Document of The World Bank Report No: ICR2557 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-H0620 IDA-H4910) ON A IDA GRANT IN THE AMOUNT OF SDR 44.8 MILLION (US$65 MILLION EQUIVALENT) TO THE REPUBLIC OF MALAWI FOR A MULTI-SECTORAL HIV/AIDS PROJECT (MAP) April 9, 2013 Human Development Network AFTHE Africa Region CURRENCY EQUIVALENTS (Exchange Rate Effective May 31, 2003) Currency Unit = Malawi Kwacha (MKW) MKW 91.999 = US$ 1 US$ 0.01087 = MKW 1 FISCAL YEAR July 1 – June 30 ABBREVIATIONS AND ACRONYMS AIDS Acquired Immune Deficiency Syndrome AF Additional Financing AfDB African Development Bank ANC Antenatal Care ART Antiretroviral Therapy ARV Anti-Retro Viral BCI Behavioral Change Interventions BCC Behavior Change Communication BSS Behavioral Surveillance Surveys CAS Country Assistance Strategy CBO Community-Based Organization CDC US Centers for Disease Control and Prevention CHAI Clinton Health Access Initiative CHBC Community Home-Based Care CIDA Canadian International Development Agency CMS Central Medical Stores CSO Civil Society Organization DACC District AIDS Coordinating Committee DALYs Disability Adjusted Life Years DHS Demographic and Health Surveys DfID Department for International Development EP&D Economic Planning and Development EU European Union FBO Faith-Based Organization FMA Financial Management Agency FMR Financial Management Report GARPR Global AIDS Response Progress Report GFATM Global Fund to fight AIDS, Tuberculosis and Malaria GDP Gross Domestic Product GMU Grant Management Unit GOM Government of Malawi GRO Grant Recipient Organization HBC Home-Based Care HCWM Health Care Waste Management HIV Human Immunodeficiency Virus HMIS Health Management Information System HTC HIV Treatment and Care IBRD International Bank for Reconstruction and Development ICR Implementation Completion and Results Report IDA International Development Association IEC Information, Education and Communication IFR Interim Unaudited Financial Report ISR Implementation Status and Results Report JICA Japanese International Cooperation Agency MAP Multi-Country AIDS Program (for Africa) MDG Millennium Development Goal MGDS Malawi Growth and Development Strategy M&E Monitoring and Evaluation MNCH Maternal, Neonatal and Child Health MOF Ministry of Finance MOHP Ministry of Health and Population MOU Memorandum of Understanding MTEF Mid-Term Expenditure Framework MTR Mid-Term Review NAC National AIDS Commission NAF National HIV and AIDS Action Framework NGO Non-Governmental Organization NORAD Norwegian Agency for Development NSF National Strategic Framework (HIV/AIDS) NSO National Statistics Office OPC Office of the President and Cabinet OVC Orphans and Vulnerable Children PDO Project Development Objective PLWHA People Living With HIV/AIDS PMTCT Prevention of Mother-To-Child Transmission PRSP Poverty Reduction Support Paper PSIP Public Sector Investment Program SADC Southern African Development Community SIL Specific Investment Loan STI Sexually Transmitted Infection SMP Strategic management plan SWAp Sector Wide Approach TTL Task Team leader UNAIDS Joint United Nations Program on HIV/AIDS UNDP United nations development Program UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session on HIV/AIDS UNICEF United Nations Children’s Fund USAID United States Agency for International Development VCT Voluntary Counseling and Testing VMMC Voluntary medical male circumcision Vice President: Makhtar Diop Country Director: Kundhavi Kadiresan Sector Manager: Olusoji O. Adeyi Project Team Leader: John Paul Clark ICR Team Leader: Enias Baganizi Malawi MULTI-SECOTRAL HIV/AIDS PROJECT (MAP) CONTENTS Datasheet A. Basic Information........................................................................................................ i B. Key Dates .................................................................................................................... i C. Ratings Summary ........................................................................................................ i D. Sector and Theme Codes ........................................................................................... ii E. Bank Staff ................................................................................................................... ii F. Results Framework Analysis ..................................................................................... iii G. Ratings of Project Performance in ISRs ................................................................... vi H. Restructuring (if any) ............................................................................................... vii I. Disbursement Profile ................................................................................................ vii 1. Project Context, Development Objectives and Design ............................................... 1 1.1 Context at Appraisal ............................................................................................. 1 1.2 Original Project Development Objectives (PDO) and Key Indicators ................. 2 1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification.............................................................................................. 2 1.4 Main Beneficiaries ................................................................................................ 2 1.5 Original Components ............................................................................................ 3 1.6 Revised Components ............................................................................................ 4 1.7 Other significant changes ...................................................................................... 4 2. Key Factors Affecting Implementation and Outcomes .............................................. 5 2.1 Project Preparation, Design and Quality at Entry ................................................. 5 2.2 Implementation ..................................................................................................... 6 2.4 Safeguard and Fiduciary Compliance ................................................................. 10 2.5 Post-completion Operation/Next Phase .............................................................. 11 3. Assessment of Outcomes .......................................................................................... 11 3.1 Relevance of Objectives, Design and Implementation ....................................... 11 3.2 Achievement of Project Development Objectives .............................................. 13 3.3 Efficiency ............................................................................................................ 17 3.4 Justification of Overall Outcome Rating ............................................................ 19 3.5 Overarching Themes, Other Outcomes and Impacts .......................................... 20 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops ... 21 4. Assessment of Risk to Development Outcome......................................................... 21 5. Assessment of Bank and Borrower Performance ..................................................... 21 5.1 Bank Performance ............................................................................................... 21 5.2 Borrower Performance ........................................................................................ 22 6. Lessons Learned ....................................................................................................... 24 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners .......... 24 Annex 1. Project Costs and Financing .......................................................................... 26 (a) Project Cost by Component (in USD Million equivalent) .................................. 26 (b) Financing ............................................................................................................. 26 Annex 2. Outputs by Component ................................................................................. 27 Annex 3. Economic and Financial Analysis ................................................................. 66 Annex 4. Bank Lending and Implementation Support/Supervision Processes ............ 80 Lending ..................................................................................................................... 80 Annex 5. Beneficiary Survey Results ........................................................................... 82 Annex 6. Stakeholder Workshop Report and Results................................................... 83 Annex 7. Summary of Borrower's ICR ......................................................................... 84 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders ....................... 89 Annex 9. List of Supporting Documents ...................................................................... 90 MAP .................................................................................................................................. 91 A. Basic Information Multi-Sectoral AIDS Country: Malawi Project Name: Project (MAP) Project ID: P073821 L/C/TF Number(s): IDA-H0620,IDA-H4910 ICR Date: 04/16/2013 ICR Type: Core ICR GOVERNMENT OF Lending Instrument: SIL Borrower: MALAWI Original Total XDR 25.40M Disbursed Amount: XDR 44.76M Commitment: Revised Amount: XDR 44.80M Environmental Category: B Implementing Agencies: National AIDS Commission (NAC) Cofinanciers and Other External Partners: NORAD UNDP Department for International Development (DFID) Global Fund to Fight AIDS, Tuberculosis and Malaria African Development Bank The Canadian Government (CIDA) B. Key Dates Revised / Actual Process Date Process Original Date Date(s) Concept Review: 08/01/2002 Effectiveness: 02/06/2004 02/06/2004 Appraisal: 03/21/2003 Restructuring(s): Approval: 07/29/2003 Mid-term Review: 06/05/2006 10/03/2006 Closing: 12/31/2008 09/30/2012 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Moderately Satisfactory Risk to Development Outcome: High Bank Performance: Satisfactory Borrower Performance: Satisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Satisfactory Government: Satisfactory Implementing Quality of Supervision: Satisfactory Satisfactory Agency/Agencies: i Overall Bank Overall Borrower Satisfactory Satisfactory Performance: Performance: C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments (if Indicators Rating Performance any) Potential Problem Project Quality at Entry Yes None at any time (Yes/No): (QEA): Problem Project at any time Quality of Supervision No 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 47 47 Health 10 10 Other social services 38 38 Sub-national government administration 5 5 Theme Code (as % of total Bank financing) HIV/AIDS 29 29 Participation and civic engagement 14 14 Population and reproductive health 14 14 Poverty strategy, analysis and monitoring 14 14 Social risk mitigation 29 29 E. Bank Staff Positions At ICR At Approval Vice President: Makhtar Diop Callisto E. Madavo Country Director: Kundhavi Kadiresan Dunstan M. Wai Sector Manager: Olusoji O. Adeyi John A. Roome Project Team Leader: John Paul Clark Christine E. Kimes ICR Team Leader: Enias Baganizi ICR Primary Author: Enias Baganizi ii F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The development objective of the national HIV/AIDS program, which the proposed MAP will support, is to reduce the transmission of HIV, to improve the quality of life of those infected and affected by AIDS, and to mitigate the impact of HIV/AIDS in all sectors and at all levels of Malawian society. Revised Project Development Objectives (as approved by original approving authority) The revised project development objective was to increase access to prevention, treatment, and mitigation services, with a focus on behavioral change interventions and addressing the needs of highly vulnerable populations, including those affected and infected by the epidemic. (a) PDO Indicator(s) Original Target Actual Value Formally Values (from Achieved at Indicator Baseline Value Revised approval Completion or Target Values documents) Target Years % of sexually active respondents who had sex with non-regular partner within the past Indicator 1 : 12 months (by gender, residence) Value 26% (F) 18% (M) 20% (M) 9.2% (M) quantitative or 8.3% (M) 5% (F) 5% (F) 0.7% (F) Qualitative) Date achieved 10/01/2004 09/30/2009 09/30/2012 09/30/2012 Comments The percent of respondents with multiple partners declined sharply for both males and (incl. % females between the baseline and closing dates of the project. achievement) Indicator 2 : % of population expressing accepting attitudes towards persons living with HIV/AIDS. Value 37% (M) 50% (M) 41% (M) quantitative or 25% (F) 50% (F) 30% (F) Qualitative) Date achieved 10/01/2004 09/30/2009 09/30/2009 Comments Although there was increase in the values of the indicator for both males and females, (incl. % the targets for both sexes were not achieved. achievement) Indicator 3 : % of people 15-49 years who are HIV positive Value quantitative or 14.2% 13.5% 12% 10.6% Qualitative) Date achieved 10/01/2004 09/30/2009 09/30/2012 09/30/2012 Comments There have been steady decline in HIV prevalence during the project implementation (incl. % period. achievement) % of orphans and other vulnerable children to whom community support is provided Indicator 4 : (by gender and residence). Value 32.5% 45% 18.5% quantitative or iii Qualitative) Date achieved 10/01/2004 09/30/2009 09/30/2009 Comments There have been changes in the definition of the denominator for this indicator between (incl. % baseline and closing dates, making it difficult to interpret the results achieved. achievement) % of sexually active males and females who report condom use during last high-risk Indicator 5 : sexual encounter (sex with non-regular cohabiting or non-regular partner) within the last 12 months B9by gender and age, 15-24, 25-49). Value 55% for males 63% for males 40.5% for males quantitative or 35% females 41% for females 31% for females Qualitative) Date achieved 10/01/2004 09/30/2012 09/30/2012 Comments This indicator was framed differently between baseline and closing dates. Retrofitted (incl. % analysis applied on the 2004 DHS data using same definition as for the 2010 DHS achievement) shows that the actual b Indicator 6 : Median age at first sex among 15-24 years olds (by gender) 19 years old for Value 18.5 years for males 18.6 years for males males quantitative or 17.4 years for 17.7 years for females 17.8 years for Qualitative) females females Date achieved 10/01/2012 09/30/2012 09/30/2012 Comments The values for this indicator slightly decreased for both males and females. This (incl. % behavior may be related to other cultural behaviors not necessarily related to HIV/AIDS achievement) in a given society and HIV/AIDS related messages may have little effect on Proportion of young people (15-24 years) who correctly identify ways of preventing Indicator 7 : transmission and who reject major misconception about HIV transmission (by gender) Value 41% for males 55% for males 44.7% for males quantitative or 30% for females 40% for females 41.8% for females Qualitative) Date achieved 10/01/2004 09/30/2012 09/30/2012 Comments This indicator improved for both males and females but fell short of the targets set for (incl. % the end of the project. achievement) (b) Intermediate Outcome Indicator(s) Original Target Actual Value Formally Values (from Achieved at Indicator Baseline Value Revised Target approval Completion or Values documents) Target Years Indicator 1 : Number of clients tested for HIV in VCT sites and % receiving results Value 1.35 million (quantitative 1.5% 10% 1.25 million (92.6%) (98%) or Qualitative) Date achieved 12/31/2002 09/30/2009 09/30/2012 09/30/2012 Comments The number and percentage of people tested for HIV and who receive their results (incl. % increased drastically between baseline and closing dates of the project. achievement) iv Indicator 2 : % of pregnant women in PMTCT, tested and receiving their results Value (quantitative 0% 50% 183,147 or Qualitative) Date achieved 12/31/2001 09/30/2009 09/30/2009 Comments The baseline was in % and the actual value at the end of the original project was in (incl. % number. This indicator was dropped for the AF. achievement) Indicator 3 : Number of persons with advanced HIV infection on ARV therapy Value (quantitative 3,000 25,000 262,986 391,338 or Qualitative) Date achieved 12/31/2002 09/30/2009 09/30/2012 09/30/2012 Comments (incl. % This indicator was largely achieved. achievement) % of HIV positive women receiving a complete course of ARV prophylaxis to reduce Indicator 4 : the risk of mother-to-child transmission. Value (quantitative 62% 70% 76% or Qualitative) Date achieved 09/30/2009 09/30/2012 09/30/2012 Comments (incl. % This indicator was achieved. achievement) Indicator 5 : Number of community home-based care visits performed. Value (quantitative 11,000 75,000 Not available or Qualitative) Date achieved 12/31/2001 09/30/2009 09/30/2012 Comments Data for this indicator was not collected and it was dropped by the end of the original (incl. % project. This indicator was formally dropped under the AF. achievement) Funds spent on HIV/AIDS programs (by government and external donors) show steady Indicator 6 : increase throughout program period Value (quantitative Unknown $292.6 $235.9 or Qualitative) Date achieved 10/01/2004 09/30/2012 09/30/2012 Comments Even though there was no baseline for this indicator, the amount available for HIV (incl. % activities in the country was significantly lower than what was available by the end of achievement) the original project. Dropped with AF. Number of local governments (district and city assemblies) with established AIDS Indicator 7 : Coordination program Value (quantitative 28 32 32 or Qualitative) Date achieved 10/01/2004 09/30/2009 09/30/2009 v Comments (incl. % Indicator achieved. Dropped at AF. achievement) Number of private companies and public institutions that have an HIV/AIDS workplace Indicator 8 : policies and mainstreaming programmes. Value (quantitative 7 15 53 or Qualitative) Date achieved 10/01/2004 09/30/2009 09/30/2009 Comments This indicator was largely achieved by the end of the original project. Dropped for the (incl. % AF. achievement) Number of STIs at health facilities which have been diagnosed, treaded and counseled Indicator 9 : according to national management guidelines. Value (quantitative 36 55 37 or Qualitative) Date achieved 09/30/2009 09/30/2012 09/30/2012 Comments This indicator was not achieved. The importance of STI control activities waned down (incl. % during the AF period. achievement) Number of condoms distributed to retail outlets (i.e. for selling) or to clinics for free Indicator 10 : distribution. Value (quantitative 19,483,258 40,000,000 34,409,273 or Qualitative) Date achieved 09/30/2009 09/30/2012 09/30/2012 Comments This indicator was not achieved although there was tangible increase in condom (incl. % distribution from baseline to the closing of the project. achievement) G. Ratings of Project Performance in ISRs Date ISR Actual Disbursements No. DO IP Archived (USD millions) 1 05/31/2004 Satisfactory Satisfactory 2.80 2 11/30/2004 Satisfactory Satisfactory 2.80 3 04/28/2005 Moderately Satisfactory Satisfactory 5.80 4 10/26/2005 Satisfactory Satisfactory 5.80 5 05/01/2006 Satisfactory Satisfactory 15.80 6 11/14/2006 Satisfactory Satisfactory 23.70 7 05/30/2007 Satisfactory Satisfactory 23.70 8 10/29/2007 Satisfactory Satisfactory 30.85 9 06/11/2008 Satisfactory Satisfactory 37.46 10 12/30/2008 Satisfactory Satisfactory 38.03 11 06/24/2009 Satisfactory Satisfactory 38.15 12 12/23/2009 Moderately Satisfactory Moderately Satisfactory 38.15 vi 13 06/29/2010 Moderately Satisfactory Moderately Satisfactory 48.15 14 03/28/2011 Moderately Satisfactory Moderately Satisfactory 53.11 15 12/14/2011 Satisfactory Satisfactory 57.93 16 06/26/2012 Satisfactory Satisfactory 61.91 17 09/29/2012 Satisfactory Satisfactory 67.83 H. Restructuring (if any) Not Applicable I. Disbursement Profile vii 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal 1. At the time of the project appraisal (2004), Malawi was among the poorest countries in the world with real Gross Domestic product (GDP) growth averaging 2 percent for 1999-2004. The population was estimated at around 10 million people. Approximately 52 percent of the population was living below the poverty line. Malawi was spending 7.2% of GDP as the percentage of public expenditure on health. Life expectancy was 49 years. The maternal mortality ratio was 620 deaths per 100,000 live births and the under-five mortality rate was 134 per 1,000 live births. 2. The HIV/AIDS epidemic in Malawi was among the most severe in the region. UNAIDS estimated in 2001 that 15% of adults aged 15-49 were infected, which translated to about 1,000,000 adults and children with HIV. At that time, there were widespread misconceptions among the population about how to prevent the disease. As a result, high risk behavior among sexually active youth and adults was common practice. 3. Most transmission in Malawi was believed to be via heterosexual contact (90%), with mother-to-child transmission a distant second (8%). Women were contracting HIV at younger ages than men and had higher prevalence rates (four to six times more in the 15-29 age group). 4. The financial and human resources of the already weak public health sector had been further strained by increasing demands to provide care, treatment and prevention services for HIV/AIDS. The health system in Malawi was weak, understaffed and struggling to manage the global burden of disease, with efforts further compromised by the need to manage the generalized HIV epidemic. 5. To respond to this massive challenge, Malawi created an enabling institutional arrangement: (i) The Office of the President and Cabinet (OPC) assumed responsibility for HIV/AIDS policy and HIV/AIDS program oversight in Malawi, (ii) the National AIDS Commission (NAC) was established in July 2001 to coordinate and facilitate the national response, and (ii) District AIDS Coordinating Committees (DACCs) were formed in the mid- 1990s in Malawi’s rural and urban districts to coordinate and monitor local HIV/AIDS initiatives. 6. The Multi-Sectoral HIV/AIDS (MAP) project was a Specific Investment Loan (SIL) for Malawi under the Second Multi-Country HIV/AIDS Program (MAP II). 7. The Bank’s support to the Malawi HIV/AIDS program stemmed from its comparative knowledge of design and implementation issues of HIV/AIDS projects. The Bank’s input into the design of the financial, procurement, and monitoring and Evaluation (M&E) systems has also proven valuable. Lastly, the flexibility of MAP financial support and the Bank’s willingness to participate in a pool funding mechanisms made the MAP support a desirable complement to assistance from other development partners. 1 1.2 Original Project Development Objectives (PDO) and Key Indicators 8. The original PDOs of the project was to reduce the transmission of HIV, to improve the quality of life of those infected and affected by AIDS, and to mitigate the impact of HIV/AIDS in all sectors and at all levels of Malawian society. These PDOs were exactly aligned with the objectives of the National HIV/AIDS Action Framework (NAF). 9. Key indicators for the original project were: (i) Percent of people who are HIV-infected (by gender, age, residence); (ii) Percent of orphans and other vulnerable children to whom community support is provided (be gender and residence); (iii) Percent of sexually active respondents who had sex with a non-regular partner within the past 12 months (by gender, residence), and (iv) Percent of population expressing accepting attitudes towards persons living with HIV/AIDS. These key indicators were extracted from indicators of the National M&E Plan of the NAF. 1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification 10. The original PDOs were revised at the time of the Additional Financing (AF) in 2009 and were replaced by one single PDO. The revised PDO was to increase access to prevention, treatment, and mitigation services, with a focus on behavioral change interventions and addressing the needs of highly vulnerable populations, including those affected and infected by the epidemic. 11. The PDO was modified to reflect changes in Regional guidance regarding PDO structure of new HIV/AIDS operations based on knowledge gained through MAP implementation experience and more scientific evidence on the epidemiology of the epidemic. 12. New key indicators were identified at the time of the AF. The new key indicators were: (i) Percent sexually active men and women (15-49 years) having sex with a more than one partner (non-regular partner) in the last 12 months; (ii) Percent of people reporting the use of a condom during sexual intercourse at last high-risk sex (sex with a non-cohabiting or non-regular partner) (by gender and age) (iii) Median age at first sex among 15-24 year olds (by gender); and (iv) Percent of young people (15-24) who both correctly identify ways of preventing transmission and who reject major misconceptions about HIV transmission (by gender). 13. These indicators for the proposed Additional Financing were aligned with the Africa Region HIV/AIDS Scorecard and Malawi’s National HIV/AIDS Monitoring and Evaluation framework which was already aligned with the agreed United National General Assembly Special Session on HIV/AIDS (UNGASS) indicators. 1.4 Main Beneficiaries 14. The primary beneficiaries of the project were identified by the type of benefits that they were to receive from the project as shown in Table 1 below. 2 Table 1: Main beneficiaries of the project Benefits Main beneficiaries Reduction in the spread of HIV/AIDS General population, especially youth, women, and vulnerable groups Improvement of care and support for people The 1 million people infected with HIV/AIDS, the 1.2 million living with HIV/AIDS (PLWHA) orphans and their associated family members Increased capacity to deal with the Rural and urban communities, vulnerable groups, civil society HIV/AIDS crisis groups, managers and staff in various sectors, health care workers Increased capacity for program coordination HIV/AIDS committees at national, district and community levels + and monitoring and evaluation implementing partners Streamed procedures for transfer of Rural and urban communities, civil society groups, saving and credit resources to communities organizations, financial institutions 1.5 Original Components 15. Project component 1: Prevention and advocacy (US$46.48 million - $14.55 from MAP project): Carrying out of activities aimed at changing behavior and preventing the transmission of HIV, including information, communication, and education activities for target populations; promotion of safe sex; prevention of sexually transmitted infections; infection prevention; prevention of mother-to-child transmission of HIV; safe handling and disposal of health care wastes; and voluntary counseling and testing. Implementers of this component were: public, private, and civil society organizations. 