Document of The World Bank Report No: ICR1949 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA-H309-NIR) ON A LOAN IN THE AMOUNT OF SDR6.7 MILLION (US$10 MILLION EQUIVALENT) TO THE REPUBLIC OF NIGER FOR A MULTI-SECTOR DEMOGRAPHIC PROJECT SEPTEMBER 30, 2013 Human Development Sector Health, Nutrition and Population: AFTHW Country Department: AFCF2 Africa Region CURRENCY EQUIVALENTS (Exchange Rate Effective September 30, 2013) Currency Unit = FRANC CFA (F CFA or XOF) US$ 1.00 = XOF511, 72621 (F CFA) US$ 1.49 = SDR 1 FISCAL YEAR January 1 – December 31 ABBREVIATIONS AND ACRONYMS AM Aide Mémoire AWP Annual Work Plan BCC Behavior Change Communication BMC Budget Management Centers CAS Country Assistance Strategy CEM Country Economic Memorandum COGES School Management Committee (Comité de Gestion des Etablissements Scolaires) CONAPO Coordination Nationale de Population COREPO Coordination Régionale de Population CMU Country Management Unit CPS Country Partnership Strategy CSP/CAS Cross-Sectoral Planning Group DALY Disability Adjusted Life Year DEP Directorate of Studies and Planning (Direction des Etudes et de la Programmation) DGPP Déclaration du Gouvernement en matière de Politique de Population DHS Demographic and Health Survey DPs Development Partners DPO Development Policy Operation EDSN Enquête Démographique de Santé/Niger eRegister Electronic Register System FM Financial Management FP Family Planning GDP Gross domestic Product GER Gross Enrolment Rate HMT Health Management Team HIV/AIDS Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome ICR Implementation Completion and Results Report IDA International Development Association IEC Information, Education & Communication IGA Income-Generating Activities IGS Inspector General of Services (at MP/RS) IMR Infant Mortality Rate INS National Institute of Statistics (Institut National de la Statistique) ISR Implementation Status Report IDA International Development Association IP Implementation Progress IRR Internal Rate of Return KAP Knowledge, Attitude, and Practice KFW German Agency for Economic Cooperation and Development KPI Key Performance Indicator LGA Local Government Authorities MDG Millennium Development Goals MEF Ministry of Economy and Finance (Ministère de 1'Economie et des Finances) M&E Monitoring and Evaluation MICSS Multiple Indicator Cluster Sample Survey MOE, Ministry of Economy MOJ Ministry of Justice MoH Ministry of Health MOD Delegated Management Contracts MOP Ministry of Population/Social action MOU Memorandum of Understanding MOF/PE Ministry of Womens' Promotion and Child Protection (Ministère de la Promotion de la Femme et de la Protection de l’Enfant) MP/RS Ministry of Population and Social Reform (Ministère de la Population et des Réformes Sociales) NA Not Applicable MTR Mid-term Review NGO Non-Governmental Organization NPV Net Present Value PAD Project Appraisal Document PDO Project Development Outcome POW Program of Work Pop/RH Population and Reproductive Health PPF Project Preparation Facility PRSP Poverty Reduction Strategy Paper PRODEM Projet Démographique Multisectoriel QAG Quality Assurance Group RAC Regional Advisory Committees RCC Regional Coordination Council RH Reproductive Health RSRC Rural and Social Policy Reform Credit SUN Scaling Up Nutrition Swap Sector Wide Approach TA Technical Assistance TC Technical Committee TFR Total Fertility Rate TOR Terms of Reference TTL Task Team Leader U5MR Under-five Mortality Rate UN United Nations UNICEF United Nations Children’s Fund UNFPA United Nations Population Fund USD United States Dollar WB World Bank WDI World Development Indicators WHO World Health Organization Vice President: Makhtar Diop Country Director: Ousmane Diagana Sector Manager: Trina S. Haque Project Team Leader: Djibrilla Karamoko ICR Team Leader: Ousmane Diadie Haidara NIGER Multi-Sector Demographic project CONTENTS Data Sheet A. Basic Information B. Key Dates C. Ratings Summary D. Sector and Theme Codes E. Bank Staff F. Results Framework Analysis G. Ratings of Project Performance in ISRs H. Restructuring I. Disbursement Graph   1. Project Context, Development Objectives and Design ................................................... 1 2. Key Factors Affecting Implementation and Outcomes .................................................. 8 3. Assessment of Outcomes .............................................................................................. 13 4. Assessment of Risk to Development Outcome ............................................................. 22 5. Assessment of Bank and Borrower Performance ......................................................... 22 6. Lessons Learned: .......................................................................................................... 24 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners............... 25 Annex 1. Project Costs and Financing ...................................................................... 26 Annex 2. Outputs by Component .............................................................................. 27 Annex 3. Economic and Financial Analysis.............................................................. 35 Annex 4. Bank Lending and Implementation Support/Supervision Processes..... 44 Annex 5. Beneficiary Survey Results ........................................................................ 46 Annex 6. Summary of Borrower's ICR and/or Comments on Draft ICR ............. 49 Annex 7. Comments of Co-financiers and Other Partners/Stakeholders.............. 53 Annex 8. List of Supporting Documents ................................................................... 54 Annex 9. Restructuring Changes ............................................................................... 55 MAP ................................................................................... ...........................................58 A. Basic Information Multi-Sector Country: Niger Project Name: Demographic Project Project ID: P096198 L/C/TF Number(s): IDA-H3090 ICR Date: 09/30/2013 ICR Type: Core ICR GOVERNMENT OF Lending Instrument: SIL Borrower: NIGER Original Total XDR6.70M Disbursed Amount: XDR6.61M Commitment: Revised Amount: XDR6.70M Environmental Category: C Implementing Agencies: Ministry of Population and Social Affairs Cofinanciers and Other External Partners: UNFPA B. Key Dates Revised / Actual Process Date Process Original Date Date(s) Concept 01/17/2006 Effectiveness: 01/08/2008 01/08/2008 Review: 04/26/2011 05/12/2011 Appraisal: 03/14/2007 Restructuring(s): 03/06/2012 Mid-term Approval: 06/19/2007 03/19/2010 06/14/2010 Review: Closing: 03/31/2013 03/31/2013 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Moderately Satisfactory Risk to Development Outcome: Substantial Bank Performance: Moderately Satisfactory Borrower Performance: Moderately Unsatisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Moderately Moderately Quality at Entry: Government: Unsatisfactory Unsatisfactory Quality of Moderately Implementing Moderately Supervision: Satisfactory Agency/Agencies: Satisfactory Overall Bank Moderately Overall Borrower Moderately Performance: Satisfactory Performance: Unsatisfactory C.3 Quality at Entry and Implementation Performance Indicators Implementation QAG Assessments Indicators Rating Performance (if any) Potential Problem Quality at Entry Project at any time Yes None (QEA): (Yes/No): Problem Project at any Quality of Yes Unsatisfactory time (Yes/No): Supervision (QSA): DO rating before Moderately Closing/Inactive status: Satisfactory D. Sector and Theme Codes Original Actual Sector Code (as % of total Bank financing) Central government administration 57 57 General education sector 5 5 Other social services 27 27 Sub-national government administration 11 11 Theme Code (as % of total Bank financing) Economic statistics, modeling and forecasting 14 14 Education for all 14 14 Gender 29 29 Personal and property rights 14 14 Population and reproductive health 29 29 Positions At ICR At Approval Vice President: Makhtar Diop Obiageli K. Ezekwesili Country Director: Ousmane Diagana Madani M. Tall Sector Manager: Trina Haque Eva Jarawan Project Team Leader: Djibrilla Karamoko John May ICR Team Leader: Ousmane Diadie Haidara Ousmane Haidara Rifat Hassan, ICR Primary Author: Maud Juquois, Sybille Cristal F. Results Framework Analysis Project Development Objectives (from Project Appraisal Document) The Project Development Objective (PDO) of the Multi-sector Demographic Program (PRODEM) is to strengthen Government’s capacity to address Niger’s demographic challenge through: (a) enabling the Ministry of Population and Social Reform (MOP) to design and implement a nationwide multi-sector program; and (b) increasing general awareness on population and reproductive health issues. Revised Project Development Objectives (as approved by original approving authority) N/A (a) PDO Indicator(s) Original Target Actual Value Formally Values (from Achieved at Indicator Baseline Value Revised Target approval Completion or Values documents) Target Years Indicators- Original PAD- Phase 1 (06/2007-4/2011) – 50.00 percent disbursement-net credit Indicator 1: At the end of the project, Annual Work Plans (AWPs) are designed, including Monitoring and Evaluation (M&E) indicators, adopted through consultations (annual reviews) with stakeholders and donors, and implemented under monthly supervision of the MOP. Value (quantitative or None 1 Dropped Dropped Qualitative) Date achieved 2007 2007 May 2011 March 2013 Comments (incl % This indicator have been dropped and replaced at the restructuring. achievement) Indicator 2: At the end of the project, 85 percent of the population over the age of 15 years has been sensitized on population and reproductive health issues. Value (quantitative or 30% Qualitative) 85% Dropped 95% (estimate) Date achieved 2007 2007 May 2011 March 2013 Comments (incl % This indicator have been dropped and replaced at the restructuring. Target achievement) exceeded; The result is estimated from the project. Indicator 3: A t the end of the project, the median age at marriage among women aged 25-49 has increased from 15.5 years to 16.5 years. Value (quantitative or 15.5y 16.5y Dropped 15.9y Qualitative) Date achieved 2007 May 2011 March 2012 Comments (incl % Target not reached but positive trend. Indicator has been dropped during restructuring achievement) (ref: DHS-MICS IV 2012). Indicator 4: At the end of the project, the percentage of children 0-5 months exclusively breastfed has increased from 13.5 percent to 20 percent. Value (quantitative or 13.5% 20% Dropped 23% Qualitative) Date achieved 2007 May 2011 March 2012 Comments (incl % Target exceeded. Indicator has been dropped during restructuring. achievement) Indicator 5: At the end of the project, prevalence of modern contraceptive use among women in union aged 20- 24 years has increased from 4.4 percent to 7 percent. Value (quantitative or 4.4% 7.0% 7.0% 8.2% Qualitative) Date achieved 2006 2007 May 2011 December 2012 Comments (incl % Target reached. The indicator as such has been moved to intermediate outcome level achievement) during restructuring and replaced by another similar indicator as PDO indicator. Source: DHSN-MICS, 2006 and December 2012. Indicators - Project Restructuring - Phase 2 (05/2011-8-03/2013) – 50.00 percent disbursement Indicator 1 : Contraceptive prevalence rate (modern methods for women aged 15 to 49) Value (quantitative or 5% 8.3% Qualitative) DHSN 2006 Date achieved May 2007 May 2007 May 2011 December 2012 Comments (incl % Positive trends. Source :DHSN-MICS, December 2012, preliminary Data achievement) Indicator 2 : Number of Annual Work Plans prepared, including the indicators, adopted and implemented each year Value 0 5 5 5 (quantitative or PRODEM Project data: 2013 Source: PRODEM Qualitative) Date achieved May 2007 May 2007 2011 March 2013 Comments (incl % Target reached achievement) Indicator 3 : Proportion of women aged form 15 to 49 who know at least one contraceptive prevalence method Value (quantitative or 72% 90% 90% 90% Qualitative) Date achieved 2006 2006 May 2011 December 2012 Comments (incl % Target was met. Source :DHSN-MICS, December 2012, preliminaries Data achievement) (b) Intermediate Outcome Indicator(s) Original Target Values Formally Actual Value Achieved Indicator Baseline Value (from Revised Target at Completion or approval Values Target Years document s) Intermediate Outcomes Indicators- Original PAD- Phase 1 (06/2007-4/2011) – 50.00 percent disbursement-net credit Indicator 1: Annual Work Plans (AWPs) and the M&E Guide, including Performance Indicators, are in place by the end of 2008 Value (quantitative or Qualitative) Not available 5 5 5 Date achieved 2007 2007 2011 2013 Comments (incl % achievement) Target reached by 2013. This indicator has been replaced by indicator 26. Indicator 2: At the mid-term of the project, 50 percent of the population over the age of 15 years has been sensitized on population and reproductive health issues Value (quantitative or Qualitative) 30% 50% Dropped Dropped Date achieved 2007 2007 May 2011 March 2013 Comments (incl % achievement) Indicator has been dropped. Indicator 3: Measures to increase the legal age at marriage are taken by Project Year 3 Value (quantitative or Qualitative) Not passed yet 2 2 0 Date achieved 2007 2007 May 2011 March 2013 Comments (incl % achievement) Not achieved but dropped. Indicators 4: At the end of 2012, 85 percent of the members of religious associations at central, regional and community level are sensitized on population and RH issues. Value (quantitative or Qualitative) 30 % 85% Replaced Peplaced Date achieved 2007 2007 May 2011 March 2013 Comments (incl % achievement) Target has been reached but replaced at restructuring. Ref: project data Indicators 5: Gross enrolment (Basic Cycle 2, national level) for girls increases from 11 percent in 2004/5 to 18 percent in 201 1/12 Value (quantitative or Qualitative) 15% 20% Dropped 17.9% Date achieved 2007 2007 May 2011 March 2013 Comments (incl % achievement) Even though dropped, trend is positive Indicator 6: At the end of 2012, 100 percent of members of networks journalists, parliamentarians, youth and researchers) are sensitized on population and RH issues. Value (quantitative or Qualitative) 0 100% Replaced 75 Date achieved 2007 2007 May 2011 March 2013 Comments (incl % achievement) Target not met but positive trend. Indicator 7: At the end of 2008, 8 regional coordination units for population and RH issues are established and operational. Value (quantitative or Qualitative) 0 8 Dropped Dropped Date achieved Comments (incl % achievement) Target met but dropped at restructuring. Source: PRODEM data Indicator 8: At the end of 2008, 36 departmental coordination cells for population and RH issues are established and operational. Value (quantitative or Qualitative) 0 36 Dropped Dropped Date achieved 2007 2007 May 2011 March 2013 Comments (incl % achievement) Target met but dropped at restructuring, Indicator 9: At the end of 2008, a national multi-sectoral M&E system is operational with a population database centralizing M&E data and spatial data from all sectors and regions Value (quantitative or Qualitative) 0 1 Dropped Dropped Date achieved 2007 2007 May 2011 March 2013 Comments (incl % achievement) Target met but dropped at restructuring. Indicator 10: At the end of 2008, a study about migration has been carried out, and the migration balance is estimated Value (quantitative or Qualitative) 0 1 Dropped Dropped Date achieved 2007 2007 May 2011 March 2013 Comments (incl % achievement) Target met but dropped at restructuring. The survey has been completed Intermediate Outcomes Indicators - Project Restructuring - Phase 2 (05/2011-8-03/2013) – 50.00 percent disbursement: Indicator 1: At the end of the project 300 sermons have been completed on Parenté responsable by preaching religious leaders in 6 regions. Value (quantitative or Qualitative) 0 300 300 316 Date achieved 2007 2007 May 2011 March 2013 Comments (incl % achievement) Indicator exceeded target. Source: DEP/MP/PF/PE. Indicator 2: At the end of the project, 100 journalists have been trained on population and reproductive health issues . Value (quantitative or Qualitative) 0 100 100 75 Date achieved 2007 2007 May 2011 March 2013 Comments (incl % achievement) Target not met but positive trend. Source: DEP/MP/PF/PE. Indicator 3: At the end of the project, all members of Parliament have been trained on population and reproductive health issues Value (quantitative or Qualitative) 0 130 130 20 Date achieved March 2013 2007 2007 May 2011 Comments (incl % achievement) Target not met. Source: DEP/MP/PF/PE reports Indicator 4: At the end of the project, three mains political organizations have been trained on population and reproductive health issues Value (quantitative or Qualitative) 0 5 3 5 Date achieved 2007 2007 May 2011 March 2013 Comments (incl % achievement) 5 Reports produced; Target exceeded. Source: DEP/MP/PF/PE. Indicator 5: Government prepared the legal text and measures to increase the minimum age of marriage Value (quantitative or Qualitative) 0 2 2 2 Date achieved 2007 2007 May 2011 March 2013 Comments (incl % achievement) Target not met (in terms of adoption). 2 Legal texts have been prepared and discussed by the MoP but the parliament didn’t pass them. Source: DEP/MP/PF/PE. Indicator 6: Health personnel receiving training on Family planning and Reproductive health issues Value (quantitative or Qualitative) 0 1000 1000 682 Date achieved 2007 2007 May 2011 March 2013 Comments (incl % achievement) Target not met. Health personals are also trained by the ministry of health. Source: DEP/MP/PF/PE. Indicator 7: Number of Femmes-Relais receiving training on Family Planning and reproductive health issues Value (quantitative or Qualitative) 0 1000 1000 270 Date achieved 2007 2007 May 2011 March 2013 Comments (incl % achievement) Target not met. The training started late in the life of the project but, continues under UNFPA and other initiatives. DEP/MP/PF/PE. Indicator 8: At the end of the project, the M&E system is in place and the demographic data had been collected and are available for all sub-sectors and regions; The M&E report has been prepared and distributed for all stakeholders and implementers Value (quantitative or Qualitative) 0 1 1 1 Date achieved 2007 2007 May 2011 March 2013 Comments (incl % achievement) Target met. The M&E system is in place and functions and distributed to stakeholders. Source: DEP/MP/PF/PE. Indicator 9: At the end of the project, prevalence of modern contraceptive use among women in union aged 20- 24 years has increased from 4.4 percent to 7 percent. Value (quantitative or 4.4% 7.0% 7.0% 8.2% Qualitative) Date achieved 2006 2007 May 2011 December 2012 Comments (incl % Target reached. Source:DHSN-MICS, 2006 and December 2012. achievement) G. Ratings of Project Performance in ISRs Actual Date ISR No. DO IP Disbursements Archived (USD millions) 1 12/21/2007 Moderately Satisfactory Moderately Satisfactory 0.00 2 04/10/2008 Moderately Satisfactory Moderately Satisfactory 1.11 3 08/04/2008 Satisfactory Moderately Satisfactory 1.11 4 12/15/2008 Moderately Satisfactory Moderately Satisfactory 1.72 Moderately 5 03/27/2009 Moderately Satisfactory 2.00 Unsatisfactory Moderately 6 09/17/2009 Moderately Satisfactory 2.73 Unsatisfactory 7 03/23/2010 Moderately Satisfactory Moderately Satisfactory 3.37 Moderately 8 12/20/2010 Moderately Satisfactory 4.24 Unsatisfactory 9 04/05/2011 Moderately Satisfactory Satisfactory 5.04 10 08/02/2011 Moderately Satisfactory Satisfactory 6.09 11 03/11/2012 Moderately Satisfactory Satisfactory 6.74 12 04/29/2012 Moderately Satisfactory Satisfactory 7.87 13 11/03/2012 Moderately Satisfactory Satisfactory 9.48 14 03/26/2013 Moderately Satisfactory Moderately Satisfactory 10.28 H. Restructuring (if any) The project was restructured twice: the first time in May 2011 and the second time in March 2012. I. Disbursement Profile 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal Country and Sector Context 1. Following political turmoil and economic decline in the 1990s, Niger underwent a fundamental political transition and consolidated democracy. The transfer of power from a military junta to a civilian government in 1999 was followed by the successful organization of legislative and presidential elections in 2004. President Tandja was reelected with a large mandate of 65 percent. Moreover, as part of the program of political decentralization, Niger’s first local elections were successfully completed in July2004. 2. With a consolidated democracy, Niger experienced revived growth performance; yet the growth spurt did not translate into poverty reduction. Growth enhancing reforms led to renewed confidence. Average GDP growth reached 4.6 percent during the 2001-2006 periods (1.3 percent above the population growth rate) and in 2007, the real GDP growth rate was 3.2 percent. However, the economy remained highly vulnerable to climatic and terms of trade shocks in unfavorable country conditions characterized by a limited natural and human resource base. The share of the population living below the poverty threshold was estimated at 60.7 percent in 2006. 3. The high rate of population growth (3.3 percent per annum) impeded Niger’s ability to reduce poverty and to meet the MDGs. The rapid population growth was primarily explained by fast decreasing infant and under five mortality rates, persistent high fertility and very low contraceptive use. The total fertility rate (TFR) was estimated in the 2006 Demographic and Health Survey (DHS) at 7.1 children per woman, one of the highest in the world. While infant mortality decreased from 123 deaths per 1,000 live births in 2001 to 81 deaths per 1,000 live births in 2006, better child survival did not seem yet to reduce the desire for large families. Given high fertility rates and short birth intervals, moreover, high levels of malnutrition for children under 5 (40 percent nationwide) was reported and seemed to be the main cause of child mortality. In addition, only 2 percent of children aged less than four months were exclusively breastfed. If demographic growth was not slowed down, Niger’s population would reach 56 million in 2050, more than four times its 2006 size (13 million inhabitants). 4. The continued high fertility rate was the result of multiple social factors that determine the reproductive behavior of Niger’s population. These factors included: the very high level of desired fertility, religious beliefs gender inequality, inadequate reproductive health (RH) and family planning services, poor levels of female literacy, early age at marriage, and poverty. Marriage was universal and early, one in two women is married by the age of 15 and almost 98 percent of women in the age group 15-49 were in union. Women’s knowledge of reproductive health (RH) was poor and contraceptive prevalence only 11 percent and 5 percent for modern methods (Source: 2006 DHS). High 1 fertility rates have also contributed to a very young age structure. Close to 50 percent of the population is under the age of 15. This in turn fuels demographic growth as many young people enter their reproductive age. 5. These realities, combined with persistent high demand for large families and beliefs in women’s subordination to men, have hampered the development of women’s participation in community life. Female primary education completion was 20 percent and female adult literacy only 9 percent. Despite a 72.9 percent female labor force participation rate, women still have little representation in civil service and professional employment. Discrimination in rural areas is even worse. Women’s social empowerment and bargaining power with their sexual partners is therefore missing to improve significantly their RH outcomes. 6. While some social indicators improved, development conditions in Niger were behind on most of the Millennium Development Goals (MDGs). According to the 2007 UN Human Development Index, the country was ranked among the lowest in the world (174th out of 177 countries). There was indication of improved access to basic education and better health outcomes. Gross primary enrollment rate increased from 41.7 percent in 2001/02 to 54 percent in 2005/06 while the completion rate rose from 25.6 percent to 40 percent during the same period. However, disparities between gender and geographical areas persisted, with the gross enrolment rate (GER) in rural areas estimated at 50 percent in 2005 compared to 52 percent for the entire country, and girls represented only 41 percent of total primary enrolment, and quality of education remained low. The prevalence of HIV/AIDS was at less than 1 percent, the lowest in Africa. Access to safe drinking water increased from 51 percent in 1998 to 59 percent in 2004 with water coverage higher in urban areas, where about 80 percent of the population had access to safe drinking water. The lack of water and sanitation infrastructure provided a breeding ground for water-borne diseases such as diarrhea, one of the main causes of child mortality. Moreover, the lack of irrigation infrastructure prevented the development of intensive agriculture, limiting agricultural production. Given the low base, the demographic pressure and low levels of resources allocated to priority sectors in the past decade, the trend in various social indicators suggested that Niger would not reach most of the MDG targets by 2015. Rationale for Bank involvement 7. The rationale for Bank intervention was based on a particularly favorable context to address demographic issues:  Government ownership: The government’s responsiveness to tackling the high demographic growth. While reproductive health and family planning remained extremely difficult topics to address in the Nigerien cultural, socio-economic and religious context, the Bank’s sector work on population1 prompted a new, evidence- 1 Niger: Providing All Nigeriens with Food, Education, and Health Care: A Demographic Perspective: World Bank report #34219-NE, November 2005. 2 based dialogue with Government on the multi-sectoral consequences of rapid population growth and high fertility.  