Document of The World Bank Report No: ICR2674 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-H3990) ON A GRANT IN THE AMOUNT OF SDR 12.3 MILLION (US$ 20.0 MILLION EQUIVALENT) TO THE REPUBLIC OF COTE D’IVOIRE FOR AN EMERGENCY MULTI-SECTOR HIV/AIDS PROJECT September 13, 2013 Africa Health Sector Unit of Human Development Network AFTHW Africa Region i CURRENCY EQUIVALENTS (Exchange Rate Effective July 31, 2013) Currency Unit = CFA Francs (XOF) XOF 1.00 = US$ 0.0020 US$ 1 = XOF 494.93 FISCAL YEAR January 1 – December 31 ABBREVIATIONS AND ACRONYMS AIDS Acquired Immune Deficiency Syndrome AIS AIDS Indicator Survey ANC Antenatal Care ARV Antiretroviral Drugs CBO Community Based Organization CDC Centers for Disease Control and Prevention CSO Civil Society Organization DHS Demographic and Health Survey FBO Faith Based Organization GDP Gross Domestic Product Global Fund Global Fund to Fight AIDS, TB and Malaria HIV Human Immunodeficiency virus HMIS Health Management Information System HMSF HIV/AIDS Multisectoral Strategic Framework IDA International Development Association ISR Implementation Status Report KAPS Knowledge, Attitudes and Practices Survey M&E Monitoring and Evaluation MAP Multi-Country AIDS Project in Africa Region MARP Most at Risk Population MoH Ministry of Health NGO Non-Governmental Organization PEPFAR President’s Emergency Plan for HIV/AIDS Relief PLWHA People Living With HIV/AIDS PMTCT Prevention of Mother to Child Transmission of HIV Infection STI Sexually Transmitted Infection TA Technical Assistance TB Tuberculosis THM Transitional Health Funds from GFATM UNAIDS Joint United Nations Program on HIV/AIDS ii UNFPA United Nations Population Fund USAID United States Agency for International Development UNFPA United Nations VCT Voluntary Counseling and Testing WHO World Health Organization Vice President: Makhtar Diop Country Director: Madani M. Tall Sector Manager: Trina S. Haque Project Team Leader: Ibrahim Magazi ICR Team Leaders: Mohamed Ali Kamil, Dominic Haazen iii THE REPUBLIC OF COTE D’IVOIRE EMERGENCY MULTI-SECTORAL HIV/AIDS PROJECT CONTENTS Data Sheet A. Basic Information B. Key Dates C. Ratings Summary D. Sector and Theme Codes E. Bank Staff F. Results Framework Analysis G. Ratings of Project Performance in ISRs H. Restructuring I. Disbursement Graph 1. Project Context, Development Objectives and Design ............................................... 1 2. Key Factors Affecting Implementation and Outcomes .............................................. 6 3. Assessment of Outcomes .......................................................................................... 16 4. Assessment of Risk to Development Outcome......................................................... 34 5. Assessment of Bank and Borrower Performance ..................................................... 34 6. Lessons Learned ....................................................................................................... 37 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners .......... 38 Annex 1. Project Costs and Financing .......................................................................... 39 Annex 2. Outputs by Component ................................................................................. 40 Annex 3. Economic and Financial Analysis ................................................................. 45 Annex 4. Bank Lending and Implementation Support/Supervision Processes ............ 49 Annex 5. Beneficiary Survey Results ........................................................................... 51 Annex 6. Stakeholder Workshop Report and Results................................................... 52 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR ..................... 53 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders ....................... 57 Annex 9. List of Supporting Documents ...................................................................... 58 MAP IBRD iv Project Datasheet A. Basic Information Emergency Multi- Country: Cote d'Ivoire Project Name: Sector HIV/AIDS Project Project ID: P071631 L/C/TF Number(s): IDA-H3990 ICR Date: 02/20/2013 ICR Type: Core ICR REPUBLIC OF COTE Lending Instrument: ERL Borrower: D'IVOIRE Original Total XDR 12.30M Disbursed Amount: XDR 12.30M Commitment: Revised Amount: XDR 12.30M Environmental Category: B Implementing Agencies: Ministère de la Santé & de la lutte contre le VIH/SIDA Co-financiers and Other External Partners: B. Key Dates Revised / Actual Process Date Process Original Date Date(s) Concept Review: 06/13/2002 Effectiveness: 10/01/2008 10/01/2008 Appraisal: 02/28/2008 Restructuring(s): Approval: 06/12/2008 Mid-term Review: 11/08/2010 01/23/2011 Closing: 09/30/2012 09/30/2012 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Moderately Satisfactory Risk to Development Outcome: Moderate Bank Performance: Moderately Satisfactory Borrower Performance: Moderately Satisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Moderately Moderately Quality at Entry: Government: Satisfactory Satisfactory Quality of Moderately Implementing Moderately Supervision: Satisfactory Agency/Agencies: Satisfactory Overall Bank Moderately Overall Borrower Moderately Performance: Satisfactory Performance: Satisfactory v C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Indicators Rating Performance (if any) Potential Problem Project Quality at Entry Yes None at any time (Yes/No): (QEA): Problem Project at any Quality of No None time (Yes/No): Supervision (QSA): DO rating before Moderately Closing/Inactive status: Satisfactory D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Central government administration 24 24 Health 38 38 Other social services 21 21 Solid waste management 5 5 Sub-national government administration 12 12 Theme Code (as % of total Bank financing) Child health 16 16 HIV/AIDS 33 33 Participation and civic engagement 17 17 Population and reproductive health 17 17 Social Inclusion 17 17 E. Bank Staff Positions At ICR At Approval Vice President: Makhtar Diop Obiageli Katryn Ezekwesili Country Director: Madani M. Tall Antonella Bassani Sector Manager: Trina S. Haque Eva Jarawan Project Team Leader: Ibrahim Magazi Ibrahim Magazi ICR Team Leader: Mohamed Ali Kamil ICR Primary Author: Mohamed Ali Kamil ICR Secondary Author: Dominic S. Haazen vi F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The emergency HIV/AIDS Multi-Sectoral Project aimed to support the government response to the pandemic by: (a) Strengthening access to and increased utilization of prevention services among vulnerable and high risk groups (such as women, youth, commercial sex workers, personnel of line ministries); (b) Improving access and utilization of treatment and care services for HIV/AIDS infected and affected persons, notably the persons living with HIV/AIDS (including PLWHA and OVC). Revised Project Development Objectives (as approved by original approving authority) NA (a) PDO Indicator(s) Original Target Formally Actual Value Values (from Revised Achieved at Indicator Baseline Value approval Target Completion or documents) Values Target Years Percentage of female sex workers reporting the use of a condom with their Indicator 1 : most recent client (disaggregated by age < 25, 25+ > Value quantitative or 95% ENSEA Report 96% NA 93% (KAP 20111) Qualitative) Date achieved 12/31/2007 09/30/2012 09/30/2012 The target was 97% achieved, although the slightly below the baseline level and the data sources are different. However, given the social and Comments behavioral impact of the crisis as described in the document, as well as the (incl. % reduced number of condoms available as a result of the crisis (see IO achievement) indicator #1, also PEPFAR reports the number of condom outlets dropped from almost 2500 in 2009 to just over 1500 in 2011), attaining a level of 93% is a commendable achievement. Percentage of women and men from 15-49 years of age having had more Indicator 2 : than 1 sexual partner in the preceding 12 months and reporting condom use during these sexual intercourse 1 Analyse des Connaissances, Attitudes et Pratiques des Professionnels(les) du sexe dans dix-huit villes de Cote d’Ivoire-Avril 2012 vii Value 33.6% (F) 29.7% (F) 14.25% (F) quantitative or 51,6% (M) NA 35.7% (M) 36% (M) Qualitative) Report AIS (2005) DHS 2012 Date achieved 12/31/2007 09/30/2012 09/30/2012 The end-line data in the final ISR shows substantial improvement over both the baseline and the target. However, this data could not be corroborated from the ECAP 2011 survey which was shown as the Comments source. For this reason, the 2012 DHS was used as an alternative source. (incl. % This survey shows condom use was almost double the target for females achievement) and 99% of the target for males. Further, the detailed analysis by region (see paragraph 85 below), shows condom use in the project regions higher than for the non-project regions (37.8 versus 32.2 percent). Percentage and number of HIV-infected pregnant women who received a Indicator 3 : completed antiretroviral treatment to reduce the risk of mother-to-child transmission Value 44% (893) quantitative or 0% 75% NA MOH 2012 Qualitative) report2 Date achieved 12/31/2007 09/30/2012 09/30/2012 Comments (incl. % The target was not achieved. achievement) Percentage and number of adults and children with advanced HIV Indicator 4 : infection receiving antiretroviral therapy Value 2,710 quantitative or 0 2,500 NA MOH report Qualitative) Date achieved 12/31/2007 09/30/2012 09/30/2012 Comments (incl. % Target was achieved, and in fact exceeded by 8 percent. achievement) * (b) Intermediate Outcome Indicator(s) Original Target Formally Actual Value Values (from Revised Achieved at Indicator Baseline Value approval Target Completion or documents) Values Target Years Number of condoms distributed (male & female) among the CSW in the 4 Indicator 1 : target Project regions. 2 Programme National de la Prise en charge des PVVIH- Rapport de fin de projet- 2012 viii Value 3,094,551 (quantitative 0 5,180,000 NA (PULMS - 2012)3 or Qualitative) Date achieved 12/31/2007 09/30/2012 09/30/2012 Comments Target was not achieved. Only male condoms were acquired and (incl. % distributed by the project. achievement) Number of sub-contracts awarded and implemented for HRG and Indicator 2 : vulnerable populations Value 81 PULMS (quantitative 0 51 NA (2012) or Qualitative) Date achieved 07/15/2008 09/30/2012 06/29/2012 Comments (incl. % Target was achieved. achievement) Number of decentralized ( department) plans developed and implemented Indicator 3 : in the four regions for Health and Education Value 24 (quantitative 0 24 NA PULMS (2012) or Qualitative) Date achieved 07/15/2008 09/30/2012 09/30/2012 Comments (incl. % Target was achieved achievement) Indicator 4 : Percentage and number of CTAIL put in place and operational Value (quantitative 0 19 NA or Qualitative) Date achieved 07/15/2008 09/30/2012 This indicator has become irrelevant with the institutional change which happened in the HIV/AIDS governance in the new government following Comments the 2011 crisis. However, with the support of the project, 13 CTAIL were (incl. % established and made operational prior to the election (54% through achievement) project implementation), indicating that this indicator was clearly on target prior to the institutional change. Indicator 5 : Health personnel receiving training 3 Projet d’Urgence Multisectoriel de Lutte contre le Sida- rapport final-2012 ix Value 2633 PULMS (quantitative 0 3000 NA (2012) or Qualitative) Date achieved 02/31/2007 09/30/2012 09/30/2012 Comments (incl. % Target was substantially (88%) achieved achievement) Percentage and number of high risk groups (FSW) who received an HIV Indicator 6 : test in the last 12 months and who came back for their test results Value 12,106 MOH (quantitative 0 10,500 NA report or Qualitative) Date achieved 09/01/2008 09/30/2012 09/30/2012 Comments (incl. % The target was achieved, and in fact exceeded by 15 percent achievement) Percentage of people from at risk-groups who both correctly identify ways Indicator 7 : of preventing Sexual transmission of HIV and who reject major misconceptions about HIV transmission. Value 28% female, (quantitative 16.0% 21.50% NA 44% male or Qualitative) KAP 2011 Date achieved 06/03/2005 (AIS report) 09/30/2012 06/29/2012 The available data for this indicator was collected in the project supported four region while the baseline data are extracted from the nationwide Comments survey. While direct comparisons are not straightforward, there is no (incl. % reason to suspect that the level of knowledge in the target regions was achievement) disproportionately higher than the national average prior to the project. The KAP survey clearly shows a significant increase over the base-line, as well as over the end-of-project target. Joint annual report of the Multisectoral HIV/AIDS Program, disseminated Indicator 8 : during the annual Meeting of the CNLS. Value 3.00 PULMS (quantitative 0.00 3.00 NA (2012) or Qualitative) Date achieved 09/01/2008 09/30/2012 06/29/2012 Comments (incl. % The target was achieved achievement) Percentage of executing agencies (public sector and civil society) that Indicator 9 : submit programmatic and financial three-monthly reports completed and on schedule Value 76.00 PULMS (quantitative 0 90.00 NA (2012) or Qualitative) x Date achieved 09/01/2008 09/30/2012 09/30/2012 Comments (incl. % The target was substantially (84%) achieved achievement) Number (Percentage) of women and men aged 15-49 who received an Indicator 10: HIV test in the last 12 months and who came back for their test results. Value 201,647 (quantitative 0 100,000 NA MOH report or Qualitative) Date achieved 09/01/2008 09/30/2012 09/30/2012 Comments (incl. % The target was achieved and actually exceeded by 100 percent achievement) G. Ratings of Project Performance in ISRs Actual Date ISR No. DO IP Disbursements Archived (USD millions) 1 06/26/2008 Satisfactory Satisfactory 0.00 2 12/12/2008 Moderately Satisfactory Moderately Satisfactory 1.47 3 06/01/2009 Satisfactory Satisfactory 1.78 4 11/30/2009 Satisfactory Satisfactory 4.77 5 06/04/2010 Satisfactory Moderately Satisfactory 7.98 6 01/26/2011 Satisfactory Moderately Satisfactory 11.28 7 12/24/2011 Moderately Satisfactory Moderately Satisfactory 15.33 8 06/26/2012 Moderately Satisfactory Satisfactory 18.71 9 10/22/2012 Moderately Satisfactory Satisfactory 19.02 H. Restructuring (if any) Not Applicable xi I. Disbursement Profile . xii 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal 1. Cote d’Ivoire is the second largest economy in the West African sub region with a population of 21.9 million (2010) of which 43% are under 15 years old and more than half are living in the rural areas. The 2005 report on Human Development (Rapport sur le Développement Humain 2005) indicated that average annual population growth rate was 3.3, the total fertility rate was estimated at 4.6, the maternal mortality ratio was 960 deaths per 100,000 live births, and the infant mortality rate was 84 deaths per 1000 live births). Life expectancy at birth had decreased from 51 years in 1998 to 45.9 years in 2003 (Rapport sur le Développement Humain 2005). 2. The country was stable for almost three decades and took advantage of this to develop its economy, achieving double digit growth. This exceptional growth was in large measure due to the dynamism of the agricultural sector, but falling prices had an impact on this growth. From 1981 to 1992, annual GDP growth averaged -0.2% and Côte d’Ivoire slipped from the rank of middle income countries into the low income group. The devaluation of the CFAF in 1994 triggered an economic rebound, but this was soon undermined by the political crisis which began in 1999. 3. The political crisis started in December 1999, culminating in a brief civil war in 2002 and resulting in the partition of the country into two zones, one under control of the Government and the other one under control of the rebels. The 2010 presidential election was followed by post electoral troubles which paralyzed the country for almost 9 months. The country is currently recovering slowly with peace prevailing in most parts of the country. Nevertheless, the reconciliation and peaceful coexistence of this multi-ethnic country remains the major challenge. 4. The political instability and the economic crisis had increased the level of poverty from 10% in 1985 to 38% in 2002 (Enquête Nationale de vulnérabilité – 2002). Social sectors, including the health sector, were also affected with reductions in the availability and use of basic social services including HIV/AIDS services. 5. At the time of the project appraisal, Cote d’Ivoire was among the countries in West Africa most affected by HIV/AIDS with HIV prevalence of 4.7 percent and an estimated 750,000 people living with HIV/AIDS, including 74,000 children aged 0-14 years. It was estimated that 65,000 adults and children had already died of AIDS. 1 6. The HIV/AIDS epidemic in Cote d’Ivoire was considered generalized with the following characteristics (AIS 2005): a. Feminization – the HIV prevalence was significantly higher among females (6.4%) compared to males (2.9%); b. Urban and geographical differences – the prevalence is higher in urban areas (7.4% for females and 3.2% for males than in rural areas (5.5% for female and 2.5% for male) ; c. Poor knowledge about HIV (only 16.5 % of females and 26% of males had a comprehensive knowledge about HIV); d. Early sexual debut - 73% of young males and 56% of young females had their first sexual relations before the age of 18 years; e. Multiple concurrent sexual partnerships (33.2% of females and 58.1% of males had extra conjugal sexual intercourse); f. Transactional sex – 2.2 % of males indicated that they pay for sex ; g. Relatively high HIV prevalence among Commercial Sex Workers (CSWs) (27% in 2004) h. Limited use of condoms during high risk sexual intercourse (12% among females and 30% among males); i. Limited access and utilization of VCT services (only 13% of females and 10% of males had ever been tested for HIV); j. Limited access and utilization of PMTCT services (only 7% of pregnant women had been counseled and tested for HIV). 