Document of The World Bank Report No: ICR2411 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-35840 TF-50111) ON A CREDIT IN THE AMOUNT OF SDR 13.3 MILLION (US$ 17.0 MILLION EQUIVALENT) TO THE CENTRAL AFRICAN REPUBLIC FOR A MULTISECTORAL HIV/AIDS, HEALTH, AND EDUCATION EMERGENCY SUPPORT PROJECT (CR. 3584-CA) September 30, 2012 Human Development Sector West and Central Africa Health, Nutrition and Population (AFTHW) Country Department AFCC1 Africa Region CURRENCY EQUIVALENTS (Exchange Rate Effective August 31, 2012) Currency Unit = Central African Francs US$ 1.00 = 521 XAF FISCAL YEAR July 1 – June 30 ABBREVIATIONS AND ACRONYMS AIDS Acquired Immune-deficiency Syndrome ARV Anti-retroviral CAR Central African Republic CAS Country Assistance Strategy CD Country Director CMO Implmentation Committee / Comité de mise en oeuvre CNLS National HIV/AIDS Coordinating Committee/ Comité National de Lutte contre le SIDA CNLS-TS CNLS Technical Secretariat CNTS National Blood Transfusion Center / Centre National de Transfusion Sanguine COGES Local health committees/ Comité de Gestion CPFOSC Cellule Provisoire de Financement aux Organisations de la Societé Civile CPLS Provincial HIV/AIDS Coordinating Committee/ Comité Provincial de Lutte Contre le SIDA CSO Civil-Society Organization DCA Development Credit Agreement DGH General Directorate for Hydraulic/ Direction Générale de l'Hydraulique EFA/FTI Education for All Program/ Fast Track Initiative EFAP Education for All Program ERR Economic Rate of Return ESMF Environmental and Social Management Framework FBOs Faith-based Organizations FMPU Financial Management and Procurement Unit FMU Financial Management Unit GDP Gross Domestic Product GFATM Global Fund to fight against AIDS, Tuberculosis and Malaria HIPC Heavily-Indebted Poor Country HIV Human Immunodeficiency Virus HMIS Health Management Information Systems HRITF Health Results Innovation Trust Fund IDA International Development Association IO Intermediate Outcome IP Implementation Progress IPD Inclusive Political Dialogue 2 I-PRSP Interim Poverty Reduction Strategy Paper ISN Interim Strategy Note ISR Implementation Status and Results ITN Insecticide-treated nets KPI Key Performance Indicator LICUS Low Income Country under Stress M&E Monitoring and Evaluation MAP Multi-sectoral Aids Program MDG Millennium Development Goals MICS Multiple Indicator Cluster Survey MHPP Multisectoral HIV/AIDS Prevention Project (prior to effectiveness) MOE Ministry of Education MOHP Ministry of Health and Population PMTCT Prevention of Mother-to-Child Transmission MWMP Medical Waste Mitigation Plan NGOs Non-Governmental Organizations NHDP National Health Development Plan NPV Net Present Value OMS Operational Manual Statement OVC Orphans and Vulnerable Children PAD Project Appraisal Document PBF Performance-based financing PDO Project Development Objectives PLWHA People Living with HIV/AIDS PMTC Prevention of Mother-to-Child Transmission PPF Project Preparation Facility PRSP Poverty Reduction Strategy Paper PSES Multisectoral HIV/AIDS, Education and Health Project (Projet multisectoriel de lutte contre le SIDA, Education et Santé), (post- effectiveness) RESEN Education Country Status Report /Rapport sur l’Etat du Système Educatif National TSS Transitional Support Strategy TTL Task Team Leaders UCM Central Drug Procurement Unit/ Unité de Cession de Médicaments UNAIDS Joint United Nations Programme on HIV/AIDS UNGASS United Nations General Assembly Special Session UNICEF United Nations Children’s Fund VCT Voluntary Counseling and Testing WHO World Health Organization Vice President: Makhtar Diop Country Director: Gregor Binkert Sector Manager: Trina Haque Project Team Leader: Gaston Sorgho ICR Team Leader: Tomo Morimoto 3 CENTRAL AFRICAN REPUBLIC Multisectoral HIV/AIDS, Health and Education Emergency Support Project CONTENTS Data Sheet A. Basic Information B. Key Dates C. Ratings Summary D. Sector and Theme Codes E. Bank Staff F. Results Framework Analysis G. Ratings of Project Performance in ISRs H. Restructuring I. Disbursement Graph 1. Project Context, Development Objectives and Design .............................................15 2. Key Factors Affecting Implementation and Outcomes .............................................21 3. Assessment of Outcomes ...........................................................................................26 4. Assessment of Risk to Development Outcome .........................................................34 5. Assessment of Bank and Borrower Performance ......................................................35 6. Lessons Learned ........................................................................................................37 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners ...........38 Annex 1. Project Costs and Financing...........................................................................39 Annex 2. Descriptive Summary of Outputs by Component ..........................................41 Annex 3. Economic and Financial Analysis ..................................................................46 Annex 4. Bank Lending and Implementation Support/Supervision Processes .............48 Annex 5. Summary of Borrower's ICR and/or Comments on Draft ICR ......................50 Annex 6. List of Supporting Documents .......................................................................53 Annex 7. Map of CAR ...................................................................................................56 4 A. Basic Information Multisectoral HIV/AIDS Country: Central African Republic Project Name: Project Project ID: P073525 L/C/TF Number(s): IDA-35840,TF-50111 ICR Date: 09/22/2012 ICR Type: Core ICR Lending Instrument: APL Borrower: GOVERNMENT OF CAR Original Total XDR 13.30M Disbursed Amount: XDR 12.40M Commitment: Revised Amount: XDR 13.30M Environmental Category: B Implementing Agencies: PSES-UGFPM Cofinanciers and Other External Partners: B. Key Dates Revised / Actual Process Date Process Original Date Date(s) Concept Review: 03/12/2001 Effectiveness: 02/15/2002 09/19/2007 06/25/2007 Appraisal: 04/23/2001 Restructuring(s): 09/21/2010 11/29/2011 Approval: 12/14/2001 Mid-term Review: Closing: 06/30/2006 03/31/2012 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Moderately Satisfactory Risk to Development Outcome: Moderate Bank Performance: Moderately Satisfactory Borrower Performance: Moderately Satisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Satisfactory Government: Moderately Satisfactory Implementing Quality of Supervision: Moderately Satisfactory Moderately Satisfactory Agency/Agencies: Overall Bank Overall Borrower Moderately Satisfactory Moderately Satisfactory Performance: Performance: 5 C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments (if Indicators Rating Performance any) Potential Problem Project at Yes Quality at Entry (QEA): None any time (Yes/No): Problem Project at any time Quality of Supervision Yes None (Yes/No): (QSA): DO rating before Satisfactory Closing/Inactive status: D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Central government administration 15 15 Health 47 47 Other social services 33 33 Sub-national government administration 5 5 Theme Code (as % of total Bank financing) Gender 14 14 HIV/AIDS 29 29 Health system performance 14 14 Participation and civic engagement 29 29 Population and reproductive health 14 14 E. Bank Staff Positions At ICR At Approval Vice President: Makhtar Diop Callisto E. Madavo Country Director: Gregor Binkert Robert Calderisi Sector Manager: Trina S. Haque Joseph Baah-Dwomoh Project Team Leader: Gaston Sorgho Jean Delion ICR Team Leader: Tomo Morimoto ICR Primary Author: Tomo Morimoto F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) Contribute to reducing HIV/AIDS prevalence in CAR and mitigating the impact of HIV/AIDS on persons living with or affected by HIV/AIDS. This will be achieved through support to public sector responses, e.g. the Ministry of Health and other public sector organizations, as well as by supporting 6 civil society responses through civil society organizations (CSOs), e.g. NGOs and private firms, and communities. The project will also be achieved through coordination, program management and M&E. Revised Project Development Objectives (as approved by original approving authority) The objectives of the project are to assist the recipient to contribute to: (a) urgent needs in the fight against HIV/AIDS, such as access to prevention, treatment, and impact mitigation services; (b) urgent social needs, such as prevention of malaria, increased access to water supply and improved primary education. The project consists of the following four components: Component 1: Support to the National Program against HIV/AIDS Component 2: Support to Emergency Health Needs Component 3: Support to Emergency Needs in the Education Sector Component 4: Support to Financial Management and Procurement. (a) PDO Indicator(s) Original Target Actual Value Formally Values (from Achieved at Indicator Baseline Value Revised Target approval Completion or Target Values documents) Years 90 percent of the population aged 15-49 will be aware of sexually transmitted infections Indicator 1 : (STI) and HIV/AIDS, and 90 percent among them will know of at least two means of avoiding HIV transmission (Development Credit Agreement, DCA 2001) Value 24.4percent for 15-24 quantitative or Data not available 90percent NA years of age at national Qualitative) level (UNGASS 2008) Date achieved 12/31/2001 12/31/2001 12/31/2001 01/31/2008 Comments The indicator was in the original PAD but eliminated before project effectiveness. No (incl. % baseline value available. Data for 15-24 years of age was 24.4percent according to UNGASS achievement) report (2008) at national level. Use of condoms at least for non-regular sexual contact in the 15-24 years age group will have Indicator 2 : increased to 60 percent (DCA 2001) 49.5 percent for age Value group 15-49 years at quantitative or Data not available 60 percent NA national level Qualitative) (UNGASS report 2008) Date achieved 12/31/2001 Comments The indicator was in the original PAD but eliminated before project effectiveness. No (incl. % baseline value available. Use of condoms for non-regular sexual contact in the 15-49 years achievement) group in the last 12 months was 49.5 percent in UNGASS report 2008. Less than 10 percent national HIV/AIDS prevalence among ante-natal women aged 15-19, as Indicator 3 : measured by sentinel surveillance systems (DCA 2001) Value quantitative or Data not available Less than 10% NA Data not available Qualitative) Date achieved 12/31/2001 Comments The indicator was in the original PAD but eliminated before project effectiveness. No (incl. % baseline nor actual value available. 7 achievement) 70 percent of people living with HIV/AIDS (PLWHA) will benefit from Pneumocysitis Indicator 4 : Carinii Pneumonia (PCP) Prophylaxis (DCA 2001) Value quantitative or Data not available 70 percent NA Data not available Qualitative) Date achieved 12/31/2001 Comments The indicator was in the original PAD but eliminated before project effectiveness. No (incl. % baseline or actual values are available. achievement) 70 percent of 2,000 communities covered under the project will provide satisfactory support Indicator 5 : to PLWHA, orphans and widows (DCA 2001) Value 70 percent of 2,000 quantitative or Data not available NA Data not available communities (1,400) Qualitative) Date achieved 12/31/2001 Comments The indicator was in the original PAD but eliminated before project effectiveness. No (incl. % baseline or actual values were available. achievement) Indicator 6 : Reduction of STI among pregnant women by 10 percent (DCA 2001) Value Reduction by 10 quantitative or Data not available NA Data not available percent Qualitative) Date achieved 12/31/2001 Comments The indicator was in the original PAD but eliminated before project effectiveness. No (incl. % baseline or actual values are available. achievement) Indicator 7 : 100 percent of all transfused blood will be screened for HIV by end of project (DCA 2001) Value 100 percent of all quantitative or Data not available NA Data not available transfused blood Qualitative) Date achieved 12/31/2001 Comments The indicator was in the original PAD but eliminated before project effectiveness. No (incl. % baseline or actual values are available. achievement) 50 percent increase in the number of patients under DOTS treatment in all prefectures (DCA Indicator 8 : 2001) Value quantitative or Data not available 50 percent increase NA Data not available Qualitative) Date achieved 12/31/2001 Comments The indicator was in the original PAD but eliminated before project effectiveness. No (incl. % baseline or actual values were available. achievement) Uses of condoms at last non-regular sexual contact in the 15-49 years age group will have Indicator 9 : increased to 90 percent (DCA 2001) Value quantitative or Data not available 90 percent NA Data not available Qualitative) Date achieved 12/31/2001 8 Comments The indicator was in the original PAD but eliminated before project effectiveness. No (incl. % baseline or actual values were available. achievement) 75 percent of military personnel will have used a condom at last non-regular sexual contact Indicator 10 : (DCA 2001) Value quantitative or Data not available 90 percent NA Data not available Qualitative) Date achieved 06/01/2007 Comments The indicator was in the original PAD but eliminated before project effectiveness. No (incl. % baseline or actual values were available. achievement) Number of men and women who accepted VCT and received test results in targeted health Indicator 11 : centers (DCA 2007) Value 118,862 (CNLS quantitative or 0 200,000 NA quarterly reports) Qualitative) Date achieved 06/01/2007 06/01/2007 03/31/2012 Comments Introduced as new indicator at the 2007 restructuring/project effectiveness. End project (incl. % achievement at 59 percent, due to delay in arrival of inputs (final lot currently being achievement) distributed). Number of adults and children with HIV receiving antiretroviral combination therapy (Core) Indicator 12 : (DCA 2007) Value 1,719 (Adult: 1,624; quantitative or 0 1,300 NA Children: 95) (CNLS Qualitative) quarterly reports) Date achieved 06/01/2007 06/01/2007 03/31/2012 Comments Introduced as ''number of PLHWA receiving ARV in targeted health centers'' at the 2007 (incl. % restructuring/project effectiveness, but modified in September 2010 restructuring to reflect achievement) IDA core indicator wording. Target achieved by 132 percent. Number of PLWHA receiving support through their associations or their national federation Indicator 13 : of associations (DCA 2007, 2010) Value 14,004 (Association quantitative or 0 2,000 8,000 reports, compiled by Qualitative) CNLS-TS) Date achieved 06/01/2007 06/01/2007 09/24/2010 03/31/2012 Comments Introduced as new indicator at the 2007restructuring/project effectiveness. Target achieved (incl. % by 175 percent. Target revised to include those benefiting from support (PLWHA x 3). achievement) Indicator 14 : Additional number of households using ITNs (DCA 2007) Value 100,000 (MoHP quantitative or 0 300,000 NA reports) Qualitative) Date achieved 06/01/2007 06/01/2007 03/31/2012 Comments Introduced as new indicator at the 2007 restructuring/project effectiveness. Target only (incl. % achieved by 33 percent as the second lot was received but could not be distributed. achievement) Number of people provided with access to "improved water sources" under the project (in Indicator 15 : rural areas) (Core) (DCA 2007) Value 0 19800 (based on NA 30,300 9 quantitative or calculation 300 Qualitative) people to benefit from one water point) Date achieved 06/01/2007 06/01/2007 03/31/2012 Comments Introduced as new indicator at the 2007 restructuring/project effectiveness as ''Number of (incl. % people having access to water points provided by the project'' but later modified to reflect achievement) IDA core indicator wording. Target achieved by 144%. Indicator 16 : Number of teachers meeting minimum teaching qualifications in targeted areas (DCA 2007) Value quantitative or 3,666 4,516 NA 4,668 Qualitative) Date achieved 06/01/2007 06/01/2007 03/31/2012 Comments Introduced as new indicator at the 2007 restructuring/ projec effectiveness. Target achieved (incl. % by 103 percent. achievement) (b) Intermediate Outcome Indicator(s) 1 Original Target Actual Value Formally Values (from Achieved at Indicator Baseline Value Revised Target approval Completion or Target Values documents) Years Indicator 1 : Number of pregnant women reached by PMTCT in targeted health centers(DCA 2007, 2010) Value 10465 (CNLS (quantitative 0 5000 9000 quarterly reports) or Qualitative) Date achieved 06/01/2007 06/01/2007 09/24/2010 03/31/2012 Comments Introduced at the 2007 restructuring as ''number of pregnant women reached by PMTCT (incl. % during the last 12 months in targeted health centers'' but wording modified to ensure achievement) cumulative data and with target increase. Target achieved by 116 percent. Number of blood transfusion pockets tested for HIV and other blood-borne infections in Indicator 2 : targeted health centers (DCA 2007, 2010) Value NA (some already tested with (quantitative LICU support in 2006 but 50000 32000 27944 (CNTS reports) or Qualitative) data not available) Date achieved 06/01/2007 06/01/2007 09/24/2010 03/31/2012 Comments Introduced as a new indicator at the 2007 restructuring but target revised later due to shortage (incl. % of blood pocket supplies. Achievement rate at 87 percent but subject to increase when final achievement) distribution of blood pockets is completed. Number of health centers implementing measures in the Medical Waste Mitigation Plan Indicator 3 : (DCA 2007) Value (quantitative 0 40 NA 31 (MoHP reports) or Qualitative) Date achieved 06/01/2007 06/01/2007 03/31/2012 Comments Introduced as a new indicator at the 2007 restructuring. Only 31 health centers supported 1 Description of Intermediate Outcome Indicator in the datasheet is limited to those under revised PDO (i.e., after project effectiveness). 