IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-H0800) ON A ADAPTABLE PROGRAM LOAN IN THE AMOUNT OF US$102 MILLION TO THE

Transcription

1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Human Development AFCC2 Africa Region Document of The World Bank IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-H0800) ON A ADAPTABLE PROGRAM LOAN IN THE AMOUNT OF US$102 MILLION TO THE DEMOCRATIC REPUBLIC OF CONGO FOR A DRC MULTISECTORAL HIV/AIDS PROJECT November 29, 2011 Report No: ICR2056

2 CURRENCY EQUIVALENTS (Exchange Rate Effective November 1, 2011) Currency Unit = Congolese Franc (CDF) CDF= US$ US$ 1.00 = 910 CDF FISCAL YEAR 2011 ABBREVIATIONS AND ACRONYMS AIDS ARV CNLS BCC CNMLS CBO CCM DHS DRC FAM FBO FMA FOSI GF GLIA HCR HIV IAD IDA I-PRSP KPI MAP MoH M&E MWMP NCU NGO NSP OVC PDO PLWHA PMLS PMTCT PNLS PNMLS Acquired Immune Deficiency Syndrome Anti-Retroviral Drugs National HIV/AIDS Committee Behavioural Change Communication National Multi-sectoral HIV/AIDS Commission Community-Based Organization Country Coordinating Mechanism (Technical Secretariat of the Global Fund) Demographic and Health Survey Democratic Republic of Congo Fiduciary & Administrative Manual Faith Based Organization Fiduciary Management Agency Forum of HIV/AIDS NGO Global Fund to Combat HIV/AIDS, TB and Malaria Great Lakes Initiative on HIV/AIDS Haut Commissariat aux Réfugiés Human Immunodeficiency Virus Internal Audit Department International Development Association Interim Poverty Reduction Strategy Paper Key Performance Indicators Multi-Country HIV/AIDS Program Ministry of Health Monitoring and Evaluation Medical Waste Management Plan National Coordination Unit Non-Government Organization National Strategic Plan Orphans and other Vulnerable Children Project Development Objectives People Living with HIV/AIDS Projet Multisectoriel de Lutte contre le VIH/SIDA (MAP/PMLS) Prevention of Mother-to-Child Transmission Programme National de Lutte contre le VIH/SIDA (National AIDS Control Program) Programme National Multisectoriel de Lutte contre le VIH/SIDA

3 PRGSP PMTCT STI TTL UNAIDS UNICEF VCT WHO Poverty Reduction and Growth Strategy Paper Prevention of Mother-to-Child Transmission Sexually Transmitted Infection Task Team Leader United Nations HIV/AIDS Commission United Nations Children s Fund Voluntary Testing and Counseling World Health Organization Vice President: Country Director: Sector Manager: Project Team Leader: ICR Team Leader: Obiageli Katryn Ezekwesili Eustache Ouayoro Jean J. De St Antoine Jean-Jacques Frere Enias Baganizi

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5 DEMOCRATIC REPUBLIC OF CONGO DRC MULTISECTORAL 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 Key factors Affecting Implementation and Outcomes Assessment of Outcomes Assessment of risks Development outcome Assessment of Bank and Borrower Performance Lessons learned Comments on Issues Raised by Borrower/Implementing Agencies/Partners Annex 1. Project Costs and Financing Annex 2. Outputs by Component Annex 3. Economic and Financial Analysis Annex 4. Bank Lending and Implementation Support/Supervision Processes Annex 5. Beneficiary Survey Results Annex 6. Stakeholder Workshop Report and Results Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders Annex 9. List of Supporting Documents Annex 10: Summary of the Borrower s ICR MAP... 50

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7 A. Basic Information Country: Congo, Democratic Republic of Project Name: DRC Multisectoral HIV/AIDS Project Project ID: P L/C/TF Number(s): IDA-H0800 ICR Date: 11/28/2011 ICR Type: Core ICR Lending Instrument: APL Borrower: DRC Original Total Commitment: Revised Amount: XDR 68.40M Environmental Category: B Implementing Agencies: SEP/CNLS Cofinanciers and Other External Partners: B. Key Dates XDR 68.40M Disbursed Amount: XDR 67.87M Process Date Process Original Date Revised / Actual Date(s) Concept Review: 06/12/2003 Effectiveness: 10/08/ /08/2004 Appraisal: 01/05/2004 Restructuring(s): 05/29/ /07/2010 Approval: 03/26/2004 Mid-term Review: 09/24/ /24/2008 Closing: 01/31/ /31/2011 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Risk to Development Outcome: Bank Performance: Borrower Performance: Unsatisfactory Substantial Unsatisfactory Unsatisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Moderately Unsatisfactory Government: Unsatisfactory Quality of Supervision: Unsatisfactory Implementing Agency/Agencies: Unsatisfactory Overall Bank Overall Borrower Unsatisfactory Performance: Performance: Unsatisfactory i

