Document of The World Bank Report No: ICR00002903 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-43360, IDA-48410) ON A CREDIT IN THE AMOUNT OF SDR 87.9 MILLION (US$ 135 MILLION EQUIVALENT) TO THE REPUBLIC OF KENYA FOR A TOTAL WAR AGAINST HIV AND AIDS (TOWA) PROJECT March 31, 2015 Health, Nutrition and Population Global Practice Eastern Africa 2 Africa Region. CURRENCY EQUIVALENTS Exchange Rate Effective March 12, 2008 Currency Unit = Kenya Shilling US$ 1.00 = Ksh70 Exchange Rate Effective May 30, 2011 Currency Unit = Kenya Shilling US$ 1.00 = Ksh86 FISCAL YEAR January 1-December 31 ABBREVIATIONS AND ACRONYMS ACU AIDS Control Unit AIDS Acquired Immune Deficiency Syndrome ARV Anti-Retroviral Drugs ARCAN African Regional Capacity Building Project for HIV and AIDS Prevention, Care &Treatment ATG ARCAN Training Of Trainers Graduate BCC Behavior Change Communication BCE Behavior Change Education CACC Constituency AIDS Control Committees CAS Country Assistance Strategy CBO Community Based Organization CfP Call for Proposal COBPAR Community Based Programme Activity Reporting Tool CSW Commercial Sex Worker DDC District Development Committee DFID Department for International Development DIR Detailed Implementation Review DTC District Technical Committees ERS Economic Recovery Strategy FMA Financial Management Agency FSW Female Sex Worker GAP Governance Action Plan GFATM Global Fund to Fight HIV and AIDS, TB and Malaria HBC Home Based Care i HBTC Home Based Counselling and Testing HCBC Home and community Based Care HIV Human Immuno-deficiency Virus HTC HIV Testing and Counselling ICR Implementation Completion Results Report ICC Inter-Agency Coordinating Committee IDA International Development Association IDU Injecting Drug User IEC Information Education and Communication IFC International Finance Corporation IGAs Income Generating Activities IMF International Monetary Fund IP Indigenous People IP-ERS Investment Program for the Economic Recovery Strategy INT World Bank’s Department of Institutional Integrity ISR Implementation Status Results Report JAPR Joint Annual HIV and AIDS Programme Review JICA Japan International Corporation Agency KAIS Kenya AIDS Indicator Survey KACC Kenya Anti-Corruption Commission KASF Kenya AIDS Strategic Framework KDHS Kenya Demographic Health Surveillance KEMSA Kenya Medical supplies Agency KHADREP Kenya HIV and AIDS Disaster Response KNAO Kenya National Audit Office KNASP Kenya National AIDS Strategic Plan LLITNs Long Lasting Insecticide Treated Bed Nets MARPs Most At Risk Populations MCG Monitoring and Coordination Group M&E Monitoring and Evaluation MIS Management Information System MSM Men who have Sex with Men MTEF Medium Term Expenditure Frameworks MTR Mid Term Review MSW Male Sex Worker NACC National AIDS Control Council NASA National AIDS Spending Assessment NASCOP National AIDS and STI Control Programme NGO Non-Government Organization NSP Needle Syringe Programs ODSS Organizational Development and Systems Strengthening OPMC Oversight and Performance Monitoring Committee OVC Orphans and Vulnerable Children OST Opioid Substitution Therapy PAD Project Appraisal Document ii PDO Project Development Objective PEPFAR President’s Emergency Plan for AIDS Relief PLHIV People Living with HIV and AIDS PLWHA People Living with HIV/AIDS PMTCT Prevention of Mother To Child Transmission PRGF Poverty Reduction and Growth Facility PRSP Poverty Reduction Strategy Paper PSI Project Sub Implementer PwD Person with a Disability RBM Results-Based Management system RFA Regional Facilitating Agency RRI Rapid Results Initiative SDR Special Drawing Rights STI Sexually transmitted infection TOWA Total War Against HIV and AIDS UNAIDS United Nations Programme on HIV and AIDS UNFPA United Nations Population Fund UNICEF United Nations Children's Fund VCT Voluntary Counselling and Testing VMMC Voluntary Male Medical Circumcision WHO World Health Organization Vice President: Makhtar Diop Country Director: Diarietou Gaye HNP Senior Global Practice Director: Timothy G. Evans HNP Global Practice Director: Olusoji O. Adeyi Practice Manager: Abdo Yazbeck Project Team Leader: Wacuka W. Ikua ICR Team Leader: Wacuka W. Ikua ICR Primary Author: Musonda Rosemary Sunkutu iii REPUBLIC OF KENYA Total War Against HIV and AIDS (TOWA) Project CONTENTS ABBREVIATIONS AND ACRONYMS....................................................................................................................... I DATA SHEET ...................................................................................................................................................... VI B. KEY DATES ..................................................................................................................................................... VI C. RATINGS SUMMARY ...................................................................................................................................... VI D. SECTOR AND THEME CODES ......................................................................................................................... VII E. BANK STAFF .................................................................................................................................................. VII F. RESULTS FRAMEWORK ANALYSIS ................................................................................................................ VIII G. RATINGS OF PROJECT PERFORMANCE IN ISRS .............................................................................................. XII H. RESTRUCTURING (IF ANY) ............................................................................................................................ XII I. DISBURSEMENT PROFILE ............................................................................................................................. XIII 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 ........ 3 1.4 MAIN BENEFICIARIES............................................................................................................................................. 3 1.5 ORIGINAL COMPONENTS........................................................................................................................................ 4 1.6 REVISED COMPONENTS.......................................................................................................................................... 6 1.7 OTHER SIGNIFICANT CHANGES ................................................................................................................................ 6 2. KEY FACTORS AFFECTING IMPLEMENTATION AND OUTCOMES ...................................................................... 9 2.1 PROJECT PREPARATION, DESIGN AND QUALITY AT ENTRY ............................................................................................. 9 2.2 IMPLEMENTATION .............................................................................................................................................. 12 2.3 MONITORING AND EVALUATION (M&E) DESIGN, IMPLEMENTATION AND UTILIZATION ................................................... 14 2.4 SAFEGUARD AND FIDUCIARY COMPLIANCE............................................................................................................... 16 2.5 POST-COMPLETION OPERATION/NEXT PHASE ...................................................................................................... 17 3. ASSESSMENT OF OUTCOMES ........................................................................................................................ 18 3.1 RELEVANCE OF OBJECTIVES, DESIGN AND IMPLEMENTATION - RATING: HIGH ................................................................. 18 3.2 ACHIEVEMENT OF PROJECT DEVELOPMENT OBJECTIVES (EFFICACY).............................................................................. 19 3.3 EFFICIENCY ........................................................................................................................................................ 29 3.4 JUSTIFICATION OF OVERALL OUTCOME RATING ........................................................................................................ 31 3.5 OVERARCHING THEMES, OTHER OUTCOMES AND IMPACTS ........................................................................................ 32 3.6 SUMMARY OF FINDINGS OF BENEFICIARY SURVEY AND/OR STAKEHOLDER WORKSHOPS ................................................... 33 4. ASSESSMENT OF RISK TO DEVELOPMENT OUTCOME.................................................................................... 34 5. ASSESSMENT OF BANK AND BORROWER PERFORMANCE ............................................................................ 35 iv 5.1 BANK PERFORMANCE .......................................................................................................................................... 35 5.2 BORROWER PERFORMANCE .................................................................................................................................. 36 6. LESSONS LEARNED .................................................................................................................................. 37 7. COMMENTS ON ISSUES RAISED BY BORROWER/IMPLEMENTING AGENCIES/PARTNERS .............................. 39 ANNEX 1. PROJECT COSTS AND FINANCING...................................................................................................... 40 ANNEX 2. OUTPUTS BY COMPONENT ............................................................................................................... 41 TABLE 2A: KEY OUTPUT ACHIEVEMENTS ...................................................................................................................... 42 TABLE 2B: ORIGINAL PROJECT DEVELOPMENT OBJECTIVE................................................................................................ 45 TABLE 2C: REVISED DEVELOPMENT OBJECTIVES - OUTPUTS .............................................................................................. 49 TABLE 2D................................................................................................................................................................ 60 TABLE 2E: OUTCOMES BY REVISED PROJECT DEVELOPMENT OBJECTIVE ............................................................................. 65 ANNEX 3. BANK LENDING AND IMPLEMENTATION SUPPORT/SUPERVISION PROCESSES ................................. 71 ANNEX 4. BENEFICIARY SURVEY RESULTS ......................................................................................................... 73 ANNEX 5. STAKEHOLDER WORKSHOP REPORT AND RESULTS........................................................................... 85 ANNEX 6. SUMMARY OF BORROWER'S ICR AND/OR COMMENTS ON DRAFT ICR ............................................ 98 ANNEX 7. COMMENTS OF CO-FINANCIERS AND OTHER PARTNERS/STAKEHOLDERS ...................................... 107 ANNEX 8. LIST OF SUPPORTING DOCUMENTS ................................................................................................ 108 MAP ............................................................................................................................................................... 109 v DATA SHEET A. Basic Information Total War Against HIV Country: Kenya Project Name: and AIDS (TOWA) Project Project ID: P081712 L/C/TF Number(s): IDA-43360,IDA-48410 ICR Date: 03/31/2015 ICR Type: Core ICR GOVERNMENT OF Lending Instrument: SIL Borrower: KENYA Original Total XDR 52.90M Disbursed Amount: XDR 87.28M Commitment: Revised Amount: XDR 87.9M Environmental Category: B Implementing Agencies: National AIDS Control Council Cofinanciers and Other External Partners: B. Key Dates Revised / Actual Process Date Process Original Date Date(s) Concept Review: 02/08/2005 Effectiveness: 03/12/2008 03/12/2008 11/18/2010 Appraisal: 10/17/2005 Restructuring(s): 03/14/2013 12/04/2013 Approval: 06/26/2007 Mid-term Review: 09/21/2009 09/21/2009 Closing: 12/31/2011 06/30/2014 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Satisfactory Risk to Development Outcome: Substantial 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: Moderately Satisfactory Implementing Quality of Supervision: Satisfactory Satisfactory Agency/Agencies: vi 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 No None at any time (Yes/No): (QEA): Problem Project at any Quality of Supervision Yes None time (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 24 30 Health 35 67 Other social services 35 Sub-national government administration 6 3 Theme Code (as % of total Bank financing) HIV/AIDS 33 25 Health system performance 17 27 Other public sector governance 17 2 Participation and civic engagement 17 40 Social Inclusion 16 6 E. Bank Staff Positions At ICR At Approval Vice President: Makhtar Diop Obiageli Katryn Ezekwesili Country Director: Diarietou Gaye Colin Bruce Practice Manager/Manager: Abdo S. Yazbeck Dzingai B. Mutumbuka Project Team Leader: Wachuka W. Ikua Michael Mills ICR Team Leader: Wachuka W. Ikua ICR Primary Author: Musonda Rosemary Sunkutu vii F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The Project development objective is to assist Kenya to expand the coverage of targeted HIV and AIDS prevention and mitigation interventions. This would be done through: (i) sustaining the improved institutional performance of the National AIDS Control Council (NACC); and (ii) supporting the implementation of the Kenya National AIDS Strategic Plan (KNASP). Revised Project Development Objectives (as approved by original approving authority) The Project Development Objectives are to: (a) expand the coverage of targeted HIV and AIDS prevention and mitigation measures; and (b) expand access to bed nets among targeted People Living with HIV and AIDS and other households in malaria risk areas. (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 Proportion of recipients of subproject grants scoring "Very Good" or "Excellent" for Indicator 1 : target achievement in the annual performance audit during the year [New]. Value 89.9% quantitative or N/A 80% (IPA Report 2014) Qualitative) Date achieved 03/12/2008 06/30/2013 06/30/2014 Comments (incl. % Achieved: The target was exceeded with an achievements rate of 112 %. achievement) Number (cumulative) of civil society/private sector grants supported by the end of the Indicator 2 : year [Revised]. Value 10,712 quantitative or 0 8,400 8,400 (TOWA FMA Qualitative) reports) Date achieved 03/12/2008 12/31/2011 06/30/2013 06/30/2014 Comments Achieved: The target was exceeded with an achievement rate of 128 %. The target was (incl. % reduced in 08/2010 to 4,000, and later increased by 4,400 back to the original 8,400 achievement) with additional financing. Proportion of sexually active youth 15- 24 who report having had sex with a non- Indicator 3 : spousal, non-regular partner in the past 12 months [Continued]. Value F=30%, M=84% (KDHS Results for KDHS quantitative or 2003) F=20%, M=70%, 2014 not yet Qualitative) available Date achieved 03/12/2008 12/31/2011 06/30/2013 06/30/2014 Comments (incl. % KDHS 2014 data not available. achievement) Indicator 4 : Proportion of youth aged 15-24 reporting condom use in the last sexual viii encounter with a non-regular partner (of those reporting sexual intercourse with a non- regular partner in the last 12 months) [Continued]. F=24 %, M=47 %, (KDHS KDHS 2014 data not Value 2003) available. F=55 %, quantitative or F=40%, M=60 % M=75%% Qualitative) F=26%, M=29% (KAIS F=67%, M=58% 2007) (KAIS 2012) Date achieved 03/12/2008 12/31/2011 06/30/2013 06/30/2014 Comments KDHS 2014 data not available. Proxy indicator from KAIS 2007 and 2012:Condom use (incl. % at first sex among women and men aged 15–24 years increased by 41 percentage points achievement) in females and 29 percentage points in males between 2007 and 2012 Percentage of households in malaria endemic areas in the districts supported by the Indicator 5 : TOWA Project that have at least one ITN [New]. Value 81.2 % quantitative or 27.6% 80% (KAIS 2012) Qualitative) Date achieved 03/12/2008 06/30/2013 06/30/2014 Comments (incl. % Added at restructuring to assess new PDO. Achieved, exceeded target by 102% achievement) Number of individuals provided with counseling and testing services (through TOWA) Indicator 6 : in the past 12 months [New] Value 5,559,540 quantitative or 0 172,045 (TOWA FMA Qualitative) Technical Reports) Date achieved 03/12/2008 06/30/2013 06/30/2014 Comments Achieved: Substantially exceeded the target with an achievement rate of more than (incl. % 3000%. achievement) Indicator 7 : Number of individuals with access to an ITN [New: Core beneficiary sector indictor] Value 5.25 million quantitative or N/A 5.1 million (Bed Net distribution Qualitative) Reports) Date achieved 03/12/2008 06/30/2013 06/30/2014 Comments Achieved: Exceeded the target with an achievement rate of 103%. A total of 5,250,000 (incl. % individuals were reached (500,000 PLHIVs assuming one PLHIV per net distributed achievement) and 4,750,000 through mass distribution, assuming 2 persons per net distributed). Number of youth reached with HIV prevention messages [New: Core beneficiary sector Indicator 8 : indictor] Value 4,880,278 quantitative or N/A 348,232 (TOWA FMA Qualitative) Technical Reports) Date achieved 03/12/2008 06/30/2013 06/30/2014 Comments Achieved: Exceeded the target with an achievement rate of 1400%. The high annual (incl. % achievements were maintained throughout the life of the project. achievement) Number of HIV+ clients provided with palliative care [New: Core beneficiary sector Indicator 9 : indictor] ix Value 10,574 quantitative or N/A 3,483 (TOWA FMA Qualitative) Technical Reports) Date achieved 03/12/2008 06/30/2013 06/30/2014 Comments (incl. % Achieved: The target was exceeded with an achievement rate 303%. 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 : Level of Stakeholder satisfaction with NACC [Continued]. 87 % Value (NACC Customer (quantitative 70% 78% 75% satisfaction survey or Qualitative) 2013) Date achieved 03/12/2008 12/31/2011 06/30/2013 06/30/2014 Comments Achieved: Exceeded both the original and revised targets with achievement rates of (incl. % 112% and 116% respectively. achievement) Issues in NACC's qualified report to be addressed by end of March of the following Indicator 2 : year [Revised] Value Yes (quantitative N/A Yes Yes (KENAO Audit or Qualitative) reports) Date achieved 03/12/2008 12/31/2011 06/30/2013 06/30/2014 Comments Achieved: Although NACC received qualified audit reports, all issues raised were (incl. % addressed satisfactorily within the targeted timeline. achievement) The proportion of KNASP M&E indicators included in the annual M&E report, Indicator 3 : disseminated and available on time for the JAPR [Continued]. Value 96% (quantitative 55% 95% 85 % (NACC M&E or Qualitative) reports) Date achieved 03/12/2008 12/31/2011 06/30/2013 06/30/2014 Comments Achieved: Exceeded both the original and revised targets with achievement rates of (incl. % 101% and 113% respectively. achievement) Proportion of registered CBOs reporting through COBPAR at the time of the JAPR Indicator 4 : (Continued). 100% [target is Value 5000 per 103 % (5163) (quantitative 65.8% 90% quarter as [NACC M&E or Qualitative) defined in Reports] revised PIM) x Date achieved 03/12/2008 12/31/2011 06/30/2013 06/30/2014 Comments Exceeded higher revised target as defined in Revised Project Implementation Manual (incl. % (103%) achievement) Number of persons who undergo testing and counseling in the last 12 months. Indicator 5 : (National, from NASCOP) [Revised]. 6.365 million Value (Global AIDs (quantitative 949,250 950,000 4.5 million Response Progress or Qualitative) Report) Date achieved 03/12/2008 12/31/2011 06/30/2013 06/30/2014 Comments Achieved: Achievement rates of 670% of the original target and 141% of the revised (incl. % target. achievement) Number of couples counseled and tested under the TOWA project up to the end of the Indicator 6 : reporting year [New]. Value 983,166 (quantitative N/A 6,305 (TOWA FMA or Qualitative) Technical Report) Date achieved 03/12/2008 06/30/2013 06/30/2014 Comments Achieved; actual number of couples tested was 156 times the original target; this (incl. % became a much higher priority than at appraisal. Target was unrealistic. achievement) Indicator 7 : Number of youth reached with BCE messages in the past 12 months [New]. Value 4,880,278 (quantitative N/A 348,232 (TOWA FMA or Qualitative) Technical Report) Date achieved 03/12/2008 03/30/2013 06/30/2014 Comments Achieved: Exceeded the original target with an achievement rate 1400%. The high (incl. % annual achievements were maintained throughout the life of the project. achievement) Number of HIV+ individuals provided with Home-Based Care (Palliative care) through Indicator 8 : the TOWA interventions in the past 12 months [New]. Value 10,574 (quantitative N/A 3,483 (FMA Technical or Qualitative) Report) Date achieved 03/12/2008 11/18/2010 06/30/2014 Comments (incl. % Achieved: Exceeded the original target with an achievement rate of 300% achievement) Number of male and female condoms distributed in the last 12 months (national, from Indicator 9 : NASCOP) [Revised]. 322 million (National Value AIDS Program (quantitative 144 million 168 million 150 million procurement and or Qualitative) Distribution Reports) Date achieved 03/12/2008 12/31/2011 06/30/2013 06/30/2014 xi Comments Achieved: Doubled baseline level; exceeded original target by 192% and revised target (incl. % by 215%. achievement) Number of long lasting insecticide treated malaria nets purchased and/or distributed Indicator 10 : [New]. 2,875,000 (TOWA Value Bed Net procurement (quantitative 0 2.8 million and Distribution or Qualitative) Report) Date achieved 03/12/2008 06/30/2013 06/30/2014 Comments (incl. % Achieved: Exceeded target with an achievement rate 103% achievement) G. Ratings of Project Performance in ISRs Date ISR Actual Disbursements No. DO IP Archived (USD millions) 1 12/20/2007 Satisfactory Satisfactory 0.00 2 05/30/2008 Satisfactory Satisfactory 0.00 3 08/29/2008 Satisfactory Satisfactory 19.25 4 12/23/2008 Moderately Satisfactory Moderately Satisfactory 19.25 5 03/16/2009 Moderately Unsatisfactory Moderately Unsatisfactory 19.25 6 11/04/2009 Moderately Satisfactory Moderately Satisfactory 19.76 7 06/14/2010 Satisfactory Satisfactory 46.85 8 06/29/2011 Satisfactory Satisfactory 82.11 9 01/03/2012 Satisfactory Satisfactory 94.38 10 07/11/2012 Moderately Satisfactory Moderately Satisfactory 104.61 11 01/03/2013 Moderately Satisfactory Moderately Satisfactory 116.80 12 10/05/2013 Moderately Satisfactory Moderately Satisfactory 134.03 13 04/13/2014 Satisfactory Satisfactory 132.54 14 06/21/2014 Satisfactory Satisfactory 132.54 H. Restructuring (if any) ISR Ratings at Amount Board Restructuring Restructuring Disbursed at Reason for Restructuring & Key Approved PDO Date(s) Restructuring Changes Made Change DO IP in USD millions Additional financing, reallocation of funds for purchase of ITNs and essential commodities and 11/18/2010 Y S S 52.85 continued fiduciary and M&E strengthening; revision of PDO and targets; extend closing date by 18 months. xii ISR Ratings at Amount Board Restructuring Restructuring Disbursed at Reason for Restructuring & Key Approved PDO Date(s) Restructuring Changes Made Change DO IP in USD millions Extend closing date from June 30, 2013 to December 31, 2013 to allow for full implementation of activities by CSOs; implement 03/14/2013 N MS MS 118.55 actions for specific needs of IPs and revise the PIM; complete the delayed IE; and to reallocate resources. Extend the closing date from December 31, 2013 to June 30, 12/04/2013 N MS MS 134.03 2014 to allow full use of funds for project activities, and to reallocate funds. If PDO and/or Key Outcome Targets were formally revised (approved by the original approving body) enter ratings below: Outcome Ratings Against Original PDO/Targets Satisfactory Against Formally Revised PDO/Targets Satisfactory Overall (weighted) rating Satisfactory I. Disbursement Profile xiii 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal Economic Development and Poverty 1. When the project was prepared, the Kenyan economy was growing at around 6 percent annually. Macro-economic reforms were being carried out, but structural reforms remained incomplete. The Government prepared an Economic Recovery Strategy (ERS) for Wealth and Employment Creation, reached an agreement with the International Monetary Fund (IMF) on a Poverty Reduction and Growth Facility (PRGF) program, moved to improve relationships with donors, and developed new strategies for socioeconomic development 1. 2. Income inequality was high with regional income disparities. About 56 percent of households were estimated to be below the poverty line in 2003. The AIDS epidemic contributed significantly to the poverty and desperation of many Kenyans, with over 1.4 million people infected with HIV (including 156,000 children), about 200 new infections daily among adults and slightly over 100,000 deaths annually. Governance and Anti-Corruption 3. Available evidence at the time suggested that corruption had declined, but was still apparent especially in the process of obtaining permits and tax evasion. There was deterioration in the judiciary and in the administration of government procurement. The Government set ambitious goals for governance improvement, adopted some important measures, and made progress in reforming public resources and administration. However, progress in implementing the governance strengthening program and in achieving results was mixed. 4. Parts of the World Bank portfolio, including the HIV and AIDS Program, were faced with significant governance problems. A series of reviews and special audits conducted since 2004 identified a range of problems including weaknesses in financial management systems; lack of fraud risk management; weak oversight by senior Government officials; inconsistent application of the World Bank’s Procurement Guidelines; and failure to share lessons learned and best practices. The 2006 Detailed Implementation Reviews (DIRs) also confirmed corruption risks in Bank-funded operations although the risks differed across sectors. HIV and AIDS Epidemic and Response 5. The HIV epidemic in Kenya was heterogeneous and still a massive threat. Among adolescents and adults aged 15 to 64, HIV prevalence was estimated at 7.1 percent 1 During the 1990’s Kenya’s economic performance was weak and real per capita income contracted by an average of 0.5 percent annually. 1 representing 1.4 million people. Women were more likely to be infected (8.4 percent) than men (5.4 percent). Most new infections were in young people, with girls most at risk. In the 15 to 24 years age group, women were four times more likely to be infected (5.6 percent) than men (1.4 percent). 6. The impact of HIV and AIDS on the economy was devastating and the epidemic remained the greatest development challenge that Kenya has faced. In 2005, it was estimated that the GDP was 14.5 percent lower than it would have been without AIDS. At the household level, the impact was profound with 36 percent of children from HIV- affected households dropping out of school, compared to 25 percent from non-HIV- affected households; and health expenditure was 75 percent higher in households with HIV-related illnesses. 7. The heterogeneity of the epidemic demanded that higher priority be given to several key drivers of the epidemic: (a) increased targeting of priority activities for youth, especially young women; (b) addressing issues of poverty; (c) gender inequality, gender- based and sexual violence; (d) stigma and discrimination; (e) injection safety in health care settings; and (f) targeting significantly higher risk activities and populations, notably:(i) sex work, both commercial and transactional in nature; (ii) HIV transmission within marriages or ‘regular/stable’ partnerships; (iii) intergenerational sex involving younger women and older men, along with casual sex and concurrent sexual partnerships; (iv) injecting drug use, combined with effects of alcohol abuse; and (v) men-having-sex-with- men (MSM). 8. The Government, together with a wide range of stakeholders, developed the second Kenya National HIV and AIDS Strategic Plan (KNASP II) for the period 2005/06 to 2009/10. The objectives were to reduce the spread of HIV, improve the quality of life of those infected and affected, and mitigate the socio-economic impact of the epidemic. 1.2 Original Project Development Objectives (PDO) and Key Indicators 9. The PDO was to assist Kenya to expand the coverage of targeted HIV and AIDS prevention and mitigation interventions. This would be done through: (a) sustaining the improved institutional performance of the National Aids Control Council (NACC); and (b) supporting the implementation of the KNASP. 10. The Key Performance Indicators (KPIs) were: (a) NACC composite score on the annual independent performance evaluation; (b) Proportion of overall targets met for NACC-funded programs in civil society/private sector and public sector beneficiaries; (c) Five key outcome indicators for prevention and mitigation namely: (i) Proportion of youth aged 15 to 24 years reporting condom use in the last sexual encounter with a non-regular partner; (ii) Proportion of sexually active youth 15 to 24 years who report having had sex with a non-spousal, non-regular partner in the past 12 months; (iii) Number of persons who undergo testing and counseling; (iv) Orphans and Vulnerable Children (OVC) receiving care/support in the past 12 months; and (v) Number of male and female condoms distributed. 2 1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification 11. The Revised PDO was to: (a) expand the coverage of targeted HIV and AIDS prevention and mitigation measures; and (b) expand access to bed nets among targeted People Living with HIV and AIDS and other households in malaria risk areas. 12. The revised KPIs were: (a) Proportion of recipients of subproject grants scoring “Very Good” or “Excellent” for target achievement in the annual performance audit during the year; (b) Number (cumulative) of civil society/private sector grants supported by the end of the year; (c) Proportion of youth aged 15-24 reporting condom use in the last sexual encounter with a non-regular partner (of those reporting sexual intercourse with a non- regular partner in the last 12 months); (d) Proportion of sexually active youth 15- 24 who report having had sex with a non-spousal, non-regular partner in the past 12 months; (e) Percentage of households in malaria endemic areas in the districts supported by the TOWA Project that have at least one Insecticide treated (ITN); and (f) Number of individuals provided with counseling and testing services (through TOWA) in the past 12 months, and three core beneficiary indicators: (i) Number of individuals with access to an ITN; (ii) Number of youth reached with HIV prevention messages; and (iii) Number of HIV+ clients provided with palliative care. 13. The PDO and KPIs were revised during the (adaptive) restructuring that provided additional financing, approved by the Board on November 18, 2010. The revised PDO reflected the increased focus on providing bed nets to prevent malaria. Following a global study (that included Kenya) that showed the impact of mass distribution of long lasting insecticide treated nets (LLITNs) on the morbidity and mortality on women and children, the Government of Kenya responded through a policy of Universal Coverage of LLITNs in high malaria endemic areas. The TOWA project was restructured to support the scale up of LLITNs in high risk areas of the country. The original funding of US$4 million for procurement of 500,000 LLITNs for PLHIV was increased to US24 million to procure a total of 2.8 million LLITNs and expand the beneficiary group to include women and children through mass distribution of bed nets. In addition, KPIs were revised to (i) clarify definitions of some key indicators, especially success criteria for grants under the Call for Proposals (CfPs); (ii) adjust some targets upwards in light of additional financing and early project results; and (iii) extend the closing date by 18 months to facilitate the achievement of the revised targets and the planned impact evaluation. 1.4 Main Beneficiaries 14. (a) Populations at high risk of contracting and transmitting HIV and for whom preventive services were at the time very limited--commercial sex workers (CSWs), MSM, intravenous drug users (IDUs), the disabled, prisoners, highly mobile populations such as truck drivers and migrant workers, and sero-discordant couples -- would benefit from expanded access to preventive services enabling them to reduce their risk of HIV infection. (b) Targeting priority activities with largest impact in preventing HIV would benefit youth especially girls; women including widows; workers in small and medium enterprises and micro enterprises and the informal sector; and people exposed to sexual violence. (c) Provision of mitigating interventions to OVCs and people living with HIV and AIDS 3 (PLWHA) would enable children to stay in school, provide additional income and improve nutrition and other aspects of well-being. (d) Systems and capacity were to be strengthened to enable improved performance in agencies responsible for providing or supporting HIV services: (i) the NACC and its decentralized structures: the Constituency AIDS Control Committees (CACCs) and the District Technical Committees (DTCs); (ii) selected public sector ministries and departments (listed in paragraph 23); (iii) Civil Society Organizations; (iv) Research institutions and University. 1.5 Original Components 15. The project had two key components: (1) Strengthening NACC’s role in governance and coordination; and (2) Continuing support for program implementation. Component 1: Strengthening Governance and Coordination Capacity (US$29.8 million; US$19.7 million) 2: 16. The component provided support to strengthen the NACC for managing and implementing the long-run response to HIV in Kenya, and to enhance capacity to use resources from all sources effectively for results. There were four sub-components: 17. Sub-Component (1a): Strategic Leadership (US$I3.4 million; US$8.1million): support for: (i) regular strategic reviews of the KNASP -- primarily the Joint Annual Programme Review (JAPR) and the mid-term review of the Program; (ii) sustain Program operations through providing operating costs of Constituency AIDS Control Committees (CACCs), District Technical Committees (DTCs) and NACC Field Officers; (iii) limited minor works to ensure an efficient operating environment; (iv) institutional capacity building of NACC, mainly training for staff, technical committees, and the NACC board and its committees; (v) advisory support and technical assistance for NACC to prioritize, strengthen and focus Program targeting to be more strategic and selective; and (vi) strategic communications including information education and communication (IEC), mass media, etc. supporting the NACC Program. 18. Sub Component (1b): Accountability and Verification (US$8.5 million; US$6.0million): to procure independent consulting firms for five tasks: (i) Financial Management Agency (FMA) to manage financial aspects of grants made under the Project; (ii) compliance verification agency (CVA) to check compliance of grant proposals with the terms and conditions of the CfP for grants; (iii) Performance Auditor, to verify that grants are used for the purpose intended, combining technical audit and financial audit (value for money); (iv) Procurement Management Agency (PMA) to monitor procurement by the NACC; and (v) external Financial Auditors. 19. Sub Component (1c): Information-based Management (US$4.9 million; US$3.5million): Activities to improve the local evidence base for decision making 2 The cost figures relate to: (i) the combined IDA, DFID (expected) and Government financing, excluding the contingency amount; and (ii) the IDA allocation alone, again excluding the unallocated contingency amount. 4 through: (i) developing the Management Information System (MIS); (ii) further strengthening the M&E system and reporting; and (iii) operational research. 