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Implementation Completion Report (ICR) Review - Second Multisectoral Hiv/aids Control Project


  
1. Project Data:   
ICR Review Date Posted:
12/30/2013   
Country:
Benin
PROJ ID:
P096056
Appraisal
Actual
Project Name:
Second Multisectoral Hiv/aids Control Project
Project Costs(US $M)
 35.0  33.92
L/C Number:
C4290
Loan/Credit (US $M)
 35.0  33.92
Sector Board:
Agriculture and Rural Development
Cofinancing (US $M)
   
Cofinanciers:
Board Approval Date
  04/05/2007
 
 
Closing Date
12/31/2011 06/30/2012
Sector(s):
Other social services (34%), Health (32%), Central government administration (21%), Sub-national government administration (9%), Solid waste management (4%)
Theme(s):
HIV/AIDS (33% - P) Other social development (33% - P) Population and reproductive health (17% - S) Nutrition and food security (17% - S)
         
Prepared by: Reviewed by: ICR Review Coordinator: Group:
Judyth L. Twigg
Denise A. Vaillancourt Christopher D. Gerrard IEGPS2

2. Project Objectives and Components:

a. Objectives:


    According to the Financing Agreement (p. 6) and Project Appraisal Document (PAD, p. 6), the project’s objective was “to help the Recipient implement its new 2006-2010 National Strategic Framework for boosting its national response to HIV/AIDS by contributing to increasing and improving the coverage and utilization of prevention services, treatment and care for specific high-risk and vulnerable groups.”

b. Were the project objectives/key associated outcome targets revised during implementation?
No

c. Components:

The project contained three components:

1. Social Mobilization and HIV Prevention (appraisal, US$ 11.90; actual, US$ 11.87 million). This component was to provide funds for scaling up of HIV/AIDS prevention activities, carried out mostly as subprojects by local communities, civil society, community-based organizations, and the private sector to support persons living with HIV/AIDS and vulnerable groups such as youth, commercial sex workers, and orphans/vulnerable children. Activities under this component were also to include psychological and economic support to infected and affected persons. These activities were to be grouped under two subcomponents: (a) support for community and non-governmental organizations prevention activities to encourage behavior change, and (b) support for impact mitigation activities.

2. Access to Treatment Care, and Impact Mitigation (appraisal, US$ 15.40; actual, US$ 13.43 million). This component, to be implemented by the National Program against HIV/AIDS (PNLS), was to provide care and treatment as well as research services. Specific activities were to include the provision of antiretroviral drugs, training of health staff, the restructuring of some health facilities to better integrate HIV/AIDS services, nutritional and psychosocial support for infected and affected persons, the establishment of new testing and diagnostic centers, the strengthening of epidemiological surveillance and monitoring, and strengthening of research and collaboration between modern and traditional medicine.

3. Coordination, Management, and Monitoring and Evaluation (appraisal, US$ 7.00 million; actual, US$ 7.29 million). This component was intended to provide support for a unified national and decentralized coordination system and leadership, a uniform national monitoring and evaluation system, and the coordination and management of the Project Administration Unit. Specific activities were to include training and workshops, provision of equipment, support for operating expenses, and recruitment of a financial management agency. M&E activities were to include support for periodic behavioral and biological surveillance among the general population and high-risk groups, vulnerability mapping of high-risk groups, periodic surveys on service quality, and impact evaluations.

The components were not changed at either of two project restructurings.

d. Comments on Project Cost, Financing, Borrower Contribution, and Dates

Project Cost: During two restructurings in 2010 and 2011, allocation of funds to the components was adjusted. In 2010, the adjustments accounted for higher than anticipated costs for rehabilitation works and equipment and for a depreciation of the dollar. In 2011, the reallocation shifted funds to the purchase of medical equipment, drugs, and reagents with the aim of scaling up activities related to prevention of mother-to-child transmission; to compensate, cuts were made to grants to civil society organizations, with that grant program tightening its focus on high-risk groups and quality of projects over quantity.

Financing: The project was financed by a US$ 35 million (equivalent) Credit from the International Development Association. According to the project team, only a small part of the difference between planned and actual project costs was due to dollar/XDR exchange rate gains; neither the project team nor the ICR provided an explanation for the majority of the difference.

