Document of The World Bank Report No: ICR1873 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-H1490 TF-55014) ON A IDA GRANT IN THE AMOUNT OF SDR 16.2 MILLION (US$ 25.00 MILLION EQUIVALENT) TO THE EURASIAN ECONOMIC COMMUNITY FOR A CENTRAL ASIA AIDS CONTROL PROJECT June 26, 2012 Human Development Sector Unit Europe and Central Asia Region CURRENCY EQUIVALENTS (Exchange Rate Effective June 2012) Currency Unit = USD SDR 1 = US$ 1.51 US$ 1 = SDR 0.66 FISCAL YEAR January 1 – December 31 ABBREVIATIONS AND ACRONYMS ASO AIDS Service Organizations PAD Project Appraisal Document CAAP Central Asia AIDS Project CACO Central Asia Cooperation Organization PANCAP Pan-Caribbean Partnership Against AIDS CARHAP Central Asia Regional HIV/AIDS Programme PDO Project Development Objectives CARISA Central Asia Regional Information System CPC/U Country Project Coordinator/Unit PEPFAR President's Emergency Plan for AIDS DFID UK Department for International Development Relief DGA Development Grant Agreement PHRD Policy and Human Resource EurAsEC Eurasian Economic Community Development Grant FM Financial Management PLWHA People Living with HIV/AIDS PMU Project Management Unit FMR Financial Monitoring Report QALP Quality Assessment of Lending Portfolio GAA Grant Assumption Agreement QER Quality Enhancement Review GAC Governance and Anti-Corruption RAF Regional AIDS Fund GAMET Global AIDS Monitoring and Evaluation Team RF Results Framework GFATM Global Fund to Fight AIDS, TB & Malaria ROC Regional Operations Committee GMS Grant Management System RPMU Regional Project Management Unit HIV/AIDS Human Immunodeficiency Virus/Acquired RPSC Regional Project Steering Committee Immune Deficiency Syndrome SDR Standard Drawing Rights ICR Implementation Completion Report STIs Sexually Transmitted Infections IDA International Development Agency SW Sex Workers or Sex Work IDF Institutional Development Fund TAP Treatment Acceleration Program IDU Injecting Drug Users or Intravenous Drug Use TB Tuberculosis IEC Information, Education and Communication TWG Technical Working Group ISR Implementation Status Report UNAIDS United Nations Program on HIV/AIDS M&E Monitoring and Evaluation UNDP United Nations Development Program MSM Men having Sex with Men UNGASS UN General Assembly Special Session MoFA Ministry of Foreign Affairs UNODC United Nations Office on Drugs and MoH Ministry of Health Crime MoU Memorandum of Understanding US CDC United States Center for Disease Control MTR Mid-Term Review USAID United States Aid Agency NGO Non-Governmental Organization WHO World Health Organization OSI Open Society Institute Vice President: Philippe H. Le Houérou Country Director: Saroj Kumar Jha Sector Manager: Daniel Dulitzky Project Team Leader: Nedim Jaganjac ICR Team Leader: Baktybek Zhumadil Central Asia AIDS Control 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 ...................................................................................................... 16 4. Assessment of Risk to Development Outcome ..................................................................... 21 5. Assessment of Bank and Borrower Performance ................................................................. 22 6. Lessons Learned.................................................................................................................... 24 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners....................... 25 Annex 1: Project Costs and Financing ...................................................................................... 28 Annex 2: Outputs by Component ............................................................................................. 30 Annex 3. Economic and Financial Analysis ............................................................................. 35 Annex 4. Bank Lending and Implementation Support/Supervision Processes ........................ 39 Annex 5: Beneficiary Survey Results ....................................................................................... 41 Annex 6: Stakeholder Workshop Report and Results .............................................................. 41 Annex 7: Summary of Recipient’s ICR and/or Comments on Draft ICR ................................ 42 Annex 8: Comments of Cofinanciers and Other Partners/Stakeholders ................................... 57 Annex 9: List of Supporting Documents .................................................................................. 58 Annex 10: List of Memoranda of Understanding and Partnership Agreements....................... 59 Annex 11: Revisions of the PDO and Results Framework ....................................................... 61 MAP .......................................................................................................................................... 63 A. Basic Information Central Asia AIDS Country: Central Asia Project Name: Control Project Project ID: P087003 L/C/TF Number(s): IDA-H1490,TF-55014 ICR Date: 06/26/2012 ICR Type: Core ICR GOVERNMENTS OF Lending Instrument: SIL Borrower: CENTRAL ASIA Original Total XDR 16.2M Disbursed Amount: XDR 16.182M Commitment: Revised Amount: XDR 16.2M Environmental Category: C Implementing Agencies: Eurasian Economic Community (EurAsEC) Integration Committee Secretariat Cofinanciers and Other External Partners: DFID B. Key Dates Revised / Actual Process Date Process Original Date Date(s) Concept Review: 01/26/2004 Effectiveness: 08/10/2005 11/04/2005 06/23/2009 01/14/2010 Appraisal: 12/06/2004 Restructuring(s): 12/20/2010 09/28/2011 Approval: 03/15/2005 Mid-term Review: 10/13/2008 10/13/2008 Closing: 12/31/2010 12/31/2011 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Moderately Unsatisfactory Risk to Development Outcome: Significant Bank Performance: Moderately Unsatisfactory Borrower Performance: Moderately Unsatisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Moderately Moderately Quality at Entry: Government: Unsatisfactory Unsatisfactory Moderately Implementing Quality of Supervision: Moderately Satisfactory Satisfactory Agency/Agencies: Overall Bank Moderately Overall Borrower Moderately Performance: Unsatisfactory Performance: Unsatisfactory C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Indicators Rating Performance (if any) Potential Problem Project Quality at Entry No None at any time (Yes/No): (QEA): Problem Project at any Quality of Yes None time (Yes/No): Supervision (QSA): Substantial to High risk, DO rating before Moderately QALP rating Moderately Unlikely to Closing/Inactive status: Unsatisfactory (September 2008) meet PDOs D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Central government administration 25 25 Health 65 65 Law and justice 3 3 Other social services 7 7 Theme Code (as % of total Bank financing) HIV/AIDS 40 40 Health system performance 20 20 Personal and property rights 20 20 Tuberculosis 20 20 E. Bank Staff Positions At ICR At Approval Vice President: Philippe H. Le Houérou Shigeo Katsu Country Director: Saroj Kumar Jha Dennis N. de Tray Sector Manager: Daniel Dulitzky Armin H. Fidler Project Team Leader: Nedim Jaganjac Joana Godinho ICR Team Leader: Baktybek Zhumadil F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The Central Asia AIDS Control Project had the following original development objectives: (i) Reduce the growth rate of the HIV/AIDS epidemic in Central Asia in the period 2005-10; (ii) Establish a sustainable mechanism in Central Asia - the Regional AIDS Fund - that would serve as a vehicle for financing HIV/AIDS prevention and control activities in the Region beyond the end of the project; (iii) Contribute to better regional cooperation in Central Asia, and effective inter-sectoral collaboration between public sector, non-governmental organizations (NGOs) and private sector on HIV/AIDS control in this region. Three out of the five original PDO indicators were partially achieved, and two others were not achieved. Out of the ten Intermediate Outcome indicators, two were achieved, and eight others were partially achieved (see Table 3). Revised Project Development Objectives (as approved by original approving authority) The PDOs were formally revised on January 14, 2010. The earlier PDOs were replaced by a single revised PDO, which stated: The Project will contribute to controlling the spread of HIV/AIDS in participating countries in the Central Asia Region by establishing regional mechanisms to support national HIV/AIDS programs. All the three indicators for the revised PDO were achieved. Nine out of the twelve Intermediate Outcome indicators were achieved, and the remaining three indicators were partially achieved (see Table 4). (a) PDO Indicator(s) Indicator Baseline Value Original Target Formally Actual Value Values (from Revised Achieved at approval Target Completion or documents) Values Target Years1 HIV/AIDS incidence/growth rate (original indicator, deleted at restructuring in January Indicator 1 : 2010) Value quantitative or 5.5/100,000 <10/100,000 n/a Qualitative) Date achieved 01/01/2005 12/31/2010 01/14/2010 Comments (incl. % Not achieved. Marked as ―n/a‖ in the 09/19/2009 ISR (last ISR prior to the restructuring). achievement) At least 60% of groups at risk covered by the Regional AIDS Fund activities (original Indicator 2 : indicator, deleted at restructuring in January 2010) Yr1: 10% Value Yr2: 25% quantitative or 5% n/a Yr3: 40% Qualitative) Yr4: 55% 1 The date of restructuring is used as the achievement date for the original (prior to the January 14, 2010 Level I restructuring) indicators, unless an indicator explicitly specifies ―mid-term review‖ as the target achievement date. Indicator Baseline Value Original Target Formally Actual Value Values (from Revised Achieved at approval Target Completion or documents) Values Target Years1 Yr5: >60% Date achieved 01/01/2005 12/31/2010 01/14/2010 Partially achieved. This indicator was not accurately and consistently monitored (ISR dated 09/19/2009 indicates: ―80% of funds go to services. No report of size of group at Comments risk. Assessment to be carried out in fall 2009‖). At the same time, according to the (incl. % RPMU/EurAsEC’s MTR Progress Report of September 2008, there was an increase in achievement) financing of broadly defined ―highly vulnerable groups‖2 from Rounds 1 to 3: 44% to 78.8% in Kazakhstan, 46% to 67% in Kyrgyzstan, 25% to 95.9% in Tajikistan, 38.1% to 68.4% in Uzbekistan, and 71% to 100% for regional grants. Stakeholders consider Regional AIDS Fund performance satisfactory (original indicator, Indicator 3 : deleted at restructuring in January 2010) Yr1: 50% Yr2: 60% Value 0% (no Regional AIDS Yr3: 70% quantitative or n/a Fund in place) Yr4: 80% Qualitative) Yr5: 90% of stakeholders Date achieved 01/01/2005 12/31/2010 01/14/2010 Partially achieved. This indicator was not measured and monitored (ISR dated 09/19/2009 indicates: ―n/a‖, ―Assessment to be carried out in fall 2009‖). However, qualitative evidence from various assessment reports indicates increased levels of stakeholder Comments satisfaction with RAF performance, especially following the improvements introduced in (incl. % its processes, procedures, and priority funding areas (see also Intermediate Outcome achievement) Indicator No.17). Source: Mid-term Evaluation of Central Asia AIDS Control Project, In Develop-IPM, July 30, 2008; and Rapid Assessment of Implementation and Effectiveness of the Regional AIDS Fund, Deryabina, 2010. Regional AIDS Fund is financed beyond the life of the project (5 years) (original Indicator 4 : indicator, deleted at restructuring in January 2010) Yr3: 10% Value Yr4: 20% quantitative or 0% (no external financing) 0% Yr5: 30% of external Qualitative) financing Date achieved 01/01/2005 12/31/2010 01/14/2010 Not achieved. As per the indicator’s precise definition, the RAF was not able to attract any direct external financing by the restructuring date while the target value for Yr4 was Comments 20%. At the same time, (i) the idea of the regional grants program per se attracted the (incl. % US$1.9 million equivalent of DFID co-financing at the design stage, (ii) CAAP’s achievement) frequently mentioned high-level advocacy and legislation-related work, institutional strengthening, methodological and research work, extensive capacity building and awareness raising indirectly played important catalytic role by creating enabling 2 Defined as SWs, IDUs, prisoners, PLWHA, MSM, and migrants. Three rounds of small grant proposals took place by mid term. Indicator Baseline Value Original Target Formally Actual Value Values (from Revised Achieved at approval Target Completion or documents) Values Target Years1 environment for other donors’ then current and additional financing for HIV activities in the region, e.g. CARHAP/DFID, CAPACITY/USAID, GFATM, PEPFAR (see Annex 2). National Coordination Mechanisms and RPSC integrate representatives of Indicator 5 : governments, NGOs and donors; and meet at least twice a year (original indicator, deleted at restructuring in January 2010) RPSC and NAC Value RPSC was established established and meet quantitative or No NAC or RPSC and met at least three at least twice per year Qualitative) times per year (Yr2 to Yr5) Date achieved 01/01/2005 12/31/2010 01/14/2010 Partially achieved. (i) RPSC was established by the Decision of the CACO Council of the Heads of States dated October 6, 2005, met at least 3 times per year (Yr1 through Yr6), and issued 33 decisions over the whole implementation period. However, other than Comments representatives of the four governments and UNAIDS, RPSC did not include (incl. % representatives of NGOs and donors. (ii) The country AIDS coordination bodies generally achievement) included representatives of governments, NGOs and donors and met at least twice per year. However, they were either (a) established before and/or without the support of the project, or (b) not merged into one National AIDS Coordination mechanism, or (c) focused mainly on coordinating the work with the Global Fund. Develop institutional framework to inform policies at national/regional levels (new Indicator 6 : indicator, introduced at restructuring in January 2010) Value Institutional No or weak institutional Institutional quantitative or framework framework framework developed Qualitative) developed Date achieved 01/14/2010 12/31/2011 12/31/2011 Achieved. The developed institutional framework includes: (i) EurAsEC Regional Strategy on HIV Control in Central Asia for 2009-2015; (ii) sentinel and electronic surveillance systems in the four countries; (iii) annual Forum of Partners; (iv) Inter- Parliamentarian Working Group on HIV/AIDS and Regional Technical Working Group Comments of religious leaders; (v) revisions to HIV/AIDS legal framework in Tajikistan, Kyrgyzstan (incl. % and Uzbekistan as well as in Azerbaijan and the published handbook of HIV-related legal achievement) frameworks in the four countries; (vi) four Regional Training Centers and institutionalized training programs and modules. However, there was no regional framework to provide technical support for SW and IDU interventions, aside from limited training for injection safety (see Intermediate Outcome Indicators No.11 and 12). Thus, spending on these core groups was a minority of the total RAF funds use (See Annex 3). Central Asia RAF is established (new indicator, introduced at restructuring in January Indicator 7 : 2010) Value Central Asia Central Asia RAF is quantitative or No Central Asia RAF RAF is established Qualitative) established Date achieved 01/14/2010 12/31/2011 12/31/2011 Comments Achieved. The Central Asia RAF was formally established on October 19, 2007 through (incl. % the RPSC Decision No.9. achievement) Note that there is an inconsistency in baseline and actual achievement dates, i.e., the RAF Indicator Baseline Value Original Target Formally Actual Value Values (from Revised Achieved at approval Target Completion or documents) Values Target Years1 had already been in place at the date preceding the baseline date for this indicator. Strengthen the capacity and cooperation between the public, nongovernmental Indicator 8 : (NGOs) and the private sectors on the regional and national levels (new indicator, introduced at restructuring in January 2010) Value Strengthened No or low capacity and Strengthened capacity quantitative or capacity and cooperation and cooperation Qualitative) cooperation Date achieved 01/14/2010 12/31/2011 12/31/2011 Achieved. Capacity of and cooperation between the public, non-governmental and the private sectors were strengthened through (i) support to establishment of sentinel and electronic surveillance in the region; (ii) annual Forum of Partners; (iii) training of Comments trainers and cascade national trainings provided by the RTCs in respective areas; (iv) (incl. % involvement of parliament members, journalists and religious leaders across the region in achievement) advocacy work; (v) attendance of international conferences, seminars, and study tours; (vi) training provided in the framework of the 229 sub-projects funded from the RAF (see Annex 2). (b) Intermediate Outcome Indicator(s) Indicator Baseline Value Original Target Formally Actual Value Values (from Revised Achieved at approval Target Completion or documents) Values Target Years Approval of updated regional and national strategies before project mid-term Indicator 1 : review (original indicator, deleted at restructuring in January 2010) Approval of updated No regional HIV strategy in Contribution made to Value regional and national place; national strategies in improvement of (quantitative strategies before place but need national legal or Qualitative) project mid-term improvements frameworks on HIV review Date achieved 01/01/2005 12/31/2010 10/13/2008 Partially achieved. Regional Strategy on HIV Control in Central Asia for 2009-2015 was developed and approved by the Council of Ministers of Health of EurAsEC in October Comments 2009, i.e., after and based on recommendation of project MTR (October 2008). National (incl. % HIV strategies/programs were developed and adopted without the support of the project. achievement) However, by mid-term review, CAAP contributed to updates of HIV-related legal frameworks in Kyrgyzstan, Tajikistan, and Uzbekistan. Source: http://www.caap.info/ Sentinel and second generation surveillance established throughout the region by the Indicator 2 : 2nd year (original indicator, deleted at restructuring in January 2010) Yr1: 20% Value Yr2: 50% SS established in 18 (quantitative Pilot in 5 oblasts Yr3: 75% pilot sites throughout or Qualitative) Yr4&5: 100% of the region the region covered Date achieved 01/01/2005 12/31/2010 01/14/2010 Indicator Baseline Value Original Target Formally Actual Value Values (from Revised Achieved at approval Target Completion or documents) Values Target Years Achieved. Sentinel surveillance was fully established in 13 initial pilot sites by Comments 02/28/2008, ahead of schedule and with considerable savings under the Memorandum of (incl. % Agreement between CAAP and CDC/CAR (3 in Kazakhstan, 3 in Kyrgyzstan, 3 in achievement) Tajikistan, 4 in Uzbekistan). By the restructuring date, five additional sites were established and supported (3 in Kyrgyzstan and 2 in Tajikistan). Regional M&E established by mid-term (original indicator, deleted at restructuring in Indicator 3 : January 2010) Value Regional M&E Regional M&E (quantitative No regional M&E system established by mid- established partially or Qualitative) term by mid-term Date achieved 01/01/2005 12/31/2010 10/13/2008 Partially achieved. Achievements by the mid-term included: (i) national capacity in M&E supported since 2006 by seconding local experts to national AIDS centers or AIDS coordination bodies (one in Kazakhstan, one in Kyrgyzstan, three in Tajikistan, and two in Uzbekistan); (ii) two rounds of sentinel surveillance conducted at the 13 pilot sites; (iii) Comments CA Regional Information System on HIV/AIDS (CARISA: http://carisa.info) finalized, (incl. % and official agreements of the four countries to publish sentinel surveillance results on achievement) CARISA obtained in March 2008 (though Uzbekistan requested support for a country- level website for the National AIDS Country Committee, separate from CARISA). At the same time, the piloting of the HIV electronic surveillance system was delayed due to late finalization of the software. Schools of Public Health in Kazakhstan and Uzbekistan routinely carrying out Indicator 4 : training of staff from public agencies, NGOs and private sector by mid-term (original indicator, deleted at restructuring in January 2010) Capacity for offering Regular training Value regular training established and (quantitative No regular training courses courses not fully frequent training or Qualitative) established by mid- courses offered term Date achieved 01/01/2005 12/31/2010 10/13/2008 Partially achieved. Although the Schools of Public Health were not involved in the training activities, the progress by the project mid-term included: (i) establishment in June 2008 of 4 Regional Training Centers (RTC) in the following areas: HIV prevention among youth, Harm reduction, HIV prevention among migrants, and Treatment, care and Comments support for PLWHA; (ii) establishment of partnerships with American International (incl. % Health Alliance, International Organization for Migration, EurAsian Harm Reduction achievement) Network, UNODC, and UNESCO to further develop the RTCs; (iii) development of basic modules and curricula for regional training of trainers in the four respective areas; (iv) 20 regional training sessions conducted. Source: Mid-Term Review, Progress Report, EurAsEC, September 2008 Amount of large grants approved (original indicator, deleted at restructuring in January Indicator 5 : 2010) Value Yr1: US$1 M Yr1: US$0 M (quantitative 0 Yr2: US$2.8 M Yr2: US$2.9 M or Qualitative) Yr3: US$4 M Yr3: US$1.4 M Indicator Baseline Value Original Target Formally Actual Value Values (from Revised Achieved at approval Target Completion or documents) Values Target Years Yr4: US$3.5 M Yr4: US$3.7 M Yr5: US$1 M Yr5: US$0 M Cumulative (Yr1-4): Cumulative (Yr1-4): US$11.3 M US$8 M Cumulative (Yr1- Cumulative (Yr1-5): 5): US$12.3 M US$8 M Date achieved 01/01/2005 12/31/2010 01/14/2010 71% Achieved. By the restructuring date, targets for actual annual amounts of large Comments grants approved were achieved in Yr2 and Yr4 only. The cumulative target amount (incl. % envisaged for Yr4 (US$11.3 M) was achieved at 71% by the restructuring date. achievement) Source: Aide Memoire of June 6-16, 2011 Implementation Support Mission and data from RPMU. Amount of small grants approved (original indicator, deleted at restructuring in January Indicator 6 : 2010) Yr1: US$0.3 M Yr1: US$0 M Yr2: US$0.7 M Yr2: US$0.5 M Yr3: US$1 M Yr3: US$1.4 M Value Yr4: US$0.9 M Yr4: US$1.8 M (quantitative 0 Yr5: US$0.3 M Yr5: US$2.8 M or Qualitative) Cumulative (Yr1-4): Cumulative (Yr1-4): US$2.9 M US$3.7 M Cumulative (Yr1- Cumulative (Yr1-5): 5): US$3.2 M US$6.5 M Date achieved 01/01/2005 12/31/2010 01/14/2010 Comments Exceeded at 128%. By the restructuring date, small grants in the total amount of US$3.7 (incl. % M (Rounds 1-3) had been approved and already implemented. achievement) Funds granted and disbursed annually as planned3 (original indicator, deleted at Indicator 7 : restructuring in January 2010) Yr1: US$1.3 M Yr1: US$0 M Yr2: US$3.5 M Yr2: US$1.1 M Yr3: US$5 M Yr3: US$2.4 M Yr4: US$4.4 M Yr4: US$4.6 M Value Yr5: US$1.3 M Yr5: US$4.4 M (quantitative 0 Yr6: US$1 M or Qualitative) Cumulative (Yr1-4): Cumulative (Yr1-4): US$14.2 M US$8.1 M Cumulative (Yr1- Cumulative (Yr1-6): 5): US$15.5 M US$13.5 M 3 The aggregate amounts of funds planned to be granted in each year are the sums of target amounts of large and small grants to be approved (Intermediate Outcome Indicators No.5 and 6). In assessing the achievement of disbursement targets by year, an assumption is made that all grant funds approved/granted in a certain year had to be disbursed during the same year. This does not seem rational (especially, regarding the 18-month large grants); however, this was how the approved grant amounts were actually budgeted. Indicator Baseline Value Original Target Formally Actual Value Values (from Revised Achieved at approval Target Completion or documents) Values Target Years Date achieved 01/01/2005 12/31/2010 01/14/2010 57% Achieved. By the restructuring date, annual aggregate amounts of disbursed small Comments and large grants consistently lagged behind the annual approved amounts, except for Yr4. (incl. % The cumulative disbursement target for Yr4 (US$14.2 M) was achieved at 57% by the achievement) restructuring date. Source: Data from RPMU. At least 75% of users express satisfaction with RAF performance (original indicator, Indicator 8 : deleted at restructuring in January 2010) Value 0% (no Regional AIDS At least 75% of users (quantitative n/a Fund in place) express satisfaction or Qualitative) Date achieved 01/01/2005 12/31/2010 01/14/2010 Partially achieved. This indicator was not monitored (neither RPMU/EurAsEC’s MTR Progress Report of September 2008, nor Bank’s ISRs presented any information on this indicator). However, qualitative evidence from various assessment reports indicates Comments increased levels of users/grant recipients’ satisfaction with RAF performance, especially (incl. % following the improvements introduced in its processes, procedures, and priority funding achievement) areas (see also Intermediate Outcome Indicator No.17). Source: Mid-term Evaluation of Central Asia AIDS Control Project, InDevelop-IPM, July 30, 2008; and Rapid Assessment of Implementation and Effectiveness of the Regional AIDS Fund, Deryabina, 2010. 10% of groups at risk covered in the first year; 25% in the second year; 40% in the Indicator 9 : third year; 55% in the fourth year; and over 60% in the fifth year (original indicator, deleted at restructuring in January 2010) Yr1: 10% Value Yr2: 25% (quantitative 5% Yr3: 40% n/a or Qualitative) Yr4: 55% Yr5: >60% Date achieved 01/01/2005 12/31/2010 01/14/2010 Partially achieved. This indicator was not accurately and consistently monitored (ISR dated 09/19/2009 indicates: ―80% of funds go to services. No report of size of group at Comments risk. Assessment to be carried out in fall 2009‖). At the same time, according to the (incl. % RPMU/EurAsEC’s MTR Progress Report of September 2008, there was an increase in achievement) financing of broadly defined ―highly vulnerable groups‖4 from Rounds 1 to 3: 44% to 78.8% in Kazakhstan, 46% to 67% in Kyrgyzstan, 25% to 95.9% in Tajikistan, 38.1% to 68.4% in Uzbekistan, and 71% to 100% for regional grants. Funds disbursed by component and year as planned (US$ million) (original indicator, Indicator 10 : deleted at restructuring in January 2010) Value Yr1: US$4 M Yr1: US$1.8 M 0 (quantitative Yr2: US$6.3 M Yr2: US$3.1 M 4 Defined as SWs, IDUs, prisoners, PLWHA, MSM, and migrants. Three rounds of small grant proposals took place by mid term. Indicator Baseline Value Original Target Formally Actual Value Values (from Revised Achieved at approval Target Completion or documents) Values Target Years or Qualitative) Yr3: US$7.7 M Yr3: US$5.1 M Yr4: US$6.2 M Yr4: US$7.7 M5 Yr5: US$2.7 M Yr5: US$7.2 M Cumulative Yr6: US$1.5 M disbursement (Yr1- Cumulative 4): US$24.2 M disbursement (Yr1-4): Cumulative US$17.7 M disbursement (Yr1- Cumulative 5): US$26.9 M disbursement (Yr1- 6): US$26.4 M Date achieved 01/01/2005 12/31/2010 01/14/2010 Comments 73% achieved. By the restructuring date, actual total amounts disbursed by end-year (incl. % dates lagged behind the originally set values, except for Yr4. The cumulative target achievement) amount envisaged for Yr4 (US$24.2 M) was achieved at 73% by the restructuring date. Regional strategic framework for HIV/AIDS developed (new indicator, introduced at Indicator 11 : restructuring in January 2010) Regional Strategy on HIV Regional Value Control in Central Asia for strategic Regional strategic quantitative or 2009-2015 is in place framework for framework for Qualitative) (approved on October 16, HIV/AIDS HIV/AIDS developed 2009) developed Date achieved 01/14/2010 12/31/2011 12/31/2011 Achieved. Regional Strategy on HIV Control in Central Asia for 2009-2015 was approved by the Council of Ministers of Health of EurAsEC in October 2009. However, Comments this document was notably weak on IDU and SW, which have been identified as the key (incl. % epidemic drivers for the region. achievement) Note that there is an inconsistency in baseline and actual achievement dates, i.e., the regional HIV strategy had already been in place at the date preceding the baseline date for this indicator. 