing care and treatment for PLWHA, including ART; and (iii) involving PLWHA in prevention programs. (v) Engaging in a multisectoral approach through involvement of key line ministries other than health and civil society: The project was to promote multisectoral involvement, among key sectors, such as education, labor, and the armed forces, NGOs and community based organizations, by setting aside funds for the multisectoral agencies to implement prevention programs. In addition, the project was to support and strengthen technical and implementation capacity and increase advocacy to heighten high-level political commitment in other sectors as well as at central and dzongkhag levels. 2. Rationale for Bank involvement The Bank was financing HIV/AIDS programs in India, Bangladesh, Sri Lanka, and Pakistan through both IDA credits and grants. As one of the largest financiers of HIV/AIDS control programs in the world, the Bank would bring to the fore global and regional expertise and experience in assisting Bhutan. In addition, the Bank's unique experience in Bhutan, from analytical work and previous and ongoing investments in many sectors (i.e. education) would enrich the project design and implementation strategy. The Bank's involvement would create a higher visibility politically and socially to the issue of HIV/AIDS and underscore the cross-sectoral development dimension of HIV/AIDS. Moreover, the Bank would emphasize improving existing national program to produce the greatest impact, strengthening the capacity of local institutions in the public and private sectors, and providing regular and sustained implementation support required for scaling up, enhancing, and accelerating Bhutan's fight against HIV/AIDS and STIs. Bank assistance would represent the largest source of funds for HIV/AIDS and STI prevention and control in Bhutan, complementing the financial and technical support from other development partners. 1.2 Original Project Development Objectives (PDO) and Key Indicators The project aimed to reduce the risk of HIV and STI transmission among the general population, in particular among groups with high risk sexual behaviors. Key outcome indicators were:  Percentage of persons reporting condom use with last non-regular sex partner increased from <20% at project start to 60% among priority groups and 30% among the general population at project end; and  Percentage of patients with selected STIs at health care facilities who are appropriately treated accordingly to the updated national guidelines increased from <20% in baseline (Year 2) to 60% at project end. 1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification 3 There was no revision to the PDO or key project indicators. However, a number of process indicators were informally added in 2005 and they were monitored during project implementation together with the original indicators. 1.4 Main Beneficiaries According to the PAD, key beneficiaries would include:  General population;  Six priority groups: long distance drivers, migrant workers, commercial sex workers, drug users, out-of-school youth and armed forces;  People living with HIV/AIDS;  STI patients; and  National institutions involved in the fight against HIV/AIDS 1.5 Original Components (as approved) Component 1 – Prevention of HIV/AIDS and STIs (US$ 2.00 million): This component was to promote political and societal leadership in the fight against HIV/AIDS, improve community knowledge and attitudes about HIV prevention, promote risk-reducing behaviors amongst priority groups and increase access to condoms. Component 2 – Institutional strengthening and building capacity (US$ 1.66 million): This component was to enhance the ability of national institutions to lead the fight against HIV through training and technical assistance and to strengthen laboratory and blood transfusion services. Component 3 – Care, support and treatment of AIDS and STIs (US$ 1.00 million): This component was to establish VCT services, strengthen management of STIs and HIV/AIDS comprehensive care and treatment approach, including introduction of ART) and improve infection control and waste management in health facilities. Component 4 - Strategic information for HIV/AIDS and STIs (US$ 1.11 million): This component was to promote evidence-based decision making by improving health information management, strengthening operations research capacity and instituting M&E and second generation surveillance systems. 1.6 Revised Components There was no revision to the components. 1.7 Other significant changes Project closing date was extended by 18 months (from December 31, 2009 to June 31, 2011) due to slow disbursement. The objective of project extension was to complete project activities. 4 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry The project was prepared in ten months (from July 2003 to April 2004). Positive aspects of project preparation and design include the followings:  Project preparation was preceded by a period of policy dialogue, stakeholder consultations and technical assistance (June 2002-March 2003) during which a technical note „HIV/AIDS Situation in Bhutan‟ was prepared. This period of engagement with the RGOB and stakeholders significantly facilitated subsequent project preparation.  Key lessons from HIV/AIDS projects in the region and elsewhere the world were taken into account in the project design, including the following: (i) prevention of HIV and STIs to be the core of the response in the early stage of the epidemic; (ii) prevention and treatment to go hand-in-hand given their biological and social synergy; (iii) essential involvement of key stakeholders from public and private sectors, civil society and development partners in the HIV/AIDS response; and (iv) HIV/AIDS information base to be critical for policy making and planning.  A social assessment was conducted for PLWHA and five groups deemed to be at higher risk for HIV/AIDS (commercial sex workers, truck drivers, migrant workers, armed forces and drug users). This qualitative study helped inform the project preparation.  The project made good use of existing national systems rather than setting up new institutional arrangements. For example, at appraisal, the Multi-sectoral Task Forces (MSTFs) were already in place at the dzongkhag level. Although they were not funded or fully operational at the time, MSTF held the promise of a multi-sectoral response at the grass-root level. The project design capitalized on this by including MSTF in the implementation arrangements.  There was close collaboration with key development partners (DANIDA, WHO, UNFPA and UNICEF) in the preparation of the project. However, some aspects of project preparation and design could have been improved. These include the following:  Although a HIV/AIDS situational analysis was done, the project was prepared in the absence of a National HIV/AIDS Strategic Plan (NSP). NSP was formulated much later during project implementation (2008). In retrospect, it would have been better for the country to develop such a plan first with the support of the Bank and other development partners to form the basis for the project preparation. That way, project activities could have been formulated as a subset of the NSP and the ownership and commitment of the MOH to the project could have been increased.  The project rightly identified a lack of human resource capacity in the MOH as a significant implementation risk. However, the risk mitigation measures (recruitment of the Program Manager for NACP, establishment of Project 5 Management Team) were not adequate. In retrospect, the number of project activities could have been reduced and more focused to address this constraint.  While emphasizing the importance of the information base for decision making, the project itself was prepared in the absence of critical data. At appraisal, the team did make an effort to utilize all the information available at hand on the characteristics of the HIV/AIDS epidemic in Bhutan to form the analytical basis for the project. However, data availability was very limited. For example, there was no reliable information on the most at risk populations (MARPs), their risk behaviors, levels of HIV infection, and the coverage of key interventions among them. In retrospect, a baseline quantitative survey to better identify MARPs and their characteristics as part of project preparation could have been beneficial to project design and the Result Framework.  At the time of appraisal, the critical roles of civil society organizations (CSOs) in providing HIV/AIDS services to MARPs, who are often hard-to-reach and marginalized, were well recognized internationally. Although the Project Appraisal Document recognized CSOs to be “emerging� and “limited� in Bhutan, it did not explicitly identify the lack of CSOs as an implementation risk in order to come up with mitigation measures in the project design. The relatively recent emergence of CSOs in the country has come about through legislations and a regulatory framework governing CSOs. These were methodically introduced over a period of time but not in a timely fashion to benefit this operation. As the result, the lack of CSOs hindered the delivery of HIV/AIDS services under the project.  The project did not identify a number of other risks which later materialized and manifested themselves as obstacles to project implementation: (i) low commitment to targeted interventions for the MARPs; (ii) very high turn-over of staff in the MOH and other implementing agencies; (iii) low capacity in procurement; and (iv) governance issues. 2.2 Implementation Despite a slow start, project implementation was on track until mid-2007. An MTR was conducted in November 2006 which did not identify major issues other than the need to increase HIV/AIDS interventions for MARPs and strengthen M&E. From early 2008 to closing, the project became a problem project at several points in time. Although there was no formal project change or restructuring, the work plan was significantly modified in 2009 to avoid duplication with the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) activities. As the result, most of the multi-sectoral activities were no longer supported by the project. Positive factors and events which influenced project‟s achievements:  More funding for HIV/AIDS from the Global Fund: In February 2008, the GFATM approved a grant of US$ 2.44 million for Bhutan‟s application „Scaling- up HIV prevention services among youth and other vulnerable population groups through multi sectoral approach‟ under Round 6. The GFATM grant represented 6 a significant increase in available resources for HIV/AIDS in the country and had the potential to compliment the project funding for better results in HIV/AIDS.  Commitment of Bhutan‟s Royal Family to the fight against HIV/AIDS: The Royal Family demonstrated a high level of commitment to HIV/AIDS control. Their highly visible involvement in HIV/AIDS public events and campaigns generated good advocacy which worked in the project‟s favor.  Commitment of implementers at the grass root level: Implementers at the grass root level also demonstrated a high level of commitment to the project as well as to the response to HIV/AIDS in general.  The significant increase in the global knowledge on what works in HIV/AIDS: For the early HIV/AIDS projects funded by the Bank, the evidence base on what works in HIV/AIDS was rather limited. On the contrary, the Bhutan HIV/AIDS project was implemented in more favorable environment in which there was a significant increase in the global and regional knowledge on HIV/AIDS, both from the biomedical and operational points of view. Negative factors and events which influenced project‟s achievements:  Severe shortage of human resources: This cross-cutting constraint was identified at appraisal as a significant project risk. However, the proposed mitigation measures (recruitment of the program manager for NACP, the establishment of the Project Management Team or PMT) were inadequate and unable to overcome this constraint which existed at various levels of project implementation. Human resource constraints were especially prominent in NACP, PMT, the procurement team, the Information and Communications Bureau (ICB) as well as in the area of Health Care Waste Management.  Very high turnover of staff at all levels: The above-mentioned shortage of human resources was compounded by a very high turnover of RGOB staff and consultants working on the project at all levels, including the NACP, PMT, line ministry focal points, and the procurement team. For example, during the project implementation period there were: o five different project coordinators; o four changes in the NACP manager position; and o three different procurement officers In fact, there were periods during which there was no one in charge of the program or the project. This problem was exacerbated by poor hand-over procedures. Due to the lack of overlap, incoming staff often were not briefed and given key project documents by their predecessors. As the result, there was little institutional memory of the project in the NACP, PMT and line ministries. This severely handicapped project implementation. The Bank team (with only one change of task team leader in 2005) was the only factor that remained constant for the most part of the implementation period and helped the MOH facilitate handovers among their staff by sharing documents.  