Public Disclosure Authorized

Document of

The World Bank

Report No: ICR0000842

Public Disclosure Authorized

IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-35890 IDA-3589A)

ON A CREDIT IN THE AMOUNT OF SDR 15.7 MILLION (US$ 20.0 MILLION EQUIVALENT) TO THE REPUBLIC OF MADAGASCAR FOR A MULTISECTORAL STI/HIV/AIDS PREVENTION PROJECT

Public Disclosure Authorized

June 25, 2008

Public Disclosure Authorized

AFTH3 AFMMG Africa Region

CURRENCY EQUIVALENTS (Exchange Rate Effective April 16, 2008) Currency Unit = Ariary 1.00 = US$ 0.000604 US$ 1.00 = 1,656.34 FISCAL YEAR July 1 June 30 ABBREVIATIONS AND ACRONYMS
AIDS CAS CBO CSW DALY DHS FMA GNI GTZ HIV IBRD IDA IDU IEC ISR KAP M&E MAP MICS Acquired Immune Deficiency Syndrome Country Assistance Strategy Community-Based Organization Commercial Sex Worker Disability-Adjusted Life Year Demographic and Health Survey Financial Management Agency Gross National Income Deutsche Gesellschaft fr Technische Zusammenarbeit Human Immunodeficiency Virus International Bank for Reconstruction and Development International Development Association Injecting Drug Users Information, Education and Communication Implementation Status Report Knowledge, Attitudes and Practices Monitoring and Evaluation Multi-Country HIV/AIDS Program Multiple Indicator Cluster Survey MIS MoH MSM NAC NGO OED PAD PDO PHRD PIU PLWHA PMTCT PPF PSI QAG QER STI USAID VCT Management Information System Ministry of Health Men who have Sex with Men National AIDS Council Non-Governmental Organization Operations Evaluation Department Project Appraisal Document Project Development Objective Policy and Human Resources Development Project Implementation Unit Person Living With HIV/AIDS Prevention of Mother-To-Child Transmission Project Preparation Facility Population Services International Quality Assurance Group Quality Enhancement Review Sexually-Transmitted Infection United States Agency for International Development Voluntary Counseling and Testing

Vice President: Obiageli Katryn Ezekwesili Country Director: Robert R. Blake Sector Manager: Lynne D. Sherburne-Benz Project Team Leader: Maryanne Sharp ICR Team Leader: Patrick M. Mullen

MADAGASCAR Multisectoral STI/HIV/AIDS Prevention Project

CONTENTS

Data Sheet A. Basic Information

B. Key Dates .................................................................................................................. iv C. Ratings Summary ...................................................................................................... iv D. Sector and Theme Codes ........................................................................................... v E. Bank Staff................................................................................................................... v F. Results Framework Analysis ...................................................................................... v G. Ratings of Project Performance in ISRs ................................................................. viii H. Restructuring (if any).............................................................................................. viii I. Disbursement Profile ................................................................................................. ix 1. Project Context, Development Objectives and Design............................................... 1 2. Key Factors Affecting Implementation and Outcomes .............................................. 4 3. Assessment of Outcomes .......................................................................................... 10 4. Assessment of Risk to Development Outcome......................................................... 19 5. Assessment of Bank and Borrower Performance ..................................................... 19 6. Lessons Learned ....................................................................................................... 21 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners .......... 22 Annex 1. Project Costs and Financing.......................................................................... 24 Annex 2. Outputs by Component ................................................................................. 25 Annex 3. Economic and Financial Analysis................................................................. 31 Annex 4. Bank Lending and Implementation Support/Supervision Processes ............ 33 Annex 5. Beneficiary Survey Results ........................................................................... 35 Annex 6. Stakeholder Workshop Report and Results................................................... 36 Annex 7. Borrower's ICR ............................................................................................. 37 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders....................... 60 Annex 9. List of Supporting Documents ...................................................................... 61 MAP

A. Basic Information
Country: Project ID: ICR Date: Lending Instrument: Original Total Commitment: Madagascar P072987 06/25/2008 APL XDR 15.7M Project Name: L/C/TF Number(s): ICR Type: Borrower: Disbursed Amount: Multisectoral STI/HIV/AIDS Prevention I Project IDA-35890,IDA-3589A Core ICR GOVERNMENT OF MADAGASCAR XDR 15.5M

Environmental Category: B Implementing Agencies: UGP/PMPS Cofinanciers and Other External Partners:

B. Key Dates
Process Concept Review: Appraisal: Approval: Date 04/03/2001 11/14/2001 12/14/2001 Process Effectiveness: Restructuring(s): Mid-term Review: Closing: 12/13/2004 12/31/2006 12/23/2004 12/31/2007 Original Date 11/12/2002 Revised / Actual Date(s) 11/12/2002

C. Ratings Summary
C.1 Performance Rating by ICR Outcomes: Risk to Development Outcome: Bank Performance: Borrower Performance: Satisfactory Moderate Satisfactory Moderately Satisfactory

C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Satisfactory Government: Satisfactory Implementing Quality of Supervision: Satisfactory Moderately Satisfactory Agency/Agencies: Overall Bank Overall Borrower Satisfactory Moderately Satisfactory Performance: Performance:

C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Indicators Performance (if any) Potential Problem Project No at any time (Yes/No): Problem Project at any time (Yes/No): DO rating before Closing/Inactive status: Yes Satisfactory Quality at Entry (QEA): Quality of Supervision (QSA):

Rating Satisfactory None

D. Sector and Theme Codes

Original Sector Code (as % of total Bank financing) Central government administration Health Other social services Theme Code (Primary/Secondary) Gender HIV/AIDS Participation and civic engagement Population and reproductive health Secondary Primary Secondary Secondary Secondary Primary Secondary Secondary 13 77 10 13 77 10 Actual

E. Bank Staff
Positions Vice President: Country Director: Sector Manager: Project Team Leader: ICR Team Leader: ICR Primary Author: At ICR Obiageli Katryn Ezekwesili Robert R. Blake Lynne D. Sherburne-Benz Maryanne Sharp Patrick M. Mullen Patrick M. Mullen At Approval Callisto E. Madavo Hafez M. H. Ghanem Arvil Van Adams Claudia Rokx

F. Results Framework Analysis

Project Development Objectives (from Project Appraisal Document) The PDO is to support the Government of Madagascar (GOM) efforts to promote a multisectoral response to the HIV/AIDS crisis and contain the spread of HIV/AIDS on its territory. To do so, the project will build capacity and scale up the national response to HIV/AIDS and sexually transmitted infections (STIs), a key risk factor and contributor to the spread of HIV/AIDS.

The project supports four components: 1) Financial Assistance to the Development of Sector Plans and Pilots; 2) A Fund for STI/HIV/AIDS Prevention and Non-Medical Care-taking Activities; 3) Monitoring and Evaluation; and 4) Program Management and Strengthening of Institutional and Organizational Capacity.
Revised Project Development Objectives (as approved by original approving authority)

(a) PDO Indicator(s) Original Target Formally Actual Value Values (from Revised Achieved at Indicator Baseline Value approval Target Completion or documents) Values Target Years An increase of condom use during last sex with non-regular partners among men Indicator 1 : from 2.3 % to 15%, and among women from 0.3% to 7% by the end of the project in Antananarivo and Tamatave. 6% women 7% women 0.3% women Value 13% men 15% men 2.3% men quantitative or (nationwide) (in Antananarivo (in Antananarivo & Qualitative) (2003-04 DHS) & Tamatave) Tamatave) Date achieved 11/26/2001 12/31/2006 01/01/2004 Comments (incl. % Indicator was modified due to data availability (details in main text). achievement) Reduction of the proportion of people aged 15-49, having at least one sex Indicator 2 : partner, other than a regular partner in the last twelve months. Value not available quantitative or not available Qualitative) Date achieved 11/26/2000 12/31/2007 Comments Indicator was modified due to data availability (details in main text). (incl. % achievement) Decrease in prevalence of gonorrhea among CSW from 25% to below 15% by Indicator 3 : the end of the project Value 15% not available quantitative or 25% Qualitative) Date achieved 11/26/2001 12/31/2006 12/31/2007 Comments Indicator was modified due to data availability (details in main text). (incl. % achievement) Indicator 4 : Increase proportion of people knowing at least three ways to prevent getting

infected with HIV (women from 57% to 80% and men from 44% to 90%). Value 42% women 57% women 80% women quantitative or 46% men 44% men 90% men Qualitative) (2003-04 DHS) Date achieved 11/26/2001 12/31/2006 01/01/2004 Comments Indicator was modified due to data availability (details in main text). (incl. % achievement) By 2006, increase condom use during last sex to 35 percent among commercial Indicator 5 : sex workers (CSW) Value 67% 30% 35% quantitative or (2006 Behavioral (1995 survey) Qualitative) Survey) Date achieved 12/31/1995 12/31/2006 07/01/2006 Comments Indicator included in Credit Agreement. (incl. % achievement) (b) Intermediate Outcome Indicator(s) Original Target Actual Value Formally Values (from Achieved at Indicator Baseline Value Revised approval Completion or Target Values documents) Target Years Increase by 5 % annually the number of civil society organizations conducting Indicator 1 : HIV/AIDS prevention (promotion of safe sex, distribution of condoms) activities financed by the project. 1,514 civil society organizations Value (quantitative 0% 20% increase conducted or Qualitative) HIV/AIDS prevention Date achieved 12/14/2001 12/31/2006 12/31/2007 Comments (incl. % Indicator included in Credit Agreement. achievement) Increase the coverage of peer group IEC events financed by the project (one-onIndicator 2 : one or small groups) by 10% annually among high risk groups (CSWs, uniformed men, miners, high school students). 883,874 total Value participants in peer 10% annual 0% (quantitative group IEC (CSWs, increase or Qualitative) youth 15-14 years, men and women) Date achieved 12/14/2001 12/31/2006 12/31/2007 Comments Indicator included in Credit Agreement. (incl. % achievement)

Indicator 3 :

Increase the number of condoms distributed and sold by private/NGO sector by 20% annually. 12.4 million annually 12/31/2006 6.8 million annually 12/31/2006

Value (quantitative 6 million annually or Qualitative) Date achieved 12/14/2001 Comments Indicator included in Credit Agreement. (incl. % achievement)

G. Ratings of Project Performance in ISRs

Date ISR Archived 04/12/2002 11/07/2002 02/24/2003 05/20/2003 12/08/2003 04/23/2004 12/01/2004 05/31/2005 12/27/2005 07/28/2006 01/16/2007 07/17/2007 11/28/2007 Actual Disbursements (USD millions) 0.00 0.00 1.29 2.56 5.35 7.89 12.26 14.29 16.11 17.93 19.73 21.06 24.13

No. 1 2 3 4 5 6 7 8 9 10 11 12 13

DO Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory

IP Satisfactory Satisfactory Unsatisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Satisfactory Moderately Unsatisfactory Moderately Satisfactory

H. Restructuring (if any) Not Applicable

I. Disbursement Profile

1. Project Context, Development Objectives and Design

1.1 Context at Appraisal

The project was prepared in 2001 as part of the first phase of the World Banks MultiCountry HIV/AIDS Program (MAP), approved by the Board in 2000. Madagascar is an island country of 590,000 square km, with an estimated population in 2001 of 16 million. Adult HIV prevalence in Madagascar was thought to be under 1%, although there was great uncertainty due to questions about the reliability of surveillance data. Surveillance by the Ministry of Health (MoH) indicated 0.05% prevalence in 1988, 0.09% in 1993 and 0.30% in 1998, interpreted in the National Strategic Plan for 2001-06 as exponential growth. Such indications of growth in prevalence, weakness in the surveillance system, and the presence of the following risk factors led to the worry that the country may be on the verge of a wider epidemic, following the path of other countries in the region.

The prevalence of sexually-transmitted infections (STIs), believed to be a major risk factor for HIV infection, was very high, as studies of pregnant women found 12% were infected with syphilis in 1995. Risky sexual behavior was thought to be common. The 1997 Demographic and Health Survey (DHS) found that 38% of never-married women aged 15-24 reported having sex in the previous 12 months. Qualitative information on a number of social norms and practices raised concern, including early separation of adolescent girls from their families, and the practice of casual sex while traveling. Utilization of condoms, a basic preventive measure, was low. In 1997, among those who had sex in the past 12 months, only 1% of women aged 15-49 used a condom the last time they had sex. Knowledge of the disease was low. Although the 2000 Multiple Indicator Cluster Survey (MICS) found that 65% of women aged 15-49 had heard of HIV/AIDS, only 30% knew the three major means of prevention: abstaining from sex, using condoms, or having sex with only one faithful and uninfected partner. Stigma and fear were associated with the disease. Given the very low prevalence, the general population was hardly, if at all, affected by the disease. Infection was feared and vulnerable groups, such as sex workers, were socially marginalized. The existence of some vulnerable groups, such as men who have sex with men (MSM) and injecting drug users (IDU), was not recognized. With an estimated gross national income (GNI) per capita of US$ 250 per capita in 2001, poverty was considered a general risk factor, as the poor, less educated, and residents of rural areas, were less likely to know of HIV/AIDS and preventive measures, and to have less access to condoms and STI treatment. Transactional sex in return for economic support was thought to be common. In a context of political and economic change, the islands exposure to the rest of the world was growing, particularly through increasing tourism.

The first diagnosed case of HIV infection in Madagascar was in 1987. A National STI and HIV/AIDS Control Program was established in 1988 under the Ministry of Health. In 2001, in an effort to strengthen the multi-sectoral character of the response as well as international partnerships, a National Coordination Cell was established under the Prime Ministers Office with the responsibility for overall coordination and implementation of the National Strategic Plan for 2001-06. The Plans overall objectives were: i) to maintain HIV prevalence below 1% through implementation of preventive measures; and ii) ensure the well-being of people living with HIV/AIDS (PLWHA) through psychosocial and medical support and social, legal and economic measures.
1.2 Original Project Development Objectives (PDO) and Key Indicators

The PDO is to support the Government of Madagascars efforts to promote a multisectoral response to the HIV/AIDS crisis and contain the spread of HIV/AIDS on its territory. To do so, the project will build capacity and scale up the national response to HIV/AIDS and sexually transmitted infections (STIs), a key risk factor and contributor to the spread of HIV/AIDS. The key indicators are listed in Table 1.1
Table 1. Key project indicators i) ii) iv) v) vi) An increase of condom use during last sex with non-regular partners from 2.3% to 15% among men and from 0.3% to 7% among women by the end of the project in Antananarivo and Tamatave; Reduction of the proportion of people aged 15-49, having at least one sex partner, other than a regular partner in the last 12 months; Decrease in prevalence of gonorrhea among CSW from 25% to below 15% by the end of the project; and Increase proportion of people knowing at least three ways to prevent getting infected with HIV (women from 57% to 80%, men from 44% to 90%); and By 2006, increase condom use during last sex to 35% among commercial sex workers (CSW).

1.3 Revised PDO and Key Indicators, and reasons/justification

The PDO was not revised. Aides-memoire and Implementation Status Reports (ISR) refer to the indicators specified in the Project Appraisal Document (PAD), with modifications in their formulations due to availability of data. The initial choices of indicators reflected the situation of lack of data during project preparation, and they were reformulated as survey and second-generation surveillance data (supported by the project) became available. This did not require formal restructuring since the substance of what was measured by the indicators (HIV/AIDS awareness and knowledge, sexual

These are key performance indicators specified in the Project Appraisal Document (PAD) (26 November 2001), with the exception of indicator vi) which is included in an Annex to the Development Credit Agreement (14 December 2001). Also, in the Annex to the Credit Agreement, indicator i) does not refer to Antananarivo and Tamatave, while indicator ii) is formulated as follows, By 2006, increase the proportion of people aged 15-49 who have reduced the number of sexual partners in response to the perceived risk of contracting HIV by 20 percent.

behavior, condom use, and STI prevalence), as well as the populations referred to by the indicators (men, women, high-risk groups), were unchanged.
1.4 Main Beneficiaries

The PAD states that the project will target the groups most vulnerable to HIV infection and support the capacity of communities to prevent the spread of infection, at the same time as benefiting the countrys general population. Institutions dedicated to combating HIV/AIDS are also expected to benefit from capacity building.
1.5 Original Components
Table 2. Project components 1. Financial Assistance to Develop Sector Plans and Pilots (US $2.2 million) Development of plans for the prevention of HIV/AIDS in eight sectors: education, health, information/culture/communication, infrastructure, labor, population, rural development, and security. On the basis of these plans, pilot activities were to be implemented for eventual scale-up. 2. Fund for STI/HIV/AIDS Prevention Activities (US$ 15.0 million) Preventive Activities Fund to support: i) Sub-projects implemented by non-governmental organizations (NGOs) and community-based organizations (CBOs) including prevention and support activities such as mass media, workshops, peer communication, counseling and non-medical care and support; ii) Social marketing of condoms and STI treatment kits; iii) Marketing of the Fund and facilitation of sub-projects; iv) Operational costs of the Fund; and v) Strengthening the capacities of implementing entities. Financial management was to be handled by a contracted agent and technical support to implementing NGOs and CBOs was to be provided by contracted facilitators. 3. Monitoring and Evaluation (US $ 1.8 million) Establishment of a management information system for the project, support to HIV/AIDS surveillance, surveys of target groups and evaluation and operational research studies. 4. Project Management and Strengthening of Institutional and Organizational Capacity (US$ 2.0 million) Technical assistance, staffing, training and equipment for the HIV/AIDS coordination and implementing bodies, including the project implementation unit (PIU).

1.6 Revised Components

Project components were not revised.

1.7 Other significant changes

The government that took power in 2002, almost a year after project approval, made significant changes to the institutional framework for the national HIV/AIDS response, reflecting the new Presidents strong commitment to combating the disease. Amendments to the Credit Agreement reflected the establishment of the National AIDS Council (NAC) under the Presidency, replacing the previous coordination body. Regional and local HIV/AIDS coordination structures were also to be created with support from the project. In a major shift in implementation arrangements, a 2002 government decree assigned implementation of the project to the NAC Executive Secretariat so that it essentially became the PIU.

