3. Assessment of development objective and design, and of quality at entry.
The Sexually Transmitted Infections Project (STIP) was conceived as a project to sustain momentum and strengthen the control of AIDS and other sexually transmitted infections in Uganda, as part of the country's response to the severe impact of the HIV/AIDS epidemic on the general population and on the economy. At the time, funding from the Global Program on AIDS (GPA) of the WHO - that had provided significant support between 1987 and 1992 to the National AIDS Control Program (NACP) of the Ministry of Health (MOH) - was running out. However, the national HIV prevalence among adults was still estimated at about 15% and Uganda was being referred to as the epicenter of the HIV epidemic.
The Bank had initially proposed a Community Health and AIDS Project (CHAP) as a follow up to the Bank-supported Uganda First Health Project to address health policy issues and support efforts to contain the growing AIDS epidemic. Given the seriousness of the AIDS crisis and the perceived complicated design of CHAP, however, the original project was split into two projects--STIP, which was to focus specifically on STD and HIV interventions, and the District Health Services Pilot and Demonstration Project (DHSP Cr. 2679-UG), which was intended to support a broad set of health sector reform initiatives, including the rehabilitation of the health infrastructure in Uganda. The delays involved in designing CHAP, and later splitting it into two projects--both of which involved significant consultations with relevant partners--explains, to some extent, the long time taken to prepare STIP. Also, as discussed later in the report, this decision to split CHAP into two projects: (a) STIP, focused more on inputs such as drugs and condoms relevant to STIs and HIV/AIDS, in addition to prevention; and (b) DHSP, focused on broader policy and institutional reform and infrastructure development, had significant implications for STIP.
STIP was designed to achieve three main objectives: (a) To prevent sexual transmission of HIV by promotion of safer sexual behavior; provision of condoms; promotion of Sexually Transmitted Diseases (STD) care seeking behavior; and provision of effective STD care; (b) To mitigate the personal impact of AIDS by provision of support for community and home based care; social support for people living with AIDS; provision of drugs for opportunistic infections, including protective supplies for district health facilities; and effective tuberculosis (TB) management; and (c) To support institutional development to manage HIV prevention and AIDS care by strengthening the districts' capacity to plan, implement, and monitor integrated AIDS related activities; and strengthening the national capacity to provide adequate technical support on health issues related to AIDS.
The project objectives were clear and in line with Government's White Paper on Health Policy (1993) and the HIV/AIDS National Operational Plan (1993), and were also consistent with the World Health Organization (WHO) technical guidelines for National AIDS Programs. Further, the Bank had supported projects with STD and HIV control components in other countries, from which lessons could potentially be drawn. The project design was based on existing programs--most notably the NACP in the Ministry of Health--under whose broad ambit STIP was to be implemented. STIP was also intended to complement health sector and HIV/AIDS programs being supported by donors such as USAID, UNFPA, UNICEF, DfiD, SIDA and KfW, of which the last two were co-financiers of STIP, while DfiD provided parallel support. Given the emergency nature of the project, and with the Bank-supported First Health Project under the Ministry of Health (MOH) just having been completed, the Bank decided that the Ministry of Health (MOH), which was familiar with IDA procedures, could--with appropriate capacity building during the project--successfully manage the STIP project. Overall, the project was seen to be responsive to borrower circumstances at the time, given the high level of commitment of both government and civil society to HIV/AIDS and the fact that the project was building on an existing program (i.e., the NACP). On the other hand, at the time of project design, Uganda's institutions--including the MOH--were still weak, as the country was just recovering from years of civil strife. The Uganda AIDS Commission (UAC)--set up under the Office of the President with support from various international partners, including the Bank--had successfully outlined a multisectoral AIDS control strategy. However, the Bank, in consultation with the GoU, made a determination that, because of capacity constraints, the Commission was not ready to take over the leadership of STIP. Further, evidently, the UAC had at the outset tried to take on an implementation role, in addition to its primary coordination function. A subsequent debate within the government led to a decision to separate the coordination and implementation function and assign them to different government agencies. At any rate, due to a combination of these factors, STIP was implemented under the stewardship of the MOH through the creation of a Project Coordination Office (PCO), staffed largely by personnel from the project implementation unit of the First Health Project. The implications of project coordination by the MOH, rather than by the UAC, for promoting a truly multisectoral response to HIV, are discussed later in the report.