20. Sub Component (1d): Capacity Building of Implementing Partners (US$3.0 million; US$2.1 million): to strengthen grant performance by: (i) provision of technical support to community-level grantees (capacity building and facilitation); (ii) networking and facilitation at regional level for needs assessment, coordination, and the public-private sector interface; and (iii) for coordination of processes such as responding to CfPs, participating in the JAPR, strengthening monitoring and reporting, social accountability, and public disclosure. Component 2: Support for Program Implementation (US$81 million; US$57.3 million) 21. This component made financial resources available to civil society, and public sector, private sector and research institutions, for initiatives within the KNASP, and for procurement of essential commodities. The component had three sub-components: 22. Sub-component (2a): Grant Awards (US$53 million; US$37.5 million): grants to civil society and the private sector, for result-based proposals and activities in areas and for populations prioritized within the KNASP framework and identified in annual JAPRs. Proposals were assessed and selected on the basis of their expected results, using a set of clear rules and criteria. 23. Sub-component (2b): Mainstreaming Public Sector Programs (US$8 million; US$5.7 million): for mainstreaming HIV in the public sector, within the priority areas in the KNASP. The funds were expected to amplify interventions planned by the targeted ministries in their own Medium Term Expenditure Frameworks (MTEFs), Budgets and Annual Plans of Operations and not to fund separate projects or work-plans. As indicated in the KNASP, key public sectors important in the fight against HIV and AIDS were targeted. The initial public sectors targeted were: Transport, Agriculture (including cooperatives, livestock and fisheries), Health, Education (including Teachers Service Commission, Commission of Higher Education and Ministry of Science and Technology), Governance (Judiciary, Ministry of Justice and Constitutional Affairs, Attorney General, Kenya Police, and Police Administration); and Directorate of Personnel Management. The list of priority sectors would be examined during each JAPR and revised based on the priorities identified. The Project would also support the African Regional Capacity Building Project for HIV and AIDS Prevention, Care &Treatment (ARCAN) follow-up activities to train 813 ARCAN Trainer Graduates and help achieve cascading training between 2006 -2009. 24. Sub-component (2c): Essential Commodities (US$20 million; US$14.7 million): procurement and distribution of selected malaria and TB commodities essential to the fight against HIV and AIDS for which there were funding gaps: (i) US$12 million for condom procurement; (ii) US$4 million toward procurement of first line TB drugs; and (iii) US$4 million toward procurement of ITN for free distribution among PLWHA in malaria zones; and (iv) if necessary, small amounts of other commodities such as test kits, laboratory equipment and reagents on a highly limited basis. 5 1.6 Revised Components 25. The components remained the same. The only change in the project components was to rename the subcomponents as thematic areas, and change the name of the original sub-component 1c to Evidence Based Management. 1.7 Other Significant Changes Amendments to the TOWA Project Financing Agreement (FA) 26. The FA was amended to adjust the project to the delayed availability and cancelling of planned DFID co-financing, and to allow for rapid procurement of additional bed nets (Table 1). Table 1: Amendments to the TOWA Project SN Date Amendment Comments August To increase the share of expenditures covered by IDA, IDA contribution was increased to cover the original 2008: from 71 percent to 100 percent until June 30, 2009, and UK Department for International Development reduce the IDA percentage back to 42 percent from July (DFID) planned allocation in year-1 and year-2 with 1, 2009 to June 30, 2010. the expectation that the IDA share would drop back when DFID funding became available in year-3 August, To maintain the disbursement rate at 100 percent until This amendment was made for the percentage of 2009 June 30, 2010, with IDA funding then planned to be just expenditures covered by IDA to be maintained at 31 percent from July 1, 2010 to June 30, 2011 (and 71 100 percent until June 30, 2010, as DFID support percent thereafter). The co-financing deadline for the had not been forthcoming in FY09. DFID financing was also moved to July 31, 2010. August, To effect an increase in the procurement prior This amendment was part of a country-wide change 2009 review threshold for the TOWA project in procurement review thresholds and fiduciary parameters. August To: (a) increase the disbursement percentage from 31 This amendment was to recognize that DFID would 2010: percent to 100 percent in FY11; (b) Reallocate Project not be co-financing the Project, and to make funds principally to allow for urgent procurement of additional funds available for procurement of additional bed nets; and (c) remove the dated covenant on urgently needed bed nets for the malaria program. the DFID Co-financing Agreement. Changes in Project Cost and Financing 27. The project cost at appraisal was US$115 million and the actual project cost was US$135 million. The project was originally financed by an IDA credit of SDR 52.9 million (US$80 million), 70 percent of the original cost with joint funding expected from DFID (US$33 million) and US$2 million from Government. The Additional Financing request of US$55 million approved in November 2010 provided for: US$33 million to “replace” the planned co-financing DFID had been unable to provide; an additional US$10 million to scale up the malaria bed net program 3; and $12 million to facilitate achievement of the revised targets, including the full implementation of grants under the fourth and fifth CfP (Tables 2 and 3). 3 For a total provision under the TOWA of US$24 million 6 Table 2: Additional Financing Cost breakdown Activity Extra financing (US$ million Additional call for proposals – Grants 23.2 Malaria Program (Bed nets, Distribution and Other Activities) 9.5 Other Commodities including Clearing and Distribution Costs (Condoms, TB drugs) 6.7 Strategic Leadership 6.5 Fiduciary Accountability 4.8 Other Programmatic Expenditure and M&E 4.3 TOTAL 55 Table 3: Additional Costs by Component – IDA Financing Component Original Cost Additional Financing Revised Cost (after restructuring) US$M US$M US$M Governance and Coordination 21.8 16.6 38.4 capacity Strengthening Program Implementation 58.2 38.4 96.6 TOTAL 80 55 135 28. The allocation of proceeds was modified twice during the project (see Table 4 below): Table 4: The allocation of proceeds under the project. CHANGES IN THE ALLOCATION OF PROCEEDS DURING THE PROJECT Category Amended and Original Additional Additional Percentages Restated financing Financing Financing of Original current re- (Expressed current re- Expenditure Financing allocation in SDR) allocation to be (Expressed in request request Financed SDR) (Expressed in (Expressed in SDR) SDR) 1. Goods (except as covered by category 3) 17,900,000 18,157,000 4,990,000 6,625,000 100% 2. Works (except as covered by Category 3) 530,000 163,000 17,000 109,000 100% 3. Goods, Works or services financed by Subproject Grants 24,600,000 24,897,000 22,093,000 19,779,000 100% 4. Consultants services & audits 7,200,000 6,578,000 2,680,000 3,606,000 100% 5. Training and Workshops 700,000 860,000 900,000 437,000 100% 6. Incremental Operating Costs a) NACC 1,970,000 1,657,000 2,640,000 3,134,000 100% b) KEMSA Operating Costs - 588,000 1,680,000 1,310,000 100% TOTAL AMOUNT 52,900,000 52,900,000 35,000,000 35,000,000 7 Project Restructuring 29. The first (level 2) restructuring 4 was done at the same time as the fourth Amendment of the Financing Agreement, approved by the Country Director in August 2010. The restructuring: (i) reallocated funds to continue to enable the increased disbursement percentage from IDA to adjust for planned DFIF co-financing not becoming available, and (ii) enabled the urgent purchase of additional bed nets (amounting to US$10 million) for the malaria program. 30. The second (level-1) restructuring 5 was for the additional financing credit for the Project approved on November 18, 2010 by the Board. The additional financing of US$55 million was to: (i) make up for the US$33 million funds from DFID, which was not going to be available as co-financing, to fund the fourth and fifth CfPs; (ii) allocate another US$10 million (bringing the total provision under the TOWA to US$24 million) to scale up the malaria bed net program and help attain universal coverage of bed nets in the high malaria risk areas of the country (Table 2); (iii) support the project restructuring and restore some of the funding, especially for commodities, that had been reallocated (mainly to bed nets) in August 2010; (iv) respond to the triggering of the safeguards policy for IP; (v) allow for completion of the planned IE that was delayed and to enable data on population- level performance indicators to be obtained from the planned AIDS and malaria indicator surveys; (vi) extend the Project for another 18 months, particularly to continue fiduciary and M&E strengthening, and to achieve the revised PDO and increased KPI targets (see para 12). Table 5: Additional Financing – Additional Outputs Indicator Original Target Restructured Incremental output Revised project Target with additional Target (August 2010) financing Number of Grants carried 8,400 4,000 4,400 8,400 out through CBOs/NGOs Number of bed nets 500,000 1,700,000 1,100,000 2,800,000 procured 4 Level -2 restructuring approved by the RVP applies to cumulative extensions of closing date of two years or more; Policy exceptions/waivers (on a case by case basis) OR Level -2 restructuring approved by Country Director applies to all other project modifications other than Level 1 and Level 2(RVP approved). These include changes such as: changes in outcome indicators or targets; modifications in project scope or design; addition or cancellation of project activities or components; changes from a safeguards category C to B; reallocation of proceeds and/or cancellation of funds; changes in executing units or currency denominations, implementation plans or schedules; New action plans to bring a poorly performing project back on track; new reporting requirements (or other adjustments to improve implementation); Extension of new loan/credit/grant closing dates; New implementation dates that under terms of the legal agreement may be put into effect by notice. 5 Level-1 restructuring- Approved by the Board applies to modifications in a project’s Development Objectives (DOs) or changes in the safeguard category—from a lesser category set in the Project Appraisal Document (PAD) to a Category A, or trigger of a new safeguard policy. Level One restructurings are submitted to the Board of Executive Directors for approval under absence of objection (AOB) procedures. 8 31. The third restructuring (level 2) was approved on March 14, 2013 by the Country Director to extend the closing date from June 30, 2013 to December 31, 2013 to allow for: (i) full implementation without compromising quality of activities by CSOs who had already been contracted; (ii) implementation of actions to address specific needs of Indigenous People (IPs) and revision of the project implementation manual to address the needs of IPs as the normal call for proposals was unlikely to meet the needs of this special group; (iii) completion of the Impact Evaluation (IE) that was delayed due to longer than envisaged time to contract the survey firms. The IE was expected to provide valuable lessons on innovative approaches for HIV and AIDS prevention; (iv) reallocation of resources to activities needing additional funds and to ensure utilization of the remaining Credit. The development objectives and targets of the project remained the same. 32. The fourth restructuring (level 2) on, December 4, 2013 approved by the Country Director, was to extend the closing date from December 31, 2013 to June 30, 2014 to enable: (i) final completion of project activities at an advanced stage, delayed when the Government introduced changes in the financial system in keeping with the new constitution that resulted in substantial delays in getting funds to the project; (ii) reallocation of funds to enable full utilization of the remaining Credit, redirecting resources to activities needing additional funds, including procurement of additional condoms for an amount of US$2 million to avert a national stock-out while Government organizes long term procurement with the Global Fund. 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry 33. The project was prepared in two years from 2005 to 2007, reasonable given the scope, and need to address carefully various audit issues raised and for thorough preparation especially on issues of systems and fiduciary measures. Results from a thorough analysis of the governance and anti-corruption situation in the country, governance of the national HIV and AIDS program and of other World Bank projects and programs were incorporated into project design 6. Care was taken to ensure that the TOWA project design responded to the governance challenges encountered under KHADREP including the weak structural issues under the NACC. 34. The preparation was grounded in extensive country analysis. Careful analysis of the epidemiology and burden of HIV and AIDS in Kenya guided the focus. Project design also benefited from studies of the shortcomings and strengths of national HIV programs (including IEG’s 2005 review), and the best available and respected scientific evidence and technical advice, knowledge and expertise on HIV and AIDS within the Government of Kenya, the United Nations (UN) Joint Team on HIV and AIDS, and the World Bank. The project design followed the requirements and criteria for repeater project under the Multi- 6 Including recommendations from efficiency monitoring unit (EMU) of the Office of the President following an , investigative review of the NACC; results from an independent Forensic Audit of the KHADREP; and Detailed Implementation Review (DIR) conducted by the World Bank Department of Institutional Integrity (INT) confirmed the earlier findings of the Government’s own investigations and the Forensic Audit, that the KHADREP Project had “strong indicators that were consistent with potential fraud, corruption and collusion. 9 Country HIV and AIDS Program (MAP) for Africa, which had evolved to be more prioritized than the original MAP. 35. Steps were taken to complement plans for further governance strengthening measures, as part of the design work for the TOWA Project; notably the enhanced processes, systems and control measures for program coordination, public sector and civil society programs, Monitoring and Evaluation, management and governance 7. There was clear evidence that the NACC was committed to carrying out governance reforms and monitoring and evaluation strategies that would make the TOWA Project a success story for Kenya 8. 36. Board approval was delayed by 20 months because of the post-election issues that the country was dealing with. 37. The project was aligned with: Kenya’s strategy for economic growth with poverty reduction as defined in the Investment Program for the Economic Recovery Strategy (IP- ERS) for Wealth and Employment Creation; the Poverty Reduction Strategy Paper (PRSP); and World Bank development assistance strategies for Kenya. The design reflected the focus of the CAS of May 2004 and findings from the CAS Progress Report of March 2007 that reaffirmed World Bank commitment to support the fight against HIV and AIDS. The 2010 additional financing was consistent with the Country Partnership Strategy (CPS) for 2010-2013 which identified investing in human development as one of its basic priorities, and aimed at achieving more inclusive growth and reducing inequality and social exclusion. 38. Rationale for Bank Involvement: The World Bank’s extensive experience in supporting national HIV programs and strong commitment to harmonization and alignment was greatly valued. The TOWA Project was expected to: (a) continue to support further institutional strengthening and governance improvements in the NACC; (b) fill important gaps in the financing of the KNASP; (c) contribute to the harmonization and alignment agenda in Kenya through enhanced partnership among the World Bank, DFID and UN System in support of the KNASP; and continue to support NACC’s coordination of all HIV and AIDS stakeholders in Kenya within the framework of KNASP and an annual JAPR process. 7 Most notable among the many lessons and recommendations distilled and incorporated in the project design were: (a) A results-oriented and performance-based award mechanism for grants; (b) Limiting participation of community-based organizations to those with established track records of performance; (c) Introduction of transparent decision making processes with full disclosure of information; and (d) Recruitment of independent Fiduciary Agents (as listed in paragraph 16). Responsibility for project coordination and management was placed in the NACC. 8 Development of Governance Action Plan and the risk management matrix; adoption of risk management policy; introduction of performance contracts and wealth declarations; capacity building program in NACC, creation of the Internal Audit Division, M&E strengthening and CACC training. 10 Assessment of Project Design 39. The project was well designed, with appropriate objectives and indicators (given the available data) and a results framework that established clear links from activities to some coverage outcomes. While the PDO committed the project to expand the coverage of targeted HIV and AIDS prevention and mitigation measures, the indicators measuring the coverage of most key interventions especially for most at risk populations were limited with the exception of coverage data for the youth 15-24 years. At the time of project preparation and restructuring for additional financing, data on MARPs was not available. This was a major bottleneck to effective targeting and programming for MARPs. A MARP size estimation consensus report was only produced in 2013 that provided population size estimates and coverage baseline data for some identified indicators for MARPs. The project used output data to monitor provision of services to key populations, tracking the number of people in various MARP groups reached, but estimating MARP total population sizes (and hence coverage levels) remains a challenge due to the private nature of sexual activity and criminalization of MARP-related activities. 40. The design responded to three main challenges facing Kenya’s HIV response -- the need for: (i) further governance strengthening and enhanced strategic leadership by the NACC; (ii) increased targeting and focus on results; and (iii) improved harmonization and alignment among development partners. The design included robust institutional strengthening to address the challenges and weakness that had dogged the KHADREP project. Strategic review and adjustment each year through the JAPR process would contribute strongly to (ii) and (iii), enable better “learning-by-doing,” and ensure a strong participatory and community-focused approach, noted to be a strength of the Bank’s response to HIV in Africa. Strategic allocation of funds primarily to lower levels was informed by previous experience, which had shown the comparative advantage of reaching out to the community level, because it ensured wider geographical coverage to target beneficiaries in more effective and efficient ways. The project performance and monitoring indicators were derived from the results and monitoring framework of the KNASP. Extensions of the project enabled most targets to be met and exceeded; the few that were dramatically over-achieved appear to have been poorly set, and should have been revised. 41. The Government of Kenya’s commitment on HIV was demonstrated before and during project preparation. The Government had declared HIV and AIDS a national disaster in 1999, and established the NACC to coordinate a multi-sectoral national response. The National HIV Response has been guided by a series of national strategic plans starting with the Kenya National HIV and AIDS Strategic Plan of 2000 to 2005 (KNASP I). The TOWA project was designed as an integral part of the implementation of the Kenya National HIV and AIDS Strategic Plan II and III focussing on HIV prevention and mitigation measures at the community level and through public sector mainstreaming. Commitment and ownership was demonstrated in a letter of policy support for the TOWA project issued by the Finance Minister on April 12, 2007, confirming the Government’s commitment to transparency and accountability and enhancing governance and fighting corruption in Kenya. 42. Kenya was perceived as a high risk environment. The Project Appraisal Document (PAD) and Project Paper gave a candid and realistic assessment of project risks. Project 11 planning sought to mitigate the governance risks experienced under the KHADREP. The main risks identified were: (a) Failure of partners and the Government to effectively coordinate their support for the KNASP and the National Malaria Strategy; (b) Weak institutional capacities of implementing agencies, especially at the district, constituency and community levels, that could adversely impact PDO achievement; and (c) Vulnerability to fraud and corruption especially in contract award and management and decentralized procurement. The mitigation measures as stated were appropriate. Quality at Entry 43. There was no formal Quality at Entry assessment by the Quality Assurance Group (QAG). 2.2 Implementation 44. Initial delays were due to the time needed to recruit the fiduciary strengthening consultants, the post-election violence in early 2008 and slow procurement of essential commodities. Despite the slow start and challenging period in the early years of the project, overall, project implementation and progress towards the PDO was satisfactory for much of the project life, except for mainstreaming HIV in public sector programs, and delays in carrying out the audits of the grants. Project management and oversight improved significantly over time, and almost all planned activities were completed by the time of project closure with 100 percent disbursed SDR 87.28 million). Factors that contributed positively to implementation of planned activities: 45. Strong participation by the vibrant NGO/CSO community and an effective process for setting priorities for grant awards: Prioritized results areas were selected annually based on the framework of the KNASP and areas identified as priorities in the Joint HIV and AIDS Programme Review (JAPR). Actual interventions were selected after assessing which proposals had best potential to achieve results contributing to the national objectives. 46. Clearly documented procedures, guidelines and standards for the granting mechanism and JAPR: Grant selection, guidance and implementation monitoring was done through a decentralised structure comprising the NACC Secretariat, District Technical Committees, and the Constituency AIDS Control Committees at district and constituency level, with guidance and oversight from the independent fiduciary agencies. 47. Good organization; and effective performance monitoring, fiduciary control and accountability: The project implementation arrangements were practical and well aligned with NACCs existing decentralized structures. HIV was mainstreamed in the district development programs with effective coordination, supervision and monitoring of the response at grassroots levels. Project performance was continually monitored through the project Results Framework and the Fiduciary Agencies, who provided effective fiduciary controls (although weak fiduciary capacity of some NACC structures at the decentralized level posed some challenges). 12 48. Extensive capacity building: NACC capacity was strengthened through setting up sound financial and reporting systems, and technical and managerial training for NACC staff at all levels. The capacity of PSIs to plan, network, coordinate, mobilize local resources, manage their finances, monitor and report on their sub-projects was enhanced through technical and advisory services. The Board was trained on how to provide oversight of the national response Factors that contributed negatively to implementation of planned activities 49. Weak capacity of some project sub-implementers (PSIs): The grant proposal format and very detailed guidelines were technically challenging to some potential applicants, and inadequate skills in proposal writing in some made it difficult for good ideas to be funded. 50. The grant process did not follow intended timelines: Project guidelines envisaged at least two calls for proposals each year, and grants to be made within two months of the advertisement. The project was not able to meet these standards, application deadlines were short, the vetting process took long, and selecting priority areas for various groups proved difficult. Only five CfPs were done within the life of the project March 2008- June 2014. 51. Implementation delays: (i) Procurement of essential commodities (bed nets, TB drugs and condoms) was delayed by slow clearance by the Kenya Bureau of Standards. (ii) Failure to execute the planned co-financing agreement with DFID delayed project implementation from 2007-2010. (iii) The volatile political climate in 2007-2008, post- election violence and activity of vigilante groups in some regions were disruptive. (iv)The change-over to the new Government, with mergers of some state departments and expansions of others, also slowed implementation. 52. NACC Organizational challenges: (i) The NACC was hampered by the lack of an appropriate legal framework and independence to effectively execute its mandate; (ii) there was limited staff capacity in regional field offices to cover and support all districts; (iii) NACC’s planning and performance management functions did not cascade well to decentralized levels, leading to the general failure of the decentralized structures to develop local plans was envisaged under the KNASP III; (iv) the Oversight and Performance Monitoring Committee (OPMC) did not fully succeed in building strong linkages across different parts of the KNASP program that would help prevent duplication of efforts and capacity gaps, and steer joint planning processes. 53. There was no effective coordination of Behavior Change Communication and Education (BCC/BCE) activities. A BCC consortium was formed but remained inactive for most of KNASP III implementation. Cultural, social, privacy and religious factors make it difficult to develop effective messages about HIV; technical and strategic communication skills to do this are scarce. 54. It was inherently difficult to reach marginalized groups most at risk for HIV (MARPs). Lack of baseline data for MARPs including services being provided was a challenge. Although Kenya’s Constitution highlights values, human rights and fundamental freedoms that are essential for advancing the rights of MARPs, there are 13 limited policy and legal enforcement tools for helping address the needs and issues of MARPs. 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization KNASP M&E 55. A comprehensive National HIV and AIDS M&E framework was developed so all stakeholders could use one agreed country-level monitoring and evaluation system 9. The National M&E Framework to a large extent ensured that the national HIV indicators and targets; subsystems for data collection, entry and reporting as well as coordination of the M&E national response were in place. Different data collection subsystems were used including: (a) COBPAR System used by CBOs to capture data on HIV interventions at the community level, CBO financial resources by source, beneficiary, results areas, and timeliness and completeness; (b) Behavioral Surveillance Surveys to systematically monitor behavioral trends and risky behavior patterns over time among MARPs and capture data on HIV prevalence and related behavior change among MARPs in in hotspots; (c) Facility-Based Sentinel Sero-prevalence Surveillance Surveys especially for PMTCT; (d) The Health Management Information System gathered data on HIV prevention, care and treatment services at all health facility levels including at the community level, including HIV and STIs prevalence in the general public and MARPs; (e) The KDHS 2014 and KAIS 2012 gathered information on HIV and STI incidence and prevalence, coverage of services on prevention, mitigation and treatment; and (f) The Kenya HIV and AIDS Research Coordinating Mechanism (KARSCOM) provided data and information from various research studies. Project M&E Design 56. The project design gave concerted attention to M&E, which had been weak under KHADREP. The project M&E was designed within the overall context of the KNASP M&E. By appraisal of TOWA, the NACC had made considerable progress in strengthening M&E systems. A new community-based monitoring system was designed, with a comprehensive CBO database, the Program Activity Reporting (COBPAR) System, and Financial reporting system. Clear procedures and systems were also designed for reporting by AIDS Control Units (ACU) and key sectoral public sector entities, and for interagency coordination for national reporting. 57. The evaluation criteria for the project reflected in the PDO and indicators focused on inputs, outputs, and outcomes (access and behavior change), but not impact. This would normally be grounds for criticism, but it can be seen as a sensible decision given the difficulties of measuring changes in HIV incidence. Most indicators meet the SMART criteria. The exceptions are the two indicators on sexual behavior (condom use, non-regular sexual partners) – these rely on self-reported data which are subject to social desirability bias and not reliable even to measure trends. Biological data are expensive and logistically challenging to collect, but data on prevalence of selected STIs was expected to be available. 9 End Term Review of Kenya National AIDS Strategic Plan III, 2009/10-2012/13 14 M&E implementation 58. Despite the delay in project effectiveness, the NACC implemented almost all M&E activities in the project’s original first-year work plan on schedule using alternative funding sources, including rolling out the KNASP M&E Framework and the comprehensive KNASP M&E Implementation Manual and complementary TOWA Project M&E Implementation Manual. The M&E Division recruited and trained an M&E Coordination Specialist, a database administrator and analyst/programmer. The COBPAR system database for grant reporting was made accessible through the NACC’s new local area network/wide area network (LAN/WAN). Monitoring and Coordination Groups (MCG) were set up for each priority area, with members from all relevant key implementing agencies and strategic partners. Formal linkages were created with entities responsible for other sources of data. The M&E Technical Working Group was revived and actively coordinated M&E activities, standards and essential funding for M&E. The project funded the HIV testing module of the KDHS 2007, and part of the costs of the KAIS 2012. NACC produced a “Data Booklet” summarizing new epidemic information. For most of project implementation, the M&E systems worked well, and data collection targets were generally met (details in next section). M&E data quality 59. An analysis of the indicators in M&E Framework for KNASP III showed that 22 (40%) out of 55 indicators had baseline targets and 2013 status, hence it was possible to determine the level of progress. However, 33 (60%) of the indicators lacked baseline indicators or targets, including indicators for most key populations - MSMs, sex workers, and IDUs. In some instances the framework used outdated 2003 or 2007 baseline values which could have changed by the time the plan began to be implemented 10. 60. The end term review of the KNASP III showed that the reporting subsystems were utilized. The NACC end term evaluation of the grants and mainstreaming public sector programs also indicated evidence of a relatively efficient performance, monitoring and accountability system with 85 percent adequacy of monitoring. All CBOs engaged in HIV related activities were expected to report their activities to NACC using the COBPAR. Reporting levels were good, although less so among civil society actors who were not funded by NACC through the TOWA funds. Although the PSIs were expected to report every quarter most reports were submitted long after the deadline. 61. While there was a high rate of reporting from health sector (Pillar 1) and civil Society (Pillar 3), the reporting rate for the public sector was below 50 percent and the majority of reporting related to service coverage, not service quality. Concerns were raised about data quality with respect to completeness, accuracy and double reporting. These were addressed by the fiduciary agents (mainly FMA and PA) for CSOs funded by TOWA. The CSOs had the targets set with support from the FMA and were not allowed to proceed to the next stage, or funded unless they met the targets and resolved any data concerns. 10 End Term Review of Kenya National AIDS Strategic Plan III, 2009/10-2012/13 15 M&E data utilization 62. All Constituency AIDS Coordination Committees and District Technical Committees were trained in collecting, analyzing and using data for effective programming. Current data on the epidemic and response were used in each Joint Annual Programme review (JAPR) to identify gaps and set priorities for the next year. The MCGs were responsible for monitoring progress against the results framework. They provided stakeholders with a forum for cooperation to overcome implementation delays and bottlenecks as well as making specific recommendations for policy action to the Inter- agency Coordinating Committee (ICC), for example, to develop specific new guidance for serving Indigenous People. The data from the KDHS 2007 and KAIS 2012 (partly financed through the project) guided the priorities and strategies of the new Kenya National Strategic AIDS Plan. The End Term Review of KNASP III reported that data and results from M&E and research were used for informed decision making by HIV and AIDS actors in the country. In particular, the country sharpened the focus on MARPs in response to results from the 2008/2009 KDHS and the “Know Your Epidemic and Know Your Response” study which showed increased transmission among key populations and increased HIV prevalence among married couples. The controversial message ‘Tia Condom Mpangoni’ (ensure you have a condom in your plan) was one such message developed to respond to the evidence. The data also informed key messages about VMMC in Nyanza and Turkana. 2.4 Safeguard and Fiduciary Compliance 63. Safeguard compliance under the project was Satisfactory: The project was appraised as a Category B project. As a repeater project, the TOWA Project used existing arrangements for safeguards issues, which had been successfully implemented under the KHADREP. The national medical waste management action plan was updated and disclosed and implemented under the Health Sector Support Project. Enhanced concerns about Indigenous People triggered Safeguard policy OP 4.10 during preparation for the additional financing, on the criterion of being structurally subordinate to the dominant societies and the state, leading to marginalization and discrimination. An Indigenous People Planning Framework (IPPF) was prepared, disclosed on the Borrower’s website and in the World Bank’s Info Shop, and successfully implemented through targeted assistance in local sub-projects. 