Document of The World Bank

Public Disclosure Authorized Report No: ICR00003307

IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-41040 and IDA-51240)

ON A

Public Disclosure Authorized CREDIT

IN THE TOTAL AMOUNT OF SDR24.1 MILLION (US$36.00 MILLION EQUIVALENT)

TO THE

REPUBLIC OF MADAGASCAR

FOR A

Second Multi-Sectoral STI/HIV/AIDS Prevention Project Public Disclosure Authorized

May 29, 2015

Health, Nutrition and Population Global Practice (GHNDR)

Public Disclosure Authorized Africa Region

CURRENCY EQUIVALENTS (Exchange Rate Effective January 31, 2015) Currency Unit = Ariary US$1.00 = 2,793.84 Ariary US$1.00=SDR0.71

ABBREVIATIONS AND ACRONYMS AIDS Acquired Immunodeficiency Syndrome MTCT Mother to Child Transmission AGF Financial Management Agency MTR Mid-Term Review ANC Antenatal care MWMP Medical Waste Management Plan ART Antiretroviral Therapy NAC National AIDS Council ARV Antiretroviral NGO Non-governmental Organization BCC Behavioral Change Communication NSP National Strategic Plan CBO Community based organizations OF Organisme de Facilitation (Facilitating CD4 Cluster of differentiation 4 Organization) CLLS Comité Local de Lutte contre le SIDA(Local OI Opportunistic Infection AIDS Committee) OP Operational Policy CNLS Comité National de Lutte contre le SIDA OPCS Operations Policy and Country Services (National AIDS Council) ORT Organization de revue technique (Technical DHS Demographic and Health Survey Review Organization) ES Executive Secretariat (National AIDS Secretariat) PAD Project Appraisal Document GDP Gross Domestic Product PDO Project Development Objectives HIV Human Immunodeficiency Virus PLLS Comité Provincial de Lutte contre le SIDA ICR Implementation Completion Report (Provincial AIDS Committee) IDA International Development Association PLWHA Persons living with HIV/AIDS IDU Injecting Drug Users PMTCT Prevention of Mother-to-Child Transmission IEC Information, Education and Communication PIU Project Implementation Unit (UGP) IMF International Monetary Fund RBF Results-based Financing ISN Interim Strategy Note RF Results Framework ISR Implementation Status Report SA Special Account FA Financing Agreement SALAMA National Drug Procurement Agency FAP Fund for STI/HIV/AIDS Prevention SOE Statement of Expenditures FM Financial Management STI Sexually-transmitted Infections FMA Financial Management Agency (FMA) SW Sex Worker GOM Government of Madagascar TB Tuberculosis GFATM Global Fund to Fight AIDS, TB and Malaria UN United Nations MAP Multi-Country HIV/AIDS Program UNAIDS United Nations Program on HIV/AIDS MDGs Millennium Development Goals UNFPA United Nations Population Fund M&E Monitoring and Evaluation UNICEF United Nations Children's Fund MICS Multiple Indicator Cluster Survey USAID United States Agency for International MIS Management Information System Development MMR Maternal Mortality Ratio VCT Voluntary Counseling and Testing MOH Ministry of Health and Family Planning WHO World Health Organization MSM Men Who Have Sex with Men MSPP Multisectoral STI/HIV/AIDS Prevention Project

HNP Director: Olusoji Adeyi Country Director: Mark Lundell Practice Manager: Abdo Yazbeck Project Team Leader: Jumana N. Qamruddin ICR Team Leader/Author: Maria E. Gracheva

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REPUBLIC OF MADAGASCAR Second Multi-Sectoral STI/HIV/AIDS Prevention Project

CONTENTS

A. Basic Information ...... iv 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 ...... xviii H. Restructuring ...... xviii I. Disbursement Profile ...... xix

1. Project Context, Development Objectives and Design ...... 1 2. Key Factors Affecting Implementation and Outcomes ...... 11 3. Assessment of Outcomes ...... 23 4. Assessment of Risk to Development Outcome ...... 34 5. Assessment of Bank and Borrower Performance ...... 35 5.1 Bank Performance ...... 35 5.2 Government Performance ...... 35 6. Lessons Learned...... 39 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners...... 40

Annex 1. Project Costs and Financing ...... 41 Annex 2. Outputs by Component...... 43 Annex 3. Economic and Financial Analysis ...... 49 Annex 4. Bank Lending and Implementation Support/Supervision Processes ...... 56 Annex 5. Beneficiary Survey Results ...... 58 Annex 6. Stakeholder Workshop Report and Results ...... 59 Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR ...... 60 Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders ...... 78 Annex 9. List of Supporting Documents ...... 79 Annex 10: Targeted Communes under the project ...... 80 MAP : Targeted Communes under the project ...... 80

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A. Basic Information

Second Multisectoral Country: Madagascar Project Name: STI/HIV/AIDS Prevention project Project ID: P090615 L/C/TF Number (s): IDA-41040, IDA-51240 ICR Date: 05/14/2015 ICR Type: Core ICR Lending Instrument: SIL Borrower: REPUBLIC OF MADAGASCAR Original Total XDR 20.20M Disbursed Amount: XDR 23.03M Commitment: Revised Amount: XDR 23.50M Environmental Category: B Implementing Agencies: Secrétariat Exécutif du Comité National de Lutte contre le SIDA (National AIDS Council), Ministry of Health and Family Planning B. Key Dates Revised / Actual Process Date Process Original Date Date(s) Concept Review: 02/22/2005 Effectiveness: 01/05/2006 01/05/2006 12/28/2011 Appraisal: 04/01/2005 Restructuring(s): 06/14/2012 08/05/2014 Approval: 07/12/2005 Mid-term Review: 12/15/2008 12/15/2008 Closing: 12/31/2009 09/30/2014 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Moderately Satisfactory Risk to Development Outcome: Substantial Bank Performance: Moderately Satisfactory Borrower Performance: Moderately Satisfactory

C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Moderately Quality at Entry: Government: Moderately Satisfactory Unsatisfactory Implementing Quality of Supervision: Moderately Satisfactory Moderately Satisfactory Agency/Agencies: Overall Bank Overall Borrower Moderately Satisfactory Moderately Satisfactory Performance: Performance: C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Indicators Rating Performance (if any) Potential Problem Project Quality at Entry Yes None at any time (Yes/No): (QEA):

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Problem Project at any Quality of Yes None time (Yes/No): Supervision (QSA): DO rating before Satisfactory Closing/Inactive status: D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Health 35 50 Other social services 65 50

Theme Code (as % of total Bank financing) Gender 14 15 HIV/AIDS 29 55 Other social protection and risk management 14 5 Participation and civic engagement 14 10 Population and reproductive health 29 15

E. Bank Staff Positions At ICR At Approval Vice President: Makhtar Diop Gobind Nankani Country Director: Mark Lundell James P. Bond Practice Abdo Yazbeck Laura Frigenti Manager/Manager: Project Team Leader: Jumana N. Qamruddin Nadine T. Poupart ICR Team Leader: Maria E. Gracheva ICR Primary Author: Maria E. Gracheva

F. Results Framework Analysis

Project Development Objectives (from Project Appraisal Document) The MSPPII's development objectives are to support the Government of Madagascar’s efforts to promote a multi-sectoral response to the HIV/AIDS crisis and to contain the spread of HIV/AIDS on its territory.

Revised Project Development Objectives (as approved by original approving authority) To increase utilization of STI/HIV/AIDS, and maternal and child health, nutrition services in project areas (revised under Additional Financing approved June 14, 2012).

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(a) PDO Indicator(s): The table below contains a total of 21 indicators: 10 original indicators (of which targets for 4 indicators were revised during the December 2011 Level 2 restructuring), 3 new indicators (added during the December 2011 restructuring, 1 of which was a core sector indicator), and 7 new indicators (added during the June 2012 Additional Financing, 4 of which are core sector indicators) and 1 indicator added at Implementation Completion Report (ICR). During the August 2014 restructuring, baselines and targets were changed for 5 indicators. Data comes from the following sources: DHS – Demographic Health Survey - co-financed by the project BSS – Biological Surveillance Survey – co-financed by the project ESC – Behavioral surveillance survey - repeated field surveys (2004, 2006, 2008, 2010, 2012) - co-financed by the project IV – Independent Verification Agency reports (2011 & 2013) financed by the project Original Target Formally Actual Value Values (from Revised Achieved at Indicator Baseline Value approval Target Completion or documents) Values Target Years Indicator 1 : 20% decrease in syphilis prevalence among sex workers - original Value 13.3% (20% quantitative or 16.6% (BSS 2005) 15% 15.8% reduction) Qualitative) Date achieved 06/01/2005 12/31/2009 12/31/2012 12/31/2012 NOT ACHIEVED: The target was revised during the December 2011 Comments restructuring based on a 2010 BSS of 15.6% prevalence. The actual result at (incl. % the end of the project ended up being lower than the 2005 figure by 5% against achievement) the target of 20%. % of respondents (age 15-24) who can both correctly identify ways of preventing Indicator 2 : the sexual transmission of HIV and reject major misconceptions about HIV transmission and prevention (by age and gender) - original Value 19.4% (female) 40% (female) 22.5% (female) quantitative or 15.7% (male) 35% (male) 26% (male) Qualitative) DHS DHS 2008/9 Date achieved 06/01/2005 12/31/2009 12/31/2009 Comments NOT ACHIEVED: indicator dropped at December 2011 restructuring. The (incl. % latest ENSOMD survey from 2012 provides almost the same data for actuals: achievement) 22.9% female and 25.5% for males. % of people in high-risk groups (sex workers, truck drivers, military) who can Indicator 3 : cite three methods of HIV/AIDS prevention - original SW: 61% SW: 74% Military: 57% Military: 62.9% Value SW: 50% SW: 75% Truckers: 58.3% quantitative or Truckers: 52% Truckers: 85% (2009) Qualitative) Military: 48% Military: 85% Youth: Youth: 68% male 64.3% male 67% female 64.4% female Date achieved 06/01/2005 12/31/2009 12/31/2012 12/31/2012 Comments PARTIALLY ACHIEVED (for sex workers and military based on revised (incl. % baselines): ESC data. Not achieved for youth and truckers. This indicator was

vi achievement) changed during the December 2011 restructuring to include youth aged 15-24 (the baseline used 2006 data, 66.8% (male) and 65.8% (female). The targets set were for end 2012 and represented 1.2% increase over baseline. The targets were not met for youth and were actually 2% greater for males than the 2009 value. The indicator on truckers was dropped at this time. Baselines for SWs and military were also changed to 60% and 53% respectively to reflect 2006 data and targets were set at 1% increase for SWs and 4% increase for the military. % of targeted groups (sex workers, youth, military) who can cite three methods Indicator 4: of HIV/AIDS prevention in project areas. SW: 63.6% SW: 67% SW: 72.2% (2013) Value Military: 74.6% Military: 78% Military: 41.3% quantitative or Youth: Youth: Youth: Qualitative) 48.3% male 54% male 72.2% male 49.8% female 56% female 70.1% female Date achieved 12/31/2010 9/30/2014 9/30/2014 ACHIEVED: Targets surpassed for youth and SWs; not achieved for the Comments military. Independent Verification Agency data. This indicator was added (incl. % during the 2012 AF to reflect work carried out in project areas. The baselines achievement) were changed slightly in August 2014 restructuring, as follows: SW: 63.6%; Military: 75%; Youth: 49% male and 50% female. % of people in high-risk groups (SW, truck drivers, military), who reject two Indicator 5: major misconceptions about HIV/AIDS transmission - original SW: 52.9% Value SW: 48% SW: 85% Truckers: 62% quantitative or Truckers: 60% Truckers:90% Military: 88% Qualitative) Military: 78% Military: 90% BSS 2010 Date achieved 06/01/2005 12/31/2009 12/31/2009 Comments (incl. % NOT ACHIEVED: Indicator dropped at December 2011 restructuring. achievement) % of youth 15-24 exposed to STI/HIV/AIDS communication activities/products Indicator 6: in the previous 6 months (by source of information) - original

Value 75% (female) 84% (female) 70.4% (female) quantitative or 76% (male) 84% (male) 67% (male) Qualitative) BSS 2010 Date achieved 06/01/2005 12/31/2009 12/31/2009 Comments (incl. % NOT ACHIEVED: Indicator dropped at December 2011 restructuring. achievement) % of population aged 15-49 who do not express discriminatory attitudes towards Indicator 7: PLWHA (by age and gender) - original 15-49 15-49 15-49 6.3% (female) 12.5% (female) 4.5% (female) Value 13.3% (male) 21% (male) 6.1% (male) quantitative or Qualitative) 15-24 15-24 15-24 6.1% (female) 12% (female) 5.5%/7.5%(female) 10.3% (male) 18% (male) 6.3%/11% (male)

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DHS data DHS data 2009/2012 Date achieved 06/01/2005 12/31/2009 12/31/2009 & 2012 NOT ACHIEVED: Indicator dropped at December 2011 restructuring. The restructuring paper of December 2011 provides different baseline (15% from Comments BSS in 2006) and actual (25.5% and 24%) data based on field surveys carried out (incl. % in 2008. Incidentally, ESC data from 2012 shows a decline from the 2008 achievement) figures, at 17.7% (female) and 17.9% (male). The ENSOMD 2012 data approximates the DHS data, 4.1% female and 4.7% for males. % of men and women aged 15-24 and 15-49 who report the use of a condom in Indicator 8: their last act of sexual intercourse with a non-regular partner in the last 12 months in project areas - original 15-24 15-24 15-24 5.4% (female) 13% (female) 8.8% (female) 12.2% (male) 24% (male) 6.6% (male) DHS Data DHS data 2009

15-24

45% (female) 15-24

47% (male) 30.9% (female)

70% military 29.5% (male)

ESC data 62.1% military

Value 2012 target ESC data 2012 quantitative or

Qualitative) 15-24 15-24

30% (female) 52.7% (female)

35% (male) 58.8% (male)

2014 target Ind. Ver. Report

(in project 2014

areas)

15-49 15-49 15-49 7.4%(female) 4.6% (female) 12% (female) 7.6% (male) 13.1% (male) 26% (male DHS data 2009 DHS data Date achieved 06/01/2005 12/31/2009 2012/2014 2009/2012/2014 PARTIALLY ACHIEVED: Indicator was revised during the December 2011 restructuring to drop the age group 15-49 and to include the youth 15-24. Baseline for youth 15-24 was 40.7% (female) and 34.2% (male) and 47.8% military (2006 data per restructuring paper). The targets were revised Comments downward for females and males during the AF preparation in 2012 and the (incl. % indicator was changed to reflect that it would be measured in project areas. achievement) Based on DHS and ESC data, the indicator was not achieved. However, using data from the Independent Verification report in 2014, in project areas, indicator was achieved for female and male youth. The ENSMOD 2012 data for 15-49 age group has actuals as 9.3% females and 8.3% for males. % of men and women aged 15-49 who report having sex with a non-regular Indicator 9: partner in the last 12 months - original Value 16.8% (female) 9% (female) 2.1% (female) quantitative or 38.1% (male) 20% (male) 16% (male) Qualitative) DHS 2004 DHS 2009

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Date achieved 06/01/2005 12/31/2009 12/31/2012 Comments ACHIEVED (target surpassed): The 2012 ENSOMD survey has actual data for (incl. % males as 4.6% and females as 0.62%. achievement) % of SWs reporting the use of a condom in their last act of sexual intercourse Indicator 10: with a client – original (revised to include achievement in “project areas”) Value 76% 90% 86% quantitative or ESC 2005 (in project 86.3% (IVR 2014) Qualitative) areas) Date achieved 06/01/2005 12/31/2009 12/31/2012 9/30/2014 Comments ACHIEVED: this indicator target was revised during the December 2011 (incl. % restructuring based on a new baseline of 78.1% in 2010. achievement) % of truckers and military who report the use of a condom in their last act of Indicator 11: sexual intercourse with a non-regular partner in the last 12 months in project areas - original Value Truckers-52.1% Truckers-54% Truckers-75% quantitative or Military -63.6% Military -56% Military -75% Qualitative) ESC data 2009 Date achieved 06/01/2005 12/31/2009 12/31/2009 Comments (incl. % NOT ACHIEVED: Indicator was dropped at December 2011 restructuring. achievement) % of military who report the use of a condom in their last act of sexual Indicator 12: intercourse with a non-regular partner in the last 12 months in project areas – new Value quantitative or 43.7% 70% 66% Qualitative) Date achieved 12/31/2010 09/30/2014 12/31/2013 Comments PARTIALLY ACHIEVED: Indicator added at AF. Data from the (incl. % Independent verification agency. achievement) % of youth aged 15-24 that have received an HIV test in the last 12 months and Indicator 13: who know their results (by age and by gender) Value 15.8% (female) 8.7% (female) 22% (female) quantitative or 15.7% (male) 7.7% (male) 20% (male) Qualitative) ESC 2012 Date achieved 12/31/2006 12/31/2012 12/31/2012 Comments (incl. % NOT ACHIEVED: Indicator added at December 2011 restructuring. achievement) % of SW that have received an HIV test in the last 12 months and who know Indicator 14: their results (by gender) Value 49.1% 49.5% quantitative or 64% ESC 2006 ESC 2012 Qualitative) Date achieved 12/31/2006 12/31/2012 12/31/2012

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Comments NOT ACHIEVED: Indicator added at December 2011 restructuring. (Also (incl. % cited in April 2014 National Report). achievement) % of youth, military and SW that have received an HIV test in the last 12 months Indicator 15: and who know their results in project areas. Value Youths (13.9%) Youths (47.4%) quantitative or Military (48.7%) % increase Military (73%) Qualitative) SW (53.8%) SW (83.4%) Date achieved 12/31/2010 12/31/2013 12/31/2013 Comments ACHIEVED: Indicator added at ICR. Data from the Independent verification (incl. % agency. achievement) Pregnant women tested positive and treated for syphilis during prenatal Indicator 16: consultations in project areas (Number) Value quantitative or 179 1913 2139 Qualitative) Date achieved 12/31/2010 09/30/2014 9/30/2014 Comments (incl. % ACHIEVED (target surpassed): Indicator added at AF. achievement) Pregnant women receiving antenatal care during a visit to a health provider Indicator 17: (number) – core sector indicator Value 60,381 (2010) quantitative or 127,547 108,415 140,989 57,242 (2012) Qualitative) Date achieved 12/31/2010 & 12/31/2012 09/30/2014 7/24/2014 9/30/2014 ACHIEVED (target surpassed): Indicator added at AF. The target was lowered to 108,415 and the baseline was also changed to 57,242 using Comments 12/31/2012 data, per August 2014 restructuring. The target was revised (incl. % downward at restructuring to reflect the condensed period of AF; however, the achievement) actual data for December 2013 already shows that 112,251 women received care, thereby surpassing that revised target. No. of children 0-24 months obtaining monthly adequate minimum weight in Indicator 18: project areas (number) Value 47,704 (July 2011) quantitative or 50,215 51,834 48,200 (Dec 2012) Qualitative) Date achieved 07/31/2011 09/30/2014 9/30/2014 Comments ACHIEVED (target surpassed): Indicator added at AF. Baseline revised in (incl. % August 2014 restructuring. achievement) Indicator 19: Children immunized (number) – core sector indicator Value 52,810 (2010) quantitative or 113,941 96,850 132,226 53,214 (2012) Qualitative) Date achieved 12/31/2010 & 12/31/2012 09/30/2014 7/24/2014 9/30/2014

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ACHIEVED (target surpassed): Indicator added at AF. The baseline and target was revised during August 2014 restructuring. The Restructuring paper and the final Implementation Status Report (ISR) also includes an indicator on Comments child immunization under 5 for polio but the data are the same as for the total (incl. % children immunized. The target was revised downward at restructuring to reflect achievement) the condensed period of AF; however, the actual data for December 2013 already shows that 102,615 children were immunized, thereby surpassing that revised target. People with access to a basic package of health, nutrition or reproductive services Indicator 20: (number) – core sector indicator Value 0 (2010) quantitative or 395,349 336,047 403,025 283,203 (Dec 2013) Qualitative) Date achieved 12/31/2013 09/30/2014 7/24/2014 9/30/2014 Comments (incl. % ACHIEVED (target surpassed): Indicator added at AF. achievement) Direct project beneficiaries (number), of which female: (a) for HIV interventions Indicator 21: in project areas, and (b) for health and nutrition interventions in project areas – core sector indicator 1,929,774 - of 1,960,856 (of 234,069 (of which 63% which 64% female which 71% female) Value female) (a) 135,210 (a) 150,325 quantitative or (a) 58,061 (50%) (51%) (61%) Qualitative) (b) 0 (b) 265,250 (b) 932,410 (61%) (59%) 12/31/2012 and 9/30/2014 for (a) 12/31/2012 and Date achieved 12/31/2010 which was revised 09/30/2014 for (a) at AF, and (b) and (b) added at AF Comments ACHIEVED (target surpassed): Indicator added during December 2011 (incl. % restructuring. achievement)

(b) Intermediate Outcome Indicator(s) – The following table includes 13 original indicators, 9 new indicators added during the December 2011 restructuring, and 9 new indicators added during Additional Financing in 2012 (of which 3 are core sector indicators). Baselines and targets were also revised during the 2012 AF (2 indicators) and the August 2014 restructuring (7 indicators).

Original Target Actual Value Formally Values (from Achieved at Indicator Baseline Value Revised approval Completion or Target Values documents) Target Years Comp 1 - The National Strategic Plan for HIV/AIDS is revised and disseminated Indicator 1 : by the end of 2006 - original Value NSP updated and NSP updated and (quantitative NA disseminated disseminated or Qualitative)

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Date achieved 6/1/2005 12/31/2009 12/31/2012 Comments (incl. % ACHIEVED achievement) Comp 1 - Annual Reporting allows identifying each donor contribution to the Indicator 2 : program in a coherent manner (number) - original Value Annual report Annual reports (quantitative NA issued issued annually or Qualitative) Date achieved 6/1/2005 12/31/2009 12/31/2012 Comments (incl. % ACHIEVED achievement) Comp 1 - The national communication plan is updated according to Indicator 3 : recommendations of midterm evaluation - original Value National communication National Plan updated and (quantitative strategy developed in communication disseminated or Qualitative) 2004 strategy updated Date achieved 6/1/2005 12/31/2009 12/31/2012 Comments (incl. % ACHIEVED achievement) Comp 2 - Number of STI treatment kits sold in public and private sectors - Indicator 4 : original Value 175,000 1,742,500 (2009) (quantitative 817,500 annually=700,000 2,493,500 3,536,000 (2012) or Qualitative) total Date achieved 1/5/2006 12/31/2009 12/31/2012 12/31/2012 Comments ACHIEVED: Target was revised during the 2012 AF and substantially (incl. % surpassed. achievement) Comp 2 - Number of condoms distributed and sold through the public sector and Indicator 5 : NGO programs per year in project areas - original Value 500,000 annually 15,000,000 (2009) (quantitative 25,000,000 = 2,000,000 total 25,000,000 (2012) or Qualitative) Date achieved 6/1/2005 12/31/2009 12/31/2012 12/31/2012 Comments ACHIEVED: Target was revised during the 2012 AF and this indicator was (incl. % amended to add “in project areas”. achievement) Indicator 6 : Comp 2 – ARV treatment guidelines are adequate and implemented - original Value Guidelines ARV protocol (quantitative finalized revised (2008) or Qualitative) Date achieved 6/1/2005 12/31/2009 12/31/2009 Comments (incl. % ACHIEVED achievement)

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Indicator 7: Comp 2 – Syphilis treatment distributed in public health centers in project areas Value (quantitative 3,280 5,740 5,822 or Qualitative) Date achieved 12/31/2010 9/30/2014 9/30/2014 Comments (incl. % ACHIEVED: Indicator added at AF. achievement) Comp 2 – Number and % of pregnant women tested for syphilis during prenatal Indicator 8: consultations Value 500,000 986,682 (quantitative 54,806 80% 36% or Qualitative) Date achieved 1/5/2006 12/31/2012 12/31/2012 ACHIEVED: Indicator added at December 2011 restructuring. Target Comments substantially surpassed for the number. However, the target was not met for (incl. % the % as apparently health service providers were replaced while the new ones achievement) had not yet received training on provision of care for STDs (per explanation in final ISR). Comp 2 – Number of condoms distributed through the public sector and NGO Indicator 9: programs per year in project areas Value (quantitative 1,500,000 10,000,000 17,655,417 or Qualitative) Date achieved 12/31/2012 9/30/2014 9/30/2014 Comments (incl. % ACHIEVED: Indicator added at AF. Target surpassed. achievement) Comp 2 - Number of SW, Youth aged 15-24 (by gender) and Military tested for Indicator 10: HIV in the last 12 months and received their test results in project areas Value (quantitative NA 76,760 127,092 or Qualitative) Date achieved 9/30/2014 9/30/2014 Comments ACHIEVED: Indicator added at AF. Target surpassed. The breakdown for (incl. % the total achieved number is as follows: 44,627 youth 15-24 (male); 46,448 achievement) youth 15-24 (female); 20,498 sex workers; and 15,519 military. Indicator 11: Comp 2 – Number of pregnant women receiving iron folic acid in project areas Value (quantitative 81,994 114,792 184,482 or Qualitative) Date achieved 12/31/2012 9/30/2014 9/30/2014 Comments ACHIEVED: Indicator added at AF. Target surpassed. Baseline revised in (incl. % August 2014. The original baseline was 5,943 for end 2010. December 2013 achievement) data showed that 143,339 women received iron folic acid. Comp 2 – Number of children under five receiving Vitamin A supplementation Indicator 12: in project areas – core sector indicator Value 310,010 587,774 499,608 772,324

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(quantitative or Qualitative) Date achieved 12/31/2012 9/30/2014 9/30/2014 9/30/2014 ACHIEVED: Indicator added at AF. Target surpassed. Baseline and target Comments revised in August 2014. The original baseline was 332,808 for end 2010. The (incl. % target was revised downward at restructuring to reflect the condensed period of achievement) AF; however, actual data from December 2013 already showed that 618,348 children received vitamin A. Comp 2 – Number of pregnant women attended their first antenatal visit before Indicator 13: the end of the first quarter (<4 months) of pregnancy in project areas Value (quantitative 22,776 63,774 44,642 43,112 or Qualitative) Date achieved 12/31/2012 9/30/2014 9/30/2014 9/30/2014 Comments ACHIEVED: Indicator added at AF. Baseline and target revised in August (incl. % 2014. The original baseline was 13,925 for end 2010. achievement) Indicator 14: Comp 2 – Number of births attended by skilled personnel in project areas Value (quantitative 17,020 47,654 33,358 39,442 or Qualitative) Date achieved 12/31/2012 9/30/2014 9/30/2014 9/30/2014 Comments ACHIEVED: Indicator added at AF. Target surpassed. Baseline and target (incl. % revised in August 2014. The original baseline was 14,348 for end 2010. achievement) Comp 2 – Number of children under five treated with Zinc/SRO for diarrhea in Indicator 15: project areas Value (quantitative 16,500 28,000 32,203 or Qualitative) Date achieved 12/31/2012 9/30/2014 9/30/2014 ACHIEVED: Indicator added at AF. Baseline revised in August 2014. The Comments original baseline was 12,374 for end 2010. However, the target was kept as (incl. % 28,000 to reflect the condensed period of the AF even though it was already achievement) known that the indicator reached 29,889 in December 2013. Comp 2 – Number of children under five enrolled in the growth monitoring and Indicator 16: promotion program in project areas Value (quantitative 161,259 189,717 161,259 193,975 or Qualitative) Date achieved 12/31/2012 9/30/2014 9/30/2014 9/30/2014 ACHIEVED: Indicator added at AF. Baseline and target revised in August Comments 2014. The original baseline was 189,717 for end 2010. The target was revised (incl. % downward at restructuring to reflect the condensed period of AF; however, the achievement) target was kept the same during the August 2014 restructuring even though it was known that the actual number in December 2013 already reached 193,656. Indicator 17: Comp 2 – Health personnel receiving training (number) – core sector indicator Value NA 282 347

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(quantitative or Qualitative) Date achieved 12/31/2012 9/30/2014 9/30/2014 Comments (incl. % ACHIEVED: Indicator added at AF. Target surpassed. achievement) Comp 2 – Number of women involved in growth monitoring and promotion Indicator 18: activities in project areas Value (quantitative 88,227 104,451 88,783 114,968 or Qualitative) Date achieved 12/31/2012 9/30/2014 9/30/2014 9/30/2014 ACHIEVED: Indicator added at AF. Baseline and target revised in August Comments 2014. The original baseline was 103,146 for end 2010. The target was almost the (incl. % same as baseline and was kept the same during the August 2014 restructuring to achievement) reflect the condensed period of the AF although it was already known that in December 2013 the actual number of women was 105,211. Indicator 19: Comp 3 - % of FAP funds allocated to hot spots - original Value (quantitative NA 75% annually 76% or Qualitative) Date achieved 6/1/2005 12/31/2009 12/31/2009 Comments (incl. % ACHIEVED: 100% of target achievement) Comp 3 – Number of CLLS implementing and monitoring their PLLS on Indicator 20: monthly basis - original Value 288 (quantitative NA annually=1,080 570 or Qualitative) total Date achieved 6/1/2005 12/31/2009 12/31/2009 Comments (incl. % NOT ACHIEVED: 53% of target. achievement) Comp 3 – Number of local organizations (CBOs) receiving capacity building in Indicator 21: STI/HIV/AIDS by OF (assuming 666 CBOs first year and 738 in subsequent) – original Value (quantitative NA 709 total NA or Qualitative) Date achieved 6/1/2005 12/31/2009 12/31/2009 Comments (incl. % NOT ACHIEVED: CBOs received training but the number is uncertain. achievement) Comp 3 – Number of interpersonal communication activities carried out per Indicator 22: commune per year (Groupe d’écoute-GE and Individual counseling-IC) – original Value NA GE: 59,012 total GE: 9, 445 total

