Document of The World Bank Report No: ICR2056 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-H0800) ON A ADAPTABLE PROGRAM LOAN IN THE AMOUNT OF US$102 MILLION TO THE DEMOCRATIC REPUBLIC OF CONGO FOR A DRC – MULTISECTORAL HIV/AIDS PROJECT November 29, 2011 Human Development AFCC2 Africa Region CURRENCY EQUIVALENTS (Exchange Rate Effective November 1, 2011) Currency Unit = Congolese Franc (CDF) 1.0 1 CDF= US$0.00105 2.0 US$ 1.00 = 910 CDF FISCAL YEAR 2011 ABBREVIATIONS AND ACRONYMS AIDS Acquired Immune Deficiency Syndrome ARV Anti-Retroviral Drugs CNLS National HIV/AIDS Committee BCC Behavioural Change Communication CNMLS National Multi-sectoral HIV/AIDS Commission CBO Community-Based Organization CCM Country Coordinating Mechanism (Technical Secretariat of the Global Fund) DHS Demographic and Health Survey DRC Democratic Republic of Congo FAM Fiduciary & Administrative Manual FBO Faith Based Organization FMA Fiduciary Management Agency FOSI Forum of HIV/AIDS NGO GF Global Fund to Combat HIV/AIDS, TB and Malaria GLIA Great Lakes Initiative on HIV/AIDS HCR Haut Commissariat aux Réfugiés HIV Human Immunodeficiency Virus IAD Internal Audit Department IDA International Development Association I-PRSP Interim Poverty Reduction Strategy Paper KPI Key Performance Indicators MAP Multi-Country HIV/AIDS Program MoH Ministry of Health M&E Monitoring and Evaluation MWMP Medical Waste Management Plan NCU National Coordination Unit NGO Non-Government Organization NSP National Strategic Plan OVC Orphans and other Vulnerable Children PDO Project Development Objectives PLWHA People Living with HIV/AIDS PMLS Projet Multisectoriel de Lutte contre le VIH/SIDA (MAP/PMLS) PMTCT Prevention of Mother-to-Child Transmission PNLS Programme National de Lutte contre le VIH/SIDA (National AIDS Control Program) PNMLS Programme National Multisectoriel de Lutte contre le VIH/SIDA PRGSP Poverty Reduction and Growth Strategy Paper PMTCT Prevention of Mother-to-Child Transmission STI Sexually Transmitted Infection TTL Task Team Leader UNAIDS United Nations HIV/AIDS Commission UNICEF United Nations Children’s Fund VCT Voluntary Testing and Counseling WHO World Health Organization Vice President: Obiageli Katryn Ezekwesili Country Director: Eustache Ouayoro Sector Manager: Jean J. De St Antoine Project Team Leader: Jean-Jacques Frere ICR Team Leader: Enias Baganizi DEMOCRATIC REPUBLIC OF CONGO DRC – MULTISECTORAL HIV/AIDS PROJECT CONTENTS Data Sheet A. Basic Information B. Key Dates C. Ratings Summary D. Sector and Theme Codes E. Bank Staff F. Results Framework Analysis G. Ratings of Project Performance in ISRs H. Restructuring I. Disbursement Graph 1. Project Context, Development Objectives and Design ................................................... 1 2. Key factors Affecting Implementation and Outcomes .................................................. 6 3. Assessment of Outcomes ............................................................................................. 10 4. Assessment of risks Development outcome ................................................................ 18 5. Assessment of Bank and Borrower Performance ......................................................... 19 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 ..................................................................... 33 Annex 4. Bank Lending and Implementation Support/Supervision Processes................. 34 Annex 5. Beneficiary Survey Results ............................................................................... 36 Annex 6. Stakeholder Workshop Report and Results ....................................................... 37 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR ......................... 38 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders ........................... 39 Annex 9. List of Supporting Documents .......................................................................... 40 Annex 10: Summary of the Borrower’s ICR .................................................................... 41 MAP .................................................................................................................................. 50 A. Basic Information Congo, Democratic DRC Multisectoral Country: Project Name: Republic of HIV/AIDS Project Project ID: P082516 L/C/TF Number(s): IDA-H0800 ICR Date: 11/28/2011 ICR Type: Core ICR Lending Instrument: APL Borrower: DRC Original Total XDR 68.40M Disbursed Amount: XDR 67.87M Commitment: Revised Amount: XDR 68.40M Environmental Category: B Implementing Agencies: SEP/CNLS Cofinanciers and Other External Partners: B. Key Dates Revised / Actual Process Date Process Original Date Date(s) Concept Review: 06/12/2003 Effectiveness: 10/08/2004 10/08/2004 05/29/2007 Appraisal: 01/05/2004 Restructuring(s): 06/07/2010 Approval: 03/26/2004 Mid-term Review: 09/24/2008 09/24/2008 Closing: 01/31/2011 05/31/2011 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Unsatisfactory Risk to Development Outcome: Substantial Bank Performance: Unsatisfactory Borrower Performance: Unsatisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Moderately Quality at Entry: Government: Unsatisfactory Unsatisfactory Implementing Quality of Supervision: Unsatisfactory Unsatisfactory Agency/Agencies: Overall Bank Overall Borrower Unsatisfactory Unsatisfactory Performance: Performance: i C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Indicators Rating Performance (if any) Potential Problem Project Quality at Entry Yes None at any time (Yes/No): (QEA): Problem Project at any Quality of Yes 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) Health 23 26 Other social services 45 27 Sub-national government administration 32 47 Theme Code (as % of total Bank financing) HIV/AIDS 40 59 Population and reproductive health 20 18 Social risk mitigation 20 23 Tuberculosis 20 E. Bank Staff Positions At ICR At Approval Vice President: Obiageli Katryn Ezekwesili Callisto E. Madavo Country Director: Eustache Ouayoro Emmanuel Mbi Sector Manager: Jean J. De St Antoine Joseph Baah-Dwomoh Project Team Leader: Jean-Jacques Frere Suzanne Piriou-Sall ICR Team Leader: Enias Baganizi ICR Primary Author: Enias Baganizi F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The development objective of the MAP/PMLS is to mitigate the negative impact of the HIV/AIDS epidemic on the stabilization, recovery, and development of the Democratic Republic of Congo (DRC). This will be achieved by: (i) Reducing the risk of sexual, intravenous and vertical transmission of HIV; (ii) Improving the health status and quality of life of people living with HIV/AIDS; and ii (iii) Mitigating the socio-economic impact of the epidemic on vulnerable groups. Revised Project Development Objectives (as approved by original approving authority) Government of DRC has a higher level objective of slowing the spread of HIV/AIDS in the general population. The project will support the Government by (i) increasing the access to STI and HIV/AIDS treatment; (ii) mitigating the health and socio-economic impact of HIV/AIDS at the individual, household, and community level; and (iii) building strong and sustainable national capacity to respond to the HIV/AIDS epidemic. (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 Number of pregnant women living with HIV who receive ARVs to reduce the Indicator 1 : risk of MTCT 70% (2007 Value restructuring) quantitative or 1% 35% 804 1,200 (2010 Qualitative) restructuring) Date achieved 10/08/2004 10/08/2004 06/07/2010 10/31/2010 The indicator changed from being expressed as a percentage to becoming a Comments number. The targets in percentages - 35% for original target and 70% for the (incl. % 2007 restructuring - the country was far from achieving these targets (3.7% in achievement) 2010) Number of adult and children with HIV receiving ARVs (in areas targeted by the Indicator 2 : project 70% of advanced Value 2,200 number of PLWHA HIV+ needing quantitative or who receive quality 20,000 ARVs (2007 7,940 Qualitative) medical care restructuring) 10,000 (2010 restructuring) Date achieved 10/08/2004 10/08/2004 06/07/2010 10/31/2010 Comments This indicator was achieved at 79.4% with regard to the target set at the last (incl. % restructuring in 2010 but certainly fall short below the target set for 2007 (70%) achievement) and the original target (20,000) Indicator 3 : Number of OVC with schooling provided through the project Value 15,000 (2007 4% of orphans assisted quantitative or 20% and 2010 31,618 with tuition and schooling Qualitative) restructuring) Date achieved 10/08/2004 10/08/2004 06/07/2010 05/31/2011 Comments This indicator was by far achieved for the 2007 and 2010 targets. Also, according (incl. % to the 2009 MICS results, 63% of OVC were receiving support for schooling or achievement) education. Indicator 4 : Persons aged 15 and older who receive counseling and testing for HIV and iii receive their results 800,000 (2007 Value restructuring) quantitative or 1,500 25,000 302,308 300,000 (2010 Qualitative) restructuring) Date achieved 10/08/2004 10/08/2004 06/07/2010 10/31/2010 The target values varied greatly from the original and the 2 restructurings. The Comments indicator was achieved just over 100% with regard to the 2010 target but fell (incl. % short of the 2007 target (800,000). The original 25,000 target was for sure an achievement) underestimat (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 Number of units of blood collected which are qualified according to national Indicator 1 : norms countrywide by the end of the project 600 number of service outlets carrying out blood safety activities (2007 Value 42% of blood donated restructuring) (quantitative tested for HIV and 60% 200,000 224,309 or Qualitative) Hepatitis B & C number of units of blood collected according to national norms (2010 restructuring) Date achieved 10/08/2004 10/08/2004 06/07/2010 03/31/2011 Comments This indicator changed in nature and wording during the 2 restructuring, making (incl. % it difficult to judge about its achievement. With regard to the last 2010 target, it achievement) was achieved at 112%. Indicator 2 : Number of STI cases treated according ton ational norms (per year) 300,000 (2007 Value restructuring) (quantitative NA 50,000 102,074 100,000 (2010 or Qualitative) restructuring) Date achieved 10/08/2004 10/08/2004 06/07/2010 05/31/2011 Comments Again this indicator target changed greatly in value from 50,000 to 300,000 at (incl. % the first restructuring in 2007 to 100,000 at the last restructuring in 2010 achievement) (achieved at 102%) Indicator 3 : % of Ministries targeted byt the project with operational Unit of HIV/AIDS Value N/A N/A 100% 60% iv (quantitative or Qualitative) Date achieved 10/08/2004 10/08/2004 06/07/2010 03/31/2011 Comments (incl. % This indicator was achieved at 60%. achievement) Indicator 4 : Number of condoms distributed 25,000,000 condoms Value 20% of CSW using distributed (quantitative 60% 27,650,946 condoms at last sex (2007 and or Qualitative) 2010 restructuring) Date achieved 10/08/2004 10/08/2004 06/07/2010 03/31/2011 Comments This indicator completely changed from percentage of CSW using condoms at (incl. % last sex to the number of condoms distributed. It was achieved 110%. achievement) G. Ratings of Project Performance in ISRs Actual Date ISR No. DO IP Disbursements Archived (USD millions) 1 09/24/2004 Satisfactory Satisfactory 0.00 2 06/14/2005 Moderately Satisfactory Satisfactory 13.61 3 12/20/2005 Moderately Satisfactory Satisfactory 18.80 4 06/29/2006 Unsatisfactory Moderately Satisfactory 20.17 5 02/09/2007 Unsatisfactory Moderately Satisfactory 27.24 Moderately 6 06/29/2007 Moderately Satisfactory 32.79 Unsatisfactory Moderately 7 12/28/2007 Moderately Satisfactory 36.98 Unsatisfactory Moderately Moderately 8 06/28/2008 44.43 Unsatisfactory Unsatisfactory Moderately Moderately 9 12/27/2008 50.91 Unsatisfactory Unsatisfactory Moderately 10 06/26/2009 Moderately Satisfactory 58.73 Unsatisfactory Moderately 11 12/20/2009 Moderately Satisfactory 70.85 Unsatisfactory Moderately Moderately 12 06/28/2010 85.42 Unsatisfactory Unsatisfactory Moderately 13 03/26/2011 Moderately Satisfactory 102.01 Unsatisfactory Moderately 14 09/18/2011 Unsatisfactory 103.80 Unsatisfactory v H. Restructuring (if any) ISR Ratings at Amount Board Restructuring Disbursed at Restructuring Reason for Restructuring & Approved Restructuring Date(s) Key Changes Made PDO Change DO IP in USD millions 05/29/2007 Y U MS 32.79 - Seaparate the functions of the MAP project coordinator and the PNMLS Coordinator 06/07/2010 N MS MU 82.97 - Modify activities under the community component - Revise project key indicators - Reallocate project funds If PDO and/or Key Outcome Targets were formally revised (approved by the original approving body) enter ratings below: Outcome Ratings Against Original PDO/Targets Unsatisfactory Against Formally Revised PDO/Targets Unsatisfactory Overall (weighted) rating Unsatisfactory I. Disbursement Profile vi 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal 1. The Government of the Democratic Republic of Congo (DRC) officially recognized the existence of HIV/AIDS in 1984, thus becoming one of the first African countries to acknowledge the danger of the epidemic. 2. However, as a result of the pillaging that occurred from 1991 to 1993 (which robbed the National AIDS Control Program of all its equipment) and the cessation of international cooperation (resulting in the departure of the major donors and research teams), the fight against HIV/AIDS nearly came to a halt from 1990 to 1999. 3. The effort to fight AIDS began again in 1999 with the preparation of the National Strategic Plan (1999-2008) to Combat HIV/AIDS (NSP).1 Its aim was to support the development of the country by controlling the spread of the HIV/AIDS epidemic and by mitigating its impact on individuals, families, and the community. Moreover, in accordance with the objectives pursued by earlier plans, the purpose of NSP was to design the necessary mechanisms in all sectors of national life in order to reduce the spread of HIV and sexually transmitted infections (STIs) and to minimize their impact on the community. A National Multisectoral Committee to Combat AIDS (CNMLS) was established in the Ministry of Health in 2001.2 4. Beyond the NSP, the Government’s primary focus on HIV/AIDS was once again demonstrated during the preparation of the 2002 Interim Poverty Reduction Strategy Paper (I-PRSP), as one of the long-term objectives of the strategy was to improve living conditions for the Congolese people. 5. Since the re-engagement of the World Bank in 2001, the HIV/AIDS problem has been reframed. The first actions of the comprehensive control effort were financed by the Bank in the amount of US$8 million under the NSP framework to support the Government’s multisectoral strategy. This strategy was defined well before this approach was internationally accepted. 