ICRR 13126 Report Number : ICRR13126 IEG ICR Review Independent Evaluation Group 1. Project Data: Date Posted : 09/10/2009 PROJ ID : P071505 Appraisal Actual Project Name : HIV/AIDS Prevention US$M ): Project Costs (US$M): 30.0 30.0 & Control Proj. Country : Dominican Republic Loan /Credit (US$M): Loan/ US$M ): 25.0 25.0 Sector Board : HE US$M): Cofinancing (US$M ): Sector (s): Health (87%) Central government administration (13%) Theme (s): HIV/AIDS (33% - P) Participation and civic engagement (17% - S) Child health (17% - S) Population and reproductive health (17% - S) Gender (16% - S) L/C Number : L7065 Board Approval Date : 06/28/2001 Partners involved : Closing Date : 12/31/2006 07/31/2008 Evaluator : Panel Reviewer : Group Manager : Group : Judyth L. Twigg Roy Gilbert Monika Huppi IEGSG 2. Project Objectives and Components: a. Objectives: a. Objectives: Following two formal amendments, three sets of objectives applied over the following periods during project : First period: Jan 31, 2002 to Sept 17, 2004, covering 24.4% of disbursements • To assist the Borrower in reducing the spread of the HIV/AIDS epidemic. Second period: Sept 18, 2004 to July 28, 2006, covering 23.5% of disbursements • To assist the Borrower in reducing the spread of the HIV/AIDS epidemic • Carrying out emergency projects Third period: July 29, 2006 to July 31, 2008, covering 52.1% of disbursements • To assist the Borrower in reducing the spread of the HIV/AIDS epidemic • To reduce the risk of HIV transmission and improve the quality of life of those infected and affected by the HIV epidemic. The second restructuring was introduced to align the project and its objectives with new country needs stemming from changes in the financing and management of the national response to the epidemic (new Government administration, new management team in charge of the HIV/AIDS Presidential Council (COPRESIDA), and new resources (grant from the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM)). b.Were the project objectives/key associated outcome targets revised during implementation? Yes If yes, did the Board approve the revised objectives /key associated outcome targets? Yes Date of Board Approval: 07/29/2006 c. Components (or Key Conditions in the case of DPLs, as appropriate): First and second periods: Jan 31, 2002 to July 28, 2006, covering 47.9% of disbursements A. Prevention/Promotion Activities to Reduce HIV/AIDS Transmission (original, US$ 17.2 million; actual US$ 3.2 million), including design and implementation of information, educational, and communication (IEC) programs; design and implementation of programs to promote the use of condoms, their distribution, access to condoms, and quality control related to condoms; a program for the promotion, administration, and distribution of pre-packed treatments for syndromes associated with sexually transmitted infections (STIs); a pilot program in at least six of the Borrower’s provinces to provide nevirapine to pregnant women and newborn children, advice to mothers with respect to breastfeeding alternatives, and baby formula supplements to newborn children whose mothers are infected with HIV/AIDS; and strengthening of the technical capacity of public and private laboratories and blood banks in the Borrower’s territory. B. Diagnosis and Basic Care of Individuals Affected by HIV/AIDS (original US$ 4.8 million; actual US$ 4.3 million), including design and implementation of a program that will promote voluntary testing and counseling for HIV/AIDS; design and implementation of a program on home care of HIV/AIDS patients; establishment of basic AIDS health care units in local and provincial basic health care facilities located in areas with the highest prevalence of HIV/AIDS cases; implementation of a directly observed treatment national response for tuberculosis patients; and carrying out of a program for children orphaned by HIV/AIDS. C. Strengthening of HIV/AIDS Surveillance, Project Coordination, Monitoring and Evaluation, and Research (original US$ 7.75 million; actual US$ 6.3 million), including strengthening of the Ministry of Health’s (MOH’s) disease surveillance system; carrying out a research program on HIV/AIDS; strengthening the capacity of the Project Coordination Unit (PCU) to assist the Borrower in implementation, monitoring, and supervision of the project; and carrying out of annual technical evaluations to monitor and evaluate the implementation of the project. Third period: July 29, 2006 to July 31, 2008, covering 52.1% of disbursements A. Strengthen the Coordination and Management of the National Response (original US$ 3.3 million; actual US$ 6.3 million), including activities to strengthen the coordination of the National Response, including those required to reorganize it and to develop a new ten-year National Strategic Plan (PEN) and a corresponding monitoring and evaluation system. Activities