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(quantitative IC: 4,425,840 total IC: 142,244 total or Qualitative) Date achieved 6/1/2005 12/31/2009 12/31/2009 Comments (incl. % NOT ACHIEVED achievement) Comp 3 – Number of beneficiaries reached by group and interpersonal Indicator 23: communication activities per year (Groupe d’écoute-GE and Individual counseling-IC) – original Value GE: 590,112 total GE: 420,247 total (quantitative NA IC: 1,475,280 total IC: 519,906 total or Qualitative) Date achieved 6/1/2005 12/31/2009 12/31/2009 Comments NOT ACHIEVED: However, it is nonetheless impressive that almost 1 million (incl. % beneficiaries were reached through communication activities, especially given achievement) the brevity of the implementation of this component (2.5 years) Comp 4 – Annual Operation Plan reflects recommendation of Consolidated Indicator 24: Annual Report – original Value 6 plans (quantitative 0 Annual plan implemented or Qualitative) Date achieved 6/1/2005 12/31/2009 12/31/2012 Comments (incl. % ACHIEVED: In 2010, 4 plans were completed, per original plan. achievement) Indicator 25: Comp 4 – Number of national surveys and studies undertaken Value (quantitative 4 13 13 or Qualitative) Date achieved 1/5/2006 12/31/2012 12/31/2012 Comments (incl. % ACHIEVED: Indicator added during December 2011 restructuring. achievement) Comp 4 – Number of health personnel trained in monitoring and evaluation – Indicator 26: core sector indicator Value (quantitative NA 100 166 or Qualitative) Date achieved 12/31/2006 12/31/2012 12/31/2012 Comments ACHIEVED: Indicator added during December 2011 restructuring. Target (incl. % surpassed. achievement) Comp 4 - % of PLWHA reference centers having submitted monthly reports Indicator 27: within 15 days of the end of the month Value (quantitative 96% 98% 91% or Qualitative) Date achieved 12/31/2011 12/31/2014 12/31/2014

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Comments (incl. % NOT ACHIEVED: Indicator added during December 2011 restructuring. achievement) Comp 4 - Quarterly Independent Verification Agency Reports submitted within Indicator 28: 45 days of the end of the quarter Value (quantitative 5 6 6 or Qualitative) Date achieved 12/31/2012 12/31/2014 12/31/2014 Comments (incl. % ACHIEVED: Indicator added during December 2011 restructuring. achievement) Comp 4 - Monitoring committee meetings held within 2 weeks of submission of Indicator 29: quarterly Independent verification Agency Report Value (quantitative 5 6 6 or Qualitative) Date achieved 12/31/2012 12/31/2014 12/31/2014 Comments (incl. % ACHIEVED: Indicator added during December 2011 restructuring. achievement) Indicator 30: Comp 5 - % of capacity building plan implemented by year - original Value (quantitative 33% 100% 100% or Qualitative) Date achieved 6/1/2005 12/31/2009 12/31/2012 Comments (incl. % ACHIEVED achievement) Indicator 31: Comp 5 - % of PIU audits without reserves Value (quantitative 100% 100% 100% or Qualitative) Date achieved 12/31/2010 12/31/2014 12/31/2014 Comments (incl. % ACHIEVED: Indicator added during December 2011 restructuring. achievement) Indicator 32: Comp 5 - % of Interim Financial Reports submitted by deadline Value (quantitative 100% 100% 100% or Qualitative) Date achieved 12/31/2010 12/31/2014 12/31/2014 Comments (incl. % ACHIEVED: Indicator added during December 2011 restructuring. achievement)

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G. Ratings of Project Performance in ISRs

Actual Date ISR No. DO IP Disbursements Archived (USD millions) 1 08/15/2005 Satisfactory Satisfactory 0.00 2 12/21/2005 Satisfactory Satisfactory 0.00 3 02/16/2006 Satisfactory Satisfactory 0.00 4 10/06/2006 Satisfactory Satisfactory 0.00 Moderately 5 06/29/2007 Satisfactory 2.25 Unsatisfactory 6 12/04/2007 Satisfactory Moderately Satisfactory 3.81 7 06/27/2008 Satisfactory Moderately Satisfactory 9.06 Moderately 8 12/27/2008 Satisfactory 13.81 Unsatisfactory Moderately 9 06/04/2009 Moderately Satisfactory 15.40 Unsatisfactory 10 09/14/2009 Moderately Satisfactory Moderately Satisfactory 15.40 Moderately 11 05/18/2010 Moderately Satisfactory 17.67 Unsatisfactory Moderately 12 11/17/2010 Satisfactory 21.23 Unsatisfactory 13 07/11/2011 Moderately Satisfactory Satisfactory 25.80 14 07/25/2011 Moderately Satisfactory Satisfactory 26.18 15 12/12/2011 Moderately Satisfactory Satisfactory 27.38 16 05/02/2012 Satisfactory Satisfactory 28.05 17 12/24/2012 Satisfactory Satisfactory 29.38 18 06/24/2013 Satisfactory Satisfactory 31.74 19 12/31/2013 Satisfactory Satisfactory 34.25 20 07/05/2014 Satisfactory Satisfactory 35.35 21 09/27/2014 Satisfactory Satisfactory 35.35

H. Restructuring

ISR Ratings at Amount Board Restructuring Disbursed at Restructuring Reason for Restructuring & Approved Restructuring Date(s) Key Changes Made PDO Change DO IP in USD millions Extension of Closing Date by 12/31/2009 MS S 15.37 two years to complete activities Level 2 restructuring to revise components, the Results 12/28/2011 MS S 26.70 Framework, implementation arrangements, extension of

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ISR Ratings at Amount Board Restructuring Disbursed at Restructuring Reason for Restructuring & Approved Restructuring Date(s) Key Changes Made PDO Change DO IP in USD millions Closing Date by one year, and to reallocate funds Additional Financing to change PDO, add new activities and to 6/14/2012 S S 27.60 revise the Results Framework (extending the Closing Date by 21 months) Level 2 restructuring to revise 08/05/2014 S S 35.35 baselines and targets and to reallocate funds

I. Disbursement Profile

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1. Project Context, Development Objectives and Design

1.1 Context at Appraisal Country, Political and Economic background. The Republic of Madagascar is the fourth- largest island in the world. Until the late 18th century, Madagascar was ruled by a fragmented assortment of shifting socio-political alliances and by the early 19th century, most of the island was united and ruled as the Kingdom of Madagascar. The monarchy collapsed in 1897 and the island was absorbed into the French colonial empire. Since Madagascar gained independence from France in 1960, the country witnessed a significant downturn, with real per capita Gross Domestic Product (GDP) declining by over 25% during the last four decades to US$290 in 2005, at the time of project appraisal. Caused in part by inward looking, highly protectionist policies and poor governance, this economic outcome resulted in significant deterioration of physical and human capital. The country also went through several political transitions marked by numerous popular protests, several disputed elections, impeachments, two military coups and one assassination. In fact, since the early 1990s, the country experienced three separate political crises, in 1991, 2002 and 2009. In 1991, after contested elections in 1989 and subsequent violent protests, International Monetary Fund (IMF) and World Bank assistance was suspended. Conditions for the resumption of aid were not met until the President was impeached and an interim government established later that year. In 2001, another political crisis lasted for eight months leading to an economic downturn, with GDP declining by 13%, costing Madagascar millions of dollars in lost tourism and trade revenue as well as damage to infrastructure.

The negative economic impact of the 2001 crisis was gradually overcome through progressive economic and political policies. GDP growth rebounded, reaching 9.8% in 2003, and the economy continued to grow at 5% per year for the next several years. Similarly, progress was made to reduce poverty, which declined to 66% from its peak level of 80% at the time of the 2002 crisis. Having met a set of stringent economic, governance and human rights criteria, Madagascar became the first country to benefit from the Millennium Challenge Account in 2005 and the IMF agreed to write off half of Madagascar's debt in 2004. However, in the latter half of his second term, President Ravalomanana was criticized for his increasing authoritarianism and that benefits from his policies were not evenly spread throughout the population, producing tensions over the increasing cost of living and declining living standards among the poor and some segments of the middle class.

Despite this marked economic recovery under Ravalomanana, Madagascar was still among the world's poorest countries. Compounding this, 2004 (start of project preparation), was marked by exogenous shocks including two cyclones, a sharp depreciation of the exchange rate and a 27% inflation rate (although it declined to 10% by 2006). At the time of project appraisal in 2005, the population of Madagascar was estimated at roughly 18 million, 70% of which was rural, (77% of the rural population living in poverty as compared with 44% of urban inhabitants in 2001). The main reasons for persisting poverty and low levels of development included: (i) lingering effects of the kleptocratic rule which prevailed under Ratsiraka (during that period, GDP per capita decreased by 40%), (ii) an economy mostly tied to resource extraction, (iii) lacking infrastructure (10% of roads paved), (iv) geographic isolation, (v) relatively small population to incentivize the development of foreign trade, (vi) generally poor education outcomes, and (vii) environmental

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degradation of 90% of Madagascar's forests while 25-30% of the country burned every year from agricultural fires. Soil erosion was and continues to rob the country's agricultural capacity and further impoverish rural populations. In sum, since independence, Madagascar has experienced continuous cyclical fragility as a result of political and economic crises and exogenous shocks.

Health sector outcomes. Progress was made to improve health services and outcomes in the two decades preceding project appraisal. Child immunization rates against such diseases as hepatitis B, diphtheria and measles significantly improved (60% increase in 20 years) indicating low but increasing availability of basic medical services and treatments. The number of births assisted by skilled medical personnel had increased although the maternal mortality ratio (MMR) was still extremely high at roughly 530 per 100,000 births in 2005 (DHS). Infant and child mortality rates had declined significantly by mid-2000s. Between 1990 and 2004, under-five mortality rate declined from 166 per 1,000 live births to 94, on target to achieve 47 by 2015 (MDG goal). Infant mortality rate (IMR) was 58 in 2004 vs. 102 in 1990. While short term malnutrition had decreased, children continued to face a significant morbidity risk due to poor nutrition, with 50% of under- five being stunted due to chronic malnutrition.

Despite progress made, access to quality medical care remained beyond the reach of many. Improving health outcomes became a key goal of the second-generation poverty reduction strategy, the Madagascar Action Plan (MAP), 2007-2011, which set very ambitious targets in the areas of maternal and child mortality, fertility rate, malaria, tuberculosis, sexually transmitted diseases and HIV/AIDS prevention, and reduction of malnutrition in children under the age of five. In line with the MAP, the health sector strategy formulated by the Ministry of Health, Family Planning and Social Protection (MOH) in the Plan de Développement du Secteur Santé (PDSS), identified a number of key bottlenecks to increased access and use of health services and improvements in health indicators in Madagascar: (i) poorly equipped health centers and low levels of capacity to produce and deliver health services, especially in rural and remote areas and weak managerial capacity at the level of communes; (ii) inadequate and uneven staffing of health facilities, especially in rural and remote areas; (iii) low levels of health financing and inefficiencies in resource allocation (Madagascar spent around US$6 per capita on health care in 2005, significantly lower than the average for sub-Saharan Africa, excluding South Africa, of US$15.4 per capita); and (iv) inadequate demand for health services and low levels of utilization (only 10 percent of the population reports an illness annually, and of this, only 40 percent seeks care from qualified medical personnel).

Sexually Transmitted Infections (STIs) and HIV/AIDS. Madagascar’s rates of STIs, a key risk factor and contributor to the spread of HIV/AIDS, were and remain among the highest in the world. A 2000 study of 1,000 sex workers in two regions revealed that 82% had at least one STI. Syphilis among pregnant women was 14.8% in 1998 and was reduced to 6% by 2003 (DHS 2003-2004) but remained high among sex workers at 16.6% in 2005 (it was as high as 35% in some regions in 1998). The 2003-2004 DHS found active syphilis prevalence was 6.3% among adults aged 15-49. As mentioned above, the quality of health services remained poor, with frequent interruptions in the supply of basic medicines affecting the ability to diagnose and treat STIs. HIV/AIDS was first diagnosed in Madagascar in 1987, but unlike many other Sub-Saharan African nations, the HIV prevalence has remained under 1% despite high rates of STIs. The epidemic was mainly concentrated within high-risk and vulnerable groups such as sex workers, truck drivers,

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uniformed personnel, and youths, and is concentrated in particularly vulnerable communes judged to be at high-risk of sexual transmitted infections (PLACE study 2003). These include areas around mines, meeting places such as cattle/zebu markets, tourist sites, ports, train stations, airports, alcohol sale sites, etc.

In 2005, HIV prevalence was estimated at 0.7% (UNAIDS) of the adult population. In pregnant women, HIV prevalence was 1.1% according to a 2003 survey study (corrected in 2005 to 0.95%). Among STI patients, HIV prevalence increased from 0% in 1999 to 0.58% in 2005, and among sex workers, from 0% in 1996, 0.25% in 1998, and to 1.3% by 2005. The 2005 Project Appraisal Document (PAD) noted that the apparent paradox between high STIs and low HIV prevalence may be due to: (i) relatively low herpes prevalence, (ii) generalized circumcision, (iii) limited transport infrastructure, and (iv) the island’s isolation, although this factor has and continues to be questioned. While these factors certainly play a role, the large discrepancy between high STI rates and low HIV prevalence rates is still not entirely clear today.

This paradox is further complicated by persistently low levels of knowledge about HIV/AIDS and very high risk behaviors among the general population, particularly among the highest-risk group categories such as sex workers, military, youth, IDUs and MSM. 2005 data shows that only 19.4% of males and 15.7% of females (respondents aged 15-24) could correctly identify ways of preventing the sexual transmission of HIV and reject major misconceptions about HIV transmission and prevention. The same data shows that 66% of youths (15-24), 50% of sex workers, 48% of military, and 52% of truckers could cite three methods of HIV/AIDS prevention. Among the youths (15-24), roughly 8% claimed they had received an HIV test and knew their result. Almost 50% of sex workers claimed they were tested and knew their result (2006 data).

Meanwhile, risky behaviors among high-risk groups included early initiation of sex, simultaneous multiple partners, and unprotected sex. For example, condom use was extremely low in 2005 despite distribution of 32 million condoms and intensive promotion of condom use through mass media campaigns and sub-projects carried out under the first International Development Association (IDA) supported HIV/AIDS project (MSPPI) which was implemented between 2001 and 2007. In the general population (15-49 age group), only 4.6% of males and 13.1% of females reported using condoms the last time they had sex. In the same age group, 38% of males and 16.8% of females (as reported in the 2004 DHS) reported having sex with a non-regular partner in the last 12 months. Only 5.4% of females and 12% of males (aged 15-24), 54% of truckers, and 56% of military reported the use of a condom in their last act of sexual intercourse with a non-regular partner in the last 12 months. In 2005 (ESC), 76% of sex workers reported the use of a condom in their last act of sexual intercourse with a client.

The country’s low levels of knowledge about HIV/AIDS and high-risk behaviors were reflected in an extremely high prevalence of stigma and discrimination against people living with HIV/AIDS (PLWHA). The DHS 2005 data showed that 94% of women (ages 15-49) and 87% of males (15- 49) reported discriminatory attitudes towards PLWHA. Notably, these rates are similar (and even more alarming than those in some of the neighboring African countries; e.g. in South Africa, 37% reported having accepting attitudes toward PLWHA (defined as a composite of 4 indicators - 2003 DHS). Likewise, in Tanzania, only 27.2% of women and 36.7% of men had accepting attitudes towards PLWHA (HIV indicator survey 2003-2004).

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Government strategy to fight HIV/AIDS: At the time of appraisal, The Government of Madagascar (GOM), at the highest level, was deeply committed to curbing the spread of STI/HIV/AIDS. President Marc Ravalomanana personally spearheaded the national response to the epidemic. At the end of 2002, he established the National AIDS Committee (Comité National de Lutte Contre le SIDA – CNLS) and appointed an Executive Secretariat (ES) to coordinate the implementation of the National HIV/AIDS Program. Under the President’s leadership, the ES mobilized public opinion and worked closely with non-governmental organizations (NGOs), community-based organizations (CBOs) and church groups to ensure that HIV/AIDS awareness was created at the community level, with active support for the promotion of condoms. In line with the UNAIDS “The Three Ones” principle, the GOM adopted a National Strategic Plan for HIV/AIDS (NSP) (2001-2006), one single Monitoring and Evaluation Plan, and a National HIV/AIDS Communication Strategy, which had two key pillars: (i) media campaigns focusing on the general population; and (ii) targeted community-level communication to affect behavior change and reduce stigma. A thematic group, made up of the representatives from the UN agencies and the World Bank, was established under the auspices of UNAIDS to advise the GOM on developing and implementing the response to the epidemic. All HIV/AIDS related activities undertaken by donors and other development partners were consistent with this NSP.

Rationale for Bank Assistance: Support for the Second Multi-sectoral STI/HIV/AIDS Project (MSPPII), approved in 2005 and the Additional Financing for health, nutrition and STI/HIV/AIDS activities approved in 2012, need to be seen as part of the broader continuous effort by the World Bank and the entire development community to improve Madagascar’s health and nutrition outcomes as well as to curb the HIV/AIDS epidemic. The Bank had supported these sectors through a number of health specific and multi-sectoral projects as well as continuous policy and program dialogue. These included the Health Sector Improvement Project (1991-1999) and the follow-on Second Health Sector Support Project (1999-2007). These projects supported the improvement of the population's health status through more accessible and better quality of health services, especially primary health care services in rural areas. The second project received a supplemental credit of US$18 million in May 2005 to support priority health programs (with an emphasis on endemic infectious diseases, reproductive health and nutrition) and to strengthen health sector management and administrative capacity within MOH, especially at provincial and district levels. This was followed by a third project - Sustainable Health Systems Development project, US$10 million (2007-2009). During this time, the Bank provided support to the MOH to transition to a pooled financing arrangement and a sector-wide approach with the signature of the International Health Partnership Compact between the GOM and 22 development partners in 2008. The Bank also supported two nutrition projects, the Food Security and Nutrition, US$21.3 million (1993-1998) and the Second Community Nutrition Project, US$47.6 million (1998-2011). All of these operations were successfully implemented and rated as Satisfactory in their final evaluations and confirmed as such by the World Bank Independent Evaluation Group (IEG). Currently, the Bank is also financing the Emergency Support to Critical Education, Health and Nutrition Services Project, US$65 million and US$10 million Additional Financing which ends in July 2016.

From 1999-2007, the Bank financed the first Multi-sectoral STI/HIV/AIDS Project (MSPPI), US$20 million. The rationale to support the follow-on MSPPII by the Bank was mainly to ensure the continuation of the efforts made under the MSPPI and to help mobilize the needed resources

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for the NSP at the urgent request of Government. In 2005, the Global Fund just began its efforts by financing US$6.3 million under Round 2 (2004-2007), to complement financing for HIV/AIDS testing and treatment. Therefore, the Bank’s US$30 million support to MSPPII was critical to the program in order to continue and reinforce efforts already made as well as to expand support for STI control, care of people living with HIV/AIDS (PLWHA), and more intensive targeting of prevention measures to high-risk groups. Indeed, the Bank’s financing also had the advantage of needed flexibility to finance activities, including treatment, as a donor of last resort, if and when there were gaps in the program financing. Lastly, the Bank was also uniquely positioned to share its cross-country experiences in the design, implementation and evaluation of the Bank’s Multi- country AIDS Programs (MAP). By 2005, the Interim Review of the MAP was completed and the Bank team was able to introduce some of the lessons of the review into the design of the project, namely the high cost-effectiveness of prevention interventions focused on high risk groups.

1.2 Original Project Development Objectives (PDO) and Key Indicators

The MSPPII's development objectives were the same as those of the first project (MSPPI). Those objectives are “to support the Government of Madagascar’s efforts to promote a multi-sectoral response to the HIV/AIDS crisis and to contain the spread of HIV/AIDS on its territory.”

Even though the official objective in the legal agreement and in all internal Bank documents remained as stated above, it is important to note that the PAD elaborated in the paragraph directly under the PDO statement that the project was a departure from the first project because it would also provide support for increased access to medical and non-medical care for PLWHA and that it would put a stronger emphasis on at-risk groups in high prevalence areas (highly vulnerable communes).1

The key performance indicators are presented in the ICR Datasheet, above, and marked whether they were “original,” “revised” or “new”. Section 2.3 on Monitoring and Evaluation below provides a detailed description of the Results Framework, including the changes introduced during the project.

1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification

The December 2011 Level 2 restructuring revised the Results Framework substantially (see Section 2.3); meanwhile, the PDO remained the same.

1 These communes were to be identified through a “PLACE” study in 2005 based on a PLACE pilot which was carried out in May 2003. This method used ethnographic and contextual data rather than blood testing to identify areas judged be at high-risk of sexual transmitted infections, such as mines, cattle markets, tourist spots, ports, etc.). The preparation of the 2005 PLACE study was ongoing at the time of Board submission of this project, as reflected in the PAD.

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The Additional Financing (AF), approved on June 14, 2012, changed the PDO: “To increase utilization of STI/HIV/AIDS, and maternal and child health, nutrition services in project areas.” The AF also revised the Results Framework again to reflect the new PDO and new and revised activities under the AF. This is further detailed in Section 2.3 below.

1.4 Main Beneficiaries

This second multi-sectoral STI/HIV/AIDS project was to intensify and build capacity of key government institutions dedicated to combatting HIV/AIDS to carry out the national response to HIV/AIDS and STIs, a key risk factor for and contributor to the spread of HIV/AIDS. Therefore, the beneficiaries were to be those institutions and the population of Madagascar (the 15-49 age group). However, given the worrisome epidemiological situation at appraisal, the project was to put an even stronger focus than the original project on activities for at-risk groups in high prevalence areas. This meant a focus on 15-24 youth, sex workers, truckers, and the members of the military. The project was also to expand services to other affected groups (e.g., orphans and other vulnerable children). Lastly, the project was to improve the quality of life of persons living with HIV/AIDS through increased access to quality medical care and to non-medical support services.

Under the Additional Financing, the main beneficiaries were to be pregnant/lactating women and young children who would benefit from nutrition and health services, in addition to the 15-24 youth and sex workers who would benefit from HIV/AIDS interventions.

1.5 Original Components

Component 1: Harmonization, donor coordination and strategies (US$1.5 million). This component included: (i) Development of mechanisms for coordinating donor activities in the Sector to ensure better impact and cost-efficiency of HIV/AIDS interventions; (ii) Reviewing and updating the National Strategic HIV/AIDS Plan (2001-2006); (iii) Implementation of STI/HIV/AIDS communication strategy and action plan through carrying out of mass media information campaigns and supporting NGOs and CBOs with communication materials and toolkits to implement grass-root communication sub-projects; and (iv) Financing of Sector strategies and action plans in each of the Sectors (limited to 2-3) which focus on high-risk groups and which have been found to be most effective (through the “impact effectiveness” assessment supported under the component). Institutionalization of the relationship with the various sectors would be supported (e.g. periodic working groups, participation in strategic decisions, such as the revision of the NSP).

Component 2: Support for health sector response (US$3.5 million). This component complemented funding to the health sector provided under the Second Health Sector Support (SHSS) project (US$40 million) that was approved in 1999 and received AF US$22 million in 2006. The SHSS closed on December 31, 2007. This component was to provide a stronger role for the health sector in combatting STI/HIV/AIDS, specifically: (i) support for STI control through improved training on a syndromic approach and financing STI kits; (ii) support for care and treatment of PLWHA through expansion of Voluntary Counseling and Testing (VCT) centers in all 111 district hospitals and health centers in high-risk areas, psycho-social, nutritional and other

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support, and financing Antiretrovirals (ARVs) (complementing funding of ARVs by the Global Fund) and drugs for opportunistic infections, and prevention of MTCT; and (iii) other health sector activities such as support for the establishment of laboratories, blood transfusion centers, installation of incinerators, training of staff and medical waste management.

Component 3: Fund for STI/HIV/AIDS prevention and care-taking activities (FAP) (US$16.5 million). This component was to continue to support the FAP established under the MSPPI but reoriented its focus on places where the population was at the greatest risk of being infected (75% of the FAP funds were to be allocated to these high-risk areas). The FAP was to finance Grants to support STI/HIV/AIDS prevention sub-projects undertaken by the private sector, civil society and not-for-profit organizations, including: (i) condom distribution; (ii) grassroots communication activities that shift focus from general knowledge to behavioral communication for change; (iii) home-base care and other support for PLWHA; (iv) programs for orphans and vulnerable children; (v) activities with at-risk groups to increase their demand for HIV/AIDS services, (vi) training of peer educators and community-based counselors, (vii) activities that aim at reducing stigma and discrimination against PLWA; and (viii) workplace HIV/AIDS plans for the public sector. This component was also to finance the management and operation of the FAP.

Component 4: Monitoring and Evaluation (US$2.9 million). This component was to support the national Monitoring and Evaluation (M&E) plan through a single M&E system, specifically: (i) the development of a management information system (MIS) to generate and collect key performance indicators data, financial data, input and operational data for the project; (ii) track the evolving status of the epidemic by carrying out epidemiological surveys (second generation surveillance), including annual behavioral surveys among high-risk groups to measure behavioral change and knowledge, and sentinel surveillance surveys of clients at antenatal clinics (pregnant women, STI patients, and SWs), as well as special purpose studies on specific target groups; and (iii) carry out impact studies to inform the course of the epidemic and any required reorientations in the National HIV/AIDS program.

Component 5: Project Management and capacity building (US$2.5 million). This component was to support the institutional and operational modalities established under MSPPI at the central level (CNLS, MSPPII Council and UGP) and new structures established at the regional level (BCR), following the creation of regions in 2004. This component was to finance staff, equipment and operating costs at each level of implementation as well as technical assistance and training based on annual capacity building plans.

1.6 Revised Components

The components were revised twice, during the December 2011 restructuring and during the 2012 Additional Financing, as follows:

December 28, 2011 Level 2 restructuring: This restructuring was actually planned since 2008 and most of the elements were outlined in an in-depth Midterm Review (MTR) Report in December 2008; the review recommended a number of changes (discussed in detail below in Section 2.2), including changes to components. The changes were meant to be formalized in a restructuring paper soon after the MTR but this was not possible due to the political crisis which

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ensued at the start of 2009 preventing Bank staff to interact with any ministerial appointee. At that time, as a result of the political crisis, the Bank suspended the entire Madagascar portfolio and only lifted the suspension in 2011 (formally approved by the Bank’s senior management) which subsequently allowed for the preparation of the Interim Strategy Note (ISN) and for the portfolio to be restructured. This also allowed for projects such as this one to be restructured. Hence, the official project restructuring took place only in December 2011. Nonetheless, practically most of the changes were in fact put in place by late 2009/early 2010 (when the project suspension was lifted for Components 2, 4 and 5 on humanitarian grounds). In other words, the project needs to be considered as de facto restructured as of early 2010 albeit legally the changes were only recorded in December 2011. This restructuring introduced the following changes to project components to improve their overall effectiveness:

Component 1: completed and closed at the end of 2008.

Component 2: The total estimated cost of this component more than tripled from US$3.5 million to US$12.5 million in order to further strengthen the health sector response particularly affected by the political crisis and its aftermath. Specifically, the component was expanded to finance: (i) additional support for STI control through improved training, and acquisition and distribution of laboratory and testing equipment, condoms, in addition to STI kits; (ii) support for care and treatment of PLWHA through expansion of VCT centers in district hospitals and health centers, acquisition of laboratory and testing equipment and ARVs, acquisition and distribution of diagnostic tools and drugs for prevention of MTCT and treatment of opportunistic infections, and training of health personnel; (iii) other health sector activities such as support for the establishment of laboratories, blood transfusion centers, installation of incinerators, training of staff and medical waste management; and (iv) contracting NGOs using performance-based contracts to support the provision of package of health and related services targeting most-at-risk groups (sex workers, military and youth) and PLWHA, including STI and HIV/AIDS prevention and treatment activities.

Component 3: This component was dropped from the project, reserving US$7.4 million to finance activities carried out prior to restructuring. It was essentially replaced by Component 2 as the FAP activities proved to be less effective at targeting highest at-risk groups and also suffered from governance issues which came to light through a 2008 Special Audit. The audit revealed US$745,569.36 in ineligible expenditures which the Government had to return (see implementation section below).

Component 4: This component was increased by US$1.4 million to a total of US$4.3 million to reflect even greater support to information systems, surveys and strengthening internal and external verification mechanisms. Specifically, in order to enhance the overall evidence base of the epidemic, and to improve the use of program data for decision-making, three additional studies were to be financed: (i) Enquête Comportementale et Biologique to measure outcome level indicators; (ii) Study on Chemo – sensibility to antibiotics; and (iii) Etude sur la stratégie de prise en charge des infections sexuellement transmissible to provide information on developing future approaches to combatting HIV/AIDS.

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Component 5: This component was increased by US$1.5 million to a total of US$4 million, as presented in the restructuring paper. This increase reflected the need to finance operating costs associated with the extension of the project Closing Date by one year and to make up for the short-fall in financing since the original funds were meant to last only until 2009 (original closing date).

