Document of The World Bank IMPLEMENTATION COMPLETION AND RESULTS REPORT (IBRD-70650) ON A LOAN IN THE AMOUNT OF US$25 MILLION TO THE

Transcription

1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Document of The World Bank IMPLEMENTATION COMPLETION AND RESULTS REPORT (IBRD-70650) ON A LOAN IN THE AMOUNT OF US$25 MILLION TO THE GOVERNMENT OF THE DOMINICAN REPUBLIC FOR A HIV/AIDS PREVENTION AND CONTROL PROJECT Human Development Department Caribbean Country Management Unit Latin America and the Caribbean Region March 31, 2009 Report No: ICR

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3 CURRENCY EQUIVALENTS (Exchange Rate Effective as of July 31, 2008) Currency Unit = Dominican Republic Pesos (RD$) RD$ 1.00 = US$ US$1.00 = RD$ FISCAL YEAR January 1 - December 31 ABBREVIATIONS AND ACRONYMS ABP Grassroots-Public Sector Partnerships (Alianzas de Base Poblacional) LIL Learning and Innovation Loans AIDS Acquired Immune Deficiency M&E Monitoring and Evaluation Syndrome ART Anti-retroviral Therapy MAP Multi-Country HIV/AIDS Program ARV Anti-retroviral MIS Management Information System BCC Behavior Change Communication MOH Ministry of Health BSS Behavioral Surveillance Survey MTCT Mother-to-Child Transmission BMWM Biomedical Waste Management MTR Mid-Term Review CAS Country Assistance Strategy NGO Non-Governmental Organization CBO: Community-Based Organization PAD Project Appraisal Document CDC Centers for Disease Control of the United States PEN HIV/AIDS National Strategic Plan (Plan Estratégico Nacional) CMU Country Management Unit PDO Project Development Objective CONAPOFA COPRESIDA National Population and Family Council HIV/AIDS Presidential Council (Consejo Presidencial para el SIDA) PLWHA PMTCT People Living with HIV/AIDS Prevention of Mother-to-Child Transmission CSO Civil Society Organization PNRTV National Program to Reduce Vertical Transmission of HIV CSWs Commercial Sex Workers QER Quality Enhancement Review DCA Development Credit Agreement SIAI Integral Care Information System DIGECITSS Sexually Transmitted Infections and AIDS Control General Directorate (Dirección General de Control de Enfermedades de Transmisión Sexual y SIDA) SESPAS Secretariat of Public Health & Social Assistance (Ministry of Health)

4 DOT Directly Observed Therapy (Treatment for Tuberculosis) SNIG National HIV and AIDS Management Information System FM Financial Management STI Sexually Transmitted Infection GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria HIV Human Immunodeficiency Virus TB Tuberculosis SS+ Sputum Smear Positive (TB infection test) IADB Inter-American Development Bank TTL Task Team Leader IEC Information, Education and Communication UNGASS United Nations General Assembly Special Session (United Nations Agreement on M&E Indicators and the name of the reports on these indicators produced by the countries) KAP Knowledge, Attitude, and Practice VCT Voluntary Counseling and Testing KPI Key Performance Indicator Vice President: Country Director: Sector Manager: Project Team Leader: ICR Team Leader: ICR Author: Pamela Cox Yvonne Tsikata Keith Hansen Fernando Montenegro Torres Fernando Montenegro Torres Carmen Carpio

5 Dominican Republic HIV/AIDS Prevention & Control Project 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 CONTENTS 1. Project Context, Development Objectives and Design Key Factors Affecting Implementation and Outcomes Assessment of Outcomes Assessment of Risk to Development Outcome Assessment of Bank and Borrower Performance Lessons Learned (both project-specific and of wide general application) Comments on Issues Raised by Borrower/Implementing Agencies/Partners...35 Annex 1. Project Costs and Financing before and after Restructuring...36 Annex 2.Output by Component...37 Annex 3. Economic and Financial Analysis...42 Annex 4. Bank Lending and Implementation Support/Supervision Processes...42 Annex 5. Beneficiary Survey Results...43 Annex 6. Stakeholder Workshop Report and Results...43 Annex 7. Summary of Borrower s ICR and/or Comments on Draft ICR...44 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders...46 Annex 9. Indicators introduced in the Implementation Letter with the Third Amendment...46 Annex 10. List of Supporting Documents...48 Map IBRD

6 A. Basic Information Country: Dominican Republic Project Name: DO-HIV/AIDS Prevention & Control Proj. Project ID: P L/C/TF Number(s): IBRD-70650,TF ICR Date: 03/31/2009 ICR Type: Core ICR Lending Instrument: APL Borrower: Original Total Commitment: Environmental Category: B Implementing Agencies: COPRESIDA Cofinanciers and Other External Partners: CARIBBEAN REGION USD 25.0M Disbursed Amount: USD 25.0M B. Key Dates Process Date Process Original Date Revised / Actual Date(s) Concept Review: 11/15/2000 Effectiveness: 01/31/2002 Appraisal: 04/23/2001 Restructuring(s): 06/05/ /29/2006 Approval: 06/28/2001 Mid-term Review: 04/18/ /08/2005 Closing: 12/31/ /31/2008 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Risk to Development Outcome: Bank Performance: Borrower Performance: Moderately Satisfactory Moderate Moderately Satisfactory Moderately Satisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Moderately Unsatisfactory Government: Moderately Satisfactory Quality of Supervision: Satisfactory Implementing Agency/Agencies: Moderately Satisfactory Overall Bank Overall Borrower Moderately Satisfactory Performance: Performance: Moderately Satisfactory i

7 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 Satisfactory 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) Central government administration 13 Health Theme Code (Primary/Secondary) Child health Secondary Not Applicable Gender Secondary Not Applicable HIV/AIDS Primary Primary Participation and civic engagement Secondary Secondary Population and reproductive health Secondary Secondary E. Bank Staff Positions At ICR At Approval Vice President: Pamela Cox David de Ferranti Country Director: Yvonne M. Tsikata Orsalia Kalantzopoulos Sector Manager: Keith E. Hansen Charles C. Griffin Project Team Leader: Fernando Montenegro Torres Patricio V. Marquez ICR Team Leader: ICR Primary Author: Fernando Montenegro Torres Carmen Carpio F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) Assist the Government of the Dominican Republic (GODR) in curbing the spread of the Human Immune-deficiency (HIV) epidemic through the scaling up of programs and activities targeted to high risk groups, expanding awareness about HIV/acquired Immune-deficiency Syndrome (AIDS) among the general population; and strengthening institutional capacity to ensure the effectiveness and sustainability of the effort. ii

8 Revised Project Development Objectives (as approved by original approving authority) Reduce the risk of HIV transmission and improve the quality of life of those infected and affected by the HIV epidemic by reorganizing the National Response, developing a National Strategic Plan and a corresponding monitoring and evaluation system, and implementing selected interventions. (a) PDO Indicator(s) Indicator Baseline Value Original Target Values (from approval documents) Formally Revised Target Values Actual Value Achieved at Completion or Target Years Indicator 1 : % of persons that needed ARV treatment and received it in the last 12 months Value quantitative or Qualitative) 2,581 (14%) 7,500 (47%) 9,651 (52%) Date achieved 12/31/ /31/ /31/2008 Comments (incl. % achievement) Percentages refer to the most recent estimates of denominator made by DIGECITTS (25,983 individuals). Estimates have changed from lower to higher figures since 2004 until Indicator 2 : Number of male and female condoms distributed to users (sexually active adult population). Value quantitative or Qualitative) 1,589,993 3,589,993 8,028,466 Date achieved 12/31/ /31/ /31/2008 Comments (incl. % achievement) Indicator 3 : Population aged 15 to 49 who voluntarily requested an HIV test, received the test and received their results within the last 12 months. Value quantitative or Qualitative) 82, ,991 Date achieved 12/31/ /31/ /31/2008 Comments (incl. % achievement) Indicator 4 : Percentage of health facilities providing birth attendance that provide prophylactic treatment according to national norms. Value quantitative or Qualitative) 60% 80% 78% Date achieved 12/31/ /31/ /31/2008 Comments (incl. % achievement) Denominator represents the universe of health facilities eligible to manage prophylactic treatment according to national norms. iii

9 Indicator 5 : Percentage of patients with STIs who are appropriately diagnosed and treated according to national guidelines of all STI patients. Value quantitative or Qualitative) 46,285 69, ,213 Date achieved 12/31/ /31/ /31/2008 Comments (incl. % achievement) Numbers reflect absolute numbers of patients treated in public facilities due to lack of data to produce sufficiently meaningful estimates for the denominator (total number of individuals with STIs) (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 National Strategic Plan prepared, including intervention lines for each target population Previous NSP expired in 2004 New NSP developed and disseminated NSP was developed and disseminated, and it includes intervention lines for each target population Date achieved 12/31/ /31/ /31/2007 Comments (incl. % achievement) Monitoring and evaluation system of the national response fully functional: Indicator 2 : design reflecting a consensus across all alliances, under implementation with information available on some indicators, a first annual report on status of National Response Value (quantitative or Qualitative) No national monitoring and evaluation system in place M&E system fully operational M&E system fully designed and functional: First Annual Report for UNAIDS produced with new system Date achieved 06/30/ /31/ /31/2008 Comments (incl. % achievement) Indicator 3 : Amount of investments in HIV/AIDS prevention and control by financing source and implementing agency Value (quantitative or Qualitative) US$ 15,595,693 US$ 28,158,931 Date achieved 12/31/ /31/2007 iv

10 Comments (incl. % achievement) Indicator 4 : Main objective of this indicator was to reflect that organizations involved in the National Response had increased their institutional capacities to absorb external resources for executing activities for HIV/AIDS prevention and control. Annual percentage of public schools with teachers that have been trained in life skills and actually taught this subject Value (quantitative or Qualitative) Date achieved 12/31/ /31/ /31/2008 Comments (incl. % achievement) Numbers reflect absolute numbers based on agreed target due to changes in official designation of public schools eligible for this program (age groups) Indicator 5 : Number of organizations that provide technical and financial support for preventive interventions among high risk groups for the population Value (quantitative or Qualitative) Date achieved 12/31/ /31/ /31/2008 Comments (incl. % achievement) G. Ratings of Project Performance in ISRs No. Date ISR Archived DO IP Actual Disbursements (USD millions) 1 11/09/2001 Satisfactory Satisfactory /10/2002 Satisfactory Satisfactory /11/2002 Satisfactory Satisfactory /18/2003 Satisfactory Satisfactory /05/2003 Satisfactory Satisfactory /26/2004 Satisfactory Satisfactory /03/2004 Satisfactory Satisfactory /24/2004 Satisfactory Unsatisfactory /03/2005 Satisfactory Unsatisfactory /19/2005 Moderately Unsatisfactory Unsatisfactory /30/2005 Moderately Moderately Unsatisfactory Unsatisfactory /20/2006 Moderately Unsatisfactory Moderately Satisfactory /20/2006 Moderately Satisfactory Moderately Satisfactory /12/2007 Moderately Satisfactory Moderately Satisfactory /18/2007 Moderately Satisfactory Moderately Satisfactory /22/2007 Moderately Satisfactory Moderately Satisfactory /30/2008 Moderately Satisfactory Moderately Satisfactory v

11 H. Restructuring (if any) Restructuring Date(s) Board Approved PDO Change ISR Ratings at Restructuring DO IP Amount Disbursed at Restructuring in USD millions 06/05/2006 N MU MU /29/2006 Y MU MS Reason for Restructuring & Key Changes Made 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 Moderately Unsatisfactory Against Formally Revised PDO/Targets Moderately Satisfactory Overall (weighted) rating Moderately Satisfactory I. Disbursement Profile vi