In 2004 the government shifted somewhat the strategic focus of the Fund, although within the broad parameters described in the PAD. The PAD indicated that the project would support grassroots response by NGOs and civil society as well as scaling up of ongoing preventive and care activities that address risk factors. In 2004 the government put greater emphasis than had been the case to date on support to grassroots response by civil society, although support to preventive and care services continued. The emphasis shifted to support for micro-scale sub-projects (under US$ 3,000) implemented by CBOs under a local response strategy. The menu of possible activities was as follows; i) Advocacy with opinion leaders and communication through social networks; ii) Mass communication; iii) Interpersonal communication and peer education; iv) Group activities; and v) Psychosocial support to people affected and infected by HIV/AIDS. In 2006, the local response strategy adopted the additional goal of creating demand for voluntary counseling and testing (VCT), with VCT services being established with Global Fund financing. Other changes included: (i) amended allocations to expenditure categories (in 2005), to purchase additional STI treatment kits and mobile cinemas, expand training, and increase the number of NAC local offices; (ii) project extension (in 2006) by one year, largely due to slower than expected disbursements that year; and (iii) increases in the proportion financed by the credit for all expenditure categories to 100% to address problems due to lack of counterpart funds which particularly affected local purchases of goods.2

2. Key Factors Affecting Implementation and Outcomes

2.1 Project Preparation, Design and Quality at Entry

Project design incorporated lessons from the experience of countries that seemed to have been able to control the epidemic (particularly Uganda, Senegal and Thailand) and reflected a balance between the MAP strategy (with a particular emphasis on the multisectoral approach and involvement of civil society) and a more targeted servicedelivery approach, in particular by emphasizing STI treatment, condom distribution, and scaling up of preventive interventions targeting hotspot areas. A Quality Enhancement Review (QER) during preparation of the Madagascar project stated the following:
The Panel [] urged the Region to take the opportunity to blend the best aspects of the MAP approach participation, partnership, client-driven strategic direction, multisectoral, learning-by-doing, use of existing mechanisms, etc. and the proven approaches to HIV/AIDS risk management in lower prevalence circumstances targeting of high risk groups, intensive surveillance, tailored IEC and universal condom availability.

A Quality at Entry Assessment by the Quality Assurance Group (QAG) rated the design Satisfactory, similarly stating that it was very much tailored to the unique epidemiological profile of Madagascar, rather than adopting a template that might have been more convenient in the MAP context. The QAG assessment commended the

Previously, in 2003, the proportion had been temporarily raised to 100% for all categories due to exigencies of the 2002 political crisis.

project preparation team for involving the country team as a whole as well as, despite considerable difficulties, other partners and stakeholders. High government ownership was also noted, although difficulty in the relationship with the Ministry of Health (MoH) was suggested in the QAG report. The QAG assessment focuses mostly on implementation arrangements, concluding that they were complex in relation to the existing capacity, capacity-building activities were not clearly specified, and numerous conditions of effectiveness relating to establishment of basic implementation capacity indicated low readiness for implementation. The QAG rated the risk assessment as satisfactory. Risks that were identified as substantial were that PIU capacity would be insufficient to adequately manage the project and that the public sector would fail to work adequately with the private sector and NGOs to ensure the development of effective sector plans. Overall, the risk assessment is focused on micro-level technical and implementation issues without stepping back to assess the broad risks to whether the project strategy was adapted to the epidemiological situation, given the uncertainty during preparation.3 Nevertheless, the need for better information and learning from pilot experiences is both recognized in the PAD and reflected in the overall learning-by-doing strategy. The project strategy drew on available epidemiological and behavioral studies of HIV/AIDS in Madagascar as well as the experiences of previous and ongoing projects financed by other donors, such as a condom social marketing program. A PHRD grant and the PPF were also used to finance numerous studies and pilot interventions that informed the project strategy. However, it is not clear that findings had an important influence on the project during the early stages of implementation.
2.2 Implementation

The project was not formally restructured with regard to its objectives and indicators nor did it have at risk status at any point. Implementation can be described in three phases. i) Delays in effectiveness and start-up (2002). As noted above, implementation arrangements were significantly changed in 2002, bringing the PIU under the responsibility of the Executive Secretariat of the NAC. These changes came with a new government that took office following several months of political instability during 2002. Project preparation had been accelerated in order for the Credit Agreement to be approved by the 2001 parliamentary session, but this did not ultimately occur until the end of 2002. At the same time, capacity problems in the PIU delayed other effectiveness conditions, indicating that the QAGs concern about readiness for implementation was indeed founded. Project effectiveness was delayed to about a year after Board approval ii) Acceleration in implementation (2003-05). The institutional changes at the end of 2002 brought the project closer to decision-makers, particularly the NAC Executive
3

The macro-level risk of political instability, which came to pass, was also not mentioned, although it is difficult to see how the team could be prescient on this issue.

Secretariat and, importantly, the new President who had strong public commitment to combating HIV/AIDS. These factors allowed for the project to take-off in 2003, as the planned implementation structures, particularly the Preventive Activities Fund and its contracted Financial Management Agent and Facilitating Organization, were put in place. The Facilitating Organization spurred a large number of sub-project applications many of which were subsequently revealed to be of poor quality and possibly fraudulent accelerating disbursement from the Preventive Activities Fund. By 2005, project disbursement was such that preparation of a repeater project was fast-tracked. iii) Disbursement delays and extension (2006-07). The demands of coordination and policy development increasingly diverted attention of the NAC Executive Secretariat away from implementation of the project (this was one of the lessons, cited by the PAD, of a 2001 review of initial implementation of the MAP 1 projects). Until 2006, the project was the major source of financing for the national program, but with the start of implementation of a Global Fund grant by the NAC Executive Secretariat, attention and capacity was further diverted. At the same time, quality problems with the Preventive Activities Fund sub-projects led project management to put in place additional review steps and problems in their implementation led to delays. The contract of the Facilitating Organization was not renewed, leaving a gap with regard to support to project development and implementation by CBOs. Other factors affecting project disbursement during this period were a lack of counterpart funding, transfer from the country of key staff of partners and the Bank team, poor communication between project management and the Bank team, and diversion of attention to preparation and start-up of the repeater project. Disbursement delays caused the IDA project to be extended by one year (from end 2006 to end 2007). The MAP template advocates decentralized and local control and implementation as well as (perhaps somewhat in contradiction) warning against complex implementation arrangements. On paper, the national HIV/AIDS program supported by the project in Madagascar was decentralized, with regional and local coordination bodies. However, the structure is better characterized as deconcentrated, as the regional coordination committees reported to the national committee, which set overall strategic direction and priorities. In addition, although the majority of projects were over this threshold (in line with the local response strategy), sub-project proposals over US$ 3,000 required central level approval. Procedures for the Preventive Activities Fund became even more complex in implementation than envisioned in the PAD, involving a variety of actors at different levels, including the project steering committee, the NAC, the NAC Executive Committee, a technical review body under UNAIDS, the Financial Management Agent and its regional branches, the regional HIV/AIDS committees and their technical coordinators, the Facilitating Organization and its regional branches, local HIV/AIDS committees, and regional and local political and administrative authorities. As noted above, quality problems in the first batch of sub-projects led to strengthened review processes as well the decision to not renew the contract of the Facilitating Organization. The number of actors involved and approvals required, combined with proposal

development and reporting requirements that were often beyond the capacities of CBOs, led to a slow process of approval and disbursement. Some of the procedural features of the Fund inhibited the strategic coherence and continuity of the interventions, particularly the very short time-frame of sub-projects (six months) and the absence of a mechanism to encourage repeat projects and CBOs who have proven their capacity. The multisectoral response supported by Component 1 showed weaknesses in implementation, as line ministries showed poor engagement in developing sectoral strategies and implementing pilot projects. Project financing for these activities was not under the control of line ministries, and in a situation of many demands and low capacity, the HIV/AIDS response was often not a priority. Subsequent to the mid-term review, which identified this issue, efforts to strengthen coordination with the health sector were evidenced by a formal accord between NAC and MoH in 2007 while greater coordination with health services at the local level included establishing VCT services (financed by the Global Fund) in health facilities rather than in stand-alone centers as was done previously. Coordination with the health sector improved, while the education ministry implemented HIV/AIDS activities financed by the project in collaboration with partners such as UNICEF. The projects mid-term review in 2004 and its 2006 evaluation of the Preventive Activities Fund found that, consistent with the stated strategy of wide coverage of local interventions, sub-projects were widely but thinly spread across about half of the communes in the country. The assessment also found that communes considered to be most vulnerable were not sufficiently targeted by sub-projects and that generally the target populations of sub-projects represented a large proportion of the general population (rural populations, women, youth). Later in the implementation period, the project started modifying its local response strategy, supporting a mapping of vulnerable communes and encouraging targeting of more specific vulnerable groups, and this strategy has been adopted by the repeater project. Overall, despite limitations, the project developed an effective implementation structure both at the national and decentralized levels that did not exist before, including effective implementation of the Preventive Activities Fund with the support of a contracted financial management agent. Coordination structures, involving national and international partners, were also effectively established at both the national and regional levels.
2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization

The monitoring and evaluation plan had two axes: i) monitoring of project activities; and ii) measurement of the broader impact of the project and the national program as a whole. Monitoring of project activities, particularly the Fund sub-projects, was to be based on a management information system (MIS). After significant effort, a database was put in place by the Financial Management Agent that was effective in providing information on financial inputs. The project compiled basic output information (number condoms distributed, number of people reached by awareness-raising activities, etc) from sub-project reports but links to the financial data are not effectively made as intended.

Community-based monitoring mechanisms, mentioned in the PAD, were not put in place. Nevertheless, both the financial database and compilation of information on outputs were regularly reported and broadly influenced strategy, for example with regard to the geographical distribution, target groups and technical content of the sub-projects. This was supplemented by a significant number of field evaluations of sub-projects by project management. Evaluations of the sectoral pilot projects financed by Component 1 were done and a technical evaluation of the sub-projects financed by the Preventive Activities Fund was initiated late in the implementation period. Measurement of the broader impact of the project and the national program was to be done largely by surveys to measure behavior. Improvement in disease surveillance, implemented by MoH, was to be supported by other donors. The project nevertheless supported a second-generation surveillance sero-prevalence survey4 of pregnant women in 2003 that found 1.1% prevalence and this had a significant impact on the broader strategic discussion. It raised the possibility that the epidemic was spreading into the general population, supporting the shift in emphasis to mass awareness-raising through community-level micro-projects. The project contributed financing to the 2003-04 DHS, which similarly influenced the national program as well as the project, as it showed progress on HIV/AIDS awareness, but still-high prevalence of reported STI symptoms and persistently low condom utilization rates. These findings supported the projects continued financing of STI treatment and condom distribution and led to a greater focus on these issues in the repeater project. Second-generation surveillance behavioral surveys of vulnerable groups (youth, pregnant women, truckers, soldiers, sex workers) were financed by the project in 2004 and 2006, while sero-prevalence surveys of specific groups were done in 2005 and 2007. These studies were instrumental in filling knowledge gaps about the epidemic, and their findings contributed to a shift back towards a more targeted approach near the end of the project but were mostly influential on the repeater project. They also provided baseline estimates for M&E of the repeater project. The project financed a number of analytical studies including vulnerability mapping, qualitative studies of high-risk groups and an analysis of the epidemiological situation that brought together the various sources of data. After the mid-term review, the NAC Executive Secretariat strengthened its M&E capacity by hiring M&E specialists and developing with partners an M&E plan for the national program. Overall, the project made significant progress in strengthening M&E of both the project itself and the national program, with some weaknesses with regard to regular linking and analysis of the available data in order to influence operations and policy, although study findings did have important impacts at the strategic level.

The second generation of HIV/AIDS surveillance emphasized active surveillance, involving seroprevalence and behavioral surveys of target populations located in broadly geographically-representative surveillance sites (opposed to passive surveillance based on screening of clients of routine services, usually antenatal care). These surveys, however, cannot be considered population-representative in the same way as household surveys such as the DHS and MICS, since the sites are not randomly-selected.

2.4 Safeguard and Fiduciary Compliance

The project was compliant with safeguards requirements, adopting the environmental assessment and medical waste management plan developed under an IDA-financed health project as well as supporting implementation, notably by financing health staff training and construction of 22 hospital incinerators. After initial problems during project start-up related to limited capacity in the PIU, financial management and procurement were generally satisfactory. They were rated unsatisfactory for a period in 2006 when capacity of the implementation agency was insufficient. Audits determined that the project incurred about US$ 50,000 in ineligible expenditures. Delays in counterpart funding of the required proportions of expenditure categories affected implementation and led to adoption of 100% financing by the credit during the last year of the project.
2.5 Post-completion Operation/Next Phase

The US$ 30 million Second Multisectoral STI/HIV/AIDS Prevention Project was prepared in 2005 in anticipation that the first project would be fully disbursed earlier than planned. Disbursement problems in 2006-07, however, required an extension to the first project and delayed the effective start-up of the second project. Approved in July 2005, the second project became effective in January 2006 but started significant disbursements only towards the end of 2007 for the reasons that affected the first project discussed above. The second project uses the same implementation mechanisms and adopts broadly the same strategy as the first project. The main differences are as follows.

Stronger focus on high-risk groups in areas known to have a higher prevalence than other regions, including mandating that 75% of the Preventive Activities Fund will be targeted to these areas and specifying key outcome indicators that refer to high-risk groups (sex workers, truck drivers, soldiers). Emphasis on working to achieve changes in behavior among specific groups as opposed to mass awareness-raising. Much more focused multisectoral strategy, aiming at only the health, education and security sectors. Stronger role for the health sector is exemplified by a project component to finance health services, particularly STI treatment and care and treatment of PLWHAs. Emphasis on analysis of surveillance and M&E data.

These adaptations, notably the greater focus on high-risk groups and service-delivery, reflect a re-shifting of the strategic orientation of the first project late in its implementation. However, the second project does not address the possible limitations with the implementation arrangements discussed above (capacity problems, complexity, centralized decision-making combined with a deconcentrated structure, the combined policy/coordination and implementation roles of the NAC Executive Secretariat). Such problems became manifest with disbursement delays during start-up of the repeater project in 2006-07. The repeater project adds to the already large number of actors involved in implementation by planning for a contracted M&E agent. There is evidence, however, that the government is resistant to significant contracting of external entities, particularly internationally-based. Although the Financial Management Agent is 9

currently operating, neither the planned M&E agent nor the NGOs to be contracted as Facilitating Organizations have been put in place. Alternative methods (ie. more directly supporting and using government structures) to improve M&E and provide support to implementing CBOs should be explored.

3. Assessment of Outcomes
3.1 Relevance of Objectives, Design and Implementation

One of the eight priorities of the 2007-12 Madagascar Action Plan is a commitment to health, family planning and combating HIV/AIDS, with the specific objective of keeping adult HIV prevalence under 1%. In addition, the President continues to show strong commitment in this area. The 2007-11 Bank Country Assistance Strategy (CAS) supports the Madagascar Action Plan, including the HIV/AIDS objective. The epidemiological situation in Madagascar also remains similar to 2001, as HIV prevalence among adults remains under 1% while many risk factors for expansion of the epidemic are still in place. The project was designed in a context where the high STI prevalence in particular led to the fear that the epidemic could be on the verge of exploding. Although the information base has vastly improved since then with the various sero-prevalence and behavior surveys, the notion that the country is at great risk remains current. Is the project relevant to this epidemiological situation? The 2000 MAP template provides guidance on strategies for countries with low and stable prevalence (defined as under 5% among adults) and those with high and growing prevalence. Although including behavior change communication (BCC) interventions targeting high-risk groups, the guidelines for low prevalence countries do not emphasize this and also recommend scaling-up existing interventions to national scale as well as wide access to VCT. Generally, a variety of evaluations, particularly 2004 and 2007 reviews of the MAP as well as a 2005 study by the Banks Operations Evaluation Department (OED), have noted a lack of sufficient emphasis by the MAP projects on interventions targeting high-risk groups. Consequently, the Banks 2007 strategy for phase two of the MAP contains a greater emphasis on prioritization and targeting, particularly in lowerprevalence situations. The Madagascar project adapted the MAP approach (non-medical multi-sectoral and community-based interventions) to the country context, particularly by including support to service delivery (STI treatment and condom distribution) and specifying that vulnerable areas (hotspots) and groups would be targeted. Throughout implementation the project maintained a balance between these two approaches. Although the shift in emphasis to broad coverage of community-based activities (and of VCT services) swung the pendulum one way a the midpoint of the project, the project continued to support NGO-implemented programs targeting specific groups as well as distribution of condoms and STI treatment kits. The pendulum swung back towards more a more targeted and service-oriented approach during the last years of the project, spurred by lessons learned

10

(ie. the mid-term review and 2006 evaluation of the Fund), better data on high-risk groups, as well as the global discussion on the lessons of the first phase of the MAP. At the same time, it is not clear that an even greater focus on targeted prevention and service delivery would have been appropriate or even possible. First, there was very little information available on high-risk groups both due to lack of data and to high levels of stigma. Government and some partners suggest that population-wide awareness and stigma of the disease needed to be addressed before greater emphasis on high-risk groups was possible. A related notion is that it was necessary to address the broader population in order to reach those bridge groups who have contact with the traditional high risk groups but are difficult or impossible to identify. At the same time, the IDA project was only part of the national program, with other parts supported by other donors, particularly VCT services financed by the Global Fund and NGO-implemented services (for example health services targeting groups such as sex workers as well as condom social marketing) financed by bilateral donors. Finally, the fear of a generalized epidemic underlay the strong political commitment to a population-wide and community-level response.
3.2 Achievement of Project Development Objectives

The PDO is to support the Government of Madagascar to promote a multisectoral response to the HIV/AIDS crisis and contain the spread of HIV/AIDS on its territory. To do so, the project was to scale up the national response to both HIV/AIDS and sexually transmitted infections (STIs), considered a key risk factor and contributor to the spread of HIV/AIDS. The strategy was to increase knowledge of HIV/AIDS and STIs, incite changes in behavior (risky sexual behavior and condom utilization), increase demand for relevant services (condoms, STI treatment, VCT), and improve coverage of services. Key indicators measured performance on these various aspects of the strategy. A number of indicators were modified due to data availability, with many relying on secondgeneration surveillance behavioral and sero-prevalence surveys supported by the project between 2004 and 2007. Indicator estimates are provided in Table 3. Data sources are the 2003-04 DHS and a series of second-generation surveillance surveys of large sample sizes of specific at-risk groups, and are considered to be of good quality. Awareness and Knowledge. An important focus of the project was to improve population-wide awareness and knowledge of STIs and HIV/AIDS, particularly through community-level activities, in order to reduce stigma, encourage behavior change and stimulate demand for services. The project was the major source of financing for this part of the national strategy. In the context of the multisectoral approach supported by Component 1, only three of the eight sectors successfully implemented pilot projects. However, the component also supported mass communication activities that included radio and television programming, distribution of over 4,000 solar/hand-powered radios accompanied by the creation of community listening groups, distribution of school materials, pamphlets and activity kits, and a toll-free question line (ligne verte) particularly-used by youth. Along with other partners, the project contributed to a mobile cinema program. A total of 3,355 sub-projects were financed by the Preventive