Additional Financing June 2012: The AF provided (approved June 14, 2012) US$6 million to mainly further increase support for the Health Sector Response, under Component 2, by expanding financing to health service providers to strengthen their capacity in the provision of maternal and child health services as well as nutrition services at facility level in a selected number of poorest districts in 5 regions. This was meant to bridge the gap in the Bank’s support for the health sector in a context of severely constrained resources at a time when Bank financing for a health project was not yet available. The ongoing Emergency Support to Education, Health and Nutrition Project was only approved on November 29, 2012 and is building on previous interventions as well as on work carried out under MSSPII’s AF. The AF also continued the financing of HIV and STI-related interventions, focusing on testing, treatment and Behavior Change and Communication (BCC) for high-risk groups (sex workers, military and youth) using performance-based contracts with NGOs.

Component 2 now included additional US$5.18 million for the following specific activities: (i) Integrated package for pregnant women at facility level (US$1.28 million) during antenatal consultations, including: prevention of mother-to-child transmission (PMTCT), tracking and treatment of syphilis, supplementation of iron and folic acid, tetanus vaccinations, intermittent preventive medication against malaria, and distribution of impregnated mosquito nets. (ii) Integrated package for children under five at facility level (US$0.18 million): Promotion of good practices and breastfeeding and nutrition for mothers and children, Vitamin A supplementation, vaccinations, distribution of impregnated mosquito nets, treatment of diarrhea with oral rehydration salts and zinc, prevention and treatment of malaria, and integrated treatment of childhood diseases (IMCI). (iii) Support to Health and Nutrition services at community level (US$1.44 million): Provision of nutrition inputs, recruitment of NGOs to support community nutrition sites, and support to community workers for nutrition assigned to Community-based Nutrition Program sites in Fokontany, in an effort to enhance their skills in awareness raising and counseling, referrals of malnourished children, weighing, and culinary demonstrations. (iv) Support for HIV/STI prevention among the most-at-risk population (US$1.42 million): Continued support to at-risk populations, including professional sex workers, military and youth between ages 15-24 in BCC, distribution of condoms and VCT. Syphilis test and consumables for pregnant women would also be provided. (v) Improving quality of treatment to PLWHA (US$0.56 million): Support for operational costs of treatment centers for PLWHAs and of associations engaged in psychosocial treatment. (vi) Continued support for implementation of Medical Waste Management Plan (US$0.15 million): including supervision and maintenance of incinerators.

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(vii) Design and implementation of a results-based financing pilot (US$0.15 million): in a few districts, to support health service delivery at health facility and community levels. Component 4: Monitoring and Evaluation (US$0.42 million): This component was to continue to fund original activities as well as the following additional activities: 1. Monitoring and Supervision (US$0.71 million): This was to include (i) putting in place an information system to rapidly collect data for monitoring of project activities; and (ii) provision of mobile phones to Basic Health Centers and community health workers to facilitate reporting and communication. 2. Evaluation (US$0.35 million): This was to include: (i) continued support for the Independent Verification Agency to evaluate progress of implementing NGOs in health, nutrition and HIV/AIDS; (ii) execution of second surveillance study; and (iii) final evaluation of the Project.

Component 5: Project Management and Capacity Building (US$0.40 million): This component was to continue to provide support for technical supervision by the PIU and relevant functions within the MOH related to project activities, including the SE and the CNLS.

1.7 Other significant changes

In addition to the revisions discussed above, the following changes were made during the project’s implementation:

1. Suspension of Bank’s portfolio (March 17, 2009) subject to OB/BP 7.30 Dealing with a De Facto Governments, whereby all applications for replenishment of Designated Accounts were put on hold. As of November 10, 2009, disbursements for key projects in Madagascar, including for Component 2, 4 and 5 of this project were allowed to resume on an exceptional basis for humanitarian reasons. 2. Extension of the Closing Date (letter dated December 29, 2009) by 24 months until December 31, 2011 in order to ensure the completion of project activities due to early delays in implementation and delays caused by the 2009 political crisis. 3. Change in implementation arrangements was made following recommendations in the December 2008 MTR to refocus the role of the Executive Secretariat (ES) of the CNLS vis-à- vis the project. In early 2010, the responsibility for project implementation shifted from the ES/CNLS PIU (which managed funds by the Global Fund, Agence Française de Développement and resource from the Government of Monaco to the Ministry of Health PIU which had the required capacity given its involvement in the implementation of several Bank supported health projects. 4. Level 2 restructuring approved on December 28, 2011 (Amendment to the Development Credit Agreement, dated February 15, 2012) to extend the Closing Date by an additional 12 months until December 31, 2012 to complete implementation of activities delayed due to the political crisis under a new component structure (discussed above), to change the Results Framework, and to reallocate funds across different expenditure categories. (see table below) 5. Cancellation of SDR 604,607.58 from the original Credit (letter dated June 25, 2013) which represents an unspent amount from the original Credit.

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6. Additional Financing was approved on June 14, 2012 and became effective February 22, 2013, revising the PDO, adding funds for new and revised activities, and changing the Results Framework. 7. Level 2 restructuring approved on August 5, 2014 (July 24, 2014 restructuring paper) to change indicator baselines and targets to more appropriately reflect the effective start date of the AF and to reallocate funds under the Additional Financing Credit to ensure the financing of the Results-based financing (RBF) pilot. (See table below).

Table 1: Credit Re-Allocations by Expenditure Category (in SDR) Original Revised Revised Actual Expenditure categories (Dec. 2011) (July 2012) Expenditures (Jan 2015)

Original Credit (IDA41040) (1) Goods and civil works 2,700,000 6,700,000 6,874,716.42 6,874,716.42 (2) Consulting services, including 4,110,000 8,100,000 8,126,486.66 8,126,486.66 training and audits (3) Grants 9,900,000 3,200,000 2,687,726.37 2,687,726.37 (4) Operating Costs 1,420,000 2,200,000 1,856,017.15 1,856,017.15 Unallocated 2,070,000 Cancelled (-604,607.58) (-604,607.58) Total 20,200,000 20,200,000 19,544,946.60 19,544,946.60 Original Revised Actual Additional Financing Credit (August 2014) Expenditures (IDA51240) (Jan 2015) (1) Goods, Consultant Services, 2,500,000 2,774,000 2,358,045.27 Training and Audits (2) Goods and Services for Grant 100,000 229,000 82,854.39 Part1B(ii) (3) Operating Costs 1,300,000 897,000 991,731.78 Total 3,900,000 3,900,000 3,432,631.44

2. Key Factors Affecting Implementation and Outcomes

2.1 Project Preparation, Design and Quality at Entry

Timing of preparation: The second Multi-sectoral STI/HIV/AIDS Prevention Project (MSPPII) financed by an IDA Credit of US$30 million was prepared just under 6 months (from Project Concept in February 22, 2005 to Board approval on July 12, 2005) as a repeater operation of MSPPI which was a US$20 million IDA Credit approved on December 14, 2001 and still under implementation when MSPPII was approved. In fact, the preparation of the follow-on project was undertaken jointly with the MTR of the first project in December 2004. At that time, there was a strong Government commitment and demand for this repeater operation, with the original Government request being US$10 million higher than what was subsequently approved. The ES/CNLS estimated that even with the Global Fund contribution of US$6.3 million (2004-2007) and the expected contribution of US$9 million from the AfDB (2005-2007), there would be a financing gap of US$31 million to finance the necessary activities until the end of 2007. The MTR confirmed that there was indeed an urgent need to prepare the second project, estimating that the 11

first project would be fully disbursed by December 2005. At MTR, the total disbursements for the first project were only 54% and the Closing Date was December 31, 2006. Although questions about the realism of the plan to fully disburse the remaining 46% of project funds in 1 year were raised at the February 2005 PCN meeting for MSSPII, the team replied that the majority of these funds were already committed and reinforced the Government’s request to prepare the project urgently. This was confirmed by this ICR in discussions with the Task Team Leader at that time. The minutes of the February 2005 PCN meeting reflect full agreement by the meeting’s chair to proceed with a very tight preparation timetable, scheduling appraisal within 2 weeks of the PCN, in March 2005. Actual appraisal took place in April, with negotiations in June and approval in July 2005.

Lessons: The design of this repeater project, could therefore only rely on the lessons reflected in the 2004 MTR of the first project. Some of the lessons were subsequently also endorsed in the MSPPI ICR completed three years later, in June 2008 (MSPPI was actually extended for a year until December 31, 2007 due to implementation delays as well as a change in the project’s orientation towards smaller sub-projects implemented by CBOs). The MTR lessons included, inter alia, the: (i) need to focus on high risk groups given the low prevalence of the epidemic, and more emphasis on financing sensitive HIV surveillance surveys; (ii) lack of a uniform system of monitoring indicators among donors and by CNLS, requiring a better coordination and harmonization mechanism and strategy for better use of data for decision making; (iii) inadequate counterpart funding to support project activities; (iv) the need to develop a national communications strategy; (v) the need to strengthen project implementation arrangements; (vi) the need for a stronger and more direct health sector involvement in the management of the response; and (vii) the need to improve the quality of medical care and non-medical support services for PLWHA by financing a more comprehensive approach to addressing HIV/AIDS, through prevention, care and treatment.

Project design: While many of these important lessons were taken into account in the design of the MSPPII, as clearly visible in the structure of the components (see above), several key elements of the design could have likely benefitted from a more thorough appraisal. First, the PDO was kept the same as the first project, and while broadly consistent with the overall National Program objectives and the thrust of the project, the PDO did not reflect the important changes envisioned by the second operation, i.e. a much greater emphasis on targeting high risk groups through a comprehensive approach to the epidemic, including a greater role for the health sector. The focus on targeting high-risk groups was mentioned in a supporting paragraph of the PDO, but was not reflected in the main PDO statement, nor was it included in the legal agreement and in subsequent project documents. The decision to retain the same PDO may have been a simple reflection of the need to demonstrate continued support to Madagascar’s efforts in the fight against HIV/AIDS. However, in retrospect, this reflected an old strategy adopted under the first project which did not prove to be effective because most of the effort was focused on the general population and was not targeted (the MSPPI was downgraded to Moderately Unsatisfactory for outcome by the World Bank’s Independent Evaluation Group mainly due to its limited ability to target high-risk groups and affect behavior change among high-risk populations most exposed to the risks of transmission).

Secondly, the MSSPII’s intention, as presented in the PAD, was to re-orient a larger volume of financing toward high-impact activities in a much more limited geographic area, focused on high-

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risk communities. In fact, the PAD mentions that the project would undertake a demographic and epidemiological profile to identify “hot” spots. In addition, the PAD mentions that a cost- effectiveness analysis would be undertaken to assess which of the eligible sub-project activities are likely to be the most effective in changing knowledge and behavior in high-risk areas. These pieces of critical analysis were clearly not completed during project preparation even though the minutes of the PCN meeting specifically requested the team to carry out this work urgently. The PAD does not include an economic analysis, and only refers to the general analysis carried out for the Multi-Country HIV/AIDS Program for the Africa Region as a whole. Instead of carrying out more in-depth analyses, project preparation was done very quickly in 4.5 months (unnecessarily in retrospect since the first project continued for another 2 years), and the repeater operation, like the first project, essentially began continuing broad support for general information, education and communication activities through CBOs and NGOs carrying out hundreds of projects throughout the country. A more targeted approach was adopted in 2010 in response to the acknowledged relative ineffectiveness of the originally designed project to target high-risk groups.

Implementation arrangements: A third area which likely required additional in-depth analysis at preparation was the implementation arrangements; specifically, no review was carried out of institutional/organizational arrangements and the roles of various parts of the structure and the complex arrangements were not mentioned as a potential risk in the PAD at all. Instead, the same arrangements developed under the first project were continued under the second project, and the opportunity to revisit and revise these in view of the intended changed nature of the project was lost; likely, it was not perceived to be necessary since the 2004 MTR of the first project noted that these arrangements were carefully designed and seemed to be working. Interestingly, the PAD did not say that these arrangements were complex and potentially inefficient and that only half of the local structures established to support the Fund for STI/HIV/AIDS prevention and care taking activities (FAP) were actually operational (this was pointed out in the ICR in 2008 that by the end of the first project in 2007, this was the prevailing situation). The PAD questioned whether the Project Implementation Unit (UGP) would have the capacity to re-orient the project activities to target more at risk communities, but noted that this would be mitigated by having the review of the “hot” spots carried out and the hiring of Facilitating Organizations (OFs) to help communities develop local plans to fight HIV/AIDS and to help CBOs develop their applications for sub-project financing. Later on, the 2008 MTR Issues paper for the second project, and the ICR for the first project, clearly raised implementation arrangements as a major issue in delaying implementation because of the multi-tier review process, as well as their inability to truly target areas of greatest need. In fact, the 2008 MTR recommended an in-depth review of roles and responsibilitiES/CNLS, as well as the actual suspension of Component 3 which supported the FAP.

2.2 Implementation

The project had a complex history, with many changes taking place, and was implemented for more than 9 years since approval on July 12, 2005 to closure on September 30, 2014. This period can be generally broken into five separate distinguishing reference points, each representing and explaining key factors behind implementation progress and changes made during the course of the project.

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1. Delayed project start-up: While project effectiveness was originally expected in October 2005, it was delayed until January 5, 2006. Reasons cited for the effectiveness delay was the hiring of project auditors. However, first disbursements under the project were not registered for another year and a half, until mid-2007 (only an advance to the Special Account) and Bank ISRs report limited progress mainly due to capacity weaknesses of the PIU in the ES/CNLS which was challenged with coordinating the implementation of the HIV/AIDS program with multiple donors and managing projects funded by five difference sources (Government budget, IDA project, UNDP, GTZ and the Global Fund). Also, the focus was not so much on starting the new project, but on the completion of the first project. As noted above, the risk of MSPPI not fully disbursing by the end 2005 was pointed out during the Concept review meeting for MSPPII in early 2005 by two peer reviewers and their caution unfortunately proved to be correct. In fact, the first project needed to be extended until December 2007 to complete all activities (a 2 year delay from original expectations at the time of preparation of MSPPII). In retrospect, neither the Government nor the Bank adequately assessed the realism of completing implementation in 2005 which led to a decision to rush the preparation of MSPPII (as the minutes of the Decision meeting suggest).

Following a 2-year period of limited progress, a number of the implementation and management weaknesses started to be addressed and project disbursements rapidly increased, reaching US$12 million by December 2008. This Phase I saw a flurry of nation-wide prevention activities in 22 regions under Component 3 (targeting 761 communes of the total 1,549), with 2,817 communication and prevention sub-projects. During this time, the HIV testing was significantly scaled up with the number of VCT centers increasing from 49 in 2004 to 779 by 2009.

During this early period of implementation, one issue emerged which required a substantial amount of attention from both the Government and Bank teams, and its resolution lasted until the end of 2012. This also affected the continuation of Component 3 and contributed to the subsequent restructuring. During the October 2008 supervision mission, the Bank was informed by ES/CNLS about allegations of corruption in the implementation of Component 3 - the Fund for Prevention of STI/HIV/AIDS (FAP) in the regions of Diana and Sofia. On this basis, the Bank requested that all further implementation of the FAP be suspended, and that contracts with the Financial Management Agency (AGF), recruited to manage this Component, and the Facilitation Organizations (OFs) be put on hold. A Special Audit was carried out by Ernst and Young and their report presented in January 2009 identified that ineligible expenditures under Component 3 were incurred as a result of inadequate book-keeping and accounting practices on the part of the CBOs and weak supervision on the part of the AGF. The total US$745,569.36 of ineligible expenditures took a considerable amount of time to agree on as it required a detailed review of all documentation. In October 2010, the Bank sent the notification letter with the final calculated amount to the Ministry of Finance (MOF) requesting a repayment schedule. In a letter on January 7, 2011, the MOF proposed a repayment schedule through December 2013. Regrettably, due to internal management decisions on the status of the Madagascar portfolio, the Bank was only able to respond to the MOF 10 months later, in a letter dated October 17, 2011, requesting a revised repayment schedule from the Government with the full amount to be repaid by the end of 2012. In the meantime, in August 2011, the Government already made the first reimbursement tranche totaling US$74,557 and proposed a revised schedule, complying with the Bank request. These actions resulted in the Bank’s ability to upgrade the Financial Management (FM) rating of the project to Moderately Satisfactory. These actions were critical as they enabled the Bank to obtain

14 a policy exception from the Vice President of Operations Policy and Country Services (VP OPCS) and the VP and Controller on December 22, 2011 necessary to approve the second extension of the Closing Date which was required due to these outstanding ineligible expenditures. The total amount was subsequently fully reimbursed by the GOM in November 2012 in accordance with a repayment schedule agreed with the Bank, satisfying the Bank requirement that these ineligible expenses needed to be returned by the Closing Date of the original project (December 31, 2012). 2. Mid-term Review (MTR). This joint review with Government was very participatory, (including attendance by the President), and had the effect of significantly and positively impacting on the future course of project implementation by laying out the issues impeding implementation and recommending several key changes which were eventually made and improved implementation effectiveness. In November 2008, the Bank team prepared a MTR Issues Paper, analyzing roughly 2 years of implementation, to be used during the December 2008 MTR. At that point, the project had disbursed US$12 million, representing 40% of the total Credit, with one year to go before the original Closing Date. Following allegations of inappropriate use of funds which emerged in October 2008 and the subsequent Special Audit, the Bank downgraded the rating for Component 3 to Unsatisfactory and the overall rating for implementation progress to Moderately Unsatisfactory. Against this general background, some of the main findings and recommendations of the MTR were as follows: (a) Institutional/management issues: Program and project management by the ES/CNLS was found to be inefficient, with a complex top-down hierarchical organizational structure, a multitude of staff with unclear roles and mandates (resulting in high staff turn-over), lack of delegation, poor internal communications, ineffective program coordination with other sectors and partners because staff were busy managing donor funding, including for this project, and chronic implementation delays due to weak project management. The MTR recommended to: (i) clarify/rationalize the ES/CNLS mandate as the HIV/AIDS coordinating, monitoring and evaluation body to which all stakeholders in the HIV response are accountable; (ii) streamline ES/CNLS size and clarify staff roles and responsibilities; (iii) transfer the responsibility for the HIV/AIDS response to regions with greatest needs (8 priority regions were to pilot the new approach) in line with the Government’s decentralization policy; and (iv) separate the project management function from the ES/CNLS’s core responsibility for program oversight.

(b) Implementation challenges of the Fund for STI/HIV/AIDS Prevention (FAP): This local response funding structure for sub-projects by CBOs and NGOs had a multi-tier complex review process with different entities responsible for reviewing proposals depending on their amount. Proposals over $100,000 were reviewed by the Project Council, proposals between $25,000-$100,000 were reviewed by a Technical Review Organization (ORT) based in the UNAIDS office, while small proposals over $3,000 were first reviewed by the Facilitating Organizations (OF) (one in each region) before the final review by ORT. The OFs were also responsible for helping CBOs to draft proposals. Lastly, a Financial Management Agency (AGF) was to approve the financial viability of proposals and make payments to CBOs and NGOs for approved sub-projects. Exacerbating this complex structure, the December 2008 MTR found numerous problematic issues. Firstly, the 2008 institutional audit carried out before the MTR revealed that 50% of OFs (rehired by regions as part of the new decentralized approach) did not have the necessary capacity; this was not surprising given that most were only hired in April 2008 and did not receive training until September 2008. The revised Procedures Manual for the FAP was also only completed by October 2008. Secondly,

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exceedingly large numbers of applications approved were less than US$3,000, thus making it virtually impossible to carry out any evaluation of these and also raising the possibility of systemic avoidance of oversight. Thirdly, there were reports by local technical staff about some NGOs receiving funds without having undergone any reviews while other NGOs waited for months to get funds for approved proposals. Lastly, because the focus was so much on approvals and financing, little work was done to evaluate the actual results of these sub-projects. As mentioned above, the FAP was suspended before the MTR and remained as such until Component 3 was officially cancelled during the December 2011 restructuring. The MTR proposed that a new simpler mechanism at the regional level is used to target high-risk groups, with technical support in the regions to be provided by the Regional Coordination Unit in line with the Government’s decentralization approach. The ORT would be kept to review proposals after the regional review.

(c) Other operational weaknesses were identified, as follows: (i) Mixed response from an estimated of 10 originally envisaged sectors in the development of their sector strategies with four sectors, National Defense, Civil Service, Education and Health establishing and implementing their strategies. This response was due to lacking ownership from some sectors, lack of specificity in their plans which were subsequently rejected by the ES/CNLS, and structural changes within sectors. The result was that Component 1 which supported this work was declared closed after the MTR and all work except in the mentioned sectors was put on hold. (ii) Disbursement delays for critical health sector activities underscored the need for greater implementation autonomy of MOH to enable effective acquisition of necessary health sector inputs for the diagnosis, ARV treatment, opportunistic infection treatment and nutritional support for AIDS patients. To correct this, a separate Special Account was opened by the PIU in the MOH so that the availability of funding would not be a constraint for the implementation of Component 2. The MTR noted that MOH needed capacity building both in terms of technical leadership and rational planning of inputs, such as drugs, test kits which experienced periodic stock-outs. To improve this situation, the MTR recommended stronger coordination with regional and district staff in the planning of inputs as well as improving the VCT strategy, including post-test counseling to ensure better results in the continuum of care, and improving access to screening by integrating VCT in the minimum package of basic health training and services. (iii) The MTR also found that there was insufficient use of M&E data for decision- making and delays in implementation of various surveys, particularly sentinel surveillance studies. The MTR recommendation was to intensify the work on surveys and thereby improve access, analysis, reliability and use of statistical data for decision making, especially data concerning key sectors which would allow them to integrate their efforts in a multi-sectoral approach to the national response on HIV/AIDS. The MTR also suggested to revise the RF of the project to better reflect the PDO and component activities.

As mentioned above, the intention following the MTR was to restructure the project in order to streamline implementation and improve the chances for the project to meet its objectives. Unfortunately, directly following the MTR came the January 2009 political crisis which played a role in delayed restructuring until it was finally completed in December 2011.

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3. Political Crisis of 2009. The project was severely affected by a popular uprising in early 2009 when opposition leader and then-mayor of Antananarivo, Andry Rajoelina, led a protest movement in which President Ravalomanana lost power in an unconstitutional process widely condemned as a coup d'état. In March 2009, Rajoelina was declared by the Supreme Court as the President of the High Transitional Authority, an interim governing body responsible for moving the country toward presidential elections. As a result, many bilateral donors and intergovernmental organizations froze aid and suspended regular diplomatic relations with Madagascar, causing economic development to stagnate and reversing many of the gains achieved under the previous administration. On March 17, 2009, the Bank suspended all disbursements under the Madagascar portfolio in line with Operational Policy 7.30, Dealing with De Facto Governments. In November 2009, this suspension was lifted on exceptional basis for certain projects on humanitarian grounds. This included resumption of financing for this project with implementation allowed under three components (Components 2, 4 and 5). Component 1 was completed by the end of 2008 and Component 3 was suspended as a result of corruption allegations and because it was deemed to be ineffective in delivering interventions to the targeted population. Although disbursements and activities were allowed to go ahead, it is important to note that the Bank team was not authorized to have dialogue with Ministers and other high-level decision makers, thus making it hard to resolve more complex operational issues that required a political decision.

In 2010, a new constitution was adopted by referendum, establishing a Fourth Republic, which sustained the democratic, multi-party structure established in the previous constitution. Following a lengthy mediation process led by the Southern African Development Community (SADC), Madagascar held UN-supported presidential and parliamentary elections in 2013. Former finance minister Hery Rajaonarimampianina defeated Ravalomanana’s favored candidate Jean-Louis Robinson in a presidential runoff and was inaugurated in January 2014.

Effects of the 2009 political crisis. Madagascar's GDP in 2009 was estimated at US$8.6 billion, with a per capita GDP of US$438 with approximately 69% of the population living below the national poverty line threshold of one dollar per day. The 2009 political crisis significantly weakened the economy and quality of life remains low for the majority of the Malagasy population. Tourism dropped by more than 50% in 2009 compared with the previous year, and many investors were wary of entering the uncertain investment environment. GDP growth rate declined from the previous average of 7% to 2.6% by 2013 and per capita income was barely US$400 by 2011. The Bank’s 2012 Interim Strategy Note pointed out that poverty levels increased by 9 percentage points since 2005, with 76.5% of households living below the poverty line in 2010, one of the highest rates in Africa (2011 World Development Indicators). Indeed, it has been estimated that by 2012, there were additional 4 million people in poverty compared to 2008.

While Madagascar already lagged behind on key health and nutrition indicators, the political and economic crisis had the effect of reducing both the external and internal funding for the health sector. The government budget for the operation of the health centers at the district level was reduced by 30% in 2010 as compared to 2008. Likewise, external funding declined from 16.3% in 2008 to 3% in 2010. This reduced financing resulted in the closure of 10% of primary health care facilities and associated reduction of antenatal care coverage from 73.4% in 2008 to 62.1% in 2010. Utilization of basic health centers and prenatal consultations decreased by 20% from 2008-2011. By 2010, Madagascar had an average of three hospital beds per 10,000 people and a total of 3,150

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doctors, 5,661 nurses, 385 community health workers, 175 pharmacists and 57 dentists for a population of 22 million. Therefore, whatever gains were made prior to the 2009 crisis were quickly erased. By 2012, MMR was 478 per 100,000 births (MDG Survey), compared to 498 in 2008 and far from the MDG of 149 per 100,000. The IMR in 2011 was 41 per 1,000 births, with an under-five mortality rate at 61 per 1,000 births. Chronic malnutrition remained highly prevalent, with 50% of children under 5 being stunted, severely underweight and 27% of pregnant women being severely underweight and anemic. Alarmingly, the rate of acute malnutrition, climbed from 4.7% in 2008 to 7.4% in 2011 for children under 5. Additionally, the lack of hygiene (10% of rural population with access to improved sanitation facilities, 2009 data), and the lack of access to drinking water (29% of rural population with access to improved water source, 2008 data) significantly exacerbated these poor health outcomes, only encouraging the development of such infectious diseases as respiratory ailments, tuberculosis and hepatitis.

4. Changed implementation arrangements and refocused project activities (2010-2012). Following the MTR, and because of the political crisis and the suspension of the project, during 2009, many staff resigned in the ES/CNLS. Therefore, by the time the suspension was lifted in November 2009, there was a renewed challenge on how to improve project performance given the constraints and past history. It was also clear that the project needed to be extended in order to fully complete its activities which became all the more critical given the political and economic situation. Therefore, a decision was taken to implement the recommendations of the December 2008 MTR, first by making a change in implementation arrangements. The Bank-supported Sustainable Health Systems project closed in December 2009 and its PIU (in the MOH) had the necessary capacity and experience, and was already directly involved in the implementation of Component 2. Therefore, instead of recruiting new ES/CNLS staff, it was agreed to shift project implementation to the MOH PIU. A Memorandum of Understanding was signed on February 10, 2010 between ES/CNLS and the PIU which outlined the new implementation structure until the new Closing Date of December 31, 2011. The responsibility for project oversight and coordination remained with the ES/CNLS while the MOH PIU took on project management responsibility. The ES/CNLS Executive Secretary still maintained the role of the National Director of the project while the National Coordinator of the PIU became the Assistant Director.

The second major change was a refocused effort on prevention activities targeted on high risk groups. Since Component 3 was suspended, the decision was made in 2009/2010 to hire 5 national and international NGOs on performance-based contracts, directly targeting youths, sex workers and the military. The first set of contracts (2010-2012) were carried out in 17 regions (38 districts), and the second part was carried out from 2012-2014 in 10 regions (21 districts). This new implementation modality was instrumental in changing the course of the project. More details on this work is found below in the project outcome section.

5. Additional Financing (2012-2014). The impetus for preparing this AF was to provide urgently needed support for health and nutrition services following the 2009 political crisis by filling the financing gap left by the December 2007 closure of the successful eight-year Bank-financed Health Sector Support Project II, the December 2009 closure of the Sustainable Health System Development project, and the July 2011 closure of the Second Community Nutrition Project. The Bank team had initially prepared a US$63 million Joint Health Sector Support Project which was meant to be presented to the Bank’s Board of Executive Directors in January 2009, but given the

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political crisis, the Bank could not approve the operation at that time. Therefore, the AF, approved in mid-2012 (as part of the Madagascar portfolio restructuring), served as a bridge financing arrangement while a new health operation was under preparation. The AF continued the Bank’s long engagement in the health sector, using resources pulled from other projects as part of an intensive restructuring of the Bank’s Madagascar portfolio. Its implementation had the positive additional aspect of supporting the established implementation capacity and a partnership arrangement with other donors in the sector. Because of Government approval delays in Parliament (AF document was submitted late), the AF only became effective on February 22, 2013, eight months after Board approval and three months after the approval of the Emergency Support to Critical Education, Health and Nutrition Services Project (approved November 29, 2012). This effectiveness delay left only a year and half for implementation of the AF activities until the September 2014 Closing Date. Despite the delays and the overlap with the new multi-sectoral project, the AF still served an important purpose of carrying out critically important health and nutrition activities, a results-based health pilot, and continued prevention activities through five NGOs, under performance-based contracts. Therefore, the AF allowed the new operation to build on its lessons as well as laid a useful foundation for any future operation involving these sectors.