The design of the project directly responded to the government's decentralization policy. However, the project was designed with a sense of urgency in order to cope with the rapid evolution of the HIV/AIDS situation in Uganda. Accordingly, the project had a district-focus that involved the decentralization of financial and general management responsibilities to the districts at a time when the appropriate capacity and authority were still being established at district level. From this perspective, the project's district focus, coupled with the increasing AIDS burden, placed a management and budgetary strain beyond the capacity of the districts to cope. The project also seems to have overestimated the MOH's coordination abilities, even considering the training and capacity building activities proposed in the project in recognition of the limited capacities existing in the Ugandan government at that time. This was particularly the case with procurement, as evidenced by the significant procurement problems faced by the project throughout its implementation. Given the long gestation period involved in developing STIP, and despite the demands imposed by the AIDS epidemic (which were significant), these issues could have been better addressed by the Bank, as discussed later in this report.
On the other hand, the project provided for a wide range of implementers at different levels that enabled implementation of a broad mix of interventions targeting various groups. Thus, the same district focus that proved to be an impediment to project implementation, particularly at the beginning, also helped to move the front-line for dealing with the AIDS epidemic to the grassroots, and facilitated faster capacity building within the districts. The project was also able to support implementation of activities in other sectors through NGOs and CBOs. Even the few who have criticized the claims of a Ugandan HIV/AIDS success story (e.g., see Justin Parkhurst, 2002) acknowledge that the success can be attributed, to a large extent, to the synergy between NGOs, faith based groups and CBOs, and the government which has "implemented a uniquely creative and strategic policy approach to enable non-state actors in their individually targeted messages of prevention. It is lessons from this joint approach that need to be learned..." (p. 79). NGOs have played an especially important role in the home based care of PLWHA.
At about the same time, Uganda had also begun work on a Sexual and Reproductive Health Strategy; but there seems to have been relatively little cross-fertilization between this nascent strategy and the design of STIP. The country had also initiated a major program of political and administrative decentralization, supported by several far-reaching policy decisions. The project, therefore, had to adopt a decentralized approach to implementation, which accentuated the challenges related to capacity building. Furthermore, there were also other ongoing reform efforts--such as the reform of the civil service--that had significant health sector ramifications. These factors posed serious risks to the project. Remedial measures such as capacity building and institutional strengthening included in the project were intended to partly mitigate these risks. Also, the DHSP, designed at the same time, was expected to specifically address institutional and capacity constraints in the districts and center, and to support the Ministry of Health in implementing the government's decentralization program.
The following targets, relating primarily to the first of three STIP project components, were identified in the Staff Appraisal Report (SAR) as measures of project performance, and evidently reflected what was seen to be feasible at the time.
* At least 50% of the target population able to cite two acceptable ways of protection from HIV;
* Condom use with non-regular partners increased by 50%;
* Reported casual sex partnerships reduced by 20%; and
* 70% of individuals seeking STD care receiving appropriate STD treatment.
These key targets were not revised during the course of project implementation. However, a broader set of indicators (called "Key Performance Indicators") were identified at the mid-term review, and followed to a limited extent in the Project Status Reports. These indicators are included in Annex 1.
3.2 Revised Objective:
The project objectives remained unchanged during the course of the project.
3.3 Original Components:
In accordance with its stated objectives the project had the following three components:
Component 1: Prevention of Sexual Transmission of HIV ($35 million): Prevention of sexual transmission of HIV was to be achieved through the following subcomponents: promotion of safer sex behavior by awareness raising, community mobilization and targeted behavioral interventions; provision of condoms; promotion of STD care seeking behavior and provision of effective STD care. Prevention of Mother to Child Transmission (PMTCT) and Voluntary Counseling and Testing (VCT) were not part of the project design; however, the project was to later support the procurement of test kits, and the training of counselors following the successful implementation of VCT activities by the AIDS Information Center with funding from other donors. PMTCT activities, adopted in later years of the project, were largely supported by other donors.