6. It was remarkable to note that DRC had already a national strategic plan and a HIV/AIDS coordination structure when the project was prepared. During the preparatory phase the Bank and the client agreed: (i) to replace the National Committee with the National Multisectoral Committee to Combat AIDS (CNMLS), which was placed under the responsibility of the President of the Republic;3 (ii) to take exceptional steps to implement the project, including the subcontracting of administrative and management responsibilities; and (iii) to use multiple execution agencies, including non-governmental 1 NSP was implemented with the support of WHO, UNDP, and UNAIDS, among others. 2 Decree No. 1250/CAB/MIN/S/AJ/KIZ/015/2001 of December 9, 2001, created a National Multisectoral Committee to Combat AIDS (CNMLS) in the Ministry of Health, with wide representation from the main public and private stakeholders, to supervise and coordinate the implementation of the National Strategic Plan. It replaced CNLS, which had been set up on May 28, 1987. 3 Decree No. 04/029 of March 17, 2004, creating and organizing the National Multisectoral Program to Combat AIDS (PNMLS). 1 organizations (NGOs) and umbrella groups. Thus, DRC was able to meet the four conditions needed to access Multi-Country HIV/AIDS Program for Africa (MAP) II funds. 7. It is within the above context that the Project concept note was first drafted in 2003 and approved in January 2004. This was shortly after the 2002 fragile political agreement for a transition Government intended to last for three years. The Project was formulated at the time when the Bank considered HIV was a “development issue� and not solely or predominantly a “health issue�. This was partly reflected in the fact that the first TLL of the project came from the agriculture sector and was a strong advocate for community engagement. 8. It’s also important to note that the project concept and appraisal preceded the engagement of the Global Fund (GF) and PEPFAR, and certainly well before either were able to provide any resources to the fight against HIV in DRC. The presence of these new and significant donors in DRC captivated the attention of the Government and drew heavily on the limited human resources available in the health sector. The GF created a new entity, the Country Coordinating Mechanism (CCM), which was under the MOH control and not under the National AIDS Authority (PNLMLS) created earlier by the Government with Bank’s assistance. 9. At the time of project preparation, the entire health system of the country was in shambles in post-conflict era and this situation didn’t improve throughout project’s implementation. Indeed, expenditure on health per capita is currently at $13 and the total expenditure on health as a percentage of GPD was just 2% in 2009 (WHO, Global Health Observatory, 2009). These figures are very low even by African standards. 10. Besides, the nature of the HIV epidemic in the country was not well understood. HIV prevalence was unknown and it was unclear what was driving the epidemic at the time of Project appraisal. 1.2 Original project development objectives (PDO) and Key Indicators 11. Originally, the development objective was to mitigate the negative impact of the HIV/AIDS epidemic on the country’s growth, by: (i) Reducing the risk of sexual, intravenous and vertical transmission of HIV; (ii) Improving the health status and quality of life of people living with HIV/AIDS; and (iii) Mitigating the socio-economic impact of the epidemic on vulnerable groups. The original key performance indicators (KPI) of the project are presented in the table below. 2 Table 1: Original Key Performance Indicators PDO Key Indicator 60% of sex workers targeted by the program report using condoms during their last sexual encounter At least 35% of pregnant women have access to PDO 1: HIV/AIDS infection rates are reduced Mother-to-Child transmission prevention program 70% of donated blood is tested for HIV and Hepatitis B&C 20,000 PLWHA receive quality medical treatment PDO 2: Quality of life of PLWHA is improved 50% of target health zones have community services for PLWHA available 20% of orphans are assisted with tuition and PDO3: Socio-economic impact of HIV/AIDS on schooling vulnerable populations is mitigated Discrimination against PLWHA (as defined in DHS+) is reduced by 30% 1.3 Revised (and approved) project development objectives (PDO) and Key Indicators, and reasons/justification 12. The project went through two approved restructurings. The first one, done in July 2007, was a generic umbrella regional restructuring. This restructuring was not addressing any specific implementation problem nor responding to information associated with a better understanding of the epidemiology of HIV in the country. Rather, it was meant to take into account: (i) change in the international environment with regard to the fight against HIV/AIDS, in particular the experiences with other MAPs and (ii) the need to harmonize MAP indicators across countries. 13. During the 2007 restructuring, the objectives of the project were modified by agreement between the Government and the International Development Association (IDA). The new project development objective (PDO) was to assist the Recipient in: (i) increasing access to STI and HIV/AIDS treatment; (ii) mitigating the health and socio- economic impact of HIV/AIDS at the individual, household, and community level; and (iii) building strong and sustainable national capacity to respond to the HIV/AIDS epidemic. 14. For the June 2010 restructuring, the PDO was not changed at all. The aims of the restructuring was to: (i) separate the functions of the coordinator of the Bank project implementation unit and the coordinator of the national body responsible for HIV/AIDS programs, in order to allow more focus on project implementation and at the same time ensuring sustainability of the national response ; (ii) modify activities under the community component to shift them from multiple community micro-projects to community outreach programs using a limited number of large actors ; (iii) revise the project’s key indicators and targets to adjust them to the revised project activities and address the current difficulties in obtaining some of the data ; and (iv) reallocation of budget categories into a single expenditure category for the uncommitted resources of the loan to facilitate disbursement as the project nears completion. 15. During the two restructuring exercises (2007 and 2010), the original Key Performance Indicators were modified/replaced as follows in table 2. 3 Table 2: New Key Indicators after the two restructuring exercises in 2007 and 2010 Original Key Indicator Modified Indicator (2007 Modified Indicator (2010 restructuring) restructuring) 60% of sex workers targeted by 25,000,000 number of condoms 25,000,000 number of condoms the program report using distributed by the Project distributed by the Project condoms during their last sexual encounter At least 35% o f pregnant 70% of HIV infected pregnant 1,200 pregnant women living women have access to Mother- women receive a complete with HIV receive antiretroviral to-Child transmission course of ARV prophylaxis to to reduce the risk of MTCT (in prevention program reduce the risk of Mother To areas targeted by MAP.) Child Transmission (MTCT) in areas targeted by MAP by the end of the project. 70% o f donated blood is tested 600 service outlets carrying out 200,000 number of units of for HIV and Hepatitis B&C blood safety activities have been blood collected and which are established countrywide by the qualified according to national end of the project norms - 800,000 persons aged 15 and 300,000 persons aged 15 and older received counseling and older who received counseling testing for HIV and received and testing for HIV and their test results in areas targeted received their test results by the MAP by the end of the project 20,000 PLWHA receive quality 70% men and women with 10,000 adults and children with medical treatment advanced HIV infection HIV receiving antiretroviral receiving antiretroviral combination therapy (in areas combination therapy in areas targeted by the MAP.) targeted by the MAP by the end of the Project 50% of target health zones have At least 5,000 subprojects Dropped community services for PLWHA (sensitization, community available services for PLWHA) by NGO, CBO and FBO have received support 20% of orphans are assisted with 15,000 orphans and other 15,000 orphans and vulnerable tuition and schooling vulnerable children whose children with schooling households received care/ provided through the project support in past 12 months Discrimination against PLWHA Dropped - (as defined in DHS+) is reduced by 30% - - Number of Sexually Transmitted Infection (STI) cases treated according to national norms - - % of ministries targeted by the project with an operational Unit for HIV/AIDS control 4 1.3 Main beneficiaries 16. The original intended beneficiaries of the project were the general population and vulnerable groups in particular. Gradually, the country further refined the target populations to include the prison population, people living with HIV (PLWHA), displaced persons (especially women), orphans and other vulnerable children (OVC); persons working in dangerous conditions, such as men in uniform, truckers, and miners; and groups in which the prevalence of infection was rapidly increasing, namely, young people and women. 1.4 Original components 17. Component 1: Response of the public sector - US$40.4 million. Under this component, the project had to assist and support the mobilization of public institutions in the fight against the epidemic by mainstreaming HIV/AIDS activities in their regular work program. The component was further structured into two sub-components: (a) Program of the Ministry of Health (US$21.1 million), and (b) Program of the other ministries (US$19.3 million). 18. Component 2: Response of the non-governmental sector - US$l7.9 million. This component had two sub-components: a) Private sector entities/Public enterprises (US$7.3 million) and b) NGOs, faith-based organizations, professional associations (US$l0.6 million). 19. Component 3: Support for community initiatives - US$l9.3 million. The component’s objective was to increase the impact of HIV/AIDS activities by transferring the responsibility for identifying priorities, and preparing and implementing micro- projects directly to the beneficiaries in rural and urban areas. 20. Component 4: Coordination & Communication (US$11.3million), monitoring and evaluation (US$8 million), capacity building (US$3.2 million) - Total: US$22.5 million. This component had three sub-components: (a) Coordination and Communication; (b) Monitoring and evaluation, and (c) Capacity-building/Technical Studies). 1.5 Revised components 21. The components were not formally revised during the implementation of the project despite the revision of the project development objectives during the 2007 restructuring. 1.6 Other significant changes 22. During the execution of the project, the original loan agreement was amended several times in order to: (i) modify the fiduciary procedures; (ii) revise the development objective and project outcome indicators; and (iii) reallocate project funds. One amendment to extend the project closing date from January 31, 2011 to May 31, 2011 was approved. 23. Procedures were also modified: (i) in April 2009, to raise the prior review thresholds for procurement; and (ii) in June 2010, to reallocate the remaining amounts in various budget categories into a single category in order to facilitate disbursement of the unspent funds. 5 24. The project development objective was revised in July 2007 following the restructuring of eight MAP projects; and indicators were modified: (i) in July 2007, solely on the basis of the first umbrella restructuring of the project; and (ii) in June 2010, following the outcome of the mid-term review and gaps identified in the definition of the indicators and availability of data. 2. Key factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design, and Quality at Entry Preparation 25. During the preparatory phase of the Project, the Bank team spent tremendous amount of time trying to understand the context under which the project would be implemented. Several visits were organized all over the country including pre-concept, concept, pre-appraisal and appraisal missions even in Eastern Congo which was still extremely unstable at the time. The preparatory budget (PHRD US$959,029) was substantial and was used to develop various aspects of the Project including the:: ¾ Socioeconomic and environmental assessments (US$177,545); ¾ Development of appropriate operational design, mechanisms, and instruments for efficient project implementation , supervision, and monitoring ($300,980); ¾ Strengthening the capacity and ownership of key implementing entities ($223,220); ¾ Feasibility studies on designing innovative approaches ($166,500); and ¾ Other studies needed for the preparation of the Project ($90,784). 26. Preparatory activities continued throughout 2002 and 2003. They focused on: (i) evaluating the capacities of sectors to be included in the project; and (ii) developing manuals of procedures for the project in general and the component related to community initiatives in particular (with a study on monetary transfer modalities in localities having no access to banks). Despite all these studies, there was no epidemiological analysis carried out to better understand the nature of the HIV epidemic and this was one of the weaknesses of the preparation process. 27. Lessons learned during the field visits around the entire country, including zones still at war in the Eastern parts of the country, were used to shape the design of the project. However, more PPF funds should have been used to collect the necessary baseline data that were to be used as reference to evaluate the performance of the project. 28. The project was consistent with the objectives o f the Transitional Support Strategy (TSS) approved by the Bank in 2001. The TSS had to support the Government’s goal to: (i) consolidate peace, (ii) stabilize the macroeconomic and fiscal framework, (iii) improve governance; and (iv) rebuild social services and meet basic needs. 6 Design 29. Given the situation in DRC and the requirements of MAP II, the project was designed to support the implementation of the National Strategic Plan to Combat AIDS in all the provinces of the country, in both rural and urban areas, and in a variety of sectors. 