2.3 Monitoring and Evaluation Design, Implementation and Utilization

Design: The PAD Annex 1 contained 10 PDO indicators (of which targets for 4 indicators were subsequently revised during the December 2011 restructuring). This original design of the RF and M&E arrangements was generally reflective of the project design, i.e. the PDO indicators included HIV/AIDS knowledge and behavior indicators focused on youth 15-24, broader population 15-49, and high-risk groups which the PAD defined as sex workers, military and truckers. The high-risk group did not include Injection Drug Users (IDUs) and MSM, for example, and the PAD does not specifically address why these particularly high-risk populations were not included. However, it was clarified during the ICR preparation that the choice to support select high-risk groups was based on a division of responsibilities among donors; for example, the Global Fund was supporting IDUs and MSM under its program. The entire set of indicators was validated by the UNAIDS Thematic Group in April 2005. In terms of intermediate outcome indicators, the PAD contained 13 indicators which were linked to the five project components. The PAD included baselines for 9 out of 10 outcome indicators and there were targets provided for all project indicators. The data was based on existing DHS and behavioral surveillance surveys.

The project (through its Component 4 on M&E) aimed to strengthen the national M&E system which was initially developed with support from the original MSPPI project. Although significant progress was made under MSPPI, this project needed to ensure a fuller integration of the Management Information System (under a common platform) and better use of second generation surveillance data for national programming and decision-making. Therefore, MSSPII included financing for the collection of additional data through epidemiological and behavioral surveys and ensuring its real-time use. M&E specialists were to be placed in the Regional Coordinating Bureaus to guide the implementation of M&E system at the sub-regional level and to ensure good quality data collection. The project was also to finance a consultant to work closely with the ES/CNLS staff to analyze this data on an annual basis and make programmatic recommendations. Lastly, Lot Quality Assurance Sampling (LQAS) was to support collection of data in project areas and measure project–specific impact.

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Implementation: The Results Framework was officially revised for the first time on December 23, 2011; however, plans existed to revise the indicators as early as 2008, prior to the MTR (as reflected in Implementation Status Reports). The November 2008 MTR issues paper recommended to broaden the high-risk groups from sex workers to include military and pregnant women. It also claimed that some indicators were measuring only 15-49 age group when in reality, of the 10 outcome indicators, only 1 was exclusively focused on that group. In fact, all other original indicators were designed to measure progress by gender and by the different age groups. Nonetheless, the 2011 Restructuring Paper claimed that the original set of indicators needed to be streamlined and certain indicators needed to be modified to reflect strengthened focus on high risk groups and to rectify the existing disconnect between activities and intermediate and outcome indicators. Indicators which were no longer relevant or measurable were dropped. The proposed changes to the RF were in fact reflecting the accompanying re-focusing of the project to support better targeting on high-risk groups, to reinforce the supply side of the fight against STI/HIV/AIDS and to improve the care and treatment of PLWHA.

Indeed, as a result of the December 2011 restructuring, 5 of the 10 PDO indicators were dropped, leaving 1 indicator on syphilis prevalence among sex workers (#1), 1 knowledge indicator on citing three methods of HIV/AIDS prevention expanded to include youth and dropping the truckers (#3), and 3 behavior indicators on use of condom among youth and sex workers during the last sexual intercourse with a non-regular partner (#8, 9, 10). The targets of four of the five remaining outcome indicators were also changed at that time. In addition, 3 new indicators were added (#13, 14, 21), 2 of which measured percent change among youth and sex workers who received an HIV test in the last 12 months and knew the result and the third indicator was a core sector indicator measuring number of beneficiaries in line with the new internal mandate by the Bank to collect standardized data across projects. During this restructuring, 8 new intermediate outcome indicators were also added (although the restructuring paper does not include the mention of that change; the paper breaks the list of original and revised PDO indicators into 7 outcome and 7 intermediate outcome indicators. In the subsequent ISRs and in the AF paper, this distinction is no longer made, however.) While the December 2011 restructuring paper explicitly intended to eliminate the stated disconnect between project activities and indicators, the paper did not go into detail about how this was actually accomplished. The December 2011 restructuring also further strengthened Component 4 focusing on the M&E system. An additional three studies were included in the project to provide biological and behavioral data, as well as sensibility to antibiotics, and data from the experience of NGOs on how best to develop future approaches to combatting HIV/AIDS on a national scale.

The 2012 AF made further revisions to the RF, but mainly focused on adding indicators to reflect the changed nature of the project, expanding utilization of maternal and child health and nutrition services. At this time, 7 new outcome indicators were added (#4, 12, 16, 17, 18, 19, 20), 3 of which are HNP core sector indicators. Baselines and targets were also changed for 1 outcome indicator (#8). Also, 11 new intermediate outcome indicators were added at this time, 2 of which are core sector indicators. Baselines and targets were also revised for 2 intermediate outcome indicators. The design of these indicators appears to be thorough, based on latest estimates and survey data, and the AF paper is detailed and provides information on sources of data.

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The RF was further revised in August 2014 to change baseline data for some indicators from 2010 to 2012 and to revise targets downward. This was done at the request of the Government to correctly reflect the revised implementation period (April 2013-September 2014) due to the 9- month delay in the start-up of the AF. The August 2014 restructuring changed baselines and targets for 5 outcome indicators and 7 intermediate outcome indicators. While the general sentiment behind this change of the RF is entirely understandable, changing targets for indicators 1.5 months prior to project closure did not make a great difference in terms of achievement of targets. Indeed, in several cases, actual achievements were already known to have been reached and yet the targets were still revised downward. These indicator targets would have been met regardless.

Utilization: The project provided support for key surveys which would not have otherwise been carried out due to their prohibitive cost. These surveys were instrumental in providing evolving information and data to enable policy makers to closely monitor the epidemiological and behavioral trends. The ES/CNLS greatly appreciated the project’s contribution in this area and has utilized this data to develop and implement its revised National Strategic Plan 2013-2017.

2.4 Safeguard and Fiduciary Compliance

Procurement. The ES/CNLS was responsible for all procurement under the project, supported by consultant specialists. Considering the success of the MSSPI, the risks were rated as moderate. The procurement officer was recruited in 2008 and procurement activities were well advanced until 2009. However, at this time, the Borrower had to deal with the repayment of the amount ineligible due to the mismanagement of the FAP. It was decided to transfer the management of the Project and mainly procurement to the MOH PIU (UGP/Santé) which has always demonstrated its efficiency in project management. In 2010, and taking into account the progress made since the resumption of the project, and the quality of the documentation of procurement packages, the rating for procurement was Moderately Satisfactory. In 2011, despite some delays, goods were delivered and procurement was found to be Satisfactory and this rating was maintained until the end of the project in 2014.

Financial management. The FM aspects of the project were initially handled by a FM team under the ES/CNLS. However, following the 2009 Special Audit, US$745,569 was identified as ineligible expenditures under Component 3 (Fund for STI/HIV/AIDS Prevention and Care-Taking Activities) which were incurred as a result of inadequate book-keeping and controls on the part of CBOs and weak supervision on the part of the Financial Management Agency hired to manage those activities. At that stage, FM was assessed as Moderately Unsatisfactory.

Starting from 2010, project management was moved from the ES/CNLS PIU to the MOH PIU in order to improve FM and ensure the functioning of appropriate internal controls. As mentioned earlier, the project was also restructured to exclude the activities under Component 3 which had entailed ineligible expenditures (these were fully reimbursed to the Bank).

Subsequent to changes made in the December 2011 restructuring, the project had adequate FM arrangements over the remaining implementation period. The quarterly financial reports and annual audit reports were submitted to the Bank on a timely basis and recommendations made during implementation support missions were appropriately implemented. Internal controls were 21

spelled out in a Procedures Manual and compliance with the procedures was monitored by the Internal Controller. As a result of the improvement measures, the project’s FM was rated Satisfactory at the project’s final closing date.

Safeguards. MSSPII supported activities to strengthen the health system and enhance the MOH’s institutional capacity to improve access and utilization of health services, especially those linked to testing and treatment of STIs/HIV/AIDS. This could lead to increased medical waste production in the different types of health facilities which could adversely affect the environment and affect the local population if not managed and eliminated appropriately. Therefore, OP4.01 Environmental Assessment was triggered and the environmental category of the project was “B”. With technical assistance from the Bank, the GOM prepared a national Medical Waste Management Policy in July 2005. Subsequently, a National Medical Waste Management Plan (MWMP) was developed and the supervision missions noted the MOH’s strong commitment to the implementation of the plan. Project support as well as support from other donors contributed to MWMP implementation which was rated Satisfactory and Moderately Satisfactory during the life of the project.

The MWMP included proper disposal of hazardous bio-medical waste and a bio-safety training program for staff of all hospitals, health centers and community-based programs, including traditional midwifes and practitioners, who may be involved in HIV/AIDS testing and treatment. Operational activities were conducted mainly to disseminate tools for the elaboration of medical waste management plans in health facilities, trainings of health staff and provision of incinerators to hospitals. The implementation of the MWMP recorded the following results: • 200 small-scale burners to burn medical waste in all 200 health centers rehabilitated under CRESANII; • 61% of public hospitals (77 health centers) sensitized to the National MWMP; • 30% (or 37 health centers) elaborated medical waste management plans; • 10% of the CSB (120 health facilities) sensitized to develop their own medical waste management plans; • 44 incinerators built; • The National Policy and its tools have been circulated to the partners, the DRS, the DSSS and 120 public hospitals and health facilities; • The training modules are available on CDs; • The cascade training processes have been provided to the hospitals and health centers at the interregional and regional level: 16 regions, 1044 (DSS and CHD) trainers have been trained; • In the health sector, a coordinator unit (SAGS), in charge of the supervision and monitoring of the implementation of the National Medical Waste Management Policy is operational.

2.5 Post-completion Operation/Next Phase

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Previous efforts by the Bank, including under the original project and its AF, led to scaled-up interventions currently supported under the Emergency Support to Education, Health and Nutrition Services Project (approved in December 2012 and closing in July 2016) in the total amount of US$65 million, of which US$37 million supports health and nutrition interventions. The ongoing project also includes an estimated US$2.42 million for HIV/AIDS activities (of which there is a performance-based contract with an NGO for prevention activities in the amount of US$956,078). In February 2014, the Bank approved US$10 million in AF for this emergency operation to support nutrition activities. Future Bank support will be based on the program outlined in the upcoming Country Partnership Framework (CPF) which is expected to be discussed at the Bank’s Board of Executive Directors by the end of 2015. To inform the CPF, a Systematic Country Diagnostic is being finalized and is expected to be presented to the Bank’s Board of Executive Directors in May 2015. Based on the past 25 years of Bank experience in Madagascar and lessons learned in HIV/AIDS, health and nutrition, future engagement will not likely include a stand-alone HIV/AIDS project, but will be a multi-sector comprehensive approach focusing on critical areas where the Bank can be most effective with close linkages to international partners working in these sectors.

3. Assessment of Outcomes

The following assessment of project outcomes is based on analysis of three project phases because of the distinct features of each phase. Phase 1 (2005-2009) encompasses the original project design prior to the MTR and restructuring. Phase 2 (2010-2012) assesses the original project in its redesigned form, taking into account the restructuring which was formalized in December 2011 but which in fact was already in effect since the start of 2010. Finally, Phase 3 (2012-2014) assesses the period of AF.

3.1 Relevance of Objectives, Design and Implementation

Objective: The project development objectives were directly relevant and consistent with the National Strategic Plan (NSP) for HIV/AIDS (2001-2006), the subsequent NSP of 2007-2012, and remain relevant to the current NSP of 2013-2017. Control over STIs and HIV/AIDS remains a priority for the GOM. Even though HIV prevalence is estimated at 0.4% in the 15-49 age group, HIV prevalence is significant among high risk groups (14.7% among MSM, 7.1% among IDUs, and 1.3% among sex workers). Likewise, STI infection rates remain stubbornly high in the general population and among these high risk groups, with rates of syphilis at 15.6% among sex workers, 16.7% among members of the military, and 3.4% among pregnant women. Also, major efforts are required to control vertical HIV transmission with only 2.8% of HIV positive pregnant women receiving ARVs (the use of antenatal care is only 50%, with only 56% of health care centers offering HIV testing). Likewise, there is a significant gap between those currently receiving ARV treatment (695), those needing treatment (19,000), and the total estimated number of people living with HIV/AIDS (54,000). Meanwhile, high risk behaviors, low knowledge, and very high stigma against PLWHA only fuel the epidemic. Hence, the targeting of prevention interventions on high- risk groups remains the main objective of the current NSP, as well as improved health response to diagnose and treat HIV-infected individuals. The NSP also places importance on reinforced communication campaigns for high-risk groups and for the general population in the most vulnerable areas of the country.

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The original project objectives were and also remain consistent with the Millennium Development Goal 6 (to halt and reverse the spread of HIV/AIDS and malaria and other diseases by 2015; to develop a global partnership for development). The project was part of the broader Multi-Country HIV/AIDS Program for Africa (MAP) which the Bank supported to realize the UNAIDS principle of “The Three Ones”, one national authority for HIV/AIDS, one strategic framework, and one monitoring and evaluation system. The 2004 Interim Review of the MAP by the Bank made a set of recommendations which the MSPPII adopted in its design, inter alia, taking into account the needs of the entire health sector in the response to the epidemic, and tailoring project design to unique epidemiological, economic, behavioral and social circumstances of individual countries. Lastly, the project was consistent with the Bank’s Country Assistance Strategy (October 2003) under pillar 3.

While the PDO during Phase 1 was Substantially relevant to the country’s goals (and for continuity and expediency reasons for a repeater project), it became only Modestly so during Phase 2. While the re-designed project placed emphasis squarely on targeting high-risk groups, the PDO remained as it was under Phase 1. To be entirely relevant, it should have likely been adapted to reflect the new emphasis placed on targeting high risk groups and to reflect a greater role to be played by the health sector in relation to management of STIs and treatment and care of PLWHA.

The relevance of the AF PDO during Phase 3 was and remains High given lagging indicators concerning pregnant women and children under five which were further exacerbated after the 2009 political crisis, as discussed above. The PDO is entirely consistent with the Bank’s Interim Strategy Note (2012) which explicitly proposed that the Bank needs to continue to intervene in health and nutrition as priority sectors. The AF PDO was also consistent with MDGs 4 and 5 on maternal and child mortality and was also in line with the MOH strategy for the health sector. In relation to HIV/AIDS, the AF PDO was very relevant and realistic, specifically mentioning project areas where services and interventions were to be rendered.

Design: The project design evolved in line with the changes made in the NSPs and was coordinated at the highest level with the Executive Secretary of CNLS in charge of the national HIV/AIDS response. Indeed, by looking at the original project design and its subsequent important restructurings, clearly, the project modified activities from ones focusing on mass communication campaigns as supported by the MSPPI for the general population to those targeted to the highest vulnerable communes and the highest risk groups within them. Indeed, the project design meant to target interventions on high risk groups using a vulnerability analysis of communes (carried out in 2006 and repeated in 2012, financed by UNDP) as a key element to make interventions more effective. The project also improved on the original design by including support to the health sector in order to ensure a more comprehensive approach to HIV/AIDS; this included intensive screening, treatment and support for PLWHA as well as support for STI management. Therefore, on balance, relevance of design was Modest in Phase 1 (2005-2009) and was Substantial for Phase 2 (2010- 2012). Under the AF, the health sector received additional support for STI/HIV/AIDS as well as reproductive and nutrition services which were all Highly relevant and consistent with global lessons on HIV/AIDS prevention, with lessons from MSSPI and previous health and nutrition projects supported by the Bank. Implementation of the AF was targeted to the Madagascar’s five

24 most vulnerable regions. Although imperfect in implementation (particularly in the early period when many sub-projects were implemented with varying degrees of effectiveness), the project’s design remained relevant and consistent with the NSP. The design of the RF, as discussed above, was also relevant to the overall objectives (despite the many changes). Indeed, the current NSP (2013-2017) includes eight top priorities to address the HIV/AIDS epidemic, all of which were essential elements of project design.2

Implementation: The relevance of the implementation approach used to support the main prevention measures under Component 3 was Modest during Phase 1, using the mechanism developed under MSSPI. This involved continued reliance on a multitude of NGOs and CBOs implementing an assortment of small-medium size sub-projects which ranged from various forms of communication campaigns to raise awareness among the general population, encouraging testing among certain target groups, prevention measures such as distribution of condoms. These interventions were targeted on severely and moderately vulnerable communes and interviews with stakeholders demonstrated that these efforts were positive in raising the overall visibility of the National HIV/AIDS Program. However, stakeholders also acknowledged that the epidemic is concentrated in high-risk groups and that direct, focused efforts carried out in the later part of the project through a limited number of larger NGOs (5) under performance-based contracts made more sense and were more effective. Therefore, relevance for implementation was Substantial in Phase 2 and Phase 3 of the project. However, the recommendation from numerous interviews conducted by the ICR author among various stakeholders pointed out that the scope of the effort certainly needed to be further widened, particularly with respect to youths who are susceptible to getting infected given the persistently poor indicators in terms of their behavior and knowledge. Had this targeted and focused approach been used from the beginning, there could have possibly been even more progress in changing attitudes and behaviors among the most at risk groups.

The overall rating for project relevance is Modest for Phase 1, Substantial for Phase 2 and High for Phase 3 in view of the above arguments.

3.2 Achievement of Project Development Objectives

The achievement of the project development objective is based on the original and revised PDO. The original PDO was to “to support the Government of Madagascar’s efforts to promote a multi- sectoral response to the HIV/AIDS crisis and to contain the spread of HIV/AIDS on its territory.” The assessment of this objective is based on progress against key performance indicators and overall project implementation during Phase 1, Phase 2 and Phase 3 each of which represents a clear distinction in terms of implementation before and after the 2009 political crisis as well as a different implementation approach used in Phases 2 and 3. The revised objective under the AF

2 The NSP 2013-2017 priorities are: (i) intensify efforts to promote safe sexual behaviors, especially among key high-risk populations; (ii) strengthen supply of syndromic STI management; (iii) improve quality of VCT with increased coverage of high-risk groups; (iv) expand and improve prevention of PMTCT; (v) ensure blood safety; (vi) expand and improve quality of care of PLWHA; (vii) create a more favorable environment for the care and development of orphans and other vulnerable children; and (viii) strengthen monitoring, evaluation and coordination mechanisms for a national response to HIV/AIDS.

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was “to increase utilization of STI/HIV/AIDS, and maternal and child health, nutrition services in project areas.” The table below presents a summary of achievement of PDO and Intermediate Outcome indicators (IO) across the three phases to facilitate understanding of the otherwise complicated history of RF changes and achievement.

Phase 1 Phase 2 Phase 3 original Original and Dec Original, Dec 2011 and PDO indicators indicators 2011 indicators 2012 AF indicators 1 (new - core) 5 (new, of which 3 core) Surpassed 1 1 (original) 1 (Dec 2011-core) 1 (original); 1 (new at 1 (original); 1 (added at Achieved 1 ICR) ICR); 1 (new) Partially achieved 2 2 (original) 2 (original); 1 (new) Not achieved 6 2 (new); 1 (original) 2 (Dec 2011); 1 (original) Total 10 9 15 Total surpassed, achieved 4 (U) 6 (MS) 12 (S) and partially achieved 40%+ 66%+ 80%+ IO indicators Surpassed 1 (new) 7 (new); 1 (Dec 2011) 9 (targets 2 (new); 6 (Dec 2011) 6 (new); 9 (original) Achieved revised for 2) 9 (original) 2 (new- targets revised

Partially achieved August 2014) 1 (Dec 2011) 1 (new); 4 (original) Not achieved 4 4 (original) Total 13 21 32 Total surpassed, achieved 9 (MS) 16 (MS) 25 (MS) and partially achieved 69.2% 76.2%+ 78.1%+ 57% 77% 95% Weighted Average MU MS HS Rating scale: HU/U (0-40%); MU (41-64%); MS (65-79%); S (80-94%); HS (95-100%) Note: %+ signifies that total % does not reflect some indicators surpassing their targets. A weighted average was calculated using the following scale (Surpassed=1.5x; Achieved=1x; Partially Achieved=0.75x). The ratings were not weighed in favor of the last 2 phases or their timing even though it is clear that the project greatly benefitted from changes made in the design and was thereby able to meet its objectives despite political turmoil.

PDO #1: Original & revised project (Phases 1 and 2) The objective was to provide support to the national effort by: (i) promoting a multi-sectoral response, and (ii) containing the spread of HIV/AIDS. In terms of the first sub-objective, the project was moderately successful as only a few sectors, notably National Defense, Civil Service, Education, and Health and Family Planning, all prepared their sector strategies and plans. The project began with a plan to work with 10 sectors in total, but in the end, only these few prepared their sector actions plans. According to the ES/CNLS, a number of other plans were rejected as they did not meet the ES/CNLS standards. Importantly, the sectors which did participate were some of the most important, and while they progressed in the implementation of their plans successfully, their involvement was short-lived as this work was carried out under Component 1

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which closed at the start of 2009 after the political crisis and was not rekindled under the project as only critical components were left. Component 1 was deemed essentially achieved by the Bank team, with the final rating of Moderately Satisfactory given the engagement of key sectors and because the Component also supported a number of important activities to strengthen the NSP and its implementation (capacity building in setting up regional and local coordination units) as well as development and implementation of a communication plan. Clearly, after the closure of Component 1, work continued to be carried out by the various sectors, in spite of the project, e.g. the education, defense, and health sectors were extensively involved in this effort during the entire project period. It must be noted that the multi-sectoral approach indeed permeated the entire set- up under the national program, with regions and districts heavily involved in prevention and communication efforts through the Government’s new decentralized approach, relying on a variety of agencies, CBOs, NGOs, and media. Multi-sectoral activities were carried out jointly with a number of other donors, with clear separate mandates for each. Therefore, the efforts made under the project need to be seen in this light as well. Overall, the achievement of this objective can be considered as Moderately achieved (the rating of Modest does not reflect the efforts made while a rating of Substantial implied only minor weaknesses).

The second sub-objective to contain the spread of HIV/AIDS was aided in two ways: (i) screening, prevention and treatment efforts; and (ii) improved M&E. The first part of this effort entailed prevention, treatment and care measures, including, inter alia, communication and outreach to the general population, targeted prevention for high-risk groups, condom promotion and distribution, significantly increased screening/testing for HIV/AIDS, provision of drugs for PLWHA as well as for opportunistic infections, care of PLWHA. The list of all activities undertaken particularly under Component 2 and 3 are described in Annex 2 and the exhaustive list and a map of communes targeted is in Annex 10. The efforts made need to be assessed separately for each project phase.

Phase 1 interventions were carried out nationally, across 22 regions, targeting “hot” communes identified to be most vulnerable (communes identified in the UNDP financed 2006 vulnerability study). 3 A total of 761 of 1,549 communes were reached, with 2,817 communication and prevention sub-projects of which 1,745 were completed (contracts with 57 NGOs/CBOs and 724 associations). Interventions were mainly focused on two levels of vulnerability, “severely vulnerable communes” (94 of 119 reached=79%), and “moderately vulnerable communes” (193 of 338 reached = 57%). A total of 76% of FAP funds were focused on these most vulnerable communes. One of the most enduring and successful aspects of this work was the significantly increased testing which was strongly encouraged as part of awareness messaging. As a result, while in 2005, only 11,146 people were tested, in 2007 the number reached 351,806 and 427,800 in 2008. Likewise, the number of VCT centers increased from 49 in 2004 to 779 by 2009 during this time to support this increased demand. A number of other health interventions were also carried out in support of prevention interventions, such as acquisition of STI treatment kits, reagents, ARV drugs, training materials for health centers, and the acquisition of 15 million condoms. The total population targeted through these efforts (of estimated 23 million people in Madagascar) is presented below. The calculation is based on the total number of people targeted

3 See Annex 10 for a list of total communes reached by the project.

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(2.8 million) in “severely vulnerable” communes under each of the 2,817 sub-projects of the total number targeted (5.8 million). Phase 1 (2005-2009): Population covered with awareness efforts in 22 regions total targeted “severely vulnerable” % of total in each 6 provinces & 5 cities population communes province/city ANTANANARIVO 2,246,560 1,163,574 52% ANTSIRANANA 253,065 77,799 31% FIANARANTSOA 282,522 77,489 27% MAHAJANGA 162,855 100,713 62% SAMBAVA (city) 367,746 243,730 66% TOAMASINA 536,672 423,703 79% TOLAGNARO (city) 674,478 568,637 84% TOLIARA 1,049,543 143,882 14% ANTSIRABE (city) 135,516 56,693 42% MAINTIRANO (city) 41,469 14,792 36% MANAKARA (city) 59,904 15,600 26% 5,810,330 2,886,612 50%

While this was a significant effort, the types of interventions were mostly communication and awareness for the general population and for some high risk groups which tends to have lower to medium impact than targeted prevention measures under Phase 2 (see more details on the Economic analysis below). Indeed, despite previous efforts of similar nature and during Phase 1, the outcomes of these interventions are mixed for the general population in Madagascar. For example, the current syphilis prevalence among sex workers(15.8%) is essentially the same as it was in 2005 (16.6%) and prevalence of other STIs remains high; general knowledge of HIV/AIDS transmission is still low among youths and only marginally better since 2005 (PDO indicator 2) although improvements were made among sex workers, military and truckers (10-20% points increase in knowledge- PDO 3,5); meanwhile, discriminatory attitudes towards PLWHA are incredibly high (95% average – PDO indicator 7); high risk behaviors remain a concern (low condom use in the general population- PDO indicator 8) although progress was made in this regard in project areas among sex workers and the military (PDO indicators 10, 12) and incidence of sex with non-regular partners was reduced (20 percentage point reduction from 2005 - PDO indicator 9). Therefore, on balance the types of interventions to contain HIV/AIDS carried out during Phase 1 are likely to have had a modest/moderate impact although the impact of increased testing was very high.

By contrast, Phase 2 and Phase 3 interventions were intentionally targeted by 5 NGOs on a select high-risk group (150,325 people) in 120 communes (reaching 72% of “severely vulnerable” communes – see table below) in 16 regions, focusing their efforts on sex workers (12,412), military personnel (13,004) and youth ages 15-24 (124,909). The results of these interventions were much more encouraging as most of the work was done using peer educators closely engaged with each type of group. For example, average 71% of youth knew three main modes of transmission in 2014 as compared with an average of 49% in 2010 (PDO indicator 4); the indicator for condom use

28 among the youth surpassed the target by 23% on average (PDO indicator 8); the same indicator for sex workers was also met, achieving 86.3% by 2014 (PDO indicator 10).

Phase 2 and Phase 3 (2010-2014): Number of Prevention Interventions by NGOs

number of vulnerable % of total Regions ASOS PSI ADRA MSM SISAL total communes communes targeted by NGOs 1 Analamanga 3 22 25 23 92% 2 Vakinankaratra 2 2 2 6 4 67% 3 Bongolava 1 1 1 100% 4 Itasy 2 11 13 13 100% 5 Sava 4 4 8 6 75% 6 Haute Matsiatra 1 4 5 3 60% 7 Amoron'i Mania 5 5 1 20% Atsimo 8 Atsinanana 6 6 6 100% Vatovavy 9 Fitovinany 3 3 3 100% 10 Boeny 2 2 2 100% 11 Sofia 1 4 5 2 40% 12 Betsiboka 1 1 1 100% 13 Alaotra Mangoro 1 2 10 13 13 100% 14 Analanjirofo 3 3 6 0 0% 15 Atsimo Andrefana 2 12 14 1 7% 16 Androy 7 7 7 100% TOTAL 14 16 14 42 34 120 86 72%

A final independent verification survey of activities carried out by NGOs under performance based contacts was completed in 2014. Each NGO had to meet a certain percentage of agreed performance targets (quantitative and qualitative) in order to get fully paid for the work. As the table below shows, the overall performance of these NGOs was found to be excellent with just a few exceptions. One NGO in particular had challenges working with the military, pointing out that while prevention activities were successful in the first round, the second round was not as successful because the group targeted changed in composition entirely due to military movements in 2013, and therefore, the survey likely did not do full justice to the actual achievements. Nonetheless, the tables clearly show that overall performance targets were largely met, and therefore, Phase 2 and Phase 3 prevention interventions are considered as Substantially achieved.

Target groups (2010-2011) 5 NGOs Performance (%) Performance payments Sex workers and youth 15-24 PSI 117.90 8% bonus Military and youth 15-24 ADRA 102.30 5% bonus Military and youth 15-24 MSI 96.60 full payment

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Sex workers SISAL 76.70 8% withheld Youth 15-24 ASOS 63.90 15% withheld

Target group LOT 5 NGOs Performance (%) Performance payments 2012-2014 1 ASOS 118.6 8% bonus 2 MSI 129.4 10% bonus Youth 15-24 3 MSI 104.8 5% bonus 4 MSI 78.6 8% withheld 5 MSI 112 8% bonus 1 SISAL 93.4 5% withheld Sex workers 2 PSI 97.8 full payment Military 1 ADRA 64.5 15% withheld

In addition to prevention, the project also supported the acquisition and distribution of 17.6 million condoms per year in project areas, the purchase of STI treatment for 5,822 health centers (3.5 million STI treatment kits sold in public and private sector), screening for HIV/AIDS of sex workers, military and youth (127,092 tested in one year-2014), testing and treatment of pregnant women for syphilis (2139 women), expanding VCT to all district hospitals and basic health centers (CSB2), treatment and care sites for AIDS patients, purchase of treatment of opportunistic infections for reference centers, strengthening the network of psychosocial support in 8 regions using the MADAIDS NGO network, and establishing a Logistics Management Information System to monitor drug supplies (using mobile phones). These health sector interventions were a critical part of ensuring that key population groups such as pregnant women and high-risk groups received testing and that treatment and care was provided to PLWHA.