11

Activities Fund, of which 2,611 were implemented by CBOs. The vast majority focused on communication and education at different levels: population-wide, community, and interpersonal. However, the communication efforts focused on HIV/AIDS, neglecting awareness and knowledge about STIs Table 3 indicates that HIV/AIDS awareness and knowledge increased among women (ages 15-49) in the general population between 2000 and 2003-04, as well as among youth (ages 15-24), sex workers, truckers and soldiers. Trends in additional indicators of the knowledge of women aged 15-49 between 2000 and 2003-04 measured by household surveys similarly show improvement. For example, in 2000, 36% of women knew that condoms helped prevent infection (2000 MICS), compared to 51% in 2003-04 (2003-04 DHS). An indicator for stigma shows improvement, even though at a low level, as around 8% of young men and women said they had a positive attitude towards persons infected with HIV in 2004, compared to around 14% in 2006. This is notable given the notion discussed above that the project helped reduce stigma, thereby allowing a more robust targeting of high-risk and marginalized groups later in the project and by the repeater project. Anecdotal evidence indicates that stigma remains high but has ameliorated, as PLWHA have started to present themselves publicly and the existence of men who have sex with men (MSM) and injecting drug users (IDU) has started to be acknowledged. Sexual Behavior. One of the points of communications activities is to influence sexual behavior. The 2001 PAD indicates that evaluations of IEC programs in Madagascar indicated that they generally focused on providing information rather than on changing behavior, and that this would be addressed by the project. Estimates for the revised indicator given in Table 3 suggest that, compared with 2004, a lower proportion of young women in 2006 reported sex with more than one partner, but men reported an increase in risky sexual behavior. On the other hand, similar behavioral surveys found that among soldiers, 40% reported more than one partner in 2004, compared to 35% in 2006. Among truck drivers, the proportions were 48% in 2004 and 39% in 2006. The 2005 PAD for the repeater project echoes the first PAD, stating that communication efforts until that point focused on raising awareness so that the program should then turn to emphasizing change in behavior. Nevertheless, the available evidence on change in sexual behavior is mixed, suggesting that among some groups the practice of riskier sexual behavior has lessened. Condom Utilization. Increased use of condoms is another change in behavior intended to be encouraged by project activities. On the demand side, an important component of communication activities was to raise encourage condom use as a means of prevention. On the supply side, the national program, with contributions from various partners, distributed a total of 67 million condoms during the project period, of which about 20 million were financed by the project. In collaboration with other partners, the national program introduced a new condom brand and marketing specifically targeting young people, who the data showed were more likely to use them.

12

Table 3. Key indicators Baseline Awareness and knowledge Original key indicator Increase the proportion of women (from 57% to 80%) and men (from 44% to 90%) who know at least three ways to prevent HIV infection Revised indicator Proportion of women and men aged 15-24, sex workers, truckers and soldiers who know three ways to prevent HIV infection 2003-04 Outcome 2006-07

30% women (2000 MICS)

42% women 46% men (2003-04 DHS) 57% women 63% men 50% sex workers 52% truckers 48% soldiers (2004 Behavioral Survey)

not available

not available

66% women 67% men 61% sex workers 55% truckers 53% soldiers (2006 Behavioral Survey)

Sexual behavior Original key indicator Reduction of the proportion of people aged 1549, having at least one sex partner, other than a regular partner in the last 12 months5 Revised indicator Proportion of women and men aged 15-24 years who had more than one sexual partner in the previous 12 months

not available

not available

not available

not available

26% women 39% men (2004 Behavioral Survey)

22% women 44% men (2006 Behavioral Survey)

In the Annex to the Credit Agreement, this indicator is formulated as follows: By 2006, increase the proportion of people aged 15-49 who have reduced the number of sexual partners in response to the perceived risk of contracting HIV by 20 percent. Available data do not allow for attribution of change in sexual behavior to increased knowledge of HIV/AIDS, and indeed this is likely impossible to measure.

13

Baseline Condom utilization Original key indicator By 2006, increase condom use during last sex to 35 percent among commercial sex workers (CSW)6 Original key indicator An increase of condom use during last sex with non-regular partners from 2.3% to 15% among men and from 0.3% to 7% among women by the end of the project in Antanarivo and Tamatave.7 Revised indicator Condom use by sexually-active women and men aged 15-24 for "commercial" and "noncommercial" sex

2003-04

Outcome 2006-07

30% (1995 survey)

77% (2004 Behavioral Survey)

67% (2006 Behavioral Survey)

0.3% women 2.3% men (in Antanarivo and Tamatave) (data source not documented) not available

6% women 13% men (nationwide) (2003-04 DHS)

not available

20% women "commercial" sex 15% women "non-commercial" sex 24% men "commercial" sex 20% men "non-commercial" sex (2004 Behavioral Survey)

25% women "commercial" sex 19% women "non-commercial" sex 20% men "commercial" sex 16% men "non-commercial" sex (2006 Behavioral Survey)

STI prevalence Original key indicator Decrease in prevalence of gonorrhea among commercial sex workers (CSW) from 25% to below 15% by 2006 Revised indicator Prevalence of syphillis among commercial sex workers (CSW)

25% ( not documented)

not available

not available

31% (1995 survey)

18% (symptoms) (2004 Behavioral Survey)

12% (sero-prevalence) (2007 Sero-Prevalence Survey)

6 7

This key indicator is included in the Annex to the Credit Agreement but not the PAD. Antananarivo and Tamatave are not mentioned in the Annex to the Credit Agreement.

14

In line with this strategy, as well as due to data availability, a key indicator was been modified to refer to condom use by youth (ages 15-45), which increased with commercial partners for both men and women. With regard to non-commercial partners, women reported increased condom use while there was slight decline reported by men (Table 3). Another key indicator referred to condom utilization by sex workers, which was measured to have declined from 77% in 2004 to 67% in 2007. However, this high level of utilization can be compared to a 1995 survey estimate of 35%. Similar studies among other high risk groups found that in 2004, 78% of soldiers reported using a condom with their most recent commercial partner, while the proportion in 2006 had declined to 71%. Among truck drivers, in 2004, 68% reported using a condom with their most recent commercial partner, while in 2006 the proportion was similar at 69%. Both key indicators for the project relate to condom use during higher-risk sex and the available data indicate that this has increased among youth and is at high levels among more specific high-risk groups (sex workers, soldiers and truck drivers), although reported utilization seems to have declined between 2004 and 2006-07 for sex workers and soldiers. Among all of these specific groups, reported condom use is significantly lower for sex with non-commercial partners, suggesting that people generally are less likely to use condoms during sex that they may consider less risky. Consistent with this, overall condom use measured by population-representative surveys remains very low, although it has increased over time. In 1997, among all women aged 15-49, 0.7% currently used condoms, increasing slightly to 1.1% in 2003-04. Condom use by unmarried sexually-active women was low, but increased from 2.6% in 1997 to 5.8% in 2003-04. STI Prevalence. Access to treatment and condom use are considered important determinants of change in STI prevalence. With regard to treatment, the project contributed to the governments program along with the IDA-financed health project and other partners, notably USAID and the NGO Population Services International (PSI). Standard treatment kits, developed in order to reduce prescription errors and improve access to effective treatment, were social marketed by PSI through the private sector and were also adopted by the government for highly-subsidized distribution through public sector health facilities. The two complementary channels significantly increased access to effective STI treatment. The project financed over 1.3 million kits and training of 4,480 public and private sector health workers in the syndromic approach to the management of patients with STIs. The project also financed 200,000 diagnostic kits for syphilis screeing of pregnant women. According to the health information system, the annual number of STI cases reported by primary health care services rose from around 90,000 in 2000 to about 200,000 in 2001-02, 260,000 in 2003, coming down somewhat to 150,000-175,000 in 2004-06. These figures do not include large numbers of people who self-treated using social marketed kits.

15

One of the projects key indicators was changed to refer to syphilis due to data availability. Although available data suggest improvement between the 1990s and 2007, differing methodologies prevent valid comparison between 2005 and 2007 (Table 3).8 Nevertheless, comparable sero-prevalence estimates from studies of pregnant women indicate a decline from 8.2% in 2003 to 4.4% in 2007. HIV Prevalence. HIV prevalence is no longer used as an indicator for such projects due to a variety of measurement and attribution issues. Nevertheless, in the Madagascar context, every piece of evidence points to adult prevalence remaining under 1% due to consistently low incidence, although there are indications of growth in the epidemic in some geographic areas and among some groups.9 Among the general population, as coverage of VCTs expanded, the proportion who tested positive declined from 0.22% in 2004 to 0.05% in 2007.10 Among pregnant women, the 2003 survey found 1.10% prevalence, while a 2005 survey found 0.15%, and a 2007 survey found 0.21%. Among STI patients, HIV prevalence remained at 0% between 1990 and 1999, rising to 0.64% in 2000, 0.7% in 2005 and 0.28% in 2007. Among commercial sex workers, measured prevalence was similarly 0% between 1990 and 1996, but 0.25% in 1998, 1.28% in 2005 and 0.52% in 2007. In 2008, only 158 people in the country have been identified as HIVpositive and receive treatment. Why HIV prevalence has remained so low despite the continuing presence of risk factors is not known, although possible factors could be the continuing relative isolation of the island, the nearly universal male circumcision, the possibility that STIs are not as an important risk factor as previously thought, and perhaps other unknown biological factors. At the same time, a number of the factors targeted by the national program, and this project in particular, postulated to have an impact on the spread of the epidemic, have shown improvement. The IDA project was a major component of the national program, representing over 50% of available financing during the period of implementation.
3.3 Efficiency

A number of studies of specific programs have provided cost-effectiveness estimates for the interventions supported by the project, ranging from US$ 67 to 5,213 per averted infection, and US$ 1 to 261 per Disability Life Year Saved (DALY). For most of the interventions, estimated cost per DALY is under US$ 300 and usually under US$ 100.11

The 2003, 2005 and 2007 studies were second-generation surveillance surveys that measured prevalence by serological test. 9 This discussion is based on a draft analysis of the epidemiological situation financed by the project in 2007, as well as the project-financed 2003 sero-prevalence survey of pregnant women, and the 2005 and 2007 sero-prevalence surveys of pregnant women, STI patients and sex workers (the results for 2007 are not yet official). 10 This is due to the fact that the first VCTs were established in cities and higher prevalence areas, expanding to rural and lower-prevalence areas. The 2007 figure is for the period up to October. 11 World Bank (2007) The World Banks Commitment to HIV/AIDS in Africa: Our Agenda for Action, 2007-2011, Washington, (citing Bertozzi et al., 2006).

16

This can be compared to estimated costs per DALY of treatment of childhood illnesses of US$ 9 to 219, and US$ 82 to 409 for maternal and neonatal care.12 Simulations of different prevalence situations may lead to a different conclusion.13 In a lower prevalence situation, the models indicate that prevention among sex workers (SW) and men who have sex with men (MSM) are the most cost-effective, while blood safety, condom distribution, prevention of mother-to-child transmission (PMTCT), and workplace programs have a medium level of cost effectiveness. The models suggest that community mobilization, mass media, STI treatment, and education interventions are least cost-effective in a low prevalence situation. These are among the most important activities supported by the project, even though the project also supported condom distribution and some interventions targeting sex workers. Nevertheless, such models cannot account for the particular circumstances of each country. For example, it is clear that in Madagascar, despite its low HIV prevalence, the high STI rates make condom distribution and STI treatment more cost effective than in other contexts. Over the course of six years, from approval end-2001 to completion end-2007, the average annual cost of the project was US$ 3.5 million or approximately US$ 0.20 per capita. The IDA project represented approximately half of total HIV/AIDS financing during this period (so that total HIV/AIDS financing averaged US$ 0.40 per capita annually). This average annual total HIV/AIDS funding during the period was equivalent to about 7% of total public sector health spending (domestic and international) of about US$ 6 per capita in 2005 and to about 14% of international donor support to the sector (which represented about half of total public sector spending).14 Average annual total HIV/AIDS financing also represented approximately 4% of average annual development aid to the country (excluding debt relief) during the 2002-07 period. On the one hand, there are clearly more significant health problems causing a much larger burden of morbidity and mortality in the country. In a situation of very low public financing for health services, it may be questioned whether this was the best use of available international funds. On the other hand, the low prevalence situation is precisely the moment when it may be most appropriate (and efficient) to make significant investments to prevent expansion of the epidemic, a point made by an influential 1999 World Bank report that analyzed the evolution of the epidemic in other countries up to that point.15 The equivalent of 7% of total public sector health spending was probably not an unreasonable investment to attempt to reduce the risk of growth in the epidemic.

Jamison, D. et al. (eds.) (2006) Disease Control Priorities in Developing Countries (Second Edition), Oxford University Press and the World Bank, New York and Washington. 13 World Bank (2008) The World Banks Commitment to HIV/AIDS in Africa: Our Agenda for Action, 2007-2011, March, (citing Bollinger and Stover, 2007). 14 Source for health spending data is WHO. 15 World Bank (1999) Confronting AIDS: Public Priorities in a Global Epidemic (Revised Edition), Oxford University Press, New York.

12

17

3.4 Justification of Overall Outcome Rating

Rating: Satisfactory The project is relevant to current priorities. Although there may be debate over the question of whether the project was fully relevant to the epidemiological situation, it maintained a balance between the MAP strategy of advocacy, awareness-raising and community-mobilization, and more targeted and service delivery-oriented interventions. With regard to achievement of the PDO, for the most part, progress is evident on the key indicators. The major contribution of the project to raising awareness and knowledge is evident. There is mixed evidence with regard to changes in sexual behavior. Although condom use among the general population remains low, utilization levels are higher when sex is perceived as more risky, and condom use is at high levels among high-risk groups. The project has likely significantly contributed to a reduction in STI prevalence. The interventions supported by the project have been found to be cost-effective in other contexts. The project represented the major part of the national program during its first four years of implementation, financing significant institutional development at the national, regional and local levels.
3.5 Overarching Themes, Other Outcomes and Impacts (a) Poverty Impacts, Gender Aspects, and Social Development

Poverty and gender disparities contribute to HIV/AIDS risk factors, for example commercial and transactional sex. Project activities increased awareness of such risky sexual behavior among communities, drawing attention to their economic and social roots. The Preventive Activities Fund adopted a strong focus on community-based activities in rural areas, where the population is generally poorer than in urban areas.
(b) Institutional Change/Strengthening

In line with the capacity-building aspect of the PDO, the project had a significant impact on institutional capacity, with the greatest effect at national and local levels, involving creating the program under the Presidency and creation of regional and local HIV/AIDS committees and plans. Among the 1,549 communes, local HIV/AIDS committees were put in place in 1,014, of which 664 are reported to be effectively operational and 519 have developed local action plans. Considering the strength of the central NAC and its regional and local structure, essentially a new HIV/AIDS sector has been created, even though multisectoral interventions at the local level developed over the course of the project. The mixed policy and implementation role of the NAC was replicated at the regional level, causing similar diversion of attention from strategy and coordination to implementation of the Preventive Activities Fund. Among line ministries, the multisectoral strategy supported by Component 1 did not lead to significant institutional capacity-building, although implementation coordination with the health and other sectors improved improved towards the end of the implementation period and led to a health sector component of the repeater project.

18

(c) Other Unintended Outcomes and Impacts (positive or negative)

Two related possibly unintended outcomes are evident. First, it is likely that in many communities, particularly in rural areas, mobilization interventions supported by the project may be among the few such activities bringing people together in a common forum for discussion. For example, the listening groups formed around the handpowered radios surely do not confine their discussions to HIV/AIDS issues but must raise and address other community concerns. The mobile cinemas also brought communities together, spurring wide-ranging discussion. A second and related point is that, by raising awareness, reducing stigma, and openly discussing sexual issues, project activities have likely contributed to opening space for discussion of reproductive health issues more broadly as well as to greater tolerance for diversion from traditional norms. For example, a toll-free phone line (ligne verte) supported by the project provides youth in a particular with a forum for questions and discussions about sexuality and reproductive health.
3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops

Not applicable.

4. Assessment of Risk to Development Outcome

Rating: Moderate Although the project contributed to improvements in various risk factors, the risk of growth in the epidemic remains. For example, although improved, STI rates remain high, high-risk sexual behaviors remain prevalent and condom use among the general population remains low. At the same time, the country continues to experience greater economic and social openness to the outside world (for example through mining and tourism) that contributed to the fear of the epidemic that was evident during project preparation. The repeater project, benefiting from significant advances in knowledge of the shape of the epidemic, and focusing on vulnerable areas and groups in a context of greater population-wide awareness and reduced stigma, contributes to mitigating the risk.