Borrower Contribution: No Borrower contribution was planned.

Dates: The Mid-Term Review took place in January of 2010. The project was restructured twice: first, on December 21, 2010, to adjust baseline indicators and target values to take into account newly available data and to reallocate funds; and second, on June 10, 2011, to adjust focus to quality of prevention interventions and to reallocate funds toward prevention of mother-to-child transmission (the only project indicator that was lagging at that point). At the second restructuring, the project’s closing date was also extended by six months, from December 31, 2011 to June 30, 2012, to provide time for completion of planned activities. The production of the ICR was delayed by one year to wait for results of a 2012 Demographic and Health Survey.


3. Relevance of Objectives & Design:

a. Relevance of Objectives:

Relevance of Objectives is rated Substantial. At appraisal, prevalence of HIV/AIDS in the general population was about 2%, but was as high as 25% in commercial sex workers. The government was committed to fighting HIV/AIDS and had just finalized its second Strategic Plan for Fighting HIV/AIDS (2006-2010), which focused on six strategic axes: coordination, partnership and resource mobilization; prevention and promotion of testing; access to care and treatment; support to infected and affected persons and respect for human rights; strategic information; and monitoring and evaluation. Funding for HIV/AIDS was a serious problem, as a sizeable funding gap (US$ 160 million) existed even in the presence of multiple development partners. The Bank’s current Country Partnership Strategy (2013-2017, p. ix) does not recommend investing new Bank resources in HIV/AIDS in Benin, citing the epidemic as having been stabilized (p. 7). The government’s current HIV/AIDS strategic plan (2012-2016) continues to focus on prevention, treatment, care and support, with a focus on community mobilization and specific targeting of high-risk groups, in order to maintain relatively low prevalence levels.

b. Relevance of Design:

Relevance of Design is rated Substantial. The project’s planned activities were logically and plausibly tied to its expected outcomes. The PAD (p. 6) cites women, youth, commercial sex workers, and the staff of some key ministries as the vulnerable and/or high-risk groups to be targeted for enhanced prevention services, and persons living with HIV/AIDS (PLWHA) and orphans and vulnerable children (OVCs) as the groups to be targeted for enhanced treatment and care. Targeting of female sex workers was especially critical, as HIV prevalence levels were 10-20 times higher among female sex workers than among women in the general population, and several-fold higher among male clients of female sex workers than among men in the general population. Importantly, the project’s design explicitly and deliberately provided for targeting of funds toward organizations with expertise and experience reaching female sex workers and other high-risk groups (PAD, pp. 21, 38). However, the PAD does not mention other high-risk groups routinely cited as important along the Abidjan-Lagos corridor (border officials, vendors, vulnerable women and girls living along the corridor, truck drivers, and other mobile populations), although it does envisage the mapping of high-risk groups under Component 3. Planned investments for treatment, care, and support were tightly linked to the objective of increasing utilization and coverage of services.


4. Achievement of Objectives (Efficacy) :

In addition to the Bank, other donors active during the project period included the Global Fund (US$ 68 million through 2010), the African Development Bank (US$ 4 million/year through 2008), the United States Agency for International Development (US$ 7 million through 2010), the Government of Denmark (US$ 8.8 million through 2010), and part of the US$45.6 million allocated by the Global Fund for five countries for the Abidjan-Lagos Corridor. According to the ICR (p. 13), the Global Fund primarily funded treatment, while the Bank was the main financier for prevention interventions. In a Stakeholders’ Workshop conducted at the end of the project, beneficiaries reported that the Bank’s interventions were crucial in funding prevention services that other donors “did not care to cover” (ICR, p. 21). Much or most of the achieved outcomes related to prevention can therefore plausibly be attributed to the project.

Most data provided are from Demographic and Health Surveys (DHS, 2011-2012), or a Second Generation Survey for STI and HIV/AIDS (ESDG, 2008 and 2012). Most baseline data are from the 2008 ESDG. The ICR does not specify the source for 2006 baseline data.