Enabling technical and strategic environment: The government developed in 2007 an appropriate action-oriented Declaration of Population Policy (Déclaration du Gouvernement en matière de politique de population – DGPP). A Strategic Framework along with an overall Work Plan was being prepared with the support of UNFPA, a new law on Reproductive Health (RH) was passed in May 2006, and legislation was adopted to provide free contraceptives in public facilities.  Comparative advantage: the Bank had a clear comparative advantage through its ability to carry out multi-sectoral dialogue and experience in multi-sector approaches as well as in building government's capacity to plan and manage development programs around sectoral strategies, including strengthening the fiduciary framework.  Country development challenges: The Bank was best placed to help link the efforts on population and RH to the broader framework of macro-economic reform and poverty alleviation efforts through its ongoing development policy lending as well as other investment operations that were intended to affect directly or indirectly population and reproductive health outcomes (including a health and an education operations).  Past Bank experience in the population sector: The Bank could best leverage its past experience in Niger and in Sub-Saharan Africa and best customize lessons learned to the Nigerien context.  Partnership: The main donor with the Bank in the population and reproductive health sector in Niger was the United Nations Population Fund (UNFPA). Both organizations have worked closely to support the population agenda in Niger and were complementing each other in their areas of intervention. They were also best placed to help build consensus and leverage additional support for population and reproductive health activities from other donors. 8. The FY03-05 CAS planned a sector work to help the government design policy responses to issues of population. The Project was prepared following the finalization of the sector work on population and approved as the new Country Assistance Strategy (CAS) covering FY08-11 was being finalized since the timing of the new CAS had been set so as to be aligned with the finalization of the Second PRSP. Specifically, addressing the demographic issue was treated in the new CAS as a cross cutting issue with expected outcome to increase awareness of and access to family planning. 9. The Bank’s participation in the country’s efforts to slow the rapid rate of population growth was consistent with Niger’s second Strategy for Accelerated Development and Poverty Reduction (PRSP II). The Project’s interventions were to support the PRSP II’s second strategic objective to Develop Human Capital through Equal Access to Quality Social Services and to the pillar of Slowing Population Growth for which the government intended to improve access to RH services, promote delayed marriage for young girls and work toward greater social comprehension of the links between population and economic growth. The issue of population growth was also identified as a fundamental and cross-cutting issue. 3 1.2 Original Project Development Objectives (PDO) and Key Indicators (as approved) Project Development Objective 10. The objective of the Project (PDO) is to strengthen the Recipient’s capacity to address its demographic challenges through: (i) enabling the Ministry of Population to design and implement a nationwide multi-sector population program; and (ii) increasing general awareness on population and reproductive health issues. 11. The Project would contribute to three main objectives of the Government’s population policy (DGPP) to increase the age at marriage, increase the contraceptive prevalence rate (modern methods) and promote full breastfeeding (6 months exclusive and 24 months prolonged). Key Indicators 12. The extent to which the PDO of the Project was to be attained by the end of the Project was measured by five Key Performance Indicators (or PDO indicators) monitored through intermediate outcome indicators. The PDO indicators were: 1. Annual work programs (AWPs) are designed, including monitoring and evaluation (M&E) indicators, adopted through consultations (annual reviews) with stakeholders and donors, and implemented under monthly supervision of the MOP. 2. 85 percent of the population over age 15 has been sensitized on population and reproductive health issues. 3. The median age at marriage among women aged 25-49 has increased from 15.5 years to 16.5 years. 4. The percentage of children 0-5 months exclusively breastfed has increased from 14 percent to 20 percent. 5. Prevalence of modern contraceptive use among women in union aged 20-24 has increased from 4.4 to 7 percent. 13. It should be noted that three PDO indicators were dealing with issues of birth spacing and fertility decline. The broader agenda of reproductive health was addressed under the IDA-funded Institutional Strengthening and Health Sector Support Project. Also, the AWPs were meant to enhance the mobilization of the stakeholders and donors. 1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/justification 14. The PDO was not revised. However, PDO indicators and intermediate outcome indicators were modified during the May 2011 restructuring in order to align them with the changes in Project’s components and new activities to strengthen the supply side for 4 family planning and RH services. Table 1 in Annex 9 details the changes made to the indicators. 1.4 Main Beneficiaries 15. The intended beneficiaries of the Project were the general population, women, traditional and religious leaders, couples and youth girls and boys, women’s groups, research teams, the media, journalists, technical ministries (Population and Social Affairs; Women’s Promotion and Child Protection; Public Health and Endemic Diseases; Basic Education and Literacy; Secondary and Superior Education, Research, and Technology; Justice; Interior and Decentralization; and Territory Administration and Community Development), governmental entities at regional and municipal levels, the parliament, political parties, national organizations, the National Institute for Statistics, and the Project teams. 1.5 Original Components (as approved) 16. The US$10 million Project included the following components:  Component 1: Advocacy and Communication (US$4.24 million): Supporting nationwide and culturally sensitive advocacy, information, education and communication (IEC) and behavior change communication (BCC) campaigns, including through broad mass media campaigns and other means of communication, dissemination of the works of researchers, decision-makers and other stakeholders, aiming at all components of the Recipient’s society, including its leadership, traditional authorities and religious leaders.  Component 2: Women’s Autonomy and Couples’ Empowerment (US$1.22 million): Strengthening women social status and autonomy both at central and regional levels, including through support to: (i) enhance women’s economic opportunities; (ii) trigger legal reforms, including measures aimed at raising the minimum age at first marriage; and (iii) reinforce efforts to improve female school enrollments and performance.  Component 3: Harmonization and Coordination of Multi-sector Interventions (US$0.90 million): Supporting the organization of a national program approach to population and reproductive health issues, including through: (i) the implementation of the Government Declaration on Population Policy; (ii) the preparation of annual work programs; and (iii) the launching of a population program approach.  Component 4: Capacity Building and Monitoring and Evaluation (US$3.64 million): Support to: (i) institutional strengthening; (ii) capacity building in the Ministry of Population and its partners; and (iii) improving data collection, analysis, dissemination and utilization. 5 1.6 Revised Components 17. The May 2011 restructuring reduced the number of components from four to three. Component 2 (Women’s Autonomy and Couples’ Empowerment) was discontinued although its key activities were moved under the new Component 1 (Advocacy, Communication, and Coordination). Specifically, the revised Project’s components were as follows: 18. Component 1: Advocacy, Communication, and Coordination (US$4.5 million): Supporting nationwide and culturally sensitive advocacy, information, education and communication (IEC) and behavior change communication (BCC) campaigns, including through broad mass media campaigns and other means of communication, dissemination of the works of researchers, decision-makers and other stakeholders, aiming at all components of the Recipient’s society, its leadership, traditional authorities and religious leaders, including: (a) IEC and BCC at community level; (b) multi-sector advocacy and communication such as advocacy directed at the Recipient’s governmental entities at the central, regional and municipal levels, the Recipient’s parliament, political parties operating on the Recipient’s territory, national organizations, the media and the journalists; (c) IEC and BCC to strengthen women’s economic opportunities; (d) promotion of girls’ schooling; and (e) support to the Recipient’s ministry responsible for justice for the preparation of the legal framework for woman’s and child’s protection. 19. Changes: The Component’s activities remained essentially the same, but included the main themes of former Component 2, as well as the harmonization and coordination of multi-sector interventions, formerly under component 3. The Component also helped align Project’s activities with those of other IDA-funded projects in Niger. 20. Component 2: Strengthening the Supply of Reproductive Health Services (US$1.8 million): Strengthening the capacity of the Recipient’s ministry responsible for health for the provision of reproductive health services through development of guidelines and material, provision of training material and equipment, training of nurses, midwives and community health workers, and provision of contraceptive products. 21. Change: The new Component was to address the supply side constraints to reducing demographic pressure at the community level that were not sufficiently tackled by other IDA interventions, especially the Health operation. The Component was to train community health workers as they play an important role in complementing services provided by health centers and posts by promoting family planning at the community level, and distributing contraceptive products. Finally, the component was to finance contraceptives to satisfy increased needs and smooth out distribution flows. 22. Component 3: Capacity Building and Monitoring & Evaluation (US$3.7 million): Institutional strengthening and capacity building of the entities involved in the implementation of the Project, including nongovernmental organizations carrying out Project activities in the regions and districts, to support the implementation of the Project 6 activities; data generation, collection, analysis, dissemination and utilization; project management, financial management, and supervision. 23. Changes: The Component essentially covered the same activities included in the former component 4 (capacity building, maintenance, and data collection, analysis, and dissemination, including US$1.2 million to contribute to the financing of a new DHS for 2011). In addition, training of NGOs in project and financial management and the supervision of projects implemented by NGOs in the regions and districts were added. The Component was also to support the fiduciary management of the Project which remained under the responsibilities of the MOP. 24. Summary of original and revised Components: Original Component Revised Component C1 – Advocacy and Communications (US$4.24 m) C1- Advocacy, Communications, and Coordination (US$4.5 m) C2 – Women’s Autonomy and Couples C2 – Strengthening the Supply of RH services Empowerment (US$1.22 m) (US$1.8 m) C3 – Harmonization and Coordination of Multi- C3 – Capacity Building and M&E (US$3.7 m) sector Interventions (US$0.90 m) C4 - Capacity Building and M&E (US$3.64 m) 1.7 Other significant changes: 25. In addition to the changes in the PDO and intermediate outcomes indicators and reduction in the number of components that led to the introduction of new activities to strengthen the supply of and demand for family planning and RH services, the following changes were introduced during the May 2011 restructuring: (i) a modification of the institutional arrangements to ensure the contracting out of advocacy activities to NGOs and other ministries and to give an increased role to the Ministry of Health (MOH) for RH supply-side activities; and (ii) an adjustment of the flow of funds. 