5. Assessment of Bank and Borrower Performance

5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry

Rating: Satisfactory As discussed above, project design was based on the MAP strategy but adapted to the country context. At the same time, project design, particularly the Preventive Activities Fund, was sufficiently flexible to accommodate the governments shift in emphasis towards population-wide community mobilization for prevention and an eventual shift back towards a more targeted approach. Nevertheless, complexity of the implementation arrangements likely contributed to delays.
(b) Quality of Supervision

Rating: Satisfactory

19

The Bank team was prompt in providing support when capacity problems became evident. A possible exception was 2006, when the project experienced significant disbursement delays and ultimately needed to be extended by one year, partly due to communication problems between the Bank team and the Client. Nevertheless, the team recovered the situation by instituting regular video-conferences, stepping-up supervision and extending the project completion date. At the same time, it is evident that the teams input on technical issues during supervision was consistently of high quality, aided by the presence of health specialists in the field throughout most of the implementation period. In particular, the teams technical input provided a balance to the governments strong emphasis on community-based communication activities, contributing to maintenance of support for more targeted and service delivery-oriented activities. The Bank team closely collaboration with other partners, including bilateral donors, multilateral institutions and NGOs, on technical and strategic issues, contributing to the national programs success in for the most part ensuring complementarities between different projects.
(c) Justification of Rating for Overall Bank Performance

Rating: Satisfactory The design of the project, which contributed to its Satisfactory Overall Outcome Rating, combined with the Bank teams responsiveness to implementation issues and work on technical issues, justify an overall rating of Satisfactory.
5.2 Borrower Performance (a) Government Performance

Rating: Satisfactory Delays in start-up were largely due to institutional uncertainties and capacity limitations, combined with a political crisis in 2002. However, this became vastly outweighed by the strong political commitment and leadership provided by the President, shown to be an essential factor to effective HIV/AIDS responses in other countries. However, along with this commitment came close political attention to project operations, particularly the subprojects financed by the Preventive Activities Fund. There was poor engagement by many of the sectors involved in the multisectoral approach, although lessons from this have been translated into a more focused approach in the repeater project.
(b) Implementing Agency or Agencies Performance

Rating: Moderately Satisfactory Consistent with the strong presidential commitment, the NAC Executive Secretariat provided clear strategic direction and strong leadership to the national program and the project. The Executive Secretariat quickly spurred the project to recover from its start-up delays and effectively steered it through the mid-term shift in strategy. It also effectively coordinated the various sources of donor financing as the complementarities between the IDA project and the Global Fund program illustrates. Related to this however, are the capacity problems that the Executive Secretariat experienced when adopting this programmatic approach, as it attempted to provide strategic direction and coordination at the same time as managing the implementation of two IDA projects, the Global Fund

20

program, and other donor financing. With some lag, the Executive Secretariat addressed the slow-down in project implementation in 2006 by putting in place the required capacity. Although the government effectively contracted a number of non-governmental actors to contribute to implementation, in particular the Financial Management Agent, its failure to adequately replace the Facilitating Organization, or fill its functions through some other means, had an impact on implementation of the Preventive Activities Fund. Similarly, a reluctance to contract larger NGOs for implementation of sub-projects, particularly relating service-delivery, may have slowed implementation and caused inefficiencies. Finally, the relatively limited decentralization of decision-making power was not consistent with the structure of regional and local HIV/AIDS committee that was put in place. Overall, however, examined over the entire timeframe of the project, implementation is assessed as moderately satisfactory in that the planned mechanisms were developed, such as the Preventive Activities Fund, that effectively implemented the project as intended.
(c) Justification of Rating for Overall Borrower Performance

Rating: Moderately Satisfactory16

6. Lessons Learned
Lessons drawn from the experience of the Madagascar project generally mirror those of the MAP as a whole, described in the Banks 2007 strategy document. The following can be mentioned in particular.

Collecting and analyzing good data on the characteristics of the epidemic and on the behaviors of the general population and specific groups is well-worth the cost. The various studies and surveys partly or fully-financed by the project had a great impact on strategy discussions later in implementation and in particular on the design of the repeater project. In particular, investment in second-generation surveillance surveys of high-risk groups, starting in 2003, provided badly needed data to reduce uncertainty and shape the response. Achieving a multisectoral response is very challenging and requires attention to the interests, capacities and incentives of the relevant stakeholders. A focused approach, as adopted by the repeater project, and allowing greater control of resources by sector ministries and other actors, is called for. Similarly, encouraging coordination at the local level, particularly with health and education services, requires consideration of interests and incentives. Generally, an effective balance between a decentralized bottom-up approach and a more centralized top-down strategy is difficult to achieve. The former is necessary to ensure community participation, relevance and ownership of interventions, while the latter is required for technical quality and coherence with the necessary strategy to address the particular epidemiological situation.

16

According to the guidelines, given that one aspect of Borrower performance has been rated Moderately Satisfactory, the overall rating is Moderately Satisfactory.

21

In a situation of limited capacity, a tendency to add project-specific implementation agents should be questioned. The implementation structure of the project, although overall effective was quite complex, with a variety of actors involved in sub-project formulation, review and financing. More thought should be given to how to more effectively strengthen existing structures (governmental and non-governmental). The importance of the enabling environment, particularly political, still needs to be emphasized. In a low-prevalence situation, where for most people the presence of the virus was invisible, Presidential leadership made all the difference to raising awareness, establishing a strong HIV/AIDS coordination and implementation structure, and spurring implementation of this IDA project and other programs.

7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners

(a) Borrower/implementing agencies

The NAC Executive Secretariat emphasized the projects impact with regard to population-wide awareness and reduction of stigma, emphasizing the high-level political commitment to a population-wide response. The work of the first project in this area paved the way for the second projects greater focus on vulnerable areas and high-risk groups, including groups such as MSM and IDU that were not even recognized as existing several years ago. The various studies supported by the project, particularly the second-generation surveillance surveys done regularly since 2003-04, have been very important in addressing the knowledge gap about high-risk groups and shaping the strategic orientation of the program. However, the Executive Secretariat indicated that capacity limitations among NGOs and CBOs will be an important challenge for implementation of a more targeted strategy. The Executive Secretariat described its objective of transitioning from project-based to program-based implementation, emphasizing the benefits in terms of coordination and complementarities between different donor-funded programs. An example is how the Preventive Activities Fund sub-projects were used to incite demand for VCT services financed by the Global Fund. However, it is not clear that the capacity issues described previously will allow for effective implementation of this vision in the short term.
(b) Cofinanciers

Not applicable.
(c) Other partners and stakeholders

Representatives of bilateral and multilateral partners were interviewed. One of the partners was involved in project preparation in 2001 and indicated that it was technically well-grounded and participatory. The partners emphasized the projects results in terms of institution-building, awareness-raising, and reducing stigma. It was suggested that greater focus on high-risk groups early in the project would not have been possible given awareness and stigma levels among the population and government officials. Implementation was a learning process so that it is now with the second project that there is greater focus on targeting and service delivery. Examples of some other countries in

22

southern Africa, where policy-makers are still in denial about the epidemic, were cited. Nevertheless, one partner questioned appropriateness of the national programs emphasis on population-wide access to VCT given the epidemiological situation. Partners indicated that an important project outcome was the development of national institutions for the response to HIV/AIDS but questioned the sustainability of the structure at the same time as emphasizing the need for a better-functioning project steering committee and further decentralization of decision-making. It was also pointed out that the fact that the IDA projects finance salaries of national program staff may put the Bank in a more privileged position than other partners. Representatives of NGOs and CBOs were also interviewed. The governments adoption of innovations, such as STI treatment kits, piloted by NGOs was lauded. There is a perception that government is reluctant to use NGOs, in particular international, to scaleup service delivery, preferring to develop government-run systems. NGOs and CBOs indicated that the Preventive Activities Fund sub-projects had a significant impact on population-wide and community-level knowledge and awareness, promoting open discussion and social mobilization. They were unhappy with the long and complicated procedures and reporting requirements involved in obtaining approval and financing, as well as with the lack of longer-term support for well-functioning sub-projects.

23

Annex 1. Project Costs and Financing

(a) Project Cost by Component (in USD Million equivalent) Components 1.FINANCIAL ASSISTANCE TO DEVELOP SECTOR PLANS AND PILOTS 2. FUND FOR STI/HIV/AIDS PREVENTION ACTIVITIES 3. MONITORING AND EVALUATION 4. PROJECT MANAGEMENT AND STRENGTHENING OF ORGANIZATIONAL AND INSTITUTIONAL CAPACITY BUILDING Total Baseline Cost Physical Contingencies Price Contingencies Total Project Costs Front-end fee PPF Front-end fee IBRD Total Financing Required Appraisal Estimate (USD millions) 2.00 13.90 1.50 Actual/Latest Estimate (USD millions) 3.12 13.59 0.71 Percentage of Appraisal 156 % 98 % 48 %

1.80

4.44

247 %

19.20 0.60 1.20 21.00 0.00 0.00 21.00

21.89 0.00 0.00 21.89 0.00 0.00 21.89

104 %

(b) Financing Type of Cofinancing Appraisal Actual/Latest Estimate Estimate Percentage of Appraisal (USD (USD millions) millions) 1.00 0.57 57 % 20.00 0.45 21.89 0.45 109 % 100 %

Source of Funds Borrower International Development Association (IDA) JAPAN: Ministry of Finance - PHRD Grants

24

Annex 2. Outputs by Component

Table 4 lists output and process indicators used by the project, specified in the Credit Agreement as well as subsequently in aides-memoires. Component 1. Financial Assistance to Develop Sector Plans and Pilots (US $2.2 million) This component was to finance development of the multisectoral strategy for combating HIV/AIDS, supporting development of sector strategies and operational plans for eight sectors, and pilot projects to guide further development of the strategies. The focus sectors were education, health, information/culture/communication, infrastructure, labor, population, rural development, and security. Although sector strategies were developed for each of these sectors, only the sectors of labor, infrastructure/transport/tourism, and security implemented pilot projects, for a total of 5 pilots. There is no information on the impact of these projects with regard to HIV/AIDS-related indicators, nor is it evident that the pilots had an effect on further strategy and program development. It is notable that the government was not able to implement a pilot project in the education sector, which is so important to improving knowledge and awareness. For many of the sector ministries, HIV/AIDS was one issue among many demanding limited resources and capacity. At the same time, they did not directly control the funds allocated to support the response in their sector, which undermined their engagement. Nevertheless, late in the project, this component supported a significant part of the health sector response through training of 4,480 health workers in STI diagnosis and treatment. The main lessons of this component are reflected in the repeater project which supports a more focused response in a limited number of priority sectors, including a separate component on the health sector. This component was also used to finance related activities that are not described in the PAD but supported the shift in strategy to focus on the local response and on populationwide awareness-raising. The component supported development of regional and local HIV/AIDS committees and strategies. At the local level, local HIV/AIDS committees were established in 1,014 of the 1,549 communes, although 664 were effectively operational and 519 elaborated HIV/AIDS strategies. The Preventive Activities Fund financed by Component 2 was to support implementation of these strategies, which were intentionally limited to small feasible actions (petites actions faisables). The component also supported communications activities, including standard communication materials (billboards, pamphlets, guides for organizers and journalists), television and radio programming, over 4,000 hand-powered radios and related listening groups, 19 mobile cinemas, and a toll free advice and help line (ligne verte). The project also supported various regional, national and international workshops and conferences.

25

Table 4. Output and process indicators specified in the Credit Agreement Target Component 1. Financial Assistance to Develop Sector Plans and Pilots (US $2.2 million) Sectoral Strategies/pilots are developed and implemented Results of 8 pilot projects mainstreamed Outcome

8 sectoral strategies developed 5 pilot projects implemented Total 2,611 CBO subprojects Total 1.85 million people reached, mostly general population 20 million free distribution (project) 47 million social marketing (partners)

Component 2. Fund for STI/HIV/AIDS Prevention Activities (US$ 15.0 million) Increase by 5% annually the number of civil society organizations conducting HIV/AIDS prevention (promotion of safe sex, distribution of condoms) activities financed by the project. Increase the coverage of peer group IEC events financed by the project (one-onone or small groups) by 10% annually among high risk groups (CSWs, uniformed men, miners, high school students). Increase the number of condoms distributed and sold by private/NGO sector by 20% annually.

20% increase

40% increase

12.4 million

Component 3. Monitoring and Evaluation (US $ 1.8 million) MIS is effectively utilized.

Financial MIS in place but limited capacity for cross-referencing Component 4. Project Management and Strengthening of Institutional and Organizational Capacity (US$ 2.0 million) By 2005, all procurement will have followed IDA procedures Yes Yes Coordination by UGP is timely and effective (based on 5 point index described Yes Yes in Operational Manual).

Yes

26

Component 2. Fund for STI/HIV/AIDS Prevention Activities (US$ 15.0 million) This component represented the major part of project financing and was to finance subprojects implementing preventive interventions as well as social marketing of condoms and STI kits. A total of 3,257 sub-projects were financed. Illustrating the importance of the community-based strategy, 2,611 sub-projects (80.2%) were implemented by CBOs in accordance with the local response strategy. International NGOs implemented 6 sub-projects (0.2%), national NGOs implemented 42 sub-projects (1.3%), national associations implemented 529 sub-projects (18.2%), and private firms implemented 6 sub-projects (0.2%). Over 80% of sub-projects were under US$ 3,000, while a further 16% were between US$ 3,000 and 10,000. As it is formulated, an output indicator used by the project, referring to an annual percentage increase in the number of sub-projects implemented by CBOs, does not make sense since the baseline was zero. Nevertheless, the over 2,000 CBO-implemented sub-projects would likely have exceeded any (arbitrary) target adopted at preparation.
Table 5. Themes included by sub-projects Number of sub-projects * Advocacy Mass media Mass awareness-raising Information, education and communication (IEC) Behavior change communication (BCC) Communication through community groups Communication through traditional healers Communication through schools Inter-personal contact Production of audio-visual material Psychosocial support to PLWHA Care for STI patients * One project could include more than one theme. 1,662 140 1,344 2,885 1,023 2,143 113 135 2,753 17 9 72

By far the majority of sub-projects involved IEC activities at the population, community and inter-personal levels (Table 5). The number of people reached by these activities has been aggregated by the project from sub-project reports. It is apparent that a significant proportion of the population has been reached, but the emphasis on high-risk groups apparent in the output indicator adopted at preparation is not evident during implementation. Most activities targeted the general population or large proportions of it (women, youth). Nevertheless, a certain number of people considered more vulnerable were targeted, particularly later in implementation. For example, the project reports that 1,312 sex workers were reached by inter-personal IEC activities in 2006. An element of the governments local response strategy was to improve knowledge and awareness among the rural population, and this is reflected in the fact that 88% of subprojects were implemented in rural communes. The government strategy also emphasized wide coverage, so that all of the 23 regions received some support through sub-projects, although the proportion of total Fund financing varied between regions from 0.8% to 16.4% (Table 6). The region of Analamanga, containing the capital Antananarivo, received the

27

largest proportion of financing, partly because it is the base for some of the larger mass communications and NGO-implemented sub-projects.
Table 6. Preventive Activities Fund financing by region % of total Fund financing multiple regions Anosy Androy Atsimo-Andrefana Menabe Ihorombe Atsimo-Atsinanana Vatovavy-Fitovinany Haute Matsiatra Amoron'i nia Analanjirofo Atsinanana Alaotra-Mangoro Melaky Betsiboka Boeny Sofia Bongolava Vakinakaratra Analamanga Itasy Sava Diana Total 8.40 0.84 2.01 6.3 2.72 1.02 1.58 3.67 4.20 1.87 5.83 8.72 4.54 0.89 1.52 5.66 3.66 1.44 3.85 16.41 2.68 4.11 8.08 100.0

The project mapped communes by level of vulnerability based on a number of indicators. The 10% of communes that were classified as highly vulnerable received 23% of sub-projects, indicating a certain level of targeting. The 28% of communes classified as moderately vulnerable accounted for a similar proportion of the number of sub-projects 31%.
Table 7. Knowledge of HIV/AIDS among women aged 15-49 1997 n= Have heard of HIV/AIDS Know that condoms can help prevent HIV/AIDS Know that someone appearing healthy can transmit the HIV virus Sources are 1997 and 2003-04 DHS and 2000 MICS. 7,060 68.9 18.8 34.4 2000 7,097 65.4 36.0 .. 2003-04 7,949 79.0 50.8 48.0

Impact in terms of improved awareness and knowledge can be seen in the key indicators discussed in the main text as well as additional data shown in Table 7 and Table 8. For example, population-representative surveys found that the proportion of women who knew 28

that condoms can prevent HIV infection rose from 36.0% in 2000 to 50.8% in 2003-04. However, second-generation surveillance behavioral surveys of young people 2004 and 2006 found high levels of knowledge with slower or no improvement over the two year period, suggesting that it may be more difficult to reach greater numbers once proportions with the relevant knowledge attain 70-80%.
Table 8. HIV/AIDS knowledge and attitudes among men and women aged 15-24 years men 2004 n= Have heard of HIV/AIDS Know that condoms can help prevent HIV/AIDS Know that someone appearing healthy can transmit the HIV virus Have a positive attitude towards persons infected with HIV 2,584 94.6 85.4 67.1 8.2 2006 3,917 95.7 88.0 71.2 13.7 2004 2,802 95.5 82.4 68.0 8.4 women 2006 4,233 94.3 82.8 64.8 13.4

Sources are 2004 and 2006 second-generation surveillance behavioral surveys among youth.

Accompanying the increased emphasis on community-based activities midway through the project was the intention to create demand for VCT services, the provision of which were being financed by the Global Fund and other sources. No relevant indicator was adopted by the project, but available data on utilization of VCT provides an indication of the impact of the project in terms of inciting demand. The number of VCT services went from 15 in 2003 to 503 in 2007, while the number of people tested rose from around 10,000 in 2004 to over 225,000 in 2007. The second-generation surveillance surveys of youth found that in 2004 3.3% of men aged 15-24 had been tested for HIV, rising to 7.4% in 2006. Among women in 2004, 4.3% had been tested (n = 2,802), compared to 7.9% in 2006. Because almost all CBO projects were under US$ 3,000, the breakdowns by number of subprojects (such as in Table 5) do not reflect the importance in financial terms of the different themes nor the different types of implementing organizations. The CBO sub-projects were oriented towards IEC while the NGO projects often involved service delivery. The main service-delivery activities supported by this component were the purchase and distribution of condoms and STI treatment kits. Both interventions were will coordinated with other partners and indeed represented a contribution to scaling up of activities developed in particular by USAID and PSI. Although the PAD stated that the project would support social marketing of condoms, in fact this was done by the other partners, while condoms financed by the project were distributed free through health services. Of the total of about 80 million condoms distributed during the implementation period, the project financed 20 million. Similarly, the project supported distribution at highly-subsidized prices of STI treatment kits through public sector health facilities, while the other partners social marketed identical kits through private sector drug sellers and health service providers. The project financed the distribution of 907,500 CURA 7 kits and 422,500 GENICURE kits.17 The project also financed 200,000 diagnostic kits for screening of pregnant women in order to prevent congenital syphilis.

Under the syndromic approach to management of STIs, infections are diagnosed and treated according to the symptoms and clinical signs. The CURA 7 kits are intended to treat infections with genital discharge symptoms and the GENICURE kits are used to treat ulcerative infections.