Increase and improve the coverage and utilization of prevention services for specific high-risk and vulnerable groups is rated Substantial, based on outcome data related to behavior change among female sex workers, the primary group at high risk for contracting and transmitting HIV infection.

Outputs:

Capacity building was carried out for implementing agencies, line ministries, community-based organizations, and various HIV/AIDS-related associations. Activities included training, workshops, development of communications programs, development of workplace strategies and policies, and provision of furniture and equipment. Staff, equipment, training, and studies were provided in support of development of the Project Administration Unit and a national monitoring and evaluation system. Four annual joint reviews and work planning exercises were carried out by all donors, under the coordination of Permanent Secretariat of the National Committee for the Fight against HIV/AIDS (SP/CNLS), meeting the target.

Six Provincial Centers for the Fight against AIDS (CDLS) became operational, meeting the target. 53 Local Centers for the Fight against AIDS (CCLS) became operational, surpassing the target of 48. 16 public sector organizations supported and/or implemented HIV/AIDS interventions, surpassing the target of 15. 100% of implementing agencies (public sector and civil society) were submitting monitoring and financial reports to SP/CNLS by the end of the project, meeting the target.

985 community-based subprojects and 1,178 community action plans were financed, surpassing the original target of 800 subprojects and the revised target of 700 subprojects. According to the ICR (p. 13), most of these subprojects involved ether behavior change activities for youth and women, or condom distribution. The ICR (p. 28) also reports that these subprojects prioritized work with PLWHA, commercial and clandestine sex workers, youth and adolescents, women, and traditional healers and midwives, with projects also reaching fishermen, drug users, transport workers, refugees, men having sex with men, motorbike taxi operators, and vendors, but it does not provide specific information on these interventions. Importantly, about 50 subprojects targeted female sex workers (ICR, p. 14), although the ICR does not provide information on numbers of sex workers reached or coverage.

5.6 million persons were reached with programs involving community outreach, information/education/communication, and/or behavior change communication, surpassing the original and revised target of 1.5 million. Outreach activities included radio programming and prevention plans implemented by twelve line ministries. These line ministry action plans included: (i) prevention activities for raising awareness and providing communication to encourage changes in sexual behavior and practices; (ii) advice and promotion of voluntary HIV/AIDS testing; (iii) advocacy, communication, and availability of information and guidance on HIV/AIDS matters in the ministries themselves; and (iv) psychosocial counseling for infected persons.

7.6 million male and female condoms were distributed, not meeting the original target of 11 million, but surpassing the revised target of 3.5 million.

The cumulative number of persons ages 15 and older who underwent voluntary counseling and testing in the last twelve months and know the results increased from 175,086 in 2008 to 1,035,740 in 2012, surpassing the original and revised target of 375,000.

In a Beneficiary Survey, 83% positively cited the regularity of information/education/communication activities and 72% positively cited the free provision of condoms.

Outcomes:

The percentage of young women and men ages 15-24 who both correctly identify way of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission increased from 36.82% in 2006 (34.1% for young men and 39.6% for young women), later revised to 21.5% in 2008, to 67.6% in 2012, surpassing the revised target of 45% but not meeting the original target of 75%. For this and the following indicators with revised baseline data from 2006 to 2008, the ICR (p. 3) is unclear on whether the revision is considered to correct a false baseline, or is considered to represent real change over that two-year period.

The percentage of young women and men ages 15-24 reporting the use of a condom during the last sexual intercourse with a non-regular or non-cohabitating partner (of those reporting sex with a non-regular partner in the last twelve months) increased from 59.9% in 2006 (70% for young men and 51.8% for young women), later revised to 49.5% in 2008, to 68.1% in 2012, surpassing the revised target of 65% but not meeting the original target of 85%.

The percentage of sex workers reporting using a condom with their most recent client increased from 69.2% in 2006, revised to 79.7% in 2008, to 84.9% in 2012, almost meeting the original and revised target of 90%. Another non-project data source (a Population Services International report) indicates that this percentage was consistently high but increasing, at 91.7% in 2007, 92.3% in 2009, and 94.6% in 2011.

No outcome data are provided for other high-risk and vulnerable groups.