Component 2: Mitigation of Personal Impact of AIDS ($22.4 million): Under the project, mitigation of the personal impact of AIDS was to be achieved through: provision of support for community and home-based care and social support for people living with AIDS; provision of drugs for opportunistic infections and clinical and protective supplies; and training of staff in care of persons with AIDS including diagnosis and management of tuberculosis.
Component 3: Institutional Development ($10.7 million): Under institutional development, the project was to strengthen the capacity of districts to plan and manage AIDS activities, and the capacity at the national level to provide adequate technical support on issues related to health and AIDS. In addition, the project was to further strengthen existing HIV/AIDS surveillance, monitoring and evaluation, and operational research activities.
Overall, Components 1 and 3 of STIP were appropriate, reflected current knowledge and experience at the time, and were directly related to the achievement of project objectives. Component 2, however, seems to have focused almost exclusively on the impact of HIV at the level of the individual. Less attention seems to have been paid to the significant impacts of the epidemic at the household and population level, and to the sectoral and economic impacts of the epidemic, which are now widely acknowledged to be important elements in the fight against HIV/AIDS. It must be noted that these broader impacts of HIV/AIDS were only beginning to be recognized at the time of STIP's design. In that sense, the project's focus on treatment and care--rather than exclusively on preventive efforts--and the fact that it supported treatment initiatives in sectors other than health, such as in the army, police, and prisons are to be lauded. Nevertheless, the need for broad-based, multisectoral action in national HIV/AIDS control programs is a valuable lesson learned from STIP.
At the time of project design, there were no completed or formally evaluated Bank projects that were similar to STIP (although the Bank did initiate such projects in Zimbabwe in 1993 and in Kenya in 1994) that could offer precise guidance on best practice. Nevertheless, as noted, there were a number of the Bank's health projects that had STD control and AIDS components that provided useful lessons. STIP was designed in close collaboration and with the active participation of several partners--local and international --involved in HIV/AIDS initiatives in Uganda. As noted, the project components reflected ongoing activities/interventions being implemented by other partners, thereby avoiding a duplication of effort. For example, blood safety, which was supported by the European Union (EU), was excluded from the project during project design.
The project was consistent with the WHO recommendation at that time that STI treatment is a cost-effective strategy to prevent HIV transmission. The Human Immunodeficiency Virus (HIV) that causes AIDS is primarily a sexually transmitted disease in Sub-Saharan Africa, and is largely preventable through the same precautions used to prevent other sexually transmitted infections (STIs). In addition to being painful, and potentially contributing to chronic health problems and infertility, by the early 1990s a growing body of evidence suggested that the presence of other STIs facilitated the transmission of HIV. Moreover, research in Africa suggested that early diagnosis and treatment of STIs might reduce the risk of HIV transmission. Subsequent research, however, has shown that the impact of STI treatment on HIV transmission may depend of a number of factors, including the type of STI, whether the STI is ulcerative, the quality and coverage of STI treatment programs, sexual behavior patterns, and the extent to which HIV transmission is limited to high risk groups as opposed to having spread to the general population (Fleming and Wasserheit 1999; Rottingen, et al. 2001).
3.4 Revised Components:
The project components remained unchanged throughout the project life. However, blood safety, which was largely supported by the European Union, and was therefore not included as a project component, was later given limited support by STIP due to shortfalls in EU funding.
3.5 Quality at Entry:
Project concept, objectives and approach: The project design reflected existing conditions at the time: (a) Uganda was just emerging from civil strife that had crippled public institutions, including in the health sector; (b) Support from the GPA and other donors for HIV/AIDS interventions was ending, although the prevalence of the epidemic was its highest and was severely affecting the economy; (c) The government was involved in a major decentralization program; (d) The government and civil society organizations were fully committed to the fight against HIV/AIDS. In this environment, a stand-alone project implemented through a decentralized arrangement including civil society organizations was considered necessary in order to mount a vigorous program to mitigate the impact of HIV/AIDS.