Decline in commitment to the project by the MOH leadership: In the second half of the project, there were signs of reduced commitment and attention of the MOH 7 leadership to the project. First, there was the failure to appoint an NACP Manager and Project Coordinator for long stretches of time, as noted above. Second, when the Project Coordinator position was eventually filled, the MOH did not ensure that the person had adequate management skills and experience. Third, the MOH did not convene the NAC (which was supposed to meet twice a year) in 2010 to provide oversight and guidance for the project. As the result of reduced MOH‟s attention, project management was affected after mid-2007. Project management, especially with regard to coordination, procurement and M&E was particularly inadequate in the last four years of project implementation (out of a total of seven years).  NACP‟s very limited technical support to implementers at lower levels. NACP was supposed to be the glue that holds the national HIV/AIDS program together, as well as act as the provider of technical support and guidance to various implementers. However, NACP‟s leadership role did not fully materialize during project implementation due to a shortage of human resources in NACP as well as a lack of MOH‟s facilitation for NACP to fulfill its role. As the result, implementers especially in the other line ministries and in the dzongkhags received very little technical advice and almost no supervision by NACP.  Lack of NGOs/CSOs as service providers: Elsewhere, it has been demonstrated that NGOs/CSOs can be very effective implementers of targeted interventions for MARPs. In fact, they have been shown to be better at reaching out to marginalized groups such as CSWs, MSM, etc. than government actors. Unfortunately, civil society is only nascent in Bhutan and their role has been very limited. This greatly hindered the implementation of targeted interventions for marginalized MARPs. However, this constraint was beyond the scope of the project to address given Bhutan‟s political economy at the time.  Delayed coordination between the GFATM grant and the World Bank-financed project: GFATM funding, while a positive development as discussed above, also had untoward effects on the Bank-financed project for two key reasons. First, the work program of the GFATM grant was not well coordinated with the World Bank-financed project which resulted in duplications of activities, especially in 2008. This problem was flagged by the Bank team and was subsequently corrected in 2009. As a result, the support for multi-sectoral activities was no longer included under the project from 2009 onward as they became part of the GFATM-financed work program. Second, with the increase in funding and the workload, the absorptive capacity of the country was exhausted. This contributed to slow disbursement of both the Bank- and GFATM financed activities.  RGOB‟s investigation of corruption in the MOH: During the last two years of the project, the MOH was subject to audits by the Royal Audit Authority (RAA) and investigations by the Anti Corruption Commission (ACC) after a series of articles in national newspapers in 2009 alleged irregularities in procurement practices in the ministry. Due to the RGOB‟s inquiry, both the incumbent and the previous head of the procurement unit were temporarily suspended. This left the MOH procurement team severely understaffed.  Limited targeting of most at-risk groups with preventive interventions: Although targeted preventive interventions for high risk groups were featured in the PDO 8 and project design, the implementation of such interventions did not take off in earnest during most of the project period. In prevention, there was much a stronger focus on information, education and communication (IEC) for the general population. This challenge was flagged by the Bank team as early as July 2005 and consistently raised in the aide-memoires and management letters. The Bank team provided support by mobilizing technical assistance in targeted preventive interventions for risk groups. Two initiatives – one for IDU (implemented by REWA, a NGO) and the other for CSW (by HISC) – made very little headway. The IDU initiative ended in February 2008 after less than one year of implementation. The CSW outreach program was canceled in December 2010 due to HISC‟s limited capacity and low commitment by the MOH. In 2010 and 2011, at the urge of the Bank team, a sexual network study was conducted in Bhutan‟s two biggest urban areas of Thimphu and Phuntsholing (with the latter being the commercial hub on the southern border with India). On this basis, targeted interventions were revived toward the end of the project with pilot programs focusing on specific venues (hotels, bars and karaoke clubs) and specific population groups (truckers, CSWs) using outreach. However, this came too late to make a substantial impact under the project. 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization M&E Design: The project design has a strong focus on improving the information base for decision making in HIV/AIDS with a separate component for this purpose. This very positive feature was not commonly seen in the first-generation HIV/AIDS projects funded by the Bank. The project indicators are mostly outcomes in nature, reflecting a deliberate choice to prioritize higher level results. The methodologies and strategies for data collection were clearly defined in the PAD. However, there are three key issues with the M&E design. First, in the Results Framework, the project would need to rely on three different surveys to generate data for 9 out of 12 project indicators. Each of the surveys was to be carried out in at least two rounds to monitor progress. The number of surveys and studies was, therefore, highly ambitious for a small country with limited capacity such as Bhutan. In particular, the plan to implement three rounds of the general population survey -- at baseline, midterm and end-of-project -- was excessive for a low- level epidemic country such as Bhutan and not in line with WHO/UNAIDS guidelines for second generation surveillance1. Second, the M&E design did not include time-bound process indicators which could be used on a more frequent basis to monitor project progress and hold implementers accountable along the lines of “who is responsible for what output and by when�. As a consequence, the reporting requirements for implementers at different levels and arrangements for routine monitoring were not 1 WHO/UNAIDS 2000 Guidelines for Second Generation HIV Surveillance does not recommend monitoring HIV infection and behaviors in the general population in low level epidemics. Instead it recommends surveillance systems to focus on most-at-risk groups in such settings, 9 sufficiently defined in either the PAD or the Operations Manual. Third, baseline data for several indicators are not reliable. For example, the two PDO indicators and Immediate Result Indicators No. 1, 7 and 8 would require surveys to generate baseline data. However, such surveys had not been implemented in Bhutan at the time of appraisal. Consequently, baseline data in the PAD are unreliable, which, in turn, rendered corresponding targets unrealistic and not very meaningful. In the M&E framework, one can infer that the expected outcomes are to be solely attributable to project inputs and outputs. This is understandable because at appraisal, the project was the key source of funding for HIV/AIDS in Bhutan. However, during project implementation, additional resources from GFATM were obtained. In this context, it should be recognized that GFATM grant contributes to the achievement of the PDOs as well. The M&E design is rated as Modest (2 out of 4 point scale). M&E Implementation: M&E implementation was a challenge for the project until the very end. Routine data related to project activities were not collected systematically. There were no standard reporting formats or reporting schedule for implementers to report project activities back to the NACP and PMT. There was no information system in the PMT to keep track of project activities either. In 2005, the project team added 20 new process2 indicators for the purpose of activity monitoring, although such indicators were not processed formally to be part of the official Results Framework. While the project could benefit from additional process indicators, the number of such indicators was excessive and created an extra burden on the implementing agency which failed to monitor them in a systematic manner. Subsequently, it fell on the Bank to take the lead in coordinating M&E and data collection during each mission. The project made little headway in introducing a culture of information-based planning and decision making. For example, the results of surveys implemented under the project were not widely disseminated to all implementers as inputs for their work plans. It was only toward the end of the project that a factsheet was prepared by the MOH to provide information on key survey findings. Although a large number of program officers, managers and health workers (641 in total) were trained in the use of data for management, routine M&E data were not used for providing feedback to implementers for supervision purposes and/or corrective follow-up. As discussed above, three major surveys were envisioned by the project, with at least two rounds per survey. However, due to the limited capacity within MOH, only the following were carried out: - One round of the HIV/AIDS General Population Survey (GPS) in 2006; 2 Of the 20 process indicators, two were eventually dropped and 18 remained at project end. Please see the ICR datasheet for information on the 18 process indicators. 10 - One round of HIV/AIDS Behavioral Surveillance Survey (BSS) for high risk groups in 2008; - The first round of the Health Facility Survey (HFS) in 2009; and - The second round of the HFS for a subset of facilities in 2011. A rapid assessment on sexual networks was conducted in Thimphu (2010) and Phuntsholing (2011). A retrospective study on the risk factors of HIV/AIDS infections in Bhutan was also carried out in 2011. All the surveys were implemented late in the project cycle (around MTR or after), so they could not serve as start-of-project baselines. Except for the Health Facility Survey, they were not implemented in two rounds; consequently, it was not possible to gauge progress over time. Some key project indicators could have been monitored by the surveys, but they were not included in the survey instruments. For example, the second PDO indicator and process indicator No. 17 could have been monitored by the 2011 Health Facility Survey, but they were not. Similarly, the Immediate Result Indicator No. 6 could have been monitored by the 2006 GPS and the 2008 BSS, but it was not. This represents a missed opportunity in M&E as well as a disconnect between the surveys/studies and the Results Framework during implementation. Nevertheless, the surveys have significantly improved the information base on HIV/AIDS in Bhutan insofar as they have established baseline data for Bhutan for the first time. They also provided useful inputs for the development of the 2012-2016 National HIV/AIDS Strategic Plan in Bhutan. Implementation of M&E is rated as Modest (2 out of 4 point scale). 