8 C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Indicators Performance (if any) Potential Problem Project Yes at any time (Yes/No): Problem Project at any time (Yes/No): DO rating before Closing/Inactive status: Yes Moderately Unsatisfactory Quality at Entry (QEA): Quality of Supervision (QSA): None None Rating D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Health Other social services Sub-national government administration Theme Code (as % of total Bank financing) HIV/AIDS Population and reproductive health Social risk mitigation Tuberculosis 20 E. Bank Staff Positions At ICR At Approval Vice President: Obiageli Katryn Ezekwesili Callisto E. Madavo Country Director: Eustache Ouayoro Emmanuel Mbi Sector Manager: Jean J. De St Antoine Joseph Baah-Dwomoh Project Team Leader: Jean-Jacques Frere Suzanne Piriou-Sall ICR Team Leader: Enias Baganizi ICR Primary Author: Enias Baganizi F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The development objective of the MAP/PMLS is to mitigate the negative impact of the HIV/AIDS epidemic on the stabilization, recovery, and development of the Democratic Republic of Congo (DRC). This will be achieved by: (i) Reducing the risk of sexual, intravenous and vertical transmission of HIV; (ii) Improving the health status and quality of life of people living with HIV/AIDS; and ii

9 (iii) Mitigating the socio-economic impact of the epidemic on vulnerable groups. Revised Project Development Objectives (as approved by original approving authority) Government of DRC has a higher level objective of slowing the spread of HIV/AIDS in the general population. The project will support the Government by (i) increasing the access to STI and HIV/AIDS treatment; (ii) mitigating the health and socio-economic impact of HIV/AIDS at the individual, household, and community level; and (iii) building strong and sustainable national capacity to respond to the HIV/AIDS epidemic. (a) PDO Indicator(s) Indicator Indicator 1 : Value quantitative or Qualitative) Baseline Value Original Target Values (from approval documents) Formally Revised Target Values Actual Value Achieved at Completion or Target Years Number of pregnant women living with HIV who receive ARVs to reduce the risk of MTCT 70% (2007 1% 35% restructuring) 804 1,200 (2010 restructuring) Date achieved 10/08/ /08/ /07/ /31/2010 The indicator changed from being expressed as a percentage to becoming a Comments number. The targets in percentages - 35% for original target and 70% for the (incl. % 2007 restructuring - the country was far from achieving these targets (3.7% in achievement) 2010) Number of adult and children with HIV receiving ARVs (in areas targeted by the Indicator 2 : project Value quantitative or Qualitative) 2,200 number of PLWHA who receive quality 20,000 medical care 70% of advanced HIV+ needing ARVs (2007 restructuring) 10,000 (2010 restructuring) 7,940 Date achieved 10/08/ /08/ /07/ /31/2010 Comments (incl. % achievement) This indicator was achieved at 79.4% with regard to the target set at the last restructuring in 2010 but certainly fall short below the target set for 2007 (70%) and the original target (20,000) Indicator 3 : Number of OVC with schooling provided through the project Value quantitative or Qualitative) 15,000 (2007 4% of orphans assisted with tuition and schooling 20% and 2010 restructuring) 31,618 Date achieved 10/08/ /08/ /07/ /31/2011 Comments (incl. % achievement) This indicator was by far achieved for the 2007 and 2010 targets. Also, according to the 2009 MICS results, 63% of OVC were receiving support for schooling or education. Indicator 4 : Persons aged 15 and older who receive counseling and testing for HIV and iii

10 receive their results 800,000 (2007 Value restructuring) quantitative or 1,500 25, , ,000 (2010 Qualitative) restructuring) Date achieved 10/08/ /08/ /07/ /31/2010 The target values varied greatly from the original and the 2 restructurings. The Comments indicator was achieved just over 100% with regard to the 2010 target but fell (incl. % short of the 2007 target (800,000). The original 25,000 target was for sure an achievement) underestimat (b) Intermediate Outcome Indicator(s) Indicator Indicator 1 : Value (quantitative or Qualitative) Baseline Value Original Target Values (from approval documents) Formally Revised Target Values Actual Value Achieved at Completion or Target Years Number of units of blood collected which are qualified according to national norms countrywide by the end of the project 600 number of service outlets carrying out blood safety activities ( % of blood donated restructuring) tested for HIV and 60% 200, ,309 Hepatitis B & C number of units of blood collected according to national norms (2010 restructuring) Date achieved 10/08/ /08/ /07/ /31/2011 Comments (incl. % achievement) This indicator changed in nature and wording during the 2 restructuring, making it difficult to judge about its achievement. With regard to the last 2010 target, it was achieved at 112%. Indicator 2 : Number of STI cases treated according ton ational norms (per year) Value (quantitative or Qualitative) NA 50, ,000 (2007 restructuring) 100,000 (2010 restructuring) 102,074 Date achieved 10/08/ /08/ /07/ /31/2011 Comments (incl. % achievement) Again this indicator target changed greatly in value from 50,000 to 300,000 at the first restructuring in 2007 to 100,000 at the last restructuring in 2010 (achieved at 102%) Indicator 3 : % of Ministries targeted byt the project with operational Unit of HIV/AIDS Value N/A N/A 100% 60% iv