Increase and improve the coverage and utilization of treatment and care services for specific high-risk and vulnerable groups is rated Substantial, based on exceeded numerical targets for provision of antiretroviral therapy and psychosocial and nutritional support for PLWHA.

Outputs:

The project deliberately complemented interventions of the Global Fund and other financiers by supporting testing, increased access to services for prevention of mother-to-child transmission, purchase of some antiretrovirals, promotion of testing and treatment for sexually transmitted infections and opportunistic infections, blood safety activities, capacity building for health staff, management of medical waste, nutritional support for PLWHA, strengthening of epidemiological surveillance, and support for traditional medicine. Laboratory equipment and consumables were provided, and laboratory and treatment facilities were rehabilitated and/or provided with operational funding.

Faith-based and charitable organizations and other community-based groups were financed for subprojects involving antiretroviral treatment and management of opportunistic infections, care for infected children, nutritional support, and psychosocial care and counseling. The project subsidized an unspecified number of existing or new facilities for provision of antiretroviral treatment. 71,539 persons were trained in HIV/AIDS service delivery, surpassing the original target of 50,000 and the revised target of 65,000.

88 community-based subprojects focused on helping PLWHA to start or continue income-generating activities. PLWHA associations were supported at the departmental and national levels.

The project supported OVCs by providing access to a national minimum package of support that had been identified by the Ministry of Family, Women, and Children. The project also funded eight training facilities "to help keep OVCs in schools" (ICR, p. 36); the ICR does not specify what specific activities were implemented in these training facilities.

Outcomes:

22,522 people were provided with antiretroviral therapy, surpassing both the original target of 3,300 adults/900 children and the revised target of 19,000 adults/2,000 children. The ICR does not provide information on coverage. The project team later provided information that the UNAIDS 2012 Benin report indicated that, in 2011, 89.2% of people in need of ARV treatment were receiving treatment, but no numerator or denominator were provided.

The percentage of HIV-infected pregnant women receiving a complete course of antiretroviral prophylaxis to reduce the risk of mother-to-child transmission increased from 52% in 2006, later revised to 52.8% in 2008, to 58% in 2012 (1,560 women), not meeting the target of 70% (2,689 women).

14,273 PLWHA received psychological support, surpassing the original target of 10,000 and the revised target of 8,000. 7,791 PLWHA received nutritional support from the project, surpassing the original and revised target of 5,000. The ICR does not provide information on coverage; the project team later explained that an assessment of the number of people in need was not done.

Care and support was provided to 12,197 households with orphans and other vulnerable children, surpassing the original and revised target of 2,500. The ICR does not provide information on the content of this support, or on coverage. The project team later added that the orphans received primarily tuition, school supplies, and school feeding support, and that no assessment of the total number of needy households was done.


5. Efficiency:

Efficiency is rated Modest.

The project's emphasis on prevention in general and on high-risk populations in particular (especially the support and tracking of commercial sex workers and young people ages 15-24) indicates efficient use of resources, especially given that other donors supporting HIV/AIDS were largely focused on treatment and care. Line ministries were efficiently prioritized for participation in the project based on their potential effectiveness in reaching the greatest coverage and targeting of vulnerable groups for prevention and care; key line ministries included the Ministries of Education; Youth; Family, Women, and Children; Agriculture; and Defense, and their activities targeted not just their own staff but also their key clients (ICR, p. 29). Project administration was carried out by existing institutional entities, rather than creating new ones. Existing health workers (mostly nurses) were provided with additional training to provide high-quality HIV/AIDS treatment services, a more cost-effective strategy than recruiting new health workers (such as doctors) (ICR, p. 19). A 2010 evaluation of the performance of the Fiduciary Management Agency found that the grants to community organizations were managed efficiently. Collaboration with other donors was also efficient on the treatment front, with the Bank's interventions complementing the Global Fund's support for treatment. Operating costs amounted to less than 14% of total project costs, an improvement over the 19% ratio in a previous HIV/AIDS project in the country.