64. Financial Management (FM) compliance under the project is rated Satisfactory: The FMA provided oversight on all aspects of grant management, including managing the grant award process, making financial payments to subproject grant recipients and collecting and verifying financial and program monitoring data. The subproject grant recipients were required to submit quarterly targets per indicator. Funding flows according to detailed work plans and budgets were linked to the indicator quarterly targets. The FMA field officers at provincial level built capacity of the subproject grant recipients and monitored their performance in FM. Disbursements of both the original and additional financing improved over time. Recognizing the adequacy of the FM and disbursement arrangements of the Project managed by qualified accounting staff under the NACC, a recommendation was made to use existing FM arrangements as per the original project appraisal document for the Additional Financing credit. 16 65. Procurement compliance was Moderately Unsatisfactory: Procurement of essential commodities faced many delays and challenges in the early years of the project due to weak NACC capacity at national and local levels. In 2010, during preparation of the additional financing, the procurement risk remained “high”. Alternative mechanisms of procurement were sought through the UN. Although these also faced substantial delays, a decision was made to continue procurements with the UN agencies. Subsequently, KEMSA’s capacity was strengthened through IDA support to the Ministry of Health, and later procurements for the TOWA project were done successfully through KEMSA. 2.5 Post-completion Operation/Next Phase 66. Transition arrangements are cause for concern, especially regarding funding. The HIV response in Kenya has benefitted from a clear national strategic agenda to which all partners have contributed in a coordinated manner. Sustaining the gains made through Kenya’s national response is an urgent challenge. The NACC has put in place transition arrangements to try and ensure financial sustainability, institutional sustainability, and political sustainability of the gains made under the TOWA project. 67. Financial Sustainability: Most funding for HIV in Kenya has come from external sources, (Global Fund to Fight HIV and AIDS, TB and Malaria (GFATM), Presidential Emergency Plan for AIDS Relief (PEPFAR), World Bank credits, JICA and DFID), with the government contributing about 18 percent. To cope with the phasing out of external funding, Kenya has set up an HIV Trust/Investment Fund. An HIV investment unit was set up in the NACC in fiscal year 2015/16 to plan how to source and leverage funding. The HIV Fund is expected to implement innovative financing mechanisms to raise resources that will be ring-fenced for high priority areas and interventions and underfunded areas within the HIV response as identified in Kenya’s Strategic Framework. Strong efforts are being made to ensure value for money through improving the efficiency and effectiveness of HIV services. Kenya is also seeking to learn how other countries are financing their HIV/AIDS programs and promoting cost effective cost-saving models of HIV service delivery. 68. Institutional Sustainability: With the ongoing devolution, NAC is making efforts to ensure that resources are allocated to HIV and AIDS programs. NACC will continue to advocate for HIV in the country, and to provide strategic guidance and technical support, coordination and mobilization of resources, while the HIV and AIDS services will be funded from County Budgets. NACC has met with Country Governors to lobby for increased HIV funding, and there are ongoing negotiations with the National Government. Follow-up is needed to ensure County budgets include clear budget lines for HIV and are able to effectively respond to HIV prevention and control. NACC is seeking ways to sustain the investment in strengthened governance, institutional structures, M&E capacity and other capacity of various service providers. 69. Political Sustainability: In response to the political changes, NACC has set up an HIV framework rather than an HIV plan. Recognizing the constitutional role of the Counties in funding and implementing HIV activities, NACC has been helping each Country develop HIV plans, with the help of partners especially UNAIDS, other development partners. NAC is advocating for HIV and AIDS through continuous dialogue 17 and mobilization of Government including the Office of the President, the First Lady, Members of Parliament, County Governors and County First Ladies to ensure political sustainability of HIV and AIDS support in the counties and the country. 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation - Rating: High 70. Relevance of the original and revised objectives remains High. Kenya still has a severe and heterogeneous HIV epidemic, with high levels of malaria in parts of the country. The objectives are fully consistent with Kenya’s Investment Program for the Economic Recovery Strategy pillar-2 and 3 which focus on continued efforts to reduce the spread of HIV and improving governance respectively; (b) KNASP II 2005/06-2009/10 that focused on prevention of new infections; improving the quality of life of people infected and affected by HIV and AIDS; and mitigating the socio-economic impact; continued in KNASP III 209/10-2012/13 and KASF 2014/2015-2018-2019; (c) other national policies: the Vision 2030 health goals; National Malaria Policy and Malaria Strategy 2009-13; National Guidelines for Comprehensive Management of Health Risks and Consequences of Drug Use aimed at providing guidance on improving the effectiveness of Needle Syringe Programs (NSP), Opioid Substitution Therapy (OST) and other prevention programs for MARPs; and the Education Sector Policy on HIV and AIDS that aims to develop programs to enhance HIV prevention, care and support for school pupils and education personnel. The objectives also align with the joint Bank-IFC CAS pillars on strengthening public sector management and accountability, monitoring and evaluation capacity; and investing in people for poverty reduction including continued support for the HIV and AIDS response; the World Bank Kenya Country Partnership Strategy FY 2010-2013; and the United Nations General Assembly targets for scaling up HIV prevention, treatment, care and support, and mitigation of its socio-economic impacts for achievement of Millennium Development Goal (MDG)#6. 71. Project design relevance is rated high. The detailed results chains in the PAD and Project Paper links the project development outcomes to intermediate results; project activities were carefully chosen for their expected contribution to these results. The strong focus on community action and annual priority setting through the JAPR to guide each grant round maintained strong targeting on the needs of population groups where current data indicated most new infections were occurring. Components to improve governance, coordination and implementation capacity proved their continued relevance over the project life. During restructuring, the project design was explicitly reaffirmed. 72. Implementation arrangements remain substantially relevant. The TOWA project was designed as an integral part of the implementation of the KNASP II and III, specifically to support scaling up priority targeted HIV prevention and socio economic interventions, and strengthening the NACC. The implementation arrangements remained the same after restructuring and were integrated within NACC and its decentralised structures with clear division of roles and responsibilities. NACC remained focused on its key mandate of coordination and ensuring and enhancing stakeholder participation. The project through the JAPR and other NACC committees at national and decentralised levels 18 nurtured and supported strong partnerships with stakeholders including development partners. 73. Overall rating of relevance is high: Given the high relevance of objectives and design and substantial relevance in implementation, project relevance is rated as high. 3.2 Achievement of Project Development Objectives (Efficacy) 74. The original and revised PDOs define outcomes (expanded coverage and access) to be achieved that are very directly linked to output indicators. These are expected to reduce new infections through behavior change, but, as noted above, no data are available for the two behavior change outcome indicators (condom use and non-regular sexual partners among young people). The data reported below documents that most other indicator targets were exceeded. The question of whether these outputs and outcomes can reliably be attributed to the project rather than to other funding rests on the reliability of the data sources. Four factors promote confidence in the data: the use of independent agents and audits, the joint annual reviews at which project monitoring data and progress were openly discussed with all partners and stakeholder representatives; routine Bank procedures for procurement review and payments; and NACC’s commissioning of an independent assessment of the project at its end. Grant sub-implementers had to report quarterly and submit original receipts and activity returns to the FMA, the independent audits verified reporting. The original PDO also specified that the project result in sustained improvement of the NACC’s performance, and defined clear measurable associated indicators; and that the project should contribute to implementing the national AIDS plan. The links between project activities and these two outcomes are also direct, their achievement is assessed in subsequent paragraphs. No objectives or targets for impact on the epidemic were defined, (such as reduced HIV incidence) which is difficult to measure, available data are presented below. Original PDO 1: Sustaining the improved institutional performance of the NACC 75. During the initial years of the project, NACC achieved improvements in institutional performance, although not all the targets for the outcome, intermediate outcome, and output indicators were fully achieved before the November 2010 restructuring (Tables 6, 7). Improved M&E performance has been described above. The NACC composite score on the annual independent performance evaluation was “good”, short of the target of “very good”. The target proportion of overall targets met for NACC- funded programs in civil society/private sector (beneficiaries) and public sector (beneficiaries) was fully achieved with achievement rates of 103 percent and 147 percent respectively (Table 6). Table 6: Level of achievement of project outcome indicators for the original PDO 1. SN Original outcome indicators (PAD) Baseline Original Actual value achieved Target November 2010 1. NACC composite score on the annual independent Very Good Very Good Good(Independent Performance performance evaluation. Evaluation Report) 2. Number of quarterly performance contract 4 4 4 NACC M& E Reports monitoring to the government (COBPAR) 19 SN Original outcome indicators (PAD) Baseline Original Actual value achieved Target November 2010 3. Proportion of overall targets met for NACC- N/A 70% 82.4% (FMA Technical funded programs in Civil society Reports) 4. Proportion of overall targets met for NACC- N/A 70% 88% (FMA Technical Reports) funded programs to the Public sector beneficiaries 76. By the 2010 project restructuring, seven of the 12 original intermediate outcome targets were fully achieved or exceeded, one fell slightly short (Table 7, line 10), and four indicators were either in process or not yet due. Table 7: Level of achievement of intermediate outcome indicators for the original PDO 1. SN Original intermediate outcome indicators (PAD) Baseline Original Actual value achieved Target November 2010 1. High level satisfactions with NACC as shown in 58% High 78% (Independent annual satisfaction survey Performance Evaluation Report) 2. Proportion of CACCs and DTCs which function N/A 89% 100% CACCs and 97.2% according to performance indicators (143/147) 3. Annual audit report for NACC demonstrating unqualified unqualified ongoing transparent and accountable financial management 4. Publications of NACC annual financial report published published Planned 5. Proportion of funds received by NACC that are 80% 85% 100% expended annually 6. The proportion of KNASP M&E indicators included 53% 85% Planned in the annual M&E report, disseminated and (57/106) available on time for JAPR 7. Number and proportion of proposals received by N/A 80% Pending NACC that are rated as meeting CFP criteria for approval each year 8. Proportions of overall targets met for NACC funded N/A 70% 81.8% programs in civil society and private sector 9. Number/proportion of registered CBOs reporting N/A 80% 7,652 (>80%) through COBPAR at the time of the JAPR 10. Number and proportion of priority sector ministries, 33/43 100% 40/42 (95%) divisions, that have identified their needs in HIV and (77%) AIDS programmes, costed them and engaged MTEF process to fund them and are able to monitor and report on expenditures 11. Coordination meetings held with participation from 12 ICC 12 ICC 12ICC 4MCG (NACC key stakeholders (ICC meetings and MCG meetings) 4 MCG 4MCG Coordination Meeting Minutes) 12. JAPR with participation from principle development Yes Yes Yes (NAC JAPR Reports) partners, implementing partners from civil society, private sector and public sector 77. Output targets in 3 of 5 areas were achieved or exceeded, there were shortfalls in the other two (See Table 2b, Annex 2 for more details): • Eleven costed annual work plans were developed, surpassing the target of 10. • The 1,722 civil society and private sector organizations supported per year fell short of the target of 2,500; the cumulative number of 2,372 was 40% of the target of 5,900. 20 • 12,075 grant proposals received from private and civil society exceeding the annual target of 5,000; the cumulative 16,348 grant proposals received exceeding the target of 11,800 • 15 million male and female condoms were being distributed monthly, well above the target of 13 million • 7 public sector organizations were supported in mainstreaming, well below the target of 21 78. NACC’s institutional performance was sustained and improved after restructuring. Table 8 shows all five targets for NACC performance on governance and coordination met or exceeded by the end of the project, as measured by independent audits and surveys. NACC was able to develop KNASP III, the Kenya AIDS Strategic Framework 2014/2015 - 2018/2019, a National AIDS Spending Assessment (NASA) and the HIV and AIDS Sustainable Financing Paper. The independent 2014 end term review of KNASP III noted that NACC successfully spearheaded day-to-day coordination of KNASP III implementation. Table 8: NACC Governance and coordination capacity strengthening, outcome indicators SN Project outcome indicator (POI) or Intermediate outcome Baseline Original Actual value achieved by indicator (IOI) Target June 2014 1. POI#1: Proportion of PSIs scoring “Very Good” or N/A 80 89.9%. (IPA Report “Excellent” for target achievement in the annual audit 2014) during the year 2. IOI#1: The level of Stakeholder satisfaction with NACC 70% 75% 87%. (NACC Customer (2007) satisfaction survey report 2013) 3. IOI#2: Issues in NACC’s qualified report to be addressed N/A Yes Yes (External Audit by end of March of following year. Reports by KENAO) 4. IOI#3: The proportion of KNASP M&E indicators included 55% 85% 96% (NACC M&E in the annual M&E report, disseminated and available on Reports through COBRA time for the JAPR system) 5. IOI# 4. Proportion (or Number) of registered CBOs 65.8% 100% 103% (5163) [NACC reporting through COBPAR at the time of the JAPR. 5000 M&E Reports (Note: target of 5000 was defined in the Revised TOWA project implementation manual) 79. In executing its coordination mandate, NACC was supported by the Inter-Agency Coordinating Committee (ICC) 11 and the OPMC. The ICC effectively coordinated the JAPR; ensured inclusion of all development partners, (i.e., the Global Fund Country Coordinating Mechanism, TOWA-World Bank, Government of Kenya, UK- Department for International Development (DFID), Joint UN Team, Development Partners for Health, GAVI, including Private sector and Civil society umbrella organizations. 11 The ICC was a multi-stakeholder forum that oversaw the national prevention, treatment, social protection and other sub-committees that monitored and coordinated delivery of the higher-level results. It included representatives from key national ministries, faith-based communities, People Living with HIV, the private sector, NGOs, and other civil society groups. 21 80. The project achieved this objective largely through: strengthening NACC strategic leadership, governance and management capacity through training and new monitoring and information systems; provision of advisory and technical services; and incremental operating costs for the NACC Secretariat and its decentralized structures; and the extensive and carefully managed grant program with annual strategic targeting to define priority results areas for the interventions. Original PDO 2: Implementation of the KNASP 81. KDHS 2009 data for two of the original PDO 2 key outcome indicators was not available to measure the two behavior change indicators (Table 9). Given the unreliability of self-reported data on sexual behavior and that distribution of condoms does not guarantee their use, most weight is given to indicator 3. By November 2010, 4.5 million people had benefited from the project support, of whom 61 percent receiving counseling and testing, 25 percent received targeted behavior change communications, and 14 percent received specialized HIV services (Annex 2). Through the community grants mechanism, 2.7 million people were counseled and tested. The project made a major contribution to increasing the number of people knowing their HIV status, particularly in higher risk groups, and their being able to access prevention services, treatment, care and support. Table 9: Level of achievements of key outcome indicators for prevention and mitigation SN Key outcome indicators (PAD) Baseline Original Actual value achieved by Target November 2010 1. The proportion of youth aged 15-24 reporting F 24 % F30% 2009 KDHS data not available condom use in the last sexual intercourse with a M 47% M 80% hence progress could not be non-regular partner (or those reporting sexual (KDHS measured intercourse with non-regular partner in the last 12 2003) months) 2. Proportion of sexually active youth 15 to 24 years F 30% F 25% 2009 KDHS data not available who report having had sex with a non-spousal, non- M 84% M 80% hence progress could not be regular partner in the past 12 months. (KDHS measured 2003) 3. Number of persons who undergo testing and 750,000 900,000 3,471,567. counseling. (NACC Reports) 4. Number of male and female condoms distributed. 120m 156m 180 million (NACC procurement and Distribution Reports) Revised Development Objectives Revised PDO 1: Expand the coverage of targeted HIV and AIDS prevention and mitigation measures 82. Scale up of HIV prevention and mitigation interventions greatly exceeded project targets (Table 10), reaching 22 million people in all. The project funded 10,712 sub-project grants to civil society/private sector Project Sub-Implementers (PSIs) -- 98% of the 10,912 proposals approved, and 128 percent of the target (Table 10 line 1), with steady increases throughout the project (Figure 1). The total cost of US$53.308 million was close to planned expenditure of US$ 53.175 million. The project accounted for about one third of the 29,157 22 civil society/private sector organization projects supported under KNSAP III between 2009 and January 13, 2014 (others were supported through NASCOP with funding from PEPFAR, UNAIDS, GFATM, World Bank and JICA). Table 10: Level of achievements of project outcome indicators, Core beneficiary indicators for prevention and mitigation measures, and strategic and targeted programs SN Project outcome indicators (PP) Baseline Original Revised Actual value Target Target achieved by June 2014 1. POI#2: Number (cumulative) of civil society/private 0 8,400 8,400 10,712 (FMA sector grants Reports) 2. POI#3: Proportion of sexually active youth 15- 24 F=24%, F=20% KDHS 2014 data not who report having had sex with a non-spousal, non- M=34% M=70% available. regular partner in the past 12 months (KDHS 2007) 3. POI# 4. Proportion of youth aged 15-24 reporting F=26% F=40% F=55% KDHS 2014 data not condom use in the last sexual encounter with a non- M=29% M=60% M=75% available. regular partner (of those reporting sexual intercourse (KDHS with a non-regular partner in the last 12 months) 2003) (KDHS 2014 data not available. A proxy indicator KAIS II 2012: from KAIS on condom use at first sex among women F=67% and men aged 15–24 years increased by 40 M=58%) percentage points in females and 29 percentage points in males between 2007 and 2012) 4. POI# 6. Number of individuals provided with 0 172,045 5,559,540 counseling and testing services (through TOWA) (FMA Reports) 5. IOI#6. Number of couples counseled and tested N/A 6,305 983,166 (FMA under the TOWA project up to the end of the Technical Reports) reporting year. 6. Core beneficiary indicator: Number of HIV+ clients N/A 3,483 10,574 provided with palliative care. (FMA Reports) 7. Core beneficiary indicator: Number of youth N/A 348,232 4,880,278 reached with HIV prevention messages. (FMA Reports) 83. KDHS 2014 data for the two original PDO 2 key outcome indicators was not available. A proxy condom use indicator from KAIS 2012 showed very large increases in reported condom use at first sex among women and men age group 15-24 years compared to KAIS 2007: from 26% to 67% for women and from 29% to 58% for men. While in this self-reported data has very large confidence intervals, the very large increase suggests that there may in fact have been an improvement. Figure 1: TOWA Sub-projects grants to civil society/private sector (cumulative) 15000 No. of PSI granted 10000 5000 0 Year 23 84. The ‘Know Your Epidemic, Know Your Response’ analysis done in 2008 showed the need to target MARPs. The study showed that MSMs contributed 15% of new infections; FSWs and their clients 14%; and IDUs 4% of new infections. Greater attention was then given to MARPs, but there were no reliable MARP size estimations across the country, or data on what services reached them. The lack of data on MARPs was a major bottleneck for effective targeting and programming. A more recent mapping study estimated that MARPs accounted for 33 percent of new infections among adults (CGPH et al, 2012). 85. Under the TOWA, 16 percent (1228) of the civil society/private sector grants targeted MARPS (13 percent / US$6.9 million of total grant expenditure) in line with the KNASP III prioritization of MARPS for HIV prevention and care. More than 7.5 million MARPs were reached. Support under TOWA greatly contributed to increased uptake of HIV services by MARPs over the period 2008 to 2013 with: (i) 1,616,585 MARPs mobilized and sensitized on HIV and AIDS –121% of the target of 1,332,145; (ii) 999,143 (113%) against an initial target of 878,360 of MARPs were counselled and tested; (iii) 3,006 -- 108% OF THE ORIGINAL TARGET OF 2,779 PEER EDUCATORS WERE TRAINED TO PROVIDE HIV and AIDS preventive education; and (iv) MARPs received 3,438,288 condoms, 118% of the target of 2,904,408 12. For more achievements of MARPs reached under the TOWA –see table 2c in annex 2. 86. HCT: The project reached 5.6 million individuals with counselling and testing annually (32 times the target) and 983,166 couples (155 times the target) (see Table 10). Overall the percentage of people ever testing for HIV more than doubled over the life-cycle of the project and KNASP III from 34% in 2008 to 72% in 2012 (KAIS 2012). 87. The 322 million condoms procured and distributed under the project was more than twice the target (Table 10). Focused targeting resulted in 4.9 million youths reached with HIV prevention messages under TOWA, 14 times the target, with increased reach throughout project implementation. Provision of palliative care to 10,574 people was three times the target (Table 10). 88. Voluntary Medical Male Circumcision (VMMC): The number of people reached with behavior change communication messages on VMMC under the Total War on HIV and AIDS (TOWA) for the period 2008/2013 rose to 243,403(117%) of the original target of 207,413. 11,754 males (140%) were provided with or referred to VMMC services against an originally planned target population of 8,399 males; 2,258 (110%) people were trained to support VMMC against a target of 2,040 13. 89. Overall, the VMMC prevalence rose from 85% in 2007 to 91% in 2012 nationally, and from 48% to 66% in Nyanza (KAIS 2012). 12 Final Report for End Term Review of Kenya National AIDS Strategic Plan III, 2009/10-2012/13 13 Final Report for End Term Review of Kenya National AIDS Strategic Plan III, 2009/10-2012/13 and FMA Technical Reports 2014. 24 Figure 2: Level of Achievement of VMMC through TOWA and support through NASCOP by other partners. 90,000 78,565 80,000 70,105 70,000 60,000 50,000 40,000 30,000 20,000 13,364 10,067 11,105 10,000 6,899 1,452 1,450 0 Number of male Number of IEC Number of people Number. of people provided and /or messages/materials reached with BCC trained to support referred for VMMC developed/disseminated messages-VMMC VMMC services -VMMC -VMMC Planned 70,105 6,899 1,452 13,364 Actual 78,565 10,067 1,450 11,105 Specialized HIV and AIDS Services 90. A total 854,272 people benefited from other specialized services at a total cost of US$ 2.54 million. This included: (i) palliative care to PLWHA (reported above); (ii) outreach, education and condom promotion and provision to 1,440 community leaders and 80,000 community members of vulnerable and marginalized groups (VMG); (iii) support for 43,481 orphans and vulnerable children (OVC, see Figure 3); and (iv) services to prevent mother-to-child transmission for 403,097 mothers. However, only 9 in 1000 OVC received at least one type of OVC support (KAIS 2012), and the 53 percent of pregnant women who accessed PMTCT service was below the KNASP III target. Figure 3: Support to OVC 43, 481 Orphans and Vulnerable Children were reached with various support services Skills and Inputs Material Support 3% Nutrition Nutrition 16% 25% Shelter IGA 8% Education Clothing Psychsocial Shelter 4% 8% Medical Ass Medical Ass Psychsocial 11% Education IGA 11% Clothing Material Support 14% 25 Public Sector Mainstreaming 91. The project provided US$2.95 million to 51 public sector institutions, matching their own funds mobilized through the MTEF process, to scale up planned HIV mainstreamed interventions in the public sector in line with KNASP II and III priorities. Although this component fell short of targets, achievements included: • Establishment of ACUS (although structural, staffing, and organizational challenges impeded their ability to mainstream HIV within their Ministries/Agencies). • Increased sensitization on HIV and AIDS through peer education and distribution of IEC materials • Development of Work place HIV policy • Increased distribution of condoms • HIV stigma at the work place was openly discussed to encourage positive attitudes towards people living with HIV (PLHIV); the Kenya Network of Positive Teachers and the Kenya Prison Service ACU are good examples. 92. Overall achievement of revised PDO#1 is rated satisfactory given the many outcome indicators on prevention and mitigation measures that were achieved or surpassed; the numbers of beneficiaries reached through targeting of high risk populations using drop- in centers, support groups and networks, wellness centers, and stand alone and integrated sites providing HIV-related services for MARPs and a Human rights approach to increase demand and access to services by MARPs; the strategic and financial support to PSIs focusing on initiatives in line with the KNASP and responding to priorities and targets identified through the JAPR based on set criteria; the increased supply and strong uptake of VMMC services through early and continuous engagement and sensitization of local community leaders/elders, politicians, youth, and women’s groups on the importance of VMMC in HIV prevention. In addition, linkages and relationship among stakeholders for concerted effort against HIV and AIDS were enhanced -- a key factor in the dramatic increase in HCT was the effectiveness of the HCT Technical Working Group in pulling all partners together. Revised PDO2: Expand access to bed nets among targeted People Living with HIV and AIDS and other households in malaria risk areas. 93. The project procured and distributed 2.88 million Insecticide-treated bed nets (ITNs) in eight high malaria burden counties 14. Cumulatively, 5.25 million individuals (500,000 PLHIVs through targeted support and 4.75 million through mass distribution) in malaria endemic areas were reached with an ITN under the project (assuming that two people would use each ITN provided through general distribution, and one beneficiary per ITN in targeted distribution). 14 Bomet, Kericho, Mombasa, Lamu, Taita Taveta, Kwale, Kilifi, and Tana River Counties 26 Table 13: Level of achievements of project development indicator and intermediate outcome indicators for malaria prevention and control SN Indicator (PP) Baseline Revised Revised Actual value achieved by Baseline Target June 2014 1. POI# 5. Percentage of households 27.6% N/A 80% 81.2% (KAIS II 2012, in malaria endemic areas in the Coast endemic region) districts supported by the TOWA Project that have at least one ITN - 2. Core beneficiary indicator: Number N/A 250,000 5.1 million 5.25 million ( TOWA of individuals with access to an Bed net Distribution ITN. Reports) 3. IOI#10. Number of long lasting 0 500,000 2.8 million 2.88 million (TOWA bed insecticide treated malaria nets net Procurement and purchased and/or distributed. Distribution Reports) 94. The post distribution survey found that 91.7 percent of households in the endemic areas own at least 1 bed net; over 75 percent of the households own 2 bed nets. According to the World Malaria Report 2014, access to treated nets, improved testing and effective treatment of malaria are credited with success against malaria in Kenya and globally. (Rainfall is also an important factor.) Malaria deaths in Kenya have fallen steadily from 26,017 deaths in 2010 to only 135 deaths in 2013, despite over two million cases of malaria infection recorded in Kenya in 2013 (14th highest in Africa). 95. Procurement and distribution of other essential commodities: The project also procured and distributed US$1.9 million worth of drugs to help strengthen the response to TB in Kenya. All TB patients were screened for HIV and all HIV positive people were screened for TB and those found positive were put on treatment. Over 100,000 patients benefited from these drugs. 96. Based on the high coverage of bed nets in high malaria endemic areas, achievement of revised PDO 2 is rated Satisfactory. Considering data on actual use of bednets (from the malaria beneficiary survey), and noting that other factors may have contributed (such as low rainfall and improved health seeking behavior and treatment) it is plausible that the highly successful distribution of bednets contributed to considerably lower incidence of malaria and reduced morbidity and mortality from malaria in children under five and pregnant women in two of the three targeted areas. KNASP III Outcomes during the life of TOWA Project that indicate impact to which the project contributed. 97. BCC was one of the key HIV preventive strategies in KNASP III. The end term review of KNASP III showed non-achievement of many prevention outcome targets including low consistent condom use, but notable gains in decreased prevalence among youth, and strong increases in HIV testing, uptake of male circumcision, and prevention of mother-to-child transmission. • 30.1 million people were sensitized on HIV through BCC or HCT (youth, MARPs, couples, and general public) • There was no difference among young people (women and men combined) aged 15 to 24 years reporting sexual debut before the age of 15 years in KAIS 2007 (24%) and KAIS 2012 (21%). However, significantly fewer men aged 15-24 reported sexual 27 debut before the age of 15 years (27% in KAIS 2012 compared with 347% in KAIS 2007). • Reported condom use at first sex among women and men aged 15–24 years was 67% and 58%, respectively in KRAIS 2012; much higher than the 26% among women and 29% in men in KAIS 2007. Condom use among youth aged 15 to 24 years was significantly lower for women and men who had their sexual debut before age 15 years (53% and 34% respectively) than for those who had their sexual debut at 15 years or older (70% and 65% respectively). 98. VMMC: The percentage of men circumcised in the country rose from 85% in 2007 to 91% in 2012 and from 48% in Nyanza district to 66% (KAIS, 2012). 99. Increased HCT uptake: The levels of HIV testing in adults aged 15 to 64 years more than doubled, from 34 percent in 2007 to 72 percent in 2012, close to Kenya’s national goal of 80 percent coverage by 2013 (KAIS 2012). Women were more likely to have ever been tested for HIV (80 percent) than men (63 percent). Knowledge of HIV status among HIV-infected persons tripled from 16 percent in 2007 to 47 percent in 2012. The TOWA contributed about 15 percent of all national counseling and testing. 100. Prevention of mother to child transmission (PMTCT) coverage increased from 73% in 2009 to 90% in 2012. The MTCT had fallen to 10-15% over five years from 27%, as per the early infant diagnosis (EID) program implementation data (NASCOP 2012). 101. Decreased HIV incidence: Overall HIV incidence was stable between 2007 and 2012 and across all age groups at 0.5 new infections /100 persons/year. Among young men and women aged 15-24 years incidence declined from 1.1% in 2007 to 0.9% in 2012. 102. Decreased HIV prevalence: According to KAIS 2012, HIV prevalence continued to decline slowly among younger age groups. HIV prevalence among men and women aged 15 to 49 years decreased from 7.1% in 2007 to 5.6% in 2012 (Figure 6). This is despite the increase in prevalence that would be expected from expanded access to ART. Among youths, HIV prevalence declined significantly between 2007 and 2012: from 3.5% in 2007 to 1.1% among young persons aged 15-19 years, and from 7.5% to 4.6% among the 20-24 year group. Figure 6: HIV Prevalence by Age group between 2007- 2012. 28 3.3 Efficiency Rating: Substantial 103. The efficiency analysis draws on peer reviewed literature on cost-effective analysis of HIV/AIDS and malaria interventions, to assess whether the project funds were allocated efficiently, to interventions for which there is strong evidence, and whether the project activities achieved value for money in the way they were implemented. Allocative efficiency was served by strategic targeting of project resources based on careful analysis of the epidemic and response during project preparation, and reallocation of resources during implementation to the activities that were showing the best progress and results; and in response to evidence-driven adjustment in HIV response priorities, such as the strong focus on rapid expansion of VCT during the final three years of the project. Cost effectiveness analysis of Voluntary Counselling and Testing (VCT), distribution of condoms, and male circumcision 104. Condom use is a significant determinant of survival for HIV positive people and an effective means of HIV prevention. In Kenya, about 45% of new HIV infections occur among men and women aged between 25-44 years 15, most due to unprotected sex. The number of new infections in Kenya was estimated as 98,000 in 2013 16. HIV positive people using condoms faced a 52.8% lower risk of death compared to patients not using condoms, even when the same were on ARTS 17. A total of 332.85 million condoms were distributed through the project. There were minimal condom stocks lost in the supply chain. This applies also to the bed nets provided through the project - the number of condoms and LLINs procured matched the number of the commodities delivered and distributed. The project used the existing national distribution arrangements to deliver LLINs, a further efficiency that avoided duplication. 105. An article published in The Lancet in 2000 provided an estimate of the cost- effectiveness of HIV counselling and testing in Kenya. 