11 (quantitative or Qualitative) Date achieved 10/08/ /08/ /07/ /31/2011 Comments (incl. % This indicator was achieved at 60%. achievement) Indicator 4 : Number of condoms distributed Value (quantitative or Qualitative) 20% of CSW using condoms at last sex 60% 25,000,000 condoms distributed (2007 and 2010 restructuring) 27,650,946 Date achieved 10/08/ /08/ /07/ /31/2011 Comments This indicator completely changed from percentage of CSW using condoms at (incl. % last sex to the number of condoms distributed. It was achieved 110%. achievement) G. Ratings of Project Performance in ISRs No. Date ISR Archived DO IP Actual Disbursements (USD millions) 1 09/24/2004 Satisfactory Satisfactory /14/2005 Moderately Satisfactory Satisfactory /20/2005 Moderately Satisfactory Satisfactory /29/2006 Unsatisfactory Moderately Satisfactory /09/2007 Unsatisfactory Moderately Satisfactory /29/ /28/ /28/ /27/2008 Moderately Unsatisfactory Moderately Unsatisfactory Moderately Unsatisfactory Moderately Unsatisfactory 10 06/26/2009 Moderately Satisfactory 11 12/20/2009 Moderately Satisfactory 12 06/28/ /26/2011 Moderately Unsatisfactory Moderately Unsatisfactory 14 09/18/2011 Unsatisfactory Moderately Satisfactory Moderately Satisfactory Moderately Unsatisfactory Moderately Unsatisfactory Moderately Unsatisfactory Moderately Unsatisfactory Moderately Unsatisfactory Moderately Satisfactory Moderately Unsatisfactory v

12 H. Restructuring (if any) Restructuring Date(s) Board Approved PDO Change ISR Ratings at Restructuring DO IP Amount Disbursed at Restructuring in USD millions 05/29/2007 Y U MS /07/2010 N MS MU Reason for Restructuring & Key Changes Made - Seaparate the functions of the MAP project coordinator and the PNMLS Coordinator - Modify activities under the community component - Revise project key indicators - Reallocate project funds If PDO and/or Key Outcome Targets were formally revised (approved by the original approving body) enter ratings below: Outcome Ratings Against Original PDO/Targets Unsatisfactory Against Formally Revised PDO/Targets Unsatisfactory Overall (weighted) rating Unsatisfactory I. Disbursement Profile vi

13 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal 1. The Government of the Democratic Republic of Congo (DRC) officially recognized the existence of HIV/AIDS in 1984, thus becoming one of the first African countries to acknowledge the danger of the epidemic. 2. However, as a result of the pillaging that occurred from 1991 to 1993 (which robbed the National AIDS Control Program of all its equipment) and the cessation of international cooperation (resulting in the departure of the major donors and research teams), the fight against HIV/AIDS nearly came to a halt from 1990 to The effort to fight AIDS began again in 1999 with the preparation of the National Strategic Plan ( ) to Combat HIV/AIDS (NSP). 1 Its aim was to support the development of the country by controlling the spread of the HIV/AIDS epidemic and by mitigating its impact on individuals, families, and the community. Moreover, in accordance with the objectives pursued by earlier plans, the purpose of NSP was to design the necessary mechanisms in all sectors of national life in order to reduce the spread of HIV and sexually transmitted infections (STIs) and to minimize their impact on the community. A National Multisectoral Committee to Combat AIDS (CNMLS) was established in the Ministry of Health in Beyond the NSP, the Government s primary focus on HIV/AIDS was once again demonstrated during the preparation of the 2002 Interim Poverty Reduction Strategy Paper (I-PRSP), as one of the long-term objectives of the strategy was to improve living conditions for the Congolese people. 5. Since the re-engagement of the World Bank in 2001, the HIV/AIDS problem has been reframed. The first actions of the comprehensive control effort were financed by the Bank in the amount of US$8 million under the NSP framework to support the Government s multisectoral strategy. This strategy was defined well before this approach was internationally accepted. 6. It was remarkable to note that DRC had already a national strategic plan and a HIV/AIDS coordination structure when the project was prepared. During the preparatory phase the Bank and the client agreed: (i) to replace the National Committee with the National Multisectoral Committee to Combat AIDS (CNMLS), which was placed under the responsibility of the President of the Republic; 3 (ii) to take exceptional steps to implement the project, including the subcontracting of administrative and management responsibilities; and (iii) to use multiple execution agencies, including non-governmental 1 NSP was implemented with the support of WHO, UNDP, and UNAIDS, among others. 2 Decree No. 1250/CAB/MIN/S/AJ/KIZ/015/2001 of December 9, 2001, created a National Multisectoral Committee to Combat AIDS (CNMLS) in the Ministry of Health, with wide representation from the main public and private stakeholders, to supervise and coordinate the implementation of the National Strategic Plan. It replaced CNLS, which had been set up on May 28, Decree No. 04/029 of March 17, 2004, creating and organizing the National Multisectoral Program to Combat AIDS (PNMLS). 1