7. Based on these indicators, the populations at higher risk for acquiring and transmitting HIV included sero-discordant couples, uniformed service members, ex- combatants, commercial sex workers, economically vulnerable women and girls, truckers and mobile populations, sexually active youth, and orphans and vulnerable children. The major factors contributing to the spread of the HIV infection included early sexual debut, intergenerational and multiple concurrent sexual partnerships, poor knowledge about HIV transmission and prevention methods, and low condom use. 8. The initial Government response to the HIV epidemic was introduced in 1986 with the development and implementation of short and medium-term plans by the National AIDS Program under the Ministry of Health. In comparison to the other countries, Cote d’Ivoire was the first African country to launch an ARV program in 1998 with the support of UNAIDS. In 2001, a Ministry was established which was exclusively dedicated to leading the fight against HIV/ADS (Ministère de la Lutte contre le SIDA) with specific tasks which included coordination, advocacy, and resource mobilization. A multi sectorial approach became a cornerstone of the anti-HIV/AIDS strategy, and the Ministry was a strong advocate for this strategy. 9. The 2002-2005 HIV/AIDS National Strategic Plan was only partially implemented because of the political situation in the country and the constantly changing coordinating bodies for the national HIV response. 2 10. The rationale for Bank involvement included the Bank’s comparative advantage versus other donors to pull together countries and partners, especially in the context of AIDS programming; its ability to work across various line ministries and sectors; and the fact that HIV growth was a threat to human capital, economic growth, and overall poverty reduction. Compared to the available funding for the implementation of the National Strategic Plan (2006-2010) from domestic sources and contribution from donors, the World Bank financial support to the plan was relatively small with specific objectives to fill the identified strategic gaps which were determined according to two dimensions: geographic coverage and service provision. a. To fill the geographic gap, four regions out of nineteen regions of the country were identified on the basis of the level of the HIV epidemic, existing support from other partners, and ethnic composition of the population (taken into account to ensure a balance between ex-warring parties and avoid triggering political backlash); b. With regard to service provision, prevention stood out as being desperately under- funded with less than a quarter of the total estimated budget of the National Strategic Plan dedicated to prevention activities. Within prevention, emphasis was to be placed on the groups most likely to contribute to new infections, such as sex workers, and on the activities combining a low cost per capita and a relatively high-risk target, such as school-based prevention. c. In these four regions, the project was designed to scale up available support, strengthening and rationalizing ongoing activities, and launching new activities in line with the NSP (National Strategy Plan). The aim was to ensure full coverage of vulnerable and high-risk groups. 11. Being a fragile and post-conflict country, Cote d’Ivoire has suffered from exacerbation of risk factors (large population movements, increased number and movement of armed men, widespread sexual violence, etc.) that are associated with the spread of the disease. Thus, the AIDS epidemic in such conditions required a rapid and flexible response which was possible to be delivered under OP/BP 8.0. The use of the streamlined procedures allowed under OP/BP 8.00 was to help ensure timely processing of the operation in direct support of the immediate needs of the Government in addressing the AIDS pandemic. It was also to make it possible for the project to reach its “cruising speed” faster and to be implemented in a more flexible manner, for example by allowing start-up activities to begin with an interim arrangement. 1.2 Original Project Development Objectives (PDO) and Key Indicators (as approved)   12. The objective of the Project was to support the Recipient’s response to the HIV/AIDS pandemic, focusing on four (4) Regions, by: (a) strengthening access to and increasing utilization of prevention services among vulnerable and high-risk groups, such as women, youth, commercial sex workers, and personnel of line ministries; and (b) improving access to and utilization of treatment and care services for HIV/AIDS infected and affected persons, notably persons living with HIV/AIDS, orphans, and vulnerable children.   3 13. The four focus regions included the following: (i) the Savannah Region in the north of the country, the Mountain and former Moyen Cavally Region in the West, the Lagoons Comoé Region in the South, and Abidjan. The total population of these regions is estimated at 10.5 million (the last census was in 1998), which represented approximately 48% of the total population of the country.  14. Over and above the activities in the four focus regions, the project financed some interventions with country-wide coverage to strengthen the national prevention effort. For example, the instruments and mechanisms developed for the intensive IEC campaigns targeting commercial sex workers and vulnerable youth were piloted in the four focus regions but later expanded to other areas of the country.  15. The logical results chain toward the achievement of project development objectives led from the inputs to increase the national capacities to implement project activities which should be translated into the following outcomes: increased knowledge and awareness of HIV, increased safe sexual practice, and improved access to and utilization of HIV/AIDS prevention, care and treatment services. A set of four PDO indicators were selected to monitor the progress toward the Project Development Objectives a. Percentage of female sex workers reporting the use of a condom with their most recent client; b. Percentage of women and men from 15-49 years of age having had more than 1 sexual partner in the preceding 12 months reporting condom use during their last sexual intercourse; c. Percentage and number of HIV-infected pregnant women who received a completed antiretroviral treatment to reduce the risk of mother-to-child transmission; d. Percentage and number of adults and children with advanced HIV infection receiving antiretroviral therapy (disaggregated by sex and age). 1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification NA 1.4 Main Beneficiaries 16. The primary beneficiaries of the project were the vulnerable and high risk groups such as (i) Commercial sex workers (male and female), (ii) Orphans and vulnerable children (OVC), (iii) people living with HIV/AIDS and affected individuals and families, and (iv) particularly vulnerable youth and women which include women living in low- income neighborhoods of the urban centers in the four focus regions. These included two regions formerly controlled in whole or in part by the rebels (in the north and west) and two controlled entirely by the Government (in the south and Abidjan). As noted in paragraph 13, the total population of the focus regions is estimated at 10.5 million. 4 1.5 Original Components (as approved) 17. The Project is in the amount of US$20 million and consists of four components: 18. Component 1: Social mobilization and HIV/AIDS Prevention Services for vulnerable and high risk groups (US$6.4 million. This component supported the implementation of social mobilization and HIV/AIDS prevention activities by national and international NGO’s. These activities were planned to be implemented mainly in the four regions and targeting identified the high risk beneficiary groups noted above. 19. In addition, this component provided support to the private sector in these regions to set up HIV/AIDS committees in agro industrial enterprises which had implemented various HIV/AIDS prevention activities in the workplace. It also financed several country wide interventions such as intensive Information Education and Communication campaigns targeting commercial sex workers and vulnerable youth, as well as mass campaigns for the general public to improve knowledge about HIV/AIDS and reduce the stigmatization of PLWHA and other high-risk groups. 20. Component 2: Public Sector Interventions: Prevention and Care (US$7.8 million). This component was intended to support the provision of prevention and treatment services in the four focus regions by the Ministry of Health (subcomponent 2.1) and to support the three key Ministries (Education, Defense and Interior) which had a mandate to cover the target groups that could not be easily reached through the NGOs. These target groups included youth who are in school, the armed forces, and the police respectively (subcomponent 2.2). 21. Component 3: Capacity Building (US$3.3 million): This component aimed to facilitate effective implementation of the project by building the capacity of project implementers: key technical Ministries (Education, Health, Social affairs, Youth, etc.) and civil society members. The component also financed strengthening of the performance of the four regional project coordination units. 22. Component 4: Coordination, Management, Monitoring and Evaluation (US$2.5 million): The component supported the overall coordination, monitoring and evaluation of the project by funding (a) the incremental operating costs for the Project Implementation Unit (PIU); (b) the fiduciary management firm; and (c) the establishment of a comprehensive, computerized national monitoring and evaluation system for HIV/AIDS-related activities. 1.6 Revised Components NA 1.7 Other significant changes NA 5 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry Identification/Preparation 23. Initial project identification started in November 2000 and was extended until August 2002. A concept review was held in June, 2002 with a $50 million project being envisioned using the classic Multi-Sectoral AIDS Project (MAP) approach. 24. Once the PCN review was completed, a PHRD Grant in the amount of $1 million was provided for project preparation. This grant was almost three-quarters utilized before it closed in 2005. The deteriorating political situation in September 2002 prevented further preparation activities. In December 2003, following the first peace agreement, project preparation continued and the project was appraised in March and April, 2004, still with an allocation of US$50 million. In November 2004, due to the political turmoil in the country, the World Bank suspended its entire program in the country and as a result the preparation process was once again frozen. 25. Following the peace agreement in 2007 and the appointment of a national Unity government, the Bank lifted the suspension of its operations in the country. A new ISN was developed and the Bank decided to support the country under OP/BP 8.0. 26. Project preparation was re-launched in February 2008 and it was decided to reduce the project amount to US$ 20 million to target just four regions. In addition, there were a number of developments on the ground which affected preparation of this version of the project, including: (i) availability of a new HIV/AIDS strategic plan (2006-2010) which was designed based on the recent evidence about the epidemiological situation (AIDS Indicator Survey 2005) and (ii) availability of more resources for HIV/AIDS which were mobilized from external donors such as Global Funds, PEPFAR, etc. 27. The HIV/AIDS National Strategic Plan (2006-2010) guided the identification of priority areas as well as the target populations for the World Bank supported Emergency Multi-Sectoral HIV/AIDS Project. The National Strategic Plan focused on seven pillars of interventions such as prevention, care and support, coordination, monitoring and evaluation, etc. The Plan also specified a clear organization and coordination framework at the national, regional, district and local level (Section 4.3) The total estimated budget was US$594 million of which 56% was dedicated to care and support and less than a quarter to the prevention activities. About 96% of the total budget was secured, with the major contributor being the US Government through the PEPFAR. 28. Taking these factors into consideration, the World Bank developed a new set of interventions consistent with the HIV/AIDS National Strategic Plan (2006-2010) which identified the priority areas as well as target populations. The new project design focused on the following pillars: prevention, care and treatment and monitoring and evaluation for evidence based policy. It aimed at filling the strategic gaps (both in terms of geography and service provision) and exploit synergies with ongoing efforts. 6 29. The strategic gaps would be filled through the focus on four underserved regions of the country – two of which being under the control of the rebels – a well as prevention activities with emphasis on most at risk populations such as sex workers and their clients which were the drivers of the epidemic. 30. In sum, due to the ongoing fragility and intermittent conflict situation, preparation of this project entailed multiple disruptions and re-design, with 6 years between the initial PCN Review in June 2002 and eventual Board approval in June 2008. Design 31. The design reflected the experience and lessons learned by the country while implementing HIV/AIDS activities in such areas as promotion and distribution of condoms for female sex workers, care and treatment of STIs, care and support of people infected and affected by HIV/AIDS including orphans and vulnerable children, involvement of NGO’s (local and international) and empowerment of civil society. The involvement of the NGO’S (local and international) to reach some target populations was considered an advantage since (a) these populations are often discriminated against and marginalized, and therefore avoid contact with public services and (b) the public sector often lacks the capacities and experience to provide such services. 32. The project design has also incorporated the lessons learned from the evaluation of HIV/AIDS MAP projects in Africa. Lessons include the need for strong political leadership and commitment; country ownership as a process of empowerment; a multi sectorial and decentralized approach; focus on high risk and vulnerable groups; and the use of an independent agency to carry out fiduciary functions. The design stresses the need for efficient partnership and collaboration to ensure better coordination of the national HIV response. The overall supervision role of the National HIV/AIDS Control Council (NACC) chaired by the Head of State with the participation of representatives from all socio-professional groups including associations of people living with HIV/AIDS was clearly indicated in the PAD. 33. A project Implementation Unit (PIU) created at central level under the Ministry in charge of HIV/AIDS (Ministere de la Lutte contre le SIDA) was in charge of daily management of the project. The PIU was composed of contracted staff recruited through a competitive process including a National Coordinator (NC), a Public Sector Program Officer; a Civil Society Program Officer; a Monitoring and Evaluation Officer; a Capacity Strengthening Officer; and a Fiduciary Management Team (FMT), which was in charge of Financial management and procurement aspects. This PIU complemented the Ministry, which did not have specific expertise on financial management and procurement in Bank-financed projects, and had a limited number of staff who were fully committed to other duties. A PIU was therefore considered an appropriate vehicle. 34. At the decentralized level, the management of project activities as well as overall coordination of the national HIV/AIDS response was given to the existing Regional AIDS committees. It was agreed that the project would provide the needed support to these regional institutions to meet their obligations. 