16. Project component 2: Treatment, care, and support (S$144.90 million - $4.0 from MAP project): Carrying out of health-care interventions aimed at reducing HIV/AIDS morbidity and mortality, including clinical health-care and treatment of opportunistic infections and other HIV- related illnesses, provision of anti-retroviral drugs, and community-based and home-based delivery of nursing and palliative care and nutrition to patients. Implementers of this component were: public, private, and civil society organizations, with the MOHP taking the lead in coordinating the health sector response. 17. Project component 3: Impact mitigation (US$ 12.24 million - $0.95 from MAP project): Carrying out of activities aimed at mitigating the impact of the HIV/AIDS epidemic on vulnerable social groups, including provision of educational support and training for orphans and vulnerable children, development of income generation activities for vulnerable households, provision of community-based and institutional care for orphans, and provision of psycho-social support for affected families. Implementers of this component were: public, private, and civil society organizations (Ministry of Gender and Community Services, Ministry of Youth, Sports, and Culture, Ministry of Finance (MOF), Economic and Planning development (EP&D), international and national NGOs, faith based organizations (FBOs), community based organizations (CBOs), local governments, etc.). 18. Project component 4: Sectoral mainstreaming (US$8.97 million - $4.85 from MAP project): Support to public institutions, private companies, and civil society organizations to mainstream HIV/AIDS in their policies, core business and workplace to address HIV/AIDS impacts, establishment of institutional focal points and support groups, carrying out of HIV/AIDS awareness training and sector-based impact assessments, carrying out of knowledge, attitudes and practices surveys and seroprevalence testing, and preparation and implementation of human resource management strategies to manage HIV/AIDS induced attrition. 3 19. Interventions under this component would be carried out by public, private, and civil society organizations, with assistance from specialized NGOs, PLWHA associations, and partner institutions. 20. Project component 5: Capacity-building and partnerships (US$29.71 million - $3.4 from MAP project): Carrying out of activities aimed at building the capacity of NGOs, faith- based communities, community-based organizations, sector institutions, local governments, business associations and private companies to implement a multi-sectoral response to the HIV/AIDS epidemic through, inter alia, development of long-term strategies and operational frameworks, design and carrying out of HIV/AIDS training programs, building of planning and management skills, support for leadership and governance of the HIV/AIDS national response, and strengthening of the coordination of HIV/AIDS programs at district and community levels and of coalitions among organizations involved in the expansion of HIV/AIDS programs. 21. Public, private, and civil society organizations will be responsible for implementing their institutional capacity strategy with support from expert individuals and organizations. 22. Project component 6: Monitoring, evaluation, and research (US$9.59 million - $2.9 from MAP project): Carrying out of activities to enable the effective assessment of the HIV/AIDS epidemic and national response, including carrying out of biological and behavioral surveys, poverty analyses, program activity and financial monitoring, and priority specialized studies. 23. The NAC M&E officer and Research officer would take the lead in coordinating activities under this subprogram and generating the annual M&E and annual research report. 24. Project component 7: National leadership and coordination (US$22.85 million - $4.35 from MAP project): Support in policy development and monitoring, advocacy and resource mobilization, strategic planning and annual reviews, development and operation of information tools, implementation of national coordination mechanisms and creation of special ad hoc task forces, NAC operations and management, and carrying out of procurement and financial audits. 25. Activities in this component would be implemented by the NAC directly, in collaboration with technical experts and local stakeholders. 1.6 Revised Components 26. No change in project components was made at the time of the additional financing (AF) approval in 2009. 1.7 Other significant changes 27. No significant changes were noted during the implementation of the project. 4 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry Preparation 28. The project team made a bold choice to support HIV/AIDS operations in Malawi through an HIV/AIDS sector-wide approach (SWAp) by participating in the pool funding mechanisms at a time when there was much pressure to design the operation as many other MAP projects. 29. The MAP project was designed around the 2005 – 2009 NAF that was later extended to 2010-2012. In 2003, NAC and national stakeholders initiated the development of a programmatic framework to guide the implementation of the NAF - the Strategic Management Plan (SMP). The task team actively participated in the development of the SMP. 30. Both development of the SMP and the project design were conducted in a very participative process. In addition to working with the NAC Secretariat, NAC Board of Commissioners, and pooled funding mechanisms partners, the project team worked closely with the MOF and the Economic Planning and Development (EP&D) department to ensure that the proposed national HIV/AIDS program was fully consistent with the Poverty Reduction Support Paper (PRSP), and to ensure that it was classified as a priority program for inclusion in the Public Sector Investment Program (PSIP) and its funding included in the Mid-term Expenditure Framework (MTEF). As a result, as of the fiscal year 2003, NAC appeared for the first time in the national budget document with its own budget line. 31. The project team and pool funding mechanisms partners discussed joint oversight arrangements and how to manage the supervision relationship. The proposed supervision arrangement was built around joint six-monthly reviews to examine NAC progress reports, audit reports, and independent consultant reports. 32. During the project preparation, financing modalities for operating the pooled funding account were discussed in depth with NAC and MOF staff. Procurement clinics were held with civil society stakeholders to disseminate information about procedures contained in the NAC Procurement Manual to be used by grant recipients. Project design 33. After the design of the SMP in 2003, NAC invited its external development partners to provide their financial assistance in support of the SMP, on the basis of a joint annual work plan, using joint financial, procurement, and reporting mechanisms, rather than funding multiple HIV/AIDS projects each requiring parallel systems with tracking and reporting to individual partner's funds. The Bank responded positively and accepted to be part of the pool funding mechanisms partners. 34. The SMP was composed of seven major subprograms: (i) prevention and advocacy; (ii) treatment, care and support; (iii) impact mitigation; (iv) sectoral mainstreaming; (v) capacity 5 building and partnerships; (vi) monitoring evaluation and research; and (vii) national leadership and coordination. These seven SMP subcomponents constituted the seven components of the MAP project in the project appraisal document (PAD). 35. The pool funding mechanisms partners agreed to support the SMP and subscribed to agreed common systems for planning, financial management, financial and program reporting, procurement, auditing, and monitoring and evaluation and program reviews. Through the HIV/AIDS pool funding mechanisms, the partners agreed to fund the implementation of joint integrated annual work plans with agreed outputs and timeframes. Partners also agreed that funded activities would be subject to Bank’s fiduciary framework, including its financial and management, procurement, and anti-corruption guidelines. 36. Towards the closing of the original project, the task team sought approval for an AF in order to (i) scale up activities under the original project given the success achieved in scaling up HIV prevention and treatment services, and the critical importance of continuing to address the AIDS epidemic in Malawi; (ii) modify the original PDO, to reflect the new Regional requirements for HIV/AIDS operations, and (iii) request a three-year extension of the project closing date from September 30, 2009 to September 30, 2012. No change in project components was proposed. The only proposed change to the project’s implementation modalities involved the flow of funds, with respect to holding a designated account at the same reserve Bank of Malawi as other pool funding mechanisms partners, instead of a standalone account at a commercial bank. Quality at entry 37. The programmatic framework as presented in the draft PAD was reviewed during the Joint Review with national stakeholders and the NAC Board of Commissioners, and was endorsed as the framework for joint work programming. 38. A financial management capacity assessment of the NAC and key implementing partners was carried out prior to appraisal. It was noted that the program would be implemented in a high risk environment. The main risk would come from the multiplicity of implementing local NGOs at the district level, many with limited management capacity. However, adequate mitigation measures and controls were put in place to manage the bulk of the risks that would arise to partner and basket funds on-granted by NAC to implementing partners. 39. NAC gave priority to preparation of operational manuals, clarification of key responsibilities, formation of coalitions, and assessment of institutional capacity. To facilitate start-up of program activities immediately after MAP effectiveness, NAC prepared an annual work plan and procurement plan with stakeholder input, and selected the financial management agency (FMA) and Umbrella organizations so that the Grants facility would be operational during the first quarter of the first year. 2.2 Implementation 40. The implementing agency for the project was NAC, supported by line Ministries and other public institutions, civil society organizations and PLWHA. 6 41. Pool funding mechanisms partners met on a regular basis as planned to discuss progress and bottlenecks in the implementation of the SMP, and the bank task team participated actively in all the meetings. Coordination among partners seemed to work properly throughout the project implementation period. This explains why the pool funding mechanisms partners continued to work together under the same arrangements during the implementation of the next national strategic plan (2012 – 2016) and the new Bank funded HIV/nutrition project also used these arrangements. 42. With assistance from the pool funding mechanisms partners, the improved capacity of the health delivery system to provide equitable access to ARVs and drugs for the management of HIV-related infections resulted in treatment, care and support increasingly dominating the national response with support from the donors, and in particular the GFATM. 43. However, while the GFATM earmarked most of its funding to ARVs treatment, the Bank along with other pool funding mechanisms partners concentrated their efforts on prevention activities, including the PMTCT program which made significant gains during the project implementation period. 44. All pool funding mechanisms partners actively participated in the preparation of all annual work plans as well as joint annual reviews which were both coordinated by NAC. It is on the basis of these commonly agreed upon annual plans that every partner disbursed funds for their implementation. There was harmony between pool funding mechanisms partners and this is the reason why all of them agreed to continue with the same partnership to support the new NSF. 45. NAC conducted a mid-term review (MTR) of the 2004-2009 NAF on behalf of all the pooled funding partners. In general, the MTR found that the interventions implemented as part of the multi-sectoral response have yielded positive results in the area of ARV treatment, public awareness campaign, VCT, and home-based care. 46. However, some shortcomings were also noted, including (i) capacity constraints in almost all civil society organizations in terms of human resources and skills, (ii) poor integration of HIV services, (iii) unequal access for coverage of HIV/AIDS services between rural and urban areas, (iv) some services to OVC were not fully implemented due to insufficient resources, and (v) there were some problems with procurement and supply chain management. 47. During the AF these shortcomings were addressed with different level of successes. Poor capacity of civil society organizations was addressed through the continuous engagement of implementing partners by building their capacity through training, mentoring, supervision and provision of equipment. 48. Poor integration was addressed through integration of HIV and reproductive health services. In addition, effective integration of PMTCT and ART increased access to treatment among women, who are disproportionately affected by the epidemic. 7 49. Unequal access for coverage of HIV/AIDS services was addressed through increase in ART sites, including in rural areas. Some additional measures such as the push system and use of community based distribution agents were implemented to increase the availability of HIV prevention services at facility and community levels. 50. With regard to OVC, NAC facilitated improved targeting mechanisms, as well as sustainable mechanisms for providing this support to the target groups. However, the shortage of funds from the GFATM for this activity negatively affected the number of OVC that the program was able to reach. 51. Finally with regard to procurement and supply chain management problems, reforms are currently underway at CMS, which has been now established as a Public Trust. Its Trustees have been appointed and have since commenced their functions. The Trustees will strengthen the capacity of CMS. Furthermore, a Supply Chain Management Agent was recruited as an interim measure to assist in this regard. 52. 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization Design 53. The NAC developed a national Monitoring and Evaluation Plan 2006-2010 in line with the National HIV and AIDS Action Framework (NAF) 2005-2009. The Monitoring and Evaluation Plan was aligned and harmonized with the NAF and enhanced the principle of the “Three Ones� (One agreed HIV/AIDS Action Framework that provides the basis for coordinating the work of all partners; One National AIDS Coordinating Authority, with a broad based multi-sector mandate; and One agreed country level Monitoring and Evaluation System). 54. In an effort to support the Government and development partners’ desire to harmonize monitoring and evaluation arrangements, the PDO and results framework for the original project were designed to align with those for the NAF. This is in line with the World Bank’s desire to support the strengthening of the entire health system for sustainability purposes and Government ownership. The performance indicators in the PAD, which were selected from the larger list of indicators in the NAF, were relevant to the project. 55. The results framework for the AF was a subset of the overall framework for the NAF and was also congruent with Malawi’s Universal Access indicators and targets. 56. With the AF, outcome indicators for the project were restructured in order to be aligned with the new Africa Region HIV/AIDS regional scorecard. In addition, the task team dropped some intermediate indicators and replaced them with new ones chosen from the M&E framework. The choice of the new indicators was influenced by new knowledge gained from the implementation of MAPs. In addition, the choice of new intermediate indicators needed to focus more on measuring access to HIV/AIDS services rather than scaling up services as was the case during the original project. 8 57. Some selected indicators, however, were not clearly defined or their definition changed between the baseline and the closing of the project. There are pitfalls when selected indicators are not clearly defined since the onset of the project. There were positive achievements on a number of indicators accomplished under this project. However, the definition of two outcome indicators changed between baseline and the closing date of the project, making any inference on the progress made on these indicators very difficult. 58. Some other indicators where not appropriate given new knowledge in M&E. It is not clear for example why the indicator on HIV prevalence was kept for the AF. The HIV prevalence may take time to decrease even in the event of a successful project because this is a chronic condition. In addition, the scaling up of ARV may have an impact on keeping the HIV prevalence high through longer survival of HIV infected patients taking the drugs. Implementation 59. A comprehensive logical framework of the NAF, the operational plan with implementation responsibilities, and the first year work plan for M&E were prepared and field tested, and training on M&E for all stakeholders was conducted in June 2003. 60. Districts were responsible for completing the Local Authority HIV/AIDS Reporting Form to capture data on all non-health related HIV activities in the district, and to share this information with NAC on a quarterly basis using the Local Assembly Quarterly Service Coverage Report. Health related data was captured through the Health Management Information System (HMIS). Data was collected from health facilities on a monthly basis and reported to Local Assemblies (District Health Officers) on a quarterly basis. A comprehensive review of the HMIS was undertaken. After the review, the HMIS was upgraded to capture more HIV/AIDS related indicators. 61. Some minor problems were notice at the beginning on the project with data quality. Efforts were undertaken to improve the quality of data collection, and management within the National M&E system. A Monitoring and Evaluation Information System Technical Working Group has been appointed by the NAC to advise on the M&E system. Utilization 62. Project funds enabled a clear improvement of the knowledge of the epidemic in Malawi thanks to the availability of several study reports that were conducted over the duration of the project. 63. The various reports such as the sentinel surveys, the behavioral and biological studies and the Demographic and Health Surveys (DHS) have all brought out empirical evidence on the state of the HIV response in Malawi. 64. NAC, in collaboration with various partners, produced the country's national response progress reports currently referred to as Global AIDS Response Progress Report (GARPR) but formally known as the UNGASS Report, which are submitted to the UN. In addition, NAC also 9 submitted Country HIV Epidemic Update reports to the Southern African Development Community (SADC) Secretariat. 65. In order to make available HIV and AIDS research based information, National Research Dissemination Conferences were held during the project implementation period. Websites have also been developed both at NAC and in partner organizations and this has resulted in easy accessibility of research findings. In addition, an inventory of research information in an HIV and AIDS data base was developed and linked to the SADC website and is accessible through the NAC website. This site has all the research documentation in the SADC region. Moreover, one can access all the literature on research nationally and internationally. 2.4 Safeguard and Fiduciary Compliance 66. A procurement assessment of the NAC and key implementing partners was carried out prior to appraisal. It was noted that the program would be implemented in a high risk environment, arising from the multiplicity of implementing partners, many with limited procurement skills. 67. With respect to the multiplicity of implementing partners, potential grant recipients were screened for organizational and financial capacity before grants were approved. Separate grant agreements were signed with each grant recipient defining, among other things, the financial accounting and reporting rules to be observed by the recipient and sanctions to be applied in case of breach of the rules. The recruited FMA and umbrella organizations were responsible for monitoring compliance with these guidelines, and audits by independent auditors were performed to verify the accuracy of reporting. 68. During the implementation, procurement consulting services was retained by NAC to assist the Secretariat and implementing partners with procurement tasks, as required. In addition to the procurement agent for specialized HIV/AIDS drugs, MOHP and partners worked together to put in place an institutional development / capacity building program for the CMS with the aim of upgrading procurement procedures, skills, and commodities management/distribution over the medium term. Over the long term, there are plans to establish a Trust to replace the current CMS to enable greater institutional sustainability in the pharmaceuticals sector, which is particularly critical given the expanding national ARV treatment program. 69. All financial audit reports had unqualified audit opinions. Agreed Financial Management Action Plans have generally been implemented and, in instances where the Action Plan has not been fully implemented, NAC has provided a satisfactory explanation to justify not taking an indicated action. 70. The project’s final procurement and financial management was rated satisfactory as there was adherence to the Bank Guidelines, Malawi Public Procurement Law, and NAC Procurement Manual. Timely payments were made to bidders, there were no complaints or mis-procurements under the project, and finally there was excellent recordkeeping. 71. NAC has consistently provided timely responses to audit queries. Procurement cycle management (and supply chain management) has improved over the course of the operation. The 10 Procurement Improvement Action Plan has been developed to further strengthen NAC procurement capacity. 72. All legal covenants have been met and the implementation of the waste management plan proceeded in a satisfactory manner. The Health Care Waste Management Plan for the original project was developed in a participatory manner with Government and key stakeholders. The implementation of this plan was assessed as satisfactory by the MTR and continued to be satisfactory until the closing of the project. 2.5 Post-completion Operation/Next Phase 73. In terms of post-completion operation, the Bank has committed to continued support to the national HIV/AIDS response through US$80 million over the next five years (2012-2017). Out of this total amount, US$50 million will address HIV and AIDs prevention interventions. Whilst this will support the overall implementation of the NSP (2011-2016), there are earmarked resources to scale up implementation of high impact and cost effective HIV prevention interventions such as VMMC and PMTCT. 74. The GFATM has also shown commitment towards concluding negotiations on the Single Stream Funding (SSF) Grant with the Malawi Government. This is a consolidated grant for the Round 1 Phase 2 Rolling Continuation Chanel (RCC) and Round 7 Phase 2 HIV Prevention grants for the country, following the new GFATM's grant architecture on similar disease country grants. The total amount for the SSF is about US$208 million over a period of two years (April 2012 to June 2014), with the majority of the resources planned for the integrated ART/PMTCT program. 75. From a process perspective, the institutional arrangements, procedures, and systems put in place with MAP and partner assistance are expected to be sustainable and to continue to be in use beyond the project closing date. The strengthening of skills and knowledge among civil society groups, private companies, and public sector institutions is expected to result in lasting capacity in the public and private sectors to undertake such HIV/AIDS programs in future. However, financial sustainability will continue to depend on external financial partnerships for the foreseeable future. 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation Relevance of objectives 76. The relevance of objectives is rated High. 77. The project adheres to the basic objectives of the second Malawi Growth and Development Strategy 2011-2016 (MGDS-II), and the revised (2010-2012) National HIV and AIDS Action Framework (NAF). The project and its objectives are reflected in the Country Assistance Strategy (CAS) (FY2007-FY2011) under Pillar 3: Decrease vulnerability at the household level from HIV/AIDS and malnutrition. 11 78. The project objectives are aligned with the overall goal of the new 2011-2016 NSP which is to prevent the further spread of HIV infection, promote access to treatment for PLHIV and mitigate the health, social-economic and psychosocial impact of HIV and AIDS on individuals, families, communities and the nation. 79. The Joint Financing Agreement between the Government of Malawi and its funding partners, including the Bank, reflects agreements and commitments made to the UNAIDS principles of the ‘Three Ones’, the 2011 Political Declaration on HIV/AIDS, the Paris Declaration on Aid Effectiveness, The Accra Agenda for Action and the Busan Partnership for Effective Development Cooperation. 80. Finally, these project result outcomes are well aligned with the new World Bank Africa Region Strategy under pillar 2: “Vulnerability and Resilience,� which centers on reducing vulnerability and building resilience to the idiosyncratic health shocks due to HIV/AIDS, malaria and other diseases. Relevance of design 81. The relevance of design is rated Substantial. 82. The technical aspects of the NAF have been aligned with international best practice, particularly given the increasing focus and resource allocation on prevention. While GFATM mainly supported ARV treatment activities, most of the funds from the MAP project were directed towards prevention activities both in the original and AF projects. 83. Different components of the project were well aligned with the subcomponents of the NAF in the spirit of the SWAp arrangement. The content and selected interventions of the Malawi NAF which the project supported were appropriate and in line with current recommended practice. Relevance of implementation 84. The relevance of implementation is rated Substantial. 