4 regional centers established and are providing support to policies in at least 4 Indicator 12 : areas (e.g. epidemiological surveillance, injection safety, harm reduction, stigma reduction, etc.) (new indicator, introduced at restructuring in January 2010) 4 regional 4 RTCs established; The Concepts of centers support to Value establishment of 4 RTCs established and epidemiological quantitative or were approved by the RPSC providing surveillance, injection Qualitative) Decision No.13 dated June support to safety, harm 12, 2008. policies in at reduction, and stigma least 4 areas reduction provided Date achieved 01/14/2010 12/31/2011 12/31/2011 Comments Partially achieved. The 4 RTCs were established, mostly building on existing institutions (incl. % and infrastructure, initially in the following areas: (i) HIV prevention among youth; (ii) 5 Yr4 and Yr5 disbursements include DFID co-financing: US$0.94 M and US$0.61 M equivalent, respectively. Indicator Baseline Value Original Target Formally Actual Value Values (from Revised Achieved at approval Target Completion or documents) Values Target Years achievement) Harm reduction; (iii) HIV prevention among migrants, and (iv) Treatment, care and support for PLWHA. The RTC on HIV prevention among youth was later re-designed as a training program only, and the RTC on Epidemiological Surveillance was established instead, through the RPSC Decision No.23 dated December 24, 2009. Support to policies in epidemiological surveillance and harm reduction was provided through the two respective RTCs and the related activities under Subcomponent 1.1; support to policies in injection safety and stigma reduction was provided through the related activities under Subcomponent 1.1 (collaboration on injection safety with CDC, regular activities of the Inter-Parliamentarian Working Group). However, no specific effort on SW-based transmission was organized. At least 3 rounds of sentinel surveillance with involvement of NGOs are conducted Indicator 13 : (new indicator, introduced at restructuring in January 2010) Value At least 3 quantitative or 3 rounds conducted rounds 4 rounds conducted Qualitative) conducted Date achieved 01/14/2010 12/31/2011 12/31/2011 Comments Exceeded at 133%. 4 rounds of sentinel surveillance with involvement of NGOs were (incl. % conducted in the period from 2007 to 2010 with involvement of NGO’s and a total of 16 achievement) national surveillance reports were prepared and disseminated widely. Technical capacity of public sector and NGOs in policy development, grant Indicator 14 : management/implementation and service provision is enhanced (new indicator, introduced at restructuring in January 2010) Value Technical capacity is low as Enhanced Enhanced technical quantitative or indicated by failure to obtain technical capacity Qualitative) grant funds from GFATM capacity Date achieved 01/14/2010 12/31/2011 12/31/2011 Partially achieved. Technical capacity of the public sector agencies and NGOs was enhanced through (i) the creation of a pool of regional and national trainers on project Comments design, implementation and monitoring in collaboration with IDF Grant activities; (ii) (incl. % training provided by the RTCs in respective areas; (iii) participation in international study achievement) tours; (iv) training provided under the 229 sub-projects funded from the RAF (See Annex 2). Specific technical assistance in delivery of peer-based condom interventions for SW was weak or absent. Communication capacity on HIV/AIDS related issues among stakeholders (e.g. Indicator 15 : parliamentarians, religious leaders, journalists, NGOs, etc.) improved (new indicator, introduced at restructuring in January 2010) Value Improved Improved No or weak communication quantitative or communication communication capacity Qualitative) capacity capacity Date achieved 01/14/2010 12/31/2011 12/31/2011 Achieved. Communication capacity among stakeholder groups was enhanced through (i) Comments the establishment and regular work of the Regional Technical Working Groups (incl. % (parliamentarians and religious leaders); (ii) training in HIV/AIDS awareness for achievement) religious leaders and journalists; (iii) writing competitions for journalists; (iv) international study tours. However, sustainability of this capacity beyond the project Indicator Baseline Value Original Target Formally Actual Value Values (from Revised Achieved at approval Target Completion or documents) Values Target Years period without further support is questionable. At least 4 grant cycles implemented (new indicator, introduced at restructuring in Indicator 16 : January 2010) 4 cycles of small Value 3 cycles of small grants and 4 grant cycles grants and 3 cycles of quantitative or 2 cycles of large grants implemented large grants Qualitative) implemented implemented Date achieved 01/14/2010 12/31/2011 12/31/2011 Partially achieved. At the time of the restructuring, 3 cycles of small grants and 2 cycles Comments of large grants had largely been implemented (though most of the Round 3 small grants in (incl. % Kazakhstan, Tajikistan, and Uzbekistan were still under implementation). By project achievement) completion date, 4 cycles of small grants and 3 cycles of large grants were implemented, and 2186 small and 11 large sub-projects were funded. Indicator 17 : Strategy for RAF developed (new indicator, introduced at restructuring in January 2010) Value RAF Strategy in place (RAF Strategy for Strategy for RAF quantitative or Handbook of 2005) RAF developed developed Qualitative) Date achieved 01/14/2010 12/31/2011 12/31/2011 Achieved. The RAF strategy outlined in the RAF Handbook (consisting of the RAF Manual, Grant Recipient and M&E Manuals developed in 2005) was revised twice and re-approved by RPSC in May 2008. Since then, the refined RAF Handbook served as an efficient and transparent mechanism to distribute grant funds according to specified Comments procedures, and was considered for adoption or adaptation by other donor organizations, (incl. % including the Global Fund. However, the approval of the EurAsEC Regional HIV achievement) Strategy in October 2009 had not led to further development of RAF as a financing and implementation mechanism for the Strategy. Note that there is an inconsistency in baseline and actual achievement dates, i.e., the RAF Strategy (RAF Handbook) had already been in place at the date preceding the baseline date for this indicator. Mechanism to distribute funds is in place (new indicator, introduced at restructuring in Indicator 18 : January 2010) Value Mechanism to Mechanism to Mechanism to distribute quantitative or distribute funds distribute funds is in funds is in place Qualitative) is in place place Date achieved 01/14/2010 12/31/2011 12/31/2011 Achieved. By the end of the project, the Regional and National Technical Evaluation Committees, RPMU, and the contractual arrangement with UNDP for provision of Comments fiduciary services at the country level succeeded to serve as a transparent and efficient (incl. % mechanism to distribute grant funds according to the procedures set forth in the refined achievement) RAF Handbook. Note that there is an inconsistency in baseline and actual achievement dates, i.e., all the 6 Out of the total 221 small grants approved, one grant in Kazakhstan and two grants in Uzbekistan were cancelled due to implementation start-up delays or poor performance. Indicator Baseline Value Original Target Formally Actual Value Values (from Revised Achieved at approval Target Completion or documents) Values Target Years above elements, comprising the grant distribution mechanism, had already been in place at the date preceding the baseline date for this indicator. RPMU fully staffed and operational (new indicator, introduced at restructuring in Indicator 19 : January 2010) Value RPMU fully RPMU fully staffed and RPMU fully staffed quantitative or staffed and operational and operational Qualitative) operational Date achieved 01/14/2010 12/31/2011 12/31/2011 Achieved. Following the recommendations of the Bank’s MTR and subsequent missions, Comments the RPMU achieved its full operational and implementation capacity by October 2009 (incl. % and maintained it until the end of the project. It also successfully managed on behalf of achievement) EurAsEC an additional Bank-administered US$3 million equivalent grant for Central Asia Regional One Health Project (TF-98346). Procurement and financial management in place and satisfactory to the Bank (new Indicator 20 : indicator, introduced at restructuring in January 2010) Procurement Procurement and and financial Value Procurement and financial financial management management in quantitative or management in place but not in place and place and Qualitative) fully satisfactory to the Bank satisfactory to the satisfactory to Bank the Bank Date achieved 01/14/2010 12/31/2011 12/31/2011 Achieved. Procurement and financial management were upgraded to ―Satisfactory‖ status in September 2009 and June 2010 respectively, and this status was maintained until the Comments end of the project. The last ISR No.14 dated December 27, 2011 assessed the overall (incl. % financial management and procurement as ―Moderately Satisfactory‖ and ―Satisfactory‖, achievement) respectively, for the life of the project. Source: ISR No.11 dated 09/19/2009 and subsequent ISRs; FM Implementation Support Mission Report of June 2010 and subsequent FM reports. RPMU is in compliance with GAC policies (new indicator, introduced at restructuring Indicator 21 : in January 2010) Value RPMU is in RPMU is in quantitative or n/a compliance with compliance with Qualitative) GAC policies GAC policies Date achieved 01/14/2010 12/31/2011 12/31/2011 Achieved. The Procurement Post-Review Implementation Support Mission Report dated Comments November 24-25, 2010 identified no evidence of fraud/corruption (the last procurement (incl. % post-review mission, as there were no contracts subject to post review in the remaining achievement) implementation period). Indicator 22 : M&E/MIS systems in place (new indicator, introduced at restructuring in January 2010) Value M&E/MIS M&E/MIS systems in quantitative or M&E/MIS systems in place systems in place place Qualitative) Date achieved 01/14/2010 12/31/2011 12/31/2011 Indicator Baseline Value Original Target Formally Actual Value Values (from Revised Achieved at approval Target Completion or documents) Values Target Years Achieved. All required Project Management Reports timely prepared and submitted on a Comments monthly and quarterly basis to EurAsEC, and on a quarterly basis to WB and DFID. (incl. % Project bulletins prepared and disseminated on a quarterly basis. achievement) Source: Aide Memoire of the November 26-December 3, 2010 Implementation Support Mission. G. Ratings of Project Performance in ISRs Date ISR Actual Disbursements No. DO IP Archived (USD millions)7 1 06/23/2005 Moderately Satisfactory Satisfactory 0.00 2 01/18/2006 Moderately Satisfactory Satisfactory 0.00 3 04/19/2006 Moderately Unsatisfactory Unsatisfactory 1.05 4 09/22/2006 Moderately Satisfactory Moderately Satisfactory 1.42 5 11/29/2006 Moderately Satisfactory Moderately Satisfactory 1.42 6 03/14/2007 Moderately Satisfactory Satisfactory 2.56 7 02/05/2008 Moderately Satisfactory Moderately Satisfactory 5.09 8 12/24/2008 Unsatisfactory Unsatisfactory 9.77 9 06/29/2009 Unsatisfactory Unsatisfactory 13.26 10 09/19/2009 Moderately Unsatisfactory Moderately Unsatisfactory 14.34 11 02/17/2010 Satisfactory Satisfactory 17.18 12 10/11/2010 Satisfactory Satisfactory 21.66 13 02/14/2011 Satisfactory Satisfactory 24.05 14 12/27/2011 Moderately Unsatisfactory Moderately Satisfactory 24.88 7 These amounts do not include US$1.55 million equivalent of DFID co-financing. H. Restructuring ISR Ratings at Amount Board Restructuring Disbursed at Restructuring Reason for Restructuring & Key Approved PDO Restructuring Date(s) Changes Made Change DO IP in USD 8 millions Reallocation of SDR 325,000 from Category (5) Unallocated to Category (4) Operating Costs due 06/23/2009 N U U 12.95 to the higher than expected operating costs, including 7% in fees paid to UNDP for sub-grant management and disbursement. Changes to PDO and Results Framework due to unrealistic original PDO, considerable measurement difficulties in tracking the first PDO, and 01/14/2010 Y MU MU 16.73 weaknesses in the Results Framework; reallocation of Grant proceeds across expenditure categories to support regional policy and coordination activities and project management. Extension of the closing date from December 31, 2010 to September 30, 2011 to (i) complete final 12/20/2010 N S S 22.57 deliverables and payments for grants program; and (ii) fully utilize savings. Extension of the closing date from September 30, 2011 to December 31, 2011 to (i) allow disposal of 09/28/2011 N S S 24.88 physical assets and project files; and (ii) help with the ICR preparation. 8 These amounts do not include US$1.55 million equivalent of DFID co-financing. I. Disbursement Profile 1. Project Context, Development Objectives and Design 1. The Central Asia AIDS Control Project was approved on March 15, 2005. The Development Grant Agreement was signed on May 12, 2005, and the Grant became effective on November 4, 2005. The beneficiary countries were Kazakhstan (population 16.5 million), the Kyrgyz Republic (population 5.6 million), Tajikistan (population 7.6 million) and Uzbekistan (population 28.1 million). It was the first-ever multi-country AIDS project in the Europe and Central Asia Region (ECA) and was financed by the IDA13 Pilot Program for Regional Projects. The US$26.9 million equivalent of donor financing included US$25.0 million equivalent grant from IDA and US$1.85 million equivalent grant from the UK Department for International Development (DFID). 1.1 Context at Appraisal 2. There was global concern about potentially explosive growth of HIV prevalence in the four countries of the region. While overall prevalence in the general population in the region was believed to be quite low (<0.5%), it was clear that these levels might increase, particularly due to increased transmission from the key high-risk groups of injecting drug users (IDU) and sex workers (SW). Sector work produced for this project 9 identified IDUs and SWs as the key drivers of the epidemic for this region (paragraph 25) and also the strategies to reduce overall growth of HIV prevalence in the population by reducing transmission within and from these high-risk groups. 10 Complementary strategies required raising general population awareness. Similar strategies had been adopted in non-African HIV epidemics, such as in India.11 3. Political and institutional factors hindered direct delivery of services to marginalized high-risk groups. Indeed, dialogue in the ECA region around HIV/AIDS as a development priority had faced issues of denial of transmission modes, indifference to high-risk groups, and weak technical capacity in the regional technical agencies (such as UNAIDS) and countries. After the collapse of the Soviet Union in 1991, each country faced challenges including significantly lower funding for public health, a need to modernize their inherited public health institutions, and the need to address cross-border issues such as the migration of high-risk groups. Finally, cooperation in public health across the countries was weak. 4. The commitment to HIV/AIDS control, especially in addressing controversial issues like IDU and SW was mixed across the countries. The Central Asia AIDS Declaration signed during the Central Asian Conference on HIV/AIDS on May 16-18, 2001 between the four governments represented some regional cooperation. However, open discussion of IDU, SW and sexual 9 Project Appraisal Document, Central Asia AIDS Control Project (Report No: 31429-ECA), page 4; February 2005. 10 Confronting AIDS: Public Priorities in a Global Epidemic, The World Bank, Oxford University Press, 1999; Jha P. et al, The evidence base for interventions to prevent HIV infection in low and middle income countries. Commission on Macroeconomics and Health, Working Group 5 Paper no.24. (http://whoindia.org/LinkFiles/Commision_on_Macroeconomic_and_Health_05_02.pdf) 11 Project Appraisal Document, Second National HIV/AIDS Control Project in India (Report No: 18918-IN); May 1999. 1 transmission was lacking. Moreover, a non-governmental organization (NGO) sector to advocate for such marginalized groups did not exist under the Soviet system. 5. Rationale for the Bank involvement included: (i) the Bank’s comparative advantage versus other donors to pull together countries and partners; and (ii) the fact that HIV growth was a threat to human capital, economic growth and poverty reduction. 1.2 Original Project Development Objectives (PDO) and Key Indicators 6. The Project Appraisal Document (PAD) stated that the overall objective of the project was to contribute to minimizing the potential negative human and economic impact of a generalized HIV/AIDS epidemic. The PAD stated that the project would: i. Reduce the growth rate of the HIV/AIDS epidemic in Central Asia in the period 2005-10; ii. Establish a sustainable mechanism in Central Asia - the Regional AIDS Fund (RAF) - that will serve as a vehicle for financing HIV/AIDS prevention and control activities in the Region beyond the life of the project; and iii. Contribute to better regional cooperation in Central Asia, and effective inter-sectoral collaboration between public sector, NGOs and private sector on HIV/AIDS control in this region. 7. The achievement of the original PDOs was to be measured by the following outcome indicators as identified in Annex 3 of the PAD and Supplemental Letter to the Development Grant Agreement (DGA) dated May 12, 2005: i. HIV/AIDS Incidence Rate (in the PAD) or HIV/AIDS Growth Rate (in the Supplemental Letter); ii. At least 60% of groups at risk covered by the RAF activities; iii. Stakeholders consider RAF performance satisfactory; iv. RAF is financed beyond the life of the Project (5 years); and v. National Coordination Mechanisms and Regional Project Steering Committee (RPSC) integrate representatives of Governments, NGOs and donors and meet at least twice a year. 1.3 Revised PDO and Key Indicators 8. The original PDOs were formally revised on January 14, 2010 and replaced with the following: The Project will contribute to controlling the spread of HIV/AIDS in participating countries in the Central Asia region by establishing regional mechanisms to support national HIV/AIDS programs. 2 9. The achievement of the revised PDO was to be measured by the following outcome indicators as identified in the Restructuring Paper dated December 18, 2009: i. Develop institutional framework to inform policies at national/regional levels; ii. Establish a Central Asia RAF; and iii. Strengthen the capacity and cooperation between public, NGO, and the private sectors at the regional and national levels. 10. The justifications listed in the Restructuring Paper were:  Unrealistic PDO: the original PDO of reducing the HIV/AIDS incidence/growth rate was a higher-level objective which depended on efforts outside the project’s influence and for which the project could not be reasonably held accountable.  Measurement difficulties: relying on trends in the growth rate of the epidemic was problematic because the incidence in Central Asia was based on HIV case reporting which represented only a fraction of new infections occurring in the region.  Weaknesses in the Results Framework (RF), which had limited capacity to measure performance of project activities or their contribution to the expected outcomes. Specifically, several outcome and intermediate indicators were not directly related to Project activities or did not have baseline or target values. 1.4 Main Beneficiaries 11. The direct beneficiaries of the project investments at appraisal were the highly vulnerable or vulnerable groups (IDU, SW, men having sex with men [MSM], prisoners, trafficked people, migrants, truckers, cross-border traders, at-risk youth), people living with HIV/AIDS (PLWHA), and families in the general public who benefited from the awareness raising, prevention, treatment, and care services provided through the RAF grants. Public agencies, NGOs and the private sector organizations were to benefit from strengthened institutional capacity to counteract HIV infection, and the four governments were to benefit indirectly from the inter-sectoral and regional collaboration. The main beneficiaries remained the same after the restructuring. 1.5 Original Components12 12. The project had three components. 13. Component 1. Regional Coordination, Policy Development and Capacity Building (US$7.5 million or 27.8 percent of total project costs). This component aimed to: (i) establish a legal environment that facilitates the implementation of the HIV/AIDS Regional Strategy, including prevention work with highly vulnerable groups such as IDU, CSW, MSM, prisoners and mobile populations; (ii) improve information and decision-making based on good quality epidemiological data; and (iii) build capacity of public agencies, NGOs and the private sector engaged in HIV/AIDS control. This component included three sub-components, as follows: 12 The estimated component costs in this Section include contingencies. 3 14. Sub-component 1.1 Regional HIV/AIDS Coordination and Policy Development. This sub-component was to focus on national and regional coordination of HIV/AIDS programs; and further establishment of a regional strategic and regulatory framework that would facilitate prevention and control of HIV/AIDS in Central Asia. It was to finance (i) the activities of the RPSC, national coordination mechanisms, and establishment of links between the national and regional coordination; (ii) further strategic and policy development; (iii) necessary local and international technical assistance to elaborate and/or amend proposed strategies and regulations; (iv) studies that would inform the policy formulation process and regional meetings for policy review. Training and technical assistance was to be provided for (i) strengthening national and regional inter-sectoral coordination mechanisms for HIV/AIDS control, including establishing the RPSC at the regional level; (ii) reviewing and revising legislation affecting vulnerable groups (including anti-discrimination and decriminalization laws); (iii) advocating and communicating about HIV/AIDS; (iv) adopting standardized approaches to diagnosis and treatment of HIV/AIDS and sexually-transmitted infections (STIs); and (v) facilitating procurement of commodities. 15. Sub-component 1.2. Surveillance and Regional Monitoring and Evaluation Systems. This sub-component was to finance sentinel and second-generation surveillance systems that track drug use, STIs, HIVAIDS and TB at the regional level. The sub-component was also to contribute to the development of monitoring and evaluation (M&E) systems to monitor the regional spread of the epidemic and the impact of regional epidemic drivers, such as drug use and migration - and that was to enable evidence-based planning and decision-making. The M&E system was to be able to provide information on: (i) inputs, processes and outputs of programs financed by Governments, NGOs and international agencies working on HIV/AIDS prevention and control; and (ii) outcomes and impact of those programs. Assistance was to be provided to improve data collection, analysis, and reporting practices; gaps in diagnostic capacity and training were to be addressed. 16. Sub-component 1.3. Human Resources Development. This sub-component was to finance: (i) curriculum development; (ii) development, publication and dissemination of training materials; (iii) travel and subsistence for regional meetings; (iv) training of trainers at the regional level; and (v) establishment of the Regional Prevention Resource Network. Training at the national level was to be financed by developing partners active in the region (DFID, USAID, GFATM, OSI, etc.). Under the Policy and Human Resource Development (PHRD) Grant, a consultant was to help prepare a HIV/AIDS Training Plan. 17. Component 2. Central Asia Regional AIDS Fund (US$16.7 million or 61.9 percent of total project costs). This component was to establish a demand-driven RAF to finance initiatives that would contribute to containing the rapidly growing epidemic of HIV/AIDS and STIs. This grant facility was considered consistent with the regional scope of the Project and was expected to (i) promote regional cooperation; (ii) allow for better coverage of gaps in AIDS-related activities; (iii) increase transparency over the use of grant funds; (iv) encourage grant applicants from participating countries, through evaluation criteria, to target projects in priority areas; and (v) build local capacity to develop and manage projects. The grant was to finance goods, consulting services, training, resources for sub-projects, and operating costs. The RAF was to manage two schemes: a large grants scheme and a small grants scheme. Initially, both schemes 4 were to be managed by the RPMU; the small grants scheme was to be decentralized to the country level for management by national coordinating bodies. 18. Component 3. Project Management (US$2.8 million or 10.4 percent of total project costs). The Regional Project Management Unit (RPMU) was being contracted to work with the Kyrgyz Health Reform Project Management Unit (PMU) for the duration of the PHRD Grant, but was to move to Almaty for project implementation. All RPMU staff had been selected, and the Project Executive Director was contracted before appraisal. Other key staff were contracted before effectiveness. This component was to finance 15 RPMU staff, office equipment and furniture, technical assistance, training and operating costs of the RPMU, support to operating costs for the RPSC and Technical Working Groups (TWG), and staff time and operating costs for the Country Project Coordinator/Unit (CPCs). The component was also to finance Project M&E System and Management Information System (MIS), including Financial Management and Accounting System, and annual financial audits. 1.6 Revised Components 19. There were no revisions to the components. 