14 organizations (NGOs) and umbrella groups. Thus, DRC was able to meet the four conditions needed to access Multi-Country HIV/AIDS Program for Africa (MAP) II funds. 7. It is within the above context that the Project concept note was first drafted in 2003 and approved in January This was shortly after the 2002 fragile political agreement for a transition Government intended to last for three years. The Project was formulated at the time when the Bank considered HIV was a development issue and not solely or predominantly a health issue. This was partly reflected in the fact that the first TLL of the project came from the agriculture sector and was a strong advocate for community engagement. 8. It s also important to note that the project concept and appraisal preceded the engagement of the Global Fund (GF) and PEPFAR, and certainly well before either were able to provide any resources to the fight against HIV in DRC. The presence of these new and significant donors in DRC captivated the attention of the Government and drew heavily on the limited human resources available in the health sector. The GF created a new entity, the Country Coordinating Mechanism (CCM), which was under the MOH control and not under the National AIDS Authority (PNLMLS) created earlier by the Government with Bank s assistance. 9. At the time of project preparation, the entire health system of the country was in shambles in post-conflict era and this situation didn t improve throughout project s implementation. Indeed, expenditure on health per capita is currently at $13 and the total expenditure on health as a percentage of GPD was just 2% in 2009 (WHO, Global Health Observatory, 2009). These figures are very low even by African standards. 10. Besides, the nature of the HIV epidemic in the country was not well understood. HIV prevalence was unknown and it was unclear what was driving the epidemic at the time of Project appraisal. 1.2 Original project development objectives (PDO) and Key Indicators 11. Originally, the development objective was to mitigate the negative impact of the HIV/AIDS epidemic on the country s growth, by: (i) Reducing the risk of sexual, intravenous and vertical transmission of HIV; (ii) Improving the health status and quality of life of people living with HIV/AIDS; and (iii) Mitigating the socio-economic impact of the epidemic on vulnerable groups. The original key performance indicators (KPI) of the project are presented in the table below. 2

15 Table 1: Original Key Performance Indicators PDO PDO 1: HIV/AIDS infection rates are reduced PDO 2: Quality of life of PLWHA is improved PDO3: Socio-economic impact of HIV/AIDS on vulnerable populations is mitigated Key Indicator 60% of sex workers targeted by the program report using condoms during their last sexual encounter At least 35% of pregnant women have access to Mother-to-Child transmission prevention program 70% of donated blood is tested for HIV and Hepatitis B&C 20,000 PLWHA receive quality medical treatment 50% of target health zones have community services for PLWHA available 20% of orphans are assisted with tuition and schooling Discrimination against PLWHA (as defined in DHS+) is reduced by 30% 1.3 Revised (and approved) project development objectives (PDO) and Key Indicators, and reasons/justification 12. The project went through two approved restructurings. The first one, done in July 2007, was a generic umbrella regional restructuring. This restructuring was not addressing any specific implementation problem nor responding to information associated with a better understanding of the epidemiology of HIV in the country. Rather, it was meant to take into account: (i) change in the international environment with regard to the fight against HIV/AIDS, in particular the experiences with other MAPs and (ii) the need to harmonize MAP indicators across countries. 13. During the 2007 restructuring, the objectives of the project were modified by agreement between the Government and the International Development Association (IDA). The new project development objective (PDO) was to assist the Recipient in: (i) increasing access to STI and HIV/AIDS treatment; (ii) mitigating the health and socioeconomic impact of HIV/AIDS at the individual, household, and community level; and (iii) building strong and sustainable national capacity to respond to the HIV/AIDS epidemic. 14. For the June 2010 restructuring, the PDO was not changed at all. The aims of the restructuring was to: (i) separate the functions of the coordinator of the Bank project implementation unit and the coordinator of the national body responsible for HIV/AIDS programs, in order to allow more focus on project implementation and at the same time ensuring sustainability of the national response ; (ii) modify activities under the community component to shift them from multiple community micro-projects to community outreach programs using a limited number of large actors ; (iii) revise the project s key indicators and targets to adjust them to the revised project activities and address the current difficulties in obtaining some of the data ; and (iv) reallocation of budget categories into a single expenditure category for the uncommitted resources of the loan to facilitate disbursement as the project nears completion. 15. During the two restructuring exercises (2007 and 2010), the original Key Performance Indicators were modified/replaced as follows in table 2. 3

16 Table 2: New Key Indicators after the two restructuring exercises in 2007 and 2010 Original Key Indicator Modified Indicator (2007 restructuring) 60% of sex workers targeted by 25,000,000 number of condoms the program report using distributed by the Project condoms during their last sexual encounter At least 35% o f pregnant women have access to Motherto-Child transmission prevention program 70% o f donated blood is tested for HIV and Hepatitis B&C 70% of HIV infected pregnant women receive a complete course of ARV prophylaxis to reduce the risk of Mother To Child Transmission (MTCT) in areas targeted by MAP by the end of the project. 600 service outlets carrying out blood safety activities have been established countrywide by the end of the project - 800,000 persons aged 15 and older received counseling and testing for HIV and received their test results in areas targeted by the MAP by the end of the project 20,000 PLWHA receive quality medical treatment 50% of target health zones have community services for PLWHA available 20% of orphans are assisted with tuition and schooling Discrimination against PLWHA (as defined in DHS+) is reduced by 30% 70% men and women with advanced HIV infection receiving antiretroviral combination therapy in areas targeted by the MAP by the end of the Project At least 5,000 subprojects (sensitization, community services for PLWHA) by NGO, CBO and FBO have received support 15,000 orphans and other vulnerable children whose households received care/ support in past 12 months Dropped - Modified Indicator (2010 restructuring) 25,000,000 number of condoms distributed by the Project 1,200 pregnant women living with HIV receive antiretroviral to reduce the risk of MTCT (in areas targeted by MAP.) 200,000 number of units of blood collected and which are qualified according to national norms 300,000 persons aged 15 and older who received counseling and testing for HIV and received their test results 10,000 adults and children with HIV receiving antiretroviral combination therapy (in areas targeted by the MAP.) Dropped 15,000 orphans and vulnerable children with schooling provided through the project - - Number of Sexually Transmitted Infection (STI) cases treated according to national norms - - % of ministries targeted by the project with an operational Unit for HIV/AIDS control 4