The second part of the effort to contain the spread of HIV/AIDS was the projects’ great emphasis on improving M&E capacity through recruitment and training of M&E specialists at central, regional and sub-regional levels, revision of the National M&E Plan and information system, the development of tools and surveys, including strengthening of the epidemiological surveillance of STIs, TB and HIV/AIDS, carrying out second generation (biological and behavioral) surveys and other specific studies. This combined effort enabled the collection, analysis and dissemination of data across all levels for a more informed response in the fight against HIV/AIDS. A total of 13 different surveys were carried out under the project. This work was closely coordinated with the UNAIDS.

Although additional studies need to be carried out, such as a more in-depth study on syphilis and its relation to HIV/AIDS, data collected has provided UNAIDS with information to better and more accurately estimate the trends in the epidemic. According to the latest UNAIDS estimates (May 2014), prevalence rates among adults aged 15-49 have decreased from 0.7% in 2005 to 0.4% in 2014. This is based on data collected during the course of the project as well as through surveys financed by other donors. Although an overall reduction in prevalence cannot be a single measure of success or failure in curbing the HIV/AIDS epidemic, because increased testing and treatment measures may actually increase prevalence in the short-term, the data does indicate that the epidemic is still contained within high-risk groups. According to the 2014 ES/CNLS Report on the AIDS Response, 99.3% of new infections come from groups including MSM, IDUs, sex

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workers and their clients. HIV prevalence is 14.7% for MSM, 7.1% for IDUs, and 1.3% among female sex workers. Given the relatively large portion of financing by the project in support of the National AIDS response, it can be inferred that the project did contribute to the containment of the epidemic.

PDO#2 – during AF (Phase 3) The objective under the AF was to increase utilization of STI/HIV/AIDS, maternal and child health, and nutrition services in project areas. The support for the STI/HIV/AIDS under the AF was roughly 30% of the total AF cost and the success of these prevention and treatment services are described above. The main part of the support during this AF phase was to provide bridge financing before the Emergency Support to Critical Education, Health and Nutrition Services Project was approved in November 2012. Therefore, the effort on maternal and child health and nutrition was limited to the poorest areas in 5 regions (143 health centers and 659 nutrition sites). The services included antenatal consultations, PMTCT, iron and folic acid supplementation, vaccinations, vitamin A supplementation, distribution of mosquito nets, prevention and treatment of malaria, integrated treatment of childhood diseases, and provision of nutrition inputs, culinary demonstrations, awareness raising and counseling, and referrals of malnourished children. This work was also supported through performance based contracts and a voucher system for drugs.

The outcomes of these interventions, inter alia, include:

(i) increase in pregnant women receiving antenatal care during the visits to a healthcare provider from 57,242 in 2012 to 140,989 by 2014, surpassing the target (PDO indicator 17); (ii) increase in the number of children 0-24 months from 48,200 in 2012 to 51,834 in 2014) obtaining monthly adequate minimum weight (PDO indicator 18); (iii) increase in the number of children immunized from 53,214 in 2012 to 132,226 in 2014 (PDO indicator 19); (iv) increase in the number of people with access to a basic package of health, nutrition and reproductive health services from 283,203 in 2013 to 403,025 in 2014 (PDO indicator 20); (v) number of pregnant women receiving folic acid increased from 81,994 in 2012 to 184,482 in 2014 (IO indicator 11); and (vi) increase in the number of children receiving vitamin A more than doubled from 2012 and 2014 (IO indicator (12).

A number of other indicators also shows overall increased access to services and increased utilization. On the basis of this highly concerted and effective effort over a period of less than 2 years, the overall rating for PDO2 is High.

3.3 Efficiency

Economic impact of prevention and treatment. An economic and financial analysis (see Annex 3) was carried out during the preparation of this ICR using available data from ES/CNLS, UNAIDS, and the MOH PIU. The analysis demonstrates that the overall impact of interventions is Substantial.

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While it is not feasible to estimate the precise economic and financial benefits for Phase 1, the types of interventions carried out (mass media, communications, education, screening, condom promotion and distribution for the general population and some target groups such as sex workers and youths aged 15-24) point to a low to medium range impact, based on the findings of an economic analysis on HIV/AIDS done under the Bank Multi-Country HIV/AIDS Program for the Africa Region (2004). In the case of Madagascar, a low prevalence country, the report suggests that the most cost-effective interventions are targeted prevention measures on the highest risk groups such as sex workers, as well as on PMTCT, rather than on general communication campaigns. Therefore, efficiency for Phase 1 is relatively Modest given that some important prevention work was indeed carried out among high-risk groups in highly vulnerable areas.

Given the exact available data on the types of interventions and the number of people reached during Phase 2 (2010-2014), the economic and financial analysis was carried out on the prevention and treatment and care activities. The analysis reveals a positive return on investment which makes these interventions economically worthwhile, with efficiency for this Phase 2 rated High given the benefit-cost ratios calculated. With respect to prevention, the project averted an estimated total of 1,683 new HIV infections. Based on high and low averted productivity loss estimates, the Net Benefits of prevention is between US$17,115,734 and US$24,831,254, with benefit-cost-ratios of 4.7/1 and 6.4/1, respectively. The HIV treatment and care component financed the treatment of 695 HIV patients. That resulted in a Net Benefit of US$3,783,421, with a benefit-cost-ratio of 9.8/1.

Cost-effectiveness of Maternal and Child interventions: The AF supported an integrated package of services provided for pregnant women and children under 5 in the poorest areas in five regions. The package included health and nutrition services considered to be low cost and yielding high and immediate impact on the lives of women and children. These services were carried out through an NGO network that also used an innovative voucher system for medicines as well as performance-based contracts. The efficiency of these interventions was High given the very short and focused time frame available. The project reached beneficiaries in 143 health centers and 659 nutrition sites through 33 NGOs and was able to fully disburse all available funds.

Efficiency of implementation: The length of the project period (with two extensions of the original Closing Date), was affected by start-up delays when the first project was still being implemented, and then by the 2009 political crisis, without which the project would have likely been implemented in 5-6 years which is an average implementation period for Bank-financed projects. Therefore, given that project implementation actually started in mid-2007, and considering the constraints faced and the efforts made to improve implementation to enable the project to disburse fully, the overall efficiency of implementation is considered as Modest to Substantial.

Based on the individual ratings above, the overall rating for efficiency is Substantial.

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3.4 Justification of Overall Outcome Rating Rating: Moderately Satisfactory

Overall Phase 1 (2005-2009) Phase 2 (2010-2012) Phase 3 (2012-2014) rating Relevance Substantial Modest High Substantial Moderate for PDO1 (i); Substantial Efficacy Modest PDO1 (ii) Substantial High Efficiency Modest High High Substantial Outcome Moderately Moderately Rating Unsatisfactory Satisfactory Highly Satisfactory

Given the above analysis by the project’s three phases, the final outcome rating could be Satisfactory using the ICR guidelines. However, given the less than satisfactory performance during Phase 1 of the project, it is more fitting to rate the project as Moderately Satisfactory. This rating is also supported by the analysis of weighted ratings against project disbursements (see table below). Three scenarios were used to calculate the rating in order to demonstrate the effects of restructuring of December 2011. Overall, the ratings under the three scenarios provide an average weighted value of 4.34 which is consistent with a Moderately Satisfactory rating.

Original PDO Revised PDOs 2005-2012 2012-2014 Overall Comments (AF) An average rating of 3.5 MU (2005-2009) is used to reflect the 1 Rating HS MS MS (2010-2012) overall period from 2005-2012. 2 Rating value 3.5 (MU/MS) 6 Three weights are used to demonstrate the 3 project phase and to record that the 15.3(Dec 2009) 20.4 (Dec 2009) restructured project Total disbursed started to be 3 26.47(Dec 2011) 9.3(Dec 2011) 35.7 US$ million implemented under its 29(Dec 2012) 6.7(Sept 2014) new design at the start of 2010 which was officially recorded 2 years later in December 2011. Weight 43%(Dec 2009) 57% (total disbursed/final 4 74%(Dec 2011) 26% 100% disbursed amount of 81%(Dec 2012) 19% US$35.7 million) 1.51 3.42 4.93 Weigh value 5 2.59 1.56 4.15 (2 X 4) 2.80 1.14 3.94 MS (4.34 6 Final rating average) Note: HU (1); U (2); MU (3); MS (4); S (5); HS (6);

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3.5 Overarching Themes, Other Outcomes and Impacts (a) Poverty Impacts, Gender Aspects, and Social Development While the project was not an explicit poverty-targeted intervention, the prevention activities were targeted to the most at risk communes in the 22 regions of Madagascar. The ranking of these communes took into account the overall health indicators, access to health services, overall prevalence of risk behaviors, and a variety of other factors, many of which are directly correlated with increased poverty. Also, the activities under the AF focused on 5 regions with especially high poverty and low maternal and child health outcomes, in line with the 2011 poverty map and the DHS 2009, with the exception of the results-based pilot which was implemented in 29 health centers of 1 district, in 1 better-off region. The poverty ratios in the 5 regions ranged from 55.5- 94.4% for urban areas against a national average of 54.2%, and from 84.7-94.5% for rural areas against a national average of 76.5% (2010 data). This clearly indicates that the poorest regions benefitted under the project. Also, given the exceedingly high poverty levels overall, with almost 80% of the population living on less than US$1.25/day, and 92% living on less than US$2/day, measures supported by the project to provide testing, counseling and treatment for STI/HIV/AIDS as well as preventative and curative maternal and child health and nutrition services had clear direct poverty impacts on the population as these high-impact low cost interventions tend to do. In addition, the longer-term effects of prevention activities will be felt in the future in terms of averted direct and indirect costs of treatment and care as well as in terms of increased productivity of PLWHA and improved overall livelihood.

(b) Institutional Change/Strengthening The project had a Substantial impact on institutional development, both in terms of providing the necessary support to the development of an effective mechanism at the ES/CNLS but also in expanding capacity of line ministries, and strengthening capacity at regional and district offices charged with the implementation of the HIV/AIDS and health response. Institutional strengthening was a major part of the project design, with a stand-alone component on Monitoring and Evaluation which provided critical financing for important surveillance work which would otherwise not have been financed. This has increased the availability of quality data on the variety of HIV/AIDS and STI indicators and has thereby increased overall awareness about the main drivers of the epidemic.

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

3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops NA

4. Assessment of Risk to Development Outcome Rating: Substantial The risk to development outcomes is considered to be Substantial. Although the NSP has general support in the GOM and the ES/CNLS is equipped to coordinate and manage the response to STI/HIV/AIDS, with close collaboration from MOH and other relevant sectors, financial resources for the program are simply insufficient to manage an effective response. Total funding for the HIV/AIDS program (of which 90% is financed by international donors (see Annex 1 Table C for a summary of program financing from 2006-2014) has been cut in half from 2011 to 2013, while

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the Government share of that reduced amount has actually increased from 2.4% to 9.1% in the same period. The Global Fund is expected to provide US$17 million from 2015-2017 (next round approval expected July 2015) but this will only cover an estimated 15% of the needs in the sector. Meanwhile, subsequent to this project, funding from the Bank for HIV/AIDS has been limited to a very small amount as part of the support under the Emergency project currently under implementation. The ES/CNLS has very limited funding (US$400,000) per year (staff salaries, costs for meetings and supervision activities), sufficient to only coordinate activities financed by other sources. In view of these financial constraints, the ES/CNLS, with technical support from UNAIDS, is preparing an Investment Case Concept Note which will lay out the needs of the program and demonstrate the cost-effectiveness and the urgency of investing resources in a low prevalence setting, such as Madagascar, by targeting prevention activities to high risk groups in the most vulnerable communes. This Concept Note is expected to show that making these investments now rather than waiting for a generalized epidemic would be the best use of limited resources available to Madagascar. This Concept Note will also be used to coordinate a comprehensive response, including support from Government, international and bi-lateral donors as well as the private sector.

5. Assessment of Bank and Borrower Performance

5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry Rating: Moderately Unsatisfactory This repeater project was prepared very quickly, with preparation finalized in roughly 4.5 months. This rapid response by the Bank was a direct reflection of the Government’s expressed strong interest and commitment in the follow-on operation which was highlighted in the internal Bank reviews. The project built on the original operation but improved on the earlier approach by including a health component to respond to the testing and treatment needs and by using a prevention approach to be implemented in the most vulnerable communes (75% of project funds were to be allocated to “hot” or high-risk communes). The design also relied on small sub-projects to be implemented at the grass-root level by CBOs. The Bank team ensured that the project was aligned with the existing CAS and the National HIV/AIDS Program, and provided a continuum of support from the original project, without interruption in service delivery. The project ensured that the financing gap calculated by the Government would be covered for the next several years. Indeed, the Bank’s support for the National Program was absolutely critical given that its financing would account for roughly 30%, with the Global Fund financing another 15%. The risks were reasonably well identified and the RF was developed using the standard HIV/AIDS indicators which were endorsed by UNAIDS. Implementation arrangements were the same as used by the National Program and by the original project for continuity purposes. Therefore, the overall sense was that the preparation time was commensurate with the final design.

In retrospect, however, project preparation was carried out too quickly without a more in-depth appraisal of several key issues, including: (i) completion pace of the original project was overestimated (only 53% was disbursed by September 2006 whereas the Bank expected the project to be fully disbursed by the end of 2005); (ii) analysis of “hot” communes was planned but could have been carried out if the preparation time was longer; (iii) recommended analysis at the PCN and Decision meeting of effectiveness of interventions under the original project was not carried

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out, again because of the tight timetable to deliver this project; (iv) a more in-depth institutional review of capacity for project and program management by the main implementing agency, including the capacity of CBOs and NGOs, was not carried out although the Bank did acknowledge that this was likely a risk; and (v) economic analysis was not carried out although a reference was made to a general analysis done for the MAP which concluded that the cost-effectiveness of HIV/AIDS interventions depended on the type of the epidemic and the types of targeted interventions. Even though a low prevalence scenario indicated that the most effective interventions were those targeted on sex workers and PMTCT, the project design was focused on communication campaigns in high-risk areas, which is a higher cost and lower impact design. The fact that the project was re-designed mid-way to correct this emphasis indicates that the preparation could have benefitted from a more rigorous effort. Therefore, the overall rating for the Bank at entry is Moderately Unsatisfactory.

(b) Quality of Supervision Rating: Moderately Satisfactory During the early phase of the project, there was very limited activity, with the Bank team mainly supervising the original project which was extended until December 2007. The same Task Team was involved in supervision as during preparation for the first five years although the Task Team Leader changed after two years of implementation. During this initial two-year period, the Bank’s ISRs were essentially the same, rating the project as Satisfactory saying that start-up delays were due to the original project still being active and that the ES/CNLS PIU was focused on multiple donors and that it was hard to concentrate on this project. Government sources also point to insufficient communications with the Bank during this initial period with late Bank no-objections blamed for delays in implementation. The first time that any data was entered for the project indicators was October 2007 at which time a decision was also made to delay the MTR to the end of 2008. The overall realism of Satisfactory project ratings by the Bank has to be questioned for this early period when the total disbursements were only 15% in October 2007, 2 years from project closing. There were also some internal inconsistencies between ratings and the text of the ISRs, e.g. Component 1 was described as not-successful and yet rated as Moderately Satisfactory. The overall rating for implementation progress and other components fluctuated several times between MS and MU although there was actually little implementation progress. In general, this period saw little progress and mixed reporting by the Bank although there were regular, well- written Aide-memoires and good recommendations to improve progress.

While the start-up phase was challenging, subsequent Bank efforts to turn this project around were significant. When implementation picked up in 2007 and 2008, the Bank did a thorough review of progress and recommended a number of improvements. These were described in detail in the Implementation Section above. The Bank also took immediate corrective steps in suspending Component 3 when corruption allegations surfaced and recommended a Special Audit that later identified ineligible expenditures. The Bank team prepared an excellent MTR Issues Paper in 2008 and kept a very close eye on the project, undertaking regular reviews and ensuring that steps were taken, especially concerning the resolution of the ineligible expenditure issue. During the political crisis, the Bank was also very responsive and flexible in allowing three components to be implemented during the suspension period of the entire portfolio. This was critical for the continuity of service provision and greatly impacted the eventual outcome of this project. Also, when the health project closed in 2009, the Bank used the opportunity to improve the management

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of this project by recommending to transfer the responsibility to the MOH PIU. This turned out to be a very effective decision. All these recommendations were finally reflected in the formal project restructuring in December 2011 which the Bank team clearly wanted to undertake ever since 2008 as this is mentioned in almost every ISR. Unfortunately, the restructuring was delayed as a result of the political crisis and the suspension of the portfolio, as discussed earlier. Importantly, the necessary corrective measures were taken and were already being implemented and there were frequent and regular Bank supervision missions which reviewed project progress in detail and attempted to resolve additional bottlenecks through this process.

Lastly, the Bank did an excellent job in ensuring continuity of support for the critical needs in the health sector through the preparation of AF which also provided funds for NGO contracts for targeted prevention of HIV/AIDS. The design of the AF was very poverty focused and included a number of innovative approaches such as the results-based financing pilot and the voucher scheme providing free medications for pregnant women and children under 5. The design of the AF was effective and the lessons of its implementation have been used by the Emergency project currently under implementation. The Government programs targeting women and children will also be able to build on these lessons.

(c) Justification of Rating for Overall Bank Performance Rating: Moderately Satisfactory The overall rating reflects the Bank’s overall positive and strong support to the GOM’s efforts to fight HIV/AIDS and to strengthen the health and nutrition sectors during the last decade. Issues during the design phase as well as the political constraints outside the Bank’s control had a negative effect on the project. However, through a number of concerted efforts such as flexibility during implementation, restructuring and AF, the Bank was able to impact positively on the final outcome of the project. Therefore, on balance, the rating is Moderately Satisfactory.

5.2 Borrower Performance (a) Government Performance Rating: Moderately Satisfactory During project preparation and subsequent several years, the Government of Madagascar was deeply committed to curbing the spread of HIV/AIDS with the program personally spearheaded by the President from 2005-2009. The Government had and continues to have a clear National Strategic Plan, aligned with UNAIDS “Three Ones” principle. The Government has an established mechanism for the coordination and management of the program and the project financed by the Bank as well as other donors. This includes the CNLS at the center with its ES to oversee and coordinate the program (Executive Secretary overseeing project implementation), the Regional HIV/AIDS Prevention Committee (CRLS) and 22 Regional Coordination Units (UCR) charged with day-to-day management of activities and liaising between the ES/CNLS and Local HIV/AIDS Committees (CLLS) which are in turn responsible for developing a local plan in the fight against HIV/AIDS and mobilizing the local population and resources.

During project implementation, the Government took steps to improve the operational effectiveness of the program at all levels, through an external institutional review which was carried out in 2008 (see below). The Government also responded effectively to necessary changes in the project design and to the need for greater effectiveness in project management. The decision

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by Government, under advisement by the Bank and the ES/CNLS was to transfer responsibility for day-to-day project management to the PIU of the health project to manage the remaining period of implementation (2010-2014), which greatly improved implementation. Also, the Government took on the challenge associated with corruption allegations in 2008 by carrying out the 2009 Special Audit, and took steps to correct the identified ineligible expenditures by returning the funds per agreements with the Bank. The Government also supported the proposed project restructuring and was eager to ensure that resources would be spent on the most effective interventions.

Clearly, the 2009 political crisis had a major deleterious effect on the country and also on the project. This resulted in serious implementation delays which required two project extensions until the end of 2012. Despite the enormity of the challenge, the implementation mechanisms put in place turned out to be quite effective and the project was able to fully disburse its funds and complete all planned activities. The implementation of the AF was especially effective, with all funds disbursed within 1.5 years.

The Government (with ES/CNLS in charge) clearly understands the overall need for a targeted response to HIV/AIDS. With reduced donor funding, the Government has increased its own share of the budget, as discussed above. Nonetheless, this only represents 9% of the program needs and the Government has to take a proactive approach to ensure that the program remains viable in order not to lose the momentum gained during previous years.

(b) Implementing Agency or Agencies Performance Rating: Moderately Satisfactory

Overall responsibility for program implementation rested with ES/CNLS, with the ES (Project Director) overseeing day-to-day project implementation by the Project Implementation Unit (PIU) inside CNLS. Initial years of implementation were marked by inefficiencies and delays, including delays in initiation of key activities, hiring consultants, conducting various studies, approving annual work plans, procurement plans, carrying out evaluations of activities, etc. The heavy organizational structure of the ES/CNLS with 76 staff (one of the largest national AIDS committees in the world) and the PIU suffered from a lack of internal communications, lack of delegation of authority and weak management capacity of staff. In response to these challenges, and to align itself with the Government policy on decentralization, in 2008, ES/CNLS took on an institutional review of its functions. The review identified several constraints and recommended steps required to improve existing arrangements, including the need to: (i) revitalize the ES/CNLS mandate on being in charge of setting strategic directions of the HIV/AIDS response, i.e. to focus ES/CNLS’s role on coordination, planning, monitoring and evaluation of the HIV/AIDS Program; (ii) delegate the management of the response to the regions in accordance with the national decentralization policy by transferring to regions funds management responsibility; (iii) clarify roles and responsibilities of the ES/CNLS staff, also streamlining staff composition; and (iv) separate program coordination functions from project management functions.

Based on these recommendations, a new organizational structure was put in place which reflected reorientation from centralized management to delegation of authority to the regions, more rapid decision-making, and more clarity and efficiency of processes. Importantly, the responsibility for project management was transferred to the PIU already in place in the MOH. The initial step in

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this transfer was already made in 2008 when MOH took over the direct responsibility for implementing Component 2 of the project (health response) by taking over procurement, FM and disbursement (under its own Special Account for that component). The previous arrangement of having a single Special Account managed by the ES/CNLS proved to be ineffective with severe delays in disbursement of funds for MOH activities. Subsequently, at the start of 2010, the PIU/MOH took over the responsibility for overall project management, with ES/CNLS continuing its oversight and coordination functions. Given that only three components were left to be implemented, including the latest Component 2 on health response, this new set-up made much more sense.

After this change, the PIU/MOH worked effectively to jump-start the implementation of the project and implementation became much more effective, also enabling the ES/CNLS to focus on the priorities for the national program, coordination, partner dialogue and monitoring and evaluation. Project implementation improved to the point where project ratings for both the PDO and IP were upgraded to Moderately Satisfactory by November 2011. This also enabled the AF to be prepared and approved given that one of the pre-conditions for AF was satisfactory implementation of the parent project. Given the urgency to address the needs in the health sector, the turning-around of this project was all that more significant. All in all, 60% of total project funding, plus the new AF, was disbursed in 4 years despite the effects of the political crisis which lingered until the end of 2013 when national elections took place.

(c) Justification of Rating for Overall Borrower Performance Rating: Moderately Satisfactory The overall rating for the Borrower performance is a reflection of a challenging project start-up, the highly challenging political and economic context, and the immense efforts made to implement a project which changed its design and management structure mid-way. The rating is a testament to the willingness and ability of the original implementing agency to learn and adapt to changing circumstances, and the energy with which the new PIU took on its new role.

6. Lessons Learned

The lessons of this project can be broken down into two categories, i.e. those reflecting (a) project weaknesses that other projects should aim to avoid to ensure a more effective implementation; and (b) project strengths that could be inspirational for current and future operations.

(a) Project weaknesses • For repeater projects to be effective, (i) sequencing/timing needs to be considered carefully to avoid a situation, as in this project, where the first two years were spent on completing the implementation of the first project rather than starting the second; (ii) teams need to take time to carry out the necessary analysis in order to identify the most effective activities and approaches carried out under the original project; (iii) implementation arrangements should be re-assessed; (iv) lessons of the parent project should be taken into account. • If project restructuring involves substantial changes to the design of components, and re- aligning of RFs and costs, teams should review more carefully if the PDO should also be changed to adequately reflect the restructuring.

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• In countries such as Madagascar, where high-risk groups are still the main drivers of the HIV/AIDS epidemic, project efforts and expenditures should be concentrated on these groups to yield maximum results. Given that youth (under 15 years of age) represent roughly 50% of the population, are prone to high-risk behaviors and have low levels of knowledge about transmission and high stigma, awareness efforts through peer educators should be targeted on this group more forcefully.

(b) Project strengths • Rigorous selection process (clear selection criteria, terms of reference, competitive process, including an interview) for peer educators is critical to ensure that they can be effectively trained and carry out prevention activities in the way intended. • Use of mobile phones to simplify/reduce time lags, for example for updating information on drug stock-outs in health centers, should be considered by similar projects as a potentially very low cost and very high impact design feature. • A flexible approach to implementation, including finding non-traditional solutions to resolving implementation bottlenecks, should be systematically encouraged. In the case of this project, a transition to an experienced MOH PIU mid-way was a critical decision which paved the way to a successful completion of the project. The alternative would have been a painful lengthy process of re-hiring and training of staff of the previous PIU which would have taken substantial time and may not have led to the same results. • As this project demonstrated in its efforts to improve data collection and analysis, approaches to management of HIV/AIDS programs need to be periodically reviewed and rethought based on latest data and implementation success rates. This requires a continuous learning process among key partners and stakeholders involved so that lessons are regularly incorporated for better management of the program. • In active fragile state contexts, Bank financing can play an important role in protecting valuable and well-established implementation and program management capacity, which is critical for both current and future implementation of sectoral programs. In the case of Madagascar, the US$6 million in Additional Financing was critical to the preservation of institutional structures, service delivery systems and capacities built over several years and this incremental investment was significantly less than building systems from the ground up if these institutions and systems collapse. • Challenging contexts can be seen as an opportunity to find more creative mechanisms to continue support for critical services to beneficiaries. Rather than exiting the country completely or solely relying on parallel systems with NGOs, the Bank worked with the client to design financing that largely focused on existing regional, district and community level systems to maintain service delivery while ensuring that adequate fiduciary safeguards were designed for the context.

7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies: The ICR was shared with the Government of Madagascar (including ES/CNLS and the MOH PIU) and comments were received from the Executive Secretary of the ES/CNLS acknowledging the opportunity which this ICR has provided to re- evaluate the mixed and challenging history of the last decade of the fight against STIs, HIV/AIDS and the need to continue a more focused effort on high-risk groups. (b) Cofinanciers & other partners and stakeholders (NA)

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Annex 1. Project Costs and Financing

(A) Project Cost by Component (in USD Million equivalent) Appraisal Revised Additional Total final Actual/Latest Percentage of Estimate estimates Financing estimate by Estimate Appraisal Components (June 2005) (Dec. 2011 (May 2012) component (Jan 2015)5 (of total restructuring4) estimate)

Component 1: Harmonization, 100% donor coordination and 1.5 2.9 0.0 2.9 2.9 strategies Component 2: Support for 98.8% health sector response (renamed as Health and 3.5 12.5 5.2 17.7 17.5 Nutrition Services under Additional Financing) Component 3: Fund for 92% STI/HIV/AIDS prevention and 16.5 7.4 0.0 7.4 6.8 care-taking activities Component 4: Monitoring and 117% 2.9 4.3 0.4 4.7 5.5 Evaluation Component 5: Project 102% management and capacity 2.5 4.0 0.4 4.4 4.5 building Total Baseline Cost 26.9 31.1 6.0 37.1 37.2 100% Physical Contingencies 0.8 Price Contingencies 2.3 Total Project Costs 30.0 31.1 6.0 37.1 37.2 100% Total Financing Required 30.0 31.1 6.0 37.1 37.2 100% Note: AF Paper allocations differ from those provided by UGP-Santé final report in November 2014 which had the following numbers for Component 3 (US$3.25 m); Component 4 (US$1.15 m); and Component 5 (US$1.60 m).

The table below represents the latest disbursements per the Bank’s client connection system, after the 4 months grace period. SDR SDR total % Total historical Total % disbursed commitment disbursed disbursed (US$) commitment US$ disbursed 19,595,392.42 20,200,000.00 97.01% 30,506,316.65 30,000,000.00 101.7% 3,438,671.07 3,900,000.00 88.17% 5,207,687.61 6,000,000.00 86.8% 23,034,063.49 4,100,000.00 95.58% 35,714,004.26 36,000,000.00 99.2%

4 Amounts as presented in the Project Paper for the Additional Financing, May 31, 2012. Using the SDR/US$ exchange rate of December 23, 2011 when the restructuring was approved, the total amount is essentially the same, US$31 million (Component 2 being $12.4 million instead of $12.5 as presented above.)

5 The actual component costs at the end of the project were confirmed by the Project Implementation Unit (UGP of the MOH). However, historical disbursed total in the Bank’s Client connection for the project is US$35.71 million for the original project and AF, not US$37.1 million. In fact, SDR 604,607.58 was cancelled (component 3) and the AF did not disburse SDR 460,808.28 (US$653,117.41 equivalent).