85. The same institutional arrangements from this project were used to design the next HIV/AIDS and Nutrition project to be supported by the World Bank and other partners in the country, thereby demonstrating the relevance of this project’s institutional arrangement for its implementation. 86. In terms of implementation performance, all components have been rated moderately satisfactory or higher throughout the project life. Overall implementation has remained on track with cumulative disbursements reaching 100% of the additional financing. 87. Rating: Given the relevance of objectives (high), design (substantial) and implementation (substantial), the overall rating is Substantial for both the original and AF phases of the project. 12 3.2 Achievement of Project Development Objectives 88. Although the achievements below cannot be attributed to the sole contribution of the Bank supported project (as part of the pool funding mechanisms), the Bank’s contribution to the national program results achievements were substantial. 89. For example the Bank’s contribution to the strengthening of the NAC to become a functional coordinating body as well as strengthening its leadership and fiduciary capacities. As noted early in this document, it was under the Bank’s leadership and consistent dialogue with the Government that NAC appeared for the first time in the national budget document with its own budget line. 90. In addition, the Bank contribution was recognized in its convening power to bring the Government and the majority of pool funding mechanisms partners to concentrate their contributions to prevention efforts so that available resources are not diverted to ARV treatment only. 91. Also, the project team and a pool funding mechanisms partners agreed to support “one� program framework (the SMP) and subscribed to agreed common systems for planning, financial management, financial and program reporting, procurement, auditing, and monitoring and evaluation and program reviews. Clearly these arrangements contributed to high level of efficiency observed during the implementation of the program. 92. Finally, in looking at the results below, the reader should consider the fact that, unlike specific projects, the expected results of programs (like the one supported under this MAP project) have a longer time frame, with no fixed end-point. However, trends data clearly show that the national effort is on the right trajectory. a) Original PDO results achievement (outcome level) Original PDO #1: Mitigate the social and economic impact of HIV/AIDS in all sectors and all levels of Malawian society 93. The achievement of original PDO 1 is rated Modest. Table 2: Level of achievement of outcome indicators for the original PDO#1 Original PAD indicators Baseline value Original target Actual value achieved values by September 30, 2009 (end of phase one) % of people who are infected (by gender, age, 14.2% 13.5% 12.0% residence) % of orphans and other vulnerable children to 32.5%% 45% 18.5% whom community support is provided (by gender and residence) Source: 2006 MICS 13 94. The percentage of people who are HIV positive (the prevalence of HIV) has decreased from a baseline value of 14.2% to 12.0% in 2009. 95. During the same period, the numbers of new HIV infections have declined over the past years due to the contributions of multiple prevention and control interventions, including ART. The number of people with HIV infection who were receiving ARV by September 2009 was 147,497; largely surpassing the original target of 25,000. There have been slight but steady reductions over time in the number of new cases of HIV. Table 3: Estimated number of HIV new infections in Malawi (2006-2010) Indicator/Year 2006 2007 2008 2009 2010 Adults (15+) 61,107 57,535 56,204 56,671 56,477 Children (0-15) 26,743 25,966 24,469 23,863 22,863 Total 87,850 83,501 80,673 80,534 79,340 Estimated adult incidence (%) 1.05 0.96 0.91 0.89 0.86 96. The figures in table 3 above show that there has not been much progress in terms of the percent of orphans and other vulnerable children (OVC) to whom community support has been provided. However, an in-depth analysis of this indicator shows that there has indeed been an increase in the number of supported OVC over time. The denominator for this indicator changed over time to include all orphans irrespective of the HIV status of deceased parents. 97. According to UNICEF, this changed the number of estimated OVCs from about 1.2 million to over 2 million. Therefore, even though more children were receiving care and support; as there are more vulnerable children, the percentage of OVCs receiving support has decreased because the increase in the number of supported OVCs didn’t keep up with the sudden increase in the new denominator. Original PDO #2: Reduce the transmission of HIV 98. The achievement of the original PDO2 is rated Modest Table 4: Level of achievement of outcome indicators for original PDO#2 Original PAD indicators Baseline value Original target Actual value achieved by values September 30, 2009 (end of phase one) % of sexually active respondents who 26% males 18 % M 22% males had sex with non-regular partner within the past 12 months (by gender, 8.3% females 5%F 6.5% females residence) Source: 2004 DHS Source: 2006 MICS 99. The percentage of sexually active respondents who had sex with a non-regular partner within the past 12 months has decreased between baseline data (2004 DHS) and the end of the original project in 2009 (2006 MICS). However, the values for both males and females were still short of the targets set for the end of the original project. 14 100. There are however problems in trying to compare data from DHS to MICS surveys because the 2 do not use the same methodologies. Since this indicator was retained for the AF, there is better explanation of its achievement below under the revised PDO indicator where 2004 DHS data are compared to 2012 DHS data. Original PDO #3: Improve the quality of life of those infected and affected by HIV/AIDS 101. Rating: The achievement of the original PDO #3 is rated Modest. Table 5: Level of achievement of outcome indicators for original PDO#3 Original PAD indicators Baseline value Original target Actual value achieved by values September 30, 2009 (end of phase one) % of population expressing 37% males 50 % males 41% males accepting attitudes towards persons living with HIV/AIDS 25% females 50 % females 30% females 102. Like for the original PDO #2, the indicator for PDO #3 improved over the course of the project implementation period, but fell short of the original targets for both males and females. b) Revised PDO indicator results achievement Revised PDO: Increase access to prevention, treatment, and mitigation services 103. Rating: The achievement of the revised PDO is rated Modest. Table 6: Level of achievement of outcome indicators for the revised PDO Revised Indicators Baseline revised Formally revised Actual value achieved at (Additional Financing) indicator target values completion (September (September 2012) 30, 2012) % of people 15-49 years of age who are 12% 12% 10.6% HIV positive % of sexually active males and females 22% males 20% males 9.2% males having sex with more than one partner (non-regular partner) within the previous 6.5% females 5.0% females 0.7% females 12 months Source: 2006 Source: 2010 DHS MICS Proportion of sexually active males and 57.5% males (for 63% males 40.5% males (for the age females who report condom use during last the age 15-24) group 15-24) high-risk sexual encounter (sex with non- cohabitating or non-regular partner) within 39.5% females (for 41% females 31% females (for the age the last 12 months (by gender and age, 15- the age 15-24) group 15-24) 24 years, 25-49 years) Source: 2006 Source: 2010 DHS MICS 20.0% males (15- 24 years) 15.9% females (15-24 years) Retrofitted 2004 DHS 15 Median age at first sex among 15-24 year 18.6 years (males) 19 years (males) 18.5 males olds (by gender) 17.7 years 17.8 years 17.4 females (females) (females) (20-24 years old) Source: 2006 Source: DHS 2010 MICS Proportion of young people (15-24 years) 41.9% males (for 55% males 44.7% males who correctly identify ways of preventing 15-24 years old) transmission and who reject major misconceptions about HIV transmission 30% females (for 40% females 41.8% females (by gender) 15-24 years old) Source: 2010 DHS Source: 2006 MICS 104. HIV prevalence among the adult population continued to decline from 12% in 2009 at the time of the AF to 10.6% in 2012 at the closing of the project. In parallel, the percent of respondents with multiple partners in the past 12 months sharply decreased from 22% in males and 6.5% in females to 9.2% in men and 0.7% in females, respectively. 105. For the indicator on percent of people reporting condom use at last high risk sex, the percentages fell for both men and women. This is therefore an extremely worrying trend as it would imply that although there are fewer respondents reporting multiple partners in last 12 months (see previous indicator), those who do are less likely to use a condom. However, this indicator was framed differently between the baseline and the 2010 DHS making inferences from the data a little bit complicated. Having “multiple sexual partners� was defined at baseline as having more than one sexual partner in the last 12 months. It is not the exact definition of “high risk partner� used in 2010 DHS which is defined as having sex with a non-regular partner or non-cohabiting partner. 106. Retrofitted analysis applied on the 2004 DHS data using the same definition as for the 2010 DHS shows that the actual baseline was 15.9% for female and 20.0% for males, suggesting an increase in condom use (by almost 100%) in high risk situations between the 2 periods of time. 107. For the indicator on the median age at first intercourse among 15-24 years, the values slightly decreased for both males and females. This behavior may be related to other cultural behavior not necessarily related to HIV/AIDS in a given society. Therefore, in order to change this behavior, messages should be more general than the ones provided for HIV/AIDS mitigation. 108. The 2010 DHS found that 41.8 % of women and 44.7% of men had “comprehensive� knowledge of HIV/AIDS, slightly short of the target for males and surpassing the target for females. However, when you unpack the data, most young (15-24 year-old) women and men know that HIV can be prevented by having sex with just one uninfected partner (85%), abstaining from sex (80%), and using condoms (70%). The separate figures for men and women are very similar. 109. The achievement for the revised PDO is rated modest: among the 5 indicators measuring the revised PDO, 3 were achieved (if we consider the 2004 DHS retrofitted analysis results for condom use in high risk sexual encounters) and two partially achieved. 16 3.3 Efficiency 110. Rating: The overall efficiency of the project is rated Substantial. 111. Most of the data used for the efficiency analysis are from the Burden of Disease Estimates for 2011 and the potential effects of the essential health package (EHP) on Malawi’s health burden (Cam Bowie) and the multi-country analysis of treatment costs for HIV/AIDS (MATCH) conducted by the Clinton Health Access Initiative (CHAI, October 2012). Methodologies used for both studies are in Annex 3 (Economic and Financial analysis). 112. Figure 1 shows results from the resource mapping study for a cost effectiveness analysis of interventions by disease burden averted. The analysis showed that it costs approximately US$29 to avert a health life year lost through the provision of ARVs. This is less than the provision of malaria treatment ($42), providing malaria bednets ($95), and spraying insecticides inside homes ($133), all of which have been shown to have a big impact on decreasing infant mortality and maternal rates. Figure 1: Direct Costs* per disability adjusted life years (DALYs) averted by intervention 2011 $350 $13,094 $300 $250 $3,660 $200 Above figures not to scale Means that it costs ~$29 $150 to avert a healthy life year $133 lost through ARV $95$108 $100 $65 $74 $29 $32 $39 $42 $43 $50 $0.4 $2 $2 $3 $3 $5 $6 $7 $8 $14 $17 $18 $20 $21 $29 $29 $0 Ob.&neonatal… Eye, Ear and Skin… Family planning… Case management in… Case management of… Case management of… Dysentry treatment Treatment of mental illness Syphillis in Pregnancy TB detection and treatment Epilepsy treatment Treatment of Wounds Physical Rehab. Vaccines (EPI) HIV HTC OI treatment Malaria- IPT CBHBC Malaria- Bednets Malaria- IRS Malaria-ACT pMTCT Supplementary Feeding Severe Acute Malnutrition ARI treatment ARVs Notes: *Direct costs includes drug and supplies, does not include indirect costs such as HR, infrastructure etc. Intervention effectiveness data for interventions do not necessarily come from the same sources- best available data was used. Source: Burden of Disease Estimates for 2011 and the potential effects of the EHP on Malawi’s health burden (Cam Bowie) 113. In terms of allocative efficiency, the same resource mapping study showed that providing ARVs is highly efficient when compared to other HIV interventions (Figure 2). Available data in 2009-2012 show that more than 700,000 healthy live years which would have been lost due to HIV were averted because of ARVs. This number represents 83% of DALYs averted for 68% of allocated funding. 17 114. Also, another allocative efficiency measure is that pool funding partners’ contributions were allowed to be used to support institutional and operational support costs of the NAC as long as these operational support costs do not exceed ten percent (10%) of the total annual budget. Institutional and operational supported costs here refer to all costs associated with the NAC Board of Commissioners and Secretariat (salaries, building costs, materials, equipment, external audits etc.). These costs have been as high as 40% to 60% in some of MAP supported projects in other countries. Figure 2: Comparison of DALYs averted against funding allocation DALYs 710,884 85,593 29,414 14,268 averted* 7,756 6,002 0 ~710,884 healthy life years 90% 83% which would have been lost due 80% to HIV were averted because of 68% ARVs 70% 60% 50% 83% of DALYs averted 40% due to ARV, however, 30% ARV receives 68% of 20% 10% 10% 9% 6% 10% 3% 2% 2% 1% 4% 1% 0% 2% 0% ART HTC OI STI Community Prevention of Nutritional based care MTC support % of DALYs averted % of Funding transmission Notes: - Intervention effectiveness data for interventions do not necessarily come from the same sources- best available data was used. - Direct program spending only does not include system spend *Latest DAILY averted information available from 2009-2010. These are only interventions that the study analyzed. Potential DAYs could be averted with other interventions Source: Burden of Disease Estimates for 2011 and the potential effects of the EHP on Malawi’s health burden (Cam Bowie) 115. CHAI conducted a multi-country analysis of treatment costs for HIV/AIDS (MATCH) in Malawi and 4 other countries in Africa (Ethiopia, Rwanda, South Africa and Zambia). The objective of the study was to identify opportunities to improve efficiency and effectiveness of HIV treatment. 116. When compared to other countries, the average cost of treatment per patient per year was relatively the lowest in Malawi: US$136 (Cost ranges from US$80 – US$241 pppy) compared to US$233 in Rwanda, US$186 in Ethiopia, US$278 in Zambia and US$864 in South Africa (figure 3). As a matter of fact, Malawi has the lowest costs in terms of personnel, ARV and laboratory costs. 18 Figure 3: Average cost of treatment per patient per year by country (US$) $900 $800 Personnel ARVs Labs Other $700 Reaching universal access in  $600 Malawi should be within our  Cost PPPY $500 means, costing only $136 per  year to treat an ART patient at  $400 the facility level $300 $200 $100 $- Rwanda Malawi Ethiopia Zambia RSA Source: CHAI: Facility-level costing of HIV treatment (ART) at health facilities in Malawi, Rwanda, Zambia, South Africa, and Ethiopia 3.4 Justification of Overall Outcome Rating Summary of ratings, by components 117. OPCS guidelines for overall outcome rating of a project with formally revised project objectives recommend using a weighting system that takes into account the performance of the project in achieving its development objectives before and after the restructuring as well as the level of disbursement associated with each period. This system was applied to rate the project’s outcome in the tables below. Table 7: Summary of ratings by original PDOs Criteria PDO Relevance Effectiveness Efficiency Result Mitigating the socio-economic impact Substantial Modest Substantial Moderately Satisfactory of HIV/AIDS in all sectors and all levels of the Malawian society Reduce the transmission of HIV Substantial Modest Substantial Moderately Satisfactory Improve the quality of life of those Substantial Modest Substantial Moderately Satisfactory infected and affected by HIV/AIDS Summary of ratings Substantial Modest Substantial Moderately Satisfactory Rating total Moderately Satisfactory Table 8: Summary of ratings, by revised PDOs Criteria PDO Relevance Effectiveness Efficiency Result Increase access to prevention, Substantial Modest Substantial Moderately Satisfactory treatment, and mitigation services Summary of ratings Substantial Modest Substantial Moderately Satisfactory Rating total Moderately Satisfactory 19 Table 9: Overall final outcome rating Rating Ratings Against original PDOs Against revised PDOs Overall 1. Rating Moderately Satisfactory Moderately Satisfactory - 2. Rating value 4 4 - 3. Weight (% of disbursed 56.7% 43.3% 100% before/after change) 4. Weight value (2x3) 2.27 1.73 4.00 5. Final rating - - Moderately Satisfactory 118. Overall outcome rating: On the basis of the ratings above on the relevance of objectives, design and implementation, the achievement of the project development objective and the project efficiency, the overall outcome rating of the project is Moderately Satisfactory. 3.5 Overarching Themes, Other Outcomes and Impacts (a) Poverty Impacts, Gender Aspects, and Social Development 119. HIV/AIDS transmission in Malawi as elsewhere has a significant gender dimension, associated with gender inequality and poverty. The Government of Malawi implemented interventions aimed at transforming cultural attitudes which place men and women at high risk for transmission, expanding life-skills education for school children and adolescents, increasing alternative income earning opportunities for female headed households, and reducing stigma for PLWHA. MAP supported these interventions and so contributed positively to resolution of social issues identified above. (b) Institutional Change/Strengthening (particularly with reference to impacts on longer-term capacity and institutional development) 120. Throughout project implementation, NAC has been a stable agency in terms of both governance and management – a particularly notable achievement within the challenging context of Malawi. Through the years, NAC has been clarifying its roles and responsibilities, consolidating its internal systems, and recruiting the necessary staff to perform its functions. 121. Representatives of civil society and the public sector were empowered during the implementation of this project to: (i) oversee the implementation of the project in their capacity as members of the Board of Commissioners of NAC and as members of the national TWG and its sub-groups; (ii) implement HIV/AIDS interventions funded through the grants facility; and (iii) benefit from the range of activities supported by the national program. 122. With contribution from the project, the Malawi Partnership Forum for HIV/AIDS has been established, in addition to sectoral coordinating structures such as the Department of Human Resource Management and Development for the public sector; the Malawi Business Coalition Against HIV/AIDS for the private sector; the Malawi Interfaith AIDS Association for the faith-based community; the Malawi Network of People Living with HIV/AIDS; and Malawi Network of AIDS Service Organizations. 20 (c) Other Unintended Outcomes and Impacts (positive or negative) 123. N/A 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops (optional for Core ICR, required for ILI, details in annexes) 124. N/A. 4. Assessment of Risk to Development Outcome 125. Rating: High. 126. Financial sustainability of the national response continues to be the major risk. The national HIV/AIDS response is heavily dependent on partner funding, with an estimated 3 percent of resources from Government and 97 percent from external sources. 127. Available resources are estimated at US$181 million in 2012/13 but are expected to decline to US$172 million in 2020/21, as a result of anticipated decline in international partner support to the HIV/AIDS program. 128. Under this scenario, there is a financing gap of US$44 million in 2012/13, growing to US$419 million in 2020/21. The financing gap in 2012/13 is equivalent to 0.7% of GDP and 2.6% of total Government expenditure. By 2020/21, this will rise to 5.5% of GDP and 19.8% of total Government expenditure. 129. In order to fill this gap a number of additional domestic sources of financing were explored, including increases in public sector integration and private sector contributions, introduction of airline, airtime, alcohol and tobacco levies, increases in general taxation and efficiency savings. 130. Even if all these alternative sources were implemented, the financing gap would still remain very large. By 2020/21, the financing gap would reach US$ 284 million. This would translate to 3.7% of GDP or 13.4% of Government expenditure for that year. 131. There is no short or medium term prospect of Malawi having the ability to afford its ARV program. A key conclusion is that the current strategy of large scale up of ARV treatment is unsustainable and will depend on external financing unless a significant reduction in new HIV infections can be achieved. 5. Assessment of Bank and Borrower Performance 5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry 132. Rating: Satisfactory. 21 133. The preparation process was highly participatory, with extensive consultations with PLWHA, representatives of national and international NGOs, partners, and various other stakeholders. Project preparation involved a process of extensive consultations, analytical activities, stakeholder analyses, and consensus building among key actors across multiple organizations and agencies from the health sector. 134. The Bank and pool funding mechanisms partners strategically directed its funding towards prevention and advocacy activities leaving treatment, care and support to the GFATM. 135. Risk assessment was thorough and realistic, with appropriate mitigation measures proposed and implemented. Key identified risks included NAC limited capacity to coordinate and administer the project, the risk of being unable to match demand for services with adequate supply, and possible fiduciary difficulties faced by decentralized institutions and agencies with weak capacity. Mitigation included such measures as working to attract additional financiers (DfID provided additional resources), and establishing systems for training, capacity building, and accountability in the NAC and decentralized entities. 136. Operational manuals, clarification of key responsibilities, formation of coalitions, and assessment of institutional capacity were done during project appraisal. (b) Quality of Supervision 137. Rating: Satisfactory 138. The task team enjoyed relative continuity (three TTLs over the life of the project), and its assessments of project performance were straightforward and frank. 139. The project team provided adequate technical and fiduciary support to NAC during the project implementation. This positive contribution from the Bank was recognized during the ICR preparation by both NAC and pool funding mechanisms partners. 140. Throughout the project implementation phase, Bank staff provided appropriate capacity- building support for procurement. 141. Fiduciary challenges were met in a timely way and financial management performance of the project improved through time, supported by Bank oversight and the development and implementation of a Financial Management Improvement Action Plan. (c) Justification of Rating for Overall Bank Performance 142. Rating: Given the rating for the Bank performance in ensuring quality (satisfactory) and the quality of supervision (satisfactory), the overall rating for the bank performance is Satisfactory. 5.2 Borrower Performance (a) Government Performance 22 143. Rating: Satisfactory. 144. During the project appraisal, technical working papers assessing the progress of the national response and recommending priority actions were presented to the multi-stakeholder Joint Review (JR) meeting which was opened by the Minister for Presidential Affairs and closed by the Vice President of the Republic. These prior actions demonstrated the Government’s commitment to the HIV/AIDS crisis response in the country. 145. The political commitment was also acknowledged through the search for long-term sustainability response which resulted in the development of a “Sustainable Financing Options Paper� for further guidance on in-country resource mobilization for the response. 146. The Government committed itself to providing US$ 2 million per year to NAC for implementation of the SMP. Equally important, the Government introduced a separate authorization within each public sector agency’s recurrent budget (2% Other Recurrent Transactions ministerial allocations) to be used to initiate and implement HIV/AIDS programs within their respective sector sphere of activities. 147. The Government provided an enabling environment for the project and supported the development of a sector-wide-approach to managing the flow of external assistance to the HIV management and control in the country. It successfully met the commitments made in the context of this approach, including increasing its share in the pool funding mechanisms over years. (b) Implementing Agency or Agencies Performance 148. Rating: Satisfactory 149. The NAC, as implementing agency of the project, was strengthened in its capacity and ability to become a true coordinating body throughout the course of the project implementation. 150. Over an eight year period, the NAC, as the implementing agency, developed and refined its operational approach and implementation arrangements through independent periodic assessments and internal and external audits of financial management, procurement, grant facility management and the performance of grant recipient organizations (GROs). 151. The NAC provided timely quarterly Financial Monitoring Reports (FMR) according to the format in the Operational Guidelines at the end of each quarter. The quarterly FMR contained information on financial activity, and procurement actions, including explanations of the variance of expenditure against budget (if any). 