26. The proposed changes in Project design and implementation arrangements were driven by three main factors: (i) the slow progress in Project implementation; (ii) the imbalance in the design between activities to stimulate demand and those to ensure an increased supply of RH services; and (iii) an overly centralized management of the Project. The responsibilities for implementing the Project were clearly specified (see table 2 of Annex 9) between the MOP, technical ministries, associations of traditional chiefs and religious organizations and contracted NGOs as well as the disbursement arrangements. Most of the reallocation of grant proceeds originated from committing the unallocated category and the remaining funds from the Project Preparation Facility (PPF). 27. The Project underwent a second restructuring in March 2012 in order to reallocate grant proceeds. The reallocation was necessary to ensure that important activities received enough funding to enable the Project to attain its development objectives. These activities related to (i) the production of communication toolkits for increased awareness activities, (ii) support to the contracted NGOs launch of awareness campaigns in villages 7 to promote the implementation of IEC/BCC activities, and (iii) intensified supervision role of the MOP and its regional offices to ensure better implementation of the IEC/BCC campaigns and better monitoring of the Project results (see Table 3 in Annex 9). 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry 28. Soundness of background analysis: The preparation team, composed of national and international health and population experts grounded the preparation of the Project in key population-related documents and policies prepared by the Government of Niger, in particular the Declaration of National Population Policy and the actions recommended in the 2005 Nigerien population projections, namely the increase of the age at marriage, the increase of contraceptive prevalence rate (modern methods), and the promotion of full breast-feeding. The preparation was also strongly informed by best practices in the design of population interventions and the findings of the 2006 sector work on population, Providing All Nigeriens with Food, Education and Health care, and the new Country Economic Memorandum (CEM). The main findings and recommendations of the sector work on population were that: (i) high fertility rate was the result of multiple social factors; (ii) the demographic challenge needed to be addressed through a multi-sectoral approach; (iii) on the demand-side, policies should focus on increasing the age of marriage, enhancing women’s education and autonomy, and on using a multimedia approach to disseminate messages aimed at changing traditional beliefs and behaviors regarding childbearing and the value of children; and (iv) on the supply side, efforts should focus on expanding access to contraceptive methods, increasing social marketing of contraceptives, and expanding culturally sensitive family planning services. The CEM concluded that achieving the MDGs would require decisive policy actions to decelerate population growth to be taken both on the supply and demand sides. 29. In addition, the Project’s preparation was complemented by the series of Development Policy operations (Rural and Social Policy Reform Grant – RSRC), specifically the preparation of RSRC-2 and key investment operations, among them the health and education Projects. The RSRC series was to support in-country actors to enforce existing legislation governing the age of marriage for women, with a view to raising that age as one means of reducing infant and maternal mortality and of delaying the onset of childbearing with the goal of supporting lower fertility rates in the medium term. The prior action for the RSRC-2 on population was to organize and hold a national forum to build consensus on demographic and gender issues and the African Charter on women’s rights. The prior action was met. 30. The preparation team incorporated key lessons learned from the closed first population project, such as: (i) the project objective should be realistic so as to be feasible within the established timeframe of the life of the project. To that effect, the Project was mostly a technical assistance and capacity building operation; (ii) the design of the project should be based on a sound knowledge of the sector context; (iii) reliable baseline data are essential; (iv) projects implemented through various ministries require well- 8 defined monitoring and supervision systems with a capacity to address and resolve constraints in a flexible, proactive manner; (v) key stakeholders’ involvement increases ownership and sustainability; and (vi) complementarity between investment/TA operations and DPOs is needed to address population issues at different levels (including the policy and legal level). 31. Rationale for the Bank’s intervention: The rationale of the Project was very strong since reducing the high rate of population growth was crucial to the overall economic prosperity and development of Niger. Although, while the topics of RH and family planning remained very difficult in the Nigerien cultural, socio-economic and religious context, there was agreement that it was the right time to support the government’s population policy. 32. Assessment of Project Design: There was consensus between the Government and the development community on the way the challenges needed to be addressed (multi-sectorality, demand and supply side interventions, building government’s capacity). Therefore, the design of the Project reflected such elements and included the appropriate activities to support the government in addressing its population challenge. The design also reflected the QER panel and Decision meeting’s recommendation that, given the ongoing activities and the IDA financing constraint, the Project was to focus on filling the gaps that other health and education interventions in Niger had left, therefore concentrating mainly on family planning and population issues. 33. However, the MOP had been recently created. An assessment of its capacity was carried out and recommended that the ministry be supported through the provision of technical assistance in the areas of communication, M&E, gender and project management in order to enhance its capacity to implement the Project. As a new ministry, the MOP also had untested authority to influence other stakeholders involved in the population agenda. Moreover, suggestions by the QER panel to use a bottom-up approach for the national awareness campaign and to use community health workers for contraceptives distribution and promotion of family planning were not followed through. 34. Adequacy of government’s commitment, stakeholder involvement and participatory process: The government had demonstrated strong commitment to better manage the demographic challenge as evidenced by new policies and actions. It worked proactively with the Bank and all development partners involved in the population topic as well as the broader human development agenda. Analytical work produced on population was disseminated to high level officials as well as to a selected wide audience. However, some groups of society and rural populations were less (or not) engaged or were not committed to the government’s population agenda given the sensitive nature of the topic and its close connection with traditional and religious beliefs. 35. Assessment of Risks: The risks identified during preparation were mostly underestimated given the difficult country context in which the Project was to be implemented and mitigations measures not adequate enough. In particular, resistance to government interventions in population and RH issues remained strong. Moreover, 9 human and institutional capacity was a challenge at all levels in Niger due to years of deteriorating conditions in public sector management, political instability and brain drain. These circumstances created little confidence from average Nigeriens, especially the ones living in rural areas where traditional authority holds sway, in the government's ability to deliver development programs or social services, and they were skeptical when officials requested their participation. 36. In February 20, 2007 a quality enhancement review (QER) was held for the multi- sectoral demographic project (PRODEM). The Panel’s main recommendation to the project was: (i) to clarify that the intervention is part of a more complex, multi-sector agenda in Niger ii) the team consider Performance Based arrangements with NGOs- on carrying the awareness campaign and monitoring results throughout Niger, iii) Make the best of a bottom-up approach and iv) target female education as crucial determinant of fertility. 2.2 Implementation 37. The first few years of Project implementation were faced with several impediments:  Delayed recruitment of key staff to support the MOP: while the Plan for technical assistance for the implementation of the Project was adopted, the recruitment of some key technical experts took a long time. For instance, the communication expert financed by UNFPA was not finalized until 2010. Also, with the resignation of the first two procurement specialists (PS)2, a new recruitment process was initiated in 2010 for another PS. This left the MOP without the needed technical assistance to implement in a timely manner the Project.  Disagreement on implementation responsibility: despite the agreed implementation arrangements at negotiations, the MOP decided that it would implement all the Project’s activities. The Bank team held several meetings with the Minister and his team to clarify the implementation arrangements but the Minister remained reluctant to delegate to the technical ministries and to contract with NGOs to implement key activities. This matter was also raised with the Prime Minister.  A tense political context: 2009 was marked by a year-long political crisis related to President Tandja's efforts to extend his mandate beyond the end of his second term. The National Assembly was dissolved in May 2009 and a new Constitutional Court appointed, enabling to push forward with a constitutional referendum in August 2009 that extended President Tandja’s mandate for an additional three years. This led to the February 2010 Coup. Niger also faced a coup attempt in July 2011. 38. All the above factors contributed to a tough implementation environment that led to a slow implementation of the Project. Procurement of equipment, vehicles, Project administration, and the preparation of several action plans took place as planned to 2 The first two PS resigned, one due to conflict with the Minister of Population and the other because he was ineligible due to the fact that he was still employed by another IDA funded project. 10 improve the capacity of the MOP to implement and monitor the Project. However, advocacy activities throughout the regions and districts remained limited and the women’s empowerment component was not implemented due to lack of strategy. At the time of the Mid Term Review (MTR), the disbursement ratio was 37 percent. 39. In its assessment of the Quality of Bank Supervision in March 2010, the Quality Assurance Group (QAG) panel indicated that while the implementation problems were identified satisfactorily, they were not adequately reflected or followed up in implementation support reports (ISRs) or aide-mémoires. QAG also considered that the Bank team should have reacted earlier to the non-implementation of the women’s empowerment component, implementation problems of the communications component and the disconnect between actions promoting demand and any formal arrangements or resources for a strategic supply plan to meet the demand. In addition, QAG noted that the Bank’s advice was appropriate, except for the women’s empowerment component, and that efforts to address significant risks during supervision were adequate. However, it felt that the advice and efforts only resulted in limited impact. Therefore, QAG assessed the quality of supervision as unsatisfactory. 40. The June 2010 MTR concluded that, if the current trend continued, the Project was unlikely to reach its development objectives and recommended some changes in the Project design and its implementation arrangements. Based on the recommendations of the MTR and the Regional management’s view that the political will of the transitional regime to address the demographic issue was strong as well as the commitment to the Project, the Project was restructured in May 2011. The time lapse between the MTR and the restructuring of the Project was the result of the institutional change for the MOP. Indeed, following the February 2010 Coup, the MOP was merged with the Ministry of Women’s Affairs; a new minister was appointed and the replacement of key MOP staff dragged, including the appointment of the new Secretary General in charge of coordinating the Project. 