included consultancies, training, administration, and management. B. Support Public Sector Organizations in the Prevention and Control of HIV/AIDS (original US$ 4.6 million; actual US$ 6.8 million), aimed at reducing the risk of HIV transmission and improving the quality of life of PLWHA through the provision of technical assistance to line ministries and other public organizations in the planning and implementation of both the PEN and its first two-year operational plan. This component also included the rehabilitation and refurbishment of HIV/AIDS Health Care Units, and the purchase and distribution of pharmaceuticals, reagents, and other medical and non-medical supplies. C. Support Civil Society in the Prevention and Control of HIV/AIDS (original US$ 5.2 million; actual US$ 2.8 million), aimed at supporting the participation of civil society in general and grass-roots organizations in particular in the planning and implementation of the PEN and the first two-year operational plan. This component featured a new model of civil society engagement involving grass-roots partnerships, Alianzas de Base Poblacional (ABP). This second revision of the objectives also changed all of the project indicators to match the changes in the objectives. There were no components designed to implement the second-period objective of carrying out emergency projects. d. Comments on Project Cost, Financing, Borrower Contribution, and Dates: Costs/Financing: The first amendment of the project (December 4, 2002), provided for retroactive financing of US $250,000 for eligible expenditures already incurred by the Government for prevention and control of HIV /AIDS. The second amendment (August 18, 2004) added a new expenditure category, “Emergency Projects,� in the amount of US $200,000 for goods, civil works, and services for rehabilitation of health facilities in the Jimani Region affected by natural disaster. Ultimately, the Government used only US $ 92,850 for this purpose. The third amendment (July 29, 2006) included an arrangement where loan and counterpart funds were used to fully finance distinct and separate project activities. This arrangement simplified payment procedures and facilitated the decentralization of some project activities to civil society and public sector organizations using the new ABP model . The third amendment also introduced a new disbursement category, “Grants to Eligible Civil Society Organizations .� The fourth amendment (December 19, 2007) reallocated funds from the third to the first component, shifting funds from civil society activities that could not be completed prior to the closing date and for which other donor funds had become available, to the completion of baseline studies on high risk groups . Disbursement during the economic crisis of 2003-2004 was slow, with irregular allocations of counterpart funding limiting project implementation. In March 2005, more than three years after project effectiveness, only about US$ 7 million, of less than 30% of the loan amount, had been disbursed . The third amendment (July 29, 2006) allowed for faster disbursement and sped project implementation . US$ 13.4 million (43% of the loan) was disbursed in the first three years of the project, and US$ 17.1 million (57% of the loan) was disbursed during the two years after the third amendment. By March 2008, three months before project completion, all loan funds were disbursed . Dates: The third amendment extended the closing date by 12 months to December 31, 2007, in order to provide additional time to achieve the revised objectives . The fourth amendment extended the closing date by an additional six months to July 31, 2008, mainly to complete a baseline study . 3. Relevance of Objectives & Design: 24.4% of disbursements, 1/31/ First period (24. 17/04) 31/02 – 9/17/ 04) is rated Substantial : Objectives - Substantial . The objectives are consistent with the 2005 Country Assistance Strategy and with the country’s efforts toward achievement of the Millenium Development Goals . They are also consistent with the country ’ s Poverty Reduction Strategy for the 2003-2015 period. The HIV/AIDS epidemic remains one of the most important challenges for public health and the fight against poverty and inequality in the country . The adult HIV prevalence rate was 1.1% in 2008 (UNAIDS data), and prevalence among the poorest income quintile in 2007 was 1.8%, compared with 0.4% for the richest quintile (DHS, 2008). The Dominican Republic has a concentrated HIV /AIDS epidemic, with higher HIV rates among risk groups than in the general population . HIV prevalence among MSM in 2004 was 11%, and among primarily Haitian residents of informal settlements was 3.2% in 2007. However, the speed of initial project preparation, prompted by the perceived urgency of addressing the epidemic, meant that there was insufficient collection and analysis of country -specific