17 1.3 Main beneficiaries 16. The original intended beneficiaries of the project were the general population and vulnerable groups in particular. Gradually, the country further refined the target populations to include the prison population, people living with HIV (PLWHA), displaced persons (especially women), orphans and other vulnerable children (OVC); persons working in dangerous conditions, such as men in uniform, truckers, and miners; and groups in which the prevalence of infection was rapidly increasing, namely, young people and women. 1.4 Original components 17. Component 1: Response of the public sector - US$40.4 million. Under this component, the project had to assist and support the mobilization of public institutions in the fight against the epidemic by mainstreaming HIV/AIDS activities in their regular work program. The component was further structured into two sub-components: (a) Program of the Ministry of Health (US$21.1 million), and (b) Program of the other ministries (US$19.3 million). 18. Component 2: Response of the non-governmental sector - US$l7.9 million. This component had two sub-components: a) Private sector entities/public enterprises (US$7.3 million) and b) NGOs, faith-based organizations, professional associations (US$l0.6 million). 19. Component 3: Support for community initiatives - US$l9.3 million. The component s objective was to increase the impact of HIV/AIDS activities by transferring the responsibility for identifying priorities, and preparing and implementing microprojects directly to the beneficiaries in rural and urban areas. 20. Component 4: Coordination & Communication (US$11.3million), monitoring and evaluation (US$8 million), capacity building (US$3.2 million) - Total: US$22.5 million. This component had three sub-components: (a) Coordination and Communication; (b) Monitoring and evaluation, and (c) Capacity-building/Technical Studies). 1.5 Revised components 21. The components were not formally revised during the implementation of the project despite the revision of the project development objectives during the 2007 restructuring. 1.6 Other significant changes 22. During the execution of the project, the original loan agreement was amended several times in order to: (i) modify the fiduciary procedures; (ii) revise the development objective and project outcome indicators; and (iii) reallocate project funds. One amendment to extend the project closing date from January 31, 2011 to May 31, 2011 was approved. 23. Procedures were also modified: (i) in April 2009, to raise the prior review thresholds for procurement; and (ii) in June 2010, to reallocate the remaining amounts in various budget categories into a single category in order to facilitate disbursement of the unspent funds. 5

18 24. The project development objective was revised in July 2007 following the restructuring of eight MAP projects; and indicators were modified: (i) in July 2007, solely on the basis of the first umbrella restructuring of the project; and (ii) in June 2010, following the outcome of the mid-term review and gaps identified in the definition of the indicators and availability of data. 2. Key factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design, and Quality at Entry Preparation 25. During the preparatory phase of the Project, the Bank team spent tremendous amount of time trying to understand the context under which the project would be implemented. Several visits were organized all over the country including pre-concept, concept, pre-appraisal and appraisal missions even in Eastern Congo which was still extremely unstable at the time. The preparatory budget (PHRD US$959,029) was substantial and was used to develop various aspects of the Project including the:: Socioeconomic and environmental assessments (US$177,545); Development of appropriate operational design, mechanisms, and instruments for efficient project implementation, supervision, and monitoring ($300,980); Strengthening the capacity and ownership of key implementing entities ($223,220); Feasibility studies on designing innovative approaches ($166,500); and Other studies needed for the preparation of the Project ($90,784). 26. Preparatory activities continued throughout 2002 and They focused on: (i) evaluating the capacities of sectors to be included in the project; and (ii) developing manuals of procedures for the project in general and the component related to community initiatives in particular (with a study on monetary transfer modalities in localities having no access to banks). Despite all these studies, there was no epidemiological analysis carried out to better understand the nature of the HIV epidemic and this was one of the weaknesses of the preparation process. 27. Lessons learned during the field visits around the entire country, including zones still at war in the Eastern parts of the country, were used to shape the design of the project. However, more PPF funds should have been used to collect the necessary baseline data that were to be used as reference to evaluate the performance of the project. 28. The project was consistent with the objectives o f the Transitional Support Strategy (TSS) approved by the Bank in The TSS had to support the Government s goal to: (i) consolidate peace, (ii) stabilize the macroeconomic and fiscal framework, (iii) improve governance; and (iv) rebuild social services and meet basic needs. 6