30. The original project’s objectives were realistic given the scientific knowledge available at the time of project’s appraisal. The original objectives were appropriate in terms of their ability to achieve the PDOs. However, when the project was revised in 2007, one of the objectives was to increase access to STI and HIV/AIDS treatment. Access to STI shouldn’t have been included as an objective because at that time there was compelling evidence that the treatment of STIs had no proven impact on mitigating HIV infection. Quality at Entry 31. A quality enhancement review (QER) of the proposed project was conducted in November 2003. The QER identified the following problems: (i) the loan amount seemed too big given the country’s problems with disbursement and the amounts expected from the Global Fund; (ii) the likely overlap of responsibilities between PNMLS and the other structures involved in fighting HIV/AIDS was identified as a problem for smooth project implementation as well as (iii) the weak technical capacity of the implementing agency. 32. The results framework also suffered from insufficient baseline data and from indicators that were not clearly defined. One consequence of this was that targets for some indicators were defined based on guesses rather than on knowledge of the true situation of the HIV/epidemic. Indicators were later revised during the two restructuring exercises to be more specific. 2.2 Implementation 33. The most significant factor which affected the implementation of the Project was the inadequate management capacity at the central level, coupled with extensive leadership turn-over. The project has known five TTLs on the Bank’s side; and five Ministers of Health and four different Managers (project Coordinators) of the Implementing Agency (PNMLS). The management capacity at the central level (PNMLS) was hampered by the inability to change the poorly performing leadership. This was due to internal rivalries within government entities, especially between the Office of the Prime Minister and the Ministry of Health regarding who had the power to change the leadership. Two of the PNMLS Managers were in acting position for long periods of time hampering their ability to take decisive necessary actions to improve the project implementation. 34. The second factor influencing implementation was the insufficient attention given to decentralized supervisory and capacity building responsibilities as well as the weak programmatic, technical and fiduciary capacity at decentralized levels. 35. Besides the extensive turn-over of Bank TTLs, when the Project was launched, there was a management decision to have the first TTL based in Washington without a dedicated staff person in-country. Such a person was needed on the ground at the outset of the project implementation given the particular nature of the country (huge and 7 diverse), and the sectoral politics. Moreover, the project required coordination with other development partners. 2.3 Monitoring and Evaluation (M&E) Design, Implementation, and Utilization M&E Design 36. During the preparatory phase, the PAD had proposed sharing monitoring and evaluation responsibilities between: (i) surveillance, for which the Ministry of Health would be responsible, possibly assisted by national institutes and laboratories and technical partners; (ii) sectoral health activities (blood transfusion, treatment of STIs, PMCT, IO, among others), for which the technical programs of the Ministry of Health would be responsible; (iii) activities to be carried out by PNMLS, assisted by provincial coordinators and grant recipients; and (iv) financial management, for which FMA would be responsible, assisted by the Bank (for the Risk-Sharing Facility (RSF) review) and internal and external auditors. This may have appeared reasonable on paper but in practice it was unclear who in the end was in charge of coordinating the overall M&E system. 37. The M&E normative framework, considered as a National Monitoring and Evaluation plan, governs and regulates the implementation of the national monitoring and evaluation system and lists the national indicators applicable to all actors involved in combating HIV/AIDS in DRC. However, the project indicators were not fully in accordance with the national indicators. This was due to the fact that the MAP had its own set of core indicators that were to be used by all countries benefiting from this program. M&E Implementation and use 38. The adoption of the M&E framework was followed by an action plan, guides for indicators, and training tools and manuals. However, the data collected have not been systematically analyzed and processed. 39. At the PNMLS level, several factors have negatively affected the availability of technical and financial data, namely: (i) the weak capacities of decentralized bodies to document data on completed activities; and (ii) the lack of sufficient qualified technical staff, supplies, and working tools. 40. With regard to financial data, PNMLS has reliable information going back to the beginning of the project, and has had analytical tools since it began to use the accounting software TOMPRO in 2008. 2.4 Safeguards and Fiduciary Compliance 41. Environment and management of medical waste: At the time of appraisal, the project was listed under category B, given the risks involved in medical waste management for medical personnel and the communities surrounding health facilities. A plan was prepared and approved by the Bank in December 2003. There is a Health Sector Rehabilitation Support Project which has a medical waste management plan that covers HIV/AIDS activities. Therefore, the project didn’t need to duplicate efforts to implement its own medical waste management plan. 8 42. Procurement: Despite the recruitment of an agency responsible for procurement (PWC – Price Water House Coopers - which assumed at the same time the fiduciary responsibilities), the supervisory mission of March 2006 observed weaknesses linked to factors such as: (i) lack of understanding of procurement procedures in general; (ii) ignorance of the procedures set forth in the loan agreement (IS IT A LOAN OR A CREDIT AGREEMENT?); and (i) implementation of provisions and procedures contrary to the provisions of the loan agreement SAME QUESTION. The recruitment of an additional procurement expert in 2007 helped to gradually improve the capacities of the project, which have been rated as moderately satisfactory or satisfactory since June 2008. After the 2008 Institutional Audit, the fiduciary and procurement roles were separated and a procurement unit was created within the PNMLS and the fiduciary element was assumed by a new FMA, the KMPG. 43. Financial management and disbursement: On the basis of the analysis contained in the PAD, the risks posed by financial management, given the country's post- conflict situation and the complexity of the project, were considered high. The recruitment of the fiduciary management agency (FMA), the opening of various special accounts, the elaboration of detailed procedural manuals, and the hiring of external auditors (for the technical and financial aspects) helped somewhat in reducing these risks. However, the supervisory mission of March 2006 revealed that the fiduciary management of the project did not meet the minimum standards for rigor and transparency generally required in projects financed by the World Bank. 44. The situation has remained critical for almost two years. Another World Bank supervisory mission in October 2008 judged the financial performance of the project to be very unsatisfactory, in view of: (i) the existence of significant but non-reimbursed ineligible expenditures for more than two years; (ii) lack of adequate budgetary management; (iii) persistent weaknesses in the control system, linked to organizational dysfunction; and (iv) the poor performance of the outgoing FMA (PWC). It was not until December 2009 that financial management was rated satisfactory under the auspice of the new FMA, the KPMG (Klynveld Peat Marwick Goerdeler) accounting firm. 45. The final financial supervision visit found that the project has complied with the obligations of financial reporting and auditing. However, according to the financial supervision report, the fiduciary risk remains substantial and performance in financial management was considered moderately unsatisfactory. In addition, according to the financial mission findings, the financial losses of the project are estimated (May 27, 2011) to be USD 7.86 million comprising: (i) USD 2.78 million not recovered from the initial deposit in the designated accounts of, (ii) the over- commitment of USD 2.54 million due to an acceleration of commitments and payments in the last month before the original closing date of the project, (iii) related expenses deemed not to conform to the agreements signed in 2005 of USD 1.78 million, and (iv) disputed claims by the PNMLS of USD 0.76 million. Given the problem with this over commitment, the financial management should have been rated unsatisfactory. 2.5 Post-completion Operations/Next Phase 46. Despite the difficulties encountered during its implementation, the project contributed to a number of activities that could assist future efforts to combat HIV/AIDS. 9 With regard to the strategic and regulatory framework, the country has a national plan for the period 2010-2014 and operational plans at the provincial level. The national plan recognizes the complex nature of the epidemic and confirms the principles and approaches that should guide the effort to control HIV/AIDS in the coming years. At the legislative level, Act No. 06/18 of July 20, 2006, on the protection of the rights of PLWHA, could help attenuate discrimination in DRC. 47. At the institutional level, the recent separation of political and strategic responsibilities from project coordination functions in PNMLS is a step that has been anticipated since the preparatory phase of the project. This was long overdue since it was one of the recommendations of the 2008 Institutional Audit. 48. Technically speaking, the project's support for MODs (Delegated Management Contracts) in prevention activities (condom distribution, community awareness-raising, blood transfusion), purchase of inputs (STI and ARV drugs), and building of provincial capacities should contribute to the sustainability of the project activities, at least in the short term. 49. Also the Bank has submitted an AF request to the Board for the Health Sector Rehabilitation Support project in which part of the funds are requested as an interim arrangement while waiting for availability of other sources of funding HIV activities in the future, including probably from the Global Fund. 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation Relevance of objectives 50. The relevance of the three original project’s objectives as well as two of the revised project’s objectives are rated substantial and one revised objective (which include treatment of STI) is rated modest. The objectives rated are consistent with the current Country Assistance Strategy (CAS 2008 – 2011) in which fighting the spread of HIV/AIDS and promoting community dynamics are two of the five pillars which reflect the same pillars in the country’s Poverty Reduction and Growth Strategy Paper (PRGSP). However, after restructuring, one of the three new PDOs (increasing the access to STI and HIV/AIDS treatment) was moderately relevant because at the time of the restructuring it was common knowledge that there is no direct link between treating STI and mitigating HIV. Relevance of design and implementation 51. The relevance of design and implementation is rated modest before and after the restructuring. The four components of the project at appraisal (which remained the same after the two restructurings) would have achieved the intended development objective if they had been effectively and efficiently implemented. However, the Project was too ambitious in its efforts to be implemented country-wide rather than choosing a limited number of provinces where the Project could have maximized its impact. 52. Little progress towards the Project’s development objectives was achieved at the time of the 2007 restructuring. There had already been fiduciary problems and the project 10 was partially frozen for 16 months. Instead of taking this opportunity to address the country specific problems (and eventually revise the components and reorient the project in terms of design and implementation arrangements) the restructuring focused instead on harmonizing MAPs across countries. This was a missed opportunity to better address the needs of the country with regard to new available evidence in HIV/AIDS mitigation (e.g concentration on most-at-risk populations, geographic concentration, etc…). 53. Although the Project’s budget is relatively large ($102 million), it is unclear whether the project, as designed to cover the entire territory of Congo with enormous challenges travelling to some areas of the country, could effectively and efficiently achieve the stated development objectives. Also the Project may have underestimated the challenges (monetary and technical efforts) in building the capacity of decentralized entities in a post-conflict country. 54. As discussed earlier, the implementation of the Project suffered from limited technical and managerial capacity at both the central and decentralized levels. The implementation suffered as well from a relatively long period of frozen funds due to fiduciary problems with the first FMA. 3.2 Achievement of Project Development Objectives 55. Too many changes of indicators made it difficult to follow them through and the absence of baseline data made the situation worse and the inability to collect information on some of them didn’t help either. After the 2007 restructuring, some of the data on original indicators were no longer collected as planned at appraisal. For example, no data is available on the share of sex workers using condoms at their last sexual intercourse. a) Original PDO 1: HIV/AIDS infections rates are reduced Table 3: Level of achievement of original PDO 1 indicators Baseline value Original target values Actual value achieved Original PAD indicators (Year 6: End of at completion or Target Project) Years (May 2011) % of sex workers reached by 20% 60% Data not available the program report using condoms during their last sexual encounter Number of people a year visit 1,500 25,000 302,308 VCTs PNLS report (2005- 2010) + Project data % of pregnant women who 1% 35% 32.6% (2007)* have access to Mother-to- Preliminary report on Child transmission prevention national HIV/AIDS program response Number of people/year who - 50,000 102,074 are treated according to PNLS report (2005- acceptable standard for STI 2010) + Project data % of donated blood is tested 42% 60% 52% for HIV and Hepatitis B&C Preliminary report on national HIV/AIDS response * This was the latest data available on PMTCT 11 56. The indicator on the number of people who visited VCT centers (302,308) was by far surpassed both for the targets before (1,500) and after restructuring (25,000). 