12 Project Context, Development Objectives and Design 1.1 Context at Appraisal 1. This project was one of two 1 simultaneously prepared as part of a horizontal Adaptable Programmatic Lending (APL) Program for Caribbean countries to combat and control the HIV/AIDS epidemic. Data from the 2001 period reported that 360,000 people were living with HIV/AIDS in the Caribbean, but suggested that due to underreporting, the figure could actually have been more than half a million people, placing the Caribbean region second only to Sub-Saharan Africa in HIV prevalence. Several Caribbean Governments expressed the political will to initiate and scale up national responses to HIV/AIDS. The Bank s response was influenced by two factors: A sense of urgency that came from data and analysis suggesting that a rapid response was needed to avoid a widespread epidemic in the Caribbean; and the potential benefits of a regional approach, which promised economies of scale in the areas of surveillance and program evaluation. By the end of the 1990s, the Bank had decided to commit US$100 million for a Regional Horizontal HIV/AIDS APL Program with a design similar to the Multicountry HIV/AIDS Program (MAP) developed for the Africa region. Under the program each country would obtain a separate loan and/or credit to finance its own national HIV/AIDS Prevention and Control Project. The Multi-Country Human Immunodeficiency Virus /Acquired Immunodeficiency Syndrome (HIV/AIDS) Prevention and Control for the Caribbean Region APL was approved by the Bank s Board in At the time of project appraisal for the Dominican Republic HIV/AID Project, conditions in the country alluded to a rapidly spreading disease and heightened the urgency for a national level intervention. In the Dominican Republic, HIV was first identified in 1983 and the first studies suggested that the epidemic was concentrated in high-risk groups, particularly commercial sex workers and men who have sex with men. However by the end of the 1990s analysis of available data estimated an adult prevalence rate of 2.3 percent. This rapid changes in the prevalence rate suggested that the country faced an imminent transition from a concentrated to a widespread HIV/AIDS epidemic. In 1998 a series of studies and data estimates suggested that the epidemic was spreading at an alarming rate. 3. By1998 a series of studies and data estimates suggested to policy-makers that the epidemic was spreading at an alarming rate. The Sexually Transmitted Infections and AIDS Control General Directorate (Dirección General de Control de Infecciones de Transmisión Sexual y SIDA - DIGECITSS) of the Ministry of Health (Secretaría de Estado de Salud Pública y Asistencia Social - SESPAS) estimated that roughly 12,000 people in the Dominican Republic were HIV positive. This figure was about nine times the total reported accumulated cases, and it was estimated that over 16,000 had already 1 The other one was the Barbados HIV/AIDS Project. 1

13 died as a consequence of AIDS. 2 According to 1998 data from PAHO/WHO, HIV prevalence among Haitian migrant workers and Dominicans of Haitian descent living in the bateyes 3 was estimated to be 5.7 percent in In 1998, nine hundred cases of AIDS deaths were reported to SESPAS, making it the leading cause of death from infectious disease. Official mortality data estimated that AIDS was the principal cause of death among women of reproductive age In 1999 the Dominican Republic CAS (19393-DO) made explicit reference to an HIV/AIDS project as one of several instruments through which to increase the poor s access to the benefits of social development and economic growth. On January 8, 2001, the Dominican Republic s Presidential HIV/AIDS Council, known as COPRESIDA (Consejo Presidencial del SIDA), was created to spearhead and coordinate the national HIV/AIDS strategy. COPRESIDA was also made responsible for coordinating the development and implementation of the National Strategic Plan (Plan Estratégico Nacional para la Prevención y el Control de las ITS, VIH y SIDA - PEN), ensuring greater emphasis on stakeholder participation, improving integration and cross-sector collaboration, and the wider use of effective interventions. 1.2 Original Project Development Objectives and Key Indicators 5. The original Project Development Objective (PDO) was: to assist the Borrower in reducing the spread of the HIV/AIDS epidemic through: (a) the increase in health prevention and control programs targeted in particular to high risk groups of population; (b) the expansion of awareness with respect to HIV/AIDS infection and prevention amongst the Borrower's population; and (c) the strengthening of the institutional capacity of the Participating Entities and the Participating Agencies to ensure the effectiveness and the sustainability of the Project. 6. The outcome indicators outlined in the Loan Agreement s supplemental Implementation Letter dated June 29, 2001, against which the GODR and the Bank agreed to measure the project performance, are as follows: 50 percent reduction in the rate of reported HIV cases; 30 percent to 50 percent increase in the number of men and women aged who report using a condom in their last sexual intercourse with a non-regular partner; 15 percent reduction in the rate of HIV infection attributed to vertical transmission; 2 F. Cáceres, I. Duarte, A. de Moya, E. Pérez Then, J. Hasbún, and M. Tapia. Análisis de la Situación y la Respuesta al HIV/AIDS en República Dominicana, Bateyes are settlements where large concentrations of people of Haitian descent and recent Haitian migrants live. Bateyes have a high concentration of households living in extreme poverty and with high rates of illiteracy. Originally they were located near the sugar cane fields and mills, but nowadays they are found throughout the country wherever employment opportunities exist. Most recently bateyes have formed near large construction projects and in touristic areas. 4 Dirección General de Estadísticas, SESPAS, Informe Anual

14 20 percent reduction in the number of reported sexually transmitted infections (urethritis) in men aged 15-49; 50 percent decrease in the number of HIV-infected women under the age of 20; Less than 1 percent increase in HIV prevalence among women of childbearing age attending prenatal care services by 2004; 85 percent of detected SS+ cases treated with DOTS; 30 percent increase in the number of AIDS patients cared for at home. 1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification 7. The project was amended four times. Only two amendments changed the PDOs, and only one amendment was a first order restructuring. Table 1 summarizes the amendments and changes introduced. Table 1 Dominican Republic: Loan 7065-DO HIV/AIDS Prevention and Control Project Summary of Amendments Amendment / Date First Amendment (12/04/2002) Main Changes Introduced - Retroactive financing for eligible expenditures already incurred by GODR for prevention and control of HIV/AIDS Second Amendment (08/18/2004) - Revised PDO - New additional PDO: Carrying out emergency projects - Schedule 1 amended to include new expenditure category, Emergency Projects, US$200,000 for goods, civil works and services for rehabilitation of health facilities in the Jimaní Region affected by natural disaster. Third Amendment (07/29/2006) - Revised PDO (1 st order restructuring) - Revised Project Indicators - Replacement of original components with three different Project components - 100% loan financing where the Bank and Project agreed on which activities each would finance entirely instead of sharing the financing per activity - Adoption of Bank s May 2004 procurement guidelines - Extension of the Loan closing date by 12 months to December 31, 2007 Fourth Amendment (12/19/2007) - Revised Indicators - Reallocation of funds among categories. Additional funds reallocated from civil society activities (Component 2) that could not be completed prior to completion date to Component 1 for completion baseline with studies on high risk groups) - Extension of the Loan closing date by 6 months to July 31,

15 8. The first amendment was conducted soon after project effectiveness in April The project was amended to retroactively finance some eligible expenditures already incurred by the GODR. Expenditures were made to begin organizing a coordinated national response against the HIV/AIDS epidemic while the project attained effectiveness. 9. The second amendment was a response to a national emergency. In 2004 severe rains hit the Dominican Republic with avalanches affecting the Jimaní region in the southeast near the border with Haiti. The core PDOs were left unchanged, but a new PDO was added to help the Borrower use loan funds to address this national emergency. The PDOs were: (i) the increase in health prevention and control programs targeted in particular to high risk groups of population; (ii) the expansion of awareness with respect to HIV/AIDS infection and prevention amongst the Borrower s population; and (iii) the strengthening of the institutional capacity of the Participating Entities and the Participating Agencies to ensure the effectiveness and the sustainability of the Project; and (b) carrying out Emergency Projects. A new expenditure category was introduced for supporting the government in rebuilding and providing needed equipment for health facilities. The Government requested the use of US$200,000 for rehabilitation of health facilities in the Jimaní region but ended up using only US$92,850. For this reasons this amendment had little impact on diverting funds from the fight against the HIV/AIDS epidemic. 10. The third amendment introduced the final change to the PDOs to align the project with new country needs stemming from changes in the financing and management of the national response against the epidemic. This amendment also changed all the project indicators to match the new PDOs changes (first order restructuring). In 2004, a new administration took power in the Dominican Republic, and the president appointed a new director in charge of COPRESIDA. The new management team in charge of the National Response was endowed with new resources (a GFATM grant) and greater institutional capacity to lead and coordinate international donors, and public and private country partners in the national response to the epidemic. Under its new leadership COPRESIDA also developed a new model of partnership between public sector and civil society built around grass-roots organizations known as Alianzas de Base Poblacional (ABP). 11. The PDOs set forth in the third amendment were to reduce the risk of HIV transmission and improve the quality of life of those infected and affected by the HIV epidemic by reorganizing the National Response, developing a National Strategic Plan and a corresponding monitoring and evaluation system, and implementing selected interventions. 12. Table 2 below provides a side-by-side comparison of the Project s evolving PDOs. 4

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17 Table 2 Dominican Republic: Loan 7065-DO HIV/AIDS Prevention and Control Project Comparison of Original and First and Second Revision of Project PDOs Original PDO To assist the Borrower in reducing the spread of the HIV/AIDS epidemic through: - (i) the increase in health prevention and control programs targeted in particular to high risk groups of population; - (ii) the expansion of awareness with respect to HIV/AIDS infection and prevention amongst the Borrower s population; - (iii) the strengthening of the institutional capacity of the Participating Entities and the Participating Agencies to ensure the effectiveness and the sustainability of the Project. First Revision of PDOs (2 nd Amendment 2004) To assist the Borrower in: 1. reducing the spread of the HIV/AIDS epidemic through: - (i) the increase in health prevention and control programs targeted in particular to high risk groups of population; - (ii) the expansion of awareness with respect to HIV/AIDS infection and prevention amongst the Borrower s population; - (iii) the strengthening of the institutional capacity of the Participating Entities and the Participating Agencies to ensure the effectiveness and the sustainability of the Project; 2. carrying out Emergency Projects. Second and Final Revision of PDOs (3 rd Amendment 2006) To reduce the risk of HIV transmission and improve the quality of life of those infected and affected by the HIV epidemic by reorganizing the National Response, developing a National Strategic Plan and a corresponding monitoring and evaluation system, implementing selected interventions. 13. The fourth and final amendment to the Loan Agreement (December 19, 2007) made a final revision to some of the indicators of the Project Results Framework which essentially had been overhauled as a result of the third amendment 5. The Key reason for these final adjustments was the Bank s commitment to align the project results 5 The final Project Results Framework was essentially the same as that developed and introduced in the third amendment. The fourth amendment changed some indicators of the results framework related to the second objective to align project indicators relevant to measure progress to the PDOs with indicators of the new National M&E Framework. Indicators of the new M&E Framework were selected through a broad and extensive process of discussion and consensus building with all key stakeholders, including the active participation of civil society organizations. 6

18 framework indicators with those from the new M&E system and to ensure timely data for the indicators selected. 14. Table 3 below is the Project s Final Monitoring and Evaluation Framework included in the Implementation Letter in the Loan Agreement s fourth and last amendment This amendment introduced an additional disbursement category ( Eligible Public Organizations ) to make disbursement categories fully consistent with changes introduced in the third amendment. Table 3 Final Project Results Framework Included in the Fourth and Final Amendment Development Objective Reorganizing the National Response, developing a National Strategic Plan and a corresponding monitoring and evaluation system Reducing the risk of transmission and improving the quality of life of those infected and affected Intervention Area National Strategic Plan Monitoring and Evaluation Absorption capacity of resources Care and Treatment Social Marketing of condoms Voluntary Counseling and Testing Results Indicators Targets National Strategic Plan fully developed and reflecting a consensus across alliances, including intervention lines for each target population Monitoring and evaluation system of the national response fully functional Increased absorption of resources available to finance the National Response Improved coverage of anti-retroviral treatment Improve availability of condoms Improve the population s knowledge about its serological status National Strategic Plan prepared, including intervention lines for each target population Design of the national monitoring and evaluation system fully developed, reflecting a consensus across all alliances Monitoring and evaluation system under implementation, information on some indicators is available Monitoring and evaluation system fully functioning, a first annual report about the status of the National Response is widely distributed Amount of investments in HIV/AIDS prevention and control by financing source and implementing agency % of persons that needed ARV treatment and received it in the last 12 months Number of male and female condoms distributed to users (sexually active adult population) Population aged 15 to 49 who voluntarily requested an HIV test, received the test and received their results within the last 12 months December 2006 October 2006 March 2007 December 2007 Targets to be defined dependent on baseline to be available in Dec : 33% (2,800) 2006: 70% (5,000) 2007: 85% (7,500) 2006: 1,589, : 3,589, : 82, : 170, : 250,000 7