1.7 Other significant changes 20. Change in Grant Recipient. The original Recipient of the Grant, Central Asia Cooperation Organization (CACO), was subsumed into a larger political and economic regional organization, Eurasian Economic Community (EurAsEC) through a decision taken by the CACO Council of Heads of States on October 6, 2006. A Grant Assumption Agreement between IDA and EurAsEC as the new Recipient was signed on November 17, 2006. 21. Reallocations of funds. There were two reallocations: the first on June 23, 2009 through the Country Director’s approval and the second on January 14, 2010 as part of the Level I restructuring approved by the Board of Executive Directors (see Annex 1 Table (d)). The first reallocation partially compensated for the higher than expected operating costs, and the second one provided additional support to regional policy and coordination activities under Component 1 and to project management under Component 3. 22. Restructuring. In addition to the reallocation of funds, the January 14, 2010 restructuring introduced changes to PDO and Results Framework (RF) as described in Section 1.3. Also, RAF processes and manuals were revised twice, in 2007 and 2008 (see Section 2.2).13 23. Closing date extensions. The closing date was extended twice for a total of twelve months, from December 31, 2010 to September 30, 2011 and from September 30, 2011 to December 31, 2011, to: (i) complete final deliverables and payments; (ii) fully utilize savings; (iii) allow disposal of physical assets and project files; and (iv) help with the ICR preparation.14 13 There was no requirement to process these revisions as formal restructuring at that time. 14 Both were Level II restructuring through acting Regional Director’s letter of December 20, 2010 and Regional Director’s letter of September 28, 2011. 5 The standard four-month Grace Period did not apply to this operation as the Recipient did not have funds to finance essential RPMU staff to complete transactions. The project closed on December 31, 2011. 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry 24. Project preparation: The project was prepared in 13.5 months: Concept Review was in January 2004 and Board approval on March 15, 2005. Project preparation was supported by a Japanese Trust Fund15 for (i) the design and preparation of Components 1 and 2; and (ii) the establishment of the RPMU. The original date of grant effectiveness set as August 10, 2005 was extended at the request of the CACO by 90 days to complete fulfillment of the effectiveness conditions. Positive factors that influenced project performance: 25. Sound epidemiological basis and lessons learnt: An extensive epidemiological and institutional analysis of the four overlapping epidemics in Central Asia—HIV/AIDS, IDU, STIs, and tuberculosis—and the pivotal role of IDUs and SWs in driving HIV epidemic was carried out between 2001-2004 and published in the two well-received main papers: ―HIV/AIDS and Tuberculosis in Central Asia: Country Profiles‖ and ―Reversing the Tide: Priorities for HIV/AIDS Prevention in Central Asia‖. The Bank team also tried to reflect important lessons learnt from analytical work and other projects in the design of this regional project. These included inter alia (i) advocacy at the highest levels of government and need for an inter-sectoral approach; (ii) use of early, aggressive prevention interventions targeting vulnerable and highly vulnerable groups; (iii) stakeholder participation and predominant role of local NGOs; (iv) need for significant investment in policy and management capacity; (v) effective surveillance and M&E system; and (vi) outsourcing fiduciary functions for increased efficiency and effectiveness. While most of these were implemented successfully, efforts to operationalize some others presented challenges, e.g. targeting highly vulnerable groups and M&E arrangements, in particular. 26. Stakeholder involvement and participatory processes: The Bank project team consulted widely with partners including DFID (co-financier), UNAIDS, USAID, CDC, GFATM, WHO, and UNODC, among others. The Bank actively facilitated a participatory process, including organization of a study tour to the Caribbean to learn from the experience of the Pan-Caribbean Partnership against AIDS. Regional and national-level policy and technical workshops with government counterparts, donors’ meetings, and NGO roundtables reviewed the project design and implementation arrangements. A number of workshops and analyses took 15 PHRD Grant (TF53750) was signed on September 8, 2004, with an original closing date of March 15, 2005, which was extended once until June 15, 2005. The delay was due to the establishment of the RPMU and selection of individual consultants and firms. Of the total amount of US$889,300, US$751,988 (85%) was disbursed. Following the closure of the PHRD grant, DFID supported the staff costs and RPMU operations for an amount of US$32,700 equivalent. 6 place within the relatively short and intensive period of time from November 2003 to December 2004. 27. Regional approach: A strength of the project (but also a challenging feature) was its use of a novel regional approach, using the IDA13 Pilot Program for Regional Projects. The regional approach involved high risks of failure, low government ownership from each country and complex management arrangements (see paragraphs 32-34, 43, 45). 28. An Institutional Development Fund (IDF) Grant,16 implemented by the Republican AIDS Center of Kazakhstan in consultation with the Republican AIDS Centers in the Kyrgyz Republic, Tajikistan and Uzbekistan, resulted in the following outputs: (i) design and implementation of a training of trainers program, (ii) handbooks published in local languages for grant-implementing organizations on planning, implementing, and managing HIV/AIDS-related activities as well as for government agencies on establishing partnerships and procuring HIV/AIDS-related services from local NGOs and international organizations; and (iii) strategy on institutionalization of the training program and evaluation of the program’s impact and effectiveness. Due to delays by the Ministry of Health of Kazakhstan in signing the grant Letter- Agreement for nearly 9 months after the Grant approval in January 2005, Grant implementation was transferred to the Kazakh National Association of Organizations for AIDS-related Service and implemented in coordination with CAAP capacity building activities. 29. Adequate attention to project supervision and partnering arrangements: The World Bank Regional Operations Committee endorsed a detailed Supervision Plan, including appropriate budget allocations. The Plan took into account the number of countries, sectors, and organizations involved as well as the complexity of the project design and technical assistance needs. Additional funds were allocated by DFID to support project supervision. Less effective factors that influenced project performance: 30. Project design. The overall objective of the project was consistent with the identified sector issues and the Bank’s regional assistance strategy for Central Asia, i.e. the need to urgently address the growing epidemic of HIV in the region. Unfortunately, the project design was complex and had several weaknesses that constrained its implementation for several years. The most important ones were (i) the unrealistic PDO of ―reducing the growth rate of the HIV/AIDS epidemic in Central Asia in the period 2005-10‖ and flaws in the underlying RF (paragraphs 10, 51-52); (ii) the under-specification of technical activities known to be effective in slowing the spread of HIV, aggravated by unforeseen technical assistance on effective strategies to support NGO service delivery to high-risk groups; and (iii) complex governance and institutional arrangements giving rise to considerable risks described below. 31. The project lacked a strong justification of regional versus alternative approaches (this issue was also raised by the QER review). The PAD suggested regional character of major epidemic drivers, economies of scale, common constraints/solutions and sharing of best practices 16 Signed on October 21, 2005, the IDF Grant (TF054787) was closed on October 21, 2008. Of the total amount of US$289,000, US$257,342 (89%) was disbursed. 7 as main justifications for a regional project but those were not fully reflected in the project design. For example, delineation between national and regional level activities was not entirely clear. At appraisal, the benefit of a systematic evaluation of several new regional HIV projects financed by the Bank was not yet available (indeed, the ICR team recommends this as a follow- up activity, see paragraph 101). 32. Risk assessment. Project risks were underestimated, in particular, those related to the political economy of the region as well as the governance and implementation arrangements with CACO. The Bank had identified the risk of low government commitment to implement the project. However, rating of this risk as low to moderate appears to have been optimistic in view of the lack of familiarity of the countries with a regional approach, mistrust among the countries, a tendency to deny HIV or sexual transmission, and the weak public health agencies in the countries. Assessment of commitment and ownership should have been based on the level of commitment to institutional and policy reform and other indicators stronger than the signature of a non-binding Memorandum of Understanding and attendance at regional fora. 33. The choice of a new regional organization (CACO), with virtual governance structure and lack of prior experience with such operations, as a suitable legal framework for implementation of the project was an important risk. The PAD did not mention this governance risk explicitly, except in the context of financial management and fiduciary issues as well as in terms of the low to moderate risk of ―limited experience to fully develop the proposed regional project‖. 34. The risk of implementing a novel regional HIV/AIDS operation in Central Asia was taken by the Bank consciously given the expected benefits and as a best possible alternative to having four separate legal agreements with the countries. However, most of the stakeholders interviewed for this ICR suggested that the project governance, management and implementation arrangements could have been more thoroughly elaborated prior to implementation. For example, the Project Operational Manual of June 2005 (a condition of effectiveness) contained only basic information on project steering, management and implementation arrangements. In particular, this was true with regard to RPSC procedures and its interactions with the Recipient. 35. Weak anticipation of technical assistance for project implementation. The mentioned sector work identified that NGO capacity was limited in the region. However, the project preparation did not adequately seek to envisage and commission a technical counterpart to ensure that NGOs could work with high-risk groups not only on information campaigns but behavior change (safe injection practices for IDUs and condom use in commercial sex, both with peer-education).17 Moreover, it was known during implementation that GFATM funding would attract more NGOs to HIV/AIDS. It was clear that UNAIDS (which mostly plays an advocacy and coordination role) could not provide this specific technical assistance. The CDC provided useful technical assistance for antenatal clinic surveillance, but did not fully cover the gap for delivery of targeted interventions for high-risk groups. UNODC’s reviews of project activities 17 For example, the Soros Foundation was commissioned under the Moldova AIDS Control Project to build technical capacity of small NGOs, which was reported as an effective arrangement (Implementation Completion and Results Report, Moldova AIDS Control Project (Report No: ICR0000937), April 2009. 8 and sub-grants aimed at harm reduction among high-risk groups, and the late establishment of RTCs could not compensate for this kind of practical technical guidance and training. The large grants program might have been designed for technical assistance to smaller NGOs funded via the small grants program, but this design was not chosen. Regional models, such as those from the DFID-funded CARHAP, existed, as well as those in other countries. 36. Sub-optimal readiness for implementation of a complex regional project. This regional project was prepared faster than the average preparation time for the region at that time (the period of 13.5 months from the Concept Review stage to the Board approval vs. an average of 22 months for country-level projects in the region). 18 The task team invested significant efforts to ensure quality at entry (see paragraph 37). However, there were a few important issues, which probably required more time to address properly. These were related to insufficient elaboration of (i) technical design details (see paragraph 35), (ii) legal framework requirements to establishing the RPMU in either of the countries (paragraph 44), and (iii) arrangements for contracting fiduciary support for the project (paragraphs 58-59). 37. Overall Quality at Entry: Internal Bank reviews (Quality Enhancement Reviews on May 20 and 27, 2004 and Regional Operations Committee Review on November 18, 2004) raised concerns similar to those above. Based on the factors presented in this section, the ICR team rates overall project quality and readiness at entry as Moderately Unsatisfactory. 2.2 Implementation 38. The project succeeded in delivering most of the outputs under the three components and mostly achieving or partially achieving its expected outcomes after the formal restructuring of January 2010 (see details in Annex 2, Section 3.2, and Data sheet). There were positive and more challenging factors that played a role in implementation: Positive factors that influenced project performance: 39. Partnerships, coordination, and communication: Partnership arrangements (Annex 10) helped coordinate technical activities (e.g., on sentinel surveillance with US CDC, on strengthening civil society participation with USAID-funded CAPACITY project, etc.), effectively built institutional and human resource capacity (paragraphs 80-81), facilitated regional dialogue and cooperation (paragraph 82), and minimized duplication in resource use. The annual Forum of Partners served as an effective venue for coordinating joint efforts, such as agreeing on a unified grant application form and evaluation procedures among the grant- providing projects (CAAP, CARHAP, GFATM, and CAPACITY). 40. Intensive supervision by the Bank and partners included regular joint missions with DFID, UNAIDS, CDC and other agencies, participation of the Bank Health Sector Manager and Country Sector Coordinator in the Mid-Term Review (MTR) and subsequent missions and 18 Based on ICR authors’ analysis, the average length of preparation of IBRD and IDA investment operations in Central Asia in the period 2001-2007 was 22 months (Kazakhstan-31.6; Kyrgyz Republic-12.8; Tajikistan-12.7; and Uzbekistan-31.4). 9 video-conferences, and candid and reasonably bold mid-term assessment of the implementation progress and bottlenecks. Due attention was paid to providing specialized technical assistance to improve project implementation. Especially important was the assistance with streamlining / simplification of the RAF guidelines and manuals in May 2007. It facilitated implementation of the large grants program, which was stalled because of the complexity of the RAF guidelines. In addition, in 2008, DFID seconded to the RPMU a deputy director whose main responsibilities were to provide organizational and managerial support to CAAP and help build sustainable management capability of the RPMU team. 41. Sustaining involvement of Uzbekistan in the project. Despite the suspension in Uzbekistan’s membership in EurAsEC in November 2008, the leaderships of EurAsEC and Uzbekistan took the wise decision to sustain involvement of Uzbekistan as project beneficiary. 42. Strong focus, particularly around the MTR, on project efficiency and grant disbursement: Decisions and agreements to this effect included (i) increase in the ceiling for small grants from US$20,000 to US$50,000; (ii) allowing conditional approvals of grant proposals to encourage improvement of reasonably good ones; (iii) streamlining the grant process and manuals, actively sourcing proposals to target service delivery to high-risk groups and extending the implementation of successful sub-grants for increased service coverage; (iv) budget reallocations within Component 1 to better progressing key activities (such as surveillance) and use of accumulated savings and cancellations under Component 2 to support critically important regional activities, such as RTCs (see footnotes in Annex 1). Less effective factors that influenced project performance: 43. Political ownership: Together with the RPMU, the Bank team displayed considerable efforts to build political ownership at the Deputy Prime-Minister level via the RPSC. This led to high-level visibility of the project. At the same time, the project faced considerable challenges in securing political commitment from the countries due to their lack of familiarity with a regional approach and various tensions among the countries. This was partly compensated by good relations at the technical level. 44. Delay in operationalizing the RPMU occurred in part because of the mismatch between the agreed status of the RPMU and the legal framework in Kazakhstan. Resolution of the related legal and administrative barriers required extraordinary efforts from all the concerned parties and necessitated several RPSC dedicated sessions, multiple individual meetings and letter exchanges. Specifically, it took 17 months from the Decision of the CACO Council of the Heads of States on the establishment of RPMU to its becoming operational (see Table 1). The ISRs of that period repeatedly mentioned substantial impact of the delays on the overall efficiency of project operation, procurement and financial planning and management activities. 45. Unclear roles and responsibilities of the new structures with complex arrangements, e.g., regional approvals for large grants, but country approvals for small grants. Furthermore, after the merger of CACO into EurAsEC, involvement of additional member-countries in the project decision-making contributed to delays. Thus, the signature of a Grant Assumption Agreement (GAA) took six months after the communication from the World Bank to EurAsEC, 10 and the GAA was declared effective following another nine months (see Table 1). Also, as mentioned in the QALP report of September 2008, no re-assessment of institutional and governance arrangements took place following the merger of CACO into EurAsEC. This led to confusion about the exact role of EurAsEC in project implementation and created unnecessary tensions during the subsequent period. Table 1: CAAP Legal and Administrative Processes Timeline October 6, 2005 Heads of State Council of CACO approved DGA, RPMU Charter and the establishment of RPSC and RPMU. October 6, 2005 Heads of State Council of CACO approved CACO- EurAsEC merger. November 4, 2005 DGA became effective. March 9, 2006 RPMU was established in Almaty as a corporate foundation/non-profit organization, Special Account was opened. May 20, 2006 The World Bank sent a letter to EurAsEC Secretariat on the need for the Association and EurAsEC to conclude a GAA. September 5, 2006 Host Agreement between Kazakhstan and RPMU signed. November 17, 2006 Grant Assumption Agreement between IDA and EurAsEC was signed. December 8, 2006 Host Agreement was ratified by Kazakhstan. January 23, 2007 Letter from Kazakhstan Ministry of Economy and Budget Planning on project tax exemptions was received. January 26, 2007 Host Agreement became effective based on a formal notification from Kazakhstan Ministry of Foreign Affairs on completion of required internal procedures. February 15, 2007 Applications for RPMU staff accreditation in Kazakhstan were submitted to Kazakhstan Ministry of Foreign Affairs, with accreditation to be granted in 10 business days. February 15, 2007 GAA effectiveness deadline was extended from February 15, 2007 to April 15, 2007. February 19, 2007 RPMU was accredited by Kazakhstan Ministry of Foreign Affairs as a tax- exempted international organization. August 15, 2007 Grant Assumption Agreement was declared effective. 46. Limited initial capacity of RPMU, specifically inadequate staff capacity in management, procurement and M&E aspects, and in the RAF component. Efforts of the first RPMU Executive Director were mostly focused on forging consensus on various policy issues among the RPSC members. Less attention was paid to core project management and implementation mandate.19 However, with specialized technical assistance, accumulated experience and changes after the MTR, the RPMU capacity had gradually improved, also with the hiring of a full-time Office Manager/Coordinator in October 2009. 47. Frequent senior personnel changes within the Recipient representation (Table 2). Even though the project had little control over this factor, the frequent changes at both the Deputy Prime-Minister and Minister of Health level of the RPSC affected implementation. 19 As documented in the MTR and subsequent mission aide memoires up to October 2009 and reflected in unsatisfactory ratings for ―Implementation Progress‖ and ―Project Management‖ in ISRs of that period. 11 Table 2: Total Number of Staff Changes in Country-level Leadership of the Project Kazakhstan Kyrgyz Republic Tajikistan Uzbekistan RPSC: 5 RPSC: 11 RPSC: 2 RPSC: 3 MoH: 5 MoH: 6 MoH: 3 MoH: 2 Note: RPSC = Deputy Prime-Minister (or Minister of Health for Kazakhstan); MoH = Minister of Health 48. Insufficient focus on high-risk groups. The implementation phase did not sufficiently identify and remedy the design problems, including the under-specification of activities known to be effective in slowing the spread of HIV, leading to a poor targeting of high-risk groups by the project. Implementers had very different understanding of who were at risk.20 As a result, many of the grant activities did not target the most at-risk groups, and did not consist of cost- effective interventions, especially before the MTR. Annex 3 presents an analysis of the small grant projects and finds that only a minority of the spending of the total number of sub-projects was focused on a relatively broad set of risk groups (IDUs, SWs, prisoners, MSM, PLWHA, and migrants). 21 After the MTR, focus of the small grants scheme on the most-at-risk groups increased. Indeed, Annex 3 finds a modest improvement in spending on high-risk groups after the MTR. 49. Delay in project restructuring. Flaws in the appropriateness of the original PDOs and the underlying RF became evident in the second year of the project. 22 Subsequently, attempts to re-formulate the PDO and RF were undertaken (Annex 11). The revisions made in 2007 and 2008 were approved by the RPSC (June 8, 2007 and July 11, 2008), and EurAsEC endorsed the 2007 revisions in the letter dated August 28, 2007. Another round of revisions in 2008 required a renewed formal approval and request for project restructuring from the Recipient, as the RPSC decision of July 2008 was insufficient to process an amendment to the DGA. The MTR mission of October 2008 emphasized the need for a substantial restructuring given the apparent lack of progress, wide range of pending issues, and only 27-percent disbursement at mid term23. It also noted that failure to restructure the project may result in partial or full cancellation of the grant. Despite agreements to restructure the project 24 , internal reconciliation of the request for restructuring within EurAsEC took almost 8 months. The Bank received the formal request on September 30, 2009 when 55.5 percent of all the funds had been disbursed. Due process for restructuring was followed, and the restructuring was approved when a total of 67 percent of the IDA and DFID grant funds had been disbursed. 50. The above challenges in implementation were reflected in the QALP report of September 2008 and the later restructuring of the project. The QALP rated the likelihood of achieving the original PDOs as Moderately Unlikely. It also indicated that some of the ISR ratings were 20 Minutes of the audio-conference between RPMU and World Bank task team, March 19, 2009. 21 Even though youth and migrants constitute two risk groups and were targeted by the project, scientific evidence suggests that they contribute fewer new infections relative to other risk groups, such as IDUs and SWs. (ref. Confronting AIDS: Public Priorities in a Global Epidemic, The World Bank, Oxford University Press, 1999). 22 Aide Memoires and ISRs of late 2006-early 2007. 23 The denominator for this estimate included the signed amounts of both IDA and DFID grants. In fact, the disbursement from IDA grant only was 33 percent at mid term. 24 Aide Memoire of February 10-13, 2009 Mid-Term Review Follow-Up Visit. 12 unduly positive, but recognized the appropriate and intensive efforts on improving project and financial management performance. 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization Rating: Moderately Unsatisfactory 51. M&E Design is rated Moderately Unsatisfactory: The PAD and DGA Supplemental Letter included five outcome indicators and eight intermediate results indicators. In addition to the PDO realism and measurement difficulties (see Section 1.3), some outcome indicators were unrealistic and not easily measurable in the specified format, e.g., ―At least 60% of groups at risk covered by the RAF activities‖. Even with a known denominator for this indicator, the ambitious target may not have been realistic. It would have been more appropriate, for example, to specify this indicator as ―At least 60% of the RAF activities/funds are focused on groups at risk‖. 52. The lack of observable progress during implementation was conditioned by the following factors in the project design: (i) missing baseline data for most of the original indicators at project start up; (ii) the weakness in aligning the project inputs with reductions in HIV transmission; (iii) the lack of reasonably well-functioning M&E systems and capacity at the country and regional levels; and (iv) unwillingness of the countries to share accurate data on HIV/AIDS and associated IDU and SW. 53. M&E Implementation is rated Moderately Unsatisfactory: Without a formal revision of the PDO, the extensive efforts to revise the RF and strengthen M&E system were not fully successful. In particular, there has been large emphasis on process and efficiency indicators and much less on how project outputs aligned with the outcome of reduced HIV transmission. There were, for example, no clear indicators that would attempt to provide a ―denominator‖ for coverage with needle exchange programs and condom programs for high-risk groups. Also, the choice of some indicators was questionable, e.g., attribution of the number of needles, syringes and condoms distributed, despite these goods being directly financed by the Global Fund. The QALP report of September 2008 and the MTR of October 2008 identified the need for more consistent and relevant indicators. 