Document of The World Bank FOR OFFICE USE ONLY Report No:ICR0000121 IMPLEMENTATIONCOMPLETIONAND RESULTS REPORT (IDA-35960-BEN) CREDIT IN THE AMOUNTOF SDR 17.8MILLION (US$23.OO MILLION EQUIVALENT) TO THE REPUBLIC OF BENIN FOR A MULTISECTORAL HIVIAIDS PROJECT March 15,2007 SustainableDevelopmentDepartment CountryDepartment 15 Africa Region I I IThis documenthas a restricted distributionand maybe used by recipientsonly in the performanceof their official duties. Its contents may not otherwisebe disclosed without World Bank authorization. CURRENCY EQUIVALENTS (ExchangeRate Effective 12/28/2006) Currency Unit =CFAFranc US$1.OO = CFA Franc499 Fiscal Year January 1December 31 ABBFCEVIATIONSAND ACRONYMS AGeFlB Agence de Financement des Initiatives de Base (Agency for Financing Grass-roots Initiatives) AIDS Acquired Immune Deficiency Syndrome ARV Antiretroviral (drugs) CALS Comite' d2rrondissement de Lutte contre le SIDA (District Level HIVIAIDS Control Committee) CAS CountryAssistance Strategy CBO CommunityBased Organization CCLS Comitd Communal de Lutte contre le Sida (Communal HIVIAIDS Control Committee) CDLS Comite'Departemental de Lutte contre le Sida (DepartmentalHIVIAIDS Control Committee) CIDA Canadian International DevelopmentAssistance CNLS Comite'National de Lutte contre le Sida (National HIVIAIDS Control Committee) CSO Civil SocietyOrganization CVLS Comite' Villageois de Lutte contre le Sida (Villagelevel HIVIAIDS Control Committee) EU European Union GTZ Gesellschaftfur Technische Zusamrnmenarbeit (German Agency for Technical Cooperation) HIV Human ImmunodeficiencyVirus IDA International Development Association IEC Information Education Communication M&E Monitoring and Evaluation MAP Multisectoral HIVIAIDS Program for Afiica MOH Ministry of Health MTCT Mother To Child Transmission NGO Non-Governmental Organization PERAC Public ExpenditureReform Adjustment Credit PLWHA People Living With HIVIAIDS PMU Project ManagementUnit PNLS Programme National de Lutte contre le Sida (NationalHIVIAIDS Control Program) .. 11 PPLS Projet Multisectoriel de Lutte contre le VWSIDA STIs SexuallyTransmissible Infections UNAIDS United Nations AIDS Program UNDP United Nations DevelopmentProgram UNICEF United Nations Children'sFund USAID United States Assistance for International Development Acting Vice President: Hartwig Schafer Country Director: James P. Bond Acting SectorManager: Francois G. Le Gall Proiect Team Leader: Nicolas Ahouissoussi I BENIN MULTISECTORAL HIVIAIDS PROJECT CONTENTS A.Basic Information.............................................................................................................. v B. Key Dates........................... ............................................................................................ v C. Ratings Summary................................................................................................................ v D. Sector and Theme Codes................................................................................................... vi E.Bank Staff........................................................................................................................... vi F.Results FrameworkAnalysis.............................................................................................. vi G.Ratings of Project Performance in ISRs ............................................................................ ix H.Restructuring(if any)......................................................................................................... ix I. Disbursement Profile .......................................................................................................... ix 1.Project Context, Development Objectives,and Design....................................................... 1 2.Key Factors Affecting Implementation and Outcomes ......................................................4 3. Assessment of Outcomes..................................................................................................... 7 4.Assessment of Risk to Development Outcome..................................................................13 5.Assessment of Bank and Borrower Performance.............................................................. 13 6.Lessons Learned..............................................................................................................16 7.Comments on Issues Raised by BorrowerIImplementingAgenciesPartners....................17 Annex 1.Project Costs and Financing..................................................................................19 Annex 2.Outputsby Component...........................................................................................20 Annex 3.Economic and Financial Analysis..........................................................................24 . Annex 4.Bank Lending and ImplementationSupportJSupervision Processes......................25 Annex 5.Beneficiary SurveyResults .....................................................................................27 Annex 6. StakeholderWorkshopReport and Results......................................................... 29 Annex 7. Summaryof Borrower's ICR andlor Comments on Draft ICR ..............................31 Annex 8.Comments of Cofinanciers and other PartnersIStakeholders.................................50 Annex 9.List of SupportingDocuments ...............................................................................52 MAP (IBRD 33372)...............................................................................................................54 A. Basic Information Multi-Sectoral Country: Benin Project Name: HIV/AIDS Project Project ID: P073118 L/C/TF Number(s): IDA-35960,IDA-3596A ICR Date: 03/15/2007 ICR Type: Core ICR Lending Instrument: APL Borrower: REPUBLIC OF BENIN Original Total XDR 17.8M Disbursed Amount: XDR 17.3M Commitment: Environmental Category: B Implementing Agencies: Unité de Gestion du PPLS Cofinanciers and Other External Partners: B. Key Dates Process Date Process Original Date Revised / Actual Date(s) Concept Review: 04/19/2001 Effectiveness: 07/17/2002 07/17/2002 Appraisal: 07/30/2001 Restructuring(s): Approval: 01/04/2002 Mid-term Review: 02/15/2005 02/28/2005 Closing: 09/15/2006 09/15/2006 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Satisfactory Risk to Development Outcome: Moderate Bank Performance: Satisfactory Borrower Performance: Satisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Satisfactory Government: Satisfactory Quality of Supervision: Satisfactory Implementing Agency/Agencies: Satisfactory Overall Bank Overall Borrower Performance: Satisfactory Performance: Satisfactory C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Performance Indicators (if any) Rating Potential Problem Project Yes Quality at Entry None at any time (Yes/No): (QEA): i Problem Project at any Quality of No None time (Yes/No): Supervision (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 17 17 Health 59 59 Other social services 24 24 Theme Code (Primary/Secondary) Gender Secondary Secondary HIV/AIDS Primary Primary Health system performance Secondary Secondary Participation and civic engagement Primary Primary E. Bank Staff Positions At ICR At Approval Vice President: Hartwig Schafer Callisto E. Madavo Country Director: James P. Bond Antoinette M. Sayeh Sector Manager: Francois G. Le Gall Joseph Baah-Dwomoh Project Team Leader: Nicolas Ahouissoussi Nicolas Ahouissoussi ICR Team Leader: Nicolas Ahouissoussi ICR Primary Author: Turto Asseri Turtiainen F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) In accordance with the main goal of the MAP, the development objectives of the proposed project are : (i) to accelerate, intensify, diversify, and empower the response of civil society and the public sector to the HIV/AIDS epidemic. (ii) to build capacity in both civil society and the public sector to achieve and sustain this scaled up response. The outcome indicators on which data have been collected were as follows: The number of pregnant women ages 15 to 24 attending antenatal clinics who test positive for syphilis to be reduced by at least 2 percent in reference to the baseline study ii The percentage of women testing HIV/AIDS positive at antenatal clinics who are provided with a complete course of HART to prevent mother to child transmission to be at least 50 percent HIV prevalence among core transmitter groups (commercial sex workers, truck drivers, youth, etc.) would decrease by 20 percent in reference to the baseline survey . The key output and process indicators measured the following: (a) the number of HIV/AIDS subprojects and the amount to be used for their financing; (b) the HIV/AIDS- related services and their quality at the health centers; (c) capacity building at the local level, including the men and women trained in implementing agencies and traditional healers and midwives educated in HIV/AIDS topic; and (d) the number of public-sector organizations that have elaborated and implemented their Action Plans. Revised Project Development Objectives (as approved by original approving authority) The Project Development Objectives were not changed during the project period. (a) PDO Indicator(s) Original Target Formally Actual Value Indicator Baseline Value Values (from Revised Achieved at approval Target Completion or documents) Values Target Years Build capacity in both civil society and public sector to scale up and diversify Indicator 1 : their efforts to stabilize the transmission of HIV/AIDS by empowering active community participation and multi-sectoral. 33% of 100% of communes; communes; Value Existing capacities 33% of 61% of quantitative or negligible in both civil communities; communities; Qualitative) society and public sectors 50 public and 47 public and private sector private sector agencies agencies Date achieved 06/15/2002 09/15/2006 09/15/2006 Comments (incl. % achievement) Indicator 2 : Accelerate, intensify, diversify and empower the response of civil society and the public sector to the HIV/AIDS epidemic 100 NGOs, CSOs 652 NGOs, CSOs or associations and Associations Value Some activities against work on have worked on quantitative or HIV/AIDS but only in a HIV/AIDs HIV/AIDS Qualitative) small scale except in health sector prevention and prevention and care activities; care; 19 public sector 32 public sector iii agencies have agencies have implemented prepared and strategies and implemented their annual plans strategies and annual plans Date achieved 06/15/2002 09/15/2006 09/15/2006 Comments (incl. % achievement) (b) Intermediate Outcome Indicator(s) Original Target Formally Actual Value Indicator Baseline Value Values (from Achieved at approval Revised Completion or documents) Target Values Target Years Increased knowledge, organizational capacities and resources in communities Indicator 1 : and/or associations to effectively implement activities for the fight against AIDS. A total of 1,300 to 2,000 community- 3137 community- level committees level committees Value Limited knowledge and against HIV/AIDS have been (quantitative no resources for would be established and or Qualitative)implementing HIV/AIDS activities. established, prepared trained and subprojects elaborated documents. subprojects. Date achieved 06/15/2002 09/15/2006 09/15/2006 Comments (incl. % achievement) Indicator 2 : Strengthened and expanded response of non-health public sector and private sector organizations. 50 non-health public and private sector 1,136 women and 1,765 men worked Value Very limited response organizations will in 100% of (quantitative from non-health public install their focal communes and all or Qualitative)and private sector units and organizations. implement their ministries have action plans for appointed focal figthing against points HIV/AIDS. Date achieved 06/15/2002 09/15/2006 09/15/2006 Comments (incl. % achievement) Indicator 3 : Enhanced quality of care and availability of health care services and information iv of prevention, care and treatment of HIV/AIDS. Value At least 50% of (quantitative not available women tested HIV 56% or Qualitative) positive received ARV therapy Date achieved 06/15/2002 09/15/2006 09/15/2006 Comments (incl. % achievement) G. Ratings of Project Performance in ISRs Actual No. Date ISR Archived DO IP Disbursements (USD millions) 1 04/23/2002 Satisfactory Satisfactory 0.00 2 11/07/2002 Satisfactory Satisfactory 0.59 3 05/12/2003 Satisfactory Satisfactory 1.52 4 11/04/2003 Satisfactory Satisfactory 3.38 5 05/13/2004 Satisfactory Satisfactory 7.55 6 11/10/2004 Satisfactory Satisfactory 11.35 7 04/15/2005 Satisfactory Satisfactory 15.16 8 10/16/2005 Satisfactory Satisfactory 18.48 9 05/25/2006 Satisfactory Satisfactory 24.29 H. Restructuring (if any) Not Applicable v I. Disbursement Profile vi 1. Project Context, Development Objectives, and Design This section is descriptive and is taken from other documents e.g. PAD/ISR; it is not evaluative. 1.1 Context at Appraisal Brief summary of country macroeconomic and structural/sector background, rationale for Bank assistance etc. 1. In the context of appraisal the prevalence of HIV/AIDS in Benin was difficult to estimate with precision, because epidemiological surveillance and notification systems were weak, people had limited access to formal health services, and the social stigma associated with the disease remained strong. Nonetheless based on a 2000 Epidemiological Surveillance Survey, UNAIDS concluded that the national rate in that year was 2.5 percent, with wide variations between men and women, different regions of the country, and different occupations. In 1996 the overall male-to-female ratio of infection was estimated at 2:1, but by 2000 the ratio was estimated at 1:1. Most distressingly, the male-to-female ratio of infection for the 15 to 24 age group alone, by 2000, was 1:2. Similarly, the prevalence of HIV/AIDS in rural areas had grown to 5.4 percent, in contrast with 1.9 percent in urban areas, and among sex workers in urban areas it was 55 percent. Studies done by the National HIV/AIDS Control Program (Epidemiological Surveillance Survey) in the early 1990s identified sex workers as a high-risk group. Overall, UNAIDS estimated that 78,000 persons between the ages 15 and 49 were living with the virus in Benin in 2000, and that 5,600 persons had died from AIDS in 1999. 2. Awareness of the disease and its modes of transmission had continued to increase, but was still not universal in 2000. About 30 percent of women and 10 percent of men surveyed had received insufficient information on HIV/AIDS, its transmission, and the means of prevention (2001 Demographic and Health Survey). The perception of risk for each individual was even less well understood, with more than 50 percent of both men and women -- including young people, single people, and clients of prostitutes -- believing that they were not at risk. 3. The value added by World Bank support was considered to be fourfold: (a) the Bank had experience, and thus an advantage in relation to other donors, in mobilizing substantial financial resources for scaling up the national program; (b) the Bank, through its macro dialogue with the country on the Public Expenditure Reform Adjustment Credit and the Poverty Reduction Strategy Paper, was in a position to help the Government mainstream a multi-sectoral approach to HIV/AIDS within the country's overall financial and development strategy; (c) at the regional level, the Bank was instrumental in changing the perception of the HIV/AIDS epidemic from a `medical issue' to a `development issue'; and (d) there were no other significant financers such as the Global Fund at the time. 1 1.2 Original Project Development Objectives (PDO) and Key Indicators (as approved) 4. In accordance with the main goal of the MAP, the development objectives of the proposed project were: (a) to accelerate, intensify, diversify, and empower the response of civil society and the public sector to the HIV/AIDS epidemic, and (b) to build the capacity in both civil society and the public sector to achieve and sustain this scaled-up response. 5. The outcome indicators on which data were collected were as follows: · That the number of pregnant women aged 15 to 24, attending antenatal clinics, and who test positive for syphilis should be reduced by at least 2 percent in reference to the baseline study. · That the percentage of women who test HIV/AIDS positive at antenatal clinics, and are provided with a complete course of HART to prevent mother-to- child transmission, should be at least 50 percent. · That HIV prevalence among core transmitter groups (sex workers, truck drivers, youth, etc.) should decrease by 20 percent in reference to the baseline survey. 