19 Development Objective Intervention Area Prevention of Mother-to-Child Transmission Treatment of sexually transmitted infections other than HIV Information, Preventive, Educational, and Behavioral Change Interventions Results Indicators Targets Decrease the transmission from mother to child Improve the diagnosis and treatment of STIs Improving provision of Sexual Education Programs in Public Schools Improve high risk groups access to health promotion and preventive activities % of health facilities providing birth attendance that provide prophylactic treatment according to national norms % of patients with STIs who are appropriately diagnosed and treated according to national guidelines of all STI patients Annual percentage of public schools with teachers that have been trained in life skills and actually taught this subject Number of organizations that provide technical and financial support for preventive interventions among high risk groups for the population 2005: 60% 2006: 75% 2007: 80% 2005: 70% 2006: 80% 2007: 90% 2006: 23% 2007: 35% 2006: : Main Beneficiaries (original and revised, briefly describe the primary target group identified in the PAD and as captured in the PDO, as well as any other individuals and organizations expected to benefit from the project) 15. Original. Given the mixed nature of the epidemic in the Dominican Republic (generalized and concentrated), the Project Appraisal Document (PAD) established that the project would benefit the entire population as well as a certain number of population groups considered most at risk of HIV infection, including: (a) street children; (b) adolescents in and out of school; (c) population with low perception of risk of HIV infections; (d) population with signs and symptoms of STIs; (e) women who have prenatal checkups; (f) commercial sex workers; (g) men who have sexual relations with other men; (h) health services personnel; (i) armed forces personnel; (j) other groups at high-risk of HIV infection (inmates, residents of bateyes, inter Municipal transportation drivers); and (k) Persons Living with HIV/AIDS (PLWHA). 16. Revised. The third project amendment was aimed at aligning the project with the national response to reduce the risk of HIV transmission. Therefore the main beneficiaries of the project were the same as those of the national response: the general population with an emphasis on the poor and high risk groups. In support of COPRESIDA s efforts to actively engage civil society and particularly grass-roots organizations, the third amendment aligned resources to fit this new bottom-up approach to optimize direct participation of public sector and civil society organizations in the planning and implementation of both the new ten-year strategic plan and corresponding M&E system. COPRESIDA organized the national response through a system of public sector and civil society organizations partnerships (Alianzas de Base Poblacional - ABPs). The ABPs included the key target populations of the national 8

20 response and of the project: (a) Children and Adolescents National Alliance; (b) Women s Alliance; (c) Alliance of Young Adults (d) Alliance for PLWHA and their families; (e) Bateyes Alliance of grass-roots organizations working in settlements with high concentrations of populations of Haitian descent; (f) Migrant Populations; (g) People with disabilities; (h) Men Having Sex with Men (MSM) and Transsexuals; (i) Commercial Sex Workers Alliance; (j) Alliance of NGOs working with imprisoned individuals. 1.5 Original Components 17. Component 1. Promotion/Prevention to Reduce HIV Transmission (US$17.20 million, 58 percent of the loan) aimed at supporting the development of five costeffective priority interventions: (a) information, education, and communication (IEC) activities to reduce HIV/AIDS transmission, with emphasis on high-risk groups; (b) condom social marketing programs, with emphasis on high-risk groups; (c) improved management and treatment of STIs; (d) interventions to prevent mother-to child transmission of HIV; and (e) quality control of HIV testing in blood bank and laboratories. 18. Component 2. Diagnosis, Basic Care and Support of Individuals Affected by HIV/AIDS (US$4.8 million, 16 percent of the loan) aimed at supporting the implementation of the following diagnostic and basic care interventions: (a) organization of voluntary HIV testing with pre- and post-test counseling services; (b) support of home care for HIV/AIDS patients; (c) establishment of basic AIDS Health Care Units; (d) implementation of directly observed treatment (DOT) regimens for tuberculosis (TB) patients; and (e) support to children orphaned by AIDS. 19. Component 3. Strengthening HIV/AIDS and STI Surveillance; and Project Coordination, Monitoring, Evaluation and Research (US$7.75 million, 26 percent of the loan) aimed at supporting improvements in the HIV/AIDS and STI disease surveillance system; as well as providing support for project coordination, monitoring, evaluation and research. 1.6 Revised Components 20. The revised components are described below: 21. Component 1. Strengthen the Coordination and Management of the National Response (US$3.3 million, 25 percent of remaining loan resources) aimed at assisting the GODR in the development of a new ten-year National Strategic Plan (PEN), a new M&E system and studies for constructing a baseline for the M&E system. The PEN, the M&E system and the baseline studies were to be developed within the framework of a broad national consensus and strategic partnerships with a wide range of stakeholders centered on around the ABPs. 9

21 22. Component 2. Support Public Sector Organizations in the Prevention and Control of HIV/AIDS (US$4.6 million, 35 percent of remaining loan resources) aimed at reducing the risk of HIV transmission and improving the quality of life of PLWHA through the provision of technical assistance to line ministries and other public organizations in the planning and implementation of both the National Strategy and its first two-year operational plan. This component also included the rehabilitation and refurbishment of the HIV/AIDS Health Care Units (Unidades de Atención Integral) as well as the purchase and distribution of pharmaceuticals, reagents, and other medical and non-medical supplies for the prevention and control of HIV and AIDS. 23. Component 3. Support Civil Society in the Prevention and Control of HIV/AIDS (US$5.2 million, 40 percent of remaining loan resources) aimed at supporting the participation of civil society in general and grass-roots organizations in particular in the planning and implementation of the National Strategy and the first two-year operational plan. Explanation of Changes in Project s Components 24. The Project components were revised under the third amendment to the Loan Agreement (07/29/2006). The design of new components focused on improving institutional capacity to manage efficiently financial resources from various partners, to lead and coordinate the development and implementation of a new national strategy and a monitoring and evaluation system with direct participation of civil society. Additionally, the amendment facilitated the use of loan resources to bridge existing financing gaps by expanding the eligibility of expenditures to match the scope of activities of the national response, and by simplifying administrative procedures where appropriate. In contrast to the original Project design, activities of the revised components 2 and 3 would contain, for example, all aspects of treatment and care including treatment with anti-retroviral drugs, key inputs needed for monitoring HIV+ patients and determination of timing and effectiveness for the use of ARVs, and other activities to go beyond awareness and to focus on behavioral change in particular in high risk groups. 25. Additionally, project restructuring supported operational plans to be carried out within the new model of civil society engagement involving grassroots partnerships, Alianzas de Base Poblacional (ABP). COPRESIDA had adopted a bottom-up approach to ensure ample debate and participation of civil society and national engagement in the fight against the HIV/AIDS epidemic. 1.7 Other Significant Changes (in design, scope and scale, implementation arrangements and schedule, and funding allocations) 26. Disbursement Categories. The third amendment to the Loan Agreement in July 2006 introduced a new disbursement category, Grants to Eligible Civil Society Organizations (CSOs), thus fostering greater involvement of community-based 10

22 organizations in the project implementation. This was also done to align the project with the new approach of COPRESIDA, which assigns to civil society an important role in planning and implementation. The new financing mechanism adapted to the Dominican Republic context the new fiduciary framework of the World Bank for improving the performance of HIV/AIDS projects Extension of the Project Closing Date. The project was extended twice for a total of 18 months. The first extension, for 12 months, came in July 2006 as part of the third amendment. Its objective was to provide the Government with the time to achieve the revised PDO, in particular the organizational and institutional strengthening of the National Response. The second extension, for 6 months, was granted in December 2007 as part of the fourth amendment. Its objective was to consolidate and expand Project achievements, mainly the completion of a baseline. This also entailed, carrying out a study on high-risk groups with an innovative methodology (Respondent Driven Sampling RDS) that involved the active participation of NGOs and grass-root groups while yielding data which can be analyzed statistically for more accurate understanding of the epidemic among MSM, commercial sex workers and drug users. 28. Simplified Implementation Procedures. The third amendment changed the Project s cost-sharing arrangements and adopted the Bank s revised procurement guidelines of May The third amendment introduced 100 percent financing, thus allowing the Bank and Government each to fully finance an agreed set of activities. The new arrangement simplified payment procedures and facilitated the decentralization of some project activities to civil society and public sector organizations using the new bottomup model (ABPs). This arrangement was a departure from the previous set-up where an activity was financed in part by Bank funds and in part by Government funds, requiring complicated cost-sharing and payment mechanisms and sometimes slowing down project implementation. 29. The Bank s new procurement guidelines (May 2004) provided more flexibility and increased the efficiency of the use of loan funds. For instance, the new procedure eliminated aggregate thresholds for procurement procedures, which facilitated the financial management of an increasingly decentralized implementation design. The new guidelines also called for the mandatory use of a procurement plan to support a more flexible planning and improved coordination across donors (mainly with activities funded by the GFATM). 30. Reallocation of Funds. The fourth amendment to the Loan Agreement in December 2007 reallocated resources from Component 3 to Component 1 to facilitate the efficient use of donor funds. Donor funds were increasingly available to scale up activities implemented by civil society. With the reallocation of funds, data for the baseline completion was collected and analyzed providing key information previously not available for fine-tuning the national response and monitor progress toward prevention and control of the epidemic among key high risk groups. 6 World Bank HIV/AIDS Program: A Guidance Note on Disbursement Procedures 11

23 Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry Project Preparation 31. Perceived Urgency, Accelerated Project Preparation and Sufficiency of Background Analysis. At the time of project preparation no large-scale financial commitment had been done for the Caribbean to fight the HIV/AIDS epidemic. The estimated insufficiency of funds to prevent and control what seemed to be an HIV/AIDS epidemic that could easily spread beyond high risk groups enhanced the sense of urgency in public opinion and among decision-makers. As a result a fast-track plan for projection preparation was devised. The project was based on the needs and goals proposed in The Caribbean Regional Strategic Plan of Action , which was developed by an HIV/AIDS Caribbean Task Force (CARICOM) and endorsed by the Caribbean governments. The World Bank study, HIV/AIDS in the Caribbean: Issues and Options, served as background analysis for the strategy developed by the project and provided available lessons from international experiences that to be taken into account for the project development. These two documents provided broad HIV/AIDS analytical information and an overview of main sector issues in the region. However the country information collected and analyzed was insufficient for adapting the general model of national response to the specific institutional realities of the Dominican Republic. 32. Project Design. PDO targets were too ambitious, and the Project s design underestimated the complexity of coordinating concerted efforts in the public sector. Furthermore, institutional arrangements were not optimal to foster broad stakeholder participation, in particular the engagement of civil society. The project design required detailed and intensive coordination efforts of activities to take place across multiple line ministries. During the first years of implementation COPRESIDA lacked the necessary leadership to steer large well-established public sector organizations such as the Ministry of Health and Education to implement a project that would be the engine for the Dominican Republic s HIV/AIDS prevention and control. The project design placed the greatest responsibility for civil society engagement on units of line ministries with no experience and resources to engage an increasingly large number of NGOs and other civil society organizations willing to be directly involved in the implementation of the national response. 33. Risk Analysis. The project preparation focused on a very few and narrow set of risks. The rating of weak project management as a negligible risk does not seem to have been carefully considered. In fact management deficiencies had a substantial impact during the project s first years. Additionally, during preparation the analysis did not seem to consider all the risks stemming from giving the responsibility for civil society engagement to line ministries with overstretched human resources and low budgets. The measures identified to minimize the risks were not sufficiently developed to match existing risks. Mitigation measures were either too general (i.e. continuous monitoring) or not directly related to the most important risks that could affect project 12

24 implementation (i.e. financial management support from the PCU of another Bank s project in the health sector). 2.2 Implementation 34. Unforeseen Economic Crisis and its Impact During First Years of Project Implementation. The Dominican Republic suffered a major economic crisis and social unrest in 2003, which significantly limited the GODR s capacity to organize the Project s envisioned broad multisectorial response. Project implementation was negatively affected by this unforeseen large economic crisis that had broad impact on the stability of both private and public sectors reducing fiscal resources, counterpart funding, effectiveness of strategic planning, and resources for capacity building. 35. Government s Renewed Commitment. In 2004, with a new administration in power and the economic crisis subsiding, the GODR focused again on reorganization of the national response. COPRESIDA s director and top management were replaced, and the new leadership was charged with responsibility for reinvigorating the national response. The new director emphasized COPRESIDA s need to exercise its stewardship over the national response to the epidemic and empower civil society s stakeholders. At first the project s activities were slowed because COPRESIDA first focused on securing disbursements from a grant from the GFATM. However, in 2005 COPRESIDA and the Bank agreed on a six-month rapid response operational plan and initiated discussions on restructuring the existing project to better match the new country needs. Project implementation increased considerably in the first semester of Key Amendments and Accelerated Project Implementation. The implementation of this project, activities, and schedule of execution were significantly determined by the third amendment, which was a first order restructuring of the project. With new grant resources from the GFATM 7 and existing funds from the Bank s loan, COPRESIDA focused on strengthening its stewardship capacity to ensure complementarities of activities carried out by multiple public and private organizations, and to better harness diverse sources of funding. COPRESIDA was empowered to overhaul the public sector response to HIV/AIDS and coordinate the development of a new national strategy to ensure broad consensus and active participation of civil society. As a result the GODR had access to new financial resources and was endowed with larger institutional capacity to respond to the epidemic at a national scale. 37. Bank s response to Improve Project Design to Match New Country Needs. The third amendment was critical to expedite a timely response to better support the new national response model that COPRESIDA was spearheading with funds both from the GFATM and the World Bank. Key elements introduced in the third amendment for improved project implementation included: a single operational plan for the national response, of which activities financed by the Bank would only be a part; financing an expanded 7 A grand total of 48.5 million USD for Phases 1 and 2, starting with 14 million in 2006 and the rest in