57. By 2007, when the data on PMTCT coverage was being collected, the coverage was at 32.6% for the country (168 health zones out of 515 were covered in PMTCT services for pregnant women). This is the same for the indicator on STI cases treated according to national norms. The target was achieved at more than 200%. 58. With regard to the percent of donated blood tested for HIV and hepatitis, it was estimated in 2007 that 79% of health zones were covered in terms of blood transfusion, but only 52% were tested for these infections. 59. Only two of the five outcome indicators for PDO1 were achieved, two others were close to their targets; no data was available for one of the indicators. The effectiveness of original PDO1 is therefore rated modest. b) Original PDO 2: Quality of life of PLWHA improved Table 4: Level of achievement of original PDO 2 indicators Original PAD indicators Baseline value Original target Actual value achieved at values (Year 6: End completion or Target Years of Project) (May 2011) Number of PLWHA who 2,200 20,000 7,940 receive quality medical PNLS report (2005-2010) + treatment in project Project data, and UNGASS report supported zones % of target health zones 0 50% N/A which have community services for PWLHA available 60. The number of PLWHA who received quality medical treatment in zones covered by the Project was far below the original target. 61. The percentage of health zones which had community services for PLWHA is unknown because data on the indicator ceased to be collected after the 2007 restructuring (indicator was dropped). 62. The achievement of original PDO 2 is therefore rated negligible given the limited ability to achieve the first indicators under this PDO and the impossibility to measure the second one. 12 c) Original PDO 3: Socio-economic impact of HIV/AIDS on vulnerable populations is mitigated Table 5: Level of achievement of original PDO 3 indicators Baseline value Original target Actual value achieved at completion Original PAD values (Year 6: or Target Years indicators End of Project) (May 2011) % of orphans assisted 4% 20% 36,292 with tuition and (MAP contribution : 20,667) schooling Project data (2009) Reduced discrimination 100% 70% 9% against PLWHA (as defined in DHS+) 63. It is difficult to measure the percentage of OVC assisted with tuition and schooling because the total number in need of the services is not determined for DRC. By the end of 2009, a cumulative number of 36,292 OVC had been assisted with schooling support (with 57% coming from direct Project’s contributions. 64. With regard to the indicator on reduced discrimination against PLWHA, according to DHS results (2007), only 9% of the Congolese people have a tolerant attitude toward PLHIV; the MICS 3 study (2009), which uses another method of calculation, arrived at nearly the same conclusion (7% tolerance level). The project’s original development objective has not been met. 65. The achievement of original PDO 3 is therefore rated negligible. d) Revised PDO 1: Increase access to STI and HIV/AIDS treatment 66. As shown in table 6 below, four of the six revised PDO 1 outcome indicators were achieved when the 2010 restructuring targets are considered. However, when compared to the 2007 restructuring targets, only one indicator (number of condoms distributed) was achieved, four indicators were not achieved and no data for one indicator was available (number of service outlets carrying out blood safety activities). 67. The target for the number of pregnant women living with HIV who receive ARVs to reduce the risk of MTCT changed from being expressed as a percentage to a number after the second restructuring. In terms of its achievement, the country was far from reaching the target. Only 3.7% of pregnant women in need of ARV received it in 2010, far from the 70% target set at the first restructuring. The indicator also fell short of the target set at the second restructuring (804 women put on ARV versus a target of 1,200). 13 Table 6: Level of achievement of revised PDO 1 indicators Revised Indicators Formally Revised Indicators Formally Actual value (2007 restructuring) revised target (2010 restructuring) revised target achieved at values values completion or (2007) (2010) Target Years (May 2011) Number of condoms 25,000,000 Number of condoms 25,000,000 27, 650,946 distributed by the distributed by the PNLS report Project Project (2005-2010) + Project data Persons aged 15 and 800,000 Persons aged 15 and 300,000 302,308 older received older who receive PNLS report counseling and testing counseling and testing (2005-2010) + for HIV and received for HIV and receive Project data their test results in areas their test results targeted by the MAP by the end of the project % of HIV infected 70% Number of pregnant 1,200 804 pregnant women women living with HIV PNLS report receive a complete who received ARVs to (2005-2010) + course of ARV reduce the risk of Project data, prophylaxis to reduce MTCT (in areas and UNGASS the risk of Mother To targeted by MAP) report Child Transmission (MTCT) in areas targeted by MAP by the end of the project. Number of STIs cases 300,000 Number of STIs cases 100,000 102,074 treated according to treated according to PNLS report national norms (per national norms (per (2005-2010) + year) year) Project data Number of service 600 Number of units of 200,000 322,295 outlets carrying out blood collected which PNTS report blood safety activities are qualified according (2005-2010) + have been established to national norms Project data, countrywide by the end countrywide by the end and UNGASS of the project of the Project. report % of men and women 70% Number of adults and 10,000 7,940 with advanced HIV children with HIV PNLS report infection receiving receiving ARVs (in (2005-2010) + antiretroviral areas targeted by the Project data, combination therapy in MAP) and UNGASS areas targeted by the report MAP by the end of the Project 68. As for the indicator on the number of persons 15 years and older who receive counseling and testing for HIV and receive their results, the target numbers varied greatly between the two restructuring events. The target set towards the end of the Project in 2010 (300,000) was achieved but fell short of the 2007 target (800,000). 14 69. Data for the indicator on the number of service outlets carrying out blood safety activities is not available, but we know that 85% of the health zones (436 health zones in total) were providing blood transfusion services by the end of 2010. However, the number of units of blood collected by the end of 2010 was 322,295, well over the target set for the 2010 restructuring (200,000). 70. The overall effectiveness of the first revised PDO 1 is rated Modest. Only two out of six indicators of the revised PDO 1 after the 2007 restructuring were achieved. Although four out of six of the indicators were achieved after the 2010 restructuring, one may have the impression that the 2010 restructuring had the ultimate goal of making the Project’s achievements of the PDOs look good. e) Revised PDO 2: Mitigate the health and socio-economic impact of HIV/AIDS at individual, household, and community level Table 7: Level of achievement of revised PDO 2 indicators Revised Indicators Formally Revised Indicators Formally Actual value (2007 restructuring) revised target (2010 restructuring) revised target achieved at values values completion or (2007) (2010) Target Years (May 2011) Number of orphans and 15,000 Number of orphans 15,000 20,667 other vulnerable and vulnerable Project data children whose children with (2010) households received schooling provided care/ support in past 12 through the project. months 71. The target for this indicator was achieved at 138%. The achievement of the revised PDO 2 is therefore rated as substantial. f) Revised PDO 3: Build strong and sustainable national capacity to respond to the HIV/AIDS epidemic Table 8: Level of achievement of revised PDO 3 indicators Revised Formally revised Revised Indicators Formally Actual value Indicators target values (2010 restructuring) revised target achieved at (2007 (2007) values completion or restructuring) (2010) Target Years (May 2011) - - % of Ministries 100% 60% (2010 figure) targeted by the Project with operational Unit for HIV/AIDS control 72. The target for this indicator was achieved at 60%. The achievement of the revised PDO 3 is therefore rated modest. 15 3.3 Efficiency 73. Some elements of design and implementation may have contributed to the reduction of the project’s efficiency. The desire to provide funds for each component of the NHA Plan rather than focusing on a few critical thematic areas certainly diluted the Project’s capacity to efficiently achieve its development objectives. The same is true for the ambitious scope of the project to cover the entire country rather than concentrating efforts on a carefully chosen limited number of provinces. 74. There were also problems of allocative efficiency. Only 40% of the funds were originally allocated to the component focusing on the response to the public sector, knowing that the entire country’s health system was very weak in the aftermath of the conflict. This was made worse in actual spending, as the percentage of the funding level for this important area fell to 29.6% when Coordination and Communication took a lion share of about 48.6% in actual spending. The allocative efficiency became even more problematic after the second restructuring in 2010 just three months before the original closing of the Project. The reallocation of funds was partially made to ensure the Project funds would be used by the closing date without regard to effectiveness. 75. In terms of cost-effectiveness, although the exact cost per each output/outcome indicators was unavailable, it is clear that spending $54 million over the life of the project to put 7,940 patients on ARV, treat a cumulative number of 804 pregnant women on ARV to prevent PMTCT, assist a cumulative number of 38,299 with schooling, and provide just over 100,000 STI treatments per year was well over the expected acceptable costs for alternatives. As an example, on average in other countries, in 2004 the cost of treating one patient by ARV was $1,100 per year (it subsequently dropped to $355 by 2009). It costs around $2 per STI case treated and $150 per pregnant women put on ARV to prevent transmission to babies. Adding to the burden of these costs, 25 million condoms burned in the warehouses of the Federation of the National Pharmaceutical Procurement Centers (FEDECAME – Federation des Centres d’Achat des Medicaments) which has its insurance and compensation process is underway. 76. The net present value of the project interventions couldn’t be determined because it is calculated in the PAD based on the reduction in HIV prevalence. It is now known that new advances in HIV mitigation (scaling up PMTCT and full scale ARV treatment for all HIV positive) could have an impact on the prevalence, stabilizing it or even increasing it by increasing survival among PLWHA. In addition, the true prevalence of HIV in the general population is unknown. 77. Given the above facts, the efficiency of the Project is rated negligible both before and after the restructuring. 16 Table 9: Allocation of loan proceeds by component categories Component Original allocation in $US Actual disbursement in SUS million (%) million (%) Component 1: response to the $40.4 (39.4%) 30.8 (29.6%) public sector Component 2: Response to the $17.9 (17.4%) 17.1 (16.4%) non-governmental sector Component 3: Support to $19.3 (18.8%) 5.1 (4.9%) community initiative Component 4: Coordination and communication, and monitoring $22.5 (22.0%) 50.6 (48.6%) and evaluation Unallocated $2.2 (2.4%) 0.6 (0.5%) Total $102 (100%) 104.2 (100%) 78. Summary of ratings, by components 79. OPCS guidelines for outcome rating of a project with formally revised project objectives recommend using a weighting system that takes into account the performance of the project in achieving its development objectives before and after the restructuring as well as the level of disbursement associated with each period. We used this system to rate this project outcome in the tables below. Table 10: Summary of ratings by original PDOs Criteria PDO Relevance Effectiveness Efficiency Result Reduce the risk of sexual, Substantial Modest Negligible Modest intravenous and vertical transmission of HIV Improve the health status and Substantial Negligible Negligible Modest quality of life of people living with HIV/AIDS Mitigating the socio-economic Substantial Negligible Negligible Modest impact of the epidemic on vulnerable groups Summary of ratings Substantial Negligible Negligible Unsatisfactory Rating total Unsatisfactory Table 11: Summary of ratings, by revised PDOs Criteria PDO Relevance Effectiveness Efficiency Result Make treatment of STI and Modest Modest Negligible Unsatisfactory HIV/AIDS more accessible Mitigate health and socio- Substantial Substantial Negligible Moderately economic impacts of the epidemic Satisfactory on individual, households, and communities Build strong, sustainable national Substantial Modest Negligible Unsatisfactory capacity to respond to HIV/AIDS epidemic Summary of ratings Substantial Modest Negligible Unsatisfactory Rating total Unsatisfactory 17 Table 12: Overall final outcome rating Rating Ratings Against original PDOs Against revised Overall PDOs 1. Rating Unsatisfactory Unsatisfactory - 2. Rating value 2 2 - 3. Weight (% of disbursed 33% 67% 100% before/after change) 4. Weight value (2x3) 0.66 1.34 2.00 5. Final rating - - Unsatisfactory 3.4 Justification of Overall Outcome Rating 80. On the basis of the ratings above on the relevance of objectives, design and implementation, the achievement of the project development objective and the project efficiency, the overall outcome rating of the project is unsatisfactory. 3.5 Overarching Themes, Other Outcomes and Impacts (a) Poverty Impacts, gender Aspects, and Social Development 81. The fight against HIV/AIDS and STI has always been one of the five pillars of the poverty reduction and growth strategy in DRC (PRGSP). With most Congolese families living below the poverty line, and with the population constantly growing every year, the country has found it enormously difficult to take care of its most vulnerable people. The promulgation of Act No. 08/011 of July 14, 2011, on the protection of people living with or affected by HIV/AIDS, which governs the national HIV/AIDS policy in DRC, represents the State’s effort to deal with the poorest and most vulnerable groups. 