ICRR 13215 Report Number : ICRR13215 IEG ICR Review Independent Evaluation Group 1. Project Data: Date Posted : 02/22/2010 PROJ ID : P071371 Appraisal Actual Project Name : Multisectoral Hiv/aids US$M ): Project Costs (US$M): 36.00 42.99 Control And Orphans Project Country : Burundi Loan/ US$M): Loan /Credit (US$M): 36.00 42.99 Sector Board : HE Cofinancing (US$M): US$M ): Sector (s): Other social services (36%) Health (30%) General public administration sector (14%) Vocational training (10%) Primary education (10%) Theme (s): HIV/AIDS (23% - P) Social safety nets (22% - P) Participation and civic engagement (22% - P) Vulnerability assessment and monitoring (22% - P) Conflict prevention and post-conflict reconstruction (11% - S) L/C Number : C3684 Board Approval Date : 06/27/2002 Partners involved : Closing Date : 12/31/2006 11/30/2008 Evaluator : Panel Reviewer : Group Manager : Group : Judyth L. Twigg Kris Hallberg IEGSE ICR Reviews IEGSE 2. Project Objectives and Components: a. Objectives: As stated in the Development Credit Agreement (DCA), the project’s objectives were to assist the Borrower in (a) slowing the spread of HIV/AIDS in the Borrower’s population, and (ii) mitigating the impact of HIV/AIDS on persons infected with or affected by HIV /AIDS within the Borrower’s territory. b.Were the project objectives/key associated outcome targets revised during implementation? Yes If yes, did the Board approve the revised objectives /key associated outcome targets? No c. Components (or Key Conditions in the case of DPLs, as appropriate): The project had five components : 1. Public Sector Response (original, US $9.00 million; actual, US $16.55 million ), to expand HIV/AIDS activities implemented by public sector entities, including the preparation and execution of Action Plans . Measures to be taken included conducting meetings, festivals, and information, education, and communication (IEC) activities; promoting the use of condoms; expanding counseling as well as psychological and material support for people living with HIV/AIDS (PLWHA) and their families; improving early detection and treatment of opportunistic infections (OIs) and sexually transmitted infections (STIs); improving safe blood transfusions; controlling mother -to-child transmission; investing in skills training and revenue -generating activities for PLWHA and their families; reviewing and reforming relevant laws and regulations; and preparing gender -responsive, sector-specific communications plans. 2. Civil Society Response (original, US $13.00 million; actual, US $8.19 million ), to increase HIV/AIDS control activities initiated and implemented by grass -roots organizations and communities (as well as some initiatives of private sector enterprises ) in the areas of prevention, mitigation, and capacity building proposed in the National Strategic Plan. Measures to be taken included conducting meetings, festivals, and IEC activities; promoting the use of condoms; expanding counseling as well as psychological and material support for PLWHA and their families; improving early detection and treatment of OIs and STIs; improving safe blood transfusions; controlling mother-to-child transmission; investing in skills training and revenue -generating activities for PLWHA and their families; and providing home, community -based, and outpatient hospital care for PLWHA . 3. Orphans Integration and Education (original, US $7.00 million; actual, US $6.16 million ), to support the placement of orphans with their extended families, or with unrelated families; provide orphans with scholarships for primary education and vocational training; strengthen the economic and nutritional well -being of families that care for orphans through investments to supplement nutrition and income -generating activities; and provide training for the informal job market to older adolescent orphans . 4. Capacity Building for Program Design, Implementation, Monitoring and Evaluation (original, US $4.00 million; actual, US$ 5.93 million ), to reinforce the capacity of public and private agencies in the design, implementation, and monitoring of HIV/AIDS control activities. 5. Capacity Building for Project Management and Coordination (original, US $3.00 million; actual, US $6.16 million ), to ensure efficient coordination of the project ’s HIV/AIDS control activities by all concerned parties . d. Comments on Project Cost, Financing, Borrower Contribution, and Dates: In early 2004, three indicators were added to the 10 original key performance indicators (KPIs). Two new indicators were related to the number of persons receiving Voluntary Counseling and Testing (VCT) and antiretroviral treatment (ARV); at the start of the project, ARVs had been considered too costly to provide to people living with HIV /AIDS (PLWHA). The third new indicator was related to number of orphans placed in families . An amendment to the project dated March 4, 2005, increased the percentage of IDA financing to 100% of all categories of credit expenditures, in response to serious counterpart financing problems due to major deterioration in the country’s macroeconomic situation. The amendment required the Government to meet all current outstanding counterpart financing commitments and debt, which was subsequently done . The ICR presents seemingly contradictory information about counterpart financing; on p . 