17

29

Component 3. Monitoring and Evaluation (US $ 1.8 million) This component was to establish a management information system (MIS) for monitoring of the project and to finance surveys and studies to measure the broader impact of the national program. After some difficulty, an MIS was put in place, concentrating on financial data. Basic output data were compiled from sub-project reports but links to the financial data could not be effectively made by the MIS as intended. The project made a significant contribution to surveillance and M&E of the national program, contributing to the 2003-04 DHS and financing a series of second-generation surveillance sero-prevalence and behavioral studies between 2003 and 2007. Operational research on the pilot programs financed under Component 1 was not done as intended in the PAD. The project supported the development of an M&E strategy for the national program. Component 4. Project Management and Strengthening of Institutional and Organizational Capacity (US$ 2.0 million) This component was to support institutional development of the national program and project implementation structures. The project financed the national and regional NAC structures established by the government in 2002, as well as supported the creation of local committees. The process indicators for this component relate to implementation of procurement procedures and effective coordination by project management. The project reports that both were attained.

30

Annex 3. Economic and Financial Analysis

A number of studies of specific programs have provided cost-effectiveness estimates for the interventions supported by the project, as shown in Table 9. In these situations, estimated cost per Disability-Adjusted Life Year (DALY) is US$ 300 and usually under US$ 100. This can be compared to estimated costs per DALY of treatment of childhood illnesses of US$ 9 to 219, and US$ 82 to 409 for maternal and neonatal care.18
Table 9. Estimated cost-effectiveness of specific programs (US$)19 Per HIV infection averted VCT (Kenya and Tanzania) VCT (Chad) Peer-based programs (Cameroon) Condom distribution and IEC (South Africa) Condom social marketing (Chad) STI treatment (Kenya) STI treatment (Tanzania) STI treatment (South Africa) STI treatment (Chad) 270-376 891-5,213 67-137 378-4,094 77 11-16 326 2,093 1,675 Per DALY saved

14-19 45-261 3-7 19-205 4 1 16 105 84

Simulations of different prevalence situations may lead to a different conclusion. Table 10 presents results of models of the cost-effectiveness of different interventions in different prevalence situations, assuming various levels of effectiveness in terms of proportion of infections averted. In a lower prevalence situation, the models indicate that prevention among sex workers (SW) and men who have sex with men (MSM) are the most cost-effective, while blood safety, condom distribution, prevention of mother-to-child transmission (PMTCT), and workplace programs have a medium level of cost effectiveness. The models suggest that community mobilization, mass media, STI treatment, and education interventions are least cost-effective in a low prevalence situation. These are among the most important activities supported by the project, even though the project also supported condom distribution and some interventions targeting sex workers. Nevertheless, such models cannot account for the particular circumstances of each country. For example, it is clear that in Madagascar, despite its low HIV prevalence, the high STI rates may make condom distribution and STI treatment more cost effective than otherwise.

Jamison, D. et al. (eds.) (2006) Disease Control Priorities in Developing Countries (2nd Edition), World Bank. World Bank (2008) The World Banks Commitment to HIV/AIDS in Africa: Our Agenda for Action, 20072011, March, citing Bertozzi et al. (2006).
19

18

31

Table 10. Classification of interventions by modeled cost-effectiveness and impact20 East and Southern Africa (higher prevalence) Impact (% of Infections Averted) Low Medium (0-10%) (10-20%) SW MSM Community mobilization VCT Education Mass media STI treatment PMTCT Condom distribution

Cost per infection averted Low (< US$ 1,000) Medium (US$ 1,0003,000) High (> US$ 3,000)

High (> 20%)

Blood safety

Cost per infection averted Low (< US$ 1,000) Medium (US$ 1,0003,000) High (> US$ 3,000) MSM

Central and West Africa (lower prevalence) Impact (% of Infections Averted) Low Medium (0-10%) (10-20%) SW PMTCT Workplace programs

High (> 20%)

Blood safety Condom distribution Community mobilization Mass media STI treatment Education

20

World Bank (2008) The World Banks Commitment to HIV/AIDS in Africa: Our Agenda for Action, 20072011, March, citing Bollinger and Stover (2007). Two scenarios are presented: East and Southern Africa and Central and West Africa. Madagascar, with its low prevalence, is considered more analogous to Central and West Africa despite its geographical location.

32

Annex 4. Bank Lending and Implementation Support/Supervision Processes

(a) Task Team members Names Lending
Henri Aka Saholy Andriambolomanana Anne Bossuyt Susanne Holste Katherine Kuper Jean-Pierre Manshande Gervais Rakotoarimanana Claudia Rokx Sandra Rosenhouse Maryanne Sharp Raj Soopramanien Procurement Spec. Program Assistant Consultant Sr Transport Spec. Sr Urban Spec. Sr. Health Spec. Sr Financial Management Spec. Lead Health Specialist Sr Population & Health Spec. Sr Operations Spec. Lawyer

Title

Unit

Responsibility/ Specialty

TTL

Supervision/ICR
Henri Aka Procurement Spec. Norosoa Andrianaivo Language Program Assistant Slaheddine Ben-Halima Procurement Spec. Anne Bossuyt Consultant Therese Fergo Projects Officer Anne-Claire Haye E T Consultant Cecelia Kennedy Disbursement Spec. Jean-Pierre Manshande Sr Health Spec. Montserrat Meiro-Lorenzo Sr Public Health Spec. Patrick M. Mullen Health Spec. Stefano Paternostro Lead Economist Jean-Paul Peresson Consultant Nadine T. Poupart Senior Economist Andrianina Noro Rafamatanantsoa Assistant Michele Rajaobelina Program Assistant Gervais Rakotoarimanana Sr Financial Management Spec. Nathalie Ramanivosoa Assistant Sylvain Auguste Rambeloson Sr Procurement Spec. Liliane Randrianarivelo Consultant Herinjara Maria Ranohatra Assitant Ando Tiana Raobelison E T Consultant Claudia Rokx Lead Health Specialist Maryanne Sharp Sr Operations Spec.

AFTH3 CHEDR AFTH3 AFTH3 AFTH3 AFTH3 AFTH3 MNSHD TTL

AFTFM AFTPC

AFTH3 AFTH3 TTL TTL

33

(b) Staff Time and Cost Stage of Project Cycle Lending FY01 FY02 FY03 FY04 FY05 FY06 FY07 FY08 Total: Supervision/ICR FY01 FY02 FY03 FY04 FY05 FY06 FY07 FY08 Total: Staff Time and Cost (Bank Budget Only) USD Thousands (including No. of staff weeks travel and consultant costs) 22 21 101.78 78.14 0.00 0.00 0.00 0.00 0.00 0.00 179.92 0.00 25.17 99.75 150.06 170.74 82.38 47.97 32.77 608.84

43

6 19 39 43 20 11 15 153

34

Annex 5. Beneficiary Survey Results

Not applicable.

35

Annex 6. Stakeholder Workshop Report and Results

Not applicable.

36

Annex 7. Borrower's ICR

RAPPORT DE CLOTURE DU PROJET PMPS 1

1. CONTEXTE Madagascar se distingue, parmi les pays du continent Africain, par une prvalence du SIDA encore trs faible. Mais lenvers, cest aussi un pays o les infections sexuellement transmissibles restent problmatiques et alarmante, notamment la syphilis, avec le risque de provoquer une explosion dune pidmie du SIDA. La prvalence du SIDA, jusquici infrieure 1%, a augment petit petit lors de cette dernire dcennie et constitue une menace non seulement de sant publique mais galement conomique et sociale. En 2001, la cration dun Projet Multisectoriel de Prvention des IST/VIH/SIDA (PMPS) est de mise pour soutenir les efforts du Gouvernement Malgaches travers le financement du PSN pour endiguer la propagation des IST/VIH/SIDA. Il sagit, principalement, dapporter une rponse multisectorielle base large avec la participation active des organisations communautaires, des ONG et de la socit civile tous les niveaux,avec lappui des agences dexcution dans le renforcement de capacits. Le projet a ainsi appuy laction nationale lencontre du VIH/SIDA et des Infections Sexuellement Transmissibles (IST), en fournissant des fonds pour des actions immdiates dans les zones rouges identifies au dbut. Ce projet, de la srie Multi country AIDS Programme de la Banque Mondiale, sinscrit dans le plan de dveloppement de Madagascar (DSRP) sur la base des quatre critres suivants : (i) lintgration du VIH/SIDA dans la politique de dveloppement du gouvernement qui a dvelopp le PSN en 2001, (ii) lexistence dune institution de coordination du VIH/SIDA pour la coordination des efforts multisectoriels, (iii) lutilisation des dispositifs existant pour rpondre aux problmes du VIH/SIDA et (iv) l'accord du gouvernement pour financer des agences dexcution comme la socit civile.

2. CADRE HISTORIQUE ET DEROULEMENT DU PROJET Ce premier Projet Multisectoriel pour la Prvention du Sida (PMPS 1) vise appuyer le Gouvernement de Madagascar dans sa rponse multisectorielle lpidmie du VIH afin de contenir la propagation de linfection dans la population malgache. Selon laccord de crdit sign le 14 dcembre 2001, le projet dune dure de cinq ans (2001-2006), est financ hauteur de 21.000.000 USD dont 20.000.000 USD par lInternational Development Association (IDA) et 1.000.000 USD par le Gouvernement Malagasy. La premire date de mise en vigueur du projet tait au mois de novembre 2002. Le retard tant d aux conditions pralables de mise en vigueur. La date de clture du projet initialement prvu pour le 31 dcembre 2006 a t reporte au 31 dcembre 2007. Dune manire globale, la premire anne du projet (2002) a t surtout marque par la mise en place des mcanismes institutionnels doctroi de financement. Les annes suivantes se distinguent par une consolidation des acquis institutionnels et lacclration des interventions et des appuis aux structures de mise en uvre. 3. PRESENTATION DU PROJET PMPS 1 31. OBJECTIF DU PROJET PMPS 1

37

Le projet PMPS 1 sinscrit dans le cadre dfini par le DSRP et le PSN 2001-2006 dont les principaux objectifs sont de (i) mitiger limpact social et conomique des IST/VIH/SIDA Madagascar, rduire la prvalence des IST/VIH/SIDA et (iii) dassurer la prise en charge des personnes vivant avec le VIH/SIDA. Avec la coordination du groupe thmatique de lONUSIDA, le projet PMPS 1 a t labor en coopration avec les autres bailleurs pour montrer un esprit de rassemblement, de participation et de partenariat. En effet, ce groupe a prpar un Programme Inter Agence pour appuyer le PSN du Gouvernement dans lequel tous les bailleurs de fonds spcifient la forme de leur participation. Le projet sest intgr dans les programmes dj existant et a dvelopp une synergie avec les interventions en cours. 32. LES COMPOSANTES DU PROJET Le projet comporte quatre (4) composantes : 1) 2) 3) 4) Appui aux stratgies sectorielles et stratgies locales Fonds dAppui la prvention des IST, du VIH et du Sida Systme de suivi - valuation Gestion du projet et renforcement des capacits.

La Composante 1 appui llaboration des stratgies sectorielles et la mise en uvre de projets pilotes et des stratgies locales. Son rle est dapporter un appui financier au gouvernement pour llaboration de stratgies sectorielles de prvention des IST/VIH/SIDA afin de mettre en uvre une vritable rponse multisectorielle de prvention et dajuster le plan stratgique nationale. Cette composante a appuy aussi le volet communication de la rponse nationale. La composante 2 concerne lappui financier pour la prvention et la prise en charge non mdical des IST et du VIH/SIDA. Il sagit de mettre disposition des institutions nationales, rgionales ou locales des fonds pour aider dans lexcution dactivits lies la prvention contre les IST/VIH/SIDA, afin de (i) contribuer la ralisation concrte des objectifs dfinis par la stratgie nationale de prvention des IST/VIH/SIDA, (ii) contribuer lidentification des besoins spcifiques IST/VIH/SIDA, (iii) contribuer lmergence de structures locales et/ou communautaires capables doprer efficacement dans ce domaine, (iv) contribuer dvelopper et/ou amliorer les capacits dintervention des institutions impliques dans la prvention contre les IST/VIH/SIDA La composante 3 fait partie du cycle du projet proprement dit car cest le suivi valuation . Cette composante (i) effectue le suivi de progrs des activits finances par le projet, (ii) value limpact des activits du projet et (iii) apporte un appui la ralisation dtudes dans le cadre de la composante1 La composante 4 consiste lappui au (i) Financement du fonctionnement du projet travers le paiement du personnel du projet, dquipement, des cots doprations, dassistance technique ponctuelle, (2) lappui aux activits de renforcement des organismes nationales charges de la lutte contre les IST/VIH/SIDA, et des structures charges de lexcution du projet.

33. LES OBJECTIFS DU PROJET PAR COMPOSANTE Le tableau ci-aprs rsume les objectifs du projet par composante
Composantes 1- Appui llaboration des stratgies sectorielles et la mise en uvre de projets pilotes et des Objectif de la composante Apporter un appui financier au gouvernement pour llaboration de stratgies sectorielles de prvention Indicateurs du projet Au terme de lanne 1 : tous les secteurs ont labors des tudes sectorielles

38

stratgies locales

des IST/VIH/SIDA afin de mettre en uvre une vritable rponse multisectorielle de prvention et ajuster le plan stratgique nationale

2- Appui financier pour la prvention et la prise en charge non mdical des IST et du VIH/SIDA

3- Suivi valuation

4- Gestion de projet et renforcement de capacit institutionnelle et organisationnelle

Mettre disposition des institutions nationales, rgionales ou locales des fonds pour aider dans lexcution dactivits lies la prvention contre les IST/VIH/SIDA, afin de (i) contribuer la ralisation concrte des objectifs dfinis par la stratgie nationale de prvention des IST/VIH/SIDA, (ii) contribuer lidentification des besoins spcifiques IST/VIH/SIDA, (iii) contribuer lmergence de structures locales et/ou communautaires capables doprer efficacement dans ce domaine, (iv) contribuer dvelopper et/ou amliorer les capacits dintervention des institutions impliques dans la prvention contre les IST/VIH/SIDA Objectifs de la composante sont (i) effectuer le suivi de progrs des activits finances par le projet, (ii) valuer limpact des activits du projet et (iii) apporter un appui la ralisation dtudes dans le cadre de la composante1 (i) Financer le fonctionnement du projet travers le paiement du personnel du projet, dquipement, des cots doprations, dassistance technique ponctuelle, (2) apporter un appui aux activits de renforcement des organismes nationales charges de la lutte contre les IST/VIH/SIDA, et des structures charges de lexcution du projet.

Au terme de lanne 2 : tous les 8 secteurs ont pilots au moins un sous projet Au terme du projet : chaque secteur aura gnralis au moins 1 de ses projets pilotes Augmentation de 5% par an du nombre dorganisations de la socit civile menant des activits de prvention du VIH/SIDA Augmentation de 10% par an de la couverture par des vnements dIEC pairs parmi les groupes haut risques (TS, mineurs, lycens, militaires) Augmentation de 20% par an du nombre de condoms distribus par le secteur priv/ONG) Augmentation de 200 par an du nombre de mdecins privs forms lutilisation de kits IST Le nombre de sous projet mis en uvre atteignant leurs objectifs dclars augmente de 10% par an

Le SIG est pleinement fonctionnel au terme de lanne 1 Les donnes sur les groupes cibles couvertes sont utilises pour dfinir les priorits du financement pour les annes venir Le processus de passation de march de la banque a t appliqu pour tous les contrats en 2005 LUGP a men une coordination efficace entre les principaux partenaires (selon les indices inclus dans le Manuel de procdure)

34. FINANCEMENT DU PROJET PMPS 1 LAccord de Crdit sign le 14 dcembre 2001 entre LAssociation Internationale de Dveloppement (lAssociation) a accept de mettre la disposition de LEmprunteur (le Gouvernement de la Rpublique de Madagascar) aux conditions stipules ou vises dans lAccord, un crdit dun montant gal la contre valeur de QUINZE MILLIONS SEPT CENT MILLE DROITS DE TIRAGES SPECIAUX (DTS 15 700 000) (dsign par Crdit et Financement ) pour contribuer au financement du Projet Multisectoriel pour la prvention du VIH/SIDA.