data for adapting a general model of a national response to the specific needs of the Dominican Republic. As a result, the project’s targets were overly ambitious . Design - Modest . The project was prepared on a fast track and was based on needs and goals proposed in the HIV/AIDS Caribbean Task Force (CARICOM) Caribbean Regional Strategic Plan , endorsed by Caribbean governments. The project’s original design appropriately contained interventions specifically geared toward prevention of HIV infection among groups practicing riskiest behaviors (and therefore most likely to spread HIV and generate a larger number of secondary infections ), which include young women, migrants from Haiti, residents of bateyes (primarily Haitian communities where sugar workers live ), sex workers, men who have sex with men (MSM), and residents of provinces with high rates of tourism . Project design underestimated the complexity of coordinating efforts in the public sector. The HIV/AIDS Presidential Council (COPRESIDA) lacked the necessary leadership to coordinate efforts of the ministries of health and education and other ministries . The line ministries lacked the experience and resources to engage civil society effectively . Institutional arrangements did not encourage broad stakeholder participation, in particular the engagement of civil society . 23 .5% of disbursements, 9/18/ Second period (23. 28 /06) 18 /04 – 7/28/ 06 ) is rated Modest : Objectives - Substantial . The project’s objective to assist the Borrower in reducing the spread of HIV /AIDS remained relevant in this period. The added objective to carry out emergency projects to rehabilitate health facilities in the Jimani region was relevant, as this area was one of the poorest in the country and the natural disaster was hindering access to basic health services . Design - Modest . Project design for the objective to reduce the spread of HIV /AIDS did not change significantly under this revision of objectives and therefore remains substantial . It should be noted, however, that project documents contain minimal information on activities to be financed under the added objective related to emergency projects, including no indication that any components were added to achieve this objective . 52 .1% of disbursements, 7/29/ Third period (52. 31 /08) 29 /06 – 7/31/ 08 ) is rated Substantial : Objectives - Substantial . The revised objectives remained relevant as discussed previously, with enhanced relevance based on the revised objectives adding care and treatment for those affected and infected by the epidemic as appropriate based on new country needs and new possibilities for treatment . The design of the project after the second revision of objectives harmonized the project ’s objectives and targets with those of the country ’s strategy, filling funding and technical assistance gaps and permitting the Government to establish nationwide priorities and identify the most appropriate source of funding . Design - Modest . This amendment introduced a revised design that included a good model of civil society engagement that was new to the Dominican Republic, including a new disbursement category in the Loan Agreement, although there were no provisions explicitly designated to provide incentives for civil society organizations to focus on prevention interventions among these high -risk groups. There is no indication that the line ministries were responsible for activities with high -risk groups under the third amendment . This amendment complemented appropriately the availability of other sources of financing (primarily the Global Fund to Fight AIDS, Tuberculosis, and Malaria). However, the revised project design under this amendment was less explicit than the original project design in matching activities to objectives, reducing the clarity of the results chain . None of the project’s main indicators incorporated a focus on high -risk groups. 4. Achievement of Objectives (Efficacy): Following IEG/OPCS guidelines, this review will assess the achievement of each objective separately, noting the percentage of project disbursements and time period that apply to each objective AIDS /Reduce the Risk of HIV Transmission (objective applies to 100% Prevent the Spread of HIV /AIDS/ 100 % of disbursements, throughout the entire project ): Substantial Outcomes : Data on indicators commonly used as proxies for HIV incidence (behavioral data, syphilis rates, etc .) were not available at the time the ICR was written, but the TTL provided a recently -published article with additional data (Daniel T. Halperin, et al., “Understanding the HIV Epidemic in the Dominican Republic : A Prevention Success Story in the Caribbean?