IEG Report Number: ICRR14795 ICR Review Independent Evaluation Group 1. Project Data: Date Posted: 08/24/2015 Country: Barbados Project ID: P106623 Appraisal Actual Project Name: Barbados Second Project Costs (US$M): 94.39 76.17 Hiv/aids Project L/C Number: Loan/Credit (US$M): 35.0 35.0 Sector Board: Health, Nutrition and Cofinancing (US$M): 0 0 Population Cofinanciers: Board Approval Date : 08/07/2008 Closing Date: 11/30/2013 11/30/2014 Sector(s): Public administration- Health (85%); Health (15%) Theme(s): HIV/AIDS (70%); Population and reproductive health (20%); Health system performance (10%) Prepared by: Reviewed by: ICR Review Group: Coordinator: Judith Hahn Gaubatz Judyth L. Twigg Lourdes N. Pagaran IEGPS2 2. Project Objectives and Components: a. Objectives: According to the Project Appraisal Document (PAD, page 8) and the Loan Agreement (page 5), the project objectives were as follows:  To increase the adoption of safe behaviors , in particular amongst key populations at higher risk ;  To increase access to prevention , treatment and social care , in particular for key populations at higher risk ;  To increase capacity of organizational and institutional structures that govern the National AIDS Program ;  To increase use of quality data for problem identification , strategy definition , and measuring results . The project objectives were unchanged throughout the project period; however, one key outcome target (the percentage of youth who report the use of a condom) was significantly revised. Therefore, this review assesses project outcomes before and after the project restructuring in July 2011. b.Were the project objectives/key associated outcome targets revised during implementation? Yes If yes, did the Board approve the revised objectives/key associated outcome targets? No c. Components: Component 1: Prevention and Care (Appraisal: US$ 89.65 million; Actual: US$ 72.22 million): This component was to finance three programs within the government's National Strategic Plan for HIV Prevention and Control (2008-2013): i) National Program Coordination and Institutional Strengthening; ii) Scaling Up Prevention Efforts; and iii) Improving Diagnosis, Treatment and Care. i) National Program Coordination and Institutional Strengthening: This program aimed to strengthen the capacity of the public sector, private sector and civil society partners to coordinate, monitor and evaluate their activities. Activities included: improved coordination among agencies; routine reporting on AIDS cases and deaths; periodic surveillance on seroprevalence and behavior; and redesign of the M&E system to more effectively collect high quality data. ii) Scaling Up Prevention Efforts: This program aimed to increase access to preventive services, including behavior change communications, especially among key populations at higher risk (sex workers, men who have sex with men, prisoners and youth). Activities included: research on knowledge and practices of high risk populations; development of high-impact behavior change communication strategies; and implementation of strategic actions. These activities were to be largely carried out by civil society organizations, who would prepare proposals and receive funding according to results-based agreements. iii) Improving Diagnosis, Treatment, and Care: This program aimed to increase the length and quality of life of people living with HIV. Activities included: HIV rapid testing services; training for health care workers and social workers on treatment; and establishment of referral systems for social care. Component 2: Institutional Strengthening (Appraisal: US$ 4.47 million; Actual: US$ 3.86 million): This component was to provide training and technical assistance for the National HIV Plan. Activities included: periodic reviews of the surveillance system; quality audits; and standardization of data collection methodologies. Under the first project restructuring in July 2011, development of a Health Information System was added to the project activities. Under the second project restructuring in March 2013, the institutional arrangements were modified such that project coordination and financial management functions were transferred from the National HIV/AIDS Commission to the Ministry of Finance; procurement, monitoring, and evaluation functions were also transferred to the Ministry of Health. These changes were intended to improve leadership and project management capacity, and accelerate disbursements, for the remainder of the project period. d. Comments on Project Cost, Financing, Borrower Contribution, and Dates: Project cost  The actual project cost was US$ 76.17 million, out of the planned US$ 94.39 million. The shortfall was due to underutilization of project funds for prevention activities and care activities (Component 1); the government has noted the ambitious nature of the projected activities. Financing  The project was financed in part by a Bank loan of US$ 35.0 million, which disbursed in its entirety.  According to the PAD (page 8), the project was to follow a Sector Wide Approach (SWAp) such that funding for Component 1 activities was pooled with government funds to finance the National AIDS Program.  