Page 1 PROJECT INFORMATION DOCUMENT (PID) APPRAISAL STAGE Report No.: AB5785 Project Name Population and HIV AIDS Additional Financing Region AFRICA Sector Health (60%);Other social services (20%);Central government administration (20%) Project ID P105724 Borrower(s) REPUBLIC OF CHAD Ministry of Economy and Planning Chad Implementing Agency Ministry of Economy and Planning PO Box 286 Chad Tel: (235-2) 517-153 bachar_brahim07@yahoo.fr Population & AIDS Control Project Ministry of Plan N'Djamena Chad Tel: 235 52 65 16 IMS@intnet.td Environment Category [ ] A [X] B [ ] C [ ] FI [ ] TBD (to be determined) Date PID Prepared May 27, 2010 Date of Appraisal Authorization December 5, 2007 Date of Board Approval June 24, 2010 1. Country and Sector Background The political instability experienced by Chad during the last three decades has severely compromised the country’s economic and social development, and the country’s most vulnerable groups (women and children) have witnessed a further deterioration of their already precarious living conditions. To date, an estimated 80% of the Chadian population live with less than $1/day and the country ranks 173 out of 177 on the UNDP Human Development Index scale (UNDP 2006). In addition to that, the continued turmoil and unrest in the neighboring countries has resulted in an influx of refugees. This situation, along with the particularly high fertility rate (6.3 in 2005), has inevitably contributed to a rapid population increase and considerably overstretched the capacity of health services across the country. A 2005 national HIV survey found adult HIV prevalence at 3.3%, with a peak at 8% in the capital N’Djamena. Incidence among women is higher than among men, even more so among young girls between the age of 15 and 25, with an estimated 200 000 people, including children, living with HIV in the whole country (WHO, 2007). The main factors contributing to vulnerability to HIV/AIDS include low Page 2 condom use, multiple sexual partners, poverty, low education status of women and girls, socio political insecurity, conflict and limited access to AIDS services. The Bank-financed Second Population and HIV/AIDS Prevention Project was approved on July 12, 2001 and became effective on April 11, 2002. The closing date is currently January 31, 2008. The total amount of the credit is SDR 19.5 million (US$24.56 million equivalent). As of October 22, 2007, SDR 18.8 million of the IDA Credit amount has been disbursed, which is around 99 percent of the total credit. Since the reorientation of project activities in accordance with the recommendations of the mid-term review and following the re-launching of activities in June 2006 after suspension of the portfolio, the project is achieving good results on the ground with respect to the decentralized local response approach for sexually transmitted infections (STIs) and HIV/AIDS. Achievement of the project development objective and implementation progress is currently satisfactory. An assessment on progress towards achieving the project development objectives indicates that these are likely to be achieved with respect to the HIV/AIDS indicators. Knowledge about HIV/AIDS has increased in both men and women and the use of condoms has increased for both men and women (respectively in 1997 and 2004, for men from 1.8% to 24. 6%, for women 2.6% to 17%) and for military personnel, use during nonunion sexual contacts, has greatly increased (67.6%). Objectives Project objectives would remain unchanged from the original project. The development objective of the project is to contribute to changing the behavior of the Chadian population to reduce the risk of: (i) HIV infection; and (ii) too closely spaced and/or unwanted pregnancies. 2. Rationale for Bank Involvement Renewed Bank Engagement in Social Sectors: A 2010-2012 Bank Interim Strategy Note (ISN, forthcoming) confirms the Bank’s continued engagement in social sectors which can have a direct impact on the population and poverty. This includes work in the health sector. HIV Prevalence Remains High: Although the official HIV prevalence rate appears to have stabilized at around 3.3 percent according to the 2005 HIV prevalence survey, high rates of STIs coupled with high-risk sexual behavior could translate into a rapid increase in the number of new HIV infections. Heterosexual transmission is the predominant mode of transmission with high- risk groups emerging as a result of certain socio-cultural characteristics of Chad (i.e. frequent conflicts, the status of women, activities linked to the oil field development in the South). High risk groups include commercial sex workers (with a prevalence rate of 20 percent in 2009 1 ), truckers (10 percent 2 ) and the military (7 percent 3 ). Women still remain at a higher risk of infection and prevalence rates tend to be higher among women than men. In a country where a large share of the population is not aware of their HIV status and where the capacity of health services nationwide is overstretched, targeted interventions (such as those expected under the additional financing) are critical to prevent the epidemic from spreading further. 1 2009 UNAIDS survey among commercial sex workers. 2 2005 national HIV prevalence survey. 