18 It reported results of a controlled trial which suggested that Voluntary Counselling and Testing (VCT) 10,000 people in Kenya could avert 1104 infections in the following year, at an average cost per HIV infection averted of US$ 249, and cost per Disability Adjusted Life Year of only US$13- 27. Sensitivity and economic analysis by the researchers indicated that it would be most cost-effective to target HIV positive people (who do not know their status), women, and 15 Kenya AIDS Indicator Survey, 2012 16 Kenya AIDS Strategic Framework, 2014. 17Owino, 2013 Cost-effectiveness and survival analysis of HIV and AIDS testing and treatment in Kenya. 18 Sweat et al, 2000. Cost-effectiveness analysis of voluntary HIV counselling and testing in reducing sexual transmission of HIV in Kenya and Tanzania, Lancet 356: 113-121. A 2012 review of literature published between 1990 and 2010 concluded that there was “growing evidence that VCT can change HIV- related sexual risk behaviors thereby reducing HIV-related risk, and confirming its importance as an HIV prevention strategy.” Fonner, Denison, Kennedy, Reily and Sweat, 2012, Voluntary counseling and testing (VCT) for changing HIV-related risk behavior in developing countries, Cochrane Collaboration, DOI: 10.1002/14651858.CD001224.pub4 29 couples (especially sero-discordant couples). This research suggests that the 5.25 million people tested for HIV under the TOWA project was a highly cost-effective intervention. Applying the Sweat et al estimated parameters, the TOWA project potentially averted 609,960 HIV infections, and may have saved approximately 151 million dollars, if each averted infection saves USD 249. 106. As noted above, male circumcision (VMMC) reduces risk of HIV transmission by 60%, and is highly cost effective in a high prevalence context like Kenya. 19 AN expert panel concluded that one HIV infection could be prevented for every five to 15 men circumcised in settings with high levels of HIV and low rates of male circumcision, at a cost of US $150 to $900 per HIV infection averted over 10 years. By comparison, estimates of discounted lifetime treatment costs per HIV infection typically exceed US $7,000. 20 Funding for this project activity meets a very high standard of allocative efficiency. There is also strong independent evidence of the (technical) efficiency with which VMMC has been scaled up in Kenya, through a focused implementation strategy using outreach sites and fixed clinical facilities supported by multiple implementing agencies within regions with the highest HIV prevalence and lowest male circumcision rates, supplemented by services provided via mobile sites to deliver VMMC in underserved areas. 21 A peer- reviewed assessment of VMMC facility preparedness and correct performance of procedures in 2011 and 2012 in four countries found that Kenya maintained high levels of service quality at-scale, scoring generally higher than the 3 other countries (although shortages in drugs for HIV post-exposure prophylaxis and antibiotics were noted). In a systematic assessment of six clinical efficiency indicators, almost all facilities sampled in Kenya met three indicators, and the authors reported that “in Kenya the results have contributed to revamping of the theatre environment, use of commercially-bundled kits with disposable instruments, and more frequent supervisory visits to assure quality”, i.e., adoption of other efficiency measures. 22 107. Grants: In addition to strategic targeting of project resources based on careful analysis of the epidemic and response, allocative efficiency was also served by the annual selection of priority results for each round of grants. Over 11,000 grants were funded, selected from more than 27,000 proposals. Training project sub-implementers (PSIs), competition for grants, and restricting participation to PSIs with proven track records, all contributed to efficiency. PSI skill training included leadership, proposal writing, financial management, budgeting and budgetary execution, networking and advocacy. Increased PSI 19 Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, et al. (2005) Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med 2: e298. 20 UNAIDS/WHO/SACEMA Expert Group on Modelling the Impact and Cost of Male Circumcision for HIV Prevention (2009) Male Circumcision for HIV Prevention in High HIV Prevalence Settings: What Can Mathematical Modelling Contribute to Informed Decision Making? PLoS Med 6(9): e1000109. doi:10.1371/journal.pmed.1000109 21 Jennings et al, 2014, Quality of Voluntary Medical Male Circumcision Services during Scale-Up: A Comparative Process Evaluation in Kenya, South Africa, Tanzania and Zimbabwe. PLoS ONE 9(5): e79524. doi:10.1371/journal.pone.0079524 22 Bertrand JT, Rech D, Omondi Aduda D, Frade S, Loolpapit M, et al. (2014) Systematic Monitoring of Voluntary Medical Male Circumcision Scale-Up: Adoption of Efficiency Elements in Kenya, South Africa, Tanzania, and Zimbabwe. PLoS ONE 9(5): e82518. doi:10.1371/journal.pone.0082518. The only measure not adopted in Kenya is use of electrocautery to stop bleeding more quickly than suturing 30 efficiency is evident in improvements in target achievement by PSIs from 69% in rounds 1, 2 and 3 to 89% in rounds 4 and 5. The average grant amount was US$5,000, the unit costs of the services delivered through the grants was kept low because many grant implementers were volunteers or local workers on modest stipends. 108. The grant program also provides an example of NACC’s effort to improve efficiency during implementation. Initially, EPOS Health Management, a German consulting firm, was contracted to continuously monitor the performance of PSI, and ensure conformity with approved work plans. Approximately 541,128 USD was allocated for this. EPOS audited 2002 PSI in two years. After two years, the model was changed, and individual local consultants were contracted to conduct performance audits. Within four months, the local consultants audited 1500 PSI, about 75% of the number audited by EPOS over two years. This was efficient and cost saving, and contributed to capacity building in Kenya. The Internal Audit Unit of NACC investigated CSOs identified by the performance auditors with fiduciary irregularities or other performance constraints. Between 2011 and the project end, a total of 950 CSOs were identified for investigation (8% of all grantees). The final ISR reported that 559 (59%) had been checked and cleared by the Internal Audit Department, 374 CSOs (39%) cases were still open, and only 8 had needed to be reported to the Ethics and Anti-Corruption Commission. 109. This assessment of the allocative and implementation efficiency of many of the project activities and components suggests that a rating of satisfactory is warranted. 3.4 Justification of Overall Outcome Rating 110. The project registered clear achievements across service delivery areas and met its development objectives as measured by achievements of project indicators and most intermediate outcome indicators for both the original and the revised project objectives. Table 14: Summary of rating of original PDOs PDO Criteria Relevance Effectiveness Efficiency Result Expand the coverage of targeted High Substantial Substantial Satisfactory HIV and AIDS prevention and mitigation interventions Sustaining the improved High Modest Substantial Moderately institutional performance of the Satisfactory National AIDS Control Council (NACC) Supporting the implementation of High Substantial Substantial Satisfactory Kenya National AIDS Strategic Plan (KNASP) Rating total High Substantial Substantial Satisfactory Table 15: Summary of rating of revised PDOs PDO Criteria Relevance Effectiveness Efficiency Result 31 Expand the coverage of targeted High Substantial Substantial Satisfactory HIV and AIDS prevention and mitigation measures Expand access to bed nets among High Substantial Substantial Satisfactory targeted people living with HIV and AIDS and other households in malaria risk areas Rating total High Substantial Substantial Satisfactory Table 16: Overall rating in light of changes in the PDOs Objectives Against Against revised Overall original PDOs PDOs 1 Rating Satisfactory Satisfactory - 2 Rating value 5 5 - 3 Weight (% disbursed 42.5% 57.5% 100% before/after PDO change 4 Weighted value (2x3) 2.13 2.88 5 5 Final rating (rounded) Satisfactory 3.5 Overarching Themes, Other Outcomes and Impacts Poverty and Gender Aspects 111. The Project addressed poverty and inequity by expanding access to prevention and mitigation services among underserved populations (see annex 2). Increased access to HIV treatment, care and support services is likely to have improved the quality of life of people affected and infected with HIV. The income-generating activities provided to 5016 households with OVCs (104% of the target) through the project directly reduced poverty, and the life-prospects of children who the project enabled to stay in school. 112. National HIV prevalence among the age group 15-65 years is estimated to be 5.6%, equivalent to 1.2 million Kenyans (KAIS 2012). HIV prevalence among women is higher (6.9%) than for men (4.4%); women are 58% of all people living with HIV (NACC and NASCOP, 2012). Young women aged 20-24 years are three times more likely to be infected than young men of the same age group. HIV prevalence is six times higher in adolescent girls aged 15-19 than in adolescent boys. The strengthened M&E systems collected gender disaggregated data to enable women and girls to be targeted to address gender disparity. In consultation with development partners and other stakeholders, the Government took deliberate actions to create a gender-sensitive decision-making environment in the HIV response. These included: developing a gender mainstreaming action plan, and implementing recommendations from the HIV Prevention Summit for Women. 113. Sexual Gender Based Violence (SGBV) and Gender Based Violence (GBV) remain as critical drivers of the epidemic, with women and young girls bearing the greatest brunt. At least 1 in 5 Kenyan women (20.5%) experienced GBV in 2010 compared to 15.9% in 32 2003 23. However, positive gains have been made. HIV prevalence in young women fell faster than in young men between KAIS 2007 and 2012. Women are more likely to have been tested than men (80% versus. 63%). 114. Gender power imbalances are still drivers of the epidemic. Inequities that reduce women’s opportunities and intensify their vulnerability to HIV infection continue to be experienced, including acute unmet need for family planning and other sexual and reproductive health services, which potentially limit their access to health information, condoms, and support in negotiating safe sex. Other Unintended Outcomes and Impacts (positive or negative) 115. The strengthened capacity among the PSIs created confidence in development partners and financing institutions to channel resources through them for implementing HIV programs. For example, GFATM through the Red Cross asked the most effective TOWA sub-implementers to become lead implementing agents for activities funded by GFATM. 116. Communities gained socio-economic benefits from the grant mechanism that provided IGA to women and OVCs to enhance sustainability of funded interventions, with continued benefits in the future from profitable IGAs. However, there is room to improve the setting and management of these IGAs. 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops Beneficiary Survey to Assess Impact on LLIN Ownership and Use (Revised PDO 2): 117. Post LLINs Distribution Results: The National Malaria Strategy 2009-2017 principally aims at reducing morbidity and mortality caused by malaria by two thirds between 2007/2008 and 2017. An important strategic approach to achieve this goal was to protect at least 80% of people living in malaria risk areas by appropriate malaria prevention interventions with Long-lasting Insecticide treated nets (LLIN) by 2013. 118. Household ownership of any type of net or campaign LLIN: Net ownership increased after the mass net campaign. The average number of any type of net per household increased from 1.0 (KMIS 2010) to 2.8 in rural areas; the same is noted in average number of LLINs owned per household from 0.9 in 2010 to 2.7 as seen in the evaluation. In the three malaria endemic zones, ownership of at least one net of any type increased as follows: Lake region increased from 70.7% (KMIS 2010) to 88.3, Coast region from 69.6% to 86.7%, Highland region from 59.5% to 85.7%. 119. Ownership of at least one LLIN in the Lake endemic region increased from 54.4% in 2010 to 83.4%, in the Coast endemic region from 56.5% to 82.6%, and in the Highland region from 48.5% to 83.5%. The average number of LLINs owned per household more than doubled to: 2.24 in Lake endemic region, 2.15 in Coast endemic, and 2.51 in 23 Kenya National Behavioral Survey 2010. 33 Highlands region. The results show equitable distribution of nets across the wealth quintiles therefore enabling the poorest to access LLINs equally to the rich. 120. Household retention of campaign LLIN: There was equal ownership of nets in rural (93.8%) and urban areas (92.7%). In both urban and rural settings, the mean nets distributed per household were the same three (3) which conforms to 62.5% of the households receiving three or more nets at the distribution point. Although some nets were disposed of by households after the mass net campaign, the pattern of LLIN ownership across wealth quintiles differed little with the lowest quintile recording ownership at 90.6%, and the highest quintile recording 91.4%. 121. Net usage: Use of LLIN the previous night in the endemic areas was reported at 36.5% of all household members, with Lake reporting lower usage of 30.4% compared to 35.5 in Highland, and 49.8% in Coast. Overall use of LLIN was low among the children aged below five years (29.3%) and 5-14 years (29.7%) compared with other age groups. Still focusing on children under 5 years, usage in rural areas was lower (27.5%) than in urban areas (39.6%), and lowest in the Lake area at 16.3% compared to Highland (28.3%) and Coast (53.9%). This is a major concern for malaria prevention through use of LLIN in the Lake region where malaria is most prevalent and a major killer disease in children. 122. Reduced Malaria Incidence: The End Term Review of the KNASP showed reduced Malaria incidence in both Coast and Highland endemic regions - post distribution, consistent with reported increased use of nets. Stakeholder Workshops: 123. During the project the NACC engaged stakeholders through consultative workshops. Two National workshops were held among the various Fiduciary agents including the Performance Auditor, Financial Management Agency, Procurement Agency and Independent Compliance Verification Agency together with the World Bank and NACC staff. NACC held consultations with: 290 CACC Coordinators, the parliamentary Committee on Health and the Project Management Unit; and all 47 Governors of the 47 Kenyan counties in the face of devolution in Kenya in September 2014. The 47 Governors agreed to increase the allocation of county budgets to HIV, especially to benefit mothers and children; and to rely on NACC to provide technical support on County specific needs As part of TOWA project closure, NACC held brought together development partners, government agencies, implementers and other stakeholders to discuss issues arising from the implementation of the project. The detailed findings and results of the consultative meetings and conferences and the beneficiary survey can be found in Annex 7. In summary, the closure workshop noted: (a) project objectives had been achieved; (b) the importance of its decentralized design and its ability to reach and impact communities; (c) the appreciation of the World Bank’s proactivity and rigor in supervising and guiding the project; and (d) concern about the sustainability of the achievements and activities supported under the project. 4. Assessment of Risk to Development Outcome Rating: Substantial 34 127. The risk is Substantial that the PDO achievements will not be sustained, because of inadequate funding. International resources contributed 80 – 84 percent of the funding for KNASP III, but most donor support/agreements have ended or will end soon. The NACC has however, put in place transition arrangements for resource mobilization to ensure continued support to the gains made under the TOWA project, and also to try and ensure the institutional and political sustainability of Kenya’s HIV programs. 124. Financial Sustainability: Most funding for HIV in Kenya has come from external sources, (Global Fund to Fight HIV and AIDS, TB and Malaria (GFATM), Presidential Emergency Plan for AIDS Relief (PEPFAR), World Bank credits, JICA and DFID), with the government contributing about 18 percent. To cope with the phasing out of external funding, Kenya has set up an HIV Trust/Investment Fund. An HIV investment unit was set up in the NACC in fiscal year 2015/16 to focus on developing a model to source and leverage funding. The HIV Fund is expected to implement innovative financing mechanisms to draw new resources that will be ring-fenced for high priority areas and interventions and underfunded areas within the HIV response as identified in Kenya’s Strategic Framework. Secondly, strong efforts are being made to ensure value for money through improving the efficiency and effectiveness of HIV services. Third, through policy dialogue, Kenya is seeking to learn how other countries are financing their HIV/AIDS programs and promoting cost effective cost-saving models of HIV service delivery. 125. Institutional Sustainability: With the ongoing devolution, NAC has made efforts and will continue to ensure that resources are allocated to HIV and AIDS programs. NACC will continue to advocate for HIV in the country, provide strategic guidance and technical support, coordination and mobilization of resources, while the HIV and AIDS services will be funded from County Budgets. NACC has met with Country Governors to lobby for increased HIV funding, and there are still ongoing negotiations with the Government. Follow-up is needed to ensure County budgets include clear budget lines for HIV and Counties are able to effectively respond to HIV prevention and control. NACC is seeking ways to sustain the investment in strengthened governance, institutional structures, M&E capacity and capacity building of various service providers. 126. Political Sustainability: In response to the political changes, NACC has set up an HIV framework rather than an HIV plan. Recognizing the constitutional role of the Counties in funding and implementing HIV activities, NACC has been helping each Country to come up with their HIV plans, with the help of partners especially UNAIDS, other development partners and also earlier using TOWA funding. NAC has begun its advocacy for HIV and AIDS through continuous dialogue and mobilization of Government including the Office of the President, the First Lady; Members of Parliament, County Governors and County First Ladies to ensure political sustainability of HIV and AIDS support in the counties and the country. 5. Assessment of Bank and Borrower Performance 5.1 Bank Performance 35 (a) Bank Performance in Ensuring Quality at Entry Rating: Satisfactory 127. Although preparation of the TOWA project was done in a difficult context marred by poor governance and corruption, the project preparation and design was consultative, evidence based, and thorough. The team performed very well in delivering a project that was fully aligned with Government and Bank priorities and global development goals. The design was informed by robust wide ranging analysis including of the prevailing political, governance and corruption situation in the country and the disease burden of HIV and AIDS. Project design fully reflected the lessons learned from the KHADREP and previous Bank supported HIV and AIDS projects including recommendations from the DIR, the 2005 IEG review of Bank AIDS support, and lessons from AIDS projects and programs supported by other development partners. During project design, the team ensured that they complied with requirements and criteria established for “repeater projects” under the MAP. 128. The fiduciary assessment of capacities in procurement and financial management were thorough. Capacity building initiatives were based on the identified implementation arrangements to ensure readiness for implementation. Relevant safeguards were properly assessed and addressed in the project design. Institutional arrangements were within the existing NACC and decentralized structures. Design and preparation for improved M&E received intensive effort. (b) Quality of Supervision Rating: Satisfactory 129. The team carried out implementation support missions of high quality; the problem- solving approach of the team is evidenced in mission reports and analysis. Mission teams included specialists with diverse expertise. A good practice of these missions was the thorough follow up on decisions taken in previous missions. The Bank team paid special attention to the fiduciary capacity of the NACC, followed up and made appropriate recommendations to assist the NACC to fulfill its mandate of project management and overall coordination of the national response. Through the HIV partnership and JAPRs, support from development partners was excellent. This, coupled with the enthusiasm and commitment from the participating institutions helped the NAC implementing team to proactively manage emerging implementation problems. The team was proactive in conducting financial and procurement and reviews and monthly review meetings with NACC to monitor the Implementation progress. The team provided consistently useful guidance and support to the NACC Secretariat. (c) Overall Bank Performance - Satisfactory 5.2 Borrower Performance (a) Government Performance – Moderately Satisfactory 36 130. Government demonstrated strong commitment and ownership throughout project development and implementation, and notably to improving governance. Relevant HIV policies and strategies are in place and were updated as needed. Hiring of additional staff was timely, but several agencies contributed to delays in hiring fiduciary agents, and the decentralization towards the end of the project disrupted financial flows and completion of activities. (b) Implementing Agency or Agencies Performance - Satisfactory 131. NACC - There is a general recognition that the national coordination mechanism for the HIV epidemic has broadly improved and is performing as expected, and that NACC has provided strategic leadership, oversight and political mobilization for the national response. The NACC secretariat has also actively managed the day-to-day coordination of KNASP III implementation, including execution of the decisions of the Board and Inter- agency Coordinating Committee; convening stakeholder meetings; and coordinating the decentralized governance systems as expected under KNASP III 24. As mentioned above, the capacity of NAC was developed with significant support from the project. The staff showed high level of professionalism and dedication to achievement of the objectives of the project. 132. During project preparation, the NACC developed an action plan for improving governance and accountability and put in place four fiduciary agencies namely: an independent Financial Management Agency; an independent procurement monitoring Agency; an independent Compliance Verification Agency; and an independent Performance (‘value for money’) Auditor. The performance of the project was continually monitored through the Project’s Results Framework and feedback provide to the implementing agencies. 133. PSIs – The performance of CSOs was Satisfactory. The CSOs showed a high level of engagement in the fight against HIV and AIDS including their willingness and commitment to address the challenges of HIV and AIDS at community level. They demonstrated high levels of transparency and accountability in implementing the sub- projects although capacity challenges still remained an issue. 134. Public Sector: Performance of other public sector entities HIV mainstreaming was moderately unsatisfactory. Disbursements were slow; eventually resources had to be reallocated to other fast performing activities. 135. RFAs, CACCs and DTCs performance was satisfactory. They facilitated and supported communities to write fundable proposals, followed up on implementation and monitored performance. 6. Lessons Learned 24 Final Report for End Term Review of Kenya National AIDS Strategic Plan III, 2009/10-2012/13 37 136. Realistic independent assessment of project progress is an effective mechanism that improves project management and service delivery. The use of fiduciary Agents to improve governance and accountability and enhance performance in the implementation of the project proved very effective in supporting NACC to achieve significant performance in accountability, monitoring and evaluation; and consequently improved service delivery and overall efficiency of the PSIs. The institutional strengthening of NACC and its decentralized structures to continue the performance improvement achieved under the TOWA project needs to continue and be sustained. 137. Using independent fiduciary and monitoring agents helps to identify problems of inappropriate use of disbursed funds early on and effectively address them in a timely manner them rather than waiting for the external audit at the end of the year. This contributed to efficient use of the project resources and improved accountability. Once local capacities in the country are built, such support could be sourced from local consultants at much lower cost. 138. Effective mechanisms to channel resources and technical assistance to the community level with clear guidelines on required results is an important ingredient to ensure achievement of sustained results. The project made financial resources available to civil society, public sector, private sector, universities and research institutions, focusing on initiatives in line with the KNASP and responding to priorities identified through the JAPR. The granting mechanism achieved remarkable results. The project now has an enormous amount of information on experiences under sub granting to PSIs. The use of PSI for community led interventions supported by grants through CfP is a good innovative approach of getting resources to beneficiaries. This approach directly involves the affected and infected persons and enables their participation in interventions that bring added value to HIV/AIDS at local level. This innovation can be replicated in other areas where similar Bank support/financing is ongoing. 139. When grassroots communities are facing crisis, it is possible to turn the crises into opportunities for improving lives in the community. This has been demonstrated under the project by ensuring that communities own the process and that resources (no matter how small) are made available and skills are built. 140. Streamlining institutional arrangements and roles during project design, and providing needed training to fulfill roles is a necessity for avoiding implementation delays: The project was implemented within NACCs existing devolved national structures comprising Nine Regional Offices and DTCs coordinated by the District Development Officer. The DTCs formed the technical arm of the district development level agenda on HIV and AIDS programs; and the CACCs coordinated and supervised HIV and AIDS activities at the community/constituency level. Although the project experienced effectiveness and initial implementation delays, after follow up and capacity building, implementation picked up. There is need to ensure that continuous capacity building in maintained in the light of inadequate capacity issues that were identified at the lower levels. 141. Strong investment in capacity building at all levels is essential to foster local development impact. Capacity building of Community Based Organizations requires sustained facilitation and a responsive program. The regional facilitating agencies, district 38 and constituency AIDS committees effectively played this role. Such capacity building helped some of the CBOs to access funding from other sources. The capacity built at the community level through the PSIs, RFAs, DTCs and the CACCs allowed communities to engage in the development processes thereby creating a positive impact on the levels of poverty among rural communities. 142. It is important to promote domestic financing in the design of critical disease control initiatives such as HIV/AIDS which require long term resource commitments lest they are impacted by vagaries of donor financing. 143. Learning by doing and effective use of program data are critical for fine tuning programs during implementation. This is very well institutionalized in the project through the Joint Annual Program Reviews which helped to adjust the project inputs. 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies 144. The rating of the TOWA project as satisfactory and the rating of NACC as satisfactory based on the on the oversight role NACC provided to the National Response and the Capacity building for the project implementers is noted. A statement from Mr. Henry Mutwiri, representative of the National Treasury, noted that the TOWA project was less problematic than other projects. (b) Co –financiers 145. The proposed co-financing with DFID did not come through, as noted earlier in this ICR. However, DFID continued to support capacity building of RFAs during the life of the project and seconded a staff to World Bank Kenya CO to work on Bank supported HIV and AIDS projects and programs including policy dialogue. (c) Other partners and stakeholders 146. None 39 Annex 1. Project Costs and Financing (a)Project Cost by Component (in USD Million equivalent) Main Thematic Appraisal Actual/Latest Area Estimate Estimate Percentage Components (USD (USD of Appraisal millions) millions) Strategic Leadership Accountability and Component A: Verification Governance and Evidence and Base 43.938 42.163 96 Coordination Capacity Management Strengthen Capacity Building of implementing Partners Grant Awards Mainstreaming in Component B: Program the Public Sector 91.062 92.837 102 implementation Essential Commodities Total Baseline Cost 135.00 135.00 100 Physical Contingencies 0.00 0.00 0.00 Price Contingencies 0.00 0.00 0.00 Total Project Costs 135.00 135.00 100 Front-end fee PPF 0.00 0.00 .00 Front-end fee IBRD 0.00 0.00 .00 Total Financing 135.00 135.00 Required (b) Financing Appraisal Actual/Latest Type of Co- Percentage Source of Funds Estimate Estimate financing of Appraisal (USD millions) (USD millions) Borrower 2.00 2.00 100 International Development 80.00 135.00 169 Association (IDA) United Kingdom 33.00 0 0 Note: At Appraisal, co-financing from UK DfID of US$33 million was expected, and IDA contribution of $80 million was planned. Co-financing was not able to be provided, and IDA provided additional funds during implementation. 40 Annex 2. Outputs by Component Background: The Total War against HIV and AIDS (TOWA) Project commenced in 2007 and closed on June 30, 2014. The project was valued at USD 135 million. 41 The original PDO was to assist Kenya to expand the coverage of targeted HIV and AIDS prevention and mitigation interventions through: (a) Sustaining the improved institutional performance of the NACC; and (b) Supporting the implementation of the KNASP. The project had two components: (a) Strengthening Governance and Coordination Capacity; (b) Support for Program Implementation. The Revised Project Development Objective was; (i) Expand the coverage of targeted HIV and AIDS prevention and mitigation measures and (ii) Expand access to bed nets among targeted People Living with HIV and AIDS and other households in malaria risk areas. The Project had two components; (1) Strengthening governance and coordination capacity with four thematic areas: Strategic Leadership; Accountability and Verification; Evidence Based Management; and Capacity Building of Implementing Partners; (2) Program Implementation with three thematic areas: Grant Awards; Mainstreaming in Public Sector; and Essential Commodities. Table 2a: Key Output Achievements Component 1: Strengthening Governance and Coordination Capacity Sub- Outputs Component Strategic • Annual Joint AIDS Program Reviews (JAPR) Leadership • KNASP Development, • Mid Term and End Term Reviews of KNASP, • Capacity building of NACC staff and its decentralized structures • Financed operation costs of NACC decentralized structures. • Kenya Demographic and Health Survey Plus (DHS+ includes the HIV module) was conducted in 2008/2009 • Kenya AIDS Indicator Survey 2012 • Biological and Behavioral Surveillance Survey of MARPs • Kenya Service Provision Assessment Survey, 2010 • Kenya National AIDS Spending Assessment study to assess all HIV expenditure in the country - KNASA Accountability • Grants Management Information System (GMIS) Monitoring and Coordination Groups (MCG) for each Priority and Area under KNASP II and III pillars. Verification • Engaged and maintained the services of independent fiduciary agents (FMA, PMA, CVA, and PA) and external financial auditors. The Fiduciary Agents played a key role monitoring the implementation of the project. Evidence a) Held JAPRs Based b) Strengthened the Management Information System (MIS) Management c) Supported Kenya Demographic Health Survey 2008/09, the HIV testing module and KAIS 2012. d) Strengthened and Monitoring and Evaluation systems of HIV projects and programs. • Launched KNASP M&E Framework; • Developed comprehensive KNASP M&E Implementation Manual; • Developed TOWA Project M&E Implementation Manual; • Developed reporting procedures by AIDS Control Unit (ACU) and key sectoral public sector entities; • Developed procedures for the interagency coordination for national reporting. • Produced a “Data Booklet” summarizing the principal, up-to-date information about the epidemic. • Developed Comprehensive CBO database • Developed the Community Based Program Activity Reporting (COBPAR) System, and created formal linkages with NACC’s new Local area network/Wide area network (LAN/WAN) and FMA 42 • M&E Division strengthened - recruited M&E Coordination Specialist; Database Administrator and Analyst/Programmer. • Strengthened and revived M&E Technical Working Group became active in coordinating M&E activities, standards and essential funding for M&E. 1. Midterm review of the strategic plan 2. An evaluation of the cash transfer for the OVC programme 3. End term evaluation of the KNASP III 4. HIV Programme Efficiency and Sustainability and HIV Response Evaluations 1. Evaluation of the PMTCT Programme using the Efficiency and Effectiveness Framework in the Nyanza Provincial General Hospital 2. Census for the TOWA Project Impact Evaluation Study on BCC targeting the Youth in Bondo and Kisumu East districts 3. Final Report for End Term Review of Kenya National AIDS Strategic Plan III, 2009/10- 2012/13; including 4. End of project evaluations of the components of the TOWA project. 5. Developed and launched 47 county-specific HIV and AIDS profile reports to create ownership of the HIV and AIDS response in the devolved government. Capacity • The TOWA project supported capacity building for: building of • Eight (8) Facilitating Agents (RFAs) to build the capacity of Community Based Organization. A total of 8,394 Implementing Project Sub Implementers (PSIs) were trained by the RFAs. Partners • One out four trained organizations successfully applied and received funding from TOWA with over 80 percent of funded project sub implementers achieving their project targets as verified by an independent Performance auditor. • Over 40 Percent of the TOWA PSI had more than one source of funds, aa indictor of sustainability Component 2: Program Implementation Sub- Outputs Component Grant Awards 1. The TOWA project cumulatively financed 10,712 project implementers over the period of implementation against a target of 8,400 2. Access to HIV counseling and testing • Cumulatively facilitated counseling and testing of 5.6 million clients through project funded PSIs who provided the HIV CT services. • Contributed to about 15 percent of the CT program clients under NASCOP. • During the project implementation period the percent of those who have ever been tested more than doubled 3. Community Mobilization • 22 million people were reached through Community Mobilization and advocacy at all levels. 