19 Design 29. Given the situation in DRC and the requirements of MAP II, the project was designed to support the implementation of the National Strategic Plan to Combat AIDS in all the provinces of the country, in both rural and urban areas, and in a variety of sectors. 30. The original project s objectives were realistic given the scientific knowledge available at the time of project s appraisal. The original objectives were appropriate in terms of their ability to achieve the PDOs. However, when the project was revised in 2007, one of the objectives was to increase access to STI and HIV/AIDS treatment. Access to STI shouldn t have been included as an objective because at that time there was compelling evidence that the treatment of STIs had no proven impact on mitigating HIV infection. Quality at Entry 31. A quality enhancement review (QER) of the proposed project was conducted in November The QER identified the following problems: (i) the loan amount seemed too big given the country s problems with disbursement and the amounts expected from the Global Fund; (ii) the likely overlap of responsibilities between PNMLS and the other structures involved in fighting HIV/AIDS was identified as a problem for smooth project implementation as well as (iii) the weak technical capacity of the implementing agency. 32. The results framework also suffered from insufficient baseline data and from indicators that were not clearly defined. One consequence of this was that targets for some indicators were defined based on guesses rather than on knowledge of the true situation of the HIV/epidemic. Indicators were later revised during the two restructuring exercises to be more specific. 2.2 Implementation 33. The most significant factor which affected the implementation of the Project was the inadequate management capacity at the central level, coupled with extensive leadership turn-over. The project has known five TTLs on the Bank s side; and five Ministers of Health and four different Managers (project Coordinators) of the Implementing Agency (PNMLS). The management capacity at the central level (PNMLS) was hampered by the inability to change the poorly performing leadership. This was due to internal rivalries within government entities, especially between the Office of the Prime Minister and the Ministry of Health regarding who had the power to change the leadership. Two of the PNMLS Managers were in acting position for long periods of time hampering their ability to take decisive necessary actions to improve the project implementation. 34. The second factor influencing implementation was the insufficient attention given to decentralized supervisory and capacity building responsibilities as well as the weak programmatic, technical and fiduciary capacity at decentralized levels. 35. Besides the extensive turn-over of Bank TTLs, when the Project was launched, there was a management decision to have the first TTL based in Washington without a dedicated staff person in-country. Such a person was needed on the ground at the outset of the project implementation given the particular nature of the country (huge and 7

20 diverse), and the sectoral politics. Moreover, the project required coordination with other development partners. 2.3 Monitoring and Evaluation (M&E) Design, Implementation, and Utilization M&E Design 36. During the preparatory phase, the PAD had proposed sharing monitoring and evaluation responsibilities between: (i) surveillance, for which the Ministry of Health would be responsible, possibly assisted by national institutes and laboratories and technical partners; (ii) sectoral health activities (blood transfusion, treatment of STIs, PMCT, IO, among others), for which the technical programs of the Ministry of Health would be responsible; (iii) activities to be carried out by PNMLS, assisted by provincial coordinators and grant recipients; and (iv) financial management, for which FMA would be responsible, assisted by the Bank (for the Risk-Sharing Facility (RSF) review) and internal and external auditors. This may have appeared reasonable on paper but in practice it was unclear who in the end was in charge of coordinating the overall M&E system. 37. The M&E normative framework, considered as a National Monitoring and Evaluation plan, governs and regulates the implementation of the national monitoring and evaluation system and lists the national indicators applicable to all actors involved in combating HIV/AIDS in DRC. However, the project indicators were not fully in accordance with the national indicators. This was due to the fact that the MAP had its own set of core indicators that were to be used by all countries benefiting from this program. M&E Implementation and use 38. The adoption of the M&E framework was followed by an action plan, guides for indicators, and training tools and manuals. However, the data collected have not been systematically analyzed and processed. 39. At the PNMLS level, several factors have negatively affected the availability of technical and financial data, namely: (i) the weak capacities of decentralized bodies to document data on completed activities; and (ii) the lack of sufficient qualified technical staff, supplies, and working tools. 40. With regard to financial data, PNMLS has reliable information going back to the beginning of the project, and has had analytical tools since it began to use the accounting software TOMPRO in Safeguards and Fiduciary Compliance 41. Environment and management of medical waste: At the time of appraisal, the project was listed under category B, given the risks involved in medical waste management for medical personnel and the communities surrounding health facilities. A plan was prepared and approved by the Bank in December There is a Health Sector Rehabilitation Support Project which has a medical waste management plan that covers HIV/AIDS activities. Therefore, the project didn t need to duplicate efforts to implement its own medical waste management plan. 8

21 42. Procurement: Despite the recruitment of an agency responsible for procurement (PWC Price Water House Coopers - which assumed at the same time the fiduciary responsibilities), the supervisory mission of March 2006 observed weaknesses linked to factors such as: (i) lack of understanding of procurement procedures in general; (ii) ignorance of the procedures set forth in the loan agreement (IS IT A LOAN OR A CREDIT AGREEMENT?); and (i) implementation of provisions and procedures contrary to the provisions of the loan agreement SAME QUESTION. The recruitment of an additional procurement expert in 2007 helped to gradually improve the capacities of the project, which have been rated as moderately satisfactory or satisfactory since June After the 2008 Institutional Audit, the fiduciary and procurement roles were separated and a procurement unit was created within the PNMLS and the fiduciary element was assumed by a new FMA, the KMPG. 43. Financial management and disbursement: On the basis of the analysis contained in the PAD, the risks posed by financial management, given the country's postconflict situation and the complexity of the project, were considered high. The recruitment of the fiduciary management agency (FMA), the opening of various special accounts, the elaboration of detailed procedural manuals, and the hiring of external auditors (for the technical and financial aspects) helped somewhat in reducing these risks. However, the supervisory mission of March 2006 revealed that the fiduciary management of the project did not meet the minimum standards for rigor and transparency generally required in projects financed by the World Bank. 44. The situation has remained critical for almost two years. Another World Bank supervisory mission in October 2008 judged the financial performance of the project to be very unsatisfactory, in view of: (i) the existence of significant but non-reimbursed ineligible expenditures for more than two years; (ii) lack of adequate budgetary management; (iii) persistent weaknesses in the control system, linked to organizational dysfunction; and (iv) the poor performance of the outgoing FMA (PWC). It was not until December 2009 that financial management was rated satisfactory under the auspice of the new FMA, the KPMG (Klynveld Peat Marwick Goerdeler) accounting firm. 45. The final financial supervision visit found that the project has complied with the obligations of financial reporting and auditing. However, according to the financial supervision report, the fiduciary risk remains substantial and performance in financial management was considered moderately unsatisfactory. In addition, according to the financial mission findings, the financial losses of the project are estimated (May 27, 2011) to be USD 7.86 million comprising: (i) USD 2.78 million not recovered from the initial deposit in the designated accounts of, (ii) the over- commitment of USD 2.54 million due to an acceleration of commitments and payments in the last month before the original closing date of the project, (iii) related expenses deemed not to conform to the agreements signed in 2005 of USD 1.78 million, and (iv) disputed claims by the PNMLS of USD 0.76 million. Given the problem with this over commitment, the financial management should have been rated unsatisfactory. 2.5 Post-completion Operations/Next Phase 46. Despite the difficulties encountered during its implementation, the project contributed to a number of activities that could assist future efforts to combat HIV/AIDS. 9