6. The key output and process indicators measured the following: (a) the number of HIV/AIDS subprojects and the amount to be used for their financing; (b) HIV/AIDS- related services, and their quality, at the health centers; (c) capacity-building at the local level, including the men and women trained in implementing agencies as well as the traditional healers and midwives educated about HIV/AIDS; and (d) the number of public- sector organizations that have elaborated and implemented their Action Plans. The individual indicators, targets, and achievements are presented in Section F. 1.3 Revised PDO and Key Indicators (as approved by original approving authority), and reasons/justification 7. The Project Development Objectives were not changed during the project period. 1.4 Main Beneficiaries (original and revised) Brief description of the `primary target group' identified in the PAD and as captured in the PDO, as well as any other individuals and organizations expected to benefit from the project. 8. The project aimed to sensitize, mobilize, and empower the nation's entire population to fight HIV/AIDS; this outcome could only be achieved through activities that reached out to everyone. With limited funds available, the project also allowed for targeted activities (e.g. at a high-risk group or high-risk locality) if the group or locality in question was identified as a priority by a community, a sectoral ministry, or the CNLS (Comité National de Lutte contre le Sida, the National HIV/AIDS Control Committee). The people currently infected with HIV/AIDS in Benin, estimated at 160,000, were expected to figure highly on a community's list of priorities. Other target groups included females aged 12 to 24; males aged 15 to 29; cross-border or long-distance lorry drivers and taxi drivers; high- risk groups living along Benin's borders with Togo and Nigeria; male and female military and police personnel; sex workers; male and female migrant workers; and the families and 2 street children who scavenge at dumpsites. In addition and from the beginning of 2005 when the project started financing ARV drugs, 2,000 AIDS patients have received the necessary medications through the project-supported PNLS (Programme National de Lutte contre le Sida, the National HIV/AIDS Control Program). 9. The organizations expected to benefit from the project were those that accompanied and supported communities in the fight against HIV/AIDS. They could be grouped as follows: (a) urban and rural communities, private-sector organizations, sector ministries, public organizations and agencies, and the CNLS; and (b) NGOs in the health sector, traditional associations, professional and occupational organizations, faith-based associations, and private agencies. All these targeted groups identified at the project design stage were reached throughout the project's life. 10. It should be noted that the project's resources were thinly spread in order to create awareness throughout the country and civil society; the follow-up project will focus on targeted approaches and move from creating awareness to changing behavior. 1.5 Original Components (as approved) 11. The project was designed to support the implementation of the National HIV/AIDS Strategy through three core components: Component A: Support to the civil society response The civil society response consisted of three subcomponents: · The strengthening of the institutional capacities of community-based organizations and civil society organizations, the implementation of awareness campaigns, and the training for and preparation of community subprojects. · The provision of community grants for executing subprojects. · The provision of financial support to civil society organizations that deliver prevention activities and care in communities. Component B: Support to the public sector response (including the health sector) This project component was expected to provide follow-up support for public sector activities, through two subcomponents: · Non-health sector Action Plans in line ministries and public and private institutions at the national level, to build their capacity to carry out short- and medium-term HIV/AIDS Action Plans. · Health sector interventions and activities to help expand the coverage and improve the efficacy of the HIV/AIDS program of the Ministry of Health, through the PNLS, the National HIV/AIDS Control Program, and a Program for Promotion of Traditional Medicine and Pharmacology. Component C: Support to project coordination, management, and monitoring and evaluation · Three activities were to be financed under this component: · The strengthening of the capacity of the CNLS and the PMU to coordinate, administer, and monitor and evaluate the project. 3 · The strengthening of the capacity of departmental, commune, arrondissement, and village committees to coordinate, and monitor and evaluate subprojects. · The implementation of monitoring and evaluation (M&E) and financial management activities. 1.6 Revised Components 12. The project components were not revised. 1.7 Other significant changes I.e. in design, scope and scale, implementation arrangements and schedule, and funding allocations. 13. At the end of 2004, the World Bank approved the financing of ARV drugs for 2,000 AIDS patients under Component 2, but this amendment did not change of the project's scope. This demonstrates the flexibility in the MAP I design, in this case responding to the country needs by scaling up treatment. 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design, and Quality at Entry (Including whether lessons of earlier operations were taken into account, risks and their mitigations identified, and adequacy of participatory processes, as applicable) 14. Benin's National AIDS Control Program began in 1987; a short-term plan and the first medium-term prevention and control plan were designed and implemented between then and 1993. A second medium-term plan, which launched the Government's multi- sectoral but still limited approach in the form of the PNLS under the Ministry of Health, ended in 2001. However because a genuinely multi-sectoral HIV/AIDS approach was new to Benin, the project (MAP I, or PPLS) was prepared as a collaboration between the Government and the World Bank team. During preparation, potential stakeholders held a five-day workshop and identified the project contents. In addition, a team comprising staff from key ministries, NGOs, and representatives from associations of people living with HIV/AIDS was commissioned to follow through with project preparation. 15. Multi-sectoral projects were new in Africa, but the preparation team benefited from lessons and documents prepared for other MAPs as well as from the guidance of previous workshops. In fact an 18-country workshop on community participation and HIV/AIDS organized in Mwanza, Tanzania, in June 2000 showed that behavioral change can be achieved, notably through the identification and implementation of HIV/AIDS action plans that are based on community participation. Possibly even more relevant were the lessons of several community-based, social sector projects in Benin, which identified 10 potential risks for PPLS in the Project Appraisal Document (PAD). As it turned out the mitigating measures proved to be adequate, and the measures to avoid most risks were identified during project implementation. The only risk identified at appraisal and for which the 4 mitigating measures were not sufficient was the inability of the Government to provide counterpart funds. 16. There was no quality-at-entry review at the beginning of the project, but in light of the comprehensive planning done at preparation, the stakeholders' involvement, the consistency of the objectives with the CAS and the Government's strategy, and the fact that all components were essentially implemented as envisaged, the quality at entry can be considered as satisfactory. The project preparation was based on the knowledge and data available at the time. 2.2 Implementation (Including any project changes/restructuring, mid-term review, Project at Risk status, and actions taken, as applicable) 17. The project was implemented essentially as planned, and there was no restructuring of the project during its four-year period. The midterm review was thorough and provided plenty of operational advice and recommendations, but it did not affect the structure of the project; the project was never in a `risk' status. The only major problem occurred at the end of the project, when the World Bank cancelled a part of the project funds (696,265 euros, or about US$800,000) because of procurement errors (see Section 5). 18. In the beginning of project implementation there were some difficulties in collaboration with the Ministry of Health, since the project was not under the direct tutelage of the National HIV/AIDS Control Program (PNLS) which is a directorate of the Ministry of Health. However, through intense dialogue between the Bank project team and the Ministry of Health and given the flexibility of the Project Implementation Unit, these difficulties were sorted out and very good collaboration was established. The Ministry of Health, through the PNLS, was directly in charge of all related medical aspects including acquisition of medical equipment, drugs, tests, reagents, VCT, etc. This fruitful collaboration set the stage for the key role MOH has played in coordinating and directing the establishment of ALCO and linking the country project with ALCO. 2.3 Monitoring and Evaluation (M&E) Design, Implementation, and Utilization 19. Africa-wide studies and Benin-specific assessments have pointed out weaknesses in coordination and M&E. Originally the project envisaged the establishment of a nationwide, uniform M&E system. The start was however very modest, as only one person without significant M&E experience was recruited for the task at the CNLS. At appraisal the team had anticipated getting the system designed and implemented for all HIV/AIDS projects within a year or two, but it took the full project period to establish a steering committee of all stakeholders, including donor agencies, with UNAIDS leadership; to find financing and recruit consultants to design the system and write the necessary documents; and to run workshops to gain the endorsement of all partners. However at the end of the four-year project, a unified M&E system for HIV/AIDS has now been developed and is ready for use when the follow-on project begins. 5 20. Meanwhile, PPLS established its own project-specific M&E system early on, which has produced the required quarterly and annual reports on time. In addition it has provided much statistical data and other information, which, together with specific studies on HIV/AIDS, have provided a relatively good basis for the HIV/AIDS strategy of 2006-2010. PPLS also organized a number of special evaluation studies with the help of consultants (see Annex 2). Nevertheless this project-specific M&E system was not linked to the overall national health M&E system; the follow-up project is expected to address this weakness, as a nationwide, unique M&E system framework has already been designed and is ready to be used. 2.4 Safeguard and Fiduciary Compliance (Focusing on issues and their resolution, as applicable) 21. There were no safeguard issues other than compliance with environmental requirements. 22. Like other MAP projects, PPLS was placed in Category B for environmental purposes. Consequently, international consultants prepared a comprehensive Clinical Waste Management Plan as a condition of effectiveness of the project. With funds available from PPLS, the plan was to carry out systematic training and capacity-building (on the subject of HIV/AIDS waste management) for all health personnel responsible for managing existing Incineration and Waste Management Units in medical facilities. Also, under the Government's Public Investment Program, a model incinerator, designed by the Ministry of Health and constructed locally, was to be provided for most of the decentralized health facilities; more complex imported models, complying with international norms, were to be allocated to centralized health facilities. 23. The project provided funds for training health personnel as planned. In addition and as budgeted, it provided equipment, medicines, and HIV/AIDS testing materials for health centers and laboratories. Training the health personnel has reportedly changed the way that medical waste is now treated, but despite the Government's good intentions budget constraints have prevented the purchase of more advanced incinerators for decentralized health facilities. The Government is proposing that this need be met under the follow-on project. It is worth noting that the Bank is the only institution that supports the Government's interest in addressing the waste management issue. 24. There were no major fiduciary problems during project implementation, except for one procurement case at the end of the project (see 10.2). The annual financial accounts were submitted on time and there were no qualified audit reports. 2.5 Post-completion Operation/Next Phase (Including transition arrangement to post-completion operation of investments financed by present operation, Operation & Maintenance arrangements, sustaining reforms and institutional capacity, and next phase/follow-up operation, if applicable) 25. The Government asked the World Bank for a credit of US$35 million to continue and expand the multi-sectoral approach implemented by the PPLS. The Bank received the 6 Benin Government's project preparation report and an appraisal was carried out in November 2006, with MAP II scheduled to become effective in June 2007. The next project has taken into account the lessons learned from the first project. The Government is concerned about its ability to sustain the institutional capacity developed during PPLS; not only did PPLS end several months before MAP II is due to start, but most other multi- and bilaterally financed projects on HIV/AIDS have expired (the only new projects under implementation are financed by AfDB and the Global Fund). The Government's organizational setup for HIV/AIDS remains in place, but may be in danger of deteriorating if adequate funding is not available for continuing HIV/AIDS activities. 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design, and Implementation To current country and global priorities, and Bank assistance strategy 26. The objectives of the PPLS, the design of the project, and its implementation are still fully relevant to the current strategy of Benin and the World Bank CAS. 27. In early 2006 Benin unveiled a new, ambitious strategy to fight HIV/AIDS (the Cadre Stratégique National de Lutte contre le VIH/SIDA/IST). It is based on the same multi-sectoral approach as the PPLS. The following `principles', as presented by the Chairman of the CNLS (the President of the Republic) in the new strategy paper, are appropriate for evaluating the relevance of the objectives, design, and implementation of the PPLS: · The approach must be national, multi-sectoral, well-coordinated, and involve `all living forces'. · All interventions that have proved to be cost-effective must be scaled up. · All persons who need them must have access to HIV/AIDS prevention information, care, and treatment. · The rights of people living with HIV/AIDS must be respected, and the latter must be allowed to fully participate in prevention efforts and in the care and treatment of infected people. 28. Finally, the World Bank's current CAS accords a very high priority to HIV/AIDS prevention and care. 3.2 Achievement of Project Development Objectives Including a brief discussion of causal linkages between outputs and outcomes, with details on outputs in Annex 2 29. The development objectives of the proposed project were to (a) accelerate, intensify, diversify, and empower the responses of civil society and the public sector to the HIV/AIDS epidemic, and (b) build capacity in both civil society and the public sector to achieve and sustain this scaled-up response (see Section 1). 30. On the basis of the following analysis, the achievement of Project Development Objectives is rated as satisfactory. 7 31. Inputs. The project provided inputs to the fight against HIV/AIDS, in the form of financing activities. These were intended to: · Facilitate the civil society response (strengthening of the institutional and technical capacities of community-based organizations (CBOs) and civil society organizations (CSOs); financing of CBO subprojects; and financing of CSOs): US$11.3 million. · Facilitate the development of specialized anti-HIV/AIDS units (Focal Points) in Government ministries; finance HIV/AIDS programs in non-health ministries; and supplement the resources obtained from other sources by the Ministry of Health to produce audiovisual materials, improve the capacity of personnel in HIV/AIDS matters, and acquire reagents, medicines, and equipment: US$9.3 million. · Strengthen the capacity to coordinate, monitor, and evaluate the HIV/AIDS program in Benin and to facilitate operational and financial management of the MAP project: US$4.9 million. 