54. The work on electronic surveillance system that started in 2007 had delays in consulting services for software development and testing. The progress on operationalizing the web-based Grant Management System, the electronic client database, and Central Asia Regional Information System was also limited until the restructuring. Those systems lacked the capability to provide complete and relevant information for M&E and decision-making purposes. Interruptions in staffing of M&E function at the RPMU level also contributed to the general shortcomings in this area. 55. M&E Utilization is rated Moderately Satisfactory: The adage that ―what gets measured, gets done‖ applies here. The weakness of the M&E indicators and their frequent informal changes in the RF, in turn, contributed to a lack of clarity among NGOs in the small grants program, and among policy makers as to the most effective ways to reduce HIV transmission. Moreover, there was insufficient use of sentinel surveillance data to inform subsequent project 13 strategic priorities, regional HIV/AIDS strategy and policy changes, and the small grants program focus. 56. On the positive side, funding in support of 18 pilot sites for sentinel surveillance activities in the four countries helped establish strong ongoing national surveillance systems, which have the potential to lead to sustained policy changes. Given the lack of surveillance systems in most of the participating countries, this achievement should not be underestimated. The sentinel surveillance sites are likely to inform future measurement of HIV in the region, and will improve the validity and quality of future projections done by UNAIDS. Thus, they represent an important and sustainable system-wide investment as part of long-term M&E. 2.4 Safeguards and Fiduciary Compliance 57. Safeguards implementation is rated Satisfactory. The environmental impact of the project was rated C, therefore, no environmental assessment was required. The project only involved minor renovations of the RPMU and CAAP national office premises. 58. Financial Management (FM) is rated Moderately Satisfactory. In spite of a clear FM Action Plan at appraisal stage, the project experienced delays in establishing its own automated FM system until June 200625. This was mostly due to the delay in operationalizing the RPMU and resulted in a downgrade of FM rating to Unsatisfactory in April 2006. Given the high FM risk of the project, FM supervision was conducted every six months. After initial delays, the quarterly FMRs were submitted regularly and timely and found satisfactory by the Bank. On the other hand, the outsourcing of fiduciary services posed challenges in implementation including: (i) delays in contracting country-level fiduciary support services due to lengthy negotiations with UNDP; (ii) problems with timeliness and accuracy of financial reporting by UNDP country offices and resulting delays in small grant disbursements; (iii) UNDP financial safeguards causing limitations on actual availability of funds; and (iv) higher than expected operating costs, including 7 percent in fees paid to UNDP, that required reallocations of funds on two occasions. 59. Accounting and internal control systems were improved over time, though some weaknesses in financial budgeting and reporting remained. By 2010, all the issues raised in the initial management letters were gradually and satisfactorily addressed by the RPMU, and this was reflected in the upgrade of the rating to Satisfactory in June 2010 up to the project closing. In 2010, staffing and implementation arrangements between UNDP country offices were further enhanced, and the contract with UNDP Uzbekistan office was extended to complete implementation of the fourth round of small grants in Uzbekistan. Owing to these efforts by RPMU and UNDP and intensive supervision by the Bank, the flow of funds and disbursements substantially improved over time. In general, withdrawal applications were prepared regularly with supporting documentation complete. DFID grant was fully disbursed by August 31, 2010, and IDA grant was almost entirely disbursed by the revised closing date. 25 The establishment of a FM system satisfactory to the Bank was a Board presentation condition. This was formally met by contracting the Kyrgyz Health Reform PMU to provide FM support to the project until the RPMU had established its own FM system. Following its relocation to Almaty in March 2006, RPMU essentially operated without a functioning FM system until June 2006. 14 60. Project audits were conducted annually, with the audit reports submitted to the Bank by the due dates starting with the audit report for 2008. Subsequent audit reports and management letters did not raise any major issues. 61. Procurement is rated Satisfactory. With the exception of a few delayed packages, the majority of contracts were awarded according to the agreed procurement schedule and provisions. The recruitment of a specialist experienced in international procurement in early April 2007 significantly improved the procurement capacity and performance of the RPMU. The format of the Procurement Plan allowed for easy location of all the required information. Procurement Plans were updated as required. 62. While UNDP handled procurement on behalf of small grants recipients at the country level, the large grant recipients handled their procurement themselves. The RPMU’s review of procurement arrangements for grant proposals before submission to the Bank followed the provisions of the Grant Recipient Handbook. 63. By project completion, five procurement ex-post reviews were conducted for the project. The provided recommendations were usually properly implemented before the next ex-post review mission. Both the procurement review mission of late 2008 for country-level activities in Kyrgyzstan and an Independent Procurement Review in March-April 2010 identified no major issues and rated the procurement performance satisfactory. Only some procurement-related deficiencies were noted, such as the lack of regular physical inspections to grant recipients’ sites, which occurred due to the shortage of staff at RPMU and UNDP national offices. 2.5 Post-completion Operation/Next Phase 64. Funding for HIV/AIDS has continued to grow in the region, mostly from the GFATM. External assistance for HIV/AIDS has risen for all the four countries. All the countries are following the regional standards on surveillance. Funding from PEPFAR for AIDS treatment will include an element of strengthening these M&E systems. Some RTCs receive government support (e.g., Kazakhstan and Uzbekistan), others are funded with donor resources (GFATM for Tajikistan); however, their sustained functioning at the regional level in the near future is questionable. A regional HIV/AIDS strategy document, developed under the auspices of EurAsEC, has been adopted but is weak on strategies for IDU and SW populations. The Bank has continued to play a positive role in encouraging various partners to work together at the country level. 65. The enhanced managerial capacity of the RPMU allowed it to manage on behalf of EurAsEC an additional Bank-administered US$3 million equivalent grant for the Central Asia Regional One Health Project. Implemented between March-September 2011, it focused on analytical activities and action planning for control of zoonotic and food-borne diseases and aimed at advancing the intra-regional cooperation arrangements established under the CAAP. 15 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation Rating: Modest 66. At the time of the ICR, the relevance of the project’s original (though partially ambitious) and revised objectives to the current epidemiological challenges are rated Substantial for several reasons: (i) HIV transmission in the region continues to be driven by IDU and SW. Indeed, a greater proportion of new infections are now arising from SW (see Annex 3); (ii) UNAIDS projections suggest that the growth of HIV has not yet stabilized in any of the countries26 (however, the sentinel surveillance data suggest some plateau patterns from 2008- 2010 for some of the countries); (iii) there is an ongoing need for modern public health structures in these countries; and (iv) regional HIV control has been a key aspect of poverty reduction and the Bank’s overall assistance strategy in the region.27 67. The relevance of the design focusing the bulk of the IDA and DFID grants on a regional grants program at the time of considerable expansion in country-specific GFATM support is rated Modest, especially in view of the insufficient focus on high-risk groups, which was out of alignment with the (ambitious) PDO. Similarly, the design of the RAF envisaged reviews of large grant proposals by the Regional Technical Evaluation Committee, and of small grant proposals by National Technical Evaluation Committees, with little strategic synergy between the two processes. However, in some key areas, such as harmonization of strategies, standardized sentinel and electronic surveillance, and training, regional approaches remain highly relevant. Similarly, a design that would build technical capacity of NGOs to provide specific services, such as needle exchange and condom provision, both with peer education and social support to high-risk groups, remains relevant in the region. The ongoing technical assistance by CDC for sentinel surveillance in some of the countries is an example of focused regional assistance. While the project successfully influenced religious leaders across the region to consider HIV/AIDS issues, it was difficult to align their support toward greater tolerance of public health efforts to deliver services to IDUs and SWs. 68. The relevance of the implementation arrangements is rated Modest. Governance and implementation arrangements with CACO, as designed, had some inherent risks described in Section 2.1 above. Moreover, no re-assessment of institutional and governance arrangements took place following the merger of CACO into EurAsEC prior to effectiveness. EurAsEC, the new Grant Recipient, has a mandate for regional integration in economic matters and has political legitimacy. However, it does not have any special expertise in the management of health projects and even less in the sub-specialized areas of HIV interventions. Given the EurAsEC Healthcare Council’s policy development and coordination role, it would have been expedient to consider creating a sustainable specialized regional health structure, perhaps initially within 26 www.unaids.org/en/regionscountries/regions/easterneuropeandcentralasia/ 27 Central Asia Regional Framework Paper. World Bank, February 2004, and most recent Country Assistance/Partnership Strategies for the four countries (except for the Interim Strategy Note for the Kyrgyz Republic for FY12-13, whose main focus is on emergency recovery and stabilization, following the recent political and social instability). 16 EurAsEC, or to institutionalize regional TWGs that proved effective, so as to play this role. Such structure could transform over time into a regional equivalent of Centers for Disease Prevention and Control and seems feasible given the historical existence of standardized health agencies under the Soviet era. 3.2 Achievement of Project Development Objectives Rating: Modest for the original PDOs, Substantial for the revised PDOs 69. Evaluation of outcomes against the original PDOs is not easily possible given the change in the PDOs, plus the changes in the RF. The project had some partial achievements against the benchmarks of regional mechanisms prior to the formal PDO revision (Table 3). At the same time, some of the investments made during the early phase of the project yielded benefits during the latter two years, especially related to NGO training, regional cooperation and parliamentary exchanges, and in surveillance. Moreover, despite the delay in revising the PDOs formally as explained in paragraph 49, there was a dialogue to restructure the project and to identify and correct certain deficiencies well before formal PDO revision. Table 3. Status of Progress Against Original Project Indicators Status 5 PDO Indicators 10 Intermediate Outcome % of Indicators (IO) Total 1/PDO1 3/PDO2 1/PDO3 4 IO/C1 5 IO/C2 1 IO/C3 Achieved 1 1 13% Not Achieved 1 1 13% Partially Achieved 2 1 3 4 1 73% Progress not attributable to Project 70. Achievement of the revised PDO is rated Substantial (Table 4) based on the fact that some regional policy development and coordination efforts occurred, a workable sentinel surveillance system was established, institutional capacity in the region strengthened, and because the small grants program adopted a slightly sharper focus on high-risk groups over the last two years. Table 4. Status of Progress against Revised Project Indicators Status 3 PDO Indicators 12 Intermediate Outcome % of Indicators Total 5 IO/C1 3 IO/C2 4 IO/C3 Achieved 3 3 2 4 80% Not Achieved 0% Partially Achieved 2 1 20% Progress not attributable to Project 71. Revised PDO for Component 1: Regional Coordination, Policy Development and Capacity Building is rated Satisfactory. This component’s relevance remains Substantial, its achievement and efficiency are also rated Substantial. By the end of the Project, two of the five intermediate results indicators for this component were achieved, one was exceeded, and two other were achieved partially. The indicator for regional support of policies in four areas was 17 achieved fully in two areas (epidemiological surveillance and stigma reduction) whereas it was not achieved in injection safety and harm reduction as well as SW-based transmission aspects. 72. Revised PDO for Component 2: Central Asia Regional AIDS Fund is rated Moderately Satisfactory. The relevance of the RAF is rated Modest (see paragraph 67), but its achievement and efficiency are rated Substantial. By the end of the Project, two of the three intermediate outcome indicators (exclusively process indicators) were achieved and one was achieved partially. The contribution of the RAF, including the large grants, toward stabilization or reversal of HIV growth was marginal, at best. Commendably, better targeting of high-risk groups was implemented after the MTR by reducing the number of priority funding areas from 19 to 3.28 At the same time, the streamlined RAF Grant Recipient Manual, extensive training and practical implementation experience did contribute to increasing capacity of NGOs to obtain and implement grants (also from other donors), as evidenced by local NGO consortia receiving large grants in Rounds 2 and 3. 73. Revised PDO for Component 3: Project Management is rated Satisfactory. The relevance, achievement, and efficiency are all rated Substantial. With capacity gained over the course of the project, the RPSC and RPMU performed increasingly well on their project steering and management mandate. The significant over-spending under this component versus the appraisal estimate was mainly due to underestimated cost of outsourced fiduciary services at appraisal (see Annex 1). All four indicators for this component were achieved, and EurAsEC/RPMU and the Bank made substantial efforts to address remaining deficiencies in M&E, project and financial management. 3.3 Project Efficiency Rating: Substantial 74. The original economic analysis conducted at the appraisal estimated returns on investment based on reductions in new HIV cases. Given that the project objectives were revised to no longer measure this outcome, it is possible to update these economic analyses only crudely (Annex 3). This finds that even modest increases in coverage of IDUs and SWs (about 40,000 and 15,000 respectively) would reduce new HIV infection by about 6,000 cases. This number of avoided infections, when valued as about 20 years of health life per averted infection, with each health year of life worth about 3 times regional GDP, together yield a positive rate of return. Also some of the regional efforts, particularly on sentinel surveillance, harmonization of strategies and introduction of a (albeit weak) regional HIV/AIDS strategy document, and the fact that the project has assisted with building capacity of NGOs in the region to expand HIV prevention services together imply that some efficiencies were achieved. Moreover, the recurrent costs of the efforts to governments are minimal. Costs, in purchasing power terms, for the various activities were within norms established for other NGO-based projects.29 28 Mid-Term Review Progress Report, EurAsEC, September 2008 29 Bertozzi et al, HIV/AIDS Prevention and Treatment, in Jamison D.T. et al, Disease Control Priorities in Developing Countries, 2nd Edition, World Bank, Oxford University Press, 2006, Chapter 18. 18 3.4 Justification of Overall Outcome Rating Rating: Moderately Unsatisfactory 75. Based on the detailed analysis above, the ICR rates relevance as Modest, achievement as Modest, and efficiency as Substantial, yielding an overall outcome rating of Moderately Unsatisfactory. Further supporting analysis was based on the following quantitative assessment: Table 5. Combined overall project achievement rating Rating/Scale Against Original PDOs Against Revised PDOs 1. Rating Moderately Moderately Unsatisfactory Satisfactory 2. Rating value 3 4 30 31 3. Amount disbursed 17.67 out of 26.41 8.7432 out of 26.41 4. Weight (% disbursed before/after PDO 67% 33% change) 5. Weighted value (rating by disbursement 3*.67=2.01 4 * .33=1.32 6. Final rating (rounded and weighted) 3.33 Moderately Unsatisfactory Source: OPCS, ICRR Guidelines (rev. October 2011), Annex B, pp. 42ff. 76. As per the standard ICR guidelines for rating the outcome of projects with formally revised objectives, the ICR team assigned outcome ratings for the original and revised PDOs based on the achievement status of all the respective indicators. The two ratings were further weighed by the amounts disbursed prior to restructuring and post-restructuring (67 vs. 33 percent, respectively). Such weighing has a strong impact on the overall outcome rating. The application of the standard ICR guidelines for weighing achievements by disbursement is problematic in this case, as the original PDO rating does not capture and reward the extensive efforts to correct the original PDOs, which were initiated much before the actual date of the restructuring. For reasons noted in paragraph 49, the formal restructuring was not possible in 2008, which resulted in a larger share of disbursements against the chosen unrealistic original PDO, thus giving much heavier weight to the respective Moderately Unsatisfactory rating. The ICR team admits that the ratings are open to interpretation. Simply one change from Modest to Substantial in any one of the three components of the overall outcome rating would result in an overall rating of Moderately Satisfactory. 77. The clear positive features are sentinel surveillance, mechanisms that were able to initiate regional dialogue and collaboration on HIV issues in such a multi-dimensional region as Central Asia, important enhancements in HIV legal framework of the countries ensuing from that dialogue, standardized training with some of the developed courses institutionalized, transparent and efficient grant distribution mechanism, and development of NGOs in the region, including enhanced grant application and management capacity of NGOs. The less effective features deal 30 Includes US$16.73 M equivalent of IDA grant and US$0.94 M equivalent of DFID grant proceeds disbursed prior to the restructuring. 31 Includes US$24.86 M equivalent of IDA grant and US$1.55 M equivalent of DFID grant proceeds. 32 Includes US$8.13 M equivalent of IDA grant and US$0.61 M equivalent of DFID grant proceeds disbursed after the restructuring. 19 with the insufficient focus of the RAF on behavior change among IDUs and SWs that reduces transmission of HIV, and lack of attention to building technical capacity of NGOs in the region on HIV prevention and treatment. This is in the context that the HIV prevalence continues to increase in most of the region (with some suggestion of possible attenuation in at least Kazakhstan). 78. Although achievement of PDOs measured through the PDO indicators cannot only be attributed to the project as other elements are at play, including support from the Global Fund, CDC, etc., much has been accomplished, and the project has made an important contribution to the achievements described above. 3.5 Overarching Themes, Other Outcomes and Impacts (a) Poverty Impacts, Gender Aspects, and Social Development 79. Although the project did not have a specific poverty focus, the literature on HIV/AIDS has established that programs that decrease transmission help reduce the numbers of poor households who have to resort to more expensive HIV treatments. Similarly, while the project did not have an explicit gender aspect, empowering of SWs and female IDUs via targeted interventions does enable better economic opportunities for these women. Finally, the project’s contribution toward social development was chiefly through the above mechanisms, as well as helping form the basis for a more inclusive regional HIV/AIDS strategy. Marginalized groups such as IDUs, SWs and MSMs still face considerable difficulty in the region, but the efforts at regional dialogue appear to have created a more enabling environment for services to be delivered to such marginalized populations. (b) Institutional development impact 80. The Project financed significant investments in training and was successful in improving overall surveillance systems in HIV/AIDS programs, thus contributing to institutional capacity building. In addition, collaboration with international partners, including the technical agencies – WHO, UNAIDS, and CDC, as well as the Global Fund helped promote a coordinated effort for the implementation of HIV/AIDS activities. 81. By its nature, a regional project will have difficulty identifying and strengthening specific country-based institutions that remain after the project. Notwithstanding this, some of the efforts, specifically establishment and support of 4 RTCs, 18 sentinel and 25 electronic surveillance sites, developed and institutionalized training courses, training of several hundreds of regional trainers and national specialists, and strengthening of regional NGOs’ capacity to apply for and manage grants through 229 sub-projects, have all been positive developments. The management capacity of the RPMU was built to the level that it was able to successfully manage on behalf of EurAsEC an additional Bank-administered US$3 million equivalent grant for the Regional One Health Project. The Republican AIDS Centers in each of the countries have also been strengthened in surveillance, and training aspects. 20 82. The initiated key regional mechanisms of dialogue will likely be sustained, in part because of EurAsEC’s presence and interest in regional cooperation. 33 A regional HIV strategy has been developed but is notably weak on IDU and SW. The regional standards for surveillance are likely to be sustainable and useful, in part because of demand from forthcoming PEPFAR funding (and, hence, ongoing technical support from CDC). It is unclear whether the regional investments will actually shape priorities setting and alignment of country-specific inputs with reductions in HIV transmission from IDU and SW (e.g., Inter-Parliamentarian Working Group effort may not specifically support delivering condoms and safe needles to high-risk groups). 83. Close coordination and synergies with partners have resulted in some efficiency at the country level, for example, through strengthening the Republican AIDS Centers in at least three of the countries, and enabling them to benefit from GFATM funding as well as PEPFAR funding for AIDS treatment. (c) Other unintended outcomes and impacts 84. Azerbaijan revised its HIV legal framework in 2010 as a result of participating in the CAAP-supported Inter-Parliamentarian Working Group on HIV. 4. Assessment of Risk to Development Outcome Rating: Significant 85. The risk at the time of the ICR to development outcomes is considered significant for the following reasons:  Increasing importance of HIV transmission from SW (away from IDUs) with only limited efforts to reduce marginalization, police harassment, and other enabling efforts that might change behavior in these groups. Moreover, reliable measurement of the number, mapping and scope, practice patterns of SW continues to be a gap and is not covered under the sentinel surveillance. There is little technical assistance planned in the region to meet these gaps.  Increased global funding, including GFATM and PEPFAR, but concern about government sustainability (as well as differences in the economic growth prospects of resource-richer versus poorer countries in the region).  Increased political tensions between the countries may decrease cooperation on HIV. While better ownership over HIV is now evident across all the countries (largely, due to the CAAP), more specific concerns linger about the commitment to focus on high-risk groups and build sustained public health institutions that can create scientific and programmatic opportunities for HIV prevention and treatment.  Relatively nascent civil society sector (but one strengthened by the project) and even more nascent private sector leadership on HIV prevention and treatment. 33 As evidenced by the continued regional collaboration within EurAsEC in the context of public health in general, and infectious diseases and migration in particular; Minutes of the 10 th session of the Healthcare Council of EurAsEC, Astana, June 16, 2011. 21 5. Assessment of Bank and Borrower Performance 5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry Rating: Moderately Unsatisfactory 86. The project design built on the findings of earlier sector work and incorporated a number of important lessons learnt. The preparation was also strong on donor coordination, sensitization at the prime-ministerial level, and adequate attention to supervision and partnering arrangements. 87. However, there were important gaps in ensuring readiness for implementation of a new regional effort (e.g., RPMU establishment, outsourcing fiduciary support), and insufficient Bank attention to high risks of the project at the outset, related to political economy, governance/implementation arrangements with CACO, and fiduciary risks. Similarly, no re- assessment of institutional and governance arrangements took place following the merger of CACO into EurAsEC prior to effectiveness. Importantly, the chosen PDOs and indicators had considerable flaws, and baseline data for most indicators were not in place with large gaps at the outset. Finally, aside from the under-specification of technical activities flagged by the QER, technical assistance on effective strategies to support NGO service delivery to high-risk groups was not envisaged, even though this need was identified in the earlier sector work. All these collectively led to delays in the start up of the project and challenging implementation during the first three years. (b) Quality of Supervision Rating: Moderately Satisfactory 88. M&E technical assistance was inadequate in fixing inconsistencies in the RF effectively (most indicators chosen were process indicators), and the proposed changes to the RF varied from mission to mission, with none of them being fully implemented until the restructuring.34 89. Due to the novelty and complexity of the project, the Bank team closely monitored the project implementation through regular joint missions with partners, participated in major consensus-building and dissemination events organized by the project, and involved Bank management at critical times during implementation. The Bank paid substantial attention to project management, financial and disbursement issues, and to improving RAF functioning, including regular fiduciary reviews and adequate mobilization of international technical assistance in these areas. The 2008 MTR was notably focused, strong, blunt and correctly identified serious management problems. Subsequent corrective efforts have benefited from a TTL with public health training, and from the dialogue to ensure project implementation remained on track. A dialogue was also initiated with the countries on a regional public health platform, and the Bank helped EurAsEC implement the Regional One Health Project to further strengthen regional collaboration and support the ―Health in All Policies‖ approach to public health in Central Asia. 34 As documented in the Aide Memoire of June 2011 Implementation Support Mission. 