82. Various studies and surveys have revealed the growing feminization of the epidemic, and the project has funded ministries and NGOs specializing in interventions for women. Priorities built into the Project such as those related to PMTCT and some of specific CSO-supported activities contributed to enhanced attention to girls and women. (b) Institutional Change/Strengthening 83. The AIDS Coordinating Authority (PNMLS) has been extensively supported by the Project from early days. Also, the project helped consolidate and strengthen the capacities of decentralized bodies (in all provinces and in ten districts) and of hundreds of NGOs, umbrella groups, and communities. (c) Other Unintended Outcomes and Impacts (positive or negative) 84. No unintended outcome and impact to report. 3.6 Summary of Findings of Beneficiaries Survey and/or Stakeholders Workshops 85. Beneficiary survey/stakeholder workshop not done 4. Assessment of risks Development outcome 86. The risk that the results of the project will not be sustainable after it closes is considered Substantial. 18 87. The sustainability of development outcomes achieved by the Project is not guaranteed. For example, the financing of MOD has certainly contributed to the results, but perhaps to the detriment of the improvement of health services, which at present remain very weak to address HIV mitigation efforts alone. 88. Second, setting up coordinating bodies to carry out initiatives in the provinces has established the presence of the national program, but the lack of a technical and financial means will endanger the future of these structures and the priority activities they are supposed to be carrying out. 89. Third, in a country where the financial resources for fighting HIV/AIDS are provided almost exclusively by external sources, the continued pursuit of the project objectives will be in jeopardy if the Government doesn’t put in its spending budget resources for the HIV/AIDS fight. 5. Assessment of Bank and Borrower Performance 5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry 90. Bank performance in ensuring quality at entry, the Bank is rated moderately unsatisfactory. 91. The preparatory phase occurred in the context of: (i) generalized poverty; (ii) certain behaviors (precocious sexual relations, multi-partner sex, population mobility, and others); (iii) a weak response to the epidemic owing to the prolonged conflict (especially in the East) and the departure of international and national experts and financial resources, (iv) weak central government, and (v) weak health systems at all levels. However, instead of adapting the Project to the particular situation in DRC, the preparatory team adopted and systematically applied the standard MAP country model. 92. The team analyzed the capacities of the public and private sectors and of NGOs, but it did not study community-based organizations (CBOs). Moreover, certain critical elements were not sufficiently taken into account: (i) institutional arrangements at the central level (including with other partners, especially the Global Fund); (ii) the decentralization modalities, in particular the definition of the roles and responsibilities of provincial and district-level bodies; (iii) the difficulties of setting up a monitoring and evaluation system; and (iv) the problem of human resources (including weak technical capacities and abysmal wages in DRC). 93. Moreover, the preparatory phase had properly categorized the project risks as high, but in reality, the mitigation measures were not strong enough to address the situation. 94. In addition, the results framework didn’t have baseline data for many of the indicators and target setting for those indicators was not realistic and correct because it was based on guesses rather than availability of reliable data on these indicators. 19 95. At the document level, it was noted that the Bank did indeed provid the project implementation team in DRC (a French speaking country) with a French version of the PAD. (b) Quality of Supervision 96. The quality of supervision by the Bank was clearly unsatisfactory. 97. Relative to the length of the entire project (2004-2011), the number of official supervision visits with Aide Memoires (six in all over seven years) was too low to have any significant impact or to correct mistakes on time. During these few supervision visits, the composition of the team was not always appropriate. The only available Aide Memoire before the 2007 restructuring shows that the supervision done in March 2006 was composed only by the TTL on the side of the Bank, and a number of representatives from other development agencies (CDC, UNICEF, WHO, UNAIDS). While collaboration among partners is beneficial, a team made up almost exclusively of partners could not necessarily detect inherent problems in project implementation. An M&E Specialist is mentioned as a supervision team member only in the September 2009 supervision visit. Therefore, the poor monitoring arrangements and results framework could not be addressed in time. 98. As discussed above, the 2007 restructuring did not address some of the real issues the project was facing and the 2010 restructuring came too late to make any palpable impact to achieve the project objectives. 99. During the same period, the project had five TTLs (average of 20 months per TTL). This did not give any of them enough time to truly understand the realities of the problems the project faced to find adequate solutions. Also, it appears the Bank management was not interested in finding lasting solutions to a known problem project. 100. There were significant issues with financial management at the beginning of the project which worsened toward the closing date. Legal actions undertaken following these fiduciary problems by some of the implementing agencies are threatening the current portfolio with legal orders to freeze special accounts of Bank-financed operations in the country. (c) Justification of Rating for Overall Bank Performance 101. The Bank performance is rated unsatisfactory because the weaknesses in the preparation of the project considering the inappropriate geographic and activity-related scope, the poor supervision of the operation and the inability to remove the project from the "problem project" category. 5.2 Borrower's performance (a) Government Performance 102. The Government’s performance was also rated unsatisfactory. 103. There was lack of leadership at the Government level, with internal rivalries between key Government institutions (namely the office of the Prime Minister and the Ministry of Health) responsible for parts of the project’s implementation. Likewise, lack 20 of leadership at the coordinating body and weak technical capacity both at the central and provincial levels hampered the proper implementation of the project. 104. There have also been too many changes in leadership at the Ministry of Health (which had, in the beginning of the project, the chairmanship of the CNMLS). There were five Ministers of Health during the course of the Project. Partly due to this reason, during the entire project life, only two meetings of the CNMLS, the Multisectoral Coordinating Body chaired by the Minister of Health, were held. 105. On the other hand, the capacity of the Ministry of Health, which was responsible for a major part of the project activities, was constrained at both the central and provincial levels. In addition, there was inadequate funding of recurrent costs and poor remuneration of staff, making many projects exclusively dependent on external sources of funding. 106. Political interference and corruption occurred in the process of selecting the Coordinators of the National Coordinating Body (PNMLS) which delayed the hiring of the first Coordinator for several months. Once in place, there were delays in removing any Coordinator despite poor performance and delays in taking necessary actions to improve project implementation pace. (b) Implementing Agency or Agencies Performance 107. The performance of the implementing agency is rated unsatisfactory. 108. Performance of implementing agencies was rated unsatisfactory given the long period of poor performance by PWC, the over commitment issue along with managerial problem, low technical capacity, poor performance and weak leadership at the PNMLS. 109. The responsibilities for executing the project were shared between: (i) the National Multisectoral Program to Combat AIDS (PNMLS), created by Presidential Decree No. 04/029 of March 17, 2004; and (ii) the fiduciary management agency (PWC), which was recruited through an international bidding process and was assigned responsibility for procurement and financial management. It was ultimately replaced by the KPMG which was in charge on the fiduciary management only and a separate procurement unit was created at the PNMLS level. 110. According to the evaluations of the Bank’s ISRs, the performance of PNMLS has been rated, with a few exceptions, moderately unsatisfactory since June 2006, despite the project’s progress and the performance of the components of the response. 111. On the other hand, according to the evaluations of the Bank’s ISRs, the performance of the initial FMA (PWC) was moderately unsatisfactory as a whole, but with variations depending on the function and the period. The performance of the current FMA (KPMG) has been satisfactory since December 2009 up until the January 2011 financial supervision visit. However, it is under the same KPMG that the Project overcommitted more than $5 million towards the end of the Project. (c) Justification for Rating of Overall Borrower Performance 112. Given the performance of the Government (unsatisfactory), PNMLS and the FMAs (unsatisfactory), the Borrower's performance was rated unsatisfactory. 21 6. Lessons learned 114. Lack of realism and phasing in a project design and implementation in a conflict or post-conflict country can undermine the Project ability to achieve its development objectives. This project undertook to cover the entire country after a conflict which left the country with weak institutional systems. Identification of some hotspots along with concentrating efforts in limited number of easily accessible provinces may have increased the chance of the Project to achieve its development objectives. In a post-conflict country, an in-depth understanding of initial institutional capacity and what mitigation options are available should be part of project preparation. 115. In a post-conflict country, swift and frequent restructuring exercises may be necessary in order to adapt the project design and implementation as the situation changes and new data become available. This project was implemented at the beginning as an emergency operation and as in many other operations of such nature, lack of data that provides the evidence-base for an M&E framework and a clear results chain at the outset can make it difficult to draw any causal relationship between observed/unobserved results steaming from the Project activities. 116. Strict adherence to global project frameworks can undermine undertaking necessary adjustments to adapt a project to the specific situation of a particular country. Frameworks such as MAP, Avian Influenza, and Food crisis present the advantage that once the Board has approve the framework, then it become easy to expedite project. However, during implementation, a country’s specific context should prevail in order to undertake necessary restructurings to maximize the chances to achieve the development objectives. 117. In a country with particularly weak capacity, it is imperative to have a TTL in the field at the onset of the Project and avoid frequent TTL changes. It takes at least one full year for a TTL to better understand a project in depth and therefore an additional couple of years at least are needed to ensure continuity and smooth implementation of the project. The absence of a TTL on the ground at the outset of a Project in a conflict or post-conflict country, with very weak structural systems, can critically affect the ability of p0rojects to achieve their development objectives efficiently. The early presence of a Bank team on the ground allows the TTL to identify problems early on and be more pro- active in proposing necessary restructuring and adjustments to the project implementation. In this regard, management needs to support The Project team in providing the needed resources and time to undertake intensive Project modification. 118. Similarly, in weak capacity environments, the Bank needs to exercise intense fiduciary oversight even when international firms have been hired to provide fiduciary services. Given the ineligible payments and over-commitments that happened during the project, hiring specialized FMA and implementing agencies alone may not be sufficient for ensuring smooth technical and financial implementation of the project. 119. Donor driven projects from the beginning to the end without proper incremental integration into the Government budget processes poses a substantial risk to the sustainability of development outcomes. Lack of leadership and commitment in monetary contribution by the Government has a negative impact on both the achievement of the project development objectives and sustainability of achieved results and causes an 22 acute problem when the project closes. Also, the creation of an independent coordinating body outside the Ministry of Health can create some level of frustration which leads to lack of ownership when the Project closes and the structure dissolves. 