32. Outputs. Project inputs, including those for coordinating the fight against HIV/AIDS in Benin and for managing the operations and finances of the project, facilitated extensive outputs that generally exceeded the targets set at project appraisal. The principal outputs included the following: · A multi-sectoral approach, which engaged virtually the entire society in the anti- HIV/AIDS campaign. All relevant stakeholder groups participated in the project's work, and a wide range of activities were implemented in the public, civil-society, and private sectors (as illustrated below). This was per the overall MAP objectives approved by the Board in 2000. · Under `local responses', the project covered all 77 communes (municipalities) and funded subprojects in 3,137 communities, reaching 61 percent of the population. · The project helped to establish 33 associations for people living with HIV/AIDS (PLWHAs). Because of the project PLWHAs now testify publicly about HIV, and accept to be part of the sensitization process to convince peers of the existence of the disease. · Committees for fighting HIV/AIDS were established in 2,288 villages of the total 3,754 (61 percent), in all 77 communes (municipalities), and in six regions (each with two departments). · Caisses de solidarité [`solidarity funds'] have been established, and accept funds reserved for the care of people living with HIV/AIDS under the community subprojects. · Orphans, children, and other vulnerable persons are being looked after. · Community-level care of PLWHAs has been initiated. · Activities to educate people about HIV/AIDS have been organized at the village level. · The religious community has been mobilized in the fight against HIV/AIDS. · Testing for the HIV virus has started in penitentiaries. · Sex workers have been organized into associations to fight HIV/AIDS. 8 · Under the `public-sector organizations including health sector response', the project was the main source of funding for HIV testing in the country throughout the project's four-year duration, and the number of HIV-tested persons (202,000, with 1,223 positive tests) exceeded the targets. · As a result of the modification of the project's activities (i.e. through the project- supported PNLS), 2,000 AIDS patients were able to get the necessary antiretroviral medications. · A large number of traditional healers and voodoo practitioners received HIV/AIDS training (166 by the Ministry of Health, and 8,351 under the components of community subprojects). · Under the `civil society response', the project mobilized 652 NGOs and CSOs as well as 52 local radio stations for the fight against AIDS. Project funds were used to build up the capacity of the CNLS and its extensive field network. · Focal Point Units were established in 21 ministries; these units and 26 other public sector agencies prepared and implemented anti-HIV/AIDS plans. 33. Outcomes. The first development objective (to accelerate, intensify, diversify, and empower the response of the civil society and the public sector to the HIV/AIDS epidemic) was fully attained or exceeded, with practically no shortcomings in individual activity targets. An important outcome was the establishment of a large network of committees and units (in the public, civil society, and private sectors) that were trained to inform the population about the dangers and treatment of HIV/AIDS. Equally important was the building up of a well-functioning mechanism to coordinate activities and send financial resources to all parts of the country, including the smallest communities, for implementing their HIV/AIDS action plans. The HIV/AIDS committees at all levels gained knowledge of, and competence in, the implementation of subprojects. These outcomes are expected to improve the implementation of similar projects (including other social sector projects) in Benin in the future. 34. As for the second development objective, to build capacity in both the civil society and the public sector to achieve and sustain a scaled-up response, the outcomes were also satisfactory as evidenced by large-scale involvement of civil society in the work of the project, the public sector outputs, and the increased activities and efficiency of the Ministry of Health. However the performance in some ministries was uneven, and according to the Project Evaluation Forum held for stakeholders September 11-13, 2006, "the uniform strategy regarding the Focal Point Units in the ministries was unsatisfactory, because of its failure to take into account the special features and requirement of different sectors and because of frequent changes of personnel and/or the unavailability of personnel for HIV/AIDS-related tasks" (see Annex 2). Also, many field-level committees lacked the funds to carry out their functions effectively (see Section 3). 35. Overall the project exceeded expectations in its support to the Government, in establishing an enabling environment and institutional capacity to facilitate the use of other donor financing, and in addressing HIV/AIDS as a longer-term development challenge. 36. Accounting was carried out for many CSO subprojects, using scorecards to increase social accountability. In addition to the use of this successfully tested mechanism, other governance and accountability measures for the follow-up project will include publicizing 9 the proposals that are awarded in the public media and local notice boards; using investigators as needed when there is suspicion; and using joint CBO/NGO/CSO databases, especially when multiple donors are involved. 37. None of these outcomes, or very few of them, would have been possible without the project and the financial support by IDA. This project was by far the largest of its kind in Benin, having more funds and covering larger areas and population groups than any other donor project. If not for the project, neither the donors nor the Government would have been able to expand their commitments substantially to compensate for any lacking funds. During the latter part of the project period Benin received important support from the Global Fund, but this support was directed entirely to the health sector and Benin would thus not have been able to build up the public sector and society-based structures that the project assistance facilitated. It is worth noting that GFATM support to MOH and IDA's support to the PLNS complemented each other, and capitalized on the strengths of these institutions to scale up the response. Moreover, without this project the multi-sectoral approach of the fight against HIV/AIDS would not have become a reality in Benin. In fact because of this project the fight against the disease has now effectively been understood by all stakeholders as a development problem and not only a health issue (including among health sector partners), and nearly all sectors have been engaged in the fight. 38. Impact. It is difficult to estimate the impact of an HIV/AIDS project in such a short period (four years), particularly because the activities accelerated toward the end of the project cycle. The HIV/AIDS rate in Benin provides no guidance in this respect, because different methods were used to measure the rate of prevalence before and after the project (see Section 1). 39. Nonetheless, there are some indications of positive impacts. According to project- financed studies, more than 95 percent of the population of Benin is aware of the dangers of HIV/AIDS and of the ways to avoid it. Behavioral change has been observed in at least two aspects: (a) the number of people volunteering to take the HIV test (202,000) far exceeded the expectations at appraisal, in fact the health-sector laboratories had difficulty keeping up with demand; and (b) the use of condoms has become more common. Although the number of condoms distributed by the project is not particularly impressive (845,000 male condoms and 1,500 female condoms), it is significant to note that as a result of the project's initiative the `social marketing' of condoms is now organized through 913 small shops and street vendors all over the country. 40. The consultants who carried out the Government's final evaluation of the project, reported the following findings on the basis of their extensive fieldwork: · Discussions about HIV/AIDS in the villages are now much easier and more `relaxed' than before. · The stigmatization of PLWHA and their relatives has been reduced, and people have `come out' in larger numbers and also agreed to participate in the work of PLWHA. · Acceptance of the need to address HIV/AIDS issues has increased among individuals and communities, as evidenced by the numbers of people who are taking the voluntary HIV test and the participation of the population in the community committees. 10 · Although community arrangements for looking after AIDS patients are not yet common, the need to tackle this problem is now commonly discussed in all HIV/AIDS committees and by local HIV/AIDS-trained persons. 3.3 Efficiency (Net Present Value/Economic Rate of Return, cost effectiveness, e.g. unit rate norms, least cost, and comparisons; and Financial Rate of Return) 41. Separate, project-specific financial and economic analysis is not applicable to multi- sectoral HIV/AIDS projects. There is no financial analysis done by any donor on the cost of treatment and/or prevention. This will be addressed by the follow-up project. 3.4 Justification of Overall Outcome Rating (Combining relevance, achievement of PDOs, and efficiency) Rating: Satisfactory 42. The overall outcome is satisfactory, on the following grounds: · The objectives of the PPLS, the design of the project, and its implementation are still fully relevant to the current strategy of Benin and the World Bank CAS. · Achievement of the Project Development Objectives (PDOs) is satisfactory. For the part of the project that dealt with community mobilization, the results, attaining or exceeding nearly all output targets, could be rated as highly satisfactory. However because the activities relating to the public sector were slightly less successful (as mentioned earlier the performance of the different ministries was uneven, and many of the field-level committees lacked the funds to carry out their functions effectively and with adequate motivation), the overall rating for achievement of Project Development Objectives is given as satisfactory (see Beneficiary Survey Results in Annex 5 and Stakeholder Workshop in Annex 6). · The efficiency indicators, while lacking economic and financial rates of return, are acceptable for the type of activities and target groups that the project dealt with. · Using the number and increase of voluntary HIV/AIDS tests as a proxy (the 202,000 tests exceeded any expectations in this respect), the effectiveness of the project's messages has been satisfactory at least. · The achievements of the programs conducted by the Ministry of Health were commendable, and included the production of three television films, three fictional documentaries, and six news items on television; the multiplication of brochures and pamphlets on HIV/AIDS; the strengthened capacity of staff (220), NGO trainers (78), and traditional healers (166); the supply of reagents, medicines, and laboratory equipment; and special initiatives, such as organizing the training of traditional healers and voodoo priests. An example of the latter was broadly publicized and discussed in Benin, when the project and the Ministry of Health organized an extensive information and voluntary testing occasion for the devotees of voodoo at the 11 convention in Hèvié, about 35 km from Cotonou. As a result, more than 300 persons volunteered for an HIV test (with confidential results). Traditional healers testified that the training had convinced them that they must advise young people to use condoms, to avoid HIV, and not to trust traditional methods of prevention. Voodoo priestesses for their part declared that they had worked with the project already prior to the Hèvié occasion, and learned that they must not use the same blades or knives for several persons when carrying out rituals or performing traditional scarring. · The project helped to create and support an enabling environment for multi- donor response and scaling-up. All partners agree on the need to promote the `three ones', but they are not yet ready to pool funds in one program. However they are willing to plan annual activities and budgets together under the guidance of the CNLS, as well as to participate in joint implementation supervision missions. · Coordination with the Ministry of Health has significantly improved, and the CNLS and PNLS are working together effectively. · Social accountability and governance have improved with the use of score cards, whereby a voice was given to the communities in appreciating the receipt and management of funds by their peers. · Multi-sectorality in the fight against HIV/AIDS has become common sense; nearly all sectors have been engaged in a fight, which was perceived for a long time as only a health issue. 3.5 Overarching Themes, Other Outcomes and Impacts (If any, where not previously covered or to amplify discussion above) (a) Poverty Impacts, Gender Aspects, and Social Development 43. The project was not aimed at poverty reduction, but project authorities indicated that HIV/AIDS has a disproportionately severe effect on poor people: the latter are less knowledgeable about HIV/AIDS and thus more vulnerable, and it is more difficult for them to access service facilities. The project, through its local community approach, has reduced inequality in this respect. Overall, the project very much contributed towards poverty reduction by contributing to a healthier population, healthier PLWHA who can continue to be part of the work force, income generation activities for PLWHA, and addressing the legal rights of PLWHA and their dependents. 44. Gender concerns were regarded at appraisal as an important theme (after fighting HIV/AIDS, assuring the participation of stakeholders, and engaging civil society). Taking gender concerns as an important aspect of the project was appropriate, because women in Benin are twice as vulnerable to HIV as men (see 6.1). The project has promoted the standing of women in many ways, not least by requiring that women participate in communal, district, and village committees. As a result, about one-third of the members of these committees are women. Also, the strong visibility of female employees in the PPLS office, as well as in the CNLS and its branches, bears witness to the improved appreciation of women in Benin's society. 12 45. The project has also promoted social development by bringing together people of different social classes and groups, including sex workers and people living with HIV/AIDS, through gradually improved participatory approaches in the planning, implementation, and evaluation of project activities. (b) Institutional Change/Strengthening (particularly with reference to impacts on longer- term capacity and institutional development) 46. The project financed long-term capacity building (see Section 3). It helped build up an HIV/AIDS network consisting of the CNLS and its branches in the departments; Focal Units in all ministries and in numerous other public agencies; community-, district-, and department-level approval and monitoring committees; and hundreds of now-experienced NGOs. The project also facilitated the HIV/AIDS training of 9,166 local community leaders, 98,797 peer educators, 121 lay supervisors (agents d'accompagnement), community representatives (porte-paroles), 58 committees of the caisses de solidarité, 220 health-sector employees, and more than 8,000 traditional healers and midwives. These achievements represent long-term capacity-building and provide an institutional basis of sustainability that, with continued financing, will survive. 47. The project helped to consolidate the working relationship between CNLS and PNLS and the acceptance of CNLS as the coordination body of the fight against HIV/AIDS in the country. (c) Other Unintended Outcomes and Impacts (positive or negative, if any) 48. No negative outcomes or impacts have been noted; the one possibly negative impact (a televised public service announcement that may not have conveyed the intended message) was quickly corrected. 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops (optional for Core ICR, required for ILI, details in annexes) 49. Summaries of the Beneficiary Survey at midterm, and the Stakeholder Workshop at the end of the project, appear in Annexes 5 and 6 respectively. 4. Assessment of Risk to Development Outcome Rating: Moderate 50. The project helped to establish an enabling infrastructure to fight HIV/AIDS, all project components were implemented essentially as projected at appraisal, and nearly all the risks identified at appraisal were mitigated with the measures listed in the appraisal report. 