152. In addition, NAC provided biannual Program Monitoring Reports according to the format in the Operational Guidelines at the end of each semester. The biannual Program Monitoring Report contained information on program output achievements, financial and procurement activities including explanations of the variance of expenditure against budget (if any) and the linkage between programmatic performance and financial performance, as well as the result of any audits that were undertaken in the preceding period. 23 153. NAC provided key guidance to decentralized entities and implementing agencies, dedicating a significant amount of time to training and capacity-building of implementers, particularly in relation to M&E and fiduciary/accounting requirements. 154. There were some shortcomings during the project implementation period but satisfactory mitigation measures were taken by NAC to allow the implementation of the project to continue with less difficulty. (c) Justification of Rating for Overall Borrower Performance 155. Rating: Given the rating for the Government performance (satisfactory) and for the implementing agency (satisfactory), the overall rating of the borrower performance is rated Satisfactory. 6. Lessons Learned 156. A sector-wide approach to HIV/AIDS can help a country with a generalized epidemic achieve positive results, efficiently. This is achieved through (i) reducing the administrative burden on the coordinating body (NAC) through joint work programming, accounting, and reporting systems, (ii) enabling the coordinating body to develop a strategic, integrated approach to coordinating the national response, and (iii) building local ownership of the national program as a whole. 157. Pooled funding mechanisms are an efficient tool to support HIV National Strategic Plan. The tool should be flexible enough to allow contributors to earmark their contributions. The project demonstrated that the system can be flexible enough to accommodate earmarking for some types of activities and this mechanism was the most preferred one for the new Bank supported HIV/Nutrition project where approximately half of the funds have been earmarked for specific prevention activities. 158. Government ownership and setting up proper functional institutional arrangements is critical to achieving results. Under this project high level commitment and funding contribution into the pool funding mechanisms certainly allowed the project to achieve its positive results. 159. There are benefits of centralized procurement for common items and high value capital goods in addressing capacity constraints of sub-grantees. The implementing agency for this project used this approach and sub-grantees were satisfied with the solution because this allowed them to concentrate most of their time on implementing activities rather than on procurement processes. 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies 160. The following comments were provided by the pooled funding mechanism partners through the NAC on the draft ICR. These comments were addressed in the final ICR after 24 discussion with present stakeholders during a meeting held on March 7, 2013 in the NAC Board Meeting room. a) General Comments � The report is well balanced as it highlights both achievements and weaknesses � The report is quite comprehensive in scope and adequately covers the original and additional financing period performance � The issues are clearly articulated and easy to comprehend � There is need to clearly explain the assessment criteria (during the presentation/meeting) to partners for common understanding b) Specific Comments � The acronym section needs to be revisited to make some corrections (typos and descriptions) � There are some sub-sections that are blank and it is not clear whether this is intentional � The duration of the NSP is supposed to be 2011 to 2016 (aligned to the MGDS II). This needs to be corrected throughout the document � “Pooling Funds Mechanism� should be replaced by “Pool Funding Mechanism� throughout the document � There is need for another round of editing to clean up the document � There is need to maintain consistency in the reporting tense (areas indicated in the document) � The indicator on condom use needs to add a bit of context i.e. there is an increase in condom use when the 2010 DHS indicator is retrofitted into the 2004 DHS data. (b) Cofinanciers 161. The draft ICR was shared with the pool funding mechanism partners through NAC but no comments were received. (c) Other partners and stakeholders 162. N/A 25 Annex 1. Project Costs and Financing (a) Project Cost by Component (in USD Million equivalent) Appraisal Estimate (USD Actual/Latest Estimate Components Percentage of Appraisal millions) (USD millions) Prevention and advocacy 30.55 30.55 100% Treatment, care and support 7.00 7.00 100% Impact mitigation 2.95 2.95 100% Sectoral mainstreaming 7.85 7.85 100% Capacity building and partnerships 5.40 5.40 100% Monitoring, evaluation and research 4.90 4.90 100% National leadership and coordination 6.35 6.35 100% Total Baseline Cost 65.00 65.00 100% Physical Contingencies 0.00 0.00 0.00 Price Contingencies 0.00 0.00 0.00 Total Project Costs 0.00 0.00 Front-end fee PPF 0.00 0.00 .00 Front-end fee IBRD 0.00 0.00 .00 Total Financing Required 0.00 0.00 (b) Financing 1. Original project Actual/Latest Appraisal Estimate Percentage of Source of Funds Type of Cofinancing Estimate (USD millions) Appraisal (USD millions) Africa Development Bank Pool funding mechanisms 0.6 0.5 83.3% Borrower (Government) Pool funding mechanisms 10 10 100% Canadian International Pool funding mechanisms 10 10 100% Development Agency DFID Pool funding mechanisms 7.2 17 236.1% GFATM Pool funding mechanisms 196.14 223 113.7% US Government Other 2 2.9 145% IDA grant Pool funding mechanisms 35 35 100% NORAD Pool funding mechanisms 10.0 17.8 178% UNDP Pool funding mechanisms 3.8 3.3 86.8% TOTAL 274.74 319.5 116.3% 2. Additional Financing Appraisal Estimate Actual/Latest Source of Funds Type of Cofinancing Percentage of (USD millions) Estimate Appraisal (USD millions) Borrower Pool funding mechanisms 6 10.8 180% IDA Pool funding mechanisms 30 30 100% GFATM Pool funding mechanisms 191.3 124.7 65.2% DFID Pool funding mechanisms 13.9 21.5 154.7% Norway/Govt. Sweden Pool funding mechanisms 5 2.5 50% TOTAL 246.2 189.5 77.0% 26 Annex 2. Outputs by Component Component 1: Prevention and Advocacy 1.1 Behavioral Change Communication/Information, Education and Communication (BCC/IEC) 1. BCC/IEC materials are crucial to facilitate behavioral change in the general population and even population groups with special needs. There has been an increase in the number of materials distributed from year to year until 2009/10 fiscal year, when a decreasing trend in IEC material distribution was noticed and this was confirmed by the report of the Independent Review of the National Response to HIV and AIDS. Good progress was also made on production of IEC materials for people with special needs though in the 2011/12 fiscal year, nothing was achieved in this category. Over the years there has also been a notable shift in behaviour change communication messaging from the traditional development and distribution of Information, Education and Communication (IEC) materials to one-on-one communication and interactive performance sessions. This, therefore, led to a significant decrease in the production of IEC materials as shown on the figure 1 below. Figure 1: Communication Materials Developed and Distributed 3,500,000 3,000,000 3,017,066 2,749,626 2,500,000 IEC Materials 2,000,000 1,979,605 1,787,208 1,500,000 1,523,025 1,419,692 1,000,000 500,000 546,681 0 2005/6 2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 (sept 2012) Fiscal Years (July � June) 2. As a way of complementing the print media and additional effort to reach out to all populations, various HIV and AIDS messages and information were also aired on TV and various radio stations. Figure 2 below shows the trend in the number of hours for both TV and radio broadcasting of HIV and AIDS messages across the years. In the recent years, focus has also been on supporting community radio stations to participate in HIV and AIDS message broadcasting so as to reach the rural communities in the country. 27 Figure 2: Trend in Radio and TV hours of broadcasting HIV and AIDS information 1,400 1,200 1,000 Number of Hours 800 600 400 200 0 2011/12 2003/4 2004/5 2005/6 2006/7 2007/8 2008/9 2009/10 2010/11 (Sept 2012) TV Hours 0 109 76 150 139 138 190 202 362 Radio Hrs 0 297 616 1,112 1,113 1,099 904 1,159 3. As a result of behavioral change interventions, there has been some level of achievement as far as positive change of behavior is concerned. For example at baseline of the program, the proportion of sexually active women (15-49 years) having sex with more than one partner (non- regular partner) in the last 12 months was at 8.3 percent and has since decreased to 0.7 percent in 2010 and that for men has also decreased from 26% to 9.2%, respectively. 1.2 Promotion of Safe Sex 1.2.1 Condom Programming 4. Condoms are a common method of preventing HIV transmission during sexual intercourse which accounts for 88% of HIV transmission (Malawi HIV Prevention Strategy). Generally, there has been an increase in the number of condoms distributed over the years as illustrated in Figure 3 below. It also shows very low distribution of female condoms, though there has been an improvement over the years. 28 Figure 3: Male and Female Condoms Distributed 40,000,000 35,000,000 30,000,000 Number of Hours 25,000,000 20,000,000 15,000,000 10,000,000 5,000,000 0 2011/1 2009/1 2010/1 2004/5 2005/6 2006/7 2007/8 2008/9 2 (sept 0 1 2012) Male Condoms n.a. 20,944,4926,678,1432,090,8720,980,2218,601,0121,049,5926,461,0733,369,07 Female Condoms na 0 109,057 115,444 324,743 303,997 924,487 1,365,5151,440,362 5. As a result of increased condom uptake there has been an increase in the proportion of sexually active population using the condom during high risk sex as reported by the MDHS 2010. Table 1 below shows that the magnitude of change is more in women, compared to men. Table 1: Percentage of Sexually Active Population Using Condoms at Last High Risk Sex Category MDHS 2004 MDHS 2010 Male 20.0 24.6 Female 15.9 27 1.3 Prevention of Mother to Child Transmission 6. The PMTCT program is crucial as it significantly contributes to HIV prevention efforts of the national response to HIV and AIDS. There has been a change in the PMTCT policies from 2003 to 2012 following the 2006 and 2010 WHO PMTCT recommendations. Following the adoption of the 2010 WHO guidelines/recommendations, Malawi started implementing an integrated ART/PMTCT program from 1st July, 2011, through the introduction of the Option B+. Option B+ entails the immediate initiation on ART for life for all HIV positive pregnant women, regardless of their CD4 count, in an effort to reduce transmission of HIV from mother to child and also improve the health status of the HIV positive mothers. This has then, resulted in increased numbers of HIV positive pregnant women starting on ART. Figure 4 below shows the coverage of PMTCT from 2004. There has been an increasing trend in provision of PMTCT 29 services. There was a significant increase in PMTCT uptake in 2007 and 2008 and this is the same period when the number of sites providing a minimum PMTCT/ART package also increased significantly as shown in figure 5 below. Figure 4: ART Coverage for PMTCT 35,000 32,251 32,039 30,000 29,689 29,184 26,184 ART Coverage for PMTCT 25,000 20,000 16,551 15,000 10,000 9010 5,000 5,076 2,179 0 2004 2005 2006 2007 2008 2009 2010 2011 2012 (Sep) Calendar Years (Jan to Dec)  7. There has been an increase in the number of sites providing PMTCT. The increase was significant from 2007/8 fiscal year after the 2006 WHO PMTCT recommendations as shown in figure 5 below: Figure 5: Number of ANCs providing Minimum PMTC/ART Package 573 600 486 454 454 454 ANC Clinics on PMTCT 500 400 300 200 100 40 60 17 31 0 2003/4 2004/5 2005/6 2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 (Sept 2012) Fiscal Years (July � June) 30 1.4 HIV Counseling and Testing 8. HTC is very crucial in HIV and AIDS management as it is the entry point for all other services, including treatment care and support. Over the years, HTC uptake has increased as a result of innovative approaches that were put in place including door to door testing, moonlight testing and mobile site service provision, to complement the traditional HTC in static sites. From 2003 to September 2012 a total of 10,072,349 HIV tests were conducted. Figure 6 below shows HTC uptake across the years. Figure 6: Number of People Counseled, Tested and Received their Results in the Last 12 Months 2,500,000 2,136,924 2,000,000 1,712,170 1,773,267 People Tested 1,500,000 1,724,190 1,083,304 1,000,000 661,400 500,000 482,364 283,461 215,269 0 2003/4 2004/5 2005/6 2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 (Sept 2012) Fiscal Years (July � June) 9. The number of HTC sites has increased seven times from 2003 to 2012. There were only 118 static HTC sites in 2003 and by September 2012 there were 810 static sites. Figure 7 below shows the trend in establishment of HTC sites; the increase in the number of HTC sites also explains the increase in HTC uptake. Apart from these static sites there were also other 322 outreach HTC sites by September 2012. 31 Figure 7: Number of sites offering HTC services 900 810 778 713 735 800 Number static HTC sites 700 588 600 500 351 400 250 300 118 146 200 100 0 2003/4 2004/5 2005/6 2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 (Sept 2012) Fiscal Years (July � June) 10. In a bid to prevent transmission of HIV from mother to child, all pregnant women are required to undergo HTC. This will enhance timely action and necessary referral by health care workers when a woman is found HIV positive. Figure 8 below shows the trend in HTC uptake by pregnant women in antenatal clinics. Figure 8: HTC Uptake in ANC 600,000 500,000 483,252 # of pregnant women 411,204 400,000 424,294 300,000 327,400 333,335 200,000 100,000 137,996 26,791 43,345 52,904 0 2003/4 2004/5 2005/6 2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 (Sept 2012) Fiscal Years (July � June) 1.5 Handling and Disposal of Health Care Wastes 11. Health Care Waste Management (HCWM) Policy was developed in 2003 to guide handling and disposal of health care waste in light of an imminent increase in the production of 32 infectious waste that the then practices and disposal system could not handle adequately. The National Health Care Waste Management (HCWM) Policy was also translated into a 5 years national plan of action (July 2003-June 2008). In the same year the HCWM Guidelines were developed as part and parcel of the Health Care Waste Management (HCWM) Policy. 12. In 2007, the HCWM training manuals for support staff and qualified Health Workers were developed and translated into vernacular language. The National Health Care Waste Management coordinating body was also formed in the same year and continues to meet at least twice a year. In 2008, procurement and delivery of Health Care Waste Management equipment and supplies for the first 6 piloted districts was conducted as illustrated in table 2 below: Table 2: Quantities of HCWM equipment and supplies procured Item Quantities ordered Quantities procured Black Plastic Bags 20,000 20,000 Red Plastic Bags 10,000 10,000 Yellow Plastic Bags 20,000 20,000 Wheel barrows 200 40 Ash scrapers 800 34 Shovels 800 800 Heavy duty gloves 800 101 Bin (plastic with wheels) 200 5 Rakes 800 800 13. To enhance quick roll out of the policy, training of trainers (TOT) on HCWM was first conducted to 6 pilot districts of Mzimba, Salima, Mchinji, Ntcheu, Mangochi and Chikwawa in 2008. In 2011 TOT on HCWM was conducted to additional 3 pilot districts (Nkhata Bay, Rumphi and Karonga) and one central hospital (Mzuzu). A total of 100 trainers (5 trainers from each of the 10 institutions, comprising: the DEHO, In-charge of Clinical Services, In-charge of Nursing Services, Infection Prevention Coordinator and EHO or Assistant Environmental Health Officer responsible for HCWM) were trained. Dissemination of the HCWM and Injection Safety (IS) Policies were done only to piloted institutions. 14. A study was conducted in Malawi with support from CDC with the aim of reviewing the HIV testing and counselling program and to make recommendations on how to improve the quality of services. The study conducted in mid-2012 revealed that there are issues with handling and disposal of health care wastes. The study showed that there is improper disposal of wastes such that sharps, test device and paper napkin are sometimes disposed together in one bin despite the universal guidelines that advocate that various types of biomedical waste be segregated from each other. The Government is therefore working on strengthening adherence to the stipulated guidelines on HCWM. Component 2: Treatment, Care and Support 2.1 Treatment of Opportunistic Infections 15. The weakened immune system due to HIV infection increase chances of illnesses arising due to opportunistic infections (OIs). Ensuring consistent availability of necessary OI prophylactic and treatment drug is therefore critical in managing HIV and AIDS clients. 33 16. Over the years the availability of OI drugs has been monitored. In 2006/7 fiscal year 64% of health facilities were reported to have no OI drug stock outs. In 2010/11 fiscal year, 69% of the health facilities had no stock-outs, which represented a slight improvement from the last reported data. 17. Currently the country is continuously making efforts to address issues of persistent stock- outs of OI drugs, among other pharmaceutical and medical supplies, by strengthening the procurement and supply chain management system. This is evident through the on-going reforms and technical assistance at the Central Medical Stores. 18. The situation of four special opportunistic infections has been monitored over the years and these are Tuberculosis (TB), Kaposi’s Sarcoma (KS), Oesophageal Candidiasis (OC), and Cryptococcal Meningitis (CM). The graphs on figure 9 below show the trends in these OIs. Generally, there has been a decreasing trend in the new cases identified and treated for OIs over the years, except for Kaposi’s sarcoma, whose trend is almost constant. Figure 9: OI New Cases Treated per Year 30000 25000 20000 Number of new Cases 15000 10000 5000 0 2005 2006 2007 2008 2009 2010 2011 2012 (sep) TB 25140 26971 25893 23724 24237 22570 20,383 15,645 KS 1,163 2,218 2,211 2,423 2,056 2,109 2,203 1,537 OC 5,220 5,103 5,450 5,298 4,408 4,372 2,367 872 CM 2,132 2,231 2,203 3,049 2,054 2,039 1,038 499 34 2.2 Provision of Antiretroviral Therapy 19. In Malawi, the Antiretroviral Therapy (ART) program was introduced in 2003. In 2005, the second ARV and OI scale up plan (2006-2010) was finalized. The main goal of the plan was to scale up to about 250,000 patients ever started on ART by the end of the year 2010. In 2011 the new integrated ART/PMTCT Policy was developed following the WHO 2010 recommendations for HIV treatment. The new policy entails early initiation on ART for HIV positive individuals as the CD4 count for one to be initiated on ART was increased from 250cels/mm3 to 350cels/mm3. Furthermore, the policy introduced Option B+, which entails the immediate initiation on ART for life for all HIV positive pregnant women, regardless of their CD4 count, in an effort to reduce transmission of HIV from mother to child and improve the general health status of the HIV positive mothers. This has therefore led to increased numbers of people on ART. 20. The program initially started in nine sites in 2003, covering less than 4,000 people. Since then the program has expanded, such that by September 2012, the country had registered a cumulative total of 535,502 ART beneficiaries who had ever started on ART. Out of these, 391,338 were alive and on ART as at September 2012. Figures 10 below show the trend in the ART program coverage. Figure 10: People ever started on ART and people alive and on ART 600,000 500,000 400,000 Number of people 300,000 200,000 100,000 0 2011/1 2009/1 2010/1 2003/4 2004/5 2005/6 2006/7 2007/8 2008/9 2 (sept 0 1 2012) Ever�started on ART 4,000 13,183 38,817 85,168 146,856 223,437 312,476 382,953 535,502 Alive and on ART 3,000 10,761 29,087 59,980 100,649 147,497 198,846 276,897 391,338 21. The steady increase in ART coverage was facilitated by the necessary increase in the number of health facilities certified to provide ART. Figure 11 below shows this rapid increase over time. 35 Figure 11: Number of sites offering ART Services 700 641 600 500 449 Number of sites 377 400 300 221 200 163 141 83 100 9 24 0 2003/4 2004/5 2005/6 2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 (Sept 2012) Fiscal Years (July to June) 2.3 Community Home-Based Care 22. As the number of PLHIV increases, the gap continues to widen between the demand for, and the availability of health care services. Relying mainly on the family and community as caregivers, community home-based care (CHBC) has become a significant contributor in ensuring the continuum of services that includes treatment, care and support of those infected and affected by HIV and AIDS. In the 2004 – 2005 fiscal year, Malawi developed the ‘guidelines on HBC’ to guide all HBC programs in the country. The number of patients supported in CHBC programs has been increasing until when the ART program was scaled up. 23. In 2007/8 fiscal year the Integrated CHBC Model and training package was finalised and adapted for Malawi. The model was disseminated in the following year. Since the commencement of the CHBC program, there have been trainings for health care workers and volunteers to manage the program in a skilled manner. By the end of 2009/2010 fiscal year 3,834 volunteers and 1,103 health care workers were trained in HBC. 24. In 2009/10 fiscal year the country developed the Palliative Care Guidelines, which were disseminated in the same year. Trainings for health care workers in palliative care also started in the same fiscal year. Figure 12 below shows the number of households with chronically ill persons receiving various kinds of support. Generally, there is a decreasing trend in the households benefiting due to the rolling out of the ART program that has tremendously reduced the number of PLHIV who are bed-ridden. The CHBC program, however, has experienced a 36 challenge of inconsistent reporting by various players in the program, hence the unexplained sudden increase in the year 2009/2010. Figure 12: Households with chronically ill persons reached with support 577,135 600,000 558,384 500,000 427,996 400,000 Households  300,000 249,000 202,578 200,000 151,613 143,141 100,000 0 2005/6 2006/7 2007/8 2008/9 2009/10 2010/11 2011/12 (Sept 2012) Fiscal Years (July to June) 2.4 Nutrition for HIV and AIDS Patients 25. The HIV and AIDS epidemic has had a devastating impact on health in general and nutrition in particular, hence the need for a special focus on and use of resources for nutrition as a fundamental part of the comprehensive package of care for PLHIV. This is crucial as the HIV and AIDS epidemic has extensively affected populations where malnutrition is already endemic. It is also scientifically proven that improved nutritional status enhances ART acceptability, adherence and effectiveness. Therapeutic foods were provided to PLHIV during the period of the project. Therapeutic Feeding Guidelines and Protocols were developed in 2005 and were reviewed in the 2009/2010 fiscal year. By the end of the 2010/2011 fiscal year 95% of ART sites were providing therapeutic food for HIV patients. Figure 13 below shows that there has been an increase in the number of HIV and AIDS patients accessing therapeutic feeding. This is because with the rapid scale up of the ART program, it was also equally important to scale up nutrition and nutrition education programs. 37 Figure 13: HIV and AIDS Patients Provided with Therapeutic Feeding 140,000 131,460 Number of HIV and AIDS Patiensts  120,000 100,000 80,000 60,000 45,069 40,000 30,000 28,395 20,000 22,069 19,205 0 2005/6 2006/7 2007/8 2008/9 2009/10 2011/12 (sept 2012) Fiscal Years (July to June)  Component 3: Impact Mitigation 26. A number of interventions aimed at mitigating the negative economic and psychosocial effects of HIV and AIDS, through improvement in quality of life of PLHIV, OVC and other affected individuals and households were implemented during the period 2003 to 2012. The interventions implemented ranged from economic empowerment, provision of material and other forms of support, such as building capacity in spiritual and psychosocial support for the affected households. 3.1 Support to Orphans and Vulnerable Children 27. Cumulatively, a total of 282, 234 Orphans and Vulnerable Children (OVC) have been supported with education bursaries between 2003 and 2012 as can be seen from Figure 14 below. The support provided has mostly been financial in form of tuition fees. It will be noted that the numbers for those supported has significantly declined as more and more resources are now being directed towards high impact prevention (e.g. PMTCT, Voluntary Medical Male Circumcision) and treatment interventions while still maintaining a fraction of support for impact mitigation interventions, in the wake of declining resources for HIV and AIDS. This notwithstanding, there are other implementing partners that are providing educational support but their input has not been comprehensively and systematically reported over the years. 38 Figure 14: OVCs provided with educational support and training 85,996  84,486  68,506  31,364  27,245  20,000  7,732  1,391  2004�05 2005�06 2006�07 2007�08 2008�09 2009�10 2010�11 2011�12 3.2 Income Generation Activities for Vulnerable Households 28. Interventions aimed at economically empowering households and communities affected by the epidemic were implemented during the period 2003 to 2012. These were aimed at assisting households to reduce their exposure to economic risk and improving their ability to cope once a loss has occurred and building the capacity of community-based safety nets and support groups. This would in turn help households to avoid jeopardising their long-term survival by being able to meet their short-term needs. 29. There is documented evidence of noticeable impacts of the IGAs implemented as in some communities, fruits of the businesses and initiatives that were established some years back are still enjoyed to this date. These IGAs included tailoring; carpentry; tinsmith; bakeries; livestock and poultry rearing; crop and vegetable production. Some of the benefits that have been derived from the various initiatives include general skills acquisition and availability of some income to purchase basic needs. 