4. Behavior Change Communication. • Over 7.5 million Most at Risk population were reached with BCC. 5. Voluntary Medical Male Circumcision (VMMC) • 10,067 males were provided with or referred for VMMC services against a target of 6,899. • Proportion of circumcised men in targeted region has increased by over 30 percent. 6. Support Orphans and Vulnerable Children • 43,481Orphans and Vulnerable children were reached with various services which included skills and input, material support, nutrition, IGA, psychosocial support, medical assistance, clothing, shelter, and education. 7. Vulnerable and Marginalized Groups • 1,440 VMG community leaders on HIV and AIDS awareness, HTC, condom promotion and the VMG project design, mobilizing • 80,000 VMG community members within VMG and barazas, • Distributed 89,536 male and 2,133 female condoms. • Sensitized and trained 288 VMG resource persons as peer educators. Mainstreaming • A total of 51 public institutions were funded under the TOWA project. Public Sector • Out of proposals valued at USD 4,000,000 submitted, the TOWA project funded USD. 3,500,000. Programs 43 Essential 1. Anti TB drugs: Commodities • Over 100,000 patients benefited from the Anti TB drugs. 2. Bed Nets • 2.8 million bed nets procured • 500,000 distributed to People Living with HIV and 2.3 million through mass distribution to high malaria endemic regions in Coast and Rift valley. • An estimated to have benefited 5.2 million people • Contributed to increased household ownership of Insecticide Treated Nets (ITNs). • Contributed to reduced malaria incidence in both Coast and Highland endemic regions after distribution of the Nets. 3. Condoms • Procured 322,848,000 million condoms. TOWA was the country’s main source of male condoms during the implementation period. 44 Table 2b: Original Project Development Objective - Outputs Total War Against HIV and AIDS - KENYA Result Framework Indicator Baseline Year 1 2007/2008 Year 2 2008/2009 Year 3 2009/2010 Year 4 2010/2011 value Target Actual Target Actual Target Actual Target Actual* * Project Outcome Indicators 1 NACC composite score on annual Very Very Good Very Very Good Very Good Very N/A independent performance Good Good Good Good Good evaluation 2 Number of quarterly performance 4 4 4 4 4 4 4 4 contract monitoring to the government 3 Proportion of overall targets met N/A 60% N/A 65% 81% 70% 82.4% 80% for NACC- funded programs in Civil society 4 Proportion of overall targets met N/A 60% N/A 65% N/A 70% 88% 80% for NACC- funded programs to the Public sector beneficiaries Key outcome indicators for prevention and mitigation programs 5 Proportion of youth aged 15-24 F- - F 30% F-39.5%, - - - reporting condom use in the last 24%,M- M 50% M-64.6% sexual intercourse with a non- 47% regular partner( of those reporting (KDHS sexual intercourse with a non- 2003) regular partner in the last 12 months 45 Total War Against HIV and AIDS - KENYA Result Framework Indicator Baseline Year 1 2007/2008 Year 2 2008/2009 Year 3 2009/2010 Year 4 2010/2011 value Target Actual Target Actual Target Actual Target Actual* * 6 Proportion of sexually active F-30%, - F 25% F-33%, - - - youth aged 15-24 who report M-84% M 80% M-83% having had a sex with a non- (KDHS spousal, non-regular partner in the 2003) last 12 months 7 Number of persons who undergo 800,000 949,250 2,500,000 3,471,567 950,000 - testing and counseling 750,000 850,000 900,000 8 Number of condoms distributed 120M 132 122M 144,000 146.4M 156M 180M 168M - Intermediate Outcome Indicators 9 High level satisfactions with 58% High 70% High 65% High 78% High NACC as shown in annual satisfaction survey 10 Proportion of CACCs and DTCs N/A 60% 203/210 (97%) 70% 195/210 (93%) 80% 210/210 (100%) 90 which function according to reported through Reported through CACCS and performance indicators COBPAR 100% COBPAR 143/147 (97.2%) CACCs submitted received proposals 68/71 DTC Submitted proposals 11 Annual audit report for NACC Unqualifi Unquali Except for' Unquali Except for' Unqualifi Ongoing Unquali demonstrating transparent and ed fied reservation fied reservation ed fied accountable financial management 12 Publications of NACC annual Publishe Publish Published Publish In progress Publishe Planned Publish financial report d ed ed d ed 46 Total War Against HIV and AIDS - KENYA Result Framework Indicator Baseline Year 1 2007/2008 Year 2 2008/2009 Year 3 2009/2010 Year 4 2010/2011 value Target Actual Target Actual Target Actual Target Actual* * 13 Proportion of funds received by About 80% 67% 85% 57% 85% 100% 90% NACC that are expended annually 80% (last year of KHADR EP) 14 The proportion of KNASP M&E 57/106 75% 59/106 (55%) 80% 44/55 (80%) 85% planned 95% indicators included in the annual (53%) M&E report, disseminated and available on time for JAPR 15 Number and proportion of N/A 70% 3272 (76.5%) 80% N/A 80% Pending 80% proposals received by NACC that are rated as meeting CFP criteria for approval each year 16 Proportions of overall targets met N/A 60% N/A 65% 81.30% 70% 81.8% 80% for NACC funded programs in civil society and private sector 17 Number/proportion of registered N/A 60% 5,261 70% 7,600 80% 7,652 90% CBOs reporting through COBPAR at the time of the JAPR 18 Number and proportion of priority 33/43 85% 38/42 (90%) 90% 40/42 (95.%) 100% 40/42 (95.%) 100% sector ministries, divisions, that (77%) have identified their needs in HIV and AIDS programs, have costed them and engaged MTEF process to fund them and are able to monitor and report on expenditures 47 Total War Against HIV and AIDS - KENYA Result Framework Indicator Baseline Year 1 2007/2008 Year 2 2008/2009 Year 3 2009/2010 Year 4 2010/2011 value Target Actual Target Actual Target Actual Target Actual* * 19 Coordination meetings held with 12 ICC 12 ICC 12 ICC 12 ICC 12 ICC 12 ICC 12 ICC 12 ICC participation from key 4MCG 4MCG 4MCG 4MCG 4MCG 4MCG 4 pillar 4MCG stakeholders (ICC meetings and MCG meetings) 20 JAPR with participation from Yes Yes Yes Yes Yes Yes Yes Yes principle development partners, implementing partners from civil society, private sector and public sector Output Indicators 21 Annual external audit report Done Done Done Done Done Done planned Done 22 Number of costed annual work N/A 10 10 10 11 10 11 Done plans developed by division 23 Number of civil society and N/A 1,400 N/A 2,000 650 2,500 1,722 2,500 private sector organizations R1; 19 supported under TOWA ( Per R2; 1699 year) R3; 4 Number of civil society and N/A 1,400 N/A 3,400 650 5,900 2,372 8,400 private sector organizations supported under TOWA (Cumulative) 24 Number of grant proposals N/A 2,800 4,273 4,000 N/A 5,000 12,075 5,000 received from private and civil R2; 6,905 society per year R3; 5,170 48 Total War Against HIV and AIDS - KENYA Result Framework Indicator Baseline Year 1 2007/2008 Year 2 2008/2009 Year 3 2009/2010 Year 4 2010/2011 value Target Actual Target Actual Target Actual Target Actual* * 24 Number of grant proposals N/A 2,800 4,273 6,800 4,273 11,800 16,348 16,800 received from private and civil society (Cumulative) 25 Number of male and female 10 11 12M 12 12.2M 13 15M 14M condoms distributed monthly Million monthly 26 Number of public sector 33 21 0 21 9 21 7 21 organizations supported in mainstreaming Table 2c: Revised Development Objectives - Outputs Sub-components and Primary Activities/ Outputs Unit of Planned outputs Actual outputs %age measure Achievement IFR3-Final Jan 2014 Planned outputs Final cumulative- Jan 2014 COMPONENT 2 - PROGRAM IMPLEMENTATION A. Sub Grant Award: Grants to NGOs, CBOs, Private Sector based on CfPs(PSIs) 1.Counseling and Testing Services-Hard to Reach Areas(CT-HTR) Number reached through community mobilization -CT HTR No. 232,245 320,283 138% Number of people counselled and tested-CT HTR No. 162,010 170,322 105% Number of people/peer educators trained to provide HIV/AIDS prevention No. 556 4,794 862% education-CT HTR 49 Sub-components and Primary Activities/ Outputs Unit of Planned outputs Actual outputs %age measure Achievement 2.Counseling and Testing - Youth especially females & older OVC Number reached through community mobilization-Youth No 315129 516506 164% Number of people counseled and tested-Youth No. 183132 225363 123% Number of people/peer educators trained to provide HIV/AIDS prevention No. 1650 1271 77% education-Youth Counseling and Testing Most at Risk Population Number of Long Distance Track Drivers reached through Community Mobilization No. 54005 64530 119% Number of Long Distance Track Drivers Counseled and tested No. 24839 30279 122% Number of Long Distance Track Drivers Counseled and tested No. 7680 11448 149% Number of people/peer educators trained to provide HIV/AIDS prevention 1000 1880 188% education Long Distance Track Drivers 4.Counseling and Testing (MARPS) services-People who Inject Drugs (PWID) Number of Drug Users reached /Mobilized No. 37379 44801 120% Number of People who Inject Drugs counseled and tested No. 1380 1467 106% 5. Counseling and Testing- General Population(GP)-All Calls No. 3,689,200 4,398,362 119% Number of people mobilized and sensitized on HIV/AIDS- Number of people counseled and tested No. 2,149,975 2,274,725 106% Number of people/peer educators trained to provide HIV/AIDS prevention No 5,320 5,388 101% education this quarter Number of IEC messages/materials developed/disseminated No. 64,190 70,913 110% Number of referrals made for further services No. 28,190 22,308 79% Number of people trained on condom use and disposal No. 20,618 19,158 93% Number of condoms distributed No. 1,613,220 2,100,927 130% 6. Most At Risk Populations( MARPs) No. 935,637 1,185,814 127% Number of people mobilized and sensitized on HIV/AIDS-CT-MARPS 50 Sub-components and Primary Activities/ Outputs Unit of Planned outputs Actual outputs %age measure Achievement Number of people counseled and tested-CT-MARPS No. 596,833 701,933 118% Number of people/peer educators trained to provide HIV/AIDS prevention No. 2,779 3,006 108% education-CT-MARPS Number of IEC messages/materials developed/disseminated-CT-MARPS No. 41,225 59,885 145% Number of referrals made for further services-CT-MARPS No. 9,252 9,247 100% Number of people trained on condom use and disposal-CT-MARPS No. 29,230 24,980 85% Number of condoms distributed-CT-MARPS No. 523,700 556,130 106% B. Behavior Change Communication (BCC) 7. BCC Couples Number of couples reached with BCC messages-BCC Couples No. 197,199 272,395 138% Number of couples counseled and tested-BCC Couples No. 32,468 33,961 105% No. 1,876 1,898 101% Number of peer educators trained to provide HIV/AIDs education-BCC Couples No. 101,275 126,616 125% Number of IEC messages/materials developed/disseminated-BCC Couples Number of referrals made for further services-BCC Couples No. 705 745 106% Number of couples trained on condom use and disposal-BCC Couples No. 43,702 77,132 176% Number of condoms distributed-BCC Couples No. 644,686 753,480 117% 8. .Behavior Change and Education for Youth Number of youth reached with BCE messages- No. 2,098,380 2,668,787 127% Number of youth counseled and tested No. 182,711 172,916 95% Number of youth leaders co-opted / Peer Educators trained to provide HIV/AIDs No. 24,721 27,427 111% education No. 1,141,054 1,280,922 112% Number of IEC messages/materials developed/disseminated Number of youth trained on condom use and disposal No. 486,473 540,635 111% Number of condoms distribute to Youth No. 3,583,531 4,071,525 114% 51 Sub-components and Primary Activities/ Outputs Unit of Planned outputs Actual outputs %age measure Achievement No. 22,153 26,682 120% Number of Youth equipped with life skills/to delay sexual debut 9. Behavior Change Communication MARPS Number of MARPs reached with BCC messages No. 651,160 870,413 134% Number of MARPs counselled and tested No 90,135 94,779 105% No. 3,240 3,779 117% Number of peer educators trained to provide HIV/AIDs education Number of IEC messages/materials developed/disseminated No. 264,083 297,901 113% No. 78,028 93,653 120% Number of couples trained on condom use and disposal Number of condoms distributed No. 1,763,503 1,965,863 111% 10. Behavior Change Communication- Fisher Folks Number of Fisher Folk reached with BCC messages No. 107,854 155,338 144% Number of Fisher Folk counseled and tested No. 4,152 5,206 125% No. 395 535 135% Number of peer educators trained to provide HIV/AIDs education to fisher folks Number of IEC messages/materials developed/disseminated No. 68,450 109,022 159% Number of couples trained on condom use and disposal No 6,726 8,442 126% Number of condoms distributed No 176,615 190,277 108% C. Home Based Care Services (HBCS) 11. HCBC Number of caregivers Trained on HBC &HIV related services-HBCS No. 23829 25398 107% Number of caregivers receiving psycho-social Support-HBCS No. 18625 19100 103% Number of caregivers provided with IGA support-HBCS No. 13422 13513 101% No. 3609 3597 100% Number of PLWHAs provided with food and nutritional support-HBCS Number of PLWHAs receiving palliative care services-HBCS No. 33498 31837 95% 52 Sub-components and Primary Activities/ Outputs Unit of Planned outputs Actual outputs %age measure Achievement Number of PLWHAs referred for further services-HBCS No. 3679 3841 104% No. 33352 34623 104% Number of caregivers & PLWHAs accessing HIV related services-HBCS D. Capacity Building for Communities 12. Community strengthened to support PLWHIV(CSSP/PWP) No. 561,892 695,947 124% Number of PLWHA reached with HIV messages/sensitized/mobilized-PWPs Number of PLWHA counseled and tested-PWPs No. 51,445 55,926 109% Number of people/peer educators trained to provide HIV/AIDS prevention No. 4,476 4,908 110% education-PWPs Number of IEC messages/materials developed/ disseminated-PWPs No. 165,202 237,941 144% Number of PLWHA trained on condom use and disposal-PWPs No. 572,674 1,072,348 187% Number of condoms distributed –PWPs No. 814,790 805,806 99% Number of PLWHA accessing HIV services No. 5,860 5,300 90% Number of PLWHA supported with Psycho-social support No. 2,475 2,535 102% Number of PLWHA Trained on PMTCT No. 1,650 2,404 146% Number of PLWHA equipped with Public speaking skills No. 114,744 124,403 108% Number of people trained on human rights and positive attitude towards PLWHA. No. 187,663 212,532 113% E. Voluntary Medical Male Circumcision(VMMC) Number of people reached with BCC messages-VMMC No. 70105 78565 112% No 6899 10067 146% Number of male provided and /or referred for VMMC services -VMMC Number. of people trained to support VMMC No. 1452 1450 100% No. 13364 11105 83% Number of IEC messages/materials developed/disseminated-VMMC F. PMTCT/PMTCT Number of pregnant women Mobilized/sensitized-PMTCT/PMTCT+ No. 213,000 283,799 133% Number of pregnant women counseled and tested-PMTCT/PMTCT+ No. 80,015 88,859 111% 53 Sub-components and Primary Activities/ Outputs Unit of Planned outputs Actual outputs %age measure Achievement Number of people/peer educators trained to provide HIV/AIDS prevention No. 2,327 2,286 98% education-PMTCT/PMTCT+ 10,900 12,650 116% Number of IEC messages/materials developed/disseminated-VMMC Number of pregnant women counseled on Infant feeding options- No. 5,748 18,267 318% PMTCT/PMTCT+ Number of PMTCT clients/couples provided with PMTCT+ services- No. 7,725 12,172 158% PMTCT/PMTCT+ G. Minimum Package Support of Orphans and Vulnerable Children Number of OVC supported with Nutrition-OVC Support No. 10288 10868 106% Number of OVC supported Shelter-OVC Support No. 1478 3720 252% Number of OVC supported Education-OVC Support No. 4305 4604 107% Number of OVC supported Clothing-OVC Support No. 6116 6055 99% Number of OVC supported with medical assistance-OVC Support No. 3365 4606 137% Number of OVC supported Psychosocial support-OVC Support No. 1307 1771 136% Number of OVC supported with Other Material Support-Blankets etc.-OVC No. 6035 6841 113% Support Number of OVC supported with income generating activities (IGAs)-OVC Support No. 3486 3557 102% Number of guardians / caregivers provided with skills and inputs, for IGA (seeds, No. 1336 1459 109% rabbits, goats, etc.)-OVC Support H. CfP Target Area: Counseling and Testing MARPS No 396,508 430,771 109% Number of people mobilized and sensitized on HIV/AIDS Number of people counseled and tested No 191,392 202,431 106% Number of people/peer educators trained to provide HIV/AIDS prevention No 1,855 2,070 112% education- Number of IEC messages/materials developed/disseminated No 52,296 49,972 96% Number of referrals made for further services No 10,481 10,603 101% 54 Sub-components and Primary Activities/ Outputs Unit of Planned outputs Actual outputs %age measure Achievement 9,267 18,345 198% 6.Number of people trained on condom use and disposal Number of condoms distributed 617,205 916,295 148% I. CfP Target Area: Counseling and Testing for Couples Number of people mobilized and sensitized on HIV/AIDS No 1,823,866 2,408,562 132% Number of people counseled and tested No 773,000 870,412 113% Number of people/peer educators trained to provide HIV/AIDS prevention No 4,359 4,426 102% education 53,674 53,019 99% 4.Number of IEC messages/materials developed/disseminated Number of referrals made for further services- No 35,455 34,667 98% No 35,087 34,799 99% .Number of people trained on condom use and disposal Number of condoms distributed No 2,460,999 3,137,267 127% Number of people accessing Family Planning services by PLHIV and their 30,512 26,821 88% partners J. CfP Target Area: BCC -Youth-CACC Number of youth reached with BCC messages- No 3,311,056 3,665,859 111% Number of youth counselled and tested No 19,770 26,187 132% 3.Number of youth leaders co-opted/ Peer Educators trained to provide HIV/AIDs No 22,325 23,336 105% education-BCC Youth Number of IEC messages/materials developed/disseminated-BCC Youth No 412,486 437,958 106% Number of youth trained on condom use and disposal-BCC Youth No 205,953 261,252 127% Number of condoms distributed-BCC Youth No 2,806,244 3,607,995 129% K. CfP Target Area: PLHIV Group mobilization -Peer Support & facility Linkage -CACC Number of PLHIV reached with HIV Messages/sensitized-PLHIV Groups No 167,239 193,239 116% Mobilize Number of PLHIV counseled and tested-PLHIV Groups Mobilize No 7,934 8,992 113% 55 Sub-components and Primary Activities/ Outputs Unit of Planned outputs Actual outputs %age measure Achievement Number of people/peer educators trained to provide HIV/AIDS prevention No 2,020 2,442 121% education-PLHIV Groups Mobilized Number of IEC messages/materials developed/disseminated-PLHIV Groups No 182,938 187,217 102% Mobilized No 1,746 1,796 103% Number of PLHIV trained on condom use and disposal-PLHIV Groups Mobilize Number of condoms distributed -PLHIV Groups Mobilize No 315,752 381,176 121% L. Prevention With Positives Support in line with Basic Care package(BCP)-CACC Number of PWP reached with HIV Messages-PWP Support BCP No 1,077,541 1,277,329 119% No 314,462 343,421 109% Number of PWPs & family members counselled and tested-PWP Support BCP Number of people/peer educators trained to provide HIV/AIDS prevention No 8,794 11,806 134% education--PWP Support BCP No 141,667 150,282 106% Number of IEC messages/materials developed/disseminated--PWP Support BCP No 27,538 32,907 119% Number of referrals made for further services/posttest-clubs)--PWP Support BCP No 43,117 59,802 139% Number of PW trained on condom use and disposal-PWP Support BCP No 2,933,040 4,014,737 137% Number of condoms distributed To PWPs & their partners-PWP Support BCP Number of PW accessing HIV services-PWP Support BCP No 4,340 4,317 99% Number of PW supported with Psycho-social support-PWP Support BCP No 3,840 5,030 131% No 44,771 49,911 111% No. of PLHIV accessing family planning services-PWP Support BCP No 16,132 15,940 99% No. of PLHIV referred for screening and treatment of TB-PWP Support BCP No of PLHIV in functional post-test clubs No 22,626 21,477 95% Number of PLHIV reached with PW minimum package No 157,880 170,533 108% M. CfP Target Area: Support Established Community Health Units-for HIV &AIDS service integration No of functional community units supported to fully integrate HIV and AIDS No 1,465 1,573 104% services 56 Sub-components and Primary Activities/ Outputs Unit of Planned outputs Actual outputs %age measure Achievement No Community Health Workers &Community Health Workers capacity built to No 56,873 58,650 103% provide HIV & AIDS services No. of Community Health Units dialogue and planning meetings facilitated that No 10,657 28,699 269% address issues of HIV & AIDS No. of Community Health Units linkages to health facilities No 4,743 4,858 102% No of Community Health Units with referral system on HIV and AIDS-Baseline No 13,329 13,131 99% First time. CU Support Costs Incurred KES N. Voluntary Male Medical Circumcision Number of people reached with BCC messages-VMMC No 137,308 164,837 120% Number of male provided with VMMC services -VMMC No 1,500 1,687 112% No. of people trained to support VMMC No 588 808 137% No 50,939 50,350 99% Number of IEC messages/materials developed/disseminated-VMMC Number of referrals made for further VMMC services-VMMC No 8,520 9,312 109% Number of People trained on condom use and disposal-VMMC No 80 80 100% Number of condoms distributed -VMMC No 142,000 153,150 108% O. Sero Discordant Couples – CACC Number of discordant couples reached No 290,591 348,861 120% Number of couples counselled and tested- PLHIV No 48,276 55,261 114% No. of couples /peer educators trained No 1,198 1,228 103% Number of IEC messages/materials developed/disseminated-PLHIV Groups No 22,369 20,779 93% Mobilize Number of referrals made for further services No 1,870 2,077 111% Number of couples trained on condom use and disposal No 9,663 11,881 123% Number of condoms distributed- PLHIV No 520,800 663,817 127% P. Discordant couples-CACC 57 Sub-components and Primary Activities/ Outputs Unit of Planned outputs Actual outputs %age measure Achievement Number of couples reached - Discordant No 390,189 637,829 163% Number of couples counselled and tested-Discordant couples No 50,771 58,704 116% No. of couples trained No 1,519 1,470 97% No 5,060 6,637 131% Number of IEC messages/materials developed/disseminated-Discordant Number of referrals made for further services-legal, psychosocial & crisis No 6,171 6,013 97% management Number of couples trained on condom use and disposal No 11,316 16,599 147% No. of condoms distributed- Discordant couples No 1,827,630 2,327,976 127% Number of self-help groups and PLHIV groups strengthened No 21,513 23,552 109% Number of persons whose capacity has been strengthened No 79,024 94,006 119% Q. stigma& Discrimination No. of people reached with relevant messages-Anti stigma No 1,949,604 3,017,135 155% Number of people counseled and tested-Anti stigma& Disc No 9,770 10,046 103% No. of people trained – Anti- stigma No 261 249 95% No. of IEC materials distributed and disseminate- Anti-stigma No 163,962 169,193 103% Number of referrals made for further services No 3,436 3,969 116% Number of people trained on condom use and disposal No 5,337 6,321 118% No. of condoms distributed- Anti-stigma No 556,116 750,520 135% R. Behavior Change Communication General Population No. of persons reached with the various messages-GP No 4,721,273 5,531,703 117% No. of People counselled and tested-GP No 35,624 38,109 107% No. of people/peer educators trained to provide HIV/AIDS education-BCC GP No 8,810 9,893 112% No. of IEC materials disseminated per service area-GP No 187,253 215,174 115% No. of referrals made for further services-BCC GP No 1,605 1,371 85% No. of People trained on condom use and disposal-BCC GP No 42,126 54,063 128% 58 Sub-components and Primary Activities/ Outputs Unit of Planned outputs Actual outputs %age measure Achievement No. of condoms distributed- GP No 1,753,247 2,313,278 132% S. Counseling and Testing Couples-DTC Number of people mobilized and sensitized on HIV/AIDS- CT Couples-DTC No 143,029 177,900 124% Number of people counseled and tested- CT Couples-DTC No 73,986 78,793 106% Number of people/peer educators trained to provide HIV/AIDS prevention No 617 586 95% education -CT Couples-DTC No 1,099 1,196 109% Number of people trained on condom use and disposal- CT Couples-DTC Number of condoms distributed- CT Couples-DTC No 358,750 492,234 137% 59 Table 2d: Revisions to Objectives and Indicators Revised PDO The revised Project development Objectives are to: (i) expand the coverage of targeted HIV and AIDS prevention and mitigation measures; and (ii) expand access to bed nets among targeted People Living with HIV and AIDS and other households in malaria risk areas. Revised Definition of Success will be measured as the proportion of beneficiaries scoring “Very Good” or “Excellent” for ‘Success” of grants target achievement. The need to change the definition of “success” arose from confusion with the under the CFPs initial grants under the Total War Against HIV and AIDS (TOWA) as to whether the focus should be on the performance of individual grants or the achievement of aggregate targets. The new indicator will measure success at the level of the individual subproject grant beneficiary. However, the end-of-Project target for the subproject beneficiaries will still be for at least 80 percent of the grants to be rated as successful, using the new definition. Specific Project The target for the total number of grants would be restored from about 4,000 (the target in the Outcome Indicator recently restructured Project) to 8,400. The original target for the TOWA was 8,400, but the target was reduced as part of the restructuring of the Project, with funding then being reallocated away from grants and commodities to additional bed nets. New Project Outcome The new indicator will be a percentage of households that have more than one insecticide-treated Indicator bed net (ITN) in malaria endemic areas. A new intermediate outcome indicator is also introduced to reflect the purchase of the additional bed nets 25 Impact Evaluation The focus of the impact evaluation will be on determining the effect of Behavior Change Interventions on the prevention of HIV amongst the youth, in Nyanza Province. 25While the actual use of bed nets would normally be a better indicator, a more modest indictor reflecting household Access to bed net is proposed, in view of the limited role of TOWA in supplying the nets to the national malaria Program. 60 Revisions to the Results Framework Comments/ Rationale for Change PDO Current (PAD) Proposed To assist Kenya to expand the coverage (a) expand the coverage of To reflect the project’s contribution to scale-up of of targeted HIV and AIDS prevention and targeted HIV and AIDS insecticidal bed net supply in support of the new mitigation interventions. This would be prevention and mitigation National Malaria Control Strategy. done through (i) sustaining the improved measures; and institutional performance of the National (b) Expand access to bed nets AIDS Control Council (NACC): and (ii) among targeted people living supporting the implementation of Kenya with HIV and AIDS and other National AIDS Strategic Plan (KNASP). households in malaria risk areas. PDO indicators Current (PAD) Proposed change* POI# 1. NACC composite score on the Dropped. Because; (i) this is an intermediate outcome under the annual independent performance re-stated PDO; and (ii) NACC performance is evaluation. captured under other intermediate outcome indicators (e.g., the new IOI#1 and IOI#2). POI# 2. Proportion of overall targets met Revised: POI#1. Proportion of The proposed indicator measures the performance of for NACC-funded programs in: Project Sub Implementers (PSIs) individual beneficiaries based on the four parameters Civil society/private sector scoring “Very Good” or used by the Independent Performance Auditor instead (beneficiaries); and Public sector “Excellent” for target of aggregate performance. 26 These parameters (beneficiaries). achievement in the annual include: actual targets achieved versus the planned performance audit. targets, quality of target evidence, risk of double accounting of targets, validity of variances observed and evidence of outreach activities. The performance audit assigns each subproject grant beneficiaries an overall score, which helps grading them in to excellent, very good, fair, bad and very bad Categories. The public sector component of the original indicator has been dropped to reflect the significant reduction in funding allocated to public sector interventions in the Additional Financing. Revised: POI#2. Number Indicator promoted (from IOI) to POI level to reflect (cumulative) of civil society/ the renewed focus on scale-up. Though this is not private sector grants supported perfect outcome indicator, it was decided (WB/Kenya by the end of the year. team on October 21, 2010) to retain it at POI level since an increased capacity to perform by beneficiaries is a critical pre-requisite to the attainments of outcomes. It was also highlighted that a similar indicator existed (at POI level) in the original and approved Project Appraisal Document (PAD). POI# 3. Proportion of sexually active Continued: POI# 4. Proportion The HIV AND AIDS literature suggests that self- youth 15- 24 who report having had sex of sexually active youth 15- 24 reported behavioral data tends to overstate true with a non-spousal, non-regular partner in who report having had sex with behavior and needs to be validated with STI incidence the past 12 months. a non-spousal, non-regular data. During implementation of the project, trends in partner in the past 12 months. STI incidence (e.g., syphilis incidence) will be used to validate the trends in self-reported behavioral data. 26 The revision in this indicator is motivated by the imprecision of the earlier definition. A more explicit definition, as provided here, allows for consistency in reporting. 61 Revisions to the Results Framework Comments/ Rationale for Change POI# 4. Proportion of youth aged 15-24 Continued: POI# 3. Proportion The HIV AND AIDS literature suggests that self- reporting condom use in the last sexual of youth aged 15-24 reporting reported behavioral data tends to overstate true encounter with a non-regular partner (of condom use in the last sexual behavior and needs to be validated with STI incidence those reporting sexual intercourse with a encounter with a non-regular data. During implementation of the project, trends in non-regular partner in the last 12 months). partner (of those reporting STI incidence (e.g., syphilis incidence) will be used to sexual intercourse with a non- validate the trends in self-reported behavioral data. regular partner in the last 12 months). New: POI# 5. Percentage of The indicator matches the scope of the project households in malaria endemic (emergency procurement of bed nets). Furthermore, areas in districts supported by TOWA remains primarily an HIV AND AIDS project the TOWA Project that have at as the funding for malaria constitutes 18% of total least one ITN. project funds (US$24 million out of US$135 million) and 18% of the Additional Financing operation (US$10 million out of US$55 million). In due recognition that bed net utilization is the ultimate aim, the project will track bed net utilization as a complementary indicator during the project implementation. Both indicators are available in the Malaria Indicator Surveys (MIS) planned once every three years. Since TOWA nets will only be distributed in the Coastal Counties only, the appropriate disaggregated value from the MIS will be used. An alternative, and more regular, data source is the post- distribution evaluation that is carried out three months after nets are distributed. New: POI# 6. Number of Number of persons undergoing Counseling and persons who undergo testing and Testing is an appropriate measure of service coverage. counseling in the past 12 months When the trend of this indicator is analyzed in the (under the TOWA project). context of IOI#5 (National number counseled and tested in the last 12 months-from National Aids and STI Control Programme (NASCOP), it provides a measure of TOWA contribution to the national CT output. POI# 5. Number of persons who undergo Dropped as POI. Indicator demoted to IOI level. testing and counseling in the past 12 months (National figure, from NASCOP). POI# 6. Orphans and Vulnerable Children Dropped. OVC interventions are no longer being included in the (OVC) receiving care/support in the past Call for Proposals from round 3 as they are being 12 months. supported through a separate World bank funded project. POI#7. Number of male and female Dropped as POI. Indicator was demoted to IOI level. condoms distributed in the past 12 months. Intermediate Results indicators Current (PAD) Proposed change* IOI#1. Level of stakeholder satisfaction Continued: IOI# 1. Level of with NACC. stakeholder satisfaction with NACC. IOI#2. The proportion of Constituency Dropped. Complete data for all four elements of the indicator AIDS Control Committees (CACCs) and not consistently available each year. Indicator dropped 62 Revisions to the Results Framework Comments/ Rationale for Change District Technical Committees (DTCs), by NACC and by World Bank (WB) project which function according to performance management. indicators (see OM for definition). [Similar to Kenya National AIDS Strategic Plan (KNASP) 4.4.3]. IOI#3Annual audit report for NACC Revised: IOI# 2. Issues in The revision removes any ambiguity regarding timing. demonstrating transparent and NACC’s qualified report to be accountable financial management. addressed by the end of March [KNASP 4.3.5]. of the following year (yes/no). IOI#4. Proportion of funds received by Dropped. NACC may however continue to track the indicator the NACC that are expended annually. for operational purposes. [KNASP 4.3.6]. IOI#5. The proportion of KNASP M&E Continued: renumbered as indicators included in the annual M&E IOI#3. The proportion of report, disseminated and available on KNASP M&E indicators time for the Joint Annual Programme included in the annual M&E Review (JAPR) [KNASP 4.1.7 and report, disseminated and 4.5.7]. available on time for the JAPR. IOI#8. Proportion of registered Continued: IOI#4. Proportion of Community Based Organizations (CBOs) registered CBOs reporting reporting through the Community Based through COBPAR at the time of Programme Activity Reporting tool the JAPR. (COBPAR) at the time of the JAPR. [TOWA specific—similar to KNASP 4.1.4]. Revised: IOI#5. Number of Demoted from the POI level. persons who undergo testing and counseling in the last 12 months. (National, from NASCOP). New: IOI#6. Number of couples Replaces POI#5 in the PAD and captures the current counseled and tested in the past major cause of new infections as a significant part of 12 months under the TOWA new infections (44%) in Kenya occur in couples who project. engage in heterosexual activity within a union or regular partnership. IOI#6 is currently being tracked by NACC. Although there may be substantial overlap between IOI#5 and IOI#6, it was agreed (by WB/Kenya Team) to keep both indicators since IOI#5 can serve as a useful denominator for the new POI#6) New: IOI# 7. Number of youth Measures the reach of HIV prevention services to the reached with BCE messages in youth. the past 12 months New: IOI# 8. Number of HIV+ New: Measures the contribution of the project to HIV individuals provided with Home- AND AIDS mitigation. This indicator could also Based Care (Palliative care) move to POI level but there are already 6 (many) through the TOWA interventions indicators at POI level in the past 12 months IOI#17. Number of male and female Revised: IOI#9. Number of male Demoted from the POI level. Majority of condoms condoms distributed [M&E 42, SC 10]; and female condoms distributed procured/distributed by NASCOP come from the and in the last 12 months (national, TOWA project (for the next two years, all are TOWA from NASCOP). condoms). 