2.4 Safeguard and Fiduciary Compliance Safeguards: The project had an Environmental Category B rating. For most of the project implementation period, compliance with environmental safeguards was rated Moderately Satisfactory by the Bank team except for the first year of the project when compliance was deemed Satisfactory. After much delay, most activities in the agreed Health Care Waste Management (HCWM) Work Plan were carried out. These included development of HCWM Guidelines and a standardized training module, procurement, distribution of HCWM equipment and supplies, and training of health care workers in HCWM. Delays were mostly due to low capacity in both procurement and HCWM. The institutional arrangements for HCWM did not include fully functioning HCWM committees which, although established, were not active in all hospitals. Little is known about actual compliance with environmental safeguards at the facility level as there are no routine monitoring and evaluation mechanisms in place. The Health Facility Survey in 2009 shows that 65% of facilities complied with national HCWM guidelines. Unfortunately, the second round of the survey in 2011 did not include HCWM assessment in the survey instrument. Financial Management Generally speaking, project FM arrangements were satisfactory during the life of the project. These arrangements were mainstreamed into RGoB‟s own country systems using budgetary, fund flows, internal control and accounting processes. The project‟s 11 financial reports were derived from these systems and proved to be reliable and timely. However, in the latter part of the project life, several internal control issues were observed, including the identification of non-project related expenditures during Statement of Expenses (SOE) and implementation reviews, leading to the rating of the FM performance to be revised to Moderately Satisfactory. Similar to other projects in the Bhutan portfolio, grant disbursement was slow. This was due, in part, to delays in reporting of MSTF expenditures by the dzongkhags. Dzongkhags are by definition not accountable to the line ministries. This resulted in difficulties in obtaining financial reports. Oversight by the PMT in the MoH over the use of project funds for the dzongkhag-level expenditures remained weak. Disbursement under the project was based on SOEs instead of Interim Unaudited Financial Reports (IUFR). This required a separate exercise of reconciliation of expenditures as per books of accounts with withdrawal claims submitted to the Bank by the Ministry of Finance. Reconciliation did not materialize for the most part of the project period and most audit reports did not have significant observations by the auditors. Procurement: The project was procurement-intensive with about 60% of grant proceeds allocated for the procurement of goods, works and services. Because of five different entities handling procurement, the procurement planning, monitoring and coordination became difficult, resulting in delays in the award of contracts from the beginning of the project period. The PMT, which was to act as nodal agency for the project, could not reduce the delays despite its best efforts. Such delays in procurement contributed to slow implementation of various activities such as surveys, BCC activities, the Laboratory Information System, etc. There were also long periods when the project was without an updated procurement plan. Selecting and retaining trained procurement staff was also a major challenge. Even where trained procurement staffs were available, they were working simultaneously for many departments and unable to dedicate RGOB procurement procedures were used instead of agreed Bank procurement procedures. The project also faced problems due to different procurement procedures of funding agencies, such as the World Bank and the GFATM. Due to procurement mistakes noted in Bank reviews, misprocurement was declared in some cases. Problems were also noted in downstream supply chain management resulting in difficulties in demand forecasting, as well as in monitoring inventories and record keeping of distributed stocks. There was an overall lack of standardization, particularly for test kits. The project would have benefitted from closer Bank guidance and implementation support for procurement. The Task Team Leader (TTL) did endeavor to obtain this, but with limited success. For the projects which are handling Bank-financed procurement for the first time, it is equally important to improve communication between the project team and the Bank task team so that procedural deviations could be identified and avoided ex- ante. 12 2.5 Post-completion Operation/Next Phase With the closing of the World Bank-financed project, HIV/AIDS activities are being funded by the Global Fund and RGOB‟s own resources. However, the GFATM grant is expected to close in 2012, leaving RGOB funding (currently estimated at US$ 0.2m per year) as the only source of funding for HIV/AIDS. To prepare for the next five-year plan period, the MOH prepared the Second National Strategic Plan for the Prevention and Control of STIs and HIV/AIDS (2012-2016) in June 2011. The Strategic Plan aims to maintain the institutional arrangements for the HIV/AIDS response which were supported by the project, namely the NAC, NACP, MSTF, selected line ministries, NGOs/CBOS, etc. The next step would be to cost out the strategic plan to determine the resource envelope required for the HIV/AIDS response in Bhutan. On that basis, the MOH will use the cost estimates to mobilize both internal and external resources for the implementation of the plan. 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation Relevance of PDOs: The project aimed to reduce the risks of HIV and STI transmission among the general population and, in particular, among groups with high risk sexual behaviors. At the time of the ICR, Bhutan remains a very low HIV prevalence country (around 0.2% among adult aged 15-49 according to UNAIDS estimates), while the neighboring northeastern Indian states and Nepal have already been experiencing generalized or concentrated epidemics. The potential cross-border issues in HIV and the importance of intervening early while HIV prevalence remains low are still applicable. With an estimated number of 5,000 new cases of STIs per annum, the burden of STI-related morbidity is likely many times more important than that of HIV, justifying STI control as a public health priority in its own right. In this context, the objective of reducing the risk of HIV and STI remains relevant at the time of the ICR. There is now a general consensus in the area of HIV/AIDS control that in a low prevalence setting it is critical to improve the coverage and quality of proven interventions for people whose behavior puts them at high risk of infection, and to intercept young cohorts of such groups as early as possible before they become infected3. For this reason, the reference to the general population in the PDO is less relevant, while the dimension of targeting high risk groups remains highly relevant. Bhutan has severe constraints in human capacity for HIV/AIDS/STI response. It is critical to build the country‟s capacity to better respond to HIV/AIDS/STI. While many 3 From the Macro-economic to the Molecular: New Evidence About and Implications for the Global HIV Epidemic. Wilson, Gorgens and Kusak. Presentation at the Human Development Week, World Bank 2011. 13 of the project activities aimed to serve this purpose, capacity building was not reflected in the PDO. In summary, the relevance of the PDO is rated as Substantial. Relevance of design: The Project has a very comprehensive design with all the elements of a typical national HIV/AIDS response (prevention, treatment, care and support, institutional strengthening, capacity building, strategic information, etc.) using a multi-sectoral approach with a range of implementers inside and outside the health sector at all levels. Although this comprehensive approach is commonly used in a high prevalence setting, it can still be relevant for a low level HIV prevalence country with adequate implementation capacity. However, for a country with both very low HIV prevalence and severe human resource constraints such as Bhutan, the relevance of this design is not as high. A large number of components and activities can overwhelm a country‟s implementation capacity. In this context, a more streamlined design with a stronger focus on interventions for high risk groups would have been more suitable for Bhutan. The relevance of design is also impeded by a lack of targeting mechanisms for high risk groups. Although targeting high risk groups was mentioned as a priority, both the PAD and the OM did not specify how high risk groups should be identified and targeted. While almost fifty percent of the people known to be living with HIV/AIDS were from the capital city, Thimphu, and the largest commercial center on the border with India, Phuentsholing, there was no explicit geographical targeting in the design. The relevance of design is somewhere between Substantial and Modest. Relevance of implementation: The relatively large number of multi-sector implementers at various levels overstretched the coordination capacity of the MOH and the PIU. The National HIV/AIDS Program was staffed by only one full-time person for most of the project implementation period. This was also the case with the PMT. In this context, managing, coordinating and monitoring a large program involving six MOH departments/divisions, six non-health ministries, 20 dzongkhag health authorities and 20 dzongkhag MSTFs as envisioned in the Operational Manual would be an impossible task. It was very difficult for PMT and NACP to ensure timely inputs for them, assist in the preparation of annual work plans, procurement of goods and services, monitoring progress and financial matters, as well as provide technical inputs. Communications and logistical issues posed great challenges for the PMT. Consequently, in terms of implementation, the project took decentralization to the extreme. Implementers, particularly those at the lower levels, planned, budgeted and implemented their work programs independently with minimal coordination, technical guidance, support, supervision and monitoring from the central level. 14 There were no specific institutional arrangements for targeted interventions for high risk groups such as CSWs, IDUs, etc. as envisioned in the PAD and OM. Such interventions were supposed to be a project priority. Given the dearth of civil society organization, the project seems to make the assumption that government actors would be the implementers of such targeted interventions. However, marginalized high risks groups are not the traditional constituencies of such government bodies (including those at the lower levels such as the MSTF) and tend to be neglected. The relevance of implementation is rated Modest. On balance, the relevance of objectives, design and implementation is rated Substantial. 3.2 Achievement of Project Development Objectives Assessment of achievement of PDO on the basis of the two outcome indicators Outcome Indicator 1: Percentage of persons reporting condom use with last non-regular sex increased from less than 20% at project start to 60% among priority groups and 30% among the general population at the project end. While condom use is measured in both the general population and most at risk groups, the PAD clearly states that in a low prevalence setting like Bhutan, the greatest impact will be achieved if the target high risk populations are reached with effective interventions. This reflects also the global consensus in HIV/AIDS control. For this reason, the coverage of interventions among priority groups is given greater weight. At appraisal, there were no reliable survey data on condom use in the general population and high risk groups. The figure used as baseline data in the PAD (namely, less than 20% of condom use) refers to the proportion of condom use among people who used family planning methods and is health facility based. Therefore, this information is not suitable as baseline data for this outcome indicator. The lack of reliable baseline data makes it hard to determine whether the target “60% among priority groups and 30% among the general population at the project end� was realistic. During project implementation, condom use was measured in the general population and high-risk groups. According to the 2006 HIV/AIDS General Population Survey, 74% of the general population used condoms in last sex with a non-regular partner. According to the 2008 BSS for the most at risk populations, condom use in last sex with a non-regular partner was below 60% among female bar workers4 (38%-54%) in both Thimphu and Phuentsholing and 35% among non-Bhutanese migrant workers in Thimphu. For the other MARPs, condom use was higher than 60% (Table 1). If the baseline data is 4 The 2008 BSS used female bar workers as a proxy for female commercial sex workers. The validity and reliability of this proxy remains unclear in Bhutan. 15 presumed to be accurate, it can be concluded that the target was met for the general population in 2006 and partially met for high risk groups in 2008. However, as the baseline information employed is not an accurate measure of the indicator, as discussed above, and there was only one round for the BSS and the GPS, it is not possible to assess and attribute change to the project with regard to this outcome indicator. Table 1: Condom use in last sex with non-regular sex partner (%), BSS 2008 Type of risk groups Thimphu Other location IDUs 70% Female bar workers 38-50%5 54% (Phuentsholing) Non-Bhutanese 35% 71% (Mongar) migrant workers Military 85% Police 61% 82% (Samdrup Jongkhar) Taxi drivers 91% 100% (Phuentsholing) Truckers 97% 84% (Samdrup Jongkhar) Source: BSS 2008 (MOH) Outcome Indicator 2: Percentage of patients with selected STIs (i.e. urethral discharge in men, and genital ulcers in men and women) at health care facilities who are appropriately treated accordingly to the updated national guidelines increased from <20% at baseline to 60% at project end. The first round of Health Facility Survey (2009) was implemented late in the project cycle (five years after project effectiveness). Using a combination of direct observation and reported knowledge, it showed that only 25–30% percent of patients with STIs were treated correctly, which was significantly below the target. A second round of the survey was carried out in May 2011 using a subset of questions in the 2009 HFS instrument. As direct observation was not used in the May 2011 survey round, information could only be generated for providers‟ competence in STI management, which is entirely different from the second outcome indicator. For this reason, comparisons between the two rounds cannot be made. According to the latest HFS, 70% of health workers know how to treat urethral discharge, 23% know how to treat male genital ulcers and 28% know how to treat female genital ulcers. Given the well-known and significant gap between what providers know and what they actually do6, the percentages of patients with these three STIs who are appropriately treated according to national guidelines are most likely to be 5 For female bar workers, there were different questions related to this topic in the questionnaire (condom use in last sex with new commercial sex partner, in last sex with regular commercial sex partner, etc.), hence the range of values. 