29, it indicates that the Borrower contributed US$ 0.70 million, but on other pages, it indicates that IDA financing covered 100% of project costs. Second and third amendments, dated March 30, 2006 and June 1, 2007, reallocated Credit proceeds, significantly increasing financing of grants for civil society organization (CSO) subprojects. These increases enabled the project ultimately to fund 564 of the 572 approved CSO subprojects by project ’s end. The total amount spent on the response of CSOs was significantly larger than the amount listed in Section 2c above, as US$ 3.50 million of the spending under Component 1 was for grants to CSO subprojects . Even taking this into account, the project spent more than anticipated on strengthening the public sector response and on project coordination, and less than anticipated on CSO activities. Ultimately, 27.2% of project funds were sent to civil society . The ICR does not explain these deviations from the original spending plans . The project’s closing date was extended after the mid -term review (MTR), after it became obvious that previous disbursement lags would make it impossible to fully expend the credit proceeds by the original closing date . Disbursement lags were primarily due to favorable SDR -dollar exchange rate fluctuations, increasing total Credit financing by 19%; the slow process of putting in place essential conditions for effective implementation including capacity building across the public sector and CSOs; and initially weak financial planning . 3. Relevance of Objectives & Design: Relevance of Objectives is rated Substantial . The project supported Burundi ’s Multisectoral HIV/AIDS Program and its underlying 2002-2006 National AIDS Strategic Plan. Combating the HIV/AIDS epidemic was designated as one of four strategic pillars of the country ’s 2006 Poverty Reduction Strategy paper, with attainment of the other three pillars largely dependent on slowing the epidemic and mitigating its effects . The objectives are also consistent with the 2008 Country Assistance Strategy, specifically with its objectives to improve access to social services and consolidate social stability. There are estimated to be 800,000 orphans currently in Burundi, with about 25% of those HIV/AIDS orphans. HIV/AIDS prevalence rates continue to be high in rural areas, where 90% of the population resides. Relevance of Design is rated Modest . The PAD contains a convincing results chain linking key activities to be financed by the project, output indicators, anticipated outcomes, and the project development objectives (although it is not clear that there was a mechanism in place to steer CSO subprojects /activities toward highest-priority interventions). The design process was highly participatory, with regular consultations and focus groups with key stakeholders. Other than institutional capacity constraints, risks were well identified and mitigation plans put in place . The relatively late integration of the component on social integration and education of orphans (done in mid-2001, when a previously separate orphans ’ project then under preparation was integrated ) presented substantial risks, as the project executing agency had no expertise or experience in the area of orphans . This risk was largely mitigated through the recruitment of appropriate personnel and review committees . The ICR states that project design and the national plan it supported were informed by a series of surveys and studies commissioned by the Government to better understand local attitudes and barriers to behavioral change, particularly among vulnerable groups (children, women, and youth). However, although the PAD identifies key high -risk groups such as sex workers, long -distance truck drivers, members of the armed forces, and displaced persons /refugees, it is not clear that there were interventions designed specifically to reach and benefit those groups . A national seroprevalence survey in 2007 found HIV prevalence to be lower in the general population than was thought at the time of project design, indicating that project activities related to prevention would have been appropriately focused on high risk groups (specifically displaced persons, with a prevalence rate of 4.46%, and female sex workers, with a prevalence rate of 38%). There are discrepancies in phrasing and target values for some indicators between the PAD and DCA, and appraisal baseline values were incorrect for some indicators (with no source found for the appraised data ). Because of the paucity of accurate HIV/AIDS data at the time of project preparation and appraisal, unrealistic targets were set for two of the core outcome indicators . For the two indicators related to orphans, there were no baseline data and therefore no solid basis for setting targets . 