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies 120. The three issues raised by the comments received from the Client were taken into account in the final version of this report. (b) Cofinanciers 121. N/A (c) Other partners and stakeholders 122. N/A 23 Annex 1. Project Costs and Financing Table 13: Project Cost by Component (in USD Million equivalent) Actual/Latest Appraisal Estimate Percentage of Components Estimate (USD (USD millions) Appraisal millions) Component 1: Response to public $40.4 $30.8 39.4% sector Component 2: Response to non- $17.1 $17.1 17.4% Governmental sector Component 3: Support to community $19.3 $5.1 18.8% initiative Component 4: Coordination and $22.5 $50.6 22.0% Communication, and M&E Unallocated $2.2 $0.6 2.4% Total Baseline Cost $102.0 $104.2 100% Physical Contingencies 0.00 0.00 0.00 Price Contingencies 0.00 0.00 0.00 Total Project Costs $102.0 $104.2 Front-end fee PPF 0.9 0.00 .00 Front-end fee IBRD 0.00 0.00 .00 Total Financing Required $102.9 0.00 Table 8: Financing Appraisal Actual/Latest Type of Percentage of Source of Funds Estimate Estimate Cofinancing Appraisal (USD millions) (USD millions) Borrower 0.00 0.00 .00 IDA LOAN FOR HIV/AIDS 102.00 0.00 .00 24 Annex 2. Outputs by Component a) Results achievement by PDO Table 14: PDO 1: Make treatment for STI and HIV/AIDS more accessible Original PAD Baseline Original Revised Formally Revised Formally Actual indicators value target Indicators revised Indicators revised value values (2007 target (2010 target achieved at (Year 6: restructuring) values restructuring) values completion End of (2007) (2010) or Target Project) Years (May 2011) % of sex 20% 60% Number of 25,000,000 Number of 25,000,000 27, 650,946 workers reached condoms condoms PNLS report by the program distributed by the distributed by (2005-2010) report using Project the Project + Project condoms during data their last sexual encounter Number of 1,500 25,000 Persons aged 15 800,000 Persons aged 15 300,000 302,308 people a year and older received and older who PNLS report visit VCTs counseling and receive (2005-2010) testing for HIV counseling and + Project and received their testing for HIV data test results in areas and receive their targeted by the test results MAP by the end of the project % of pregnant 1% 35% % of HIV infected 70% Number of 1,200 804 women who pregnant women pregnant women PNLS report have access to receive a complete living with HIV (2005-2010) Mother-to-Child course of ARV who received + Project transmission prophylaxis to ARVs to reduce data, and prevention reduce the risk of the risk of UNGASS program Mother To Child MTCT (in areas report Transmission targeted by (MTCT) in areas MAP) targeted by MAP by the end of the project. Number of - 50,000 Number of STIs 300,000 Number of STIs 100,000 102,074 people/year who cases treated cases treated PNLS report are treated according to according to (2005-2010) according to national norms national norms + Project acceptable (per year) (per year) data standard for STI % of donated 42% 60% Number of service 600 Number of units 200,000 224,309 blood is tested outlets carrying out of blood PNTS report for HIV and blood safety collected which (2005-2010) Hepatitis B&C activities have are qualified + Project been established according to data, and countrywide by the national norms UNGASS end of the project countrywide by report the end of the Project. 25 Table 15: PDO 2: Mitigate health and socio-economic impacts of the epidemic on individuals, households, and communities Original PAD Baselin Original Revised Formally Revised Formally Actual indicators e value target Indicators revised Indicators revised value values (2007 target (2010 target achieved (Year 6: restructuring) values restructuring) values at End of (2007) (2010) completion Project) or Target Years (May 2011) Number of 2,200 20,000 % of men and 70% Number of 10,000 7,940 PLWHA who women with adults and PNLS receive quality advanced HIV children with report medical infection HIV receiving (2005- treatment receiving ARVs (in 2010) + antiretroviral areas targeted Project combination by the MAP) data, and therapy in areas UNGASS targeted by the report MAP by the end of the Project % of target 0 50% Number of 5,000 Dropped health zones subprojects which have (sensitization, community community services for services for PWLHA PLWHA) by available NGO, CBO and FBO that have received support % of orphans 4% 20% Number of 15,000 Number of 15,000 38,299 assisted with orphans and orphans and Project data tuition and other vulnerable vulnerable schooling children whose children with households schooling received care/ provided support in past through the 12 months project. Reduced 100% 70% Dropped discrimination against PLWHA (as defined in DHS+) 26 Table 16: PDO 3: Build strong, sustainable national capacity to respond to HIV/AIDS epidemic Original PAD Baselin Original Revised Formally Revised Formally Actual indicators e value target Indicators revised Indicators revised value values (2007 target (2010 target achieved (Year 6: restructuring) values restructuring) values at End of (2007) (2010) completion Project) or Target Years (May 2011) - % of 100% 60% (2010 Ministries figure) targeted by the Project with operational Unit for HIV/AIDS control b) Results by component Component 1: Response of the Public Sector 113. Access to services for PLHIV in targeted health zones (HZ): The results relating to access to services are shown in the following table: Table 17: Access to services for PLWHA Indicators 2004 2005 2006 2007 2008 2009 2010 # and % of health zones having access to: Care Na 100 (19%) 27 (5%) 56 (11%) 83 (16%) 59 (11%) 123 (24%) Distribution Na 97 (19%) 143 (28%) 133 (26%) 173 (34%) 194 (38%) 217 (42%) of OI drugs Distribution 10 (2%) 27 (5%) 123 (24%) 140 (27%) 170 (33%) 184 (36%) 239 (46%) of ARVs Total (%) 14% 19% 21% 28% 28% 37% Source: PNLS Reports (2006-2010) 114. Compared to the objective of reaching 50% of health zones, the project contributed to the coverage of 37% by 2010. 115. Condom distribution: The results of condom distribution are presented in the following table. 27 Table 18: Condom distribution Indicator 2005 2006 2007 2008 2009 2010 Number of condoms distributed Annual - 15,227,360 21,656,058 17,305,231 8,011,247 country total MAP 11,832,498 2,716,961 4,460,852 2,079,034 792,500 5,761,762 contribution (17.8%) (20.6%) (12.0%) (9.9%) and % MAP 11,832,492 14,549,450 19,010,302 21,089,336 21,881,836 27,643,548 cumulative total Source: PNLS Report (2005-2010), Project data 116. The project was able to meet the target of distributing 25 million condoms. The annual contribution from MAP has been somewhat variable, but it should be noted that the project has just bought 38.4 million condoms for distribution in the coming years. However, approximately 25 millions of these perished in a warehouse which caught fire before they were dispatched to respective Provinces for distribution. 117. Number of persons who sought counseling and testing, and received the results, in the zones targeted by the project: The results, at country level and for the project as a whole, are shown in the following table: Table 19: Use of VCT services Indicator 2004 2005 2006 2007 2008 2009 2010 Number of health zones with VCT services Number na 98 157 125 171 181 251 Percentage na 19% 30% 24% 33% 35% 49% Number of persons using VCT services per year Country total 59,379 209,067 719,046 874,133 1,030,214 1,205,074 1,499,545 MAP 40,795 64,921 87,035 219,781 320,966 299,687 contribution %MAP 31% 12% 25% 31% 27% 20% Source: PNLS Reports (2005-2010), Project data 118. In terms of the objectives of providing services the target of the 2010 restructuring (300,000) was achieved but it was well below the 2010 restructuring target of 800,000. The original target at the project appraisal (25,000) was certainly an under estimate of what the Project could achieve. 119. HIV seropositive pregnant women who benefited from all the services provided by PMCT: The results for the country program and for the project are presented in the following table: 28 Table 20: Enrollment of pregnant women into PMTCT program Indicator 2004 2005 2006 2007 2008 2009 2010 Number of HIV+ pregnant women Estimated total # 110,842 136,110 142,970 99,491 117,854 117,854* Total tested 1,702 2,471 4,667 5,392 3,834 3,189 6,461 Total positive treated 846 1,725 3,435 1,855 1,776 2,232 4,314 # positive 93 1 38 0 362 310 treated/Annual MAP # positive 93 94 132 132 494 804 treated/Cumulative MAP Percentage of HIV+ pregnant women treated % of total estimated 1.6% 2.5% 1.3% 1.8% 1.9% 3.7% (% MAP) (0.08%) (0.01%) (0.03%) (0%) (0.3%) (0.3%) % of total tested 49.7% 69.8% 73.6% 34.4% 46.3% 70.0% 66,8% (% MAP) (3.8%) (0.02%) (0.7%) (0%) 11.4%) (4.8%) Source: PNLS reports (2005-2010); UNGASS reports, Project data * In the absence of this data for 2010, we used the 2009 value 120. The indicator changed from being expressed as a percentage to becoming a number. The targets in percentages - 35% for original target and 70% for the 2007 restructuring - the country was far from achieving these targets (3.7% in 2010). With regard to the objective of treating 1,200 positive pregnant women in the project zone, the cumulative number, as at December 31, 2010, was 804. 121. Treatment of sexually transmitted infections (STIs) in accordance with national norms: The results for the country program and for the project can be seen in the following table: Table 21: Treatment of STI according to national norms Indicator 2005 2006 2007 2008 2009 2010 Health zones (HZ) having access to STI services # of HZ with STI 199 244 221 270 241 279 services Percentage 39% 47% 43% 52% 47% 54% # of STI cases correctly treated Country total 302,786 435,494 213,472 247,586 210,590 329,053 MAP 45,058 6,978 5,469 6,865 19,888 18,117 contribution (#) MAP 14.9% 1.6% 2.6% 2.8% 9.4% 5,5% contribution (%) Source: PNLS reports (2005-2010) 122. The project far exceeded the target of 50,000 (original target) and 100,000 (2010 restructuring target) cases treated in accordance with national norms but it’s well below the 2007 restructuring target of 300,000. 29 Treatment of PLHIV: Table 22 below shows the results for the country and project: Table 22: Number of PLWHA on ARVs Indicator 2005 2006 2007 2008 2009 2010 Cumulative number of PLWHA put on ARVs Country total 9,096 17,561 21,874 24,645 34,967 43,878 MAP contribution 42 226 4,862 15,410 23,598 7,940 % MAP 0.5% 1.3% 22.2% 62.5% 67.5% 18% % of PLWHA 2.7% 5.4% 6.3% 8.9% 12.4% 14.6% receiving ARVs Source: PNLS reports (2005-2010), UNGASS reports, Project data 123. This indicator was achieved at 79.4% (7,940/10,000) with regard to the target set at the last restructuring in 2010 but certainly fall short below the target set for 2007 (70%) and the original target (20,000). 124. Blood transfusion: The results for the country program are presented in the following table: Table 23: Blood transfusion services Indicator 2005 2006 2007 2008 2009 2010 Health zones (HZ) having blood transfusion (BT) services Total # of HZ with BT 343 411 411 426 418 436 services % of HZ with BT 67% 80% 80% 83% 81% 85% services Safety control of collected blood # of units collected 263,754 Na 266,761 249,821 228,624 322,295 # complying with 263,100 267,492 155,378 246,153 211,219 224,309 norms % controlled 100% 58% 99% 92% 70% Source: PNLS reports (2005-2010), UNGASS reports, Project data 125. The original target of controlling 60% of the blood supply in testing for HIV and Hepatitis B & C was achieved The same is true for the 2010 restructuring target of collecting 200,000 units of blood in accordance with national norms. The exact number of health facilities carrying out blood safety activities was unknown at the time of this ICR preparation. 126. Building strong, sustainable national capacity to respond to the HIV/AIDS epidemic: This indicator has to do with the establishment, by the ministries targeted by the project, of a unit responsible for HIV/AIDS control. Since 2007, the eight ministries targeted by the project have established such a unit. Moreover, eight other ministries and Parliament have also set up HIV/AIDS units. Component 2: Response of the non-Governmental Sector and Component 3: Support to Community Initiatives 127. Sex workers: Compared to the objective that 60% of sex workers targeted by the program report using condoms during their last sexual encounter, the 2007 DHS results 30 showed a result of 61.4%. The target has thus been met but the contribution of the Project to the achievement of this target is hard to ascertain. 128. Orphans/OVC: With regard to the indicator target that 20% of orphans have received schooling or education provided by the project, the third Multiple Indicator Cluster Survey (MICS 3) (2009) confirms the figure of 63%. It’s not clear; however, what has been the contribution of the project to this indicator. As for the 2007 and 2010 target of providing schooling to 15,000 orphans and other vulnerable children, the project has reached a cumulative number that surpasses the target. Table 24: Support to OVC Indicator 2005 2006 2007 2008 2009 # receiving support in past 12 7,398 1,769 11,280 8,030 7,815 months Cumulative # receiving 7,398 9,167 20,447 28,477 36,292 schooling support MAP contribution 4,402 10,967 16,655 18,308 20,667 %MAP 60% 120% 81% 64% 57% Source: Project data 129. By the end of 2009, the country-level objective of providing assistance and/or care to at least 15,000 orphans and other vulnerable children over the past 12 months has not been met. 130. Tolerant attitude: According to DHS results (2007), only 9% of the Congolese people have a tolerant attitude toward PLHIV; the MICS 3 study (2009), which uses another method of calculation, arrived at nearly the same conclusion (7% tolerance level). The project objective has not been met. g) Subprojects: The project results in terms of financing subprojects are summarized in the following table: Table 25: Number of subsidies/subproject per component Component 2004- 2006 2007 2008 2009 2010 Total % 05 Public 32 41 140 69 143 81 506 16.8% Private 20 37 77 14 33 22 203 6.7% NGO/Umbrella 224 127 282 64 525 444 1,666 55.2% organizations Community 38 27 137 0 288 152 642 21.3% Total 314 232 636 147 989 699 3,017 100% Source: Project data 131. The project was unable to reach the target in terms of supporting at least 5,000 subprojects (sensitization and community support for PLHIV, among others). However, just looking at the number of sub-projects with no indication of how well they perform seems insufficient. Component 4: Coordination and communication, M&E, and capacity building 132. The project has also: (i) arranged for coordination in all the provinces of DRC and in some districts; and (ii) financed training in various fields, including the management of programs to fight HIV/AIDS. 31 133. In addition to the indicators set out in the loan agreement, other measures could be added. For example, with regard to the composite index of national policies, DRC has made systematic progress since 2003, as shown in the following table: Table 26: Evolution of national policy index Score 2003 2005 2007 2009 Global score 35.0 44.0 60.0 80.0% % (of 130 points) 27% 34% 46% 62% Source: UNGASS report. 