Document of The World Bank IMPLEMENTATION COMPLETION AND RESULTS REPORT (IBRD-46820) ON A LOAN IN THE AMOUNT OF US$60 MILLION UKRAINE FOR A

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1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Document of The World Bank Report No: ICR IMPLEMENTATION COMPLETION AND RESULTS REPORT (IBRD-46820) ON A LOAN IN THE AMOUNT OF US$60 MILLION TO UKRAINE FOR A TUBERCULOSIS AND HIV/AIDS CONTROL PROJECT December 28, 2009 Human Development Sector Unit Ukraine, Belarus and Moldova Country Unit Europe and Central Asia Region

2 CURRENCY EQUIVALENTS (Exchange Rate Effective 12/1/2009) Currency Unit = Ukrainian Hryvnia (UAH) 1.00 = US$0.12 US$ 1.00 = UAH8.14 FISCAL YEAR ABBREVIATIONS AND ACRONYMS AIDS Acquired Immunodeficiency Syndrome MSM Men who have sex with men Alliance International HIV/AIDS Alliance MTCT Mother to Child Transmission ART ARV Antiretroviral Therapy Antiretroviral Virus Network All-Ukranian Network of People Living with HIV/AIDS Non-Communicable Disease NCD CAS Country Assistance Strategy NGO Non-Governmental Organization CD4 Cluster of differentiation 4 PATH CPS CPS (Country Part. Strategy) PAD Project Appraisal Document CSW Commercial Sex Worker PDO Project Development Objectives DOTS Directly Observed Treatment Short Course PIU Project Implementation Unit ECA Europe and Central Asia PPU Project Preparation Unit EU European Union PLWHA Person living with HIV/AIDS FMR Financial Management Report PMTCT Prevention of Mother to-child Transmission FSU Former Soviet Union QEA Quality at Entry Assessment GDP Gross Domestic Product QER Quality Enhancement Review GF Global Fund STD Sexually Transmitted Disease HAART Highly Active Antiretroviral Therapy STI Sexually Transmitted Illness HIV Human Immunodeficiency Virus TB Tuberculosis IBRD ICB ICR IDU IRR ISR LA M&E MDRTB MOH International Bank for Reconstruction and Development International Competitive Bidding Implementation Completion Report Injecting Drug User Internal Rate of Return Implementations Status Report Loan Agreement Monitoring and Evaluation Multiple Drug Resistant in TB Ministry of Health TTL UN UNAIDS UNDP UNPFA UNGASS UNICEF USAID VAT VCT WHO Task Team Leader United Nations United Nations Program on HIV/AIDS United Nations Development Program United Nation Population Fund United Nation General Assembly Special Session on HIV/AIDS United Nations Children s Fund United States Agency for International Development Value Added Tax Voluntary Counseling and Testing World Health Organization Vice President: Philippe H. Le Houerou Country Director: Martin Raiser Sector Manager: Abdo S. Yazbeck Project and ICR Team Leader: Maria E. Gracheva ICR Author: Maria E. Gracheva

3 COUNTRY Project Name CONTENTS Data Sheet A. Basic Information B. Key Dates C. Ratings Summary D. Sector and Theme Codes E. Bank Staff F. Results Framework Analysis G. Ratings of Project Performance in ISRs H. Restructuring I. Disbursement Graph 1. Project Context, Development Objectives and Design Key Factors Affecting Implementation and Outcomes Assessment of Outcomes Assessment of Risk to Development Outcome Assessment of Bank and Borrower Performance Lessons Learned Comments on Issues Raised by Borrower/Implementing Agencies/Partners Annex 1. Project Costs and Financing Annex 2. Outputs by Component Annex 3. Economic and Financial Analysis Annex 4. Bank Lending and Implementation Support/Supervision Processes Annex 5. Beneficiary Survey Results Annex 6. Stakeholder Workshop Report and Results Annex 7. Summary of Borrower s ICR and/or Comments on Draft ICR Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders Annex 9. List of Supporting Documents MAP

4 A. Basic Information Country: Ukraine Project Name: Tuberculosis and HIV/AIDS Control Project Project ID: P L/C/TF Number(s): IBRD ICR Date: 12/28/2009 ICR Type: Intensive Learning ICR Lending Instrument: SIL Borrower: UKRAINE Original Total Commitment: USD 60.0M Disbursed Amount: USD 41.7M Revised Amount: USD 43.4M Environmental Category: C Implementing Agencies: Ministry of Health State Department of Prisons Cofinanciers and Other External Partners: B. Key Dates Process Date Process Original Date Revised / Actual Date(s) Concept Review: 06/26/2000 Effectiveness: 01/06/2004 Appraisal: 01/22/2002 Restructuring(s): Approval: 12/19/2002 Mid-term Review: 02/13/ /30/2006 Closing: 06/30/ /30/2009 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Risk to Development Outcome: Bank Performance: Borrower Performance: Unsatisfactory Substantial Unsatisfactory Unsatisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Unsatisfactory Government: Unsatisfactory Quality of Supervision: Unsatisfactory Implementing Agency/Agencies: Unsatisfactory Overall Bank Performance: Unsatisfactory Overall Borrower Performance: Unsatisfactory i

5 C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Indicators Performance (if any) Potential Problem Project No at any time (Yes/No): Problem Project at any time (Yes/No): DO rating before Closing/Inactive status: Yes Highly Unsatisfactory Quality at Entry (QEA): Quality of Supervision (QSA): Satisfactory None Rating D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Central government administration 5 5 Health Law and justice Other social services 5 Theme Code (as % of total Bank financing) HIV/AIDS Health system performance 25 Other communicable diseases E. Bank Staff Positions At ICR At Approval Vice President: Philippe H. Le Houerou Johannes F. Linn Country Director: Martin Raiser Luca Barbone Sector Manager: Abdo S. Yazbeck Armin H. Fidler Project Team Leader: Maria E. Gracheva Jean J. De St Antoine ICR Team Leader: ICR Primary Author: Maria E. Gracheva Maria E. Gracheva F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) DO is reduced tuberculosis and HIV/AIDS morbidity and mortality through an effective National Strategy for TB Adapted to World Standard, and an HIV/AIDS Program largely focused on prevention of transmission of the disease among high-risk groups. ii