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(B) Financing Type of Appraisal Estimate AF Actual/Latest Estimate Percentage of Source of Funds Cofinancing (USD millions) Financing (USD millions) Appraisal Borrower 0.00 0.00 0.00 IDA Credit 30.00 6.00 37.2

(C) Total contributions to the National AIDS Program by various sources of funds from 2006-2014 Total public funding Multilateral US$ US$ (central, Global Fund (UNDP, UNFPA, World Bank Bi-lateral Ye ar municipal and local US$ UNICEF, UNAIDS, US$ contributions Govt & Fund for OMS, BIT, PAM) Social Security) 2014 2,095,593.72 595,654.10 574,729.98 1,225,000.00 330,890.81 2013 1,082,325.80 612,603.08 788,137.68 4,870,000.00 499,106.85 2012 2,328,308.16 468,579.12 1,651,371.61 2,130,000.00 1,434,688.26 2011 4,238,209.92 342,899.68 1,661,418.31 6,150,000.00 2,525,942.02 2010 1,509,072.52 102,941.40 1,417,795.35 5,630,000.00 2,060,367.67 2009 29,530.39 194,553.29 1,927,319.09 1,650,000.00 2,208,364.41 2008 5,365,118.21 2,191,315.68 10,250,000.00 4,192,321.33 2007 1,086,719.05 7,291,059.13 3,810,000.00 3,557,289.64 2006 2,229,738.71 9,166,749.87 4,424,647.36 total 11,283,040.51 10,998,806.64 26,669,896.71 35,715,000.00 21,233,618.36 Source: ES/CNLS; Figures for WB contribution is derived from the Bank’s internal client connection system using historical disbursed figures.

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Annex 2. Outputs by Component

Component 1: Alignment and donor coordination (actual cost US$2.9 million) Sub component 1.1: Harmonization and donor coordination • Meetings of the National AIDS Council (NAC) • Review of the institutional arrangements for the National HIV / AIDS Program and PMPS II • Development of planning tools, including: (i) inventory (with mapping and software) of interventions and available resources; (ii) identifying the sources, amounts, and uses of financing provided by the technical partners; and (iii) periodic updating of the database; • Strengthening of information exchange via: (i) identification and networking of focal points for the components of the national and regional responses; (ii) information sharing with partners through a website ES/CNLS and workshops; and (iii) establishment of an Information and Documentation Centre of the CNLS • Funding of integrated joint reviews of the health sector

Sub-component 1.2: Update the National Strategic Plan • Review/Dissemination of the National Strategic Framework (NSP), operational plan, and Monitoring and Evaluation Plan for 2007-2012 • Strengthening the regional planning response by: (i) establishing Regional Coordination Units (UCR) comprising at least 3 technical and financial staff; (ii) providing training and technical support; and (iii) updating the 22 Regional Plans • Strengthening of the planning of the (most at risk) local/municipal response (CLLS) by developing PLLS: 1,254 towns have CLLS including 832 with PLLS, comprising 78% of the municipalities in the country • Assessment of the needs of orphans and other vulnerable children (OVC) in the country • Review of current standards and guidelines and development of a management strategy for OVC in public and private institutions • Creation of a network and support services for all OVC national (a steering committee for OVC already in place)

Sub component 1.3: Communication Strategy and Action Plan STI / HIV / AIDS • Revitalization of the "communications" technical committee; studies to: (i) identify the reasons for the gap between supply and demand of existing care; and (ii) evaluate the impact of condom promotion strategies • Revision of the national communication strategy and development of specific action plans (against discrimination, for increasing demand for services, etc.) • Development of 4 regional communications plans (Diana, High Matsiatra, Atsimo Andrefana, Boeny and Atsinanana), developed on the basis of the specific and local context • Development and dissemination of Information Education and Communication (IEC) materials and specific communication tools to the workplace: e.g. 405 giant posters, 92 posters for bus shelter, 20,000 posters on specific themes, 2.5 million leaflets on HIV, 1,000,000 THF STI, 320,000 comics for young ... • Campaigns to (i) promote condoms; (ii) reduce the stigmatization of PLWHA; and (iii) promoted the diagnosis and management of STIs and HIV testing. • Organization of media campaigns conveying messages on STIs, HIV and AIDS (2007)

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• Development/Implementation of advocacy programs to: (i) increase the involvement of national/local leaders in the fight against STIs and HIV/AIDS; (ii) promote reduction of the number of sexual partners and/or condom use among young men. • Development and implementation of a capacity building program to strengthen: (i) communication by the mass media; and (ii) interpersonal communication of local leaders and influential informal networks to strengthen basic communication. • Establishment of 4000 listening groups; support for increased coverage of these groups through acquisition of: (i) 6 video mobile units (VMU) with training on the management of the VMU; (ii) 42 contracts (of 100 initially planned) with local radio partners; and (iii) 8500 solar powered and hand-cranked radios. • Distribution of awareness kits on HIV/AIDS to support local leaders in the fight against HIV/AIDS STI in their areas of responsibility

Sub-component 1.4: Strategies and sectoral action plans • Recruitment of a Consultant to provide support to the various sectors to develop sectoral plans integrating HIV and AIDS • Development of security sector subprojects for Military and Education sector • Financing a project under Security Service Civic, targeting people in these remote rural areas (including sex workers) of Analamanga Regions (Ambalanjanakomby) Betsiboka (Ankazobe II) and Ihorombe (Satrokala) • Support for integrating HIV/AIDS programs in vulnerable sectors by (i) strengthening the sectoral strategic groups and focal points set up under the PMPS 1; and (ii) revitalizing the Multisectoral Technical Committee (JTC) • Support to industrial and commercial enterprises to take into account the impact of STI / HIV / AIDS • Evaluation of "efficiency" and "impact" of project support received by major line ministries and public administrations in the field of HIV / AIDS

Component 2 (Original Financing): Support to the health sector response (actual cost US$17.5 million) Sub component 2.1: Support for the management of STIs • Revision of the STI prevention strategy and HIV / AIDS, by defining the minimum package of activities • Development / Validation of a revised strategy, an Operational Plan, and norms for diagnosis and treatment of STI comprising screening for syphilis and HIV among sex workers and other higher risk groups (such as customers of sex workers men in uniform, prisoners, youth, etc.) • Training of 990 health aids integrated service offering STI, VCT, PMTCT • Inclusion of the STI registration kits in the list of essential medicines, acquisition and staffing for the benefit of various tests Health centers, reagents, subsidized STI kits with necessary supplies in the public and private sector risk areas • Development of training materials and training: (i) public health care providers and private syndromic approach; and (ii) 1100 new health workers by INSPC; • Staffing and training in the use of these tests for CSB2 in the screening program for pregnant women and their partners

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• Restructuring / Strengthening the National Research Laboratory (NRL) capacity for biological monitoring, quality control and biomedical research, etc. • Acquisition of 18 types of consumables and small equipment for the NRL and the 17 pilot sites, including Génicure, Cura 7 kits, RPR test reagents, Determine tests (with quantities for the second and third tests), and Benzathine penicillin • Extension of syphilis tests in all Health Facilities, following the results of the evaluation (by the co NRL and CDC Atlanta, and the availability of 23 laboratory technicians who received Training of Trainers in this area for scaling up services • Drug resistance studies and development of quality assurance laboratory systems • Pilot studies programs to promote the fight against STIs in the sex workers and important "bridge populations" of HIV comprising the multiplication of health records and tracking sheets for sex workers improve services for the management of STIs • Preparation of a condom distribution strategy, purchase of 15 million condoms to cover national needs, and acquisition of 2000 condom dispensers; • Recruitment of 5 NGOs to provide behavioral change support to the populations most at risk to the transmission of HIV • Evaluation of NGOs by the Independent Verification Agent (IVA)

Sub-component 2.2 Support to care and treatment of PLWHA • Revitalization of technical committees overseeing diagnosis, treatment, and support of PLWHA • Revision of the diagnostic guide and national protocol for ARV treatment, dissemination to the referring physicians, and training of ARV prescribers • Development of an HIV/AIDS national nutrition policy by for HIV positive pregnant women and children born to HIV positive women • Study of the financial implications of a total or partial subsidy policy of support for PLWHA • Expansion of VCT to all district hospitals and basic health centers level 2 (CSB 2) in high- risk areas • Organization of 22 regional workshops to train 649 providers for voluntary HIV counseling and testing • Operational support for 47 centers capable of providing care and support to PLWHA, including upgrading 58 referral doctors • Strengthening laboratory capacity for the national laboratory (including a generator), reference centers, including: (in Antananarivo and Mahajanga) with Cluster of Differentiation 4 (CD4)counters, and regional hospitals • Expansion/strengthening of PLWHA treatment sites in the provinces, including: (i) acquisition of 33 portable CD4 counters with reagents for the national laboratory and 24 reference centers • Acquisition of key inputs (ARVs, opportunistic infections, etc.) in line with national standards and guidelines for monitoring of 500 PLWHAs and 125 potential new cases • Regular supply of reference centers with ARV Drugs and against Opportunistic Infections • Strengthening the community network of psychosocial support in 8 regions using the Madaids NGO network • Improved quality of psychosocial care for PLHWA, through the implementation of Results-Based Financing (RBF) with contracts with 3 Associations

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Sub Component 2.3: Other measures of response of the health sector • Audit of the drug supply system for the component related to STI / HIV / AIDS and implementation of corrective measures for SALAMA • Establishment of an Logistics Management Information System (LMIS) in reference centers with communications capabilities (cell phones) to monitor stock supplies • Development of a national action plan by the Environmental Health Service • Implementation of the Programme of Universal Precautions and hospital waste management policy including: (i) training in waste management and universal precautions in 8 regions; (ii) delivery and maintenance of incinerators and waste management materials to 22 health care facilities; and (iii) supervision • Evaluation of the results of the implementation of the National Policy on Medical Waste Management (PNGDM)

Component 2 (Additional Financing): health, nutrition and STI/HIV/AIDS Sub-component 1: Integrated Management of pregnant women in ANC at health facilities • Introduction of a system of reimbursement (linked to FANOME) of medicines in children under 5 years of age seen in outpatient clinics and pregnant women in 143 CSB • Recruitment of 33 NGOs working in nutrition activities and 143 voucher agents to establish the payment of invoices for the functioning of the reimbursement system. • Posters and information materials to inform pregnant women and mothers of children under 5 years on the drug reimbursement system • Training workshops and planning with the leaders of 143 CSB to identify training needs and priority activities • Preparation and distribution of management tools: registers, prescription forms, health cards, etc. • Recruitment of 5 NGOs to provide behavioral change support to the populations most at risk to the transmission of HIV • Evaluation of NGOs by the Independent Verification Agent (IVA)

Sub-component 2: Integrated Management of pregnant women and children at community level • Recruitment of 33 NGOs, 66 Training Facilitators, and 659 Community Nutrition Assistants to implement the community nutrition strategy in 659 nutritional sites • Provision of an operating budget for the National Community Nutrition Program and the 5 Regional Nutrition Organizations • Recruitment of Technical Assistant in charge of monitoring and evaluation (4 July 2013) • Monitoring / Supervision of NGOs and Community Nutrition Assistants by the national and regional nutrition agents • Acquisition of nutritional recordkeeping materials (registers, nutrition education guides) • Development of Nutrition IEC kits and materials (flipcharts, masking tapes, markers) • Acquisition of kitchen utensils, cooking equipment, cooking demonstration sheets, etc. • Mass distribution of drugs mass against NTDs (lymphatic filariasis, schistosomiasis, STH)

Component 3 (Original Financing): Support Fund for the prevention of STI/HIV/AIDS and support for PLWHA (actual cost US$6.8 million) Sub-components 3.1 and 3.2: Funds and Fund Management • Funding of an independent agency (FMA) to manage the Support Fund Prevention (FAP)

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• Establishment/Assessment of 11 regional facilitation bodies to strengthen local response • Revision of the planning tools, identification of the most effective/efficient actions for eligible financing, and monitoring of the local response • Recruitment of NGOs/CBOs to carry out communication activities for behavioral change targeting high-risk groups through group and interpersonal communications to promote the testing, condom use and the utilization of STI services

Sub component 3.3: Financing of core projects • In 2008, 781 contracts were signed contracts with 57 NGOs/CBOs and 724 associations; a total of 2817 sub-projects were funded by the FAP, of which 1,745 (62%) were completed; All the activities of the FAP were suspended in October 2008 while operational and financial audit was conducted by an international firm.

Component 4: Monitoring and Evaluation System (actual cost US$5.5 million) Sub-component 4.1: Monitoring • Revision of the National Monitoring and Evaluation Plan and development/Financial support for implementation of the roadmap • Revision of the health management information system/Design and dissemination of monthly management information tools for all health facilities • Strengthening M&E Unit capacity by: (i) recruitment of technical assistance and M&E specialists at central level and staff at regional and sub-regional levels; and (ii) training of medical and nursing staff and M&E agents • Strengthening communication to ensure rapid data collection via 368 mobile phones and development of a feedback system to partners at different levels • Joint monitoring and supervision missions including the participation of partners • Creation of a website • Implementation of a pilot project for results-based financing, including: (i) recruitment of consultants to monitor NGO activities; (ii) recruitment of an independent verification agency (IVA) to periodically evaluate NGO performance levels against stated objectives; (iii) completion of procedures manuals and training; and (iii) final evaluation of the performance of the IVA

Sub component 4.2: Collection of epidemiological data • Collection of available data on the status/dynamics of the HIV epidemic in Madagascar to validate and identify data gaps for monitoring the spatial and temporal dynamics of the epidemic and projection studies of its impact on vulnerable sectors • Creation of a database epidemiological, clinical and biological STIs and HIV / AIDS • Strengthening of the epidemiological surveillance of STIs, TB and HIV / AIDS, including second generation surveillance (biological and behavioral)

Sub-component 4.3: Impact / Assessment Studies • Biological and behavioral survey on syphilis and HIV • Study of the chemo sensitivity of STI germs • IP6 / IP7 survey evaluating training on the syndromic approach for diagnosing and treating STIs

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• Annual LQAS surveys to measure the impact of the project in areas at high risk of the project • Baseline and follow-up surveys to: (i) evaluate the effectiveness of prevention and treatment interventions by the project; (ii) create a database consolidating all the data about results and impacts; and (iii) prepare an annual report on "Results and Strategic Shifts" for submission to the World Bank and Partners Forum • Publication of UNGASS reports (2008, 2010, 2012, and 2014) • Evaluation of the communication strategy • Mid-term review and final Project Evaluation/Completion Report

Component 5 (Original Financing & Additional Financing): Project Management (actual cost US$4.5 million) Sub-component 5.1: Project Management • Support for extension staff and operating costs of the Regional Coordinating Offices • Support for strengthening the skills of technical staff to support the implementation of the components of PMPS II • Support for operational coordination structures for: (i) developing annual work plans; (ii) monitoring PMPS semi-annual reports; and (iii) preparing annual reports. • Development of two PMPS II Implementation Manuals: February 2006 and January 2010 • Training of NAC staff (public health and management) and PIU staff (management of World Bank-financed projects) • Assessment/Implementation of the Action Plan to strengthen the procurement capacity of the PIU / PMPS

Subcomponent 5.2: Audits • Conduct of two institutional audits to examine the organization of the response to HIV centrally and at peripheral level • Internal and external institutional audit of the SE / CNLS designed to reorganize its structure and develop a program approach • Annual accounting and financial audit of PMPS and FAP

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Annex 3. Economic and Financial Analysis

1. Introduction Madagascar is among the few countries in Sub-Saharan Africa with low prevalence of HIV/AIDS, estimated at 0.4% in 2013. An estimate by UNAIDS is that 54,000 people were living with HIV/AIDS in Madagascar in 2013. There were approximately 3,100 new HIV infections in 2013, showing a 39 percent decline in the number of new infections from about 5,100 in 1990. It is estimated that HIV prevalence among adults gradually increased from 0.2% in 1990 to 0.7% in 2006. Since then, it has been on a declining trend. Meanwhile, deaths due to AIDS have remained at roughly 5200-5500 people per year since 2005, according to UNAIDS estimates. The literature indicates that the relatively low HIV prevalence can be attributed to a combination of factors including geography (i.e. being Madagascar being an island), the limited infrastructure capacity curtailing movement of the population within the island, and the widely spread practice of circumcision (about 95 percent of males were circumcised in 2013).

Figure 1. Numbers of people living with HIV, new HIV infections, AIDS deaths, and prevalence, 1990-2013

New HIV infections People living with HIV

Estimate Low High 100000 80000 12000 10000 60000 8000 40000 6000 20000 4000 0 2000 0 Estimate Low High

AIDS deaths HIV prevalence among adults (%) 8,000 1.2 7,000 1 6,000 5,000 0.8 4,000 0.6 3,000 0.4 2,000 1,000 0.2 0 0

Estimate Low High Estimate Low High

Source: UNAIDS, May 2014

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2. The Economic Impact of HIV Prevention Activities

Phase 1 (2005-2008): No economic or financial analysis was actually carried out during the preparation of this project or during project restructuring. The PAD did refer that project design was informed by the detailed economic analysis on HIV/AIDS done under the Bank Multi-Country HIV/AIDS Program for the Africa Region (Report No. 20727 AFR, paragraphs 76-78 - 2004). The analysis demonstrated the impact of the epidemic on economic development and poverty as well as the cost-benefit of HIV/AIDS interventions. This report presented 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, such as in Madagascar, the report indicated that prevention among sex workers (SW) is most cost- effective, while PMTCT and workplace programs have a medium level of cost effectiveness and medium impact. Blood safety and condom distribution have a medium cost-effectiveness and low impact. The report also showed that community mobilization, mass media, STI treatment, and education interventions are least cost-effective with low impact in a low prevalence situation. The majority of activities carried out during Phase 1 included mass media, communications, education, screening/testing and condom promotion and distribution for the general population, as well as for some target groups such as sex workers and youths (15-24). Therefore, it can be inferred that the impact of these activities was in the low to medium range. However, it is important to note that 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 screening and treatment more cost effective than the model would show.

Central and West Africa (lower prevalence) Impact (% of Infections Averted) Cost per infection averted Low Medium High (0-10%) (10-20%) (> 20%) Low (< US$ 1,000) MSM SW Medium (US$ 1,000- Blood safety PMTCT 3,000) Condom distribution Workplace programs High (> US$ 3,000) Community mobilization Mass media STI treatment Education

Phase 2 (2010-2014): The prevention efforts under this phase included peer educator outreach (incl. training and education of peer educators), condom distribution, promotion of screening tests for STIs and HIV/AIDS, outreach activities for youths, plays, leaflet distribution, local radio announcements, training to department officials, heads of communes and health centers. These prevention activities carried out by the 5 NGOs successfully targeted high-risk population groups, including the youth between the ages 15-24, military personnel and sex workers. The prevention activities targeted a total of 150,325 beneficiaries, 124,412 of which were the youth (83 percent of all beneficiaries), 13,004 were military personnel (9 percent) and 12,412 (8 percent) were SWs. Caveats. First, it was not possible to calculate the exact number of new HIV infections averted each year and averted productivity losses annually, as it was not clear how many beneficiaries the

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project was able to reach annually. Therefore, the calculation of averted infections uses the total number of beneficiaries targeted during the 4 years. Secondly, available prevalence rates of HIV for each risk group were used as proxies to estimate the averted number of new HIV infections. However, these figures should be interpreted with caution, as HIV prevalence, by definition, not only represents the new HIV infections but also older cases at a specific point in time.

Methodology. Despite these difficulties, the impact of project activities could be assessed by estimating (i) the total number of productive life years saved, (ii) the averted loss of productivity, and (iii) the averted high cost of treatment. The average number of productive years saved per person is estimated by subtracting the retirement age from the average year of HIV infection. The averted loss of productivity is calculated by multiplying the number of averted new HIV infections by the average lifetime productivity loss averted. Calculating the average lifetime productivity loss averted entails establishing a low- and a high-estimate. The low-estimate indicates the total productivity loss averted over the productive life span if the individual is infected with HIV in the absence of prevention activities and receives adequate care. In this scenario, adequate care is assumed to avert some degree of productivity loss and increases life expectancy compared to an infected patient without care. The high-estimate assumes that the infected patient receives no care, resulting in further deterioration of productivity and lower life expectancy compared to an infected patient who receives care.

The assumptions are as follows:

• The prevalence rate for each high-risk group are 1.16% for the youth, 0.5% for military personnel and 1.36% for SWs.6 • On average, an averted infection provides an individual with 29 more years of productive life. This is calculated as retirement age of 60 years minus the average age of HIV infection of 31 years.7 • The average value of the first year of productive life saved is US$463 in 2013, the equivalent of GDP per capita (current US$). The average value of the subsequent productive years until retirement were discounted with a rate of 3%. It is assumed an annual GDP per capita growth rate8 of 0.2% over the period. • On average, it takes 5 years for the disease to progress and translate into productivity losses and health care costs for individuals.

6 The HIV prevalence for military personnel was not available at the time of writing this report. This calculation assumes that the prevalence of HIV for military personnel is the same for all adults. This figure is considered a conservative estimate keeping in mind that military personnel has higher prevalence of syphilis, the presence of which increases the risk of acquiring and transmitting HIV.

7 The average age of HIV infection is calculated by averaging the HIV infection age of 27.5 years for females and 34.4 years for males.

8 This figure is from the latest available data with a positive growth value from World Development Indicators, 2015.

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• On average, an infected patient with adequate care lives 25 years after infection and loses 10% productivity after infection. • On average, an infected patient without adequate care lives 8 years after infection and loses 20% productivity. This may be a conservative estimate since the loss of productivity may be experienced earlier or at greater level. • The average cost of care per patient is US$457, which is calculated as the weighted average of the cost of first line of ARV treatment of US$403 and the cost of second line of ARV treatment of US$583 (7:3 ratio). This figure does not include treatment cost of opportunistic infections. Summary of findings. Table 2 summarizes the benefits of averting new HIV infections and is comprised of the number of averted HIV infections, years of productive life saved, loss of productivity (by averting infection avoiding loss of productivity and shortened life expectancy), and the averted cost of care.

Table 2. Benefits of HIV prevention activities carried out under project component Type of The number of Averted Years of Averted loss of productivity Averted cost of beneficiary project HIV productive care beneficiaries infections life saved Low estimate High estimate Youth 124,909 1,449 42,092 2,141,936 8,785,373 16,554,190 ages 15- 24 Military 13,004 65 1,882 96,117 394,235 742,85 4 personnel SWs 12,412 169 4,904 249,537 1,023,503 1,928,57 7 Total 150,325 1,683 48, 884 2,487,591 10,203,111 19,225,620

Based on the attribution rates (prevalence) for each high-risk group, the project averted a total of 1,683 new HIV infections, the majority of which are the youth between the ages of 15-24. Furthermore, the prevention activities covered under the project averted loss of productivity between US$2,487,591 and US$10,203,111. These activities also resulted in savings of US$19,225,620 from AIDS treatment.

The HIV prevention activities targeted towards these high-risk population groups have additional benefits that are not captured in this assessment. Firstly, by targeting the youth, the project helped efforts to address the spread of HIV among young people in reproductive age, which results in decline in life expectancy, labor supply and overall productivity. The young people in Madagascar are particularly at risk of HIV infection due to injected drug use, unfavorable sexual behaviors (e.g. unprotected sexual activity, multiple sexual partners) and the lack of HIV/AIDS awareness. Furthermore, it should be noted that the main benefits of these prevention activities are borne from targeting a large number of the youth population. In fact, the benefits of targeting the youth is arguably greater since the low- and high-estimate figures do not take into account the long-term benefit of maintaining a healthy youth population on the labor force (e.g. averted high rates of absenteeism, high labor force turnover, increased healthcare cost).

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Secondly, by targeting the military personnel, the project contributed efforts to address the high prevalence of STIs among the members of military. The literature indicates that the presence of STIs increase the risk of HIV transmission. The recent studies show that the prevalence of syphilis is significantly higher for military personnel (16.7%) than the overall national average (3.8%). Finally, the literature shows that the SWs are among the most vulnerable to HIV infection due to having multiple sex partners, inconsistent condom use, social and legal factors (e.g. stigmatization and marginalization), injected drug use and mobility. They are also among the most perceptive to HIV prevention efforts9 and in general, the most cost-effective group to target.

The total cost and estimated total benefits from STI/HIV/AIDS prevention activities is shown in Table 3. Based on the estimated total benefits and cost, the project resulted in net benefits between US$17,115,734 and US$24,831,254. Keeping in mind that the annual government budget for HIV/AIDS was about US$4 million, including loans, the benefits of the prevention component are high.

Table 3. Cost-Benefit Analysis Low- estimate High-estimate Total Benefits 21,713,211 29,428,731 Total Cost (4,597,477) (4,597,477) Net Benefits 17,115,734 24,831,254 BCR 4.7/1 6.4/1

3. The Economic Impact of HIV Treatment and Care Activities The World Bank provided US$430,567 for HIV treatment and care activities, including procurement of ARVs for a portion of infected patients under treatment between 2009 and 2014 (695 by 2014). Prior to project implementation, in 2008, there were reported 384 people were living with HIV and 162 infected patients received HIV treatment and care, corresponding to about 42% treatment coverage. In the course of project implementation, the reported cases of people living with HIV/AIDS and the number of treated patients increased steadily. By 2014, there were reported 1,191 people living with HIV and 744 people received treatment and care in 2014. Based on these estimates, treatment coverage reached 62% in 2014. It should be noted that there are significant disparities between these actual numbers and UNAIDS estimates (see Figure 1) of people living with HIV, new HIV infections, and AIDS deaths.

9 Efforts to achieve sizable reductions in national HIV prevalence in countries like Cambodia, the Dominican Republic and Thailand were supported by initiatives targeting SWs and their client networks. 53

Figure 2. The reported number of people living with HIV and people on ARV treatment 1,400

1,200

1,000 People living with HIV People under treatment 800

600

400

200

0 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Methodology. The economic impact of HIV treatment and care activities carried out under the project component can be estimated in terms of (i) the number of productive life years saved and (ii) the averted loss of productivity. To estimate the averted loss of productivity, it is assumed that the beneficiaries of treatment and care component would not have received adequate care in the absence of the Project. As before, it is assumed that on average, an infected patient with adequate care lives 25 years after infection; it takes 5 years for the disease to translate into productivity loss; and the average value of the first productive life year saved is as before US$463 in 2013.

Findings. Table 4 shows the stream of benefits from HIV treatment and care component of the project. The treatment and care activities carried out under this component targeted 695 infected patients and resulted in 17,375 years of productive life years saved and averted loss of productivity valued at US$4,213,988.

Table 4. HIV treatment and care component benefits Year Number of people under Years of Year Productivity losses treatment through project productive averted life saved 2009 100 2,500 2014 606,329 2010 125 3,125 2015 757,912 2011 125 3,125 2016 757,912 2012 125 3,125 2017 757,912 2013 100 2,500 2018 606,329 2014 120 3,000 2019 727,595 Total 695 17,375 4,213,988

The stream of costs and benefits of HIV treatment and care activities under the project component is shown in Table 5. An annual break down of costs associated with the treatment component of the Project was not available. In the absence of this data, the annual costs are extrapolated based on the assumption that the yearly cost of treatment and care activities is proportional to the number of patients received care in that year.

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Table 5. Cost-Benefit Analysis Year Costs Benefits Net Benefits 2009 61,952 (61,952) 2010 77,440 (77,440) 2011 77,440 (77,440) 2012 77,440 (77,440) 2013 61,952 (61,952) 2014 74,343 606,329 531,987 2015 757,912 757,912 2016 757,912 757,912 2017 757,912 757,912 2018 606,329 606,329 2019 727,595 727,595 Total 430,567 4,213,988 3,783,421

Based on these costs and benefits, the net present value of the HIV treatment and care component is US$3,371.872 (based on a 3% discount rate as earlier). The benefit-cost-ratio is 9.8/1.

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Annex 4. Bank Lending and Implementation Support/Supervision Processes

(a) Task Team members Names Title Unit Lending Maryanne Sharp Operations Officer AFTH3 Nadine Poupart Sr. Economist, TTL AFTH3 Jean-Pierre Manshande Sr. Health Specialist AFTH3 Joseph Valadez Sr. M&E Specialist HDNGA Andrianina Noro Rafamantanantsoa Team Assistant AFTH3 Mead Over Lead Health Economist DECRG Gervais Rakotoarimanana Sr. Financial Management Specialist AFTFM Sylvain Rambeloson Sr. Procurement Specialist AFTPC Joan MacNeil Sr. HIV/AIDS Specialist & Peer Reviewer HDNGA John May Sr. Population Specialist & Peer Reviewer AFTH2 Patricio Marquez Lead Health Specialist & Peer Reviewer ECSHD Michael Fowler Sr. Finance Officer LOAG2 Sameena Dost Counsel LEGAM Supervision Lubna Bhayani Consultant AFTHE - HIS Rene Bonnel Lead Economist AFTP4 - HIS Diane De Bernardo Consultant AFTH3 - HIS Philippe Jacobe De Naurois Consultant GENDR Paul-Jean Feno Senior Environmental Specialist GENDR Anne-Claire Haye E T Consultant MNSHD - HIS Astania Kamau Language Program Assistant AFTSE - HIS Jean Charles Amon Kra Sr Financial Management Specialist GGODR A. Mead Over Consultant AFRCE Stefano Paternostro Practice Manager GSPDR Ellena Rabeson Operations Officer AFMMG Andrianina Noro Rafamantanantsoa Program Assistant GHNDR Francois Marie Maurice Sr Financial Management Specialist AFTME - HIS Rakotoarimanana Sylvain Auguste Rambeloson Senior Procurement Specialist GGODR Ando Tiana Raobelison E T Consultant AFTHE - HIS Lova Niaina Ravaoarimino Procurement Specialist GGODR Rosalia Rodriguez-Garcia Consultant GHNDR Sariette Jippe Program Assistant GHNDR Maryanne Sharp Country Operations Adviser LCC2C Michele Tarsilla Consultant OPCRX-HIS Joseph Byamugisha Sr. Financial Management Specialist GGODR Joseph J. Valadez Senior Monitoring & Evaluation AFTHD - HIS Eleonora Del Valle Cavagnero Health Economist GHNDR Ece Amber Ozcelik Junior Professional Associate GHNDR Jumana Qamruddin Task Team Leader GHNDR

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Voahirana Hanitrianiala Rajoela Health Specialist GHNDR Maria E. Gracheva Senior Operations Officer GHNDR

(b) Staff Time and Cost Staff Time and Cost (Bank Budget Only) Stage of Project Cycle USD Thousands (including No. of staff weeks travel and consultant costs) Lending FY05 26.11 153.36

Total: 26.11 153.36 Supervision/ICR FY06 8.17 68.92 FY07 28.45 78.92 FY08 36.79 103.47 FY09 40.88 102.41 FY10 11.26 75.03 FY11 39.77 171.48 FY12 63.94 168.32 FY13 57.05 189.14 FY14 28.06 108.71 FY15 15.35 87.56

Total: 329.72 1,153.96

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Annex 5. Beneficiary Survey Results NA

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Annex 6. Stakeholder Workshop Report and Results NA

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Annex 7. Summary of Borrower's ICR and/or Comments on Draft ICR

EXECUTIVE SUMMARY: SEPTEMBER 2014 Dr. Rafiringason Rigobert Dr. Jean François Xavier Project Background, Development Objectives and Design Between 2005 and 2012, the epidemics type concentrated within key populations that are the most at risk of infection in Madagascar is confirmed by epidemiological surveys surveillance. HIV prevalence is evaluated less than 1% (0.4% in 2013) in the adult population at large. But the high prevalence of STIs, including syphilis (6.4% among women- EDS 2008-2009) would be a major cofactor of HIV transmission. This also reflects the magnitude of risk behaviors. Moreover, growing poverty remains a major vulnerability factor. The broad guidelines in response to STIs, HIV and AIDS in Madagascar drew their sources from three (3) basic documents: (i) the Madagascar Action Plan (MAP); (Ii) the Madagascar Action Plan for an effective response to HIV and AIDS; and (iii) the National Strategy for the Fight against STIs 2007-2012.