The Bank's support for the disbursement of funds at district, rather than at central, level was a significant departure for World Bank projects at that time, and signaled a new approach embracing decentralization and a broader definition of partnership. Despite glitches during implementation, which are to be expected with a new approach, the project was inscribed in an acceptable policy framework, which included the adoption of a district health planning approach and the development of a policy on home-based care. The project pursued the strategic priorities of controlling the HIV/AIDS epidemic through evidence-based, cost-effective, STI prevention and treatment interventions. The preparation of the project followed a participatory approach whereby key stakeholders--such as government departments, NGOs, CBOs and the donor community--were closely involved. In fact, as noted, the enlistment of non-state actors in the fight against HIV represents one of the greatest successes of the government, and this partnership--which was furthered by STIP--was instrumental in Uganda's being able to reverse the course of the epidemic in the country. The Bank played a very significant role at both the design and implementation stage to further this collaboration and foster a sincere partnership between the government and civil society. Indeed, this example of public-private collaboration stands out as a model for all developing countries seeking to confront the HIV/AIDS issue head-on.
A critical question for which the mission failed to find a persuasive answer is why a decision was made to have the MOH, and not the UAC, as the Executing Agency for STIP. While, as noted, the lack of adequate capacity at the UAC was suggested as the primary reason, and while it is true that after over ten years since its inception, the UAC is still trying to clearly define its leadership role in AIDS control in Uganda, it is equally true that significant investments had to be made to enable the PCO in the MOH to play this role effectively. It is not entirely clear why these investments in capacity building, with similar results, could not have been made within the UAC. In addition to avoiding tensions between the UAC and the MOH, which are only now being addressed, such investments might have significantly broadened the scope and reach of STIP in AIDS control beyond the health sector (which clearly dominated STIP) to involve the other relevant sectors. The fact that the UAC had positioned itself as an implementing agency (with the risks of over-centralization that this might entail) could surely have been addressed through an effective policy dialogue with the government. Furthermore, while the project did establish AIDS control programs in other ministries, the mechanisms for ensuring multisectorality, whereby the line ministries would address HIV/AIDS in their work-plans and budges, were not particularly effective (although the MOH did have significant success in engaging civil society actors from various sectors at the community level). Also, while it should be acknowledged that STIP was but one component of the National AIDS Control Program (NACP), a greater focus on these institutional, governance and coordination issues--which might have been better accomplished by the UAC which (unlike the MOH) had that mandate--could have significantly strengthened the multisectoral response. To the extent that STIP could not be implemented as a truly multisectoral HIV/AIDS response, the failure of the Bank to adequately support the UAC as the focal point for AIDS control activities in Uganda--through a more proactive engagement in the policy dialogue with the Government of Uganda--must be seen as a missed opportunity. Of course, it should be noted that the thinking on a multisectoral approach to AIDS control has evolved over the years, and the approach was not as refined in 1994 (when STIP was designed) as it is today. To the extent that a multisectoral response is being pursued in the Uganda AIDS Control Project under the Multi-Country AIDS Program (MAP), this is a step in the right direction.
Although STIP was conceived and designed as a traditional project, despite the co-financing provided by SIDA and KfW, it ended up providing broad programmatic support. This was because the project's (technical) implementation was to be led and coordinated through the NACP at the center, and the District Medical Offices at district level, against a background where the relationship of various donor projects, including STIP, to the Government's broader national HIV/AIDS program was not made explicit--although there was a general understanding that the various donor-supported projects under the NACP would be "closely coordinated". While the Bank did make attempts to bring about such collaboration by, for example, insisting on STIP submitting work plans of all district activities in order to better position STIP in these activities, it is fair to conclude that the overall coordination among the individual projects contributing to the NACP program could have been far more active and effective. Partly as a result of the problems with collaboration, despite the relative technical soundness of the project, which included a comprehensive District Monitoring and Evaluation Framework Matrix covering both program and project indicators that was prepared based on WHO guidelines, insufficient attention was given to monitoring and evaluation of the project throughout the life span of the project. The NACP collected only program indicators, almost completely neglecting the project specific indicators. This was one of the more serious deficiencies in project design, and had a significant negative impact on the implementation of the project.
