|1. Project Data:
ICR Review Date Posted:
|Multi-sectoral Aids Project (map)
Project Costs(US $M)
Loan/Credit (US $M)
|Health, Nutrition and Population
Cofinancing (US $M)
|African Development Bank, CIDA, DFID, Global Fund, US government, NORAD, UNDP
Board Approval Date
|Central government administration (47%), Other social services (38%), Health (10%), Sub-national government administration (5%)|
|HIV/AIDS (29% - P)
Social risk mitigation (29% - P)
Population and reproductive health (14% - S)
Participation and civic engagement (14% - S)
analysis and monitoring (14% - S)|
||ICR Review Coordinator:
|Judith Hahn Gaubatz
||Judyth L. Twigg
||Christopher D. Gerrard
|2. Project Objectives and Components:|
a. Objectives:According to the Project Appraisal Document (PAD, page 2) and the Development Grant Agreement (page 17), the project objectives were:
- To reduce the transmission of HIV;
- To improve the quality of life of those infected and affected by AIDS; and
- To mitigate the impact of HIV/AIDS in all sectors and at all levels of Malawian society.
The project objectives were formally revised at the time of approval of Additional Financing in 2009. The revisions reflected updated understanding about the epidemic, drawn from project implementation experience and epidemiological analysis. According to the Financing Agreement (page 13), the revised project objective was:
- To increase access to HIV/AIDS prevention, treatment, and mitigation services, with a focus on behavioral change interventions and addressing the needs of highly vulnerable populations, including those affected and infected by the epidemic.
b. Were the project objectives/key associated outcome targets revised during implementation?
If yes, did the Board approve the revised objectives/key associated outcome targets?
Date of Board Approval: 09/18/2009
c. Components:The project components, described below, remained the same under both the original and revised objectives. Actual project costs per component were not available, as the project funds were pooled with other funds into the national HIV/AIDS response program. AF = Additional Financing from the Bank.
1. Prevention and Advocacy (Appraisal: US$46.5 million; AF: US$16.0 million; Actual: n/a ): This component aimed to change behavior and prevent transmission of HIV. Possible activities included: behavior change communications and information and education campaigns for target populations (not identified in the Project Appraisal Document); promotion of safe sex (including among youth), through means such as condom distribution; voluntary counseling and testing; prevention of mother to child transmission; and prevention of HIV infection caused by improper handling of health care waste. Public, private and civil society entities were to implement the interventions.
2. Treatment, Care and Support (Appraisal: US$144.9 million; AF: US$3.0 million; Actual: n/a ): This component aimed to reduce the morbidity and mortality associated with HIV/AIDS. Possible activities were divided into two clusters: clinical care and treatment; and community/home-based care. Under clinical care and treatment, activities were to include advanced treatment for opportunistic infections and provision of anti-retroviral treatment. Under community/home-based care, activities were to include delivery of nursing care, basic treatment of opportunistic infections, palliative care, and nutrition supplements. Public, private and civil society entities were to implement the interventions, with the Ministry of Health and Population taking the lead in coordinating the health sector response.
3. Impact Mitigation (Appraisal: US$12.2 million; AF: US$2.0 million; Actual: n/a ): This component aimed to mitigate the impact of the HIV/AIDS epidemic on particularly vulnerable members of society such as orphans and other vulnerable children, widows and widowers, and the dependent elderly. Possible activities included: educational support and training for orphans and vulnerable children; income generation activities for vulnerable households; community-based and institutional care for orphans; and psycho-social support for affected families. Public, private and civil society entities were to implement the interventions.
4. Sectoral Mainstreaming (Appraisal: US$9.0 million; AF: US$3.0 million; Actual: n/a ): This component aimed to enable public institutions, private companies, and civil society organizations to mainstream HIV/AIDS in their workplaces and in their core businesses. Possible activities included: revision of national labor legislation and public service regulations; establishment of institutional focal points; formation of support groups; awareness training; and revisions to human resource management practices.
5. Capacity-Building and Partnership (Appraisal: US$29.7 million; AF: US$2.0 million; Actual: n/a ): This component aimed to build the capacity of public, private and civil society organizations to implement a multi-sectoral response, such as developing long-term strategies, operational frameworks, and technical skills. Possible activities included: training in HIV/AIDS interventions, planning, and management; leadership and coordination at district and community levels; and outreach to constituents.