22 (c) Justification of Rating for Overall Bank Performance Rating: Moderately Unsatisfactory 90. The overall rating was assigned on the basis of the overall design at entry, ensuing delays in implementation, substantial efforts around the MTR, and strong supervision at the later stages. The Bank recognized problems early in implementation and made attempts to improve performance, even despite substantial delay in the formal restructuring. 5.2 Recipient Performance (a) CACO/EurAsEC Performance Rating: Moderately Unsatisfactory 91. There were substantial initial delays in legal registration, staffing, tax status, and accreditation of the RPMU despite agreements by all the CACO-member countries to house RPMU in Almaty. There was also a significant delay in restructuring the project and in governance-related issues. Mobilization of technical assistance on effective strategies and approaches to reach high-risk groups was insufficient. 92. EurAsEC implemented MTR recommendations on financial and managerial matters seriously. EurAsEC’s recognition of early implementation problems, follow-up work on project management after the MTR and efforts to support better performance were all positive features. Moreover, the leadership of EurAsEC made the decision to sustain involvement of Uzbekistan as project beneficiary despite the suspension of its membership in EurAsEC. (b) RPMU and RPSC Performance Rating: Moderately Satisfactory 93. Early implementation, capacity, and management problems were resolved gradually and satisfactorily over the course of the project. RPMU performed its mandate, which focused on efficiency and flow of funds and not on technical assistance. The RPSC issued 33 decisions during the project, mostly focused on policy dialogue and enabling frameworks. Some matters, such as signing Memorandums of Understanding (MoUs) between project and other partners, re- allocating budget amounts of up to US$100,000, recruiting RPMU support staff, and composing evaluation committees for procurement of consultants, were appropriately delegated to RPMU. Within its mandate, RPSC appeared to make mostly sound decisions, but could not compensate for the design and implementation drawbacks of the project. (c) Justification of Rating for Overall Recipient Performance Rating: Moderately Unsatisfactory 94. The rating was assigned mostly based on insufficient ownership, delays in project implementation and restructuring as well as in operationalizing the scientific evidence on effective strategies to control the growth of HIV in the region, identified also in earlier sector work. 23 6. Lessons Learned 95. A regional HIV/AIDS project needs to be guided by a regional HIV/AIDS strategy. A regional HIV/AIDS strategy would provide the strategic framework for a regional HIV/AIDS project to support. For this reason, ideally, a regional HIV/AIDS strategy should have been formulated during project preparation or at least during the early phase of project effectiveness to guide the project implementation. Unfortunately, the regional HIV/AIDS strategy was not developed and adopted until October 2009, which was one year after MTR. 96. A regional HIV/AIDS project needs to focus on activities for which the regional approach has comparative advantages. By definition, the categories of activities for which the regional approach has comparative advantages include (i) cross-border / trans-boundary issues, (ii) regional public goods, and (iii) activities which can benefit from the economies of scale. For the first category, HIV/AIDS is a cross-border issue when (i) there are significant population movements among the countries; and (ii) the mobile populations are the drivers of the epidemic. For the second and third categories, the project was more successful with activities for which the regional approach was appropriate, such as those under Component 1 (more regional public goods and economies of scale in nature). A lesson for future regional projects should be to clearly delineate and have the right mix of regional activities, where justified and country- specific activities where cost-benefit ratio is clear to countries and contributes to increasing overall ownership. 97. Realistic assessment of all risks, their adequate mitigation, and robust readiness for implementation are critical. Risks potentially compromising implementation, including political economy, institutional/implementation arrangements, and fiduciary risks should be realistically assessed and properly mitigated at the outset. This is even more crucial for novel and complex projects facing challenging environments with new institutions and various conflicting interests. 98. Realistic objectives and robust indicators are essential to achieve and measure results. Although the project in many respects was exemplary in its inherent relevance to Bank policies and country strategies, it proved once again the need for (i) objectives and performance indicators to be carefully selected; (ii) an adequately designed M&E system to be in place at the start of implementation; and (iii) appropriate arrangements to be in place to ensure that information is used strategically for decision making. 99. Close coordination with development partners at preparation is critical. Close coordination and collaboration with the key partners at the design stage was useful in enabling reasonably clear and complementary roles. However, this coordination was less successful at levering effective changes in HIV/AIDS strategies (e.g., open emphasis on IDU and SW) across the four countries during project implementation. 100. Appropriate and continuous staffing with skilled technical staff remains important in high-risk projects. The risks associated with this project were underestimated at appraisal. The right composition of a task team, including specialized public health and epidemiological skills for HIV/AIDS projects and strong operational skills, is required to supervise complex 24 projects in challenging environments. Such skills should be a key feature identified during project preparation and presented in supervision plans. 101. Regional projects are high risks but also have their own rewards. What happened under CAAP confirms the previous findings on regional projects; namely, they invariably involve higher risks than country-based projects because of political economy constraints and ensuing lower ownership 35 , less clear accountability from the counterpart, and usually more reliance on process versus specific outcome indicators. However, the regional approach also enables, through peer pressure, changes in laws and policies for each country, which happened to some extent in this project. Therefore, ongoing efforts are required to bridge standards in public health in the Central Asia region given the close inter-dependence of the countries, despite considerable political and economic obstacles. In order to inform future regional operations, this ICR recommends a Bank-wide review of lessons learned from regional HIV projects, including CAAP. 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Recipient/implementing agencies 102. Authorities contacted by the ICR mission had mixed comments on the project. There was near uniform agreement that the early implementation arrangements and delays were unsatisfactory, and more attention should have been paid to better preparing the project for implementation. There was praise for the efforts to correct the project in more recent years. The benefiting country stakeholders also recognized that the project created some regional dialogue on HIV/AIDS where little existed before, and left behind important components of training, sentinel surveillance and NGO capacity for managing small grants. All expressed a concern that aside from PEPFAR and GFATM funding at the country level, there would be no regional funding/technical support after CAAP. 103. The health authorities of the four countries, UNAIDS (represented in RPSC), and EurAsEC overall acknowledged the important role of the project in supporting national HIV programs, developing regional HIV strategy, financing grants and strengthening regional policy dialogue, capacity and collaboration for counteracting HIV epidemic. 104. In its comments on the draft ICR, the Ministry of Health of Uzbekistan: (i) questioned the sufficiency of time needed for a full-fledged assessment of such a comprehensive regional project; (ii) regarding the poor targeting of high-risk groups, explained that because of complementarities with other programs in the country, in particular the GFATM support to prevention activities among vulnerable groups between 2005-2011 (average coverage of 85 percent for each target group achieved in 2010), the Country Coordination Committee decided to direct CAAP support to improving HIV-related legal framework, strengthening M&E system, creating enabling environment for activities of other programs, building local capacity in project development and management, as well as in epidemiological surveillance and ART treatment; and (iv) disagreed with the assessment of the project achievements, which should have been 35 Regional Projects, A QAG Learning Review, paragraphs 91 and 93; February 2010 25 assessed based on comprehensive study of the full set of activities and status of achievement for each indicator. 105. Commenting on the draft ICR, EurAsEC disagreed with the statements on (a) sources of project risks, pointing out, instead, to the lack of familiarity with a regional approach in health care area; (b) weak anticipation of technical assistance for project implementation, referring to the involvement of AIHA, UNODC, CDC, WHO; (c) poor targeting of high-risk groups, explaining that the project had to focus at the outset on building capacity of AIDS-servicing organizations whose number was very low, and on creating enabling environment for implementation of harm reduction programs with subsequent increase in their funding; (d) limited contribution of religious leaders to de-stigmatization of IDUs and SWs. It also questioned (a) the assessment of the project impact and assessment methodology, (b) analysis of the small grants program, and (c) appropriateness of rating the project based on the increase in funding from the GFATM. EurAsEC requested that (a) the rating of the RAF Component be upgraded to Substantial / Satisfactory, (b) the overall outcome rating of the project be revised. 106. In its comments on the draft ICR, UNAIDS expressed some disappointment with the overall outcome rating of Moderately Unsatisfactory while acknowledging the ―inappropriate target setting during the project development stage‖, which ―influenced negatively the performance‖ and led to the project restructuring. 107. The ICR team concurred that the project made an important contribution to harmonization of strategies and strengthening policy dialogue, collaboration, and institutional capacity for counteracting HIV epidemic in the region, as recognized in the ICR. The team further confirms that the statements and conclusions in the document were based on a comprehensive desk-review of a large amount of documents and data, which were not limited only to the project. Besides, the assessment presents a balanced synthesis of feedback from all the stakeholders (including IDU, SW, and MSM groups) in all the four countries36. In order to respond to the disagreements with the assessment and ensuing ratings, the ICR has been refined with clarifications on the standard Bank methodology for rating the outcome of projects with formally revised objectives, which further substantiate the initial ratings. The ICR team also kept the argument of insufficient focus on high-risk groups as valid in view of (i) the explicit design of the RAF Component ―to support cost-effective initiatives in the field of HIV/AIDS prevention and control‖, (ii) the scientific evidence on the most cost-effective strategies reinforced by the earlier sector work, (iii) the efforts of the project in this direction, and (iv) the facts-based analysis of the small grants spending in Annex 3. 108. The rest of the comments have been taken into account and incorporated as far as feasible in the final version of this ICR. The full Recipient’s contribution to this ICR is included in Annex 7. 36 The visits to Uzbekistan and Tajikistan benefitted from additional technical support provided by the Central Asia Regional HIV/AIDS Advisor whose contribution is gratefully acknowledged by the ICR team. 26 (b) Cofinanciers 109. DFID comments on the project during the ICR mission were similar to those from the Recipient and benefiting countries, and are reflected in this document to the extent possible. DFID has originally planned a ―silent partner‖ role but was pulled into more of the managerial aspects with the earlier delays. When provided the draft ICR for comments, DFID raised no issues and expressed its agreement with the content of the document. (c) Other partners and stakeholders 110. CDC played a key role in designing and sustaining the surveillance efforts and also expressed concern on the changes in the RF and deficiencies in the M&E aspects at the outset. They praised the coordination of the project at the outset. 27 Annex 1: Project Costs and Financing (a) Project Cost by Component Actual/Latest Appraisal Estimate Percentage of Components Estimate (USD (USD millions) Appraisal millions) Coordination, Policy and Capacity 6.96 8.24 118.4%37 Building Regional AIDS Fund 16.64 14.31 86.0%38 Project Management 2.52 3.99 158.3%39 Total Baseline Cost 26.12 26.54 101.6% Physical Contingencies 0.00 Price Contingencies 0.86 Total Project Costs 26.98 26.54 98.4% (b) Financing Actual/Latest Appraisal Estimate Percentage of Source of Funds Estimate (USD millions) Appraisal (USD millions) Borrower/Recipient40 0.08 0.13 162.5% IDA Grant 25.00 24.86 99.4% DFID Grant 1.90 1.55 81.6%41 Total 26.98 26.54 98.4% 37 Reallocations of 2010 (Annex 1 (d)) provided additional financing for regional policy and coordination activities under Component 1. Savings and cancellations from grants activities were used to further support Component 1 activities in 2011 (regional initiatives, electronic surveillance, RTCs). 38 Savings and cancellations from grants (US$962,007) were used to further support Component 1 activities in 2011. 39 Higher than expected operating costs included (i) UNDP fiduciary services (US$849,790 vs. US$120,000 initially planned); (ii) high cost of living and operating out of Almaty (RPMU payroll, relocation and housing allowances for non-resident staff, bank and communication costs). 40 Recipient’s in-kind contribution (staff time, office facilities, and utilities). 41 The DFID Grant was fully disbursed; the difference in appraisal and actual amounts is due to exchange rate fluctuations and related financial losses. 28 (c) Project Cost by Category Actual Disbursement Appraisal Estimate Percentage of Categories (USD millions) (USD millions) Appraisal (1) Goods 3.19 2.18 68.3% (2) Consultant Services, including 6.47 121.6% 5.32 Audit, and Training (3) Sub-projects RAF 15.51 13.56 87.4% (4) Operating Costs 2.96 4.33 146.3% Total 26.98 26.54 98.4%42 (d) Reallocations of funds (in SDR equivalent) Categories Original First reallocation, Second reallocation, allocation June 2009 January 2010 Amounts Categories Amounts Categories reallocated after reallocated after reallocation reallocation Goods 1,950,000 - 1,950,000 700,000 to 1,250,000 Category (2) Consultants’ services 2,860,000 - 2,860,000 - 4,000,000 including audit and training Sub grants under Part B 8,420,000 - 8,420,000 - 8,420,000 of the project Operating Costs 1,350,000 - 1,675,000 - 2,410,000 Unallocated 1,620,000 325,000 to 1,295,000 440,000 to 120,00043 Category (4) Category (2) 735,000 to Category (4) 42 The project incurred a total of US$0.41 M in exchange loss. 43 This amount of US$200,000 equivalent was further reallocated in 2011 to finance goods in Component 1 and operating costs in Component 3, US$100,000 to each category respectively, based on RPMU’s delegated authority. 29 Annex 2: Outputs by Component Planned outputs at Component Actual outputs/outcomes at ICR Appraisal Component 1: Sub-component 1.1: Regional HIV/AIDS Coordination and Policy Development Regional - TA for regional - 4 Partners’ Forums conducted; Coordination, HIV/AIDS - Regional strategy on prevention of HIV/AIDS developed Policy coordination; and endorsed by the Healthcare Council of EurAsEC; Development - National - 5 inter-parliamentarian meetings convened, which led to and Capacity coordination revisions of HIV-related laws in Kyrgyzstan, Tajikistan, Building workshops; Uzbekistan, and Azerbaijan; (US$8.24 M) - Regional - Comprehensive handbook of HIV/AIDS-related legal coordination framework in the four countries developed and disseminated conferences; widely; - TA for regional - Research on assessment of needs in use of disposable policy harmonization; medical instruments in state medical organizations in project - Regional policy countries; development - Research study ―Evaluating safe injection practices and workshops; catheterization of vessels in the Central Asian countries‖ - Studies on risk carried out with support from CDC; groups; - 7 international conferences attended: - Study tours; (a) ―Intergovernmental consultation for Central Asian - TA for design of countries on HIV prevention among IDUs‖ in Tehran; regional (b) ―International conference on HIV/AIDS for Eastern communications Europe and Central Asia‖ in Moscow; campaign; (c) ―8th International Congress on AIDS in Asia and the - Airtime and goods Pacific‖ in Colombo; for regional (d) ―18th International Conference on the Reduction of communications Drug Related Harm‖ in Warsaw campaign; (e) ―First Asian Consultation on the Prevention of HIV - TA for Component Related to Drug Use‖ in Goa; coordination; (f) ―21st International Conference on Harm Reduction‖ in - IT equipment and Liverpool; office furniture for (g) ―XVIII International Conference on HIV/AIDS Issue‖ Component; in Vienna. - Incremental - 4 study tours related to exchange of experience in the area operating costs. of AIDS prevention conducted: (a) Study tour ―Learning from the Transatlantic Partners Against AIDS (TPPA) and GLOBUS Project ―Experiences on HIV/AIDS control‖ in Russia; (b) Training course "International Principles of TB and HIV Control: Laboratory Diagnosis, Management and Surveillance" in UK; (c) Study tour of Central Asian decision makers to Portugal: ―Supportive harm reduction policies in practice: Portuguese case‖; (d) Central Asia Regional Economic Cooperation (CAREC) workshop and study tour on HIV/AIDS to China titled ―AIDS control & Harm reduction: exchange and 30 Planned outputs at Component Actual outputs/outcomes at ICR Appraisal cooperation in Central Asia‖. Sub-component 1.2: Surveillance and Regional Monitoring and Evaluation Systems - TA for M&E system - Report on needs assessment in HIV epidemiological development; surveillance training in Central Asian region developed; Regional workshops - Mid-term assessment of HIV/AIDS Epidemic Prevention on surveillance and State Program and its social and economic effects in the M&E; Kyrgyz Republic for 2006-2010 conducted; - HIV/AIDS - 2 training events in Ukraine conducted: (a) study tour to laboratory equipment Kiev to learn best practices in epidemiological surveillance and supplies (KZ, KG, and (b) training course in Yalta: ―Methods in HIV/AIDS TJ, UZ); surveillance in high-risk populations; - Quality assurance - 18 pilot sites for sentinel surveillance were established: 3 in equipment (KZ, KG, Kazakhstan; 6 in Kyrgyzstan; 5 in Tajikistan and 4 in TJ, UZ); Uzbekistan; - Test kits for sentinel - 13 of 18 pilot sites were supplied with lab equipment and surveillance (KZ, KG, consumables, refrigerators, chamber freezers, power TJ, UZ); generators, vehicles and IT equipments; staff trained; - Connection fee for - Test systems procured on annual basis since 2007 for laboratory electronic primary level (screening tests) and confirmative level (expert surveillance (KZ, KG, tests) for diagnosing selected high-risk groups for three TJ, UZ); infections: HIV, hepatitis C and syphilis (approximately - IT equipment and 4,000 test kits, each of which can be used 96 times); software purchase for - Up to 7200 units of data per country were collected and further development of inputted into EpiInfo software, with short-term expert surveillance and M&E assistance; (KZ, KG, TJ, UZ); - Food baskets, mobile phone sim cards, etc. were procured - Vehicles (KZ, KG, and used as incentive for survey participation; TJ, UZ); - 528 specialists at 18 sentinel surveillance pilot sites received basic training on how to carry out surveillance; - Sixteen (16) national sentinel surveillance reports prepared between 2007-2010 and disseminated at well-attended national conferences; - 112 experts trained in voluntary counseling and testing, and 240 lab experts received basic and advanced training in laboratory research quality control; Electronic surveillance software was developed; - 8 sets of IT equipment and other network supplies were supplied to AIDS Centers to improve communications at national level; - 120 specialists trained in electronic surveillance through 3 regional training events. Most of them received extensive on- the-job training by the software developer and RPMU trained staff. 31 Planned outputs at Component Actual outputs/outcomes at ICR Appraisal Sub-component 1.3: Human Resources Development - Training of lab - Needs assessment report for the Central Asian Training and personnel in M&E Information Center on Harm Reduction; (KZ, KG, TJ, UZ); - Study of level and factors of vulnerability of labor migrants - Training of in relation to infection and spread of HIV in Uzbekistan; epidemiologists (KZ, - 4 Regional Training Centers were established on (a) KG, TJ, UZ); Epidemiological surveillance (Kazakhstan), (b) Harm - TA and regional reduction (Kyrgyzstan), (c) HIV prevention among migrants workshops for (Tajikistan), and (d) Treatment, care and support to PLWHA development of (Uzbekistan); curriculum for NGOs, - Training program on prevention of HIV among youth was TP, uniformed services developed in Kazakhstan and shared with the other three (KZ, KG, TJ, UZ); countries; - Regional (ToT) and - 5 study tours conducted: national training for (a) ―Initiation of Adult ART training course with ToT NGOs, TP, uniformed component‖ at Lavra AIDS Clinic Training Center in services; Ukraine; - TA and equipment (b) Training course ―Advance ART with ToT component‖ for Regional in Russia; Prevention Resource (c) Study tour to the Center for treatment of disease Network creation; dependency through pharmacotherapy method in Lithuania; - TA and regional (d) Study tour to Monar (Krakow) to learn experience of workshops for rehabilitation center for expansion of harm reduction services development of Central Asia; curriculum for opinion (e) Study tour to Zagreb on strategic planning and leaders; management of knowledge hubs; - Regional (ToT) and - 330 specialists at regional level and 557 specialists at national training for national level were trained at RTCs in respective areas journalists and (prevention of HIV among migrants and their family religious leaders; members, advocacy on harm reduction, ART for adults, - Publication and gender aspects of HIV/AIDS, etc.); dissemination of - 24 journalists were trained in regional ToT training events curricula and training and 122 journalists were subsequently trained in national materials; cascade training workshops to improve coverage of - Training for grant HIV/AIDS issue in the region; applicants; - Assessment study on the role and involvement of religious - Equipment and leaders in HIV prevention activities in Central Asia was connection fee for carried out. Subsequently, ToT manual for Muslim religious videoconferencing leaders was developed; facilities; - Regional working group was established to build capacity - Operating costs of of religious leaders, which convened 5 times; Regional Prevention - Study tour to Cyprus was conducted to enhance knowledge Resource Network; of Muslim religious leaders from Central Asia; - Operating and - 93 religious leaders were trained in regional ToT training maintenance costs of events, and 63 religious leaders were subsequently trained in videoconferencing national training workshops; facilities. - Training course for trainers in HIV/AIDS was integrated 32 Planned outputs at Component Actual outputs/outcomes at ICR Appraisal into the curriculum of Islamic Universities in Tajikistan. 34 contracts for goods (US$1,259,935) and 223 consultancy contracts (US$1,612,328) were concluded under Component 1. Planned outputs at Actual outputs/outcomes at ICR Appraisal Component 2: - Small and large - Grant Recipient Handbook and RAF Operational Manual Regional AIDS grants (IDA); were developed (subsequently, revised twice to incorporate Fund - Small and large lessons learned over the course of grant distribution cycle); (US$14.31M) grants (DFID); - 7 grant cycles were carried out (4 cycles for small grants - Int. and local TA for and 3 cycles for large grants); identification of - 221 small grants (US$6.5 M) and 11 large grants (US$8 M) critical investment were approved; areas; - 4 TA contracts were signed to evaluate large project - Int. and local TA for proposals and their progress between 2007-2010 (one per sub-project evaluation; year); - Local TA for sub- - One TA contract was signed to evaluate RAF impact and project supervision; one contract was signed to audit use of funds by selected - TA for Regional sub-project recipients; AIDS Fund - Over 103.5 thousand IDUs reached with HIV prevention management services; (Component - Over 331 thousand migrants and around 40 thousand sex coordination); workers were reached with HIV prevention services; - IT and office - 31.9 thousand of PLWHA were reached with care and equipment and support services (including palliative care); furniture for - Nearly 2 million needles and syringes (procured mainly by Component; the Global Fund) distributed among IDUs under harm - Incremental reduction services; operating costs. - 1.6 million condoms (procured mainly by the Global Fund) distributed among risk groups. 