However, there were shortcomings. While the focus of prevention interventions on female sex workers was efficient, other important risk groups appear to have received less or no attention, or little information is provided on activities: male clients of female sex workers, vulnerable women and girls along the Abidjan-Lagos corridor, vendors, truck drivers, and other mobile populations. Mapping, targeting, and measuring of high-risk behaviors and vulnerabilities on the corridor (truck stops, borders, marketplaces, etc.) appears not to have been systematically undertaken and documented even though this was planned under Component 3. The major emphasis (and measuring) of female sex workers was necessary, but not sufficient, to address Benin's risk profile in an efficient manner. Furthermore, the ICR documents a large number of community projects without grouping them and assessing their outputs/outcomes for particular risk groups. The ICR states that millions of beneficiaries were reached without specifying what reached them and how they were reached, and with what outputs or outcomes. Without information on coverage of whom, and with what, it is difficult to assess the cost-effectiveness of prevention interventions.

a. If available, enter the Economic Rate of Return (ERR)/Financial Rate of Return at appraisal and the re-estimated value at evaluation:


Rate Available?
Point Value
Coverage/Scope*
Appraisal:
No
%
%
ICR estimate:
No
%
%

* Refers to percent of total project cost for which ERR/FRR was calculated

6. Outcome:


The project’s objectives and design were substantially relevant. The objectives were aligned with country conditions and Bank strategy at the time of appraisal, and with current government strategy. Project design is rated substantial, as the planned activities were logically and plausibly linked to anticipated outcomes. The planned focus on female sex workers was particularly strong. Achievement of both objectives is rated substantial, as progress was registered on all measured dimensions of prevention, treatment, and care, with the exception of prevention of mother-to-child transmission. The project was administered in a cost-effective manner, but other than female sex workers, it is not clear that it efficiently mapped or targeted groups at highest risk of contracting and transmitting HIV infection. Taken together, these achievements are indicative of moderate shortcomings, resulting in an Outcome rating of Moderately Satisfactory.

a. Outcome Rating: Moderately Satisfactory

7. Rationale for Risk to Development Outcome Rating:

Financial risk is moderate. While the Bank has no plans for a next phase, the Global Fund has increased its support to the national HIV/AIDS strategy so that there is no funding gap, and the Global Fund has agreed to take over financing of most of the prevention activities previously funded by the Bank. However, this degree of reliance on donors carries inherent risk.

Institutional risk is also moderate. Institutional arrangements that the project helped to establish are still in place and are functioning effectively. The SP/CNLS coordinates the entire national response; ministries are acting on well-elaborated action plans; institutional and technical capacities of community and non-governmental organizations have been enhanced; and health facility capacity to implement HIV/AIDS interventions, including testing and treatment, have been increased.

a. Risk to Development Outcome Rating: Moderate

8. Assessment of Bank Performance:

a. Quality at entry:

The project was prepared under a strong rationale for Bank involvement, taking advantage of experience gained under the previous HIV/AIDS project in Benin, and leveraging Bank support to attract other development partners. Background analysis was thorough, drawing on various reports specific to Benin and more generally on the multisectoral HIV/AIDS project (MAP) experience in Africa. Preparation took note of weaknesses in coordination of activities and of M&E that caused inefficiencies in the previous project. Other important lessons learned from previous project experience included the need for community engagement with HIV testing, the importance of a participatory approach overall, the importance of effective use and dissemination of stigma reduction messages, and the effectiveness of a multi-channel approach to reach PLWHA. Risks, most notably those related to M&E and the leadership capacity and staffing of the SP/CNLS, were appropriately identified, though the mitigation measures for the latter proved to be insufficient. The results framework was complete at entry, though the values of some baseline indicators were shown later to be inaccurate. The decision to use a private financial management agency was appropriate.

Quality-at-Entry Rating: Satisfactory

b. Quality of supervision:

The Bank made sure that each supervision mission included at least one fiduciary specialist, facilitating regular fiduciary reviews as well as training when necessary. Other specialists were brought in as needed when bottlenecks arose. For example, an environmental specialist was consulted when there were weaknesses in management of biomedical waste. The project team was quick to identify difficulties in the division of responsibilities between the SP/CNLS and the Project Implementation Unit, facilitating resolution of the issue by contracting with an external consultant to do an institutional review. The Mid-Term Review process was appropriately used to correct imprecision in some indicators and imbalances in allocation of funds to project categories. However, there is little information provided on prevention interventions, mapping, or monitoring targeted at high-risk groups beyond female sex workers.