6 This is also referred to as the “know-do� gap. It is well documented in health literature. For example, a 2009 study by Leonard and Masatu in Tanzania shows that patients systematically receive health services with quality below required levels. However, administered tests for health workers indicate that the level of knowledge amongst the health workers is much higher than their practice suggests. (Professionalism and the know-do gap: exploring intrinsic motivation among health workers in Tanzania. Health Economics. 2010 Dec;19(12):1461-77) 16 much less than 70%, 23% and 38%, respectively. This means at project closure, the percentage of patients with genital ulcers who are properly treated would be well below the target of 60%. Assessment of achievement of PDO on the basis of other output data Given the difficulties to gauge project achievement on the basis of very limited and incomplete data availability for the two outcome indicators (especially for outcome indicator number 1), other output data are also examined, especially the coverage of targeted interventions for high risk groups, which should be the crux of prevention efforts in a low prevalence setting such as Bhutan. Despite the stated priority of targeting MARPs, the project made little headway in improving the coverage of targeted interventions for such groups as discussed above. At the project end, NACP‟s estimates of active commercial sex workers were between 200 and 300 in Thimphu, and 50 and 100 in Phuentsholing. The HISC outreach program for CSW was only reactivated toward the end of the project in 2011. Only 32 CSW in Phuentsholing and less than a dozen in Thimphu were reached by non-peer outreach workers at project end. Their exposure to the interventions was also very short, less than six months. Besides these two urban centers, there was neither information on sex workers in other areas of the country and nor interventions for them. In the absence of a harm reduction strategy and program, injecting drug users were not benefitting from clean needle and syringe exchange services or Opioid Substitution Therapy. Little was known about men who have sex with men (MSM) in Bhutan and the project did not have any specific interventions for this group. As the main mode of HIV transmission is heterosexual (more than 90%) in Bhutan, HIV can be primarily considered as an STI. In this setting, STIs are therefore an important and sensitive biomarker of high-risk behaviors for HIV transmission. However, the coverage of HIV interventions among non-HIV STI patients remained low. Accordingly to the 2011 Health Facility Survey, around one third of non-HIV STI patients received condoms. Only 19% of STI patients in 2010 and 26% in 2011 (January to April) were provided with VCT services. This represents a weak link between HIV/AIDS and STI activities and a lack of service integration. Police, army personnel, truckers and taxi drivers were better reached with awareness raising and condom promotion, although the exact numbers of beneficiaries under the project cannot be ascertained. Around 75% of the general population reported easy access to condoms in 2006 (GPS 2006). Easy access to condoms was much less for high risk groups: IDU (30%); female bar workers (30-36%); migrant workers (2-14%); police (24-44%); army personnel (32%); taxi drivers (62%), truckers (18%-47%) according to the BSS 2008. For a detailed discussion of the project achievement, please see the ICR datasheet. In summary, out of two PDO indicators, one is partially achieved if the baseline data is accepted as accurate, while the other is not achieved. Out of ten Immediate Outcome Indicators, eight are either not achieved or not monitored and only two targets are met. The project performed better with regard to additional process indicators with targets for 12 achieved and six not achieved (Table 2). 17 Table 2: Summary of project achievement according to the indicators PDO indicators Immediate outcome Additional process indicators indicators Total number 2 10 18 Achieved 1(partially)* 2 12 Not achieved 1 5 6 Not monitored 0 3 0 *only if baseline data is taken at face value Achievement of the PDO is rated Modest. 3.3 Efficiency Due to the fact that the project only has one round of survey data, it is not possible to conduct economic analyses to assess the project‟s efficiency. However, efficiency is likely to be Modest for various reasons. First, there was little targeting of the drivers of the epidemic and geographical hotspots for the most of the project period. Second, the integration of HIV/AIDS and STI services was limited. Third, the MOH‟s weak harmonization and coordination of GFATM activities and the project‟s work plan also made the project less efficient. 3.4 Justification of Overall Outcome Rating With a Substantial rating for project relevance, a Modest rating for project efficacy and a Modest rating for efficiency, the overall outcome rating is Moderately Unsatisfactory. 3.5 Overarching Themes, Other Outcomes and Impacts Project relevance: (a) Poverty Impacts, Gender Aspects, and Social Development HIV/AIDS is a well known cause of poverty. By limiting the spread HIV and mitigating its consequences, the project was expected to help to prevent or reduce HIV-related poverty. Unfortunately, the extent of the project's poverty reduction impacts cannot be quantified due to the lack of data. However, given Bhutan‟s very low HIV prevalence as well as relatively low rate of urban poverty, the impact on poverty measures is likely to be negligible. (b) Institutional Change/Strengthening Institutional strengthening is assessed as substantial. A national HIV/AIDS policy and the first National Strategic Plan were adopted. These helped lay the foundation for the second National Strategic Plan which is now under development. Guidelines were developed and disseminated for VCT, HIV/AIDS care, treatment and support, blood 18 safety, STIs, infection control and health care waste management. A gonococcal antimicrobial resistance surveillance system was established. Both clinical laboratories and the public health laboratory were strengthened with the provision of equipment, training and supplies, as well as the establishment of a national quality assurance program. The number of laboratories meeting quality standards in HIV testing was 78% in 2011. The Laboratory Information System (LIS) is now fully operational. NACP was strengthened in terms of capacity, but not staff numbers. The blood bank network was significantly strengthened with equipment, training, the development and implementation of blood safety policies and guidelines with the support of the project. Various staffs in the MOH were trained, but due to the high turnover, many are no longer working in the area of HIV/AIDS. With regard to project management, many staff and implementers were trained in financial management and procurement. MSTFs have been strengthened and their capacity in working across sectors increased as a result of their involvement in the project. While there are only a handful of NGOs/CBOs in Bhutan, the establishment of the first network of PLWHA (Lhaksam) with the support of the project marked a very important milestone in civil society‟s response to HIV/AIDS. (c) Other Unintended Outcomes and Impacts (positive or negative) N/A 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops N/A 4. Assessment of Risk to Development Outcome The risk to development outcome is significant for the following reasons: Human resource constraints: Despite the increased capacity in HIV/AIDS control owing to the project‟s support, Bhutan continues to face tremendous challenges in human resources for health, in general, and for HIV/AIDS control, in particular. Given the past trend, high turn-over of staff will remain a problem for the national HIV/AIDS response. While NACP is central to the management, coordination and M&E of the national strategic plan, at the time of project closing, it remained severely understaffed. Nascent civil society: The recent establishment of the first CSO of PLWHA in Bhutan is a positive development. However, the very few number of civil society organizations in Bhutan will continue to pose an obstacle to implementation of HIV/AIDS interventions for high risk groups. Failure to prioritize targeted interventions for high risk groups: The second national strategic plan for HIV/AIDS clearly makes the case for targeting high risk groups with adequate coverage of effective interventions. However, the lack of commitment as well as the capacity to target such groups remains a significant risk to development outcomes. 19 Adequate financing for the national HIV/ADS strategic plan: With the closing of the Bank-financed HIVAIDS project as well as the GFATM‟s support coming to an end soon, it will fall upon the RGOB to continue financing the NSP. So far, the RGOB has been spending around US$ 0.2 million per year on HIV/AIDS control in addition to World Bank and GFATM‟s resources. This would call for increased government funding for the NSP. 5. Assessment of Bank and Borrower Performance 5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry The project was prepared in a relatively short period of ten months. For project preparation, the team ensured adequate consultations and detailed preparation for the start-up period. While the project took a very comprehensive approach to HIV/AIDS and STI control, preparation and design could have been strengthened by: (i) the development of a national HIV/AIDS/STI strategic plan during project preparation; (ii) sole focus on prevention of HIV/AIDS and STI for high risk groups in the PDO; (iii) more focused multi-sectoral approach and streamlined project design; (iv) adequate risk mitigation measures for human resource constraints; and (v) more realistic result framework and targets. Project preparation benefited from a Quality Enhancement Review in January 2004. A Quality at Entry Assessment by the World Bank‟s Quality Assurance Group (QAG) was carried out in July 2005. It praised the project‟s strategic relevance, design, technical, economic and fiduciary aspects and risk analysis. A Satisfactory rating (2 out of 6, with 1 being the highest rating) was given to the project by the QAG panel. Given the design shortcomings noted above, the Quality at Entry Assessment may have been over optimistic in its rating. On the contrary, a subsequent Quality Assessment of Lending Portfolio by QAG in 2009 gave a Moderately Unsatisfactory rating (4 out of 6) for the project‟s quality of design, citing inadequate focus on MARPs in PDO and project approach, complexity of design, and inadequate attention to the institutional constraints. On balance, the Bank performance in ensuring quality at entry is rated Moderately Satisfactory. (b) Quality of Supervision There was a relatively low turn-over in terms of task team leadership on the Bank‟s side with only two TTLs throughout the project cycle. The first TTL was responsible for project preparation and the first year of implementation. The second TTL took over in November 2005 and worked on the project until its closing. This was helpful for implementation support, given the high turn-over of the MOH technical staff working on HIV/AIDS. Supervision missions were conducted every six months on average. The Bank team involved various HIV/AIDS specialists in supervision, who provided valuable technical inputs. The Sector Manager also participated in supervision and supported the 20 policy dialogue when the project was at a critical junction. An on-time MTR was conducted in November 2006. Generally speaking, supervision documents identified implementation bottlenecks which can be grouped in three categories: (i) HIV/AIDS/STI technical issues (e.g. targeting risk groups, BCC, social marketing of condoms, surveys); (ii) financial management, (iii) procurement, and (iv) other project management issues (e.g. planning and budgeting for results, routine M&E, coordination). The Bank team was more proactive in the first two groups of issues, and less so for the last two. More support could have been given to procurement as well as general, non-fiduciary project management challenges. This type of implementation support would have been as critical given the limited management and coordination capacity in the NACP and PMT. The 2009 Quality Assessment of Lending Portfolio by QAG gave a Moderately Unsatisfactory rating (4 out of 6) for Quality of Bank supervision, citing a lack of Bank‟s forceful and targeted follow-up on persistent problems, inadequate use of performance indicators and shortcomings in procurement support and oversight. While the World Bank team consistently diagnosed an array of problems in project implementation, many suggestions offered by the Bank failed to be implemented. This failure indicated that a more fundamental approach could have been used by the World Bank team such as project restructuring to address underlying causes of implementation constraints. With regard to health care waste management, although the Bank team diligently followed up on this topic, the support of a World Bank HCWM specialist was given only one time. According to the QAG report, as project ratings in Implementing Support Reports (ISRs) were overly optimistic, there were also issues with the candor and realism of ISRs. A detailed analysis of Bank supervision is found in Annex 4. The Bank's performance in ensuring quality supervision is rated Moderately Unsatisfactory. (c) Justification of Rating for Overall Bank Performance With a Moderately Satisfactory rating for Quality at Entry and a Moderately Unsatisfactory rating for Quality of Supervision, the overall Bank performance is Moderately Unsatisfactory. 