6 contracts for goods (US$69,969) and 10 consultancy contracts (US$180,251) were concluded under Component 2. Planned outputs at Actual outputs/outcomes at ICR Appraisal Component 3: - TA for Regional - Project Operational Manual was developed; Project Project Management - 14 staff at regional and 12 staff at national level were Management (RPMU); involved in project implementation; (US$3.99 M) - TA for country - 20 training events attended by RPMU staff on technical coordination (CAAP and fiduciary issues; National - 4 project national offices were renovated (US$19,400 in Coordinators); total); 33 Planned outputs at Component Actual outputs/outcomes at ICR Appraisal - TA for M&E, - IT and office equipment was procured for RPMU and baseline studies, MTR; national offices (US$121, 500). One vehicle was procured - Outsourcing for RPMU (US$34,500); administrative and - Incremental operating costs, including office running costs, fiduciary services rental of cars for the national offices, office supplies and (procurement, FM, stationery, translation services and travel expenses); accounting, - Approximately 50-60 project monitoring visits were carried translation); out annually by RPMU staff; - Training for RPMU - External support was provided by IT experts to national staff; offices; Conferences; International TA was engaged to assess project management - IT and office and structure; equipment and - 5 audited reports prepared by independent auditors and furniture; submitted to the Governments, EurAsEC and World Bank; - Annual financial - Quarterly Progress Reports were prepared timely and audits; submitted to Governments, EurAsEC and World Bank; - Incremental - Detailed project brochures were developed in 2008 (mid- operating costs of term) and 2010 (final) to disseminate project results; RPMU; - 33 implementation-related decisions of RPSC were issued - RPMU non-resident over the course of the project. staff relocation and housing allowances. 13 contracts for goods (US$142,748) and 115 consultancy contracts (US$1,689,620) were concluded under Component 3. 34 Annex 3. Economic and Financial Analysis Epidemiological context: The overall epidemiological scenario in the region suggests that the absolute levels of HIV infection will continue to increase (See review by Thorne et al, cited above). UNAIDS projections for the region, based on the spectrum model predict ongoing growth in HIV in all four countries.44 The proportions of new infections arising from SWs appear to be gradually displacing the proportions arising from IDUs. The trends among young pregnant women, as a surrogate for new HIV infection show some attenuation in Kazakhstan. However, considerable methodological uncertainties exist on interpretation of these trends. Indeed, a key recommendation of this ICR is for systematic analyses of the entire sentinel surveillance data to sort out key trends and changes over time. In the context of overall increases (or at least no demonstrable decreases) in HIV infection in the region, the impact of the project can best be understood as to whether it decreased transmission in specific groups, or if it enabled a better response (via surveillance, training, capacity building, leverage of additional funds, etc.) for the future. The starting point is to look at expenditures from the RAF on various risk groups. RAF small grants spending: Analyses of the spending on small grants show the following key features. These data were provided by RPMU for all countries. Some duplication of numbers is expected as a small proportion of all grants covered multiple risk groups. The key findings are:  Only 22 percent of the overall project spending on small grants and 21 percent of all sub-projects focused on broad high-risk groups (IDUs, SW, prisoners and MSM). Of these, there is little doubt that IDUs and SWs are the ―core‖ high-risk groups, and the spending on these two groups alone was even lower.  Spending on these broad risk groups varied considerably, being highest in Tajikistan (49% of total spending) and only 5% in Uzbekistan. Uzbekistan spent over 54% of funds on lower risk groups of medical personnel and other general populations.  The absolute number of IDUs and SWs covered was about 36,000 and 14,000, respectively. Estimates of the total number of IDUs and SWs in the region are not known (i.e., denominators), and thus what proportion of the eligible population the project might have covered. This is a recommended follow up step from this ICR.  The unit costs per beneficiary vary greatly across the countries. The highest costs per beneficiary were generally for People Living with HIV/AIDS (PWLHA). 44 www.unaids.org/en/regionscountries/regions/easterneuropeandcentralasia/. 35  The highest absolute numbers of any group covered were migrants (0.5 M) and youth (0.4M), but these groups are not likely to contribute many new infections and have low seroprevalence rates (see sentinel surveillance data).  The focus on high-risk groups improved slightly after the MTR and formal restructuring. This focus was evident in the adjusted grant spending patterns, increased attention of NGOs to high-risk groups and reflected in the various aide memoires. Also, by the later stages, more diffusion of practice in reaching high-risk groups with condom provision was available from bilateral organizations’ project (e.g. CARHAP) experience and from wider diffusion of the NGO training materials from CAAP. Economic and Financial Analysis: The PAD had an economic analysis with estimated rate of return. However, this was based on assumptions about how many cases of HIV infection and HIV/AIDS deaths might be avoided from the original project design that envisioned attenuation of the HIV epidemic. With the revised project DOs, it is not possible to estimate the economic benefits using comparable methods. However, very crudely, if the project covered (conservatively) about 40,000 IDUs and 15,000 SWs, these would, based on the literature, represent about 5,000 new HIV cases avoided from injection and about 1,000 avoided from SW. These 6,000 avoided cases represent about 20 years of Disability Adjusted Life Years (DALY; weighted by age preference and a discount rate of 3 percent), or about 120,000 DALYs saved over a 20-year period. If each DALY is valued (again conservatively) at three times the regional average GDP of US$600/capita (adjusted for a 5 percent annual income growth), then the non-discounted value would be US$260 million, or in discounted (at 3 percent) terms, about US$77 million. The discounted project costs are about US$22 million (assuming an inflation rate of 11 percent). Thus, in crude terms, the total economic benefit exceeds the projected costs several fold. This further suggests that high coverage of high-risk groups might have made the economic returns from the project even greater. However, the estimation is sensitive to the value of life- if each healthy year of life is valued only at average per capita income, then the project has only modest overall benefit. Finally, the lack of alignment of outputs of the project with the reduced HIV transmission effectively means that it is quite difficult, if not impossible, to assess the economic returns from the rest of the project. Surveillance activities generate important information effects and as public goods, it is hard to evaluate the returns from such information. Indeed, it might be plausible that the economic returns from the rest of the small grants program would be zero. A recommendation from this ICR is to organize a formal economic analysis of the project. Finally, a full fiscal impact is not undertaken here. The surveillance, operations and maintenance costs associated with the project are quite small (the total annual cost for all Regional Training Centers, including programmatic and operating costs (salaries, communication, etc.), is only about US$0.6 million), and can be easily accommodated within the annual health budgets of the four countries. There is no recurrent cost liability with the RAF (small grants program), and indeed some external assistance from GFATM and PEPFAR will continue a few of these grants, albeit only at national levels. The project had originally envisioned the RAF funding being transferred to other sources, but this goal was dropped at restructuring. Thus, the overall fiscal burden associated with the project is small. 36 Table A3.1 - Analysis of spending by the RAF by risk groups (whole project) High-risk groups Lower risk groups % on high risk Medical groups/total IDUs SWs Prisoners MSM Migrants Youth PLWH personnel Others All groups spending Kazakhstan No 14 11 8 2 5 9 16 11 19 95 37% $ total $333,545 $168,140 $298,841 $97,000 $226,814 $233,781 $325,261 $249,181 $249,181 $2,149,920 40% No beneficiaries 13903 4693 10948 4604 8707 37402 2510 1861 15392 100020 34% $ per beneficiary $24 $36 $27 $21 $26 $6 $130 $134 $16 $21 Kyrgyzstan No 3 1 2 0 10 11 7 5 25 64 9% $ total $21,293 $339 $17,826 $0 $272,427 $114,254 $83,410 $38,326 $99,815 $647,690 6% No beneficiaries 1807 120 982 0 138109 216255 833 1321 38574 398001 1% $ per beneficiary $11.78 $2.82 $18.15 -- $1.97 $0.53 $100.13 $29.01 $2.59 $1.63 Tajikistan No 14 10 1 1 14 8 2 6 10 66 39% $ total $289,818 $148,774 $5,000 $29,791 $225,743 $52,498 $20,818 $29,840 $119,008 $1,723,571 27% No beneficiaries 5435 7561 126 298 33942 25350 700 596 1270552 1344560 1% $ per beneficiary $53.32 $19.68 $39.68 $99.97 $6.65 $2.07 $29.74 $50.07 $0.09 $1.28 Uzbekistan No 6 3 0 0 25 10 16 30 41 131 7% $ total $160,855 $31,672 $0 $0 $1,086,301 $144,635 $417,450 $475,988 $437,884 $2,754,785 7% No beneficiaries 14719 1229 0 0 476441 103887 12797 17336 573342 1199751 1% $ per beneficiary $10.93 $25.77 NA NA $2.28 $1.39 $32.62 $27.46 $0.76 $2.30 All countries No 37 25 11 3 54 38 41 52 95 356 21% $ total $805,512 $348,925 $289,842 $126,791 $1,811,286 $545,169 $846,939 $793,334 $905,887 $7,275,965 22% No beneficiaries 35864 13603 12056 4902 657199 382894 16840 21114 1897860 3042332 2% $ per beneficiary $22 $26 $24 $26 $3 $1 $50 $38 $0 $2 37 Table A3.2 - Analysis of spending by the RAF on high risk groups (stratified pre- and post-MTR) High risk groups % on high risk groups/total IDUs CSWs Prisoners MSM spending Post- Post- Pre- Post- Pre-MTR MTR Pre-MTR MTR MTR MTR Pre-MTR Post-MTR Pre-MTR Post-MTR Kazakhstan No. of projects 2 12 1 10 3 5 0 2 23% 42% $ total $13,942 $319,604 $11,043 $157,097 $52,726 $214,290 $0 $97,000 21% 50% No beneficiaries 1758 12145 247 4446 3688 7260 0 4604 16% 44% $ per beneficiaries $8 $26 $45 $35 $14 $30 -- $21 Kyrgyzstan No 1 2 1 0 2 0 0 0 13% 6% $ total $19,310 $1,983 $339 $0 $17,826 $0 $0 $0 20% 0% No beneficiaries 568 1239 120 0 982 0 0 1% 1% $ per beneficiaries $34.00 $1.60 $2.82 -- $18.15 -- -- -- Tajikistan No 3 11 8 2 1 0 0 1 32% 50% $ total $13,022 $276,797 $101,818 $46,956 $5,000 $0 $0 $29,791 43% 55% No beneficiaries 3379 2056 6761 800 126 298 17% 0% $ per beneficiaries $3.85 $134.63 $15.06 $58.70 $39.68 -- -- $99.97 Uzbekistan No 5 1 3 0 0 0 0 0 13% 1% $ total $137,433 $23,422 $31,672 $0 $0 $0 $0 $0 18% 1% No beneficiaries 13509 1210 1229 0 0 0 0 0 2% 0% $ per beneficiaries $10.17 $19.36 $25.77 NA NA NA NA NA All countries No 11 26 13 12 6 5 0 3 19% 23% $ total $183,707 $621,805 $144,872 $204,053 $75,552 $214,290 $0 $126,791 22% 26% No beneficiaries 19214 16650 8357 5246 4796 7260 0 4902 3% 2% $ per beneficiaries $10 $37 $17 $39 $16 $30 NA NA 38 Annex 4. Bank Lending and Implementation Support/Supervision Processes (a) Task Team members Responsibility/ Names Title Unit Specialty Lending Dorothee B. Eckertz Senior Operations Officer ECSH1 Joana Godinho Sector Manager LCSHH Michael T. Mertaugh Consultant IEGPS Michael Mills Consultant AFTHE Sherly Rajan Resource Management Assistant PA9CT Julie Wagshal Budget Assistant CCRDR Supervision/ICR Galina Alagardova Financial Management Specialist ECSO3 Bibigul Alimbekova Consultant ECSHD Ainoura Alzhanova Resource Management Assistant ECACA Anne Margreth Bakilana Economist ECSH1 Dorothee B. Eckertz Senior Operations Officer ECSH1 Amy Evans Consultant ECSS1 Joana Godinho Sector Manager LCSHH Ana Holt Health Specialist ECSH1 Dilnara Isamiddinova Senior Operations Officer ECSO1 Nedim Jaganjac Senior Health Specialist ECSH1 Elena Karaban Communications Officer ECAEX Katja Kerschbaumer Junior Professional Associate ECSHD Arsen Khadziev ET Consultant ECSHD Naushad A. Khan Lead Procurement Specialist SARPS Hannah M. Koilpillai Senior Finance Officer CTRFC Gyulaiym Kolakova Team Assistant ECCKG Vladimir Kolchin Economist ECSP1 Nurbek Kurmanaliev Procurement Specialist ECSO2 Jody Zall Kusek Adviser HDNGA Lusine Mirzoyan Consultant HDNGA Rianna L Mohammed Health Specialist AFTHE Nino V. Moroshkina ET Consultant ECSH1 Matluba Mukhamedova Communications Officer ECCUZ Tawhid Nawaz Operations Adviser AFTHD Son Nam Nguyen Senior Health Specialist ECSH1 Irina Nizamova Program Assistant ECCKA Senior Financial Management John Otieno Ogallo ECSO3 Specialist Igor Oliynyk ET Consultant ECSHD 39 Tamer Samah Rabie Senior Health Specialist ECSH1 Karthika Radhakrishnan Senior Program Assistant SASHD Flora Salikhova Consultant ECSHD Asel Sargaldakova Senior Health Specialist ECSH1 Nikolai Soubbotin Senior Counsel LEGEM Anara Tokusheva Program Assistant ECCAT Natalia Tourchina Team Assistant ECCKG Merrell J. Tuck-Primdahl Senior Communications Officer DECOS Joseph J. Valadez Consultant SASHD Juliana C. Victor-Ahuchogu Consultant AFTDE Yuling Zhou Senior Procurement Specialist ECSO2 Betty Hanan Senior Consultant ECSHD Baktybek Zhumadil Operations Officer ECSH1 Gabriel Francis Program Assistant ECSHD Regina Nesiama Program Assistant ECSHD Aigerim Aiguzhina Team Assistant ECCKZ (b) Staff Time and Cost Staff Time and Cost (Bank Budget Only) Stage of Project Cycle USD Thousands (including No. of staff weeks travel and consultant costs) Lending FY04 16.88 182,349.60 Supervision/ICR FY05 84.50 308,702.10 FY06 82.22 245,992.50 FY07 68.47 222,859.50 FY08 56.05 202,162.30 FY09 77.85 178,066.20 FY10 36.85 152,271.20 FY11 42.82 287,348.70 FY12 26.29 130,774.00 Total: 481.45 1,898,216.10 40 Annex 5: Beneficiary Survey Results N/A Annex 6: Stakeholder Workshop Report and Results N/A 41 Annex 7: Summary of Recipient’s ICR and/or Comments on Draft ICR CENTRAL ASIA AIDS CONTROL PROJECT PROJECT COMPLETION REPORT 42 1. DESCRIPTION AND PROJECT START UP 1. Central Asia has been experiencing four overlapping epidemics - HIV/AIDS, drug abuse, sexually transmitted infections (STIs), and tuberculosis (TB) - that mostly have youth at its center. Since 2001, the World Bank has carried out sector work on HIV/AIDS, STIs and TB in Central Asia’. In November 2003, the Bank and UK’s Department for International Development (DFID) initiated discussions with the Governments of Central Asia about the possibility of financing a regional operation that will further assist implementation of the regional and country-specific strategies to control HIV/AIDS. 2. The Central Asia AIDS Control Project (CAAP) funded by the World Bank and the DFID was implemented since 2005 in four Central Asian Countries: Kazakhstan, Kyrgyzstan, Tajikistan and Uzbekistan. 3. The CAAP was the first regional initiative in the Central Asia Region in the area of HIV response. Launching this initiative was risky and challenging at the same time since there had been no similar previous experience in the region, and it was not clear ex ante whether the implementing body, with its proposed structure, would manage to be efficient and effective on both regional and national grounds. Difficulties and bottlenecks were enormous; these needed to be overcome in order to bring the initiative to success. 4. The development objective of the project was stated as ―Contribute to controlling the spread of HIV/AIDS in participating countries in the Central Asia Region by establishing regional mechanisms to support national HIV/AIDS programs‖. 5. The outcome indicators were: i) to develop institutional framework to inform policies at national/regional levels; ii) to establish of Central Asia Regional AIDS Fund; and iii) to strengthen the capacity and cooperation between the Public, Nongovernmental (NGOs) and the Private sectors on the Regional and National levels 6. The project consisted of three components: Component 1 (US$ 7.3 million) was aimed at: (a) creating a favorable environment for the implementation of an appropriate HIV/AIDS regional strategy; (b) improving information and decision-making based on the quality epidemiological data; and (c) strengthening institutional capacity; Component 2 (US$ 15.5 million) - the Regional AIDS Fund (RAF) that was established to finance, through sub-projects, national and regional initiatives; and Component 3 (US$ 3.7 million) consisted of the Project Management and M&E. This component financed project management and monitoring and evaluation of the whole project. 7. The Eurasian Economic Community (EurAsEC) who was the main Recipient of the IDA grant is the successor of the Central Asia Cooperation Organization that provided legal framework for the project. The project management arrangements were detailed in the document CAAP’s Operational Manual. The high-level management of CAAP was implemented through a Regional Project Steering Committee (RSC) composed of the Vice-Prime Ministers of Kyrgyzstan, Tajikistan and Uzbekistan, the Minister of Health of Kazakhstan, as well as UNAIDS representative. The RSC was designed to provide CAAP with strategic direction, discuss complex regional issues, and serve as a policy forum to reflect the views and concerns of the benefiting countries on policy development and regulatory harmonization for HIV. The actual project implementation was done by the RPMU and national project offices. Also, on the national level, fiduciary and grant administration procedures were implemented with the support of the United Nation Development Program (UNDP). 2. PROJECT DESIGN, IMPLEMENTATION AND IMPACT 8. In general, the project was implemented in line with project implementation plan and by Project Year (PY) - 4 and achieved most of its forecasted outputs with exception of delayed implementation of certain sub-component activities. Due to savings made over the project implementation and with the purpose of utilizing all the project resources, the Grant was first extended until September, 2011. This also allowed 43 smooth preparation and start up of Regional One Health Project, which was implemented by the efforts of the same team. For the purpose of full completion of the project and closing all accounts, based on the Decision of RSC and agreement between Recipient and Bank, the project was further extended until the end of December 2011. 9. In terms of funds disbursement, 99.5% of allocated US$25.00 million IDA grant was utilized. DFID’ funds in the amount equivalent to US$1.55 million (including exchange difference) was fully disbursed in 2010. Disbursement of funds by components was as follows: Component 1 – US$ 8.24 mln or 118.4% of the component funds; Component - 2 – US$14,31 mln or 86.0% of the component funds and Component 3 – US$3.99 mln or 158.3% of component budget. Lower than planned disbursement of the Component 2 is explained by the fact that some of the last implemented sub-projects were partially cancelled and not all of the funds were utilized. Taking into account that grant distribution cycle process took at least 1 year time, the unutilized resources under Component 2 were redirected to other activities in the last project implementation year. Detailed activities carried out within the scope of each component are given below. Component 1: Regional Coordination, Policy Development and Capacity Building 10. To facilitate regional coordination and policy development, 4 partners’ forums were organized by the project on an annual basis since 2007. The results of these assured better coordination of activities, improved dialogue, discussion and agreement of priority issues in the prevention of HIV/AIDS. During the forums, decisions were made to harmonize the efforts made by all interested parties. One of the key results of the Partners Forum was the Regional Strategy on prevention of HIV/AIDS that was developed over the years and discussed with Partners. In October 2009, during another Health Council meeting under EurAsEC, the draft of Regional strategy was approved and disseminated to the stakeholders. 11. 5 annual meetings of Interregional Parliamentary group also contributed to harmonization of the efforts in the area of legislation framework. During the project life, Tajikistan made amendment to its law in HIV/AIDS, Uzbekistan prepared amendment to the law which is at the stage of adoption, and Kyrgyzstan prepared draft law that covered the issues of harm reduction and substitute therapy. Parliamentarians from Azerbaijan who joined CAAP also contributed to the development of a new law on HIV/AIDS in their country that was adopted in 2010, which is considered as an unexpected project outcome. At the end of 2010, normative acts compilation handbook was developed by the project and disseminated on national levels. 12. During the second half of 2010, assessment of safe injection and vascular access practices in health care facilities was conducted in all the four countries with the support of CDC. A total of 81 specialists were trained by CDC who carried out field works. Preliminary results were discussed during the regional conference in December 2010, final versions were presented in September 2011 in Almaty. 13. Research on needs assessment in use of disposable medical instruments in state medical entities in Kazakhstan, Kyrgyz Republic, Tajikistan and Uzbekistan was carried out by a consulting firm, results of which were discussed during the project final conference in December 2010. Ministries of Health welcomed the assessment and used the findings and recommendations in their planning activities. 14. Surveillance and regional M&E systems sub-component was focused on supporting two areas: sentinel surveillance (SS) and electronic surveillance (ES). 15. 13 sentinel surveillance sites were established and supported by the project since the beginning of the project. At later stages, with the request of the countries, additional 5 sites were included into the project. Support was provided in the form of procurement and supplied of lab equipments and consumables, and subsequent trainings, refrigerators, power generators, vehicles, IT equipments and other goods, as well as training AIDS Center’s personnel. On an annual basis starting from 2007, project procured test systems for primary level (screening) tests and confirmative level (experts) tests for diagnosing selected high-risk groups for three infections: HIV, hepatitis C and syphilis. For the purpose of the collection of data, special registration forms were completed that were entered into Epi-Info database software. The volume of the 44 forms varies from country to country and reaches up to 7200 forms in a country. To attract people for interviewing, various incentives were provided such as package of food, mobile phone sim cards, etc. 16. In terms of capacity building of the medical personnel involved in the surveillance process, epidemiologists, lab specialist, dispensary personnel, IT experts and others received basic and advance level of trainings on data collection, entry, processing and analysis and preparation of reports. 3 separate trainings were conducted in each of the project benefiting countries and a total of 528 specialists were trained. 17. Sixteen (16) national sentinel surveillance reports were prepared and disseminated between 2007- 2009 through national conferences in which government sector representatives, NGOs and international partners participated. The results of the SS were used for preparation of grant proposals, national programs on HIV/AIDS prevention and country reports. Besides, national workshops were conducted on voluntary consulting and testing for 112 representatives of NGO and AIDS Centers and basic and advanced training workshops for control of the quality of the lab researches for 240 lab experts. 18. For the part of Electronic Surveillance, software was developed by experienced IT firm on monitoring of the HIV/AIDS infections. The software was first developed in Kazakhstan and after successfully testing, it was adopted in other three project countries. An effort was made on improving the Internet connection between the republican AIDS centers and regional centers in each country through procurement of IT equipment and other network supplies. 19. 3 regional meetings were conducted for training of 120 specialists of AIDS Centers who are currently involved in ES implementation. Most of them went through extensive on the job trainings by the software developers and RPMU trained staff. Besides, a study tour was organized for 8 experts from CAR to Ukraine were ES has been implemented successfully. 20. At this moment in 25 pilot sites of 4 countries the ES is fully established and operational. It is expected that GF funded projects and new ICAP Project who is funded by PEPFAR will continue expanding the program in CA. 21. The sub-component human resource development primarily focused on establishment of Regional Training Centers and their capacity building, which was supported through Regional AIDS Fund component as well, through providing grants. A total of 4 RTC’s were established during the project life which were targeted i) organization of epidemiological surveillance on HIV–infection (located in Kazakhstan), i) implementation of harm reduction programs (located in Kyrgyzstan) iii) prevention of HIV-infection among migrants (located in Tajikistan) and iv) treatment, care and support to PLWH (located in Uzbekistan). All four RTC established successfully and are operational to date, though sustainability of their operations on regional level is still questionable. Nevertheless, a few of them are getting government and international donors support on a national level. Necessary capacity building was conducted and required office equipments and other supports provided. With the support of CAAP trainers manuals were developed for each RTC for conducting regional ToT and national training of trainers. The gross of 330 specialists on regional level and 557 specialists on national levels were trained in various fields by RTC’s. For development of training manuals and conducting trainings, national as well as international experts were recruited. Not once study tours were organized to forefront centers (Saints Petersburg, Odessa, Kiev, Krakow, Zagreb). Works on establishment of RTC were carried out together with international partners: AIHA, IOM, Eurasian Harm Reduction Center, UNODC. 22. In order to improve awareness of the HIV/AIDS issue among the population, project worked closely with journalists and religious leaders. A total of 24 journalists were trained through regional seminars who further trained 122 journalists on a cascade basis on the national levels, which led to better coverage of the HIV/AIDS issue in the region. Trainings were conducted in close collaboration with UNESCO. 23. Regional working group was established to work in the area of building capacity of the religious leaders that convened 5 times. Manual was developed for Muslim religious leaders that highlighted 45 addressing the HIV/AIDS issue from religious point of view. Basic and advanced training was conducted with the support of international expert. Besides, a study tour was organized by the Project to Cyprus to enhance the knowledge of the CA Muslim religious leaders. 112 religious leaders were trained through regional seminars and 63 religious leaders through national seminars. The training course for trainers on HIV/AIDS was integrated into the curriculum of Islamic Universities in Tajikistan Component 2: Regional AIDS Fund - RAF 24. As stated above initially a total of US$ 15.5 million (US$ 13.65 million from the World Bank and US$ 1.85 million from DFID) were allocated for RAF. It is necessary to note that DFID funds were used only for financing the sub-projects. RAF operations and grant administration is based on the comprehensive RAF Handbook (that includes RAF Manual and Grant Recipient Handbook) which was developed by RPMU in 2005 and later revised by international experts. By the end of 2010, the project implemented four grant rounds and approved US$6.5 million for small country-level grants and implemented three grant rounds and approved US$8.0 million for the large regional grants. Overall, the project financed 221 small (up to US$50,000) country-specific grants and 11 large regional grants focused on provision of HIV prevention and care support services to the most at-risk populations at least in two countries. 