During the first restructuring in July 2011, Bank financing of Component 2 was increased from 79% to 100% due to the government's difficulty in providing counterpart funding and the negative impact of the global economic and financial crisis. Borrower contribution  The government provided US$ 41.17 million out of the planned US$ 59.39 million. The shortfall was due to the government's difficulty in providing the planned counterpart funds as a result of the global economic crisis. Dates  July 2011: The project was restructured to refine key indicators and targets by clarifying definitions and updating target figures based on newly available data. The amount of funds allocated to civil society grants was reduced from US$ 502,000 to US$ 150,000, due to the limited number of civil society organizations operating in the country as well as the delayed launch of the grant program.  March 2013: The project was restructured again to extend the final target years for several indicators (from 2012 to 2013), given the timing of completing the relevant surveys.  November 2013: The project was restructured again to further extend the final target years to 2014. The project closing date was also extended from November 2013 to November 2014, in order to allow completion of surveillance activities. 3. Relevance of Objectives & Design: a. Relevance of Objectives: At the time of project appraisal in 2008, the HIV prevalence rate in the country was estimated at 1.5%, and AIDS constituted the greatest burden of infectious disease for the adult (15-49 years old) population. Although recent years had seen a marked increase in access to treatment and care, there had been only modest improvements in increasing knowledge and behavior change. Therefore, the objectives of this project specifically focused on increasing behavior change among key populations at higher risk and sustaining access to treatment and care. The objectives remained highly relevant to the country's National Strategic Plan (2005-2025), which identified HIV/AIDS as one of the major threats to its economic growth. Although there is no official Bank country assistance strategy for Barbados due to its graduation from IBRD, the objectives are still highly relevant to the Bank's corporate priorities to combat HIV/AIDS and infectious diseases, given the regional public goods nature of the operation. Relevance of the objectives is rated High under both the original and restructured project. b. Relevance of Design: The scaling up of behavior change interventions was likely to achieve the intended outcome of adoption of safe behaviors, particularly as it focused on targeting higher risk populations that had been identified through prior project and analytic work. The scaling up of treatment/care interventions for people living with HIV, by shifting implementation to local clinics, was also likely to achieve the intended outcomes of increased access to services. Finally, the institutional strengthening interventions, particularly technical assistance on surveillance and management of M&E data, were also likely to achieve the objectives related to increasing capacity. However, the lack of clarity in the role of the Ministry of Health, given its technical importance in implementing HIV/AIDS interventions, was a shortcoming in the project design. In addition, while project preparation documents clearly acknowledged the challenge of reaching stigmatized populations, a strategy for overcoming these challenges was not clear. Relevance of the design is rated Substantial under both the original and restructured project. 4. Achievement of Objectives (Efficacy): To increase adoption of safe behaviors , in particular amongst key populations at higher risk The PAD (page 4) identifies higher risk populations as male and female sex workers, men who have sex with men, youth, prisoners, and unemployed women. According to the ICR (page 3), the project design focused on the first three of those groups. Interventions targeting prisoners and unemployed women do not appear to be included in the project design, and therefore no outcome data are reported. Outputs  Prevention programs targeted to key populations at higher risk. Interventions included risk reduction counseling, behavior change communication, and condom promotion, and were implemented by both public sector agencies (Ministries of Health, Education, Labor, Tourism, Transport, and Housing) and NGOs. The number of programs increased from 2 in 2008 to 27 in 2014, following a high of 52 in 2012. This achieved the target of 11 programs by 2013. See data reported under the second objective ("to increase access to preventive services") for coverage of such programs.  Distribution of almost 3 million condoms. This surpassed the target of 700,000 by 2013. There is no information provided in the ICR on the recipients of the condom distribution, although the project team clarified that the project provided condoms to both the general population and targeted groups (tourists, youth, sex workers, and men having sex with men) Outcomes Knowledge  The percentage of young women and men aged 15-24 years indicating sexual relations as a way of transmitting HIV was maintained at a high level during the project period. The percentage was 94.3% in 2006, 92.3% in 2009, 96.7% in 2011, and 99.6% in 2014.  The percentage of men having sex with men (MSM) who received an HIV test in the last 12 months and knew their results is reported to have increased from 50% in 2009 to 100% in 2014. However, the ICR acknowledges that due to stigma and discrimination, the project was not able to reach the majority of MSM. Behavior - youth and general adult population  The percentage of young men and women aged 15-24 years reporting the use of a condom the last time they had sex with a non-marital non-cohabitating sexual partner increased from 21% in 2006 to 71.7% in 2014. This surpassed the original target of 31% and the revised target of 60%.  