3.3 Provision of Community-based and Institutional Care for Orphans 3.3.1 Legislative and Policy Environment 30. The period under review saw a number of legislative and policy documents being drafted and adopted. In 2003, the Government of Malawi and stakeholders developed the National Policy for Orphans and Other Vulnerable Children. In 2005, the National Plan of Action (NPA) for OVC w a s de ve l ope d i ni ti al l y for the period 2005-2009, a nd l a t er extended to 2011. The NPA called for the rapid scale up of interventions supporting children affected by the HIV epidemic. The overall goal of the NPA was to build and strengthen Government, family and community capacity to scale up the national response for the survival, growth, protection and development of children affected by AIDS. The Policy and the NPA therefore, provide a 39 solid framework for the national response to the OVC crisis experienced in Malawi. Another major milestone on issues related to OVC was the enactment of the Child Care, Protection and Justice Act in 2010. This Act provides a comprehensive framework that addresses the issue of children affected by HIV. The Act has provisions to protect children from discrimination and exclusion from essential services on the basis of their HIV status. The Act further provides for the establishment of alternative care structures for children affected by AIDS. 3.3.2 Establishment of Child Care Institutions 31. Orphanhood has in some instances led some children to be temporarily or permanently deprived of their family environment and such a context necessitates that they be provided with alternative care in an institution. However, placing of orphans and other vulnerable children in institutions should be the last resort after failing to take care of them in the community. Factors such as HIV, child abuse and neglect, endemic poverty, migration and family breakdown have contributed to an increase in the number of children requiring alternative care. A 2010 survey found that there are 104 Child Care Institutions (CCIs) in Malawi and these are orphanages, special needs centers and reformatory centers. 32. It was found that out of these CCIs 63 were orphanages. A total of 6,040 children were in these institutions and 66% of these children were in orphanages. Seventy one percent (71%) of the children in institutions were orphans. Children including orphans in these CCIs appreciated the fact that they were in institutions because their needs such as food, clothes and school fees for those in secondary school were being met. It is evident therefore, that CCIs in Malawi are contributing significantly towards responding to the HIV epidemic by addressing the needs of OVC. 3.3.3 Establishment of Community Based Child Care Centers 33. Over the years, the Ministry of Gender, Children and Community Development has been promoting the establishment and management of Community Based Child Care Centers (CBCCs) as one way of responding to the needs of OVC in Malawi. These CBCCs are owned and run by communities themselves. In such centers children are exposed to learning, they also play using outdoor as well as indoor playing materials. Above all, they are given food. In most cases, members of the community contribute food, money and other resources in order to run these centers. They also have communal gardens, which are a major source of food for the CBCCs. 34. The attendance by children of these centers ensures that orphans have access to food at least once a day. There is further evidence that pre-primary schooling as it happens in CBCCs, enhances school readiness, increases enrolment and retention in schools, reduces class repetition, improves academic performance, increases primary completion rates and overall, it also improves the health and nutrition status of children. A study commissioned in 2006/2007 by UNICEF and conducted by the Centre for Social Research shows that there are 5,665 CBCCs in Malawi with half of them located in the southern region. 40 35. A total of 410,000 children were enrolled in the CBCCs in 2006 to 07. UNICEF estimates that in 2011 a total of 771,000 children aged 3-5 accessed CBCCs and a further 187,500 accessed children’s corners. The CBCC study also looked at the proportion of children who attend CBCCs who are orphans or children with special needs. Overall 21.9% of the children enrolled in the CBCCs in Malawi are orphans while a smaller proportion (3.5%) are children with special needs. 3.4 The Social Cash Transfer Program 36. The Social Cash Transfer Program (SCTP) was designed to alleviate poverty, reduce malnutrition and improve school enrolment by delivering regular and reliable cash transfers to very poor households that are also labor constrained. It was designed to reach Malawi’s 10% poorest households. The program started as a pilot in Mchinji District and was then rolled out to Salima, Likoma, Chitipa, Mangochi, Machinga and Phalombe. Ministry of Gender, Children and Community Development is the line ministry responsible for implementing the SCTP, in collaboration with the Ministry of Local Government and Rural Development. The SCTP activity implementation is decentralized and managed by respective Local Councils, where the District Social Welfare O f f i c e i s k e y . The N a t i o n a l S o c i a l S u p p o r t P o l i c y ( NSSP) provides p o l i c y guidelines for the SCTP. On average, each household in the program receives MK2, 000 (US$12) per month, depending on the size of the household and number of school aged children in the household. Figure 15 below shows the number of households that have benefited from the SCTP for the years 2008, 2010 and 2011. Figure 15: Social Cash Transfer Beneficiaries 60000 50000 40000 30000 20000 10000 0 2008 2010 2011 Households 10014 28158 27925 Orphans 41974 50895 48220 37. An evaluation of the program has generally shown that recipients reported that prior to the transfers their households were living in destitute, lacking food and basic necessities, facing HIV related stigma and were often sick. With the transfers, things changed: the prevalence of under-weight went down; food security improved; and school enrolment and retention increased among other benefits. 41 3.5 External Support for Households with Orphans and Vulnerable Children 38. The huge problem of OVC that the country is experiencing, coupled with limited coverage of the Social Cash Transfer Program and the generally opting out of communities from having their children in institutional homes, necessitates the need for providing households keeping OVC with support. Figure 16 below provides a breakdown of support provided to OVC over the years. 39. As can be seen from the figure, relatively high numbers of OVC are being supported in their households and this is anticipated to be the case for the foreseeable future. Figure 16: Provision of Social Support  90,000  80,000  70,000  60,000  50,000  40,000  30,000  20,000  10,000  � 2004�05 2005�06 2006�07 2007�08 2008�09 2009�10 2010�11 2011�12 Provision of Social Support 6,000 1,337 3,564 64,215 35,492 82,747 82,084 Component 4: Sectoral Mainstreaming 40. In a bid to ensuring sustainability of the HIV and AIDS interventions under implementation, the Government of Malawi, through the National AIDS Commission, has been promoting integration of HIV and AIDS issues into the day-to-day operations of all sectors. Both the National AIDS Commission and its partners have undertaking various capacity building and technical support initiatives on both internal and external mainstreaming, targeting most organizations. The efforts Undertaken have greatly been helped by the creation of the Malawi Business Coalition against AIDS (MBCA), an institution responsible for championing HIV and AIDS mainstreaming among the private sector in Malawi. The Department of Human Resource Management and Development (DHRMD) on the other hand, is responsible for coordination of HIV and AIDS mainstreaming activities for the public sector, including the parastatals. 42 4.1 Support to Public Institutions, Private Companies, and Civil Society Organizations to Mainstream HIV/AIDS in their Policies 41. Over the years some remarkable progress has been registered in the area of support provision for mainstreaming. The Government has, among others, created a fully-fledged Department of Nutrition, HIV and AIDS in the Office of the President and Cabinet to look into issues of policies regarding HIV and AIDS in the country. In line with the mandate of the office, five staff from the Department have been deployed in key Government ministries to coordinate HIV and AIDS activities. The Government has also deployed District AIDS Coordinators in all 32 Local Councils to support coordination of HIV and AIDS activities at that level. These have greatly helped in moving the response at that level as they have been instrumental in coordinating activities for community based organizations and other players. Government has also created a separate office in the DHRMD responsible for HIV and AIDS, where among others policies governing Government employees and HIV and AIDS have been looked into. The office has again come up with a position on the allocation of funds for HIV and AIDS interventions in the workplace that has culminated into allocating 2% of Other Recurrent Transaction (ORT) budget for use on HIV and AIDS related activities. This has been undertaken so as to ensure effective utilization of HIV and AIDS resources, as well as enhance monitoring of HIV and AIDS interventions in the public sector. By the time of compiling this report, an evaluation of implementation of the 2% ORT had been planned and it is anticipated that the results would inform the best modalities for implementation of the same. 42. The MBCA on the other hand has done well in terms of ensuring that HIV and AIDS mainstreaming is done in the private sector. Figure 17 below reveals that cumulatively a total of two hundred and forty nine organizations have been mobilized to have functional workplace programs by the Malawi Business Coalition against HIV and AIDS. Mainstreaming HIV in the workplace especially in the private sector is done well both internally and externally as private businesses and companies are an integral part in the response to the HIV and AIDS. Figure 17: Private Sector Organizations with Workplace Committees oriented by MBCA 80 75 70 69 60 50 44 40 30 31 20 20 10 10 0 2005�2006 2006�2007 2007�2008 2008�2009 2009�2010 2010�2011 43 43. In terms of programming, notable areas that have been introduced include internal programs within the workplaces that consist of training and peer education to ensure that workers are aware of HIV transmission and how this can be prevented. Another notable area is that of condom programming where condoms have been made easily accessible to staff members within the various organizations through condom dispensers and peer educators. There has also been the incorporation of the ART program in the workplace where people are able to access ART within clinics in their own organizations. 44. The incorporation of HIV programs in the workplace have helped t o reduce stigma and discrimination. Some companies go further than their own workplace and advocate for increased engagement in HIV and AIDS work by other companies, sectors, communities and consumer groups. Several businesses and companies are seen as an additional financing source in an environment of limited resource availability. MBCA h a s a b l y represented the private sector response to the epidemic and has proven to be a good example of how mainstreaming should be done and coordinated in the private sector. 45. All of the above notwithstanding, specific grants from the NAC Grants Facility have been given to Government Ministries and Departments, Civil Society and Parastatals among others, to ensure that issues of mainstreaming are taken care of. These grants have enabled the various constituencies of the response to train and mobilize many on issues of mainstreaming HIV and AIDS and managing the same in the workplace. Figure 18 below gives a picture where in 2005 to 2006 fiscal year there were only 44 workplace committees, rising to 576 functional workplace committees by 2012. Figure 18: Number of Functional Work Place Committees 700 600 500 576 400 300 200 100 139 44 0 2005/2006 2008/2009 2011/2012 4.2 Establishment of institutional HIV and AIDS Focal Points Persons and Support Groups 46. The number of HIV and AIDS focal points persons trained per year over the years has been on the increase as can be seen from the Figure 19 below; This implies that the number of competent people providing support to colleagues in the workplace has been on the increase, thereby making it easier for people to get the necessary support on HIV and AIDS related issues. The focal point persons are also assisted by competent peer educators, who have also been trained in large numbers over the years, so to ensure that the various cadres of people in the work place are supported, in areas of HIV and AIDS education, counseling and referrals. 44 Figure 19: HIV Focal Point Persons Trained 1800 1600 1643 1400 1200 1000 800 600 400 446 200 42 0 2005/2006 2008/2009 2011/2012 47. There has also been formation of support groups that have served as one of the ways to reduce issues of stigma and discrimination. Through these support groups, PLHIV get a sense of belonging, support and encouragement to seek help after seeing colleagues declaring their sero- status. The setting up of Malawi Network of People Living with HIV (MANET+) and the National Association of People Living with HIV in Malawi (NAPHAM) has greatly assisted in mobilizing PLHIV and also helped them share experiences of living positively through the interactions that the membership does provide. 4.3 Development and Implementation of Human Resource Management and Development Strategies to Manage HIV/AIDS Induced Attrition 48. As explained above, the allocated 2% of Government’s ORT budget has been utilized towards supporting HIV and AIDS activities in the workplace. One of the notable areas where this fund has been utilized is the provision of nutrition supplements for PLHIV. This has been done in order to encourage healthy lifestyles for the HIV positive staff, while at the same time ensuring that they do not lose their productivity. 49. The coming in of the HIV and AIDS focal point persons in the offices has also helped to have staff that are living with HIV to be able to balance work related issues and their own health needs. Depending on one’s own condition, organizations have been able to come up with flexible task options on staff that are on lifelong treatment, in order not to overstrain their physical capabilities due to ailments. These scenarios have in the long run helped staff to remain relatively healthy and continue providing services in the workplace in the presence of HIV. Component 5: Capacity Building and Partnerships 50. A number of initiatives aimed at building capacity of all implementing partners and enhancing issues of partnerships have been undertaken during the period under review. This has 45 mainly been done in order to ensure increased capacity and participation in planning, decision making and action, amongst all players in the national response. 5.1 Building the Capacity of Multi-sectoral Implementing Partners 51. The HIV and AIDS response has been decentralized to Local Council level in order to adequately reach out to the communities. The decentralization of the response was further enhanced by the creation of the position of District and City AIDS Coordinator within the District and City Councils. The position was introduced into the Local Government set up around 2004. The creation of the position necessitated a lot of capacity building initiatives directed towards the Councils so as to fully equip the post holders and in the process enable the Councils to realign them towards embracing HIV and AIDS issues in a broader development perspective. This position is at the heart of HIV and AIDS coordination at the Council level as they help in streamlining Local Council plans so that they accommodate HIV and AIDS programs. They also help in coordinating with NGOs and other players at that level on implementation of HIV and AIDS activities. 52. Councils have also over the years benefitted from substantial amounts of support that have been provided to them by means of information technology equipment, vehicles, motorcycles and bicycles to help towards mobility for effective monitoring and supervision. Several training programs directed towards identified key players on a wide ranging of HIV and AIDS management issues. 53. Over the years, training institutions like the Malawi Institute of Management and the Staff Development Institute have been contracted to deliver specialized and tailor made trainings to support implementation on the ground. Through this initiative a number of people have been oriented and equipped with such knowledge as monitoring and evaluation; financial management; mainstreaming and general project management among others. 54. Financial support has also been provided to the Local Councils through District Implementation Plans in order to facilitate the role of the Councils in managing the response at that level. This support enables Councils to ably coordinate implementation of HIV and AIDS activities for all players, including Civil Society, Faith Based and Community Based Organizations. 55. During the period under review, support has also been provided towards the training of medical doctors, pharmacists, nurses, laboratory technicians and other health cadres. Table 3 below provides the numbers for those supported. 46 Table 3: Training of Health Workers 2004 to 2012. Institution Course Completed In College Total MBBS 100 80 180 COLLEGE OF MEDICINE Bachelor of Pharmacy 39 37 76 MLS 0 24 24 MMED 0 25 25 KAMUZU COLLEGE OF Bachelor of Nursing (Generic) 0 74 74 NURSING Master’s Degree 0 32 32 Malawi College of Health Sciences Certificate in Clinical Medicine 86 0 86 56. Another important initiative during the period under review has been the provision of salary top-ups to 6,798 health workers. This was specifically implemented in order to provide an incentive that would improve staff retention, thereby ensure continued service provision by qualified health workers. 5.2 Support for Leadership and Governance of the National Response to HIV and AIDS 57. With policy and oversight support provided by the Department of Nutrition, HIV and AIDS in the Office of the President and Cabinet, NAC as the coordinator of the National Response to HIV and AIDS has been able to engage higher levels of authority in Government, civil society and private sector on issues of HIV and AIDS programming. Several high level meetings for the Cabinet, Members of Parliament, Principal Secretaries, Chief Executives, District Commissioners and Directors have been held over the years. For example, in 2006 alone 32 Principal Secretaries, 193 Members of Parliament, 14 Cabinet Ministers, 90 Chief executive Officers and 40 District Commissioners were courted on HIV and AIDS issues. This special groups of senior position holders were targeted so as to secure good will and leadership at the highest decision making levels to support HIV and AIDS initiatives within various institutions. 5.3 Strengthening Coordination of HIV and AIDS Programs at District and Community Level 58. A number of activities directed towards strengthening of the response at district and community level have been undertaken. These have mostly been directed towards the structures available at that level. Presented in detail below are activities that have been carried out focussing on each individual structure: 59. District Executive Committee (DEC): The main development coordination structure at the district level is the District Executive Committee (DEC). The DEC comprises the District Commissioner (DC), Director of Planning and Development (DPD), heads of assembly directorates, representatives from other government institutions, representatives of NGOs and nominated members. These are key members of the Council management by virtue of their 47 positions. As such, specific trainings and support have been targeted at them in order to ensure that they are equipped with the necessary knowledge and skills on HIV and AIDS programming. 60. District AIDS Coordinating Committee (DACC): DACC is responsible for coordinating the district response. DACC membership includes 10-15 from all sectors represented in the district assembly and serves for a period not exceeding two consecutive calendar years. Members of DACC include District HIV and AIDS Coordinator (DAC) as Secretary, Director of Finance (DoF), Director of Planning and Development (DPD), Human Resources Development and Management Officer or Director of Administration, HIV and AIDS Focal Point Persons from all Government Ministries or Departments (Health, Agriculture, Social Welfare, Youth, Education, Police, etc.) NGOs, CBOs, and FBOs. NGOs, CBOs and FBOs constitute 50% of DACC membership. Much support has been given to the DACC towards strengthening their supportive role and responsibilities outlined under Box 1 below: Box 1: Responsibilities for DACCs (Adopted from NAC, 2004 p.36, full version refer to Guidelines for District Assemblies Response to HIV and AIDS in Malawi, 1st Edition, November 2004) 1. To ensure that all members and staff of the DA are familiar with the responsibilities of the DA in addressing HIV and AIDS, and the role that the DACC can play in supporting this process. 2. To ensure that all community stakeholders are familiar with the procedures and requirements for submitting work plan proposals for funding, and that the process is transparent and equitable. 3. To meet with DACCs from other districts to share lessons learned. 4. In coordination with the Umbrella Organizations, to review and recommend proposals on HIV and AIDS from organizations in the DACC Technical district, Subcommittees: in a transparent and needs-based manner Each DACC has the liberty to constitute technical subcommittees 5. The DACC should based onathe maintain nature database on HIV of HIV and AIDS and AIDS program areas.technical issues in the district. DACC 6. To identify gaps in service provision and provide transparent requests for proposals to fill the gaps technical 7. subcommittees To ensure act HIV as technical that the DA has District and AIDS Plan think-tanks that is developed for DACC. with in coordination all relevanttechnical Common local stakeholders subcommittees 8. To identify andinclude work with OVC, Proposal HIV and AIDS Review, Focal points Youth, in all district Prevention departments and Behaviour that are responsible Change, for mainstreaming activities and monitoring their progress Community 9. Home Address obstacles Based that Care departments (CHBC) or partners and may face in Resource coordinating andmobilization. implementing the HIV and AIDS Plan technical Sector-based subcommittees 10. To plan, organize are and coordinated relevant by action support inter-sectoral on HIV sector and AIDS department (e.g. Youth by District Youth 11. To identify capacity building support needed for effective implementation of district response and facilitate access to such support Office). Much 12. To ensure that effort has gone there is updated towards database equipping of AIDS activities these sub-committees and organizations in the district involvedso as to in HIV and effectively AIDS programs carry 13. their out activities. To facilitate communication and reporting on the District HIV and AIDS Plan within the DA, the DC, NAC and the general public Community AIDS Coordinating Committees (CACCs), Village AIDS Coordinating 61. Committees (VACCs) and CBO networks: Coordination of HIV and AIDS response at Traditional Authority and Village level is done through the Area Development Committee (ADC) and Village Development Committee (VDC), respectively CACCs, VACCs and CBO networks remain the common coordination mechanisms for the HIV and AIDS response at the relevant level. Component 6: Monitoring, Evaluation, and Research 6.1 Assessment of the HIV/AIDS Epidemic and National Response 6.1.1 Sentinel Surveillance Surveys 62. HIV surveillance is conducted in selected antenatal clinics in Malawi on a regular basis. Initially the surveillance was conducted once every year but from 2001 the surveillance is conducted once every two years. The main objective of the survey is to provide data for monitoring HIV and Syphilis trends in Malawi. The surveillance targets pregnant women that come for their first ante-natal care visit. These are tested for Syphilis and residual blood from 48 syphilis testing is dried on a filter paper and sent to the Community Health Sciences Unit (CHSU) reference laboratory for HIV testing. The Sentinel Surveillance Survey Reports therefore computes trends on HIV and Syphilis as illustrated on figures 20 and 21 respectively. Figure 14 shows that HIV prevalence has generally been declining in the country from 16.5% in 1994 to 10.6 in 2010. Figure 20: National HIV trends in pregnant women 63. On prevalence of syphilis, the report shows that although there has been an observed decline in the overall syphilis prevalence trend from 1996 to 2007, in 2010, prevalence of 1.2% was observed which was similar to 2007. Figure 21 shows yearly trend of syphilis prevalence. Figure 21: Syphilis prevalence trend by year 1.2 1 0.8 Prevalence(%) 0.6 0.4 0.2 0 49 64. Furthermore, the Sentinel Surveillance Survey Reports also show projections on key indicators on HIV and AIDS using the data for the year of the survey. Table 4 below shows the projections. Such statistics are vital as they aid in planning of the national response to HIV and AIDS. Table 4: Summary table of important indicators HIV Population 2005 2006 2007 2008 2009 2010 2011 2012 HIV Adults + Children 936,926 933,966 933,674 931,060 926,623 923,058 917,407 911,975 HIV population (15-49) 752,271 743,257 734,223 724,903 714,791 706,815 701,644 700,261 HIV Adults 15+ 778,392 769,669 761,801 754,257 746,604 742,086 741,373 745,616 HIV 15+ female 457,464 452,623 448,308 444,041 439,802 437,375 437,102 439,720 HIV population- Children 158,534 164,297 171,873 176,803 180,018 180,972 176,033 166,359 Prevalence Prevalence Adult 13 12.47 11.94 11.43 10.92 10.45 10.03 9.67 Prevalence- Males aged 15 to 24 3.7 3.39 3.06 2.77 2.5 2.26 2.08 1.95 Prevalence- Females aged 15 to 24 9.35 8.54 7.67 6.87 6.11 5.42 4.84 4.37 HIV Prevalence- Children 2.68 2.7 2.74 2.74 2.7 2.63 2.47 2.25 New infections Number of new HIV infections 88,054 79,001 69,351 63,883 58,943 52,229 42,902 33,796 New HIV infections- Adult 60,299 52,115 43,997 41,070 36,540 32,587 30,618 27,959 New HIV Infections- Children 27,755 26,887 25,355 22,812 22,404 19,642 12,284 5,837 Incidence Adults 15-49 1.11 0.92 0.78 0.69 0.59 0.52 0.46 0.4 AIDS Deaths Annual AIDS deaths 77,276 74,741 