41. The May 2011 restructuring proved highly relevant as it put the Project back on track and boosted implementation through:  The resolution of implementation bottlenecks thanks to the changes in the implementation responsibilities3 for the revised components, the recruitment of NGOs 4 to implement IEC ad BCC activities at the community level, the delegation to other technical ministries for the implementation of specific activities or components (i.e. MOH for the implementation of Component 2) and the funding of the MOH for the supply of modern contraceptives at the 3 The restructured Project allocated responsibilities for project implementation to four institutions, as follows: 33 percent (of project cost) to NGOs, 26 percent to the MOH, and 19 percent to the Institute of National Statistics, leaving 22 percent for direct execution to the MP/SR. 4 After the initial contracting of the NGO ANIMAS SUTURA in April 2010 to conduct communication and multimedia activities at the local level, 21 new NGOs and development associations were contracted in December 2010 in the context of the strategy of "make-do" with the aim to ensure the sustainability of activities after the Project’s life. 11 community level. This reduced the burden of Project implementation for the MOP and fit better with the Ministry’s technical capacities.  A more conducive management of the MOP, the addition of two advisers and the outsourcing of key activities. 2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization 42. M&E Design: At the time of preparation, the set of indicators for the Project was mainly formulated based on the 2006 DHS and the Multiple Indicators Cluster Sample Survey (MICSS). Indicators were therefore deemed appropriate to measure achievement of the Project. A Project component was designed with an aim to focus on data collection, analysis, dissemination and utilization as well as training of the MOP staff, a structure within the MOP was in charge of M&E, and UNFPA helped establish the M&E standards comprising national annual review of progress and results starting the second year of the Project. The M&E design framework was therefore judged to be adequate. Finally, a follow up DHS has been conducted before the end of the Project. 43. M&E Implementation and Utilization: A national multi-sectoral M&E system was developed with a population database centralizing M&E data and some spatial data from sectors and regions and made operational, although with some delays. The adoption of the M&E framework was followed by an action plan, guides for indicators, and training tools and manuals. Data was collected from the National Institute of Statistics and implementing ministries, analyzed and exchanged through the M&E quarterly reviews. This was seen as a good practice by the government and donors. Population data were also collected and reported on by the government albeit hampered at times by the unstable political situation. In addition, the AWPs, including M&E indicators, were prepared, endorsed by stakeholders and donors, and implemented by the MOP. The Project contributed to carry out two surveys (2012 DHS and the General Census of the population) and the assessment of the migration level in the country. With regard to financial data, the MOP had reliable information going back to the beginning of the Project and analytical tools since it began to use the accounting software TOMPRO in 2007. At the decentralized level, the Project was affected by the availability and use of data due to the weak capacity of decentralized coordination bodies to document data on completed activities because of lack of sufficient qualified technical staff, supplies, and working tools and inadequate data management and use for the large amount of data generated by the civil society. 2.4 Safeguard and Fiduciary Compliance 44. The Project fell under environmental category C. Therefore, no safeguard policies were triggered. In January 2009, the Bank conducted a post review of procurement contracts. The review found some irregularities in the purchase of office supplies and cleaning products, prompting the Bank to send a letter to the authorities in June 2009 requesting full procurement compliance from now on. 12 2.5 Post-completion Operation/Next Phase 45. The project contributed to reinforce the capacity within the MOP and to strengthen the policy dialogue and coordination with donors. The M&E framework put in place by the Project led to the establishment of a donor’s coordination and M&E system for the sector. The institutionalization of the practice of data collection, analysis and exchanges through the M&E quarterly review conducted by the sector should not be compromised by the Project closing. The Project also provided an overarching framework for coordinating population-related activities with key sectors (health, education, justice, etc.). Also, by building the capacity of decentralized levels and NGOs and CSOs through delegated management contracts for IEC/BCC activities, the Project helped strengthen the organizational capacity of the MOP to implement its sector program. All of the above contribute to ensuring the sustainability of efforts to promote RH service and family planning activities by allowing the MOP to mobilize donors to finance activities for the implementation of the national policy. To that effect, umbrella NGOs and CSOs have secured funds from other donors to continue their activities allowing for the continuation of key RH and family planning activities. This is all the more promising since long term interventions are needed to sustain the behavior changes and to keep the momentum on the policy dialogue. 46. The Bank will continue its support to the population challenge through the preparation of a multi-sector operation covering demographic and RH matters. The objective of the new project, scheduled to be approved in FY15, will be to contribute to improve access to health services and to strengthen public service supply side capacity so as to reduce the high fertility levels. Special emphasis will be placed on promoting gender equality, women's empowerment and health promotion with the support of other donors. 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation 47. Relevance of Objectives: The overall strategy of the Project was aligned with the key population policy document prepared by the Government of Niger. The Project aimed to build a national response to address the demographic challenge of Niger, enable the Government to design a nation-wide multi-sector population program, and increase general awareness on population and reproductive health issues. This was consistent with the country’s PRSP and Bank assistance strategy. Also, given Niger’s demographic and development circumstances, the Project’s strategic relevance was highly relevant and remained so during Project implementation due to the continued pressure put by a high population growth on the country’s resources and government services such as health and education and the need for adequate policy actions. Such relevance was further demonstrated when the country was hit by a food crisis. This reinforced the importance to tackle the demographic pressure through population and RH interventions and policies. Therefore, the relevance is judged high. 13 48. Relevance of Design: Given the diverse factors that influenced a country’s fertility and population growth, the multi-sectoral approach and focus on increasing awareness and strengthening the MOP capacity were appropriate. However, the Project team eluded the supply side dimension for RH services during Project Preparation as the preparation team thought it would be handled by the Health operation. Additionally, while the design of the Project was realistic, it proved difficult to implement given the difficult and instable country context and the divergent views between the MOP and the Bank on the implementation arrangements of the Project. Nevertheless, the 2011 restructuring rightly addressed the initial shortcomings and was deemed highly relevant. Also, the Project was not intended to address the broader agenda of RH (which was tackled under the IDA-funded Institutional Strengthening and Health Sector Support Project) and therefore its PDO formulation was appropriate. Therefore the relevance of design is judged substantial overall (and high after the restructuring). 49. Relevance of implementation: The relevance of implementation before the 2011 restructuring is judged to be modest. Given that the MOP was newly established and its capacity to carry out its mandate needed to be strengthened, the implementation arrangements should have been further thought through and responsibilities for activities’ implementation clearly defined to minimize the risk for implementation issues. After restructuring, implementation bottlenecks were resolved thanks to the changes in the implementation responsibilities for the revised components, the recruitment of NGOs to implement IEC ad BCC activities at the community level, and the delegation to other sector ministries for the implementation of specific activities or components. These measures put the project back on track. As a result, the relevance of implementation is rated substantial after the restructuring. 3.2 Achievement of Project Development Objectives 50. With the 2011 restructuring of the Project, three indicators were replaced and two dropped. Overall, while some specific parts of the PDO are more specifically linked to some of the PDO indicators (such as enabled design with the AWPs), the achievement of the PDO can be measured through all the PDO indicators (i.e. enabling the implementation of the population program should lead to higher contraceptive use). We therefore review below all the key PDO indicators distinguishing between before and after restructuring. Before restructuring 51. Overall, the achievement of the PDO before restructuring can be considered Moderately Unsatisfactory. In part, this is due to overly ambitious indicators, in some other part to bottlenecks in implementation and the imbalance between demand and supply-side activities. 52. The original outcome indicator “AWPs are designed, including M&E indicators, adopted after annual consultation with stakeholders and donors, and implemented under monthly supervisions of the Ministry of Population” was only modestly achieved. 14 53. The capacity of the MOP to design and implement a multi-sector program had been improved but remained very weak. Few ministries were fully involved in the implementation because of coordination capacities. The Project scaled back from its original capacity strengthening objective from program wide to project specific focus during the 2011 restructuring. Clearly, there was limited ability of the MOP to coordinate and/or effectively influence population-related activities and programs of other relevant ministries. 54. Progress on related intermediate indicators was also slow with the target of 8 regional coordination units and 36 departmental coordination cells for population and RH issues (CONAPO, COREPO) only modestly achieved. Regional coordination units were installed, but not functional, with considerable duplication of activities with regional health directorates. 55. The original outcome indicator of “85 percent of the population over the age of 15 sensitized on population and reproductive health issues” (Mid-term target was 50 percent as per related intermediate indicator) was not achieved by 2011, although it was achieved by 2013. This was clearly a very ambitious indicator which was replaced at restructuring by a more realistic one. 56. The original outcome indicator “the median age at marriage among women aged 25-49 has increased from 15.5 to 16.5 years” was not achieved and was moving slowly. As above, this was an ambitious indicator, requiring behavioral and legal change, which was dropped at restructuring, upon the understanding that the DPO would be a better instrument to hold the government accountable on matters of policy and legal changes (supported by TA through the Project). 57. The outcome was not achieved, as well as related measures to increase the legal age at marriage by Project Year 3 and the adoption of broader legal texts envisaged in support of government’s national population policy (one in year 3 and one in year 4) – prepared but not adopted. This is due to the fact that there was a strong opposition and resistance by some religious fundamentalist groups which were opposing the country's commitment to take the appropriate measures and laws regarding girls' protection and women empowerment in society. 58. Nonetheless, it is worth highlighting that substantial efforts were made to reach out to the Islamic community, including messages tailored to Islamic sensibilities on raising age at marriage for girls and boys and girls schooling. Also, after restructuring, with the involvement of NGOs, traditional communication channels/media (radio, theatre, skits, song contests, comic strips were used, including interpersonal communication strategies and traditional and religious leaders) were used to reach out to religious leaders. 59. Additionally, the women’s autonomy and couples’ empowerment component helped expand knowledge/improve prospects of poor and marginalized women and support girls’ school enrollment and women’s literacy through actions at the level of the 15 Ministry of Education, including targeting female education as part of national awareness campaigns. After restructuring, NGOs supported school management committees (COGES) in carrying out community level outreach and sensitization on the importance of female schooling in districts where the gender gap in enrollment is greatest, while providing to local level women’s associations (foyers féminins) in key disadvantaged areas, equipment and materials specifically aimed at alleviating domestic task burdens. 