The legal framework of PMPS II and FA is defined, in addition, by bilateral agreements between the Republic of Madagascar and the International Development Association (IDA): Credit Agreement No. 4104-MAG dated July 13, 2005 of a SDR 20.2 million amount for the PMPS II (US$30 million) and Credit Agreement No. 5124 concluded July 27, 2012 in a SDR 3.9 million amount (i.e., US$6,000,000) for the PMPS II - Additional Financing.

Development objectives for PMPS II consist in supporting the Government's efforts to promote a multi- sectorial response to the HIV/AIDS crisis and containing the spread of HIV/AIDS over its territory. Moreover, it initially includes five components, namely i) Component 1: Harmonizing, coordinating donors and strategies, (ii) Component 2: Support to the response of the health sector; (iii) Component 3: Support funds to the prevention of STIs, HIV and AIDS and management; (iv) Component 4: Monitoring and evaluation; and (v) Component 5: Project Management. The PMPS II runs from 2005 to 2012.

The Additional Financing (AF) or PMPS II - FA expands the scope of PMPS II Project with a view to providing a set of low-cost, high-impact essential interventions in the areas of health, nutrition and HIV/AIDS, to vulnerable groups, namely pregnant women and under five years old children and to the populations the most exposed to HIV/AIDS risk, thus helping to mitigate some of the negative impacts of the current political crisis that the country is currently experiencing regarding population well-being. For a period of 18 months extending from April 2013 to September 2014, PMPS II FA is structured as follows (i) Component 1: Strengthening Health, Nutrition and HIV/AIDS Services; (ii) Component 2: Monitoring and Evaluation, and (iii) Component 3: Project Management and Capacity Building

1. Key Factors Affecting Implementation and Results PMPS II was designed in 2005 and started only in 2007. Although POA PMPS II 2006 obtained the notice of non-objection in November 2006, no implementation was completed in 2006 given that GIS was not yet functional. The National 2007-2012 Strategic Plan served as a reference framework. And a Project Implementation Manual was designed in February 2006. Two institutional audits of central and peripheral levels were made in 2008. It was found out that few structures created in 2002 worked and fulfilled their mandates. The various committees and councils left the ES/CNLS without control and the latter, in agreement with the PTF, and facing the difficulty of outsourcing some of its actions, has evolved into an executive agency rather than a multi-sector coordination structure. Restructuring was necessary.

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Component 1 relating to harmonizing and coordinating donors was suspended from 2010, most set goals were reached. For Component 2, support to the health sector to provide care and support to PLWHA was provided more or less normally. In addition, allegations of resources misuse in implementing FAP component 3 came out of supervisions. Some dysfunctions in processing tenders and awarding funding to FAP subprojects have been reported while those in charge of monitoring, supervision and evaluation of subprojects were overwhelmed by the excessive number of sub-projects. The institutional audit also noted the low level of technical capacity of OFs in charge of supporting local response sponsors. FAP activities were suspended temporarily and permanently thereafter. The arrangements put in place, such as AGF and OFs have been cancelled. The mid-term in December 2008 issued the need to restructure the ES/CNLS and the update of the Project Manual. Component 4 relates to monitoring, to collection of epidemiological data and to audits and evaluations. Finally, component 5 has experienced management punctuated by amendments, suspensions, and restructuring at the beginning of the project. It was more stable afterwards.

The 2009 political crisis occurring in Madagascar has led to the suspension of disbursements. Furthermore, ineligible expenditures worth approximately US$509,344.36, of which US$434,010.36 on the FAP had to be repaid by the Borrower, by instalments and become conditionality. Thereafter resumed disbursements in late 2009 involved only 3 components (2, 4 and 5) and a two-year extension was secured taking into account of funds availability (January 2010 to December 2011). A reformed second Implementation Manual was designed. Following the suspension of disbursements in 2009, much of the key personnel at the UGP PMPS in the ES/CNLS left. The remaining team, composed mostly of assistants could not respond satisfactorily and opportunely to the requirements of the Project. PMPS II management was then transferred to the UGP Santé. ES/CNLS therefore fulfilled the role of National Project Director in charge of management and coordination while the CN-UGP Santé played the role of Assistant Manager by assuming with his team the technical and fiduciary management of the Project. The project was restructured in December 2011. This consisted in (i) maintaining the deemed relevant project components, i.e., Component 2 (the health sector response) component 4 (Monitoring and Evaluation) and component 5 (Project Management); (ii) reallocating existing funds, (iii) revising the indicators to achieve the project development objectives; and (iv) extending the closing date until the end of 2012. In February 2012, the appointment of a new National Coordinator of the UGP was carried out without the prior agreement of both parties, so which was not consistent with the terms set in the initial Credit agreement. The request by the Bank to begin a process of repealing the Decree was honored. Finally, a two year (2013-2014) Additional Fund for revising the Project development objectives terminates PMPS II which thus extends from 2005 to 2014.

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3. Evaluation of Results Evaluation of results includes technical evaluation and financial evaluation. 3.1 Technical Evaluation The achievement of the Development Objective (PDO) of PMPS II is measured through the following key indicators:

B-2 Progress of Impact and Results Indicators of PMPS II End of 2011 Objectives Initial position in 2006 Progress as of 31/12/2011 Observations end 2012 N° Indicators Description Targets Verification % achievements Data Data Sources Objectives 2012 Impact Indicators 1 Syphilis prevalence rate among female Sex workers 16.6% Report from ESB 15% 15.6% 96.15% Data from ESB 2010 sex workers 2005 Results Indicators 2 Percentage of target groups (15 to 24 Men 66.8% Report from ESC 68% 66.3% Data from ESC 2008 years youth, sex workers and soldiers) 2006 who could name three ways of 97.5% preventing HIV/AIDS. Women 65.8% 67% 62.6% 93.4% Sex workers 60% 61% 58.90% 96.5% Militaries 53% 57% 55.20% 96.8% 3 Percentage of population aged 15 to 49 Men 38.1% Report from EDS 20% 15.5% 129% Data from EDS 2008- who reported having had sex with a 2003-2004 2009. Largely exceeded Women 16.8% 9% 2.1% casual partner in the past 12 months 428% target values especially among women. 4 Percentage of target groups (15- to 24- Men 34.2% Report from ESC 45% 40.4% 89.7% Data from ESC 2008 year youth, soldiers) reporting having Women 40.7% 2006 47% 43.8% 93.2% used a condom at last sex with a casual Soldiers 47.8% 70% 63.6% 90.8% partner in the last 12 months 5 Percentage of sex workers reporting Sex workers 79.4% Report from ESC 86% 84.8% 98.6% Data from ESC 2008 having used a condom at last sex with a 2006 client 6 Percentage of aged 15 to 24 young Men 7.7% Report from ESC 20% 18% 90% Data from ESC 2008 people having performed HIV testing Women 8.7% 2006 22% 21.2% and received results 96.4% 7 Percentage of Sex workers having Sex workers 49.1% Report from ESC 64% 59.6% 93.1% Report from ESC 2008 performed HIV testing and received 2006 results 62

B-2 Progress of Impact and Results Indicators of PMPS II End of 2011 Objectives Initial position in 2006 Progress as of 31/12/2011 Observations end 2012 N° Indicators Description Targets Verification % achievements Data Data Sources Objectives 2012 8 Number of direct beneficiaries of the 234 069 1 929 774 1 417 515 73.4% Report 2011 of PMPS II project and proportion of women 63% women 64% 66% 103% Objectives exceeded

Most indicators set under the PMPS II Project are achieved at over 90% PLWHA data in 2013 is as follows: Number of PLWHA New cases Deceased Lost sight of Recovered lost sight of PLWHA under ARV monitored PLWHA 1162 179 11 74 45 670 Data from 2014 UNAIDS estimate the number of PLWHA in Madagascar at 53,000; the percentage of PLWHA receiving ARV treatment at 1% in 2013. As for mothers receiving PMTCT, the percentage is estimated at 3% in 2013 according to the same source.

Waste management and universal precautions. As part of a holistic response of the Project against the HIV/AIDS epidemics, tangible achievements have been identified in the areas of universal precautions and waste management. The Project has enabled providing technical assistance as support to the LNR and PNLS, allocating budget to the Department of Environmental Health for supervising the waste management program and implementing universal precautions, and training in waste management and universal precautions for the benefit of some 243 Health Workers from 161 Health Facilities in 08 Regions, delivery in two waves of 33 Monfort type incinerators to referral hospital centers ensuring medical care and monitoring to PLWHAs, and providing 08 supervision missions in 2012 in waste management plan, including the incinerators, scheduled in 2012 until October: In particular, completing a study in initial needs assessment for implementing the National Policy on Medical Waste Management through information collection and supervision missions conducted with 95 FS of 33 districts FS in 18 DRSP for capitalizing experiences in waste management in March 2011. The final report, developed with the assistance of a World Bank Environmental Safeguards specialist, has been put to disposal from December 20, 2011.

As for the Additional Funds (AF), achieving the Millennium Development Goal (ODP) is measured through the following results indicators:

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A-2 Observation Period: Additional Financing PMPS II 2013-2014 Intermediate Result 2: The quality and availability of basic health and nutrition services for pregnant women and under five children and of STIs / HIV /AIDS prevention and treatment services for populations the most exposed to risk have improved in the areas covered by the project Progress IRI Baseline 2010 Observations value Cumulative Values Verification Progress at April 2014 Déc 2013 Source value value End 2013 30 June 2014 1. Number of syphilis Project Exceeded. treatment distributed in Reports Situation 2013 : public health centers in areas 3,280 6,641 4,920 5,740 source RMA covered by the project 2. Number of condoms Project Exceeded. distributed by the public Reports Situation 2013 : sector and NGO programs 0 17,571,703 8,500,000 10,000,000 sources RMA, per year in the areas covered Report T6 NGO by the project 3. Number of Sex workers, Exceeded. 15 to 24 years young people Sex workers: Reports from Situation 2013 : Sex workers: 0 Sex workers: 0 Sex workers: 20,498 (by gender) and soldiers 15,840 the sources RMA, having benefited from an independent Report T6 NGO HIV test in the last 12 verification Men:18,750 months and who know the Men: 0 Men: 0 Men:,44,627 agency Women: results thereof in the areas Women: 0 Women: 0 Women:,46,448 19,050 covered by the project Soldiers: Soldiers: 0 Soldiers: 0 Soldiers:,15,519 12,150 4. Number of pregnant Reports from Objective women receiving MINSAN achieved supplements of folic acid and 59,430 (2010) 143,339 98,393 114,792 iron in the areas covered by the project 5. Number of under five Reports from Objective children receiving Vitamin A MINSAN achieved 332,808 618,348 503,806 587,774 supplements in areas covered by the project 6. Number of pregnant Reports from Exceeded women having had their first MINSAN prenatal visit before the end 13,925 25,485 54,663 63,774 of the first quarter of pregnancy (<4 months) in areas covered by the project 7. Number of births attended Reports from Exceeded by skilled personnel in the 14,348 25,803 40,847 47,654 MINSAN areas covered by the project 8. Number of under five Reports from Objective children receiving zinc/SRO MINSAN achieved supplements against diarrhea 12,374 29,889 24,000 28,000 in areas covered by the project 9. Number of under five Reports from Objective children enrolled in a growth nutrition achieved monitoring and improving 189,717 193,656 189,717 189,717 centers program in the areas covered by the project 10. Health staff numbers Project Objective 0 166 282 282 receiving training (number) Reports achieved 11. Number of women Not achieved Reports from participating in monitoring PNNC and improving growth 103,146 105,211 103,797 104,451 centers activities in the areas

covered by the project Intermediate Result 4 : Improved monitoring capabilities and real-time data are used to introduce changes to the program

Progress IRI Baseline 2010 Cumulative target values

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December Fin 2013 30 Verification 2013 September Source 2014

13. Percentage of referral centers for PLWHIV/AIDS having submitted their Reports from Objective not achieved 96% (2011) 94% 97% 98% monthly reports within 15 PNLS days after the end of the month 14 Operational system for GIS / SMS = data collection rapid data collection Reports from system of PEC PVVIB including (GIS / SMS) the logistics data established by an independent International Consultant HNI verification consisting of 338 cell phones NA 4 5 7 agency acquired and dispatched some 347 Heads of CSB, 18 District Technical Agents and 3 GCR trained and applying the specific operating procedure of the project. 15. Number of available reports assessing CCC The quarterly evaluation of NGO activities conducted by Project activities is provided by the NGOs with the population, NA 4 5 7 Reports Agency for Independent especially groups at high risk Verification. All NGOs have of infection and of exceeded the planned indicators. transmitting HIV Available Report of Second ESBC 2012 1 1 Project The ESBC 2012 final report was Generation Monitoring started Reports approved and distributed in the Survey month of August 2013 Evaluation study of NA 1 - Call for Expression of Interest for performance-based funding the recruitment of NGOs to carry out the study was launched on June 22, 2013. Intermediate Result 5: The project is implemented in accordance with the standards and procedures set out in the implementation manual.

16. Percentage of audits of the Project implementation units not 100% NA 100% 100% Reports Audit planned for 2014 mentioning reservations

At the end of this technical analysis, PMPS Project II is rated moderately satisfactory, whereas FA PMPS II is rated satisfactory.

3.2 Financial Analysis PMPS II and FA are under two credit agreements between the International Development Association (IDA) and the Government of the Republic of Madagascar. The first one -PMPS II was entered into with credit agreement MAG-4104 in a SDR 20.2 million amount (or US$31,700,264) spreading from 2005 to 2012. For the second one - PMPS II FA or Additional Funds (FA), credit agreement 5124-MAG, the amount is SDR 3.9 million (or US$ 6 million) and it extends from 2013 to September 2014.

3.2.1 PMPS II Fiduciary Tables Per expenditure category, the credit is distributed as follows: N° EXPENDITURE CATEGORIES CREDIT (SDR) CREDIT (US$) % expenditures to be financed 1 GOODS AND WORKS 2,700,000 4,237,164.00 100% foreign 2 CONSULTANTS, TRAINING AND 4,110,000 6,449,905.20 100% foreign WORKSHOPS 3 BASIC PROJECTS FUNDING 9,900,000 15,536,268.00 100% foreign 4 OPERATING EXPENSES 1,420,000 2,228,434.40 100% foreign

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Per component distribution is as follows: N° COMPONENTS DESCRIPTION ALLOUE DTS USD 1 HARMONIZING AND COORDINATING DONORS AND STRATEGIES 1,018,061.81 1,597,664.00 2 SUPPORT TO HEALTH SECTOR RESPONSE 1,989,178.98 3,121,658.36 3 SUPPORT FUNDS TO STI / HIV / AIDS PREVENTION and MANAGEMENT OF SICK 11,450,198.96 17,969,026.20 PEOPLE 4 MONITORING and EVALUATION 1,934,819.83 3,036,351.46 5 PROJECT MANAGEMENT 1,716,856.83 2,694,297.76 CONTINGENCIES IN MATERIALS 543,273.39 852,569.80 CONTINGENCIES IN PRICES 1,547,610.20 2,428,695.64 TOTAL 20,200,000.00 31,700,264,.00 PMPS II actually extends from 2007 to 2012. It underwent three phases: the period from 2007 to 2009, followed by a first extension phase from 2010 to 2011 with a restructuring of expenditure categories and components; and a final extension phase in 2012. The initial allocations were changed in each phase. COMPONENTS Initial Initial Initial % achievements Allocations Allocations Allocations against the (PAD Forecast) (PAD (PAD Forecast) 2010-2011 (US$) Forecast) (US$) programming 2009 (US$) 2011 2010 1 1,597,664 1,500,000 2,919,751.54 100% HARMONIZING AND COORDINATING DONORS AND STRATEGIES

2 SUPPORT TO HEALTH SECTOR RESPONSE 3,121,658.36 3,500,000 12,796,957.34 88% 3 SUPPORT FUNDS TO STI / HIV / AIDS PREVENTION and 17,969,026.20 16,500,000 7,318,728.58 100% MANAGEMENT OF SICK PEOPLE 4 MONITORING and EVALUATION 3,036,351.46 2,900,000 4,398,627.99 70% 5 PROJECT MANAGEMENT 2,694,297.76 2,500,000 4,077,981.56 104% CONTINGENCIES (MATERIALS AND PRICES) 3,281,265.44 3,100,000 TOTAL 31,700,264 30,0000,000 31,512,047.02 86% Achievements per component were at 86% of the amounts programmed in 2010-2011. Components 1 and 3 - not eligible for the extension phase of the PMPS II - and Component 5 paid budgeted arrears on each component. Deliveries and payments were spread over two years 2010-2011. More or less important delays by suppliers in relation to delivery dates agreed in contracts have been recorded thus postponing the start of activities. The year 2012 still experienced another restructuring of forecasts or allocated credit. Disbursement by expenditure category is then as follows: Recent allocation Total disbursement 2007-2012 Percentage EXPENDITURE CATEGORIES 2012 2007-2012 (USD) 1 CIVIL WORKS 6,641,600 6,607,698 99.49% 2 SUPPLIES AND GOODS 7,396,700 7,825,904 105.80% 3 DRUGS AND INSECTICIDES 3,153,900 2,991,227 94.84% 4 CONSULTANCY SERVICES, TRAINING AND AUDIT 6,825,300 6,883,351 100.85% 5 OPERATING COSTS 4,982,500 4,507,820 90.47% 6 UNALLOCATED TOTAL 29,000,000 28,816,026 99.37%

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For the year 2012 the project disbursed an amount estimated at US $ 2,627,463, distributed to component 2 - Support to Health Sector response, in component 4 - monitoring and evaluation, and to component of Project management. In sum, US$29,000,000 was allocated to PMPS II from 2007 to 2012. And the total disbursement during this period, which is the total duration of PMPS II, is US$28,816,026, i.e., 99.37% of the credit allocated.

The problems encountered are at the level of (i) relatively low disbursement at the beginning of period because of an overestimation of the estimated budget, the non-occurrence of a large part of the activities by similarity with the activities of PMPS I, the strategy change or the slowness of preparations; (ii) the suspension of FAP in October 2008 owing to irregularities in Fund management; (iii) the socio-economic problems experienced by the country in 2009 followed by a suspension of any supply of the project account, resumed only in 2009 for arrears payment; (iv) the numerous restructuring experienced by the project during extensions. The financial part of PMPS II is rated moderately satisfactory.

3.2.2 PMPS II-FA (or FA) Fiduciary Tables Per expenditure category, the FA is as follows:

CATEGORIES Amount Amount % eligible expenditures (SDR) (US$) (including taxes) 1 CONSULTANT SERVICES INCLUDING 2,500,000 3,846,000 100% TRAINING AND AUDIT PROVISIONS 2 SUPPLIES AND SERVICES FUNDED UNDER 100,000 154,000 100% COMPONENT 1(B)(II) 3 OPERATING COSTS 1,300,000 2,000,000 100% TOTAL 3,900,000 6,000,000

P Per expenditure category, disbursement status as of August 31, 2014 is as follows: CATEGORIES Final Allocation Achievements % Balance (US$) August 31, 2014 1 CONSULTANT SERVICES INCLUDING TRAINING AND 4,247,904 3,097,437.03 72.91% 1,150,466.97 AUDIT PROVISIONS 2 SUPPLIES AND SERVICES FUNDED UNDER 354,404 164,859.93 46.51% 189,544.07 COMPONENT 1(B)(II) 3 OPERATING COSTS 3,397,692 1,198,111.19 35.26% 2,199,580.81 6,000,000 4,459,978.48 74.33% 1,540,021.52

Balance is 25.66% P Per component disbursement status is as follows:

67 COMPONENTS Initial Disbursement % Credit balance % credit August 31, 2014 Disbursement Par amount August 31, 2014 rapport (USD) au total 1 HEALTH, NUTRITION AND 3,251,869 2,855,873.66 87.82% 395,995.34 06.59% HIV/AIDS SERVICE BUILDING 2 MONITORING AND 1,147,883 685,644.45 59.73% 462238.55 07.70% EVALUATION 3 PROJECT MANAGEMENT AND 1,600,249 918,460.37 57.39% 681,788.63 11.37% CAPACITY BUILDING TOTAL 6,000,000 4,459,978.48 74.33% 1,540,021.52 25.66% Disbursement amounts to US$4,459,978.48 as of August 31, 2014 - equivalent to 74.33% of initial amount Remaining balance is estimated at US$1,540,021.52, i.e., 25.67% of the initial amount allocated.

The difficulties encountered are (i) the delay in the date of entry into force and the first disbursement which caused a delay in implementation and low disbursement; (Ii) the recruitment of 33 NGOs for the implementation of nutrition activities which was delayed because of the legal status of some NGOs; and (iii) the budget allocated to the implementation of the funding model based on the results, which was underestimated at planning. The financial part of FA is rated satisfactory.

4. Institutional Audit The Institutional Audit assesses institutional capacity in the implementation of PMPS II and FA project. Two implementation manuals of PMPS II were developed: the first one in February 2006 and the second one in January 2010. In addition, two institutional audits were conducted together under the Project. The first one performed in May 2008 relates to external institutional audit of the organization' of response to HIV at the central level. The second one of the same type approached the peripheral level. As described previously, institutional arrangements were restructured after 2009 with the extension of the project in 2010. Innovations have still been introduced with the second extension. The period of the 2013 -2014 Additional Fund is another step of the Project. For the second Manual of 2010, institutional arrangements for PMPS II include several levels: 1) the PMPS II advisory, supervision and coordination bodies; 2) the management bodies and 3) the technical implementation bodies.

4.1 PMPS II ADVISORY, SUPERVISION AND COORDINATION BODIES

Two bodies are involved in advising and overseeing the implementation of the PMPS: a) PMPS Board; and b) the ES/CNLS. a) PMPS Board: PMPS Board is the structure for monitoring and coordinating PMPS II. PMPS Board consists of seven (07) members representing the following institutions and organizations: The Presidency, the Ministry of Finance and Budget (MFB), the Ministry in charge of Health, The Executive Secretary of CNLS, international partners, the civil society and associations of PLWHA. b) ES/CNLS (ES/CNLS). The ES/CNLS is the body that provides strategic guidance in responding to HIV/AIDS, and ensures the effectiveness of the three principles of oneness. It provides policy and strategic support, promises partnerships, mobilizing resources at the national and international levels and guarantees the protection of human rights. As a guarantor of the alignment and harmonization of contributions from stakeholders in responding to AIDS, ES/CNLS sees to the implementation of PMPS II in accordance with the National Strategic Plan. The management of PMPS II was then delegated to UGP Santé. Moreover, with the extension of the project, arrangements for conducting the implementation concluded between the ES/CNLS and the UGP define the obligations of the ES/CNLS. The fact of being connected to the President’s office of the Republic witnessed the importance granted to the country regarding the fight against HIV/AIDS. The Executive Secretary of CNLS is the National Director of PMPS II FA in charge of steering and coordination. As such, he provided donor coordination and, for other sectors, coordination with the latter’s sub-projects and the corresponding Strategic Groups - Infrastructure, Tourism, Transport and Population, as well as implementation of mechanisms responsible for regional coordination of the AIDS response.

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4.2 MANAGEMENT BODY The main management body the Unit for managing the Projects supporting the Health Sector (UGP). It is under the technical supervision of the Ministry in charge of Public Health 10 of which it is connected to the Secretariat General Staff according to the organization chart. Its main task is to coordinate the implementation of activities of PMPS II, to ensure effective and efficient management of the resources available to the project, and ensure the proper implementation of the project. The Unit for managing the Projects supporting the Health Sector (UGP) provided the management of PMPS II and FA in the second phase of the Project. Effective collaboration between UGP and ES/CNLS has led the project to completion. ES/CNLS provided the National Project Management. The National Coordinator of the UGP Santé played the role of the Deputy Director. The rest of the team is based within the UGP Santé: The National Director and Deputy Director played a key role in representing the national side for negotiating disbursement resumption, repayment terms, the two extensions of the project and obtaining the Additional Fund. Fiduciary management is provided by the UGP Santé under the guidance of National Project Coordinator.

4.3 TECHNICAL IMPLEMENTATION BODIES Such implementing agencies include: a) The Ministry in charge of Public Health and b) the Civil Society Organizations (OSCs). a) The Ministry in charge of Public Health, called Vice Prime Minister’s office in charge of Public Health was between August 2009 and July 2010 responsible for the management of the health sector facing HIV and AIDS by Decree No. 2009-1220 of 6 August 2009. The Service for Fighting against STIs and AIDS (SLISTS)11 is the structure within such ministry that is responsible for implementing and monitoring programs for prevention and therapeutic management of STIs and HIV according to established norms and standards, and according to the broad lines of the National Strategic Plan (PSN). The areas of prevention and management under biology as well as essential studies and surveys are devoted to the Service of National Reference Laboratory (LNR). ). SALAMA Central Purchasing body provided remarkable services in the acquisition and delivery of essential products and medicines to the fight at the Health Districts services. Contracts with the technical assistant to the PNLS (previously SLIST) and technical assistance with the SLNR have been carried out, given the proven importance of their input in implementing the activities of their assignment entities.

b) The Civil society. The Civil society relates to Grassroots Community Organizations (OCB) involving the population, to associations of PLWHA and to those of other people most at risk such as MADAIDS or other FIMIZORE, or MSM FIFAFI. The activities of psychosocial support associations helped find again lost sight of PLWHA in the intervention regions, thereby keep the active file of monitored PLWHA. NGOs were also mobilized throughout the PMPS II and FA. Existing NGOs which were proven and documented are a little different; as they were financed on results, on well-defined targets in priority areas in a given period, they contributed positively to reaching the objectives set at the end of PMPS II and FA: PSI, MSM, ADRA, ASOS and SISAL that were recruited during the Project extension phase depending on performance-based contract in 120 communes in 16 Regions of Madagascar. The cost for funding NGO participation remains high and difficult to sustain. However, the concept of civil society, mobilizing the population on a voluntary basis, including

10Prior to 2009, the Ministry in charge of Health is called Vice Prime Minister’s office in charge of Public Health (VPCSP); it is only during the transition from 2009 to 2013 that the department became again Ministry of Public Health.

11SLIST became PNLS afterwards = National Program for the Fight against STI / HIV / AIDS.

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people involved in a cause and a work that improves their living conditions, which may require from government authorities transparency and good governance remains to be developed thereafter.

The First Implementation Manual differs slightly from the above -mentioned structures. Prior to 2009, the coordination structures were reinforced by (i) the Multi-sectorial Technical Committee (CTM), which was mandated to ensure that the multi-sectorial nature of the fight is reflected in the operationalization of the National Strategic Plan In order to remedy the absence of CNLS, ES/CNLS initiated the partners forum in which the Government, the United Nations system, the bilateral and multilateral cooperation agencies, the civil society and the private sector are represented. The terms of reference that were developed are not specific enough and such forum, an informal body, was not endowed with power, or organization. It cannot act in place of CNLS and does not have the rights required to drive the ES/CNLS. However, such forum is a place for exchanges among various actors involved in the fight against HIV/AIDS.

At the intermediate level, the Inter Regional Offices and the UCR (Regional Coordination Units) contributed to the development of Regions integrated plans and served as a reference to any action at the intermediate level. Unfortunately, the process of decentralization in the country did not experience tangible and significant progress; as sectorial efforts that were almost deprived of resource allocation, of power and skills transfer are not viable and sustainable. Significant efforts were also provided to the peripheral and local level, with the implementation at local level of Local committees to Fight against AIDS (CLLS). Plans to Fight against AIDS were thus developed. In 2008, the 1254 communes had CLLS and 832 ones had their PLLS. And municipalities were categorized into highly vulnerable and moderately vulnerable. It should however be noted that the suspension of funding for OCB in the implementation of local plans acted as a brake to, or even wiped out the gains in local response.