6. Monitoring, Evaluation and Research (Appraisal: US$9.6 million; AF: US$2.0 million; Actual: n/a): This component aimed to strengthen M&E capacity to track the epidemic and national responses, and to assess the effectiveness of various interventions under different local and cultural conditions. This component was to support development of the M&E system of the National AIDS Commission. Activities were to include biological and behavioral surveillance, poverty analysis, project monitoring, and research studies.
7. National Leadership and Coordination (Appraisal: US$22.9 million: AF: US$2.0 million; Actual: n/a): This component aimed to strengthen national leadership and coordination capacity, particularly of the National AIDS Commission. Activities were to include: policy development and monitoring; advocacy and resource mobilization; strategic planning and reviews; and support for the operations of coordinating entities (including decentralized District AIDS Commissions) and various task forces.
d. Comments on Project Cost, Financing, Borrower Contribution, and DatesProject cost
- The project cost at appraisal was US$274.7 million. The actual project cost was US$509.0 million.
- The original IDA grant. amount was US$35.0 million. Additional Financing (AF) of US$30.0 million was approved in 2009, for a total IDA grant of US$65.0 million. The AF was requested in order to scale up activities to sustain achievements.
- A number of external donors provided co-financing for the project through a pooled funding mechanism. The original co-financed amount was US$229.7 million. Through additional donor contributions, the actual co-financed amount was US$423.2 million.
- The Borrower contribution at appraisal was US$10.0 million. Through additional contributions, the actual Borrower amount was US$20.8 million. Counterpart funds were provided with no problems reported.
- In September 2009, Additional Financing in the amount of US$30.0 million was approved, along with formal revisions to the project development objectives and indicators. The closing date was also extended from September 2009 to September 2012.
|3. Relevance of Objectives & Design:|
a. Relevance of Objectives:Original: High
Given the high HIV prevalence rate among adults in the country (2001 UNAIDS estimate: 15.0%; 2010 sentinel surveillance surveys from antenatal clinics: 10.6%), the project objective to reduce HIV transmission is highly relevant. With a significant proportion of the population infected with HIV (approximately one million people), the objectives to improve quality of life and to mitigate the impact of the epidemic on those infected and affected are also highly relevant. Addressing the HIV epidemic is a high corporate priority of the Bank, while improving access to quality HIV/AIDS services is a specific results outcome identified in the Bank's Country Assistance Strategy for FY2013-2016. The country's Growth and Development Strategy for 2012-2016 also identifies effective management of the HIV/AIDS epidemic as one of nine priority areas.
The objectives were fine-tuned during the project restructuring, with a more immediate-term and realistic objective to increase access to HIV/AIDS services. The revised objective had continued high relevance to country conditions, Bank strategy, and country strategy.
b. Relevance of Design:Original: Substantial
The project interventions reflected established international practice in responding to the HIV/AIDS epidemic and were likely to contribute to the intended outcomes in prevention, treatment, and mitigation. Care and mitigation activities were important elements in the project design, given the significant numbers of people (including orphans and vulnerable children) infected and affected by HIV/AIDS. Capacity building support was also critical given the limited financial and human resources in the public health sector. Prevention remained a strong focus of the project design, and interventions were based on the knowledge that sexual intercourse accounted for most of HIV transmission modes (around 90%) and that there were widespread misconceptions among the population on how to prevent transmission. According to the project team, the project contributed to a financing pool for the implementation of the National AIDS Framework (NAF) and later the National Strategic Plan for HIV and AIDS (NSP), which identified activities specifically targeting the drivers of the epidemic such as teachers, police officers, female sex workers, female border traders, female estate workers, male vendors, truck drivers, and fishermen,
The revised project design sustained focus on prevention, amidst a global context of rapid treatment scale-up, and further sharpened focus on behavior change interventions, including for targeted high risk groups.
|4. Achievement of Objectives (Efficacy) :|
Donor and government funds for the national HIV/AIDS program were pooled into a single funding basket. The Bank's share of funding in the pooled financing mechanism was US$65.0 million out of US$509.0 million. Although this amount comprised only 12.8% of the total project funding, approximately half of the Bank's funding (US$30.55 million out of US$65.0 million) was directed towards prevention activities, and the Bank-supported capacity building activities (particularly strengthening national leadership and fiduciary capacity) made notable contributions.