The percentage of young men and women aged 15-24 years who have had sex with a non-regular partner decreased from 29.4% in 2009 to 12.8% in 2013. There was no project-specific target reported in the ICR.  The percentage of young men and women aged 15-24 years who have had sexual intercourse before the age of 15 decreased from 19.6% in 2006 to 12% in 2014. This surpassed the target of 15%.  The percentage of adults with two or more regular partners who reported the use of a condom increased from 52.4% in 2009 to 72.6% in 2013. There was no project-specific target reported in the ICR.  The percentage of adults reporting the use of a condom the last time they had sex with a non-marital non-cohabitating sexual partner increased from 80.0% in 2009 to 86.2% in 2013. “Consistent” condom use increased from 48.6% to 54.5%. There were no project-specific targets reported in the ICR. Behavior - men having sex with men and female sex workers  The percentage of males reporting the use of a condom the last time they had sex with a male partner decreased from 65% in 2007 to 56.9% in 2014. The national program target was 75%. However, as noted in the ICR (page 10), the relevant survey reached only 126 out of the intended 400 participants.  The percentage of female sex workers reporting the use of a condom with their most recent client was not known because the planned survey was not conducted. While there was substantial evidence of improved behavior change among youth, there was insufficient evidence of improved behavior change among the key groups at higher risk (sex workers and men who have sex with men). Given this latter shortcoming, achievement is rated Modest for both original and revised targets. To increase access to prevention , treatment and social care , in particular for key populations at higher risk Outputs  Prevention programs targeted to key populations at higher risk. The number of programs increased from 2 in 2008 to 27 in 2014, following a high of 52 in 2012. This achieved the target of 11 by 2013. The number of civil society organizations working with key populations at higher risk increased from 2 to 10.  Provision of anti-retroviral treatment to people living with HIV and to HIV+ pregnant women. The actual number of people living with HIV who are receiving treatment is not reported in the ICR.  Care programs providing housing support, food bank, and psychosocial support.  Training of 408 health care providers in HIV testing and counseling. This surpassed the target of 250. Outcomes Prevention  The percentage of men who have sex with men who were reached with prevention services increased from 3.5% in 2009 to 54.4% in 2014.  The percentage of female sex workers who were reached with prevention services increased from 16.5% in 2009 to 44.5% in 2014.  The percentage of identified HIV-positive pregnant women who gave birth in the last 12 months receiving a complete course of ARV increased from 87.5% in 2009 to 100% in 2011 and 2012. However, the percentage decreased to 90.9% in 2013 due to two cases of HIV-positive pregnant women who failed to complete the course of ARV treatment. According to a detailed review conducted by the project (as reported in the ICR, page 15), there were missed cases due to the following systemic issues: the rapid HIV tests performed in labor did not provide the result prior to delivery; the results of previous HIV tests in other facilities were not recorded or available to health staff; patient reported stigma as a barrier to early access to care.  The proportion of infants born to HIV+ mothers who are HIV+ decreased from 2.6% in 2006 to less than 1% in 2013. This achieved the target of maintaining the proportion under 5%. Treatment  The proportion of people living with HIV receiving anti-retroviral treatment was 80%. Of those, 70.1% on first line treatment achieved "virological success" within the first six months of treatment, according to the project definition of success; according to the WHO definition of success, the proportion was 92.5%. Social Care  The number of people living with HIV and/or families accessing the food bank increased from 250 in 2008 to 474 in 2013. This surpassed the target of 375.  46 people living with HIV received training to improve life skills; 75 female sex workers received training in alternative employment skills. Achievement of this objective is rated Substantial, due to evidence of increased coverage of preventive, treatment, and care services. To increase capacity of organizational and institutional structures that govern the National AIDS Program Outputs  Preparation of a National HIV/AIDS Strategic Plan for 2014-2018.  Training of over 50 public sector staff on HIV work planning and program development.  Disbursement of over US$ 180,000 through the civil society organization grant system.  Training of 408 health care providers in HIV testing and counseling. This surpassed the target of 250.  Development of program guidance documents including: policy document on prevention of mother to child transmission, national HIV prevention plan, policy on HIV testing, national HIV research agenda, and strategic framework for the health sector response.  Conducting of three national knowledge, attitudes, beliefs and practices surveys, a behavioral surveillance survey among men having sex with men, an initial formative assessment for a female sex workers behavioral surveillance survey, and a stigma and discrimination survey. Outcomes  According to the ICR (page ix), the HIV/AIDS Strategic Plan was strongly evidence-based, incorporating information from epidemiological data, knowledge and behavior surveillance reports, results from the stigma and discrimination survey, two M&E assessments, the grant system consultant report, and the Virtual Health Research Unit.  