6 Revised Project Development Objectives (as approved by original approving authority) (a) PDO Indicator(s) Indicator Indicator 1 : Value quantitative or Qualitative) Baseline Value Original Target Values (from approval documents) Formally Revised Target Values Actual Value Achieved at Completion or Target Years TB Indicators: TB Prevalence (in general population and prisons (original indicator) # total number of patients under observation (5 observation groups) /100,000 (all) 4491/100, /100,000 (all) Reduced (prisons) 5744/100,000 (prisons) Prevalence (6,700 all TB cases of 143,000 inmates in 2009) Date achieved 12/31/ /30/ /31/2008 Comments (incl. % achievement) TB prevalence has been decreasing in the general population after a steady & rapid increase up to 2004 (219.1/2005;212.3/ 2006; 200.6/2007), most likely due to increased availability of drugs. Indicator 2 : TB Indicators: New TB cases and relapses recorded annually (new indicator) Value quantitative or Qualitative) 77.5/100,000 (all) /100,000(prisons) 75-77/ (all) 77.8/100,000(all) 938.6/100,000 (only new cases) (prisons) Date achieved 12/31/ /30/ /31/2008 Comments In 1999, the rate was (54.4/100,000) and increased to 80.9/2004; 84.1/2005; (incl. % 83.2/2006; 79.8/2007. achievement) Indicator 3 : TB Indicators: TB Mortality (general population and prisons) (original indicator) Value quantitative or Qualitative) 21.8/100,000 (all) Goskomstat data 103/100,000 (prisons) Reduce by 15% (general population) Reduce by 20% (prisons) 22.1/100,000 (all) Goskomstat data 71/100,000 (prisons) Date achieved 12/31/ /30/ /31/2008 Comments (incl. % achievement) Combined data for MOH/SDP show a 13% increase in mortality from 17.7/2003 to 21.2/2008. Although SDP data shows a decrease in mortality by 31% over 5 years. Indicator 4 : TB Indicators: MDR TB in general population and prisons (original indicator) Value quantitative or Qualitative) 2.5% (general population) (MDR in 1995 was 1.5%) Reduce by 20% N/A (prisons) 7% (general population) 18% (prisons) Date achieved 12/31/ /30/ /31/2008 Comments (incl. % TB Institute date for general population. MDR TB has gradually increased over the past five years: 2.5%/2004; 3%/2005; 5%/2006; 5.5%/ % has been iii

7 achievement) estimated in Kherson Oblast where many released prisoners settle. Indicator 5 : TB Indicators: DOTS Coverage # new indicator (access of the population to high quality DOTS) 60% (MoH estimate) Value 100% (in quantitative or 15% Targrt 100% accordance with Qualitative) Law) MOH & WHO official data Date achieved 12/31/ /30/ /31/2007 Comments (incl. % achievement) National DOTS strategy was adopted in 2006 and National TB Program ( ) was adopted in February DOTS coverage was reported at 29% by WHO for 2005 and at 100% since Indicator 6 : TB Indicators: Treatment success rate in smear positive cases (original indicator) Value quantitative or Qualitative) No data available >85% in DOTS areas, first treatment results from DOTS areas expected for % cure rate based on smear analysis 59% (includes those who completed treatment but without smear analysis -5.5%) 13.6% dies 10.2% stopped treatment 12.4% had MDRTB Date achieved 12/31/ /30/ /31/2007 The first cohort analysis was done by TB Institute in 2006 and This Comments indicator represents a percentage of smear positive TB cases that became smear (incl. % negative (confirmed twice) and completed treatment course of minimum 6 achievement) months. TB Indicators: Proportion of smear positive TB cases among newly recorded in Indicator 7 : TB specialized clinics (secondary level) (# original indicator) Value quantitative or Qualitative) 26.8% (TB Institute) 50% 43% (TB Institute) 35% (WHO) Date achieved 12/31/ /30/ /31/2008 Comments This indicator is a measure of laboratory capacity which has been improved over (incl. % the last several years but remains weak. achievement) Indicator 8 : TB Indicators: Case detection rate of smear positive cases under DOTS Strategy (new indicator) Value quantitative or Qualitative) NA 70% (WHO) 55% Date achieved 12/31/ /30/ /31/2008 Comments (incl. % This indicator represents the number of smear+ cases notified over number of smear+ cases estimated. iv

8 achievement) Indicator 9 : Value quantitative or Qualitative) HIV/AIDS Indicators: HIV Incidence # newly registered cases (original indicator) 10,009 18,963 (general (general population) Reduce incidence population) 828/2002 (prisons) 2,127 (prisons) Date achieved 12/31/ /30/ /31/2008 Comments (incl. % Data obtained from National AIDS Center and SDP. achievement) Indicator 10 : HIV/AIDS Indicators Prevalence of HIV infection - HIV Infections recorded (general population) (original indicator) 1.46% (general population) IDU 14.77% (routine 1.63% (general population) IDU 13.85% Value survey) (routine survey) Decrease quantitative or IDU 10.0 # 59.0% IDU 5.5 # 82% prevalence Qualitative) (sentinel survey) (sentinel survey) CSW 19% -median prevalence 1% - prisons CSW 17% - median prevalence 3.5% - prisons Date achieved 12/31/ /30/ /31/2008 Comments (incl. % achievement) Indicator 11 : Value quantitative or Qualitative) Data obtained from National AIDS Center and WHO Office Ukraine. The total HIV+ registered cases is 141,277 at the end of HIV/AIDS Indicators: Number of new AIDS cases recorded annually (general population and prison) (# new indicator at ICR) 1,915- general 4,380 - general population; % Decrease population 120 (prisons) 299 (prisons) Date achieved 12/31/ /31/ /31/2008 Comments (incl. % Seven-fold increase since 2000 (647 new cases). achievement) Indicator 12 : HIV/AIDS Indicators: Number of AIDS deaths (general population and prison) (# new indicator at ICR) Value quantitative or Qualitative) 1,285 - general population; 70 (prisons) % Decrease 2,710 -general population; 138 (prisons) Date achieved 12/31/ /31/ /31/2008 Comments (incl. % Six-fold increase since 2000 (415 deaths recorded) for the general population. achievement) Indicator 13 : HIV/AIDS Indicators: The rate of vertical transmission of HIV (original indicator) Value quantitative or Qualitative) 8.5% Reduce by 50% 7% v