60. The original outcome indicator on the “percentage of children 0-5 months exclusively breastfed increasing from 13.5 percent to 20 percent” was exceeded reaching 23 percent in 2012. Overall, breastfeeding is a quasi-universal practice in Niger, with almost 93 percent of children who are breasted between 12-15 months. This rate falls to 23 percent when it comes to exclusive breastfeeding. It is however unclear to what extent this indicator can be related to the PDO and project’s activities and was dropped at restructuring. 61. The original outcome indicator on the “prevalence of modern contraceptive use among women in union aged 20-24 years” increasing from 4.4 percent to 7 percent was not achieved by 2011, but surpassed its target by 2012. Adding a supply-side dimension to the project after restructuring helped achieved this result in 2012 (see below). After restructuring: 62. Overall, the achievement of the PDO after restructuring can be considered Satisfactory. This is due to the resolution of implementation bottlenecks, more realistic indicators and a more balanced Project design. 63. After restructuring, the revised outcome indicator “Number of annual work programs prepared, including key indicators, adopted and implemented each year” was achieved with five work programs prepared. 64. New MOP staff accountant, procurement, financial management and M&E specialists and administration assistant) were recruited. UNFPA provided an international population communication expert for 10 months and helped the MOP to implement its communication strategy and subsequent plans. A project Steering Committee and its Subcommittee were created and functional. The Project also provided vehicles, motorcycles, office equipment and supplies and equipment for women ‘groups. 65. The Project produced a system to hold regular coordination meetings – monthly departmental meetings, quarterly regional meetings and biannual central-level meetings to review project progress and activities. A system for quarterly supervision missions to the departmental level by regional personnel and biannual supervision missions to the regional level by central level personnel was put in place. One joint field visit was undertaken each year by the Project coordination and the development partners, and a second supervision mission was undertaken by the World Bank, against a target of two joint field visits per year. Project annual reviews were carried out regularly. 16 66. These outputs contributed to achieve some key intermediate outcomes, such as putting in place an improved M&E system, and help developing the ministry’s capacity for planning. In particular, the MOP developed its three-year national population strategy (2012-2015) and an M&E system to measure enhanced sector performance and outcomes. Additionally, the MOP established processes for sector coordination and interactions with its partners (ministries, civil society and intra-sector decentralized structures). 67. At restructuring, the original indicator on population sensitization was replaced by “proportion of women aged 15 to 49 who know at least one contraceptive prevalence method”. This indicator captured better the efforts made by the Project in the sensitization of the population and was achieved reaching the target rate of 90 percent in 2012. 68. Along the line of introducing more realism in the outcome indicators, the intermediate outcome indicator on “85 percent of the members of religious associations at central, regional and community level sensitized on population and RH issues” was replaced by “300 sermons to be completed on Parenté responsable by preaching religious leaders in 6 regions”. This indicator was achieved with about 316 sermons delivered by March 2013. 69. To reach those outcomes, the Project sub-contracted with national 28 NGOs for a nationwide, culturally-sensitive IEC and BCC campaign. A communication strategy was established in 2009, followed by the development and validation of a communication plan. Two Islamic arguments were developed: first age at marriage for girls and boys/girls schooling. Communication TA was achieved through collaboration with UNFPA. The project identified communication tools, developed the communication messages and trained 100 percent of members of networks (women’s’ associations, parliament, journalists, researchers, local governments and religious leaders). Traditional communication channels community and NGOs were activated in rural areas. Results have been disseminated for effective interventions to strengthen Pop/RH policies, programs and outcomes. Over 5 million people were reached during the life of the Project. The Project also trained 682 health staffs (at district and community level) and 270 women in community based contraceptive promotion and distribution in 5 targeted regions (Taoua, Maradi, Dosso, Tillabery and Zinder). Against a target of one per year between 2007 and 2012, only three youth sensitization campaigns on population, development and RH/FP were organized at central and decentralized level, but between 2007 and 2012 two TV debates/conferences per year were organized by the journalists’ network on population and RH issues, exceeding the target of one per year. A network of researchers was trained, and subsequently organized one broadcasted a conference on population, development and RH/PF issues (although this fell short of the target of five conferences (one per year between 2007 and 2012). 70. At restructuring, the original indicator on contraceptive prevalence was replaced by “contraceptive prevalence rates (modern methods) for women aged 15 – 49”. Rates increased from 4.9 to 8.2 percent for modern methods (net of breastfeeding and 17 amenorrhea) for women in unions, aged 15-49 in 2012 highlighting a positive trend in this indicator (along the original one). 71. To increase the use of reproductive health services, the Project promoted increased distribution and use of modern contraceptive methods which generated positive outcomes. Contraceptive prevalence rate was influenced by multiple donors and factors: KFW and UNFPA along with government finance the procurement of contraceptives, its availability and free distribution in the country. MOH, with IDA’s support, was also funding contraceptive procurement and implementing it rather successfully. UNFPA and the Bank partnered to support the government in implementing its population policy and in adopting a Road Map for the reduction of maternal mortality. UNFPA also assisted the government in developing a contraceptive security plan. The Project also contributed by (i) training health staff and community based health workers in contraceptive promotion and distribution, and (ii) carrying out an extensive nationwide communication strategy to reach all end users of contraceptive in the targeted five regions. 3.3 Efficiency 72. Scope of Analysis: While an analysis was conducted on Niger’s demographic situation for the preparation of the Project (Annex 11 in the PAD), an economic analysis was not conducted. The March 2010 QAG review indicated that “given the Project’s institution-building and technical assistance nature, an economic and financial analysis was not applicable.” As such, no initial economic analysis exists with which to compare results at the end of the Project. Nor can any analysis be replicated with the latest data. However, to the extent possible, we used data available to conduct an analysis to highlight the development impact of the Project and the efficiency of the completed activities (detailed in Annex 3). In line with previous assessments of the economic impact of this type of Project (i.e. TA for capacity building and institutional strengthening), the scope of the economic analysis was limited to the areas where there was more measurable information. Since we could not reasonably estimate the economic benefit of all Project activities, the analysis of costs, benefits and efficiency was restricted to Components 1 and 25, totaling US$5.3 million (53 percent of Project costs). No specific analysis was done in the pre-restructuring phase but the lack of supply side interventions and the many implementation issues make for a modest efficiency before 2011. 73. Benefits of the Project: Components 1 and 2 addressed both demand and supply side challenges through IEC/BCC activities and the strengthening of RH service provision. These Project investments created both direct and indirect benefits for the population. The Project benefits comprised several measures of direct impact, which included greater awareness of population and RH issues, greater knowledge of contraceptive methods, higher utilization of modern contraceptive methods, increased prevalence of exclusive breastfeeding, improved capacity of health service providers to address issues of RH and family planning, and enhanced capacity of the MOP to design 5 Component 1: IEC/BCC activities to raise awareness of population and reproductive health issues; Component 2: supply-side activities to improve provision of reproductive health services. 18 multi-sector population programs. CPR (modern methods) increased from 5 percent to 8.3 percent, knowledge of contraceptives increased from 72 percent to 90 percent, and 95 percent of the population was sensitized to population and RH issues, exceeding the target. Since behavior change takes time to materialize, the full effect of BCC activities may require more time than Project implementation to emerge in a measurable way. 74. While the indirect benefits of this Project are difficult to quantify, the development impact is potentially substantial and the benefits of family planning are summarized in the table below. Indirect benefits of family planning Non-health benefits Health benefits Micro-level Macro-level Higher private health, nutrition Reduced public expenditures Reduced maternal deaths & and education expenditures per in education, healthcare and disability child other social services Lower newborn, infant and A woman’s improved ability to Higher productivity child mortality participate in the labor force Less societal burden of More time to breastfeed Higher household earnings caring for neglected children Better health and nutrition of More attention and parental care Higher savings and mothers for each child investment Economic growth 75. Since most of these indirect benefits are not short-term effects, the returns on investment will take longer than the Project implementation period to emerge. For example, smaller family size means that families can invest more in each child’s education. Measuring this requires the children to grow to age of enrolling in school and then attending school. While it is difficult to quantify the economic benefit of the indirect health and non-health effects listed above, we used data from existing literature to assess overall efficiency of the Project based on direct benefits. 76. Efficiency of the Project: We assessed the efficiency of the Project considering its costs and health benefits.  Allocative efficiency of the Project is considered as substantial after the 2011 restructuring, as increasing awareness of population and RH issues (and increasing use of modern contraception to reduce fertility) is a key strategic priority for the development of the country and was strengthened by the alignment with a supply-side component. The design of the Project was adequately allocating a large part of the funding (44 percent of the Project: US$4.4 million) to advocacy, communication and coordination, reaching 95 percent of people over 15 years old.  Productive efficiency is considered as substantial after the 2011 restructuring. The IEC/BCC activities were contracted to NGOs (selected through competitive 19 process) and religious leaders. They have a comparative advantage to implement communication activities as they were already implementing activities in the communities and were the most cost-effective way to achieve the desired output. Additionally, contracting local NGOs aimed at increasing ownership of the Project and activities. Expanding contracting to NGOs for demand-side activities and increasing investment in supply-side initiatives during the 2011 restructuring substantially contributed to improving efficiency for Project implementation. This led to a disbursement rate of 100 percent. Therefore, implementation efficiency is considered as substantial by the end of the Project.  