4. Achievement of Objectives (Efficacy): Given that Bank funds accounted for 80-90% of national program resources for HIV /AIDS until 2006, and for about 60% in 2007, it is reasonable to attribute observed outcomes to project activities . AIDS: Substantial Slowing the spread of HIV /AIDS: Outputs : The percentage of line ministries that incorporated HIV /AIDS prevention into their work plan and budgets increased from 20% in 2002 to 100% in 2008, against a target of 100%. However, according to the ICR, the quality and number of action plans and activities varied significantly across ministries, due in large part to the exodus of many highly qualified public sector staff to CSOs, external assistance agencies, and neighboring countries during the conflict . These plans, heavily focused on information, education, and communication, reached over 300,000 civil servants, their families, and sector constituents, with the vast majority (91%) of those beneficiaries reached through the ministries of education and defense . 564 CSOs were supported, against a target of 400, reaching over 760,000 beneficiaries. Subproject grant requests greatly exceeded original project expectations and targets . The majority of these projects, however, centered on mitigation rather than prevention (see below), with 13.5% of projects focusing on prevention among youth and 7.8% on prevention among the general population . Very few subprojects were targeted at prevention activities among other key vulnerable groups (only six projects focused on sex workers, one on road workers, and one on prisoners ). (The Summary of the Borrower’s ICR states that the project financed 163 subprojects for high-risk behavior groups, but it does not specify these .) The ICR also notes that it is impossible to determine from project documentation exactly what was effective and what was not in these subprojects . The number of prevention of mother -to-child transmission (PMCT) sites increased from 1 in 2002 to 63 in 2008, with 441 service providers trained, contributing directly to a ten -fold increase in the number of sero -positive women treated over this time period (from 145 in 2002 to 1,488 in 2008). Unmet needs for PMCT remain significant, however, with fewer than 8% of HIV-infected pregnant women covered by the close of the project . 4410 youth were trained a peer educators (over 30 for each of the 129 communes). 131 youth centers were created, covering all 129 communes, and 972 Stop SIDA clubs were started nationwide. However, girls 15 years of age and younger were found to be substantially underserved by these activities . Over 52 million condoms were distributed over the life of the project . Unspecified training in condom use was organized. 1,900 caregivers were trained in STI diagnosis and treatment, and 17 subprojects covering aspects of STI treatment were financed, benefiting 3,700 patients. A National Center for Blood Transfusion was built and equipped, and equipment was purchased for Regional Centers for Blood Transfusion. The quality and reliability of tests at blood transfusion centers was routinely monitored . The number of pouches of blood tested increased from 14,500 in 2002 to 20,250 in 2008. Outcomes : The percentage of 15-49-year-old who reported using a condom during their last contact with a non-regular partner increased from 12.7% in 2001 to 19.8% in 2007 (2001 and 2007 Behavioral Study Surveys). The percentage of girls 15 years old or younger who report being sexually active decreased from 32.5% in 2001 to 21.5% in 2007 (BSS). HIV prevalence among youth 15-24 years old decreased slightly, from 3.5% in 2001 to 3.1 in 2007. HIV prevalence among pregnant women ages 15-24 decreased from 5.11% in 2002 to 2.28% in 2007. The prevalence of syphilis among pregnant women ages 15-49 receiving prenatal care at sentinel sites declined from 2.39% in 2002 to 1.46% in 2007, and among pregnant women ages 15-24, decreased from 2.59% in 2002 to 1.81% in 2007. Mitigating the impact of HIV /AIDS on individuals and families : Substantial Outputs : The number of PLWHA under ARV treatment increased from 600 in 2002 to 14,343 in 2008, against a target of 12,500. 68 centers for ARV treatment were established, approximately 2,000 ARV treatment providers were trained, home-based care systems were developed, and drugs and medical equipment were supplied . The 43.7% ARV coverage rate attained in 2007 substantially exceeded the average 30% for the Sub-Saharan African region. The Ministry of Health (MOH) produced solid guidelines for treatment, certification of facilities and staff training, and projections of pharmaceutical needs . Deficiencies in the number of trained personnel, however, perpetuated inequities in access to quality HIV /AIDS care and services. The number of treated newborns of sero -positive mothers increased from 274 in 2002 to 1,299 in 2008, but coverage remained far below needs. The number of functioning