7 Risks and Mitigation measures 35. The PAD identified a number of risks that might jeopardize the implementation of the project and the achievement of development objectives if the appropriate mitigation measures were not implemented. The following major risks were identified: a. Insecurity, instability and uncertainty about holding of elections – despite the peace agreement in March 2007 and the redeployment of government administration in the areas formerly occupied by the rebels, the overall security concern remained acute. This risk was to be mitigated by close follow up and strong implementation support to the peace process by the World Bank and other key development partners; b. Insufficient implementation capacity – the decade of crisis weakened the capacity of both the public and private sector and posed a greater risk to the successful implementation. In view of the decentralized governance arrangement, it was felt that this would require the presence of competent and dynamic individuals both at the national and at the regional level. The establishment of the Project Implementation Unit to monitor overall project implementation, the use of Regional AIDS Committees to act as regional coordinating units, and the inclusion of a Capacity Building Component were all thus intended to strengthen the capacity of implementing agencies and to support sectorial focal points; c. High governance and fiduciary risk – governance and transparency indicators of the country were among the worst in the world. The control environment was very weak and the impact of internal audits and external audit bodies was not effective. Throughout the project preparation, the Bank took a number of precautions to ring-fence the operation against governance problems and address fiduciary risks, including: (a) reliance on an independent fiduciary management agency, and (b) independent audits of the Project; d. The disrupted health system in 2 regions formerly controlled by the rebels – including the insufficiency of human resources, nonfunctioning health facilities, lack of leadership at the regional and local level, and weak governance systems was also identified as a risk. Mitigation measures included government initiated redeployment of required human resources, and project support to this process. It was acknowledged, however, that the complete redeployment would take time; e. Weak capacity of the Public Health Pharmacy – to supply drugs and medical equipment: In order to mitigate this risk, the project carried out international procurement through UN agencies. 36. There was no formal Quality-at-Entry review. 8 2.2 Implementation 37. The project was implemented in an extremely difficult political and security environment. It was approved on June 12, 2008 and became effective (October 1, 2008). The establishment of a functional PIU including the project's fiduciary unit was a condition of effectiveness and was completed more than 90 days after the signing of the Financing Agreement, thus delaying effectiveness. This delay raised the effectiveness flag. Further, by the time the project become effective, the country was divided into two zones, one controlled by the government and one by the rebellion. Since the official launching of the project in January, 2009, implementation has not been linear and has encountered many constraints and as a consequence, the IP rating was changed three times, moving between Satisfactory to Marginally Satisfactory. 38. Between October 2008 and February 2009, the project focused on putting in place the implementation prerequisites such as the recruitment of the project staff, the validation of project implementation manual and guidelines, and the development and approval of the annual work for the first calendar year of the project. The 2009 work plan was mainly focusing on the recruitment of implementing agencies; procurement activities (NGOs) and the service delivery activities started only in 2010. Unfortunately, the presidential election in the last quarter of 2010 and the post-election crisis during the first semester of 2011, which was exacerbated by armed conflict, stopped implementation for almost nine months before activities resumed in June 2011. 39. Despite the severe ongoing constraints, the PIU team as well the task team conducted regular supervision of the project in order to ensure smooth implementation of project work program. Considerable attention and support was given by the PIU team to the Regional coordination unit in the project supported four regions. 40. The election and post-election crisis prevented the planned Mid-Term review (MTR) which was scheduled for October 2010, from taking place. It was eventually done in January 2011, when the situation permitted it. As an alternative to the MTR, the government project team, with the support of the World Bank team, undertook a review of the project with the objective of assessing project achievements and constraints. 41. Although the implementation of all project components faced difficulty, the health subcomponent (2.1) suffered more. The disruption of the health system in the 2 regions formerly controlled by the rebels, the lack of human resources, and the lack of leadership at the regional and local level delayed the launch of health related activities considerably. Progress was further hampered by frequent stock-outs of re-agents and drugs. 42. This impact on project implementation was not unique to the Bank-financed project. For example, according to a PEPFAR report, some of their project activities declined by 60 to 90 percent between (their) FY09 and FY11 (October 2009 to September 2011), increasing only in FY12. Figure 1, below, shows some of these results: prevention and training activities appear to have been the most affected; which also represents a significant portion of the Bank supported interventions. 9 Figure 1 – Impact of the Crisis on PEPFAR Activities   43. While similar activity level data is not available for the Bank project, the quarterly disbursements show much the same pattern (Figure 2), clearly indicating that project implementation was significantly affected by external factors beyond the control of those implementing and supporting the project. After the initial allocation and a gradual scale- up of project activities, disbursements settled in at around $1.5 million per quarter for a full year – for a respectable disbursement rate of 31% during this period. The crisis later in 2011 led to virtually no disbursements for 6 months, followed by an increase towards the end of the project as the country situation improved and implementation once again ramped up. 10 Figure 2 – Quarterly Project Disbursements 2.5 Millions 2.0 1.5 1.0 0.5 0.0 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 FY09 FY10 FY11 FY12 44. Despite this difficult beginning and constraints during the implementation, more than 85% of planned project activities were executed, including: (i) NGOs were recruited to implement social mobilization activities, care, and support to vulnerable groups such as CSW, PLHIV, OVC, etc.; (ii) IEC activities were conducted targeting the large group of population through local radio stations; (iii) the private sector was supported to establish workplace HIV/AIDS clubs which delivered HIV/AIDS prevention activities; and, (iv) 59 health facilities were supported to provide HIV related activities. 45. As of the project closing date (September 30, 2012), the grant was fully disbursed although the disbursement was low at the beginning and more than half of the funds (58%) were disbursed during the last two years of the project. 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization M&E Design 46. The HIV/AIDS National Strategic Plan (2006-2010) is comprised of a national monitoring and evaluation framework which tracks evolution of the HIV epidemic and monitors the performance of the national response to HIV/AIDS. This framework has defined a set of indicators (outputs, outcomes and program performance) with a well- documented data collection methodology to allow efficient tracking of the progress made. 47. The M&E subcomponent of the project was designed to ensure availability of data required to monitor progress towards achievement of the project development objectives while strengthening the overall National HIV/AIDS M&E system. The proposed M&E arrangements under the project included a combination of routine health services data, monitoring on HIV/AIDS program activities, periodic behavioral and biological surveillance surveys, and periodic surveys on the coverage and quality of services. Box 1 below outlines the various surveys that were either full or partially funded by or otherwise available to the project. 11 Box 1 – Population Based Surveys Two general population surveys were available during the project timeframe. First the AIDS Indicator Survey (AIS 2005), was conducted in 2005 and provided comprehensive indicators on knowledge, attitudes, behavior and HIV/AIDS status. It covered 5,183 females and 4,503 males aged 15-49 in 4,368 households. A Demographic and Household Survey (DHS 2012) was done in 2012 and included 10,060 females and 5,135 males aged 15-49 in 9,689 households. As a standard DHS survey, it included many other topics, but had good coverage or HIV/AIDS related knowledge, attitudes and behaviors as well as HIV prevalence through testing, as in the AIS 2005. Aside from the oversampling of females, the approaches with respect to HIV/AIDS were consistent. Both surveys included regional level data (8 regions), with roughly equal sampling between regions (around 400 households per region in the AIS and around 850 per region in the DHS). During the course of the project, three separate surveys were undertaken covering knowledge, attitudes and practices relating to HIV/AIDS and STD. One of these covered the general population and the other two of focused on commercial sex workers (CSW) and one covered the general population. The sample size, coverage and specific questions varied between the three surveys. The first one was the “Comportements, Attitudes et Pratiques des Professionnelles du Sexe vis-a-vis des IST/VIH/SIDA dans 8 Départements les Plus Affectées par la Crise en Côte d’Ivoire” (Behavior, Attitude and Practice of Sex Workers vis-a-vis STD / HIV / AIDS in 8 Departments Most Affected by the Crisis in Ivory Coast). It was done in 2007 and is taken as the baseline in several indicators (referred to as ENSEA 2007. In total, 2,461 CSW were surveyed, with about half of those in the city of Abidjan (1 213) and the rest in 7 other cities in the country (Yamoussoukro, San-Pedro, Man, Duékoué, Danané, Daloa et Bouaké. The second survey was done in 2011: “Analyse des Connaisances, Attitudes et Pratiques des Professionnel (les) du Sexe dans 18 Villes de la Côte d’Ivoire” (Analysis of Knowledge, Attitudes and Practices of Commercial Sex Workers in 18 Cities of Côte d'Ivoire – KAP 2011). In total, 5,720 female and 468 male sex workers were surveyed from cities in were both in project focus regions and those not covered by the project and the analysis provided to date does not differentiate between the two groups of cities. The third survey was a general population survey entitled: “Enquête connaissances, attitudes et pratiques sur les IST et le VIH/SIDA dans les régions des lagunes, des montagnes, des savanes et du sud Comoé” (Survey of knowledge, attitudes and practices on STD and HIV / AIDS in the areas of Lagunes, Montangnes, Savannes and southern Comoé). Known as ECAP 2011, it was a general population survey of focus regions as well as Abidjan, although the presence of the capital city was not noted in the title. The survey covered 3,339 persons aged 10-49 years in 1,499 households, distributed equally among the five areas. 48. Project performance indicators were a subset of the national monitoring and evaluation framework and the baseline data as well as the targets were clearly defined in 12 the PAD. However, there are discrepancies between the source used for the baseline and the source proposed and/or eventually used to track the progress, which limited data comparability. Part of this was due to the fact that national survey data (AIS 2005) had to be used for some of the baseline indicators, but since eventual project had more limited geographic scope, focusing on only 4 regions, the national level baseline data was not appropriate. Fortunately, as indicated above, since both the AIDS Indicator Survey of 2005 and the DHS of 2012 included many of the same indicators and also contained disaggregation at the regional level, these two surveys facilitated analysis of the likely impact of the project using population-level survey data, although the regions used are not a perfect match for the intervention areas of the project, The 2012 DHS data (final report pending) only became available well into the preparation of the ICR, and in fact extensions of the ICR delivery date were required in order to take advantage of it and fully analyze this data.   M&E Implementation and Utilization 49. With regards to the operationalization of the M&E subcomponent, the following activities were implemented: a. In addition to having staff in country to monitor progress on an ongoing basis, periodic formal supervision missions were also conducted to ensure timely implementation of the work program and to undertake the quality audit of reported data by implementing agencies; b. Regional and Sectoral mid-term reviews of the work program were conducted; c. Financed the development of a strategy on HIV/AIDS vulnerability and response among the youth. UNICEF collaborated to develop the TOR, and UNICEF and UNFPA are now developing activities based on this document. d. 346 persons were trained on M&E of HIV/AIDS; e. Quarterly project progress with all routine data were prepared and widely distributed; f. The project provided support to the 2012 DHS survey, which proved to be a major element in the evaluation of project performance; g. The project also funded the KAP study in the four project supported regions. 50. Despite the early initiation of M&E activities, data informing the project outcomes indicators were not always available at the time of the ISR completion, mainly due to the timing of the surveys required to produce the data. Thus, the data for two out of the four PDO indicators were made available only in December 2010 and for the two others only in 2011 after completion of the survey. 51. In sum, the timing of the data availability for some indicators did not facilitate regular monitoring of the project, but the data provided through the M&E plan and some of the activities financed under the project were key to support the final evaluation. However as noted in Box 1, the lack of comparability in the geographic areas covered by the different surveys made comparisons difficult. Overall, the M&E activities for this project are rated Moderately unsatisfactory. 13 2.4 Safeguard and Fiduciary Compliance 52. Environment and management of medical waste-At the time of the appraisal, the project was listed as Category B because the project was not expected to have substantial adverse environmental effects. The main environmental issue deserving attention was Medical Waste Management. 53. As the Medical Waste Management Plan was more than five years old, the Plan was updated by the Ministry of Health. It was disclosed in the country and at the Infoshop on November 1, 2002. The project supported the implementation of the updated plan in the project zone through training of health personnel and communal workers, installation of four incinerators and provision and distribution to the health centers of appropriate equipment. The implementation as well as the impact of the project on the environment was monitored regularly as an element of supervision missions. 54. Financial management and disbursement: The project appraisal had identified high fiduciary risk and has proposed appropriate mitigation measures such as contracting out the fiduciary management to an independent fiduciary management agency and conducting regular independent audits of the Project. These mitigation measures were implemented and during the project implementation period, the Financial Management was rated satisfactory. However the rating has been downgraded in November 2009 from satisfactory to moderately satisfactory because of the increased risk associated with having numerous partners working at the national level as well as the regional, departmental and communal levels. In order to mitigate this risk, the project hired an internal auditor to strengthen the project financial management system. Throughout the project life time all the IFRs have been produced on time and all audit reports have been produced on time and were unqualified. 55. Disbursement was low during the first two years of the project with 26.8% of project funds disbursed compared to 65.6% planned. As noted above, this was due to a number of factors, including delays in project effectiveness and several periods where Bank-financed activities came to a stand-still across the board due to conflict. However, as indicated below, the grant was fully disbursed by the closure of the project. Table 1: Disbursement level in percentage Year Planned Actual 2008 27.20 7.34 2009 38.40 19.48 2010 34.24 29.56 2011 0.16 20.29 2012 0.00 23.30 Total 100.00 99.97 14 56. Procurement- The project was assisted by two procurement specialists and annual procurement plans were prepared and implemented satisfactorily. No complaints were recorded during the life of the project. Accordingly, Procurement has been rated satisfactory throughout the project life. 2.5 Post-completion Operation/Next Phase 57. The government has developed and adopted a new HIV/AIDS National Strategic Plan for the period of 2011-2015 to guide the National HIV/AIDS response. The total cost of the plan was estimated at US$ 870 of which 67% was already secured by 2011. The government is working toward filling the remaining gap. 58. With respect to the current project, the government has developed an exit strategy, and for the transition period adequate financial resources (740 million CFA or USD 1.5 million equivalent) were mobilized to finance the activities in the short term. Beyond this, the government has put in place a National Fund for HIV/AIDS through taxes imposed on alcohol and tobacco purchases with the objective to finance care and treatment of HIV/AIDS. The Global Fund and other development partners will continue to support HIV/AIDS prevention, treatment, and care activities. 