25 scope of project eligible expenditures, including antiretroviral drugs (ARV); aligning project activities with the development and implementation of the new 10-year National Strategic Plan; more effective targeting of resources to the most vulnerable population groups through the ABPs; and allocating resources for direct participation of Civil Society Organizations (CSOs). The enhanced project design introduced by the restructuring allowed for faster disbursement and speeded-up project implementation. Where US$ 13.4 million (43 percent of the total loan) had been disbursed in the first three years of the project, during the two years following the third amendment, US$ 17.1 million (57 percent of the total loan) was disbursed. 38. Furthermore, because the national response lacked a comprehensive approach to Monitoring and Evaluation (M&E), the Bank through the Bank s Global AIDS Monitoring and Evaluation Team (GAMET) also provided technical assistance to COPRESIDA to develop an M&E system and baseline of a national M&E system. COPRESIDA s national coordination ensured that the M&E framework would be developed with the participation of a broad group of stakeholders, including civil society with an emphasis on grass-roots groups. The Project indicators were also revised to align them to the M&E framework initiatives. 2.3 Monitoring and Evaluation Design, Implementation and Utilization 39. The original M&E system design involved an overly complex coordination and relied on multiple surveys and analyzing public sector data. The M&E design did not identify clear roles and responsibilities for the flow and consolidation of information. Also the capacity required by the PCU to coordinate and conduct complex studies needed for the M&E system was underestimated. Data collection and analysis responsibilities were dispersed in multiple existing systems without clearly identifying how the reporting functions would be coordinated and consolidated. A baseline on epidemiological aspects, knowledge, attitudes and sexual behavior, coverage and quality of services, and budgetary allocations for HIV/AIDS and related programs was to be collected through a survey conducted at the beginning of the project. Data for outcome and impact indicators was to be collected through a series of studies conducted by line ministries. 40. As part of the third amendment in 2006 an agreement was reached on a plan for developing an M&E system that reflected the changes introduced to the Project and the National Response. In order to support the development and implementation of an M&E system and construct a baseline, the Bank provided technical assistance through the GAMET. M&E Implementation 41. Before the third amendment, COPRESIDA periodically collected data on activities implemented by the line ministries, civil society organizations and other implementing agencies, and then compiled them into semi-annual or quarterly progress reports focusing on the status of implementation by component and by project expenditures. Although fragmented, important data from the national response was collected by the 14

26 MOH providing some information for the project s M&E system. Data on epidemiologic surveillance and coverage of health services for PLWHA was systematically collected by DIGECITSS. In addition an innovative web-based database on PLWHA was developed by DIGECITSS. 42. Implementation of the new Project s M&E system started after the third amendment. To avoid duplication of efforts and exploit synergies with activities supported by other development partners the new Project s M&E system included indicators selected from those developed within the framework of a new national M&E system. The first step was to conduct broad consultations and build consensus on a specific conceptual framework and to select a preliminary set of indicators for the new national M&E system. The selection of M&E indicators was conducted jointly with the ABPs and other national and international partners, including the GFATM and the UNAIDS office in the Dominican Republic. 43. This participative approach was carried out in three stages: First a conceptual framework for the M&E system was developed; later a baseline was established; and finally with the new data both the National Strategy and M&E design and implementation were be refined. The first two stages of the construction of the M&E system supported by the project and produced the following main results: (i) A comprehensive survey of all the existing M&E activities dispersed around many institutions in the public sector and the bulk of those conducted by NGOs and civil society; (ii) building a consensus on a single M&E system to consolidate data from multiple sources including existing sub-systems in the public sector and NGOs and other civil society activities; and (iii) agreed-upon steps for gradual implementation of the M&E starting with the construction of a baseline. 44. Studies to collect data for a comprehensive baseline for the new M&E system were coordinated by COPRESIDA with the technical assistance of GAMET and the United States Centers for Disease Control (CDC) and with funding from other development partners including USAID. The studies included an innovative and participative approach to collecting and analyzing data from high risk groups. In cooperation with USAID and MACRO International, the country s fifth Demographic and Health Survey (DHS) was developed in The survey included a large and comprehensive module specifically devoted to HIV/AIDS with a sample sufficient to obtain estimates at the provincial level. The project indicators were also aligned with indicators from UNGASS 8 and the Global Fund. To complement the baseline the first phase of a study with an innovative participative approach to collect hard data to infer statistically significant analysis on high risk populations (MSM, CSWs and drug users) was conducted focusing on behavioral and analysis of prevalence of HIV/AIDS, Syphilis, Hepatitis B and C. 8 Such indicators were the level of knowledge about HIV among youth, the condom use rate, the percentage of orphans receiving school support, the percentage of youth living with HIV) 15

27 M&E Utilization 45. Before project restructuring in 2006 (third amendment), the Project s M&E was fragmented and therefore the use of information limited. However, some of Line Ministries involved in the project (e.g. Education and Youth) collected data that did help inform decision making on specific interventions. For example, available data on sexual debut was used to determine the grade in which to start HIV/AIDS education. Utilization of epidemiological and health care data collected by DIGECITSS guided the action of DIGECITSS in a wide range of medical areas from policies on the adequate monitoring of PLWHA to expansion of peer counseling. The collected information was used to monitor progress of coverage of services and treatment to PLWHA. 46. A key outcome of the project achieved after the third amendment has been the support for a participative development of an M&E conceptual framework, selection of indicators, and assistance in construction of a baseline. Since information became available for the baseline from the HIV/AIDS module of the 2007 DHS, it has been use by COPRESIDA and various stakeholders involved in the implementation of operational plans of the new national response. Information from the studies on high risk groups would provide also critical information for new interventions and an update of the 10-year national strategy. 2.4 Safeguard and Fiduciary Compliance (focusing on issues and their resolution, as applicable) 47. Environment. The environment category of the Project at the time of appraisal was B. Considering that a new Environmental Law was passed in 2001 and that another Bank health sector project 9 already included support for activities to improve biomedical waste management (BMWM), the environmental assessment recommendations focused on selected complementary activities that the Project would support. The Project would revise an operational manual for medical waste and disposal based on an environmental assessment of waste generated by HIV/AIDS programs and activities. As a result the Manual for Biomedical Waste Management and Bio-security for HIV Infection Control was developed. 48. During the discussions and negotiations for the third amendment it was agreed the project would focus on specific HIV/AIDS BMWM issues to avoid duplication of efforts with the new health project (The Dominican Republic Health Sector Reform APL1). Also guidelines for contracts on civil works were incorporated into the Operational Manual. At the time of the last supervision mission, although the guidelines had not been consistently incorporated in all the civil work contracts, the Bank environmental specialist reviewed documentation that confirmed that the Project had executed the agreed activities on BMWM. Documentation reviewed showed that numerous workshops took place to ensure public and private health care workers were 9 The Dominican Republic Provincial Health Services Project. 16

28 properly trained, including a module on hazardous biological and infectious waste management which was also incorporated into the required curriculum of health professionals by the Secretary of Higher Education in Science, Technology and Universities. 49. Financial Management. Overall the financial management was satisfactory. At the beginning of project implementation there were delays in submitting FMRs, but this was corrected. After 2005, when the new administration changed COPRESIDA s management team, the financial management team of the PCU was considerably strengthened, and after the third amendment in 2006 COPRESIDA s financial management was highly satisfactory. 50. Disbursement. Project disbursement started at low speed (reflecting the low levels of execution of Project s activities) but picked up after 2005 reaching its peak in the last 18 months of project execution in 2007 and first semester of During the economic crisis of 2003 and until 2004, irregular allocations of agreed counterpart funding limited project implementation and disbursement. However in the following years disbursements increased rapidly and by March 2008, three months before the completion of the project, all loan funds had been disbursed. Table 4. Amounts disbursed by year (in US$) Year Amount disbu rsed 1,482,885 1,643,960 3,458,638 3,363,665 5,638,450 8,272,883 1,124,229 Source: SAP, Project Portal 51. Procurement. During the first years of Project implementation, while institutional capacity was being built and the execution of activities was slow, COPRESIDA demonstrated sufficient capacity to handle all procurement responsibilities adequately according to Bank s guidelines. However when Project implementation accelerated rapidly during 2006 and 2007, COPRESIDA s capacity to handle procurement activities was stretched thin. Three main factors caused a dramatic increase in the burden of planning, coordination and execution activities assigned to the procurement team: (i) rapid incorporation in operational plans of a large number civil society organizations at a scale never before experienced; (ii) the implementation of a larger number of activities funded with the new resources from GFATM; and, finally, (iii) the third 10 During the only first two months of 2007, 112 procurement processes were conducted against a total of 583 for 2006 (Procurement Post Review, 2007) 11 This amount (the remainder of the project) was disbursed in the first quarter of The total amount includes a decrease of US$15,288 of funds cancelled by the Bank due to misprocurement. 17

29 amendment of 2006, which facilitated an expanded scope of activities financed by the Bank including strong support for building ownership and consensus for the new National Strategy and M&E Framework. To cope with increasing number of activities specialization on activities (i.e. shopping and national and international bidding) was introduced along with hiring new additional junior staff. However, quality control of procurement activities declined reaching a critical level when the most senior procurement staff member was replaced by personnel without sufficient qualifications. 52. The post review conducted in 2007 showed various problems in planning and execution of procurement activities that in two cases seriously compromised adherence to the Bank s procurement guidelines. As a result, in the Bank declared misprocurement in two activities carried out during FY06 for a total amount of USD$15,300. Immediately after the results of the procurement review the Bank team agreed with COPRESIDA on a plan to strengthen the procurement unit s capacity. The plan included hiring of a Chief of Procurement Unit with demonstrated experience in procurement processes with multilateral agencies to oversee the entire procurement processes; hiring an international consultant with solid experience in procurement of activities in projects financed by the Bank to provide training and advice; and execution of all procurement activities with prior review until the Bank approved an updated procurement plan. After the no objection of the last procurement plan was granted COPRESIDA could continue with procurement activities that did not need prior review without requesting no objection to the Bank as the procurement team deemed that the procurement unit strengthening plan key objectives had been achieved. 2.5 Post-completion Operation/Next Phase 53. In the last year of Project implementation COPRESIDA identified different sources of funding to ensure continuity of the national response once the project closed. First a second operation was considered but finally the Government decided to instead request additional funds for an emergency loan to support the GODR response to floods that took place at the end of Therefore, COPRESIDA has led discussions with the MOH to secure financing for those activities that had been financed by the Bank s loan that could not be financed with GFATM funds. The MOH identified budget funding to finance several activities that had been financed by the Bank including acquisition of inputs for laboratory exams and staff from ambulatory HIV/AIDS health care units (Unidades de Atención Integral). Furthermore, within the framework of implementation of the mandatory universal health insurance, ARV for PLWHA would eventually be covered paid by the corresponding insurance schemes. Finally, in order to strengthen national institutional capacity to respond to the epidemic discussions are being held so that procurement and distribution of ARV would be ensured by procurement eventually conducted by the national agency for essential medicines through international competitive bidding. 54. Finally one of the most important efforts to ensure sustainability of the national response was the successful request for additional grant funding from the GFATM. The country s request for additional funding for the existing grant agreement (second round) 18