10 (incl. % under component 1 (HIV) received support, thus an achievement rate of 80 percent. achievement) Indicator 4 : Number of public sector HIV action plans developed and implemented (DCA 2007) Value (quantitative 0 4 NA 4 (CNLS-TS) or Qualitative) Date achieved 06/01/2007 06/01/2007 03/31/2012 Comments (incl. % Introduced as new indicator at the 2007 restructuring. Target achieved. achievement) Indicator 5 : Number of youth HIV action plans developed and implemented (DCA 2007) 85 action plans (from Value 35 associations) 100 (action (quantitative 0 40 (Youth association plans) or Qualitative) reports, compiled by CNLS-TS) Date achieved 06/01/2007 06/01/2007 03/31/2012 Comments Not clear if the initial target counted number of associations instead of number of action (incl. % plans. Project claims that the target was 100 action plans from 40 associations, in which case achievement) target achievement rate is 85 percent. Indicator 6 : Long-lasting insecticide-treated malaria nets purchased and/or distributed (DCA 2007) Value 100000 (distributed)/ (quantitative 0 300000 NA 366,000 (purchased) or Qualitative) (MoHP reports) Date achieved 06/01/2007 06/01/2007 03/31/2012 Comments Introduced at the 2007 restructuring as ''number of ITNs distributed through the project''. (incl. % Distribution only achieved by 33 percent as the second lot was received but could not be achievement) distributed. Square-meter area drained (through project) of (previous) standing water and marshlands Indicator 7 : identified by population as major cause of malaria transmission (DCA 2007) Value (quantitative 0 Not available Not available Not available or Qualitative) Date achieved 06/01/2007 06/01/2007 03/31/2012 Comments Indicator dropped due to limited budget and participating communities' priorities (no demand (incl. % demonstrated for drainage of standing water and marshlands). achievement) Number of improved community water points constructed or rehabilitated under the project. Indicator 8 : (DCA 2007) Value 101 (DG Hydraulic (quantitative 0 30 NA reports) or Qualitative) Date achieved 06/01/2007 06/01/2007 03/31/2012 Comments Introduced at the 2007 restructuring as ‘number of new rural community points established (incl. % through the project'' but modified to reflect core indicator wording. achievement) Indicator 9 : Student/books ratio in targeted areas (DCA 2007, 2010) Value (quantitative 6.7 2.8 by end 2008 1.85 1.85 (MoE reports) or Qualitative) 11 Date achieved 06/01/2007 06/01/2007 09/24/2010 03/31/2012 Comments (incl. % Introduced as new indicator at the 2007 restructuring. Target achieved. achievement) Indicator 10 : Number of textbooks purchased and distributed (core) (DCA 2007) Value (quantitative 66,310 155,560 155,560 88,530 (MoE reports) or Qualitative) Date achieved 06/01/2007 06/01/2007 03/31/2012 Comments Introduced as a new indicator at the 2007 restructuring. Target reduced (though not officially) (incl. % thus achievement rate remains at 57 percent vis à vis the original target. achievement) G. Ratings of Project Performance in ISRs Date ISR Actual Disbursements No. DO IP Archived (USD millions) 1 04/03/2002 Satisfactory Satisfactory 0.00 2 07/30/2002 Satisfactory Satisfactory 0.00 3 11/26/2002 Satisfactory Satisfactory 0.00 4 05/25/2003 Satisfactory Satisfactory 0.00 5 11/24/2003 Satisfactory Satisfactory 0.00 6 05/06/2004 Satisfactory Satisfactory 0.00 7 06/28/2004 Satisfactory Unsatisfactory 0.00 8 10/13/2004 Satisfactory Unsatisfactory 0.00 9 04/25/2005 Satisfactory Unsatisfactory 0.00 10 10/25/2005 Unsatisfactory Unsatisfactory 0.00 11 12/20/2005 Unsatisfactory Unsatisfactory 0.00 12 06/09/2006 Unsatisfactory Unsatisfactory 0.00 13 03/02/2007 Unsatisfactory Unsatisfactory 0.00 14 06/27/2007 Satisfactory Satisfactory 0.00 15 11/05/2007 Satisfactory Moderately Satisfactory 0.00 16 04/17/2008 Moderately Satisfactory Moderately Satisfactory 3.46 17 08/31/2008 Moderately Satisfactory Moderately Satisfactory 3.98 18 03/16/2009 Moderately Satisfactory Moderately Satisfactory 5.94 19 06/30/2009 Moderately Satisfactory Moderately Satisfactory 6.89 20 12/19/2009 Moderately Satisfactory Moderately Satisfactory 8.90 21 06/28/2010 Satisfactory Satisfactory 11.26 22 02/22/2011 Satisfactory Satisfactory 14.29 23 12/17/2011 Satisfactory Satisfactory 17.22 24 03/31/2012 Moderately Satisfactory Moderately Satisfactory 18.32 H. Restructuring (if any) Restructuring Board Approved ISR Ratings at Amount Reason for Restructuring & Key Date(s) PDO Change Restructuring Disbursed at Changes Made 12 Restructuring in DO IP USD millions 05/30/2007 N U U 0.00 NA A Level 1 restructuring to: (i) change the PDO and project components from exclusive focus on HIV/AIDS to include emergency response to critical social needs resulting from the crisis (results framework updated accordingly); (ii) modify the 06/25/2007 Y U U 0.00 institutional and implementation arrangements to reflect the involvement of new sectors; and (iii) extend the project closing date for the second time from June 30, 2007 to September 30, 2010 to allow three years for project implementation. A Level 2 restructuring (CD approval) to: (i) reallocate credit proceeds within categories ; (ii) update the results framework to align it with reflect the Bank's core 09/21/2010 N S S 12.35 indicator wording as well as to adjust the targets; and (iii) extend the project closing date for the third time from September 30, 2010 to March 31, 2012. Reallocation of credit proceeds within categories to achieve possible 11/29/2011 N S S 17.22 cost savings and needed increases in other areas. 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 NA Against Formally Revised PDO/Targets Moderately Satisfactory Overall (weighted) rating Moderately Satisfactory 13 I. Disbursement Profile 14 1. Project Context, Development Objectives and Design 1.1 Context (country background) 1. The Central African Republic (CAR) has experienced a long period of political instability and armed conflict, bad governance and poor socio-economic outcomes. At the time of original project appraisal in 2000, an estimated 67 percent of the population of 3.6 million was living under the poverty line; CAR can therefore readily be characterized as one of the poorest countries in the world. Recurrent conflicts have led to a deterioration of all social indicators, making it unlikely that CAR could achieve most of the Millennium Development Goals (MDGs) by 2015. In 2000 CAR was ranked 165 out of 173 in the human development index according to the UNDP Human Development Report (2002), with life expectancy at birth estimated at 44.3 years, well below the average for sub-Saharan African countries. 2. The past decade in particular has seen a vicious cycle of periodic mutinies and coup attempts, all of which have led to the destruction of infrastructure and social services. In February 2002, CAR fell into non-accrual status due to its accumulated arrears. As a result, most of the donors withdrew from their support to the country. The World Bank was no exception: it suspended its entire portfolio from February 2002 until the country cleared its arrears in November 2006. The multisectoral HIV/AIDS Prevention Project (MHPP) was approved by the Board and signed in December 2001, but never became effective until suspension was lifted and the project was restructured in 2007. 3. In March 2003, the country underwent a regime change and the establishment of a transitional government, which successfully held national elections in 2005, marking an important step towards stability. Peace talks resulted in a peace agreement with key rebel groups in 2007 and 2008, which led to the holding of an Inclusive Political Dialogue (IPD) in December 2008. The National Unity Government, headed by the incumbent president, was formed in January 2009, but the security situation remains uncertain due to sporadic violence. 4. The World Bank’s Country Re-Engagement Note (CRN) developed in 2004 marked the re- establishment of the Bank’s relationship with CAR. The Note proposed that the Bank’s assistance program focus on two building blocks, with one aimed at improving delivery of basic social services. The Note explicitly mentioned the focus on HIV/AIDS prevention and control, while also stressing the need for other emergency social service recovery programs. 5. The CRN was superseded by an Interim Strategy Note (ISN) for FY2007-2008 which was jointly prepared by the African Development Bank and the World Bank. The ISN sought to harmonize support from CAR’s key development partners and to demonstrate their shared resolve to: (i) address the country’s aggravated arrears problem; (ii) facilitate access to the Highly Indebted Poor Countries (HIPC) initiative and the Multilateral Debt Relief Initiative (MDRI); (iii) support government efforts to provide basic services; and (iv) reinforce government action to stabilize the social and political environment. It also highlighted the severely deteriorating social indicators in CAR and proposed to drastically restructure the suspended MHPP in order to include other social sectors in addition to HIV/AIDS. 6. Sector Background. At the time of the original project approval in 2001, UNAIDS estimated that approximately 10.7 percent of the population aged 15-49 was living with HIV/AIDS. UNAIDS used a method based on measuring the HIV/AIDS infection rate among pregnant women and extrapolating the results to the whole population. This placed CAR as the tenth most HIV-infected country in sub-Saharan Africa. The original PAD further noted that the estimated number of deaths due to AIDS was between 13,000 and 23,000, with the number of AIDS orphans exceeding 70,000. 15 7. In 2006 at the time of project re-appraisal after suspension, a seroprevalence study conducted nationwide concluded that CAR was in the midst of a generalized HIV/AIDS epidemic characterized by high regional variations and an overall prevalence rate at 6.2 percent for 15-49 years of age. 2 The study equally concluded that: (i) the prevalence rate was much higher for women (7.8 percent) than men (4.3 percent); (ii) there were substantial differences between prefectures, ranging from 1 to 15 percent; and (iii) the far highest prevalence rate was among uniformed personnel (military, police) at 21.1 percent, followed by service occupations and unskilled workers at 8.5 percent. The 2006 study estimated a total number of seropositive people at about 200,000, most of whom are not aware whether they are seropositive or not. 8. In addition, more than ten years of civil unrest have reduced both the coverage and quality of essential social services, including provision of basic health services, primary education and access to water and sanitation. Available indicators confirm the severity of the health crisis. In 2006 Multiple Indicator Cluster Survey (MICS 3), Human development indicators in CAR were well below the sub- Saharan average, with infant mortality at 106 live births per 1,000 with a large variation between urban and rural areas, and the percentage of malnourished children under-five at 19 percent. Maternal mortality stood at 544 per 100,000, a large decrease from 1,355 per 100,000 in 2003, but still very high and far from the MDG target. In 2006 the prevalence rate of malaria infections among children under- five was estimated at 20 percent and continues to be one of the most important causes of death in CAR; at the time of the MICS survey about 36 percent possessed at least one bednet, and only 16 percent possessed at least one insecticide-treated nets (ITNs). 9. Similarly, education outcomes in CAR were among the lowest in the subregion and have experienced further deterioration from the extended period of instability. The education system suffered a loss of teachers, destruction of infrastructure, and low investment, particularly in rural areas where education services were virtually nonexistent. The teacher pupil ratio fell from 1/63 in 1987 to 1/87 in 2003 and 1/92 in 2005/2006, reaching as low as 1/160 in certain schools. The results of the recent Country Status Report (Rapport d'Etat d’un Système Educatif National - RESEN) show that knowledge of mathematics and French is among the lowest in Francophone African countries. The repetition rate is high at more than 30 percent of pupils compared with an average of 10 percent in Africa, and 40 percent of pupils drop out before completing primary school. Almost half of the teachers in the primary schools are "parent-teachers," poorly paid and living in the poorest villages. 10. Government priorities for HIV/AIDS. The development of the original project was driven by the government’s early recognition of the threat posed by the HIV/AIDS epidemic. In 2000, the government, with UNAIDS sponsorship, undertook a thorough strategic planning process to strengthen the national response to HIV/AIDS, focusing on the involvement of all sectors and civil society. In January 2001 the President of CAR issued a decree creating the National HIV/AIDS Coordinating Committee (Comité National de Lutte contre le SIDA, CNLS 3), which had the overall responsibility of leading the fight against HIV/AIDS. The Committee, directly placed under the authority of the Head of State (i.e. the President), was supported by a Technical Secretariat (CNLS-TS), which led the preparation of this MHPP. In the process the government emphasized two strategies: (i) a multisectoral approach engaging all societal actors in the fight against HIV/AIDS; and (ii) allocation of resources to both public and private sector partners in light of limited external support. 2 While the 2001 UNAIDS estimates were based on few antenatal clinics, the 2006 sero-surveillance study was based on 11 samples (including 5,413 women and 5,179 men from 15 to 49 years of age) from different parts of the country. As observed in neighboring countries such as Benin and Cameroon, this tends to yield lower estimates. 3 Created under Government Decree 01.032 of January 26, 2001, modified by Decree 02.274 of November 29, 2002. 16 11. In 2006, the Government of CAR developed an HIV National Strategic Framework 2006-2010 following the earlier version of 2002-2005, alerting the disease’s substantial threat to the economic and social development of the country. The Framework retained the following four strategic axes:: (i) strengthen the prevention programs to make the population change their behavior towards HIV/AIDS and carry out programs focusing on vulnerable population, in particular women and youth; (ii) strengthen the universal treatment for people infected or affected taking into account all aspects (psychosocial, opportunistic infections (OI), antiretroviral (ARV) treatment); and (iii) promote multisectorality in the actions to fight against HIV/AIDS and improve M&E. 12. Country Assistance Strategy (CAS) and Rationale for Bank Involvement. At the time of original project preparation in 2000, a CAS was not prepared; instead, a Transitional Support Strategy (TSS) was presented to the Board in December 1999 as part of the World Bank’s framework for post- conflict countries. The TSS emphasized fiscal consolidation, improved governance, and laying the foundations for a poverty alleviation program. An updated TSS (2002) focused on consolidating the progress achieved in public finance management and social sectors, including emergency operations, such as this MHPP. In addition, the Interim Poverty Reduction Strategy Paper (I-PRSP), dated December 2000, defined the HIV/AIDS epidemic as the main priority for assistance, along with health, education, addressing poor governance and insecurity. 13. The Bank’s assistance in CAR to the fight against HIV/AIDS was justified by the absence of mechanisms to conduct HIV/AIDS-related activities involving large social mobilization and the need to expand existing activities and coverage. CAR met the MAP eligibility criteria in that it had: (i) provided satisfactory evidence of a strategic approach to HIV/AIDS through the creation of a government-appointed working group to prepare a HIV/AIDS multisectoral strategy; (ii) established a high-level HIV/AIDS coordinating body; (iii) the government had demonstrated its willingness to use appropriate implementation arrangements, e.g. civil society organizations (CSOs) and local communities; and (iv) the government had agreed to use and fund multiple implementation agencies, e.g. government ministries, CSOs and local communities. 14. In 2006, a CAS was still not developed, but in compliance with the recommendations of CRN (2004) and ISN (2006) to expand the project scope to include other social sectors, the MHPP added components on health, primary education, and access to water and sanitation. The expansion was driven by: (i) alarmingly deteriorating human development outcomes in the aftermath of the political crisis experienced in CAR; and (ii) compelling funding requirements to address immediate needs in these sectors, particularly in the light of shortages in government revenues and other external support; and (iii) increased funding in HIV/AIDS as a result of new engagement of other partners, especially the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM). The MHPP was one of the five projects approved at the time of Bank’s re-engagement in 2006 and the only one that focused on the social sector. After more than five years of suspension, the project was finally declared effective in September 2007. 1.2 Original Project Development Objectives (PDO) and Key Indicators 15. The original PDO was to contribute to reducing HIV/AIDS prevalence in CAR and to mitigate the impact of HIV/AIDS on persons living with or affected by HIV/AIDS. However, the project was not made effective under this PDO. 1.3 Revised PDO (as approved by original approving authority), Key Indicators and reasons/justification 17 16. The project’s PDO was revised during the 2007 restructuring to assist the recipient to contribute to: (i) urgent needs in the fight against HIV, such as access to prevention, treatment and impact mitigation services; and (ii) urgent social needs, such as prevention of malaria, increased access to water and improved primary education. 17. The original PDO related to the fight against HIV/AIDS was adjusted in line with the country’s updated National Strategy against HIV/AIDS (2006-2010). The revised PDO on HIV/AIDS reflects current thinking that prevalence rates should not be used as impact indicators in MAP projects. The PDO related to addressing urgent social needs was added to: (i) address deteriorating social outcomes as a result of long political instability and conflicts; and (ii) the absence of other mechanisms to improve these poor outcomes. Consequently, the project name was changed from MHPP to Multisectoral HIV/AIDS, Health and Education Emergency Support Project (Projet multisectoriel santé, education et SIDA, PSES). Project components were also modified to reflect the revised PDO (discussed below under 1.5). 1.4. Main Beneficiaries 18. The original project intended to yield the following benefits. First, the project aimed to curtail the spread of HIV/AIDS in CAR, and targeted the entire population, especially youth, women and other high-risk groups, with a more directed community impact. Second, it would extend the productive life of people living with HIV/AIDS and suffering from opportunistic infections through the provision of better care, as well as assistance to people affected by HIV/AIDS. Third, it would increase the capacity of actors at all levels, to deal with the HIV/AIDS crisis. 