51. Two remaining risks relate to the level of development outcome and its maintenance: (a) the Government's poor financial position, and potential failure to provide public funds to keep the administrative infrastructure going until new projects can provide 13 funds to continue prevention, care, and treatment activities; and (b) the weakness of Benin's health system, which hampers the country's ability to respond to the increasing number of people who volunteer to be tested for HIV and to take care of AIDS patients under ARV medication. The follow-on phase of the Bank and Global Fund programs and other potential development assistance are expected to mitigate these risks, but Benin would need longer-term global financing support to sustain its successes under the project. Capacity needs to be built in assessments, operations, research, M&E, continued support to sustain ART, and support to improve the health system. The question of health workers needs long-term donor support. 5. Assessment of Bank and Borrower Performance (Relating to design, implementation and outcome issues) 5.1 Bank (a) Bank Performance in Ensuring Quality at Entry (i.e., performance through lending phase) Rating: Satisfactory 52. The project was satisfactorily planned, and the appraisal team included medical, social sector, financial, M&E, safeguards, and management specialists, thus ensuring that the various aspects of a multi-sectoral approach and project implementation were covered. The design of the project was good, featuring the use of an existing financial agency to disburse funds at the community level, speedily and at very low cost (only the real costs were supported by the project). It is of special interest here that this project supported the preparation of a nationwide HIV/AIDS strategy, a central coordination body, and a uniform M&E system before the term `three ones' was introduced (see more in Sections 2 and 6). The Bank ensured participatory project preparation through a commissioned team comprising key ministries staff and NGO and PLWHA associations' representatives. It also provided adequate support through the presence of the Task Team Leader (TTL) and Co-TTL, both in the Bank's Benin office, and through pre-effectiveness supervision missions. Once the project began, certain shortcomings emerged, such as the excessive number and general character of M&E indicators and the inadequacy of the operational manuals (these had to be revised early on). (b) Quality of Supervision (including of fiduciary and safeguards policies) Rating: Satisfactory 53. The project was formally supervised at six-month intervals; one of the supervision missions served as a midterm review. Given that both the TTL and Co-TTL, along with the Procurement and Financial Management Specialists, were based in the Country Office, monthly field visits were also organized on a regular basis to help solve arising problems with adequate recommendations; monthly status reports were produced (and are available in IRIS). In addition to the regular participants (TTL, financial, procurement, safeguards, and community mobilization specialists, and the project assistant), the supervision teams 14 had specialists alternate in different areas of the project, such as drugs, M&E, and communications. The aide-mémoires were thorough and contained, in addition to status reports on various activities, appropriate advice to accelerate and better implement project activities. The Bank management reviewed and commented on the Implementation Status Reports, encouraging acceleration of the project in the beginning and offering support to issues highlighted in later reports. The Government and project authorities confirmed that the supervision missions as well as the constant and timely assistance provided by the Bank team throughout the project's life had been useful. However, the Borrower complained about delays in procurement decisions, although any delays appeared to have been due to the Borrower's lack of knowledge of Bank procedures; the Bank had provided adequate training throughout the project's life. (c) Justification of Rating for Overall Bank Performance Rating: Satisfactory 54. The rating for overall Bank performance is based on the ratings of the lending operation (project identification, preparation, and appraisal) and supervision quality. The rather slow administrative procedures in approving the Government's requests for adjustments, plus the instance of a faulty procurement case that was closed just before the end of the project, justify a `satisfactory' rather than `highly satisfactory' rating for overall Bank performance. 5.2 Borrower (a) Government Performance Rating: Satisfactory 55. The Government satisfactorily carried out the usual tasks associated with obtaining a Credit from IDA (project preparation, appraisal, negotiations, and ratification of the Credit). It also supported CNLS, and managed to make its Permanent Secretariat become a recognized coordinating body for HIV/AIDS activities. Moreover, the Government strongly supported the recommendations of the supervision and midterm missions, thus enabling the acceleration of project operations. The Minister of Plan, who ensured the tutelage of the project, personally carried out several supervision missions at the community level. This shows eloquently the Government's commitment to the fight against HIV/AIDS and its desire to make this project succeed. 56. However, the `satisfactory' rather than `highly satisfactory' rating is based on the following considerations: · The Government provided only 33 percent of the counterpart funds it was committed to provide. · The procedures for approving procurement decisions and financial reports were slow, and thus delayed project implementation to some extent. · The responsible ministry made a mistake in the procurement process, causing cancellation of more than US$800,000 of the Credit; and 15 · When it became obvious that several projects, including PPLS, would close before more funds were available to continue HIV/AIDS operations, the Government did not act quickly enough to ensure that these operations would continue without interruption, and thus was at least partially responsible for inflicting hardship on some people such as patients receiving ARV drugs and orphans in need of support and education. (b) Implementing Agency or Agencies Performance Rating: Satisfactory Implementing Agency Performance: Unité de Gestion du PPLS 57. According to the implementing agency, the Project Management Unit (PMU) of PPLS, in the beginning the project's implementation was slowed by both the Bank and Benin's complicated procurement procedures. As a result, it took several months before PMU could procure the necessary goods and services, including computers. However, after this rather slow start, implementation accelerated over the project period as component targets were attained and project funds disbursed. Several inventions helped to speed up implementation, for instance beneficiary communities were linked with health centers to take care of AIDS patients; solidarity funds were also established to finance the care of these patients. The PMU was able to handle the problems that arose in all components during implementation, often in consultation with the Bank project team, CNLS, and development and project partners, with the outcome that all component output targets were achieved. MOH, through PNLS, was able to carry out all its tasks including the acquisition of laboratory equipment, tests and reagent, drugs, ARVs, and ensuring VCT etc. (c) Justification of Rating for Overall Borrower Performance Rating: Satisfactory 58. The Government's performance is rated as satisfactory, and the performance of the implementing agency was so strong and output results so impressive that an overall satisfactory rating is also justified for the Borrower performance. 6. Lessons Learned (Both project-specific and of wide general application) 59. Community mobilization. The Analytical and Advisory Activities (AAA) studies conducted in Benin and other studies have confirmed the positive impact of PPLS in Benin. An important lesson here is that persons infected with and affected by HIV/AIDS can be reached through community mobilization and the use of multiple channels. The process is demanding, as hundreds of civil society organizations must be involved and trained (652 in Benin), thousands of community-based groups established (3,137 in Benin), and nearly all government administrative infrastructure engaged, but it can be done with good planning and management and through innovative approaches. 16 60. Monitoring and evaluation. It is widely accepted that M&E are valuable tools of coordination and management in HIV/AIDS activities. However, building up a nationwide and uniform M&E system is much more demanding than project planners usually acknowledge during the design process. It requires much manpower (specialists and consultants), substantial funds, and years of time. To ensure that everyone accepts a uniform system, it helps to establish a steering committee drawn from stakeholders including donor agencies; to persuade some agencies to finance part of the process of developing the M&E system; and to appoint UNAIDS to chair the committee. 61. The `three ones'. Although the term `three ones' had not been invented when PPLS was planned and appraised, PPLS contained all of its elements (a nationwide HIV/AIDS strategy, a central coordination body, and a uniform M&E system). However, the elements of the `three ones' were not fully respected in Benin. In particular, numerous participants in the health sector implemented their own programs without coordinating them with CNLS; it did not help that the turnover of staff at CNLS was high (three Permanent Secretaries in three years). Toward the end of the project period however, the Permanent Secretariat of CNLS was strengthened and proved to be a useful means of common acceptance for the "three ones". A substantial improvement in the degree of approval of the "three ones" was noted when a uniform monitoring and evaluation system and its manual were completed (during the last year of the project). It was followed by workshops for stakeholders (including donors) and training of staff centrally and in the field. (See more about M&E in Section 2) 62. Use of a Financial Management Agency. In contrast to several other MAPs, the Benin PPLS recruited a financial management agency (FMA) to handle the downstream flow of funds while the project's financial managers (recruited competitively from open markets) handled the accounting, bookkeeping, and other fiduciary aspects. The FMA was an experienced agency (the Agence de financement des initiatives de base, or AGeFIB), that handled the sub-accounts in the field and cost-effectively passed along the funds approved for subprojects to their implementation units. It later assumed some supervision and monitoring functions in instances where the local government HIV/AIDS units were unable to carry out these tasks. 63. Several other observations made in the course of the final evaluation of the project deserve to be mentioned here: · The process through which stakeholders participate in decision-making is burdensome, but it improves understanding and support and produces better action plans for project operations (PPLS increased the participation of stakeholders throughout the project period). · Although the multi-sectoral approach is good for tackling HIV/AIDS issues, not all ministries are equally valuable in this respect and not all NGOs are effective. Selectivity and prioritization are needed for the most cost-effective results. · The community approach is good for delivering the message to villages, but the health sector may not be able or willing to respond to the resulting surge of popular demands. Health sector staff must be trained, and health facilities improved simultaneously, if the community approach is to be fully successful. 17 · The stigma associated with HIV/AIDS infection remains an important element to keep in mind in HIV/AIDS work, but it can be reduced by effective programs including public service messages delivered by radio and television. In Benin the response to such messages, in terms of volunteers for testing, was so great that the health centers had difficulty coping with the demand. · At the end of the project, it is good practice to document the experience for the benefit of follow-on projects (the staff of the PMU in Benin did so in the form of several booklets. (See Annex 6). · The use of the scorecards mechanism proved to be very useful in encouraging social accountability and good governance at the community level. This may be coupled with the publication of proposals that are awarded in the public media and on local notice boards; investigators can be used as needed if suspicion arises. 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies 64. The Borrower's observations are in Annex 7 (Summary of Borrower's ICR). (b) Cofinanciers 65. There were no cofinanciers for PPLS, but several development partners (multi- and bilateral agencies) that were working in the HIV/AIDS sector at the same time as PPLS actively collaborated with this project. Their views are summarized in Annex 8, Comments of Cofinanciers and other Partners/Stakeholders. (c) Other partners and stakeholders (e.g. NGOs/private sector/civil society) 66. A summary of stakeholders' views is in Annex 6 (Stakeholder Workshop Report and Results). A summary of beneficiary survey results at midterm is in Annex 5, Beneficiary Survey Results. 18 Annex 1. Project Costs and Financing (a) Project Cost by Component (in USD Million equivalent) Appraisal Components Estimate (USD Actual/Latest Percentage of M) Estimate (USD M) Appraisal Support to the Response of Civil Society 11.00 11.30 102.73 Support to the Response of the Public Sector (including the 8.10 9.30 114.81 Health Sector) Support to Project Coordination, Management, Monitoring and 3.90 4.90 125.64 Evaluation. Total Baseline Cost 23.00 25.50 Physical Contingencies 0.00 Price Contingencies 0.00 Total Project Costs 23.00 Front-end fee PPF 0.00 0.00 0.00 Front-end fee IBRD 0.00 0.00 0.00 Total Financing Required 23.00 25.50 (b) Financing Appraisal Actual/Latest Source of Funds Type of Percentage of Cofinancing Estimate Estimate (USD (USD M) M) Appraisal Borrower 2.43 0.00 INTERNATIONAL DEVELOPMENT 23.00 0.00 ASSOCIATION 19 Annex 2. Outputs by Component Component 1. Support to the civil society response 1. The civil society response consisted of three subcomponents: · The strengthening of the institutional capacities of the community-based organizations and civil society organizations, the implementation of awareness campaigns, and the training and preparation for community subprojects. · The provision of community grants for executing subprojects. · The provision of financial support to civil society organizations that deliver prevention activities and care in communities. 2. The achievements under Component 1 are presented in the following table, for which the data were provided by the PPLS monitoring and evaluation system. Indicator Objective/Target Result/Achievement Component 1 Number of people - 36,410 involved in the launching Sub- workshops and meetings component 1.1 Number of community - 7,419 contact persons and peer educators trained Number of community - 1,741 representatives (agents d'accompagnement) Number of Community 1,300/2,000 3,811 Committees for the fight against HIV/AIDS established, trained, and featuring a participative Subcomponent approach in the 1.2 formulation of subprojects Number of HIV/AIDS 750/1,000 3,137 committees receiving support to implement their plans of action Number of community 2,500 3,055, namely 61% of action plans implemented communities (villages, successfully, e.g. at least city and town quarters) 50% of communities Number of caisses de - 58 solidarité established Project funds used directly At least US$6 FCFA 4.1 million, or in the communities to million, that is 138% of the target finance HIV/AIDS about FCFA 3,600 activities million 20 Amount of funds - FCFA 186.1 million mobilized in the communities for funding the caisses de solidarité. Number of condom - 913 selling points established Number of support groups One national A national network of and operating, self- association of at more than 600 members. financed associations for least 25 members PLWHA 40 communal 32 communal associations associations of at with more that 40 least 10 members members each Subcomponent Number of NGOs, CSOs, 100 652 1.3 or associations implementing HIV/AIDS activities financed by the project Number of persons 200 women and 1,136 men, 1,765 women; mobilized by 200 men these working in all 77 implementing communes (100% of organizations under the communities) civil-society response, and working at least in 50% of communities Number of traditional 192 traditional 166 traditional healers healers and midwives healers and trained by the Ministry of trained and provided with midwives Health; another 8,351 the necessary information persons working in the about HIV/AIDS/STI health sector, trained prevention through the community subprojects Component 2. Support to the public sector response (including the health sector) 3. This project component was designed to provide follow-up support for public sector activities, through two subcomponents: · Non-health sector Action Plans (in line ministries and public and private institutions at the national level), to build capacity to carry out short- and medium-term HIV/AIDS Action Plans. · Health sector interventions and activities (to help expand the coverage and improve the efficacy of the HIV/AIDS program of the Ministry of Health). 