30 has been approved. The GFATM would provide of US$ 94 million over the next six years (July 2009 to June 2015). Additionally the country applied for funding of other activities within the framework of the 7th round of the GFATM and, although it was not accepted for this round it has been invited to present again its proposal for the eighth round. Assessment of Outcomes 55. The overall achievements of the project s objectives are tightly linked to the main achievements of the national response that the project supported. Data from the latest Demographic and Health Surveys conducted in 2002 and 2007 shows that the epidemic has at least stabilized and that a smooth trend to decline may have already started. Although important challenges remain regarding high risk groups and behavior change, the prevention and control of HIV/AIDS seems to be yielding positive results in key areas such as expansion of ARV and decrease in mortality. 3.1 Relevance of Objectives, Design, and Implementation 56. The PDOs, design and Implementation are rated highly relevant 57. The project s PDOs are consistent with the Country Assistance Strategy (CPS) and with the Bank Global HIV/AIDS Program of Action. The PDOs are also consistent with the Dominican Republic s Poverty Reduction Strategy for the period, launched in The HIV/AIDS epidemic remains one of the important challenges for the public health and the fight against poverty and inequality in the Dominican Republic. Current prevalence rates among the general population are still among the highest compared with other countries of Latin America (according to the 2007 DHS 0.8 percent). Furthermore the epidemic affects disproportionately the poor, exacerbating other socioeconomic inequalities. Data from shows that the prevalence among women without any formal education was 3.7, more than 12 times higher than among those with secondary education; also the prevalence among individuals from the poorest quintile is 1.8 percent, compared with 0.4 percent for the richest quintile. 59. The overall goal of the adaptive restructuring was to assist the GODR to consolidate what was achieved and complete what was missing from the three ones approach 13 with ample participation of civil society and grass-roots organizations. COPRESIDA s strategy to achieve the three ones in the Dominican Republic focused on: the design of a 12 DHS, In 2004 donors, developing countries and international organizations agreed to three core principles to better coordinate the scale up of the national AIDS responses. One agreed HIV/AIDS action framework with ample consensus to constitutes the basis for enhancing the coordinated work of all partners; one HIV/AIDS coordinating authority with broad stakeholder mandate; one agreed country-level monitoring and evaluation system. 19

31 new ten-year national strategy (one national strategy), consolidation of the institutional capacity and stewardship of COPRESIDA (one national coordinating entity), and the development and progressive implementation of an M&E system including construction of a baseline for the national response (one monitoring and evaluation system). At the time of project completion, COPRESIDA had managed to develop M&E frameworks with broad civil society participation and a two-year operational plan. Finally COPRESIDA coordinated technical assistance and funding to construct a baseline on the epidemic at the national level and among key high risk groups. 3.2 Achievement of Project Development Objectives Original PDO: To assist the Borrower in reducing the spread of the HIV/AIDS epidemic through (a) the increase in health prevention and control programs targeted in particular to high-risk groups of population; (b) the expansion of awareness with respect to HIV/AIDS infection and prevention amongst the Borrower s population; and (c) the strengthening of the institutional capacity of the Participating Entities and the Participating Agencies to ensure the effectiveness and the sustainability of the Project. 60. The achievement of the original Project Development Objective is deemed moderately unsatisfactory. 61. The achievement of the original PDOs was limited by reducing implementation of activities due to lack of institutional capacity and coordination among key implementing agencies of the public sector. COPRESIDA lacked sufficient institutional capacity to take the lead in building consensus and fostering cooperation among key stakeholders. The lack of management planning led to the implementation of disjointed and patchwork activities that did not strategically advance the PDOs. Finally, until the project was restructured through the third amendment, the design emphasized the role of the public sector in implementation, and that amplified some of the negative effects of the economic crisis and decreased counterpart funding and participation of civil society in the national response. First Revision to PDO: To assist the Borrower in reducing the spread of the HIV/AIDS epidemic through (a) the increase in health prevention and control programs targeted in particular to high-risk groups of population; (b) the expansion of awareness with respect to HIV/AIDS infection and prevention amongst the Borrower s population; (c) the strengthening of the institutional capacity of the Participating Entities and the Participating Agencies to ensure the effectiveness and the sustainability of the Project; and, (e) carrying out Emergency Projects. 62. The achievement of the first revised Project Development Objective is deemed moderately unsatisfactory. 63. The revised PDO was exactly the same as the original except that it included an additional objective: carrying out of subprojects. This was operationalized as a new expenditure category, therefore no changes to the component were made. Needed funds 20

32 were rapidly disbursed for the rehabilitation of health care units in the disaster area of Jimaní. 64. Although important complex public sector coordination and economic crisis still hindered the efficiency of project implementation, the National Response began to successfully engage public sector and civil society. Execution of activities started to pick up as institutional capacity and experience was accumulated. Key activities such as those carried out by the Ministry of Education were well underway after the second amendment. Also, in coordination with the Bank team, and 18 months before the third amendment, COPRESIDA had already launched a short-term action plan to boost project performance. New management started successfully to integrate the two major sources of funding of the National Response and to develop mechanisms for direct civil society participation. Final PDO (after the third amendment of 2006): To reduce the risk of HIV transmission and improve the quality of life of those infected and affected by the HIV epidemic by: (i) reorganizing the National Response; (ii) developing a National Strategic Plan and a corresponding Monitoring and Evaluation System; and (iii) implementing selected interventions. 65. The achievement of the second (final) revised Project Development Objective is deemed moderately satisfactory. 66. After the third amendment, as demonstrated by the Project Results Framework, the Project objectives and targets were harmonized with those of the country s strategy. Inputs financed by the project contributed to the achievement of the project s objectives by filling financial and technical assistance gaps for the GODR to achieve the national response s objectives. 67. The project design created three main broad components to complement activities that were being carried out with other sources of financing (mainly the GFATM). The operational plans of the project became part of a larger operational plan that included the activities financed by the government and by the GFATM. By expanding the scope of the eligibility of activities to comprehend the bulk of the range of activities of the National Response and by introducing 100 percent financing of eligible project activities, the Bank provided greater flexibility for the use of the loan resources. 68. Thus, the third amendment introduced a better design and more flexibility for activities planning and disbursements. The government could now establish nationwide priorities and identified the most appropriate source of funding according to the nature of the activity and the category of expenditure required. Planning and implementation of activities were now more easily done, enhancing complementarities of inputs financed with different sources of funding to better achieve an enhanced scope of outputs, avoiding duplicity of efforts and aiming for more ambitious targets. 21

33 69. Box 1 summarizes the main outputs of the project after the Third Amendment An expanded table of outcomes by component is included in Annex 2 22

34 Box 1. Highlights of main outputs of the project Strengthening of the National Response developed with broad participation, ownership and the endorsement of civil society and public and private sectors. Results: New 10-year National Strategic Plan (Plan Estratégico Nacional - PEN) The first 2-year operational plan Development of 10 Alianzas de Base Poblacional (ABP), a new approach to engage over 300 civil society organizations organized around strategic civil society and public sector partnerships in the national discussions for development of the PEN, a 2-year operational plan and the M&E framework. Development of a national M&E conceptual framework to consolidate and integrate existing data collection and analysis activities into a single unified system to monitor progress towards goals and objectives of the national response with the engagement of all key stakeholders and broad participation of civil society. Construction of the first baseline for National Response through: o o Implementation of Expanded HIV/AIDS module in the 2007 Demographic and Health Survey (DHS) with oversampling for populations in Bateyes; and Three studies with innovative methodology to produce statistically significant data on prevalence and behaviors among high risk groups nationwide: MSM, commercial sex workers and drug Users. Technical group established for monitoring implementation of bi-national agreements between the Government and Haiti to coordinate actions to better fight the HIV/AIDS epidemic on the island of Hispaniola. Plan approved by Foreign Affairs Ministry and other ministries from the Government of the Dominican Republic. The project invested roughly US$2 million in ARVs to ensure continuity in access and expansion of coverage for up to roughly 20,000 individuals. Refurbishing facilities to establish more than 25 UAIs (HIV/AIDS health units) of specialized ambulatory care across the country with an investment of US$ 2 million. Laboratory reagents for tests needed for health care of PLWHA to support the government s introduction of a large scale program for monitoring CD4 and viral loads from 2005 to 2008; more than 20,000 PLWH benefited from this program. 23

35 70. This assessment acknowledges that the national response had other important sources of financing (mainly the GFATM grant and fiscal resources). The Global Fund alone has already disbursed over US$ 48.5 million in grant funding (almost as twice as much as the WB loan) to the HIV/AIDS national response since For instance, during the last three years of Project implementation, the GFATM increased the percentage of its grant funding for ARV from 16 percent to 54 percent, while at the same time the Bank loan financed the purchase of inputs for monitoring the health of PLWHA (CD4-counting). While the Bank s loan financed the rehabilitation of health units to provide care for PLWHA and HIV testing and counseling, the Global Fund focused on the rehabilitation of medical equipments for the same health units. The inputs financed by different sources contributed collectively to the achievement of the PDOs, which were completely aligned with the objectives of the national response. 72. The project successfully assisted the GODR to develop a National Strategic Plan (Plan Estratégico Nacional ) with ample participation of civil society and broad consensus. Published in May of 2007, the National Strategic Plan was broadly disseminated and led to the development of a two-year operational plan with interventions reflecting a consensus among all main stakeholders. The new National Strategy received the endorsement of key public sector organizations, ABPs and other development partners. The relevance of the National Strategic Plan and M&E Conceptual Framework and its broad stakeholder endorsement allowed the Dominican Republic to meet all eligibility requirements for requesting a six-year extension of the GFATM s grant. 73. The Plan de Monitoreo y Evaluación , (M&E framework) was developed with technical assistance provided by the Bank s GAMET, and UNAIDS. As the result of a highly participatory consultation process, the current M&E System not only includes indicators deemed technically sound (such as those of UNGASS) but also some specific to the bottom-up approach of the national response of the Dominican Republic. A first annual report on the progress towards the targets identified by the National Response was widely distributed in January 2008 and the available data on the related indicators were systematically transmitted. The M&E system has concluded the data collection and analysis both for the general population and high risk groups. 74. The achievement of the PDO can also be analyzed through available data on the results of the National Response. Two Demographic and Health Surveys (DHS) were conducted between 2002 and The survey of 2007 included an expanded module on HIV/AIDS with oversampling of a key high risk group (people living in bateyes). The 2007 DHS has a wealth of information with key data (including prevalence) that can be compared with the results of the 2002 Survey to better understand the main trends of the epidemic. 24

36 Figure 5. Prevalence of HIV among adult individuals (ages 15 to 49 years old) by gender in the Dominican Republic in 2002 and Prevalence as a % of population 15 to 49 y.o Source: DHS, Women Men Total Population Figure 6. Prevalence of HIV among adults ages 15 to 49 years old living in bateyes in the Dominican Republic 2002 and Prevalence as a % of the population ages y.o Source: UNGASS Dominican Republic Report,

37 Figure 7. Percentage of individuals in need of ARV treatment receiving needed therapy in the Dominican Republic % 40% 42% % of people in need of ARV actually receiving ARV therapy 35% 30% 25% 20% 15% 10% 10% 19% 30% 5% 0% 2% Source: UNGASS Dominican Republic Report, The first conclusion is that the expansion of the epidemic has, at a minimum, stabilized. Prevalence rates measured by DHS in 2002 and 2007 show declines both among the general population and individuals in bateyes. (See Figures 5 and 6.) 76. Regarding gender, the prevalence rate dropped from 0.9 percent to 0.8 percent among women and from 1.1 to 0.8 percent among men. Prevalence has decreased in both urban areas (from 0.9 percent to 0.7 percent) and rural (from 1.2 percent to 1 percent.) 77. The number of PLWH in need of and receiving ARV grew from 519 in 2004, to 5,001 in 2006 to 9,651 by July By the end of 2008 there were more than 11,100 individuals in need of ARV receiving treatment, representing 42 percent of the most recent DIGECITSS estimate of the total number of individuals in need of ARV therapy. 78. Annual HIV mortality decreased from 5,142 in to 3,984 in a drop of 1,158 deaths. At the same time, survival rate (i.e. the percentage of PLWH alive after a year of ARV treatment) reached 96 percent in Using the most recent estimate of DIGECITTS of a total of 25,983 individuals in need of ARV therapy. 16 UNGASS Dominican Republic Report, (SIAI, 2007) 26

38 Figure 8. Percentage of individuals who have been tested for HIV and learned the results by gender in the Dominican Republic 2002 and 2007 % of individuals that have been tested for HIV and received results 80% 70% 60% 50% 40% 30% 20% 10% 0% Source: DHS, % Women 69% The percentage of adults ages 15 to 49 who know where to take an HIV test and of men and women who have been tested and learned the results has increased (see figures 7 and 8). 80. There is an increased awareness of preventive actions. DHS data shows that the level of awareness of condom use as a prevention method is especially high among females aged and (85 percent and 84 percent respectively) and males aged (89.7 percent). Eighty-eight percent of women and 90 percent of men are aware that a monogamous relationship with a non-infected partner was also an effective prevention strategy. Ninety-nine percent of men and women aged are aware of HIV/AIDS, while 83 percent of women and 89 percent of men in that cohort are able to identify condom use as an HIV prevention method. There are no studies to establish direct causality, but it is likely that massive IEC campaigns organized in schools across the country contributed to the higher level of awareness recorded among young people. The Ministry of Education trained 11,000 teachers on the HIV/AIDS epidemic and its prevention and control. A diploma degree in HIV counseling (consisting of 8 credits) was established at the Universidad Autónoma in Santo Domingo. 41% Men 46% 81. The overall achievement of the project is rated moderately satisfactory. 82. In essence the project experienced a turn-around after a renewed commitment by the Government and COPRESIDA. New human and financial resources and greater overall institutional capacity in project management, along with a proactive supervision team, 27