19. The 2007 restructuring maintained the expected benefits but drastically reduced the scope in light of the need to accommodate other social sectors. The geographic coverage for HIV/AIDS interventions was consequently narrowed down to 31 selected sites located at subprefectural levels in 16 prefectures, while maintaining a focus on youth, people living with HIV/AIDS (PLWHA), and women, as well as other high-risk groups such as military. Public, private and community institutions also benefited from the project. To complement new GFATM interventions in selected prefectural levels, PSES intervened at decentralized levels in more remote, rural areas. The target sites were selected on the basis of: (i) HIV prevalence established in the third MICS 3 and sero-surveillance study conducted in 2006 and 2007 respectively; and (ii) in the case where disaggregated data on HIV prevalence at subprefecture level was not available, 4 selection depended on the ‘possibility’ of higher HIV transmission risk based on vulnerability factors that had been identified. 20. Regional targets and main beneficiary selection of the newly-added social sectors were based on priorities identified by each sector: (i) the malaria subcomponent’s target prefectures for ITN distribution were selected based on outstanding gaps following previous mass distribution campaigns, targeting children under-five and pregnant women 5; (ii) community microprojects selected their target areas on the basis of the malaria prevalence rate at subprefectural levels in those prefectures where the project would be implemented, as well as on a predefined set of eligibility criteria; (iii) the education component (component 3), relied on information provided by the Ministry of Education (MoE) which included a list of teachers to be supported and areas where school materials were to be distributed 4 The sero-surveillance survey conducted in 2006 provides data at subprefecture levels, but was not available for all subprefectures. 5 The quantity of ITNs was determined based on population growth projections of the 2003 Census in the selected prefectures, multiplied by percentage of children under-five (on average 17 percent of population) and pregnant women (on average 4 percent of the population). 18 based on their national strategy and existing gaps, primarily focusing on the most underserved rural areas. 1.5 Original Components (as approved in 2001 but never became effective) Component 1: Strengthening Public Sector Response (US$3.4 million). This component intended to support public sector organizations, e.g. line ministries and public agencies, in implementing action plans against HIV/AIDS, in line with the prevention and support objectives of the project. Component 2: Strengthening Civil Society Responses (US$11.4 million). Subcomponent A: Strengthening of Responses by Civil Society Organizations. This component intended to support the HIV/AIDS action plans of CSOs and their contracts for the provisioning of specific services or purchasing of specific goods deemed necessary to implement their action plans. Subcomponent B: Small grants for communities. This was intended to stimulate responses at the community level by financing the implementation of community action plans through approved community grants. Component 3: Coordination, financial management, and monitoring and evaluation (US$2.7 million). This component intended to support the investment and operational costs of the CNLS- TS and the Financial Management Unit (FMU) of the CNLS and the Provincial HIV/AIDS Coordination Committee (CPLS) and their technical teams. The component would also support related M&E and audit activities. Project Preparation Facility (PPF) refinancing (US$0.5 million). The original amount of US$0.5 million foreseen for PPF was eventually increased to US$2.0 million in total over four PPFs. 1.6. Revised Components (Restructured in 2007 and implemented upon effectiveness) 21. The HIV/AIDS component, initially covering around 87 percent of total project financing, was reduced to about 38 percent after restructuring. The remaining 62 percent was allocated to: (i) address emergency health needs under component 2 (e.g. malaria, community projects to improve water and sanitation) (38 percent); (ii) education under component 3 (16 percent); and (iii) unallocated. While the activities still targeted the public sector, they largely focused on interventions to support CSOs and communities. Revised component 1: Support to the National Program against HIV/AIDS (US$6.47 million). Subcomponent 1 (a): Civil society responses against HIV/AIDS. Support to youth organizations, PLWHA associations and a federation of PLWHA associations. Activities would focus on behavioral changes and support for people living with HIV/AIDS and those affected by HIV/AIDS. Subcomponent 1 (b): Ministry of Health responses against HIV/AIDS. Support Ministry of Health and Population (MoHP) activities by enhancing access to services aimed at prevention, care and treatment of HIV/AIDS. Project funding for the programs by the MoHP would supplement the financing provided by the GFATM and other donors, focusing on geographic areas not covered by these donors. Activities would include: (i) increasing the use of voluntary counseling and testing (VCT) services; (ii) increasing access to ARV treatment by PLWHA; and (iii) improving compliance with national blood testing guidelines and with a medical waste management plan (MWMP). 19 Subcomponent 1 (c): Other public-sector responses against HIV/AIDS. The subcomponent supports priority activities identified by four priority public sectors (Ministries of Education, Defense, Social Affairs, and Public Services) contributing to prevention and support to affected and infected people, using annual agreements with outputs and results indicators. Subcomponent 1(d): Coordination, supervision and M&E. The project would finance the operations of the CNLS-TS and its decentralized prefectural coordinating committees (CPLS). The project would also support related M&E studies, namely a national health and HIV/AIDS study and a second sero-surveillance study. Revised component 2: Support to emergency health needs (US$6.56 million). Subcomponent 2 (a): Malaria prevention and improved access to emergency health services. This subcomponent would procure and distribute: (i) about 300,000 ITNs for pregnant women and children under five to help bridge the gap for government’s effort to achieve universal coverage; and (ii) equipment for emergency health services. Subcomponent 2 (b): Small emergency community subprojects. The project would finance small subprojects prepared by communities and CSOs to address emergency health needs, including: (i) small rural water supply systems contributing to improvement of health and reduction of transmission of infectious diseases; (ii) drainage of marshlands to reduce reproduction and spreading of mosquitos; and (iii) other works, supplies and services of an emergency nature, as identified by communities as priorities, such as small medical supplies, limited rehabilitation, training of health workers and community workers in basic preventive care. Subcomponent 2 (c): Coordination, supervision and M&E. The project would support limited financing to assist the MoHP to supervise, monitor and evaluate the project. Revised component 3: Support to emergency education needs (US$2.70 million). Subcomponent 3 (a): Training of primary schools teachers. The subcomponent aimed to improve the quality of teaching at the primary level and respond to urgent needs in providing teaching services; this would be achieved by focusing on training teachers and improving the student-to- teacher ratio. Subcomponent 3 (b): Access to educational materials in primary schools. The project would provide textbooks, small furniture, teaching kits and other educational material in primary schools in underserved areas. Subcomponent 3(c): Coordination, supervision and M&E. The project would support limited financing to assist the MoE to supervise, monitor and evaluate the activities above. Revised component 4: Support to Financial Management and Procurement (US$ 180,000). A small Financial Management and Procurement Unit for the project (FMPU-PSES) would be supported under this component whose primary purpose was to channel funds to the three sectors through their implementing agencies. The unit would include an international-level financial management (FM) specialist and a procurement specialist. Unallocated (US$1.09 million) 1.7 Other significant changes 22. The Development Credit Agreement (DCA) was amended four times during the project period: (i) First amendment (June 2006): A one-year extension (Country Director (CD) approval)of the original project’s closing date from June 30, 2006 to June 30, 2007, to allow sufficient 20 time to prepare the project restructuring following the Bank’s decision to re-engage in CAR. At this point the project had not become effective and had kept the minimum operation under the PPF as a result of portfolio suspension between February 2002 and June 2007. (ii) Second amendment (June 2007): A Level 1 Restructuring (Board approval) after the country’s re-engagement expanded the PDO and project components from an exclusive focus on HIV/AIDS to one that includes an emergency response to critical social needs resulting from the crisis. The restructuring: (i) modified institutional and implementation arrangements to reflect the involvement of new sectors; (ii) extended the project closing date for the second time from June 30, 2007 to September 30, 2010, allowing a total of three years for project implementation after its effectiveness; and (iii) updated the results framework to reflect the revised PDO. The restructuring package was approved on May 30, 2007 and the amendment to the DCA was signed on June 26, 2007. The project was declared effective on September 19, 2007, or three months after the government met all effectiveness conditions. 6 (iii) Third amendment (September 2010): A Level 2 Restructuring (CD approval) was then performed to re-allocate credit proceeds within categories where cost savings were possible and others that needed to be increased. As disbursement remained at about 50 percent, a third extension of the project closing date from September 30, 2010 to March 31, 2012 was required. The restructuring also included updating the project results framework to reflect the Bank’s core indicator wording as well as to adjust the targets. (iv) Fourth amendment (November 2011): A Level 2 Restructuring (CD approval) to reallocate credit proceeds within categories where cost savings were possible and others that needed increase. 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry (the restructured project) 23. Project Preparation and Design. The fact that the original project was never made effective and project funds remained undisbursed until the 2007 restructuring in some ways facilitated the reevaluation of project priorities, thereby allowing for a more appropriate urgent response to the crisis. The restructuring was of particular relevance as it was carried out in the context of: (i) a critical need for funding in other social sectors; (ii) linking the opportunities and eventual complementarities in HIV/AIDS provided by other bilateral and multilateral partners, such as the GFATM; (iii) redeployment of investments in the light of evolving strategic governmental orientations, such as decentralization and development at community levels; and (iv) integration of other causes of morbidity, e.g., malaria. 6 Conditions of project effectiveness were: (i) establishment of the CMO detailing functions, staffing and resources satisfactory to the Association; (ii) establishment of the FMPU-PSES; (iii) adoption of the amended project implementation manual, Financial and Accounting Manual, the M&E Manual and the Procurement Plan; (iv) appointment of financial management staff with satisfactory qualifications in CNLS-TS, MoHP and MoE to manage credit funds; and (v) the amended and restated DCA duly authorized or ratified by all necessary government action. 21 24. In December 2006, a World Bank project identification mission agreed with the government on: (i) a modified scope of HIV/AIDS interventions to reflect developments since original project approval; and (ii) priority emergency social needs in the health, education and water sectors to address new emergencies resulting from civil disturbances. During the restructuring appraisal mission in January 2007, all sectors concerned gathered around a table and discussed their strategic options. Budget repartition was determined on the basis of annual plans submitted by each sector, which was then revisited several times to keep within the overall budget envelope. 25. Risks. Risks were re-assessed at the project 2007 restructuring and identified the following critical elements: (i) continued political instability and civil unrest; (ii) shortage of institutional capacity to carry out the operations of the restructured project; and (iii) limited use or misuse of goods and services provided under the health and education emergency components by the project management unit, local elites and/or community members. While political instability remained beyond the project’s control, it was mitigated through the involvement of NGOs and communities; likewise, institutional capacity risks were mitigated by the planned institutional arrangements, integrated supervision missions and by training of potential beneficiaries in the use of goods and services provided under the project. 26. Quality at Entry. No Quality Enhancement Review was conducted at project entry 7 or during the 2007 project restructuring. 2.2Implementation 27. During the project suspension period, Project Preparation Funds (PPF) was granted on an exceptional basis. The PPF, totaling US$2 million in four phases, successfully supported: (i) the establishment and operation of the CNLS-TS and its 16 decentralized functions (CPLS); (ii) pilot activities for selected CSO and communities; (iii) capacity building of various stakeholders; (iv) mapping of HIV/AIDS prevalence in at-risk areas. 8 Activities were implemented mostly through contracts with NGOs and private entities under the leadership of CNLS. Successful implementation of PPFs led to the effective functioning of an institutional framework to fight against HIV/AIDS at central levels as well as its decentralized functions. This led to leveraging significant support from other donors who used the CNLS structures to channel their resources to support government efforts. Donors included GFATM who provided US$25 million for access to treatment in 2004 and US$16 million for orphans and vulnerable children in 2005, OPEC (US$0.5 million) and CARITAS (US$1.8 million). In addition, the various pilot activities of CSOs and communities, as well as various studies conducted under PPF, facilitated the re-orientation of the project design of the restructured project. 28. Implementation arrangements were substantially revised during the 2007 restructuring to reflect the involvement of concerned sectors, including CNLS (on HIV/AIDS-related issues) and the Ministries of Health, Education, Mining, Energy and Hydraulics (consulted on water supply and drainage-related issues). To provide effective support to these sectors, an Implementation Committee for IDA Credit (Comité de mise en oeuvre, CMO), was created as a formal inter-ministerial committee 7 The original PAD was reviewed on July 24, 2001 and contained the following recommendations: (i) revise the risk section of the PAD to fully reflect the continued political and operational risks resulting from the country’s fragility; (ii) confirm the existence of a strong government commitment and emphasize that a draft HIV/AIDS strategy was in place; (iii) clearly define the modalities of support to CNLS-TS (whether to support salaries or not); and (iv) specify implementation arrangements at decentralized levels to ensure quality of subprojects. 8 Upon exhaustion of PPF, CNLS carried out additional activities using Low-Income Country Under Stress (LICUS) grants and other donor funds. 22 to be chaired by a representative from the Ministry of Planning. In addition, a FMPU attached to this committee which consisted of an FM specialist and procurement specialist was created to: (i) centralize the procurement of major supplies for the three implementing sectors concerned; (ii) advance funds to the sectors, CSOs and communities; and (iii) manage the designated account. 29. As a result of introducing a new mechanism with a wide array of actors, the first six months after project effectiveness was mainly devoted to fine-tuning the action plans submitted by different ministries to keep within the overall budget envelope and aligning procedures. The effective launch of activities in the field occurred with the first disbursement in April 2008, although disbursement remained somewhat weak with just over 55 percent of funds disbursed in June 2010 (three months before expected project closure), thus requiring another project extension until March 30, 2012. 30. Mid-term review. A formal mid-term review was not planned given the urgent nature and the expected short project implementation period; nonetheless, a supervision mission performed a project evaluation in March 2009. The evaluation concluded that the: (i) objectives of the project remained relevant; (ii) the project had a good chance of attaining its indicators and results; (iii) a budget reallocation should be carried out to ensure all activities would be conducted as planned; (iv) the closing date should be extended; and (v) an adjustment to the project implementation manual was needed. These recommendations were implemented at the September 2010 restructuring, including a revision of the indicator targets. 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization 31. M&E Design. Key project indicators were drastically revised during the 2007 restructuring to reflect the new PDO and were substantially reduced from the original project. The M&E manual was updated with a clearly defined results framework. The revision for the HIV component was made in alignment with the MAP umbrella restructuring in which the HIV prevalence rate was removed and more focus was put on vulnerable groups. Each sector was responsible for establishing the baseline for their indicators; however, in most cases the baseline was not available as practically no interventions had been carried out by the Bank or other donors. Some indicators’ wording were further adjusted during the 2010 restructuring in line with IDA core indicators. 