Quality of Supervision Rating: Moderately Satisfactory

Overall Bank Performance Rating: Moderately Satisfactory

9. Assessment of Borrower Performance:

a. Government Performance:

The government was highly committed to the fight against HIV/AIDS, as shown by increased budget allocations in this area. It created the conditions for a strong and unified M&E system and supported the development of a single national strategic plan. However, despite strong commitment and experience gained through the previous Bank-financed HIV/AIDS project, it took eight months for the project to become effective, and implementation remained slow after effectiveness due to major bottlenecks. The eight-month gap between credit signature and effectiveness stemmed from delays in getting the Parliament to ratify the credit agreement, largely due to strained relations between the government and the Parliament (in which the President did not hold a majority). Implementation was also challenged by a 2007 Presidential Decree that limited per diems for missions and training by civil servants, reducing the motivation of health workers to attend needed training sessions and seminars (and causing Ministry of Health staff to strike). When institutional challenges arose between the SP/CNLS and the Project Implementation Unit, the government chose to change the Permanent Secretary of the CNLS twice rather than tackle directly the underlying institutional problem. According to the ICR (p. 24), the government did not fully support strengthening the capacity of the CNLS.

Government Performance Rating: Moderately Unsatisfactory

b. Implementing Agency Performance:

Under the auspices of the CLNS, the project was managed by a small Project Implementation Unit (PIU), with the support of a financial management agency (FMA). Early in implementation, a sort of “mission creep” (ICR, p. 7) occurred within the SP/CNLS, as it increasingly tried to take more direct responsibility for implementation (for example, in procurement processes), even though its designated role was one of coordination only. These jurisdiction problems slowed implementation considerably in the early stages, and were only resolved after the Bank commissioned an institutional assessment. Despite these challenges, the PIU was eventually able to steer the project and remove bottlenecks. The FMA performed effectively and efficiently in managing the funding provided for community-based subprojects.

Implementing Agency Performance Rating: Moderately Satisfactory

Overall Borrower Performance Rating: Moderately Satisfactory

10. M&E Design, Implementation, & Utilization:

a. M&E Design:

The project fully supported a validated national M&E framework. It initially relied on a set of seven key indicators, explicitly tied to each of the three development objectives. Data collection instruments, frequency of reporting, and institutional responsibility for data collection and analysis were well defined. M&E specialists were to be deployed at the national and decentralized levels. Appropriate capacity building was included in planned project activities to correct existing weaknesses. However, there was a long gap between project approval and effectiveness, with the project becoming effective only in January 2008. As a result, baseline and target values had to be reset during implementation to take into account newly available data.

b. M&E Implementation:

M&E was implemented as planned. National M&E systems, with M&E specialists posted in departmental committees and focal points in all communal committees, are fully functional. As a result, the system is increasingly recognized by all donors, who are becoming less wedded to their own separate M&E arrangements (ICR, p. 21). The 2012 Second Generation Survey for STI and HIV/AIDS (ESDG) encountered difficulties related to the organization of data collection and analysis, calling the reliability of its results into question. It is not clear that this survey was ever validated. For this reason, the ICR was delayed by one year so that 2012 DHS data could be used to assess the project’s achievements. The ICR does not report that the vulnerability mapping of high-risk groups planned under Component 3 took place, and there were no indicators to measure knowledge or behavior change among high-risk groups other than female sex workers.

a. M&E Utilization:

According to the ICR (p. 9), information collected by the M&E system was useful to project managers and the Bank team, providing real-time data allowing for changes in project proceeds and activities after the Mid-Term Review. Produced data induced an increased focus on more efficient interventions, such as those targeting high-risk groups. Routine data provided by the M&E system also showed the need to review and clarify indicators.