The National HIV/AIDS Commission took over the administration of the knowledge, attitudes, beliefs and practices survey as a result of its improved capacity.  More than half of public sector agencies submitted work plans that were consistent with national guidelines.  An assessment of the civil society grant system showed improved proposal writing skills among the 19 CSOs that received training on proposal development. All CSOs reported on their activities during the project period.  According to the ICR (page 11), the public sector expenditure monitoring system did not allow for easy identification of HIV/AIDS-related expenditures. Achievement of this objective is rated Substantial, due to evidence of increased capacity. To increase use of quality data for problem identification , strategy definition , and measuring results Outputs  Preparation of a National HIV/AIDS Strategic Plan for 2014-2018.  Training of 683 public sector and civil society staff on M&E. This surpassed the target of 125. The number of agencies/organizations that incorporated M&E components into their work plans increased from 8 to 27.  Establishment of a Virtual Health Research Unit, whose data is accessible to researchers, students, and non-governmental organizations. It is comprised of more than 5,000 scientific publications and reports on HIV in Barbados and the Caribbean.  Development of a health information system, which includes a module on HIV/AIDS. Outcomes  According to the ICR (page ix), the HIV/AIDS Strategic Plan was evidence-based, incorporating information from epidemiological data, knowledge and behavior surveillance reports, results from the stigma and discrimination survey, two M&E assessments, the grant system consultant report, and the Virtual Health Research Unit.  According to the ICR (page 17), the project provided training on M&E "through which the importance of M&E became clear and data entry began to increase as did the number of institutions incorporating M&E components into their work plans." Achievement of this objective is Substantial, due to effective implementation of planned activities, although actual outcomes are less clear. 5. Efficiency: The PAD (Annex 9) estimated an internal rate of return for the project at 32.0%. The benefits were considered as savings in hospital, outpatient, and treatment costs due to averted cases of HIV/AIDS, as well as the indirect benefits of improved health and longer lives. The costs were represented by total project costs. The project design included a strong focus on behavior change among high risk populations, a targeted approach which was likely to contribute to efficiency in prevention efforts. The ICR (Annex 3) provides an updated estimate of 38.8%. Given the limited achievements in behavior change particularly among female sex workers and men having sex with men, it is unlikely that full benefits were realized. Financial management difficulties also likely contributed to inefficiency (see Section 11b). Therefore, efficiency in the use of project resources is considered Modest. a. If available, enter the Economic Rate of Return (ERR)/Financial Rate of Return (FRR) at appraisal and the re-estimated value at evaluation : Rate Available? Point Value Coverage/Scope* Appraisal Yes 32% 100% ICR estimate Yes 38.8% 100% * Refers to percent of total project cost for which ERR/FRR was calculated. 6. Outcome: Project under original targets - Moderately Satisfactory Relevance of the project objectives is rated High and relevance of the project design is rated Substantial. Achievement of the objective to increase the adoption of safe behaviors, in particular amongst key populations at higher risk, is rated Modest including under the original targets due to insufficient evidence of improved behavior change among the key populations at higher risk (sex workers and men who have sex with men). Achievement of the objective to increase access to prevention, treatment and social care, in particular for key populations at higher risk, is rated Substantial. Achievement of the objective to increase capacity of organizational and institutional structures that govern the National AIDS Program is rated Substantial due to evidence of increased capacity. Achievement of the objective to increase use of quality data for problem identification, strategy definition, and measuring results is rated Substantial. Efficiency is rated Modest given the high project cost (US$ 76.2 million) compared to the size of the population (277,000). Project under revised targets - Moderately Satisfactory Ratings are the same as above, including for Modest achievement of the objective to increase the adoption of safe behaviors, in particular amongst key populations at higher risk under the revised targets. According to OPCS/IEG harmonized guidelines, the overall outcome rating of a restructured project is determined by weighting the proportion of the grant that disbursed before and after the project restructuring. As the overall outcome rating in this case is the same before and after restructuring, the final outcome rating is also Moderately Satisfactory , indicative of moderate shortcomings in the project's preparation and implementation. a. Outcome Rating: Moderately Satisfactory 7. Rationale for Risk to Development Outcome Rating: Institutional and technical capacity improved notably by project closing, such that the ability to implement prevention, treatment and care activities is likely to be sustained. The newly