4. Under subcomponent 1, all ministries and numerous public and private sector agencies have established Focal Point Units for Fighting HIV/AIDS (UFLS), in many cases involving several people. These UFLS were established and running in: · 21 ministries. 21 · 12 institutions (IITA, CCIB, CES, National Police, CNSS, six departmental préfectures and CPA). · 14 commercial entreprises (OPT, ORTB, CODA, IBCG, SCB, SBEE, SATOM, FLUDOR, COLAS, CIM-BENIN, SCB LAFARGE, YAHIK, TOTAL, POSTE du BENIN SA). 5. During the period 2003-2006, support to the public sector and the health sector consisted of strengthening the capacities of these Focal Point Units and financing the action plans prepared by the ministries and public and private sector agencies. Altogether 70 contracts or memoranda of understanding were signed and implemented between the respective UFLS and the Project Management Unit. Over 50 percent of the ministries have been able to mobilize additional funds for the fight against HIV/AIDS through the annual Government budgets. Of the private commercial enterprises, all (100 percent) have been able to partially finance their HIV/AIDS action plans. 6. Under subcomponent 2, support to the Ministry of Health has been provided through the PNLS (Programme National de lutte contre le Sida), the Program for Promotion of Traditional Medicine and Pharmacology, and the Program for the Fight against Dental Infections. Support to the PNLS can be summarized as follows: · Support to audiovisual activities (three television films, three fictional documentaries, and six news items on television). · Multiplication of printed materials on HIV/AIDS (brochures, pamphlets etc.). · Strengthening the capacities of staff members (220), NGO trainers (78), and traditional healers (166). · Supply of reagents, medicines, equipment, and vehicles. · Implementation of special initiatives, such as a competition for the best media presentation on HIV/AIDS; the production of a document on the standards and procedures for fighting STI; and an investigation and clarification of high-risk behavior in relation to HIV/AIDS/STIs. 7. The support provided to PNLS has allowed for the following: improved access to voluntary HIV testing at the community level; prevention of vertical transmission (MTCT); treatment and care of PLWHA; and epidemiological monitoring of STIs and the HIV virus. Component 3. Support to project coordination, management, monitoring and evaluation 8. Three activities were to be financed under this component: (a) the strengthening of the capacity of CNLS and the PMU to coordinate, administer, monitor, and evaluate the project; (b) the strengthening of the capacity of departmental, commune, arrondissement, and village committees to coordinate, monitor, and evaluate subprojects; (c) the implementation of monitoring and evaluation (M&E) and financial management activities. 9. Component 3 financed the activities of the Permanent Secretariat of CNLS, the CNLS field organization, the Financial Management Agency (AGEFiB), and the Project Management Unit, including project audits and monitoring and evaluation. For CNLS the project financed the purchase of two vehicles and a motorcycle, office materials and computers, and the fuel for the CNLS vehicles for the duration of the project. Furthermore 22 support was also given to CNLS workshops and conferences, including one for evaluation of the strategic HIV/AIDS framework; to the training of CNLS staff; and to the implementation of the M&E system. 10. The gains made in the strengthening of field-level capacities, including the training of committees, are summarized in the table above. In the case of the Financial Management Agency (AGEFiB), the project financed the recruitment and placement of support personnel, office-related improvements, and the purchase of computers for managing and monitoring project operations relating to the flow of funds to communities and, to some extent, to monitoring and supervision in the field. 11. As for monitoring and evaluation, the project envisaged the establishment of a nationwide, uniform M&E system under the CNLS. The start was very modest as only one person, without significant M&E experience, was recruited for the task at the CNLS. However with the guidance of a steering committee drawn from all the stakeholders, including donor agencies and led and partly financed by UNAIDS, a unified M&E system for HIV/AIDS has been developed and is ready for use when the follow-on project starts. 12. Early on the PPLS established its own project-specific M&E system, which has produced the required quarterly and annual reports on time. The project also financed other activities of the Project Management Unit that were essential to successful implementation. 23 Annex 3. Economic and Financial Analysis (Including assumptions in the analysis) 1. Separate economic and financial analyses are not applicable to MAPs. 24 Annex 4. Bank Lending and Implementation Support/Supervision Processes (a) Task Team members Names Title Unit Responsibility/Specialty Lending Supervision/ICR Senior Financial Hugues Agossou Management AFTFM All related financial Specialist management aspects Lydie Ahodehou A. Program Assistant AFMBJ All secretarial aspects Itchi Gnon Ayindo Procurement All procurement related Specialist AFTPC aspects Wolfgang M.T. All related disbursement Chadab Finance Officer LOAG2 aspects Ayite-Fily Senior Operations Related health aspects D'Almeida Officer AFTH2 and liaison with other partners Jean J. Delion Senior Operations Civil society response Officer AFTS2 aspects Marie-Claudine Language Program Fundi Assistant AFTS3 All secretarial aspects Midou Ibrahima Country Manager AFMCG Related health aspects Sonia Gnon Josiane Nieri-Boko Executive Assistant AFMBJ All secretarial aspects Karim Olayinka Communications Okanla Officer AFREX Communication aspects Emanuele Santi Communications Officer EXTCD Communication aspects Abdoul-Wahab Social Development Seyni Specialist AFTS3 Safeguards issues Tshiya Subayi- Orphans and Vulnerable Cuppen Operations Officer AFTH2 Children aspects Juliana Victor- Monitoring and Ahuchogu Evaluation Specialist ACTAFRICA All M&E related aspects 25 (b) Staff Time and Cost Staff Time and Cost (Bank Budget Only) Stage of Project Cycle USD Thousands No. of staff weeks (including travel and consultant costs) Lending FY01 28 67.87 FY02 45 88.03 FY03 0.00 FY04 0.00 FY05 0.00 FY06 0.00 FY07 0.00 Total: 73 155.90 Supervision/ICR FY01 0.00 FY02 10 22.46 FY03 46 74.04 FY04 52 106.28 FY05 57 112.29 FY06 39 117.40 FY07 6 30.18 Total: 210 462.65 26 Annex 5. Beneficiary Survey Results (If any) Summary 1. At midterm in the project, the PPLS contracted local consultants to carry out a sociological survey on the views of project beneficiaries. The methods of the study included sample-based interviews and inquiries, plus a review of existing project documents. The samples covered the key participants in the implementation of the project, that is, civil society organizations (CSOs), community-based organizations (CBOs), Focal Point Units in the participating ministries, CNLS and its field organization, and bilateral and multilateral agencies financing HIV/AIDS activities. 2. The study first inquired about the satisfaction of the various groups participating in the project. The CBOs generally endorsed the objectives of the project, and a large majority of them or their committee members (74 percent) believed that the actions promoted by PPLS will have the desired effect among the population, namely to change sexual behavior. More than half of the respondents stated that, as part of the strategy to fight HIV/AIDS, communication in order to alert people to the dangers of and means to avoid HIVAIDS (sensibilisation) was `extremely important'. For most of the others, communication was `important'. The views shared by the CSOs were essentially the same. Both types of organizations confirmed that PPLS was the most important source of financing for sensitizing the population on these subjects. 3. As to care and treatment (testing for HIV, providing condoms, and taking care of people with AIDS), the proximity of aid and services was considered important, even if such services could not always be arranged very near to the beneficiaries. 4. The CSOs and CBOs noted the following weaknesses in the project: some television programs may have given inappropriate messages that the people in various localities could not fully identify with; the financing procedures of subprojects were very complex and burdensome; and the rate of rejection for subprojects and financing proposals was high (18 percent, a percentage that dropped quickly once the communities learned to fill in the forms correctly). Also, the budgets reserved for the community subprojects (up to US$3,000 each, but often about US$1,000 equivalent) were too low, and the price of condoms at FCFA 35 to FCFA 50 (US$0.08 to US$0.10) per unit was too high. 5. In the public sector, appreciation of the dangers of HIV/AIDS was reported `very high' (nearly 89 percent of respondents), whereas for the rest it was `a problem'. PPLS had supported Focal Point Units in 21 ministries, and another 20 in other agencies, in the preparation and implementation of sensitization strategies and plans. This support had allowed nearly all key ministries and agencies to train their staff and carry out HIV/AIDS prevention programs. For instance assistance to the Ministry of Education (which provides more than half of public sector employment) facilitated the training of 202 educators, and allowed them to pass along the message to the nation's primary schools. The promotion of HIV testing resulted in substantially higher use of condoms in the military, and persuaded 400 military personnel to come forward for voluntary testing. 27 6. It was noted, however, that nearly all Focal Point Units had been late in implementing their plans and in using the funds allocated to them; that some had been unable to justify the expense of the first round of assistance, while others had already started with the second round of activities. Sometimes staff members in the Focal Point Units were poorly selected, and high turnover required continuous training. 7. The external agencies financing HIV/AIDS programs in Benin endorsed both the objectives of PPLS and the strategies to attain them. 8. In order to achieve wider acceptance of testing among the public at-large, and to better motivate the implementing partners, the study recommended that voluntary testing should start at the higher echelons of politicians and public administrators. The inadequacy of financial incentives was the principal cause of the lethargy and delays observed in nearly all of the commune- and community-level organizations. 28 Annex 6. Stakeholder Workshop Report and Results (If any) Summary 1. The CNLS and PPLS organized a stakeholder workshop on September 11-13, 2006, just before the project period expired. Over 100 people attended, including staff members of CNLS, PPLS, PNLS, and other HIV/AIDS projects; departmental and district-level (commune) administrators (mayors and préfets); representatives of CNLS's field network; members of the Focal Point Units in all ministries; representatives of international and bilateral organizations; members of the religious and NGO communities; people living with HIV/AIDS; staff of the Financial Management Agency that provided field services for the projects; traditional healers and midwives; several radio personalities; and some 15 journalists. 2. The participants unanimously agreed that the project, despite some inevitable difficulties in the implementation stage, has been a success. Although measuring change in sexual behavior in the short term is difficult, it was agreed that positive results had been achieved and that these results could be substantially attributed to the PPLS. Moreover a national infrastructure of institutions and agencies has been built, and this will guarantee the sustainability of the project's legacy. 3. The participants considered the following activities as special innovations: · People living with HIV/AIDS have formed their own associations. · Caisses de solidarité have been established, and accept funds earmarked for the care of people living with HIV/AIDS (under the community subprojects). · Orphans, children, and other vulnerable persons are being looked after. · Community-level care of PLWHAs has been established. · Activities to educate people about HIV/AIDS have been organized at the village level. · The religious community has been mobilized in the fight against HIV/AIDS. · Testing for the HIV virus has been started in penitentiaries. · Sex workers have been organized into associations to fight against HIV/AIDS. 4. Notwithstanding the substantial achievements of the project (nearly all objectives and targets were attained or exceeded), several shortcomings should be mentioned: · The uniform strategy regarding Focal Point Units in the ministries was unsatisfactory. This is primarily because of its failure to account for the special features and requirements of different sectors, and also because of frequent changes of personnel and/or the unavailability of personnel for HIV/AIDS- related tasks. · The project had poor results regarding the promotion of female condoms. · The rate of counterpart financing (33 percent of the committed amounts) was poor. 29 · Some objectives were only partially attained, such as the establishment of PLWHA associations and the full staffing of some Focal Point Units in the ministries. · HIV/AIDS testing, despite getting the attention of the population, was unsatisfactory because of its lack of confidentiality, tardiness in getting the results, and insufficient counseling services. · Although a basis for institutional sustainability has been provided through the new network of public, private, NGO, and religious sector representatives, financial sustainability is precarious: government financing is lacking, particularly with reference to ARV drugs, testing materials, medicines, and prevention activities. 5. An extensive and detailed report of workshop proceedings is available in the Project Files at the World Bank's Benin office (see Annex 9: List of Reference Documents). 30 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR RAPPORT D'ACHEVEMENT PROJET PLURISECTORIEL DE LUTTE CONTRE LES IST/VIH/SIDA 1 ­ INTRODUCTION Le projet Plurisectoriel de Lutte contre les IST/VIH/SIDA a été mis en vigueur le 17 juillet 2002 pour une durée de 4 ans. Déjà en février 2003, la plupart des conditions pouvant permettre une plus grande visibilité des actions du projet étaient remplies. Ainsi, au cours de cette année, les activités au niveau communautaire et au niveau du secteur public ont réellement commencé. En distinguant les grandes étapes de la mise en oeuvre du projet, on dira que l'année 2003 constitue l'année de visibilité de ses activités, l'année 2004 celle du passage à l'échelle et les années 2005 et début 2006, les années de consolidation progressive des acquis. La date de clôture du projet est intervenue au cours de la phase de consolidation des acquis du projet. Le projet Plurisectoriel de lutte contre les IST/VIH/SIDA s'est achevé avec un taux de décaissement de plus de 98% après quatre années d'activités intenses. Ce rapport d'achèvement, outre l'introduction, présente les objectifs du projet, ses composantes, sa mise en oeuvre, les principaux résultats, l'évaluation des performances des différents intervenants et les leçons apprises. 2 ­ OBJECTIFS, STRUCTURES ET MISE EN OEUVRE DU PROJET 2.1 ­ OBJECTIFS DU PROJET L'objectif général du Projet Plurisectoriel de Lutte contre les IST/VIH/SIDA est de faire ralentir au Bénin la propagation de l'épidémie du VIH/SIDA et d'atténuer son impact sur les personnes vivant avec le VIH et les personnes affectées. De façon spécifique, le projet vise à : · Accélérer, intensifier et diversifier les mesures de lutte contre le VIH/SIDA · mettre à la disposition de la société civile et du secteur public des moyens pour lutter contre l'épidémie du VIH/SIDA · renforcer les capacités de la société civile et du secteur public aux fins de la mise en place et du maintien des mesures d'intervention. 