9 Date achieved 12/31/ /30/ /31/2008 Comments (incl. % achievement) Indicator 14 : HIV/AIDS Indicators: Percentage of ante-natal clinic attendees tested positive for HIV receiving MTCT (ARV) interventions (# new indicator at ICR) Value 94.08% tested Percent quantitative or 85% positive increased Qualitative) 91% treated Date achieved 12/31/ /31/ /31/2008 Comments (incl. % Data obtained from National AIDS Center and WHO achievement) Indicator 15 : HIV/AIDS Indicators: Number of medical facilities offering Voluntary Counseling & Testing (VCT) (new indicator at ICR) Value quantitative or Qualitative) 214 Percent increased 300 independent centers for HIV testing and counseling & ARV treatment, within polyclinics; (637 special offices for counseling in raions) Date achieved 12/31/ /31/ /31/2008 Comments (incl. % achievement) Indicator 16 : HIV/AIDS Indicators: Percentage of people who correctly identify the methods of preventing HIV/AIDS transmission (new indicator) Value quantitative or Qualitative) -Young people (aged 15-24) 14% -MSM (2005) 49% -Prisoners 39% -CSW 8% (2005) -IDU 21% -Military 23% Percent increased -Young people (aged 15-24) 40% -MSM 47% -Prisoners 43% -CSW 48% -IDU 47% -Military 44% Date achieved 12/31/ /30/ /31/2007 Comments Data for 2007 were taken from UNGASS 2008 Report (and Behavioral Study (incl. % 2007 for IDUs). achievement) HIV/AIDS Indicators: # Percentage of men/women who report using a condom Indicator 17 : in their last sexual intercourse with non-regular partner (new indicator) Value quantitative or Qualitative) IDUs 21% Percent increased -General population (15-49) 72% -IDUs 84% -MSM 39% Date achieved 12/31/ /30/ /31/2007 Comments Data for 2007 were taken from UNGASS 2008 Report vi

10 (incl. % achievement) Indicator 18 : Value quantitative or Qualitative) HIV/AIDS Indicators: Percentage of CSW who report using a condom in their sexual intercourse with last client (new indicator) 80% Percent increased Date achieved 12/31/ /30/ /31/2007 Comments (incl. % Data for 2007 were taken from UNGASS 2008 Report achievement) Indicator 19 : HIV/AIDS Indicators: # Percentage of prisoners who report using a condom in their last sexual intercourse (new indicator) Value quantitative or Qualitative) 13% 15% 23% Date achieved 12/31/ /30/ /31/2007 Comments (incl. % Data for 2007 were taken from UNGASS 2006 Report achievement) (b) Intermediate Outcome Indicator(s) Indicator Indicator 1 : Value (quantitative or Qualitative) Baseline Value Original Target Values (from approval documents) Formally Revised Target Values 86% Actual Value Achieved at Completion or Target Years TB Indicators: Legal Framework for TB control, based on National TB Strategy adapted to international standard, is functional (original indicator) National TB National Program control on TB Control DOTS-based program not Legal framework program established existing adopted in endorsed by WHO accordance adopted in February with DOTS Date achieved 12/31/ /30/ /30/ /08/2007 Comments (incl. % achievement) DOTS based strategy adopted by the Government in November 2006 and Law #646-V on the -National Program Against TB # was adopted by Parliament on February 8, Indicator 2 : TB Indicators: National guidelines and training materials for TB laboratories are operational (original indicator) Value (quantitative or Qualitative) N/A Guidelines and training materials are developed Materials developed according to DOTS with WHO approval Materials have been developed by TB Institute, printed and disseminated Date achieved 12/31/ /30/ /30/ /31/2008 vii

11 Comments (incl. % achievement) Indicator 3 : Value (quantitative or Qualitative) According to MOH, training materials/modules have been developed by TB Institute on the basis of WHO modules. However, WHO only provided comments on the 1st version of the modules in October 2005 and never reviewed subsequent versions nor approved these. TB Indicators: Medical professionals and staff trained (general population and prisons) (original indicator) N/A (i)1530 TB specialists (ii)1530 TB lab specialists (iii)1500 GPs (iv)1500 nurses 6000 staff of MOH;38 seminars for prisons for 592 staff 2 seminars for 56 trainers of trainers were done for doctors and lab technicians at MOH. 61 people were trained in the SDP (36 staff from TB hospitals and 25 1st level medical units) Date achieved 04/29/ /29/ /30/ /31/2008 Comments (incl. % achievement) TB re-training course on new modules voluntarily without state/moh certification. Prisons: Of the 38 planned seminars only 5 have been conducted, attended by 61 lab technicians (10.3% of planned). Indicator 4 : TB Indicators: Laboratories at rayon level adequately equipped and operational for smear diagnosis (general population and prisons) (new indicator) Value (quantitative or Qualitative) N/A Number & % of laboratories (general population and prisons) 66% of 1st labs,, 50% of 2nd level labs and 27% of 3rd level labs have been equipped; 100% of labs were provided for SDP (85 1st level facilities and 10 3rd level) Date achieved 12/31/ /30/ /31/2007 MOH claimed that roughly 30% of needs were covered by the project. Reference Comments (Central) LAB does not function in Ukraine to date. Also, the question remains (incl. % about the adequacy of transport, functionality and comprehensiveness of the achievement) equipment delivered. TB Indicators: New Recording/reporting system is used in line with WHO Indicator 5 : standards (general population and prisons) (new indicator) Value (quantitative or Qualitative) None (general population and prisons) Reporting Forms developed New WHO approved reporting system developed and used Date achieved 12/31/ /30/ /31/2009 Recording/reporting forms were developed by the National TB Institute and were Comments based on the WHO reporting/reporting forms. These forms were validated and (incl. % approved by the WHO. Cohort studies carried out annually since 2006 using achievement) new reporting forms. Indicator 6 : TB Indicators: Public Awareness Campaign conducted (original indicator) viii