15 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation Relevance of objectives 59. The epidemiological situation of HIV/AIDS which prevailed at project appraisal and guided the definition of the project still persists. The country continues to be among those most affected by HIV/AIDS in West Africa with a high HIV prevalence in 2012 (3.7%) despite a reduction observed from 2005 level (4.7%). The HIV epidemic remains generalized and marked by gender and geographic differences. 60. The socio-economic and political crisis has engendered massive displacement of the population and disruption of the socio-economic system with a negative impact on the availability and use of basic social services including HIV/AIDS prevention, care, and treatment services. The country is in the process of a slow recovery from both political and economic crises, factors that have contributed to the spread of HIV/AIDS are persistent and the national response needs to be consolidated. Therefore, the focus on most at risk populations continues to be appropriate since these groups, while being the major drivers of the HIV/AIDS epidemic, are the most affected. The new HIV/AIDS Strategic plan (2011-2015) has confirmed the priorities reflected in the previous plan which has guided the definition of the project development objectives. 61. The PDO is in alignment with the basic objectives of the PRSP, the Interim Strategy Note (ISN) and the Country Partnership Strategy (CPS). The World Bank’s involvement in HIV/AIDS in Cote d’Ivoire is consistent with the ISN endorsed by the Board on April 1, 2008. The objectives of the ISN included Pillar 2 which was designed to “assist war-affected populations by way of community rehabilitation and support for the provision of basic social services”, including HIV/AIDS, and support to HIV/AIDS was specifically mentioned as an intervention. It is also consistent with the 2010-2013 CPS which highlighted the need to improve basic services under Objective 4, including those relating to HIV/AIDS (“Strengthened access to and increased use of HIV/AIDS prevention services; improved access and use of treatment and care services”), and also noted the gender aspect of HIV/AIDS as a cross-cutting issue, since more than twice as many women as men are infected with the disease. 62. The relevance of the project development objective is therefore rated substantial.  Relevance of design 63. The project design was based on available knowledge of the HIV/AIDS epidemic and appropriate responses. The situation analysis conducted as part of the development of the National HIV/AIDS Plan – and used during project preparation – identified most at risk populations which were both major vectors of disease transmission and key victims of the disease. 16 64. The identification of the project beneficiaries, commercial sex workers (male and female), Orphans and vulnerable children (OVC), people living with HIV/AIDS and affected individuals and families and particularly vulnerable youth and women including those living in low-income neighborhoods of the urban centers in the four focus regions was based on this situation analysis and it continues to be relevant. Moreover, the targeting of these groups fills a gap in the overall HIV/AIDS strategy for Cote d’Ivoire which was not and is still not being met by other development partners. 65. The identified HIV/AIDS prevention, care and treatment activities (HIV/AIDS awareness creation; safer sexual-behavior by both CSW and their clients, delayed first sexual intercourse; reduction in early marriage; reduced sex with non-regular partners; promotion, distribution and use of condoms; promotion and use of voluntary counseling and testing services, care and treatment of PLWHA including OVC) are still the most cost-effective activities as of today. Evidence support that the effective implementation of such interventions would significantly contribute to the control of the HIV epidemic and achievement of project development objectives. 66. The project activities are highly relevant and respond to the objectives of the project. Using NGOs and civil society organizations (CSOs) to reach defined highly vulnerable populations proved to be a key factor in ensuring that the interventions provided to these populations largely continued during the crisis. The capacities to effectively implement the project and to manage the national HIV response had been identified during project preparation as a major issue, and consequently the project included the capacity building and M&E components. 67. The relevance of the project design is therefore rated substantial. Relevance of implementation 68. The difficult political and security environment that prevailed in the country at appraisal and during the project life required great flexibility and innovation. The coordination of the project as well as the national HIV/AIDS response was under the responsibility of existing national institutions (NACS and regional Coordination Committees) which were reinforced throughout the project life. A project management Unit with competitively recruited national staff was in charge of the project implementation. This institutional set-up was adequate and allowed timely completion of the project activities and disbursement despite major upheavals and disruption arising beyond the project from the country conflict. 69. The choice of civil society organizations, mainly national NGOs and key public sector, and private institutions (e.g., helping to set up HN/AIDS committees in the various agro-industrial enterprises and by supporting various activities for the fight against HIV/AIDS in the workplace) to implement project activities was another flexible approach to deliver services to the different categories of beneficiaries in a post conflict context which prevailed and continues to prevail in the country. 17 70. The relevance of the implementation approaches for the second component in general and the health sector response in particular are also still very relevant, although external circumstances resulted in considerably delays. The PAD has highlighted the disruption of the health services in the two rebel controlled regions as a risk but the proposed mitigation (redeployment of personnel by the government) measure was outside of direct project control. In terms of implementation, the project could have envisaged the use of NGOs to deliver these essential services, if even for an interim period of time. 71. Based on this, the relevance of Project Implementation is rated Substantial. 72. Relevance of the project: Based on the above presented data on the relevance of the project’s objectives (Substantial), design (Substantial), and implementation (Substantial), the overall relevance of the project is rated Substantial. 3.2 Achievement of Project Development Objectives 73. The Project’s development objectives were as follows: PDO 1 – To strengthen access to and increase utilization of prevention services among vulnerable and high risk groups (such as commercial sex workers, mobile populations, and vulnerable women and youth). PDO 2 - – To improve access to and utilization of treatment and care services for HIV/AIDS infected and affected persons, notably the persons living with HIV/AIDS (including PLWHA and OVC). 74. PDO 1 was expected to be achieved through effective implementation of component 1 (Social mobilization and HIV/AIDS Prevention Services) and sub- component 2.2 (Support to the action plans of key Ministries such as Education and Defense), while the second development objective was implemented through subcomponent 2.1 (Health Sector). 75. Before going into the assessment of the achievement of the PDO, it is useful to consider the changing context in the country between when the project was started and when it finished. The general sense is that the impact of the conflict in 2011 resulted in a decline in indicators across the board (the causal chain being that the conflict caused an increase in poverty, a general decline in services followed by rise in risky behavior and poor social outcomes), and then a gradual improvement post-conflict. This suggests that in fact there was a “U”-shaped trajectory to many of the indicators, with the end-line values representing progress up from the bottom of the “U”, although in many cases not enough of an improvement to meet the indicator targets. 76. While it is difficult to get comprehensive data, and the nature of the timing of many of the PDO indicators meant that the baselines were collected well before the latest crisis, there is some data that may shed some light on what was going on. 18 77. In 2010, the Development Economics Group of the Bank began a panel survey of people who received counseling and testing. The original sample was 3,600 people but the researchers were able to contact only 2,011 for the follow-up survey in 2013. In addition to bracketing the conflict period, the survey was also able to stratify the sample into conflict-affected (C) and non-conflict affected (NC) groups. Three definitions of “conflict” were used: (i) any type of disorder in the respondent’s neighborhood (“Disorder”), which included 95% of the sample in the C group; (ii) someone killed in the neighborhood (“Killed”), which covered 45% of the group; and, (iii) the respondent or household members were victims of economic damage (“Economic”), which covered 27% of the sample. 78. There were clear differences in sexual behavior, both over time and between the conflict and non-conflict groups. Figure 3 shows that sexual activity increased and average of 9.6% between 2010 and 2013, while condom use declined almost 18%. This suggests a general rise in risky behavior between the two surveys, as well as differences between the conflict affected group and those not affected by conflict, and variations for different types of exposure to conflict. Figure 3 – Sexual Behavior over Time Sexually active in last 3 months Used Condom 80% 45% 40% 70% 35% Disorder Disorder Killed Killed 30% 60% Economic Economic 25% 50% 20% NC 2013 C 2013 NC 2010 C 2010 NC 2013 C 2013 NC 2010 C 2010   79. The 2013 survey had more details on risky behaviors, so the differences between the conflict and non-conflict groups can be examined in more detail. Figure 4 shows a higher proportion of those exposed to conflict had extramarital affairs, with the largest differences between those who knew of someone being killed (18%), compared to around 10% for the other 2 conflict definitions. Figure 4 – Sexual Behavior – Conflict vs. Non-conflict Extramarital partner in last 2 years 65% 60% 55% 50% 45% 40% Disorder Killed Economic Non‐conflict Conflict 19 80. Figure 5 shows both the average number of extramarital partners for different groups and the average number of partners who the respondent had paid for sex. Again, there are differences between the conflict and non-conflict groups, and between different definitions of conflict. Those who were in a neighborhood where someone was killed had higher numbers of partners and number paid for sex (36% and 22% difference respectively). It should be remembered that 45% of the respondents to the survey were included in this definition of “conflict”. There were fewer differences in these indicators between conflict and non-conflict groups when other definitions of conflict were used. While these differences do not show causal links, they do show that the social situation was in significant flux over the period of the two surveys, and between the conflict and non-conflict groups. Figure 5 – Number of Partners – Conflict vs. Non-conflict Number of extramarital partners Number Paid for Sex 3.5 4.0 3.0 3.5 2.5 3.0 2.0 2.5 1.5 2.0 1.0 Disorder Killed Economic Disorder Killed Economic Non‐conflict Conflict Non‐conflict Conflict   81. The further analysis of PDO achievement needs to be considered against this backdrop of a very volatile social situation. Further national-level analysis is also provided below. 82. PDO 1: Under component 1 and sub-component 2.2 social mobilization and HIV/AIDS prevention, care and support activities were implemented in four project supported regions by national and international NGO’s, private sector groups and the defense Ministry. The NGOs helped to carry out implementation of sensitization and counseling (both pre- and post-testing), condom distribution, outreach to MSM and CSW, support to Orphans and Vulnerable Children and palliative care for people living with HIV/AIDS. The networks provided service both to the general population and CSW, including carrying out mass sensitization campaigns, condom distribution, and counseling and testing, including PMTCT testing. Details of implemented activities and their respective outputs are presented in annex 2, below are summaries of those achievements. a. Mass communication campaigns on HIV/AIDS prevention, through 42 community radios with the technical support of the national radio and television network (RTI) b. 68 NGO’s have executed 81 subprojects focusing among other activities on social mobilization, condom promotion and distribution, behavioral changes activities, promotion of VCT, etc.; 20 c. 1,401,692 and 3,094,551 condoms were distributed to the general population and to commercial sex workers respectively. In addition, 3,866 lubricated gels were distributed to commercial sex workers; d. 48 small and medium enterprises have conducted HIV/AIDS prevention activities in the work place. e. Creation/funding of 5 HIV/AIDS prevention networks (COSI, RIP+ARSIP, REPAMASCI, RIJES); f. Support was provided to Men who have Sex with other Men (MSM) by an experienced international NGO (Heartland); g. Establishment and strengthening of 86 AIDS club in schools; h. Establishment of HIV/AIDS unit within defense forces. 83. The project was able to deliver HIV/AIDS prevention activities to an important number of identified priorities groups (see table 2). Table 2: Number and categories of target group reached by HIV/AIDS Prevention activities IEC & Category and number of behavioral Condoms VCT target groups change promotion activities CSW 15,437 15,437 12,151 MSM 5,835 5,835 OVC 16,910 PLWHA 12,341 12,341 Mobile Population 170,318 170,318 20,460 Particularly vulnerable 153,759 153,759 33,879 women Private sector workers 29,645 29,645 6,465 School children 33,101 33,101 Defense force 7,993 7,993 5,358 General Population 663,978 458,366 205,407 TOTAL 1,109,317 886,795 283,720 84. The  achievement  of  the  first  PDO  (improved  access  to  and  utilization  of  HIV/AIDS  prevention  services)  would  have  contributed  to  the  improved  HIV/AIDS  knowledge  and  to  behavioral  change.  Two  PDO  indicators  and  four  intermediate  results  indicators  were  identified  in  the  PAD  to  monitor  progress  toward  this  development  objective.    The achievement of this PDO is rated substantial: Out of the two PDO indicators, the target was 97% achieved for the first (Percentage of female sex workers reporting the use of a condom with their most recent client) despite a difficult social situation and limited condom availability (although there are some issues with data sources) and Indicator 2 (Percentage of women and men from 15-49 years of age having had more than one sexual partner in the preceding 12 months reporting condom use during their last sexual intercourse) showed substantial improvements in condom use for women and condom use very close to the target for men (See table 3). 21 Table 3: Achievement of PDO-1 Indicators. Original Target Formally Actual Value Values (from Revised Achieved at Indicator Baseline Value approval Target Completion or documents) Values Target Years Percentage of female sex workers reporting the use of a condom with their Indicator 1 : most recent client (disaggregated by age < 25, 25+ > Value quantitative or 95% ENSEA Report 96% NA 93% (KAP 2011) Qualitative) Date achieved 09/30/2012 09/30/2012 The target was 97% achieved, although the final result was slightly below the baseline level and the data sources are different. However, given the Comments social and behavioral impact of the crisis as described in the document, as (incl. % well as the reduced number of condoms available as a result of the crisis achievement) (see IO indicator #1, also PEPFAR reports the number of condom outlets dropped from almost 2500 in 2009 to just over 1500 in 2011), attaining a level of 93% is a commendable achievement. Percentage of women and men from 15-49 years of age having had more Indicator 2 : than 1 sexual partner in the preceding 12 months reporting condom use during their last sexual intercourse Value 12% (F) 29.7% (F) 14.25% (F) quantitative or 30% (M) 35.7% (M) 36% (M) Qualitative) Report AIS (2005) DHS 2012 Date achieved 12/31/2007 09/30/2012 09/30/2012 The end-line data in the final ISR shows substantial improvement over both the baseline and the target. However, this data could not be corroborated from the ECAP 2011 survey which was shown as the Comments source. For this reason, the 2012 DHS was used as an alternative source. (incl. % This survey shows condom use was almost double the target for females achievement) and 99% of the target for males. Further, the detailed analysis by region (see paragraph 85 below), shows condom use in the project regions higher than for the non-project regions (37.8 versus 32.2 percent). 85. The detailed 2012 DHS tables contain data at the regional level, which can help shed some additional light on the end-line values of PDO Indicator 2. The regions of North, West, South and Abidjan roughly cover the focus regions of the project, although they do not exactly match. If these four regions are aggregated for males (there was not a large enough sample at the regional level to do this calculation for females) the DHS shows a total for the project regions of 37.8% compared to 32.2% for the non-project regions and 35.7% overall. The published data for the 2005 AIS does not contain the detail for this indicator at the regional level. 