VCT sites increased four –fold during the project period, from 64 in 2002 to 266 in 2008. Almost 3,000 persons were trained in counseling and testing . The number of persons receiving VCT annually increased from 31,000 in 2002 to over 236,000 in 2008, against a target of 50,000/year. The number of orphans receiving school support increased from 2,500 in 2002 to 163,000 in 2006. Access to education was provided by the project through 2006, when school support was assumed by UNICEF . Between school year 2002-2003 and 2004-2005 the number of orphans receiving primary school assistance increased from 5,200 to 19,600 in the three pilot provinces, representing in 2005 virtually all of the 19,800 orphans of primary school age in those three provinces at the time . Between school year 2002-2003 and 2004-2005 the number of orphans receiving secondary school assistance increased from 176 to 1,655. 2353 local committees to defend the rights of orphans and vulnerable children (OVC) were established. The number of orphans receiving medical care through the project increased from 25,000 in 2004 to 23,700 in 2008. The number of orphans receiving psychosocial counseling through the project increased from 1,500 in 2003 to 43,500 in 2008. CSO subprojects focused primarily on mitigation, with 34.2% of subprojects serving PLWHA (56,607 total beneficiaries) and 32.1% serving OVC (57,443 total beneficiaries). 131 communal committees to defend rights of PLWHA were established. 738 persons were trained in psychosocial care of PLWHA . Revenue-generating activities (RGA) were financed for poor PLWHA, with training provided for 446 members of RGA committees and 257 PLWHA benefiting from socioprofessional reintegration . 55 subprojects focused on the prevention, diagnosis, and treatment of OIs, with approximately 2,000 health providers trained in OI treatment, 500 persons trained in home-based care, and 131,000 total OI cases treated at public, private, and community facilities. Unspecified medication for OIs was purchased . Outcomes : The percentage of orphans placed with families who advanced from one grade of primary school to the next reached 65.1% in 2008, against a target of 80%, although the target was set for three pilot provinces, and the achievement represents extension of the orphans component to all 17 provinces. The rate of promotion of supported orphans in secondary schools increased from 60.2% in 2003-2003 to 83.4% in 2004-2005. According to the ICR, enrollment, rates of promotion, and non-drop-out rates among assisted orphans were better than those of their non -orphan peers in the three provinces: in 2004-2005, 98.8% of assisted orphans were enrolled in school, compared with 84.9% of their non-orphan peers; assisted orphans ’ rate of promotion in primary school was 80.7%, compared with 65.1-77.7% in the general school-age population; the dropout rate was 4.1% among orphans, compared with 3.5-5.4% among the general school-age population. The ICR also cites attainment of new vocational /technical competencies among older orphans attending project -supported workshops, improvements in the living conditions of orphans as a result of project-supported economic and food supports, and increased identification and resolution of cases of orphan exploitation and abuse, but exact data are not provided, other than one finding that the percentage of assisted orphans reporting having just one meal per day fell from 39.7% at the beginning of the project to 18.9% at project closing. A November 2008 evaluation of orphans component found that it produced a 58.8% increase in rate of school attendance among orphans who were beneficiaries of project -financed civil society subprojects; a 57.5% improvement in the health status of the orphan and family; a 55.5% improvement in behavior; a 49.7% increase in new knowledge; and a 23.8% increase in family revenues/income (the ICR does not define what is meant by each of these indicators). Over the life of the project, 1,672 orphans were placed in family or community homes, a small percentage of the estimated 77,000 children in-country who had lost both parents; the ICR states that the placement process moved exceptionally slowly. 5. Efficiency (not applicable to DPLs): The project developed an efficient three -phased strategy to assist public sector organizations in developing HIV/AIDS action plans. Only 2.3% of the total number of subprojects, representing 1.6% of total disbursements in this category, were rated at audit as poorly performing . This efficiency resulted from development of the financing code guiding grant applications, good accountability mechanisms including performance -based contracting, a decentralized financing model in which decentralized committees were provided with financing and the authority to approve and manage small grants to CSOs, and transparency of the entire process . Relatively low-cost, community-based models were used to deliver HIV /AIDS education and services . The project overcame significant initial risk by incorporating