22 With regard to the strategic and regulatory framework, the country has a national plan for the period and operational plans at the provincial level. The national plan recognizes the complex nature of the epidemic and confirms the principles and approaches that should guide the effort to control HIV/AIDS in the coming years. At the legislative level, Act No. 06/18 of July 20, 2006, on the protection of the rights of PLWHA, could help attenuate discrimination in DRC. 47. At the institutional level, the recent separation of political and strategic responsibilities from project coordination functions in PNMLS is a step that has been anticipated since the preparatory phase of the project. This was long overdue since it was one of the recommendations of the 2008 Institutional Audit. 48. Technically speaking, the project's support for MODs (Delegated Management Contracts) in prevention activities (condom distribution, community awareness-raising, blood transfusion), purchase of inputs (STI and ARV drugs), and building of provincial capacities should contribute to the sustainability of the project activities, at least in the short term. 49. Also the Bank has submitted an AF request to the Board for the Health Sector Rehabilitation Support project in which part of the funds are requested as an interim arrangement while waiting for availability of other sources of funding HIV activities in the future, including probably from the Global Fund. 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation Relevance of objectives 50. The relevance of the three original project s objectives as well as two of the revised project s objectives are rated substantial and one revised objective (which include treatment of STI) is rated modest. The objectives rated are consistent with the current Country Assistance Strategy (CAS ) in which fighting the spread of HIV/AIDS and promoting community dynamics are two of the five pillars which reflect the same pillars in the country s Poverty Reduction and Growth Strategy Paper (PRGSP). However, after restructuring, one of the three new PDOs (increasing the access to STI and HIV/AIDS treatment) was moderately relevant because at the time of the restructuring it was common knowledge that there is no direct link between treating STI and mitigating HIV. Relevance of design and implementation 51. The relevance of design and implementation is rated modest before and after the restructuring. The four components of the project at appraisal (which remained the same after the two restructurings) would have achieved the intended development objective if they had been effectively and efficiently implemented. However, the Project was too ambitious in its efforts to be implemented country-wide rather than choosing a limited number of provinces where the Project could have maximized its impact. 52. Little progress towards the Project s development objectives was achieved at the time of the 2007 restructuring. There had already been fiduciary problems and the project 10

23 was partially frozen for 16 months. Instead of taking this opportunity to address the country specific problems (and eventually revise the components and reorient the project in terms of design and implementation arrangements) the restructuring focused instead on harmonizing MAPs across countries. This was a missed opportunity to better address the needs of the country with regard to new available evidence in HIV/AIDS mitigation (e.g concentration on most-at-risk populations, geographic concentration, etc ). 53. Although the Project s budget is relatively large ($102 million), it is unclear whether the project, as designed to cover the entire territory of Congo with enormous challenges travelling to some areas of the country, could effectively and efficiently achieve the stated development objectives. Also the Project may have underestimated the challenges (monetary and technical efforts) in building the capacity of decentralized entities in a post-conflict country. 54. As discussed earlier, the implementation of the Project suffered from limited technical and managerial capacity at both the central and decentralized levels. The implementation suffered as well from a relatively long period of frozen funds due to fiduciary problems with the first FMA. 3.2 Achievement of Project Development Objectives 55. Too many changes of indicators made it difficult to follow them through and the absence of baseline data made the situation worse and the inability to collect information on some of them didn t help either. After the 2007 restructuring, some of the data on original indicators were no longer collected as planned at appraisal. For example, no data is available on the share of sex workers using condoms at their last sexual intercourse. a) Original PDO 1: HIV/AIDS infections rates are reduced Table 3: Level of achievement of original PDO 1 indicators Original PAD indicators % of sex workers reached by the program report using condoms during their last sexual encounter Number of people a year visit VCTs % of pregnant women who have access to Mother-to- Child transmission prevention program Number of people/year who are treated according to acceptable standard for STI % of donated blood is tested for HIV and Hepatitis B&C Baseline value Original target values (Year 6: End of Project) Actual value achieved at completion or Target Years (May 2011) 20% 60% Data not available 1,500 25, ,308 PNLS report ( ) + Project data 1% 35% 32.6% (2007)* Preliminary report on national HIV/AIDS response - 50, ,074 PNLS report ( ) + Project data 42% 60% 52% Preliminary report on national HIV/AIDS response * This was the latest data available on PMTCT 11