22 86. Out of the four intermediate results indicators (table 4), the target was achieved for two indicators: Percentage and number of high risk groups (FSW) who received an HIV test in the last 12 months and who came back for their test results; and, Number (Percentage) of women and men aged 15-49 who received an HIV test in the last 12 months and who came back for their test results. The target was not achieved for one indicator: Number of condoms- male & female distributed among the CSW in the 4 target Project regions. This is likely due to the disruption of the supply chain during the crisis, which affected both the import of commodities into the country and the distribution to target groups. 87. Based on the data included in the latest ISR, it is not possible to make a judgment on progress on indicator 3 (Percentage of people from at risk-groups who both correctly identify ways of preventing sexual transmission of HIV and who reject major misconceptions about HIV transmission) because of data non-comparability. The end line data was collected by a survey in the four project regions while the baseline data were extracted from the nationwide survey. However, data presented below (Tables 7 and 8) from the AIS and DHS suggest a significant improvement for the general population, so it would be relatively safe to assume similar improvements for the target populations. Table 4: Level of Achievement of Intermediate Outcome Indicators Original Target Formally Actual Value Values (from Revised Achieved at Indicator Baseline Value approval Target Completion or documents) Values Target Years Number of condoms distributed (male & female) among the CSW in the 4 Indicator 1 : target Project regions. Value (quantitative 0 5,180,000 NA 3,094,551 or Qualitative) Date achieved 12/31/2007 09/30/2012 09/30/2012 Comments Target was not achieved, although this was likely due to the interruption (incl. % caused by the crisis. Only male condoms were acquired and distributed by achievement) the project. Percentage and number of high risk groups (FSW) who received an HIV Indicator 2 : test in the last 12 months and who came back for their test results Value (quantitative 0 10,500 NA 12,106 or Qualitative) Date achieved 09/01/2008 09/30/2012 09/30/2012 Comments (incl. % The target was achieved, and in fact exceeded by 15 percent. achievement) Percentage of people from at risk-groups who both correctly identify Indicator 3 : ways of preventing Sexual transmission of HIV and who reject major misconceptions about HIV transmission. 23 Original Target Formally Actual Value Values (from Revised Achieved at Indicator Baseline Value approval Target Completion or documents) Values Target Years Value 28% female, (quantitative 16.0% 21.50% NA 44% male or Qualitative) (KAP 2011) Date achieved 06/03/2005 (AIS report) 09/30/2012 06/29/2012 The available data for this indicator was collected in the project supported four regions while the baseline data are extracted from the nationwide survey. While direct comparisons are not straightforward, there is no Comments reason to suspect that the level of knowledge in the target regions was (incl. % disproportionately higher than the national average prior to the project. achievement) The KAP survey clearly shows a significant increase over the base-line, as well as over the end-of-project target. Number (Percentage) of women and men aged 15-49 who received an Indicator 4 : HIV test in the last 12 months and who came back for their test results. Value (quantitative 0 100,000 NA 201,647 or Qualitative) Date achieved 09/01/2008 09/30/2012 09/30/2012 Comments The target was achieved, and in fact exceeded by more than 100 percent. 88. The 2005 AIS and 2012 DHS allow us to shed some more light on these issues. In the area of testing, Table 5 and 6 show comparable data for the 4 project regions and the rest of the country, and also breaks out the two regions which were formerly under full or partial rebel control (North and West) from the other 2 project regions. These data show significant increases in testing in both the project and other regions, with roughly a tripling of annual testing in Cote d’Ivoire as a whole. While still large, the increase in the project regions is less than that of the rest of the country. 89. However, the improvements in the North and West regions are particularly stark, with an eight-fold increase in annual testing for males, and a sixteen-fold increase for females. In the South and Abidjan, the increases are more modest, since the base was that much higher. The overall level of testing in the North and West are now about two- thirds of that of the rest of the country, a significant increase over 2005. Table 5: Testing Data from 2005 AIS and 2012 DHS 2005 Female Male Tested with Test last Tested with Test last Ever tested results 12 months Ever tested results 12 months Project 16.3 14.4 4.9 12.2 10.3 4.4 Non-project 6.9 5.9 1.9 5.6 4.4 1.4 Total 12.4 10.9 3.7 9.5 7.9 3.2 24 2012 Female Male Tested with Test last Tested with Test last Ever tested results 12 months Ever tested results 12 months Project 42.0 38.6 15.5 28.5 26.6 11.6 Non-project 33.0 30.7 12.2 21.4 19.1 7.0 Total 37.8 34.9 14.0 25.4 23.3 9.6 Change Female Male Tested with Test last Tested with Test last Ever tested results 12 months Ever tested results 12 months Project 157.8% 168.6% 214.2% 134.6% 158.4% 163.5% Non-project 375.6% 419.5% 539.3% 284.5% 336.2% 392.9% Total 204.8% 220.2% 278.4% 167.4% 194.9% 200.0% Table 6: Breakout of Regions within Project 2005 Female Male Tested with Test last Tested with Test last Ever tested results 12 months Ever tested results 12 months North + West 2.6 1.4 0.7 2.2 1.8 0.7 South + Abidjan 20.5 18.4 6.3 15.2 12.8 5.5 Project 16.3 14.4 4.9 12.2 10.3 4.4 2012 Female Male Tested with Test last Tested with Test last Ever tested results 12 months Ever tested results 12 months North + West 27.5 24.4 10.0 17.8 14.8 6.0 South + Abidjan 47.9 44.4 17.8 32.8 31.2 13.8 Project 42.0 38.6 15.5 28.5 26.6 11.6 Change Female Male Tested with Test last Tested with Test last Ever tested results 12 months Ever tested results 12 months North + West 952.8% 1602.2% 1428.7% 708.9% 714.2% 795.3% South + Abidjan 133.4% 141.5% 183.7% 116.1% 143.2% 149.8% Project 157.8% 168.6% 214.2% 134.6% 158.4% 163.5% 90. While not specifically related to at-risk groups, the AIS and DHS data also shed some light on the overall level of knowledge in the project regions compared to others. First Table 7 shows the level of recognition of HIV/AIDS, with the regional break-out of project regions below. Here the project regions show a higher level of improvement for 25 females and marginally less for males. This is consistent with the focus of the project activities on females. 91. Of particular interest is the increase in knowledge in the North and West regions, which have gone from 74% for females and 81% for males to 87% and 96% respectively. Given the level of IEC activities carried out in the project (almost 2 million people reached with IEC, behavioral change or condom promotion activities, with over half of this directed to the general population), this increase in recognition is a positive indication of the possible impact of these activities. Table 7: Percent of People who Have Heard of HIV/AIDS Female Male Regions 2005 2012 Change 2005 2012 Change Project 91.0 96.6 6.1% 94.7 98.1 3.6% Non-project 88.2 93.0 5.5% 94.4 97.9 3.7% Total 89.9 94.3 4.9% 94.6 98.0 3.6% Female Male Regions 2005 2012 Change 2005 2012 Change North + West 74.1 86.9 17.3% 80.5 95.9 19.2% South + Abidjan 96.3 98.6 2.4% 99.0 99.0 -0.1% Project 91.0 96.6 6.1% 94.6 98.0 3.6% 92. A second set of tables, shown in Tables 8 and 9, show the level of knowledge of those 15-49 regarding 3 preventions methods: (i) use of a condom (Condom); (ii) limiting sex to a single uninfected partner (Single); and (iii) using a condom and limiting sex to a single uninfected partner (C+S). For both males and females, the recognition of condom use as a prevention measure is now greater in the project regions, compared to the non-project ones, and the level of increase in knowledge is significantly higher, given overall decreases in knowledge country-wide, and in particular in the non-project regions. Knowledge of other prevention measures has also grown but to as great an extent as with condom use. Again, referring to Table 2, the level of condom promotion may well have contributed to this result. Table 8: Knowledge of Prevention Practices 2005 Female Male Condom Single C+S Condom Single C+S Project 58.8 68.1 52.8 75.6 78.8 68.2 Non-project 62.8 71.0 58.6 72.5 76.8 66.3 Total 60.4 69.2 55.2 74.4 78.0 67.4 26 2012 Female Male Condom Single C+S Condom Single C+S Project 63.4 69.1 53.1 81.5 79.3 69.9 Non-project 55.8 63.8 47.2 78.2 78.8 67.5 Total 59.9 66.7 50.4 80.0 79.1 68.8 Change Female Male Condom Single C+S Condom Single C+S Project 7.9% 1.5% 0.6% 7.7% 0.7% 2.6% Non-project -11.2% -10.1% -19.4% 7.8% 2.5% 1.8% Total -0.8% -3.6% -8.7% 7.5% 1.4% 2.1% 93. Table 9 shows the same data for the project regions, broken down between the former rebel-controlled regions and those controlled by the government. Again, this table shows the differential improvement in the North and West regions, with female and male knowledge improvement with respect to condom use of 54% and 31% respectively, and smaller but still significant knowledge improvements in other areas. By contrast, knowledge in the South and Abidjan regions has stagnated or even declined marginally. The higher population in the south affects the overall averages. Table 9 - Knowledge of Prevention Practices – Regional Breakdown 2005 Female Male Condom Single C+S Condom Single C+S North + West 37.5 44.9 35.3 59.5 62.1 56.0 South + Abidjan 65.4 75.3 58.3 80.5 83.8 71.8 Project 58.8 68.1 52.8 75.6 78.8 68.2 2012 Female Male Condom Single C+S Condom Single C+S North + West 57.9 64.7 50.1 77.6 75.0 66.4 South + Abidjan 65.7 70.9 54.4 83.0 81.0 71.3 Project 63.4 69.1 53.1 81.5 79.3 69.9 Change Female Male Condom Single C+S Condom Single C+S North + West 54.4% 44.1% 42.2% 30.5% 20.8% 18.7% South + Abidjan 0.4% -5.8% -6.7% 3.1% -3.4% -0.8% Project 7.9% 1.5% 0.6% 7.7% 0.7% 2.6% 27 94. A final area to look at is HIV/AIDS prevalence, shown in Table 10. While the link between prevalence and the project interventions is much more tenuous, it is interesting to note that prevalence among females – one of the primary target groups of the project – has fallen much more quickly in the project regions, compared to the rest of the country. In contrast, the prevalence rate for males has fallen more quickly in the non-project regions and actually increased marginally in the project regions. A break-out comparison of the project regions is not shown due to the relatively low prevalence and smaller sample size of the North and West regions. Table 10: HIV/AIDS Prevalence (percent of population 15-49) Female Male Regions 2005 2012 Change 2005 2012 Change Project 7.4 5.1 -31.6% 3.0 3.1 5.6% Non-project 5.0 4.0 -19.6% 2.7 2.2 -19.3% Total 6.4 4.6 -28.1% 2.9 2.7 -6.9% 95. PDO 2: In order to achieve the second development objective, the project supported the implementation of the subcomponent 2.1 (health sector). The health subcomponent was implemented through a network of 59 health facilities (among which 36 are new) which integrated into their service package, HIV/AIDS service such as VCT, PMTCT, STI, and ART. The late start-up of the health component as well as frequent shortages of medicine and reagent has considerably affected the effective implementation of these activities. 96. A total of 51 000 pregnant women were tested and among those who were tested positive for the HIV (2,018 or 3.9 percent), 893 women (44.25 percent) received a full course of antiretroviral treatment to reduce the risk of mother-to-child transmission. 97. Another 12,341 persons affected by the HIV received appropriate medical treatment, care and support and 2,710 of those with advanced form of the disease received antiretroviral therapy. 98. Table 11 shows that one out of two targets was achieved for the second PDO. Table 11 - Level of Achievement of Second PDO Indicators Original Target Formally Actual Value Values (from Revised Achieved at Indicator Baseline Value approval Target Completion or documents) Values Target Years Percentage and number of HIV-infected pregnant women who received a Indicator 1 : completed antiretroviral treatment to reduce the risk of mother-to-child transmission Value 0% 75% 44 % (893) 28 quantitative or Qualitative) Date achieved 12/31/2007 09/30/2012 09/30/2012 Comments (incl. % The target was not achieved (59 percent achievement). achievement) Percentage and number of adults and children with advanced HIV Indicator 2: infection receiving antiretroviral therapy Value quantitative or 0 2,500 2,710 Qualitative) Date achieved 12/31/2007 09/30/2012 09/30/2012 Comments (incl. % Target was achieved, and exceeded by 8 percent. achievement) 99. Table 12 shows that of the 6 intermediate outcome indicators, one became redundant and the other 5 were either fully or substantially (over 80 percent) achieved. The indicator that became redundant was due to an institutional change in HIV/AIDS governance in the new government following the 2011 crisis, where the Ministry of HIV/AIDS was merged with the Ministry of Health. Therefore, 68% of the 13 CTAIL were established and made operational 54% through project implementation, indicating that this indicator was clearly on target prior to the institutional change, and suggesting that all IO indicators would have been met if the change had not been made. Table 12 - Level of Achievement of Second PDO Intermediate Outcome Indicators Original Target Formally Actual Value Values (from Revised Achieved at Indicator Baseline Value approval Target Completion or documents) Values Target Years Number of sub-contracts awarded and implemented for HRG and Indicator 1 : vulnerable populations Value 81 PULMS (quantitative 0 51 NA (2012) or Qualitative) Date achieved 07/15/2008 09/30/2012 06/29/2012 Comments (incl. % Target was achieved. achievement) Number of decentralized ( department) plans developed and implemented Indicator 2: in the four regions for Health and Education Value 24 PULMS (quantitative 0 24 NA (2012) or Qualitative) 29 Date achieved 07/15/2008 09/30/2012 09/30/2012 Comments (incl. % Target was achieved achievement) Indicator 3: Percentage and number of CTAIL put in place and operational Value (quantitative 0 19 NA or Qualitative) Date achieved 07/15/2008 09/30/2012 This indicator has become irrelevant with the institutional change which happened in the HIV/AIDS governance in the new government following Comments the 2011 crisis. However, with the support of the project, 13 CTAIL were (incl. % established and made operational prior to the election (54% through achievement) project implementation), indicating that this indicator was clearly on target prior to the institutional change. Indicator 4: Health personnel receiving training Value 2,633 PULMS (quantitative 0 3,000 (2012) or Qualitative) Date achieved 02/31/2007 09/30/2012 09/30/2012 Comments Target was substantially (88%) achieved, and likely would have been (incl. % achieved if not for the crisis. Figure 2 showed the impact of the crisis on achievement) PEPFAR training activities. In comparison, a figure of 88% achievement for the project is quite positive. Joint annual report of the Multisectoral HIV/AIDS Program, disseminated Indicator 5: during the annual Meeting of the CNLS. Value 3.00 PULMS (quantitative 0.00 3.00 NA (2012) or Qualitative) Date achieved 09/01/2008 09/30/2012 06/29/2012 Comments (incl. % The target was achieved achievement) Percentage of executing agencies (public sector and civil society) that Indicator 6: submit programmatic and financial three-monthly reports completed and on schedule Value 76.00 PULMS (quantitative 0 90.00 NA (2012) or Qualitative) Date achieved 09/01/2008 09/30/2012 09/30/2012 Comments (incl. % The target was substantially (84%) achieved achievement) 30 100. In summary out of the four PDO indicators, the target was achieved for two indicators; and substantially achieved for one other. For some of the indicators, there were data comparability problems that make comparisons to the baseline (on which the targets are based) difficult, for some indicators. Given the data comparability issues which were driven by the lack of appropriate geographically disaggregated data at the time of appraisal, the ICR team utilized other sources of data to assess PDO progress: the AIS national survey of 2005 and the DHS national survey of 2011/12. This comparison shows significant improvements in a number of areas in the project regions, especially when compared to the non-project areas. In many cases, the areas of improvement can be linked to the focus of project interventions. Of particular interest (see Table 10), is the fact that prevalence among females – one of the primary target groups of the project – has fallen much more quickly in the project regions, compared to the rest of the country. 101. In addition to the PDO-level analysis, the review of Intermediate Outcome indicators shows that five out of the 10 indicators were fully achieved, two were substantially achieved (84 and 88%), comparable data could not be obtained for one, and one indicator has become irrelevant due to institutional changes in HIV/AIDS governance but likely would have been achieved if the change had not been made. In light of the difficulties with the comparability of the “official” PDO indicators, the generally positive results shown from the AIS/DHS comparison, and the positive results from the IO indicators, the efficacy of the project is rated as Significant. 