M&E Quality Rating: Modest

11. Other Issues:

a. Safeguards:

The project was Category B and triggered BP/OP 4.01, Environmental Assessment. An existing medical waste management plan was updated and used for this project. To mitigate risks associated with biomedical waste, the project provided incinerators, training documents, trainings, and workshops. No environmental issues occurred during implementation, and there was full compliance with safeguard policies.

b. Fiduciary Compliance:

Fiduciary: An independent financial management agency was contracted for the project. For audit purposes, an independent accredited auditing firm was contracted for the first two years. During implementation financial management complied with Bank policies. At the end of 2008, some minor weaknesses were noted in the organization of accounting tasks, and these were quickly addressed. In addition, some expenditures were deemed ineligible by an audit conducted in 2009 (for the 2008 fiscal year). US$ 28,000 that had been inappropriately spent on gasoline was subsequently refunded by the government. With this exception, audits were on time and unqualified.

Procurement: Procurement plans were regularly prepared by the PIU, and the hiring of a procurement specialist at the beginning of the project helped to successfully implement those plans. Each Bank supervision mission included a procurement specialist. Some procurement delays were generated by long waits for approvals by the National Agency for Public Procurement Control. This bottleneck was national rather than sectoral, with all Bank projects in all sectors facing procurement delays because of this agency.

c. Unintended Impacts (positive or negative):
None reported.

d. Other:



12. Ratings:

ICR
IEG Review
Reason for Disagreement/Comments
Outcome:
Satisfactory
Moderately Satisfactory
The project’s objectives and design were substantially relevant. The objectives were aligned with country conditions and Bank strategy at the time of appraisal, and with current government strategy. Project design is rated substantial, as the planned activities were logically and plausibly linked to anticipated outcomes. The planned focus on female sex workers was particularly strong. Achievement of both objectives is rated substantial, as progress was registered on all dimensions of prevention, treatment, and care, with the exception of prevention of mother-to-child transmission. The project was administered in a cost-effective manner, but other than female sex workers, it is not clear that it efficiently targeted groups at highest risk of contracting and transmitting HIV infection. Taken together, these achievements are indicative of moderate shortcomings, resulting in an Outcome rating of Moderately Satisfactory. 
Risk to Development Outcome:
Moderate
Moderate
 
Bank Performance:
Satisfactory
Moderately Satisfactory
There were no activities or indicators to encourage and measure coverage or behavior changes in high-risk groups other than female sex workers, and no mapping/targeting of these groups (especially along the Abidjan-Lagos corridor).  
Borrower Performance:
Moderately Satisfactory
Moderately Satisfactory
 
Quality of ICR:
 
Satisfactory
 
NOTES:
- When insufficient information is provided by the Bank for IEG to arrive at a clear rating, IEG will downgrade the relevant ratings as warranted beginning July 1, 2006.
- The "Reason for Disagreement/Comments" column could cross-reference other sections of the ICR Review, as appropriate.

13. Lessons:

The following lessons are drawn from the ICR (pp. 25-26):

A thorough understanding of the dynamics of an HIV/AIDS epidemic, by population group and geographic area, is an essential prerequisite for design of effective programs and efficient investment of resources. In this case, M&E data were appropriately used to shift attention and resources toward female sex workers most at risk for contracting and spreading HIV, but attention to other high-risk groups could have been more explicitly focused and reported.

Use of a separately contracted fiduciary agency to manage a subproject component can be key to successful implementation. In this case, the PIU was freed to concentrate on coordination rather than getting involved in activities for which it did not have specific expertise.

Precise allocation of roles and responsibilities among coordinating and implementing agencies is crucial from the very early stages of a project. In this case, the SP/CNLS, with newly developed capacity and a vague mandate of coordination, experienced problematic “mission creep.”

14. Assessment Recommended?

No

15. Comments on Quality of ICR:

The ICR is clear and concise, and it follows established guidelines. Its discussion of attribution of observed results to the Bank’s interventions (as opposed to those of other donors) is straightforward and important. The ICR is also impressively careful, in its presentation of data on individual outcome indicators, to illustrate the results chain leading from project-financed interventions to those observed outcomes. It harnesses a range of available data to assess outcomes, including survey data from outside the project’s M&E system. However, it does not provide sufficient information on the large number of community-based subprojects to enable an assessment of their coverage and impact among high-risk groups other than female sex workers.

a. Quality of ICR Rating: Satisfactory

(ICRR-Rev6INV-Jun-2011)
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