62,473 59,341 56,134 48,569 41,597 32,622 Annual AIDS deaths- Adult 61,992 59,325 50,708 47,757 43,651 36,900 31,581 24,567 Annual AIDS deaths- Children 15,284 15,416 11,765 11,584 12,483 11,669 10,016 8,055 Annual AIDS deaths- Children (1-4) 5,734 5,765 3,774 3,935 4,150 3,751 3,288 2,187 AIDS orphans 576,458 603,409 615,878 623,466 623,157 612,908 597,502 573,141 ART Need Need for ART- Adult (15+) 209,138 216,777 227,342 245,890 265,915 287,918 389,968 414,592 Need for ART- Children 64,778 67,487 81,043 81,882 84,384 106,490 100,464 91,713 Mothers needing PMTCT 73,784 73,314 72,231 70,496 68,120 65,528 62,907 60,344 ART impact Deaths averted by ART 1,213 6,017 16,114 20,219 25,146 32,322 37,646 44,184 Infections averted by PMTCT 355 628 1,570 3,540 2,759 4,257 10,101 14,580 6.1.2 Behavioral Surveillance Surveys 65. From 2004 the National AIDS Commission has coordinated implementation of the Biological and Behavioral Surveillance Surveys (BBSS). This survey is a monitoring and evaluation tool designed to track trends in HIV and AIDS related knowledge, attitudes and 50 behaviors in subpopulations at particular risk of infection. The first round of the survey focused on behaviors only while the subsequent surveys included biomarkers namely HIV and syphilis testing. The second survey was conducted in 2006. The third round of the survey is expected to be conducted in 2013. Table 5 below shows some of the trends that are computed in the BBSS. 51 Table 5: Trends on key indicators in the BBSS Female Sex Make Estate Female Est. Male Police Female Police Male PS Female PS Male Vendors Fishermen Truck Drivers Indicator Workers Workers Workers Officers Officers Teacher Teacher 2004 2006 2004 2006 2004 2006 2004 2006 2004 2006 2004 2006 2004 2006 2004 2006 2004 2006 2004 2006 % who had more than one - - - 43.4 42.1 47.6 39.7 29.2 28.7 8.8 14.2 23.2 26.5 3.7 7.7 145.2 16.4 1.6 0.9 partner in the last 12 months - % who know all three methods 47.9 56.9 46.0 50.8 60.9 43.6 48.8 45.7 64.7 61.9 52.5 56.3 3.5 53.4 7.2 66.1 52.6 59.6 51.1 58.1 of HIV prevention % who correctly identify ways of preventing the sexual transmission of HIV and who - - - 0.0 31.0 36.6 31.8 39.3 35.0 26.7 23.3 1.1 39.7 0.0 57.8 47.1 53.4 44.0 50.0 - reject major misconceptions about HIV transmission % ever tested for HIV - - - 21.6 32.5 38.4 48.7 17.7 30.4 10.7 28.8 36.7 59.0 38.3 68.7 23.4 41.8 24.8 53.0 - % with accepting attitudes - 45.1 42.1 28.9 28.1 41.8 44.4 32.5 42.0 16.0 34.2 53.5 48.8 36.9 38.6 51.3 56.7 42.5 41.9 toward PLWHA - % who know any service site 93.4 92.9 89.2 94.2 83.6 88.3 95.0 85.4 74.4 80.9 69.7 68.4 90.9 97.7 91.9 98.8 92.1 96.6 91.3 98.5 that offers STI services 52 6.1.3 Demographic and Health Surveys 66. HIV sero-prevalence in Malawi is routinely estimated using sentinel surveillance among pregnant women attending selected health facilities. This methodology has significant limitations because men are excluded and because pregnant women are not representative of all women due to biases in their distribution by age as well as fecundity. Moreover, the number of sampled clinics is small and less rural than the national population distribution and they are not randomly selected, creating further possible bias. Due to this challenge it was agreed that some biomedical indicators for HIV be assessed through the DHS. From 2004 the National AIDS Commission has managed to track population based HIV prevalence through this survey. This has been possible through funding from development partners. The DHS, therefore, computes trends on various key indicators on HIV and AIDS. Table 6 below shows trends in HIV prevalence among adults (15-49 years) by their location: Table 6: Trends in HIV prevalence by sex and location MDHS 2004 MDHS 2010 Indicator Urban Rural Total Urban Rural Total HIV Prevalence (15-49) (%) Total 17.1 10.8 11.8 17.4 8.9 10.6 Men 16.3 8.8 10.2 12.0 7.1 8.1 Women 18.0 12.5 13.3 22.7 10.5 12.9 67. The DHS also measures trends in age at first sex as shown in figure 22 below. The percentage of women age 15-19 who have had sex by age 15 has steadily decreased over the past three MDHS surveys, from 17 percent in 2000 to 12 percent in 2010. By contrast, the percentage of men age 15-19 who have had sex by the age of 15 appears to have declined between 2000 and 2004, and then increased between 2004 and 2010 from 18 percent to 26 percent. The percentage of men and women age 18-19 who have had sex by age 18 has declined modestly over the time period of the three surveys. 53 Figure 22: Trends in age at first sexual intercourse 68. The DHS also shows that 10.6 percent of adults age 15-49 in Malawi are infected with HIV. Among women age 15-49, the HIV prevalence rate is 13 percent, while among men age 15-49 the HIV prevalence rate is 8 percent. HIV prevalence increases with age for both women and men. For women, HIV prevalence is highest among women age 35-39 (24 percent), which is six times the rate among women age 15-19 (4 percent). For men, the prevalence increases sharply from 1 percent among men age 15-19 to 21 percent among those aged 40-44, and drops thereafter. Figure 23 below illustrates the age pattern of HIV prevalence for women and men. Figure 23: HIV prevalence by Sex and Age 54 6.2 Program Activity and Financial Monitoring 6.2.1 Program Activity Monitoring 69. Monitoring and evaluation results are critical to bring about policy and programmatic improvements. The national response to HIV and AIDS continued to be guided by ‘One M&E System’ which is one of the tenets of the ‘Three Ones’ principle, advocated by UNAIDS for effective coordination. 70. In 2003 the first M&E plan was developed and covered the period 2003 to 2005. Being the first one, this M&E plan had set the pace towards ensuring that all stakeholders and partners are coordinated, as far as monitoring and evaluation is concerned. The next M&E framework was for the period 2006 to 2010 and was developed to monitor strides made in achieving the objectives of the National Action Framework (2005 – 2009). The third M&E plan was developed for the period 2011 to 2016 and is fully aligned to the National HIV and AIDS Strategic Plan (NSP) covering the period 2011 to 2016. 71. Despite some challenges to do with alignment of all partners’ M&E systems to the national one as stipulated in the three successive M&E plans, measuring progress in the national response to HIV and AIDS has been meaningful with the guidance provided by these M&E Plans. 72. From the onset of the project the NAC AIDS Reporting system (NACARS) was introduced to support monitoring of progress on key activities and was later changed to the Local Authority HIV and AIDS Reporting System (LAHARS) after the decentralization of reporting roles to Local Councils. 6.2.2 Financial Monitoring 73. NAC has set up the common funding mechanism for the national response to HIV and AIDS through the HIV Pool, which is also supported by the World Bank, among other Partner Partners. Financial support to the national response to HIV and AIDS is by the Government of Malawi (GoM), Multi-lateral and Bi-lateral Funding and Development Partners. The HIV Pool is governed by a Memorandum of Understanding (MOU). NAC has set up the Grants Facility, which is the vehicle for channeling resources to implementing agencies. It was originally managed by the Financial Management Agency (FMA) through a contract. In September 2007, NAC established a new Grants Management Unit (GMU) to take over the management of the Grants Facility from the FMA. Operation of the Grants Facility is governed by the NAC Grants Facility Manuals. 74. NAC has implemented the MAP through Grant Recipient Organizations with activity implementation throughout the country. The program had a dedicated Grants Management Unit that was used to monitor implementation of activities as well as ensure financial compliance. Throughout the period of the program, the program has enforced quarterly reporting on the part of the GROs for its financial monitoring purposes. 55 75. Over the period, financial capacity of GROs has been strengthened through trainings, grant management clinics and supervisory visits. This has resulted in improved financial management being realized over time from the GROs. Further, it has been a requirement that GROs be audited annually. Management letter issues and recommendations made by the audits have helped further improve financial systems and assisted in financial monitoring. There have been improvements in the extent of management issues raised over the period, signifying effectiveness of financial monitoring. 76. As an overall coordinator, NAC has installed and maintained a computerized accounting system which has continuously been used to produce reports and enhance financial monitoring during the entire period of the MAP. 6.3 Specialized Studies 6.3.1 PLACE Study 77. The Priorities in Local AIDS Control Efforts (PLACE) method is a rapid assessment method for identifying areas likely to have sexual partnership formation patterns capable of spreading and maintaining HIV infection. The method requires gathering available demographic and epidemiological data and conducting meetings with local stakeholders (community members, HIV experts, and HIV/STD service providers) to describe areas likely to have high HIV incidence and through key informant interviews, identifying sites within those HTAs where men and women meet new sexual partners such as bars, market places, work sites, and schools. Individual interviews are conducted with those that frequent these sites to assess their sexual behaviors. The method provides indications of the extent to which HIV/AIDS prevention programs and condoms are reaching these sites and provides data for future intervention programs at these sites. The first study was conducted in 2004 in Mulanje district with subsequent ones conducted in Nsanje (2005), Blantyre and Lilongwe (2007). 6.3.2 Drug Resistance Monitoring 78. Laboratory monitoring of patients receiving antiretroviral drugs is limited because of insufficient resources. Malawi ART program has largely monitored such patients using clinical criteria and CD4 cell counts according to WHO recommendations. Some studies however, have not found these determinants to be perfect predictors of viral logical failure. Consequently, the Ministry of Health in Malawi periodically samples patients initiating treatment and follows them up to monitor viral suppression and development of resistance at 12 months, following WHO guidelines. 6.3.3 Know Your Epidemic and Response 79. The Know Your Epidemic and Response exercise consolidates, assesses, analyses, and synthesizes all epidemiological data including utilization of the Modes of Transmission model to determine the major drivers of the epidemic in the country. It focuses on coverage, equity, intensity, and quality of interventions, cost effectiveness of interventions and impact of the national response. The first round of the ‘know your epidemic’ exercise was conducted in 56 Malawi in 2008. The exercise helped the country to consolidate evidence on “modes of transmission� that informed development of an evidence-based National Prevention Strategy which focused on prevention efforts that effectively reduce new infections by addressing the key drivers of the epidemic and vulnerability factors. It also helped to consolidate evidence on the impact of the national response to justify Malawi’s efforts to mobilize additional resources to finance the national response to HIV and AIDS. It assisted in consolidating evidence that informed prioritized allocation of available resources for maximum impact in terms of reducing infections, morbidity and mortality. 6.3.4 Assessment of the Impact of HIV Mainstreaming Interventions 80. In 2009 the National AIDS Commission (NAC) commissioned a study to assess the impact of HIV and AIDS mainstreaming interventions in Malawi. The main objectives of the study were to generate strategic information that would be used to understand the extent to which implementers had mainstreamed HIV and AIDS into their programs and organizations; and assess the outcome and impact of implementing mainstreaming interventions in Malawi. The findings generated information that provided an understanding of the extent to which implementers had mainstreamed HIV and AIDS into their programs and also nurture the mid- term review of the National Action Framework (mainstreaming component) and enlighten the design and implementation of mainstreaming activities in the country. The study found out that organizations were implementing very relevant HIV and AIDS interventions in line with the national response as guided by the National HIV and AIDS Action Framework (NAF, 2004). Most of the interventions were related to HIV prevention, treatment, care and support. All the organizations had agreed criteria to enable staff, their spouses and beneficiaries of their services to access HIV and AIDS services. 81. It was clear from the study findings that mainstreaming had just started in the country and few organizations fully understood the concept of mainstreaming as a process of responding to HIV and AIDS within the core functions, policies, programs and projects of the public, private and civil society. Organizations were still struggling to clearly identify the entry points or themes for mainstreaming HIV and AIDS that would ensure buy-in from all the members of staff. 82. The study also concluded that HIV and AIDS mainstreaming was an essential approach for expanding, scaling up and implementing multi-sectoral responses to HIV and AIDS in the country. The study observed that mainstreaming was crucial for addressing vulnerabilities to HIV infections and was a good starting point to engage sectors that ought to but had as yet not participated in the overall national HIV and AIDS responses. Mainstreaming would help build strong alignment to the NAF and a stronger monitoring and evaluation system coordinated by NAC. 6.3.5 Situation Analysis of Non-biomedical Interventions 83. After realizing that over the past 25 years a considerable amount of resources had been spent on both biomedical and non-biomedical HIV and AIDs interventions, in 2010 the National AIDS Commission, commissioned a study to assess coverage, intensity and quality of key non- 57 biomedical HIV and AIDS interventions that were being implemented as a response to HIV and AIDS in Malawi. 84. This study revealed Monitoring and Evaluation gaps that exist in the national response to the HIV and AIDS epidemic. It indicated that the system is not proactive as it relies on the stakeholders reporting to NAC but the reporting is not consistent and timely. The annual M&E reports are based on such data. Previously, very low numbers of people reached with NBIs had been reported; this study reported much higher numbers. It therefore called for periodic surveys in future as it will show trends in coverage of NBIs in Malawi. This survey also revealed that most stakeholders do not assess the impact of their interventions as they are just interested in reporting the number of people reached with NBIs. Currently, the Impact Mitigation TWG putting in place mechanisms that will effectively collect data on a quarterly basis that can be used to monitor trends in coverage of NBIs. Component 7: National Leadership and Coordination 7.1 The Office of the President and Cabinet-Department of Nutrition, HIV & AIDS 85. The President is responsible for the Ministry of HIV and AIDS, and provides overall leadership on matters of HIV and AIDS for Malawi. The Department of Nutrition, HIV and AIDS (DNHA) in the Office of the President and Cabinet (OPC) is the lead Government agency in the national response to Nutrition and HIV and AIDS, responsible for policy, oversight and high level advocacy. DNHA is thus central for policy issues and overall guidance for all levels of the national response. 7.2 The National AIDS Commission 86. The National AIDS Commission (NAC) was established by the Malawi Government under a trust deed to provide leadership and coordination for the national response to HIV and AIDS in Malawi. It is governed by a Board of Commissioners led by the Chairman who is appointed by the President. The other members are selected from all constituencies namely: private, public, faith, civil society, youth and PLHIV. Major roles include reviewing and approving NAC policies and procedures, annual work program and hiring of secretariat executive staff. NAC has specific roles which include the following;  Guiding the development and implementation of the NSP.  Facilitate policy and strategic planning in sectors, including local government.  Advocating and conducting social mobilization in all sectors at all levels.  Mobilizing, allocating and tracking resources.  Building partnerships among all stakeholders in country, regionally and internationally.  Knowledge management through documentation, dissemination and promotion of best practices.  Mapping interventions to indicate coverage and scope.  Facilitating and supporting capacity building.  Overall monitoring and evaluating of the national response.  Facilitating HIV and AIDS research. 58 7.3 Sectoral Response Coordination 7.3.1 Department of Public Services Management 87. The Department of Public Services Management (DPSM) is a department within the OPC which coordinates the HIV and AIDS response, particularly workplace programs, in the public sector. These include all government ministries, departments, training institutions and parastatal organizations. There is also a public sector steering committee comprising of principal secretaries and chief executives which provides policy leadership and guidance on the public sector response. Workplace programs in Local Councils rely on DPSM on policy and central level guidance on all aspects of planning and implementation to ensure effectiveness. 7.3.2 Malawi Business Coalition against AIDS (MBCA) 88. MBCA coordinates the response for private companies and business institutions. Its major roles are mobilization of companies, development of workplace programmes, reporting and evaluation of the private sector response. 7.3.3 Malawi Network of People Living with HIV (MANET+) 89. MANET+ coordinates all organizations for people living with HIV and AIDS (PLHIV). These organizations serve and advocate for issues affecting PLHIV in order to improve their welfare. 7.3.4 Malawi Network of AIDS Service Organizations (MANASO) 90. MANASO coordinates local and international NGOs implementing various HIV and AIDS activities. 7.3.5 The Malawi Interfaith AIDS Association (MIAA) 91. MIAA coordinates all faith based organizations implementing HIV and AIDS interventions. 7.3.6 National Youth Council of Malawi (NYCOM) 92. NYCOM coordinates all youth organizations implementing HIV and AIDS interventions. All these sectoral coordinating institutions are expected to collaborate with Local Councils when coordinating the national response in the districts. 7.4 Support in Policy Development and Monitoring 93. NAC has facilitated development of the following strategic documents among others:  HIV & AIDS Policy, 2003, (2003 – 2008)  National Strategic Framework, 2000, (2000-2004) 59  National Action Framework, 2005, (2005-2009; Extended to 2012)  National HIV and AIDS Strategic Plan, 2011, (2011-2016)  Universal Access for HIV prevention, treatment, care and support, 2006, (2006 – 2010)  HIV Prevention Strategy and Operational Plan, 2009, (2009-2013)  Condom Programming Strategy, 2005  Mutual Faithfulness Strategy, 2008  Abstinence Strategy, 2008  National HIV and AIDS Monitoring and Evaluation Plan, 2006, (2006-2010)  Policy on Equity in Access to Antiretroviral Therapy (ART) in Malawi, 2005  National HIV and AIDS Impact Mitigation Conceptual Framework, 2006  Voluntary Medical Male Circumcision Policy, 2012  Conceptual Framework for HIV and AIDS Mainstreaming and Guidelines, 2006  Communications Strategy for NAC and HIV and AIDS Communication Guidelines, 2007  Integrated Annual Work Plans 94. In addition to the above, NAC has played a key role by providing input into the development of the following strategic documents:  MGDS I and II, 2006 & 2011, (2006-2011; 2011-2016): Overarching National Socio- economic Development Framework (HIV&AIDS under Pillar No. 6)  National Orphans and Other Vulnerable Children (OVC)Policy,2005  National OVC Plan of Action, 2004 95. The documents produced have played a crucial role in ensuring that all players adhere to certain standards and practices in implementation of activities. The documents have also made implementation easy as they have provided the necessary direction needed for an effective response. 7.5 Resource Mobilization 96. The national response to HIV and AIDS in Malawi started to register notable program scale up around 2004, when the Government of Malawi and Development Partners including World Bank provided significant amounts of financial resources for priority intervention areas. The period 2004-2012 saw the National Response accumulating funds to US$438,783,853.48. The year 2012 saw the Rolling Continuation Channel and Round seven grants of the GFATM consolidated into a Single Stream Funding (SSF). The period under review also saw the successful implementation through to the expiry of a Memorandum of Understanding governing the National Response. The expiry of the MoU has led to Government and Partners developing a new framework that will continue to govern the funding arrangements through NAC in the subsequent years. 97. Table 7 below summarizes financial inflows received from partners, development partners and the Government of Malawi: 60 Table 7: Summary of Cash Inflows 2004 to June 2012 Sources of Funds 2004 2005 2006 2007 2008 2009 2010 2011 2012 Cum.Totals YEAR OF FUNDING NORAD 1,044,563.74 2,170,059.04 1,637,524.03 2,419,938.50 2,739,393.61 2,220,813.78 2,300,082.86 - - 14,532,375.56 GOM 1,094,739.81 1,071,428.57 1,506,917.76 1,428,571.43 2,000,000.00 1,500,000.00 4,479,165.40 933,333.33 5,707,337.54 19,721,493.86 DFID 906,284.72 - 1,770,783.73 2,607,055.45 3,992,456.14 3,607,128.23 6,192,995.01 6,621,681.48 7,953,500.00 33,651,884.76 Others/Interest 48,791.41 56,167.03 18,089.70 18,390.05 315,001.71 274,536.83 126,948.86 240,229.07 274,857.28 1,373,011.93 CIDA 2,281,635.09 953,116.56 - 3,712,605.48 - - - - - 6,947,357.13 Interest FCDA US$ 5,733.92 3,008.92 578.77 11,325.05 2,846.47 6,690.37 - - - 30,183.49 GFATM - - - 39,597,297.85 62,615,827.87 77,457,359.64 23,985,917.65 46,013,790.62 53,154,207.33 302,824,400.96 IDA 2,838,474.07 2,355,214.29 11,595,774.64 7,866,078.57 10,670,397.78 685,297.91 9,953,826.67 4,932,985.01 8,805,096.85 59,703,145.78 Total 8,220,222.77 6,608,994.42 16,529,668.63 57,661,262.38 82,335,923.56 85,751,826.75 47,038,936.45 58,742,019.52 75,894,999.00 438,783,853.48 61 7.6 Implementation of National Coordination Mechanisms 7.6.1 Malawi Partnership Forum 98. The Malawi Partnership Forum (MPF) is an advisory body to the NAC Board of Commissioners, comprising of high profile decision makers drawn from the following constituencies: public sector, private sector, PLHIV, CSOs, academia, research, national assembly and development partners. The MPF plays a very critical role in planning and reviewing the national response to HIV and AIDS in Malawi. All the coordinating structures outlined below are represented on the MPF. NAC provides management support to the MPF. 7.6.2 Technical Working Groups 99. Technical Working Groups (TWGs) are HIV and AIDS thematic groups established by NAC to provide technical guidance and make recommendations on various technical issues in the national response. They report to the MPF. 7.6.3 HIV and AIDS Development Group 100. The HIV and AIDS Development Group (HADG) is a grouping of HIV and AIDS development partners. The objectives of the HADG are to harmonize and coordinate development partner’s support to the NAF and to align development partners’ support to the integrated annual work plan. 7.6.4 Principal Secretaries Steering Committee on Nutrition, HIV and AIDS 101. This is a committee comprised of selected Principal Secretaries in Government. This was deliberately done by government so as to ensure that as technical heads, the Principal Secretaries are in the forefront championing HIV and AIDS issues across Government Ministries and Departments. The group meets bi-annually to discuss program implementation as related to HIV and AIDS activities in their specific Ministries and Departments. 7.6.5 International Non-Governmental Organizations Forum 102. This is a grouping for all international NGOs and was created so as to ensure that as groups that are implementing various activities they should be able to mobilize resources for HIV and AIDS interventions as well. It was also put in place so as to ensure that activities that are undertaken are able to be reported on. The grouping meets on a quarterly basis. 7.6.6 Local Non-Governmental Organizations Forum 103. This is a grouping of all indigenous NGOs and was put in place so as to ensure that they are able to contribute towards the fight against HIV and AIDS in a well- 63 coordinated way. The group was also constituted so as to help in articulating issues on the ground to relevant authorities. Lastly, the group was also formed so as to help on issues of reporting on all HIV and AIDS related activities. 7.7 Strategic Planning and Annual Reviews 104. The national response to HIV and AIDS in Malawi has been guided by short, medium and long term plans. The National strategic Framework for HIV and AIDS (NSF) 2000 to 2004 was the first of such initiatives to guide the implementation of HIV and AIDS programs. At its expiry in 2004, it was followed by the National HIV and AIDS Action Framework that initially covered the period 2005 to 2009 and extended to 2012. Currently, there is the Malawi National HIV and AIDS Strategic Plan (NSP 2011 – 2016), covering the period 2011 to 2016. The NSP seeks to provide continued guidance to the national response to HIV and AIDS, building on work done in the past decade. It is informed by the findings of the Community and Stakeholder consultations on the National HIV and AIDS Policy Review (March 2010), the Malawi Growth and Development Strategy II (2012 – 2016) and the Health Sector Strategic Plan (HSSP) 2011 – 2016; as well as developments in medical and scientific knowledge. 105. In addition to these mid-term strategic plans, the government through NAC has been producing specific thematic strategic documents in form of policies and guidelines to help in giving direction to implementation of all HIV and AIDS activities. These policies and guidelines include; Conceptual Framework for Mainstreaming HIV & AIDS Response into Development Policies, HIV/AIDS and Research Strategy for Malawi 2005-2007, Universal Access for HIV prevention, treatment, care and support (2006 – 2010), HIV Prevention Strategy and Operational Plan, Condom Strategy, Mutual Faithfulness Strategy, Abstinence Strategy, National HIV and AIDS Monitoring and Evaluation Plans, Policy on Equity in Access to Antiretroviral Therapy (ART) in Malawi, National HIV and AIDS Impact Mitigation Conceptual Framework, Conceptual Framework for HIV and AIDS Mainstreaming and Guidelines, Communications Strategy for NAC and HIV and AIDS Communication Guidelines and Integrated Annual Work Plans. 