2.2 ­ COMPOSANTES DU PROJET Le projet comprend trois composantes : les composantes A, B et C. - La Composante A : Fourniture d'appui aux mesures prises par la société civile Cette composante comprend trois sous composantes : la sous composante A1 concerne le renforcement de capacités des OC et des OSC, 31 la sous composante A2 concerne l'appui aux initiatives des organisations communautaires et la sous composante A3 l'appui aux initiatives des organisations de la société civile. - La Composante B : Fourniture d'appui aux mesures prises par le secteur public ; Cette composante comprend deux sous-composantes : les sous composantes B1 concerne le secteur public sauf le ministère de la santé et la sous composante B2 concerne le ministère de la santé. - La Composante C : Appui à la coordination, à la gestion, au suivi et à l'évaluation du projet. Elle comprend cinq sous composante : la sous composante C1 : Renforcement des capacités du SP/CNLS et de l'UGP, la sous composante C2 : Renforcement des capacités des CDLS, CALS, CCLS et CVLS ; la Sous composante C3 : Suivi et évaluation, la sous composante C4 : Comptabilité et gestion financière, la sous composante C5 : Audits financiers et techniques. 2.3 ­ PROCESSUS DE MISE EN OEUVRE PAR COMPOSANTES 2.3.1 - Composante A Trois (3) sous-composantes ont permis la mise en oeuvre de cette composante. A travers la sous-composante A1, le PPLS a appuyé le renforcement des capacités institutionnelles et techniques des Organisations Communautaires (OC) et des Organisations de la Société Civile. Ceci a entre autres, rendu possible, la formation des ONG et des OAL (Organismes d'appui au lancement) qui ont joué le rôle important d'intermédiation sociale entre les communautés et les différents intervenants. La sous-composante A2 concerne les dons accordés aux Organisations Communautaires dans le cadre du financement de leurs plans d'actions de lutte contre le VIH/SIDA élaborés par approche participative pour mener des activités visant à promouvoir et valoriser les changements de comportement. La sous composante A3 appuie le financement des sous projets d'Organisations de la Société Civile (OSC) portant sur des activités : · des centres de soins et de conseil ; · des structures d'appui aux enfants devenus orphelins et aux familles affectées par le VIH/SIDA ; · des associations nationales et décentralisées des tradithérapeutes ; · de dépistages volontaires et anonymes du VIH/SIDA. Dans le souci d'efficacité et en raison du fait que l'AGeFIB a des expériences antérieures en matière de gestion de projets communautaires, cette agence a été sollicitée pour assurer le transfert des fonds aux communautés et le suivi de leurs activités. Les plans d'actions communautaires et les sous projets d'OSC ne sont pas admis à recevoir des financements s'il n'y a pas eu approbation par les instances mises en place à cet effet. 32 2.3.2 - Composante B Dans le cadre de la mobilisation des organisations du secteur public (OSP), le projet a contribué dans un premier temps à la mise en place d'un cadre institutionnel favorable à l'appropriation des activités de lutte contre le VIH/SIDA/IST par le secteur public. Ensuite il a renforcé les capacités des membres des unités focales de lutte contre le VIH/SIDA puis les a appuyés à élaborer leur plan d'action de lutte contre le VIH/SIDA. Les plans d'action sont ensuite transmis au Secrétariat Permanent du CNLS pour approbation lors de la session budgétaire du CNLS. Une fois ces plans d'action approuvés par le CNLS une convention annuelle de financement est signée entre l'UGP et l'unité focale. L'appui au Ministère de la Santé Publique s'est fait à travers le PNLS et l'unité focale de ce ministère. Le PNLS élabore un plan d'action qu'il transmet au CNLS et aux différents partenaires dont le PPLS. Le plan final retenu après discussion est transmis au PPLS pour financement. Le PNLS donne ensuite les spécifications pour les acquisitions pour que l'UGP entame les procédures de passation des marchés. Notons que le PNLS est associé à toutes les étapes importantes de la passation des marchés pour les différentes acquisitions. Le ministère de la santé préside les commissions d'évaluation pour les acquisitions de médicaments, de réactifs et de matériels médicaux. 2.3.3 - Composante C En dehors des dépenses courantes qui entrent dans le fonctionnement du projet, l'Unité de Gestion du PPLS appuie techniquement et financièrement les différents acteurs, l'AGeFIB qui est une agence de gestion financière assure le transfert des fonds vers les communautés, leur donne des appuis techniques et financières et suit leurs activités. Le SP/CNLS reçoit des appuis du PPLS. Il assure la coordination de toutes les activités de lutte contre le SIDA. Cette composante assure les dépenses liées à la coordination, à la gestion, au suivi, à l'évaluation du projet, à la gestion financière et aux audits. 3 ­ PRESENTATION DES RESULTATS PAR COMPOSANTE 3.1 - Composante A La mise en oeuvre de la composante A du projet a permis d'obtenir les résultats dont les principaux sont synthétisés dans le tableau qui suit : Résultats Attendus Obtenus Ecarts Nombre de personnes touchées - 36410 lors des ateliers et réunions de A1 lancement Nombre de relais communautaires - 7419 et paires éducateurs formés 33 Nombre d'agents - 1741 d'accompagnement formés au profit des communautés Nombre des Comités 1300/2000 3811 + 1811 Communautaires de lutte contre le VIH/SIDA établis, formés et ayant conçu leurs sous projets à travers un exercice de planification participative Nombre de Comités VIH/SIDA 750/1000 3137 + 2137 A2 recevant d'appui pour mettre en oeuvre leurs plans d'actions Nombre de plans d'action 2500 3055 dans +555 communautaires achevés avec 60,95% des succès dans 50% des communautés communautés (villages et quartiers de ville) Nombre de caisses de solidarités - 58 mises en place Flux des fonds directement Au minimum 4 097 161 667 envoyés aux communautés pour 6000000 de soit 138% de financer les activités du dollars soit 3600 l'objectif VIH/SIDA. millions de FCFA prévues environ Montant mobilisé près des - 186.051.615 F communautés pour alimenter les CFA caisses de solidarité Nombre de points de vente de - 913 préservatifs créés Nombre de groupes d'appui et 1 association 1 réseau national d'associations autosuffisants et nationale de 25 d'associations opérationnels membres de plus de 600 membres. 40 associations 32 associations communales de 10 communales de membres au moins plus de 40 membres Nombre d'ONG/organisations de 100 652 +552 A3 la société civile ou associations mettant en oeuvre des activités sur le SIDA et financés par le programme 34 Nombre de personnes mobilisé par 200 femmes et 200 Nbre femmes : les organismes d'exécution et hommes mobilisés 1136 travaillant dans le cadre de la par les organismes Nbre hommes : réponse de la société civile dans d'exécution dans 1765 50% des communautés 50% des 77 communes communautés (100%) Nombre de guérisseurs Avoir 192 *166 Praticiens traditionnels ou de matrones guérisseurs de la médecine traditionnelles formés et équipés traditionnels ou de traditionnelle des informations sur la prévention matrones formés par le du VIH/SIDA et les IST traditionnelles Ministère Santé formés et équipés Publique des informations *8351Praticiens sur la prévention de la médecine du VIH/SIDA et traditionnelle les IST formés à travers les plans communauté Les différentes activités menées par les organisations de la société civile ont permis de façon synthétique de donner les résultats suivants : - une meilleure connaissance du PPLS par les communautés à la base. - l'existence en milieu communautaire des personnes outillées, capables de relayer l'information contribuant au mécanisme de pérennisation, - l'amélioration de la participation des femmes à la mobilisation sociale pour la lutte contre le VIH/SIDA (les femmes représentent le 1/3 de l'effectif des membres des comités locaux) - l'amélioration de la perception du Sida par les communautés qui reconnaissent désormais son existence et établissent des rapports analogiques entre les modes de transmission classiques et leurs pratiques quotidiennes, - l'amélioration de l'accessibilité géographique au préservatif masculin - la capacité des communautés à prendre en compte les problèmes des personnes infectées et affectées (comités porte parole des caisses de solidarité), - La plus grande visibilité de l'implication des PVVIH dans la mise en oeuvre des actions de lutte contre le VIH/SIDA) 3.1.1. Analyse évaluative de la composante A La mise en oeuvre du projet a été essentiellement basée sur une approche participative. Le PPLS a associé les bénéficiaires à chaque étape de la mise en oeuvre des activités. L'implication de ces différents acteurs a permis par exemple d'opérer le partage des charges relatives à l'exécution des activités. Cette approche a permis d'utiliser moins de ressources que possible pour la mise en oeuvre du projet. L'implication des communautés s'est faite à plusieurs niveaux : d'abord elles participent au financement de leurs plans 35 d'action en apportant 5% du financement total. Elles sont utilisées dans le suivi des plans d'actions, ce qui constitue une garantie pour la pérennisation des actions en cas d'achèvement du projet. Pour amoindrir les coûts de consultance, le projet utilise des compétences locales dans divers secteurs (assistant social, agent de santé, spécialiste en communication). Le projet s'est donc essentiellement basé sur l'existant (Utilisation des services de l'AGeFIB, Utilisation des locaux de l'AGeFIB et d'une partie du personnel d'de l'AGeFIB qui avait de l'expérience en matière de gestion financière en milieu communautaire et associatif). Tout le processus de renforcement de capacité des OC et des OSC notamment l'élaboration des modules de formation des OAL, la formation des communautés par les OAL, la formation des agents d'accompagnement communautaires était imputé sur le compte spécial B. Ce qui a augmenté les dépenses au niveau de la catégorie 3. Pour des raisons d'efficience, le projet a pris en compte les minima des montants plafonds prévus dans l'accord de crédit. Ce qui explique que pour la sous composante A2 par exemple, le projet a atteint plus de la moitié des résultats attendus en fin de projet. Les différentes actions entreprises au niveau communautaire, le recrutement et la mise au travail des OAL, l'élaboration des plans d'action communautaires, la mise en place des caisses de solidarité, sont autant d'acquis qui témoignent de l'efficacité dans la mise en oeuvre du projet. Le niveau de connaissance des communautés par rapport aux IST/VIH/SIDA s'est nettement amélioré (l'étude sur la satisfaction des bénéficiaires à mi parcours l'avait déjà révélé ; après la mi-parcours des mesures de renforcement de cet acquis ont été prises). L'auto évaluation par les cartes a été une solution pour l'instauration de la bonne gouvernance et l'apprentissage de l'autonomisation des communautés. L'implication des radios de proximité a permis de booster les communautés par rapport aux connaissances acquises. Ces radios diffusent les meilleures pratiques et conseillent sur les mauvaises pratiques. Elles ont ainsi fortement supplée aux formations classiques. 3.2 - Composante B 3.2.1 Sous Composante B1 (Appui aux mesures prises par les ministères et autres institutions) De 2003 à 2006, l'appui au secteur public autre que le secteur de la santé a consisté à : - renforcer les capacités des membres des UFLS - financer les PALS des ministères, institutions et entreprises Quarante sept (47) UFLS ont signé avec l'UGP soixante dix (70) conventions de financement. Ces UFLS se répartissent comme suit : - 21 Ministères 36 - 12 institutions (IITA, CCIB, CES, Police nationale, CNSS, les 6 Préfectures des Départements et le CPA) - 14 entreprises (OPT, ORTB, CODA, IBCG, SCB, SBEE, SATOM, FLUDOR, COLAS, CIM-BENINSCB LAFARGE, YAHIK, TOTAL, POSTE du BENIN SA) Plus de 50% des ministères ont pu mobiliser des ressources au budget national et 100% des entreprises ont toutes contribué au financement de la mise en oeuvre de leur plan d'action de lutte contre les IST/VIH/SIDA. 3.2.2 - Sous composante B2 (Appui aux mesures prises par le ministère de la santé publique) L'appui au ministère de la santé publique s'est fait à travers le PNLS, le Programme de Promotion de la médecine traditionnelle et de la pharmacopée et le Programme de Lutte contre les Affections Bucco-dentaires L'appui au PNLS se résume aux quatre points suivants : La réalisation de supports audiovisuels (3 téléfilms, 3 documentaires fictions, 6 spots) La multiplication de supports imprimés (brochures, dépliants) Le renforcement des capacités du personnel (220) des animateurs des ONG (78) et des praticiens de la médecine traditionnelle (166) L'acquisition de réactifs, médicaments, équipements et mobiliers La mise en oeuvre d'initiatives spécifiques : Concours des meilleures productions médiatiques sur le SIDA, élaboration du document de normes et procédures pour la prise en charge des IST, l'enquête de surveillance des comportements à risque pour les IST/VIH/SIDA Cet appui a permis d'améliorer l'accès des communautés au dépistage volontaire du VIH, à la prévention de la transmission verticale du VIH et à la prise en charge des PVVIH. Il a par ailleurs permis d'assurer la sérosurveillance épidémiologique des IST et du VIH. L'efficacité du projet s'est traduite dans les faits par l'approvisionnement régulier du PNLS en réactifs et en médicaments, ce qui facilite l'accès des populations au dépistage volontaire ; l'appui à la PTME par la disponibilité des réactifs de dépistage des femmes en consultation prénatale, l'appui à la prise en charge et au suivi des PVVIH puis la contribution au renforcement de la sécurité transfusionnelle. La disponibilité des réactifs a permis de contribuer à l'amélioration de la représentativité de la surveillance par réseau sentinelle, à la mise en place de la surveillance de 2ème génération puis à la réalisation de certaines enquêtes spécifiques. L'on ne doit pas oublier le renforcement des capacités du personnel. Ceci a participé à l'amélioration de la qualité des services dans divers domaines. La répartition des réactifs au niveau intermédiaire et périphérique n'est pas encore systématique. Certains des acteurs de ces niveaux d'intervention se plaignent de ne recevoir les réactifs qu'après des tracasseries multiples ou à la limite de la date de péremption. 37 La formation des praticiens de la médecine traditionnelle a contribué au renforcement de leur implication dans la lutte contre les IST/VIH/SIDA et par conséquent de la collaboration entre les deux types de médecine. Il y a aussi l'amélioration de la capacité de gestion des réactifs et médicaments (chambre froide). 3.2.3 - Analyse évaluative de la composante B La formalisation de l'existence des structures de lutte contre le VIH/SIDA dans le secteur public par des actes administratifs, est une première étape dans le processus d'appropriation et de pérennisation des actions dans ce secteur. Par cet acte, l'Etat consacre des ressources humaines à la lutte contre le VIH dans les ministères et services concernés. Cette institutionnalisation a permis aussi à certaines unités focales (MEPS, MFE) de pouvoir obtenir des bureaux dans leur ministère et une ligne budgétaire (MEPS, METFP, MMEH, MISD, MEHU) pour contribuer à la mise en oeuvre de leur plan d'action. L'un des effets importants ou changement que l'on peut signaler suite à la mise en oeuvre du PPLS est celui relatif au cadre institutionnel. Aujourd'hui, dans l'environnement des services du secteur public notamment dans les ministères et dans quelques institutions de la République, les unités focales sont une réalité, elles ne passent pas inaperçues par les activités qu'elles mènent. De même, l'appui au PNLS à travers l'acquisition de matériels de bureau et d'équipements divers a permis de renforcer les capacités techniques de ce programme du secteur santé. Le projet a eu un impact certain sur l'environnement sanitaire (la formation des agents de santé, les équipements, les médicaments et les test acquis sur le projet ont influencé positivement l'environnement sanitaire. La formation des agents de santé a induit des changements de comportement. Les zones sanitaires se sont fortement impliquées, elles ont organisé pour la plupart des séances de dépistage. Le lien établi entre les communautés et les centres de santé pour régler les problèmes de prise en charge a été bénéfique à maints égards. Cette mise en lien des communautés a permis une légère amélioration de la fréquentation des centres de santé. 3.3 - Composante C Cette composante a pris en compte les besoins de l'AGF, de l'Unité de gestion, les audits et le suivi et l'évaluation et une partie des besoins du SP/CNLS. De façon précise, il y a eu au profit du SP/CNLS, l'acquisition de deux véhicules et d'une moto, de matériel de bureau et d'ordinateurs. Le projet a contribué au financement du fonctionnement du SP/CNLS, à la formation des membres du CNLS, l'évaluation du cadre stratégique et la mise en place du système de suivi et évaluation. Pour ce qui concerne l'agence de gestion financière (AGEFiB), le projet a recruté et mis à sa disposition le personnel d'appui, a aménagé les bureaux et fourni du matériel informatique. Enfin, cette composante a pris en compte les dépenses courantes de fonctionnement du projet. 