12 Value (quantitative or Qualitative) N/A Pilot campaign conducted (i) 210,000 booklets (ii) 8 film loops (iii) 75,000 posters Campaign not carried out Date achieved 12/31/ /30/ /31/2008 Comments (incl. % TB Awareness Campaign has not been carried out. achievement) Indicator 7 : HIV/AIDS Indicators: HIV/AIDS Monitoring framework in place (new indicator) Value (quantitative or Qualitative) No framework except for MoH Decree to collect and monitor data by the list of indicators. Monitoring framework in place With support from UNAIDS and others, the M&E framework has been developed under "Three Ones" Initiative. Date achieved 12/31/ /30/ /31/2008 Comments (incl. % Data collection biannually as of achievement) Indicator 8 : HIV/AIDS Indicators: National Mass media / PR campaigns completed (original indicator) Only pilots completed. No Information Value Campaigns information materials were (quantitative None designed and campaigns delivered by or Qualitative) conducted carried out UNFPA under the project Date achieved 12/31/ /30/ /31/ /31/2008 Comments (incl. % achievement) Indicator 9 : Value (quantitative or Qualitative) NGOs do carry out sporadic and locally based activities (not financed by the project). Also, in December 2008, MOH carried out a 2 months national information campaign. HIV/AIDS Indicators: Information materials on HIV/AIDS prevention produced and distributed for Prisons # (original indicator) Information materials were None 690,000 materials delivered by UNFPA Date achieved 12/31/ /30/ /31/2008 Comments (incl. % achievement) 6 types of brochures were planned to be developed. Social analysis was carried out to prepare them but in the end they were not developed or printed because of procurement failure. Indicator 10 : HIV/AIDS Indicators: Percent PMTCT (HIV positive mothers and newborns treated) # (original indicator) ix

13 Value (quantitative or Qualitative) 88% HIV+ mothers treated each year & newborns prevented from becoming HIV positive (original population) 26 HIV+ mothers treated each year & 14 newborns prevented from becoming HIV+ (prisons) 91% Date achieved 12/31/ /30/ /31/2008 Comments (incl. % Data obtained from National AIDS Center. achievement) Indicator 11 : HIV/AIDS Indicators: Formula for children provided to HIV positive mothers # (new indicator) Value (quantitative or Qualitative) N/A Formula procured and provided Provided through regional AIDS Centers Date achieved 12/31/ /30/ /31/2008 Comments (incl. % Formula provided and financed by local budget (with help of some NGOs). achievement) Indicator 12 : HIV/AIDS Indicators: Harm reduction programs carried out (# original indicator) Value (quantitative or Qualitative) 0% 30 No harm reduction programs carried out Date achieved 12/31/ /30/ /31/2008 Comments (incl. % achievement) Indicator 13 : HIV/AIDS Indicators: Condoms provided to IDUs and CWS (# original indicator) Value (quantitative or Qualitative) -IDUs -CWS -prisoners -IDUs CWS prisoners IDUs/CWS 14,000,000 -prisoners 600,000 Date achieved 12/31/ /30/ /31/2008 Comments (incl. % achievement) Indicator 14 : HIV/AIDS Indicators: Drugs provided for treatment of opportunistic infections (new indicator) Value N/A Drugs Drugs procured by x

14 (quantitative or Qualitative) provided UNICEF in 2008 and 2009 worth $24,000,000 Date achieved 12/31/ /31/ /30/2009 Comments (incl. % achievement) Indicator 15 : HIV/AIDS Indicators: 11 new AIDS Centers equipped and functioning (# original indicator) Value (quantitative or Qualitative) N/A 11 centers Laboratory equipment, computer and office equipment was provided under the project to all AIDS centers Date achieved 12/31/ /30/ /31/2008 Comments (incl. % achievement) There is 1 national, 27 regional and 11 city AIDS centers. Computer equipment has been provided by the Global Fund (20% of total) and the Government has financed 80%. The project mostly contributed to improving laboratory capacity. Indicator 16 : HIV/AIDS Indicators: Percentage of people who correctly identify the methods of preventing HIV/AIDS transmission (new indicator) Value (quantitative or Qualitative) -Young people (aged 15-24) 14% -MSM (2005) 49% -Prisoners 39% -CSW 8% (2005) -IDU 21% -Military 23% Percent increased -Young people (aged 15-24) 40% -MSM 47% -Prisoners 43% -CSW 48% -IDU 47% -Military 44% Date achieved 12/31/ /30/ /31/2008 Comments Progress made particularly with respect to youth CSWs, IDUs and military: Data (incl. % from UNGASS 2008 Report (and Behavioral Study 2007 for IDUs). achievement) HIV/AIDS Indicators: Percentage of men/women who had more than one Indicator 17 : sexual partner in the last 12 months who report using a condom during their last sexual intercourse (new indicator) Value 69% 77% (15-19) Percent (quantitative (sex with non-regular 64% (20-24) increased or Qualitative) partner) 72% (15-49) Date achieved 12/31/ /30/ /31/2007 Comments (incl. % No real change. Data from UNGASS 2006 & 2008 Reports achievement) HIV/AIDS Indicators: # Percentage of IDUs (i) who report using a condom Indicator 18 : during their last sexual intercourse; and (ii) using sterile injecting equipment the last time they injected (# new indicator) Value (quantitative or Qualitative) (i) 21% (ii) 50% Percent increased (i) 55% (ii) 84% xi