39

Ce financement est rparti initialement comme suit :

N Catgorie 1 Catgorie de Dpenses Travaux, Biens, Equipements et Fournitures Allocation Initiale en DTS 2 000 000,00 Pourcentage d'ligibilit 100% des dpenses en devises et 80% des dpenses en monnaies locales 100% des dpenses en devises et 80% des dpenses en monnaies locales 100% des dpenses en devises et 80% des dpenses en monnaies locales

Consultants et Audits

3 300 000,00

3 4 5

Ateliers et Formations Gestion de Projet Dons Remboursement de l'Avance pour la Prparation du Projet Non Allou TOTAL

400 000,00

230 000,00 85% des dpenses effectues 100% des montants des Dons 7 700 000,00 dcaisss 470 000,00 1 600 000,00 15 700 000,00

6 7

La contribution Toutes Taxes Comprises de lEtat Malagasy se totalise 1 056 090 000,00 Ariary, soit peu prs lquivalent de DTS 363 572. 4. ANALYSE FINANCIERE Cette partie du Rapport de Clture de Projet reflte les tableaux fiduciaires standard du Projet, ainsi quune analyse financire simple du Projet. Lanalyse financire comprend deux (02) sections distinctes. Les tableaux fiduciaires Lexistence ou non des arrirs la fin du Projet avec les explications y affrentes 41. Les tableaux fiduciaires Le montant initial du crdit allou pour contribuer au financement du Projet Multisectoriel pour la prvention du VIH/SIDA se chiffre comme suit : Tableau fiduciaire
N Catgorie 1 Catgorie de Dpenses Travaux, Biens, Equipements et Fournitures Allocation Initiale en DTS 2 000 000,00 Pourcentage d'ligibilit 100% des dpenses en devises et 80% des dpenses en monnaies locales 100% des dpenses en devises et 80% des dpenses en monnaies locales

Consultants et Audits

3 300 000,00

40

3 4 5

Ateliers et Formations Gestion de Projet Dons Remboursement de l'Avance pour la Prparation du Projet Non Allou TOTAL

400 000,00

100% des dpenses en devises et 80% des dpenses en monnaies locales

230 000,00 85% des dpenses effectues 100% des montants des Dons 7 700 000,00 dcaisss 470 000,00 1 600 000,00 15 700 000,00

6 7

La contribution Toutes Taxes Comprises de lEtat Malagasy se totalise 1 056 090 000,00 Ariary, soit peu prs lquivalent de DTS 363 572. Le tableau des ralisations financires par catgorie du Projet PMPS I sanalyse comme suit la date du 07 janvier 2008 (donnes en DTS) : Crdit 3589-MAG
N Catgorie Allocation Initiale Rpartition finale du Crdit Allou 3 080 000,00 2 965 000,00 890 000,00 655 000,00 7 705 000,00 405 000,00 Dcaissement Effectif

Catgorie de Dpenses Travaux, Biens, Equipements et Fournitures Consultants et Audits Ateliers et Formations Gestion de Projet Dons Remboursement de l'Avance pour la Prparation du Projet Non Allou TOTAL

Pourcentage

1 2 3 4 5 6 7

2 000 000,00 3 300 000,00 400 000,00 230 000,00 7 700 000,00 470 000,00 1 600 000,00 15 700 000,00

2 339 645,21 2 738 952,80 777 113,44 633 368,16 7 120 360,19 403 608,69

75,96% 92,38% 87,32% 96,70% 92,41% 99,66%

15 700 000,00

14 013 048,48

89,26%

Le tableau des ralisations financires par composante du Projet PMPS I sanalyse comme suit la date du 07 janvier 2008 (en DTS) : Crdit 3589-MAG

N Composantes

COMPOSANTES

Allocation Initiale de Crdit

Allocation de Crdit rvis

Dcaissement Effectif

Pourcentage de ralisation

Appui llaboration des stratgies sectorielles et la mise en uvre de projets pilotes (8 secteurs identifis), et des stratgies locales

1 645 000,00

2 500 000,00

1 999 391,90

79,98%

41

Appui financier pour la prvention et la prise en charge non mdicale des IST et du VIH/SIDA Suivi et Evaluation Gestion de projet et renforcement des capacits TOTAL

11 214 000,00

10 359 000,00

8 711 865,04

84,10%

3 4

1 346 000,00 1 495 000,00 15 700 000,00

1 346 000,00 1 495 000,00 15 700 000,00

457 483,09 2 844 308,45 14 013 048,48

33,99% 190,25% 89,26%

Le dcaissement effectif de la composante 4 inclut la totalit du crdit consomm lors de la phase prparatoire du projet.
Dans cette perspective, la composante 1 vise apporter un appui financier (pour un montant de 2.2 millions USD) pour llaboration de stratgies sectorielles et rgionales de prvention des IST/VIH/SIDA, avec pour objectif la mise en uvre dune vritable rponse multisectorielle de prvention dans ce domaine. Cette composante est scinde en sept sous-composantes. La sous-composante 1.1 vise au dveloppement dune mthodologie efficace pour la prparation et llaboration de stratgies sectorielles. Dans un pays faible prvalence du VIH et prvalence leve des IST, comme Madagascar, la lutte contre les Infections Sexuellement Transmissibles classiques (IST : gonococcie, chlamydiase, syphilis, etc ), est lun des moyens les plus efficaces de lutter contre le VIH et le Sida car elle permettrait de rduire de jusqu 40% lincidence du VIH. Cette prvalence leve des infections sexuellement transmissibles classiques tmoigne le niveau de risque trs lev des comportements sexuels Madagascar. La prvention des IST savrait donc essentielle dans la lutte contre le VIH et le SIDA connaissant que certaines IST surtout ulcratives, comme lherps gnital et la syphilis, augmentent le risque de transmission du VIH de 50 300 fois (de lhomme la femme surtout). Le projet a contribu rduire les nouveaux cas dinfection VIH Madagascar par une plus grande prise de conscience, en mettant laccent sur des pratiques sexuelles moindre risque risque et en amliorant laccs au traitement des IST. En matire de rponse, Madagascar dispose de points forts dans la lutte contre les IST, tels que : (i) ladoption grande chelle de lapproche syndromique par les secteurs public et priv (ii) la mise disposition de kits de traitements vitant les erreurs de prescription, facile utiliser; et (iii) la mise en place du dpistage systmatique de la syphilis chez les femmes enceintes pouvant aboutir un programme dlimination de la syphilis. Faisant partie essentielle de la rponse du secteur sant face au VIH et au Sida, une stratgie nationale de lutte contre les IST a t labore, avec lappui du projet par le ministre de la sant, du planning familial et de la protection sociale. En amont de la stratgie nationale, le projet a appuy le renforcement de la rponse du secteur sant par la formation de 4.480 prestataires de sant des secteurs public et priv en prise en charge des IST par lapproche syndromique. Le projet continue dappuyer le ministre en charge de la sant dans la mise lchelle du renforcement de la comptence des prestataires sur lapproche syndromique qui est devenue une pratique courante pour la prise en charge des IST classiques. Lvaluation de son application tant dans le secteur priv que le secteur public, travers une enqute nationale, est prvu tre ralise dans lagenda 2008 du ministre de la sant et du SE/CNLS. Laccs universel au dpistage de la syphilis chez les femmes enceintes, faisant suite lvaluation des tests rapides pour la syphilis mene avec lassistance technique du Center for Diseases Control (CDC) dAtlanta et lamlioration de la bonne utilisation des kits IST restent un dfi majeur pour le ministre de la sant en adoptant le programme dlimination de la syphilis. Le comit de pilotage de la lutte contre les IST, comit multidisciplinaire sous la direction du ministre en charge de

42

la sant, en collaboration avec le SE/CNLS et regroupant les points focaux issus de la socit civile, des groupes plus exposs au risque, des secteurs cls de dveloppement et des autres ministres cls, est mis en place et oprationnel et reste le garant de lapplication et du suivi de la mise en uvre des stratgies dveloppes, tant sur la communication que le programme proprement dit. La sous-composante 1.2 prvoit llaboration des stratgies sectorielles et des plans oprationnels puis identifier des sous-projets pilotes qui vont mettre en uvre les lments cls de chacune des stratgies sectorielles labores. La sous-composante 1.3 concerne la ralisation des projets pilotes sectoriels. La sous-composante 1.4 a pour objet de dvelopper la cohrence globale des stratgies sectorielles dans une perspective multisectorielle et de contribuer une formulation plus complte et plus pertinente du Plan Stratgique National. La sous-composante 1.5 concerne loprationnalisation de la rponse locale. La sous-composante 1.6 le renforcement de la communication et le plaidoyer et la souscomposante 1.7 la diffusion d'information et les partages d'expriences. Dans llaboration des stratgies sectorielles et mise en uvre des sous-projets pilotes, 8 stratgies sectorielles ont t labores et valides (sant, ducation, travail structur, population/jeunesse, scurit, Infrastructure-Tourisme-Transport (ITT), dveloppement rural, information/communication). Cinq sous projets sectoriels ont t financs. Les deux sous-projets Travail ont t achevs en 2003 et 2004. Lvaluation des deux sous projets Infrastructures est en cours pour le secteur ITT. Un autre lment de lexcution de sous-projet sectoriel est relatif au secteur scurit pour les militaires. Un contrat a t sign avec le Ministre de la Dfense Nationale cet effet. La mise en uvre des activits est en cours. En ce qui concerne le sous-projet des sous secteurs Police et milieu carcral , le contrat pour lexcution du sous-projet a t galement sign avec une association agissant comme promoteur du projet pour le compte de la Police Nationale, mais suite aux problmes de compltude des conditions exiges, les acteurs nont pas pu dmarrer le projet et le contrat a du tre rsili. Le contrat concenrnant le sous-projet du secteur Population a t rsili compte tenu du fait quil na pas t men termes. Pour le Secteur Education : une mission dassistance technique au Ministre a t effectu en aot 2007 pour aider laborer une rponse du secteur Education et pour faire le plaidoyer auprs des instances dirigeantes. Le plan daction (quinquennal) et la budgtisation sont en cours dlaboration et en attente de validation par le Ministre et sera ensuite prsent aux diffrents partenaires pour leur positionnement. Sur l'Appui au Secteur Sant : le projet a financ directement les activits du plan dvelopp par programme IST/VIH/SIDA du Ministre, en considrant les contributions des autres partenaires. Il est noter que la faible performance de lapproche multisectorielle ne rside pas tant dans les capacits individuelles mais plutt dans la capacit organisationnelle et dans des aspects de personnalit et de comportement, chaque secteur sest impliqu des degrs diffrents, et lappropriation du volet VIH et SIDA ntait pas tout fait acquise et/ou les points focaux sectoriels au sein des ministres taient marginaliss et peu pris en considration. Dans le cadre de loprationnalisation de la rponse locale, 1014 CLLS sur 1549 communes sont mis en place dont 664 effectivement oprationnels et 519 PLLS labors. Compte tenu des capacits limites des communes, leur rle est dsormais limit llaboration de plans simples de mise en uvre, (petites actions faisables) tandis que le niveau rgional serait charg de dvelopper des plans plus stratgiques, en accord avec le PSN. Cette approche aurait comme avantage de faciliter le continuum des soins allant de la prvention (multisectorielle) aux soins et au traitement (secteur sant public et priv). Il a donc t dcid de mettre en place une task force au

43

niveau de chaque rgion qui sera charg de dvelopper un plan dactions. Treize (13) task forces rgionaux sont actuellement mis en place et oprationnels. En ce qui concerne la sous-composante 1.6, le volet Communication a t conu ds le dpart en tant quoutil daccompagnement dans lexcution du programme. Llaboration de la stratgie nen a toutefois t dcide quen 2003, aprs la mise en place du Secrtariat Excutif en octobre 2002. Cette stratgie est entre en vigueur lanne suivante, 2004. Mise au service du programme, la Communication a pour mission de contribuer au maintien du taux de prvalence en-dessous de 1%, en levant la perception individuelle et collective des risques dus linfection par le VIH, en vue dune prise dinitiative et daction pour prvenir la maladie. Les actions de communication sont dveloppes par la combinaison de la veille informationnelle qui sappuie sur des outils/moyens et canaux de communication de masse, et de la communication de proximit, ou interpersonnelle, qui se fait travers les partenaires qui interviennent sur le terrain ; le rle de lUnit tant ax sur la facilitation des interventions sur le terrain, en fournissant les capacits techniques, les moyens, les outils/matriels et le financement ncessaire laccomplissement et la mise en uvre des plans daction des diffrents acteurs (associations, prestataires, ONGs, partenaires). Lintgration est le matre-concept de la mise en uvre de lAction de Communication. A chaque stratgie ses moyens et outils, mais ceux-ci sont lis par des interactions senses produire le maximum deffet chez les cibles . Des cibles qui ne le sont que de nom car en ralit, ces cibles sont galement actrices dans le processus ou lapproche de communication. Compte tenu des paramtres socio-conomico-culturels, laudio/visuel (mission, spot, documentaires..) a t privilgi travers une politique de contractualisation (protocoles daccord) avec les grandes chanes de radio couverture nationale et de tlvision, et les petites stations de proximit couverture locale (3 stations TV et une cinquantaine de stations radio), suite une campagne de renforcement de capacits des journalistes et animateurs dantenne. Plus de 4 000 groupes dcoute ont t dots de radios-manivelle dans 04 ex-provinces (Mahajanga, Antsiranana, Fianarantsoa et Toliara). 19 Units Mobiles de Vido sont oprationnels. Mais les imprims ne sont pas en reste : une soixantaine de panneaux daffichage gants (4m X 3m) ont t implants travers toute lle. Plus de 150 000 affiches thmatiques, des millions de dpliants (Sida et IST), des milliers de guides pour journalistes, enseignants, personnels de sant, 25 000 kits danimation pour OCB, 20 000 kits pour chefs fokontany ont t produits. Le SE/CNLS a son bulletin trimestriel. Dautres outils/moyens sont galement utiliss : Ligne Verte (centre dcoute) en partenariat avec trois oprateurs tlphoniques, Centre dInformation et de Documentation avec antennes rgionales, expressions scniques (thtre, marionnettes, hira gasy, animations ludiques), diffrentes formes dexpressions artistiques (chansons, photo, clips vido), films, vnements socioculturels La majeure partie du territoire a t couverte par les interventions de Communication. Tous les grands thmes classiques ont t traits (ABCD, stigmatisation, partenariat multiple). 85% de la population ont entendu parler du VIH et du Sida, et connaissent au moins un des modes de transmission du VIH et un des moyens de prvention. Lutilisation du prservatif est accrue. Les bienfaits du dpistage sont de mieux en mieux compris (nombre croissant des tests). La propension la stigmatisation et la discrimination des PVVIH saffaiblit sensiblement. Des rseaux dducateurs pairs sont fonctionnels dans divers secteurs (jeunes, milieux de travail, TDS). Toute une chane de personnalits-cls est pied-duvre pour relayer les messages : chefs religieux, chefs traditionnels, autorits administratives, chefs dentreprise, artistes, journalistes, animateurs radio/TVCe qui est sr, cest que la Communication a une part de contribution ces mouvements de mutation. Tout est de savoir quel degr ou quelle aune mesurer cette part.

44

Du point de vue de lapproche, le focus est dsormais mis sur la problmatique du Dveloppement comme porte dentre au Sida, dans la dmarche. Dans llaboration de plan daction, la tendance est la Dcentralisation pour tre mieux en phase avec la Rponse Locale. Pour cela, une vague de formation a t organise, suivie de la mise en place de 04 Plateformes de Communication qui regroupent les communicateurs des entits qui interviennent dans le Dveloppement des Rgions concernes. Concernant les thmatiques, une orientation vers un ciblage plus serr des groupes vulnrables (TDS, HSH, jeunes, injecteurs de drogues) devra tre opre, avec des thmes spcifiquement adapts (utilisation des prservatifs, IST, partenariat multiple, usage de matriels souills, les gestes/comportements qui sauvent). Pour la sous-composante 1.7, au sujet de la diffusion d'information et les partages d'expriences, le premier forum national sest droul du 27 au 29 novembre 2003, le thme tant ax sur les jeunes et le VIH/Sida. Le deuxime forum national sur le SIDA sest tenu du 29 novembre au 1er dcembre 2004 sur le thme : Femmes, Religions et SIDA, prcd de 6 fora provinciaux. Madagascar a, outre ce forum national, organis et accueilli le colloque international de lOcan Indien sur le VIH/SIDA les 8 et 9 novembre 2004. Les participants venant des les de la Runion, Maurice, Seychelles, Comores et Madagascar ont dbattu sur laspect de leadership tous les niveaux ; le besoin norme de mobilisation de ressources ; la ncessit de mettre en place un systme de rseau ; la ncessit de mettre en place une politique dARV ; la ncessit dimpliquer les leaders traditionnels et les tradipraticiens dans la prvention. Cet vnement a vu aussi le tmoignage des PVVIH visages dcouverts. En 2005, 22 fora ont t raliss dans les 22 rgions sur le thme Dynamisation de limplication des Rgions dans la lutte contre le VIH/SIDA travers une meilleure structuration de la Rponse Locale . Lobjectif gnral est dintensifier la riposte nationale au VIH et au SIDA, la lumire de la situation pidmiologique des IST, du VIH et du SIDA au niveau des Rgions, des ripostes locales actuelles et des leons tires des expriences vcues, en centrant les efforts sur le dveloppement de la comptence locale afin que chaque individu assume pleinement ses responsabilits pour combattre ce flau. Ainsi, le forum rgional a offert une opportunit de concertation au niveau local afin dobtenir une cohrence entre les stratgies adoptes, les dispositifs rgionaux et locaux pour une riposte efficace et durable. 52. Composante 2 : Fonds dAppui la prvention des IST, du VIH et du Sida Cette composante est dabord constitue par un volet stratgique relatif lachat de kits IST et de prservatifs masculins En complmentarit aux activits dintensification de la demande travers les activits de communication menes par les organisations de la socit civile, loffre de service a t renforce par la distribution de kits premballs de traitement des IST et des prservatifs. Au travers des deux stratgies complmentaires de distribution promotionnelle par le biais des organisations communautaires de base et les organisations non gouvernementales et marketing social des prservatifs, entre les annes 2001 et 2006, on dnombre environ 80.749.377 de prservatifs distribus au niveau national depuis le dmarrage du projet, dont 49% travers le marketing social. Il est constat que lutilisation du prservatif lors du dernier rapport sexuel avec un partenaire autre que le partenaire habituel est pass de 2.3% 24,6% chez les femmes et de 0.3% 28% chez les hommes avec les partenaires de type commercial et 19,7% chez les femmes et 18,1% chez les hommes avec les partenaires de type non commercial. Pour renforcer ces acquis, le projet appuie la campagne de communication sur la lutte contre les IST classiques et en particulier contre la syphilis, un plan de communication est dvelopp et mis en oeuvre.