38 3.3.1 - Analyse évaluative de la composante C En ce qui concerne la composante C, le PPLS a fait de l'appui institutionnel au secrétariat permanent au lieu d'appuyer essentiellement les audits et les supervisions. L'appui au SP/CNLS a été orienté vers les équipements, le matériel roulant et le matériel de bureau. Ce qui a réduit la possibilité de financer les supervisions. Mais le problème est réellement dû au fait qu'une composante ne soit pas consacrée spécialement à l'appui du SP/CNLS et ses démembrements et que les ressources de cet appui étaient comprises dans la composante la moins nantie ; ceci a limité sérieusement les possibilités de financer davantage le CNLS. 4 ­ EVALUATION DES PERFORMANCES DU BENIN 4.1 ­ Le Gouvernement La mise en oeuvre du projet a permis d'enregistrer l'implication des autorités politico administratives et des autorités locales (le Ministre d'Etat, Premier vice président du CNLS, les autres ministres, les autorités religieuses et traditionnelles, les chefs de culte vodoun sont fortement impliqués dans les activités du PPLS). Le soutien et l'implication du 1er vice président du CNLS est une réalité. Il a participé en personne à plusieurs supervisions au niveau des départements où il a visité des communes et des villages au sud, au centre et au nord du pays. En tout état de cause face aux nouveaux besoins et aux contraintes de terrain, le gouvernement a été pro actif en adressant des requêtes pour la modification de l'Accord de crédit. Mais le point faible du Gouvernement est de n'avoir pas pu tenir entièrement ses promesses par rapport à la mise en oeuvre du projet. Il y a eu des difficultés de mobilisation de la contrepartie béninoise. Ce qui constitue des menaces qui pourraient compromettre la pérennisation du projet. De ce fait, la contribution réelle du gouvernement est très faible, elle n'a pu être que le tiers de ce qu'il avait prévu. Toutefois, il a accepté de financer les unités focales de lutte contre le VIH/SIDA (UFLS) qui ont pour la plupart prévu une ligne budgétaire pour la lutte contre le SIDA. La majeure partie des UFLS ont réellement été financées. 4.2 ­ Le CNLS Les activités du CNLS et de ses structures décentralisées témoignent d'une certaine organisation opérationnelle. Il existe une cohérence entres les actions menées dans le cadre de la mise en oeuvre du PPLS et les domaines du cadre stratégique national de lutte contre les IST/VIH/SIDA. Vers la fin du projet, le CNLS est devenu plus opérationnel, plus visible et plus dynamique avec la nomination du secrétaire permanent actuel. Avec sa grande expertise de la problématique du VIH/SIDA et des problèmes de santé en général, son ancienneté, son expérience professionnelle en matière de gestion et de coordination, beaucoup de choses ont été faites ces derniers mois sous le leadership du SP/CNLS malgré le problème criard d'insuffisance en ressources humaines et 39 matérielles ; il s'agit surtout des activités suivantes : revue conjointe du premier cadre stratégique national de lutte contre le VIH/SIDA/IST et élaboration du nouveau cadre stratégique, 2006-2010, évaluation de la mise en oeuvre des « Three Ones » au Bénin, rédaction du rapport UNGASS, 2005, consultation nationale sur l'accès universel à la prévention, aux soins et au traitement, élaboration du plan d'accélération de la prévention, mise en place du système national unique de suivi/évaluation et formation des agents sur le CRIS et le manuel opérationnel etc. Le SP/NCLS a été un tant soi peu renforcé le PALS/ de la BAD et le PASNALS du PNUD, deux projets localisés au SP/CNLS et placés directement sous la coordination du SP/CNLS ; Le Secrétariat Permanent a réussi à impliquer activement les autres intervenants de la lutte contre le SIDA dans sa nouvelle dynamique. Le CNLS a bénéficié de l'appui de l'ONUSIDA et de la Banque Mondiale à travers le PPLS même si les problèmes de son leadership continuent de se poser du fait de l'arrangement institutionnel actuel des projets de lutte contre le VIH/SIDA en général ; cet arrangement institutionnel n'est pas favorable aux « Three Ones ». Il faut remarquer que le taux du « turn over » est assez élevé. En quatre ans, trois Secrétaires Permanents du CNLS se sont succédés. Au niveau des départements, c'est le CDLS qui a le pouvoir d'approbation des sous- projets d'OSC et d'assurer dans le même temps, un mandat de suivi des sous-projets et plans d'actions. Mais, compte tenu du manque de moyens, les CDLS et les CCLS n'ont pas pu jouer pleinement ce rôle. Tous les moyens du projet au niveau du département ayant été mis à la disposition de l'AGF, les CDLS et les CCLS n'ont pas pu suivre les activités du PPLS sur le terrain. Grâce au PPLS, il y a eu : (i) La révolutionnarisation des points focaux qui sont devenus des unités focales. En effet avec une unité focale de 9 membres contre un pont focal de 2 membres, le risque de perte de mémoire de l'institution par l'affectation (départ) de ses membres se trouve ainsi réduit. (ii) Leur intitutionnalisation en tant que structure d'exécution du CNLS (iii) L'appropriation de leurs rôles par le CNLS et ses structures décentralisées. Ceci participe de la pérennisation des actions de lutte contre le SIDA dans le pays. Avec l'appui du PPLS et de l'ONUSIDA et du PNUD, la mise en place du système national unique de suivi et évaluation est en cours. 4.3 - L'unité de gestion du projet Dès le départ, le PPLS avait grande conscience qu'il s'agissait d'un projet qui avait un cycle de vie et qu'il fallait prendre des mesures pour la pérennisation des actions en prévision de l'achèvement du projet. C'est ce souci de pérennisation qui explique: (i) Les plans d'action communautaires sont des plans triennaux, le fait de financer un même plan pendant 3 ans participe des mesures de 40 pérennisation. Le même village ou le même quartier de ville qui a exécuté pendant trois ans de façon consécutive les activités de son plan d'action de lutte contre le SIDA finira par se l'approprier. (ii) L'approche communautaire telle que mise en oeuvre par le PPLS est elle- même une stratégie de pérennisation car contrairement aux interventions des OSC qui durent quelques mois et dont les animateurs sont le plus souvent d'une autre localité que de la localité où ils interviennent, les animateurs des plans d'actions communautaires de lutte contre le SIDA interviennent dans leur propre localité. Il existe une différence de degré et de qualité entre les effets des interventions des OSC et ceux des interventions des communautés. (iii) Le processus même d'élaboration des plans d'action s'inscrit dans une dynamique de pérennisation, les PACLS ont une assise communautaire et appropriable par la communauté, le plan triennal permet l'ancrage de bonnes attitudes au niveau de la communauté. (iv) L'approche de l'auto évaluation par les cartes (v) Les agents communaux et communautaires de lutte contre le sida (vi) Les caisses de solidarité sont des instruments de pérennisation. Le logiciel de gestion financière et comptable est acquis et exploité en version mono site. Ce qui oblige les comptables des départements à descendre pour saisir leurs opérations par période et non en temps réel. Or ce logiciel peut être acquis et exploité en site décentralisé. Cette situation entraîne un retard dans la mise à jour des comptes du projet et oblige des ateliers d'harmonisation et de traitement afin de répondre aux exigences du bailleur. Par ailleurs, l'UGP n'a pas impliqué les démembrements du CNLS. Elle a même exécuté des activités à la place des structures. L'UGP était séparée du SP/CNLS contrairement au MAP dans les autres pays; ceci n'est pas favorable aux « Three Ones ». 5 ­ EVALUATION DES PERFORMANCES DE LA BANQUE MONDIALE La Banque Mondiale a organisé de façon régulière des missions de supervision tous les 6 mois pendant la durée du projet et des visites mensuelles de terrain. Ces missions ont eu une influence bénéfique sur les activités du projet. En effet, ces missions sont sanctionnées par des recommandations qui visent l'amélioration de la mise en oeuvre du projet. Ces missions ont permis de résoudre les différents problèmes posés par la coordination du projet. Il y a eu la flexibilité de la Banque dans les différentes initiatives de modification de l'accord de crédit. Toutefois, il a été noté vers la fin du projet, un ralentissement dans les avis de non objection, justifié peut-être par la recherche d'une parfaite adéquation entre la disponibilité financière et les engagements. Par ailleurs, la notification formelle tardive par la Banque (10 jours de la date de clôture) de l'annulation du marché controversé BIO RAD et FSE n'a pas été appréciée, bien que ceci ait été annoncé bien auparavant. 41 6 ­ LEÇONS APPRISES · Le partenariat : Le PPLS a mis un accent particulier sur le partenariat. Des structures nationales et internationales telles ONUSIDA, UNICEF - CRS ­ DIRECTION DES PECHES ­ FERCAB - PACOM- AGeFIB - FNUAP - ABPF - SIDA3 - APH - PAM - MSF - CEFA, etc. ont été impliquées et la Banque a organisé des missions conjointes. Il y a eu aussi le partage d'expériences avec quelques projets MAP de la sous région, notamment ceux du Ghana, du Cameroun, du Burkina, et du Sénégal. · L'originalité du montage institutionnel : Une agence de gestion financière pour gérer la partie A du projet est un exemple original en matière de mise en oeuvre du projet. Une structure performante spécialisée en matière de gestion financière avec des réseaux existants dans le pays pour servir de passerelle entre le projet et les communautés pour le convoyage des fonds aux communautés. La leçon ici est que ceci a permis de gagner beaucoup de temps, de sauver beaucoup de ressources et d'aboutir à des résultats efficaces et efficients. · L'amélioration du seuil de passation de marchés : L'amélioration du seuil de rentabilité a contribué à réduire les délais pour certains marchés qui exigeaient des procédures trop longues. · L'augmentation du montant du compte spécial A : Très tôt le niveau du compte spécial A a été doublé comme prévu, ce qui a facilité les dépenses. La bonne planification et la bonne trésorerie ont permis de tenir le pari dans les décaissements et l'élaboration des DRF jusqu'à la fin du projet. · Exécution des catégories de dépense à 100% : La modification de l'accord de crédit pour permettre la prise en charge des dépenses à 100% sur les différentes catégories budgétaires a également facilité la mise oeuvre du projet. · Documentation de l'expérience : L'expérience du PPLS a été documentée par la publication de 5 ouvrages, la production d'affiches, de spots et de téléfilms 42 Les études réalisées Type et Titre Institution Réalisateur Année nature Population cible Objectif général Techniques de d'étude réalisation Evaluation du Cadre CNLS Secrétariat 2006 Enquête et Partenaires et Evaluer la mise en oeuvre Collecte de Stratégique National de permanant revue intervenants dans la du cadre pour la projection données par Lutte contre les IST/VIH documentaire lutte contre le de celui de 2006-2010 administration 2001-2005 VIH/SIDA au Bénin de questionnaire Manuel Opérationnel du CNLS Secrétariat 2006 Manuel CNLS, Partenaires Mettre en place un système Etude Système National de Suivi permanant des secteurs public et national de suivi et documentaire, et Evaluation privé et de la société évaluation intégrant tous les entretien et civile, les structures acteurs afin de leur concertation de coordination et permettre de contrôler et d'exécution, les d'évaluer les progrès structures d'appui à accomplis dans la riposte à la lutte contre le la pandémie du VIH/SIDA VIH/SIDA/IST. au Bénin Evaluation Finale du PPLS PPLS Geca 2006 Enquête et Partenaires et Evaluer la mise en oeuvre revue intervenants dans la du PPLS documentaire lutte contre le VIH/SIDA au Bénin Evaluation du "Three ones" ONUSIDA ONUSIDA 2005 Enquête CNLS, programme et Evaluer la performance de Collecte de projets de lutte contre la mise en mise du données par le VIH/SIDA programme administration de questionnaire Impact du Soutien INIPSA Philippe 2005 Enquête Les centres de Fournir au projet les Collecte de Institutionnel Intégré pour DANIDA Bocquier, traitement, les données de base nécessaires données par les Patients Sous Ministère Dial-IRD, patients. à l'élaboration d'une administration Traitement Antiretroviral Français Kemal méthodologie appropriée de des Affaires Cherabi, afin d'évaluer l'impact du questionnaire Etrangères IMEA... soutien institutionnel dans le cadre d'une prise en charge globale des patients 43 sous ARV dans les sites de traitement de 4 pays d'Afrique (Bénin, Burundi, Mali, Sénégal) ou le Pam fournit de l'aide alimentaire Rapport de Surveillance de PNLS, PNLS 2005 Test et Femmes enceintes, Evaluer la situation Prélèvement l'Infection à VIH et de la Coopération enquête malades tuberculeux, épidémiologique de des spécimen Syphilis au Bénin. Année Française, les travailleuses de l'infection à VIH et de la sanguins et 2004, UNDP sexe. syphilis au Bénin au cours interview de l'année 2004. Etude sur la Prise en PPLS BASP'96 2005 Enquête PVVIH, personnel Evaluer la prise en charge Collecte de Charge des PVVIH au médical, médicale des PVVIH au données par Bénin organisation de prise Bénin de 2000 à 2004 administration en charge, de responsable MSP, questionnaire, PNLS, CNLS. focus de groupe, Evaluation PPLS CERTI 2005 Enquête UGP, AGeFIB, COF, Evaluer l'impact Collecte de Epidémiologique à Mi- COS, CHD, UFLS, épidémiologique à mi- données par Parcours du PPLS OSC, PNLS, les parcours du PPLS administration centres d'études de ayant réalisé des questionnaire études sur la situation épidémiologique du SIDA au Bénin Audit Technique de la PPLS PPLS 2005 Audit UGP, AGeFIB, OC, Critiques des mécanismes et Etudes Composante A (Appui à la OSC, OAL, CNLS, stratégies de mise en oeuvre documentaires Réponse de la Société CDLS, CCLS, CALS du projet pour une et entrevues Civile) amélioration des prestations de la composante. Etude Sociologique à Mi- PPLS BeCG 2005 Enquête OSC, OC, OAL, Apprécier l'appropriation Collecte de Parcours sur les CA/CCLS, du projet dans tous ces données par Bénéficiaires du PPLS CA/CDLS, UFLS, volets en présence des administration UG/PPLS, acteurs publics et privés. de SP/CNLS, AGeFIB, questionnaire UNICEF. 44 Enquête de Surveillance de PNLS, CEFORP 2005 Enquête Les professionnels de Aider à mettre en place un Cartographie Deuxième Génération de PPLS, sexe, les système de suivi qui et collecte de VIH/SIDA/IST au Bénin Coopération routiers/camionneurs, permette d'obtenir des données par Française, les élèves et étudiants données sur les tendances administration CHA, PSI, non mariés de 15-24 socio comportementales des de USAID ans, les adolescents groupes ciblés et de fournir questionnaire et les jeunes par la même occasion des travailleurs non indicateurs sur les succès mariés de 15-24 ans des indicateurs combinés de prévention mise en place dans les sites choisis La performance et les PPLS- Victor A. 2005 Mémoire Les organisations Analyser la performance et Collecte de Mécanismes de CESAG ECLOU communautaires, les les mécanismes de données par Pérennisation du PPLS- organisations d'appui pérennisation du PPLS- administration Bénin au lancement, Bénin de l'agence de gestion questionnaire financière (AGeFIB) Les Déterminants du Désir PPLS-IRSP Patrice 2005 Mémoire Femmes âgées de 15 Etudier les déterminants du collecte de de Procréation chez les ZEKENG -49 ans ou des désir de procréation chez les données par Personnes Vivant avec le hommes âgés de 15 personnes vivant avec le entretien VIH/SIDA Suivies au ans et plus infectés VIH/SIDA suivies au individuel CNHU de Cotonou et par le VIH, membres CNHU de Cotonou. approfondi Membres de l'ONG Arc- de l'ONG Arc-en- sur la base en-ciel ciel, reçus en d'un guide consultation de suivi d'entretien. au service des maladies du sang (SMAS) du CNHU de Cotonou et au centre médical de l'ONG Arc-en-ciel. Première Enquête de PNLS- PNLS-SIDA 3 2004 Enquête Les femmes qui se Réaliser la première mesure Collecte de Surveillance de Deuxième SIDA 3 reconnaissent TS et pour la surveillance de données par Génération de qui, au moment de seconde génération (SSG) administration VIH/SIDA/IST auprès des l'étude, travaillent de l'infection au de Travailleuses de Sexe et dans les villes VIH/SIDA/IST dans questionnaire leurs Clients au Bénin. Fin mentionnées. certaines villes du Bénin et 45 2001-Début 2002 Les clients des TS (Porto-Novo, prélèvements recrutés dans les sites Abomey/Bohicon et pour test au de prostitution de Parakou principalement) laboratoire villes concernées. parmi les populations à haut risque : les TS et leurs clients. Rapport de Surveillance de PNLS Dr KIKI- 2003 Test et Femmes enceintes et Analyser les données Prélèvement l'Infection à VIH et de la FAGLA enquête consultants IST épidémiologiques sur des spécimen Syphilis au Bénin Médégan l'infection à VIH et la sanguins et syphilis ainsi que les cas interview notifiés de SIDA 2003 Enquête de surveillance des USAID, CEFORP 2003 Enquête Les professionnels de Mettre en place un système Cartographie comportements à risque FHI, PNLS sexe, les de suivi des tendances des et collecte de d'infection à routiers/camionneurs, comportements à risque afin données par VIH/SIDA/IST au Bénin les adolescents et les de fournir des administration 2001 jeunes non mariés de renseignements nécessaires de 15-24 ans à l'évaluation régulière des questionnaire (Ouvriers/artisans, efforts combinés de élèves/étudiants, prévention du filles de VIH/SIDA/IST d'une part « restauration » et fournir des données standardisées comparables au niveau international. C'est aussi la base de la mise en place d'un système de surveillance de seconde génération. Prise de Décision au Sujet PSI (USA) Anne Glick 2002 Enquête Hommes et femmes Analyse qualitative pour la collecte de des Rapports Sexuels, Kim Longfield des zones urbaines et prise de décision au sujet données à Comportement et Critère CEFORP rurales des rapports sexuels, travers des dans la Sélection de artisans/ouvriers, comportement et critère discussions de Partenaire parmi les agriculteurs/fermiers, dans la sélection de groupe. Groupes Sélectionnés de la élèves/étudiants. partenaire parmi les groupes Jeunesse Béninoise : une sélectionnés de la jeunesse Analyse Qualitative. béninoise. 