The following capacity-building outputs likely contributed to increased access to HIV/AIDS services (prevention, treatment and care, and mitigation):
- Provision of technical support to the National AIDS Commission.
- Establishment of District AIDS Coordinators in all 32 Local Councils.
- Creation of HIV workplace programs in 249 private sector organizations, including in the areas of training and peer education on HIV awareness, condom availability, and anti-retroviral treatment.
- Training of 1643 HIV Focal Point persons to provide support to colleagues in the workplace.
- Training of 497 health workers in HIV service delivery.
- Provision of salary top-ups to 6,798 health workers to improve staff retention.
- Inclusion of HIV indicators in the 2004 and 2010 Demographic and Health Surveys.
- Implementation of the Local Authority HIV and AIDS Reporting System to support monitoring of progress on HIV interventions.
- Conducting of analytical activities, including PLACE studies (Priorities in Local AIDS Control Efforts: rapid assessments for identifying areas likely to have sexual partnership formation patterns capable of spreading HIV infection); drug resistance monitoring; epidemiological analysis (to identify key drivers of the epidemic); and an impact assessment of mainstreaming HIV interventions throughout the country.
To reduce the transmission of HIV (Original)
Substantial, due to evidence of decreased risky behavior among males and females 15-24 years old, and to increases in provision of anti-retroviral treatment.
- The number of communication materials (information, education, and behavior change) distributed per year increased from 546,681 in 2005/06 to 3.0 million in 2009/10, thereafter declining to 1.5 million in 2011/12. There is no evidence provided that the communication was targeted to specific high risk populations.
- The number of male condoms distributed each year ranged from 20 million in 2004/05 to 32 million in 2006/07 to 33 million in 2011/12. There is no evidence that the condom distribution was targeted to specific high risk populations.
- The number of antenatal care clinics providing the minimum treatment package for the prevention of mother-to-child transmission increased from 60 in 2006/07 to 573 in 2011/12.
- The number of health facilities certified to provide anti-retroviral treatment increased from 221 in 2008/09 to 641 in 2011/12.
- The percentage of males (aged 15-24 years old) who correctly identify ways of preventing HIV transmission and who reject major misconceptions about HIV transmission increased from 41.0% in 2004 to 44.7% in 2012, falling short of the target of 55.0%. For females, it increased from 30.0% to 41.8%, achieving the target of 40.0%.
- The percentage of sexually active males (aged 15-24 years old) who reported using a condom during their last high-risk sexual encounter (sex with non-cohabitating or non-regular partner) within the past 12 months increased from 20.0% in 2004 to 40.5% in 2010. For females, it increased from 15.9% to 31.0%. Target values were not available as the indicator definition had changed.
- The percentage of sexually active males who had sex with a non-regular partner within the past 12 months decreased from 26.0% in 2004 to 22.0% in 2006. For females, it decreased from 8.3% to 6.5%. However, the comparability of the data (2004 Demographic and Health Survey, 2006 Multiple Indicator Cluster Survey) is questionable due to differing methodologies.
- 183,147 pregnant women received treatment for the prevention of mother-to-child transmission. 76% of pregnant women with HIV received a complete course of treatment.
- 391,338 people with advanced HIV infection were receiving anti-retroviral therapy, surpassing the target of 262,986.
The ICR also reports that the HIV prevalence rate decreased from 14.2% in 2004 to 12.0% in 2009. However, attribution of this decline to the project's activities is unclear due to the multiple factors outside of the project that could have affected prevalence rates.
To improve the quality of life of those infected and affected by AIDS (Original)
Substantial, due to evidence of increased provision of support services.
- 95% of anti-retroviral treatment sites were providing therapeutic food for HIV patients.
- The number of sites offering voluntary counseling and testing increased from 713 in 2008/09 to 810 in 2011/12, with an additional 322 mobile sites in operation.