Technical efficiency is rated high after the 2011 restructuring. The interventions included in the Project were technically sound. Components 1 and 2 together can be considered a packaged family planning program, addressing both demand- and supply-side constraints to the utilization of family planning. This type of family planning program has been identified as one of the most cost- effective development interventions to date. 6 Based on the cost-effectiveness estimates of family planning programs as documented in the literature, this analysis used the overall estimate for Sub-Saharan Africa (cost per DALY gained US$34) and the Project costs to calculate the DALYs gained in Niger. 7 An estimated 157,203 DALYs were gained from the implementation of Components 1 and 2 of Project. Since the estimate of DALYs gained is based only on direct health benefits, and the calculation excludes any indirect benefits to the population in both the short- and long-term, the estimate can be considered an underestimate of benefits gained from Components 1 and 2. 77. Given the above facts, the efficiency of the Project after restructuring is rated substantial. 3.4 Justification of Overall Outcome Rating 78. Based on the overall substantial ratings for relevance and efficiency and overall moderately satisfactory rating for efficacy, the overall outcome rating is Moderately Satisfactory. This outcome is the result of a moderately unsatisfactory pre-restructuring phase and satisfactory post-restructuring phase, each accounting for 50 percent of the total Project disbursement. 6 Levine et al. 2006. Disease Control Priorities in Developing Countries. 7 This assessment focuses on DALYs gained as it is the most comprehensive measure of health benefit available. 20 Original Project – Phase 1 (06/2007-4/2011) – 50.00 percent disbursement-net grant Project Relevance Achievement of PDO Efficiency Overall Rating (Efficacy) Substantial Modest Modest Moderately Unsatisfactory Project Restructuring - Phase 2 (05/2011-8-03/2013) – 50.00 percent disbursement-net grant Project Relevance Achievement of PDO Efficiency Overall Rating (Efficacy) High Substantial Substantial Satisfactory Overall Project Ratings – 99.5 percent disbursement of net grant Project Relevance Achievement of PDO Efficiency Overall Rating (Efficacy) Substantial Substantial Substantial Marginally Satisfactory 3.5 Overarching Themes, Other Outcomes and Impacts (a) Poverty Impacts, Gender Aspects, and Social Development 79. Priorities built into the Project such as girls’ education, women’s autonomy and empowerment, contraceptive prevalence and behavior change contributed to enhanced awareness of general population and specially of girls and women. The project reached its objective to increase women's use of contraceptives. The prevalence rate of modern contraceptives increased from 5 percent in 2006 to 12 percent in 2012 and many activities at the village level have been implemented by local health workers trained by the project on community based distribution of contraceptives and on family planning. It also financed services like the distribution of family planning commodities at village level, the BCC/IEC campaigns conducted in all regions of the country, and the reinforcement of the women economic conditions with farmer materials. (b) Institutional Change/Strengthening 80. Capacity strengthening in many areas such as policy development and M&E took place under the Project. The institutionalization of the practice of data collection, analysis and dissemination through the M&E quarterly reviews has continued post-project. Also, the Project contributed to the strengthening of the capacity of decentralized bodies (regions and districts) and provided technical assistance to NGOs, community associations and umbrella groups, thus strengthening the technical quality of their staff. (c) Other Unintended Outcomes and Impacts (positive or negative): N/A 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops; 81. See Annex 5. 21 4. Assessment of Risk to Development Outcome 82. Rating: Substantial 83. While the Project focused on the most effective interventions for IEC/BCC activities to build an impact on people’s behaviors, a long term intervention will be crucial to sustain the behaviors changes attained with the Project to have an impact on the decrease of the fertility rate. The use of qualified stakeholders at the regional and communal levels to develop an efficient implementation mechanism contributed to the Project’s results. However, given that the Government’s contribution to the MOP budget through the national budget decreased through the life of the Project and is limited, the sustainability of the communications activities and implementation arrangements put in place will greatly depend on donors’ support. Also, the IEC/BCC activities would need to be combined with activities to support women’s groups so as to strengthen women’s economic opportunities and would need to be better tailored to the communities’ needs and thus coordinated at the regional and district levels. At the institutional level, the Project lost all trained staff who implemented fiduciary and technical activities at Project closure. 5. Assessment of Bank and Borrower Performance 5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry Rating: Moderately Unsatisfactory 84. Quality at Entry: While the strategic relevance and approach of the Project was consistent with the country’s development priorities and the design of the Project was solidly grounded in key sector diagnostics endorsed by key stakeholders, in retrospect, the realism of the Project’s design and risks identified was not sufficiently adequate given the decision made to assign the coordination and implementation to the recently created MOP. The analysis of the capacities of the public sector and NGOs financed through the PPF should have been complemented by a more rigorous institutional and human resources assessment of the MOP. Moreover, implementing the Project turned out to be much more difficult than what the Bank team had thought. As a result, the technical assistance for the MOP should have been finalized during Project preparation and started as soon as the Project was approved. Also, while the government was committed to the Project’s objectives, its commitment to the Project’s design quickly was challenged by the lack of clear defined roles and responsibilities of the various governments’ institutions for the coordination and implementation of the Project’s activities. (b) Quality of Supervision Rating: Moderately Satisfactory 22 85. Supervision and fiduciary missions were conducted regularly to ensure continuity in dialogue with the Borrower and stakeholders. But, during the implementation period pre-restructuring, identified implementation problems could not be resolved. Specifically, the dialogue with the then minister of population proved difficult and the Bank team failed to get resolution of the implementation problems faced by the Project due to the minister’s willingness to have the MOP implement by itself the Project activities. Detailed reviews of the main aspects of Project financial management were carried out on a regular basis and led to marked improvements in the MOP’s FM capacity. As for the quality of procurement oversight, although the number of reviews was adequate, some delays were noted in the efficacy in handling procurement issues. With the July 2009 decision to nominate a field-based TTL that was formerly a member of the preparation team, day-to day support and just in time advice were provided. This boosted the implementation which improved significantly and allowed disbursements to reach 99.6 percent by the end of the Project. The Project amendments and the new implementation arrangements brought about by the 2011 restructuring have been highly adequate and increased the relevance of the design of the Project. (c) Justification of Rating for Overall Bank Performance 86. Based on the above, the Bank's performance is rated Moderately Satisfactory. 5.2 Borrower Performance (a) Government Performance Rating: Moderately Unsatisfactory 87. Overall government performance has been uneven over the life of the Project. The pace of implementation was compromised by delays in ensuring adequate staffing and the MOP’s insistence to implement the Project until the change of minister following the institutional change of the ministry after the 2010 Coup. The formalization of contracting agreements with NGOs took a very long time leading to a late start of the IEC/CCC communication campaigns on the ground and delays in the implementation of activities. Also, inadequate involvement of decentralized technical departments in the implementation of the activities of the NGOs for the first contracts hampered implementation. However, despite the difficult economic, socio and political environment, the Government translated its commitment to the population agenda by budgeting and disbursing resources for the main activities and gradually implemented the M&E system put in place to monitor the Project’s activities and results. The MOP also fulfilled its coordination role for the implementation of the population policy implementation by establishing end of 2012 a donor’s partnership framework. While the two legal texts to increase the legal age at marriage were prepared and submitted to the Parliament, they have not been approved yet because of the opposition of some religious leaders. 23 (b) Implementing Agency or Agencies Performance: Rating: Moderately Satisfactory 88. The MOP sub-contracted NGOs to implement the communications component and signed an MOU with some ministries (MoH, MOE, MOJ) and the National Institute of Statistics. The involvement of NGOs to organize outreach campaigns has proven effective. Training planned in the second part of the Project was not completed as expected for health personnel, "femmes relais", journalists and parliament members, because of the high turnover of key ministers and the stakeholders. (c) Justification of Rating for Overall Borrower Performance 89. Based on the above, the Borrower's performance was rated Moderately Unsatisfactory. 6. Lessons Learned: 90. The following lessons learned relate to country ownership, project design and implementation and sustainability of results.  Addressing the population agenda needs to be anchored in the highest level of government: The population agenda cannot be the sole responsibility of MOP while it is the coordinating responsibility of the MOP. As one of Niger’s top development objectives and given its multi-sectoral nature, the population agenda should fall under the mandate of the Prime Minister who is responsible for managing all ministries ensuring their full exploitation of comparative advantages to contribute to the country’s overall development. Also, the Prime Ministry should be responsible for advocacy and oversight, holding all ministries accountable for their parts in addressing the population agenda.  Technical assistance to address the population challenge should be clearly devised at all levels of society for increased country ownership. It is as important to strengthen and reinforce the need for permanent capacity building at central level as it is at the local level. Building capacity of members of regional and communal councils set up with the country’s decentralization process should bring solutions adapted to the specificities of the region or commune. This would in turn, ensure the sustainability of the interventions toward the intended goal of decelerating population growth.  Ownership of design by the government is key for successful implementation and impact on the ground: While political will was a pre-requisite for the Bank to prepare the Project, it was not sufficient. Without a full appropriation of the Project design, we are faced with a poor integration between the Project team and the government officials in charge of implementing the Project. As a clear consequence, Project implementation is sub-optimal and impact on beneficiaries may be jeopardized. 24  Awareness/sensitization approach: The IEC/BCC campaigns should be linked to the support for women empowerment in order to impact on women’s economic conditions which then can reinforce the awareness messages and activities in the general population.  Make the best of a decentralization system: Design and implement through a bottom-up approach by using decentralization and community-based system.  Culturally sensitive interventions: There is a need for specialized IEC/BCC expertise and for the design and implementation of interventions to be cognizant of local culture, needs, and issues; it points to a need for joint design; local delivery with expert oversight, supervision, follow-up and M&E. 