5.2 Borrower Performance (a) Government Performance The Ministry of Finance fulfilled all of its obligations related to the project throughout the project cycle. Government performance is rated as Satisfactory. (b) Implementing Agency or Agencies Performance The MOH‟s commitment to the project was high during project preparation, appraisal and during the first three years of implementation. There was a decline in its commitment after 2007. At project closure, two of five legal covenants were fully complied with, two partially complied with, and one complied after delay. Due to severe 21 human resource constraints, NACP was unable to provide adequate technical guidance and support to the implementers; and the PMT was unable to sufficiently fulfill its project management and coordination functions. There were strong commitments and good efforts of MSTF and selected line ministries in HIV/AIDS control, although they operated without sufficient guidance and supervision by NACP and PMT. Finally, the lack of targeted interventions for the most at-risk groups is an important indication of the Implementing Agency‟s failure to give adequate attention and prioritization to this critical dimension in HIV/AIDS control in a very low prevalence setting like Bhutan. The performance of Implementing Agency is rated Moderately Unsatisfactory. (c) Justification of Rating for Overall Borrower Performance Given the critical role of the Implementing Agency, more weight is given to its performance in the assessment of the overall Borrower performance. For this reason, overall Borrower performance is rated as Moderately Unsatisfactory. 6. Lessons Learned A National Strategic Plan for HIV/AIDS would contribute to the foundation for a HIV/AIDS project: In the absence of any kind of strategic plan for HIV/AIDS, as was the case in Bhutan, project preparation should include support for the development of such a plan prior to appraisal. The plan would then form the basis for project design and reinforce the “Three Ones� principles in HIV/AIDS response7. It would also help engage all stakeholders and build stronger commitment. Focus on most-at risk populations: In a low prevalence setting with severe human resources constraints, such as Bhutan, the best use of resources (human and financial) is to focus on HIV/AIDS interventions for MARPs. It is critical to undertake behavioral surveillance and socio-geographical mapping of MARPs prior to designing policies and program interventions. This would also provide baseline data for the Results Framework and helps set realistic targets. In addition, STI patients should be viewed as a MARP and benefit from BCC and VCT other than STI treatment. Modality to reach MARPs: Public actors are less effective and motivated to conduct outreach for marginalized MARPS such as CSW, IDU and MSM. Peer groups should be mobilized for this purpose. Streamlining multi-sectoral response: While the multi-sectoral approach can be relevant for a low prevalence country; activities should be restricted to the most critical sectors 7 The "Three Ones" principles promoted by UNAIDS are: one agreed HIV/AIDS action framework that provides the basis for coordinating the work of all partners; one national AIDS coordinating authority; and one agreed country-level monitoring and evaluation system 22 given severe human resource constraints, such as in Bhutan. Such a streamlined multi- sectoral design would facilitate implementation. Roles of NACP: First, central support to lower-level implementers should not be overlooked in the context of decentralization, as implementers at lower levels still need technical guidance and support from NACP for sound decision making. Second, given the human resource constraints in the MOH, it would have been more efficient if the NACP, the PMT for World Bank project and the PMT for GFATM, had been consolidated into a single entity. This would have greatly facilitated the coordination and management of all HIV/AIDS activities in the country regardless the financing source. M&E: M&E should be tailored to the country‟s limited capacity and characteristics of the epidemic. Information should be used to improve the evidence base for local decision making. One PMT to manage both World Bank and GFATM projects: Given (i) the need to coordinate the two initiatives and (ii) human resources constraints in the MOH, it would have been much more efficient if one PMT had been used to manage and coordinate both projects. 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies (b) Cofinanciers (c) Other partners and stakeholders 23 Annex 1. Project Costs and Financing (a) Project Cost by Component (in USD Million equivalent) Actual/Latest Appraisal Estimate Percentage of Components Estimate (USD (USD millions) Appraisal millions) 1. Prevention of HIV/AIDS and STIs 1.998 1.971 99% 2. Institutional strengthening and capacity building 1.659 1.559 94% 3. Care and treatment of HIV/AIDS and STIs 1.023 0.970 95% 4. Strategic Information for HIV/AIDS and STIs 1.105 0.887 80% Total Baseline Cost 5.785 5.387 93% Physical Contingencies 0.000 0.000 Price Contingencies 0.160 0.000 Total Financing Required 5.945 5.387 91% (b) Financing Appraisal Actual/Latest Type of Estimate Estimate Percentage of Source of Funds Cofinancing (USD (USD Appraisal millions) millions) Borrower 0.14 0.00 0% IDA GRANT FOR HIV/AIDS 5.80 5.387 91% 24 Annex 2. Outputs by Component Component 1: Prevention of HIV/AIDS and STIs ($2.00 million) Increasing access to  Condom social marketing feasibility study and strategy and use of condoms. developed (however, condom social marketing was not implemented)  60,000 grosses of condoms procured by the project, of which 40,000 grosses were disseminated through the health system  Around 1,250 condom boxes in the country Increasing  A BCC strategy developed knowledge and  Advocacy events, information campaigns with the commitment. participation of government officials and the royal family  Various IEC materials developed and disseminated  Radio and TV spots with HIV/AIDS content until 2008 as they were subsequently supported by the GFATM)  IEC campaigns conducted by MSTFs  266 health workers trained in HIV/AIDS prevention by NACP Changing attitudes  2011 sexual networking study conducted in Thimphu and behaviors among and “hotspots� identified priority groups.  Two HISC outreach programs by non-peer outreach workers established at the end of the project, with a coverage of 32 CSW in Phuntsoling and less than a dozen in Thimphu  No harm reduction strategy or program for IDU  Little information on MSM, no specific activities for them  Awareness campaigns for troops and families of the Royal Bhutan Army in all eight wings of the army. TOT conducted for focal points from all wings. Around 2,000 copies of HIV/AIDS posters distributed in the army  HIV and STI awareness and sensitization activities by Thrimshung Women‟s Group for police and prisoners (through police clinics, local hospitals and prisons)  IEC materials (bumper stickers, CDs, cassette containing songs on HIV/AIDS and STIs) developed and distributed among taxi and truck drivers  Establishment of the first PLHA network (Lhaksam) Component 2: Institutional Strengthening and Building Capacity ($1.66 million) Strengthening and National External Quality Assessment Scheme (NEQAS) in 25 expanding laboratory HIV/STI serology established for laboratories services and blood Introduction of the Laboratory Information System (LIS) bank. Capacity building for laboratory services: 3 laboratory technicians trained in LIS overseas, 76 trained in LIS in the country, 40 trained in HIV/STI diagnosis and NEQAS, 1 in HIV/HBsAg and viral load, 3 in Quality Assurance in HIV/STI, 31 in internal and external quality assurance in Neiserria gonorrhea diagnosis National Blood Policy developed and disseminated Blood Bank Standards of Operations developed and disseminated National and two regional blood banks strengthened with equipment and training. Several district hospital blood banks were also strengthened with equipment Capacity building for blood bank: 90 laboratory technicians trained on use of SOPs in blood banking processes and procedures. 15 laboratory technicians (from different blood banks) on blood banking and safe transfusion, 1 transfusion medicine specialist trained overseas in Quality Management, 241 health personnel trained on clinical use if blood Several blood donor campaigns carried out Between 2004 and 2010, share of voluntary blood donors increased from 30% to 80% in Thimphu and 32% to 46% nation-wide Enhancing technical, 2008 National HIV/AIDS strategic plan developed and management, and disseminated implementation National HIV/AIDS Steering Committee met 13 times to capacity, strategic provide guidance and oversight to the project (it did not planning and policy convene in 2010 development. 24 officials in line ministries trained in HIV/AIDS Study tours to other countries (Thailand, India, etc.), participation in regional and international workshops and conferences for leaders and implementers Training modules for key implementing agencies were developed and implemented 15 staffs trained in financial management, disbursement and procurement procedures 641 program officers and managers, DMO/DHSO trained on use of data for management (cumulative) Care, Support and Treatment of AIDS and STIs ($1.0 million) Increase access to and National guidelines on VCT developed and disseminated in use of VCT. 2008 Establishment of two free-standing VCT sites, VCT services expanded to all hospitals During the project, 7,209 persons receiving pre-test counseling in two HISC (free-standing VCT centers) with 7,015 tests 26 conducted 11,760 persons receiving pre-test counseling in JDWNRH with 10,307 tests conducted Strengthening National guidelines for adult and pediatric AIDS management management of AIDS developed and disseminated in 2006 and opportunistic 203 health workers were trained in HIV/AIDS care and infections (OI). treatment by NACP CD4 testing available at Jigme Dorji National Referral Hospital and Mongar Regional Referral Hospital with the project support 72% of known PLWHA receiving CD4 counts every 6 months Of the 167 PLWHA, 53 are on ART Management of OI is not monitored ART are available at the referral hospital level. No system for ART adherence monitoring Strengthening STI treatment guidelines updated and disseminated with project management of STIs. support Capacity building in STI management: 555 health workers trained by Feb 2007, 611 received refresher training in 2009, 42 DHOs and DMOs trained in 2010 Antibiotic susceptibility of N. gonorrhea was carried out in 4 sites (Mongar, Gelephu, Phuntsholing and Thimphu) Health worker‟s knowledge in STI management remains low: 70%, 28% and 23% of health workers knew how to treat urethral discharge, female and male genital ulcers respectively in 2011 Universal precautions Infection Control Committees established and Health Care Waste 63% staff trained on national infection control and hospital Management. waste management guidelines 29 Hospitals, 15 BHU I implements the Infection control and health care