32. M&E Implementation. The restructured project did not include an M&E component but each sector received a modest amount for coordination, supervision and M&E under their respective component. Consequently, each sector was responsible for data collection and reporting on their project outcomes, and was confined to their target areas. Originally the FMPU was supposed to recruit an M&E specialist to strengthen the M&E of the project and generally oversee progress, but this was eventually replaced with an idea to recruit a FMPU project coordinator who would at the same time oversee M&E, fiduciary issues and assume an overall coordination role. 33. Given the significant reduction in the M&E budget under the restructured project, the project could not go as far as to address some of the M&E-related structural problems commonly seen in all sectors, such as: (i) inefficiency in the data circuit from the execution level in the field to the central level; and (ii) a general absence of data analysis for decision-making to reflect the indicator progress in improving project performance. 9 Nevertheless, M&E improved after the arrival of the PSES project coordinator in 2009 through: (i) the introduction of an incentive payment for timely submission of reports; (ii) organization of quarterly review meetings presided by the CMO and attended by all sector 9 The only exception to this was the change that occurred in relation to the VCT strategy under component 1, where low testing rates triggered a shift to an advanced mobile testing strategy, resulting in significant improvement of results. 23 focal points, FMPU and CSOs to review the indicator progress and collectively validate the results; and (iii) revision of the reporting format to ensure consistency across sectors. 34. M&E Utilization. Health Management Information Systems (HMIS) were available but were not sufficiently relied upon due to poor data quality and incompleteness. In addition, while attempts were made at sectoral levels to engage in strategic discussions to improve sector performance, results monitoring generally focused on assessing the physical and financial achievements of the annual action plans and translating the results to measure overall sector performance. Nevertheless, the project supported several important studies, including MICS 4 and a second generation sero-surveillance survey, as well as a health facility survey which was used to feed into the subsequent Country Health Status Report (2012), enabling a comparison of data during pre- and post-project effectiveness period at the national level. There was also a general interest in using data from existing studies and this remained the case throughout the lifetime of the project. At an operational level, MICS 3 (2006) and sectoral studies, such as UNGASS reports and the Education Status Report (RESEN), were used to determine revised targets for the restructured project. Selection of project intervention areas for the HIV component also relied on MICS 3 data, as well as other available documents. At the policy level, data were used for the National HIV/AIDS Strategic Framework and other sectoral strategies, as described in more detail in Section 3.1. 2.4 Safeguard and Fiduciary Compliance 35. Environment and management of medical waste: The environment category of the original project at the time of appraisal was B in light of risks related to the handling and disposal of HIV/AIDS-infected materials. Financed by the PPF, a MWMP was developed and disclosed in March 2002. 36. The 2007 restructuring maintained the environment category as B as the impact was judged to be “minimal, site-specific, and manageable.� 10 The MWMP was revised and re-disclosed in November 2007. Implementation of the MWMP was foreseen under the HIV/AIDS component and was generally well implemented, although activities were somewhat restricted as a result of a reduced budget for safeguards. This resulted in: (i) interventions being limited to 31 HIV/AIDS sites instead of nationwide coverage as initially planned in order to serve the health sector at large; and (ii) the focus of activities was narrowed to areas considered as high priority (e.g. awareness raising, training and provision of adequate equipment). In addition, the financial sustainability of these activities after project closure remained under discussion in order to ensure continued technical and financial support to local health committees (Comité de Gestion, COGES) and health workers. 37. Implementation of Environmental and Social Management Framework (ESMF). As component 1a (support to CSO) and component 2b (community microprojects) involved small projects related to drainage of small marshlands and rural water supply, OP 4.01 and OP 4.04 were triggered and an ESMF was developed in November 2007. Initially the Directorate General of Hydraulic (DGH) in the Ministry of Energy and Hydraulic was responsible for the implementation and supervision of the framework but as their capacity was limited to water, this was taken over by the Ministry of Environment in 2010. The Ministry of Environment played a key role in: (i) identifying the sites for community microprojects based on their environmental screening criteria; and (ii) sensitization and training of health personnel on the MWMP. Transfer of responsibilities should have happened at a much earlier stage to avoid implementation delays. 10 Integrate Safeguard Data Sheet 2007 24 38. Procurement: During the pre-effectiveness phase under PPF, procurement was carried out by the FM Unit of CNLS-TS but this responsibility was transferred to FMPU-PSES after the 2007 restructuring. Procurement plans were adequately developed and updated and preparation of bidding documents was carried out in a satisfactory manner. The FMPU centralized inputs acquisition and contracts for all three sectors contributed to reducing the transaction costs. Nonetheless, some delays at the start-up phase were seen due to the need for close coordination between the procurement specialist and technical focal points. One difficulty encountered was a general lack of clarity in the accountability mechanism as FMPU was responsible for processing contracts, while technical aspects were entirely under the responsibility of each sector focal points. This lack of coordination resulted in the second lot of 266,000 ITNs purchased in 2009 and received in 2010, but only upon delivery was it identified that the nets did not conform to the required technical standards for distribution. Upon evaluation it was found that the ITNs delivered by the supplier had manufacturing flaws, such as the size of the mesh weaving too large to prevent mosquitos from entering inside the net. Given this technical flaw, even the potential solution of providing an additional layer of insecticide treatment was not an option. Currently there is a stalemate between the supplier and the government, and as a result, the ITNs are stocked in a warehouse in Bangui until a decision is taken by the government, while appropriate legal measures are being taken vis-à-vis the supplier. 39. Financial management and disbursement: Overall, FM did not pose a serious threat to project implementation with Implementation Status and Results (ISR) ratings consistently scored as Moderately Satisfactory or Satisfactory, with the exception of: (i) when the country’s suspension was lifted in March 2007 and no disbursement was made; and (ii) when disbursement was still low two years after effectiveness in December 2009 but measures to improve FM were not taken into account (both rated as Moderately Unsatisfactory). No issues with ineligible expenditures or unqualified external audits were encountered. 11 40. As was the case with procurement, difficulties in disbursement were seen in the initial years after effectiveness due to the new implementation arrangement; these difficulties were reflected in: (i) slow disbursement until the second half of 2009; (ii) delays in updating accounting records; and (iii) lack of timely submission of financial reports. These were resolved over time and substantially improved towards the end of project. Recording in accounting systems seems to have been adequate, although the departure of the FM specialist two weeks before project closure somewhat affected the consolidation of final results and external audits for 2011. 2.5 Post-completion Operation/Next Phase 41. To a large extent, investments financed by the project will be maintained through the following follow-on sector specific projects: • For HIV, funding from GFATM will take over the 31 PSES sites to provide treatment to patients receiving ARVs by PSES support and to continue expanding efforts on VCT and prevention of mother to child transmission (PMTCT), while the government will take over costs for CNLS-TS functions (salaries and operational costs) at both central and decentralized levels. • CAR obtained access to the Education for All Program under the Fast Track Initiative Catalytic Fund (EFA/FTI in 2009, practically taking over all education activities funded under PSES, including teacher training, recruitment and deployment of teachers to rural areas. The US$38 million fund supports implementation of phase the first of the National Education Strategy (2008- 11 At the time of ICR, the external audit 2011 had not been submitted to the Bank. 25 2011) through: (i) improving access to education through school construction and rehabilitation and (ii) enhancing the quality of education through teacher training and education materials • A US$28.3 million IDA and Health Results Innovation Trust Fund (HRITF) co-financed health operation was approved by the Board in May 2012, ensuring continued support to increasing the utilization and improving the quality of maternal and health services through performance-based financing (PBF). The project targets approximately two-thirds of CAR’s population and will benefit from existing implementation arrangement, namely: (i) utilization of FMPU; and (ii) capitalization of inputs acquired by PSES. • A US$24 million IDA-financed Additional Financing for the Emergency Urban Infrastructure Rehabilitation Project was approved in September 2010, about US$14 million of which was dedicated to water supply and drainage/flood mitigation. The project ensures some level of complementarity with the work carried out under PSES, though with emphasis on securing safe drinking water in flooding vulnerable areas. 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation 42. Alignment with the country’s development strategy and Bank priorities. The objectives of the project were fully aligned with the country’s long-term objectives and its strategic priorities. The country’s Second Poverty Reduction Strategy Paper (PRSPII) (2011-2015) continues to highlight the importance of generating sustainable equitable growth through human capital development, especially health, education and HIV/AIDS. It also continues to include in its four pillars both human capital development and access of population to basic social services. The project is fully aligned with the country’s ongoing effort to achieving the MDGs, particularly Goals 2, 3, 5, 6 and 7. 43. The project is also aligned with the following different sectoral development strategies: • The HIV National Strategic Framework (2012-2016) builds on the preceding framework 2006- 2010, focusing on: (i) strengthening prevention programs focusing on population at risk, in particular youth, commercial sex workers and uniformed personnel; (ii) strengthening PMTCT in order to eliminate HIV transmission from mother to child by 2015; and (iii) providing universal treatment to people living with HIV/AIDS or affected by HIV/AIDS; and (iv) governance of HIV/AIDS, i.e. putting into place a mechanism to efficiently implement the new National HIV/AIDS Strategic Framework. • The National Health Development Plan (NHDP) 2006-2015 calls for strengthening malaria prevention as one of its five strategic axes, through: (i) efforts to increase accessibility and utilization of ITNs targeting pregnant women and children under five; and (ii) improve hygiene and health environment to reduce the cause of malaria. The Second Malaria Strategic Plan 2007-2011 is aligned with the NHDP and aims to reduce by 50 percent mortality and morbidity linked to malaria by the end of 2011 compared to the results of 2000. 12 Similarly, the NHDP alludes to ‘encouraging the creation of decentralization funds to sustain community initiatives at district levels with support of implementing partners, targeting provision of drugs, construction and 12 Future demand remains even larger: the National Malaria Program estimated that 2.3 million bednets are needed for the next national mass campaign scheduled for 2013. 1.5 million bednets are programmed in the GFATM project, leaving a gap of 35 percent. 26 rehabilitation of health infrastructures, acquisition and maintenance of equipment, financial accessibility for treatment, supervision, maintenance of water points, etc. • The adoption of the National Education Strategy (2008-2020) constituted a major step forward on the policy front as it focused on increased access to education and improvement of the quality of education in the country. The strategy aims to achieve universal primary education by 2020 through: (i) the establishment of a new policy on the training and recruitment of teachers; and (ii) the improvement of learning quality through the provisioning of pedagogic materials. 44. The project remains highly relevant to the Bank’s priorities and development objectives. Axis 2 of the Joint Country Partnership Strategy (2009-2012) aims to rehabilitate and develop socio- economic infrastructure, focusing on improving basic service delivery and the living conditions of the population, through water treatment and sanitation, improved community participation, education, health and HIV/AIDS. 13 Similarly, the World Bank’s Africa Regional Strategy recognizes public health interventions, including basic health service delivery and water and sanitation, as a way to “build resilience to address cumulative effects or shocks�. It also highlights the importance of protecting vulnerable groups, such as people living with disabilities or living with HIV/AIDS. 45. Objectives. The 2007 restructuring drastically modified the PDO in line with the country’s updated National HIV/AIDS Strategy and sectoral strategies as previously discussed. The objectives were clear and the allocation of activity components is justified given the timing of Bank’s re- engagement and circumstances which demanded crucial support in the overall social sector. The project’s conceptual and strategic approach was, and remains, highly relevant to the country’s current priorities. This argument is supported by the fact that successor projects for sector specific operations were developed as a continuation of or on the basis of lessons learnt from PSES. 46. Design and Implementation. The project design remained relevant throughout; restructuring was not due to an inherent design flaw or implementation failure but was conceived as a flexible response to the priority needs of the social sector as a whole following a long period without external support. While the need to cover a wide array of areas with limited budget obliged a rather thin spread of resources, the core design of the revised project was realistic in the country and sector context. PSES was the only existing mechanism allowing for a rapid response in the absence of other financing by the Bank, thus serving to bridge the gap until funding for longer-term, sector-specific operations became available. It also supported the Bank’s continued dialogue with the government and partners. 47. The institutional set-up was adequate given the diverse technical knowledge required and responsibilities that lie under different ministries; although involvement of a large number of actors resulted in coordination difficulties during the initial phase. Improvements were later made to: (i) harmonize M&E-related activities (e.g. data collection and reporting); (ii) put in place a project coordinator to oversee the project and facilitate coordination between different entities; and (iii) widely disseminate the revised implementation manual to better clarify the roles and responsibilities of each actor. 48. Even in the context of emergency, the project sought to ensure sustainability whenever possible. The HIV/AIDS component addressed the immediate needs of the population by increasing access to prevention and treatment, while contributing to strengthening of the institutional framework. The health component followed a two-pronged approach, namely by fulfilling urgent needs through the purchase of commodities and also by building rural community capacity. The community approach is 13 Joint Country Partnership Strategy (CPS) for CAR for the period 2009-2012, AFCC1, July 30, 2009. 27 highlighted in the Joint Country Partnership Strategy as a way to help build social capital, provide critical services, and regenerate economic activity for future sustainability. 49. Based on the discussion above, the relevance of the development objectives, components and specific activities of the project is rated as High. 3.2 Achievement of Project Development Objectives Revised PDO 1: Contribute to meet urgent needs in the fight against HIV, e.g. access to prevention, treatment and impact mitigation services. 50. Overall, the project contributed to improving HIV-related services. The CAR Health Status Report 2012 14 indicates that availability of almost all the key health services had dropped between 2006 and 2011, with the largest drop in immunizations (19 percentage points) and family planning (14 percentage points), while the availability of HIV-related services such as VCT, PMTCT and ARV treatment has gone up by over 30 percentage points. Service utilization had also increased largely because of outreach programs and community efforts, such as VCT activities by youth and PLWHA associations, as well as PMTCT support groups which all facilitated identification of patients who were subsequently referred to nearby project-supported health centers for treatment. 51. Although part of original PDO, the HIV/AIDS prevalence rate was no longer included as a PDO indicator after the MAP umbrella restructuring in 2007, and was consequently dropped from the revised PDO. Nevertheless, it is worth noting that there has been a significant drop in the prevalence rate among key groups in CAR, partly as a result of the project. Recent survey data shows that adults aged 15-49 years decreased from 6.2 percent in 2006 (MICS 3) to 4.9 percent in 2010 (MICS 4). UNAIDS estimates for HIV/AIDS prevalence rates among pregnant women at sentinel surveillance sites reached as high as 10.7 percent in 2006 but dropped to 4.1 percent in 2010. 