63 Revisions to the Results Framework Comments/ Rationale for Change New: IOI# 10. Number of long Measures the supply of bed nets for malaria lasting insecticide treated prevention supported by the TOWA. malaria nets purchased and/or distributed. IOI#6. Number and proportion of Dropped. Will be tracked by NACC for project monitoring proposals received by the CACCs, DTCs and the NACC that are rated as meeting Call for Proposal (CfP) criteria for approval each year. [Not in KNASP--- TOWA-specific]. IOI#7. Proportion of overall targets met Replaced. Replaced with POI#2. for NACC-funded programs in civil society and private sector. [Not in KNASP—TOWA specific]. IOI#9. Number and proportion of priority Dropped. Will be tracked by NACC for project monitoring. sector entities (ministries, divisions, etc.) that have identified their needs in HIV and AIDS programs, have costed them, have engaged the MTEF process to fund them and are able to monitor and report on expenditures. [Similar to KNASP 4.5.8]. IOI#10. Coordination meetings held with Dropped. Will be tracked by NACC for project monitoring. participation from key stakeholders (ICC meetings and MCG meetings). [Similar to KNASP 4.5.5]. IOI#11. JAPR with participation from Dropped. Will be tracked by NACC for project monitoring. principal development partners, implementing partners from civil society, private sector and public sector. [KNASP 4.5.7]. IOI#12. Annual external audit report Dropped. Will be tracked by NACC for project monitoring. [KNASP 4.3.5]; IOI#14. Number of costed annual work- Dropped. Will be tracked by NACC for project monitoring. plans developed (by division); IOI#15. Number of civil society and Replaced. Replaced with POI#2. private sector organizations supported [SC 11]; IOI#16. Number of grant proposals Dropped. Will be tracked by NACC for project monitoring. received from private sector and civil society per year; IOI#18. Number of public sector Dropped. No consistent data flow on all elements. organizations supported in mainstreaming. * Indicate if the indicator is Dropped, Continued, New, Revised, or if there is a change in the end of project target value* 64 REVISED PROJECT RESULTS FRAMEWORK: Table 2e: Outcomes by Revised Project Development Objective Project Development Objective (PDO): (a) expand the coverage of targeted HIV and AIDS prevention and mitigation measures; and (b) Expand access to bed nets among targeted people living with HIV and AIDS and other households in malaria risk areas. Baseline Cumulative Target Values 29 Data Responsibi Unit of Original Progress PDO Level Results 2011 2012 2013 Frequenc Source/ lity for Measure Project To Date Comments Indicators 27 Core y Methodolo Data ment Start (2010) 28 gy Collection (2007) POI# 1. Proportion of NACC/ Computed from recipients of subproject TOWA Performanc quarters for which an grants scoring “Very Good” Percent N/A 71.6 80 80 80 Annual Performan e audit was conducted in or “Excellent” for target ce Audit Manageme the year achievement in the annual nt Agent audit during the year. POI# 2. Number (cumulative) of civil NACC society/private sector grants Number 3,637 5,637 7,137 8,400 Annual Program NACC 0 supported by the end of the Reports year. POI# 3. Proportion of Targets based on about F=30%, F=33%, Not F=25% F=20% sexually active youth 15- 24 Percent Five years KDHS NACC 10% reduction every M=84% M=83% applicable M=80% M=70% who report having had sex three years and apply 27 Please indicate whether the indicator is a Core Sector Indicator (for additional guidance – please see http://coreindicators). 28 For new indicators introduced as part of the Additional Financing, the progress to date column is used to reflect the baseline value. 29 Target values should be entered for the years data will be available, not necessarily annually. Target values should normally be cumulative. If targets refer to annual values, please indicate this in the indicator name and in the “Comments” column. 65 with a non-spousal, non- (KDHS (KDHS if a KAIS or DHS will regular partner in the past 12 2003) 2008) be done in 2012 or months. 2013 Targets based on 10% and 15% planned POI# 4. Proportion of youth increase for female aged 15-24 reporting condom F=39.5% and male respectively, use in the last sexual F=24% , every three years. encounter with a non-regular M=47% M=64.6 Not F=55% F=55% Three/Fiv KAIS/ These KNASP III Percent NACC partner (of those reporting (KDHS % applicable M=75% M=75% e years KDHS projections are for the sexual intercourse with a 2003) (KDHS same indicator but non-regular partner in the last 2008) covering 15-49 yrs. 12 months). (Targets apply if a KAIS or DHS will be done in 2012 or 2013) Malaria Three POI# 5. Percentage of Indicator Malaria Control years or households in malaria Data Survey Division plans that by Three endemic areas in the districts available (MIS) or Malaria 2013, there should be Percent 27.6% 60% 80% N/A months supported by the TOWA January Post- Division universal coverage after net Project that have at least one 2011 Distributio (100% net ownership distributio ITN. n and a use rate of 80%) n Evaluation POI# 6. Number of individuals provided with NACC counseling and testing Number 0 320,886 240,863 172,045 172,045 Annual NACC Reports services (through TOWA) in the past 12 months. Beneficiaries 30 30 All projects are encouraged to identify and measure the number of project beneficiaries. The adoption and reporting on this indicator is required for investment projects which have an approval date of July 1, 2009 or later (for additional guidance – please see http://coreindicators). 66 The first 500,000 nets distributed to PLHIV Number while the subsequent Project beneficiaries, Malaria 2.3 Malaria million nets are used 1. Number of individuals 250000 4100000 Annual Division Number 5100000 Division for with access to an ITN. achieving universal 2. Number of youth reached See IOI#7 coverage of one net with HIV prevention Number Annual NACC for NACC two people (i.e. 2.3 messages. Reports million nets x 2= 3. Number of HIV+ clients See IOI#8 4.6million) provided with palliative care. Annual NACC See IOI#7 NACC Reports See IOI#8 Intermediate Results and Indicators Baseline Target Values Unit of Data Original Progress Responsibilit Measu 2011 2012 2013 Source/ Intermediate Results Indicators Project To Date Frequency y for Data Comments Core remen Methodolog Start (2010) Collection t y (2007) Intermediate Result 1: NACC effectively coordinating program implementation Based on the bi-annual IOI# 1. Level of stakeholder Percen 70 78 75 75 75 Annual Stakeholder NACC satisfaction with NACC. t Satisfaction Survey Intermediate Result 2: Strengthened NACC accountability and financial management 67 Intermediate Results and Indicators Baseline Target Values Unit of Data Original Progress Responsibilit Measu 2011 2012 2013 Source/ Intermediate Results Indicators Project To Date Frequency y for Data Comments Core remen Methodolog Start (2010) Collection t y (2007) Audit conducted by IOI# 2. Issues in NACC’s Standard Yes/N December. Issues qualified report to be addressed by Yes Yes Yes Yes Annual Financial NACC o then to be addressed end of March of following year Audit N/A within three months. Intermediate Result 3: Operational M&E system in use for planning, project design and implementation IOI# 3. The proportion of KNASP M&E indicators included in the NACC Percen annual M&E report, disseminated 80 82 84 85 Annual program NACC t and available on time for the 55 reports JAPR. Intermediate Result 4: Capacity of implementing partners to respond effectively to report through the normal M&E tools IOI# 4. Proportion of registered NACC Percen CBOs reporting through COBPAR 65.8 95.7 100 100 100 Annual program NACC t at the time of the JAPR. reports Intermediate Result 5: Strategic and targeted programs implemented effectively through civil society and the private sector IOI#5. Number of persons who NASCOP The target for 2012 undergo testing and counseling in Numbe 3,471,56 4,060,00 4,500,00 4,236,000 Annual program NACC is based on KNASP the last 12 months. (National, from r 949,250 7 0 0 reports III. NASCOP). Since targets can IOI#6. Number of couples NACC only be known after counseled and tested under the Numbe NA 11,759 8,827 6,305 6,305 Annual program NACC grant award, these TOWA project- up to the end of r reports targets are arrived at the reporting year. by blowing up the 68 Intermediate Results and Indicators Baseline Target Values Unit of Data Original Progress Responsibilit Measu 2011 2012 2013 Source/ Intermediate Results Indicators Project To Date Frequency y for Data Comments Core remen Methodolog Start (2010) Collection t y (2007) current (2010) achievement using the same rate of increase in number of grants awarded over time (i.e. targets set proportional to the number of grants where CfP3 grants=2730, CfP4 grants=1950, and CfP5 grants=1950 whose results will be realized in 2011, 2012, and 2013 respectively) IOI# 7. Number of youth reached NACC Numbe Same as under with BCE messages in the past 12 NA 649,497 487,525 348,232 348,232 Annual program NACC r beneficiaries section months. reports IOI# 8. Number of HIV+ individuals provided with Home- NACC Numbe Based Care (Palliative care) NA 6,496 4,876 3,483 3,483 Annual program NACC Same as above r through the TOWA interventions reports in the past 12 months. Intermediate Result 6: Improved supply of essential commodities 69 Intermediate Results and Indicators Baseline Target Values Unit of Data Original Progress Responsibilit Measu 2011 2012 2013 Source/ Intermediate Results Indicators Project To Date Frequency y for Data Comments Core remen Methodolog Start (2010) Collection t y (2007) IOI# 9. Number of male and NASCOP female condoms distributed in the Numbe 146,400, 150,000, 150,000,00 150,000, Annual program NASCOP last 12 months (national, from r 144,000, 000 000 0 000 reports NASCOP). 000 IOI# 10. Number of insecticide Malaria Division of long lasting insecticide treated Numbe 2,300,00 0 500,000 2,800,000 N/A Annual program Malaria Cumulative malaria nets purchased and/or r 0 reports Control distributed 70 Annex 3. Bank Lending and Implementation Support/Supervision Processes (a) Task Team members Responsibility/ Names Title Unit Specialty Lending Wachuka W. Ikua Senior Operations Officer GHNDR Sheila Dutta Senior Health Specialist GHNDR Musonda Rosemary Sunkutu Senior PHN Specialist GHNDR Albertus Voetberg Lead Health Specialist GHNDR Hyacinth D. Brown Division Manager WFALA Moses Sabuni Wasike Sr Financial Management Specialist GGODR Victoria L. Fofanah Senior Program Assistant ECSO1 Monica Gathoni Okwirry Program Assistant AFCE2 Lucie Muchekehu Program Assistant AFCE2 Joyce Cheruto Bett Program Assistant AFCE2 Dahir Elmi Warsame Consultant GGODR Michael Mills Consultant GHNDR Alison P. Rosenberg Consultant GHNDR Jacomina P. de Regt Consultant SDV Supervision/ICR David Wilson Program Director GHNDR Wachuka W. Ikua Senior Operations Officer GHNDR Carl Adam Per Lagerstedt Sr Health Spec. GHNDR Mbuba Mbungu Consultant AFTU1 Henry Amena Amuguni Sr Financial Management Special GGODR Joel Buku Munyori Senior Procurement Specialist GGODR Lucy Anyango Musira Program Assistant AFCE2 Monica Gathoni Okwirry Program Assistant AFCE2 Lucie Muchekehu Program Assistant AFCE2 Joyce C. Bett Program Assistant AFCE2 Richard M. Seifman Consultant GHNDR Dahir Elmi Warsame Senior Procurement Specialist GGODR Musonda Rosemary Sunkutu Senior PHN Specialist GHNDR Noel Chisaka Senior Public Health Specialist GHNDR Lombe Kasonde Operations Analyst GHNDR Joy de Beyer Senior Health Economist GHNDR Evelyn Anna Kennedy Senior Operations Officer GHNDR (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 FY05 18.96 109.38 FY06 61.11 291.60 FY07 37.64 194.67 FY08 35.28 179.63 Total: 152.99 775.28 Supervision/ICR FY08/09 31.67 98.46 71 FY10 22.20 91.43 FY11 31.40 112.90 FY12 36.99 120.05 FY13 37.55 133.07 FY14 26.70 110.27 FY15 33.81 108.90 Total: 220.32 775.12 72 Annex 4. Beneficiary Survey Results Evaluation of the 2011/2012 Long-Lasting Insecticidal Treated Nets (LLINs) Mass Distribution Campaign Introduction The Health Sector is one of the key components addressing equity and socio-economic agenda of the Economic Recovery Strategy for Wealth and Employment Creation (ERS) and the social pillar of the Kenya Vision 2030. Kenya’s vision for health is to provide “equitable and affordable health care at the highest affordable standard” to her citizens. According to the Kenya Vision 2030 social pillar of Health, the country aims to provide an efficient integrated and high quality affordable health care to all citizens. There is marked progress in the health outcomes. This includes improvement in under-five mortality rates from 92 per 1,000 live births in 2007 to 74 per 1,000 live births in 2009. However, it did not achieve the year’s target of 55 deaths per 1,000 live births. Immunization coverage improved from 71 per cent to 77 per cent. Fifty three hospitals are under rehabilitation, nine of which are completed, 14 are 50 per cent complete, 26 are at below 50 per cent completion and four are at the foundation stage. The National Malaria Strategy (NMS) covering the period 2009–2017 was developed in line with the Government’s first Medium-Term Plan of Kenya Vision 2030 and the Millennium Development Goals, as well as Roll Back Malaria partnership goals and targets for malaria control. The National Malaria Strategy is based on and carries forward an inclusive partnership between the Ministry of Health and other line ministries of the Government of Kenya, a development and implementing partners in malaria control. The strategy builds on the achievements and challenges arising during the implementation of the previous NMS 2001-2010, NHSSP II 2005–2010 and the Economic Recovery Strategy (2003–2007). 31 This strategy has been reviewed and has led to the development of the revised Kenya Malaria Strategy 2014-2018 The ultimate vision of the revised Kenya Malaria Strategy is a malaria-free Kenya through the implementation of the activities that are expected to reduce morbidity and mortality caused by malaria in the various epidemiological zones by two-thirds of the 2007/08 level. The specific objectives are: • To have at least 80% of people living in malaria risk areas using appropriate malaria preventive interventions by 2017. • To have 100% of all suspected malaria cases presenting to a health provider managed according to the national malaria treatment guidelines by 2017: • To ensure that 100% of the malaria epidemic prone and seasonal transmission sub counties have the capacity to detect and timely respond to malaria epidemics by 2017. • Ensure that all malaria indicators are routinely monitored, reported and evaluated in all counties by 2017: • To increase utilization of all malaria control interventions by communities in Kenya to at least 80 % by 2017. • To improve capacity in coordination, leadership, governance and resource mobilization 31 GOK (2009). National Malaria Strategic Plan 2008 – 2017. Division of Malaria Control, Ministry of Public Health and Sanitation, Nairobi. 73 at all levels towards achievement of the malaria program objectives by 2017 Relevant to MCU approaches in malaria control, the KMS intended to achieve the objectives by providing malaria prevention measures and treatment to pregnant women and ensuring use of insecticide-treated nets by at-risk communities to significantly reduce rates of disease. Epidemiological Stratification Kenya has four malaria epidemiological zones. This stratification has been historical and related to experiences in relation to occurrence of malaria burden in the country: a. Endemic – Areas of stable malaria have altitudes ranging from 0 to 1300 meters around Lake Victoria in western Kenya and in the coastal regions. Rainfall, temperature and humidity are the determinants of the perennial transmission of malaria. The vector life cycle is usually short with high survival rate due to the suitable climatic conditions. Transmission is intense throughout the year with annual entomological inoculation rates between 30 and 100 (risk class equal to or above 20per cent). b. Seasonal malaria transmission- this epidemiological zone in arid and semi-arid areas of northern and south-eastern parts of the country experiences short periods of intense malaria transmission during the rainfall seasons. Temperatures are usually high and water pools created during the rainy season provide the malaria vectors breeding sites. Extreme climatic conditions like El Niño southern oscillation lead to flooding in these areas leading to epidemic outbreaks with high morbidity rates due to low immune status of the population (risk class less than 5 per cent). c. Malaria epidemic prone areas of western highlands of Kenya - Malaria transmission in the western highlands of Kenya is seasonal, with considerable year-to-year variation. The epidemic phenomenon is experienced when climatic conditions favor sustainability of minimum temperatures around 180 C. This increase in minimum temperatures during the long rains period favors and sustains vector breeding resulting in increased intensity of malaria transmission. The whole population is vulnerable and case fatality rates during an epidemic can be up to ten-times greater than what is experienced in regions where malaria occurs regularly (risk class 5 to less than 20per cent). d. Low risk malaria areas –this zone covers the central highlands of Kenya including Nairobi. The temperatures are usually too low to allow completion of the sporagenic cycle of the malaria parasite in the vector. However with increasing temperatures and changes in the hydrological cycle associated with climate change are likely to increase the areas suitable for malaria vector breeding with introduction of malaria transmission in areas it never existed (risk class less than 0.1 per cent). Importance of the survey The National Malaria Strategy 2009-2017 principally aims at reducing the morbidity and mortality caused by malaria in the various epidemiological zones by two thirds from the morbidity and mortality levels observed in the year 2007/2008 by the year 2017. An important strategic approach to achieve this goal has been to achieve protection of at least 80% of people living in malaria risk areas appropriate malaria prevention interventions with the Long-lasting Insecticide treated nets (LLIN) by 2013. This is in consideration that LLIN are the primary preventive tool used to protect populations at risk of malaria in Kenya. 74 Significant investments have been made since 2002 to increase the coverage of LLINs in Kenya through a variety of distribution mechanisms including: 1. Routine net distribution targeting pregnant women and children at antenatal care clinics. Nets are also distributed through the Comprehensive Care clinics to people living with HIV/AIDS 2. Social marketing: where nets are distributed at a subsidised fee of KShs 50 in identified rural shops (“dukas”) 3. Commercial: where nets are sold at the retail prices mainly in urban supermarkets and other retail outlets 4. Free mass net distribution campaigns conducted in 2006, and more recently in 2011. The three phased 2011/2012 campaign has implemented two of the three phases, and was the only campaign that targeted all members of the household. This survey therefore aimed to evaluate: the success of phase I, phase II and phase III of the 2011/2012 mass net distribution campaign; the effect of the post-distribution information on LLIN ownership, use, and retention in Nyanza, Western, and parts of Rift Valley regions. All the three phases of the survey offer an opportunity for the Malaria Control Unit (MCU) which was formerly known as the Division of Malaria Control (DOMC) to assess whether Kenya had met Universal coverage target of one (1) net for two (2) people. The results of the evaluation will also help inform future LLIN distribution strategies especially mass net distributions. The evaluation of the mass net campaign was conducted in three phases specifically Phase 1, 2 and 3. The three stage national sample survey was designed to evaluate the Global Fund, PMI, World Bank and World Vision sponsored LLIN distribution to estimate indicators of LLIN retention, usage and ownership among households within the four malaria endemic regions where mass net distribution occurred. Generally the survey was designed to collect data from randomly selected 272 clusters in the mass net distribution region. Phase 1 and 2 of the evaluation covered 205 clusters in the Nyanza, Western, and Rift Valley regions. The remaining 67 clusters; which included 20 clusters in Rift Valley (Buret, Bomet, and Nandi), and 47 in Coast Region were covered during the third phase of the evaluation. This final report covers all the three phases of the survey which looks at the progress towards reaching universal coverage through the distribution of the LLIN as stipulated in National Malaria Strategic plan 2009-2017. The survey involved interviewing respondents within randomly selected households. The respondents were asked questions about their demographic backgrounds, household characteristics, net ownership, exposure to the campaign, and malaria prevention messages. This survey also documented the nets owned through the net roster. Survey Methodology This three phased survey adopted a descriptive and cross-sectional study approach. The first two phases of the quantitative survey were conducted between November 2011 and February 2012 in 4,091 households, with 20,520 individual members, while third phase which was conducted in March 2014 covered 1,502 households with 7,663 individual members, giving a total of 5,593 households and 28,183 household members. The overall 75 response rate for the survey was 99.6%. The interviewer administered questionnaire in the first two phases of the survey was done using GPS enabled PDAs while the third phase involved use of mobile phone technology in data collection. The data was weighted to reflect the population distribution within the different malarial endemicity regions. The data was descriptively analyzed with the help of Statistical Package for Social Sciences (SPSS) version 21. Survey Findings Household ownership of any type of net or campaign LLIN; Net ownership increased after the mass net campaign in comparison to KMIS 2010. The average number of any type of nets per household increased from 1.0 (KMIS 2010) to 2.8 in rural areas; the same is noted in average number of LLINs owned per household from 0.9 in 2010 to 2.7 as seen in the evaluation. With consideration of malaria epidemiological transmission zones, the Lake Endemic region registered an increase ownership of at least one net of any type from 70.7percent (KMIS 2010) to 88.3 during the evaluation, with the Coast having an increase from 69.6 percent to 86.7 percent, while the Highland Epidemic registered an increase of 85.7 percent up from 59.5 percent during the same time period. The ownership of at least one LLIN in the lake endemic region has increased to 83.4 percent from 54.4 percent in 2010. A result that was replicated in the other regions with Coast Endemic region having an increase from 56.5 percent to 82.6 percent, while the Highland Epidemic showing an increase from 48.5 percent to 83.5 percent. The average number of LLINs owned per household has more than doubled to: 2.24 in lake endemic region, 2.15 in coast endemic, and 2.51 in highland epidemic. The results have also shown equitable distribution of net distribution across the wealth quintiles therefore enabling the poorest to access LLINs equally to the rich. Table 5a: Net ownership by Residence, Endemicity, and Social Economic Status in all Households Ownership of Ownership of Number of Ownership Ownership of Number of any net Any Net (More any nets of LLIN LLIN (More LLINs than One) owned than One) owned At least One More than One Mean At least One More than One n % n % n % N % Mean Residen Rural 3966 87.1 3200 70.2 2.58 3847 84. 3084 67.7 2.45 ce 4 Urban 835 85.9 539 55.5 2.07 756 77. 473 48.6 1.77 8 Endemi Highland 1908 85.7 1552 69.7 2.62 1859 83. 1497 67.3 2.51 city Epidemic 5 Lake Endemic 1892 88.3 1462 68.2 2.46 1788 83. 1367 63.8 2.24 4 Coast Endemic 1002 86.7 725 62.8 2.29 955 82. 692 59.9 2.15 6 Social Low 948 83.7 718 63.4 2.22 914 80. 694 61.3 2.11 Econom 8 ic Status Second 993 88.1 777 68.9 2.46 962 85. 752 66.7 2.35 4 Middle 917 88.1 720 69.1 2.52 887 85. 687 66.0 2.36 2 Fourth 976 87.8 762 68.5 2.61 936 84. 725 65.2 2.46 1 76 Highest 966 86.7 763 68.4 2.64 903 81. 699 62.7 2.37 0 TOTAL 83. 4800 86.9 3740 67.6 2.49 4602 3 3557 64.4 2.32 Universal coverage The finding suggests that universal coverage has been achieved in 58.2 percent of the households in the Coast Endemic, 60.5 percent in Lake Endemic and 63.8 percent Epidemic Highlands assessed, averaging to 61.6 percent universal coverage. This is below the target of 100 percent set by the government of Kenya and may be attributed to non- registration and disposing off the nets received during the campaign. Figure 5a: Universal Health Coverage Proportion of All Households that Met Universal Coverage 100.00% 63.80% 60.50% 58.20% 80.00% 60.00% 40.00% 20.00% 0.00% Highland Epidemic Lake Endemic Coast Endemic Table 5b: Net ownership in All Households with a Child Under-five (by Residence, Endemicity, and Social Economic Status) Ownership of Ownership of Number Ownership of Ownership of Number of any net Any Net (More of any LLIN LLIN (More than LLINs than One) nets One) owned owned At least One More than One At least One More than One n % n % Mean n % n % Mean Residence Rural 1886 88.7 1623 76.4 2.88 1837 86.5 1578 74.3 2.75 Urban 369 90.0 274 66.8 2.29 348 85.0 244 59.6 2.05 Endemicity Highland 909 88.0 796 77.1 2.97 889 86.0 771 74.6 2.85 Epidemic Lake Endemic 861 90.9 713 75.3 2.78 825 87.1 676 71.4 2.57 Coast Endemic 484 87.8 388 70.3 2.46 471 85.4 376 68.1 2.37 Social Low 474 86.8 394 72.3 2.55 459 84.2 383 70.3 2.44 Economic Second 493 89.9 411 74.9 2.76 480 87.6 397 72.3 2.64 Status Middle 426 89.3 349 73.1 2.80 417 87.4 336 70.4 2.63 Fourth 469 88.7 409 77.2 2.94 458 86.7 394 74.5 2.80 Highest 392 90.2 335 77.0 2.92 370 85.2 312 71.8 2.69 2254 88.9 1898 74.8 2.79 2184 86.2 1822 71.9 2.63 Household retention of campaign LLIN There was equal ownership of nets in rural 93.8 percent and urban areas 92.7 percent. In both urban and rural setting, the mean nets distributed per household were the same three (3) which conforms to 62.5 percent of the households receiving three or more nets at the distribution point. Some nets were disposed by households after the mass net campaign. 77 More importantly, the pattern of LLIN ownership across wealth quintiles differed with the lowest quintile recording ownership at 90.6 percent, and the highest quintile recording 91.4 percent. This is contrary to the skew in the 2010 KMIS report which showed a skew towards the highest quintile, a finding that prompted the free mass distribution campaign of 2011/2012. Net usage This survey established that use of LLIN the previous night was reported among 36.5 percent of all household members, with Lake Endemic showing lower usage of 30.4 percent compared to 35.5 in Highland Epidemic, and 49.8 percent in coast endemic. Overall use of LLIN was low among the children aged below five (5) years (29.3 percent) and people aged 5-14 years (29.7 percent) compared with the other age groups. Still focusing among the children aged below 5 years, usage among the children in rural areas was lower (27.5 percent) compared to those in urban areas (39.6 percent). Similarly usage among these children from lake endemic areas was lower (16.3 percent) compared to highland epidemic (28.3 percent) and coast endemic (53.9 percent). This is a major concern in terms of malaria prevention through use of LLIN in the Lake region where malaria is most prevalent and a major killer disease in children. Use of LLIN by All Household Members Table x above shows members of de facto household population who, the night before the survey, slept under any mosquito net, under an LLIN 32 , and among the population in households with at least one LLIN by background characteristics. In Highland epidemic, Lake endemic and Coast endemic zones, 35.5 percent, 30.4 percent and 49.6 percent, respectively slept under LLIN the night before the survey. There was an increase in the proportion of population that slept under LLIN the previous night in Highland epidemic and Coast endemic areas compared to KMIS 2010 report of 32.3 percent and 45.7 percent, in the respective areas. There was, however, a decrease in Lake Endemic from the previous 38.1 percent (KMIS 2010) to current 30.4 percent. The patterns of LLIN use across wealth quintiles favor higher socio-economic status quintiles more than the lowest (32.6 percent). The KMIS report on 2010 also showed a reversed scenario with the LLIN use skewed towards the higher quintiles than the lowest (24.9 percent) quintile, a finding that prompted the free mass distribution campaign of 2011/2012. Use of LLIN by children under five in Intervention Reached Households Table 16 below shows de facto children under five years of age who, the night before the survey, slept under a mosquito net, under a LLIN, and among children under five years of age in intervention reached households with at least one LLIN by background characteristics. Overall, 38.4 percent of children under five years of age in the intervention reached households slept under LLIN the night preceding the survey compared to 38.1 percent among household members in similar intervention reached households. In households with LLIN, a higher proportion of children slept under a LLIN the previous night (41.5 percent). Use of LIN by children under five varied with age such that the highest proportion of those aged one year in households with LLLIN used nets the previous 32 Refers to a factory-treated net that does not require any further treatment 78 night. The percentage of children who slept under LLIN the previous night was higher in urban (45.7 percent) than in rural areas (37.4 percent). The percentage increase was higher in urban settings (5 percent) where households had an LLIN compared to rural areas (2.8 percent). Use of LLIN the previous night by children in households with an LLIN was lowest in Lake Endemic areas (29.6 percent) in contrast to Highland Epidemic (41.9 percent) and Coast Endemic (64.3 percent). Fewer children among lowest quintile group (33.9 percent) slept under LLIN the previous night compared to the rest of the rest of the quintile groups. The same trend was noted even among households with an LLIN. Table 1: Use of bed nets by children under five in intervention reached households Percentage of de facto children under five years of age, who, the night before the survey slept under a mosquito net (treated or untreated), under a LLIN, and among children under five years of age in households with at least one LLIN, the percentage who slept the night before the survey under LLIN, by background characteristics. Slept under any net the Slept under LLIN the Household has an LLIN previous night previous night Slept under LLIN the previous night n % n % n % Age of the under 5 HH member <1 144 35.4 131 32.1 131 34.4 1 177 33.6 158 30.0 158 32.5 2 188 31.3 168 27.9 168 30.3 3 259 35.9 236 32.7 236 35.1 4 250 34.2 217 29.7 217 32.5 Sex of the HH member Male 530 34.4 465 30.2 465 32.9 Female 489 33.7 445 30.7 445 33.0 Residence Rural 855 32.6 765 29.2 765 31.4 Urban 163 44.4 146 39.6 146 44.3 Endemicity Highland 412 33.0 375 30.0 375 32.3 Epidemic Lake Endemic 267 22.7 205 17.4 205 18.8 Coast Endemic 340 60.0 331 58.4 331 64.8 Social Economic Status Low 215 31.9 193 28.7 193 31.6 Second 236 33.7 211 30.0 211 32.1 Middle 169 30.0 143 25.3 143 27.5 Fourth 220 34.6 202 31.8 202 34.1 Highest 178 43.2 161 39.0 161 42.3 Total (N) 1019 34.1 910 30.4 910 32.9 The same trends seen above were also observed in the use of nets by children in all households. See table below. 