the previously -separate orphans project during preparation; those risks were managed through the orphans project ’s efficient harnessing of the strong HIV /AIDS project implementing agency institutional capacity. However, there were shortcomings in efficiency as well . The project spent substantial funds on prevention activities directly among the general population, but did not ensure that the highest -risk groups most likely to spread HIV were also adequately covered, reducing the efficiency of the program . Significantly more funds than initially planned were spent on project management and coordination . The use of one-year contracts for CSOs made it difficult for those organizations to project their annual funding streams and therefore to plan efficiently (although it should be noted that the one-year contract model did facilitate quality control over contracts ); the one-year contract model also led to relatively high transaction costs for both the civil society organization and the Government /local authorities in the preparation and review of annual proposals . The ICR provides no evidence of efforts to reduce these transaction costs or to increase the length of contracts while maintaining quality control standards . For these reasons, efficiency is rated modest . ERR )/Financial Rate of Return (FRR) a. If available, enter the Economic Rate of Return (ERR) FRR ) at appraisal and the re- re -estimated value at evaluation : Rate Available? Point Value Coverage/Scope* Appraisal % % ICR estimate % % * Refers to percent of total project cost for which ERR/FRR was calculated. 6. Outcome: The project's outcome is rated as Moderately Satisfactory . The project substantially achieved its development objectives, but there were moderate shortcomings in project design and efficiency . It is not clear from the ICR that there was appropriate attention in design and implementation to interventions designed specifically to reach high -risk groups such as sex workers, long -distance truck drivers, members of the armed forces, and displaced persons/refugees with preventive interventions . The ICR notes that it is impossible to determine from project documentation exactly what was effective and what was not effective in the community -based subprojects. Finally, important baseline data were either absent or inaccurate; project design did not pay sufficient attention to development of M&E activities and baseline data . a. Outcome Rating : Moderately Satisfactory 7. Rationale for Risk to Development Outcome Rating: Eight ministries key to the fight against HIV /AIDS have integrated a solid HIV/AIDS action plan, with budget, into their sectoral strategies. The project provided essential technical and financial support for accelerating the decentralization of activities, with Provincial Committees and Communal Committees operating in all 17 provinces and 129 communes. These decentralized entities provide an institutional base for full engagement of local authorities in HIV/AIDS activities. The Bank’s follow-on project, a Second HIV/AIDS Project, was effective on October 9, 2008, and this project appears to have learned significant lessons from the first, including the need to target prevention interventions at key high -risk groups (including young women and girls), target line ministries, and improve the M&E system. Furthermore, an extensive group of additional national and international partners has been mobilized to support the National HIV /AIDS Program (although it is acknowledged that funding is not a guarantee of sustainability). However, substantial political, security, and economic uncertainties still pervade the country, and substantial dependence on external aid increases vulnerability to the current global economic downturn . Despite the existence of a strong and experienced project management agency, the roles and responsibilities of the three major lead entities – the Permanent Executive Secretariat of the National AIDS Council (PES/NAC, the implementing agency for the project ), the Ministry of Health, and the Ministry of HIV /AIDS – are still not clearly determined. Even with many financiers involved, including the Global Fund, there is still a significant funding gap in supporting National Program activities, although this has had the positive effect of forcing prioritization and effective targeting of interventions. a. Risk to Development Outcome Rating : Moderate 8. Assessment of Bank Performance: at -Entry is rated Moderately Satisfactory . Project preparation was highly participatory . Ensuring Quality -at- The team successfully managed the risks associated with the integration of the orphans project . However, the preparation team seriously underestimated the high risks associated with capacity constraints at all levels, particularly shortages of qualified personnel . Project design did not pay sufficient attention to development of M&E activities and baseline data . Fast-track preparation did not allow sufficient time to prepare the ground for project execution