45

Concernant les kits de traitement des IST, le projet dun commun accord de principe avec le CRESAN, a permis la dotation en kits de traitement IST des formations sanitaires du secteur public et du priv. Au cours du PMPS I, la distribution des kits sest faite, pour le secteur priv, au travers du marketing social (PSI, bnficiaire du FAP) depuis 2003, et au travers du Ministre de la sant via lacquisition de kits auprs de la Centrale dAchat des mdicaments essentiels Salama pour le secteur public depuis 2005. Les kits sont actuellement inscrits dans la liste des mdicaments essentiels, et la distribution est intgre au systme de distribution de la Salama. Pour les kits de traitement IST, un total de 907.500 CURA 7 et 422.500 GENICURE ont t acquis et mis disposition des services de sant sur le courant du projet. A la fin du projet, une baisse de la prvalence de la syphilis chez les travailleurs de sexe est constat, amenant la prvalence de 16,6% en 2005 12,1% en 2007 travers lenqute de surveillance biologique, soit une rduction de 4 points au bout de 2 ans. A travers le programme dlimination de la syphilis, le comit de pilotage de la lutte contre les IST a dcid du dveloppement dun nouveau kit de traitement de la syphilis adapt pour les femmes enceintes. Le ministre de la sant a galement lanc un programme de dpistage systmatique des femmes enceintes et de leur partenaire durant les consultations prnatales. Des CSB2 sont quips en agitateurs nergie solaire (projet CRESAN) qui permettent lusage des tests RPR, de consommables (test RPR, ractifs) et la formation lusage de ces tests qui sera pris en charge par le PMPS. Le projet travers le second projet multisectoriel pour la prvention du sida, souhaite continuer appuyer le secteur sant pour une rponse efficace face au IST par lachat des kits IST travers lappui la SALAMA dans la mise en uvre du programme daction pour lintgration de intrants de sant. Lautre partie de la composante concerne limplication des organisations de la socit civile dans les action de prvention des IST et du VIH. Une des grandes sous-composantes du FAP consiste appuyer les ONG et les associations but non lucratif par le biais de financement de sous projets focaliss sur la communication pour le changement de comportement. Et depuis que la stratgie nationale a mis laccent la rponse locale, un dispositif a t mis en place pour faciliter laccs des et Organisations Communautaires de Base (OCB) ce financement. Les entits finances sur le FAP ont normment contribu aux tendances positives en matire de comportements, et de mobilisation des demandes en services cliniques de prvention et de prise en charge, notamment le dpistage du VIH et la distribution de prservatifs. Pour toute la dure du projet, le nombre de sous projets financs slve 3 357, se rpartissant comme suit : dont 1,48% mis en eouvre par des ONG nationales et internationales, 18,18% par des associations nationales et 80,17% par des OCB. Toutes les rgions de Madagascar ont bnfici de ces sous projets mais des degrs diffrents, allant de 36 324 contrats, et dont 88% ont concern des communes rurales. En termes de priorit, les communes fortement vulnrables et moyennement vulnrables ont t touches respectivement 23% et 31%. Le pourcentage des sous projets ayant t mens terme slve 83,5%. 53. Composante 3 : Suivi et valuation Conscient de limportance cruciale des activits de suivi valuation, le projet soutient la mise en place dun dispositif de suivi et valuation permettant dapprcier la performance, daider la prise de dcision et damliorer la mise en uvre /ou la gestion du projet. Pour le respect des Trois principes de lunicit, il a appuy le dveloppement du plan de suivi valuation national. Le premier plan a t labor en 2003, avec lappui de lONUSIDA, a fait lobjet de revue en 2004 et valid en 2005. Le dveloppement de ce plan de suivi et les outils qui laccompagnent a t un atout pour la mise en uvre du suivi valuation. Par ailleurs, la mise en place du SIG, depuis 2003, permet deffectuer le suivi financier du projet. Les efforts ont t axs vers lamlioration de ces outils pour permettre au projet de contribuer pleinement au suivi de la mise en uvre du programme national, travers les informations relatives aux contributions financires du projet produites par le SIG et les ralisations techniques rapports par les acteurs promoteurs.

46

Dans loptique dun meilleur suivi et valuation, le projet a appuy le renforcement des dispositifs dj mis en place travers la mise en place des Bureaux de Coordination Inter Rgionale, des Units de Coordination rgionales et les Comits Locaux de Lutte contre le VIH/Sida. Ces structures ont t mobilises pour aider fournir les informations ncessaires pour le suivi valuation, travers la collecte et lacheminement des donnes collectes au niveau de leurs zones de couverture respectives vers lunit centrale. 54. Composante 4 : Gestion de projet et renforcement de capacit institutionnelle et organisationnelle Si au dbut, la rubrique GRC 4.2 na pas t prvue dans PMPS 1, elle a t ultrieurement ( partir de 2005) intgre dans la composante 4 du PMPS 1. En effet, avant la mise en vigueur de la composante 2 du PMPS 2, dans laquelle diffrentes activits mettre en uvre par le secteur sant la lutte contre les IST/VIH/SIDA ont t intgres, les activits prioritaires ont t dabord finances dans le projet PMPS 1 particulirement (i) la mise jour dune stratgie et dun plan daction budgtis pour le renforcement de la PEC des IST, (ii) lappui lapproche syndromique et valuation de son application dans le secteur priv et public, (iii) amlioration de la bonne utilisation des kits IST, (iv) lapprovisionnement en test RPR et formation leur utilisation, (v) le monitoring de la sensibilit des germes viss aux antibiotiques utiliss et (vi) lachat des kits accouchement pour femmes enceintes. Le financement de cette rubrique a permis au secteur sant de mettre en uvre des activits cls pour rpondre aux besoins de ce secteur dans la lutte contre les IST et le VIH/SIDA. Aussi, il a permis la construction dincinrateurs de type Montfort dans 10 centres de sant, la dotation de 200 000 tests RPR, la formation des agents de sant sur lapproche syndromique, lacquisition de kit accouchement pour les femmes enceintes, etc. Les indicateurs dimpact du programme ont progress de manire satisfaisante en matire de connaissance du VIH et de certains comportements. On note ainsi entre 2004 et 2006 (ESC) une amlioration significative de la connaissance dans tous les groupes cibles (TDS, jeunes, 15-24 ans, militaires et camionneurs)21, une augmentation de lutilisation du condom avec le partenaire sexuel de type commercial22 , ainsi quune diminution du nombre de partenaires multiples chez les jeunes filles de 15-24 ans (26% en 2004, 21.9% en 2006). En revanche, un point plus proccupant est laugmentation du multipartenariat sexuel chez les garons de 15-24 ans, passant de 36% en 2004 43.5% en 2006. Concernant la prvalence des IST chez les TDS, le taux demeure trs lev en 2004 (15.6%) et en 2005 (16.6%, ESB 2005). La formation de plus de 2000 agents de sant sur la prise en charge des IST classiques selon approche syndromique, co-finance par le projet CRESAN /PMPS en 2004 est lune des grandes ralisation du projet. Dans le cadre du renforcement des capacits des Organismes Nationales, le PMPS 1 contribue dans la mise en place et lappui au fonctionnement des structures de coordination dcentralises, par

Le pourcentage de personnes connaissant au moins trois moyens de prvention du VIH passe entre 2004 et 2006 : (i) chez les jeunes 15-25 ans de 53% 66.7% chez les hommes, de 57% 64.4% chez les femmes, (ii) chez les TDS, passe de 50% 60.5% (iii) chez les camionneurs, passe de 53% 59% (iv) chez les militaires, passe de 48% 52.5%

21

47

le biais des salaires des 5 BCIR (Directeur du Bureau de Coordination Inter Rgional) jusqu mars 2007 fin de leur mandat et par la participation aux frais de fonctionnement des 22 CT/UCR. Toutefois, la planification de lexcution des activits de cette composante mrite une amlioration pour raliser temps rel les activits planifies par le secteur sant, tant donn que certaines activits planifies et supposes prioritaires nont pu tre mis en uvre temps (ex : tude des rsistance aux antibiotiques, planification des activits IST, formation sur approche syndromique,etc.). En outre, il est ncessaire dapporter plus dattention sur la supervision et le suivi des activits mises en uvre pour assurer la qualit des rsultats et proposer des recommandations dans la mise en uvre ventuelle des ultrieures activits de mme type. Certain lment comme la difficult dans ltablissement des spcifications techniques semble lorigine de blocage de la ralisation de certaines activits en 2006 selon le tableau suivant : Tableau des objectifs et activits 2006 ralises par le projet/ Rsultat et indicateur
Objectifs 2006 Confection de 32 incinrateurs Monfort Supervision de la prise en charge des IST au niveau des CSB Etude sur la rsistance des microbes aux Kits IST Achat de Kit d'accouchement pour les bnficiaires Achat de ractifs RPR Organisation d'une runion de mise jour et validation du protocole de test rapide du VIH Madagascar Multiplication du schma du test biologique Tenue dun atelier de trois jours pour la redynamisation de la lutte contre les IST Ractualisation les outils de formation sur l'approche syndromique Formation des personnels des SSD sur la prise en charge des IST par l'approche syndromique Ralisations 2006/indicateurs 10 incinrateurs construits Non ralise Non ralise Non ralise Non ralise Ralise Requte en cours de prparation Spcifications techniques non disponibles Spcifications techniques non disponibles Observations Reste 22 incinrateurs (deuxime phase)

Non ralise Schma non disponible pour multiplication ralis

ralis

Non ralis

Requte non disponible

Lun des problmes rencontrs par le projet est le manque de ressource humaine spcialise en matire dlaboration de spcifications techniques . Il ne sagit pas ici dun problme isol car la plupart des projets oeuvrant Madagascar sont confronts cette carence pour les procdures dacquisition de produits fiables suivant les normes requises. Pour lanne 2007, la situation sest prsent comme suit : Tableau des objectifs pour lanne 2007
Objectifs 2007 Confection de 22 incinrateurs Monfort Ralisations 2007/indicateur Non ralise Observations Nouvelles spcifications techniques aprs valuation remises tardivement pour permettre le recrutement des entreprises au cours de lanne 2007 Activit supprime par le LNR par

Etude sur la rsistance des

Non ralise

48

microbes aux Kits IST Achat de Kit d'accouchement pour les bnficiaires Achat de ractifs RPR Mutliplication du schma du test biologique Formation des personnels des SSD sur la prise en charge des IST par l'approche syndromique

suite des besoins encore clarifier En cours Acquisition de 200 000 tests RPR En cours En cours Une partie sera finance sur PMPS 2

Compte tenu des objectifs ambitieux que le Gouvernement sest fix dans le contexte du MAP, trois dfis majeurs sont relever dans la lutte contre les IST/VIH/SIDA, et notamment : (i) le renforcement de la gestion et la coordination du programme dans la transition dune approche projet une approche programmatique, y compris les aspects fiduciaires, (ii) la mise en uvre efficace dune dcentralisation de la gestion de la rponse aux IST, au VIH et au SIDA travers des activits de rponse locale cible ; et (iii) la redynamisation du partenariat avec le secteur sant. Aprs clture du PMPS 1, le plan du secteur sant sur les IST, le VIH et le SIDA continueront tre financ sur le PMPS 2. Pour lanne 2008, il est prvu dapporter une assistance technique et financire au MINSAN, travers le Programme IST/SIDA, et de renforcer ainsi sa capacit de mise en uvre. A cet effet, une convention de partenariat est en cours entre le MINSANPFPS et le SE/CNLS, ce dernier qui va jouer le rle de coordination et de suivi et le MINSAN qui assurera lexcution. 6. EVALUATION INSTITUTIONNELLE Lexprience du projet en terme institutionnelle est une vritable mine dinformation et dapprentissage. En effet, conformment au manuel dexcution du projet, le dispositif de mise en uvre, de suivi, de contrle du projet est tabli comme suit : 61 - Organisation institutionnelle Le Conseil du PMPS institu par un dcret dfinissant ses rles et attributions, sa composition et son fonctionnement, constitue la structure de coordination du PMPS et est plac sous la tutelle administrative de la Prsidence de la Rpublique, il est constitu de dix sept membres slectionns dans le Comit National de Lutte contre le VIH/Sida pour reprsenter les diffrentes institutions ou organisations, du secteur public, du secteur priv et de la socit civile, incluant les bnficiaires (reprsentants des personnes vivant avec le VIH, ou faisant partie dun des groupes cibles les plus exposs aux risques). La Prsidence du Conseil est assure par le reprsentant de la Prsidence et le Secrtariat du Conseil par lUnit de Gestion du Projet. Le Conseil assure les missions suivantes : - Approuver le manuel de procdures du FAP, le manuel dexcution du projet, le manuel de gestion financire et comptable, et les plans oprationnels annuels budgtiss ; - Approuver le recrutement de lAgence de Gestion Financire ; - Evaluer la performance de lUGP, en concertation avec la Banque Mondiale, suivant des indicateurs de performance bien dfinis ; - Examiner et approuver les demandes de financement dans le cadre du FAP, pour les sous projets dun montant suprieur 100 000 USD ; - Examiner les rapports daudit et proposer des recommandations pour le projet, approuver les rapports techniques et financiers annuel de lUGP, examiner et approuver les comptes annuels du FAP. Le Conseil comprend un Comit daudit, dont le rle est de faciliter le travail des auditeurs externes du projet, revoir les conclusions des auditeurs et assurer lapplication de leurs recommandations. Le Conseil, mis en place au dbut du projet a assum plus ou moins correctement ses responsabilits jusquen Aot 2004. Les conditions de travail des membres du conseil, qui sont des

49

bnvoles, et le changement de fonctions de beaucoup dentre eux ont aussi plus ou moins mouss leurs engagements dans leurs rles vis--vis du projet. Dautant plus que la coordination nationale a depuis rorient lutilisation du FAP vers la rponse locale juge plus cot-efficace en matire de CCC, et rpondant plus aux besoins rels des communauts bnficiaires, donc vers des sous projets largement infrieur 25.000 USD, donc ne ncessitant pas lavis du Conseil du PMPS. LUnit de Gestion du Projet (UGP/PMPS) galement cre par dcret, est sous la tutelle administrative et technique du Secrtariat la Planification de la Prsidence de la Rpublique et sous la tutelle financire du Ministre charg des Finances et du Budget. LUGP/PMPS, conduite par un Directeur national, a pour mission principale dassurer la bonne excution du Projet Multisectoriel pour la Prvention du Sida (PMPS), travers les fonctions suivantes : Gestion oprationnelle des diffrentes des composantes selon le plan oprationnel annuel, selon les rgles et procdures de la Banque Mondiale et du Gouvernement ; Passation des marchs et dcaissements ; Gestion administrative, financire et comptable ; Suivi et Evaluation ; Si depuis la mise en vigueur de lAccord de crdit le 12 novembre 2002, lUGP/PMPS fonctionnait de faon autonome sous lautorit du Conseil du PMPS, le Gouvernement de Madagascar a dcid de confier la gestion du projet au Secrtariat Excutif du CNLS en novembre 2003 conformment aux recommandations internationales sur le renforcement de leffectivit des trois principes dunicit: lUGP/PMPS a donc intgr le SE/CNLS, avec quelques changements dans son organigramme par la nomination du Secrtaire Excutif comme Directeur National du projet, et le recrutement dun Adjoint charg de lUGP/PMPS et dun autre charg des oprations et stratgies. LAgence de Gestion Financire (AGF) est une entreprise de droit priv ayant les capacits de remplir les fonctions dfinies dans le cadre de la composante 2 du PMPS1 sous la forme dun mcanisme financier, le Fonds dAppui la prvention des IST, du VIH et du Sida (FAP). LAGF est prsente deux niveaux (i) le niveau central, charge de la gestion financire et du suivi des activits du FAP ; (ii) le niveau Rgional couvrant plusieurs rgions. LAGF a pour missions principales de : (i) (ii) au niveau central : Compiler les contrats et les besoins de financement transmis par chacun des Bureaux Rgionaux et effectuer le paiement des promoteurs et des organismes de facilitation Consolider les donnes comptables, financires et techniques relatives chacun des contrats de financements passs avec les promoteurs du FAP ; assurer la tenue de la comptabilit du FAP au niveau national ; tenir disponibles toutes donnes et informations ncessaires ralisation des actions de suivi et dvaluation au niveau provincial : Instruire tous les dossiers de financement au titre du FAP et approuver les demandes de financement au titre du FAP au dessous du montant de 100 000 USD aprs instruction par lORT pour les sous projets de plus de 25.000 USD, sur la base des critres dfinis dans le manuel de procdures du FAP ; Soumettre pour approbation au Conseil du PMPS les demandes de financement au titre du FAP au dessus du montant de 100 000 USD ; Assurer la comptabilit au niveau de chaque bureau rgional et de ses antennes ; recueillir et mettre disposition des auditeurs toutes informations dordre technique et financier requises.

Au dmarrage du projet en novembre 2002, lAGF tout dabord faisait partie intgrante de lUGP/PMPS. A partir de 2003, lAGF a t assur par le cabinet daudit Deloitte, ce jusqu la fin du projet.

50

LOrganisme de Facilitation est une institution prive sans but lucratif ou organisation de la socit civile ayant des comptences et une exprience dans la conception et la mise en uvre de projets de protection sociale, constitue un moyen mis en place par le PMPS1 pour renforcer les capacits des promoteurs et donc charg dapporter un appui lidentification et la prparation dun projet, et de former les personnes ressources des promoteurs sur les aspects techniques et managriaux. Un consortium de trois (3) organisations non gouvernementales form par PACT Madagascar, HIV Alliance International et Jereo Salama Isika (JSI) a t contractualis en Septembre 2003 pour oprer en tant quOrganisme de Faciliatation, avec des antennes dans les six (6) chefs lieux de provinces et quelques rgions. Pour des raisons de dfaillance technique dans sa mission dappui aux promoteurs, le contrat de lOrganisme de Facilitation a t rsili en 2004. Et depuis, les Coordonnateurs Techniques Rgionaux du SE/CNLS assurent transitoirement lencadrement technique des OCB et la validation finale de leurs sous projets pour sassurer de leur conformit par rapport aux plans locaux ; tandis que les propositions de sous projets soumises par les associations ou ONG ont t transmises par lAGF lOrgane de Revue Technique (ORT) pour avis technique. Cette disposition transitoire a t maintenue jusqu la fin du projet. Labsence dOF a t rpercut dfavorablement sur lencadrement technique des organisations bnficiaires du FAP, et notamment les OCB qui oprent en fin fond de brousse, et donc sur la qualit des interventions. Lorgane de revue technique (ORT) reprsent par lONUSIDA, procde la revue technique des sous projets qui lui sont transmis par lAGF pour financement par le FAP selon des procdures dfinies dans le manuel du FAP. LORT a pour mission de : Evaluer les dossiers de demande de financement en cours dinstruction (selon le montant du financement) et fournir un avis au Bureau de lAgence de Gestion Financire (AGF) charge de linstruction sur lacceptabilit un financement de chacun des dossiers ; Recevoir et valuer les rapports de suivi trimestriels et les rapports finaux prpars par les organismes de facilitation et transmettre leurs recommandations lAgence de Gestion Financire et lUGP/PMPS.