15 Date achieved 12/31/ /30/ /31/2007 Comments (incl. % SIGNIFICANT PROGRESS. Data from UNGASS 2006 & 2008 Reports achievement) Indicator 19 : HIV/AIDS Indicators: Percentage of CSW & prisoners who report using a condom in their sexual intercourse (new indicator) Value Percent (quantitative CSWs: 80% increased or Qualitative) CSWs: 86% Date achieved 12/31/ /30/ /31/2007 Comments (incl. % Progress made: Data from UNGASS 2008 Report. achievement) Indicator 20 : HIV/AIDS Indicators: NGO involvement (# original indicator) Value (quantitative or Qualitative) 0 Increased by 20% NGOs were not involved in the project at all Date achieved 12/31/ /30/ /31/2008 Comments In 2005, there were 124 NGOs operating in Ukriane, working on HIV/AIDS (incl. % issues; in 2008 this number rose to roughly 170. achievement) HIV/AIDS Indicators: # prevention programs are operational (# original Indicator 21 : indicator) Value (quantitative or Qualitative) 0 CWS -15 programs MSM # 10 programs No programs were delivered under the project. Date achieved 12/31/ /30/ /31/2005 Comments (incl. % achievement) G. Ratings of Project Performance in ISRs No. Date ISR Archived DO IP Actual Disbursements (USD millions) 1 04/30/2003 Satisfactory Satisfactory /21/2003 Satisfactory Highly Satisfactory /11/2004 Unsatisfactory Unsatisfactory /03/2004 Unsatisfactory Unsatisfactory /10/2005 Satisfactory Satisfactory /23/2005 Unsatisfactory Unsatisfactory /20/2006 Unsatisfactory Unsatisfactory /21/2006 Unsatisfactory Unsatisfactory /01/2007 Unsatisfactory Unsatisfactory /14/2008 Unsatisfactory Unsatisfactory xii

16 11 07/08/2008 Highly Unsatisfactory Highly Unsatisfactory /15/2008 Highly Unsatisfactory Highly Unsatisfactory /01/2009 Highly Satisfactory Highly Satisfactory /13/2009 Highly Unsatisfactory Highly Unsatisfactory /30/2009 Unsatisfactory Highly Unsatisfactory H. Restructuring (if any) Not Applicable I. Disbursement Profile xiii

17 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal Country background: A nation of approximately 50 million people (second largest among the Former Soviet Republics), Ukraine established its independence after the dissolution of the Soviet Union in This began a period of transition to a market economy in which Ukraine was stricken with an eight year recession. Ukraine was initially viewed as a country with favorable economic conditions in comparison to the other regions of the Former Soviet Union (FSU). However, the country experienced a deep economic slowdown. During the recession from 1991 to 1999, Ukraine lost 60 percent of its GDP and suffered five-digit inflation rates while 1/3 of the population plunged into poverty. In mid-1990s, the new President embarked on an ambitious reform program and the Ukrainian economy began to stabilize. However, although initial results were encouraging, the Government began to display lacking commitment to the reform agenda, coupled with growing paralysis in decision-making and increasing capture of the state by vested interests. These negative tendencies were noted in the April 1999 Bank Country Assistance Strategy Progress Report and the Bank operations in Ukraine were sharply curtailed at that time. However, with the November 1999 elections of President Kuchma and the appointment of a progressive Prime Minister, Victor Yushchenko, there appeared a chance for Ukraine to recoup the opportunity losses made over the previous decade. GDP began a positive trend in 2000 with 5.9% GDP growth; this continued over the period, with 9.8% growth in 2001 and 4.8% in Poverty also declined very gradually from 29.4% in 1999 to 25.6% in Sector background: The transition period with its political and socio-economic dislocations, a major contraction of the economy in 1990s, led to shrinking budgetary resources, with deleterious effects on the health status of the population. A contributing factor was also the overall deterioration in the provision of health care services as a result of decreasing budgets while Ukraine attempted to maintain its inefficient hospital-based Soviet healthcare system. As a result, from 1985 to 1999, life expectancy at birth contracted from 70 to 67 years, particularly for males (from 66 to 62 years). This was full 10 years lower than the EU-15 average for 1999 (77.2 years). Indeed, starting in 1991, Ukraine entered a demographic crisis due to its high death rates and low birth rates. By 2000, the birth rate was 7.7 births/1,000 population while the death rate was 15.5 deaths/1,000 population. This was the lowest point in Ukraine s natural rate of growth since 1990, including the present. While non-communicable diseases (NCDs) such as circulatory diseases, cancers, respiratory and digestive diseases, as well as accidents, injuries and poisonings represented most of the disease burden in Ukraine, communicable diseases which were decreasing in the late 1980s re-emerged in the early/mid-1990s, including tuberculosis (TB), sexually transmitted illnesses (STIs), and a new disease of HIV/AIDS. This trend was consistent with the experience of other FSU countries, particularly Russia, which like Ukraine faced a rapid explosion of TB and HIV/AIDS. Tuberculosis: The overall coordination and administration for TB control was the responsibility of the Ministry of Health Department of Socially Dangerous Diseases, with the implementation of TB control programs resting at oblast and rayon administrations. The formulation of technical policies and guidelines was provided by the Research Institute for Pulmonology and Phthisiology (TB Institute) under the Academy of Medical Sciences. By 1999, TB treatment services were provided at 165 specialized TB dispensaries and 98 TB sanatoria as well as in some large hospitals. The State Department of Prisons had its own 10 TB hospitals with 13,200 beds as well as isolation wards in medical units attached to many prison facilities. Based on this set-up, Ukraine had successfully controlled TB and other infectious diseases although the system was inefficient with heavy reliance on expensive diagnostic techniques, including active-case finding of TB in adult population aged 15 years and older by mass radiography 1