developed Strategic Plan 2014-2018 continues to be main strategic thrust for the National HIV/AIDS Program and reflects strong political support. Financial sustainability is also likely as the budget resources of the National HIV/AIDS Commission are considered sufficient to continue activities. However, the ability to monitor and effectively reach key populations at high risk with prevention activities is unclear. a. Risk to Development Outcome Rating : Moderate 8. Assessment of Bank Performance: a. Quality at entry: The project design was built squarely upon implementation experience from the prior Caribbean HIV/AIDS - Barbados project (P075220) and incorporated numerous lessons learned from that project as well as from growing international experience. These lessons included: increasing focus on prevention efforts, improving project monitoring and generating quality data, more effectively targeting key populations at higher risk, decentralizing care programs to reduce stigma, and increasing access to anti-retroviral treatment. The M&E design was overall satisfactory, drawing upon indicators from existing monitoring systems and incorporating important evaluative activities. However, institutional arrangements had shortcomings, as the National HIV/AIDS Commission was marked by inadequate leadership and capacity, in particular in drawing upon technical expertise from the Ministry of Health (which also lacked a central point person for project activities). The ICR (page 8) also notes that there was lack of understanding about the complex reimbursable expenditure feature of the project design, including conflicting information in the PAD and the Project Operations Manual on whether capital works were eligible for reimbursement. Risk was assessed as low, with inadequate fiduciary capacity and conservative nature of the society (therefore inhibiting work with key target groups) considered only low or modest risks; however, these risks did materialize and had some negative impact on the pace of implementation. Quality-at-Entry Rating: Moderately Satisfactory b. Quality of supervision: As noted in the ICR, although more than 40 staff from different public sector agencies received financial management and procurement training at project launch, "the training provided appeared to be inadequate; in addition, some staff left and others received no training until late in implementation" (ICR, page 8). In particular, there was confusion about the reimbursement of eligible expenditures, which contributed to underutilization of project funds. However, the Bank team took the opportunity afforded by the Mid-Term Review (December 2011) to candidly evaluate implementation challenges and restructure the project, including further refining the M&E framework. Institutional arrangements were clarified, assigning financial management functions to the Ministry of Finance and supervision functions to the Ministry of Health (which now included a Project Director), which resulted in improved implementation. Quality of Supervision Rating : Moderately Satisfactory Overall Bank Performance Rating : Moderately Satisfactory 9. Assessment of Borrower Performance: a. Government Performance: The National HIV/AIDS Commission, housed in the Ministry of Family, Youth and Sports, was the main government entity providing political and strategic leadership on HIV/AIDS. It provided a supportive policy environment for the project, including as a regional leader in ensuring broad access to treatment. However, its initial performance was marked by weak coordination capacity. Additionally, the government was not able to provide its full counterpart funding obligation due to the effects of the global economic crisis. Government Performance Rating Moderately Satisfactory b. Implementing Agency Performance: After an initial period of weak performance by the National HIV/AIDS Commission, project management functions were reassigned to the Ministry of Finance and the Ministry of Health. Project disbursements and implementation performance improved notably after this project restructuring. The Ministry of Finance carried out its financial management functions effectively, and the Ministry of Health ably conducted its procurement, M&E, and supervision responsibilities. The ICR (page 9) reports that multisectoral coordination between the different agencies improved as responsibilities of the different ministries were clarified. M&E implementation was effective, with the exception of surveillance of key at-risk populations. Although the ICR reports that the project had US$ 5.75 million of undocumented expenditures that, as of the final supervision mission, were not accounted for, the government confirmed that documentation was subsequently provided. Implementing Agency Performance Rating : Moderately Satisfactory Overall Borrower Performance Rating : Moderately Satisfactory 10. M&E Design, Implementation, & Utilization: a. M&E Design: The M&E framework drew upon the existing framework for the National HIV/AIDS Plan, which was based on technically sound UNAIDS core indicators. However, baseline data for some key populations - female sex workers and men who have sex with men - were not available, and subsequent monitoring of outcomes among these populations proved to be problematic. The ICR (page 9) also notes that given the small size of some of the target populations (i.e. HIV+ pregnant women), it may have made more sense to measure progress in terms of raw numbers rather than percentages. There were critical evaluative activities planned such as behavioral surveillance, a stigma and discrimination