LORT a t rendu fonctionnel partir de mai 2003, aprs le recrutement de lexpert en valuation technique. LORT a pleinement rempli ses fonctions avec lappui du Groupe Thmatique ONUSIDA. 62 Collaboration internationale Le Gouvernement de Madagascar, par le biais du Secrtariat Excutif du CNLS est all de lavant pour renforcer de la collaboration internationale dans le cadre des appuis techniques et financiers, et des changes internationales des meilleures pratiques dans les divers de la rponse aux IST, au VIH et au Sida. Au niveau national, le Forum des Partenaires constitue une plateforme dchanges et de consultation, permettant le renforcement de la complmentarit des efforts des partenaires internationaux et nationaux. A travers le PMPS, le pays a pu se faire connatre dans la rgion de lAfrique et mme au-del, par sa participation aux confrences et sminaires internationaux, et les consultations africaines sur les IST, le VIH et le Sida organises par la Banque Mondiale. Dailleurs Madagascar a reu de la Banque Mondiale (ACT Africa) le certificat de reconnaissance pour les efforts quil a entrepris en matire de leadership et dengagement politique. 63 Renforcement des capacits

51

La composante 4 du projet intgre les activits de renforcement des capacits des intervenants dans la rponse au Sida. Le personnel du Secrtariat Excutif et de lUGP/PMPS, les personnes ressources des Ministres cls et des organisations de la socit civile ont pu bnficier de formations, soit lintrieur du pays soit lextrieur. Ces activits concernent essentiellement des formations de courte dure (entre une trois semaines) dans les diffrents domaines techniques (e.g. prvention, prise en charge,) et managriaux (e.g. leadership, planification, suivi valuation, gestion financire, passation de marchs, gestions des intrants de sant,), ce selon les besoins spcifiques des secteurs concerns et les priorits du pays.

52

7. LES INDICATEURS DE PERFORMANCE DU PROJET 71. Tableau des Indicateurs de rsultats des promoteurs (tat consolid en juin 2007)

Indicateurs

Donnes

ETAT CONSOLIDE 2006 Objectifs Ralisations Niveau de progrs

IEC/CCC 1. Nombre de programmes de sensibilisation du VIH/SIDA produits sur des supports audio. 2. Nombre de manifestations socioculturelles/sportives pour la sensibilisation sur le VIH/SIDA (comptition, hira gasy, carnaval, thtre, concert, jeux sportifs etc.).

Nombre de programmes de radio conu par l'organisation 43 Nombre de manifestations socioculturelles et sportives organises 103 108 105% 51 119%

Nombre d'hommes touchs 3. Groupe cible : Nombre de personnes touches par les sances de sensibilisation (animation, manifestation culturelle, manifestation sportive, etc) Nombre de femmes touches Nombre de TDS touchs Nombre de jeunes 15-24 ans touchs Nombre total des personnes touches par les sances de sensibilisation de masse (manifestation culturelle, sportive, etc) 4. Nombre de personnes sensibilises travers l'ducation par les pairs ou les visites domicile Nombre de femmes sensibilises Nombre d'hommes sensibiliss Nombre de jeunes 15-24 ans sensibiliss Nombre de TDS sensibilises

403 163 610 651 450 45 076 1 059 340

480184 719 211 386 49 937 1 249 718

119% 116% 86% 111% 115%

457 286 313 944 10 432 1 288

514 942 356 374 11 246 1 312

113% 114% 108% 117%

53

Nombre total des personnes sensibilises travers l'ducation par les pairs ou les visites domicile PROMOTION DE PRESERVATIFS 5. Nombre de prservatifs (a) vendus (b) distribus gratuitement.

782 950

883 874

113%

Nombre de prservatifs distribus gratuitement/vendus

(a) 484 (b) 1 086 575

(a) 529 (b) 1 106 239

109%

Ce tableau montre que les rsultats attendus sont largement dpasss par le projet surtout en matire dIEC.

72. TABLEAU DES INDICATEURS DU PMPS I PAR COMPOSANTE

COMPOSANTE 1 Indicateurs de Base line rsultats/impact Etudes de sectoriels

Objectifs 2002 2003 1 (travail structur) chaque secteur aura gnralis au moins 1 de ses projets pilotes

REALISATION 2004 2 sous projets dvelopps (communication et scurit) 2 sous projets pilotes pour travail structur ont t mis en oeuvre 2005 5 sous projets dvelopps (sant, ducation, population, dveloppement rural, ITT) : 2006 2 sous projets ITT achevs 1 sous projet population en cours de ralisation 2007 (dcembre) Sous projets pilotes mis en uvre dans les secteurs travail (2), ITT (2). Sous projet population rsili Sous projet scurit (Police et Milieu carcral) annul - Projet militaire en cours de mise en oeuvre

Commentaires Les sous projets des secteurs sant, ducation, scurit et population nont pas abouti. La non implication de ces promoteurs ds la conception des sous projets en est la cause

A terme de lanne 1, tous les secteurs ont labors des tudes sectorielles. Au terme de lanne 2, tous les 8 secteurs ont pilots au moins 1 sousprojet. Au terme du projet, chaque secteur aura gnralis au moins 1 de ses projets pilotes

1 sous projet scurit en cours 2 sous projets pilotes ITT sont ralisation en cours de mise Refonte totale du sous projet sant en oeuvre, Morondava, sous projet non 4 sous projets appropri par pilotes (dont 2 pour ducation, rapport au 1 pour scurit et contexte actuel 1 pour sant) 2 sous projets ont reu la NO ducations de la Banque annuls mais un Mondiale

54

plan daction ducation labor

Plan de mise en uvre en cours de finalisation pour 1 sous projet scurit (APAIT) et 1 projet militaire ayant reu la NO de la Banque Mondiale en cours de validation ORT

COMPOSANTE 2 Indicateurs de rsultats/impact REALISATION 2002 Augmentation de 5% par an du nombre dorganisations de la socit civile menant des activits de prvention du VIH/SIDA (promotion de relations sexuelles sans risque, distribution de condoms) 239* 2003 2004 2005 2006 2007 (dcembre) Augmentation annuelle (en %) du nombre de nouveaux sous projet financs * : Sous projets financs (contrats UGP et AGF) A travers Educateurs A travers Educateurs A travers Educateurs Ne disposant pas de base sur le

Base line

Objectifs

Commentaires

1.524 dont 1.514 La signature de 969 623 Augmentation de Augmentation de mis en uvre par contrat sest arrte en 2006 les OCB (55%) 160% Augmentation de 57%

Augmentation de 10% par

55

an de la couverture par des vnements dIEC pairs (personne personne ou petits groupes) parmi les groupes haut risques : TS Mineurs Lycens Militaires Augmentation de 20% par an du nombre de condoms distribus et vendus par le secteur priv/ONG (1. PSI / 2. autre) Augmentation de 200 par an du nombre de mdecins privs forms lutilisation de kits IST. Le nombre de sous-projets mis en uvre atteignant leurs objectifs dclars augmente de 10% par an

pairs : 131.482 (TDS, jeunes 15-24 ans, hommes et femmes)

pairs 837.942 (TDS, jeunes 1524 ans, femmes et hommes)

pairs 883.874 (TDS, jeunes 1524 ans, femmes et hommes)

G* : 707 081 V* : 5 302 224 476 818

G* : 3 594 449 V* : 7 228 608 2 036 256

G* : 3 515 273 V* : 8 258 496 6 259 991

G* : 6 020 600 V* : 9 175 008 9 419 390

G* : 3 997 548 V*: 9 849 628 4 908 007 (SECNLS) -

nombre total de TDS, de mineurs. Les militaires sont au nombre de 30.000 individus et les lycens sont au total au nombre de 437.733. (*) donnes G* : 1 803 195 encore incomplet V* : 6 897 359* pour 2007 8 340 500* (SE/CNLS) Formation en 2007 prise en charge par PMPS 2. Nombre cumul de sous projets achevs la fin de chaque anne (sous projets dont contrat rsili non compris)

1447

2776

265

18

451

1004

2016

2793

*G : Gratuit *V : Vendu

56

COMPOSANTE 3 Indicateurs de rsultats/impact REALISATION Base line Objectifs 2002 Le SIG est pleinement fonctionnel au terme de lanne 1. 2003 2004 2005 2006 2007 (dcemb re) Commentaires

Non

Oui

Oui

Oui

Oui

Le volet finance est compltement oprationnel. Le paramtrage sur le suivi valuation ncessite une amlioration pour fournir les informations ncessaires. Ce nouveau paramtrage a une rpercussion sur le volet finance et il a t jug pertinent dintgrer les amliorations pour le SIG PMPS II.

Les donnes sur les groupes cibles couvertes sont utilises pour dfinir les priorits du financement pour les annes venir.

Oui

Oui

Oui

Oui

Oui

COMPOSANTE 4 Indicateurs de Base line rsultats/impact Les processus de passation de march de la banque ont t appliqus pour tous les contrats en 2005. LUGP a men une coordination efficace entre les principaux partenaires (selon les indices inclus dans le Manuel des Procdures)

Objectifs 2002 2003

REALISATION 2004 2005 2006 2007 (dcembre)

Commentaires

Oui

oui

oui

oui

oui

oui

oui

57

8. PERENNISATION DU PROJET La lutte contre le VIH et le SIDA est de longue haleine et ne peut se terminer en quelques annes. La volont politique des Hauts Responsables Malgaches est un garant de la Prennisation institutionnelle de la lutte Madagascar. Limportance de cette lutte pour le cot Malgache nest plus dmontrer car elle fait partie de la proccupation majeure du gouvernement travers le Madagascar Action Plan (MAP). Le Secteur Sant est trs rattach thiquement et techniquement dans la lutte contre le VIH et le SIDA. La mission naturelle des agents de sant associe lexprience du personnel et la structure solide du systme sant constituent un atout considrable dans la lutte, mme si le projet opte pour une approche multisectorielle. La redynamisation de ce secteur semble un axe de prennisation totalement rentable et efficient grce lexistence dune structure organise et oprationnelle dj en place. Pour les autres secteurs, le processus dappui lintgration effective de la rponse aux IST, au VIH et au Sida dans les ministres cls de dveloppement, travers llaboration de la Politique Gnrale de lEtat (PGE) de chacun deux et la mobilisation de ressources propres au Gouvernement. Leffet et limpact du projet doivent se sentir au niveau de la population de base. Lloignement structurel du projet par rapport la masse populaire et lexistence de plusieurs intermdiaires ne fait quattnuer le rsultat attendu de la lutte contre le VIH et le SIDA. Un rapprochement et une meilleure appropriation du projet par la population est plus que ncessaire. La dcentralisation semble lune des solutions ce problme. Non seulement elle favorise l empowerment mais aussi la bonne prise en main du problme, le dveloppement dun esprit dquipe, une focalisation sur les vrais problmes de terrain et la fin une efficacit probable garant de la prennisation. 9. LECONS APPRISES Lampleur, la dure et la porte du projet PMPS 1 font que ses ressources humaines sajoutent, se rajeunissent et se renouvellent de temps autres. Cette dynamique au sein du projet peut tre en mme temps bnfique et dsavantageuse. Bnfique car elles peuvent apporter un nouveau souffle et vitalit aux activits du projet grce lnergie nouvelle, dsavantageuse car ce changement peut perturber la mmoire institutionnelle empchant ainsi la bonne continuit des activits. Loptimisation et la stabilisation des ressources humaines sont trs importantes dans un projet dune telle envergure. Le projet a parcouru un long chemin et a vcu plusieurs expriences tant au point de vue politique, stratgique quoprationnels. Le financement des partenaires / ONG internationaux implants Madagascar en tant que facilitateur na pas obtenu leffet escompt, le travail avec certains promoteurs semble assez difficile car lefficacit est moindre etc. Ces expriences constituent un apprentissage organisationnel permettant de rflchir sur le choix et le type de partenaire dans un tel projet, les structures dcentralises existantes mise en place par lEtat, par contre, peut constituer un amarrage du projet. La dcentralisation est alors une stratgie incontournable pour assurer une vraie mobilisation sociale. Au vu des acteurs du projet en gnral, on note particulirement linsuffisance en nombre de partenaire ou organisation but lucrative mme si certaines grandes socits sadhrent la lutte contre le VIH et SIDA. En tant que projet multisectoriel, les opportunits de

58

travailler en commun notamment et surtout avec le secteur priv sont primordiales. Les expriences de ces derniers vis--vis de la population ainsi que leur potentialit, en terme de couverture gographique, nest pas ngligeable. Une politique de dcentralisation effective doit encourager suffisamment linclusion du secteur priv pour que la rponse au VIH et SIDA soit plus forte et que les expertises soient synergiques.

10. OPINION SUR LIDA Le Gouvernement Malgache a entretenu de bonnes relations avec lIDA depuis plusieurs annes. La situation conomique du pays ne lui permet pas encore de supporter toutes les actions de dveloppement par ses ressources propres, y compris la lutte contre ce flau mondial qui est le SIDA. Loctroi de fonds allou pour la rponse au SIDA, comme le PMPS, constitue une ressource supplmentaire trs sollicite par le Gouvernement. Les changes continus entre les deux entits, malgr quelque fois de divergences de point de vue, ont permis dajuster les stratgies selon les besoins rels du pays. Le FAP, tout particulirement, est une composante trs importante ayant permis de mobiliser les organisations de la socit civile vers une complmentarit avec les actions du secteur public et une dmdicalisation de la rponse. La collaboration avec les partenaires financiers, en particulier lIDA, a permis de faire un saut qualitatif dans la rponse aux IST, au VIH et au SIDA.

59

Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders

Comments of partners who were interviewed are summarized in the main text.

60

Annex 9. List of Supporting Documents

World Bank 2001-07Aides-memoire 2001-07 Project Status Reports (PSR) and Implementation Status and Results Reports (ISR) 2008 De suivi de la mise en oeuvre au suiv ax sur les rsultats: Une transition russie Madagascar, Program global de lute contre le VIH/SIDA, March. 2008 The World Banks Commitment to HIV/AIDS in Africa: Our Agenda for Action, 2007-2011, March. 2007 Madagascar Revue de Dpenses Publiques, Ralisation du Madagascar Action Plan: Analyse pour les rsultats (En cinq volumes), Volume II: Sant, June 28, Report No. 38687-MG. 2005 Project Appraisal Document on a Proposed Credit in the Amount of SDR 20.2 Million (USD 30 Million Equivalent) to the Republic of Madagascar for a Second Multisectoral STI/HIV/AIDS Prevention Project, June 13, Report No. 32319-MAG. 2001 Development Credit Agreement (Multisectoral STI/HIV/AIDS Prevention Project) between Republic of Madagascar and International Development Association, December 14, Credit No. 3589-MAG. 2001 Multisectoral STI/HIV/AIDS Prevention Project Madagascar: Institutional Capacity Assessment Report, Draft, August. 2001 Project Appraisal Document on a Proposed Credit in the Amount of SDR 15.70 Million (US$ 20.0 Million Equivalent) to the Republic of Madagascar for a Multisectoral STI/HIV/AIDS Prevention Project, November 26, Report No. 23065-MAG. 2001 Madagascar Multisectoral STI/HIV/AIDS Prevention Project: Quality at Entry Assessment. 2000 Project Appraisal Document for Proposed Credits in the Amount of SDR 45.2 Million (US$ 59.7 Million Equivalent) and SDR 37.9 Million (US$ 50.0 Million Equivalent), Respectively, to the Federal Democratic Republic of Ethiopia and the Republic of Kenya in Support of the First Phase of the US$ 500 Million Multi-Country HIV/AIDS Program for the Africa Region, August 14, Report No. 20727-AFR. 1999 Confronting AIDS: Public Priorities in a Global Epidemic (Revised Edition), Oxford University Press, New York.

Government and Project 2008 Profil pidmiologique du VIH et du Sida Madagascar, Draft, February. 2008 Decentralisation of the HIV/AIDS Response in Madagascar: A Road Map, Draft, February. 2007, Rapport de cloture du FAP I, Projet Multisectoriel pour la Prvention du VIH/Sida, Agence de gestion financire, December 31. 2007 Rapport sur les realizations techniques et fiancires 2006, Projet Multisectoriel pour la Prvention du VIH/Sida, April. 2007 Plan national de riposte au Sida pour les populations cls les plus exposes au risqu dinfection par le VIH Madagascar (2007-2012), July. 2007 Plan de Suivi et Evaluation de la rponse nationale face au VIH et au Sida 2007-2012, June. 2007 Madagascar Action Plan 2007-2012. 2007 Enqute de Surveillance Biologique, Draft.

61

2007 Comit national de lutte contre le VIH/SIDA: Rapport annuel 2006. 2006 Projet Multisectoriel pour la Prvention du VIH/Sida: Conclusions preliminaries de lvaluation du FAP, December. 2006 Guide mthodologique de la cartographie du risqu de diffusion des IST/FIH/Sida Madagascar, August. 2006 Enqute de Surveillance Comportementale Madagascar. 2005 Madagascar: Enqute dmographique et de sant 2003-2004, February, Institut national de la statistique and Macro International, Calverton, Maryland. 2004 Projet Multisectoriel pour la Prvention du VIH/Sida: Revue mi-parcours et projet de reprogrammation, December. 2004 Projet Multisectoriel pour la Prvention du VIH/Sida: Manuel de procedures du Fonds dappui la prevention du VIH/Sida (FAP), March. 2004 Enqute de surveillance comportementale relative aux IST/SIDA Madagascar, December. 2003 Socit, culture et VIH/Sida Madagascar, Rapport de synthse, April. 2003 tude combine des seroprvalences de linfection VIH et de la syphilis chez les femmes enceintes Madagascar, May-June. 2002 Projet Multisectoriel pour la Prvention du VIH/Sida: Manuel dexcution du projet, January. 2001 Plan stratgique national de lutte contre le VIH/Sida, December. 2000 MICS 2000 Madagascar: Rapport complt, Institut national de la statistique and UNICEF. 1998 Madagascar: Enqute dmographique et de sant 1997, , Institut national de la statistique, and Macro International, November, Calverton, Maryland.

Other Behets, F. et al. (2001) Sexually transmitted infections and associated socio-demographic and behavioral factors in women seeking primary care suggest Madagascars vulnerability to rapid HIV spread, Tropical Medicine and International Health 6(3): 202-211. International HIV/AIDS Alliance in Madagascar (2007) tudes sur les groupes vulnrables, February. Jamison, D. et al. (eds.) (2006) Disease Control Priorities in Developing Countries (Second Edition), Oxford University Press and the World Bank, New York and Washington. UNAIDS (2007) Practical Guidelines for Intensifying HIV Prevention: Towards Universal Access. UNAIDS (2007) The Response to AIDS in Madagascar, Best Practice Collection, November. United Nations General Assembly Special Session on HIV/AIDS (2007) Guidelines on Construction of Core Indicators, 2008 Reporting, April. USAID Madagascar (2002) STIs/HIV/AIDS Strategy.

62