18 (fluoragraphy x-ray), as well as on long hospitalizations of patients of one year or more. This system proved difficult to maintain during the transition period with declining health budgets. TB facilities, and especially laboratory services, had obsolete equipment, lacked resources and operated with scant provision of necessary supplies and reagents. Moreover, there was no internal or external system for quality control. As a result, the quality of diagnosis was poor, leading to high-levels of over-diagnosis of TB (only 35 percent of all tested patients turned out to have bacteriologically proven pulmonary TB). Also, drug supplies during the transition period were inadequate with periods where no drugs were available at all and patients were asked to buy their own medicines. Lastly, treatment guidelines were often not followed and treatment regimens differed from patient to patient (as a result of fluctuations in the availability of drugs) and were also changed during the process for the same patients. Additionally, because TB services were centralized at rayon and oblast dispensaries, access to care was reduced, particularly during the transition period, with late presentation of patients with advanced disease. This also led to high treatment default rates. In sum, this non-standardized, irregular and inadequate treatment resulted in what the WHO Review of TB in Ukraine (December 1999) called an epidemic of emergency proportions. Indeed, given these systemic weaknesses and increased poverty rates (closely associated with TB growth) during the transition period, the epidemiological situation of TB was dramatically worse by The TB case notification rate (new cases reported) more than doubled from 31.9/100,000 (1990) to 66.9/100,000 (2000). TB mortality rates almost tripled from 8.1/100,000 (1990) to 22.2/100,000 (2000). During the same period, new TB cases in the EU countries dropped from 21.3/100,000 in 1990 to 19.6/100,000 in Irregular drug supply and lack of direct observation of treatment led to massive drug resistance, with half of all patients found resistant to at least one drug and multi-resistance (resistance to isoniazid and rifampicin) present in 10-15% of new cases. Roughly 30 percent of all TB patients in Ukraine were in the prison system and in the pre-detention centers (SIZOs) in over-crowded conditions, with malnutrition, poor diagnosis and lack of drugs. At the start of project preparation in 1999, TB prevalence in the prison system was at very high levels (7%), with 14,000 TB patients of the roughly 200,000 prisoners in Ukraine, whereas it was at 1.7% only 5 years earlier. In comparison, TB prevalence in the regular population was twenty times lower, at 226.8/100,000, although this figure was also high. The TB situation was worsened by the growing epidemic of HIV/AIDS. Thirty percent of adults diagnosed with AIDS and 50 percent of those who died of AIDS had TB. Indeed, HIV infection was a major factor which contributed to the development of active TB particularly among the latent AIDS patients. HIV/AIDS: The first HIV/AIDS case was diagnosed in 1987, but by end 2001, there were 43,600 HIV cases officially registered, with 2,907 adults and children diagnosed with AIDS and 1,474 persons who died of AIDS. The most dramatic increase in new HIV cases occurred in 1995 when the total number of registered cases increased to 1,490 from 31 in 1994 after which it began to increase rapidly with 5,400 new cases reported in 1996 and 8,913 new cases reported in The same trend was seen in the prison system and by 1999 a total of 4,300 HIV-infected prisoners registered. While the total officially registered cases in the general and prison population were roughly 35,000 by 1999, the UNAIDS estimate (end- 1999) claimed that 240,000 people were HIV positive which made Ukraine the worst HIV affected country in the Europe and Central Asia Region, almost twice as high as Russia with 130,000 estimated cases. The most affected regions in Ukraine were those in the South-Eastern regions (Donetsk, Dnipropetrovsk, Odessa, Nikolaev and the Crimea Republic.) These regions were also those with the highest estimated number of intravenous drug users (IDUs) in Ukraine. In fact, the HIV epidemic was primarily concentrated among IDUs after According to Government statistics, the estimated proportion of HIV infections caused by IDUs was 83.6% in 1997 and decreased to 56.5% in 2001 and to 48.1% by 2