15 Furthermore, the prevalence rate decreased at a time when treatment coverage increased substantially; according to CNLS reports, treatment coverage at national level increased more than five-fold, from 2,860 in 2006 to 15,287 in 2010 (covering about 40 percent of all estimated people needing treatment). This would imply a larger significance in the drop in the prevalence rate as people are living longer than before. Outcome 1: Increased adoption of HIV/AIDS prevention measures and increased access to treatment. 52. Prevention of Mother to Child Transmission (PMTCT). The project served as a major source of support for PMTCT services, reaching a total of 10,465 pregnant women who were tested and who received results in targeted health centers (revised Intermediate Outcome Indicator 1), against a target of 9,000 (116 percent achievement rate). The project also provided financial support to the implementation of action plans by the PMTCT support groups. Nationwide, the PMTCT program was extended from 62 sites in 2006 to 105 operational sites by the end of 2010, representing 19.7 percent of a total 534 health facilities practicing postnatal care and deliveries. Among these were 30 PSES sites, accounting for one third of the total. 53. According to CNLS, the proportion of pregnant women who received ARV treatment in the context of PMTCT nationwide was 16.0 percent (318 of 1986 positive mothers) in 2006, 35 percent (608 of 1748 positive mothers) in 2008, with a large increase to 77.1 percent (2013 of 2604 positive mothers) in 2010. 14 Rapport sur la santé et le système de santé en Centrafrique, 2012 15 Sero-surveillance surveys 2006 and 2011 28 54. Access to ARVs. Adults and children receiving antiretroviral combination therapy in project target areas reached 1,719 (1,624 adults and 95 children), largely exceeding the initial target of 1,300 (by 132 percent) (revised PDO Indicator 2). CNLS reports that the nationwide ARV coverage between 2006 and 2011 was at 14,405 in total (13,703 adults and 702 children), with the project contribution represent about 12 percent of the overall coverage. The CNLS further estimates that the total number of effective patients needing ARV treatment is about 36,000 nationwide 16, which means that about 40 percent of people needing treatment were on ARVs. Furthermore, until 2008, ARV treatment was only provided in Bangui and in some provincial sites. Decentralization in real terms occurred from 2009 with GFATM intervention, but was still limited to large cities at prefecture levels, whereas PSES contributed to extending this to subprefecture levels. Table 1: Evolution of ARV treatment coverage in project target zones 2009 2010 2011 2012 TOTAL # of adults treated with ARV (cumulative) 820 1,158 1,624 NA 1,624 # of children treated with ARV (cumulative) 25 51 95 NA 95 Source: CNLS report Table 2: Evolution of ARV treatment coverage at national level 2006 2007 2008 2009 2010 2011 Adults (over 15) 14,462 13,703 Children (0-14 years) 825 702 Total 2,860 6,054 11,864 13,234 15,287 14,405 Source: CNLS report 55. Voluntary Counseling and Testing (VCT). The number of men and women who accepted VCT and received test results in the target health centers was 118,862 against a final target of 200,000 (partially achieved at 59.4 percent) (revised PDO Indicator 1). The low target achievement could be explained by delays in the delivery of tests and consumables; the last lot has been distributed after project closure. This number is therefore projected to increase substantially upon availability of final results. Still, the CNLS reports the total number of persons tested and received their results nationwide at 86,149 between 2006 and 2009, 17 meaning that the PSES contribution to the result is significant. The number of youths who accepted VCT and received their test results through mobilization by youth associations reached 69,427 persons against a target of 56,824 (122.2 percent achievement rate); this was made possible as a result of project’s support to 85 HIV action plans submitted by youth associations focusing on behavioral changes and promotion of VCT among youth (revised Intermediate Outcome Indicator 5). 18 56. The social and health benefits created by the project through support to PLWHA associations cannot be underestimated. PSES financed a total of 35 action plans 19 for PLWHA associations, mainly to support income-generating activities through construction and management of mini-motels, restaurants and warehouses by PLWHA. As a result, the number of PLWHA receiving support through their associations or their national federation of associations reached 14,004, largely surpassing the initial target of 7,200 (194.5 percent achievement rate) (revised PDO Indicator 3). Although an end- 16 EPP spectrum (CN/CNLS) 17 Suivi de la Déclaration Politique sur le VIH/SIDA, 2011, CNLS 18 No baseline is available. The number of action plans was targeted at 100, supporting a total of 40 youth associations, but in the end only reached 35 associations due to the unavailability of competent youth associations. 19 31 PSES sites and 4 GFATM sites. Four of these sites were not operational for security reasons, bad management, conflicts between association members, and also because of the absence of follow up. 29 project evaluation on behavioral changes was not conducted, the project contributed to reduction of stigma and discrimination against HIV/AIDS, as observed by the large number of people accepting VCTs and the frequency of PLWHA-run restaurant and mini-motels in use. 57. Blood Transfusion. The number of blood transfusion pockets tested for HIV and other blood- borne infections in targeted health centers reached 27,944 against a target of 32,000 (revised Intermediate Outcome Indicator 2). As delivery of the final lot of inputs only happened after project closure, this figure is expected to increase to the target level. The UNGASS report indicates that the proportion of transfused blood tested for HIV was at 75.6 percent in 2006 but increased to 84.2 percent in 2009, almost close to a target of 85 percent by the end of 2009. PSES was practically the only financing source for provision of blood pockets, tests, and consumables for blood transfusion during the project period, along with a modest contribution by the government. The collection and testing of 37,990 blood pockets for HIV, hepatitis and syphilis at the National Blood Transfusion Center (CNTS) between 2006 and 2010 is one of the major contributions of PSES; however, actual needs exceed these figures. 20 Revised PDO 2: Contribute to meet urgent social needs, such as prevention of malaria, increased access to water supply and improved primary education Outcome 2: Increased adoption of preventive measures against malaria 58. The project distributed 100,000 ITNs as part of the national mass distribution campaign, significantly below the initial target of 300,000 ITNs (revised PDO Indicator 4). The issue of non- compliance with technical standards of the second lot of 266,000 ITNs (that were purchased but could not be distributed) affected negatively the outcomes. Nevertheless, considering that the overall needs of ITNs estimated by the MoPH are one million in CAR, the project contributed approximately 10% of the total need. In addition, sensitization activities and training of animators and distributors supported by the project contributed in an indirect way to the government’s effort in universal bednet coverage 21. Outcome #3: Increased access to water supply 59. Overall, access to drinking water improved during the project implementation period: 67 percent in 2010 (MICS 4) compared to 52 percent in 2006 (MICS 3). Under the project, a total of 101 improved community water sources were built in various forms as part of community microprojects (revised Intermediate Outcome Indicator 7). 22 As a result, people with access to improved water sources in the project target areas increased from 7,200 to 30,300 against a target of 19,800, with a 144 percent achievement rate (revised PDO indicator 5). 23 While number of new water points built was not significant, the project’s significant contribution was the reduction of broken pumps by 10-15 percent at the country level, substantially contributing to improvements in access to water supply, as reflected in MICS. Furthermore, all the newly constructed water points were in rural areas and 20 Average production of CNTS is at 6,000 pockets of secured blood per year, representing only 19.6 percent of the country’s needs. 21 Nationwide, recent efforts supported by other partners including GFATM, UNICEF and UNITAID have brought overall progress to universal bed net coverage in CAR. When we compare the MICS 3 (2006) and MICS 4 (2010), children under- five sleeping under ITN increased from 16% to 36%. Similarly, households possessing at least one ITN increased from 16% to 47%. The figures are much higher in an impact evaluation study carried out in February 2010 under the context of Roll Back Malaria, which concluded that 70.5% of children under-five and 91.0% of pregnant women who received PNC slept under an ITN the night before, and 72.1% of households had at least one ITN. 22 Initially, an indicator measuring the area drained of standing water and marshlands identified by the population was included as a way to reduce the cause of malaria transmission at the community level, but it was dropped as water drainage was not prioritized under the community microprojects due to budget limitations. 23 Follows calculation adopted by DGH of a population of 300 persons per water point. 30 contributed to addressing the existing large disparity between urban and rural areas for household members using improved sources (85.5 percent in urban areas against 54.8 percent in rural, MICS 4). Table 3: Progress of access to community water points (population benefited) 2008 2009 2010 2011 2012 Total 7,200 4,500 16,500 300 1,800 30,300 Source: Ministry of Hydraulics Outcome 4: Improved primary education 60. The project served to maintain some level of educational service at a decentralized level, particularly in the post-war period when there were practically no schools open in rural areas. The project recruited, trained and deployed a total of 1,023 apprentice teachers to rural areas, far exceeding the initial target of 850 teachers (PDO Indicator 6). The project also supplied educational materials in a short period of time, doubling the distribution of French and math textbooks, from an initially planned 44,625 to 89,250. 61. An annual sector review conducted in May 2012 highlighted the remarkable contribution made by PSES in improving the quality of primary education, particularly at a time when other major financing was nonexistent. This is proven by: (i) the sharp decline in the pupil-teacher ratio in the targeted zones; and (ii) the decline in the French textbook to pupil ratio from 7:1 in 2008 to 1.3:1 in 2011, as well as the math textbook to pupils ratio from 6.4:1 in 2008 to 1.4:1 in 2011 (Intermediate Outcome Indicator 9). The proportion of parent teachers, generally very high for primary schools, decreased from 56.6 percent in 2008 to 42.8 percent in 2011, reflecting the increased availability of formally trained teachers. Nationwide primary school attendance for children aged 6 to 11 years old increased from 51.4 percent in 2006 (MICS 3) to 73.3 percent in 2010 (MICS 4). 24 Table 4: Project contribution to education sector 2008 2009 2010 2011 2012 Total Initial target Teachers recruited and deployed 850 173 1,023 850 French text books 44,625 44,625 89,250 44,625 Math text books 44,625 44,625 89,250 44,625 School kits 5,596 5,596 5,850 Table Banc 5,130 5,130 4,600 Wardrobe 629 629 130 Teachers' desks 120 120 130 Chairs 129 129 130 Source: Ministry of Education 62. Summary of Efficacy Rating. Based on the above analysis, the project’s efficacy is rated Substantial under the revised PDOs, given that: (i) five of the seven revised PDO indicators achieved their targets, with one of the remaining likely to be achieved upon completion of final inputs delivery; and (ii) national level data show a progressive improvement in HIV-related service availability and utilization. In addition to the direct benefits, these achievements paved the way for other partners to continue and expand the work on HIV/AIDS and health programs. Details on the indicators are available in Section F of the Data Sheet. 31 3.3 Efficiency. 63. Neither the original PAD nor the Restructuring Paper calculated the net present value (NPV) or the economic rate of return (ERR) of any of the relevant sectors. The Implementation and Completion Results (ICR) guidelines indicate that in the absence of NPV or ERR estimate; project efficiency will be measured using any other appropriate cost-effectiveness criteria to determine whether the project represented the expected least-cost solution to attain identified and measurable benefits. 64. HIV/AIDS component. The Restructuring Paper refer to the economic analysis of HIV/AIDS in Africa and provide an impact assessment on prevention, access to testing, care and treatment, as well as a cost-benefit analysis of HIV/AIDS interventions, carried out under the MAP. In summary, the project: (i) intervened in areas where it was proven to be most cost-effective for sub-Saharan Africa, namely PMTCT and blood safety (as per a study that measured cost effectiveness of different HIV/AIDS interventions and their impact) 25; (ii) made a significant contribution in leveraging external support; and (iii) was built on a good coordination mechanism with other development partners, thus avoiding duplication, especially since other donor funds for HIV/AIDS were also channeled through CNLS-TS. In addition, while donor support has steadily increased over the years, this support was mainly aimed at funding improved access to care and treatment for PLWHA, support to orphans and prevention (mainly provision of condoms), but only in the country’s capital. The project’s focus on prevention, especially in rural areas, helped reduce infection rates in these areas. 65. The target under the restructured phase focused on specific groups in selected sites where a comprehensive package of interventions encompassing VCT, PMTCT, blood safety programs and ARV treatment was implemented. Intervention sites were organized around a health facility at subprefectural levels and each site funded CSO activities through youth associations and PLWHA associations, accompanied by an NGO to provide technical support. The integrated approach allowed for: (i) reduction in costs associated with supervision, monitoring and reporting; (ii) synergies among different interventions by PLWHA and youth associations, NGOs and health facilities, from sensitization, close monitoring of identified patients and availability of treatment. In addition, integrated supervision missions which were frequently conducted bringing together all technical expertise (CNLS-TS, ministry representatives, FMPU-PSES, as well as Central Drug Procurement Unit or Unité de céssion de médicaments, UCM) had some unforeseen benefits, such as ensuring direct delivery of drugs and inputs to end beneficiaries, avoiding stock-outs and monitoring patients under treatment. In addition, these missions served as a platform to enhance technical, financial and managerial capacity at decentralized levels through coaching and capacity building. 66. Health component. The project prioritized what is considered to be one of the most cost- effective interventions for malaria control: prevention via use of ITNs by children under-five and pregnant women. Evidence from other African countries also suggests that investing in mosquito nets, if accompanied by adequate distribution and training, provides a high return in terms of reduction in prevalence. The second lot of ITNs was not distributed as planned for reasons mentioned earlier which decreases the efficiency of this component. However, considering that: (i) the total amount disbursed for this acquisition (about US$1 million out of a total US$17 million, at unit cost of US$4 per net) was relatively modest; and (ii) other activities envisaged under this component, including training of distributors as well as provision of health equipment to health facilities, were conducted as foreseen to complement other ITNs procured by different partners, this shortcoming could be considered as modest. 25 The World Bank’s Commitment to HIV/AIDS in Africa: Our Agenda for Action, 2007-2011, June 2007 32 67. The project conducted a technical audit for the community microprojects in December 2010. While this evaluation did not sufficiently address the economic efficiency of intervention, it highlighted some positive points: (i) the pertinence of the community participatory approach in enhancing ownership of the beneficiaries and raising their awareness in improving primary health care; (ii) the progressive extension of intervention zones allowed for a better learning-by-doing experience; and (iii) involvement of NGOs to accompany the process and provide technical support. In addition, the repair of the existing water pumps was a highly efficient intervention as it substantially increased water access to rural population with lower costs than building new points 68. Education component. The economic analysis of the education sector was underpinned by the results contained in the RESEN, which concludes that increasing the supply of schooling materials, the availability of teachers, and reduction in in-class training period in favor of on-the-job training, were cost-effective interventions. The extent to which the project addressed the most effective and efficient interventions for the education component can be derived from the significant cost savings made in 2008 to achieve the intended results, which led to a doubling of the number of textbooks purchased and a significant increase (by approximately 120 percent) of teachers recruited under the project. 69. Based on the discussions above, efficiency in achieving the PDOs is rated Substantial for the restructured PDO. 3.4 Justification of Overall Outcome 70. Appendix B. of the ICR Guidelines 26 mentions that project outcomes are assessed against both original and revised project objectives, weighting pre-and post-revision performance by the share of actual loan disbursements before and after the revision took place. In view of the fact that: (i) the project became effective only after the 2007 restructuring; and (ii) there was no disbursement prior to this phase, except for PPF which essentially supported the preparation of the restructured phase, assessment of project outcomes will focus on the post-restructuring phase under the revised PDO. Based on the above discussion, the overall outcome rating for the project is Moderately Satisfactory. 