� Journal of Acquired Immune Deficiency Syndrome , Vol. 51, Supplement 1, May 1, 2009). According to this newly-provided information, reported condom use at last sex with a non -married or non-cohabitating partner increased from 51% among men and 25% among women in 2002, to 68% among men and 40% among women in 2007 (DHS). The percentage of men paying for sex in the previous year decreased from 8% to 4% between 2002-2007, and the percentage of male clients reporting using condoms during their last commercial sex act increased from 74% in 2002 to 83% in 2007 (DHS). However, the percentage of sexually active men reporting two or more sex partners in the previous year remained constant at 29% between 2002 and 2007 (DHS). There are still no data on high-risk groups not explicitly surveyed by the DHS . HIV prevalence among adult men (aged 15-49) declined from 1.1% in 2002 to 0.8% in 2007, and declined from 0.9% to 0.8% among adult women over the same time period . HIV prevalence among adults aged 15-49 living in bateyes declined from 5.0% to 3.2% from 2002 to 2007. Prevalence, however, is not an accurate indicator of the spread of HIV, as it includes both incidence and mortality . Outputs : • Civil society was engaged in interventions that should have had an impact on the prevention of HIV /AIDS. 10 ABPs were formed to engage over 300 civil society organizations . Inter-Alianza, a national-level organization representing all ABPs, was established to coordinate the multisectoral involvement of civil society, grass roots, and community-based organizations. Eleven pilot projects (seemingly a small number) focusing on prevention and behavior change were conducted by 30 civil society organizations, with three of these projects deemed “best practice� cases for their innovative approach to prevention among four groups defined by the project as at -risk: children, men who have sex with men (MSM), young people, and people living in bateyes . More than 2 million condoms, a substantial percentage of total distribution in the country, were distributed by a strategic partnership between public sector organizations and civil society, using the ABP framework . Unspecified new approached to behavior change among MSM were introduced by NGOs working with MSM . • The number of organizations providing technical and financial support for prevention interventions among high-risk groups increased from 70 to 102; the ICR does not provide information on these groups, their activities, or their coverage. • Male and female condoms were distributed in increasing number : approximately 1.6 million total in 2006, and over 8 million in 2008; no target was specified. • The Ministry of Education trained 11,000 teachers on the HIV/AIDS epidemic and its prevention and control . An 8-credit diploma degree in HIV counseling was established at the Universidad Aut ó noma in Santo Domingo. The number of schools with teachers who were trained in life skills and taught the subject increased from 214 to 835; the ICR does not provide data on coverage, and no target was specified . • The percentage of health facilities providing birth attendance that provided prophylactic treatment for HIV according to national norms increased from 60% in 2005 to 78% in 2008 (target was 80%). • The number of patients with sexually transmitted infections (STIs) who are appropriately diagnosed and treated according to national guidelines increased from approximately 46,000 in 2005 to 158,000 in 2008; the ICR explains that percentage figures are not given because data are not available to produce an adequate denominator (total number of individuals with STIs )(target was 90%). 23 .5% of disbursements, 9/18/ Carry Out Emergency Projects (objective applies to 23. 28 /06): 18 /04 – 7/28/ 06 ): Negligible The ICR does not provide information on outputs or outcomes related to this objective . The TTL explains that these data are not available. Improve the Quality of Life of Those Infected or Affected by the Epidemic 52 .1% of (objective applies to 52. 29 /06 – 7/31/ disbursements, 7/29/ 08 ): Modest 31 /08): Outcomes : The percentage of people needing ARV treatment who received it increased from 14% in 2005 to 52% in 2008 (target was 85%; data from the Sexually Transmitted Infections and AIDS Control General Directorate ). No other information on the effectiveness of activities for the care and support of PLWHA is offered by the ICR, and no effort is made to determine the extent to which this outcome is attributable to Bank -financed interventions as opposed to interventions financed by other donors . Outputs : US $2 million was spent on anti-retroviral medications (ARVs) covering approximately 20,000 people. Financing was coordinated with the GFATM to ensure continuity of access for PLWHA . US $2 million was spent on refurbishing facilities to establish more than 25 HIV/AIDS health units for specialized ambulatory care across the country, reaching an estimated 19,500 people. An unspecified amount of laboratory reagents were purchased to support the Government’s introduction of a large-scale program for monitoring CD4 counts and viral loads from 2005-2008, benefiting more than 20,000 people. (The ICR does not specify, but it is assumed that the same 20,000 people benefited from these three activities; no target for these activities was specified .) The number of people ages 15-49 who voluntarily requested an HIV test, received the test, and received the results within the preceding 12 months increased from approximately 83,000 in 2005 to almost 920,000 in 2008 (target was 250,000). The ICR does not specify if other kinds of support for PLWHA were provided by the project . 