39 introduced changes needed to adapt the loan to new conditions in the fight against HIV/AIDS in the Dominican Republic. 83. The table below provides the calculations as per the ICR Guidelines weighting system for projects with formally revised project objectives. Rating Against Original PDOs Table 6. PDOs weighted rating Against Revised PDOs (2 nd amendment) Against Revised PDOs (3 rd amendment) Overall 1. Description Moderately Unsatisfactory Moderately Unsatisfactory Moderately Satisfactory 2. Value Weight 24.4% 23.5% 52.1% (US$6.11 million (US$5.88 million (US$13.02 million / / US$25 million) / US$25 million) US$25 million) 4. Weighted Final Rating (rounded) 3.3 Efficiency Comments Significant Improvement Moderately Satisfactory 84. The efficiency is rated as satisfactory. The project was design to strengthen national ownership and the three ones approach which is acknowledged as a key principle of an efficient support for the national response. Additionally, the project remained funded a series of activities (e.g. social marketing, VCT, training programs on safe-injecting behavior, ARV provision for pregnant women) recognized as the most effective in preventing HIV infection and AIDS. 18 Table 7. Cost-effectiveness ratios for different groups of interventions US Dollars Cost effectiveness Sex worker interventions STI Management Voluntary counseling and testing Cost per HIV infection averted Cost per $ $9.45 $ DALY saved Source: Ainsworth and Teokul, 2000 ARV in pregnancy against vertical transmission IEC to change risky behaviors ARV Therapy $8-12 $218 $ $276 $1,324 NA $10.51 $66.2 $720-2, Ainsworth and Teokul, 2000 Breaking the silence: setting realistic priorities for AIDS control in lessdeveloped countries - Lancet, 356:

40 85. Fifty-eight percent of the project funding for prevention activities correspond to the categories identified in the table above. The cost-effectiveness of the activities funded by the project (e.g. support to orphans, surveillance, research, monitoring and evaluation, safety of blood supply, etc) will be particularly hard due to the attribution issue and the lack of evidence of the causal link between the intervention and the identified impact. 3.4 Justification of Overall Outcome Rating 86. The Project s overall outcome is considered to be moderately satisfactory based on satisfactory relevance, moderately satisfactory efficacy (achievement of PDOs), and satisfactory efficiency. Significant progress has been made in the country s National Response to HIV/AIDS, however this assessment of the project cannot specifically pinpoint a causality link between specific inputs financed by the project that contributed to the progress made in the prevention and control of the epidemic. The project does merit recognition for its continued relevance and for its contribution to the strengthening of the national response and development of a national strategic plan and an M&E system. 3.5 Overarching Themes, Other Outcomes and Impacts (a) Poverty Impacts, Gender Aspects, and Social Development 87. The Project identified women as a priority target group from its inception throughout its execution and four amendments. The project supported the new approach developed by COPRESIDA of organizing the discussions and agreements for the National Strategy and the M&E through the ABPs including one specifically for women. The Base de Alianza Poblacional de Mujeres ABP specifically devoted to address the main gender issues related to the planning, execution, monitoring and evaluation of activities related to women and HIV/AIDS. In addition, key ministries dealing with gender issues (The Ministry of Women and the Ministry of Youth Affairs) received funding to implement activities of the 2-year operational plan developed within the framework of the new National Strategy with financial support from the Project. 88. The baseline that the Project supported with financial resources and technical assistance included data collection and analysis that provided abundant material for better understanding the differential impact of the epidemic in the population taking into consideration gender issues. Recent data shows that the number of women affected by HIV has increased over the last few years, with the male/female ratio in 2007 going from to 2 to The epidemic in the DR is predominantly driven by heterosexuals (75.7 percent). The only distinct feature of HIV infection among men and women is that its average duration is 11 years among women and 10 years among men. The prevalence rate is considerably higher (3.7 percent) among women with no education. 89. The Project also supported the engagement and active participation of immigrants and of Dominicans of Haitian descent. Entrenched pockets of poverty persist along the Haitian border and in bateyes. It is estimated that there are 230 bateyes in the country, 29

41 home to about 31,000 families or 250,000. In order to address this issue, COPRESIDA fostered the creation of the Alianza de Base Poblacional de Bateyes, which included participation of formal and informal grass-root and community groups working with women, children s and young people. (b) Institutional Change/Strengthening 90. During the first years of project implementation COPRESIDA institutional capacity was limited. When a new administration took office in 2004 the new director of COPRESIDA sought to endow the National Coordinating Entity against the HIV/AIDS with sufficient human and financial resources to enhance the institutional capacity. The project provided support for strengthening COPRESIDA during a period of development of new strategies and introduction of innovative approaches (such as ABPs). The institutional capacity proved to be sufficiently strengthened to coordinate an intensive activity geared towards engaging civil society at a massive level. 91. The simplification of procedures and the harmonization of activities to avoid duplications enhanced country ownership and the capacity to steer the national response by COPRESIDA. The strengthening of COPRESIDA was in turn critical for the country to secure and better manage new sources of funding (application for new grant resources) to support a renewed the commitment by the GODR. (c) Other Unintended Outcomes and Impacts (positive or negative) 92. The strengthening of the institutional capacity of COPRESIDA sometimes created frictions with other governmental institutions. The relationship with the MOH s unit in charge of epidemiologic surveillance and health care of sexually transmitted diseases (DIGECITSS) was transformed by a new approach that focused on civil society engagement. Chronic lack of sufficient governmental funding for DIGECITSS exacerbated at periods of time decision-making on the allocation of resources for health care, epidemiologic surveillance and preventive activities. Although DIGECITSS kept receiving funds from both the Project and the GFATM, the management of DIGECITSS sought other sources of funding and some activities were not always coordinated with COPRESIDA. 93. Other unintended outcomes included an increased dependence of NGOs and some grass-roots organizations on international funds to conduct preventive activities. Although the Project s financing of activities of grass-roots organizations and NGOs was expanded after the third amendment, access to grant funds from the GFATM may reduce the possibility of funding preventive activities carried out by civil society with public funds in the medium- and long-run. In the short term this may not represent a challenge to the sustainability of civil society s engagement, but it may hinder in the long-run the share of national resources devoted to this important aspect of the national response in the Dominican Republic. 30

42 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops N/A Assessment of Risk to Development Outcome 94. The risk to development outcome is moderate for the following reasons: 95. Institutional Risks: Unexpected changes to the direction and management teams of COPRESIDA and selection of individuals not always based on technical criteria increases considerably the risk of reducing the accumulated knowledge and institutional capacity to sustain the required leadership and complex coordination with both public sector and civil society organizations. It may also increase the risk of changing priorities. The GODR can decrease risks to continuity and consolidation of the national response by ensuring that changes in the direction and management of COPRESIDA are discussed adequately with stakeholders, and by ensuring sound managerial and technical qualifications of key staff. 96. Health care staff transition risks: The staff of health care units for PLWHA (Unidades de Atención Integral- UAIs), formerly financed by the Project, is now financed by the Government. This is a positive development for sustainability, particularly considering that staff now financed by the MOH includes peer counselors (non-medical staff composed of PLWHA that provide critical support to individuals who recently learn about their HIV status). However, MOH human resource regulations may lead to restrictions that eventually erode gains in prevention and care achieved through the UAIs. 97. Community Participation Risks: The Project was successful in the design of innovative strategies for developing a monitoring and evaluation system within a consultative process that involved Civil Society Organizations (CSOs). The CSOs were invited to openly share indicators which, from their perspective, would help determine how progress was being made in the national response. With the Project closing, a challenge will be to ensure that CSOs continue to be part of the process at this level and have access to funding by other donors to systematically sustain their role in a participatory process. While the GFATM will fund CSO activities, the Government should also play a role to mitigate risks associated with uncertain CSO funding. This underscores the need to develop longer-term funding mechanisms for the CSO response and their overall participation. Assessment of Bank and Borrower Performance 5.1 Bank Performance 31

43 (a) Bank Performance in Ensuring Quality at Entry (i.e., performance through lending phase) 98. Rating: Moderately Unsatisfactory 99. Under the Caribbean Regional APL Framework for HIV/AIDS, the Bank team was able to prepare the Project in a very short time was able to engage governmental authorities. The GODR that had recently created COPRESIDA as the designated National Coordinating Unit directly accountable to the President The original PDO was, however, overly ambitious and seemed to reflect broader regional objectives of the HIV/AIDS rather than country specific realities. The design included development of an M&E system and baseline in an unrealistic time frame. Risk analysis was not realistic. For example, the Project s management risk was considered negligible even though COPRESIDA had been created only a year before and was to be in charge of coordinating a vast and complex scope of activities. Finally, the original project design also had cumbersome administrative procedures and focused on line ministries with little experience in multisectorial coordination and institutional arrangements that turned out to be far too complex. (b) Quality of Supervision (including of fiduciary and safeguards policies) 101. Rating: Satisfactory 102. Despite the succession of five different Task Team Leaders, the quality of project supervision was enhanced quite consistently throughout the life of the project. In particular, the Bank worked closely with the implementing agency to overcome the major challenges encountered during project implementation (low counterpart funding, weaker-than- expected project management, and the need for establishing a new M&E framework and linking this to national decision-making). Regular supervision missions to the country were held and led by the Task Team Leader with the participation of technical and fiduciary experts from the Bank The Bank team demonstrated sustained commitment to identify adjustments needed to ensure responsiveness of the Project to changing country needs. The Bank team actively engaged with the PCU in discussions on how to address the weak and problem areas of the project. This intensive flow communication between the Bank and the PCU paved the way for joint decisions on actions to take to improve project implementation. The four amendments to the Loan Agreement are reflections of this continued effort at improving not only the project performance, but the implementing agency s capacity to lead the project. (c) Justification of Rating for Overall Bank Performance 104. Rating: Moderately Satisfactory 32

44 105. This rating considers both the Quality at Entry and Quality of Supervision. The rating is justified due to: (i) The original PDOs and targets, as well as overly complex design with low attention to important identifiable risks; (ii) Proactive supervision conducted by the Bank, which identified challenges and through amendments introduced necessary changes that were key to improving overall Project performance. 5.2 Borrower Performance (a) Government Performance 106. Rating: Moderately satisfactory 107. Implementation experienced several delays from discontinued counterpart funding, mostly due to a deep financial crisis affecting the country during the first years of implementation. Following the 2004 elections which placed emphasis on restoring macroeconomic stability, the Government demonstrated a stronger commitment to a sustainable response to HIV/AIDS as reflected by counterpart funding picking up and an increase in the implementation of on-the-ground project activities. The National Planning Agency (ONAPLAN) and the Presidency s Technical Secretariat showed a strong commitment to conduct a speedy but relevant restructuring of the project during the third amendment Although counterpart funding was indeed a result of the crisis, the budget for the DIGECITSS (MOH) was not sufficient. In addition, the budget depended on international sources of funding to conduct key HIV/AIDS prevention and control activities that constitute essential public health functions for which the budget must be protected. International sources of funding can complement the fiscal resources, but there are key public health functions that Government must ensure. (b) Implementing Agency or Agencies Performance 109. Rating: Moderately Satisfactory 110. The project was executed by COPRESIDA (the PCU). Before the GODR secured grant funding from the GFATM the management, technical and fiduciary staff was mostly financed by the Project. After the GFATM funds were made available the financing of the staff was jointly done with the GODR and the GFATM. During the first three years, the Project suffered from substantial implementation delays. In March 2005, more than three years after Project effectiveness, only about US$7 million, or less than 30 percent of the loan amount, had been disbursed. The economic crisis seems to have played a very important role by curtailing fiscal resources and creating uncertainties in the planning of line ministries and COPRESIDA. Nevertheless, the PCU limited administrative and technical capacity seems to also have contributed to implementation delays. During these early years of the Project, the PCU lacked a well defined strategy to plan and coordinate activities according to the annual operational plans. 33