32 Annex 3. Economic and Financial Analysis 134. Not done 33 Annex 4. Bank Lending and Implementation Support/Supervision Processes Table 27: Task Team members Responsibility/ Names Title Unit Specialty Lending Supervision/ICR Elizabeth J. Ashbourne Senior Operations Officer OPCRX HDNGA - David M. Blankhart Consultant His Lucie Lufiauluisu Bobola Team Assistant AFCC2 Anne Marie Bodo Consultant AFTHE Nestor Coffi Country Manager AFMNE Bella Lelouma Diallo Sr Financial Management Specia AFTFM L. Rodrigue Djahlin Operations Officer CAFJ5 Andre Lohayo Djamba E T Consultant AFTFM Jean Charles Amon Kra Sr Financial Management Specia AFTFM Philippe Mahele Liwoke Senior Procurement Specialist AFTPC Jean-Pierre Manshande Consultant HDNHE Thomas Mbonye Procurement Spec. AFTPC Tomo Morimoto Operations Officer AFTHE Gaspy Gedeon Muanda Consultant AFTFM Celeste Mukuna Team Assistant AFCC2 AFTH3 - Souleymane Sow Consultant HIS AFTH3 - Moise Touhon Consultant HIS Gerhard Tschannerl Consultant AFTPC Jean Jacques Frere Senior Health Specialist, Project TTL AFTHE Enias Baganizi Senior Health Specialist, ICR TTL AFTHE 34 Table 28: 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 FY03 135.52 FY04 629.28 FY05 0.00 FY06 0.00 FY07 0.00 FY08 0.00 Total: 764.80 Supervision/ICR FY03 0.00 FY04 0.00 FY05 157.74 FY06 224.22 FY07 151.17 FY08 118.11 Total: 651.24 35 Annex 5. Beneficiary Survey Results 135. Not done 36 Annex 6. Stakeholder Workshop Report and Results 136. No workshop conducted 37 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR 137. Comments were received only from the MAP Project Manager at the PNMLS and are listed below. 138. The report seems to be objective. I have three observations: 9 With regard to the 25 million condoms burned (paragraph 75): they were stored in the warehouses of the federation of the National Pharmaceutical Procurement Centers (FEDECAME – Federation des Centres d’Achat des Medicaments) which has its insurance and compensation process is underway. 9 I suggest you clarify in paragraph 33 that "two project managers were in position for long periods of time as interim, thus only in acting position". 9 In paragraph 95, please make a correction because the French version of the PAD was put at the disposal of PNMLS, and therefore the country. 139. Feedback received from the Client was partly due to the difficult elections period, demobilized and disbanded PNMLS team. 38 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders 140. N/A 39 Annex 9. List of Supporting Documents 9 DRC MAP Project Appraisal Document (March 2004) 9 DRC MAP Development Grant Agreement – H080 (April 2004) 9 MAP umbrella regional restructuring paper (May 2007) 9 Report of the Quality Enhancement Review (QER) from QAG (February 2008) 9 Mid-term review issues paper (April 2008) 9 Institutional Audit Review report (May 2008) 9 Mid-term review Aide Memoire (September 2008) 9 Processus de planification nationale stratégique multisectorielle : Rapport préliminaire d’analyse de la réponse nationale (Institute of Tropical Medicine of Anvers, February 2009) 9 Minutes of the quality enhancement review by AFTHE (October 2009) 9 DRC MAP restructuring paper (May 2010) 9 Last ISR report (June 2011) 40 Annex 10: Summary of the Borrower’s ICR Summary of Borrower’s final report on DRC Multisectoral AIDS Project 141. The Borrower hired a consultant to prepare a final report on the DRC Multisectoral AIDS project. The consultant tried to follow the layout of the Bank’s ICR. We provide here the report’s main conclusions on the ratings and lessons learned. 1. Evaluation of results 1.1 Relevance of objectives, design and implementation 142. The relevance of the development objectives, components, and activities of the project is rated Substantial for the initial project, Modest after the restructurings in 2007 and 2010, and Modest for the project as a whole. 143. Initial project (2004-2007). Given the technical orientations of the NSP and PRGSP and the confirmation that the epidemic was generalized, the original objectives, components, and activities of the project responded to lessons learned and accepted practices. In addition to the emphasis on decentralization and a multisectoral approach, the project stressed, in particular, the importance of building the capacities of participants and ultimate beneficiaries so as to enable them to continue the activities on their own, in a sustainable way. Despite the institutional and fiduciary problems encountered in effectively implementing the planned structures and procedures, the objectives and design of the project remained valid. 144. First restructuring (2007-2010). In the absence of a strategic plan for the period, the plan for implementing the road map for universal access to HIV prevention, treatment, care and support has been used as an interim document for the period 2006-2010.4 This document again confirmed that the epidemic is: (i) generalized, with an HIV prevalence rate (ages 15-49) estimated at 4.5%; and (ii) worsening among young people, women, and rural dwellers in conflict zones.5 145. In addition, at the time of the 2007 restructuring, the country had incorporated the fight against HIV/AIDS into its general development plans (PRGSP 2006-2025, CAF 2007-2010); and it had pursued its commitment with regard to universal access by agreeing, through its priority action program (PAP, 2007-2010), to adopt a sustainable financial strategy for providing ARV treatment to HIV patients. 146. The 2007 restructuring was meant to take into account: (i) new data on the status of the epidemic in the country; (ii) changes in the international environment with regard 4 In 2005, DRC had also prepared and adopted a plan to expand access to ARV treatments in DRC for the period 2005- 2009, under the 3 by 5 Initiative. 5 See Feuille de Route (Road Map) (2006-2010), pp. 2-5. 41 to the fight against HIV/AIDS, in particular the experiences of other MAPs; (iii) the increase in available financial resources and the need to harmonize them in accordance with the "three ones;" and (iv) decisions aimed at strengthening project execution procedures relating, in particular, to institutional arrangements and weaknesses in administrative and financial management. 147. The restructuring did not, however, achieve the expected results. First of all, the restructuring ignored the development objective related to prevention and added a development objective linked to institution-building; but it did not revise the indicators, so that many of them did not easily fit into the new logical framework of the project. Moreover, this first restructuring did not actually result in any other changes. 148. Second restructuring (2010-2011). In 2008, a situational analysis6 revised the assessment of the epidemic and concluded that it: ƒ was mixed, with: (i) a generalized component of about 1.2% to 1.5%;7 and (ii) a component characterized by high prevalence rates in certain population groups, in particular prostitutes, with 16.9% in 2004, soldiers (men 3.8%; women 7.5% in 2008), truckers (3.3% in 2004), and miners (2.4% in 2004);8 and ƒ also gave the impression that the epidemic was stable, or even in decline, despite the conflicts experienced by DRC from 1996 to 2003. 149. The National Strategic Plan to Combat AIDS was adopted in July 2009 by CNMLS (the decision-making and guiding entity of PNMLS) and serves as a reference point for all interventions against HIV/AIDS for the period 2010-2014. Besides the general population, NSP focuses on at-risk groups: (i) sex workers; (ii) female victims of sexual violence; (iii) internally displaced persons; (iv) workers in mobile jobs (truckers, miners, soldiers, and others); and (v) injection drug users (IDUs). 150. The restructuring of the project was not, however, based on epidemiological data, nor did it fundamentally modify the indicators or propose new changes in the 2007 restructuring. 151. In conclusion, from 2004 to 2010, the project context evolved on many levels (institutional, technical, financial, and monitoring, among others), but the project remained more or less fixed on its original approach. This approach was relevant at the beginning, but it would have been better to include more positive responses to the 6 Preliminary report, Analysis of the status of the epidemic in the process of elaborating the National Multisectoral Program to Combat HIV/AIDS in DRC, 2009-2012. 7 The 2007 Demographic and Health Survey (EDS) estimated the prevalence in the general population at 1.3% (1.6% for women and 0.9% for men), and UNAIDS (2008) validated the EDS data, situating national seroprevalence in a range between 1.2% and 1.5%. However, DRC has contested the methodology and results of the EDS and has continued to use the prevalence rate of 4.5%. 8 The situational analysis notes that there might be other vulnerable groups in the country, identified as such on the basis of fragmentary studies or anecdotal data concerning their behavior. Unfortunately, in the absence of supplementary data, it is impossible to resolve this issue. Op. cit., p. 6. 42 modifications suggested by the various missions (such as the minimum package, institutional audit, and organization of ARV drugs). 1.2 Effectiveness in meeting the project development objectives 152. With regard to progress made on the performance indicators and disbursement rates during the different project implementation periods, the project was rated Substantial, for the initial project, Low after the 2007 restructuring, Substantial after the 2010 restructuring, and modest for the project as a whole. 153. PDO 1: To make STI and HIV/AIDS treatment more accessible. The indicators contributing to PDO 1 deal with access to services and performance of services. For the reasons given above, prevention indicators are covered by this PDO. 1.3 Efficiency in achieving the project development objectives (PDO) 154. In view of the overall expenditures and results and the measures adopted during the project to improve its efficiency, performance was rated Modest for the initial project, Negligible after the 2007 restructuring, Modest after the 2010 restructuring, and modest for the project as a whole. 155. General considerations. The PAD had based the efficiency criteria for the project on: (i) the economic benefits resulting from the reduction in the number of new infections and the improvement of the economic prospects of persons living with, and affected by, the HIV epidemic; and (ii) the prompt implementation of the project so as to reap its benefits as soon as possible. Actually, given the generalized nature of the epidemic, the lack of infrastructure and human resources, and the huge size of the still unstable country, the original efficiency criteria have proved to be irrelevant. 156. Moreover, MAPs, by their nature, are inefficient in the early phases because they are called upon to (i) adapt the components (and budget allocations) and institutional arrangements to the national context; (ii) implement a high-performance planning and budgeting system that allows for the adoption of annual action plans to submit for non- objection to the Bank as soon as possible; and (iii) quickly build management capacities at the central and provincial levels. In the face of these constraints, PNMLS was able to disburse only 22% of the grant amount in the first two years, half of which was spent on management and capacity-building. 157. Lastly, since 2007, the Government made the commitment, through the PRGSP and the Priority Action Plan (PAP), to fight poverty and apply a realistic wage policy; and all the development partners agreed to provide support for staff incentives such as bonuses or honorariums as part of their interventions. 158. Specific measures. The project had taken certain steps to improve the efficiency of interventions under PDO 1, including the use of MOD (especially at the beginning and end of the project) for a significant proportion of prevention and treatment interventions: 43 ƒ UNHCR and Constellation for community awareness-raising; ƒ ASF for condom distribution; ƒ FOMETRO, Centre Victoire, and CCISD for IST; ƒ CORDAID, CTB, and GTZ for blood transfusion. 159. Unfortunately, the effort to recruit MOD staff for PMCT and VCT to implement these elements was unsuccessful. 160. As for interventions in relation to PDO 2, the project basically depended on subsidies to the public, private, and non-governmental sectors and community initiatives. This support started out timidly, however, and the results have never been adequately evaluated; technical audits, which among other things examined the situation, were not conducted annually (as stipulated in the grant agreement) and did not address the performance of the recipients.9 Even the available data on the distribution of subsidies by recipient and province have not been analyzed with a view to improving the management of interventions. 161. As for interventions under PDO 3, the Project had recruited: (i) a fiduciary management agency and a procurement expert; (ii) technical specialists in the establishment of norms, planning, and capacity-building; and (iii) internal and external auditors for financial and institutional audits. The project also conducted a mid-term review. 162. In addition, DRC participated in an evaluation of the responses to the epidemic10 in 2006, which concluded that, despite the existence of political will at the highest governmental level and efforts at coordination, the national strategy for harmonizing HIV/AIDS control interventions has been characterized by (i) poor alignment between partners with regard to national priorities; (ii) insufficient harmonization of finances; and (iii) weaknesses in coordination among the various levels of intervention and in the circulation of strategic information. 1.4 Overall project evaluation and justification 163. On the basis of ratings on criteria, results, and disbursements during the various phases of the project, the following table presents the final conclusion, which rated the project moderately unsatisfactory. 3.5 Other topics, results, and impacts 164. Poverty, gender, and social development. The fight against HIV/AIDS and STI has always been one of the five pillars of the poverty reduction strategy in DRC (PRGSP). With most Congolese families living below the poverty line, and with the population 9 The current technical audit for the years 2008 and 2009 will analyze the subsidy situation. 10 An Assessment of Country Alignment and Harmonized Support to Scaling up the HIV/AIDS Response—Provisional Report (December 2006), pp. 2-3. 44 constantly growing every year, the country has found it enormously difficult to take care of its most vulnerable people. Thus, as shown by various studies, some persons in the youngest groups, particularly girls, have become prostitutes and exposed themselves to HIV/AIDS and other STI.11 The promulgation of Act No. 08/011 of July 14, 2011, on the protection of people living with or affected by HIV/AIDS, which governs the national HIV/AIDS policy in DRC, represents the State’s effort to deal with the poorest and most vulnerable groups. 165. Various studies and surveys have revealed the growing feminization of the epidemic, and the project has funded ministries and NGOs specializing in interventions for women. 