In accordance with the content of some components, the organization of the Project benefited from the following structures before 2009: (i) The Agency for Financial Management (AGF) is a consulting firm in charge of managing the Fund to support Prevention (FAP). Such fund seeks to implement response strategies by civil society. In addition, the Agency shall review the eligibility and financial validation of sub-projects under component 2. Decentralized branches of AGF were at the provincial level. (ii) The Facilitation bodies (OF), a consortium of international NGOs, recruited and trained to provide the establishment and capacity building of CLLS, the coaching of developers in the development and implementation of sub-projects, in the implementation of interventions and the development of business relations under the FAP, and (iii) The Board of Technical Review ORTensures the technical review of sub projects from components 1 and 2. Proposals of basic projects submitted to FAP for an amount exceeding USD 10,000 were reviewed by ORT; those exceeding US$100,000 should be approved by the PMPS Board. A sub-component financed the establishment and operationalization of the structures involved in the management of FAP. The suspension of FAP II was decided following irregularities noticed in the management of the Fund: allegations of corruption, dysfunction in the processing of files submitting subprojects, and statement of low-capacity of mechanisms for monitoring, supervision and evaluation compared to the very high number of financed sub-projects. Therefore, all the activities of the Financial Management Agency were suspended in 2008 while an operational and financial audit of the FAP was conducted by an international firm.

The results of audits carried out in 2008 include an almost universal non reference to the "Three Principles of Oneness" thus creating a leadership deficit in the fight among the decentralized entities. In addition, there is a lack of local control vision centered around the universal principle of access by any Malagasy to information and services on the fight against STIs and HIV/AIDS. Such lack of local vision makes it difficult to detect the immediate and future impact of activities fighting STIs and HIV/AIDS on the population.

In sum, the current laws were more or less respected; bodies such as the CNLS did not work as they should. The partner forum could partly compensate for such failure, but requires more restructuring. In addition, the effective decentralization of the fight experienced a remarkable jump early in the project but that was difficult

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to sustain with no more resources and coordination. The use of civil society sometimes requires sometimes costly measures and requires close monitoring and objectives, as well as outcomes contracted in a well-defined area. However, tangible results were achieved at the end of the Project. A drastic change in direction occurred with the FAP in 2008. The Project leadership bodies demonstrated a significant and persistent management capacity to carry out the PMPS II FA. The institutional part of the report ICR is considered moderately satisfactory.

5. Evaluation of the Performance of the Bank (IDA) and of the Borrower (Malagasy Government and implementing agencies)

Performance of the Bank (IDA) -Despite the obstacles and difficulties encountered during the ten years PMPS II and FA existed, the Bank found the ways and means to complete the project by negotiating with the national party and in compliance with the procedures and requirements of the Bank: restructuring components, two extensions of project closing, transforming project profile into humanitarian actions with OP 7.30, integration of additional actions of the Bank in the continuation of the AIDS project such as nutrition and health, and the nature of the Emergency support of PAUSENS project targeting the Education, Nutrition and Health sectors. -Such perseverance was thus well appreciated in the effort through the portfolio review, the observance of current standards, in compliance with the changing situation in Madagascar and strengthening the sectors which have benefited from support. The project targets had to be changed, while maintaining the initial development objectives -The Bank has a pool of experts deemed very effective by the national party with regard to support and supervision of project activities: health, environment, procurement ... The support is nearby because the experts reside in Antananarivo ensuring regular and appropriate monitoring of the project progress. Regular supervisions by Bank missions, accompanied by field visits and meetings with national and international officials throughout the project were well appreciated. Aide-memoires from such missions were very useful for documenting PMPS II and FA. The support of the Bank is complementing financing from other donors such as the Global Fund and the United Nations System. Indeed, the PMPS II provides its support through capacity building among health workers, providing health centers with equipment, drugs for antiretroviral treatment, for the prophylaxis and treatment of opportunistic infections, and in reagents and consumables for biological monitoring of PLWHA. -The PMPS I and PMPS II are engaged in the decentralized and local response of fight actions. Moving in such direction ensures sustainability of the achievements. Suspending halfway such strategy is seen with suspicion by all national stakeholders. The phase-out measures from the perspective of financing of decentralized structures would have a less negative impact. The Bank has its share of responsibility in the structures institutionalized during PMPS and deleted afterwards. -The overlap of PMPS I and II PMPS was not always easy. If the procedures should be observed in justifying such overlap, it would be better to accelerate the steps wherever possible. The slow and cumbersome Bank procedures were considered moderately satisfactory by the national party. Often, finalization and validation of business plans are delayed because the notice of no objection from the World Bank on the POA and the PPM was received in April and May, as in 2008. A great number of interventions of the World Bank were deemed satisfactory.

Performance of the Borrower (Malagasy Government and Implementing Agencies) -The ES/CNLS was attached to the President’s office of the Republic of Madagascar. This demonstrated to the whole world the importance of the fight against AIDS granted by Madagascar. Such leadership at the highest level had significant impact on the success of the struggle to maintain the prevalence below 1% and was well appreciated. Commendable efforts led to the multisectoral aspect of the fight against AIDS. Sector strategic plans were developed and implemented: tourism, work environment, population, education, health, and national defense. Although enhancements in involved sectors still deserve to be revitalized to maintain the gains, such aspect is considered moderately satisfactory. The state has a regulatory role in the continued effectiveness of the plans developed.

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- The performance of the national party on the fiduciary and technical management was appreciated in certain periods of the Project, particularly during the extension periods and continuing to the allocation of additional funds. The terms of the Financing Agreement (FA) and all other agreements were completed most of the time. The agreed activities deadlines were then observed. Such skill that was largely acquired in the management of projects financed by the Bank should be transferred to the whole Ministry of Health, including at intermediate and peripheral levels and even to all sectors, public, private, and civil society.

- Failing reliable and timely data, the first National Strategic Plans to fight against HIV targeted at first the general population and the country as a whole. OCBs in the whole territory were included in the strategies and PMPS I and II were thereto aligned. All resources and efforts were mobilized in this direction. Further to the results of studies conducted in the course of Projects, amendments complied with the course of action conducted by focusing further on real groups deemed at risk (TDS young ..) in specific priority areas with appropriate NGOs (ADRA, ASOS, SISAL, PSI ..). Such lack of database handicaps the actions of the Bank and the Borrower.

- The CNLS never worked as it should despite the formalization by decree of the members regarding their duty and operation. ES/CNLS has more or less provided the substitution of such important institution by mobilizing all other sectors involved in sectorial strategic plans. The forum of partners, though representative of stakeholders, cannot substitute the CNLS. Such handicap deserves more attention at the Borrower level.

-In The first phase of the Project PMPS II, ES/CNLS under the President’s office of the Republic of Madagascar, as a Project Implementation Unit provided both the coordination of activities and stakeholders, a well as the responsibility for implementing certain activities. In addition, the Secretariat managed a great number of projects related to the fight against HIV/AIDS funded by several donors. The PMPS II was then run as a Program not as a Project. The new implementation modality of PMPS II adopted by the Borrower as from 2010, namely the greater support from the Ministry of Health in implementing the health sector response and using qualified organizations, resulted in better performance in the second phase of the project: fiduciary management was entrusted to the UGP Santé and restructuring to strengthen the health sector was conducted. ES/CNLS kept its coordination function and the development of HIV-response strategies. - Component 3 of the initial project that was implemented largely by the Financial Management Agency (AGF) responsible for Support Fund to Prevention (FAP) was suspended temporarily and then permanently after statement of irregularities and unsatisfactory use resources through the financial audit. The Procedures Manual relating to this part of the Project contained inaccuracies and shortcomings sometimes resulting in ineligible expenditures that had to be repaid by the Borrower who fulfilled its commitments.

Such component 3 contributed however to considerable awareness raising on HIV/AIDS in the whole territory of the country, at all levels of responsibility and among populations at risk, even partly. From the denial of the existence of HIV, knowledge about the disease improved and the national response experienced remarked developments, as evidenced by the three National Strategic Plans 2001-2006, 2007-2012, and 2013-2017 experienced by the PMPS II and FA. - Decentralization was always a high and strong strategy advocated by all successive leaders of the Republic of Madagascar. All agree that such component is a major prerequisite for any harmonious and successful socio- economic development. Also, any socio-economic project is based on the progress of such strategic approach as PMPS. Efforts need to be supported to carry out this process. - The PMPS II and FA lasted about ten years and covered three strategic control plans. The skills of the country improved and are waiting to be tapped in the overall governance of Madagascar. The rating assigned is moderately satisfactory.

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6. Assessment of Risks from Development Results

The sustainability of the results obtained under the PMPS II and FA that came to an end remains a major challenge for the country. The risks of keeping the gains, or not, exist since the country should always later deal with contingencies and uncertainties. Key points were recorded in that respect. A study action plan to be conducted (type, periodicity, targets, areas ...) complementing the monitoring and evaluation plan addressing, among others, studies on HIV to establish and update a national multi-sector database remains crucial to the fight against poverty in general. Thus, actions conducted with donors would be more documented and decisions based on reliable information. Resource saving will then be effective. Distributing the annual reports from all sectors, results of studies and evaluations accessible to all, including policymakers, national and international stakeholders in socio-economic development and researchers on the web site would also contribute to the completeness of such database. Such action plan and such measures are needed now that the PMPS II and FA are closed. Project verticality harms strengthening the Health Sector. Most donors (Global Fund, United Nations, European Union ...) in their interventions see to the health sector's ability to cope with their ministry, not only to the actions directed towards priority vulnerable groups (Mother, child, youth, disabled ..) and towards the fight against endemic diseases. Madagascar should be in a position to maintain the achievements of the projects and continue the targets set. This remains a major prerequisite for the continuation of development activities. Major basic functions should maintain a rational management of the entire system: planning activities, monitoring and evaluation, national information system, qualified human resources, allocation and management of financial resources, leadership among officials, governance of the entire system construction and infrastructure maintenance system ... Ensuring the strengthening of such functions in any project is a necessity.

The existence of the current Strategic Plan for the Fight against HIV and AIDS 2013-2017 is the guarantor of the continuity of actions conducted under PMPS II and Additional Fund. However, the allocation of government effective equity and the continued contribution of TFP to a maintenance fund would condition the sustainability of the achievements. The estimate of the funds required implementing such PSN amounts to at least $150 million for the upcoming 3.5 years.

Collaboration with NGOs was most of the time the approach advocated by the Project in both the first phase at the end of project. Such process is expensive and puts at a disadvantage sustainable actions, especially with NGOs and Associations working only in HIV. It would be more appropriate to adopt a more integrated approach (development -health) for OSCs for more efficiency and effectiveness and to encourage more initiatives by mobilizing resources. Partnership with the private sector, such as major development projects still remains to be promoted; this can greatly help in responding to HIV.

For the Health Sector, a National Community Policy exists to harmonize the various actions conducted at Community level and funded by various donors: Nutrition, Immunization, Water, Hygiene and Sanitation, Fight against Malaria, Family Planning.... The effectiveness of actions relating to the implementation of such Community policy is necessary for any community action against HIV/AIDS in collaboration with NGOs or not. Actual decentralization remains a major prerequisite for the local response in the fight. As long as the resources, skills and development plans are properly managed at all levels, from the central to the peripheral and Community level, the sustainability of the achievements of any social action can be only effective. It is a significant and unavoidable risk. And sustainability is in stable structures of the public sector. The launching initiative up to a cruising speed is part of actions by the sector and NGOs and associations. The commitment of the population and structures of decentralized government ministries remains indispensable.

Actions conducted under the Project will serve for the continuation of upcoming interventions for the country. These include, amongst others, the development and implementation of the National Communication Strategy, which is admittedly developed at the PMPS I but which remains a reference and has always been very helpful not only for the fight against HIV/AIDS. There should also be noted staff training on blood transfusion safety

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and universal precautions and on blood quality management. Finally, for injections security and waste management, the program supported the construction of Monfort incinerators in many hospital centers, along with training of site managers. After 2015, a key period for the MDGs, the sustainability of all was undertaken is the cross-sectional section to be considered. Indeed, all unsustainable development actions are inefficient resource uses. This is the great challenge of development.

7. Lessons Learned Project Start

The PMPS II experienced a slow startup. If initially the project duration ranged from 2006 to 2009, the beginning was effective only in February 2007. There were multiple reasons for that: the overlap of the management of PMPS II with PMPS I which was still under way, slow IDA procedures, the time taken by start- up procedures, the delay in planning due to the strategic reorientation of the FAP, which was the largest component of PMPS II, the organization that was affected by the institutional arrangement, etc. Now, such situations would be avoided by bypassing the parallel management of two or more projects, by considering the time required for the various prerequisites to the implementation of a project and by intensifying communication between the UGP and IDA. Anticipatory appropriate steps in the preparation and start-up process are still needed, particularly in terms of advocacy with national authorities (parliament and government).

Decisions on Institutional organization Admittedly the PMPS II and FA Project lasted about ten years (2005-2014) with phases of extension, restructuring and change in development objective. During these years, there was shift from the institutional arrangement for activities in prevention, care and treatment of HIV/AIDS of Project Approach to Program approach and vice versa. However, the program approach required an institutional organization of CNLS which resulted in delays in the implementation of project activities. The institutional audit conducted for this purpose led to the restructuring of the ES/CNLS by refocusing its role in the coordination, monitoring - evaluation and mobilization of resources while the own management of project operations was entrusted entirely to the Project Implementation Units (UGP), which will have some autonomy in the daily management of project activities. The Project implementation unit of the Sustainable Health Project (PDSSP), which proved its ability and experience in terms of observance of financial procedures and of the World Bank procurement was designated to assume such responsibility in the management and the implementation of PMPS II activities from its second phase . The Project management transfer to the UGP as from 2009, including the fiduciary and technical part, was carried out by assigning human resources from the UGP and the ES/CNLS. This measure satisfied the Bank and the Borrower and helped lead the project to completion.

The funding for Regional Coordination Units UCR was stopped and this had its impact on the implementation of the decentralization of response management of STIs and HIV/AIDS. This fact had huge influence on the implementation and monitoring of response activities at regional and local level. The efforts commissioning the unique system of monitoring and evaluation, among others, could not be maintained while data from peripheral and reports found it hard to recover. It was better not to establish them rather than establishing, and to delete them afterwards. The implications are difficult to manage.

Overcome the Malagasy socio-political crisis Despite the constraints and challenges faced by the project, of which the political crisis since March 17, 2009 and which placed Madagascar into the context defined by the OP/BP 7.30 procedures of the World Bank, the multiple exchanges, sometimes sustainable between IDA and the Malagasy government, helped to make decisions appropriate to national circumstances in accordance with the objectives of the Project while changing targets and intervention areas.

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Fund to Support Prevention or FAP In the first phase of PMPS II project, a device consisting of AGF, ORT and the OF was set up to manage Component 3. Indeed, much of the allocated funds was devoted to such component relating to the FAP (Prevention Support Fund) to reach the target populations (including vulnerable groups) through the local response. Unfortunately, such mechanism did not prove successful and the project had to suspend the component to set up the performance-based contracting strategy with specialized NGOs to remedy the situation and to build on the achievement of its objectives with the highest risk groups. Good results were obtained, but sustainability is still a major challenge. For component 3, recourse to qualified non-governmental organizations working in development in an integrated manner for supervising OCB and local associations would be more efficient, coupled with the implementation of appropriate risk management system.

Reliable and timely data. The National Strategic Plans for the Fight against AIDS suffered from a lack of reliable and timely data. The establishment of a national multi-sector database is part of the existence of a long-term National development Strategy as a reference to all sectors and dictating the data needs to be collected. Currently, the development of a Development Plan of the Health Sector takes it long for lack of data which may serve as for the years to come. It is therefore essential to have an integrated and performing monitoring and evaluation and epidemiological surveillance system to assist in strategic and operational planning. In addition, the Integrated Management System (SIG) held a prominent place in the management of PMPS II and FA data. SIG restructuring has been operated to integrate the monitoring and evaluation component for the updating of data and consolidation of reports received. However, over time the updating of GIS was not effective until the end of the first phase, which explains its ineffectiveness in the coordinated management of technical and financial project data. Such aspect recommends us on how important the study of the implementation of SIG, as well as the scheme to be applied as soon as the project setup phase. Similarly, capacity building among the units responsible for monitoring and evaluation at central and decentralized levels was always required: recruitment of qualified people, updating and designing appropriate documents such as the Monitoring and Evaluation Plan accompanying the 2007-2012 National Strategic Plan; the document analyzing Madagascar HIV epidemiological profile; and the Regional Integrated Plan to fight against AIDS. Indeed, data management is very important in project management and although culture of data collection, exploitation, dissemination and use remains to be instilled at all levels in Madagascar, it can be said that through good collaboration between the monitoring and evaluation officials of the ES/CNLS, PNLS and the UGP, the existing data helped the project monitoring and evaluation in PMPS II management.

Management of PLWHA Strategic Plans of Response to AIDS also benefited from the contribution of recent discoveries about the transmission of HIV. A good psychosocial and medical management of PLWHA would significantly reduce HIV transmission. Unfortunately, many HIV-positive are not managed. According to data from PNLS in 2011, while 409 people were tested HIV positive, only 190 new infections are enrolled in management. In the same year, as estimated by UNAIDS, the number of adults and children living with HIV was estimated at 42,000, whereas the number of people living with HIV in need of antiretroviral treatment in late 2011 was estimated at 19 400. A small portion of those HIV positive people are currently managed. However, this allowed for the Project to rectify focusing actions on those most at risk - such as Partners of Sex Professionals clients, PS clients, Sex Professionals of the (PS), and MSM female Partners. Having timely and reliable data proves paramount for response. Each region has at least one referral physician based at a university hospital CHU or CHRR. In addition, so-called network physicians received training for locally managing PLWHA and as relays with referral physicians. They are located at the district level and even at the level of municipalities. In order to facilitate care continuum and patient follow-up, a diagram showing referral and counter referral of patients were well developed, but were never made functional in most cases. Now, the well-being and good health of PLWHA could rely only on a continuum of appropriate and operational care. To do so, commitment, collaboration and commitment of all actors involved in the comprehensive management of PLWHA is highly recommended.

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Furthermore, the existence of the ignorant HIV positive people is a major challenge in fighting HIV/AIDS. HIV-positive people who are not yet detected, and /or people already tested but lost sight of, primary or secondary, are reaching a certain proportion in Madagascar. Related strategies are known; but deserve to be evaluated, and the bottlenecks hampering their effectiveness should be analyzed for possible strategic for seeking the ones lost sight of and support for PLWHA. Although interventions on awareness raising and mobilization of the population, especially the people the most exposed to risk to be tested, exist, further efforts are still to be deployed to find the estimated HIV positive nationally. As regards the psychosocial management right from screening up to treatment follow-up, many of interventions were conducted, and MADAIDS network, along with other partners continue their commitment in that direction. However, faults are noticed with the existence of lost sight of who are unrecovered and who should lead us towards a new reflection on psychosocial management policy.

Contracting with NGOs Contracting with NGOs characterized by the Result Based Financing (RBF) Approach is proven. Indeed, this is an innovative strategy implemented with a view of making interventions more effective and efficient. In addition, it guided the project to expand its intervention with the RBF pilot project in the health facilities in order to improve health indicators on maternal and child health. The products are sold and funding, as well as collaboration with NGO providers are packaged. We thus professionalized the approach and results were obtained. The results of early experiences helped the project to develop more elaborate mechanisms by crossing quantitative with qualitative results to improve performance. However, the need to hire an outside independent verification agency in verifying the authenticity of the results and the quality of service makes this a very costly approach, and deserves more elaborate ideas and studies to find a more sustainable mechanism in terms of efficiency.

Integrating activities Integrating Nutrition, Health and HIV operations is still in effect even under the FA. It should be especially noted that there is no direct link between nutrition and HIV in the FA in terms of activities and results. The intervention sites are often different and stakeholders are not always the same. Maybe HIV testing would be the intervention that can always be integrated, such as Family Planning. Until today, a mobilization of HIV seropositive for good management remains a major challenge in the fight against HIV / AIDS. Effective integration of awareness raising to testing and management should amount to a multi-sector action directed at the highest level of the government.

Waste Management Taking into account the cross-cutting issue of environmental protection through the medical waste management plan initiated by the project helped to educate the health staff on practicing daily management of waste in health and hospital environment and to foster in them the conscious habit of managing them effectively. However, its extension is a challenge to be implemented at national level.

Monitoring and Evaluation The monitoring-evaluation part is an important component during the PMPS II and FA. The actions advocated in the plans deserve a regular and ongoing support to any actor involved in the PMPS II and FA. The existence of a monitoring plan is an important aid and deserves to be extended to all partners collaborating in the project.

Human Resources Capacity building among staff and national organizations was mentioned and appreciated by various interviewees: in the form of training, study tour, international conferences, support and supervision. Workshops at regional, national and international level were organized as part of the Project, and this left positive impact on the skills of officials with responsibilities relating to the management of PMPS II and FA. Training on project management, procurement, financial management or disbursement were very beneficial, and remain as a contribution of the Project to national competences. These assets could be used in other projects or simply in

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improving the overall governance of the organizations involved. Nevertheless, the impact of such activity in improving project performance should be measured and felt. Furthermore, frequent in-project changes by decision-makers within ministries responsible of key sectors which are the national representatives of the Borrower, hampered the smooth running of the project implementation. This affects not only the quality of planning but at the same time delays the implementation period of activities with impacts in terms of process indicators and results.

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Annex 8. Comments of Cofinanciers and Other Partners/Stakeholders

NA

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Annex 9. List of Supporting Documents 1. Project Appraisal Document, June 13, 2005. 2. Development Credit Agreement, July 13, 2005. 3. Amended and restated Development Credit Agreement, February 15, 2012. 4. Project Concept Note & Minutes of meeting, February 2005. 5. Aide-Memoires (2005-2014) 6. Implementation Progress Reports (2005-2014) 7. Mid-Term Review Issues Paper, November 2008. 8. National Strategic Plans (2001-2006, 2007-2012, 2013-2017) 9. Memo and Additional Financing and Restructuring Project Paper, May 31, 2012. 10. Memos and Restructuring Papers (December 2011, August 2014) 11. Financing Agreement (AF), July 27, 2012 12. Implementation Completion Report of MSPPI, June 25, 2008. 13. IEG Review of the MSPPI ICR, September 12, 2008. 14. Emergency Project Paper for the Emergency Support to Critical Education, Health and Nutrition Services Project, November 13, 2012. 15. Rapport Final au Niveau des 37 Villes (Cartographie et estimation de la taille des populations clés les plus exposées aux risques du VIH/SIDA, SIMS/MSIS, November 2014. 16. Rapport d’Activité Sur la Riposte au Sida a Madagascar, CNLS, April 2014. 17. Interim Review of the Multi-Country HIV/AIDS Program for Africa, February 2004. 18. Rapport - Cartographie de Vulnerabilité des Communes de Madagascar a la propagation du VIH/SIDA, UNDP 2012. 19. MICS 2012, Madagascar, July 2013

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Annex 10: Targeted Communes under the project

Phase 1: Component 3 – FUND FOR STI/HIV/AIDS PREVENTION (200 (Source: Agence de Gestion Financière)

Severely Moderately Other Vulnerable CFV Vulnerable CMV communes Communes reached by Communes reached by reached by Regions (CFV) the project (CMV) the project the project ALAOTRA-MANGORO 6 5 20 1 32 AMORON'I MANIA 1 1 11 6 11 ANALAMANGA 4 3 14 3 70 ANALANJIROFO 8 6 22 10 10 ANDROY 2 2 15 15 5 ANOSY 3 3 5 5 16 ATSIMO ANDREFANA 15 13 19 19 16 ATSIMO ATSINANANA 3 2 21 12 12 ATSINANANA 8 6 15 10 14 BETSIBOKA 8 7 14 8 3 BOENY 8 8 16 13 23 BONGOLAVA 6 1 3 0 2 DIANA 3 3 1 1 52 HAUTE MATSIATRA 3 3 11 9 70 IHOROMBE 7 5 6 3 18 ITASY 2 2 16 13 15 MELAKY 11 8 6 6 20 MENABE 3 3 19 5 6 SAVA 5 5 17 17 13 SOFIA 2 2 22 11 44 VAKINANKARATRA 3 1 23 14 20 VATOVAVY- FITOVINANY 8 5 42 12 2 119 94 338 193 474 79% 57% Total targeted communes 761 Total communes 1549 % targeted 49%

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PHASE 2: INTERVENTION ZONES OF NGOs (2010-2014)

Districts ASOS PSI ADRA MSM SISAL TOTAL Antananarivo Renivohitra 2 20 22 Antananarivo Atsimondrano 2 2 Antananarivo Avaradrano 0 Ambohidratrimo 1 1 Andramasina 0 Anjozorobe 0 Ankazobe 0 Manjakandriana 0 Total Région Analamanga 3 22 25 Ambatolampy 0 Antanifotsy 1 1 Antsirabe I 1 2 3 Antsirabe II 2 2 Betafo 0 Faratsiho 0 Total Région Vakinankaratra 2 2 2 6 Fenoarivo centre 0 Tsiroanomandidy 1 1 Total Région Bongolava 1 1 Arivonimamo 2 2 Miarinarivo 2 2 Soavinandriana 9 9 Total Région Itasy 2 11 13 Antsiranana I 0 Antsiranana II 0 Ambanja 0 Ambilobe 0 Nosy Be 0 Total Région Diana 0 Antalaha 2 2 Andapa 2 2 Sambava 2 2 Vohimarina 2 2 Total Région Sava 4 4 8 Fianarantsoa I 1 1 Fianarantsoa II 2 2 Ambalavao 0 Ambohimahasoa 2 2 Ikalamavony 0 Total Région Haute Matsiatra 1 4 5 Ambatofinandrahana 0 Ambositra 1 1 Fandriana 4 4 Manandriana 0 Total Région Amoron'i Mania 5 5

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Befotaka 0 Farafangana 4 4 Midongy Atsimo 0 Vangaindrano 2 2 Vondrozo 0 Total Région Atsimo Atsinanana 6 6 Ikongo 0 Ifanadiana 0 Manakara Sud 1 1 Mananjary 2 2 Nosy Varika 0 Vohipeno 0 Total Région Vatovavy Fitovinany 3 3 Iakora 0 Ihosy 0 Ivohibe 0 Total Région Ihorombe 0 Mahajanga I 1 1 Mahajanga II 1 1 Ambato-Boéni 0 Marovoay 0 Mitsinjo 0 Soalala 0 Total Région Boeny 2 2 Ambatomainty 0 Antsalova 0 Besalampy 0 Maintirano 0 Morafenobe 0 Total Région Melaky 0 Analalava 0 Antsohihy 1 1 2 Bealanana 0 Befandriana Nord 0 Mampikony 0 Mandritsara 0 Port Bergé 3 3 Total Région Sofia 1 4 5 Kandreho 0 Maevatanana 1 1 Tsaratanana 0 Total Région Betsiboka 1 1 Toamasina I 0 Toamasina II 0 Antanamabao Mananampotsy 0 Vohibinany 0 Mahanoro 0

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Marolambo 0 Vatomandry 0 Total Région Atsinanana 0 Ambatondrazaka 1 10 11 Amparafaravola 0 Andilamena 0 Anibe An'Ala 0 Moramanga 2 2 Total Région Alaotra Mangoro 1 2 10 13 Fenérive Est 2 2 Mananara Nord 0 Maroantsetra 0 Nosy Boraha 1 1 Soanierana Ivongo 3 3 Vavatenina 0 Total Région Analanjirofo 3 3 6 Toliary I 1 10 11 Toliary II 2 2 Ampanihy 0 Ankazoabo atsimo 0 Benenitra 0 Beroroha 0 Betioky atsimo 0 Morombe 0 Sakaraha 1 1 Total Région Atsimo Andrefana 2 12 14 Amboasary Atsimo 0 Betroka 0 Tolagnaro 0 Total Région Anosy 0 Ambovombe Androy 3 3 Bekily 0 Beloha 4 4 Tsihombe 0 Total Région Androy 7 7 Belon'i Tsiribihina 0 Mahabo 0 Manja 0 Miandrivazo 0 Morondava 0 Total Région Menabe 0 TOTAL 14 16 14 42 34 120

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NGO INTERVENTION ZONES

Antsiranana

Vohemar ASOS 2

Antsohihy 1 MSM, 1 PSI Sambava PSI 2 Port Berge MSM 3 Andapa ASOS 2 Mahajanga II MSM 1 Antalaha PSI 2 Mahajanga I MSM 1

Soanierana Ivongo ASOS 3 Sainte Marie PSI 1 Fénérive Est PSI 2 Maevatanana MSM 1 Ambatondrazaka 2 ASOS 10 MSM

Moramanga PSI 2 Miarinarivo PSI 2 Antananarivo Reniv 10 Sisal Tsiroanomandidy PSI1 2 MSM Antsirabe I 1 PSI 2 MSM Soavinandriana MSM 9 Antanifotsy PSI 1

Antsirabe II ADRA 2 Fandriana ADRA 4 Ambositra ADRA 1 Mananjary ADRA 2 Fianarantsoa I ADRA 1 Toliara II SISAL 2 Fianarantsoa II ADRA 2

Manakara ADRA 1

Toliara I 10 SISAL Farafangana ASOS 4 1 MSM Vangaindrano ASOS 2

Sakaraha MSM 1

Beloha MSM 4 Ambovombe MSM 3

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