79 Table 5d: Use of bed nets by children under five in All Households Percentage of de facto children under five years of age, who, the night before the survey slept under a mosquito net (treated or untreated), under a LLIN, and among children under five years of age in households with at least one LLIN, the percentage who slept the night before the survey under LLIN, by background characteristics. Slept under any net the Slept under LLIN the Household has an previous night previous night LLIN Slept under LLIN the previous night N % n % n % Age of the under 5 HH <1 192 36.6 170 32.4 170 36.7 member 1 230 34.5 201 30.1 201 34.6 2 230 30.4 198 26.2 198 31.1 3 306 35.0 268 30.7 268 34.8 4 297 33.9 246 28.0 246 32.9 Sex of the HH member Male 651 34.2 558 29.3 558 33.5 Female 604 33.6 525 29.2 525 34.2 Residence Rural 998 31.7 866 27.5 866 31.7 Urban 257 46.7 217 39.6 217 46.6 Endemicity Highland 486 32.3 426 28.3 426 32.7 Epidemic Lake Endemic 315 22.7 226 16.3 226 18.5 Coast Endemic 448 56.1 430 53.9 430 64.2 Social Economic Status Low 259 31.2 221 26.7 221 31.6 Second 275 32.8 233 27.7 233 31.9 Middle 221 31.7 181 26.1 181 29.8 Fourth 269 34.8 238 30.8 238 35.3 Highest 232 41.0 210 37.1 210 43.1 Total (N) 1255 33.9 1083 30.4 1083 33.8 Use of LLIN by Pregnant Women Table X below illustrates distribution of de facto pregnant women, who, the night before the survey slept under a mosquito net (treated or untreated), under a LLIN, and among the population in households with at least one LLIN, the percentage who slept the night before the survey under LLIN, by background characteristics. The proportion of pregnant mothers sleeping under LLIN the previous night was higher in urban (52.0 percent) than among rural households (49.9 percent. Also noteworthy are higher proportions reported from Coast endemic (59.7 percent) and Lake Endemic zones (49.4 percent) compared to Highland Epidemic (46.7 percent). There was an increase in usage among all the five quintile categories post mass LLIN distribution campaign compared with the KMIS 2010 reported usage. The highest increase was noted among the highest quintile group from 29.7 percent (KMIS, 2010) to the current 65.9 percent. The proportion of pregnant women sleeping under LLIN in households having an LLIN was higher than the corresponding proportion of those sleeping under LLIN the previous night, regardless of place of residence, malaria endemicity zone or socio-economic status. Table 5e: Use of bed nets by pregnant Women in All Households 80 Distribution of de facto pregnant women, who, the night before the survey slept under a mosquito net (treated or untreated), under a LLIN, under an insecticide-treated net (ITN), and among the population in households with at least one ITN, the percentage who slept the night before the survey under ITN, by background characteristics Slept Under any net the Slept Under LLIN the Household has an previous Night previous Night LLIN Slept Under LLIN the previous Night n % N % n % Residence Rural 164 56.8 144 49.9 144 58.0 Urban 37 63.8 30 52.0 30 61.8 Endemicity Highland Epidemic 80 54.1 69 46.7 69 54.9 Lake Endemic 79 60.7 65 49.4 65 58.3 Coast Endemic 42 61.1 41 59.7 41 66.5 Social Economic Status Low 53 59.9 46 52.5 46 60.7 Second 51 56.2 46 50.7 46 55.1 Middle 28 55.9 22 43.0 22 52.0 Fourth 37 58.9 31 48.9 31 59.9 Highest 33 58.5 30 54.1 30 65.9 Total (N) 201 58.1 174 50.3 174 58.6 Table 5f: Use of bed nets by pregnant Women in Intervention Reached Households Distribution of de facto pregnant women, who, the night before the survey slept under a mosquito net (treated or untreated), under a LLIN, under an insecticide-treated net (ITN), and among the population in households with at least one ITN, the percentage who slept the night before the survey under ITN, by background characteristics Slept Under any net the Slept Under LLIN the Household has an previous Night previous Night LLIN Slept Under LLIN the previous Night N % n % n % Residence Rural 138 59.7 126 54.7 126 57.6 Urban 22 71.1 20 66.5 20 71.4 Endemicity Highland Epidemic 65 57.3 61 53.5 61 55.5 Lake Endemic 61 62.2 53 53.7 53 57.5 Coast Endemic 33 67.3 32 67.0 32 71.7 Social Economic Status Low 44 64.1 41 58.8 41 62.2 Second 44 59.1 42 56.4 42 56.6 Middle 20 50.6 18 45.2 18 50.4 Fourth 30 63.5 26 55.3 26 60.9 Highest 22 67.5 21 63.7 21 66.7 Total (N) 159 61.0 146 56.1 147 59.2 Impact of communication on net-ownership, retention and use Over 90 percent of the rural households heard about the mass distribution of LLIN compared to 85.1 percent in urban areas. Looking at the endemicity regions, the proportion that heard about the campaign differed with the Lake endemic having 93.3 percent. Highland epidemic at 90.2 percent and Coast Endemic at 80.4 percent. Based on the various approaches used prior to the campaign, community approach appears to have reached more households in both rural (42.4 percent) and urban (30.4 percent). Discussion and Conclusions The current Kenya National Malaria Strategy aims to reduce significantly the burden of malaria in the country to levels where the disease is no longer a public health problem. A number of donors and the government have invested funds in malaria awareness, 81 prevention, diagnosis and treatment. The main tool for malaria prevention is the long lasting insecticidal nets (LLIN) scaled up through free routine distribution to children and pregnant women at public health facilities and mass distribution campaigns to individuals of all ages. From March2011 – August 2012, an estimated 10.6 million nets were distributed in Nyanza, Western, and selected sub-counties in the Coast and Rift Valley regions with the aim of covering 21 million people or in the targeted sub-counties. To assess whether these targets have been reached, the use and retention of the campaign LLIN and the impact of the malaria information, education and communication activities, the Division of Malaria Control undertook an evaluation survey among a random sample of the targeted households. This survey was implemented in phases with Phase I and II being conducted from November 2011 and February 2012 and Phase III in 2014. The main objective of survey was to evaluate the Global Fund (GF), President’s Malaria Initiative (PMI), and World Vision sponsored LLIN distribution to gauge net availability, retention and use post campaigns. Net ownership increased after the mass net campaign in comparison to KMIS 2010. The average number of nets of any type increased in rural areas from 1.0 (KMIS 2010) to 2.58 per household; the same is noted in average number of LLINs owned per household from 0.9 to 2.07. With consideration of malaria epidemiological transmission zones, the Lake Endemic region registered an increase ownership of at least one any type of net from 70.7 percent (KMIS 2010) to 88.3 percent. The ownership of at least one LLIN in the lake endemic region has increased to 83.4 percent from 54.4 percent in 2010. The average number of LLINs owned per household has more than doubled to 2.24 in the same region. Looking at the entire evaluation zones, the results have also shown equitable distribution of net distribution across the wealth quintiles therefore enabling the poorest to access LLINs. The findings suggest that universal coverage has been achieved in 60.1 percent of the households in the Lake Endemic, Coast Endemic, and Epidemic Highlands assessed. This is below the target of 100 percent set by the government of Kenya and may be attributed to non-registration and disposing off the nets received during the campaign. More nets were received at the distribution points in rural (89.8 percent) compared to urban areas (82.5 percent). In both urban and rural setting, the mean nets distributed per household was the same (3) which conforms to 60.1 percent of the households receiving three or more nets at the distribution point. Some nets were disposed of by households after the mass net campaign. However, it appears that the pattern of LLIN use across wealth quintiles favor the higher (40.9 percent) in comparison to lowest (33.2 percent) quintile considering the households members using LLIN the previous night. The KMIS report on 2010 also confirmed the scenario with the LLIN use skewed towards the highest (35.1 percent) than the lowest (24.9 percent) quintile, a finding that negates the intention of the free mass distribution campaign of 2011/2012. Among under five year old children, the proportion that slept under LLIN was 30.4 percent which further confirms the low net use among children, a finding that further suggests need to critically find better approaches that should to be used promote net use during mass net distribution campaign for this particular vulnerable population. Apparently, the communication strategy might not have had great impact on who should use LLINs most. 82 Scaling up LLIN coverage and use by children under five years and pregnant women is one of the targets of the Millennium Development Goals (MDGs) and the Roll Back Malaria Partnership (RBM). 33 Targeting individual protection to these vulnerable groups is a priority of the two because these groups bear the highest risk of morbidity and mortality from malaria. 34Net use among children under five years of age reveal higher usage (39.6 percent) for LLIN in urban areas compared to 27.5 percent in rural settings. However, according to reports by epidemiological zones, Lake Endemic region registers low LLIN usage (16.3 percent) compared with Highland Epidemic region (28.3 percent) and Coast Endemic (53.9 percent). This is a major concern in terms of malaria prevention through use of LLIN in the Lake region where malaria is most prevalent and a major killer disease in children. The findings emphasize that increasing net usage in Lake Endemic regions is key towards increased overall net usage in the current among children under five years of age. The use of LLIN use by pregnant mothers remained static. The results show that 50.3 percent slept under LLIN the night preceding the survey which was similar to the reported 50 percent of 2010 KMIS. A drop realized among pregnant women living in households with LLIN (58.6 percent) compared with the KMIS 2010 (72.5 percent) is worrying and must be addressed. The low usage among the lowest quintile compared with the highest quintile in all forms nets is a sign of inequity and needs urgent attention to reverse the trend. During campaign, it is important to ensure targeted messages reach the most at-risk populations, to encourage these households to collect LLINs during the distribution day. Campaign communication involving LLINs require a significant component of behavior change communication (BCC) to ensure that people do hang and use the nets that they have received, and that these nets are used by the target groups. Interpersonal communication is often more effective in promoting change in behavior. Messages can be reinforced by mass media, visits by community volunteers, and/or health clinic staff. Over 90 percent of the rural households heard about the mass distribution of LLIN compared to 85.1 percent in urban areas. The proportion that heard about the campaign in Lake Endemic (93.3 percent) and Highland epidemic (90.2 percent) was comparable. Based on the various approaches used prior to the campaign, community health worker approach appears to have reached more households in both rural (41.3%) and urban (33.5%). Equally useful are the home visits in rural settings (27.6 percent) compared to urban areas (25.4 percent) and radio which recorded 22.5 percent and 20.8 percent, in the same settings. Amongst the methods family appears to be the approach that is equally shared by lowest (20.4 percent) and highest (21.5 percent) quintiles. In both rural and urban regions, brochures and newspapers had the effect in reaching the population regarding this campaign. Communication within the community, radio messages and home visits were the most effective channels. Outcomes The main outcome of the mass net distribution campaign was noted in several areas. More nets were received in rural (89.8 percent) compared to urban areas (82.5 percent). Registration of households was 100 percent in both rural and urban settings. Eighty-one 33 The US President’s Malaria Initiative (2006). Lancet, 368:1. 34 Nafo-Traore F, Judd EJ, Okwo-Bele JM (2005). Protecting vulnerable groups in malaria-endemic areas in Africa through accelerated deployment of insecticide-treated nets. In A joint WHO-UNICEF statement. Vol. 57. Geneva: WHO/UNICEF. 83 percent of households received the nets from government, clinic or hospital which were the points of net distribution during the mass campaign. The number of nets that were used for sleeping the previous night was statistically similar to the number of nets that were hanging for sleeping indicating an association where hanging nets are more likely to be used for sleeping. Whereas fewer households report owning at least two nets in the rural setting is compared to urban settings, the reverse is the case for households owning at least three nets for rural (61.1 percent) compared urban (52.3 percent) areas (48.3 percent). The intention of mass net distribution was to put more nets in the hands of the general population. Free net distribution enabled the rural community own more than one net which translates into more nets for household members thus increasing the likelihood of using the nets. The net campaign has also ensured that the poor benefit from this government strategy on malaria prevention. However, net usage still does not favor the lowest quintile, a finding that requires critical look at any future mass campaign if the goal is to be achieved. This notwithstanding, the campaign has increased the average number of nets of any type available per person is 2.9 from the reported 0.2 of KMIS 2010. The current result is above the targeted universal coverage of 0.5 nets per person (or one net per two people). Among children, net use in rural areas is lower for LLIN (37.4 percent) and among households with LLIN (40.2 percent). Similarly, Lake Endemic region reports low usage (27.5 percent) compared with Coast Endemic region reporting higher usage (58.8 percent). The pattern of LLIN use across wealth quintiles shows the lowest quintile usage of 33.9 percent below the highest quintiles (46.0 percent). A cause of worry is the drop in reported proportion among pregnant women living in households with LLIN (54.1 percent) compared with the KMIS 2010 (72.5 percent), and more particularly, low usage among the lowest quintile compared with the highest quintile in all forms nets. Recommendations 1. Mass net distribution campaigns in future should target households where universal coverage was not achieved 2. There is need for a follow-up/mop up campaign immediately after the mass distribution targeting households that did not achieve universal coverage 3. Messages should be targeted to heads of households to encourage net use amongst household members, especially children under five 4. Investment in communication should use channels that had widest reach 5. With increasing availability of TVs in both rural and urban settings, future campaigns should include this approach. 6. With increasing availability of TVs in both rural and urban settings, future campaigns should include this approach. 84 Annex 5. Stakeholder Workshop Report and Results TOWA CLOSURE CONFERENCE, NOVEMBER 17-18 2014 The NACC held a two day TOWA Closure Conference in November 17-18 2014. The participation included the NACC team, NACC board, Ministry of Health officials, communities, implementing and development partners. The main objectives of the conference were as follows: 1. Discuss the main issues emerging from the TOWA project. 2. Provide an opportunity to review the key findings and recommendations to inform future programming. 3. To celebrate results and appreciate the contribution of key players in the project Opening Address: In her opening remarks, the NACC Director Dr. Nduku Kilonzo stated that the purpose of the TOWA project was to invest in people, strengthen the public sector on related issues such as accountability, and reduce vulnerability among individuals and communities and overall strengthening of the HIV and AIDS response during the life of KNASP III. The Director emphasized the need to prioritize where the epidemic was, investing appropriately based on the HIV burden and ensuring the inclusion of all actors in the response. She noted that the conference was an opportunity to reflect on the lessons learnt from the project moving forward. Dr. Nduku thanked the implementing and development partners, the Ministry of Health, NACC team and NACC board for the success of the TOWA project. The Director observed that the TOWA project had contributed immensely to the notable decline in new HIV infections, prevalence and related deaths. She expressed optimism for the second phase of the project. NACC Board Chair, Prof. Mary Getui said that some of the lessons learnt were challenges that have been addressed though not all. She stated that actors in the TOWA project had benefited by being better accountants, auditors and implementers through capacity building. She noted that the project’s call for proposals was participatory from the grassroots through consultations that gave all players an opportunity to own the process. The Chair recognized the vital role played by women in ensuring the success of the TOWA project. She observed that the commodities provided and the networks developed were evidence enough that the project indeed touched lives positively. She noted that NACC will strengthen its engagement with the communities within the current devolution structures and that by the end of the conference the participants will be energized and enriched to even serve better. The representative of the World Bank Dr Gandham Ramana stated that the TOWA project being a project of the World Bank had demonstrated results. He noted that although the project started under difficult circumstances with allegations of past misappropriation and subsequent stringent measures, the end firmly tells a successful story. Dr Ramana envisaged the need for broader health system strengthening and further noted that the bank will work with the Ministry of Health to ensure the noble ambition is realized. He pledged continued financial support to complement local efforts and initiatives at both national and county levels 85 A representative from the National Treasury Mr. Henry Mutuiri thanked the implementers and development partners for their support to the TOWA project and noted that the set targets were achieved with minimum bottlenecks in relation to accountability issues. Mr. Mutuiri stated that the HIV prevalence rates had dropped as a result of the good work by various actors and that the Implementation Completion and Results Report of the TOWA project due for release later this year will document achievements and lessons learnt which will provide reference for future donor engagements. He noted that the project’s call for proposal was competitive and fair and that NACC had been proactive in the affirmative action that helped in the surpassing of the set targets. He reiterated the importance of addressing issues of sustainability. The Cabinet Secretary Ministry of Health, Dr. James Macharia appreciated the implementing and development partners for the success of the TOWA project and observed that it was the largest financing ever to the Government of Kenya in the fight against HIV and AIDS. Dr. Macharia said that the project’s success was good for instilling donor confidence for future engagements. He stated that the TOWA project had achieved its objectives among them helping reduce HIV prevalence from 7% to 5.6% though he also observed that Kenya still remained among the worst hit countries in the world. The Cabinet Secretary noted that the project had been rated as satisfactory by the World Bank and that lessons learnt in the course of its implementation included significant government contribution through different sectors, the need for investing in communities, procurement of commodities that enhanced access to services, the need to harness resources to ensure that set goals are achieved and that no one is left out in the response. Dr Macharia said that the KASF under development will harness resources for the response and that the ministry will request the World Bank for continued support through the NACC. He called for the spurring of the HIV Innovative Fund to promote sustainable financing, directing finances on high impact result areas and strengthening coordination, oversight and strategic information in line with devolution. The Cabinet Secretary hailed the Futuristic Governance Assessment carried out by the World Bank and the government of Kenya as a reference document for many countries. He reiterated that the government was fully committed to reducing new HIV infections, stigma and discrimination and ensuring treatment reaches all Kenyans through increased financing. Dr. Macharia commended the NACC for the satisfactory TOWA project performance and declared the conference officially opened. Presentations: A. Background TOWA Project Design by Mr. Ken Nyamolo. The TOWA project had a budget of US$ 135 million, with the Government of Kenya contributing US$ 2 million. His presentation highlighted the following: (a) Project safeguards and TOWA performance monitoring (b) Resource distribution with 70% of resources supporting program implementation of the Kenya HIV response as outlined in the KNASP III and the remaining 30% dedicated to improved governance and coordination. (c) Modalities for the grants to local implementing organizations including calls for proposals and operational manuals. (d) Status of disbursement's as at June 30th, 2014 indicating that 10,712 local organizations/agencies had been funded at a cost of KES. 4,431,146,355 and that 99% of the funds disbursed had been accounted for. 86 (e) Impact of TOWA project on HIV prevention, TB and Malaria control with related commodities costs. (f) Status of public sector projects (g) Challenges with the CSOs implementing TOWA and how to overcome the challenges and the lessons learnt. B. TOWA Project Outcomes by Dr. Patrick Mureithi (a) Background focusing on project commencement, value and closure. (b) Project development objective and components (c) Key achievements per result area that included outputs and outcome/impacts on; (d) Component 1: Strengthening Governance and Coordination Capacity: • Strategic leadership • Capacity building of TOWA grantees and potential grantees • Accountability and verification • Evidence based management. (e) Component 2: Support for Program Implementation; • Cumulatively financing of 10,712 projects • Counseling and testing of 5.6 million clients • 22 million people reached through community mobilization and advocacy at all levels • Supported evidence based behavior change interventions targeting the general population and Most at Risk Populations • Facilitated VMMC • 43, 481 orphans and vulnerable children were reached with various support services • A total of 51 public institutions were funded under TOWA • Supported procurement of essential commodities i.e. drugs, bed nets and condoms Comments • Although the TOWA project provide a great opportunity for capacity building there was need to bring on board new partners on the response. • HIV related stigma and bed ridden cases reduction, adherence and treatment tracing should adequately be incorporated as project results • There was need to quantify knowledge and facts on HIV and include meaningful networking between the public and private sectors as project results • There was need to use community friendly auditors for the project • It was important to facilitate and motivate volunteers in the project. • There was need for clarity on the CACCs coordination and engagement in the future. • The national results should be disaggregated by county since they contributed immensely to the project success. • The Kenya AIDS Strategic Framework under development will help counties develop own specific plans to guide the HIV response. • The recommendations of the conference will inform the Implementation Completion and Results Report of the TOWA project. C. Feedback from TOWA Project Sub Implementers. Selected groups shared experiences and the impact of the TOWA project as follows; 1. Tusemezane Family Programme 87 The presentation highlights were as follows; i. Organizational background on the description of Tusemezane Family Program and its objectives ii. Implemented TOWA projects on behavior change communication/education, behavior change communication/education in specific HIV areas and community anti-stigma and discrimination campaigns. iii. Achievements that included reaching a total of 4,178 young people with behavior change communication information and education, training 30 peer educators in promoting behavior change among the general population and reaching 5000 community members with anti-stigma and discrimination messages, among other gains. iv. Challenges such as greater demand of outreaches than the available resources and sexuality messages facing resistance. v. Lessons learnt that included the need to demystify sex and sexuality especially among the adolescence in order to address risky sexual behavior. vi. Best practices such networking and collaboration to strengthen behavior change initiatives, accommodative leadership and continuous voluntary outreaches vii. Recommendations that included enhancing information by targeting men, increasing funding allocation and enhancing HIV prevention activities at primary school level. 2. Maseno University Towa story by HIV Coordinator, Ms. Olivia Okal. Ms. Okal stated that the university was allocated sh. 5 million under the TOWA project to cater for 15, 000 students and the entire university fraternity. She noted that the funds facilitated 30 related radio shows, produced IEC material and trained 102 and 50 student and staff peer educators respectively. Ms. Okal said that the funds also supported capacity building for students and staff and further enabled sensitization towards reduction of stigma and discrimination and subsequent HIV status disclosure. She observed that the university had mainstreamed HIV into its plans and allocated funds for the response. 3. Kenya Prisons Service by Assistant Commissioner of Prisons and ACU Coordinator Ms. Mary Chepkonga. Ms. Chepkonga noted that prisons were awarded 5.8 million under Round 2 of the TOWA project that facilitated internal and external mainstreaming of HIV. She stated that over 300 prisoners were trained as trainers of trainers as 47 support groups for inmates and 10 for staff were initiated. She observed that TOWA was a capacity building project that imparted expertise on procurement, accounting and planning to the implementers. Ms. Chepkonga affirmed that the prisons had since learnt to work with the available little resources and gave Homa Bay prison as an exemplary story of success on reduced HIV prevalence and enterprising support groups. She said that under Round 3 mobile outreaches were conducted and that following the registered success of the project, PEPFAR will directly fund the Kenya Prisons Service ACU. Ms. Chepkonga called on the counties to involve prisons at the county level and on the national government to increase funding for the prisons’ response. She urged the National Treasury to review regulations to facilitate Kenya Prisons Service and the entire public sector to own bank accounts in order to accommodate donor funds for program implementation. 4. Kujitegemea HIV/AIDS Afya Support Group by Mr. Raphael Macharia 88 Mr. Macharia’s presentation highlighted the following; (a) Objectives of the group that included encouraging and increase couple testing and counseling at VCT /PMTCT site and also home based, to provide counseling on safer conception, family planning and PMTCT for discordant couples and to provide advice and referrals to respond to specific reproductive health needs of discordant couples. (b) Activities on door–to-door counseling and testing and reproductive health needs of discordant couples (c) Challenges that included resistance from a few male partners in couple HCT, most couples preferred to be tested separately hence disclosure became a challenge and funding stopped midstream affecting implementation of planned activities. (d) Lessons learnt on the use of community members (especially known PLHIV) to serve as guides as they identified and adequately prepared couples before requesting for HCT counselors. Community health workers and discordant couples’ peer educators had a great impact on the response as they worked directly with the community. 5. Malindi Anti-Retroviral Therapy (MART) Winners from Kilifi County, by Mr. Gabriel Sande Mr. Sande said that MART was formed to ensure quality of life for PLHIV through psycho- social support. He stated that the group initiated PWP among PLHIV and also capacity built members of support groups and related networks. Mr. Sande listed achievements of the group as increased condom uptake, increased testing and tracing treatment defaulters. He singled out reluctance by men to participate in HIV issues, faith healers promoting defaulting and lack of support groups for young people as the main challenges faced by the group. Mr. Sande called for the empowering of people on their rights and understanding of related guidelines. He affirmed that adherence counsellors were needed on full time basis and that there was need for capacity strengthening of communities on self-reliance skills. He also added that continuous resource allocation was necessary to sustain gains made and that it was important to mainstream GIPA/MIPA in various sectors. 6. Wajir Women for Development by Mr. Abdi Mohammed Mr. Mohammed observed that before the advent of the TOWA project stigma and discrimination was high as the local community held misconstrued perception that HIV belonged elsewhere. He however noted that with the implementation of the project the county opened up for testing and treatment. He said that the group was working with the Ministry of Health on PWP in order to curb further infections through couple testing and counseling. Mr. Mohammed stated that the group had 2 support groups engaging expectant mothers on PMTCT and that the results registered included 14 HIV free born babies. He said that Afya Plus and AMREF had funded the group based on the successes of the TOWA project. Hawa from Mandera noted that the TOWA project had enabled people to open up and disclose their HIV status and that stigma and discrimination had reduced although it was still high. It was observed that VCT uptake had improved with religious leaders sensitized on HIV and AIDS although there were high rates of denial still recorded among men. She called on those who were HIV positive to marry among themselves so as to curb the spread of HIV. 89 7. Xposha Self Help Theatre Group, Vihiga County by Mr. Victor Ijaika Bulemi Mr. Bulemi’s presentation highlighted the following; (a) Background information on vision, target groups and area of interest. (b) Best practices that included youth to youth strategies that ensured more young people were reached, working in close collaboration with the Ministry of Health offices for referrals and working closely with CACC offices in creation of linkages with other partners. (c) Challenges such as Vihiga bordering Kisumu and Siaya Counties where HIV incidences are high as it calls for more collaborations and concerted efforts in ensuring that the region moves together (d) Recommendations that included strengthening the capacity building component at the regional and county level to realize more focused groups, capacity build counties and lobby them to embrace HIV programming and funding and also fast tract the KASF so us to present a framework for sustained efforts at community level. 8. Uriri Constituency, Migori County by Ms. Jane Omamo Ms. Omamo’s presentation outlined the following; (a) Background information and aim of the group (b) Activities of the group that included community mobilization and sensitization, linkage and referral system for counseling and support services, capacity building of PLHIV and engagement in income generating activities, continued monitoring and evaluation of activities, condom distribution and defaulter tracing. (c) Achievements that included 500 PLHIV trained on family testing, disclosure, PMTCT and adherence, scaling up of condom use, increased enrolment for HIV care and treatment, increased referral for family planning services and improved quality of life for PLHIV. (d) Challenges such as cultural and religious believes, high financial expectation from the community, herbal and traditional healers, inconsistence supply of condoms and lack of IGA support by TOWA. (e) Recommendations that included increasing the general level of funding, project framework should have sustainability program for IGA support and periodic joint review at the constituency level supported by TOWA. 9. A testimony by a Mr. James Monyare from Zapapo Bee-keeping Group in Laikipia confirmed that the project facilitated HIV and AIDS awareness campaigns and VCT and treatment with an estimated coverage of 690 people. 10. A testimony by a Mr. Abdalla Dara Abduba from Tana River observed that the project targeted vulnerable and marginalized groups and helped mitigate the poverty situation in this remote location and that communities were enlightened on the dangers of cultural practices such as female genital mutilation and unsafe male circumcision that facilitated HIV transmission. Remarks NACC Board Chair, Prof. Mary Getui appreciated the groups for sharing their experiences of success and hoped that the next TOWA project would facilitate group visits for members to witness the different unique contexts of the response. She recognized the county 90 representation at the conference and further expressed optimism that the county governments will commit and plan for the HIV response. 11. Kenya Assemblies of God Kisii-Mosocho VCT Program by Rev Ezekiel. It was stated that the program focuses on mobilizing 3000 people and counseling and testing 2000 individuals in Kisii and Nyamira counties. The highlights of the presentation were as follows; i. Background of the program detailing partnerships and scope. ii. Challenges that included lack of test kits and rife stigma and how to mitigate them through speeding up of the supply process and community mobilization respectively. Other challenges included denial after testing HIV positive, use of condoms among discordance and suspicious couples. iii. Project outcomes such as many couples and youth responding to VCT services, increased uptake of condoms, posttest groups formed, increased status disclosure and reduced stigma and discrimination. iv. Lessons learnt included intensive mobilization and education within the community yielding much response to services, effective and comprehensive campaigns through various sectors can help to reduce risk behavior, advocacy can help reduce HIV related stigma and discrimination and combination approach in HIV prevention is effective. v. Sustainability focusing on strengthening organizational structures, community ownership, continuous referrals and referral linkages and networking and collaboration. 12. Reach Out Trust, Mombasa County by Mr. Rueben Ambila Mr. Ambila noted that harassment by law enforcement agencies and sharing of syringes with the risk of contracting HIV were key challenges facing the IDUs. He said that the group contributed 8% of HIV infections as some of them doubled as sex workers and MSMs. Mr. Ambila stated that the group conducted mobile HTC that reached 1000 people with 222 individuals testing HIV positive and being referred to care although defaulting was still high. He observed that 4,100 IEC targeted material was developed, 10 posttest clubs formed to help manage addiction and 120 health providers trained on IDUs to mitigate stigma and discrimination in government facilities. He also stated that the group mobilized and sensitized religious leaders to understand better the IDUs. Mr. Ambila revealed that since 2011 the organization has provided 500, 000 needles and syringes and that 70% of IDUs don’t share paraphernalia anymore. He said that the organization had trained 20 law enforcers that included the police and city inspectorate officers on understanding the IDUs. Lessons learnt by the organization included the need for community based outreach as the best way to reach the IDUs, involve communities in sustainable livelihood and include individuals living positive in HIV planning. 13. Vision Talent Group from Mukurueini County by Mrs. Zipporah Ndirangu. Mrs. Ndirangu stated that the group had trained community health workers to take care of orphans and vulnerable children since fear, stigma and denial had reigned prior to the advent of the TOWA project. She said that the group facilitated HIV testing and formed 15 support groups to follow up on nutrition and motivation. Mrs. Ndirangu listed activities by the group among them being IGAs on poultry farming, soap making, table banking, distribution of condoms, sensitizing the community and treating clients and the community. 91 She said that the group had partnered with health facilities and the government at all levels and that it had managed to attract additional funding for the response due to the registered success during the life of the TOWA project. Mrs. Ndirangu observed that the group had initiated a community innovation on ‘budding’ that ensured friendship and support for those who turned HIV positive up on testing. 14. Stay Alive For Us All (SAFUA) Group from Makueni by Ms. Jacinta Mulatya Ms. Mulatya stated that the TOWA project empowered the group focusing on advocacy, care and support and that it surpassed the counseling and testing targets after it managed to mobilize the community to be tested by the Ministry of Health VCT team. The group partnered with various like entities and linked 1, 240 individuals to care and has since initiated table banking and even attracted more donors with varied farming activities in progress. 15. Counseling and Testing in Nandi by Eunice Tarus Ms. Tarus stated that the counseling and testing targeting the general population surpassed the target and that the developed linkages with the community facilitated referrals through an integrated approach. She noted that Community Health Workers and Community Health Extension Workers were trained on counseling and managed to reach 4 community health units. Ms. Tarus said that expectant mothers were encouraged to deliver in health facilities to support PMTCT initiative. However, over expectation from the community posed a major challenge as individuals demanded food ratios and bus fare up on being referred. Community Health Workers also demanded salary for their engagement. 16. KENEPOTE- by Wellness Programme Assistant Coordinator TSC Ms. Magdalene Mwele. Ms. Mwele’s summary presentation on ‘Journey to Zero’ booklet focused on; (a) Background information on KENEPOTE and TSC (b) Objectives that included inculcating spirit of de-stigmatization of HIV positive teachers, creating a credible body of literature that may act as a reliable reference on the subject of teachers & HIV and communicating TSC and KENEPOTE efforts to address challenges posed by HIV and AIDS to the teaching profession, among others. (c) Salient features of the ‘Journey to Zero’ booklet that included legal and structural framework for workplace programmes, principles of the ILO recommendation on HIV and AIDS and the World of Work, 2010 (No. 200) and principles of the Public Sector Workplace Policy on HIV and AIDS, among others. (d) TSC best practices that included acknowledging HIV and AIDS as a workplace issue, developing a workplace policy and mainstreaming HIV/AIDS workplace issues in the commission’s strategic plan. (e) KENEPOTE best practices that included KENEPOTE being an influential network of HIV+ teachers in Kenya despite high levels of stigma and KENEPOTE having a tendency to encourage unforced disclosure, among many other practices. (f) Thematic areas covered in the booklet that included discordance, disability & HIV, leadership, management and governance, widow inheritance, social protection, legal rights to inheritance, PMTC and reproductive rights, stigma and discrimination, religious cohesion and HIV and AIDS, extending services to hard to reach populations and partnership sustaining support groups. 