106. On the other hand, on an annual basis NAC does hold Joint Stakeholder Reviews. These reviews are provided for in the Memorandum of Understanding between the Funding Partners of the National Response to HIV and AIDS and the Government of Malawi. These include the semi-annual and annual reviews. The objective of the semi- annual review is to give the National AIDS Commission, local stakeholders and its funding partners an opportunity to review implementation progress of the Integrated Annual Work Plan (IAWP), over the first six months of every financial year. It also provides an opportunity to assess the effectiveness of management, coordination and monitoring systems. The main output of these reviews is an Aide Memoire that outlines key issues and strategic actions to be undertaken in order to address the identified challenges. 64 107. In all of this, the Integrated Annual Work Plan (IAWP) continues to be the operational tool for the National Strategic Plan that forms the basis for resource allocation and tracking. 7.8 Development and Operation of Information Tools 108. The National Response to HIV and AIDS makes total and complete use of the information products of the M&E System as established by the National M&E Plan. To this effect, a number of achievements have been made in the national response with the production of a wide range of information products based on both routine and non- routine data sources. These information products have included M&E reports, research and study reports, information briefs and newsletters. 109. The information products are then disseminated to all players in the response to guide policy formulation and program planning and improvement. The reports disseminated contain right information needs of stakeholders in keeping with the ever changing nature of the epidemic and operating environment that is characterized by innovations in the various interventions. 110. These products have been shared through a number of ways including the following: national bi-annual and annual review conferences, research and best practices dissemination conferences, stakeholder program planning and review meetings, regional and zonal dissemination meetings, and websites, hard and electronic circulated mails. 65 Annex 3. Economic and Financial Analysis 1. The methodologies used in the two main studies used in the section on efficiency in the main ICR section are described below. I. Burden of Disease Estimates for 2011 and the potential effects of the Essential Health Package on Malawi’s health burden Introduction 2. An evaluation of the essential health package (EHP) using WHO Burden of Disease (BOD) methods suggests significant health gains were made by the first EHP associated with the first SWAp. An economic appraisal of the second EHP associated with the Health Sector Strategic Program (HSSP) is a useful tool to help make priorities and choose best buy interventions. This appraisal can use various approaches. One approach is to build on previous work based on Malawi’s Burden of Disease as measured by Disability Adjusted Life Years (DALYs). Various assumptions and adjustments are required because of the shortage of vital statistical data. This paper describes the methods used in updating the BOD estimates and how they have been applied to the proposed HSSP. Methods 2011 Burden of Disease 3. The estimates of the BOD are the foundation of later analysis. The 2002 WHO estimates for Malawi were assessed in 2004 and found to be robust. These estimates were updated in 2008 and used in the evaluation of the EHP. WHO is in the process of updating their estimates, using funding from the Gates Foundation, but these are not yet available. The 2002 estimates have been used to update the Malawi estimates for this study. The following approach was used: (i) Age specific mortality rates were calculated from the 2008 census providing best estimates of current infant, child and adult mortality (including females of reproductive age) using National Statistics Office (NSO) published life tables created using INDEPTH methodology. Actual deaths for 2011 were estimated using the specific death rates and 2011 population figures. (ii) NSO population projections published in November 2010 were used. (iii)Incidence rates of the 159 conditions that make up the BOD model have been assumed to remain as in 2008 except for: a. HIV/AIDS where incidences of HIV and AIDS have been taken from the 2010 SPECTRUM projections used by the MOH HIV Unit. b. Hypertension and diabetes disability levels increased to reflect results of STEP study for disability but not mortality (because the natural history of these conditions is unknown in Malawi). 66 (iv) Important diseases causing a heavy burden such as malaria have been assessed using recent survey data and found to remain similar to those used in 2008. Potential Burden averted by the EHP 4. The EHP2 updated model containing the new interventions such as mental health has been used to calculate the incidence and burden (in DALYS) of preventable or treatable conditions chosen in the EHP. Assumptions used to predict the resource based and the ideal budgets 5. The ideal scenario budget uses the following assumptions:- a. Indirect costs are based on expert MOH groups looking at i. HR – not staff establishments which are being revised, but current staff levels, attrition rates and recruitment rates based on planned pre- service outputs ii. Infrastructure – based on a survey of health facilities – their location for GIS analysis, their level of amenities such as water and electricity and their functional equipment iii. Transport based on planning assumptions about ambulance requirements – 1:50,000 etc. b. Direct costs are derived from the cost-model assuming all targets are met. Access is 100%. c. The overall apportionment of EHP to non-EHP costs assumes i. Same split as between central hospitals and other cost centers with HQ costs split 25% non-EHP and 75% EHP between 2002/3 and 2009/10 which were 84% EHP and 16% non-EHP. ii. The apportionment does not change over the 5 years. This is because while pressure to offer tertiary services such as the cancer center arises from medical advances and the profession, pressure is equally coming from the HSSP and the need to hit EHP targets. iii. This effects only direct costs as indirect costs are apportioned between EHP and non-EHP services on the basis of location of cost centers: 1. All central and 25% of HQ HR goes to non-EHP 2. All CHAM and district HR goes to EHP 3. All central and 25% of HQ other indirect costs goes to non- EHP Assumptions used in the cost model for this exercise 6. The MOH cost model used for the first EHP has been adapted by the Ministry of Health (MOH) for EHP2. The costs have been revised. Staff numbers have been revised to accommodate recent revisions of the staff establishment. A number of assumptions have been used to derive the activity estimated from the model under different funding scenarios. They are:- 67 (i) The model has been calibrated using 2009/10 activity based on HMIS data and 2010/11 estimated costs. The model over-predicts costs by 27%. This is due to drug and staff costs being less than predicted by the model because of staff absences and drug stock-outs. The effect is that activity over-predicts beneficial effect by some 20%. The model has been re-calibrated to take this into account. It is assumed that as staffing levels improve (as the Emergency HR plan increases pre-service outputs) and drug procurement and supply becomes more reliable, the resource based scenario will improve effectiveness to 90% of attendances and the ideal scenario to 100%. (ii) The core scenario used is based on the MOH resource based estimate of budgets in 2011/12 and 2015/6. It is assumed that 75% of HQ activity is to do with the EHP and the remaining 25% other non-EHP activity, and that central hospital indirect costs including staff costs are non-EHP but that all district services are EHP. It also assumes that the overall proportion spent on tertiary services of government budget stays as it was on average and stable between 2002 and 2009 at 16%. This clearly is an imprecise way of allocating the costs between EHP and non-EHP. For instance 70% of central hospital services are primary or secondary level care and staff time has been allocated only to non-EHP services. On the other hand all CHAM and MOH District level and below HR costs have been allocated to the EHP although a proportion of their work is non-EHP (perhaps 10% in MOH and 20% in CHAM institutions). (iii)The second scenario is based on an ideal estimate – all the funds required to implement the HSSP fully. This is based on an assessment by MOH expert groups looking at the indirect costs of HR, infrastructure, transport and equipment. For instance for HR they took the current staffing levels, adjusted for attrition and new recruits coming out of pre-service institutions to estimate the level of staff available in year 5 of the plan. The infrastructure costs are based on the building needs required to offer BEMOC access (8km) to over 95% of the population. Direct costs are derived from the cost model which calculates the number of patients required to receive the EHP intervention at the target level and their associated costs. (iv) By 2016 the effectiveness of patient care is assumed to have increased from 80% to 90% for the resourced based EHP scenario as facilities are better staffed and stock outs are less. The ideal scenario is assumed will achieve 100% staffing and no stock outs. (v) Access improves in both scenarios. For the resource based scenario from an access level of 65% access in 2011/2 the plan is to build new or upgrade dispensaries by 58 – 28% of the ideal level (206) required to provide 8km access to over 95% of the population – the BEMOC target. It should be noted that this 95% target has not been checked using GIS but will be in the next 6 months. The 28% increase planned for the resource based scenario improves access to 75%. (vi) Total activity and associated burden averted for the 5 years is calculated from averaging the first and 5th years of the plans and multiplying the results by 5. The size of the burden of disease alleviated has been evaluated by assuming one DALY alleviated is equivalent to the Gross Domestic Product of Malawi (based on IMF projections). 68 Prevention interventions 7. Various assumptions were used to estimate the burden of disease that has already been prevented by prevention interventions such as immunizations as to stop these would have the effect of increasing these diseases in future. To gauge what would happen if immunizations were reduced; the Sub-Saharan incidence rates of vaccine preventable diseases have been used to calculate the effect of a suboptimal immunization program, adjusted by the estimated levels of disease pre-immunization era. Clinical treatments 8. For those interventions involving clinical treatment 2009/10 HMIS data have been used, being the most recent year of currently available data. Treatments have been adjusted in two ways; by a factor for treatment effectiveness (as an example, antibiotics work in 84% of times for pneumonia in children); and by a factor measuring the affected population (as an example, 50% of adults and 70% of children registered in HMIS as malaria are not, so only half or less of the number treated will benefit from antimalarial drugs). Treatment effectiveness factors are taken from recent authoritative sources and referenced in the table. Summation of benefits of the EHP 9. The burden of disease calculated in DALYS for each intervention for 2011 (and succeeding years) can be summed to provide an overall estimate of burden averted by the program. As the costs are also contained in the EHP model it will be possible to measure the cost effectiveness of each and all interventions combined at the levels of activity agreed once funding is known. Results 10. All results are found in a folder of spreadsheets available on the COM/Community Health National Research website at http://www.medcol.mw/commhealth/publications/national%20research/national_research .htm 11. There are excel files for all 159 conditions listed, and estimates of incidence, prevalence, deaths and DALYs are available. Summary files are also available for DALYs, deaths, life expectancy, healthy life expectancy (HALES) and risk factors, by age and sex group. Spreadsheets calculating the DALYS averted by the EHP scenarios are also available for download. 69 II. Multi-Country Analysis of Treatment Costs for HIV/AIDS (MATCH): MALAWI Ministry of Health – October 2012 1. Methodology 1. For the purpose of this study, treatment is defined as the full range of HIV-related medical services provided to the patient at the facility level. This definition excludes non- medical interventions such as income-generating activities and orphans and vulnerable children (OVC) interventions, but includes treatment-related interventions such as nutritional support and adherence programs. It includes treatment-related costs incurred outside of the primary facility that are a core part of delivering outpatient services at the ART clinic, e.g. any lab costs incurred at a tertiary facility. It does not include the cost of HIV Testing and Counseling (HTC). In-patient days are not included. For all costs included, the primary recipient of the service was the HIV-positive individual (as opposed to the patient’s family or the general community). 2. The study design strikes a compromise between a detailed time-and-motion study of provider behavior and patient cohort histories in a few facilities, and a less comprehensive study of hundreds of ART facilities. The former would be ideal for revealing the quality of care and the intensity of provider effort, but would lack external validity beyond the facilities covered and have too little statistical power to support any of the most obvious of findings. The latter would reveal the broad range of cost variation across many regional and local settings, but would be unable to cast much light on the detailed breakdown of costs in each individual facility or on the possible contribution of policy instruments to reducing the cost of ART. 1.1 Site Selection 3. The 30 facilities were selected by means of a stratified random sampling method. Facilities were stratified by three criteria: (i) by region, (ii) by facility type, and (iii) by administration. Upon application of the stratification criteria, sites were chosen randomly from the available strata to ensure an unbiased and representative sample. 4. Given the relatively small sample size, stratified random sampling ensured adequate representation of facility characteristics (e.g. facility types). Several pilot facilities were selected and visited in late 2010; however, these were not included in the final analysis since the methodology changed after the pilot sites were costed. Below is further detail of the site selection methodology. A comprehensive description of the methodology used can be found in Annex 2. 5. Inclusion/Exclusion: Site selection was based on a facility list provided by the MoH; this list included all static sites providing ART in Malawi as of December 2010. Sites that had been providing ART for less than 1 year at the expected time of costing were excluded to allow for patient outcome analysis on both new and existing ART 70 patients. Additionally, although private facilities made up nearly 18% of total static sites in Malawi (51 out of 277), they only covered 3.1% of the total patient burden and were therefore excluded from the sample to allow for greater emphasis on public sites. 6. Stratification Criteria: The first stratification criterion used was the facility type: Hospital, Health Center, or Other/Special. The second criterion used was region: South, Central, or North. The third criterion used was Administration: MoH or Other. 7. Since much of the facility level administration is centralized within a district, a clustered approach was also taken to accommodate more robust data collection. If a District Hospital was selected, Health Centers within that district were prioritized only if they also fit the necessary criteria. 8. Representation Per Stratum: • Average of number of sites based on distribution of facilities and number of patients per stratum. • The average was rounded to zero decimals to determine the final number of sites per stratum • Any stratum with 0-1% representation was always rounded up to 1 so no stratum ever had a probability of zero sites being selected unless its representation was actually 0. 1.2 Data Collection Overview 9. Data collection took place over the course of 5 months, from May 2011 through September 2011. One team of 1-3 data collectors was in the field, covering an average of one site per week. 1.3 Data Sources and Collection Tools 10. Three types of data were collected: descriptive information about the site, comprehensive cost data, and patient-level data collected from charts. 11. Key data sources include the following: • Facility-level data, both electronic and paper based and other expenditure records/reports • Interviews with facility managers, accountants, patient record managers, and health care providers • Patient record review (as needed particularly for patient outcome indicators) • Aggregate data available from the Ministry of Health or elsewhere (e.g. data on prices paid for CD4 machines) • Comparable facility-level data from adjacent health care centers in the absence of data from a specific facility (e.g. running costs at similar facilities) 71 12. Data collection was conducted using a standardized tool in a dedicated software package, DatStat. DatStat is a web-based platform which was used at each facility to capture data by cost element. The tool captures all sites’ data and stores it in a common database. Data collection is built in DatStat surveys by cost element and consists of the following information: • Qualitative questionnaires • Quantitative input tables • Patient-level data questionnaire 1.4 Data Management 13. Data was collected in multiple ways: some was captured using manual surveys recorded on paper or on a computer, and some was provided as electronic data (i.e. some quantitative information). Where survey data was collected on paper, the paper copies were stored securely under direction of the principal investigator pending data entry into the online system. Data provided in electronic format was also stored securely under the direction of the principal investigator. All data entered in DatStat is stored in an oracle database located in Seattle, Washington, USA. Data was controlled through security features built into the tool and was not accessed by anyone without the appropriate permissions. 1.5 Analysis of Cost data 14. Costs were collected across five major cost categories: ARVs, Personnel, Laboratory, Investment Costs, and Other Clinical Costs. 15. As the objective was to estimate and project the real cost of ART delivery, this study used an empirical “top-down� approach to quantify the current unit cost of ART. Study teams collected the total cost of treatment at a given facility and made a series of input cost allocations to arrive at a PPPY cost. Total costs were first allocated to the HIV program, then to service delivery areas (SDAs) and to patient categories to calculate the PPPY cost. This process was followed for each cost category (ARVs, Laboratory, Personnel, and “Other Costs�). For example, in order to quantify the costs associated with treating a single pre-ART or ART patient, the study team started with total personnel costs at a given facility, assigned the portion of those costs that are incurred caring for pre-ART and ART patients using a simple allocation metric such as proportion of patient visits, and then divided the total pre-ART and ART related personnel cost by the total number of patient years. In certain cost categories, the study team complemented the top- down approach described above with a normative or “bottom-up� calculation of cost. 1.5.1 Allocation to HIV 16. Shared costs were allocated to pre-ART and ART based on assessed proportion of pre-ART and ART utilization to total facility utilization. Allocation to the HIV program was made using directly relevant measures where possible; for example, facility costs 72 were allocated based on the approximate relative share of space, equipment used for HIV services; vehicle costs by approximate share of time; and staff costs by approximate allocation of working hours per week/month. Where these estimates were unavailable, a default HIV allocation was used, where the number of visits to the ART clinic was divided by the total number of outpatient visits (including ART) to the facility in order to determine the relative allocation of facility level costs to HIV. 1.5.2 Allocation to Patient Types 17. Costs were then allocated proportionally to patient types, based on the number of patients in each category. The study reviews costs for the following patient types: 1. Pre-ART patients 2. Adult First Line Patients 3. Adult Second Line Patients 4. Pediatric First Line Patients 5. Pediatric Second Line Patients 1.5.3 Allocation to Service Delivery Areas 18. Total costs were allocated across eight service delivery areas found to be the main contributors to HIV treatment cost in order to illustrate the greatest cost components of service provision. The eight service delivery categories were determined primarily through interviews, and are listed below with a brief description. 1. ARVs – this includes only the cost of ARVs 2. Clinical care – this includes any non-ARV clinical treatment cost such as personnel time spent on clinical care, the cost of other drugs, etc. 3. Laboratory services – this includes any lab service such as lab personnel, the cost of reagents and consumables, etc. 4. Supply chain management – this includes the cost of supply chain for drugs, lab supplies, or personnel time dedicated to supply chain management 5. Outreach programs (e.g. adherence, retention) – this includes the cost of personnel or expenditures for particular outreach programs 6. Training – this includes the cost of trainings which are not directly attributable to any other service delivery area 7. Monitoring & Evaluation (M&E) and Health Management Information Systems (HMIS) – this includes any personnel time or equipment related to reporting and/or data collection 8. Facility administration and management – this includes any cost to administer and manage a site (mainly personnel costs) 73 1.6 Cost Categories 1.6.1 Patient Numbers 19. Aggregate patient data was collected to determine the patient population, including, but not limited to, the number of patients on Pre-ART versus ART, the number of initiations per month, the number of patients on PMTCT, and attrition rates. Although this category does not contain specific cost information, it identifies the denominator required to calculate per patient per year costs. 20. The total number of ART patients was determined primarily from the MoH’s Quarterly Cohort Reports. Patient numbers were recorded quarterly; to convert this to monthly numbers, an assumed linear increase/decrease per month was applied between data points. The number of patient years was then calculated by summing the total patients per month and dividing by 12 months to get an average number of patients per year. In the Cohort Reports, all 1L patients were aggregated; therefore, an assumed ratio equal to the proportion of adult to pediatric initiations during the costing year was used to disaggregate patients into Adult and Pediatric 1L. Since this study took place prior to the implementation of a formal Pre-ART program, Pre-ART patient numbers were collected primarily through an estimated ratio of Pre-ART to ART patients seen per day/week/month by health facility staff. In rare instances, Pre-ART patient numbers were collected through an Electronic Medical Records (EMR) database on-site. 1.6.2 Personnel 21. Personnel data was collected from the site itself, from the administrative body which governed that site, or from MoH centrally. The information collected includes the number of direct and indirect10 FTEs (Full Time Equivalents) involved in clinical care for ART patients, rank and salaries of each individual, funder, top-ups provided by Non- Governmental Organizations (NGOs) or other parties, benefits additions, and percent of time dedicated to ART. 1.6.3 ARVs 22. The costs for ARVs include the costs associated with providing ARVs to patients, including the actual cost of drugs and supply chain costs associated with getting drugs from the supplier to Malawi (but not the local supply chain costs of getting ARVs all the way to the facility). Systems costs like supply chain management are captured in ARV costs as a percent allocation to the supply chain SDA, and were calculated in consultation with UNICEF, the procuring agent for the MoH. The unit cost for ARVs was based primarily on the Malawi Quantification and Supply Planning Document (2011) with additional unit costs from UNICEF and CHAI/UNITAID order trackers. 23. Total consumption for the costed year was calculated by examining initial stock of a given drug, adding the amount received per month during the year (and subtracting the amount that was shared with other facilities), and then subtracting the final stock 74 amount. These quantities were multiplied by unit cost per drug to calculate total cost, which was then allocated by patient type and divided by patient years to determine the PPPY cost for each patient type. In select cases where stock card data was considered to be unreliable, bottom-up calculations were done using the patient regimen breakdown to determine consumption. 24. Direct personnel includes: Doctors, Clinical Officers, Medical Assistants, Nurses, Nurse-Midwife Technicians, Counselors, Nutritionist, HSAs, Pharmacists, Lab staff. Indirect personnel includes: Data Capturers, Administrative Clerks, On-site facility-level management/ administration, Cleaners, Security, etc. This category does not include supervisory staff at the MoH or NGOs that are not based at the facility but may visit occasionally for supervision. 1.6.4 Laboratory 25. Laboratory costs include the cost of all lab tests done for pre-ART and ART patients, and exclude other laboratory costs such as personnel and equipment, which are accounted for under other cost categories. 