3.5 Overarching Themes, Other Outcomes and Impacts (a) Poverty Impacts, Gender Aspects, and Social Development 71. From the outset, the project included a strong gender and a poverty dimension because: (i) there is clearly a feminization of the epidemic, as evidenced by studies conducted prior to and during the life time of the project (e.g. MICS 2006 found that the HIV prevalence rate among young women aged 15- 19 were three times higher than for men in the same age group); and (ii) results of the social assessment conducted at the project preparation stage concluded that women and girls are more susceptible to HIV/AIDS and are more likely to be subject to sexual abuse, other forms of violence, and were vulnerable to stigmas and social exclusion. Prevention and treatment activities therefore placed a strong focus on PMTCT, encouraging pregnant women’s VCT through support groups. 72. Addressing the poverty dimension was boosted by the project’s focus on decentralization and support for rural areas. Studies have proven that rural areas (where historically government support is much less likely to reach) have a much higher poverty rate. Both the original project, as well as the restructured one, saw a significant portion of their funds allocated to local initiatives through CSOs and community groups in order to stimulate responses at community levels. This contributed to developing the capacity of CSOs and communities, as well as multisectoral activity integration at the decentralized 26 OPCS/IEG, August 2006 and updated in June 2007 33 level. Additionally, income-generating activities appeared to have played a role in supporting poverty reduction although their real impact is difficult to assess in the absence of any documentation. 73. The project also demonstrated the importance of focusing on socially marginalized groups and at-risk populations through its support for militaries and vulnerable groups, including orphans, women and the handicapped and youth. Similarly, distribution of malaria nets followed the national protocol of targeting children under-five and pregnant women. (b) Institutional Change/Strengthening 74. The project made a significant contribution to institutional change and strengthening particularly in the following areas: • The CNLS strengthened its coordinating capacity at the national level, with the TS-CNLS managing other donor-funded HIV projects. Prefectural coordination bodies (CPLS) were established in 16 prefectures integrating local-level actors. The government will, in principle, take over the operational costs for the CNLS and CPLS functions to keep the minimum capacity in place until other funding is made available. • The project, through its implementation committee (CMO) successfully built a platform to work with a wide range of public institutions to: (i) promote a multisectoral response to HIV/AIDS and other urgent social needs; (ii) decentralize responsibilities to implement activities at each sector levels; and (iii) strengthen civil society and community capacities to improve results at regional and local levels. (c) Other Unintended Outcomes and Impacts (positive or negative) N/A 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops 75. A beneficiary assessment was not organized prior to the project nor upon completion of the project. 4. Assessment of Risk to Development Outcome Rating: Moderate 76. The risk to the development outcome is considered to be moderate. Politically, the project created a common platform for an intersectoral dialogue and gained strong support at the highest levels of government. The implementation strategy remains fully aligned with current national and sectoral strategies. Institutionally, the project contributed to establishing an institutional mechanism for a multisectoral response. An oversight function by the CMO, despite its initial challenges, certainly helped address bottlenecks in project implementation and coordination among different sectors. 77. Certain potential risks still exist, although efforts have been made to mitigate them. First, deterioration in the security situation, although a largely exogenous risk, may adversely impact the continued sustainability of the project’s achievements. Second, capacity constraints on actors at decentralized levels (NGOs, CSOs and health facilities) have been partially mitigated through integrated supervision missions and technical assistance, but experience shows that some level of continued financial support is critical to the viability of appropriate capacity building activities. Third, suitable financing levels to sustain service delivery poses a risk but significant effort has been made on this aspect, as seen in the development of various sector-specific successor projects. 34 5. Assessment of Bank and Borrower Performance 5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry Rating: Satisfactory 78. Despite the long period of project suspension due to issues related to the country's arrears, the Bank continued to support activities through the PPF and Trust Funds, all the while ensuring a constant dialogue with the client to the extent possible. Such critical support enabled the country to establish sufficient grounds and strengthen its institutional basis, leading to the mobilization of significant grant resources from other donors. These are well documented in the aide-memoires and ISRs. The Bank task team should also be credited for the restructured project preparation in a very limited timeframe as soon as the suspension was lifted, as seen in the support for the government’s prompt compliance with all the effectiveness conditions. (b) Quality of Supervision Rating: Moderately Satisfactory 79. There were a total of five Task Team Leaders (TTLs) throughout the project life. The Bank team conducted regular supervision missions and generally managed to address project challenges in proactive manner. Despite the physical absence of TTL in-country on a permanent basis, the authorities interviewed during the ICR mission expressed their satisfaction with the Bank’s technical and operational contribution to the project. 80. The Bank team was notably responsive in adapting to changes in the implementation environment as evidenced in actions taken during the suspension period, the major restructuring in 2007, and subsequent modifications to the results framework and budget reallocation. In order to enhance the quality of each component, specific independent reviews were conducted for component 1 (HIV/AIDS), component 2b (community microprojects) and component 4 (project coordination). 81. Aide-memoires and ISRs in most cases were well documented and provided a thorough analysis of the challenges and corrective measures to improve project performance. FM and procurement supervision were conducted on a regular basis conjointly during the project supervision missions and recommendations delivered on fiduciary points were pertinent. Among the somewhat weaker points were: (i) the large fluctuation in ISR ratings and in some cases overrated (e.g. procurement remained Satisfactory after the quality of the second lot of ITNs was known); and (ii) a strong focus on process and fiduciary issues but a somewhat weak focus on project outcomes, as measured by indicators until later stage of project implementation. (c) Justification of Rating for Overall Bank Performance Rating: Moderately Satisfactory 82. Bank performance in supporting the government to address urgent needs in its fight against HIV/AIDS, as well as other urgent social needs, is rated Moderately Satisfactory given the Satisfactory rating on one dimension (quality at entry) and a Moderately Satisfactory rating on the other dimension (quality of supervision). 5.2 Borrower Performance (a) Government Performance Rating: Moderately Satisfactory 83. Overall, when considering the post-crisis environment and a weakly functioning government, the borrower’s strong commitment to achieving the project’s development objectives should be acknowledged. The government is particularly commended for: (i) operating in a concerted manner to bring together all concerned actors and enhancing collaboration between different sectors; (ii) its 35 promptness in establishing the necessary institutional structures, as seen in the creation of CMO, 27 FMPU and prefectural bodies of CNLS and their technical team; and (iii) CMO’s eventual leadership in its oversight functions and commitment to achieving results. 28 84. Less emphasis was put on the follow-up of initial strategic orientations adopted in the PAD or Restructuring Paper. For example, the strengthened capacity of the UCM to provide pharmaceutical products was an important result expected by CNLS to enhance integration and complementarity of all partners financing HIV/AIDS activities, but this was limited to informal collaboration between UCM and CNLS without any systematic follow-up. Similarly, the government’s initial commitment to establishing an autonomous CSO financing agency within the government to manage different partner contributions for community projects failed to result in any material action. (b) Implementing Agency or Agencies Performance Rating: Moderately Satisfactory 85. The implementation challenges encountered early on included: (i) a measure of confusion in the division of responsibilities between certain entities given the large number of actors involved; (ii) weak ownership of M&E prior to the arrival of the PSES project coordinator; and (iii) delays in disbursement. A large number (some more than others) of these challenges were later addressed during the project implementation stage. A summary assessment of the various implementing agencies involved can be found below. • CNLS-TS. Throughout the project, the CNLS-TS functioned autonomously with strong technical capacity of key personnel, 29 which facilitated its management of different HIV/AIDS programs. Regular integrated supervision missions comprising CNLS-TS, UCM, and sectoral ministries allowed for immediate response to addressing implementation bottlenecks, as well as close monitoring of inputs reaching the end-beneficiaries. Some challenges to future sustainability include: (i) ensuring patients under treatment be absorbed by GFATM or other programs; (ii) continuation of income-generating activities at local levels in order to ensure some profitability and durability; and (iii) maintaining key personnel and operational functions of CNLS and CPLS. • FMPU-PSES. In the beginning FMPU experienced an absence of leadership, which hampered the coordination of the different sectors involved. To a large extent the arrival of the PSES project coordinator addressed these bottlenecks and performance improved significantly towards the end of the project. This also led to enhanced learning from lessons and better coordination among the fiduciary staff and sector focal points, resulting in the government’s decision to keep the core FMPU-PSES team for implementation of the successor IDA/HRITF co-financed health project. • Cellule Provisoire de Financement aux Organisations de la Societé Civile (CPFOSC). A Unit to manage CSO activities was created under direct supervision of the CMO with the purpose of channeling funds to community initiatives and providing them with technical support. Overall, while the subcomponent absorbed a large portion of project funds, CPFOSC managed to keep a small team with: (i) one technical staff responsible for reviewing, approving and ensuring quality of the proposals submitted, overseeing implementation and monitoring results; and (ii) FM staff responsible for FM and disbursement of the component, while benefiting from technical expertise of Directorates and ministries. The main challenge was that there was no civil engineer on the team 27 The CMO was created by a government decree in February 2007 and was presided by the Ministry of Planning and Economy. 28 While development of action plans and budget and their submission for Bank approval was the responsibility of CMO, the DCA in its Annex 2 1A1(c) and 1A2 (implementation arrangement) stipulated that this responsibility was assumed by CNLS. This inconsistency was never corrected. 29 The original team was replaced with a stronger team with adequate technical expertise after a negative assessment by the GFATM led to the suspension of funds in 2009. 36 despite the amount of civil works involved, contributing in some cases to the modest quality of these works. The CPFOSC later recruited a civil engineer and also enhanced collaboration with the DGH and Ministry of Environment for their technical support. • Ministry of Health. The initial confusion in the leadership role in coordinating the health component stemmed from the dual responsibilities of the MoHP Planning Department Director as member of the CMO and at the same time play the role as a focal point coordinating the health component. This was later resolved when the Chief of Malaria Services was brought in to coordinate the health component and the Director of the Planning Department continued to assume his role as member of the CMO. • Sectoral ministries. Sectoral ministries receiving support on the HIV/AIDS component generally operated autonomously and were able to produce results exceeding their initial plans despite modest financing. One shortcoming, however, was in regards to accountability, as public sector responses under the HIV/AIDS component relied on budget transfers by the CNLS-TS, which in some cases saw delays and consequently affected their implementation. (c) Rating for Overall Borrower Performance Rating: Moderately Satisfactory 86. The rating for Overall Borrower Performance is Moderately Satisfactory given the same Moderately Satisfactory rating for both government performance and implementing agency or agencies performance. 6. Lessons Learned 87. Strong ownership and the commitment of key actors could leverage significant funding and ensure continuity in the government and partner efforts even under circumstances that do not allow for normal operation. The case of CAR demonstrated this in two ways. First, the project faced more than five years of suspension before effectiveness but the government was still able to make full use of project advances and Trust Funds that were exceptionally granted to strengthen its institutional capacity, and as a result, leveraged large amount of resources from different partners. Second, once the decision on re-engagement was made, the World Bank team and the government moved swiftly with the project preparation capitalizing on what had been built in the preceding years, while adjusting the design and implementation mechanism to meet the actual needs. 88. A strategy shift in 2007 from a single HIV/AIDS operation to a multifaceted one encompassing broader social sectors promoted a higher response to needs in diverse areas. In addition, synergies were created to ensure efficient use of resources. Combining different sectors in one project helped the government tackle immediate needs; and allowed to use this opportunity to gain some time until subsequent sector-specific projects with larger development impact could be developed. This approach could potentially be used in similar fragile and complex situation. 89. A clear, well-defined institutional arrangement from the outset is crucial to achieving optimal results in a multisectoral operation. Stakeholders agreed that part of the initial implementation delays were caused by ambiguity in their division of roles and responsibilities, given the complexity of the project set-up and the numerous parties involved. This was addressed later by a clearer separation of functions between strategic direction (CMO) and operations (FMPU) and ensuring leadership on either side. In addition, this experience is a reminder that the clarity of accountability mechanisms needs to be guaranteed in order to set a firm results-oriented focus. For example, centralization of fiduciary responsibilities helped to reduce transaction costs related to procurement of key inputs, but this was achieved at the cost of accountability challenges between the technical actors and fiduciary colleagues. The economy of scale argument therefore needs to be carefully examined in this particular context. 37 90. Some of project’s creative approaches for fiduciary arrangements could provide important lessons in a context of political instability and post-conflict situations. For example, the fiduciary system was organized in such a way as to ensure that money could be channeled to areas that are remote and difficult to access, through use of intermediaries in semi-informal sectors. In addition, the project used the regular integrated supervision missions for the HIV/AIDS component as a way to deliver inputs directly to the end-beneficiaries (rather than using a transporter), while at the same time ensuring close monitoring of stocks and patients on treatment, and coaching health personnel. These approaches helped address some of the logistic challenges in post-conflict situations. 91. Use of CSOs needs to be accompanied by a realistic capacity assessment and support for capacity strengthening. The project underscored the great benefits of civil society involvement and empowerment of communities in responding to their own needs and reaching out to the most remote areas; however, adequate technical capacity of these organizations needs to be ensured. The project initially envisioned ‘competitive’ contracting for associations and community groups but the shortage of competent organizations resulted in large variations in their performance. As the technical level of local supporting NGOs is a determining factor to ensure an effective implementation of community activities in a low capacity context, it is important to identify champions, as well as involve partners in the design and implementation. The experience also exemplified the critical need to link payment with performance, based on a predefined set of indicators, in order to hold the parties accountable for their results. 