3 Idem. Page 3 Very Poor Reproductive and Child Health Outcomes: Even though antenatal care and skilled attendance at delivery has increased, maternal mortality in Chad remains high at 1,009 deaths per 100,000 live births. The risk of maternal mortality is heightened by precocious and intense fertility (6.3 children on average per women and 15-19 years old girls contributing to 15 percent of national pregnancies). Contraceptive use remains very low: in 2004, the contraceptive prevalence rate was 2 percent 4 . This is not only due to cultural barriers but is also the result of frequent shortages in family planning supplies at the health center level. Under-five mortality, which is 209 deaths per 1,000 live births, is among the third highest in the world. Limited External Support: Continued World Bank support through the additional financing is critical as the Bank is one of the few donors supporting reproductive health and child health and HIV/AIDS activities in the country. The additional financing will provide an opportunity for continued policy dialogue and support high-impact, priority interventions. Building on Successful Approaches: The project will help achieve better results on the ground by extending the integrated decentralized response to HIV/AIDS and maternal and child health activities to districts with the poorest indicators. Thus far this approach has resulted in positive trends in key health indicators. With the appropriate reinforcement of quality and scaling up, the approach would complement activities of other development partners. Going beyond Input Financing: The Government has made enormous investments in constructing new health facilities. However, results on the ground have been disappointing, mostly due to the poor performance of the health service providers. Health workers are poorly motivated, one major demotivating factor mentioned by all cadres of health workers being low salaries. Other demotivating factors mentioned were lack of supportive supervision by the Ministry of Health and poor human resource management practices, including lack of continuing education. In addition, poor infrastructure, equipment and the absence of basic amenities such as water and electricity were considered to negatively affect work performance. The focus on inputs has limited the focus on results. Given this situation, to ensure Chad makes progress towards achieving the health Millennium Development Goals (MDGs), it is critical that the health sector develop innovative financing mechanisms, such as results based financing (RBF), to motivate health service providers. RBF provides health facilities with payments based on the amount of services they provide which means a greater focus on results rather than inputs. This approach has been successful in a number of low income countries such as DRC, Rwanda, and Burundi. (Annex 1 has further details on this approach). Measuring Results: Chad, across all sectors, needs to do a better job of tracking the results of its development activities. The project will help ensure the systematic collection of epidemiological data which will provide a better understanding of the HIV epidemic (thus addressing the changing epidemiological and HIV vulnerability scenario through more tailored activities). The project will also introduce new techniques, such as health facility surveys that will strengthen service delivery and help in the design of a possible future population and basic service delivery project for Chad. The Additional Financing instrument was deemed the appropriate Bank instrument to address the 4 DHS 2004. Page 4 financial needs of the sector rather than preparing a new investment project at this time because: (i) more time is needed to allow for consolidation of the results of the new integrated local response approach to HIV/AIDS and population activities; (ii) strengthened monitoring and evaluation will be required to prepare a new phase of financing; and (iii) the IDA envelope available for Chad at this time would not allow for a full population and basic health service delivery project. Given the exceptional country conditions, Regional management has endorsed the additional financing and sees it as justified even though implies an unusually long project life (from 2001 to 2012). 3. Description The project’s components for this Additional Financing are the same as those of the Original Project, with the following modifications: (i) Component A (multi-sectoral response) would increase support to the health sector, given the important role of the sector, and provide financing to only three additional key Ministries, namely education, defense and security. (ii) Component C (social marketing) will be removed since activities under Component C are now being financed by Global Fund and KfW. This component will be replaced by the new RBF component. (iii) Activities under Component B (community interventions) and Component D (population activities) will be re-oriented to support the implementation of the decentralized and integrated approach. (iv) Finally, Component E would be expanded to strengthen monitoring and evaluation efforts as well as medical waste management. Within the above framework, in the ten health districts employing the decentralized, integrated approach to HIV/AIDS, the additional financing will finance: (i) the supply of a comprehensive package of basic maternal and child health services through mobile teams; (ii) strengthening of the existing public and private health centers and voluntary counseling and testing centers, including for medical waste management; and (iii) promotion of demand for services through social mobilization, communication and peer education activities implemented by civil society. Activities focused on HIV/AIDS prevention include, among others, testing and treatment of STIs, HIV testing and counseling, and psycho-social, medical and nutritional support to PLWHAs. Maternal and child health activities include, among others, family planning, pre-natal care, referral for assisted deliveries, and vaccination. HIV/AIDS activities would also be implemented in Ndjamena. 