waste management plan 65% of facilities complied with national policy on waste management (2009) Equipment, materials and civil works for infection control and health care waste management: 230 electrical needle cutters, 114 autoclaves, burial pit constructed for 12 districts Component 4: Strategic information for HIV/AIDS and STIs ($1.1 million) Enhancing 181 BHUs and 24 hospitals received support for HMIS management IT system was also strengthened for drug and medical supply information systems inventory system (MSD, DVED and HERM) and use of IT. 161 computers and 3 servers were procured Strengthened 30 health staffs (ADHOs, Programme Officers, Medical Record operational research Technician) trained on Research Data Analysis capacity and use of 2 staff from research unit attended the training on health research data. research Surveillance, One round of the HIV/AIDS General Population Survey (2006) 27 monitoring and One round of HIV/AIDS Behavioral Surveillance Survey for evaluation. high risk groups (2008) The first round of the Health Facility Survey (2009) The second round of the Health Facility Survey for a subset of facilities (2011) Retrospective study on the risk factors of HIV/AIDS infections in Bhutan (2011) Training of medical records personnel on data collection, recording and reporting on STI 28 Annex 3. Economic and Financial Analysis N/A 29 Annex 4. Bank Lending and Implementation Support/Supervision Processes Annex 4(a). Task Team members Responsibility/ Names Title Unit Specialty Lending Hnin Hnin Pyne Regional Coordinator WBIRP Ruma Tavorath Sr Environmental Specialist SASDI Debabrata Chakraborti Senior Procurement Specialist SARPS Celine Costello Daly Consultant SASHN Madhavan Balachandran Financial Management Specialist SDNCA Supervision/ICR Sandra Rosenhouse Sr Population & Health Specialist SASHN Madhavan Balachandran Financial Management Specialist SDNCA Debabrata Chakraborti Senior Procurement Specialist SARPS Shanker Lal Senior Procurement Specialist SARPS Mariam Claeson Program Coordinator SASHN Celine Costello Daly Consultant SASHN Cornelis P. Kostermans Lead Public Health Specialist SASHN Savinay Grover Financial Management Specialist SARFM Manvinder Mamak Sr Financial Management Specialist SARFM Shubhendu Mudgal Consultant SASHN Kumaraswamy Procurement Specialist SARPS Sankaravadivelu Ruma Tavorath Sr Environmental Specialist SASDI David Wilson Program Director HDNVP Julie McLaughlin Sector Manager SASHN Senior Health Specialist / ICR Son Nam Nguyen ECSH1 Author 30 Annex 4(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 FY04 28.85 224.61 FY05 -0.69 Total: 28.85 223.92 Supervision/ICR FY04 0.00 FY05 14.89 112.03 FY06 11.69 85.30 FY07 8.81 66.30 FY08 9.98 82.35 FY09 10.01 73.97 FY10 9.91 92.50 FY11 22.38 144.14 FY12 1.76 6.14 Total: 89.43 662.75 31 Annex 4(c). World Bank Implementation Support Missions Mission Skill mix (other than the TTL) dates Public HIV STI Procure FM HCWM Health ment Sept 17- + + + Oct 6 Dec 6-17 + + and 23-27, 2004 Mar 7-8, + + + 25, 2005 Oct 3-13, + + + + + 2005 Jan 23-24, + + + 2006 May 3-16, + + + 2006 Nov 14-28, + + + + 2006 May 26- + + + Jun 14, 2007 Nov 19-23, + + 2007 June 9-22, + + 2008 Feb 2-13, + + + + 2009 Aug 24-28, + + + 2009 Mar 23- + + + Apr 8, 2010 Nov 3-18, + + + + + 2010 May 16-27, + + + 2011 32 Annex 5. Beneficiary Survey Results N/A 33 Annex 6. Stakeholder Workshop Report and Results N/A 34 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR Annex 7(a). Government's ICR Ministry of Health National HIV/AIDS and STI Prevention and Control Project Implementation Completion Report (ICR), July 2011 1. Background By the late 1980s, most countries in South Asia, though not Bhutan, had reported cases of HIV infection. In an effort to prevent an HIV epidemic from emerging, the Government of Bhutan instituted the National HIV/AIDS and STD Control Program (NACP) in 1988, to disseminate public education programs for sexually transmitted infections (STIs) and HIV. Although HIV prevention measures were prioritized and actualized, HIV entered Bhutan‟s borders and the first two cases were detected in 1993 in a married couple at a hospital through active surveillance. This marked the end of Bhutan‟s identity as the only HIV free nation in the South Asian region. UNAIDS estimated that there were fewer than 1000 people living with HIV/AIDS in Bhutan as of the end of 2005 and the country has been classified by the WHO as having a low-level HIV epidemic (less than 0.02% prevalence) in the general population. The cumulative number of HIV infections detected was 217 as of mid 2010. These cases range from farmers in rural villages to government workers in urban settings. HIV infections have been documented to be spreading in two directions: (1) through the general population and (2) through marginalized groups of sex workers and drug users. Approximately 88% of current cases have occurred through heterosexual transmission. However, mother-to-child transmission is also an important consideration. At present, 18 children (over 10% of the total cases) have been infected through vertical transmission. Bhutan might be able to avert a potentially major HIV epidemic by increasing their current HIV prevention efforts. However, Bhutan as a country is currently in a socio- economically transitional phase, which creates challenges to HIV prevention, such as increased rural-to-urban migration patterns. This increased urbanization results in the decreased influence of traditional family and social networks. In addition, 45% of Bhutan‟s population is less than 15 years of age and 63% of the population is less than 63 years of age [6]. Based on information collected from the NACP and the census, a large proportion of the Bhutanese population are sexually active and are therefore at risk for HIV/STI through sexual risk behaviors. The Royal Government of Bhutan recognizing the threat of the unabated HIV epidemic in the small society had mobilized resources both internal and external sources to prevent the spread of the epidemic. The World Bank support for the HIV project has been the biggest single source financer for HIV prevention from 2004 to 2011. 2. The National HIV/AIDS and STI prevention and control project-World Bank 35 The World Bank Project was formalized in July 2004 with the total grant amount of USD 5.7 million. The project appraisal document was signed between the Royal Government of Bhutan and the World Bank. The Ministry of Health was responsible for managing the project. The Goal of the project was to reduce the risk of HIV/AIDS and STI transmission among the general population, in particular groups whose sexual behavior put them at high risk. The project was initially signed for the period of five years Table 1 Major time lines for the project Board Approval June 17, 2004 Effectiveness Date August 18, 2004 Original Closing Date June 30, 2009 Extended Closing Date June 30, 2011 The indicators set to measure the performance of the project included: (i) Increase in condom use in the last non-regular (paid and casual) sex partner among at risk groups and the general adult population; (ii) Increase in percentage of patients with selected STIs (urethral discharge in men and genital ulcers in men and women) presenting to health care facilities, who are appropriate treated accordingly to national guidelines. The key outcome indicators included:  Percentage of person reporting condom use with last non regular sex partner increased from <20% at project start to 60% among priority groups and 30% among general population  Percentage of patient with selected STIs at health care facilities who are appropriately treated accordingly to the updated national guidelines increased from <20% in baseline (Yr2) to 60% at project end The project plan consisted of four main components with the budgetary allocation as follows: (i) Prevention of HIV/AIDS and STIs (34%) Prevention of HIV/AIDS and STI to promote political and societal leadership in the fight against HIV/AIDS, improve community knowledge and attitudes about HIV prevention, promote risk-reducing behavior amongst priority groups, and increased access to condom (ii) Institutional Strengthening and Capacity Building (29%) Institutional strengthening and building capacity to enhance the ability of national institution to lead the fight against HIV through training and technical assistance, and will strengthen laboratory and blood transfusion services (iii) Care, Support, and Treatment of HIV/AIDS and STIs (18%) Care, support and treatment of AIDS and STIs to establish VCT services, strengthen management of STIs and HIV/AIDS (comprehensive care and treatment approach, including introduction of ART), and improve infection control and waste management in health facilities. 36 (iv) Strategic Information for HIV/AIDS and STIS (19%) Strategic information for HIV/AIDS and STIs to promote evidence based decision making by improving health information management, strengthening operation research capacity, instituting M&E and second generation surveillance systems. 3. Assessment of the project design On assessing the project design, it is felt that the project has been comprehensively designed with detailed project implementation plan (PIP) defining the roles and responsibilities of both the project management team and implementing units like NACP. The activities are linked with the overall project goals and objectives. However, the stakeholders commonly felt that there was inadequate orientation to the World Bank procurement system across the stakeholders, hence resulting in delay in implementation and caused confusion at times. Although the significant share of the project resource had been allocated in the area of prevention focusing on condom promotion and behavioral change, the project could not adequately focus on targeted intervention for high risk populations. The recruitment of the fulltime competent personnel under project was challenging task for the Ministry of Health. This is mainly due to the shortage of competent national staffs and poor turnover of the international TAs. The staffs managing the project often had to shoulder additional responsibilities beyond the project. This issue was not appropriately considered during the design of the project. NACP continually faced the issues of human resources shortages over the duration of the project. PMT should have been merged with the NACP. This could have eased the human resource shortages and at the same time could have resulted in better overall coordination of activities and resources. The stakeholders also felt that the role of the mission team of the Bank to assess the implementation process was not defined within the project operational manual. The dual approval process from PMT, MoH and further from the Bank (DC) on majority of the activities was seen crucial but posed huge administrative burden leading to the delays in implementation. 4. Achievements by Key components Component I: Prevention of HIV/AIDS and STIs  Under this components following activities were planned and carried out:  Assessment study on feasibility of condom social marketing  Procurement of condoms - 20,000 grosses of male condom each in 2005, 2007 and 2011  Procurement of 8 vehicles for condom distribution and enhancing of field monitoring and supervision of the project activities 37  Conducted high level awareness and advocacy campaigns  Conducted Media campaigns  Printing of IEC materials for BCC activities  Supported work plans of the line Ministries  Support to districts MSTFs  Support to REWA – a peer support group and PLHA net work group- Lhaksam to build their capacity. Achievement:  Awareness on HIV raised amongst the general population.  Multi-sectoral participation achieved particularly District based MSTFs  Increased access to condoms, and increased use --74% of the population reported using condoms with last irregular partner  Expansion of PMTCT and VCT services in all District hospitals  STI preventions services improved through syndromic management Component II: Institutional Strengthening and Building Capacity Following activities were outlined and carried out for this component:  National External Quality Assessment Scheme on STI/HIV serology instituted External quality assessment is essential part of laboratory quality assurance programme. Therefore, institution of NEQAS on STI/HIV serology was important to monitor the quality of tests kits and testing to obtain reliable lab results Table 2: National STI/HIV capacity building Indicator Baseline Current value Ex-country training diploma in HIV/STI diagnostic and None 1 laboratory safety Ex-country training diploma in QA in HIV/STI testing None 1 Number of laboratory technicians trained in STI/HIV diagnostic None 40 testing and NEQAS Number of ELISA washer and Reader in PHL 1 3 Number of ELISA washer and Reader for Mongar, Gelephu and None 1 P/ling hospitals Develop NEQAS protocol on STI/HIV serology None 1 Number of district hospital labs participating in STI/HIV NEQAS None 38 38 Table 3: Establishment of Laboratory Information System (LIS) in hospital to enable data collection and facilitates laboratory documentation and reporting Indicator Baseline Current value Number of district hospital laboratories that has LIS None 25 Number of ToT trained in LIS software None 3 Number of laboratory technicians trained in LIS software None 76 Number of computers procured for LIS None 4 None 44 Number of printers procured for LIS None 30 1 30 Number of server procured for LIS None 2 None 2 Achievement: Component III: Care, Support and Treatment of AIDS and STIs  National HIV/AIDS policy developed and adopted  Guideline for clinical aspects of service delivery developed  STI guidelines and Infection Control and Health Care Waste Management (IC&HCWM) guidelines developed.  