3.3 Efficiency 102. The PAD provided an economic justification for a coordinated and comprehensive response to the HIV/AIDS epidemic in Cote d’Ivoire. Cote d’Ivoire was the most HIV/AIDS affected country in West Africa (HIV prevalence of 4.7 percent) with generalized HIV epidemic marked by gender and geographic differences. Protracted politico-military crisis that affect the country since 1999 has led to significant population displacement, increased poverty, insecurity and sexual violence. 103. The economic and social impact of the epidemic was obvious; in 1998, a survey conducted to assess the impact of HIV/AIDS in education sector pointed out that 64 percent of primary teachers’ deaths were found to be due to AIDS. In the health sector, AIDS patients greatly increased the occupancy of hospital beds. The economic cost of the HIV epidemic of Cote d’Ivoire is substantial, with a model simulating the impact of the epidemic through its effect on human capital and savings suggesting that by 2010 GDP would be about 13 percent lower than what GDP would have been in the absence of the epidemic. The same model also indicated that the loss in GDP could be reduced by providing access to antiretroviral treatment. Treatment prevents the loss of adults in their prime productive years, thereby increasing the ratio of the active population to the total population; and also increases the productivity of the labor force by reducing losses in human capital. The net effect of antiretroviral treatment is estimated to offset about 32 percent of the potential loss of GDP in the case of the Cote d’Ivoire. 31 104. The level of HIV/AIDS epidemic and its socio-economic impact have pushed the government to prioritize financing the cost of the AIDS response. The government prepared 5 year strategic plans (NSP) to respond adequately to HIV/AIDS epidemic and submitted this plan to development partners for resource mobilization. The total estimated budget of the latest NSP was US$594 million of which 56% was dedicated to care and support and less than quarter to the prevention activities. About 96% of the total budget was provided by external financing, including the US Government through the PEPFAR as a major contributor. 105. The purpose of the current project was to complement national effort to tackle the increasing demand for the HIV/AIDS response and to focus on the most vulnerable and high risk groups. It supported highly cost-effective interventions such as voluntary testing and counseling, promotion and distribution of condoms, peer-based programs to educate higher-risk groups, including sex workers and youth, etc. which are known as cost-effective at US$100 or less per HIV infection averted (a commonly-used threshold for cost-effectiveness). 106. During the implementation, the project has introduced two innovative approaches which led to reductions in unit cost: a. Introduction of the use of finger pricks (a simple method similar to diabetes blood testing) which does not require laboratories has reduced the cost of mass testing. The finger prick test costs patients $4.17 per test, whereas a person tested through traditional testing is three times more ($17.73). Apart from the affordability, the use of “finger pricks” has also contributed to improved access to HIV testing; b. The massive involvement of local NGOs and faith-based organizations through direct contracting by the project compared to the prior practice whereby International NGOs recruited local NGO to implement services have led to significant reduction in the overhead and operating costs. 107. An economic analysis (Annex 3) showed that the project has a benefit/cost ratio of 1.85:1, based on DALYs averted through reaching out to most at risk groups. 108. Between the inherent economic justification of a comprehensive response to the HIV/AIDS epidemic in the country, the choice of highly cost-effective interventions, the innovative cost effective approach such as use of finger pricks, the relatively acceptable achievement of the project objectives, and the benefit/cost ratio noted above, project efficiency is rated as Substantial. 3.4 Justification of Overall Outcome Rating 109. Rating: Based on the above presented data and analysis on the relevance of the project’s objectives, design, and implementation (Substantial), achievement of PDOs (Substantial) and efficiency (Substantial), the overall outcome rating of the project is Moderately Satisfactory. 32 3.5 Overarching Themes, Other Outcomes and Impacts (a) Poverty Impacts, Gender Aspects, and Social Development 110. Gender Aspects: The epidemiological data has highlighted a feminization of HIV/AIDS epidemic in Cote d’Ivoire where in all age groups females were by far more likely to have HIV than males. Therefore, the project identified commercial sex workers and women living in low-income neighborhoods of urban center as key target groups. Women in those areas face dual challenges due to limited access to services and poor protection given by the strong social control and more conservative behaviors generally found in the countryside. In addition, women are often victims of gender based sexual violence. Despite the fact that only marginal improvements were achieved in the project outcomes related to this subgroup, they have received strong support from the project. However, there is a need for further strengthening such targeted efforts at national level so as to ensure that the women receive the deserved attention which is required to reverse the current epidemiological trend. 111. Social Development aspects: The project contributed to strengthening the capacities of civil society for a better involvement in the fight against HIV/AIDS. The social mobilization component of the project supported 68 NGO’s to implement 81 subprojects focusing among other activities on social mobilization, condom promotion and distribution, behavioral changes activities, promotion of VCT, and so on, while 5 HIV/AIDS prevention networks (COSI, RIP+ARSIP, REPAMASCI, RIJES) received financial and technical support from the project. (b) Institutional Change/Strengthening 112. The project supported the strengthening of institutional capacities to coordinate the decentralized national HIV/AIDS response. A continuous support was given to National Council for HIV/AIDS (CNLS), regional HIV/AIDS committees, line ministry committees (CMLS). The project supported the development and dissemination of essential documentation such as technical guidelines. (c) Other Unintended Outcomes and Impacts (positive or negative) 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops 113. A beneficiary survey was not conducted 33 4. Assessment of Risk to Development Outcome 114. Rating: Moderate 115. The HIV/AIDS continues to be a public concern and the government response is proportional to this concern. Government ownership of the national response to HIV/AIDS epidemic has been demonstrated through high political commitment and involvement including financial support expressed at the early stage of the HIV/AIDS epidemic, development of subsequent HIV/AIDS National Strategic Plans, development and strengthening of appropriate intuitional capacities to coordinate and manage the national response. In order to ensure the continuity of services supported by the current project, the government has mobilized adequate financial resources. For the transition period, the Government advanced 740 million CFA (USD 1.5 equivalent) to continue to finance these activities. In addition, the government has put in place a National Fund for HIV/AIDS through taxes imposed on alcohol and tobacco purchases with the objective to finance care and treatment of HIV/AIDS. The support of the Global Fund and other development partners will continue to support prevention and care activities. There have also been recent discussions between the Bank and PEPFAR regarding enhancing their collaboration in the country. Based on these various factors, especially the commitment by the Government for securing funding for its national HIV/AIDS strategic plan, the risks to development outcomes are considered Moderate. 5. Assessment of Bank and Borrower Performance 5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry Rating: Moderately satisfactory. 116. The project identification and design were based on the National HIV/AIDS Strategic Plan (2006-2011), development of which was designed based on comprehensive situation analysis of HIV/AIDS epidemic and the national response. 117. The Plan has clearly defined the priority targets groups as well the appropriate actions to reduce the burden of HIV epidemic. In addition, the plan provides detailed budget breakdown as well the existing financial gap. Therefore, the project was designed to complement the efforts of the government of Cote d’Ivoire together with its development partners in combatting the epidemic. The support from the project was entirely needs based focusing mainly on filling gaps. The project design has also benefited from the existing knowledge and experiences and lessons from the previous MAP project elsewhere. The project preparation also benefitted from a large ($1 million) project preparation grant, which was about three-quarters used and contributed both to informing the project design and ensuring project readiness. 34 118. Despite this, there were two areas where quality at entry could have been improved. First, a QER was not conducted for this project, which would have been a good idea given the security and economic uncertainties in the country. Second, the selection of indicators and baseline values should have been adjusted once the decision was made to scale back from a national program to one covering just 4 regions, and plans for regional level baseline production should have been incorporated into the overall project M&E plan. These factors contributed to the quality at entry rating. 119. Nevertheless, once the ISN was in place, the Bank moved quickly to modify preparation and push ahead with this important operation, using available data and ensuring the design was as customized as possible to the specific drivers of the HIV epidemic in Cote d’Ivoire and National Strategic Plan. (b) Quality of Supervision Rating: Moderately satisfactory 120. The presence of the World Bank team and the TTL on the ground was crucial for the timely completion of the project. Of particular note is that the project was implemented under very difficult circumstances related to the conflict and consequent disruptions and deteriorations in poverty and services in the country. Despite these issues the World Bank team was able to conduct regular supportive supervision and keep the client as well as the World Bank management informed of the situation. 121. Despite the regular proactive supportive supervisions, the task team could not conduct the midterm review as planned. The political situation which prevails in the country may be the main reason. However, as an alternative to the Mid Term review, the project team with the support of the World Bank team undertook a review of with the objectives to assess the project achievement and constraints and the outcomes of this review were presented in February 2012, seven months before the closure of the project. 122. Again, one implementation issue on the M&E front was the failure to ensure comparable data and/or suitable base-line data for several key indicators, or to change the indicators once it became clear that comparable data would not be available. Also, following Bank re-engagement after the crisis, performance targets should have been reviewed and revised to reflect what was possible in the remaining time frame. In sum, quality of Bank supervision is rated Moderately Satisfactory.. (c) Justification of Rating for Overall Bank Performance 123. Rating: Based on the Moderately Satisfactory rating for quality at entry and Moderately Satisfactory rating for quality of supervision, overall Bank Performance is rated as Moderately Satisfactory. 35 5.2 Borrower Performance (a) Government Performance Rating: Moderately Satisfactory 124. The commitment that the government of Cote d’Ivoire has demonstrated to fight against HIV/AID, since 1986 when the first comprehensive national plan was developed is commendable. The establishment in 2001) of a Ministry exclusively dedicated to fight against HIV/AID (Ministère de la lutte contre le SIDA) despite the difficult political and economic situation is an additional evidence of higher political commitment. 125. In order to ensure effective and successful implementation of subsequent national HIV/AIDS plans, the government of Cote d’Ivoire has mobilized not only external financial support but also committed domestic resources. 126. The HIV/AIDS National Strategic Plan (2006-2010) which has served as a basis for the design of the current project was developed through active participation of relevant key stakeholders including development partners. 127. In order to ensure the sustainability of the project, the government has developed an exit strategy for the current project and has mobilized substantial financial resources to sustain the results of the project. In addition, the government has established a National Fund for HIV/AIDS through taxes imposed on alcohol and tobacco purchases with the objective to finance care and treatment of HIV/AIDS. 128. Institutional reforms in 2011 resulted in merging two Ministries: the Ministry of Health and the Ministry of the fight against AIDS. This created some concerns among the stakeholders. The major concern was the preservation of the CNLS and regional coordination units. However, the new Ministry reassured partners of the government’s continued commitment to fight against HIV/AIDS. (b) Implementing Agency or Agencies Performance Rating: Moderately Satisfactory 129. The project was executed under the supervision of national HIV/AIDS council (CNLS) which is chaired by the head of state and regroups representatives of all socio- professionals groups including networks of Peoples leaving with HIV/AIDS. The CNLS was responsible for the monitoring of overall national response and inform stakeholders on progress as well constraints. Although, annual progress reports were issued regularly, the CNLS was not able to hold the annual review meeting as planned (only one meeting took place from 2008 to 2010). The institutional uncertainty which preceded the inclusion of Ministry in charge of HIV/AIDS as well the political instability which prevailed in the country may have prevent CNLS (which is chaired by the head of state) to hold regular meetings. 36 130. A Project Implementation Unit was establish under the responsibility of the Ministry in charge of HIV/AIDS to ensure the coordination, financial management and monitoring of the project. The recruitment of the PIU was a major condition of project effectiveness and was completed within more than 90 days after grant signature. The project team was in place during the whole project implementation period and has performed relatively well despite the volatile political environment. The team conducted an alternative process to the mid-term review, since a normal review was not possible. (c) Justification of Rating for Overall Borrower Performance 131. Rating: Based on a Moderately Satisfactory rating for the Government’s performance and a Moderately Satisfactory rating for the implementing agencies, the Borrower’s performance is rated Moderately Satisfactory. 6. Lessons Learned 132. Sustained political commitment at higher levels, together with the allocation of domestic resources, is essential to mobilize and effectively engage development partners in conflict prone settings like Cote d’Ivoire. The high level commitment and ownership demonstrated by the government facilitated securing of more than 96% of the budget required to implement the HIV/AIDS National Strategic Plan 2006-2011. 133. Rapid project implementation was assisted by taking advantage of the project preparation period to identify key implementation requirements and initiate required activities such as recruitment of implementing agencies, procurement of goods (drugs, reagents, medical equipment, etc.). 134. Close monitoring of the project toward the achievement of project development objectives using a simplified and well-designed M&E system is essential. This would help for regular monitoring of progress and analysis of implementation challenges for timely implementation of corrective measures. Where projects are sub-national in nature, M&E systems need to recognize this and not rely on national level data. This is especially important with respect to developing appropriate baseline data, since this cannot be developed after the fact. 135. Following events such as the 2010-2011 political crisis and subsequent re- engagement, project parameters, indicators and targets should be carefully assessed, and restructuring should be initiated where it appears that some project objectives are no longer attainable. 136. The use of local NGO’S to deliver HIV/AIDS prevention services was commendable. This service delivery modality could be applied to the provision of other services, especially for client groups where the use of public service providers is problematic. In the context of weak public health services, the involvement of non-public service providers such as NGO’s, faith-based association is a viable alternative. 