25. RAF was the first donor to provide large regional grants to the local organizations. Implementation of eleven regional grants allowed better cooperation and information exchange between different organizations working in different countries. Independent survey conducted by international experts showed that some sub-recipients that participated in implementation of the large grants rated the value of partnerships that were formed during implementation of joint regional activities even higher than the actual program results achieved during those activities and were convinced that their organizations will continue benefiting from these partnerships in the future. Detailed assessment of RAF is reflected in consultants’ report that is available publicly on project web-site. 26. The situation with availability of AIDS service organizations ready to work with RAF was a challenging issue during the first years of project implementation. In response, CAAP in conjunction with USAID-funded CAPACITY project implemented ―Community mobilization strategy‖, which focused on capacity building of potential service providers in project design, management and M&E. 27. When RAF was started none of the local organizations were ready and capable to apply for large regional grants. Therefore, during the first round RAF has agreed with international NGOs (PSI, AFEW, AIHA and JSI) that they would serve as ―umbrellas‖ for local implementing partners and would manage regional grants as principal recipients. During the first two years, RAF and its partners worked to further build up the capacity of the already experienced and respected local AIDS-servicing organizations. As the result, consortiums of several local organizations applied for funding and received large regional grants in Rounds 2 and 3. 28. The experience that these organizations received working with RAF was challenging, but gave them a great opportunity to build their capacity and increase their organizational and project management skills. Organizations improved their capacity to manage funds and projects because RAF provided them with support during the start-up and implementation (detailed RAF handbook, start-up trainings for project and finance managers and supervisory monitoring visits), but also due to the fact that RAF procedures were rather complex and sophisticated and organizations had to establish and adopt operational procedures that they did not have before. 29. Regional Technical Evaluation Committee and National Technical Evaluation Committees were established to evaluate and select large regional grants and small national grants, respectively. The members of the Committees received extensive training on evaluation process. 46 30. Overall approximately 68% of RAF funds were allocated for service provision to high-risk groups namely IDU, SW, MSM, migrants and PLWH, where the last grant round was fully targeted to high-risk populations. 31. RAF has achieved and in some cases significantly over-achieved all targets set by the project performance framework for its indicators and its implementation can be rated as fully satisfactory. 32. Funding from the RAF in the countries became de facto Institutional Development Funds where at many instances astonishing results have been achieved. This funding enabled institutions that are ready for change to move forward and implement activities that were frequently stalled by lack of operating budgets, one of the key constraints in institutional development and capacity building in participating countries. Many activities became self sustainable or were converted into government policies with far reaching effects. Examples of such sustainable integration include a training course for teachers and classroom materials on HIV prevention for youth was introduced into mandatory school curricula in Uzbekistan supported through sub-project ―HIV prevention among youth‖ by Ministry of Higher and Secondary Special Education of the Republic of Uzbekistan; second generation epidemiological surveillance sessions that were incorporated into the post graduate medical education curriculum in Uzbekistan by Tashkent State Medical Institute for Post-graduate studies; CAAP created Department for Planning, Analysis, Response and Coordination (PARC) was institutionalized under Republican AIDS Center of Uzbekistan through the Governmental resolutions; a training module on HIV and migration for nurses introduced into the curriculum of nursing schools in Tajikistan, Kyrgyzstan and in Uzbekistan under sub-project ―HIV prevention in labor migrants in Central Asian countries‖ implemented by IOM. 33. Based on project indicators, from the beginning of implementation of RAF, up to date: more than 103,5 thousand IDU’s, more than 331,0 thousand migrants, and around 40,0 thousand sex workers were reached through HIV prevention services; nearly 2,0 million needles and syringes were distributed among IDUs in harm reduction services and 1,6 million condoms were distributed among risk groups that were procured mainly by the Global Fund; 31,9 thousand of PLWH were reached through care and support services (including palliative care). 34. Besides, as a project achievement, we can state the mechanism of financing sub-grants developed under the RAF as one of the effective instruments developed in the region. Today, this mechanism is being considered by other donor organization, including the Global Fund for implementation in financing sub-projects. 35. In total, more that 230 sub-project recipients of RAF were provided with technical assistance in the area of development, implementation, monitoring and evaluation of projects. Strengthening the capacity of these organizations in the issue of project management that brought to improvement of their skills in fiduciary management, including on procurement and finance in accordance with the international practices. Component 3: Project Management and M&E 36. The Regional Project Management Unit (RPMU) was established in 2006 and was responsible to coordinate the implementation of the CAAP including program management, procurement, financial management and monitoring project activities. 37. The RPMU was established as an international fund organization and designated as Executive Body on behalf of EurAsEC for purposes of implementing the project. The highest body that is responsible for implementation of the CAAP is the Regional Steering Committee (RSC). It is a high-level regional coordination body that sets up strategic directions of the project and overseas its implementation. Having RSC at the level of Vice-prime ministers allow multi-vector interventions through the use of inter-sectoral approach to combat HIV and AIDS in the region. RSC enabled the project to discuss HIV/AIDS related policies in the region taking into account the views and interests of all countries participating in the Project. Due to a very high level representation, it was possible to bring together more sectors than just 47 the healthcare sector in the respective countries and to tackle the problem of HIV epidemic with joined forces from a multi-sectoral perspective. RSC held meeting at least 3 times a year and issued 33 decisions during the life of the project that cover different aspects of the project implementation. 38. Approximately 15 staff at head office and 4 staffs in each four countries managed the project throughout its implementation period. All project staff received various trainings and technical assistance support. Procurement and Financial experts gained extensive experience in procurement and administering funds in accordance with World Bank procedures by attending trainings and workshops, as well as receiving day-to-day support from World Bank’s team. 39. Annual work-plans and budgets were submitted to RSC and World Bank timely. RPMU timely prepared un-audited Financial Management Reports and submitted to the Government and World Bank on a quarterly basis since the beginning of the project. An independent auditing firms acceptable to World Bank conducted annual audits and over the course of project implementation no major misuse of funds was observed. All project progress reports, annual reports and project final reports and brochures were prepared timely and were also uploaded to the project web-site once published to make project more transparent and visible. 40. Monitoring and Evaluation team of RPMU received extensive support from World Bank team, who guided them in preparation of project indicators, collection of data and analyzing them. During the final year of project implementation an international consultant carried out independent evaluation of implementation of CAAP project management and structure. 41. CAAP collaborated with United Nation Development Program in implementation of the project at national and regional levels. UNDP provided on-going technical support to the CAAP in the area of fiduciary management of project activities, as well as capacity building programs. UNDP maintained a full office and programme with strong capacity in each country and, in many cases, enjoyed pre-existing partnerships with CAAP key national partners. Similarly to CAAP, UNDP tailored its approach through establishing regional mechanism for project support. UNDP country office in Kazakhstan acted as a lead office that was supported with UNDP country offices in Kyrgyzstan, Tajikistan and Uzbekistan. 42. UNDP also participated in Technical Working Groups which included representatives from different Ministries, Drug Control Agencies, NGOs, private sector. During the project implementation, TWGs assist the development of project activities including preparation of policy amendments for approval by the Regional Steering Committee; provision of expert assessment of sub-project grant applications to the Regional AIDS Fund and others. This ensured effective implementation and decision making process. 3. ANALYSIS OF ACTIONS TAKEN BY THE WORLD BANK, RECIPIENT/GOVERNMENTS AND TECHNICAL ASSISTANCE 43. At the early stages of the project implementation RPMU had some difficulties in communicating with the World Bank team, particularly on project management issues. The earlier team of the Bank (between the periods 2007-2009) was focusing very much on the micromanagement of the project and its staff, instead of focusing on the broader issues. This lead to delays in number of activities. With the change in project team from the Bank side in the middle of 2009, situation improved drastically, as the new team was focusing more on macro issues, such as dialog with the countries, the Recipient’s management – EurAsEC on possibility of expanding project results through establishment of public health platform, discussion with international partners on their support and future involvement, assessment of HIV/AIDS situation in the region, including CAAP interference, achievements and lessons learnt, attending major events initiated by CAAP (inter-parliamentary meetings, partners Forum, RSC meetings and other separate meetings with high-level people),etc. and left the project management issues to the Recipient, who is ultimately responsible for project management and performance. At the same time Bank’s new team strengthened its monitoring through regular missions, procurement post-reviews and independent assessments. 48 44. Nevertheless, the overall operation of the World Bank during course of the project implementation is assessed as efficient, useful and supportive, particularly during the last two years of project implementation. During the implementation, the project was regularly monitored by the Bank missions, assessing the status of the project components. Though in the beginning phase of the project, ranking was marginally satisfactory, in later years Bank ranked Project satisfactory. Required clearances were provided timely and adequate advice or recommendations were given. Local staff at resident mission provided continuous support for all enquiries of the RPMU. 45. World Bank conducted number of training and seminars where RPMU and other project participants managed to learn Bank procedures, and new practices. 46. Finally, at the end of the Project World Bank provided extensive guidance with procedures of closing the Project and evaluating its performance. 47. DFID’s co-financing of project activities, namely RAF component was effective and all funds were utilized during the project implementation. DFID was actively involved in supervision missions of the Bank. 48. The Recipient of Grant funds, Central Asian Cooperation Organization and its successor Eurasian Economic Community, in principle fulfilled its obligations in front of the Bank and took all the necessary actions for the support in successful implementation of the Project. Regional Steering Committee and RPMU were established in satisfactory level to the Bank. Subsequently project related documents were developed and adopted by RSC and RPMU. 49. Although with some delays, Government of Kazakhstan provided necessary conditions for RPMU to operate in the territory of the country, including immunities and privileges, exemption from the taxes and duties, office area on complimentary basis, to name a few. 50. Other Governments were also active in the lifetime of the project. In all countries, Governments issued necessary resolutions and decrees to support the smooth implementation of the Project in respective countries. Ministries of Health and their subordinate institutions were also active throughout the span of project implementation. No substantial objections and/or barriers were created by the project benefiting country Governments in successful implementation of the CAAP. 51. It is necessary to recognize the support provided to the project by other parties. Center for Disease Control and Prevention took active role in implementation of Sentinel Surveillance which they initiated back in 2003 and guidance in assessment of safe injection practices. UNAIDS provided its guidance on the overall implementation of the strategy and was represented in the Regional Steering Committee. UNDP provided substantial support in fiduciary aspect of the project on national basis and built capacity of the local small grant recipients. 52. IOM, UNODC, AIHA provided their technical expertise in the related areas to the Regional Training Centers established under the project. Active involvement of International NGOs—JSI, PSI, AFEW— helped bring best international practices and experience to Central Asian Region and thus contributed in capacity building of local NGOs. 53. Lastly, but not the least, synchronizing a number of activities with Global Fund led to efficient use of project resources. 4. SUSTAINABILITY OF PROJECT INVESTMENTS 54. The health sector reforms in Central Asia have been scaled up drastically starting from the year 2000. The generic objectives of the national wide reforms are: i) to share responsibility for health between state and patient; ii) to shift health care delivery to PHC; iii) to introduce new model of health management and health information system (HIS); iv) to strengthen maternal and child health; v) to control spread of socially significant diseases; and vi) to reform medical education system. 49 55. The Central Asia AIDS Control Project provided significant contribution to the achievement of objectives 3 and 5. This was done by providing opportunities to scale up the surveillance system including electronic surveillance and health management, by engaging diverse public and other sectors on the national and regional level in the HIV/TB prevention and by providing continuous training opportunities for NGOs and medical workers. It is rather difficult to measure the impact of the project for the health reforms of the countries at this stage. However, the outputs of the project efforts and mid-term outcomes could be referenced to understand the areas and the level of project interference. Unique opportunity to sustain better coordinated response on the regional level 56. The coordination of the project was facilitated by the high-profile Regional Steering Committee which comprised Vice-prime ministers of the project participating countries and UNAIDS coordinator. Establishment of the Regional Steering Committee (RSC) is seen as a regional coordination and harmonization mechanism of the decision-making process in the region related to implementation of the project activities. This approach has become another step in promoting the inter-sectoral approach to solution of problems related to HIV and AIDS. 57. RSC is used as one of the main driving forces for discussing the HIV/AIDS related policies in the region, taking into account the views and interests of all countries participating in the Project. 58. Due to very high level representation it was possible to bring together more sectors than just the healthcare sector in the respective countries, and to tackle the problem of HIV epidemic with joined forces, from an inter-sectoral perspective. 59. Development and approval of the Regional AIDS strategy would not be possible without existing coordination mechanisms. The Regional AIDS strategy was approved by the Council of Ministers of Health of Eurasian Economic Community in autumn 2009. The selected coordination approach proved itself effective and was used by the principal Recipient of CAAP - EurAsEC to start up not just a new but an innovative project on One Health that aimed to harmonize the preventive approach of zoonotic diseases in the Central Asia region. Implementing and sustaining Three Ones principal of UNAIDS: the work with parliamentarians 60. Enabling political and legislative environment is a key to success of any programming. HIV prevention programming in the region has benefited from the revised national legislation related to the HIV. Thus project succeeded in facilitation of those revisions by engaging in project activities parliamentarians of all project participating countries. 61. The revised legislation enables AIDS service organizations, both government and NGOs, provide uninterrupted services, prevention and treatment thereby creating equal opportunities for access to health related services for all people in need. 62. The Parliaments of Tajikistan and Kyrgyzstan in their law revision set in stone the need to work across sectors by developing and implementing the National strategic programs on the regular basis. This step enabled sustainability of Three Ones principles promoted by UNAIDS in these countries. 63. Discrimination on the basis of HIV status has also been eliminated from the legislation of project participating countries, which served as a clear sign of commitment of Central Asian countries to promote human rights and fundamental freedoms of People living with HIV and their citizens in general. Sustainability of interventions related to the quality decision making in Central Asian countries – CCM support and data collection 64. Quality and evidence base of decisions of Country Coordination Mechanisms and other stakeholders on HIV are subject to availability of reliable and up-to-date information. To ensure a synchronized approach in improving data quality, the project supported expansion of HIV sentinel surveillance in all four countries. The HIV SS program used to have spot pattern and was piloted in a few oblasts of each of 50 the project participating countries. With the joint efforts of CDC, GFATM, Ministries of Health, CAAP and civil societies of the project participating countries, HIV SS was widely implemented in all territories of Kazakhstan, Uzbekistan and in major territories of Kyrgyzstan and Tajikistan. The HIV SS was expanded into a total of 18 sites. Number of trainings and procurement of needed equipment and transportation created opportunities for the conduct of HIV SS on the regular basis. 65. Importantly, project supported institutionalizing the HIV SS in all 4 countries of the Central Asia. The success if this initiative differs from one country to another. But in general, all countries have adopted the HIV SS protocols and incorporated them into respective normative documents. Moreover, Kazakhstan and Uzbekistan developed the curricula for postgraduate students of the Medical school, so starting from 2009 all epidemiologists that work in AIDS centers were mandated to undergo this HIV SS training. This fact can be attributed to the impact of the CAAP intervention in a long run. 66. HIV electronic surveillance is another major step in improving the service provision to the People living with HIV. The project has supported development and installation of HIV ES in 25 sites. The major pilot of the system in 17 sites was implemented in Kazakhstan. Sustainability of this initiative was ensured by the countries’ efforts to continue its implementation building on the project achievements. In Tajikistan, Ministry of Health issued a decree to expand the electronic surveillance at the national level. In Kazakhstan, decree was approved by Ministry of Health to expand the electronic surveillance throughout the country. CDC supported ICAP project to continue implementation and supporting of electronic surveillance system in AIDS service centers of Kazakhstan, Kyrgyz Republic and Tajikistan. Global Fund/UNDP funded HIV prevention program in Uzbekistan, also supporting further expansion of the ES in the country. Regional TOT centres (RTC): capacity building 67. To ensure regional information exchange and training opportunities, the Project supported the establishment of the 5 regional TOT centers: 2 in Kazakhstan and one in each of the remaining project participating countries. 68. In Kazakhstan, sustainability was ensured for both the Regional TOT training center established under the CAAP and the project investments in upgrading Sentinel Surveillance. The Kazakh Regional TOT Center was set up by the CAAP with the objective to provide trainings on Sentinel Surveillance to the entire region. After the project closure, TOT center staff will become National AIDS Center staff and will be financed from state budget (related financing was included in the National Program 2011-2015). In this sense, operational sustainability is fully assured by the Government of Kazakhstan. Sustainability of the regional character of the Kazakh TOT center is uncertain though. Commitment of the neighboring countries is very low and without CAAP support in the future, the status of the Kazakh Regional TOT center will likely be downgraded to National. 69. Regarding the CAAP investment in Sentinel Surveillance in Kazakhstan, CAAP provided extensive support though procurement of equipments, vehicle, consumables and support in trainings (laboratory, epidemiology, database management etc). During the CAAP project training activities, knowledge level of the personnel was increased by at least 30%, which was measured through the regular pre/post-tests carried out during the trainings. Although, State financing procurement of the goods/consumables will be assured in the future, there are number of issues that needs to be considered, such as: i) procurement capacity of the AIDS center is weak ii) funding by State is not timely that might adversely affect timeliness of conducting surveys iii) difficulty in getting funding from Ministry of Economy as compared to getting from International Donors. Once Donors approve the budget, financing is accomplished without problem, unlike in case of the State Budget. 70. In Kyrgyzstan, CAAP project financed the establishment of Central Asian Information and Training Center on Harm Reduction by UNODC through a large grant. The Center was registered in 2008 as an NGO in Kyrgyzstan. The Government is not ready to support regional initiatives, particularly soft 51 activities (trainings, meetings, etc). There is certain likelihood that TOT Center will not be sustainable after project closing. Kyrgyzstan seems to be the only country where even the currently well functioning Sentinel Surveillance system is under serious threat of unsustainability on the long run. After significant investment in infrastructure by the CAAP (laboratory equipment and vehicles procured for three sites), the situation is such that there is no state budget allocated to consumables needed to operate the vehicles and to carry out testing (e.g., there is no state money allocated for blood filter paper). 71. In Tajikistan, the establishment of the regional TOT center was initiated under the CAAP in 2007 to address the training needs of the region on the issue of work with migrants and members of their families. By 2010, the TOT center was fully established, with 12 training modules elaborated for different target groups like state workers, NGOs, healthcare providers, religious leaders, etc. Within the CAAP framework, 2 regional and 54 national trainings were implemented after that the activities of RTC were supported through large grant (for carrying out national and regional trainings). In the initial stage (first 3 to 5 years), the TOT center will depend on international donors, with the commitment of the Center to gradually move towards self-sustainability once the capacity is strengthened and key stakeholders both from public and civil society recognize the added value of this Center. 72. In Uzbekistan, a regional TOT center was established under the CAAP to address needs for trainings on provision of treatment and care to people living with HIV in the region. The TOT Center is located in the National AIDS Center, whilst premises and facility use are free of charge. With the TA of American International Health Association, the major international partner in this initiative, TOT organized intensive on site trainings in three different cities of the Russian Federation on ART and Opportunistic Infection treatment for adults, children and prevention of mother-to-child transmission of HIV. After the closure of the CAAP, the sustainability of the Uzbek Regional TOT center will be fully assured by the Uzbek Government. The Government is planning to place the TOT Center under both Tashkent Postgraduate Institute and the National AIDS Center at the same time, and to be co-financed by both organizations. Without a future regional project, the likelihood that the TOT center will conserve its regional scope of activity is moderate. Sustainability of the Regional AIDS Fund 73. RAF funding enabled institutions ready for change to move forward and implement activities that were frequently stalled by lack of operating budgets, one of the key constraints in institutional development and capacity building in participating countries. Many activities became self-sustainable or were converted into government policies with far reaching effects. 