National STI/HIV laboratory capacity built to diagnose STI/HIV (Table 2)  Laboratory Information System (LIS) established to help data collection, documentation, reporting and forecasting of test kits/ reagents quantification (Table 3)  HIV/STI diagnosis strengthened (including PHL, Clinical Labs and District labs)- through trainings, supply of equipment, setting up quality assurance scheme, supply of test kits/reagents for screening STI/HIV during project period and establishment of LIS  A gonococcal antimicrobial resistance surveillance system established in five sentinel sites  Support to National HIV/AIDS Commission to discuss HIV policy and strategy  Procurement of computer and accessories for the Ministry of Health  The National Blood Bank Policy was developed and adopted.  National Guidelines on “Clinical Use of Blood for Doctors and Nurses� were formulated, adopted and disseminated to all the hospitals.  First version of generic, national Standard Operating Procedures (SOPs) on blood bank activities were developed and provided to all the blood banks in the country for use.  HRD strengthening through in-country and ex-country training opportunities for blood bank personnel, clinicians and nurses. Laboratory technicians were trained on quality assurance, blood bank procedures and processes and health care staff on appropriate clinical use of blood and safe bed side transfusion practices.  Blood donor campaigns both awareness campaigns and donation drives were carried out with a substantial increase in voluntary blood donations especially at the national blood bank, Thimphu since 2004.  Strengthening of blood banks through procurement of equipment and reagents (Following equipment procured and distributed to JDWNRH, Mongar RRH and 39 Gelegphu RRH: 4 Blood Storage Refrigerator, 4 Automatic Blood Cancellation with shaker; 3 Blood bank serofuge; 3 Automatic cell washers ) Table 4: Summary of progress of blood bank services Indicator Baseline Current value Number of blood bank/laboratory 5 Additional 15 including personnel trained ex-country 1 transfusion in Quality Management medicine specialist Number of blood bank/laboratory None 90 personnel trained in-country on use of SOPs Number of doctors and nurses trained None 241 in „Clinical Use of Blood‟ and „Safe Transfusion Practice‟ Percentage of voluntary blood National data not 46% national in 2010 donations available in 2004 80% at NBB, Thimphu 30% at NBB, in 2010 Thimphu in 2004 Number of blood banks equipped with None 3 basic infrastructure Component III: Care, Support and Treatment of AIDS and STIs Activities and achievement:  Establishment of two VCT centers called as Health Information and Service Centers (HIISC) in Thimphu and Phuntsholingling cities  Care and treatment guidelines for HIV/AIDS developed and implemented.  Network of Bhutanese PLHA established in 2010 as a CBO.  Procurement of ARV drugs  Procurement of Needle cutters, auto claves, protective attire and waste management equipment to improve waste disposal and infection control system  Civil works digging needle pits-12 pit constructed  Establishment of Infection control committees in the hospitals Component IV: Strategic Information for HIV/AIDs and STI Procurement of IT hardware and software for MoH and DVED Installation of LAN and establishment of the Laboratory Information System Support to changes in software, forms, reports and the users manuals of HMIS Following are the major studies conducted to improve the evidence pertaining to HIV/AIDS and STIs 1. General Population Survey, 2008 2. Behavioural Surveillance Survey, 2008 3. Health Facility Survey, 2009 4. Rapid Assessment on sexual network in Thimphu and Phuntsholing, 2010 and 2011 5. Retrospective Study on PLHA 2011 40 6. Health Financing Studies (National Health Accounts Study, Costing/Health Care efficiency) 7. GIS Mapping of Health Infrastructure and Indicators) 2011 8. End line Evaluation of STI services 2011 5. Key highlights of performances of key stakeholders Under the support of the project key implementing partners were  National HIV/AIDS Commission  National AIDS Control Program  Line Ministries ( Ministry of Education, Ministry of Home and Cultural Affairs, Ministry of Trade and Industry)  Multi-sectoral Task forces in Districts (MSTF) National HIV/AIDS Commission (NHAC) The National AIDS Committee formed in 1993 was upgraded to the National HIV/AIDS Commission in February 2004 to strengthen national coordination for HIV response and to guides HIV and AIDS policy formulation and national responses. The NHAC consists of ministerial representation from all relevant ministries and other institutions. It is the apex policymaking body on HIV/AIDS with the Health Minister as Chairperson. The National STI & HIV/AIDS Control program, Department of Public Health serves as the Secretariat to the NHAC. From 2004 to 2011 ( June ), there were 13 meetings of the National HIV/AIDS Commission out of which 11 were supported by the World Bank Project. Major policies on prevention care and treatment were formulated during the period of the World Bank. Key policies include, strengthening multisectoal response, infant feeding policies among children born from HIV infected mothers, and supportive services for sex workers, and greater involvement of people infected with HIV/AIDS. In addition, care and treatment for STI were strengthened with the expansion of the syndromic management of STIs in the country. National STD/AIDS Control Program (NACP) NACP was responsible for implementing NHAC policy directives, monitoring and implementation of HIV/AIDS and STI prevention and control activities at the national level. In addition, NACP was also responsible for implementation of STI/HIV component of the project. NACP collaborated and provided technical assistance to other implementing agencies. Line Ministries: Several line ministries like the Department of Tourism under the Ministry of Trade and Industry, the Road Safety and Transport Authority under the Ministry of Information and Communication, Armed forces and the Multi-Sectoral Task force in the districts were implementing partners and annual workplans were funded by the project. The activities were mainly focussed towards general prevention and contributed towards the component one of the project. The contribution of the line ministries and especially that of the MSTF have been vital in raising the general awareness. 41 However the progress of the line ministries was slow due to limited technical and management capacity at the Dzongkhag and line ministry level which was aggravated by limited technical support and supervision by NACP and PMT. Further ownership by the line ministries were not adequate and focal persons assigned didn‟t have adequate time as they had their own responsibilities of their parent agencies. From the later part of 2008 funding support for many of the line ministries was withdrawn as there was duplication with the Global Fund Project. Civil Society: REWA, an NGO working with drug users initiated outreach intervention to promote HIV prevention and harm reduction behaviour among drug users, principally among in- and out-of school youth in Thimphu for a period of 6 months. However the organization was closed down following some issues external to the project. The project also funded the initial capacity development of the informal network of people living with HIV/AIDS. Training manuals were developed and trainings conducted for the members. The organization has now been a full fledge NGO of people living with HIV/AIDS in Bhutan. 6. Summary of progress A lot has been done for the general population through the World Bank Project. MSTF annual work plan based activities with technical guidance from NACP has been implemented each year since 2004. Focus of the activities were mainly on creating awareness on HIV, reducing stigma and discrimination and conducting events during local festivals. World AIDS Day was observed at the national level and as well as in all of the 20 Districts each year. Media campaigns by airing HIV messages on the national television, radio programs and print media targeting the general population were done. Success among the general population could be indicated from the higher condom use rates overall in comparison to other countries in the table below. While the populations, age categories and indicator definitions are not identical, Bhutan seems to have higher condom use rates overall. GPS, 2008 found that among married male respondents, condom use at last extramarital sex encounters exceeded 80% with slightly higher rates among urban males. Among unmarried males, reported use of condoms in last sexual intercourse was in excess of 75%. 42 Table 5: A comparison of reported use of condoms in various countries Indicator Description (derived from various country reports) Indicator Value Bhutan 2006 – reported condom use with partners other than spouse in the 75-80% past year, males aged 15-49 Indonesia – 2007- Reported consistent condom use in the past 3 months, 7 to 45% with FSW (High risk occupational categories of men) India : 2004 – Proportion of males reporting condom use with last episode of 62% commercial sex Thailand -2006 Adults 18-59 with over one partner who reported condom 45% use at last sexual intercourse Nepal, 2006-2007: Adult men between 15 to 49 with over one partner, in the 30% last 12 months, who reported condom use at last sex Source: AIDS Data Hub for Asia and the Pacific – www.aidsdatahub.org (accessed 10 July 2009) Condom promotion and distribution was done mainly by establishing condom boxes at the entertainment venues and other sites in all the 20 districts. In the GPS, 75% of respondents (83% of males, 67% of females) reported easy access to condoms. Condom demonstration is held in almost all of the MSTF awareness activities. However during the various monitoring and supervision visits it was found that most of the condom boxes were empty. There is no replenishment strategy. The NACP with the support of the World Bank Project developed the VCT guidelines and trained at least two people from all the hospitals in the country. VCT is being offered in all the district hospitals. Also two free standing VCT centers under the brand name HISC (Health Information Service Center) was established in Phuntsholing and Thimphu. These two places have the highest number of cases detected. An integrated VCT center was also established at the National Referral Hospital. In the field of care and treatment, management guidelines for care and treatment of HIV/AIDS cases were developed and health workers trained on it. Guidelines on PMTCT were also developed and health workers trained. CD 4 machine procured. Currently about 54 people are on treatment. STI syndromic management guidelines were also developed and the treatment regimen were also revised. Overall about 662 medical personnel were trained on VCT, HIV care and treatment and STI syndromic management at the central level and cascading training provided to all the district hospitals. 43 For support of PLHAs, training module for PLHAs was developed and training of PLHAs conducted. One of the successes of the initiatives taken to work with PLHAs is the formation of the informal network of PLHAs which is now a fully fledged NGO of PLHAs in Bhutan. In order to build the evidence and generate strategic information several studies were conducted in collaboration with the Research unit, MoH. The following studies have been conducted with the funding support of the World Bank Project. Targeted Interventions: While lot of achievement has been made in the general populations, very little could be done in terms of targeted interventions. All though numerous plans were made to target groups like the sex workers, the implementation failed to take off. It wasn‟t until the last year of the project that something solid was initiated as part of targeted interventions. A packaged program outsourced to the University of Manitoba was initiated to target high risk groups in Phuntsholing and Thimphu. A rapid assessment on sexual networks in Thimphu and Phuntsholing was conducted and venue based interventions designed and implemented through the two HISCs. Through this project about 69 sex workers have been reached out of which 48 are registered with the HISCs for regular follow up. Gaps Prioritization of so many activities with the general population has resulted in neglect of interventions with key affected populations. Condom use during first sexual intercourse among drug users was much lower at 38% (*NBA, 2009) compared to the general population. Too much focus on HIV has also resulted in the neglect of interventions for STIs. This could be the explanation in the slight increase of STIs over the years. 