- 3,834 volunteers and 1,103 health care workers received training on community home-based care.
- See also the outputs reported above on information and education campaigns.
- The number of patients receiving therapeutic feeding ranged from 19,205 to 30,000 each year of the project period.
- The number of people receiving counseling and testing services increased each year from 215,269 in 2003/04 to 1.7 million in 2008/09. 92.6% of clients who were tested for HIV received their results, falling slightly short of the target of 98.0%.
- The number of households receiving home-based care and support ranged from 151,613 in 2008/09 to 202,578 in 2011/21, with a sudden peak to 577,135 in 2009/10. The ICR (page 36) suggests that the roll-out of the anti-retroviral treatment program in 2006 had led to a significant reduction in the number of people living with HIV/AIDS who need home-based care.
- The percentage of males expressing accepting attitudes towards persons living with HIV/AIDS increased from 37.0% in 2004 to 41.0% in 2009, falling short of the target of 50.0%. For females, it increased from 25.0% to 30.0%, falling short of the target of 50.0%.
To mitigate the impact of HIV/AIDS in all sectors and at all levels of Malawian society (Original)
Modest, due to limited evidence of outcomes.
- The number of orphans and vulnerable children receiving educational support (i.e. tuition fees) increased each year from 1,391 in 2004/05 to 85,996 in 2007/08.
- The ICR (page 38) reports that a number of interventions aimed at mitigating the negative economic and psychosocial effects of HIV/AIDS were implemented during the project period, ranging from economic empowerment, establishment of child care institutions, provision of materials, and other forms of support (including building capacity for spiritual and psychosocial support for affected households). However, specific details on the extent of services provided are not reported.
- Legislative and policy documents such as the National Plan of Action for Orphans and Vulnerable Children, and the Childcare, Protection and Justice Act were developed.
- The proportion of orphans and vulnerable children receiving community support each year decreased from 32.5% in 2004 to 18.5% in 2009. The ICR (page iv) suggests that changes in the definition of the denominator for this indicator during the project period made it difficult to interpret achievements more accurately.
- The number of households that were receiving cash transfer payments under the Social Cash Transfer Program ranged from 10,014 in 2008 to 27,925 in 2011. However, although the program was intended to reach the poorest 10% of households, there was no information to confirm whether these households were those affected by HIV.
To increase access to HIV/AIDS prevention, treatment, and mitigation services with a focus on behavioral change interventions and addressing the needs of highly vulnerable populations, including those affected and infected by the epidemic. (Revised)
See note above on capacity-building outputs, which are also relevant for achievement of the outcomes reported below.
Prevention - Modest
- See outputs reported above on "reduced transmission of HIV." As noted above, implementation of outputs among targeted vulnerable groups is unknown.
- See outcomes reported above on "reduced transmission of HIV." Data on outcomes among specific high-risk groups (identified in the National HIV/AIDS Plan as police officers, female sex workers, female border traders, female estate workers, male vendors, truck drivers and fishermen) or other highly vulnerable groups are not provided in the ICR. According to the project team, a follow up behavioral survey that would have provided such data has not yet been undertaken.
Treatment and care - Substantial
- See outputs reported above for "improved quality of life."
- See outcomes reported above for "improved quality of life."
Mitigation - Modest
- See outputs reported above for "mitigated impact."
- See outcomes reported above for "mitigated impact."
Modest, due to insufficient information. The pooled financing mechanism likely contributed to efficiency through reduced transactions costs with the use of joint systems for planning, financial management, reporting, procurement, auditing, and monitoring and evaluation among the multiple donors. A cost-benefit comparison of anti-retroviral treatment provision, as well as a cost comparison with other countries in the region, showed that the treatment activities through the project were achieved at favorable costs. However, the cost of the treatment activities as a share of the total project costs is not provided. In addition, there is insufficient information on the extent to which prevention interventions were implemented among high risk groups, which would have been a cost-effective means of preventing HIV transmission.
a. If available, enter the Economic Rate of Return (ERR)/Financial Rate of Return at appraisal and the re-estimated value at evaluation:
* Refers to percent of total project cost for which ERR/FRR was calculated