26. This cost category includes tests done on-site as well as those done at external facilities. The unit cost of lab tests includes the cost of consumables and reagents, along with the associated supply chain costs and/or sample transportation costs (if applicable). The total number of tests conducted was obtained from lab records on site and at referral labs, where available, or derived from estimates of the number of patient referrals for external labs tests (predominantly for CD4 tests) which were not recorded on site. Where possible, these estimates were validated at the referral lab conducting the test. 1.6.5 Opportunistic Infections 27. This category covers the cost of all non-ARV drugs taken by ART and pre-ART patients at the ART clinic (OI drugs used in in-patient wards or provided in other facilities or wards were not covered). As with ARVs, this cost included the actual cost of drugs and supply chain costs associated with getting drugs from the supplier to Malawi, excluding local supply chain costs. Costs were then allocated across SDAs to isolate the total PPPY cost. 28. The costing methodology for Opportunistic Infections (OIs) is similar to that for ARVs except for one critical difference: drugs for OIs are not specific to pre-ART and ART patients and can be used to treat many diseases or illnesses affecting patients outside these programs. Therefore, the study team estimated the percent dispensed of each drug to ART and pre-ART patients relative to all patients at a site, based on data that was available at the site. 29. Total consumption for the costed year was calculated by examining initial stock of a given drug, adding the amount received during the year (and subtracting the amount that was shared with other facilities), and then subtracting the final stock amount. These 75 quantities were multiplied by unit cost per drug to calculate total cost which was then allocated by patient type and divided by patient years to determine the cost per patient per year for each patient type. 1.6.6 Nutrition 30. This category covers the cost of all nutrition supplements taken by pre-ART and ART patients. Unlike ARVs and OIs, this cost includes the actual cost of nutrition commodities and the local distribution costs associated with getting commodities to the facility. The costing methodology for nutrition is similar to that for OIs, as nutrition commodities are not specific to pre-ART and ART patients and can be used to treat other malnourished patients as well. Therefore, for each commodity the percent consumed by pre-ART and ART patients was estimated. 31. Total consumption for the costed year was calculated by looking at initial stock plus total receipts less final stock for nutrition commodities. These quantities were multiplied by unit cost per commodity to calculate total cost, which was then allocated by patient type and divided by patient years to determine the PPPY cost. 1.6.7 Investment costs 32. Building costs, equipment costs, training costs, and other running costs were calculated using the top down methodology; the total cost for each category was allocated to the facility, to HIV treatment, and then to patient category and SDA. These allocated costs were then divided by patient years to calculate PPPY cost. • Building costs included the cost of the building and any renovations that have been completed, amortized if relevant. • Equipment costs included all medical and non-medical equipment used specifically for pre-ART and ART services as well as shared equipment for the entire facility. It included heavy machinery such as vehicles, IT equipment such as computers and printers, and other small equipment and furniture that are either leased or owned. • Training costs included all in-service training activities held for ART staff either within or outside the facility. • Other Running Costs included utilities, non-clinical and clinical supplies, building maintenance, security, administration/systems, and other miscellaneous recurring costs. 1.7 Categories of descriptive data included 33. These characteristics provide information on the facility setting, administration, and operations in order to additional potential determinants of cost. Categories of descriptive data included: • Facility characteristics • ART service provision • Other HIV service provision (i.e. prevention, testing, etc.) 76 • Other health service provision • Patient population characteristics • Facility management and administration • Personnel management, oversight, and administration • Staff schedule, training, and task assignments • Drug management and supply chain • Laboratory systems • Treatment of opportunistic infections • General facility costs and operations 1.8 Assessing quality of care 1.8.1 Overview 34. In order to comprehensively understand the efficiency and effectiveness of funding spent on ART, it is necessary to evaluate not only the cost of providing treatment, but also the quality of care currently provided at that cost. Lower unit cost does not necessarily represent the most desirable outcome, and the quality of care must be carefully considered before making policy recommendations. 35. While data collection and allocations of costs are relatively unambiguous and more quantitative in nature, quality of care is more complicated to assess. This section outlines the approach used to assess quality of care within the scope of this study. 1.8.2 Approach 36. The most appropriate methodology for assessing quality of service and patient outcomes is a prospective cohort-based analysis, which follows patients over time and can assess the impact of policy options such as choice of drugs and frequency of testing. The most robust analysis adjusts the costs by calculating cost per QALY (Quality- Adjusted Life Years) over several years and takes socio-economic factors into consideration. 37. This analysis, by contrast, provides a retrospective snapshot in time and is focused on the facility level, assessing selected quality indictors across three categories: complexity, process/service, and patient outcome. This approach provides limited ability to assess the level of detailed patient data necessary to arrive at a robust analysis of patient outcomes and, by extension, quality of service. Instead, this analysis provides an indicative measure of quality that can be used to inform and help evaluate the cost data for each facility. Complexity Indicators 38. Complexity indicators capture the variations of incoming cases seen by different facilities, and include both clinical and non-clinical factors. These indicators include 77 uncontrollable factors that might drive the cost and/or outcomes regardless of the facility’s service provision. • Environmental Factors provide an assessment of the overall level of health within the catchment population for a specific facility. Examples of these factors include prevalence of TB or Malaria and inform the costing analysis with epidemiological wellness characteristics that could be expected in the patient population. • Characteristics at Initiation provide a baseline from which clinical progress can be measured. 39. Understanding the HIV disease progression for patients upon initiation of pre- ART and ART will provide a valuable starting point from which to monitor progress as a result of enrolling in the pre-ART or ART program. Examples of quality indicators include median CD4, WHO stage, and TB status at initiation. Process and Service Quality Indicators 40. These indicators capture the services and amenities provided to patients within a health facility. They provide a perspective on factors that impact quality of care both internal to a facility and external within the health system, and are likely to be correlated with improved patient outcomes over time, compensating for the limited ability to directly measure those within the context of this study. • Facility Characteristics provide context from which to measure the level of care available at a facility from the perspective of an observer. Examples of facility characteristics include degradation of infrastructure, availability of utilities such as water and electricity, and adequate space for patients. • Process indicators provide insight into how closely patient management follows protocol and best practice. On the whole, a facility that closely follows protocol is likely to have better outcomes than a facility that fails to provide components of pre-ART and ART. While indicators differ between sites, several indicators can be selected to provide a proxy for good service. Process indicators include adherence to minimum frequency of tests and doctor visits, availability of essential services like laboratory testing and adherence management programs, and sufficient time for clinical visits. • System Characteristics provide context regarding the robustness of the health system infrastructure supporting facility-based services. Examples of quality indicators include the number of pharmaceutical stock outs per year, the availability of sample transportation for lab tests, and the availability of reagents/consumables to perform lab tests. Patient Outcome Indicators 41. Patient Outcome Indicators monitor the progress that has been made as a result of enrollment in the pre-ART or ART program, taking into consideration appropriate complexity indicators. Although some of these indicators are difficult to quantify due to 78 data availability and quality, they are perhaps the most essential in determining the overall quality of care for a specific pre-ART and ART program. 42. Improvements in health must be captured along with the cost of care to allow for a thorough comparison across facilities. Examples of patient outcome indicators include median CD4 count after 12 months (where available), attrition (defaulted, stopped, died), transfers, and adherence (where possible). The patient outcome indicators were collected from a sample of patient charts and supplemented with information from central data management systems where necessary. The primary indicator and most robust indicator used for the descriptive analysis is patient retention in treatment at 12 months (patients alive and on ART). For new patient, the 12-month timeframe is measured from the ART initiation date, and for established patients, it is measured at the start of the costing period. 1.8.3 Patient Chart Sampling 43. Patient chart sampling was done at all 30 facilities costed in Malawi with 100 randomly selected charts at each facility – 50 new patients and 50 established patients. New patients were defined as those whose ART initiation date was within M-12, where M represents the starting month of the costing period. Established patients were defined as those starting ART prior to M-12 and who were considered alive and on ART on or after M+6. In addition to the definitions for these patient types, several inclusion and exclusion criteria were applied in order to capture data for patients who contributed to the cost observed at the facility, and to measure patient outcomes that corresponded to the costing time period. 44. Several patient characteristics relevant to case complexity and selected patient outcomes (i.e. retention and response at 12 months) were captured in the chart abstraction. This includes initiation criteria, CD4 and weight monitoring over time, regimen data, and adherence data where available. The team also documented the number of rejected charts based on the sampling criteria and documented the respective reason for rejection. The abstraction was done using an excel template not included here. 79 Annex 4. Bank Lending and Implementation Support/Supervision Processes (a) Task Team members Responsibility/ Names Title Unit Specialty Lending Supervision/ICR Modupe A. Adebowale Consultant AFTME Sylvester Kofi Awanyo Lead Procurement Specialist EASR2 AFTH1 - Alfred Sambirani Chirwa Population & Health Spec. HIS Simon B. Chenjerani Chirwa Senior Procurement Specialist AFTPE Fenwick M. Chitalu Financial Management Specialist AFTME Sheila Dutta Senior Health Specialist AFTHE AFTH1 - Peter A. Gaius-Obaseki Consultant HIS Tesfaalem Gebreiyesus Lead Procurement Specialist SARPS Ramesh Govindaraj Lead Health Specialist SASHN Mary Green Temporary AFTEE Wedex Ilunga Senior Procurement Specialist AFTPE AFTH1 - Susanne Kraemer Consultant HIS Stella Flora Seko Manda Consultant AFTSE Steven Maclean Mhone Procurement Specialist AFTPE Francis Kanyerere Financial Management Specialis AFTME Mkandawire Donald Herrings Mphande Sr Financial Management Specialist AFTME Homira G. Nassery Operations Officer HDNHE Elizabeth Ninan Human Development Specialist AFTEE Khama Odera Rogo Lead Health Specialist CICHE Gert Johannes Alwyn Van Lead Financial Management Spec AFTME Der Linde Christopher D. Walker Lead Specialist AFTHE (b) Staff Time and Cost Staff Time and Cost (Bank Budget Only) Stage of Project Cycle USD Thousands (including No. of staff weeks travel and consultant costs) Lending FY02 13 69.99 FY03 37 226.43 FY04 2 22.95 FY05 0.00 FY06 0.00 80 FY07 0.00 FY08 0.00 Total: 52 319.37 Supervision/ICR FY02 0.00 FY03 0.00 FY04 15 85.11 FY05 89 279.21 FY06 140 331.05 FY07 48 144.29 FY08 47 118.29 FY09 26 0.00 Total: 365 957.95 81 Annex 5. Beneficiary Survey Results Not done 82 Annex 6. Stakeholder Workshop Report and Results Not done. 83 Annex 7. Summary of Borrower's ICR EXECUTIVE SUMMARY PROJECT CONTEXT, DEVELOPMENT OBJECTIVES AND DESIGN 1. The Malawi Demographic and Health Survey (MDHS 2004) estimated HIV prevalence for adults (15-49 years) at 11.8% which slightly declined to 10.6% in 2010. The Multi-sectoral HIV/AIDS Project was designed around strategic frameworks that guide the Malawi national response. The original project development objective (PDO) was ‘to reduce the transmission of HIV, to improve the quality of life of those infected and affected by AIDS, and to mitigate the impact of HIV/AIDS in all sectors and at all levels of Malawian society’. This PDO was revised in the extended project and read ‘to increase access to prevention, treatment, and mitigation services, with a focus on behavioral change interventions and addressing the needs of highly vulnerable populations, including those affected and infected by the epidemic’. 2. The original Malawi Multi-Sectoral HIV/AIDS Project amounting to SDR 25.4 million (US$35.0 million equivalent) IDA grant was effective in February 2004 and closed in September 2009. The project was extended for a period of three years and ended in September 2012, with an additional funding of SDR 19.4 million (US$30 million equivalent) IDA grant for scaling up of activities under the original financing. The project supported a comprehensive range of prevention, treatment, and social support services and has focused on increasing and strengthening programmatic, as well as management capacity. 3. The MAP Project became part of the HIV AND AIDS Pool financing mechanism which the borrower operates through the National AIDS Commission. KEY FACTORS AFFECTING IMPLEMENTATION AND OUTCOMES 4. Factors that affected implementation between 2004 and 2009 included:  Limited capacity to implement programs;  Poor integration of HIV services and cross cutting issues such as gender, human rights and culture;  Limited coverage of HIV and AIDS service;  Funding gaps,  Limited knowledge and skills in Monitoring and Evaluation (M&E) 5. From 2009 to September 2012, implementation was particularly affected by:  Limited capacity for production of IEC materials targeting people with special needs as well as delays in finalizing procurement processes  Weak procurement and supply chain management  Inadequate access to Early Infant Diagnosis (EID) services  Inadequate CD4 count testing  Inadequate resources to implement impact mitigation 84  Non comprehensive mainstreaming of HIV and AIDS particularly in the informal sector and small and medium enterprises.  Delayed and erratic reporting by strategic partners ASSESSMENT OF OUTCOMES 6. The project has overall registered positive progress towards achieving its objectives and targets. HIV prevalence of adults (15-49 years) declined from 11.8% in 2004 to 10.6% in 2010 and so have new HIV infections, from about 80,000 in 2004 to about 60,000 in 2009, then further down to 34,000 in 2012. The project objectives and other indicators were achieved as summarized below: 7. Reduction in the transmission of HIV has been achieved through partner reduction, increased and consistent condom use as well as comprehensive knowledge to be able to correctly identify ways of preventing transmission among others. 8. Improve the quality of life of those infected and affected by HIV/AIDS as shown by the number of households with chronically ill persons receiving various kinds of support. Stigma and discrimination also reduced (although few isolated pockets still exists) evidenced by increased percentage of the population expressing accepting attitudes towards persons living with HIV/AIDS. 9. Mitigate the impact of HIV/AIDS in all sectors and all levels of Malawian society. The percentage of orphans and other vulnerable children (OVCs) to whom community support is provided has increased. Government has opened up to child fostering and is encouraging families to foster or even adopt OVCs. 10. Behavioral Change Communication/Information, Education and Communication (BCC/IEC) was implemented through production and distribution of both print and electronic communication products on various thematic areas of national response, complemented by interactive/interpersonal communication, theatre for development, video shows, radio listening clubs, community and social mobilization. 11. Interventions for young people such as Life Skills Education (LSE) for both in- school and out-of-school (including those physically challenged) young people were implemented in order to empower them to make informed decisions about sex and sexuality. The subject is now compulsory and examinable. 12. Condom distribution increased over the project period despite some PSM challenges. In 2011/2012, a total of 33.4 million condoms were distributed which is close to the estimated 36 million condoms required per annum for the sexually active population. 13. Gender, human rights, and culture issues have been mainstreamed into HIV and AIDS programs at national, district and community levels. 85 14. Innovative approaches in delivery of HIV Testing and Counseling (HTC) have been introduced. These include door to door testing, couple counseling and testing, moonlight testing, and mobile services. There has been steady increase in number of people tested despite frequent stock outs of test kits. 15. Prevention of Mother to Child Transmission (PMTC) service delivery has been scaled up and Government is implementing a new treatment policy where all pregnant and lactating women are put on ARVs. The aim is to eliminate transmission of HIV from mother to child and improve the general health status of HIV positive mothers. 16. The Anti-Retroviral Therapy (ART) program started towards the end of 2003 and since then both sites and people initiated on ART has increased. To date, 391,388 people are alive and on treatment, provided from 641 sites. The program has also maintained a relatively high 12 months survival rate of about 80% over the past years. The program has also strengthened management of TB/HIV co-infection by offering HIV testing to all TB clients and referring all HIV+ TB patients to treatment. 17. Treatment of Opportunistic Infections (OIs) such as Tuberculosis (TB), Kaposi’s sarcoma (KS), Esophageal Candidiasis (OC), and Cryptococcus Meningitis (CM) have always been challenged by drug stock outs. Government is continuously making efforts to address stock out issues by strengthening the procurement and supply chain management system including improvements in commodity forecasting and quantification. 18. Community Home Based Care (CHBC) initiatives have scaled down due to the scaling up and success on the ART program. 19. Support to Orphans and Vulnerable Children through education bursaries fluctuated due to decrease in financial resources for impact mitigation interventions. 20. The Social Cash Transfer Scheme was introduced in 2006 to economically empower the ultra-poor and reduce their vulnerability to HIV. It was first piloted in 1 district but eventually scaled up to 7 districts. Government is currently collaborating with partners to scale up the program to more districts under the Social Protection Policy. 21. Resource Mobilization and Utilization. The Government of Malawi and its Development Partners/Partners, including the World Bank, signed a Memorandum of Understanding (MOU) in 2003 and established a Pool Funding Mechanism to support the national response to HIV and AIDS in Malawi. The MOU enabled Government to mobilize significant financial resources for priority intervention areas. In 2004, Government, through NAC, established the grants facility as a mechanism to provide resources to grant recipient organization (GROs) in order to implement various interventions in the national response. The funds provided by NAC to GROs have steadily increased throughout the program period. 86 ASSESSMENT OF BANK AND BORROWER PERFORMANCE World Bank Performance Assessment 22. The World Bank (the Bank) is the first multi-lateral financial institution to mobilize significant resources for HIV and AIDS in Africa and participating in a countries’ Pooled Funding Mechanism. It has always been flexible with its resources in support of the implementation of the National HIV and AIDS Strategic Plan (NSP). 23. The World Bank is a member of the HIV and AIDS Pool as well as the HIV and AIDS Partner Group (HADG). The partners meet on a quarterly basis to share information about country assistance programs of the different agencies, experiences and concerns and reach consensus on decisions in their support to the NSP and implementation of the Integrated Annual Work Plan (IAWP). These meetings have, overall, improved transparency in the way the funding partners conduct their business. 24. The World Bank reviews and provides clearances on all International Competitive Bidding (ICB) procurement on behalf of Pool Funding Partners. Through both international and local teams, the Bank has always provided technical support to the borrower during development of the MAP and has also effectively contributed to the planning and monitoring of the national response. Borrower’s Performance Assessment 25. The borrower, among others, has established strong coordination mechanisms at all levels, developed strategic documents, established funding mechanism which have improved coordination in the funding, management and reviews of the national response. The borrower has also developed and continuously improved its systems and procedures in response to the lessons learned over time and the changing operating environment. LESSONS LEARNED 26. Some of the lessons learned include:  The need to establish NAC through an Act of Parliament so that it can effectively deliver on its mandate.  Substantial funding gap due to limited funding commitments has rendered the national response financially unsustainable.  Delayed disbursements for approved grants affected continued implementation of some critical interventions.  Weak Procurement and Supply Chain Management of health products has led to delayed procurements, frequent drug stock outs, as well as misappropriation/leakages.  Strengthening capacity of implementing agencies improves their ability to effectively plan, manage and deliver HIV and AIDS.  Coordination, linkages and integration of services amongst funding and implementing partners generates synergies that facilitate rapid scale up of programs 87 such as treatment. Furthermore, integration of services improves efficiency in service delivery. CONCLUSION 27. The overall HIV prevalence and number of new HIV infections has significantly reduced. Although the new HIV infections have reduced, the current levels are still unacceptably high. 28. Recently, the funding gap is increasing and this may erode the sustainability of the gains achieved, particularly from scaling up of the treatment program. Capacity development of implementing partners will continue to strengthen and maintain the knowledge and skills. 88 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders N/A 89 Annex 9. List of Supporting Documents � Malawi Multi-Sectoral HIV/AIDS Project’s PAD � Malawi Multi-Sectoral HIV/AIDS Project’s Financial Agreement � Malawi Multi-Sectoral HIV/AIDS Project’s Aide Memoires � Malawi Multi-Sectoral HIV/AIDS Project’s ISRs � Sustainable Financing for HIV/ AIDS in MALAWI (by Andrew Kardan, Tomas Lievens, Peter Ngoma, Ed Humphrey – Oxford Policy Management) � Multi-Country Analysis for HIV-AIDS Treatment Costs (MATCH) - 10 Oct 2012 (CHAI) � Key Findings from Resource Mapping - 10 Oct 2012 (CHAI) � Reports: The independent annual reviews of Malawi national response to HIV/AIDS � Mid-term review of the Malawi of the Malawi national HIV and AIDS framework (NAF) (February 2009) � National AIDS Commission: Strategic Management Plan (SMP): 2003-2008 � National Statistical Office. (2011). Malawi Demographic and health survey 2010 � National Statistical Office. (2004). Malawi Demographic and health survey 2004. � NAC: Biannual Financial Monitoring Reports � NAC: Annual technical Progress Narrative reports � NAC: Annual progress reports for the integrated HIV&AIDS annual work plan � Malawi (2010) National HIV and AIDS Prevention Strategy (2009-2013): NAC � Malawi (2009) Draft HIV and AIDS Extended National Action Framework (NAF) 2010-2012: NAC � GFATM (2011) Final Report for the Data Quality Audit for HIV and AIDS in Malawi � Malawi (2012) Final draft National HIV and AIDS strategic plan 2010-2016: NAC 90 IBRD 33440R1 32°E 34°E 36°E To To Song we Mbeya TANZA TA NZA NI NIAA Tunduma Chitipa MALAWI Karonga 10°S Chisenga 10°S To Muyombe Nykia Chilumba (2,606 m) Chelinda Mkondowe To Muyombe Livingstonia Katumbe Rumphi Ruarwe s. Kafukule Mzuzu Mtn Euthini Nkhata NORT HERN NORTHERN Bay ZAMBIA a Viphy Mzimba Chinteche (MALAWI) Lake Mala 12°S 12°S Luwawa To Lundazi Nkhunga wi Kaluluma Nkhotakota Kasungu MOZAMBIQUE Ntchisi C E N T R A L Dowa Makanjila Bua To Mchinji Chipata Salima 14°S LILONGWE 14°S Namitete Monkey Bay To To Cuamba Furancungo Dedza Mangochi To Ulongwe SOUTHERN To Cuamba Ntcheu Balaka MOZAMBIQUE 32°E Machinga ire Sh Lake Neno Chilwa MALAW I To Lirangwe Zomba Tete Mwanza Chiradzulu CITIES AND TOWNS Blantyre Phalombe DISTRICT CAPITALS* 16°S Chikwawa Mulanje Sapitwa 16°S (3,002 m) REGION CAPITALS Thyolo To NATIONAL CAPITAL Liciro N’gabu RIVERS To Morire MAIN ROADS RAILROADS Nsanje 0 20 40 60 80 100 Kilometers DISTRICT BOUNDARIES REGION BOUNDARIES This map was produced by the Map Design Unit of The World Bank. 0 20 40 60 Miles The boundaries, colors, denominations and any other information To INTERNATIONAL BOUNDARIES shown on this map do not imply, on the part of The World Bank Vila de Sena *District names are identical to the District Capitals. Group, any judgment on the legal status of any territory, or any endorsement or acceptance of such boundaries. 36°E MAY 2012