19 2003 of total infections while the percentage of heterosexually transmitted infections grew from 11.3% (1997) to 26.9% (2001). This trend was consistent with the growing rate of sexually transmitted infections (STIs). The possibility of acquiring HIV as well as infecting a sexual partner was 5-10 higher for those suffering from an STI. The incidence of syphilis had increased from 10/100,000 in 1990 to 118/100,000 by 1995 and by 2000, 45,245 Ukranians were registered as having contracted syphilis for the first time. Also, from 1998 to 2000, the rate of increase of HIV among persons with STIs increased by 35% which indicated an increased role played by heterosexual channel in HIV transmission. This was also evidenced by an increase in women s share among the overall number of recorded HIV positive cases, from 27% (1997) to 37% (2000). The percentage of mother-to-child transmission infections also grew from 2.2% (1997) to 13.1% (2001). It must be noted that in 1998, Ukraine amended its 1991 Law On AIDS Control and Social Protection by abolishing mandatory HIV testing for IDUs, commercial sex workers (CSWs) and other special groups, which may explain the significant decrease in the overall amount of testing of IDUs starting in 1998 and the overall decrease in the number of HIV cases among IDUs, as shown in Figure 1 below. Figure 1: Number of HIV Infections in Ukraine by modes of transmission HIV/AIDS Surveillance in Ukraine ( ): National AIDS Center. As of January 2001, the Ministry of Health data reflected that 75,489 persons were drug users (although the real figure was likely several times higher) while the estimated percentage of IDUs was roughly 80% of that figure. The HIV prevalence among IDUs varied greatly by region (18%-64%), as evidenced by the results of the 2000 sentinel survey among IDUs in 6 major cities in Ukraine. Prevalence among commercial sex workers (CSWs) was estimated to range from 2.5% to 10% (1998 and 1999 sentinel surveys) with 13% among CSWs offering services along the highways in Ukraine, thus providing a bridge of HIV transmission into the general population. The age distribution of the HIV/AID epidemic was 18% in the 0-14 age group, 18% in age group and 62% in the age group. According to the 1997 sociological survey of the youth in Ukraine, roughly 10% of young age had 3 to 5 partners in the previous year of whom 3% (age group 21-24) had over 10 partners. The National survey in 1999 showed that 43% of young people had sex with more than one partner (2-5 partners) and that those with multiple partners during the previous 3 months faced the greatest risk of HIV infection. Compounding these risky behaviors was the low awareness and understanding of how HIV was transmitted. In 2004, the results of a behavioral survey showed that only 14% of young people correctly identified the methods of preventing HIV/AIDS transmission. This figure was 21% for IDUs, 23% for military personnel, and 39% for prisoners. In sum, Ukraine was a fertile ground for a rapid spread of HIV. Government Response: Against the background presented above, the TB control was clearly not effective, and the threat of a generalized HIV/AIDS epidemic in Ukraine appeared imminent by 1999/2000 when the Government of Ukraine began to work with the World Bank on the preparation of the TB and HIV/AIDS Control Project. 3

20 With respect to TB, in May 2000, a Presidential Decree was issued On Urgent Measures for TB Control and US$5 million was allocated for centralized procurement of TB drugs. Also a draft of the National TB Program was under preparation and the then Minister of Health ( ) was proposing to introduce the WHO recommended Directly Observed Treatment, Short-Course (DOTS) as a proven cost-effective strategy being used in more than 110 countries in the world at that time. The five elements of the strategy were the need to (i) ensure political commitment to strengthen TB control; (ii) introduce lower cost and more efficient approaches to TB diagnosis, with the sputum smear microscopy used as the primary diagnostic tool, supplemented by chest x-ray if necessary; (iii) introduce directly observed treatment; (iv) introduce centralized procurement of anti-tb drugs; and (v) introduce standardized case definitions and indicators. Indeed, by early 2000, there was commitment at the highest levels of Government to DOTS, including from Parliament, MOH and the SDP as well as other Ministries. The Department of Socially Dangerous Diseases was established in the MOH in 1999 in order to strengthen the response to TB as well as to HIV/AIDS. Despite this broad interest and commitment, there remained considerable resistance to DOTS from the TB Institute and from medical practitioners in Ukraine as well as other vested interest groups. Also, the new MOH minister in mid-2000 was resistant to DOTS. In the end, the Government adopted a National Tuberculosis Program (NTP) for which did not use or refer to DOTS and it was sufficiently clear that the full DOTS strategy was not entirely accepted. Indeed, as the Project Appraisal Document for the Bank-financed project pointed out, DOTS was perceived as a strategy for low-income countries and this alienated some important stakeholders. Nonetheless, the Government s strategy was named the National TB Strategy Adapted to World Standard and it did incorporate some DOTS principles. For example, in line with the new strategy, regular drug supply was re-introduced and financed under the program with increased emphasis on direct observation of drug intake. Also, the MOH issued an Order on February 6, 2002 to develop TB bacteriological diagnostic capacity and to increase focus on case detection through sputum microscopy. Unfortunately, no budget was provided for this task. Government response to the growing HIV/AIDS epidemic began in 1991 with Ukraine adopting a Law on AIDS Control and Social Protection (subsequently amended in 1998). In 1992, the National AIDS Center was established on the basis of the Institute of Epidemiology and the first program on HIV/AIDS in Ukraine, , was adopted. As the epidemic progressed, two additional programs were supported by Government, Program and AIDS and Drug Use Program for Ukraine which defined prevention measures, implementation tools and responsible institutions. Also, in August 1999, the National Coordination Council for AIDS was formed under the leadership of the Vice-Prime Minister including representatives of all major relevant ministries to carry out strategic planning with support from UNAIDS and other donor agencies. Finally, by early 2001, Ukraine was implementing its fourth National HIV/AIDS Program on Prevention of Mother-to-Child Transmission of HIV, In 2003, Ukraine submitted to UNAIDS its first report for the monitoring of progress against the Declaration of Commitment adopted at the 2001 UN General Assembly Special Session on HIV and AIDS (UNGASS). These were important steps taken but the overall response as well as budgetary allocations were still limited. In fact, the first four HIV/AIDS Programs were severely underfunded which meant that no serious efforts could be taken at the local level to stem the tide of the epidemic. Country Assistance Strategy and Rationale for Bank Involvement: In 1999, the Bank began the process of close collaboration with the Government of Ukraine on the preparation of the TB and HIV/AIDS Control Project to be financed by a Bank loan of US$60 million. The Bank was well-placed to support this operation given its extensive involvement world-wide in HIV/AIDS issues and given the urgent needs in Ukraine in this area. The project was an integral part of the FY Country Assistance Strategy for Ukraine focused on a broad-based poverty reduction strategy with an emphasis on helping civil society to increase its voice for better government and social service provision in globally sensitive areas. 4