4. Financing Source: ($m.) BORROWER/RECIPIENT 0 IDA Grant 20 Total 20 5. Implementation Page 5 The implementation arrangements under the additional financing would be the same as for the original project, as they are working well. The Ministry of Economy and Plan (MEP) is responsible for the planning, implementation and supervision of project activities through a Steering Committee presided by the Permanent Secretary ( Secrétaire Général – SG) of the MEP. The day-to-day coordination of project activities is undertaken by the Project Coordination Team (PCT), headed by a Project Coordinator under the direct supervision of the SG of the MEP. The team also includes an administrator, a procurement specialist, a monitoring and evaluation officer, two internal auditors, an accountant and a program officer in charge of component C of the project. The MOPH will continue to be responsible for the coordination and technical supervision of the health sector related activities as well as provision of qualified medical personnel and vaccines. The MEP is responsible for the provision of the contraceptives and general implementation supervision. Local response and community interventions are coordinated by FOSAP, a national fund that has been responsible for the selection, procurement, financial management, and monitoring of community sub-projects all over the country for over ten years. FOSAP will include a management with the following staff: an administrator, an assistant administrator, two program officers, a monitoring and evaluation specialist, and an accountant. Implementation arrangements, including procurement, financial management and monitoring and evaluation, are detailed in the PPLS2 Project Execution Manual, the FOSAP Grant Operational Manual and the FOSAP Administrative and Financial Manual. These manuals were reviewed again and approved in February, 2010. 2. The RBF component will be managed by a technical unit to be created within the PCT. A Purchase Performance Agency (PPA), generally a highly experienced international NGO, will be contracted to provide technical assistance to the PCT (through the provision of one technical assistant at the central level and four technical assistants at the district level), assess the capacity of health facilities, calculate the unit cost of the services, contract with health centers, verify achievement of results, and strengthen the capacity of the Government and project team in collecting, analyzing and using data from different sources. Household and facility surveys would be used to evaluate the quality of services, the knowledge skills and practices of health workers, utilization of services and the opinions and attitudes of communities regarding availability and quality of health services. Technical assistance provided by the PPA will include on-the-job training and other knowledge transfer activities so that the national teams are technically autonomous by the end of the project and support to carry out controlled (before and after) evaluation of the RBF pilot. 3. The PPA will be accountable, along with other actors, to ensure that the performance of service providers improves and that tangible results are achieved. It will have the managerial autonomy to develop and implement diverse RBF mechanisms adapted to the local context. The terms of reference (ToRs) will be prepared and an expression of interest will be published to identify interested candidates. A request for proposal will then be tendered out, and both technical and financial proposals will be requested before selecting the appropriate candidate. Selection criteria for the PPA include demonstrated project and financial management capacity. The development of an implementation manual for this component and the modalities of verification will be included in the tasks outlined in the ToRs and is a disbursement condition for this activity. Page 6 6. Sustainability The project will scale up and mainstream its activities into several Government sector programs, such as provision of STI, VCT and reproductive health services and by tapping into community organizations resources. The project emphases on institutional capacity building at the local level which is expected to enhance the sustainability of the project and its local subprojects. 7. Lessons Learned from Past Operations in the Country/Sector The project builds on a number of lessons learned from other projects and especially from implementation of the on-going project. In particular, the mid-term review of the project was held in December 2005 and made a series of recommendations to refocus project activities in order to ensure better results on the ground. These recommendations included: (i) further decentralization and more integrated response to STI/HIV/AIDS at the local level; (ii) delivery of a complementary package of services for PLWHAs; (iii) emphasis on the prevention and treatment of STIs; and (iv) renewed focus on behavioral change, through high quality peer education programs. 8. Safeguard Policies (including public consultation) The only safeguard triggered is the environmental assessment, because a medical waste management plan (MWMP) is required. This plan was disclosed in July 2007 and public hconsultations held in August 2007. 9. List of Factual Technical Documents Project Appraisal Document, Second Population and HIV/AIDS Project Annual Project Reports Annual FOSAP reports 10. Contact point Contact: Boubou Cisse Title: Economist (Health) Tel: 5359+444 Fax: Email: bcisse@worldbank.org Location: Abuja, Nigeria (IBRD) 11. For more information contact: The InfoShop The World Bank 1818 H Street, NW Washington, D.C. 20433 Telephone: (202) 458-4500 Fax: (202) 522-1500 Email: pic@worldbank.org Web: http://www.worldbank.org/infoshop