45 111. Following the 2004 elections, a new team was appointed to manage the HIV/AIDS Presidential Council. Upon the arrival of the new staff, the Council and the Bank team agreed on an emergency Operational and Procurement Plan with three objectives: (i) ensure the continuation of ongoing prevention and control activities, (ii) support the finalization of the National Strategic Plan, (iii) finalize a 12 to 18 month procurement plan in line with the priorities of the new strategic plan. These changes, combined with the 2006 Project restructuring, led to an increase in project implementation. For example, from April 2005 to March 2006, US$3.5 million was disbursed for scaled up prevention activities delivered by more than 30 public and private organizations in multiple sectors. COPRESIDA s improved performance was also the result of enhanced transparency and accountability as it begun to openly disclose most of the project documents and reports/evaluations it produced. (c) Justification of Rating for Overall Borrower Performance 112. Rating: Moderately Satisfactory 113. It is important to recognize that the causes for the implementation delays early on in the Project were due to external factors such as the economic crisis and related events that were outside the immediate, if not complete, control of the Government and that were extremely difficult to deal with. However, there were important project implementation bottlenecks stemming from ensuring a consistent selection of PCU staff with leadership, technical capacity and endorsement of all stakeholders. Finally, expressed commitments to fight the HIV/AIDS epidemic did not result in protecting agreed counterpart funding levels and key essential public health functions This rating acknowledges the corrective actions and renewed commitment taken once the new Government and the new COPRESIDA teams took office following the 2004 elections. The new Government team increased the allocation of counterpart funds in consecutive years while COPRESIDA laid out an ambitious 12-month procurement plan and developed a comprehensive 10-year National Strategic Plan. These joint actions by the Government and the implementing agency were critical in accelerating project implementation from this point on, as well as in aligning Project Design to the country s emerging needs and a new National Response. Lessons Learned (both project-specific and of wide general application) 115. In regards to project preparation, there are clear trade-offs between a fast-track approach and a more time-consuming approach based on in-depth country analysis. Even when there is international experience to draw upon to address complex development problems, every project requires an in-depth analysis to ensure that project design is based on sustainable approaches. Project designs that rely more on existing models and less on a thorough understanding of country needs and context may lead to 34

46 risky projects with delays in implementation. Less preparation can result in costly project restructuring in order to use loan resources more efficiently and effectively Coordination at the National Level. For a National HIV/AIDS project to be successful, the design of the project needs to promote country ownership by supporting and consolidating stewardship of the National Coordinating Entity When actual pooling of resources is not possible, strengthening a National Coordinating Entity leads to better coordination of resources and results. In order to make a more effective use of loan resources, virtual pools of funding can be used by fostering a single national operational plan of which project funding is only one part, under the coordination of a National Coordination Entity with sufficient institutional capacity Line Ministry activities can be enhanced if planning and implementation involves active participation of CSOs. Multisectoriality is key to the success of the national response to HIV and AIDS, especially with respect to the implementation of prevention activities. This entails getting CSOs more directly involved in the national HIV/AIDS program. Supporting the participation of CSOs from the very beginning, from the planning to the implementation and monitoring and evaluation of the National Response, can lead to more productive public and civil society partnerships. CSOs are able to provide access to hard-to-reach at-risk groups and are key for scaling up prevention and treatment efforts that effectively reach these groups. In the Dominican Republic, CSOs played a critical role in developing the response strategy to the epidemic and in directly contributing to the development of the M&E framework that resulted in broad consensus Flexibility in the design of procurement procedures can help decentralizing and expanding execution of project activities when needed but requires a PCU with sufficient institutional capacity and intensified supervision. Addressing complex problems that require the involvement of multiple stakeholders including civil society sometimes requires a more flexible design of project disbursement and procurement procedures. However, within the framework of current fiduciary architecture in investment lending projects a rapid scale up of activities without a proportional increase in institutional capacity, improved governance and human resources may lead to lower quality of planning and execution of procurement activities necessary to comply with Bank guidelines. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) (b) (c) Borrower/implementing agencies: NA Cofinanciers: NA Other Partners and Stakeholders: NA 35

47 Annex 1. Project Costs and Financing before and after Restructuring 1.1 BEFORE RESTRUCTURING: (a) Project Cost by Component (in USD Million equivalent) Components ORIGINAL Prevention/promotion activities to reduce HIV/AIDS transmission Diagnosis, basic care and support of individuals affected by HIV/AIDS Appraisal Estimate (USD millions) Actual/Latest Estimate (USD millions) Strengthening HIV/AIDS and STI surveillance; project coordination, monitoring, evaluation and research AFTER THIRD AMENDMENT (FIRST ORDER RESTRUCTURING) Strengthening the Coordination and Management of the National Response Support to Public Sector Organizations for Prevention and Control of HIV/AIDS Support to Civil Society Organizations for Prevention and Control of HIV/AIDS Total Baseline Cost Physical Contingencies Price Contingencies Total Project Costs Front-end fee PPF Front-end fee IBRD Total Financing Required (b) Financing Source of Funds Type of Cofinancing Appraisal Estimate (USD millions) Actual/Latest Estimate (USD millions) Borrower International Bank for Reconstruction and Development

48 Annex 2.Output by Component Summary of main outputs by components (after the Third Amendment) COMPONENTS Component 1: Support of the Coordination and Administration of the National Response OUTPUTS Development of the National Strategic Plan Key outputs from this component are: o New 10-year National Strategic Plan (Plan Estratégico Nacional - PEN); o The first 2-year operational plan; o The Multisectorial Strategic Framework; o Broad participation, ownership and the endorsement of civil society organizations, public and private sectors for the PEN, the first operational plans. Project resources supported consultancies, training, logistical and operational support to conduct national level discussions for the development and consensus building on a new 10-year National Strategic Plan (Plan Estratégico Nacional - PEN) The process of national discussions on the new PEN was designed to actively engage with civil society at large scale through the ABPs. The project financed a series of meetings designed to conduct an in-depth dialogue between civil society and multisectorial organizations from public and private sectors. Technical assistance and financial support provided by the project permitted COPRESIDA to develop a new approach for engagement of civil society (Alianzas de Base Poblacional - ABP) in the planning, development and implementation of the new PEN, the M&E conceptual framework and the first 2-year operational plans. Consultancies, training, operational and logistical support for workshops and local and national meetings. Ten civil society and public sector strategic partnerships for the planning and implementation of the National Response were established. As a result the mobilization and proactive participation of over 300 civil society organizations was made possible through the establishment of ABPs. Operational guidelines were developed to facilitate the participation of the ABPs in the implementation of the 2-year Operational Plan. This operational manual included a detailed description of the roles, responsibilities and functions of the ABP for the execution of activities for the National Response. 37

49 COMPONENTS OUTPUTS The technical assistance and financing also resulted in the establishment of 10 national operational committees for each of the ten ABPs to manage resources efficiently and to ensure the proactive participation of all the NGOs, grassroots and community based organizations in the national discussions on the National Response. The establishment of Inter-Alianza, a national-level organization representing all ABPs to coordinate the multisectorial involvement of civil society, grass-roots and community based organizations. Design and Implementation of the National System of Monitoring and Evaluation of HIV/AIDS With financial and technical support from Bank s Global AIDS Monitoring and Evaluation Team (GAMET), the Conceptual Framework of the National System of Monitoring and Evaluation was developed in coordination with all the ABPs, and all other key stakeholders that had been actively involved in the development of the PEN. The M&E Conceptual Framework included the general objectives, roles and functions as well as the design of flows of information to consolidate data at the national level. As a result: o o The national consensus and agreements on the design and indicators of M&E was developed, published and broadly disseminated in Progressive implementation of M&E started through the first activities carried out for planning consolidation of data for the first national report on the situation of the epidemic in 2008 collected within the new M&E framework. A baseline for evidence based policy making in the national response was constructed and as a result the country now has a wealth of data on the status of the epidemic as of 2007, including key information on high risk groups, which will be used developing new operational plans and interventions. The baseline was constructed with the results of an expanded HIV/AIDS module in the 2007 DHS survey and a set of three specialized studies for high risk groups. o The project financed US$1.5 million for the planning and implementation of an expanded HIV/AIDS study with data collected through a module of the 2007 Demographic and Health Survey (ENDESA 2007). The study was designed with a sample large enough to obtain accurate estimates even for the smaller geographical units (9 health regions and 32 provinces) not measured before. The survey included blood samples to test HIV 38

50 COMPONENTS OUTPUTS prevalence and a special module on knowledge and attitudes. o In order to establish the baseline data for the national indicators of the National Strategic Plan the project used US$0.5 million to conduct a study with an innovative sampling methodology (respondent driven sampling) which yielded statistically significant results on the status of the epidemic among high risk groups. The project with the support of GAMET and jointly with CDC s technical assistance financed by USAID conducted the first Behavioral Surveillance Survey analyzing the prevalence, information, awareness and practices of high risk groups including MSM, sex workers, and drug users Biomedical Waste Management (BMWM) The Project provided support for improving biomedical waste management in the network of health care providers from public and private sector (Unidades de Atencion Integral UAI from Ministry of Health and NGOs). As a result COPRESIDA: o o o Developed a manual for the management of the biomedical waste related to HIV/AIDS. A large-scale training plan for health care providers including evaluation materials to measure the impact of the training on knowledge and understanding was developed. About 70 percent of the health personnel was trained on BMWM for delivering HIV/AIDS preventive and health care services. Bi-national agreement between Haiti and the Dominican Republic The project assisted the Government to develop an operational plan for monitoring implementation of bi-national agreements between Haiti and the Dominican Republic to coordinate actions to better fight the HIV/AIDS epidemic in the island of Hispaniola. The monitoring plan was endorsed by national authorities of both countries (including the Ministry of Foreign Affairs and several ministries, the armed forces, multi and bilateral cooperation organizations). Funds of the project financed the establishment of one of the two joint technical groups established in each country for monitoring and following up on the binational agreements regarding HIV/AIDS. These technical groups included representatives from civil society, the United Nations, bilateral organizations, and NGOs, among others. The technical group in the Dominican Republic is in the process of being officially established (the technical group in Haiti is already established and fully functioning). Financing activities of the technical group is very 39

51 COMPONENTS OUTPUTS important since it will be in charge of monitoring the HIV/AIDS epidemic, fulfilling the bi-lateral accords, and coordinating mutually beneficial strategies of control and prevention. Component 2: Support of the public sector organizations in prevention and control of HIV/AIDS Participation of Public Sector Organizations The Project covered the technical and financial needs for the implementation of the two interventions organized by the public sector. o The Ministry of Youth Affairs (Secretaria de Estado de la Juventud) with the participation of numerous civil society organizations and other key stakeholders, discussed and reached agreements on public policies on young people and HIV/AIDS. These policies were carried out within the framework of the construction of a new public sector approach to address emerging challenges for young people in the Dominican Republic. As a result New Public Policies for Young People regarding HIV/AIDS (Políticas Públicas de Juventud para el Tema del VIH/SIDA) was developed to better address and coordinate the specific needs of this group of the population regarding the National Response to the epidemic. o An intervention to conducted by the Ministry of Women s Affairs (Secretaría de Estado de la Mujer-SEM) to link prevention of domestic violence and of HIV/AIDS. The result was the establishment of 30 municipal centers to deal with gender and HIV/AIDS issues. These centers provide assistance to local women groups to plan and implement activities for the prevention and control of HIV and related domestic violence problems affecting the poorest strata of the population. With a total investment of over US$2 million the project financed the refurbishing more than 25 UAIs (HIV/AIDS health units) across the country of the specialized ambulatory care network of providers reaching to an estimated 19,500 individuals. The Project financed inputs to support the government with the introduction of large scale testing of CD4 counts and viral loads. During 2005 to 2008 more than 20,000 PLWH benefitted from this program. This was part of the National Program for Integrated Health Attention (Programa Nacional de Atención Integral to improve monitoring of health of PLWHA and improve their quality of life and survival rates. Introducing monitoring of the health of PLWHA at a national scale represented an important step toward enhancing the efficiency of the program and bettering the quality of life of the patients. The project invested roughly US$2 million in ARVs to ensure 40