21 1.2 Original Project Development Objectives (PDO) and Key Indicators (as approved) The PDO was to reduce tuberculosis (TB) and HIV/AIDS morbidity and mortality through an effective National Strategy for TB Adapted to World Standard, and an HIV/AIDS Program largely focused on prevention of transmission of the disease among high-risk groups. An extensive list of indicators was included in Annex 1 of the PAD. The indicators were divided between those measuring success of interventions among the general population and in the prison setting. There were 7 outcome indicators for TB and 4 outcome indicators for HIV/AIDS, as well as 17 output indicators for TB and 17 HIV/AIDS indicators although in many cases they were duplicative. These indicators focused on changes in prevalence, incidence, mortality, success and coverage of prevention and treatment programs, behavior changes, as well as on institutional development and response capacity to the epidemic. It should be noted that the PAD text (page 2) had an entirely different set of HIV/AIDS outcome indicators than those in Annex 1 of the PAD. Also, importantly, the Supplemental Letter No. 2 to the Loan Agreement, dated April 15, 2003, which lists the officially agreed Monitoring and Evaluation Indicators, did not include any outcome indicators for the project. Only an extensive list of output indicators was attached (copy from the PAD Annex 1). No reason could be found by the ICR author for this important omission. 1.3 Revised PDO and Key Indicators, and reasons/justification The PDO was not revised. However, in February 2006, during the Mid-term Review of the project, additional indicators were added while other indicators were reworded and some others deleted entirely in order to better and more appropriately capture critical data on HIV and TB. Regretfully, the M&E for the project was persistently one of the weakest areas and no complete set of indicators was ever produced with updated information. Therefore, the ICR team collected extensive data on baselines, targets and actual achievements, working with Government counterparts as well as with international agencies. Special thanks must be extended to WHO, MOH, the National AIDS Center and the TB Institute for their valuable clarifications regarding TB and HIV/AIDS indicators. The ICR team also compiled additional indicators to contribute to a more complete picture of the epidemics and what the project contributed. 1.4 Main Beneficiaries: Project beneficiaries were to include: (a) high-risk groups who would benefit from targeted interventions under the project. These groups include commercial sex workers (CSW) and their clients, men who have sex with men (MSM); (b) persons living with HIV/AIDS who would benefit from better access to treatment, care and support interventions under the project; and (c) the entire population in Ukraine who would benefit from interventions aimed at the general community from reduced HIV transmission from the high-risk groups. In addition, all stakeholders of the TB system, TB patients as well as the entire Ukranian population were to benefit from the project as a result of planned improvements in diagnostics, treatment and monitoring of TB. 1.5 Original Components The project had three components, totaling an estimated US$77 million, of which the Bank was to finance US$60 million and the Government was to contribute US$17 million, as follows: Component 1: Control of Tuberculosis MOH (total estimated cost US$28.7 million). This component was to assist the MOH control the expanding epidemics of TB and MDR TB and upgrade the country s capabilities in these areas. It was to provide the MOH with the means to implement its National 5

22 TB Strategy Adapted to World Standard and to strengthen the government s capacity both at the central level (MOH, Institute of Phthisiology and Pulmonology, and the National Reference Laboratory) and in the country s 27 regions. This component included 5 sub-components, as follows: (i) Training and Education (US2.6 million). This sub-component was to be implemented by the Institute of Phthisiology and Pulmonology in Kiev, supported by 12 regional centers. Activities would include the training of TB specialists, laboratory technicians, GPs, epidemiologists, statisticians and nurses in the detection and treatment of TB as well as in the proper monitoring and supervision of treatment and outcomes. It was to finance training of trainers, vehicles, computer and office equipment, materials, per diem and travel expenses. (ii) Diagnosis (US$11.5 million). This sub-component was to finance the development of technical guidelines, the purchase of vehicles, computer, office and laboratory equipment, including microscopes and supplies to undertake smear microscopy, and equipment for culture investigation at the regional levels. National Reference Laboratory was to be strengthened to implement laboratory quality control and investigations, including culture and drug susceptibility tests. (iii) Treatment (US$10.2 million). This sub-component was to be finance first-line drugs for TB. Financing was to be done mostly by Government with US$7.6 million; however, US$2.6 was included for Bank financing of drugs in case of additional need. (iv) Public Awareness Campaign (US$1.1 million). This sub-component was to finance mass media public awareness campaigns and training and educational materials to raise awareness of TB in the general population. (v) Monitoring and Evaluation (US$3.2 million). This sub-component was to finance monitoring of compliance with treatment protocols as well as baseline studies, collection and analysis of data to monitor key project indicators. Financing for project management was included as well. Component 2: AIDS Control MOH (total estimated cost US$32.2 million). This component was to support the following three objectives of the Ukraine s Program of HIV/AIDS Prevention adopted on July 11, 2000: (i) to stabilize the epidemiological situation in the country; (ii) to reduce risky behavior among young people; and (iii) to reduce the social tension in the society and negative consequences of the epidemic. The highest priority and financing of this component was to be directed towards targeted interventions to prevent the further transmission of HIV. This component included four sub-components as follows: (i) HIV Prevention (US$22.9 million). This sub-component was to finance harm reduction programs among IDUs, CSWs, and MSM including training, advocacy, education materials, peer education programs, vehicles, syringes, condoms and supplies, and dissemination of protocols on HIV prevention. The sub-component was to also finance test kits and equipment to improve blood safety and the preparation and distribution of guidelines on the rational use of blood. A public awareness campaign was also included to increase information of the general population about HIV prevention, encourage the use of protective measures, and reduce stigma. (ii) Treatment activities (US$3.8 million). This sub-component was to support the development of treatment protocols, prevention of MTCT, drugs and supplies for the treatment of opportunistic infections, training of staff on psycho-social care and support of PLWHA, and laboratory equipment. (iii) Care and Support for PLWHA (US$2.3 million). This sub-component would increase access to services to improve the quality of life of PLWHA. This would be accomplished through the training of psychologists, social workers, welfare workers and GPs, the review and revision of curricula for physicians, nurses and other health workers, the establishment of self-help group of PLWHA and their families, the piloting of non-hospital-based care alternatives, the printing of training and education materials. 6