5. Efficiency (not applicable to DPLs): Overall efficiency is rated Modest. According to the ICR, the project funded a series of activities recognized as cost-effective in preventing HIV/AIDS, but it does not provide detailed information on amounts spent on these specific activities. The ICR reports that 58% of total project spending was on prevention activities, but data are not provided on specific activities nor on the amount of this spending that was targeted at high -risk groups, and the breakdown of spending by component does not appear to indicate that over half of project funds were allocated to prevention; UNAIDS and other sources have indicated that resources are most efficiently spent on prevention interventions targeted at high-risk groups. Under the first project design, only 18.6% of planned spending was spent on the prevention component, compared with 90% of planned spending on the treatment /care component (with absolute spending of US $3.2 million on prevention and US $ 4.3 million on treatment/care); of that spending on prevention, it is not known how much was focused on high -risk groups. The ICR cites eleven pilot projects conducted by 30 civil society groups that focused on prevention, with three cited as “best practice� for work with high-risk groups, but this is out of 300 total civil society organizations involved in the project . The TTL explains that the civil society organizations did not report their spending or activities specifically on prevention as opposed to treatment /care. Support for the line ministries appears to have been focused on treatment /care and on prevention interventions among the general population (women and youth), rather than more efficiently among groups at highest risk . ERR/FRR, Appraisal and ICR Estimate: N/A Appraisal: Net Present Value USD , IRR: 22.5% ICR estimate: N/A ERR )/Financial Rate of Return (FRR) a. If available, enter the Economic Rate of Return (ERR) FRR ) at appraisal and the re- re -estimated value at evaluation : Rate Available? Point Value Coverage/Scope* Appraisal % % ICR estimate % % * Refers to percent of total project cost for which ERR/FRR was calculated. 6. Outcome: Period Objectives Relevance Efficacy Efficiency Outcome Weight Multiply (convert (based on outcome into share of number x number disbursem wt and from 1 to ents for add 6) each period) 1/31/0 Prevent Substantial Substantial Modest Moderately .24 .96 2– spread of Satisfactor 9/17/0 HIV y (4) 4 9/18/0 Prevent Substantial Substantial Modest Moderately .23 .92 4– spread of Satisfactor 7/28/0 HIV y (4) 6 Carry out Negligible Negligible Negligibl Unsatisfact .01 .01 emergency e ory (1) projects 7/29/0 Prevent Substantial Substantial Modest Moderately .26 1.04 6– spread of Satisfactor 7/31/0 HIV y (4) 8 Improve Substantial Modest Modest Moderately .26 .78 quality of Unsatisfact life of ory (3) those affected or infected a. Outcome Rating : Moderately Satisfactory 7. Rationale for Risk to Development Outcome Rating: Budget funding will finance several activities that had been financed by the Bank through the project, including the expansion of mandatory universal health insurance to cover ARVs for PLWHA. In addition, another round of GFATM funding has been approved. However, additional resources are no guarantee of sustainability. NGOs have become dependent on international funds, and the ICR indicates that the Government may reduce its commitment to funding prevention activities carried out by civil society. The direction and management of COPRESIDA is still volatile, with staff selection not always based on technical criteria. The staff of health care units for PLWHA is now financed by the Government, increasing the possibility that MOH human resource regulations will erode gains achieved in care for PLWHA. The ICR does not address directly the issue of political commitment by the Government to the fight against HIV/AIDS. a. Risk to Development Outcome Rating : Moderate 8. Assessment of Bank Performance: at -Entry is rated Moderately Unsatisfactory . Project preparation took place on a fast track, Ensuring Quality -at- due to an estimated insufficiency of government funds to prevent and control what seemed to be an epidemic that could easily spread beyond high -risk groups. Because of accelerated preparation, many elements of the