92 Comments The participants commented as follows; (a) Kitchen gardens were best practices that offered requisite nutrition supplements by providing vegetables and fruits. (b) There was need to embrace public speaking in order to offer talks on HIV and AIDS under the ‘ambassadors of hope’ banner. (c) It was imperative that the OVCs family lineage is safeguarded. (d) IDUs should not be criminalized but instead they should be understood and assisted in the HIV and AIDS response (e) Adolescents should be helped to cope with HIV positive status and shun denial so as to stop the spread of HIV. (f) The TOWA project was about results and empowering communities at the local level. D. Kenya AIDS Strategic Framework (KASF) progress update NACC Economist Peter Kinuthia in his presentation on KASF progress update highlighted the following; Background of the KASF Development The KASF Development process began in May 2014 after undertaking the End of Term Review of the Third Kenya National AIDS Strategic Plan (KNASP III ETR) process which was a key building block to the KASF Development set to end in November 2014. The ETR Report highlighted four main issues that have since informed the development of the strategic framework. They were namely; (a) Prevention; We had made progress but more still needed to be done so as to turn the tide of new infections. (b) Treatment; we had made progress in adult ART coverage but pediatric ART coverage was still very low. (c) Monitoring and Evaluation; Data sources and Information Management continued to be a challenge even with the ‘3 Ones Principle’. (d) Sustainable Financing; Ownership of the HIV response through sustaining financing of the same domestically was of great importance. The KASF development process involves four phases as follows: (a) Phase I: Preparatory Phase (b) Phase II: Consultation and Drafting Phase (c) Phase III: Validation and Peer Review (d) Phase IV: Launch, Dissemination and Implementation 1. Vision 2. Overarching Goal 3. KASF Strategic Objectives that include; (a) Reduce new HIV infections by 75% (b) Reduce AIDS related mortality by 25% (c) Reduce (tolerance to HIV) related stigma and discrimination by 50% (d) Increase the domestic financing of the HIV response by 50% (progressively) 4. KASF Strategic Directions for each of the Specific Objectives and Enablers to complement Impact Results 5. Sustainable Financing; Fund Structure 93 6. Next Steps moving forward on peer review, editing, printing, the launch of the strategic framework slated for November 28, 2014 and subsequent rollout. Comments The participants commented as follows; • Up on successful implementation and completion of the TOWA project, the KASF provides a platform for sustainability moving forward. • The KASF document targets were too ambitious and thus should be reviewed to be realistic. • Social determination of health focusing on OVCs should be strengthened in the KASF document. • During the KASF validation meeting participants noted that the role of NASCOP was domineering in the document. • There was need for defining the role of CACCs, DASCOs, and County Health Executives and NACC Field officers in the HIV response at the devolved level in order to avoid conflict of interest. Responses Mr. Kinuthia responded to the comments as follows; • KASF development process was participatory and aims at accelerating prevention of HIV infections and therefore the KASF objective of 75% reduction in new HIV infections is not ambitious. • The strategic framework will addressed issues raised by the participants during the conference including issues on OVCs. • KASF does not tolerate stigma and discrimination of any form • A team of reviewers was looking at the KASF being finalized and that NACC was responsible for the overall results as NASCOP focuses on delivery of health services. • The KASF will outline the goals and recommended actions so as to inform the structure, roles and responsibilities of the CACCs, DASCOs, County Health Executives and NACC Field officers in the HIV response. Lessons learnt The lessons learnt by various sub implementers were summarized as follows; 1. Investing in communities and community organizations drives HIV and AIDS response positively. 2. Capacity building of local CSOs improved results 3. Monitoring and Evaluation, early identification and management of risks improved performance of projects 4. Counseling should not be restricted to HTC but should be holistic. 5. The TOWA project created linkages between CSOs and local development partners as some organizations attracted funding based on successful implementation of the TOWA project. 6. The TOWA project accelerated uptake of HTC thus making it convenient to reach government counseling and testing targets. 7. Parts of the country that were not reachable due to poor infrastructure should rely on the local based organizations to provide services 8. Introduction of the IGA component in the budget guaranteed sustainability of both CSOs and programs beyond the project life cycle. 94 9. The multisectoral approach was key to the HIV and AIDS response. 10. Strengthened systems and controls at the community level was a basis for funding by development partners. 11. Sensitizing communities on reduction of stigma and discrimination was imperative in the HIV response. 12. Community innovation approaches such as table banking, kitchen gardens, community linkages and budding (friendship) help communities cope with HIV. 13. Continuous resource allocation for programmes sustainability was necessary to sustain gains made 14. Sharing of experiences through visits by members of implementing groups was vital to witness different unique contexts in the HIV response. Conclusion and Way Forward NACC Deputy Director Finance and Administration, Mr. Dennis Kamuren observed that the TOWA project procedures for accountability were rigorous but urged the implementers to keep the resilience and hard work demonstrated. NACC Director, Dr. Nduku Kilonzo appreciated the participants for their continued good work on the HIV response and urged them to keep the same spirit of delivering results. She stated that NACC had requested the counties to constitute committees to help organize the World AIDS Day celebrations to be officiated by respective governors. The Director noted that once the KASF is launched at the national level, it will be dispatched together with the County Estimates for the governors to launch it at the county level. She called on the participants to engage with the NACC field offices in order to ensure that the World AIDS Day was a success. Dr. Nduku affirmed that NACC will engage even more so as to secure more partners on the response towards the realization of the Kenya Vision 2030 target of less than 4% HIV prevalence. NACC Board Chair Prof. Mary Getui hailed the government for continued support and expressed optimism that TOWA 2 will come forth soon. She stated that with the goodwill and commitment by various players the response will be able to achieve the ‘Zeros’ much earlier than 2030. Prof. Getui extended gratitude to the NACC board, management and secretariat and called on the CACCs to keep NACC devolved structures running effectively. She acknowledged the First Lady and the ‘Beyond Zero Campaign’ whose secretariat is housed at NACC for distributing the much needed clinics to counties. The Chair observed that all the players were important in the response and that the engagement should be seen as a calling. She reiterated the NACC board’s commitment and support to the HIV response endeavors. She finally awarded certificates to project implementers and CACCs for their exemplary performance on the HIV response in Kenya. Actual Deliverables Sharing of experiences on the impact of the TOWA project. A BRIEF OF THE NACC AND GOVERNORS CONSULTATIVE MEETING ON HIV AND AIDS HELD AT ENASHIPAI ON 29TH SEPTEMBER 2014 The following attended the meeting: 1. 25 Governors 95 2. US Deputy Chief of Mission, 3. PEPFAR Coordinator 4. 4 heads of UN agencies (UNAIDS, UNICEF, UNFPA) 5. NACC Board represented by the Chair and 3 Committee chairs 6. NACC Director and Secretariat staff The meeting started at 12.00noon up to 3pm with the following objectives: 1. Prioritization of HIV in the County plans and budgets for FY 2015/16 2. Mobilizing buy-in/ownership for the next 5 year HIV Strategy currently under development as this will be essential for delivering on the targets 3. Dissemination of the County HIV estimates, following launch of the Country HIV estimates by the Cabinet Secretary A summary of the issues raised and discussed and resolutions include: (a) Allocation of budgets to HIV, mothers and children: They are in agreement to increase resource allocations and will rely on NACC to provide technical support on County specific needs, existing resources and gaps they need to fill and to support their officers during the budget development process. (b) Procurement of HIV test kits, ARVs, condoms and TB drugs: In principle they have already agreed to central procurement through KEMSA. A paper that outlines process, quantities, distribution and reporting requirements will be useful to get a full Council resolution at their next meeting. (c) Kenya AIDS Strategic Framework: NACC and the CoG to draw an MOU that outlines all the areas that we propose delivery of the HIV response including technical support to implementation, monitoring, reporting for discussion with the Health committee and finally Council. In principle, the Governors agree to collaboration with National level in delivering the HIV response, as they need support and assistance. (d) Resources allocation: NACC to develop guidance on how HIV resources can be invested equitably in Counties (including external/partner resources). Additional issues that were discussed include: (a) A request from the Governors for better coordination of implementing partners so that they know who is working in their regions, what they are doing. NACC briefed the Governors on the implementing partner process under development with an implementation timeline of Quarter 3 and that this would be used to inform them. (b) Strengthened coordination of development partners with increased understanding of the resources available and what they are used for. NACC briefed the Governors that these are now issues for discussion currently on-going with the development partners through a forum that has been introduced and that the Cabinet Secretary has supported. (c) Ensuring utilization of the fully kitted Beyond Zero mobile clinics, (d) The Governors committed to ensuring utilization of the fully kitted mobile clinics that were being donated and recommended further engagement with their CECs. (e) Dissemination of different policies and plans, technical support to counties were discussed (f) NACC noted that the dissemination of the KASF would be undertaken together with dissemination of other policy documents. 96 (g) The Chair of the Council of Governors requested NACC to enhance staffing levels to cover each County in his opening remarks. (h) The Governors noted that the primary engagement mechanism should be the Counties and that the current structure that included Constituency AIDS Coordinators was challenging for coordination 97 Annex 6. Summary of Borrower's ICR and/or Comments on Draft ICR Summary of Borrower's ICR Project Context, Development Objectives and Design 1 During the 1990's, Kenya’s economic performance was weak and real per capita income contracted by an average of 0.5 % annually. The Government elected in December 2002, prepared an Economic Recovery Strategy (ERS) for Wealth and Employment Creation, reached agreement with the International Monetary Fund (IMF) on a Poverty Reduction and Growth Facility (PRGF) program, moved to improve relationships with donors, and developed new strategies for socioeconomic development. Inequality and poverty continued to be a major concern. About 56 % of households were estimated to be below the poverty line in 2003. Income inequality in Kenya w a s likewise high: in 1998-2002, the Gini index was 43 and the poorest 20 % of the population received only 6 % of national income, while the richest 20 % took nearly 50 %. Particularly affected w e r e the youth and especially girls, with HIV infection in young women aged 15 to 19 years being about five times higher than in men of the same age group. 2. The World Bank has been a major supporter of Kenya’s national response to the HIV and AIDS epidemic through several projects including: i. The Sexually Transmitted Infections Project (Credit 2686, US$50 million, approved December 1995); ii. The DARE Project (Credit 3440, US$54 million, approved December 2000); and iii. The KHADREP (Credit 3415, US$50 million, approved December 2000). Through the TOWA Project, IDA continued to support efforts to sustain governance improvements in the NACC. IDA played a lead role in supporting anti-corruption and governance issues in Kenya, and the TOWA Project would support further institutional strengthening in HIV and AIDS. The TOWA Project would also respond to some important gaps in the financing of the Kenya National AIDS Strategic Plan. Even though Kenya received significant amounts of money for HIV and AIDS from other external sources, there were still some significant gaps in the resourcing of the Program. 3. The project original development objective was to assist Kenya to expand the coverage of targeted HIV and AIDS prevention and mitigation interventions. This was to be done through: (i) sustaining the improved institutional performance of the NACC; and (ii) Supporting the implementation of the KNASP. In the year 2010, the Project development objectives were revised to: a) Expand the coverage of the targeted HIV and AIDS prevention and mitigation measures b) Expand access to bed nets amongst targeted PLHIV and the households in malaria risk areas. 4. The target beneficiaries under the original and the revised PDO under the TOWA project included the following: (a) NACC: The NACC institutional structures were strengthened through the TOWA Project through the governance and accountability component; (b) 98 Civil Society Organisations through the call for proposal process. They were given grants and received training to better equip them to manage the grants. A number of them have received funding from other donors due to the training received; (c) Public Sector through the mainstreaming program; (d) Private Sector; (e) PLWHIV; (f) Key Populations: The TOWA Project carried out programs targeting youth, women, sex workers, religious groups among others; (g) Population at large-Essential Commodities (universal coverage), grassroots; (h) VMGs; (i) OVCs; (j) Research Institutions; (k) Universities. 5. Performance under the project was monitored through the Project’s Results Framework. The project outcome indicators (POIs) reflect a combination of: (i) measures of institutional effectiveness of HIV and AIDS coordinating institutions (POI#1) and scope and degree of wide spread participation (POI#2); (ii) changes in overall behaviour change outcome indicators that are essential for reducing the risk of HIV transmission, attributable to all sources of finance (POI#3, POI#4 and POI#6); and (iii) measures of malaria risk reduction among households of PLHIV and other high-risk malaria households. 6. The authenticity and prudent management of the funded community level sub-projects was verified and closely monitored to ensure value for money and utmost transparency. The NACC developed an action plan for improving governance and accountability under the TOWA Project. Apart from the traditional independent external Financial Audits, the project had: (i) An independent Financial Management Agency,(ii) An independent procurement monitoring Agency, iii) An independent Compliance Verification Agency and iv) An independent Performance (‘value for money’) Auditor. Key Factors Affecting Implementation and Outcomes 1. The Project had to undergo several restructurings to ensure that the Project development Objectives are achieved. The first restructuring- level 2 was done at the same time as the fourth Amendment of the Financing Agreement approved by the Country Director in August 2010. The restructuring was for: (i) reallocation of funds to continue with the increased disbursement percentage from IDA, and (ii) the urgent purchase of additional bed nets (amounting to US$10 million) for the malaria program. The second restructuring was for the additional financing credit for the TOWA Project approved on November 18, 2010 by the Board. This followed from the fourth amendment and the restructuring approved in August 2010. There were three main reasons for additional credit: (a) The financing gap caused less than expected co-financing support; (b) Support the scale up of the Long Lasting Insecticidal Nets (LLITNs) to help attain universal coverage of bed nets within the high risk areas of the country; and (c) To build upon the initial stage of Project restructuring in August 2010 where the project original targets were lowered and Project cost tables changed to facilitate the urgent procurement of supplementary bed nets, at the expense of other commodities. The Additional Financing of US$55 million was to: (i) make up for the US$33 million funds from DFID, which was not going to be available as co-financing through the TOWA so that the fourth and fifth CfPs are fully funded and can go ahead; (ii) allocate another US$10 million to scale up the malaria bed net program (bringing the total provision under the TOWA to US$24 million); (iii) support the project restructuring and restore some of 99 the funding, especially for commodities, that was reallocated (mainly to bed nets) in August 2010; (iv) respond to the triggering of the safeguards for IP; and provide for the extended operations of the Project for another 18 months, including particularly for continued fiduciary and M&E strengthening; and revision of the PDO and KPIs. 2. Other Factors affecting Implementation Capacity Gaps Challenges: Low knowledge retention levels; Replacement of trained officials; Incomplete and inadequate financial and technical returns; Low literacy levels and accountability capacity at CBO level Financials & Accountability Challenges: Incomplete and inadequate financial and technical returns; Lack of documents to support certain types of expenditure; Heavy reliance on cash, as cheques are not normally accepted in rural areas; Default on reporting and poor record maintenance Governance and Administration Challenges: Late submission of monthly and quarterly reports by PSIs; Lack of offices for PSIs; High volumes of small transactions; Low reporting levels mostly in hard to reach areas Geographical and weather Conditions Challenges: Hard to access areas due to insecurity and/or poor infrastructure Socio-Economic Challenges: Failure by some PSIs to attend initial formal cluster training after invitation; Lack of IGA for the project implementers; Poor timing in terms of local seasons for implementers. Political Challenges: The Post-election violence of 2007/2008; Political Campaigns during the 2012 elections Programmatic challenges: Unrealistic targets for achievements; Tight Timelines for implementation; Poor documentation Assessment of Outcomes During the Project implementation period remarkable achievements were registered across various service delivery areas. Objective 1: Expand the coverage of the targeted HIV and AIDS prevention and mitigation measures i. Proportion of PSIs scoring “Very Good” or “Excellent” for target achievement in the annual audit during the year. ii. Number (cumulative) of civil society/private sector grants supported by the end of the year. 100 2. HIV Testing and Counseling Over 5.5 million people have been counseled and tested for HIV for a total cost of US$3,172,987 (42% of funds).This includes VCT for 2,119,420 Most at Risk Populations (38.4%) and VCT for a further 3,406,159 people (61.6 %) who are part of the general population. The MARPS covered include 424,466 most at risk youth, 41,727 long distance truck drivers and Commercial sex workers, 170,322 people in Hard to Reach Areas, 1467 Injecting drug Users, plus 1,481,438 MARPS without specific categorization. 3. The National HIV/AIDS Prevalence The result of the various interventions in the fight against HIV & AIDS for the country, the TOWA Project included, led to the decline in the National Prevalence rate from the Kenya AIDS Indicator Survey (KAIS) and KDHS Reports among men and women and the general population. Source: Kenya AIDS Indicator Survey 2007/2012 and Kenya Demographic and Health Survey (2003; 2008/9) 4. HIV Prevention-Condom Use and safe sex Over 7.8 million people were reached through behaviour change communication and HIV education for a total cost of USD$ 1,793,771 (24% of funds) under the TOWA Project. 101 5. Other Interventions A further 854,272 people have benefited from other specialized HIV services for a total cost of US$ 2,541,541 (44% of funds). This includes:  256,313 PLHIV that received support  403,097 mothers that received PMTCT services  67, 285 OVC that received the minimum package of care  106,511 people that received home and community based care 6. Vulnerable and Marginalized Groups (VMG’s) Vulnerable and Marginalized Groups (VMGs) were identified as those in the following hard to reach counties, Samburu, Narok, Nakuru, Laikipia, Mandera, Wajir, Garisa, Kilifi, Kwale, Lamu, Taita Taveta, Trans Nzoia, West Pokot, Bungoma, Baringo, Turkana, Marsabit and Isiolo. Routine services and implementing partners rarely reach these nomadic and black smith populations.  1,440 VMG community leaders sensitized on HIV and AIDS awareness, HTC, condom promotion  80,000 VMG community members were mobilized, mobilized and offered information and condom demonstration  328 VMG’s trained as peer educators 7. Over 43, 481 Orphans and Vulnerable Children were reached through local implementing partners with 10,288 OVCs being provided with nutritional support Objective 2: Expand access to bed nets among targeted people living with HIV and AIDS and the households in Malaria risk areas. Long lasting insecticide treated mosquito nets procured and distributed for the PLHIV (500,000) and for mass distribution (2,375,000) in Malaria endemic regions. A total of 5,250,000 individuals reached. 102 Other Unintended Outcomes and Impacts (positive or negative) • The CSOs funded under TOWA had strengthened capacities that enabled them to access other sources of funding e.g. impact funding under the WB CDD Project. • Increased MTEF funds allocation as a result of TOWA matching funds. • It served as catalytic funding opening up other counties and sub-counties to provide funds for its HIV programming in the county as part of the post TOWA sustainability • The Global Fund through the Red Cross has requested for recommendation for best TOWA implementers to be engaged in the implementation of Global Fund as lead agents. Assessment of Risk to Development Outcomes There was clear evidence that the NACC was committed to carrying out governance reforms and monitoring and evaluation strategies that would make the TOWA Project a success story for the country. However, several changes that were unanticipated at the project design occurred and threatened the achievement of the Project Development Objectives as the risks crystallized or materialized. Mitigating measures were taken. RISK IMPACT MITIGATIVE MEASURE RATING Exit of DFID as a Co- The Project Development The World Bank had to Negligible Financier in the TOWA objective not being met by the provide additional Project Project Financing(100%) for the Project to continue Volatile Political Climate in Delays in project Formation of an all-inclusive Significant 2007-2008 Post election implementation as a result of Government and Violence and Insurgence of the insecurity caused Heightened security vigilante groups in some operations regions The Promulgation of the new The Health function was The Development of KASF High Constitution and Devolution devolved to the county and KNAA bill to align as a requirement in the creating uncertainty on the NACC's operation to the Constitution NACC's existence Constitution The Ushering of the New This caused Implementation The state departments with Significant Government and merger of delays due to mix up of state unclear operations line had to state departments and departments making it difficult refund the funds to mitigate expanding others to hold individuals the risks of misuse accountable for the Project Change of the prices of The WHO Could not therefore The Use KEMSA as an Negligible streptomycin in the World procure the second Batch of alternative Procurement market the Streptomycin as part of the Agency to secure the pending Anti TB Drug Procurement Anti-TB Drugs Change of Prices for the The budgeted Quantities could Vary Quantities to fit into the Significant Goods and works to be not be procured in full making budgets already procured under the Project it impossible to obtain the project requirements Delay by WHO to procure The WHO Could not therefore Use of KEMSA as a Significant Commodities procure the second Batch of procuring agency for phase the Streptomycin as part of the two of the TB Drugs Anti TB Drug Procurement Delay by Kenya Bureau of The Project incurring Port and Use of alternative Bureaus of Significant Standards to clear Essential Container charges standard to help clear the same Commodities. Release of Containers under seal to avoid port charges 103 Assessment of Bank and Borrower Performance 1.The Bank provided the required supervision to ensure the proper functioning of the project and to strengthen the areas that needed more input or attention through its supervisory missions both operational and Financial. All prior conditions and Financing Agreements were discussed and agreed upon at entry between the Bank and Borrower and found to be satisfactory to ensure timely launch of the TOWA Project. Included in the Credit effectiveness requirements were the fulfilment and establishment of the safeguards and fiduciary arrangements as well as the M&E systems establishment. This is the Borrower of record and was therefore instrumental in designing the project safeguards and signing of the prior Conditions and the Financing Agreements. 2. The exchequer and the National Treasury provided the medium for the transfer of the project funds. The Borrower also provided disbursements Clinics for the World Project implementers highlighting key areas as absorption rates among others. The National Treasury was instrumental in the submission of the IFRs, the Withdrawal applications and direct payments that needed to be forwarded to the World Bank for Processing. 3. The NACC, as the coordinator of the project, learned several lessons which were integrated into the implementation of the TOWA project. The lessons learnt included the accountability and effective monitoring of the community grants which were a major part of the KHADRE Project. The NACC coordinated the project delivery while taking charge of the processes and agencies that were instituted as safeguards. Lessons Learned 1. A number of positive and negative lessons can be drawn from the project experience (these lessons have general applicability for similar operations). Key lessons learned are the following: a) Project Design • There was need to incorporate sustainability of future donor programs right from design stage • The engagement of Financial Management agency (FMA), Independent Compliance Verification Agency (ICVA) , Performance auditor (PA) and Procurement Monitoring Agency (PMA) denied the NACC an opportunity for institutional strengthening and capacity building • Need to shorten funds flow processes with NACC being the recipient to improve on Disbursements and Accountabilities • Need for capacity building framework to streamline capacity building in line with KASF priorities b) Stakeholders Involvement and Collaboration • Involvement of all stakeholders was essential to ensure that ownership and commitment to project implementation was maintained in relation to priority targets. • The inclusion focused efforts on communities who needed to benefit most, and to strengthen the quality of outcomes. • Scale-up of provision and access to HIV and AIDS services due to engagement of all stakeholders at all levels c) Pre-Implementation Preparations 104 • The process of community mobilization has resulted in active communities ready to go for future projects. • Some of the conditions of effectiveness of the Project were not cost-effective e.g. Independent Agencies d) Implementation Arrangements • A complex and rigid implementing arrangement did not provide the flexibility for testing of new models, quick results and maintaining political and operational independence for piloting innovative approaches. • More efficient procurement organization and procedures may have avoided some serious delays in project implementation. Frequent training on procurement procedures during implementation was necessary to avoid delays in procurement aspects. • An effective TOWA Project Performance committee greatly facilitated timely decision making that positively impacted on project implementation. • Inadequate time allowed for review of budgets and work plans during FMA trainings. • Incorporating experiences from KHADREP, effective monitoring and evaluation, early identification and management of risks improved the performance of the project • Governance and institutional strengthening arrangements were put in place based on KHADREP lessons which led to low Project implementation risks. • Use of existing government structures and process in the implementation such as Kenya Medical Supply Agency (KEMSA), KENAO, GoK Financial Procedures and M&E Systems improved the Project performance and enhanced Project savings. e) Implementation • Revision of the CfPs and Proposal Review Guidelines to incorporate pre-bidding training and feedback mechanism • International competitive bidding was a good practice that should be upheld. It encouraged competition and was cheaper in the long run. f) Impact of the Project • Capacity of project sub-implementers to implement HIV and AIDS programmes improved enabling them to access funds from other development partners. • Matching funds concept increased allocation of MTEF funds for HIV and AIDS mainstreaming in government institutions Conclusion Performance under the TOWA project was continually monitored through the Project’s Results Framework. A combination of outcome level indicators and intermediate indicators had been identified to facilitate monitoring of performance. The Project Appraisal Document (PAD and the TOWA Operation Manual) were developed to guide the Implementation of the TOWA Project. All the outcome level Indicators in PDO#1 and PDO# 2 were achieved and targets surpassed from the originally intended targets. Two indicators were used to assess the Institutional Performance of NACC: level of stakeholders’ satisfaction and status of the audit reports. The level of customer satisfaction 105 from the annual independent customer satisfaction surveys increased from 70 percent in 2007 to 87 percent in 2013. On the other hand, although all audit reports on NACC were qualified, NACC was able to address the issues of qualification within stipulated period of six months. All the intermediate indicators contributing to: (i) NACC’s effectiveness in coordinating program implementation; strengthening accountability and financial management capacity of NACC; (ii) Use of M&E system in planning, project design and implementation; and (iii) increased capacity of partners to respond effectively and report through the normal M&E tools were achieved and surpassed the targets. Trends analysis consistently showed improvements in target achievements throughout the project life. 106 Annex 7. Comments of Co-financiers and Other Partners/Stakeholders None 107 Annex 8. List of Supporting Documents 1. Project Appraisal Document on a Proposed Credit to the Republic of Kenya for a Total War against HIV and AIDS Project. May 2007 2. Project Paper on a Proposed Additional Credit to the Republic of Kenya for a Total War against HIV and AIDS Project. November 2010 3. Total War Against HIV and AIDS Project Financing Agreement 4. Total War Against HIV and AIDS Project Aide Memoires 5. Total War Against HIV and AIDS Project ISRs 6. Total War against HIV and AIDS Project mid Term Review. 2009 7. Country Assistance Strategy for the Republic of Kenya 2004 8. Country Partnership Strategy for the Republic of Kenya for the Period FY2014-2018 9. End Term Review of Kenya National AIDS Strategic Plan III, 2009/10-2012/13 Final Report. March 2014 10. GARPR Online Reporting Tool Narrative Report and Cover Sheet 11. Implementation Completion and Results Report Guidelines OPCS August 2006 (last updated on 07/22/2014) 12. Kenya AIDS Indicator Survey 2012 13. Kenya AIDS Response Progress Report: Progress towards Zero. March 2014 14. Kenya AIDS Strategic Framework 2014/2015 - 2018/2019 15. Kenya Country Partnership Strategy FY2014-2018 16. Kenya HIV Prevention Response and Modes of Transmission Analysis. March 2009. 17. Kenya National AIDS Spending Assessment Report for the Financial Years 2009/ 10- 2011/12. August 2014 18. Kenya National AIDS Strategic Plan (KNASP) II 2005/6-2009/10 19. Kenya National AIDS Strategic Plan (KNASP) III 2009/10-2012/13 20. NACC TOWA FMA Draft Final Progress Report, PWC. January 2014 21. National AIDS Control Council Report on End Term Evaluation of the Total War Against HIV and AIDS (CR 4336-KE/4641-KE), Component 1: Strengthening Government and Coordination. June 2014 22. National AIDS Control Council Report on End Term Evaluation of the Total War Against HIV and AIDS (CR 4336-KE/4641-KE), Component 2: Grants Awards and Mainstreaming Public Sector Programs. June 2014 23. National AIDS Control Council Report on End Term Evaluation of the Total War Against HIV and AIDS (CR 4336-KE/4641-KE), Component 3: Essential Health Commodities. June 2014 24. Performance Audit Report for the Total War Against AIDS Project- the National AIDS Control Council. November 2013 25. World Malaria Report 2014, WHOUNAIDS Report on the Global AIDS Epidemic 2013 108 IBRD 33426R2 K E N YA CITIES AND TOWNS MAIN ROADS DISTRICT CAPITALS* RAILROADS NATIONAL CAPITAL DISTRICT BOUNDARIES RIVERS INTERNATIONAL BOUNDARIES *not all District Capitals are shown. 34°E 36°E 38°E 40°E 42°E SOUTH SUDAN To Murle ETHIOPIA To Karungu Juba Lotikipi Plain Lokichokio Chalbi To 4°N 4°N Desert To Ramu Mandera Imi Kakuma Dila lls Lake Hi Sololo Tu r k a n a North Horr Moyale Mandera sa Turkana is Lodwar an D Marsabit el Turkw Buna El Wak UGANDA Lokichar South Horr Marsabit Tarbaj . tns 2°N Kangatet M Wajir 2°N to West Pokot do Lo g N aB Wajir Che Samburu og al ran Lak Bor ga Isiolo SO M A L I A Milgis Hil ny ls ’iro To Trans Nzoia Elgeyo/ Maralal Ng Bilesha Plain Mbale Kitale Kapedo Marakwet Ewaso Mando Baringo Archer’s Gashi Bungoma Uasin Post Garba To Gishu Tula Kampala Busia Marigat Eldoret Kakamega Isiolo Mbalambala Kakamega Laikipia D e ra To Nandi Nyahururu Meru Lak Kismaayo Butere Nanyuki Vihiga Falls 0° Siaya Mt. Kenya 0° Kisumu Kisumu Nyandarua (5,199 m) Tana Kericho Tharaka-Nithi Nakuru Nyeri Kirinyaga Homa Bay Kericho Nakuru Garissa Garissa Nyeri Embu Nyamira Gilgil Karungu Embu Nguni Bomet Murang'a Lake Migori Kisii ra Thika Ma Kiambu Bura Victoria To Narok Narok Kolbio To Bur Gavo Musoma Lolgorien Ma NAIROBI Ngang u E Nairobi Machakos Kitui Kitui erab sc arp Tana River eli Machakos Thua Plain me nt Konza Magadi Makueni Bodhei 2°S Kajiado Ya t t Ikutha Lamu 2°S To a A th i Seronera Pla tea Garsen Kibwezi u Lamu Namanga To Arusha Tsavo Kilifi Galana Tsavo To Moshi Voi Malindi INDIA N KENYA TANZANIA Taita/Taveta Mackinnon Park OCEA N This map was produced by Mombasa the Map Design Unit of The 4°S Kwale Mombasa World Bank. The boundaries, Kwale colors, denominations and 0 40 80 120 160 200 Kilometers any other information shown on this map do not imply, on the part of The World Bank Shimoni Group, any judgment on the 0 40 80 120 Miles To Dar Es Salaam legal status of any territory, or any endorsement or acceptance of such 34°E 36°E 38°E 40°E boundaries. JULY 2011