Poverty, equity, and gender/youth focus: The HIV/AIDS epidemic posed a huge threat to the economic, social, and political fabric of Uganda, in general, and to the health sector, in particular. STIP rightly determined that by preventing HIV transmission, and providing treatment and support to people already infected, the project could help in mitigating the socioeconomic and political impact of the epidemic in Uganda.
At the time of project entry, it was intended that attention would be given to certain high-risk groups to be targeted by the project, such as adolescent girls, truck drivers, the military, police, migrant workers, slum dwellers, truck drivers, and commercial sex workers (CSWs). While the design document emphasized the importance of targeting high-risk groups, the project did not establish specific mechanisms to target these groups (except, notably, for STI patients and military, police and prison personnel), nor was an overall strategy or monitoring program put in place to ensure adequate coverage of these groups. In part, the absence of effective targeting was driven by a broader discussion within the Bank on the appropriate choice between targeting the "traditional" high risk groups (CSWs and truck drivers--thereby putting emphasis on those who transmit HIV) versus targeting vulnerable groups (based on vulnerability factors associated with age, gender, income etc.--instead putting emphasis on those at the receiving end of HIV transmission). At that time, this debate was resolved in favor of the former approach. As a result (and with the benefit of hindsight), it could be argued that the international community contributed, however inadvertently, to the stigma associated with HIV/AIDS as a disease, as well as to the stigmatization of infected individuals and groups.
Furthermore, during project implementation, the impact of targeting proved to be limited, despite the laudable efforts of SIDA and DANIDA to direct attention to this issue through dialogue, sensitization of staff, training, and inclusion of a gender specialist by SIDA on the Bank supervision missions. In particular, a pre-project study found significant gender and age differences in perception of risk for HIV infection, with women and the youth being the most vulnerable. Women were also found to be more vulnerable to STI and HIV transmission, comprise the majority of caregivers for PLWHA, and lag behind in both information and behavioral change. In terms of vulnerability to disease transmission, as well as lags in information and behavioral change, the same could also be said of the youth. Yet inadequate attention was given to their specific needs in the project design. While STIP did make an attempt to address gender issues (e.g., by promoting female condoms) these initiatives had relatively limited success, and, as described later, this lack of success was reflected in the persistent gender differentials in HIV KAP and prevalence. A more targeted approach to gender- and age- specific behavior change communication; more stringent use of gender and age disaggregated data (e.g., sexual debut, KAPB on ways to prevent HIV) to document project achievements, and enhanced support to women as home based caregivers and to the youth would have considerably strengthened the gender and age-specific dimensions of the project. It should be acknowledged that, to the extent that NACP was an umbrella program of which STIP was but one component, the entire responsibility for the observed gender differentials should not be ascribed to the project. Nevertheless, since it is widely acknowledged that STIP was the single most important financial contributor to HIV/AIDS efforts in Uganda at that time--and rightly deserves a significant share of credit for the overall success of the program--the project must also take significant responsibility for the program's not addressing these gender issues adequately.
Financial management and institutional capacity analysis: Given Uganda's political realities at the time of project design, the project appropriately placed significant emphasis on decentralized implementation at the district level. At the same time, many stakeholders expressed concerns about the existing capacity at the national and district levels, as well as the sustainability of some of the project's components, given the recent initiation of a decentralized administration--perhaps expressed most forcefully by the Bank's international partners. These concerns were discussed at the various donor meetings with Bank staff, and were reflected in the appraisal report and also during the negotiation process. Nevertheless, the project significantly underestimated the capacity constraints at the district level, at least at the beginning of the project.
The established government financial management system was deemed by the Bank to be adequate to provide a steady flow of funds to the implementers at the district level. However, with commencement of project implementation, the significant problems with the flow of funds to the implementing districts became obvious. In the first two years of the project, financial management problems with delays in the issuance of authority to incur expenditures to the districts, the delays with accounting for the expended resources and the small size of the Project Special Account, all contributed to the slowing of the flow of funds. These problems could have been mitigated if a detailed financial management assessment has been undertaken and an effective financial management system, with appropriate checks and balances, including a qualified financial management specialist had been in place early in the implementation process.