37 137. In the context of post conflict and fragile situation where large parts of the population are prone to displacement and economic precariousness, the usual landscape of commercial sex work changes. This makes it difficult to find such groups in the usual public places such as bars, etc., and alternative strategies need to be developed. Moreover, due to the poverty, more young women are involved in transactional sex during such periods of uncertainty. Therefore, it is important to adjust the communication means/strategy to reach these groups. 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies (b) Cofinanciers NA (c) Other partners and stakeholders NA 38 Annex 1. Project Costs and Financing (a) Project Cost by Component (in USD Million equivalent) Appraisal Actual/Latest Percentage of Components Estimate (USD Estimate (USD Appraisal millions) millions) 1. Component - Social mobilization and HIV 6.4 5.32 32% prevention services 2. Component –Public Sector 7.8 7.61 39% 3. Capacity building 3.3 4.7 16.5% 4. Coordination, Management, 2.37 2.5 12.5% Monitoring and Evaluation Total Baseline Cost 20.00 20.00 100.0 Physical Contingencies 0.00 0.00 0.00 Price Contingencies 0.00 0.00 0.00 Total Project Costs 0.00 0.00 Front-end fee PPF 0.00 0.00 .00 Front-end fee IBRD 0.00 0.00 .00 Total Financing Required 0.00 0.00 (b) Financing Appraisal Actual/Late Type of Estimate st Estimate Percentage Source of Funds Cofinancing (USD (USD of Appraisal millions) millions) Borrower 0.00 0.00 0.00 % IDA Grant 20.00 20.00 100.00% 39 Annex 2. Outputs by Component Component 1: Social mobilization and HIV/AIDS Prevention Services for vulnerable and high risk groups. 138. The component supported the implementation of social mobilization and HIV/AIDS prevention, care and support activities in four project supported regions by national and international NGO’s. The identified activities were HIV/AIDS Information, Education and communication activities as well behavioral change communication activities with a focus on safer sexual-behavioral, delayed first sexual intercourse; reduction in early marriage; promotion and use of voluntary counseling and testing services, care and treatment of PLWHA including OVC). These activities were targeting the following high risk groups: commercial Sex workers, orphan and vulnerable children people living with HIV/AIDS, and particularly vulnerable youth and women which include women living in low-income neighborhoods of the urban centers. 139. The component had also financed a few country wide interventions such as intensive IEC campaigns targeting commercial sex workers and vulnerable youth, mass campaign for the general public to improve common knowledge about HIV/AIDS and reduce the stigmatization of PLWHA and other high-risk groups. 140. In addition, the project contributed to the improvement of mass communication campaigns on HIV/AIDS prevention through the agreement signed with the national radio and television network (RTI) to support 42 community radios for the transmission of communication materials for behavior change. 141. The project has supported 68 NGOs to implement 81 sub-projects targeting the high risk groups and focusing among other activities on social mobilization, condom promotion and distribution, behavioral changes activities, promotion of VCT. The networks of HIV/AIDS civil society groups (COSI, RIP+ARSIP, REPAMASCI, RIJES) received a financial and technical support from the project to strengthen their capacities and provide services to their members and their affiliates. 142. The subcomponent supported to Men who have Sex with other Men (MSM) by an experienced international NGO (Heartland); 143. Establishment and continuous support to four regional centers to serve as a platform for NOG’s supporting orphans and Vulnerable children 144. The project has supported the private sector through its national network (private enterprises working against HIV/AIDS in Cote d’Ivoire). Forty eight small and medium enterprises have conducted HIV/AIDS prevention activities in the work place. 145. The table below summarizes the implemented HIV/AIDS prevention activities by the categories and the number of beneficiaries. 40 Table Number of target groups reached by specific HIV/AIDS services Category and number IEC & Condoms VCT of target groups behavioral promotion change activities CSW 15,437 15,437 12,151 MSM 5,835 5,835 OVC 16,910 PLWHA 12,341 12,341 Mobile Population 170,318 170,318 20,460 Particularly vulnerable 153,759 153,759 33,879 women Private sector workers 29,645 29,645 6,465 General Population 663,978 458,366 205,407 TOTAL 1,068,223 845,701 278,362 Component 2: Public Sector Interventions: Prevention and Care 146. This component has supported Ministry of Health and three other key Ministries to deliver essential HIV/AIDS prevention, care and treatment services Sub-component 2.1: Health Sector 147. The Ministry of Health was support to deliver health related essential HIV/AIDS prevention, care and treatment services in the four projects focus regions. a. 59 health institutions of new health facilities were equipped to integrated the delivery of health related essential HIV/AIDS prevention, care and treatment services into the their basic package of services; b. The laboratory capacities were strengthened in the four region by establishment of 7 regional laboratories and reinforcing the capacities of 36 health facilities; c. Support to the prevention of blood transmission; d. Support the implementation of Medical waste management plan through procurement and installation of 4 incinerators in regional hospitals; e. Procurement and distribution of medical commodities, reagents, medicines including ART drugs; f. Training of 1145 health workers g. Reinforcement of coordination and supervision capacities of regional health department (material, technical and financial support) The below table summarizes the achievement of this subcomponent is: 41 N° Indicators Target Achievement 1 Number of Health facilities providing VCT 52 44 Number of People counseled, tested for HIV and 2 81,200 73,508 who received their results 3 % of tested persons who received their results 52 44 Number of Health facilities providing PMTCT 4 49 44 services Number of pregnant women counseled and tested 5 30,000 51,000 for HIV Percentage of HIV infected pregnant women who 6 received a completed antiretroviral treatment to 70% 44% reduce the risk of mother to child Number of Health facilities providing treatment of 7 25 20 HIV infection (ART) Number of adults and children with advanced HIV 8 2,500 2,710 infection receiving antiretroviral treatment Sub-component 2.2: Support to the action plans of key Ministries 148. This subcomponent supported the three key Ministries (Defense, Interior and Education) with the mandate to cover the target groups that cannot be easily reached by NGOs, such as youth who are in school, the armed forces and the police. 149. The Ministry of Defense and the Ministry of Interior implemented their respective action plans on national scale and were aiming to improve the knowledge, the attitudes toward HIV infected people and promotion of safer sexual behavior. The subcomponent supported the delivery of health related HIV/AIDS prevention, care and treatment services by the army and police health services in the four regions. The project has also supported to set up military personnel network for West Africa and a center for HIV/AIDS prevention (REMAFOC/AIDS) and over 7993 military personnel and their families have benefited. Over 5358 people have been tested (53% of those current military personnel). 150. The support to the Ministry of Education was limited to the project supported four regions and was aiming to complement the ongoing effort from other partners such as UNFPA, PSI and FHI. The project supported the introduction of HIV/AIDS modules for pre-teenagers, development and dissemination of curriculum for both students and teachers, and the activities of teachers associations of PLWHA. The project supported the establishment of 86 anti AIDS clubs in project supported four regions which contribute to target 33, 101 school children. 42 Component 3. Capacity Building Component 151. This component has supported the strengthening at all level (managerial and implementation level) the capacities necessaries for the successful implementation of the project. The special attention was given to the public sector which was in a bad shape compare to the NGO’s. The project has contributed to the set-up of an information center on HIV/AIDS and to the development of norms and national guidelines on the different themes which were supported such as support to commercial sex workers, ARV treatment, gender based violence, nutrition, etc. 152. The project has also contributed to the training of over 2700 people in the various sectors of interventions for HIV/AIDS prevention. It has also contributed to the development of training modules for implementation entities and five implementation manuals. It has also contributed to the overall implementation manual, to the manual for planning, monitoring and evaluation, as well as to those of the civil society and the private sector. 153. The component also the project coordination units in the four regions in order to endure competent project implementation. Component: Coordination, Management, Monitoring and Evaluation 154. The project contributed to strengthen the coordination and supervision capacities of institutions involve in the management of national HIV/AIDS response. Although the project support covered the overall organization of the coordination, management, particular attention was given to the decentralized level of coordination, line ministries and implementing agencies. Funding was provided to help set up and operationalized the CRLS in the 19 regions of the country, as well as establish the accompanying Technical Units to Support Local Initiatives (CTAIL). 155. The project has also supported to establishment of the monitoring and evaluation (M&E) system to track the achievements of all project components but also provided required support to the national M&E framework. a. Periodic supervision missions were conducted to ensure timely implementation of work program and to undertake the quality audit of reported data by implementing agencies; b. Conduct of Regional and Sectorial mid-term review of work program; c. Support to the DHS survey; d. Support was provided to the HIV/AIDS vulnerability and response among the youth managed by UNICEF; e. 346 persons were trained on M&E of HIV/AIDS; f. Quarterly project progress with all routine data were prepared and widely distributed; g. KAP study in the project supported four regions; h. DHS 2012 survey. 43 Annex 3. Economic and Financial Analysis (including assumptions in the analysis) 156. The section provides the economic and financial analysis of the project. It first summarizes the economic context within which the project operated, and then analyzes the cost-effectiveness and cost-benefit analysis of the emergency HIV/AIDS Multi- Sectoral Project. Economic Context 157. For two decades following its independence in 1960, Côte d’Ivoire stood as an island of prosperity, peace and stability on a continent beset by conflicts and poverty. A fairly rich natural resources endowment, political stability, a bold open door policy to attract a productive labor force and favorable terms of trade for its main agricultural exports helped the country achieve a strong economic performance which, by the end of the 1970s made Côte d’Ivoire the major player of the West African Monetary and Economic Union. Real Gross Domestic Product (GDP) per capita grew steadily during that period at average 6% per year. 158. A sharp reversal began in 1980 as terms of trade deteriorated precipitously and the CFAF became increasingly overvalued. From 1981 to 1992, annual GDP growth averaged -0.2% and Côte d’Ivoire slipped from the rank of middle income countries into the low income group. The devaluation of the CFAF in 1994 triggered an economic rebound, but this was soon undermined by the political crisis which began in 1999. 159. A period of political instability began with the coup d’état of December 1998. A second, failed, coup d’état on September 19, 2002 evolved into a long-standing rebellion which split the country along a north-south divide until mid-2011. The conflict brought economic activity to a standstill, severely affected basic social service delivery and further damaged the country’s social fabric. The conflict aggravated an already high unemployment rate, especially of the youth, and unemployed younger persons have been easily recruited for political gain. Poverty surveys have indicated that the number of people living below the poverty line more than quintupled between 1985 and 2008, from 10% to 50%. Poverty in rural areas increased from 49% in 2002 to 63% in 2006. Malnutrition rates are high, with 39% of children under five suffering from stunting, and almost 30% are underweight. Central, Northern and Western Côte d’Ivoire (known as CNO zone, which is also the cotton and cashew producing areas) have been particularly affected, underlining regional dimension of rural poverty. Côte d’Ivoire now ranks 166th out of 171 countries on the UNDP Human Development Index, and will be far from achieving the MDGs in 2015. 160. The political and military crisis largely ended in April 2011 and the new Government has made rapid progress in restoring security, reinstating public and social services and launching the rehabilitation of critical infrastructure. The Government is strongly committed to tackling various reforms (coffee/cocoa sector, electricity sector, the judicial system, business climate and public sector governance) that should offer opportunities to strengthen the economy and its growth potential. 44 161. Real GDP fell sharply (5.8%) in 2011, but the economy has rapidly recovered since the reopening of banks and financial institutions at the end of April 2011 and the lifting of the European Union (EU) embargo at the end of the post-election crisis. Economic activity rebounded more strongly than projected in 2012 following a contraction in 2011 induced by the crisis. GDP increased by 9.8 percent in 2012. Most economic indicators have evolved favorably since May 2011 and the economic outlook for 2013 and over the medium term is favorable. Real annual GDP growth of 8.5% is forecast for 2013-15. Economic Analysis 162. To get the benefits of the project and compare it with the costs, the “disability- adjusted life years (DALYs) averted due to intervention were estimated. The DALY extends the concept of potential years of life lost due to premature death (PYLL) to include equivalent years of healthy life lost by virtue of being in states other than good health. Following Murray and Lopez (1996) total DALYs for each case-age-sex group are calculated as the sum of burden of premature mortality (YLL) and the non-fatal burden (YLD). Thus, DALY = YLL + YLD ……………………………………………… ………….......... (1) DAYLaverted = DALYbaseline – DALYnew…………………………………………..…... (2)   YLL  NCe(ra) /(B  r)2 e( Br )  (b  r)(L  a)  1  e( Br ) a  (B  r)a  1 .......... .......... .......... (3)  KCe /(B  r) e YLD  IDW ( ra)  2 ( Br )(La )  (B  r)(L  a)  1  e(Br )a  (B  r)a  1   (4) ..........   rL  (1  K )(L / r)(1  e )   163. Where, N is the number of deaths, C is the age-weighting correction constant, r is the discount rate, B is the parameter from the age weighting function, a is the age of onset, L is the duration of disability or time lost due to premature mortality, I is the number of incident cases in the reference year, DW is the disability weight and K is the parameter which specifies whether age-weighting is specified (K=1) or not specified (K=0). 164. To analyze the DALYs averted due to the use of HIV/AIDS preventive and treatment methods, the following assumptions were used: 1) The discount rate for DALYs equals to 0.03 based on the Global Burden of Disease (GBD) standard value, the age-weighting correction constant equals to 0.1658 based on GBD value, the parameter from the age weighting function equals 0.04 based on GBD value, and financial discount rate is 3.9 %. 2) Use of condom by commercial sex workers will reduce the prevalence rate from 18.5 % (national average) to 2 %. 3) Cost per DALYs averted for condom use ranges from 19 - 205 USD (in this case the average is taken) 4) DALYs averted per 1000 condoms distributed/sold equals 5.19 45 5) The following parameters are adopted from previous studies on the estimation of unit costs of HIV/AIDS treatment in Ivory Coast (Hatt et al., 20084) after proper adjustment for inflation (3.9 %) has been made. These are: - Unit cost of counseling and testing equals 8 USD - Unit cost of antiretroviral therapy per person per year equals 459 USD - Unit cost of prevention of mother-to-child transmission per pregnant women counseled and tested equals 7.8 USD - Laboratory test per HIV positive receiving monitoring and test 47 USD 6) Life expectancy in Ivory Coast equals 55.4 years whereas; the per capita income is taken as 1570 USD. 165. The benefits of the project are analyzed based on the estimations of DALYs averted and the equivalent amounts of investment needed to bring about the same amount of benefits in terms of prevention and treatment done in similar projects. By adopting assumptions 1 and 2; and equations (3) and (4) above, the DALYs averted by use of condom by commercial sex workers equals to 253. Taking the per capita GDP of Ivory Coast as 1570 USD, the monetary amount of 253 DALYs averted equals to 397210 USD (253 *1570). Studies also indicate that cost per DALYs averted for condom use ranges from 19 - 205 USD. We take the average of this value, which is 112 USD to calculate the monetary value of the DALYs averted from use of condom reported in the project as 362208 USD (112 * 3234). Moreover, estimates made in Zambia indicate that per 1000 condoms sold/supplied, 5.19 DALYs are averted. 