89.6% knew that condoms can prevent HIV, but very few (34.7%) knew that STIs can also be prevented by condoms (*GPS, 2008). Less people have heard about STI than they have about HIV/AIDS. 82 % of the respondents from the armed forces and youths in school have heard about STIs, which is comparatively lower than their familiarity with HIV/AIDS (>95%). Only 57.9% out of school youths have heard about STIs indicating a huge knowledge gap about STIs.*(KABP survey, 2009/GPS, 2008). Given the fact that there is no condom replenishment mechanism for the condom boxes, it can be said that the condom boxes have not been effective in terms of making condom accessible to those who require it and at the time they require it. Therefore the program is considering alternative strategy of condom distribution. 7. Financial Progress: 44 Table 6: Financial summary Original Grant Adjusted Grant Approved amount USD 5.77 million USD 6.16 million Total expenditure USD 5.54 million USD 5.51. million Financial achievement 96% 89% based on the approved amount 8. Lessons learnt from project implementation  Managing multi-sectoral partnerships for HIV prevention: Under the Project, multi-sectoral partnership among the Ministries, District Administration and Community Based Organizations were explored and implemented. The monitoring of the activities was done by the Project Management Team. These partnerships provided opportunity to expand the genuine collaboration for a multisectoral response. The collaboration could have been further strengthened if the memorandum of understating had been signed and progress monitored between the PMT and the stakeholders.  Peer outreach interventions and targeting the most at risk: During the span of the project, continued efforts were made to focus most at risk for HIV in the Bhutanese epidemic context. Though the approach of focusing on the most at risk was slow, the later phase of the project was successful in targeting the people and venues where people engage in risky behaviors. The sexual network study conducted in Bhutan‟s two biggest urban cities at Thimphu, the capital and Phuntsholing the Indo-Bhutan commercial hub was the key information used for piloting the peer outreach interventions. These pilot programs focused on the venues ( hotels, bars and karoakes) and also intensified interventions among specific population groups ( truckers, taxi drivers )  Making STI services more effective: Prior to the Project, the most common STI – gonorrhea was treated with penicillin even though there health staffs knew that laboratory evidences showed gonococcal resistance to penicillin. Following the pre-project assessment was conducted by the World Bank Project to validate the resistance pattern of the gonorrhea to penicillin; syndromic management manual was revised in 2006 in which the urethral discharge treatment was modified by replacing penicillin by injection ceftriaxone. The gonococcal antibiotic susceptibility program was strengthened by introducing five sentinel sites.  Research and evidence building culture: During the phase of the project, many surveys were conducted to assess the existing evidence, evaluate the STI services and understand the overall impact in terms of change in behaviors. The surveys conducted by the implementing partners enhanced the skills and promoted understanding among the health policy makers of the necessity of research to inform public health strategies .  Health system strengthening: Besides focusing on HIV prevention, the Project was built with a focus on broad based health system and capacities. The project provided opportunity to review in depth and demonstrated improvements in 45 laboratory services, STI prevention, waste management and infection control system and health information system. The project offered avenue for reforms such as health care financing  Dedicated program staffs critical to implement the projects: To ensure smooth management of such projects, dedicated management is essential. At the start of the project, the Project Management was led by a senior official who was assigned the sole responsibility of project management. Subsequently with the higher turnover of the project management resulted in the slackening of the project activities  New approaches to logistic and supply management system: The procurement staffs at the DVED and the administration unit of the Ministry of Health were oriented on the Bank procurement system of goods and consultancies. The experience from this project could be used by the MoH and in particular the DVED to adapt the procurement manual in future.  Standard reporting framework: The Project information requirements were different from the routine Health Management Information system (HMIS). The HMIS was either too slow to adapt or was not adaptive because the forms were to be reprinted. The project resorted to developing an independent format which was not usually follow up should be included with the project document. 9. Sustaining HIV prevention and way forward: Tremendous achievements have been made with the support of the World Bank Project in terms of scaling up targeted interventions, strengthening of care and treatment for HIV/AIDS, STI management, raising t awareness, and mobilizing political commitment for HIV/AID prevention. The World Bank is the biggest financer so far for Bhutan HIV prevention control efforts since 2004 to 2011. The Ministry of Health will find it challenging to maintain a financial support to the level provided by the World Bank. However, in order to keep the momentum gained in HIV and STI prevention so far, it is crucial for the MoH to take serious efforts to secure resources. The following measures are being implemented to ensure adequate financial support with the aim to achieve sustainable programming for HIV prevention in the country: Future plans  Increase financial resource allocations from the government for STIs, care and treatment for HIV and improving surveillance system  The NACP will propose incremental government resource allocation commitment from the RGoB  ARV procurement and treatment associated costs will be mobilized from the RGoB  The DoPH will pursue with the RCSC for filling up 4 approved vacant positions of NACP  NACP will collaborate with the UN agencies for resource mobilization and support for program interventions  Explore funds for Global Fund for AIDS, TB and Malaria 46  The Five Year National Strategic Plan is revised with the termination of the project. The Strategy will be costed and a detail operational plan is being prepared. This will be advocated for funding support from various sources. 47 Annex 7(b). Government's comments on the World Bank ICR 48 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders N/A 49 Annex 9. List of Supporting Documents 1. National Strategic Plan for the Prevention and Control of STIs and HIV/AIDS, Royal Government of Bhutan, 2008 2. Review of the National Response to STIs and HIV/AIDS, Royal Government of Bhutan and Development Partners, 2011 3. Bhutan National Strategic Plan for the Prevention and Control of STIs and HIV/AIDS, 2012-2016, Royal Government of Bhutan, 2011 4. HIV/AIDS, Sexually Transmitted Infection and their risk factors in Bhutan, Fact Sheet, Department of Public Health, Bhutan 5. National Baseline Assessment-2009, Drug and Controlled Substance Use in Bhutan – at a glance, Bhutan Narcotic Control Agency, Thimphu 6. Guidebook for Drop-In Centre based services for drug & alcohol users, Bhutan Narcotic Control Agency, Thimphu 7. Guidelines on Treatment and Rehabilitation Centre for Drugs and Alcohol Dependents, Bhutan Narcotic Control Agency, Thimphu 8. Behavioural Surveillance Survey, 2008, Bhutan, National STI & HIV/AIDS Control Programme, Department of Public Health, Ministry of Health, Royal Government of Bhutan 9. Sexual Behaviours and Networks in Thimphu, Bhutan: A Rapid Assessment, National AIDS Program, Ministry of Health, Bhutan and Centre for Global Public Health, University of Manitoba, May 2010 10. Health Facility Survey for Delivery Services Related to the Diagnoses and Management of HIV/AIDS and Sexually Transmitted Infections Report, Research and Epidemiology Unit, Ministry of Health, 2009 11. Evaluation of STI services and use of STI syndromic case management in health facilities in Bhutan, Ministry of Health, 2011 12. Manual for the Dzongkhag Multi-Sectoral Task Force (MSTF) for STI & HIVAIDS Prevention and Control, Department of Public Health, Ministry of Health, Royal Government of Bhutan, Thimphu, Bhutan 13. HIV/AIDS General Population Survey Bhutan -2006, Policy and Planning Division, Ministry of Health, Royal Government of Bhutan, July – 2008 14. Technical Strategy for Prevention and Control of Sexually Transmitted Infections, Thimphu, Bhutan 2009 15. Guideline for Management of HIV/AIDS in Adults, Ministry of Health, Royal Government of Bhutan, HIV/AIDS & STI Control Program, Department of Public Health, Thimphu, Bhutan 16. Prevention of Mother to Child Transmission Guidelines, National STI & HIVAIDS Prevention and Control, Department of Public Health, Ministry of Health, Royal Government of Bhutan, Thimphu, Bhutan 50 17. Guideline for Management of Pediatric HIV/AIDS, STI & HIVAIDS Prevention and Control, Department of Public Health, Ministry of Health, Royal Government of Bhutan, Thimphu, Bhutan 18. National Guidelines for Voluntary Counselling and Testing, National HIVAIDS & STD Prevention and Control, Department of Public Health, Ministry of Health, Royal Government of Bhutan, Thimphu, Bhutan 19. Implementation Framework for the Narcotic Drugs, Psychotropic Substances and Substance Abuse Act 2005, Bhutan Narcotic Control Agency, Thimphu 20. Annual Health Bulletin 2010, Ministry of Health, Royal Government of Bhutan, Thimphu, Bhutan 21. An update on Human Immuno Deficiency Virus/Acquired Immuno Deficiency Syndrome (HIV/AIDS) (July 1, 2010), Ministry of Health, Thimphu: Bhutan 22. HIV/RPR Sentinel Sero-Surveillance Report 2006: HIV/AIDS and STI program Department of Public Health, Ministry of Health, Thimphu, Bhutan 23. Knowledge, Attitude, Practice and Behaviour Study on HIV/AIDS/STI Among Uniformed Personnel, In School and Out of School youth in Bhutan - 2009, New Era, April 2010 24. Technical Strategy for Prevention and Control of Sexually Transmitted Infections, National AIDS and STI Control Programme, Ministry of Health, Thimphu, 2009 25. Bhutan HIV/AIDS/STI Prevention and Control Project: Project Appraisal Document. World Bank 2004 26. Bhutan HIV/AIDS/STI Prevention and Control Project: Aide-memoires 27. Bhutan HIV/AIDS/STI Prevention and Control Project: Implementation Status and Results (ISR) reports. 28. Bhutan HIV/AIDS/STI Prevention and Control Project: Quality at Entry Assessment Report (QEA7). 29. Bhutan HIV/AIDS/STI Prevention and Control Project: Quality Assessment of Lending Portfolio report. 30. Committing to Results: Improving the Effectiveness of HIV/AIDS Assistance. An OED Evaluation of the World Bank's Assistance for HIV/AIDS Control. World Bank Operations Evaluation Department (2005). 51 BH UTAN 89°E 90°E 91°E SELECTED CITIES AND TOWNS 0 10 20 30 40 Kilometers DZONGKHAG (DISTRICT) CAPITALS NATIONAL CAPITAL 0 10 20 30 Miles RIVERS BHUTAN MAIN ROADS RAILROADS GEOG (SUB-DISTRICT) BOUNDARIES DZONGKHAG (DISTRICT) BOUNDARIES INTERNATIONAL BOUNDARIES Him GASA ala 92°E ya 28°N 28°N Mo u unt Ch To ains o Cona Ph Gasa Thunkar To Gamba LHUENTSE TRASHI DU E W ANG DUE Mangde 'YANGTSE PUNAKHA ODRA NG PH ODRANG THIMPHU BUMTHANG Shingkarap Punakha Lhuentse Tang Trashi Tango ’Yangtse Chari u Kullo Kuru Ch PARO Lobesa gCon Haa Paro Trongsa Jakar hu h Chu Pa ro THIMPHU Wangdue Haa Ch Khasadrapchu TRONGSA u TRASHIGANG HAA Mongar S San os Lingmithang Trashigang k k h Bumthang Torsa mt h Kisona Zhemgang MONGAR Wamrong Tendru Yebilaptsha ZH nas DAGANA Ma Chhukha Daga EM SAMCHI G Pemagatshel W a a ng AN G 27°N Damphu S A R PA N G PEMA- AM S A M D R UP 27°N G AN Chu Ch ATSHEL GATSHE GATSHEL Ton o g Panka GK HA JO N GKHA R s sa CHHUKHA IR Daifam Chu Samtse Sarpang Panbang Samdrup TS u Pheuntsholing Jongkha Nganglam To Gorumara To To To To IBRD 33373R1 Goalpare Guahati Guahati Goalpare To OCTOBER 2010 To This map was produced by the Map Design Unit of The World Bank. Guahati Alipur Duar The boundaries, colors, denominations and any other information shown on this map do not imply, on the part of The World Bank Group, any judgment on the legal status of any territory, or any endorsement or acceptance of such boundaries. 90°E 91°E 92°E