Readiness for implementation: Within the context of a rapidly evolving HIV/AIDS epidemic and resultant time constraints, the project was ready for implementation at the time of entry. For example, by the time of project effectiveness, most key staff had also been put in place. Pragmatism dictated that some anticipated inadequacies in the project design be left to be evaluated and addressed during the supervision missions and mid-term review. However, more could have been done at the time of project development to ease implementation and the disbursement of funds, even allowing for the considerable pressure on the project staff to move forward quickly in tackling the HIV epidemic. For example, the project's operational manuals had not been completed by the time of project effectiveness, which significantly slowed the implementation of the project. An insistence on the completion of these operational manuals by the Bank would, in all likelihood, have significantly speeded up project implementation and disbursement.
Risk assessment and sustainability: As noted, one of the assumptions made at the time of project design made was that, with the Bank-supported Uganda First Health Project under the Ministry of Health (MOH) just having being completed, there were institutions that were cognizant with IDA procedures, and that with some augmentation of capacities--would be able to manage the STIP project. While this was true to some extent, the First Health Project had been a far less complex IDA operation, and, as it turned out, was not necessarily an adequate preparation for STIP--particularly in the areas of procurement and financial management. The Bank also underestimated the extent of capacity building needed as well as the time required for it.
In fact, procurement problems, along with the management of supplies, turned out to be a major issue throughout the life of the project and despite significant improvements, these problems persisted at the time of project closing. These procurement problems were particularly prominent at the beginning of the project and contributed to the very slow disbursement in the first two years of the project. A proper assessment of procurement capacity and appropriate linkages to the logistics system at the initiation of the project, and the identification of appropriate options to address these issues, would have substantially streamlined project implementation. Options such as the use of a procurement agent, while they were considered, were not pursued seriously, primarily because the government believed that the use of an agent would hamper the building of procurement capacities within the public sector. STIP also failed to recognize the inherent conflict between the profit-making objective of the semi-autonomous National Medical Stores (NMS) which was retained by the project to undertake the procurement for the project--and the fact that the project was expecting the NMS to supply large volumes of drugs and supplies free of charge. The absence of a clear agreement on the appropriate role of NMS in the public sector supply of drugs and an explicit policy on cost-recovery further aggravated the situation. The handling charges of the NMS were often higher than the norm in most developing countries. The NMS was also asked to take responsibility for coordinating the supply of drugs for the project, a role it failed to perform well. Project procurement and logistics management was further weakened by the absence of a specific unit in the MOH that could be responsible for overall coordination of procurement and logistics management.
The project also seems to have underestimated the challenges associated with the decentralization process particularly in relation to capacities at the district level. To further aggravate matters, the DHSP--which was expected to address some of these institutional and capacity constraints--was not well-integrated and coordinated with STIP, despite the fact that the same PCO was responsible for the coordination of the two projects. This hindered capacity building, and therefore the planning and disbursement of funds at district level. To some extent, the emergency nature of STIP, which contrasted with the slow and incremental nature of any health sector reform effort, might have been responsible for the limited coordination. But this should have been anticipated and explicitly addressed at the project design phase itself.
The PCO provided commendable support to the project throughout implementation, which is reflected in the high rates of project disbursement and the achievement of most of the project's objectives. Nevertheless, while the PCO was clearly a necessity at the beginning of the project, more energetic attempts could have been made to better integrate the PCO with the MOH, the NACP, and the UAC, later in the project. In addition to furthering sustainability, such integration may have also addressed problematic issues such as the significant differences in the salary structures of the MOH and the PCO that created some resentment. In particular, as noted, in better integrating the PCO with the UAC, the project might have been able to reach out beyond the health sector, and provide encouragement to multisectoral initiatives.
Miscellaneous. Although an environmental assessment was not conducted as the project was classified as category C, to its credit, the project identified the handling and disposal of infectious material and procurement of protective supplies for support.
Overall, the project's quality at entry is considered satisfactory.
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|Title Annotation:||UGANDA SEXUALLY TRANSMITTED INFECTIONS PROJECT|
|Publication:||Uganda - Sexually Transmitted Infections Project|
|Date:||Jun 1, 2003|
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