46 Etude Multicentrique sur PNLS, Pr. Séverin 1999 Enquête Population générale Décrire de façon Collecte de les Facteurs qui INSAE, ANAGONOU, et les prostitués. standardisée dans différents données par Déterminent les Différences CERRHUD Dr Martin sites africains les administration de Niveaux de l'Infection à LAOUROU, distributions des facteurs de de VIH en Afrique : Résultats Mme Lydie risque des populations qui questionnaire du Bénin KANHONOU peuvent expliquer les et examen différences de niveaux de clinique et l'infection à VIH dans les prélèvements villes africaines ; suivi de la collecte de sérums pour évaluer la prévalence du VIH dans un échantillon de la population générale et obtenir une distribution des différentes souches virales. Rapport de surveillance de PNLS, PNLS 2006 Test et Femmes enceintes, Evaluer la situation Prélèvement l'infection à VIH et de la Coopération enquête malades tuberculeux, épidémiologique de des spécimen syphilis au Bénin. Année Française, les travailleuses de l'infection à VIH et de la sanguins et 2005, UNDP sexe. syphilis au Bénin au cours interview de l'année 2005. Impact du SIDA au Bénin PNLS, PNLS 2006 Enquête et Coopération projection Française, Aware HIV/AIDS Enquête de Surveillance des USAID, CEFORP 2006 Test et Les professionnels de Mettre en place un système Cartographie Comportements à Risque FHI, PNLS, Enquête sexe, les de suivi des tendances des et collecte de d'Infection à Coopération routiers/camionneurs, comportements à risque afin données par VIH/SIDA/IST au Bénin Française, les adolescents et les de fournir des administration 2005 Projet jeunes non mariés de renseignements nécessaires de SIDA3, 15-24 ans à l'évaluation régulière des questionnaire FM, (Ouvriers/artisans, efforts combinés de JHPIEGO, élèves/étudiants, prévention du Africare, filles de VIH/SIDA/IST d'une part PPLS, PSI « restauration » et fournir des données standardisées comparables au niveau international. 47 C'est aussi la base de la mise en place d'un système de surveillance de seconde génération. Suivi Biologique et FM, PNLS, PNLS 2006 Test et Les professionnels de Mettre en place un système Cartographie Comportemental des Projet Enquête sexe de suivi des tendances des et collecte de Travailleuses de Sexe au SIDA3 comportements à risque et données par Bénin des tendances sérologiques administration de questionnaire Revue interne du PNLS UNICEF 2002 Revue Femmes enceintes Evaluer l'étude pilote Revue programme PTME PNLS documentaire PTME avant de passer documentaire et enquête l'approche à l'échelle et enquête Analyse des obstacles et PNLS UNICEF 2003 Enquête Femmes enceintes Définir les étapes critiques Revue opportunités de la PTME en pour l'extension des documentaire milieu rural au Bénin : cas activités de PTME dans la et enquête de la zone sanitaire Pobè- zone sanitaire Pobè-Kétou- Kétou-Adja ouéré Adja ouéré Analyse des Obstacles et PNLS UNICEF 2005 Enquête Femmes enceintes Définir les étapes critiques Revue Opportunités à la PTME pour l'extension des documentaire dans la zone sanitaire activités de PTME dans la et enquête Djidja-Abomey- zone sanitaire Djidja- Agbangnizoun Abomey-Agbangnizoun Analyse des Obstacles et PNLS UNICEF 2006 Enquête Femmes enceintes Définir les étapes critiques Revue Opportunités de la PTME pour l'extension des documentaire en Milieu Rural au Bénin : activités de PTME dans la et enquête Cas de la Zone Sanitaire zone sanitaire Bembereke- Bembereke-Sinendé-Phase Sinendé ire de Pré-intervention PTME au Bénin : Une PNLS UNICEF 2005 Revue Femmes enceintes Faire connaître l'expérience Revue Démarche Originale et documentaire de la PTME au Bénin documentaire Prometteuse ­ Etude de Cas 48 Contribution à PNLS UNICEF 2005 Etude Enfants nés de mères Démontrer la faisabilité et Etude l'Amélioration du Suivi des prospective séropositives l'efficacité de l'intégration prospective Enfants Infectés par le VIH des activités de PTME dans analytique et dans le Cadre de la PTME les services de santé descriptive du VIH à Cotonou maternelle et infantile et évaluer le suivi des enfants nés de mères séropositives Enquête CAP des Jeunes en UNICEF UNICEF 2004 Enquête Les jeunes de 10 à 24 Identifier les connaissances Etude Matière d'IST/VIH/SIDA ans attitudes et pratiques des prospective dans la Zone Sanitaire jeunes de 10 à 24 ans, des qualitative et Pobè-Kétou-Adja ouéré parents et des prestataires quantitative de santé en matière d'IST/VIH/SIDA Enquête CAP des Jeunes en UNICEF UNICEF 2004 Enquête Les jeunes de 10 à 24 Identifier les connaissances Etude Matière d'IST/VIH/SIDA ans attitudes et pratiques des prospective dans la Zone Sanitaire jeunes de 10 à 24 ans, des qualitative et Djidja-Abomey- parents e des prestataires de quantitative Agbangnizoun santé en matière d'IST/VIH/SIDA Etude de la Stigmatisation, UNICEF UNICEF 2002 Personnes Inventorier les différentes la Discrimination et le Déni infectées ou formes de stigmatisation, de par Rapport aux Personnes affectées par discrimination et de déni Infectées et Affectées par le VIH reliées aux personnes VIH au Sein de la Famille infectées ou affectées par le et de la Communauté : Cas VIH/SIDA, analyser les du Bénin causes à l'origine de cette situation 49 Annex 8. Comments of Cofinanciers and other Partners/Stakeholders 1. There were no cofinanciers for the project, but many multilateral and bilateral agencies have been involved in operations similar to those carried out here. Most of their projects, however, had been completed by the time of the ICR mission. 2. This Annex presents the views of UNAIDS, the leader of the external assistance organizations, and of UNICEF, which have been actively promoting nutrition programs. In addition, the ICR mission sought the views of representatives of the Canadian- financed Sida 3 project, the UNDP-financed HIV/AIDS strategy development project, and the USAID-financed integrated family-health project. The latter two were the only HIV/AIDS-related projects that were active in the sector when the ICR mission visited Benin (except for a project financed by the African Development Bank that had just started, and was not active at the same time with PPLS). The mission also met with stakeholders in the form of representatives of the Ministry of Economy and Development, of the central organization of NGOs involved in HIV/AIDS work, of a treatment and care center operated by a charitable/religious organization (CARITAS), of a commune-level committee for fighting HIV/AIDS, and managers of a local radio station. The stakeholders' views are summarized in Annex 6 and are incorporated in the main text of this report. 3. UNAIDS. The UNAIDS representative emphasized the importance of implementing the `three ones' approach, namely that in Benin there must be a common HIV/AIDS strategy (already prepared for the period 2006-2010), common leadership (provided by CNLS and its Permanent Secretariat), and a uniform monitoring and evaluation (M&E) system (UNAIDS has financed the M&E software and consultant support). She also reported that PPLS inspired other development partners by its many innovations, especially the introduction of a multi-sectoral approach to fight the HIV/AIDS pandemic. As for sustainability, she suggested that building up a national coordination body (CNLS) and establishing decentralized units in Departments, communes, arrondissements, and local communities has been important but that these units still need to be strengthened, adequately financed, and better motivated than in the past. As for the relationship with the World Bank, she said that UNAIDS had been fully involved in PPLS activities and that she had regularly participated in the Bank's supervision missions. 4. UNICEF. UNICEF has actively promoted the prevention of mother-to-child transmission (PMCT) of the virus, as well as the provision of special medication and nutrition programs for infected or affected children, through collaboration with PPLS. Although congratulating PPLS for its achievements, the UNICEF representatives were dissatisfied with the amount of funds and attention set aside for the PMCT program. Not only have the funds reserved by PPLS for this purpose been insufficient, the national health sector in general is also grossly inadequate in this regard: at present only 11 percent of pregnant mothers have access to medical facilities and clinics that can do HIV testing. Although only 2 percent of these tests are positive, many children are in danger of getting the virus and their condition is likely to remain undetected and untreated. The UNICEF representatives emphasized that follow-up projects must provide more funds for testing expectant mothers, and that the number and capacity of laboratories to process 50 samples must be increased substantially. UNICEF collaborates closely with the World Bank and fully supports the `three ones' approach in Benin; UNICEF has helped prepare the national HIV/AIDS strategy for 2006-2010. The representatives were very satisfied with the World Bank endorsement of this process, while acknowledging that the financing has largely come from other sources. 5. CIDA and the Sida 3 project. The coordinator of the Canadian-financed Sida 3 project stressed that PPLS had been an important partner in the fight against HIV/AIDS. Three successive Sida projects have been operating in Benin for 15 years, targeting women and other vulnerable groups. The Sida 3 project concentrated on people who are at highest risk of getting an HIV infection, such as prostitutes (of whom some 81 percent are from neighboring countries) and truck drivers. Together with PPLS, the Sida 3 project worked on the medical follow-up of infected people and on the training of women in money-generating activities (to help them leave the sex trade). The coordinator believed that PPLS had drawn on the experience of Sida 3 with vulnerable groups; like PPLS, Sida 3 for its part has used NGOs effectively in its own approach. She underscored the need for continued information to keep people alert (sensibilisation), in which regard PPLS has been very effective. She noted that new generations of young persons are constantly reaching the age of sexual activity, and that many people who may be informed about HIV/AIDS have not necessarily `internalized' the information to the extent that they have changed their own sexual behavior. Although she was satisfied with the collaboration between PPLS and Sida 3, she criticized the slowness of the World Bank's procedures given the emergency situation in Benin; the late arrival of funds is causing a long gap between the MAP 1 and MAP 2 projects. 6. UNDP. Since 2004 UNDP has been actively supporting the development of a strategic plan for 2006-2010 in Benin, as well as operating an experimental HIV/AIDS project in one zone in the Northern Department where it has used the local response approach generalized by PPLS. Collaboration with PPLS has been indirect, in that, there have been no common contracts under which financing would have been shared; instead, PPLS and UNDP negotiated a common effort, and each has separately financed its own share. For example, UNDP and PPLS helped establish and provide continued assistance to a national apex organization for local associations of PLWHA, as well as a special program for educating national and departmental leaders on HIV/AIDS issues. 7. USAID. The USAID-financed integrated family-health project has collaborated with PPLS by using local NGOs and associations in HIV/AIDS prevention work. As one of the major achievements of PPLS, the head of the family-health project mentioned the success of prevention programs; he also acknowledged the difficulty of measuring the actual outcomes of preventive work. He pointed out that proxies can be useful though, and one measure of the success of PPLS's preventive work is the voluntary testing of the target populations. In other words if people come into a testing center and agree to take a test, it is apparent that they are responding to the HIV/AIDS messages, and the results in this case have been remarkable: whereas the testing target in 2005 was 300 per quarter (in his department?), the actual number of people coming in for tests exceeded 700 per quarter. In 2006, the quarterly number increased to 1,000. Moreover, this development also suggests that the stigmatization of HIV-infected people is declining, in that the fear of HIV is now apparently higher than that of stigmatization. 51 Annex 9. List of Supporting Documents World Bank: Project Appraisal Document on Benin Multi-Sectoral HIV/AIDS Project. December 10, 2001. World Bank: Development Credit Agreement on Benin Multi-Sectoral HIV/AIDS Project. World Bank: Supervision Mission Aide-Mémoires 1 to 9. World Bank Files, 2002-2006. World Bank: Implementation Status Reports 1 to 9. World Bank Files, 2002-2006. World Bank: Mid-Term Report (Aide-Mémoire) on Benin Multi-Sectoral HIV/AIDS Project. February 28, 2005. République du Bénin, Ministère Chargé de la Planification et du Développement, CNLS (par BeCG consultants) : Etude sociologique à mi-parcours sur les bénéficiaires du PPLS. Cotonou, février 2005. République du Bénin, Ministère Chargé de la Planification et du Développement, CNLS : Audit technique de la composante A du PPLS. Cotonou, mai 2005. République du Bénin, Ministère Chargé de la Planification et du Développement, CNLS : Evaluation finale du PPLS. Septembre 2006. République du Bénin, Ministère Chargé de la Planification et du Développement, par Consultants GECA Prospective : Evaluation finale du PPLS. Septembre 2006. République du Bénin, Ministère du Développement, de l'Economie et des Finances, CNLS (par Epiphane Sohouenou, Facilitateur ) : Forum d'évaluation finale du PPLS : Rapport général. Septembre 2006. République du Bénin, Ministère Chargé de la Planification et du Développement, CNLS (par consultants individuels) : Evaluation épidémiologique à mi-parcours du PPLS. Juillet 2005. République du Bénin, Ministère Chargé de la Planification et du Développement, PPLS personnel : Tradithérapeutes et lutte contre le VIH/SIDA au Benin. Cotonou, août 2006. République du Bénin, Ministère Chargé de la Planification et du Développement, PPLS personnel : Contribution du PPLS à la prise en charge de PVV au Benin. Cotonou, août 2006. 52 République du Bénin, Ministère Chargé de la Planification et du Développement, PPLS personnel : Lutte contre les IST/VIH/SIDA : PVVIH--maillot incontournable de la riposte. Cotonou, août 2006. République du Bénin, Ministère Chargé de la Planification et du Développement, PPLS personnel: Lutte contre les IST/VIH/SIDA : Expérience du PPLS en mileu du travail (Secteur public et privé). Cotonou, août 2006. 53 IBRD 33372 0 1E 2E 3E 4E To To Dosso Sokoto NIGER NIGER RIVER NIGER RIVER BURKINA 12N BENIN FASO MékrouMékrou Malanville Malanville Pendjari AliboriAlibori s a i n To n t KandiKandi Dapaong 11N PanjariPanjari o u SotaSota M 11N MékrouMékrou A L I B O R I a k or ATA K O R A ta A Lake Lake NatitingouNatitingou KainjiKainji Bembéréké Bembéréké Tassiné ssiné Koumongou 10N 10N DjougouDjougou OuéméOuémé B O R G O U NIGERIA To To Kabou AlpouroAlpouro OkparaOkpara Kaiama D O N G A ParakouParakou 9N 9N TOGO 0 20 40 60 80 100 Kilometers 0 20 40 60 Miles GHANA C O L L I N E S This map was produced by the Map Design Unit of The World Bank. 8N SavalouSavalou The boundaries, colors, denominations and any other information 8N shown on this map do not imply, on the part of The World Bank Group, any judgment on the legal status of any territory, or any endorsement or acceptance of such boundaries. ZouZou Dassa- Dassa- 1E Zoumé Zoumé Ouémé Couf Couffo PLATEAUPLATEAU BENIN Z O U AbomeyAbomey Cové Cové COUFFOCOUFFO SELECTED CITIES AND TOWNS Bohicon Bohicon DEPARTMENT CAPITALS 7N PobéPobé 7N To NATIONAL CAPITAL Notsé Aplahoué Aplahoué DogboDogbo RIVERS LakeLake OUEMEOUEM Vo ta Vol To M O N O E SakétéSakété Ibadan MAIN ROADS LokossaLokossa ATLANTIQUE TLANTIQUE RAILROADS MonoMono PORTO NOVO PORTO NOVO DEPARTMENT BOUNDARIES To Lomé OuidahOuidah CotonouCotonou LITTORALLITTORAL INTERNATIONAL BOUNDARIES BIGHT OF BENIN BIGHT OF BENIN 0 1E 2E Gulf of Guinea 3E DECEMBER 2005