74. Increased coverage of vulnerable populations with HIV awareness activities and mobilization of local communities, especially in rural areas, to work in HIV area was the unique and the most important input of the RAF into the national efforts to combat HIV epidemics in the region. Implementation of the RAF small grant program facilitated capacity building of local AIDS-servicing organizations and improved inter-sectoral partnerships and cooperation. Although sometimes cumbersome and complicated for inexperienced organizations, RAF procedures applied in accordance with the RAF Operations Manual helped many organizations to develop their organizational structures and procedures and made them more competitive and professional. RAF was also the first donor to give large regional grants to local organizations, which led to improved information exchange and regional cooperation. Grant selection mechanism and tools developed by RPMU for RAF were considered by most of the stakeholders as one of the most transparent and participatory in the region. 75. Although sustainability of RAF-funded initiatives and the RAF mechanism and tools itself largely depends on the availability of external funding and political will of current and future donors to continue using RAF experience, CAAP has reached its targets and developed a set of documents for transparent and justified granting mechanism which is available for national and international stakeholders and can be easily applied on the national and the regional level. 52 76. Nevertheless, many activities funded by RAF already became self-sustainable through funding of other donors (CARHAP, USAID or the Global Fund) or were converted into the government policies. As an example, to continue activities of the Regional Training Centers for HIV prevention among migrants (one of the regional grants), IOM has signed an agreement with the Population Service International (PSI) to become a sub-contractor for the USAID-funded Health Outreach Project. Within this project, it is expected that IOM will continue providing HIV prevention services to migrants and build capacity of other service providers by implementing project activities on a regional level until the end of 2015. Several local partners of the TUMAR project have continued implementation of the started comprehensive HIV-prevention model using Global Fund resources (Kurgan-Tube, Tajikistan; Aksu, Kazakhstan), as well as local administration (municipality) funds (Almaty, Kazakhstan). 77. A number of training materials developed within different RAF-funded small projects were integrated into national educational curricula. Examples of such sustainable integration include a training course for teachers and classroom materials on HIV prevention for youth that was introduced into mandatory school curricula in Uzbekistan supported through sub-project ―HIV prevention among youth‖ by Ministry of Higher and Secondary Special Education of the Republic of Uzbekistan; second generation epidemiological surveillance sessions that were incorporated into the post-graduate medical education curriculum in Uzbekistan by Tashkent State Medical Institute for Post-graduate studies; CAAP-created Department for Planning, Analysis, Response and Coordination (PARC) was institutionalized under Republican AIDS Center of Uzbekistan through the Governmental resolutions; a training module on HIV and migration for nurses was introduced into the curriculum of nursing schools in Tajikistan, Kyrgyzstan and in Uzbekistan under sub-project ―HIV prevention in labor migrants in Central Asian countries‖ implemented by IOM. 78. Similarly to the sustainability of the RAF-funded projects, sustainability of RAF granting mechanism depends on two key variables: 1) effectiveness and appropriateness of the grant financing tools and procedures developed by RAF; 2) availability of donor funds and their willingness to use developed tools and procedures. 79. In 2008, CAAP prepared and presented to EurAsEC Secretariat a set of documents, including Agreement on establishment of the Central Asia Regional AIDS Fund under the Eurasian Economic Community, RAF Development Concept and Charter. Discussion of this idea took place in 2008 and 2009 during different meetings of the EurAsEc Health Council. Further, this idea was transformed into a broader initiative of developing a Regional AIDS Strategy first, with the assumption that if the latter is approved and implemented, it would naturally lead to the need of developing a financing mechanism for its implementation. Thus, CAAP initiated discussions among partners about priority areas for the Regional AIDS Strategy, which was finalized in 2009 and approved by the Health Council of EurAsEC. The Regional AIDS Strategy contains a list of key priority areas that should be considered by all stakeholders working with HIV in the region. Implementation of this Strategy might require provision of grants to different AIDS-servicing organizations. Procedures developed and introduced by CAAP for its RAF implementation can be used to ensure the process is well-documented, participatory, country-led and transparent. Implementation of the Regional AIDS Strategy depends on the political will of the national governments and donors. However CAAP, as the result of its second component (RAF), has provided various partners with a ready-made tool in a form of a comprehensive RAF Operation Manual, which was made available to all and can be applied on the national and regional level. 5. LESSONS LEARNT AND RECOMMENDATIONS 80. Taking into consideration the fact that this is the first regional project of such nature, overall implementation of CAAP is considered satisfactory. There is a very positive impact and many project participants remained satisfied with the project. Project is expected to have its full impact on the beneficiary level in coming years as major activities were carried out in the recent two years. However 53 there were several obstacles and difficulties in project implementation that could serve as lessons learnt, leading to some recommendations for future projects. 81. The project development objectives (PDO) have been identified in participatory manner prior to the start of implementation in 2003-2005 during the consultations between IDA and Central Asian countries on the design of the project. Inability to predict the character of HIV epidemic and its potential growth in the region and globally, resulted in unrealistic planning of the project’s expected results. Thus, the original specific objectives of the project included reduction of growth rate of the HIV/AIDS epidemic. Based on the fact that this objective cannot be fulfilled within given time-frame and financial resources, as well as based on the global picture of the epidemic development, all involved parties understood that changes needed to be introduced into the PDO. Project performance was not rated satisfactory for the first three consecutive years of implementation mainly due to this incongruence. Only in 2009, with the new World Bank team leader on board, Project restructuring took place and PDO was changed as outlined in Section 4 above. Recommendation: in future, the preparation team of the Bank, its respective partners and counterparts should be careful in formulating development objectives of projects. Just relying on track trends in the growth rate of the epidemic is problematic because the incidence in some regions is based on HIV case reporting which represents only a fraction of new infections occurring in specific area/region. Specifically, due to low social-economic status as well as stigma and discrimination surrounding HIV/AIDS, it is common for members of the groups most at risk of HIV to avoid medical and social services, including HIV testing, so that the official data tend to downplay the scale of the epidemic. Thus, the baseline parameter for this PDO was likely to be underestimated. 82. Late establishment of RPMU was another factor that delayed some of the activities. Although the Development Grant Agreement between the World Bank and the Recipient signed in May 2005 foresaw the establishment of the RPMU, the RPMU was actually established in March 2006 and its legal status was certified in December 2006 when the Government of Kazakhstan ratified the host agreement signed between Ministry of Health of Kazakhstan and RPMU. Recommendations: given that in many parts of the region bureaucratic practices inherited from the Soviet time still exists, in starting up of similar project the Recipient and the Bank should be careful in identifying the conditions of the project effectiveness. An accurate action plan should be developed and Bank needs to regularly monitor implementation of the action plan. Although, it is recognized that Recipient/Borrower remains responsible for timely start up of any projects, Bank team in their best capacity should guide the Recipient/Borrower’s project team in speeding up the start up process and when necessary, the obstacles arising in the course of project start up should be conveyed to the Governments by the Bank at the highest possible level. 83. Challenges in collaboration with UNDP arose in the early years of project implementation, but the situation improved substantially later, particularly on the 5th year of project implementation. Given that it was first experience of its kind for UNDP in terms of implementation of a regional project in Central Asia and the fact that UNDP did not have a regional (sub-regional) office in Central Asia, it had to develop new mechanism to provide support to CAAP on the regional level. Regional office of UNDP in Slovakia designated Kazakhstan country office as lead office, which was responsible for coordinating other three independent UNDP country offices in the project countries. The problems started to arise when the latter country offices could not follow agreed deadlines, and reporting quality was in some cases poor. 84. While RPMU had formal communication relationship with Lead office that was responsible for consolidating reports, the lead office could not control adequately its colleagues in neighbouring country offices because of fact that neighbouring country offices were basically in the same level with lead office in terms of their formal legal status, duties and obligations. All four countries were formally accountable in front of UNDP regional office in Bratislava. In addition, the key project advisor appointed by UNDP 54 was located in Moscow, Russian Federation, that further hindered collaboration and communication between RPMU and UNDP, and within UNDP system as well. 85. In addition, UNDP faced with challenges in adopting its reporting system to the requirements of the CAAP, which was basically drawn up to meet World Bank standards and requirements. The ATLAS system of project management of the UNDP differs substantially from that of World Bank standards. This matter mainly concerned financial management and reporting. Recommendations: careful attention should be paid during the phase of project design, particularly when there are activities to be outsourced to a third party as fiduciary agent. Due consideration should be given to the experience of the fiduciary agent to run regional project, its internal arrangements with its peer agencies and most importantly the ability of the fiduciary agent to adopt to the standards and/or satisfy World Bank’s requirements. 86. Poor design of the collaboration between World Bank, Regional Steering Committee and EurAsEC could be another factor of poor project performance in early years of project implementation. Although RSC who was responsible for supervising and coordinating the CAAP, it was the EurAsEC who was ultimately accountable in front of the World Bank, because EurAsEC was the principal Recipient of the Grant, who signed the legal agreement. The lack of clear identification of the relationship between RSC and EurAsEC led to some confusion in respect to making decisions on the project implementation. Recommendations: it is highly recommended that project steering committee has clearly identified relationship with the project principal recipient, either through recipient’s representation in the board of steering committee or through clearly documented procedures describing interactions between principal recipient and steering committee and/or executive agency, whereby in the latter case, necessary steps should be taken to fully protect the interest of the principal recipient, as it is the principal recipient who is accountable to the donor. 87. Details of challenges project faced in terms of implementation are reflected in independent evaluation of CAAP project management and structure by international consultant. Nevertheless, most of the above issues were addressed effectively along the project implementation period and basically were eliminated by 2010 due to extensive experience gained and efforts of key project stakeholders. 88. Lessons learnt, particularly on management side, laid a proper foundation for One Health project that was started up quickly and implemented efficiently and effectively. One of the key factors was adopting Project Implementation Agreement between RPMU and EurAsEC that clearly identified roles and responsibilities of each party involved in the project. 6. CONCLUSION 89. Frequently, value added of the regional approach is not fully recognized or is misunderstood. Experience from CAAP presents a valuable resource for other regional initiatives and there are a number of advantages and values that regional approach can bring to implementation of national programs. In light of the aforementioned, the following arguments can be advanced to support regional activities in response to the epidemic of HIV infection : • Regional approach provides framework to raise issues that would be very difficult to address from within specific country due to political and technical constraints. Regional approach provides opportunities for peer pressure for policy change, harmonization of policies and enhances policy dialogue. 90. It is not possible to separate public health programs and political developments and fragile democracy in the region. Several countries in the region have legislation that prevents them from sending specimens of contagious agents to WHO reference laboratories for further analysis and typization. As demonstrated through CAAP, for example, with injection safety research and seminars, or with parliamentarian meetings that resulted in positive legislative changes, public health issues that might be considered even 55 as national security threats are addressed at regional level resulting in harmonization of policies and further enhancements of preventive measures. 91. The design of CAAP was unique and complex. This is the first regional initiative in the area of HIV prevention that has involved a wide group of stakeholders in the implementation on a regional level. This initiative was able to function due to the strong commitment of governments of the Central Asia Region to address this area of health. It also pioneered the use of a political umbrella organization Eurasian Economic Community to create an enabling environment for implementation of HIV prevention programs in the region. 92. The project has succeeded in a number of areas including institutionalizing the HIV sentinel surveillance, improving legal framework on HIV, platform for partners’ discussion, establishing a variety of training opportunities in the region, financing harm reduction programs, capacity building of local AIDS service providers, service delivery to population at high risks and others. The implementation of the project set the regional platform for the public health interventions in the region and can be considered as a successful pilot. Implementation of the CAAP was followed by the Central Asia One Health project that was implemented through the existing arrangements with improvements in the management arrangements that were based on the lessons learnt during the implementation of CAAP. 56 Annex 8: Comments of Cofinanciers and Other Partners/Stakeholders As stated in Section 7 (b) of the main text, when provided the draft ICR for comments, DFID raised no issues and expressed its agreement with the content of the document. 57 Annex 9: List of Supporting Documents 1. Bertozzi et al. HIV/AIDS Prevention and Treatment, in Jamison D.T. et al, Disease Control Priorities in Developing Countries, 2nd Edition, World Bank, Oxford University Press, 2006, Chapter 18; 2. Commission on Macroeconomics and Health (CMH) Working Paper Series, Paper No. 5; 3. Deryabina A. Rapid Assessment of Implementation and Effectiveness of the Regional AIDS Fund, 2010; 4. DFID Development Grant Agreement (TF055014), May 2005; 5. EurAsEC. Mid-Term Review Progress Report, September, 2008; 6. Godinho, J. et al. HIV/AIDS and Tuberculosis in Central Asia: Country Profiles. World Bank working paper No. 20. November, 2003; 7. Godinho, J. et al. Reversing the Tide: Priorities for HIV/AIDS Prevention in Central Asia. World Bank working paper series No. 54, January 2005; 8. Grant Assumption Agreement, November 2006; 9. Implementation Status Reports (2005-2011); 10. InDevelop-IPM. Mid-term Evaluation of Central Asia AIDS Control Project, July 30, 2008; 11. Japan (MoF) Development Grant Agreement (TF053750), June 2005; 12. Jha P. et al. The evidence base for interventions to prevent HIV infection in low and middle income countries. Commission on Macroeconomics and Health, Working Group 5 Paper no.24; 13. Minutes of the audio-conference between RPMU and World Bank task team, March 19, 2009. 14. Project Aide Memoires (2003-2011); 15. Project Appraisal Document, Central Asia AIDS Control Project, February 2005; 16. Project Appraisal Document, Second National HIV/AIDS Control Project in India (Report No: 18918-IN), May 1999; 17. Regional Projects, A QAG Learning Review, February 2010; 18. RPMU quarterly and annual progress reports (2006-2011); 19. RPSC Decisions (2005-2011); 20. Szabo T. Assessment of the Central Asia AIDS Control Project Management and Structure, June 2010; 21. Thorne C. et al. Central Asia: hotspot in the worldwide HIV epidemic. Lancet Infectious Diseases Journal, 10(7):479-88, July 2010; 22. World Bank Group. Country Partnership Strategy for the Republic of Kazakhstan, August 2004; 23. World Bank Group. Joint Country Support Strategy for the Kyrgyz Republic (FY2007-2010), May 2007; 24. World Bank Group. Country Assistance Strategy for the Kyrgyz Republic (FY2007-2010) Progress Report, including Joint Country Support Strategy Progress Report for the Kyrgyz Republic for the period 2007-2008, October 2009; 25. World Bank Group. Interim Strategy Note for the Kyrgyz Republic for the period FY12-13, June 2011; 26. World Bank Group. Country Partnership Strategy for the Republic of Tajikistan for the period FY10- 13, April 2010; 27. World Bank Group. Country Partnership Strategy for the Republic of Uzbekistan for the period FY12-15, November 2011; 28. World Bank. Central Asia Regional Framework Paper, February 2004; 29. World Bank. Confronting AIDS: public priorities in a global epidemic, Oxford University Press, 1999; (http://whoindia.org/LinkFiles/Commision_on_Macroeconomic_and_Health_05_02.pdf). 58 Annex 10: List of Memoranda of Understanding and Partnership Agreements Organizations Areas of cooperation Date of Responsible Notes signing person from CAAP Capacity - Legislative Review; March 17, Coordinator of MoU & Joint Project/USAID - Support to National AIDS 2006 Component 1 work plan for Coordinating Mechanism; Coordinator of 2006, 2007, - CA Risk Group Studies; Component 2 2008 - Strengthening of national M&E systems; - Strengthening of national and regional information database systems; - Implementing NGO technical trainings; - Developing HIV/AIDS Regional Training Centers; - Harmonization of Grant Application Process. CDC/USAID - Implementation of HIV Sentinel August 2, Public Health MoU & Joint Surveillance (HIV SS) and HIV 2006 Specialist work plan for Electronic Surveillance (HIV ES) Coordinator of 2007, 2008, in 13 pilot sites; Component 1 2009-2010 - Study on safe injection practices in the four CA countries. UNDP - Fiduciary services for small November Financial MoU & Joint grants in the four countries; 16, 2006 Management work plan for - Work with Parliamentarians and Specialist 2008 religions leaders. Procurement Specialist TPAA/Russia - Involvement of policy makers in September Legislative MoU HIV counteraction activities. 2006 Lawyer AFEW - Conducting the CA Forums August Public Health MoU for ―The problems of drug use and 2006 Specialist 2006, 2008, infectious diseases prevention in Coordinator of 2010 the prisons‖; Component 1 - CA Scientific Conference MoU for ―HIV/TB. Challenges and 2009 Lessons of Dual Epidemic‖. UNAIDS - Coordination of partners (Forum December Coordinator of MoU & Joint of Partners); 2007 Component 1 work plan for - Work with policy makers; Legislative 2008 - Harmonization of legislation on Lawyer HIV in CA; - Strengthening of national M&E systems. Center for Health - Development of Regional May 2007 Public Health MoU & System Training Center on Harm Specialist Work plan 59 Organizations Areas of cooperation Date of Responsible Notes signing person from CAAP Development, Reduction. Coordinator of 2007, 2008 Kyrgyzstan Component 1 Kyrgyz State Medical Institute of Retraining and Postgraduate Studies National Center - Development of Regional April 8, Public Health Work plan for Problems of Training Center/course on Work 2008 Specialist 2007, 2008 Healthy Lifestyles with Youth Coordinator of Development, Component 1 Kazakh State Pedagogic Institute of Postgraduate Studies (Ministry of Education and Science) UNIFEM - Integration of gender issues into May 2007 Public Health Joint work the developed training programs. Specialist plan for 2007, 2008 AIHA - Development of Regional May 2008 Public Health Joint work Training Center on Treatment, Specialist plan for Care and Support. 2007, 2008 CARHAP - Implementation of harm March 2008 Public Health Joint work reduction programs. Specialist plan for 2008 60 Annex 11: Revisions of the PDO and Results Framework Document PDO Wording Outcome Indicators Changes to Results Source Framework Aide memoire of Contribute to the control 1. Improved policy and enabling - Identification of Feb.12-23, 2007 of the spread of HIV in environment for regional and baseline values and Implementation Central Asia region national HIV/AIDS response; targets for included core Support Mission through the strengthening 2. Increased scale and behavioral indicators; of regional and national availability of services for most - Selection of core capacity and cooperation risk at risk populations; indicators for sub-grants. between the public 3. Increased utilization of HIV sector, NGOs and private prevention services by most at sector. risk populations; 4. Improved HIV prevention knowledge and adoption of behaviors that reduce transmission of HIV. Aide memoire of - Contribute to 1. Improve HIV prevention - Changes initiated Dec.6-14, 2007 controlling the spread of knowledge and behaviors that during February 2007 Implementation HIV in the Central Asia reduce transmission of HIV for Implementation Support Support Mission region in the period most at risk populations45 Mission finalized and 2005-2010; reached by the Project; agreed upon; 2. Increase the cooperation and - Qualitative and - Strengthen the capacity capacity for multi-sectoral, quantitative surveys and and cooperation between national and regional impact studies planned; the public, non- mechanisms involving - Elaboration of a M&E governmental (NGOs) Governments, international handbook envisaged. and the private sectors on organizations, local NGOs and the regional and national donors; levels; 3. Increase the number of Joint Multisectoral Proposals to RAF; - Establish the RAF as a 4. The share of grant proposals sustainable mechanism submitted by GOs and NGOs for financing during and jointly is increased; after project 5. Regional Partners Forum held implementation. every year; 6. RAF is established as a sustainable mechanism for financing HIV/AIDS activities during and after project implementation; 7. Successful implementation of grant cycles of regional and national grants financed from RAF; 8. Number of AIDS Service 45 SW, IDUs, prisoners, PLWHA, MSM, migrants 61 Document PDO Wording Outcome Indicators Changes to Results Source Framework Organisations trained in project management and administration. Aide memoire of Same as above 1. Improved HIV prevention - Deletion and/or Jun.15-Jul.2, knowledge and behaviors that combination of certain 2008 reduce transmission of HIV for indicators to better Implementation most at risk populations46 reflect the CAAP’s Support Mission reached by the Project: programmatic activities; a) Sex workers: Percentage of - Reduction in the SWs who received an HIV test in number of UNGASS the last 12 months and who know indicators given the their results recognition of the b) IDUs: Percentage of injecting project’s limited drug users reporting the use of capacity to impact sterile injecting equipment the national level changes in last time they injected; HIV/AIDS-related 2. RAF is established and indicators; financed beyond the life of the - Identification of Project; outputs and outcomes 3. 5 grant cycles of regional and that could and should be national grants financed from measured as well as RAF successfully implemented; results and impacts that 4. Share of Joint Multisectoral could be realistically Proposals received and funded attributed to the CAAP; by the RAF is increased; - Removal of the 5. Regional Partners’ Forum held outcome indicator for every year. prisoners; - Modifications in certain indicators’ wording and target values. Aide memoire of Contribute to controlling 1. Develop institutional - Re-wording of the Jul.12-17, 2009 the spread of HIV/AIDS framework to inform policies at PDO; Implementation in participating countries national/regional levels; - Introduction of new Support Mission in the Central Asia 2. Central Asia RAF is Intermediate Outcome Region by establishing established; Indicators; regional mechanisms to 3. Strengthen the capacity and - Introduction of specific support national cooperation between the Public, M&E management and HIV/AIDS programs. NGO and private sectors on the data collection plan; Regional and National levels. - Collection of retrospective M&E data for the revised RF. 46 Sex workers, IDUs, prisoners, PLWHA, MSM, Migrants 62 CENTRAL ASIAN REPUBLICS V 50° 60° 70° Irtysh 80° 90° o lg a MAIN CITIES MOSCOW R U S S I A N F E D E R A T I O N Novosibirsk NATIONAL CAPITALS Nizhniy Novgorod Yekaterinburg RIVERS Kazan' a Omsk INTERNATIONAL BOUNDARIES Kam ' Chelyabinsk Ob Ufa Petropavlovsk 0 100 200 300 400 500 50° Samara Pavlodar n KILOMETERS Do Kostanai Ert is t y s h) Semi (Ir 50° Saratov 40° Ural ASTANA UKRAINE Oral Lake Karaghandy Zaisan Zh a Donets'k Aktobe Volgograd iyk ( l ) Ura Don Sea of K A Z A K H S T A N Azov Vo lga Atyrau Astrakhan' Saryshaghan Lake Balkash Toretam Black Aral Sea Sea Kzlorda Almaty CHINA Sokhumi Groznyy Sy Lake rd Aktau Issyk-Kul Taraz ar iy BISHKEK Aksu a Bat'umi GEORGIA Talas Na r y n Trabzon TBILISI Caspian Shymkent KYRGYZ 40° Nukus 40° Sea TASHKENT REPUBLIC ARMENIA Dashhowuz Urgench Andizhan YEREVAN Osh TURKEY AZERBAIJAN Xankandi UZBEKISTAN Kashi BAKU Turkmenbashy Samarkand Naxcivan Lake Van T URKMENISTA N Nebitdag Bukhara TAJIKISTAN Turkmenabat DUSHANBE Tabriz Kurgan-Tyube Lake Urmia ASHGABAT Mosul Termez Eup Mary h ra tes Tigris TEHRAN AFGHANISTAN NOVEMBER 2001 IRAQ IBRD 31651 ISLAMIC KABUL This map was produced by the Map Design Unit of The World Bank. The boundaries, colors, denominations and any other information BAGHDAD REP. OF IRAN shown on this map do not imply, on the part of The World Bank Group, any judgment on the legal status of any territory, or any 50° 60° 70° endorsement or acceptance of such boundaries.