project (in particular, the M&E system) were not ready for implementation at the time the project became effective . There was insufficient capacity in the line ministries to engage civil society organizations effectively, and in COPRESIDA to coordinate the activities of the line ministries . Project preparation focused on too few and too narrow risks, particularly with regard to project management and administration . Risk mitigation measures were either too general (for example, “continuous monitoring�) or did not address the most important risks that could affect implementation (for example, using the PCU from another Bank project for financial management support ). Quality of Supervision is rated Satisfactory . The Bank worked closely with the implementing agency to overcome significant challenges throughout the life of the project, including low counterpart funding, weak project management, and M&E challenges. The four amendments to the Loan Agreement, according to the ICR, are indications of continued effort to be responsive to changing country needs . Bank resources and technical assistance contributed significantly to the overhaul of the M&E system . The Bank aligned its activities well with other donors, particularly GFATM; for example, Bank resources financed rehabilitation of mobile health units to provide care for PLWHA and HIV counseling and testing, while GFATM funds provided and rehabilitated medical equipment for those same units. at -Entry :Moderately Unsatisfactory a. Ensuring Quality -at- b. Quality of Supervision :Satisfactory c. Overall Bank Performance :Moderately Satisfactory 9. Assessment of Borrower Performance: Government Performance is rated Moderately Satisfactory . The country experienced a major economic crisis and social unrest in 2003, limiting the Government’s capacity to support planned project activities and discont inuing counterpart funding. A new administration took office in 2004, replacing COPRESIDA’s top management and reinvigorating the national response . However, this new leadership focused at first on securing GFATM grant disbursements, and did not focus on the Bank -financed project until late 2005. The National Planning Agency and the Presidency ’s Technical Secretariat demonstrated a strong commitment to effective restructuring of the project during the third amendment . Eventually, the Government developed a comprehensive ten -year National Strategic Plan that aligned project design to the country ’s emerging needs and the new national response. Implementing Agency Performance is rated Moderately Satisfactory . Early in the project, implementation delays were caused not only by lack of counterpart financing, but also by limited PCU technical and administrative capacity. In 2005-2006, however, COPRESIDA’s performance improved considerably, including enhanced transparency and accountability . There was tension between COPRESIDA and the MOH ’s unit in charge of epidemiological surveillance and health care for STIs (DIGECITSS), as the latter lacked sufficient Government funding and frequently did not coordinate its search for additional funding sources with COPRESIDA. At the beginning of the project, there were frequent delays in financial management procedures, but these were corrected after the third amendment . The procurement unit experienced significant problems in planning and execution of procurement activities, including two cases of misprocurement in 2006 for a total amount of US $15,300; this resulted in the execution of all procurement activities with prior review until the Bank approved an updated procurement plan . a. Government Performance :Moderately Satisfactory b. Implementing Agency Performance :Moderately Satisfactory c. Overall Borrower Performance :Moderately Satisfactory 10. M&E Design, Implementation, & Utilization: M&E Design : Modest . The project’s original M&E system design was overly complex and failed to identify clear roles and responsibilities for the input and flow of information . The capacity of the PCU to coordinate and conduct the complex studies required for this planned system was underestimated . As part of the third amendment, a plan for M&E development was developed that reflected the changes to the Project and the new National Response . The new plan consolidates and integrates data collection and analysis activities into a single unified system . M&E Implementation : Substantial . Before the third amendment, data was periodically collected on project activities and compiled into quarterly or semi-annual progress reports. DIGECITSS developed an innovative web -based database on PLWHA. The project assisted in the conducting of two Demographic and Health Surveys (DHS) in 2002 and 2007, with the latter survey including oversampling of one key high -risk group (people living in bateyes). An effective M&E system, however, was not put in place until