52 COMPONENTS OUTPUTS continuity in access to treatment and expansion of ARV therapy coverage for up to roughly 20,000 individuals. The Project helped the rapid expansion of ARV coverage, providing complementary financing to GFATM funds to ensure continuity in the access of PLWHA to needed antiretroviral medication. The project financed ARV when, for various reasons, there were gaps in the flow of funds from other sources, including the GFATF. The project contributed to the rapid expansion of the coverage of the treatment of HIV/AIDS by adequately financing the medical inputs in the Public Health Unit. As a result expansion of needed ARV coverage increased without interruption. Component 3: Support of the Civil Society in Prevention and Control of HIV/AIDS Participation of Civil Society Organizations 11 pilot projects for prevention and behavior change to incorporate 30 new grassroots organizations and NGOs to the network of civil society organizations working on the National Response. Three of the above described projects were deemed best practice cases for their innovative accomplishments in contributing to HIV prevention, including populations not included before. The NGOs participating in the project developed HIV prevention and control activities, directed at at-risk populations through exchanging experiences, approaches and crossfertilization among four ABPs: children, MSM, young people, and Bateyes populations (for people of Haitian descent and immigrants) Prevention Behavior Change Interventions During the implementation of the Project more than two million condoms were distributed using with the ABP framework as a strategic partnership for exploiting synergies between activities conducted by civil society and public sector organizations to enhance and reinforce the impact of social marketing of condoms. Planning and implementation of specific activities focusing on new approaches to behavioral change were introduced by NGOs working with MSM. The planning and implementation of new BCC interventions specifically designed for various groups encompassed by the broad category MSM through peer to peer was carried out by MSM grassroots organizations including. 41

53 Annex 3. Economic and Financial Analysis NA Annex 4. Bank Lending and Implementation Support/Supervision Processes (a) Task Team members Names Title Unit Lending Patricio V. Márquez Health Specialist LCSHD Reynaldo Pastor Legal Counsel LEGOP Martha Ospina Procurement Specialist LCSHD Xiomara Morel Disbursement Officer LOAG3 Heinz Weindler Disbursement Officer LOAG3 Maria Colchao Operations Assistant LCSHD Mary Dowling Project Assistant LCSHD Mario Bravo Communications Specialist EXTRO Oscar Echeverri Consultant LCSHD Fernando Sacoto Consultant LCSHD Fausto Andrade Consultant LCSHD Alberto Gonima Consultant LCSHD Supervision/ICR Patricio V. Márquez Health Specialist ECSHD Martha Ospina Procurement Specialist LCSHD Maria Colchao Operations Assistant LCSHD Mary Dowling Project Assistant LCSHD Fernando Montenegro Torres Economist (Health) LCSHH Christoph Kurowski Sector Leader LCSHD Zoila Catherine Abreu Rojas Procurement Analyst LCSPT Teresa Franco Consultant LCSSD Patricia De la Fuente Hoyes Senior Finance Officer LOAFC Vladimir T. Jadrijevic Consultant LCSEG Claudia Macias Operations Officer LCSHH Maritza A. Rodriguez De Pichardo Financial Management Specialist LCSFM Rosalia Rodriguez-Garcia Sr Monitoring & Evaluation Specialist HDNGA Rocio Schmunis Consultant LCSHH Michele Tarsilla Consultant LCSHH Sonia E. Ruiz Consultant LCSHH Natalia Moncada Program Assistant LCSHH Samia Benbouzid Program Assistant CESGM Verónica Jarrín Sr. Program Assistant LCSHH Carmen Carpio Knowledge Management Officer LCSHH 42

54 (b) Staff Time and Cost Staff Time and Cost (Bank Budget Only) Stage of Project Cycle No. of staff weeks USD Thousands (including travel and consultant costs) Lending FY FY Total: Supervision/ICR FY FY FY FY FY FY FY FY Total: Annex 5. Beneficiary Survey Results N/A Annex 6. Stakeholder Workshop Report and Results N/A 43

55 Annex 7. Summary of Borrower s ICR and/or Comments on Draft ICR Official response to the Draft Implementation Completion Report (ICR)of the World Bank Loan to the Government of the Dominican Republic for the HIV/AIDS Prevention Project. COPRESIDA has reviewed the Draft ICR of the HIV-AIDS prevention project financed by World Bank loan 7065-DO and presents here the most important considerations, comments and suggestions: The overall conclusions of the ICR that the project s performance was moderately satisfactory, along with the rating of the Bank s performance as also moderately satisfactory, shows that project performance was in balance with the Bank s performance, which can be considered a success. It is important to highlight the lessons learned that are important to be shared with authorities of the government that work with other multilateral organizations such as the SEEPyD and the Ministry of Finance (Hacienda). These include the negative effect on the implementation of the project in its early stages of delays in congressional approval, meeting the conditions needed for setting up adequately the PCU, and signing the interinstitutional agreements. Despite these obstacles, the ICR highlights that these obstacles were surmounted once a new administration took office in 2004 and also underscores the GODR s commitment, along with an acceleration in the rates of project disbursements and implementation. Clearly, the project restructuring conducted in 2006 had an impact on the satisfactory implementation of the project which is reflected in the ratings before and after this amendment. This amendment aligned the project s objectives with the vision, goals and strategic approach adopted by the national coordinating authority for the new Strategic Plan (PEN) Fundamental changes such as the inclusion of civil society organizations as participating entities of the project and the corresponding flexibility in the project s financing are key elements that should be part of the lessons learned for operations aiming at financing activities for the prevention and control of HIV/AIDS epidemic. The project had an important impact on the consolidation of the Monitoring and Evaluation System of the country and on the establishment of a baseline of national health indicators, such as those reflected in the Demographic and Health Survey - DHS (ENDESA 2007) and the behavioral studies for high risk groups. The previous point underscores the importance of highlighting with greater detail the impact that project restructuring had on the inclusion of civil society organizations as participating entities. However successful the process of restructuring and the alignment of the indicators with national priorities, the same process did not prove to be a reliable tool for establishing causality or allowing the drawing of conclusions as to whether the final outcomes of the 44

56 project could be solely attributable to its actions. An analysis of the consequences of the decisions made in regards to the design of the project in the initial stages and those made during the restructuring in 2006 in respect to the selection of the development objectives (DO) and the implementation indicators would help complete this analysis. We suggest that the World Bank conduct an evaluation study of the impact of the interventions financed by the project to achieve the project s development objectives before and after project restructuring. It is clear that the selection of project indicators that are consistent with those of the National Response and not only of the project has the advantage of making the project consistent with the national strategies. However the indicators are not reliable instruments to gauge the specific and unique contributions of the project to the National Response. It would be quite useful to have a comparative analysis of the consequences of decisions regarding project design including the selection of project objectives and the implementation letter project indicators at the beginning of the project compared with those taken during the project restructuring in 2006 We suggest initiating a dialogue between the World Bank and the government to explore the possibility of new financing for the National Response to guarantee the continuity and consolidate processes that the Bank had supported which are not eligible for other sources of financing. Among these activities we highlight: o The implementation of the national management information system as part of the National System of M&E system. o The development of interventions for prevention and control of the epidemic on certain groups of the population not included within the framework of other projects carried out with other sources of financing. o The development of a bi-national strategy with Republic of Haiti HIV/AIDS prevention control o The establishment of targets for the National Strategic Plan using the baseline data identified by activities financed by the Project. The operational performance of the PCU is considered satisfactory with technical, financial and procurement units functioning in an efficient manner, and minor suggestions are made for their strengthening. 45

57 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders N/A Annex 9. Indicators introduced in the Implementation Letter with the Third Amendment Dominican Republic HIV/AIDS Prevention and Control Project Development Objective Reorganizing the National Response, developing a National Strategic Plan and a corresponding monitoring and evaluation system Reducing the risk of transmission and improving the quality of life of those infected and affected Intervention area National Strategic Plan Monitoring and evaluation Absorption capacity of resources Care and treatment Social marketing of condoms Voluntary Counseling and Testing Prevention of Mother-to-Child Transmission Treatment of sexually transmitted infections other than HIV Discrimination and stigma Results Indicators Targets National Strategic Plan fully developed and reflecting a consensus across alliances, including intervention lines for each target population Monitoring and evaluation system of the national response fully functioning Increased absorption of resources available to finance the National Response Improved coverage of antiretroviral treatment Increase in the use of condoms among young people Improve the population s knowledge about its serological status Decrease the transmission from mother to child Improve the diagnosis and treatment of STIs Improve accepting attitudes towards those living with HIV Reduce stigma and discrimination at health facilities National Strategic Plan prepared, including intervention lines for each target population Design of the national monitoring and evaluation system fully developed, reflecting a consensus across all alliances Monitoring and evaluation system under implementation, information on some indicators is available Monitoring and evaluation system fully functioning, a first annual report about the status of the National Response is widely distributed Amount of investments in HIV/AIDS prevention and control by financing source and implementing agency % of persons that needed ARV treatment and received it in the last 12 months % of young population (15 to 24 years old) that report the use of condom in the last sexual relation with a non regular partner in the last 12 months population aged 15 to 49 who voluntarily requested an HIV test, received the test and received their results within the last 12 months % of health facilities providing birth attendance that provide prophylactic treatment according to national norms % of patients with STIs who are appropriately diagnosed and treated according to national guidelines of all STI patients % of people expressing accepting attitudes towards people with HIV, of all people surveyed, broken down by different environments (workplace, schools, etc) % of health personnel expressing accepting attitudes towards people with HIV, of all health personnel surveyed December 2006 October 2006 March 2007 December 2007 Targets to be defined dependent on baseline to be available in Dec : 33% (2,800) 2006: 70% (5,000) 2007: 85% (7500) Targets to be defined dependent on baseline to be available in Dec : 82, : 170, : 250, : 60% 2006: 75% 2007: 80% 2005: 70% 2006: 80% 2007: 90% Targets to be defined dependent on baseline to be available in Dec Targets to be defined dependent on baseline to be available in Dec

58 Reduce stigma and discrimination in the community % of PLWHA that report felt stigma Targets to be defined dependent on baseline to be available in Dec

59 Annex 10. List of Supporting Documents 3 Ainsworth and Teokul, 2000 Breaking the silence: setting realistic priorities for AIDS control in less-developed countries - Lancet, 356: Centro de Estudios Sociales y Demográficos (CESDEM) y Macro International Inc Encuesta Demográfica y de Salud República Dominicana. 3 Consejo Nacional de Seguridad Social (CNSS). Ley No que crea el Sistema Dominicano de Seguridad Social. Serie Reglamentos y Normas No. 5 3 Consejo Presidencial del SIDA (COPRESIDA).Informe de Resultados. Terminación de Ejecución. Proyecto de Prevención y Control del HIV/AIDS. Préstamo 7065-DO. Febrero República Dominicana. 3 Dirección General de Estadísticas, SESPAS, Informe Anual Dr. Alberto Fiallo Billini. Participación Social (COPRESIDA). 3 F. Cáceres, I. Duarte, A. de Moya, E. Pérez Then, J. Hasbún, and M. Tapia. Análisis de la Situación y la Respuesta al HIV/AIDS en República Dominicana, HIV/AIDS in the Caribbean Region: A multi-organization Review. The World Bank. Washington, Plan Estratégico Nacional (PEN) para la Prevención y el Control de las ITS, VIH y Sida Four volumes: Análisis de Situación y Respuesta Nacional a las ITS, el VIH y el SIDA; Marco Conceptual de Monitoreo y Evaluación, Plan Operativo Bienal ; Marco Estratégico Nacional Multisectorial. COPRESIDA. Santo Domingo, Presidencia de la República Dominicana. Reglamentos de la Ley General de Salud (42-01) Volumen 1. Mayo Edición Oficial. 3 Reporte del Sistema de Atención Integral para el VIH/SIDA - Año (SIAI), Reporte de Cierre del Proyecto del Banco Mundial. COPRESIDA Sánchez Antonio. El Modelo Dominicano de Pretación de Servicios de Salud. Una apuesta de Futuro. Abril 2005 Santo Domingo, República Dominicana. 3 The World Bank HIV/AIDS Program: A Guidance Note on Disbursement Procedures 3 The World Bank. Project Aide-Memoires. Internal documents. Washington DC 3 The World Bank. Project Appraisal Document Latin America and the Caribbean Region Multi Country HIV/AIDS Prevention and Control Program Project for the Caribbean Region (Barbados and Dominican Republic) (English). Washington, DC 3 The World Bank. Project Implementation Status Reports. Internal Documents. Washington DC\ 3 The World Bank. Proyecto de Prevención y Control del VIH/SIDA, Préstamo 7065-DO Julio 2008, Santo Domingo, República Dominicana. 3 The World Bank.HIV/AIDS In Latin America. The Challenges ahead. Anabela García-Abreu, Isabel Noguer and Karen Cowgill. HNP, March UNGASS Dominican Republic Report,

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