166. The PAD had provided for monitoring of the social impact of the project on vulnerable groups, but this activity was never carried out. 167. Development/building of institutional capacities. Two elements should be noted with regard to institutional capacities. On the negative side, the institutional arrangements currently in place have not yielded the expected results and have, since the beginning of the project, undermined the impact of PNMLS in DRC. The following do exist, however: (i) the MAP project, which finances the operations of CNMLS, including its multisectoral HIV/AIDS/STI activities, and has its secretariat in PNMLS; and (ii) Global Fund financing, which uses another coordination mechanism at the country level (CCM) and has its technical secretariat in the Ministry of Health. 168. On the positive side, the project has helped consolidate and strengthen the capacities of decentralized bodies (in all provinces and in 10 districts) and of hundreds of NGOs, umbrella groups, and communities. 2. Assessment of risks related to the attainment of development objectives 169. The risk that the results of the project will not be sustainable after it closes is considered High, because of three types of uncertainties. 170. First, in view of the changes in the focus of the project, the development and adoption of project-financed strategies are not guaranteed. For example: (i) the financing of MOD has certainly contributed to the results, but perhaps to the detriment of the improvement of health services; (ii) the implementation of awareness-raising strategies has never been consistent with the fairly slow expansion of VCT; and (iii) the distribution of ARV drugs does not sufficiently take into account the other partners present in the field, and it risks being technically incomplete.12 The current NSP, and especially the action plans, could eventually help improve the coherence of the strategies, provided that adequate leadership and financial resources are available. 11 M. Kasongo 2007; B. Lapika D., 2008. 12 See Chenin and Vreeke, Analyse de situation de l'approvisionnement en ARV en République Démocratique du Congo, March 2010. 45 171. Second, the setting up of coordinating bodies to carry out initiatives in the provinces has established the presence of the national program, but the lack of a technical and financial framework (indicated by the extreme variation in the number of staff) is endangering the future of these structures and the priority activities they are supposed to be carrying out. Without a realistic assessment and regular monitoring of the expected and actual results of these structures, it will be difficult to maintain them. 172. Third, in a country where the financial resources for fighting HIV/AIDS are provided almost exclusively by external sources, the continued pursuit of the objectives depends more on the rational alignment of available resources than on the estimate of overall needs. In attempting to estimate the gap (between available resources and needs) instead of indicating where to direct the available funds, the Medium-Term Expenditure Framework (MTEF) prepared by PNMLS has accentuated the problem of the country's dependency rather than taking into account the facts on which a more effective response could be based. 3. Evaluation of the performance of the World Bank and the Borrower 3.1 Performance of the World Bank 173. Early quality assurance. The preparatory phase occurred in the context marked by: (i) generalized poverty in certain areas; (ii) certain behaviors (precocious sexual relations, multi-partner sex, population mobility, and others); and (iii) a weak response to the epidemic owing to the prolonged conflict (especially in the East) and the withdrawal of experts and financial resources. However, instead of analyzing the particular situation in DRC, the preparatory team adopted and systematically applied the standard MAP country model. 174. The team analyzed the capacities of the public and private sectors and of NGOs, but it did not study community-based organizations (CBOs). Moreover, certain critical elements were not sufficiently taken into account: (i) institutional arrangements at the central level (including with other partners, especially the Global Fund); (ii) the decentralization modalities, in particular the definition of the roles and responsibilities of provincial and district-level bodies; (iii) the difficulties of setting up a monitoring and evaluation system; and (iv) the problem of human resources (including weak technical capacities and abysmal wages in DRC). 175. Moreover, the preparatory phase had properly categorized the project risks as high, but in the details of the PAD and in the table presenting the measures envisaged to mitigate the risks, the preparation team was too optimistic in its proposed solutions. Lastly, the project was launched only seven months after its approval. 176. As for the quality of project preparation and implementation, the World Bank rated the performance moderately unsatisfactory. 46 177. Quality of supervision. During the preparatory phase of the project, difficulties with regard to supervision were mentioned, in view of the large size of the country, the complexity of the project, and the lack of implementation capacities for World Bank projects in DRC. It had been decided to assign Bank staff to Kinshasa and seek other resources (other partners, trust funds, among others) to build supervisory capacities. Except for a period in 2008-2009, permanent staff members in Kinshasa oversaw the project13 and were supported locally by financial management and procurement experts as well as specialists from Washington D.C. in several areas (planning, monitoring and evaluation, private sector organization, drugs, and others). Despite these staff, only five supervisory missions, with aide-mémoire, were carried out during the entire project. 178. As can be seen in the progress reports on the project, ratings for the various project elements were rated Satisfactory until June 2006, when most of them became Moderately unsatisfactory or worse (mainly owing to weaknesses in financial management and procurement), and have remained at that level, more or less (apart from financial management and procurement), until today. 179. Indeed, the project was classified as a "problem project" for four years, despite a series of attempts by task team leaders (TTLs) to improve the situation, as well as two restructurings. Unfortunately, the TTLs all took different approaches (see paras. 25-26), and the restructurings incorporated points raised in informal project exchanges rather than any new elements.14 Moreover, the modification of the development objectives and the formulation of the indicators proposed by the 2007 restructuring subsequently led to problems.15 180. At the document level, it was noted that the Bank never provided the project with a French version of the PAD. The four aide-mémoires almost always arrived one or two months late, and the results of the implementation status reports (ISRs) were not shared with the project. A technical support team (TST) mission in October 2008 complemented the analysis of the project’s mid-term review, but its recommendations were not followed. Communication with the project was often strained, and long periods of time passed without any significant progress in the dialogue. 181. In terms of the quality of supervision (including the two project restructurings), the Bank rated the project performance unsatisfactory. 182. Overall evaluation of the Bank's performance and justification. Given the weaknesses in the preparation of the project and their impact on the implementation phase, together with the lack of progress in removing the project from the "problem project" category, the Bank's performance was rated moderately unsatisfactory. 13 These personnel dealt with PARSS more than with PNMLS. 14 See IDA, Proposed Umbrella Restructuring and Amendment of the Financing Agreements for the Projects under the Multi-Country HIV/AIDS Program for Africa (MAP) for the 2007 restructuring; and Paper on a Proposed Restructuring of the DRC Multisectoral HIV/AIDS Project for the 2010 restructuring. 15 Among other things, it was difficult to separate the indicators by PDO (especially for prevention). 47 3.2 Borrower's performance 183. Government performance. The Government's commitment was often cited in the documents, but this commitment is difficult to measure because the Government did not have to finance a counterpart to the Bank’s financing. However, at the political and regulatory level, the Government: (i) always supported the fight against HIV/AIDS as a pillar of the poverty reduction strategy; (ii) adopted the NSP (2010-2014); and (iii) promulgated the law protecting PLHIV and those affected by HIV/AIDS; and at the technical level, the Government, through its sectoral ministries, set up units and carried out activities to combat HIV/AIDS, but the ministries did not set aside funds in their budgets for implementing these activities. Moreover, the Government did not act in time to either resolve the institutional problems identified by the various missions or appoint a national coordinator to replace the interim coordinator, who had been on the job for nearly four years. 184. As a result of these factors, the Borrower's performance was rated moderately satisfactory. 185. Performance of the executing agency. The responsibilities for executing the project were shared between: (i) the National Multisectoral Program to Combat AIDS (PNMLS), created by Presidential Decree No. 04/029 of March 17, 2004; and (ii) the fiduciary management agency, which was recruited through an international bidding process and was assigned responsibility for procurement and financial management. 186. According to the evaluations of the Bank’s ISRs, the performance of PNMLS has been rated, with a few exceptions, Moderately unsatisfactory since June 2006, even in view of the progress of the project, in general, and the performance of the components of the response, in particular. 187. During the project, there were two FMAs: (i) PWC from October 2004 to September 2008; and KPMG after September 2008. According to the evaluations of the Bank’s ISRs, the performance of the initial FMA (PWC) was moderately unsatisfactory as a whole, but with variations depending on the function and the period. The performance of the procurement function improved in 2007, with the support of an international procurement expert for two years; the performance of the financial management task remained moderately unsatisfactory, at best. The performance of the current FMA (KPMG) has been satisfactory since December 2009. 188. Given the long period of poor performance by PWC, the project results as a whole are rated moderately unsatisfactory. 189. Overall evaluation of the Borrower's performance and justification. Given the performance of the Government, PNMLS, and the FMAs, the Borrower's performance was rated moderately unsatisfactory. 48 4. Lessons learned 190. In the DRC context, greater stress should be laid on project preparations. The PAD cited the lessons learned from other MAPs, but it did not apply them to the Congolese context; for example, (i) the institutional arrangements and monitoring and evaluation modalities reproduced the same mistakes as elsewhere; and (ii) the strengths of the fight against HIV/AIDS, which could have served as a point of departure for developing the best response, were replaced by the MAP model. MAPs that do not have “local color� or “local champions� have very little chance of success. 191. The importance of drawing a distinction between problems requiring firm management by the Bank and weaknesses that call for modifications in the agreements should not be ignored. Informal procedures ("freezes" and limited non-objections), the introduction (or imposition) of new initiatives, and restructurings have clearly been unable to solve the problems of the project, and more thought should be given to the reasons for this outcome. 49 10°E 15°E 25°E 30°E CENTRAL AFRICAN REPUBLIC SOUTH SUDAN To 5°N Ubang To Bangasso 5°N To i Kembe Bangui To Zongo Gbadolite BAS-UELE Juba Bondo Faradje NORD-UBANGI Uele Libenge Gemena Businga HAUT-UELE Titule DEM. REP. Buta Isiro Watsa Kiba li OF CONGO SUD- Aketi To Imese UBANGI Akula Lisala Pakwach Bumba ORIENTALE Wamba MONGALA C Mongbwalu Bunia UGANDA angui Aruwimi ITURI on Banalia ng nga Lake o o . Lulo Bongandanga Oub Mts Basankusu TSHOPO Bafwasende Albert EQUATEUR Yangambi Beni ba É Q U AT E U R Kisangani Butembo Margherita Peak tum Wanie Rakula (5,110 m) 0° Mbandaka Boende 0° Mi CONGO Tshu a pa NORD Lake G ABON Lubutu KIVU Edward Lake L Lo m Lua u l Bikoro T S H U A PAL Ikela mi a NORD- aba om Victoria b uil ela ak L a Lowa KIVU Goma Ul To Ruhengeri Inongo i Lake Kivu nd Betamba di Congo Yumbi To MAI-NDOMBE Kalima Bukavu Kibuye RWANDA Kutu Kindu SUD Buna KIVU KINSHASA Bandundu Lukenie Lodja Uvira To KINSHASA CITY Kasa i MANIEMA SUD- Bujumbura uru SANKURU Kama BURUNDI BANDUNDU Mangai Sank MANIEMA KIVU Ilebo KINSHASA Bulungu KASAI Malela Lusambo Kasongo Kenge KWILU K A S A� Lulimba 5°S CABINDA BAS-CONGO ORIENTAL 5°S Kikwit Idiofa (ANGOLA) To KONGO CENTRAL Mbanza-Ngungu Luebo LOMAMI Kongolo TA N Z A N I A Pointe- Boma KASAI Kananga ga Kalemie Kw K Noire Mbuji- Luku Lake ATLANTIC KASA�- Mayi ilu Matadi Feshi OCCIDENTAL u To Kabinda Kabalo Tanganyika OCEAN Damba Tshikapa Ka sa ORIENTAL TANGANYIKA KWANGO LULUA Kw K i Moba ang a Mwene-Ditu Manono i DEMOCRATIC REPUBLIC am o o Lom KATANGA Luv OF CONGO ua H A U T- L O M A M I Kapanga s. Pweto Kamina t Lueo M SELECTED CITIES AND TOWNS ba Lulua Lu PROVINCE CAPITALS* ANGOLA L Kilwa Lake m a Lu Mweru itu uff ira l ua NATIONAL CAPITAL Sandoa M Lubudi HAUT- 10°S RIVERS LUALABA KATANGA MAIN ROADS Kolwezi To 0 100 200 300 400 Kilometers Dilolo Likasi Luwingu ZAMBIA RAILROADS To Lu Lake lab ua Lucano a Malawi PROVINCE BOUNDARIES** 0 100 200 Miles Lubumbashi I IBRD 33391R2 M A L AW INTERNATIONAL BOUNDARIES This map was produced by the Map Design Unit of The World Bank. *The creation of 26 new Provinces was approved by the ratification of the 2005 Constitution, to take effect by February, The boundaries, colors, denominations and any other information ZAMB I A Sakania JULY 2011 shown on this map do not imply, on the part of The World Bank To 2009. The existing 11 Province Capitals, shown with green circles, will retain their status, with the exception of Bandundu. Kitwe Group, any judgment on the legal status of any territory, or any Future Province Capitals are shown with white circles. endorsement or acceptance of such boundaries. **The existing 11 Province boundaries and names are shown in dark green; future in light green. 25°E 30°E