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners 92. A debriefing meeting was held on the final day of the ICR mission; the Task team, Borrower, and other parties involved in project implementation participated in this meeting and agreed on the results of the indicators reported in the data sheet. In cases where some of the key inputs had not been fully distributed, 30 the Borrower agreed to provide updated data on the key indicators upon final completion of these deliveries. A summary of the Borrower’s final evaluation report is presented in Annex 7. The report takes into account the views of other partners and stakeholders (e.g. NGOs and civil society) through extensive discussions and field visits that were carried out. 30 The Bank had earlier reached an agreement with the Borrower to exceptionally allow for completion of the final distribution by June 30, 2012. 38 Annex 1. Project Costs and Financing (a) Project Cost by Component (in US$ Million equivalent) Pre-effectiveness Appraisal Actual/Latest Percentage Components Estimate Estimate of Appraisal (US$ millions) (US$ millions) Strengthening public Sector responses 3.26 0 0 (original component 1) Strengthening CSO responses (original 11.04 0 0 component 2) Coordination, project management and 2.52 0 0 monitoring (original component 3) Project preparation facility 0.5 2.0 11.5 Total Baseline Cost 17.32 2.0 11.5 Physical contingencies 0.36 0 0 Price contingencies 0.32 0 0 Total Project Costs 18.0 2.0 11.1 Front-end fee PPF 0 0 0 Front-end fee IBRD 0 0 0 Total Financing Required 0 0 Post-effectiveness (post 2007 restructuring) Appraisal Actual/Latest Percentage of Components Estimate Estimate Appraisal (US$ millions) (US$ millions) Support to HIV/AIDS (revised 6.47 5.72 88.4 component 1) Support to urgent health needs (revised 6.56 8.33 127.0 component 2) Support to education sector (revised 2.7 2.64 97.8 component 3) Support to FM and procurement Unit 0.18 2.26 1255.6 (revised component 4) Unallocated 1.59 0 0.0 Total Baseline Cost 17.5 18.95 108.3 Physical contingencies 0 0 Price contingencies 0 0 Total Project Costs 0 Front-end fee PPF 0 0 0 Front-end fee IBRD 0 0 0 39 Total Financing Required 0 0 (b) Financing Appraisal Actual/Latest Type of Percentage of Source of Funds Estimate Estimate Cofinancing Appraisal (US$ millions) (US$ millions) Borrower 1.00 0.00 .00 International Development Association 17.50 18.95 108.3 (IDA) 40 Annex 2: Descriptive Summary of Project Outputs COMPONENT 1: Support to Fight Against HIV/AIDS Subcomponent 1 (a): Response to Civil Society Prevention targeted towards youth • Financing of 85 action plans for 27 youth associations (compared to initial target of 100 action plans). Reducing stigma and support to PLWHA • Support to operational costs, vehicle and material supplies for the PLWHA network (RECAPEV). • Financing of 31 PLWHA associations to build a total of 15 restaurants, 19 mini motels and one warehouse for income-generating activities in 31 PSES sites and four Global Fund sites. • Financing of 31 NGOs (last year 17) to provide support services to youth associations and PLWHA associations. • Training of supporting 31 NGOs in procurement and community participation. • Technical support to 31 provincial technical teams to identify and help structure youth and PLWHA associations. Subcomponent 1 (b): Support to health sector responses VCT and PMTCT • Quarterly provision of equipment, laboratory consumables and tests (ELISA) for support to VCT and PMTCT in 31 health facilities. • Motorbikes and other logistical support to activities in 31 health facilities. • Support to advanced strategies to enhance VCT, resulting in the testing of 118,862 people at target health facilities. • Training of PMTCT support groups and financing of their action plans for awareness raising, partner testing of women and studies on children. • Training of health workers in 31 sites on PEC pediatrics, ARVs, new protocols for PMTCT and data collection/utilization of tools. • Training of 25 personnel responsible for media-related promotional work on PMTCT. • Support to implementation of action plans in radio and TV stations. • Testing of 10,465 pregnant women (who received results) in target health centers and access to treatment. Prevention of HIV transmission through blood transfusion • Purchase and distribution of blood testing pockets (of which 27,944 were tested) and fridges. • Training of 45 laboratory staff. • Support to federation of donor associations. • Reproduction of 200 copies of blood supply utilization manual. • Purchase of power generators in 16 sites and their maintenance. • Operational cost support to the National Blood Transfusion Center and their supervision missions (including installation missions) to health facilities. Access to ARV treatment • Purchase of laboratory testing equipment, drugs, consumables and office material to support ARV treatment. • Training of six laboratory technicians. • Support to 31 health centers for monthly testing of FOSA to transmit blood samples to laboratories. • Support to monitoring tools for patients under treatment in 31 sites. • Provision of treatment to 1,624 adults and 95 children. 41 Subcomponent 1c: Support to HIV/AIDS action plans and other public sectors Ministry of Education • Purchase and distribution of condoms (male and females) for awareness raising. • Organization of VCT campaigns in 30 localities in 15 education sectors (Bangui, Ombella and Mpoko). • Provision of Opportunistic Infection treatment and psychosocial support. • Support for the implementation of action plans and supervision by the ministry. • In sum, 1,999 teachers were tested and received results, against a target of 3,500 (57.1 percent achievement rate). 31 Ministry of Social Affairs • Organization of VCT campaigns in 16 localities to vulnerable populations, including HIV orphans, widows, handicaps, etc. • Psychosocial support to the vulnerable population that are infected. • Provision STI, OI and TTT kits in target military camps. • Distribution of condoms in target sites. • Organization of technical support missions (part of integrated supervision missions). • Support for the implementation of action plans and supervision by the ministry. • 18,448 individuals and their families were sensitized; 10,774 of them were tested and 8,948 were both tested and received results, and 332 received results. • 310 HIV orphans received school kits in 31 sites. Table 5: Project contribution to Ministry of Social Affairs in its fight against HIV/AIDS 2008 2009 2010 2011 TOTAL # people sensitized 1 415 4 232 7 470 5 331 18,448 # people tested 1 050 3 217 4 254 2 223 10,744 # people tested and received results 1 050 2 314 3 593 1 991 8,948 of which under treatment 108 91 119 14 332 Source: Ministry of Social Affairs Ministry of National Defense • Sensitization campaigns for military camps in Bouar and Bangui (flyers, condoms, animators). • Organization of VCT campaigns in military camps at Moungomba, Bambari and Bossangoa. • Provision of treatment for OIs and psychosocial support. • Support to PLWHA association ‘PLWHA in uniform’ (income-generating activity). • Support for the implementation of action plans and supervision by the ministry. • Training of 28 pair trainers. • In total, the project reached a total of 6,845 military personnel and their families in the targeted military camps; 580 of whom were found to be HIV positive, reflecting an alarmingly high rate of infection (approximately 12 percent). Similarly, a total of 1,144 people working in non- military jobs within the ministry were tested. About 8 percent of those tested were found to be HIV positive. The primary project contribution in this particular context was the creation of a PLWHA association of military personnel to support income-generating activity. 31 Some of the possible reasons for low achievement including: (i) locating PSES sites in small remote towns, whereas most most teachers live in large cities; and (ii) frequent stock-out of inputs. 42 Ministry of Public Services • Organization of a 7-week VCT campaign in Bangui. • Support to VCT campaigns in nine decentralized structures. • Distribution of condoms (male and females). • Creation of six selling points for condoms in ministerial departments. • Provision of treatment for OIs and psychosocial support. • Organization of strategic meetings with different ministry focal points. • Support for the implementation of action plans and supervision by the ministry. • A total of 9,633 people were sensitized; 8,516 of whom were tested. Of those tested, 18 men and 12 women received treatment. • While data for 2008 was not available, a high rate of testing (sensitization campaigns reached 88 percent of the population) was probably due to a strategic shift after the first year from the distribution of vouchers to on-site testing where results could be obtained on the spot. However, treatment coverage remains low (14 percent of those were found to be seropositive) as a result of insufficient inputs and the fear of stigma, especially among high-level officials. 32 Table 6 : Project contribution to Ministry of Public Services in its fight against HIV/AIDS 2009 2010 2011 2012 TOTAL # people sensitized 3,005 4,661 1,967 NA 9,633 # people tested 2,659 4,009 1,848 NA 8,516 # seropositive (men) 82 89 39 NA 210 of which under treatment 8 9 1 NA 18 # seropositive (women) 59 14 9 NA 82 of which under treatment 8 4 - NA 12 Source: Ministry of Public Services Subcomponent 1(d): Coordination, Supervision, M&E to support the National Program against HIV/AIDS Support for coordination and supervision of CNLS • Provision of office supplies, consultant and personnel, and organization of quarterly integrated supervision missions. • Capacity Development of CNLS, including training of CNLS staff and PSES staff. • Training missions by Central Medical Unit (UCM). • Support to operational cost for Central Medical Unit (UCM). Monitoring and Evaluation • Financial and technical support to provincial technical teams for data collection. • Support to PSES steering committee. • Support to execution of the second generation sero-surveillance study. • Contribution to the organization of the Multiple Indicator Cluster Survey (MICS 2010). • Establishment of the Implementation Steering Committee (CMO) and support to operational cost. Implementation of Medical Waste Management Plans (MAWMP) The project met the objective by supporting implementation of MWMP measures in the 31 targeted health centers (intermediate outcome indicator 3) through: • Sensitization materials and training manuals on MWMP. • Training of trainers of 20 staff on medical waste management at the central level. • Training of 300 health staff in 31 targeted health facilities. 32 These points were highlighted in discussions with officials during the ICR mission. 43 • Provision of material and equipment for MWMP implementation (trash bins, boots, gloves, cameras, etc.). • Support for the implementation of action plans and supervision by the Direction of Community Health (responsible for MWMP). • Construction of 30 incinerators. • Supervision missions for 50 health facilities implementing MWMP • Support to office supplies and operational costs. COMPONENT 2: Support to Urgent Health needs Fight against Malaria • Acquisition and transportation of 100,000 ITNs in three prefectures. • Support to ITN distribution campaigns. • Organization of 6 missions to sensitize the population on the use of ITNs. • Support to microprogramming and media coverage. • Training of 910 mobilizers and 1,560 community distributors on the distribution strategy and data collection. • Support to operational costs and supervision missions for the National Service for the Fight against Malaria (MOH). Provision of medical equipment and training of health personnel • Provision of medical equipment to 15 health facilities. • Training on sterilization and reanimation in health facilities. • Support to operational costs for Direction of Health Infrastructure Development (DDIS). Community microprojects • Recruitment and training of implementing NGOs (AEPs). • Contracting of AEPs. • A total of 192 community microprojects were developed and completed against an initial plan of 200 (96 percent achievement rate). In total, 46 forages, 46 water sources, 9 wells were built and health facilities rehabilitated as part of these community projects. • Support to M&E of community microprojects, including site identification missions, AEP installation and supervision missions of community microproject implementation. • Support to operational costs, identification, evaluation and planning missions, as well as regular supervision missions for the Direction of Community Health and General Direction of Hydraulics. • Staff costs, equipment and operational costs for CPFOSC. • Training on community microproject management and procurement. Table 7 : Breakdown by types of community water points constructed (population benefited) 2008 2009 2010 2011 2012 Total Forages 8 3 30 0 5 46 Sources 9 11 24 1 1 46 Puits 7 1 1 0 0 9 Total 24 15 55 1 6 101 # of people benefited 7,200 4,500 16,500 300 1,800 30,300 Source: Ministry of Hydraulics COMPONENT 3: Support to Education needs • Recruitment and training of 1,023 teachers. • Purchase and distribution of 89,250 French text books, 89,250 math textbooks, 5,596 school kits, 5,130 table benches, 629 wardrobes, 120 teachers’ desks and 129 chairs. • Freight, handling, stock and distribution costs for school materials and teachers’ salaries. 44 • Training of 22 heads of school districts and nine regional pedagogical centers on the new curricula. • Printing of 3,000 curricula. • Support to operational costs and M&E for the Ministry of Education. COMPONENT 4: Support to Financial Management and Procurement Unit • Staff cost for PSES staff (project manager, procurement specialist and FM specialist, drivers, guardians). • Financial audit. • Installation and training of accounting software (TOMPRO). • Operational and material costs, maintenance and supervision costs. • Vehicles and maintenance. 45 Annex 3. Economic and Financial Analysis HIV/AIDS component. The economic analysis of HIV/AIDS in Africa carried out under the MAP provides an assessment of the impact of prevention, access to testing, care and treatment, as well as a cost-benefit analysis of HIV/AIDS interventions in general. It concludes that: (i) reduction of AIDS-related deaths would increase the growth of GDP, and (ii) HIV/AIDS reduces the value of physical, human and social capital. However, in the absence of a project-specific analysis, project efficiency before/after, and with/without comparisons could not be measured. A study that measured the cost-effectiveness of different interventions and their impact 33 (by measuring the cost per infection averted) concluded that PMTCT and blood safety are among the most cost-effective interventions for sub-Saharan Africa, whereas VCT is relatively less cost effective. However, as this project exemplifies, the study alludes to greatly enhanced cost-efficiency when utilizing a package of mutually supportive and complementary interventions, given the cost savings associated with supervision, delivery of inputs and training of personnel. Table 8: Comparison of HIV/AIDS intervention and impact Central and West Africa (lower prevalence) Cost per Impact ( percentage of infections averted) infection Low Medium High averted (0-10 percent) (10-20 percent) (> 20 percent) Low MSM Sex Workers (< US$ 1,000) Medium Blood safety PMTCT (US$ 1,000- Condom distribution VCT 3,000) Workplace programs High Community mobilization (> Mass media US$ 3,000) STI treatment Education Source: The World Bank’s Commitment to HIV/AIDS in Africa: Our Agenda for Action, 2007-2011, June 2007 IEG suggests other criteria for assessing the benefits of MAPs, including: (i) enhanced political commitment to controlling the epidemic; (ii) expanded and strengthened national and subnational AIDS institutions to address the long-run response; (iii) mobilization of NGOs in the national response and reinforcement of their capacity to provide access to prevention and care among the high-risk groups most likely to contract and spread the infection; and (iv) enhanced the efficiency of national AIDS programs. The analysis provided in this report demonstrates that PSES has contributed to all these criteria, although the scale of this contribution remains modest. Health component 33 The World Bank’s Commitment to HIV/AIDS in Africa: Our Agenda for Action, 2007-2011, June 2007, citing Bollinger and Stover (2007). 46 Malaria: The economic analysis on malaria has been made in the context of regional and sub-regional studies. Macroeconomic projections 34 show that the impact of malaria on productivity of workers and on external investments into endemic countries i s major and has a deleterious impact on growth and poverty reduction strategies. It is estimated that malaria reduces GDP growth by approximately one full percentage point per year. The poor are affected most as they have less access to medical services, information and protective measures, and less opportunity to avoid living or working in malaria- affected areas. In fact, poor populations are at greatest risk; 58 percent of the cases occur in the poorest 20 percent of the world's population, and these patients receive the worst care and have catastrophic economic consequences from their illness. Emergency community-based microprojects: An independent evaluation of the community microproject conducted in December 2010, while not sufficiently addressing the economic efficiency of interventions, acknowledges the important contribution and strategic relevance of this subcomponent, especially with regard to: (i) the design and strategies adopted in this component address the nature of the problems, i.e. improving the health situation of the population and addressing urgent needs through a participatory process benefiting from support by NGOs; (ii) the project successfully stimulated the interest of the rural population as well as community awareness of the need to improve primary health care; (iii) access to basic health needs and water supply were significantly improved under the project; and (iv) a positive collaboration was maintained between the PSES, supporting NGOs and relevant ministries (MoHP, DGH and DSC). Education Component The economic analysis of the education sector draws on the economic analysis conducted under the Country Status Report in Education (RESEN), which concludes that in CAR increasing the supply of schooling materials along with the availability of teachers and of their services, as well as a reduction in their in-class training period in favor of on-the-job training, were cost-effective interventions. Table 9: Analysis of the cost-effectiveness of the different options of educational policy Impact on Cost- Policy options learning Cost effectiveness achievement Providing reading text-books to all pupils *** $ Very good Providing pencils to all pupils * Close to 0 Very good Reducing the class-size * $$$ Average Reducing repetition ** +++ Excellent Hiring teachers with high level of qualification and high level 0 $$$ Very poor status Initial training shorter 0 ++ Very Good Use of multi-grade, double-vacation 0 + Good School building of high standards 0 $$$ Poor Increasing of inspectors visits in schools 0 $$ Poor Increasing of real teaching time ** 0 Very Good Impact : - negative impact, 0 : no impact, * : significant impact, ** : high impact, *** : very high impact; Cost : +++ : major savings, 0 : no cost, $ : low cost, $$ : high cost, $$$ : very high cost 34 Conquering the intolerable burden of malaria: what's new, what's needed, Breman JG, Alilio MS, Mills A., Am J 1 rop \led 1111. 