166. Based on this, we estimated the monetary value of condom supplied by the project to be $25.2 million. The rest of the benefits are also calculated based on the equivalent amounts of investment needed to do the same amount of intervention in a similar socio- economic environment. For instance, the monetary value of service rendered by the project through giving antiretroviral therapy to adults and children with advanced HIV infection amounts to $1.56 million. The rest of the calculations follow the same procedure based on the number of beneficiaries of the project and the assumptions made to value the services rendered (with proper discounting and compounding wherever necessary). Table 1 gives the details of the benefits of the interventions. 4 Hatt, L., Chiristin, O., Desire, B., Stephen,M., Beatriz, Z., Lazare, S., and Gilbert, K. 2008. Costs of HIV/AIDS Medical Services in Public Health Facilities in Cote d’Ivoire. Bethesda, MD: Health Systems 20/20 Project ,Abt. Associates inc. 46 Table A3.1 Summary benefits of the project Estimates of DALY Project Description of interventions averted in benefits in number USD Female sex workers reporting the use of a condom with their most recent client 253 397,210 Women and men from 15-49 years of age having had more than 1 sexual partner in the preceding 12 months reporting condom use 362,208 HIV-infected pregnant women who received a completed antiretroviral treatment to reduce the risk of mother-to- child transmission 524,416 Number of adults and children with advanced HIV infection receiving antiretroviral therapy 1,564,859 Number of condoms distributed (male & female) among the CSW in the 4 target Project regions 25,215,330 Number of high risk groups (FSW) who received an HIV test in the last 12 months and who came back for their test results 121,838 Number of women and men aged 15-49 who received an HIV test in the last 12 months and who came back for their test results 2,029,434 Total 253 30,215,296 Source: author’s simulation 167. The present value of the benefit from the project which amounts to $30,2 million (Table 1) is far greater than the present value of cost incurred which amounts to $16,3 million USD (Table2). Hence, as the benefits are greater than the costs, the investment is reasonable. Moreover, benefit-cost ratio of the project is 1.85 which means that for every dollar invested, there will be $1.85 in benefits. Table A3.2 Present values costs (2008-2012) Year Discounted Present value of Present values of costs in USD Costs in USD benefits in USD 2008 1,470,000 1,470,000 2009 3,176,131 4,590,953 2010 2,973,541 7,392,167 2011 6,553,008 13,667,702 2012 3,166,388 16,321,059 30,215,296 Source: author’s simulation 47 Annex 4. Bank Lending and Implementation Support/Supervision Processes (a) Task Team members Responsibility/ Names Title Unit Specialty Lending Bhanoumatee Ayoung Lead Procurement Specialist OPSOR Wolfgang M. T. Chadab Senior Finance Officer CTRLA Ayite-Fily D'Almeida Senior Operations Officer AFTHE William Dakpo Procurement Specialist AFTPE Frode Davanger Senior Operations Officer CFPIR Jean-Charles De Daruvar Senior Counsel LEGAM AFTM Bella Lelouma Diallo Sr Financial Management Specia W Daniele A-G. P. Jaekel Operations Analyst AFTHW Zainab Mambo-Cisse Program Assistant AFCF2 Tonia Marek Lead Public Health Specialist AFTHE Moussoukoro Soukoule Country Program Assistant EACVQ Irene S. Xenakis Consultant AFTOS Supervision/ICR Maurice Adoni Senior Procurement Specialist AFTPW AFTM Bella Lelouma Diallo Sr Financial Management Specia W AFTM Saidou Diop Sr Financial Management Specia W Assiata Houedanou Soro Sr Program Assistant. AFCF2 Zainab Mambo-Cisse Program Assistant AFCF2 Africa Eshogba Olojoba Senior Environmental Specialist AFTN1 Carolyn J. Shelton Operations Officer AFTHE 48 (b) Staff Time and Cost Staff Time and Cost (Bank Budget Only) USD Thousands Stage of Project Cycle No. of staff weeks (including travel and consultant costs) Lending FY01 38.30 FY02 228.88 FY03 170.99 FY04 142.28 FY05 91.91 FY06 0.14 FY07 0.00 FY08 87.76 FY09 -0.80 Total: 759.47 Supervision/ICR FY09 73.06 FY10 116.98 FY11 39.60 FY12 61.15 FY13 101.50 Total: 392.28 49 Annex 5. Beneficiary Survey Results NA 50 Annex 6. Stakeholder Workshop Report and Results NA 51 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR Summary of Borrower’s ICR: 168. Implemented for a period of four (4) years (October 2008 - September 2012), the Emergency Multisectoral AIDS Project (EMAP), with the support of the World Bank, aims to increase access and the use of prevention services for vulnerable groups and high- risk groups, and to improve access to and use of treatment services and support for people infected and affected by HIV. 169. These objectives are to strengthen prevention services for HIV / AIDS, increasing access to care, treatment and support for those infected and affected, strengthen the capacity of stakeholders to implement activities and enhance coordination, management, and Monitoring and Evaluation (M & E) of the project. It is mostly implemented in four (4) regions namely the former regions of the Lagoons, Mountains, Savannah and South Comoé. 170. The project is divided into the four (4) components: (i) social mobilization and prevention services against HIV / AIDS, (ii) public sector interventions, (iii) capacity building and (iv) coordination, management, monitoring and evaluation.   171. After four (4) years of implementation and in accordance with the funding agreement and the M&E plan, PUMLS decided to make the final assessment of the project following accurate objectives. 172. The evaluation of PUMLS aims to establish the overall performance of the project and measure its contribution to the improvement of action against AIDS in Côte d'Ivoire from 2008 to 2012. This evaluation focused on the following issues: relevance, effectiveness, impact interventions of PUMLS, the link between resources and achievements of the project from 2008 to 2012, the sustainability of implemented activities, value added provided by the PUMLS and performance of the Government and the World Bank in the preparation, implementation and monitoring of the project. 173. The methodology combined literature reviews, interviews and field visits. The final evaluation mission of PUMLS covered comprehensively the general objective and specific objectives expected by the PUMLS and the World Bank, and it concerned the period from 1 October 2008 to 30 June 2012 and all regions of project intervention and targeted both the PCU, the RCU as well as the implementing agencies who have contributed to the achievement of the project at national and regional levels. 174. Overall, the mission was conducted from July to September 2012 according to the following main steps: Kick-off meeting of the evaluation mission, development and validation of the detailed methodology and tools for data collection and preparation of the interim report by the Consultant, validation of the interim report by the PCU, the Ministry 52 of Health and the Fight against AIDS and the World Bank and the preparation and transmission of the final report and evaluation tools.   175. The data analysis allowed for each PUMLS objective to identify strengths, weaknesses and the level of performance of each item rated on a rating scale of five (5) levels: Very satisfactory, satisfactory, acceptable, unsatisfactory, very unsatisfactory. 176. The general opinion of the people and organizations met, we can say that the project PUMLS is well designed and implemented. 177. In terms of relevance, the evaluation noted that the project was in line with the strategic directions of Government (NSP 2006 -2010) and the World Bank (strategic framework for fight against AIDS 2007 - 2011). According to 99% of those interviewed, it responded to national and regional needs and has especially helped to fill financing gaps. The evaluation also showed a consistency of strategies with national strategies for the make-do with 133 implementing agencies, the decentralized approach, capacity building and support for coordination. Overall adequacy was very satisfactory. 178. The level of effectiveness of the project was satisfactory. With 85% of implementation of the activities, 70% of achievement and 88% delivery (92% lessor share) to June 30th, 2012, the performance of the project was satisfactory given the context in which it was implemented. The main deficiency at this level is the low performance of impact indicators, such as those related to PMTCT and the distribution and use of condoms by Sex Workers. 179. The evaluation considers the benefits of interventions and impact satisfactory. The main forces at this level are the project's contribution to capacity building of national actors in the fight against HIV / AIDS, strengthening national coordination and integration of community activities in the system of national M & E. Almost all of the interviewees endorse these findings. Also there is a great contribution to the achievement of project results at regional level (average 35 to 50% contribution of PUMLS to regional results fight against AIDS for regions Mountains, Savannah and South Comoé in 2009 and 2010). Unfortunately, many gains observed at this level have not been documented. 180. At the adequacy of resources and achievements of the project, a cross analysis between the disbursement rate (88%), the average rate of activities implementation (85%), the achievement rate of the indicators (70%), and percentage of contract completion (95%) indicates a relative adequacy in the use of resources. We also note that 51% of spending was allocated to activities towards beneficiaries and the cost analysis of intervention shows a relative comparative advantage of PUMLS on community awareness, screening and care of OVC. This aspect was considered satisfactory. It should be noted delays in the planning of activities due to cash problems, although it has improved since the end of 2010 by increasing the initial advance. 181. Regarding the sustainability of implemented activities, it should be noted that the project itself in view of its urgent nature, had not planned activities for sustainability. The 53 evaluation also found that most agencies (especially civil society and the private sector) had stopped their operations since the funding of PUMLS stopped. However, in the opinion of actors interviewed, strategies for implementation (capacity building of implementing agencies and state structures) were likely to ensure sustainability. In addition, the steps taken by the project toward the Government (MSLS, FNLS) and other partners (Global Fund, PEPFAR partners) could ensure continuity of services. Sustainability was therefore considered acceptable by the evaluation. 182. The evaluation considered the added value of the project satisfactory. Strategies and procedures for implementation of the project have greatly contributed to the intensification of the fight against HIV / AIDS in the areas of intervention. Interviewees in this regard, often cited initial situational analysis which has involved them, the transparent choice process of implementation partners, regular meetings of CRLS led by the area prefects. 183. At Government - World Bank relations, several facts show excellent collaboration between the two entities on aspects such as planning, resource mobilization, financial management, monitoring and supervision. This is certainly a good practice that should be copied. Performance of the Government and the World Bank in the preparation, implementation and monitoring of the project was satisfactory. Areas for improvement related to the formalization of the monitoring framework of the project at the Cabinet of MSLS, strengthening the communication between the different entities of the projects and the definition of a regulatory framework more suited to the terms of implementation of projects financed donor. 184. Key Recommendations- The main recommendations selected for improving the project in the perspective of a continuation. Projects a. Identify the most appropriate strategies for high-impact activities (PMTCT, condoms) and give them more resources to better enhance the project's impact on people; b. Pay more attention to the documentation of good practices and lessons learned by PUMLS; c. Continue strengthening the capacity of the implementing agencies on the transmission of reports and satisfactory justification of funds. The Government and the World Bank a. Put in place more fluids mechanisms to improve the availability of cash in a timely manner; b. Ensure the Government's involvement in the identification and implementation of mechanisms for sustainability in project design; c. Improving the formulation of project performance indicators and determination of objectives; d. Put in place a regulatory framework for the development of a law on the status and terms of implementation of projects financed by donors; 54 e. Strengthening the synergy between the PCU and the services of Financial Control and Accounting Agency. f. This project has been a so palpable success that all call its continuity. 185. Comments from the Government on the Draft ICR (translation): Letter Subject: Comments on the completion report – PUMLS I acknowledge receipt of the completion report of the Emergency Multisectoral Project against AIDS... Thank you. Overall, this report does not call for any particular objections from me. However, some issues have been raised and I would like them to be considered in the final report. These points are elaborated in the annex to this letter. Thanking you for the excellent collaboration between Côte d’Ivoire and the World Bank, please accept the assurances of my highest consideration. ANNEX COMMENTS ON THE COMPLETION REPORT – PUMLS PROJECT 1. The main observation concerns the achievement of the target of the PDO indicator "percentage of women and men aged 15 to 49 who had more than one sexual partner in the past 12 months and reporting of having used a condom during their last sexual intercourse ". Indeed, in paragraph 86 of the document of the World Bank, it is clearly indicated that even if at the first analysis, you cannot appreciate the progress of the indicator because the denominators are not the same (regional for 2012 and national for 2005), from a secondary data analysis of regions, both in 2005 and 2012, shows that the target value of the indicator has been reached. We cannot, therefore, leave behind the value of the work done by retaining only the negative aspect while the analyses tend to show that the indicator has been reached. From our point of view, based on the results of the investigation and the analysis made by the Bank team, we consider this indicator reached. Consequently, and in light of the above comments, paragraph 85 should be reworded because on the two PDO indicators of this component, the assessment is as follows: target not met for the first indicator and target achieved for the second, in other words, 1 indicator out of 2 is achieved. Therefore, to achieve this PDO, the rating should be beyond "moderate". 2. Based on the observations made above, two out of four PDO indicators have been achieved and taking into account the appreciation of the effectiveness and efficiency of the project on one hand, general comments made by the World Bank evaluation team on 55 the project management on the other hand, the overall rating in our opinion should be "satisfactory" instead of "moderately satisfactory." 3. Section F / analysis of the results framework / b) intermediate indicators (page x). The indicator "Number of Health Personnel receiving training" is not within the project performance framework. Therefore, paragraph 100 should be wording as follows: Table no. 12 shows that, out of the five intermediate indicators, one is superfluous and the others four were either entirely or largely (over 80%) achieved. 4. In summary, according to our analysis, 2 out of the 4 PDOs have been achieved, and 2 have not been achieved. On the 9 intermediate indicators, 6 were achieved, 2 not achieved and 1 superfluous. Finally, in the current context of the fight against AIDS in Côte d’Ivoire, we believe and recommend that efforts be pursued to meet the needs of people, especially the most vulnerable (PLHIV, OVC, professional (the) sex). In addition, thoughts and actions must be taken to ensure the continuation, expansion and sustainability of the interventions of the Emergency Multisectoral Project against AIDS in Côte d’Ivoire. 56 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders NA 57 Annex 9. List of Supporting Documents 1. Plans Stratégiques Nationales de lutte contre le SIDA (2006-2010 ; 2011-2015) 2. Project Appraisal document 3. Implementation Status Reports; 4. Project Aide Memoirs 5. Aids Indicators Survey 2005 6. Analyse des Connaissances, Attitudes et Pratiques des Professionnels(les) du sexe dans dix-huit villes de Cote d’Ivoire-Avril 2012 7. Enquête connaissances, attitudes et pratiques sur les IST et le VIH/SIDA dans les régions des lagunes, des montagnes, des savanes et du sud Comoé. Novembre 2011. 8. Programme National de la Prise en charge des PVVIH- Rapport de fin de projet- 2012 9. Projet d’Urgence Multisectoriel de Lutte contre le Sida- rapport final-2012 10. Enquête Démographique et de Sante (CI 2013) 11. Rapport UNGAS (CI 2010) 12. 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