prior to project launch . As a result, many preparation activities had to be finalized during the implementation period, creating inefficient disbursement lags in the initial years . Quality of Supervision is rated Moderately Unsatisfactory . The Bank team took full advantage of the opportunity presented by the 2006 mid-term review, initiating a strategic planning exercise and an institutional assessment, and correcting course in a number of important areas (notably financial management and M&E ). The Bank country office provided important and effective procurement support . However, four changes in task team leader (TTL) between preparation and project close created some lags in oversight . Project documentation was incomplete, with a 2006 Quality of Supervision Assessment (QSA) panel commenting on the vagueness in project documents concerning what “actually happened on the ground .� Implementation Status Reports (ISRs) did not always meet Bank standards for supervision reporting, with failure to flag some issues needing decisive action, replicated information with no explanation of missed deadlines, and reporting errors /omissions on key performance indicators. Incomplete or incorrect baseline data for several key indicators were not corrected during implementation. There was not adequate compliance with environmental safeguards . at -Entry :Moderately Satisfactory a. Ensuring Quality -at- b. Quality of Supervision :Moderately Unsatisfactory c. Overall Bank Performance :Moderately Satisfactory 9. Assessment of Borrower Performance: Government Performance is rated Moderately Unsatisfactory . There was exceptionally strong commitment to the National AIDS Program from the Office of the President and from some, but not all, line ministries . Some line ministries were unwilling fully to commit staff and resources to the National AIDS Program . With primary responsibility for the National AIDS Program largely centered at the PES /NAC, some partner organizations have suggested that the Ministry of Health assumed, detrimentally, that was not accountable for the Program . As the project neared closure, the Government put in place institutional changes that made it difficult to clarify the roles and responsibilities of various ministers and vice ministers in many areas, including health and HIV /AIDS. Implementing Agency Performance is rated Moderately Satisfactory . The National AIDS Council is described as a mature, strong, autonomous, multi -sectoral, highly decentralized entity to guide and coordinate National Program activities. The PES/NAC has become a well-reputed institution, staffed by highly qualified professionals. It was proactive in identifying implementation problems and coordinating closely with the Bank team to recalibrate the project plan of action when needed . It quickly identified capacity constraints in the public and private sector, early in implementation, and put in place an effective plan to scale up activities more gradually than initially planned in order to strengthen that capacity . Procurement proceeded smoothly throughout the project, with PES/NAC helping to build capacity across diverse line ministries and CSOs involved in pharmaceutical and medical supplies procurement . NAC Provincial Committees played a major role in ensuring satisfactory technical execution, appropriate accounting, and timely and effective monitoring and reporting of CSO grants. Financial management was uneven, however, with the PAS /NAC financial team failing to submit four quarterly financial management reports in 2004-2005; following mid-term, defects were corrected, resulting in satisfactory financial management and reporting through project closure . Turnover and gaps in PES/NAC top leadership was occasionally disruptive to project implementation, and may have accounted for some of the problems with financial management. a. Government Performance :Moderately Unsatisfactory b. Implementing Agency Performance :Moderately Satisfactory c. Overall Borrower Performance :Moderately Satisfactory 10. M&E Design, Implementation, & Utilization: M&E Design : Modest . The M&E system was highly decentralized, with a multisectoral M&E team established in 2006 in each of the 17 provinces to enhance local data collection and analysis . While such decentralization is desirable in principle, in practice it led in this instance to inefficient parallel collection points and duplication of data . The indicators identified to monitor progress toward the development objectives were adequate, given knowledge available at the time of appraisal, although baseline data were of uneven quality . M&E Implementation : Modest . The challenges of establishing a reliable and responsive M&E system were not fully recognized in project design . Following mid-term review, improvements were made, with partner organizations trained in data management and analysis and more standardized data collection tools put in place . These improvements allowed PES/NAC to prepare and disseminate widely quarterly M&E reports . However, shortcomings remained: there were parallel data collection points and duplication of data; the use of multiple data collection instruments complicated data entry and management; reports from many MOH health centers and hospitals were incomplete; baseline data remained incomplete or inaccurate . M&E Utilization : Substantial . Data from the M&E system have been used extensively for strategy definition, policy orientation, and resource mobilization, shaping the national 2007-2001 strategy, improving ARV needs forecasting, and preparing applications for additional external support . However, the system was not effectively used as a day-to-day management tool for the National AIDS Program; only in the last year was M&E data used actively to redirect investment to underserved areas and hot spots . a. M&E Quality Rating : Modest 11. Other Issues (Safeguards, Fiduciary, Unintended Positive and Negative Impacts): Safeguards : The Development Credit Agreement stipulated that the Borrower prepare, within three months of project effectiveness, a medical waste management plan . The Government encountered difficulties, however, in implementing the plan, and procedures for collection, disposal, and management of medical waste posed some health and environmental risks . Lack of progress in this area was not flagged to management until three years into implementation. Under increased monitoring, by 2007 selected health staff has been trained on appropriate disposal of medical waste, and the MOH had developed guidelines and norms for health facilities . Overall, according to the ICR, the difficulties in executing the medical waste management plan stemmed more from post -conflict capacity limitations than from lack of commitment by the Borrower . Unintended Positive Impact : Strengthened CSO capacity in planning, management, and M&E of HIV /AIDS project had spillover effects, with many CSOs now routinely generating strategic plans, annual work plans, and monitoring indicators. 12. 12. Ratings : ICR IEG Review Reason for Disagreement /Comments Outcome : Moderately Moderately Satisfactory Satisfactory Risk to Development Significant Moderate Institutional development, effective Outcome : decentralization, and learning from past experience may provide a basis for managing the impact of the current global economic downturn. Bank Performance : Moderately Moderately Satisfactory Satisfactory Borrower Performance : Moderately Moderately Satisfactory Satisfactory Quality of ICR : Exemplary NOTES: NOTES - When insufficient information is provided by the Bank for IEG to arrive at a clear rating, IEG will downgrade the relevant ratings as warranted beginning July 1, 2006. - The "Reason for Disagreement/Comments" column could cross-reference other sections of the ICR Review, as appropriate . 13. Lessons: Adoption of a fast -track preparatory process has hidden costs that cannot be discounted . The extensive efforts needed over the first few years of the project period to complete core inputs required for project execution significantly slowed implementation, and ultimately contributed to the need to extend the closing date by almost two years. Careful investments in specification of and training on procedures can realize high returns . In this case, careful preparation of procedural manuals, a financing code, detailed application and evaluation forms for selecting CSO grants, use of performance-based contracts, and training of decentralized committees encouraged efficiency and imbued a strong sense of accountability for results . Projects need to be sufficiently flexible to accommodate changes in information regarding the epidemic profile (or in the epidemic itself ). In this case, initial (and incorrect) baseline data suggested that the epidemic was generalized, so the project was designed accordingly (general population-oriented mass IEC, VCT, and condom distribution). It was later found that HIV/AIDS in Burundi was heavily concentrated in select population groups and geographic areas. In such a case, evidence -based interventions, targeted and tailored to those at highest risk, are the most efficient and effective way to reduce transmission . Related to the previous point, extreme care must be taken to ensure that baseline data exist and are verified, and that the suggested methodology for obtaining data over time to track progress is feasible and cost -effective. Similarly, baseline data must be adjusted quickly if new, more reliable data sources become available, and indicators/targets must be amended as well. 14. Assessment Recommended? Yes No 15. Comments on Quality of ICR: The ICR pays careful attention to likely causal linkages between key activities financing by the project and observed outcomes, and to attribution of observed outcomes to the Bank -financed project. It addresses well the problems with HIV prevalence as a performance indicator . The ICR also explains thoroughly the instances in which project data are incomplete or contradictory . a.Quality of ICR Rating : Exemplary