survey, and knowledge and practices surveys. b. M&E Implementation: There were implementation challenges with M&E at the start of the project period. There were some difficulties in monitoring key populations, in part due to the conservative society (i.e. lack of tolerance for men having sex with men). For example, the behavioral survey on men having sex with men was only able to recruit 126 of an intended 400 participants. However, following the project restructuring when the Ministry of Health took on M&E responsibilities, performance improved. Most planned surveys were carried out, although monitoring of key populations remained problematic. c. M&E Utilization: M&E data was disseminated in annual reports, and regular meetings were conducted to discuss M&E information. The ICR (page 11) reports that data and survey results were used by public sector agencies to plan or modify programs. The ICR (page 10) also notes the increasing M&E culture built through the project's support, including the development of the evidence-based Strategic Plan for 2014-2018. M&E Quality Rating: Substantial 11. Other Issues a. Safeguards: There were no safeguard policies triggered by the project. According to the ICR, as this was a direct follow-up project to the Caribbean HIV/AIDS project, no new environmental assessment was required. Ongoing health care waste management activities were accommodated by the system that was established during the previous project. b. Fiduciary Compliance: Financial management: As reported above, initial financial management and procurement training was ineffective (see Section 8). This, combined with difficulties in understanding the reimbursable expenditure aspects of the project design and the lack of clarity in institutional responsibilities, contributed to challenges in monitoring project expenditures. There was no reporting system that specifically identified HIV/AIDS-related expenses, and public sector agencies were not always able to provide a comprehensive list of expenses related to the project (ICR, page 11). Audit reports were delayed due to the need to collect financial information from multiple agencies. A Special Audit conducted by the Bank during the last year of the project found that out of US$ 26.3 million initially identified as HIV/AIDS-related expenditures by the public sector agencies, only US$ 9.7 million was correctly identified, of which only US$ 6.3 million qualified for reimbursement by the project. This reflected the ongoing confusion about eligible expenditures throughout the project period. The ICR reports that there were still US$ 5.75 million in undocumented expenditures and that as of the final supervision mission, these expenditures were not accounted for. The ICR does not report any other major financial management problems and considers overall compliance to be moderately satisfactory. Procurement: Similar to financial management, there were some difficulties in procurement due to lack of understanding about the reimbursement of eligible expenditures. Following additional procurement training by the Bank, and the assignment of procurement responsibility to the Ministry of Health (in which there was staff with Bank experience), performance improved, and the ICR does not report on any major procurement problems. c. Unintended Impacts (positive or negative): None reported. d. Other: 12. Ratings: ICR IEG Review Reason for Disagreement/Comments Outcome: Moderately Moderately Satisfactory Satisfactory Risk to Development Negligible to Low Moderate The ability to monitor and effectively Outcome: reach key populations at high risk with prevention activities is unclear. Bank Performance: Moderately Moderately Satisfactory Satisfactory Borrower Performance : Moderately Moderately Satisfactory Satisfactory Quality of ICR: Satisfactory NOTES: - When insufficient information is provided by the Bank for IEG to arrive at a clear rating, IEG will downgrade the relevant ratings as warranted beginning July 1, 2006. - The "Reason for Disagreement/Comments" column could cross-reference other sections of the ICR Review, as appropriate. 13. Lessons: Lessons from the ICR, adapted by IEG (page 21-22):  Cultural constraints can be a barrier in monitoring stigmatized populations. In the case of this project, although the project design relied on civil society organizations to implement activities with key populations at higher risk (men having sex with men and sex workers), there was a lack of broader acceptance to conduct surveillance activities among these populations.  When monitoring small population sizes, measuring achievements using actual figures, in addition to or instead of percentages, provides a clearer picture of outcomes. In the case of this project, the targeted population of HIV+pregnant women (denominator) was small, and therefore the failure of just two women to complete treatment significantly affected the overall achievement measured in percentage terms. 14. Assessment Recommended? Yes No 15. Comments on Quality of ICR: The ICR is overall satisfactory. However, a more detailed report on prevention and treatment activities would have strengthened the results chain, i.e. what types and what proportion of prevention activities were conducted for the general population vs. among target populations; to which of those populations were condoms distributed; and how many people living with HIV received treatment. There was limited information on the results-based aspect of the civil society grant system, despite it being an innovative element of project design. a.Quality of ICR Rating : Satisfactory