after the third amendment, including a new conceptual framework, establishment of baselines, and steps for implementation . The Bank’s Global AIDS Monitoring and Evaluation Team (GAMET) contributed financial and technical support to this new Conceptual Framework of the National System of Monitoring and Evaluation . Project indicators were aligned with indicators from UNGASS and the GFATM. According to the ICR, an innovative, participatory approach to analysis of three high -risk populations (MSM, sex workers, drug users) was developed and conducted, although results of this approach are not presented in the ICR. M&E Utilization : Substantial . Even before the 2006 project restructuring, some of the line ministries involved in the project (Education and Youth) used the project’s M&E data to inform decision making on specific interventions; for example, data on age of sexual debut was used to determine the grade in which to being HIV /AIDS education. In addition, DIGECITSS data were used to determine services and treatment for PLWHA . After the third amendment, M&E data, particularly the data from the HIV /AIDS module of the 2007 DHS, have been used extensively to develop the operational plans of the new National Response . The first annual report for UNAIDS was produced with the new system in 2008. a. M&E Quality Rating : Substantial 11. Other Issues (Safeguards, Fiduciary, Unintended Positive and Negative Impacts): Safeguards: Another Bank project, the Dominican Republic Provincial Health Services Project, already included support for activities to improve biomedical waste management . This project therefore focused on select complementary activities, including the revision of an operational manual for medical waste disposal based on an environmental assessment of waste generated by HIV /AIDS programs and activities. About 70% of health personnel were trained on biomedical waste management for delivering HIV /AIDS prevention and care services . 12. 12. Ratings : ICR IEG Review Reason for Disagreement /Comments Outcome : Moderately Moderately Satisfactory Satisfactory Risk to Development Moderate Moderate Outcome : Bank Performance : Satisfactory Moderately Insufficient attention to risk Satisfactory identification and mitigation during project design led to considerable challenges throughout the life of the project. Borrower Performance : Moderately Moderately Satisfactory Satisfactory Quality of ICR : Satisfactory NOTES: NOTES - When insufficient information is provided by the Bank for IEG to arrive at a clear rating, IEG will downgrade the relevant ratings as warranted beginning July 1, 2006. - The "Reason for Disagreement/Comments" column could cross-reference other sections of the ICR Review, as appropriate . 13. Lessons: Institutional coordination is necessary as Bank -financed projects build more capacity in some agencies than in others . In this case, the strengthening of the institutional capacity of COPRESIDA sometimes created friction with DIGECITSS. When constructing project indicators, it is important not only to align indicators consistently with those of the national response, but also to make it possible to collect data sufficient to assess the specific and unique contributions of the project to that national response . In an environment increasingly crowded with other donors, there must be sufficient attention paid to assessment of attribution of outcomes specifically to Bank -financed interventions. There are clear trade -offs between a fast -track approach to project preparation during a time of perceived crisis, and a more time -consuming approach based on in -depth country analysis . In the long run, it is likely that better results will be achieved when preference is given to the latter approach . Even when there is seemingly relevant international experience from which to draw lessons, every project requires appropriately careful situation-specific analysis to ensure proper understanding of country needs . Well-intentioned but too-hasty rushing of a project into implementation can ultimately prove counterproductive, requiring costly delays and restructurings later on. 14. Assessment Recommended? Yes No Why? TThis is one of the first Caribbean MAP projects to close, and it would be useful to understand how targeting and coverage of prevention interventions was affected by the project ’s revisions. 15. Comments on Quality of ICR: The ICR provides a very clear description of the complex set of amendments throughout the project. It includes an important discussion of attribution of observed outcomes to Bank-financed interventions, in an environment with significant contributions from other donors (particularly the GFATM). However, the ICR does not clearly link outputs to outcomes, discussing primarily outputs when assessing the achievement of the project’s development objectives. a.Quality of ICR Rating : Satisfactory