24 56. The indicator on the number of people who visited VCT centers (302,308) was by far surpassed both for the targets before (1,500) and after restructuring (25,000). 57. By 2007, when the data on PMTCT coverage was being collected, the coverage was at 32.6% for the country (168 health zones out of 515 were covered in PMTCT services for pregnant women). This is the same for the indicator on STI cases treated according to national norms. The target was achieved at more than 200%. 58. With regard to the percent of donated blood tested for HIV and hepatitis, it was estimated in 2007 that 79% of health zones were covered in terms of blood transfusion, but only 52% were tested for these infections. 59. Only two of the five outcome indicators for PDO1 were achieved, two others were close to their targets; no data was available for one of the indicators. The effectiveness of original PDO1 is therefore rated modest. b) Original PDO 2: Quality of life of PLWHA improved Table 4: Level of achievement of original PDO 2 indicators Original PAD indicators Baseline value Original target values (Year 6: End of Project) Number of PLWHA who receive quality medical treatment in project supported zones % of target health zones which have community services for PWLHA available Actual value achieved at completion or Target Years (May 2011) 2,200 20,000 7,940 PNLS report ( ) + Project data, and UNGASS report 0 50% N/A 60. The number of PLWHA who received quality medical treatment in zones covered by the Project was far below the original target. 61. The percentage of health zones which had community services for PLWHA is unknown because data on the indicator ceased to be collected after the 2007 restructuring (indicator was dropped). 62. The achievement of original PDO 2 is therefore rated negligible given the limited ability to achieve the first indicators under this PDO and the impossibility to measure the second one. 12

25 c) Original PDO 3: Socio-economic impact of HIV/AIDS on vulnerable populations is mitigated Table 5: Level of achievement of original PDO 3 indicators Original PAD indicators % of orphans assisted with tuition and schooling Reduced discrimination against PLWHA (as defined in DHS+) Baseline value Original target values (Year 6: End of Project) Actual value achieved at completion or Target Years (May 2011) 4% 20% 36,292 (MAP contribution : 20,667) Project data (2009) 100% 70% 9% 63. It is difficult to measure the percentage of OVC assisted with tuition and schooling because the total number in need of the services is not determined for DRC. By the end of 2009, a cumulative number of 36,292 OVC had been assisted with schooling support (with 57% coming from direct Project s contributions. 64. With regard to the indicator on reduced discrimination against PLWHA, according to DHS results (2007), only 9% of the Congolese people have a tolerant attitude toward PLHIV; the MICS 3 study (2009), which uses another method of calculation, arrived at nearly the same conclusion (7% tolerance level). The project s original development objective has not been met. 65. The achievement of original PDO 3 is therefore rated negligible. d) Revised PDO 1: Increase access to STI and HIV/AIDS treatment 66. As shown in table 6 below, four of the six revised PDO 1 outcome indicators were achieved when the 2010 restructuring targets are considered. However, when compared to the 2007 restructuring targets, only one indicator (number of condoms distributed) was achieved, four indicators were not achieved and no data for one indicator was available (number of service outlets carrying out blood safety activities). 67. The target for the number of pregnant women living with HIV who receive ARVs to reduce the risk of MTCT changed from being expressed as a percentage to a number after the second restructuring. In terms of its achievement, the country was far from reaching the target. Only 3.7% of pregnant women in need of ARV received it in 2010, far from the 70% target set at the first restructuring. The indicator also fell short of the target set at the second restructuring (804 women put on ARV versus a target of 1,200). 13

26 Table 6: Level of achievement of revised PDO 1 indicators Revised Indicators (2007 restructuring) Number of condoms distributed by the Project Persons aged 15 and older received counseling and testing for HIV and received their test results in areas targeted by the MAP by the end of the project % of HIV infected pregnant women receive a complete course of ARV prophylaxis to reduce the risk of Mother To Child Transmission (MTCT) in areas targeted by MAP by the end of the project. Number of STIs cases treated according to national norms (per year) Number of service outlets carrying out blood safety activities have been established countrywide by the end of the project % of men and women with advanced HIV infection receiving antiretroviral combination therapy in areas targeted by the MAP by the end of the Project Formally revised target values (2007) Revised Indicators (2010 restructuring) 25,000,000 Number of condoms distributed by the Project 800,000 Persons aged 15 and older who receive counseling and testing for HIV and receive their test results 70% Number of pregnant women living with HIV who received ARVs to reduce the risk of MTCT (in areas targeted by MAP) 300,000 Number of STIs cases treated according to national norms (per year) 600 Number of units of blood collected which are qualified according to national norms countrywide by the end of the Project. 70% Number of adults and children with HIV receiving ARVs (in areas targeted by the MAP) Formally revised target values (2010) Actual value achieved at completion or Target Years (May 2011) 25,000,000 27, 650,946 PNLS report ( ) + Project data 300, ,308 PNLS report ( ) + Project data 1, PNLS report ( ) + Project data, and UNGASS report 100, ,074 PNLS report ( ) + Project data 200, ,295 PNTS report ( ) + Project data, and UNGASS report 10,000 7,940 PNLS report ( ) + Project data, and UNGASS report 68. As for the indicator on the number of persons 15 years and older who receive counseling and testing for HIV and receive their results, the target numbers varied greatly between the two restructuring events. The target set towards the end of the Project in 2010 (300,000) was achieved but fell short of the 2007 target (800,000). 14