2003 47 Annex 4. Bank Lending and Implementation Support/Supervision Processes (a) Task Team members Responsibility/ Names Title Unit Specialty Lending Supervision/ICR Jean Delion Senior Operations Officer AFTCS TTL Michel Bakuzakundi Consultant AFMCM - HIS Sectoral Responses Financial Leon-Patrice Ngueretia Consultant AFMCF Management Ningayo Charles Donang Senior Procurement Specialist AFTPC Kossi R. Eguida Economist AFTP3 Program Assistant Disbursement Ndjebet Yaka Operation Analyst AFMCM specialist Alain Lefevre Consultant AFTR2 Operations Specialist Fridolin Ondobo Financial Management Specialist AFTFM FM Specialist Bernadette Djapa Nyanjo Procurement Assistant AFCC1 Senior FM Specialist Bella Lelouma Diallo Sr Financial Management Speciast AFTFM Senior FM Specialist Francois Honore Mkouonga Consultant AFCC1 Marie-Claudine Fundi Language Program Assistant AFTAR Fathma Diana Jalloh Junior Professional Associate Eienne Nkoa Senior FM Specialist AFTFM Senior FM Specialist Ningayo Charles Donang Senior Procurement Specialist AFTPC Jean Paul Tchupo Consultant AFTHE TTL (since Giuseppe Zampaglione Country Manager LCCHN 07/02/2007) Yasser Aabdel-Aleem Awny El- TTL (since Gammal Sector Manager 03/10/2008) TTL (since Margo A. Hoftijzer Senior Economist AFTED 01/01/2008) TTL (Since Gaston Sorgho Lead Public Health Specialist AFTHE 12/11/2009) Michel Voyer Consultant AFTHE Haoussia Tchaoussala Consultant AFTPC Patrick Bongotha Consultant AFMGA Kossi R. Eguida Economist AFTP3 (b) Staff Time and Cost Staff Time and Cost (Bank Budget Only) Stage of Project Cycle US$ Thousands (including travel No. of staff weeks and consultant costs) Lending 48 FY01 29 83.34 FY02 26 111.70 FY03 0.04 FY04 0.00 FY05 0.00 FY06 0.00 FY07 0.00 FY08 0.00 Total: 55 195.08 Supervision/ICR FY01 0 FY02 3 58.83 FY03 12 84.76 FY04 12 63.07 FY05 25 96.79 FY06 17 61.43 FY07 23 178.86 FY08 37 176.87 FY09 25 122.41 FY10 25 138.12 FY11 19 151.14 FY12 6 57.55 F Total: 203.5 1189.83 49 Annex 5. Summary of Borrower's ICR and/or Comments on Draft ICR Evaluation Context. The Borrower’s final report on the Multisectoral HIV/AIDS, Health and Education Project (PSES) submitted in June 2012 has three main parts: (i) project design and preparation; (ii) project implementation; and (iii) lessons learned and recommendations. The report was based on extensive consultation with all actors involved, focusing on achievement of project objectives, performance evaluation of the parties concerned and main factors affecting the project results. The evaluation also intended to reflect the lessons learnt from the project to inform future operations in CAR. Project design and preparation. The report confirms that project development objective (PDO) ensures a multisectoral dimension to address the urgent needs in social sectors and to support implementation of the government’s Political, Economic and Social Framework (2006-2008). It further builds on directions of the Poverty Reduction Strategy Paper (2008-2010) and the National HIV/AIDS Framework 2006-2010. The report also stresses the collaborative aspect of project preparation, i.e. that the activities to be supported were identified through a common agreement between the Bank and different ministry authorities. The report highlights a weak focus on results in the project design, as lack of data availability and inexistence of a baseline study resulted in poor monitoring of project performance. However, the strategies retained to achieve projected results are in conformity with the following ongoing sectoral policies and strategies: (i) three of the main elements of the HIV component are aligned with the National HIV/AIDS Framework 2006-2010; (ii) strategic orientations for the health component (support to fight against malaria through ITN distribution, improvement of urgent service equipment at health facility level; and community microprojects through improved access to water and rehabilitation of health posts and health facilities) are aligned with the Second Generation Strategic Plan to fight against malaria (2007-2010). Similarly, the National Health Development Plan (2006-2015) envisages strengthening of the country’s institutional framework; and (iii) education component activities to improve school material provision and increase number of teachers reflect the national education sector strategy (2008-2020). The four separate components, each focusing on a specific sector, allowed for a clear separation of expected results and clear lines of accountability. However, the institutional set-up (with many actors involved in a multisectoral undertaking) was complex for an emergency project being implemented under weak institutional capacity. Implementation Performance during the start-up phase was judged to be satisfactory given that effectiveness conditions were quickly met and activities on the ground started four months after effectiveness. However, there were some shortcomings in the quality of certain processes, notably in: (i) the absence of a formal text for the creation of FMPU-PSES and CPFOSC resulting in lack of clarity in the manner they were organized and their respective roles ; (ii) the nomination of CMO members did not respect the responsibilities as defined in the execution manual, as seen in the case of MoHP Planning Department and Resource Management Directorate of Ministry of Education who acted as both a CMO member and technical focal point for the component ; these roles should have been separated and assumed by different individuals or entities. 50 Performance by component Component 1. The component’s modest disbursement rate of 73 percent is explained by the fact that, until 2009, the component suffered from : (i) reselection of intervention zones to accommodate new partner interventions (GFATM); and (ii) procurement delays of key inputs (drugs, test and consumables) that hampered activities on the ground. However, the PSES experience proved its efficacy with regard to the VCT approach, notably contributing to mitigation of stigma through advanced mobile strategies. Integrated supervision missions conducted under this component also contributed to strengthening of local level capacities and performance improvement. Component 2. This component initially suffered from a lack of clarity in its institutional set-up. The DEP Director was nominated as a member of the CMO (responsible for strategic coordination and oversight) but also had to assume a role as a focal point for the health component (supervision, technical coordination and M&E), resulting in a conflict of interest. The Head of Services for Malaria eventually took over the role of health focal point but did not have the capacity to oversee the activities related to other activities under this component (e.g. community microprojects, strengthening health facility capacities). This lack of leadership resulted in a conflict of responsibilities between some entities. As regards disbursement, this component had the largest financing with 106 percent of realization, with stable disbursement from 2008 to 2011. However, procurement suffered from deficiencies particularly with regard to non-conformity of ITNs, which meant that it was not possible to distribute two-thirds of total purchases of ITNs. Component 3. The institutional arrangement for the education component did not respect the execution manual, notably with respect to the establishment of a small FM Unit within the Ministry of Education. Accordingly, FM for this component relied on PSES PIU. Budget execution rate was 96 percent, with almost the entire amount disbursed in the first two years, thereby allowing for a smooth transition to the successor education project in the third year of the project. The component also contributed to a significant increase in the number of teachers. Component 4. The recruitment of a Project Manager in late 2009 led to an improvement in project performance and addressed the issue of leadership. Budget disbursement was 100 percent at project closure but the initial allocation constituted a mere 8 percent of total effective disbursement, and 89 percent of total disbursement came from non-allocated budgetary resources. Some activities foreseen under this project were not carried out, e.g. an impact evaluation to inform the total number of project beneficiaries. Principal Findings. • Project design should reflect an appropriate institutional framework with necessary functions for project implementation and allow for interaction between in order to create optimal conditions for project execution. • Strategic monitoring should be separated from operational monitoring. It should also ensure that ownership of those involved in providing strategic orientations. • VCT strategy proved effective and should be continued with GFATM support. Similarly, effective supervision through integrated supervision missions bringing together various competencies in intervention zones proved to be successful in enhancing project efficiency. • Strategies for maintaining project gains should be considered during the project appraisal/ implementation stage. Addressing these issues at project closure is problematic as time constraints make it difficult to develop an action plan, or there may be insufficient financial resources, or that actors may not be sufficiently motivated as they were not involved in project execution. 51 • The PSES experience confirmed that insufficient knowledge on procurement processes negatively impacted project performance. Recommendations. • Consolidation of project gains requires certain measures at the level of ministries and services concerned, notably : (i) survey on the efficacy of ITN utilization ; (ii) final evaluation of community microprojects ; (iii) effective integration of contracted teachers in the public services; (iv) technical support to ensure sustainability of water points and other works conducted under PSES; (v) evaluation on the profitability and sustainability of income-generating activities (PLWHA ); and (vi) reinforcing integrated supervision missions. • The Ministry of Planning will prepare guidelines that will help capitalize on and disseminate lessons learnt during the implementation of different public lending projects. For that, it is crucial that the ICRs of various projects are systematically made available and experiences are widely shared. This will bring additional value to improving the efficacy of international aid. • The World Bank is requested to support the MoHP Community Health Directorate (DSC) in their consolidation of community microproject activities and also support the Ministry of Planning in the establishment of a mechanism to promote and capitalize the lessons learnt. 52 Annex 6. List of Supporting Documents Government • Arrêté n°0017/2007 portant création du Comité de Mise en Œuvre du PSES, Ministère de l’Economie, du Plan et de la Coopération Internationale, Juillet 2007. • Arrêté n°0018/2007 portant nomination des membres du Comité de Mise en Œuvre du PSES, Ministère de l’Economie, du Plan et de la Coopération Internationale, Juillet 2007. • Décret n°10.358 modifiant et complétant certaines dispositions du décret n°01.032 du 26 Janvier 2001 portant création du CNLS, Décembre 2010. • Rapport de situation sur la riposte nationale à l’/épidémie de VIH SIDA CAR 2003-2005, 2006-2007, 2008-2009, 2010-2011 • Rapport d’activités 2011 au niveau pays pour le suivi de la Déclaration Politique sur le VIH/SIDA, CNLS. • Plan Stratégique National de l’Elimination de la Transmission Mère-Enfant du VIH/SIDA en RCA 2012-2016, February 2012, Ministère de la Santé Publique de la Population et de la Lutte contre le SIDA • Estimation des Flux de Ressources et de Dépenses Nationales de Lutte Contre le SIDA et les IST (REDES) 2007-2008, Présidence de la République, December 2009, Comité National de Lutte Contre le SIDA • Cadre Stratégique National de Lutte Contre le SIDA 2006-2010, June 2006, Présidence de la République, December 2009, Comité National de Lutte Contre le SIDA • Suivi de la Déclaration Politique sur le VIH/SIDA de 2011, Rapport d’activité au niveau du pays • Cadre Stratégique National de Lutte Contre le SIDA 2012-2016 (draft), Présidence de la République, December 2009, Comité National de Lutte Contre le SIDA • Cadre Stratégique National de lutte contre le VIH/SIDA 2006-2010, Comité National de Lutte contre le VIH/SIDA, Juin 2006. • Atlas of HIV and AIDS Indicators of Central African Republic 2006, June 2008, Macro International and UNFPA • Enquête de Sérologie VIH en République Centrafricaine, 2006 • Suivi de la Déclaration Politique sur le VIH/SIDA de 2011, Rapport d’activité au niveau du pays, CNLS, 2011 • Plan National de Passage à l’echelle PTPE/PECP, Ministry of Health, Population and Fight against HIV • Rapport de Situation Nationale à l’Intention de l’UNGASS (Rapport UNGASS), 2003-2005, 2006-2007, 2008-2009, CNLS • Estimation des Flux de Ressources et de Dépenses Nationales de Lutte contre le VIH/SIDA et les IST (EF-REDES, REDES 2007-2008), December 2009, CNLS, Présidence de la République 53 • Etude des Impacts du Programme “Faire Reculer le Paludisme en République Centrafricane’’ Rapport d’analyse, February 2010, United Nations Development Programme • Plan Stratégique National Faire Reculer le Paludisme 2007-2011, August 2007, Ministèere de la Santé Publique de la Population et de la Lutte contre le SIDA • Plan National de Développement Sanitaire 2006-2015, Ministère de la Santé Publique et de la Population • Elements de Diagnostic du Système Educatif Centrafricain (RESEN), Contraintes et marges de manouevre pour la reconstruction du système éducatif dans la perspective de la réduction de la pauvreté, February 2007, World Bank and Pole d’Analyse Sectorielle en Education de Dakar (UNESCO-BREDA) • Stratégie Nationale du Secteur de l’Education 2008-2020, Ministère de l’Education Nationale, de l’Alphabétisation, de l’Enseignement Supérieur et de la Recherche • Document de Stratégie de Réduction de la Pauvreté (DSRP) 2008-2010, Ministère du Plan, de l’Economie et de la Coopération Internationale, Septembre 2007. • Enquête par grappes à indicateurs multiples couplée avec la sérologie VIH 2010 (MICS 4), Résultats Préliminaires, May 2010 • Résultats de l’enquête nationale à indicateurs multiples couplés avec la sérologie VIH et l’anémie en RCA 2006 (MICS 3), January 2009, Institut Centrafricain des Statistiques, et des Etudes Economiques et Sociales (ICASEES)/ ICF Macro • Rapport sur la Santé et le Système de Santé en Centrafrique (RaSSS), May 2010, World Bank, Ministry of Health, population and fight against HIV • Comptes Nationaux de la Santé 2008 et 2009, November 2011, Ministry of Health and Population • Document de travail de la revue conjointe Banque Mondiale et Banque Africaine de Développement pour la revue du programme pays de la RCA, Ministère du Plan, de l’Economie et de la Coopération Internationale, Mars et Avril 2008. World Bank • Joint Interim Strategy Note for CAR 2007-2008, November 28, 2006, Country Department 7, Africa Region, World Bank and Country Regional Department, Central Region, African Development Bank. • Health Service Delivery in the Central African Republic: An Analysis of Health Facility Data from 2006 & 2011 (Background document of CAR Country Health Status Report), September 2011, AFTHE, Country Department Central Africa, Africa Region, World Bank. • CAR Country Health Status Report, May 2012, AFTHE, Country Department Central Africa, Africa Region, World Bank. • Public Expenditure Review, Chapter 4 (Health, Education and Infrastructure). Project 54 • Manuel d’exécution du PSES, Ministère de l’Economie, du Plan et de la Coopération Internationale, Version finale (Août 2007). • Manuel de procédures administratives, financières et comptables, Lutte multisectorielle contre le SIDA, PSES, Mai 2007. • Manuel de suivi évaluation du PSES, Ministère de l’Economie, du Plan et de la Coopération Internationale, Version finale Août 2007. • Rapport d’avancement du PSES (Volet technique), 2008. • Rapport du Cadre de Gestion Environnementale et Sociale du PSES, Mbaye Mbenguet FAYE Consultant en Evaluation Environnementale et Sociale, Juin 2007. • Rapport du Plan de Gestion des Déchets Biomédicaux du PSES, Mbaye Mbenguet FAYE Consultant en Evaluation Environnementale et Sociale, Juin 2007. • Rapport final Evaluation du niveau de mise en œuvre des mesures de sauvegarde environnementales et sociales recommandées dans le CGES et le PGDBM du PSES, Pierre François DJOCGOUE, Consultant Environnementaliste, Juillet 2010. • Evaluation technique des activités de la Composante VIH/SIDA du PSES, Dr Joseph Aimé BIDIGA, Consultant international et Massamba Antonio Blaise NGOLIO, Consultant national, Décembre 2010. • Rapport Evaluation indépendente de la sous composante 2b du projet multisectoriel santé education SIDA, December 31, 2010, Ministère du Plan, de l’Economie et de la Cooperation Internationale. • Rapport d’avancement de mise en œuvre du PSES, 2009, 2010 (Q1,2, 4), 2011 (Q1-4). • Rapport de Suivi Financier du PSES, 2008 (March-August, September –December), 2009 (Q1,2 and 4), 2010 (Q1, 3 and 4), 2011 (Q1 and 2). • Rapport d’audit comptable et financier du PSES, 2007-2008 (June 2009), 2009 (June 2010), 2010 (June 2011), 2011 (June 2012), Societé d’Expertise Comptable DIARRA. Annual action Plans and Budget, 2007-2012. • Aides-Mémoires and Implementation Status Reports, 2001-2012. • Project Appraisal Document and Restructuring Papers. • Development Credit Agreement and amendments. Others • UNDP Human Development Report (2002) • Multiple Indicator Cluster Survey (MICS) 2006 and 2010Sero-surveillance study 2006 55 16°E 18°E 20°E 22°E 24°E This map was produced by the Map Design Unit of The World Bank. The boundaries, colors, denominations and any other information shown on this map do not imply, on the part of The World Bank Aoukal é SUDAN Group, any judgment on the legal status of any territory, or any endorsement or acceptance of such boundaries. 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