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners (a) Borrower/implementing agencies 91. The borrower prepared a Project completion report summarized in Annex 7. (b) Co-financiers: Technical assistance was provided by UNFPA. (c) Other partners and stakeholders: 25 Annex 1. Project Costs and Financing (a) Project Cost by Component (in USD Million equivalent) Appraisal Actual/Latest Estimate Estimate Percentage of Components (expressed in (expressed in Appraisal SDR) SDR) Total Baseline Cost 10,177,300 10,114,616 99.6 Goods & Consultant services including audit and training 7,017,780 6,973,894 99.00 (Parts A and C) Goods & Consultant services including audit and training 911,400 874,601 95.9 (Part B) Operating Costs 98.00 1,822,800 1,791,182 PPF Refund 99.7 425,320 424,202 Unallocated - - - Total Project Costs 10,177,300 10,114,616 99.6 (b) Financing Appraisal Actual/Late Type of Estimate st Estimate Percentage Source of Funds Cofinancing (USD (USD of Appraisal millions) millions) Borrower NA 0.00 0.00 00 IDA Grant 10,177,300 10,144,616 99.6% 26 Annex 2. Outputs by Component Planned Actual Component 1: Advocacy and Communication (Total Estimated Baseline Cost: US$4.91 million) To keep population issues high on the national development agenda, modify traditional pro- natalist attitudes, promote birth spacing and RH services, strengthen links between FP and HIV/AIDS mitigation efforts, address specific issues such as obstetric fistulae, build a strong national consensus. Target populations: traditional and religious leaders, women, couples and youth. Subcomponent (a): Population and Development (Total Estimated Baseline Cost: US$3.50 million) Establish an advocacy and communication Completed. A communication strategy was strategy, encompassing all aspects of established in 2009. Communication plan population and development relationships, to developed and validated; 2 Islamic arguments be implemented at the central and decentralized developed: first age at marriage for girls and levels. boys + girls schooling. Nationwide, culturally-sensitive advocacy 2 national campaigns completed campaigns Subcomponent (b) Reproductive Health, Family Planning and Breastfeeding (Total Estimated Baseline Cost: US$1.31 million) Dissemination and implementation of IEC and All IEB/BCC activities from RH/FP and BCC activities in RH/FP; outreach campaign breastfeeding have been implemented for breastfeeding promotion as well as nationwide; reproductive health Inputs/Activities supporting both subcomponents MS/RS (Directorate of Population) holding main responsibility, collaborating with MSP and partners as relevant Nationwide, culturally-sensitive IEC and BCC campaigns: Using traditional communication channels, Use of traditional communication including interpersonal communication channels/medias to reach religious leaders and strategies, involving traditional and communities in rural areas ; 28 NGOs used religious leaders (marabouts) and NGOs active in rural areas Testing community radio, theatre, skits, completed song contests, comic strips, etc. Disseminating the results of effective completed interventions to strengthen Pop/RH policies, programs, outcomes Technical assistance to MOP in planning, Assistance done through UN agencies and implementation and evaluation government Recruitment of consultants to carry out the UNFPA communication strategy study Identification of communication tools completed Development of communication messages completed Training of key players completed Project Outcome Indicators At the end of the project, women’s fertility 200 per 1000 live births (DHS/MICS IV levels at young ages (15-19) will have 2012/preliminary report). Demographic growth 27 decreased from 199 to 180 per thousand rate remains high -RGPH: 3, 9%; recent data (original KPI/ abandoned at restructuring) also shows that fertility has increased to 7.6 infant/women. at the end of the project, the number of women 51% of women want to postpone by 2 years the who want to postpone their next pregnancy will next pregnancy (32 want to have children in the have increased from 49% to 55%. next two years): unchanged from 2006 t0 2012.( ref: DHS-MICS IV) At the end of the project, 85 percent of the population over the age of 15 years has been 95% ((ref: Project) sensitized on population and reproductive health issues At the end of the project the percentage of 2 children 0-5 months exclusively breastfed has 3% (ref: DHS-MICS IV) increased from 13.5 percent to 20 percent At the end of the project prevalence of modern contraceptive use among women in union aged 14.7% (ref: DHS-MICS IV) 20-24 years has increased from 4.4 percent to 7 percent Contraceptive prevalence rate (moderns 14% methods for women aged 15 to 49) Intermediate Outcome Indicators At the mid-term of the project, 50 percent of the population over the age of 15 years has 95% (ref: project) been sensitized on population and reproductive health issues At the end of 2012 85 percent of the members of religious associations at central, regional and 85% (ref: project) community level are sensitized on population and RH issues At the end of 2012 100 percent of members of networks (journalists, parliamentarians, youth 100% (ref: project) and researchers) are sensitized on population and RH issues Output Indicators Number of political declarations in support of PRODEM aims issued by the authorities 1 (source: project) between 2007 and 2012 (Target: 1/year) Number of legal texts favorable to the objectives of the DGPP prepared between 2007 0 (Source: project) and 2012 (Target: 2 in total, of which 1 in Year 3; 1 in Year 4) By 2012 key religious organizations implement Abandoned. Religious leaders’ plan was a plan of action concerning population, included in the national plan development and RH issues (Baseline: 30 percent; Target 80 percent) Number of youth sensitization campaigns on population, development and RH/FP issues 4 campaigns (2011- 2012) organized annually by the youth network at central and decentralized level between 2007 28 and 2012 (Target: 1/year) Number of televised debates on population, 2 televised debates each year on population development and RH/FP issues organized promotion and reproductive health were annually by the journalists’ network between organized through 3 local TV stations (RTN, 2007 and 2012 (Target: 1/year) RTT) Number of conferences concerning population, Researcher’s’ network have been trained and development and RH/FP issues organized by organized 1 conference broadcasted the researchers’ network and broadcasted (Target 1/year) Component 2: Women’s Autonomy and Couples’ Empowerment (Total Estimated Baseline Cost: US$0.94 million) Note: This Component Merged into Component 1 in May 12, 2011 Amendment to Financing Agreement To help strengthen the autonomy of women and consequently foster higher demand for birth spacing and FP services. Expand knowledge/improving prospects e of poor and marginalized, most often women, by engaging them Subcomponent (a): Support Girls School Enrollment and Women’s Literacy (Total Estimated Baseline Cost: US$0.50 million) Target female education as part of the national Women/girls were targeted for female awareness campaign, through female literacy education awareness campaigns: partner with and education projects./reinforce efforts UNICEF underway in Niger to improve female enrollment and performance. NGO support to school management Contract/MOU with Ministry of education committees (COGES) in carrying out reached community level outreach and sensitization on the importance of female schooling in districts where the gender gap in enrollment is greatest, complementing successful outreach program through COGES supported under the Bank- financed education project. Subcomponent (b): Strengthen Women’s Economic Opportunities (Total Estimated Baseline Cost: US$0.20 million) Collection and analysis of data by gender with Completed and disseminated regard to access to income generating activities (IGA)/support to the development, maintenance and use of data and statistics disaggregated by sex Technical assistance to MPF/PE to strengthen Not Completed economic and statistical analysis Research/study of obstacles to women’s Completed economic empowerment Identification of bottlenecks for access to IGA Completed Training of women at the community level to Completed help them manage IGA Provision to local level women’s associations Completed by NGO and associations: 145 (foyer feminins) in key disadvantaged areas of transportation carts et 80 motorized pumps equipment and materials specifically aimed at alleviating domestic task burdens Subcomponent (c): Legal Reform (Total Estimated Baseline Cost: US$0.24 million) 29 Support the development of laws to take into Parliamentarians have been trained, coached; « account women’s rights and gender code de L’Enfant » (being reviewed by the equity/”development of gender legal laws,” government) ; law for the protection of young including measures needed to increase the girls’ (being reviewed by Parliament), return minimum age at marriage for a second reading because the age of the first wedding (to 18 years) is blocked by the religious groups. Translation and dissemination of gender laws Completed Study of customs and practices relating to religious and girls schooling arguments marriage, divorce and other family issues, and the wide dissemination of this study Technical support to the legal reform Completed, design of the « code du status commission in drafting legislation related to personnel » marriage and family law Outreach and sensitization activities relating to gender and legal issues/implementation of the adopted laws Inputs/Activities supporting both subcomponents MS/RS holding main responsibility, collaborating with INS and MPF/PE, as relevant Link with community-driven development No common activities implemented (CDD) endeavors, in particular under the Programme d’Actions Communautaires (PAC) project. Involvement of communities in project design Completed after restructuring by NGOs (28 and implementation to allow local populations NGOs) to participate in their own development and harness their social capital Technical assistance for project Completed after restructuring by NGOs implementation and for the piloting of innovative approaches (i.e., with help of national and/or international firms or NGOs) Project Outcome Indicators At the end of the project the median age at 15,7 years marriage among women aged 25-49 has increased from 15.5 years to 16.5 years Intermediate Outcome Indicators Measures to increase the legal age at marriage Not done despite all efforts made by the are taken by Project Year 3 project: religious leaders contest and blocked the adoption of law in favor of youth, age of marriage and girls’ schooling. Gross enrollment (Basic Cycle 2, national 18% (ref: MESSRS) level) for girls increases from 11 percent in 2004/05 to 18 percent in 2011/12 Output Indicators The draft national gender policy will have been Completed in 2009 adopted, disseminated and implementation started by Year 3 Percentage of women suffering from fistulae 0.2% (DHS final data not yet available for this decreases on national level from 0.2 percent indicator) (2006 DHS) to 0.1 percent 30 Number of sensitization campaigns on women’s rights and birth spacing implemented 3/year (15) at central, regional and local levels, including radio advertisements (Target: 3 – 1 at each level – per year) Number of women’s groups/networks who have benefited from training in business 600 management skills between 2007 and 2012 (3 per year) Component 3: Harmonization and Coordination of Multi-Sector Interventions (IDA US$0.52 million) Note: This Component Dropped by Amendment to the Financing Agreement of May 12, 2011 To help organize gradually a national program approach to Pop/RH in Niger, coordinating with other national initiatives with positive population-related externalities, including: the Rural Development Strategy, the Code Rural (decentralization), the National Strategy for Development of Irrigation; the 10-year Education Project; the 10-year Strategic Development Framework; and the 5-year National Health Development Plan (among others). To help MOP coordinate, monitor and evaluate all population-related activities in Niger in line with the DGPP and its Strategic Framework and Work Plans. To help muster the necessary support from all other development sectors to improve Pop/RH outcomes, especially health and education, among others. To establish priorities among sector activities. Subcomponent (a): Support to DGPP Implementation, coordinated by the MOP (Total Estimated Baseline Cost: US$0.15 million) Dissemination activities at the central, regional Completed and community levels (MOP) Monitoring and Evaluation of the DGPP Completed implementation (MOP with UNFPA) Subcomponent (b): Support to DGPP Annual Work Plans (AWPs) (Total Estimated Baseline Cost: US$0.15 million) Support to the development of Strategic action Completed plans/annual work plans at all levels (MOP, along with UNFPA, AFD, USAID, etc.), will specify roles and responsibilities and performance indicators Organization of national annual reviews Committee met twice a year (starting in Year 2) to harmonize all contributions Subcomponent (c): Population Program Approach (Total Estimated Baseline Cost: US$0.22 million) Set up a dialogue framework with development Cadre de concertation pour le genre/enfant partners (MOP) élargie en 2012 à la population Organization of information sharing meetings with development partners to assess progress on the ground (MOP, along with UNFPA, Completed through steering committee AFD, USAID, etc.) 31 Advocacy to mobilize additional financing Process started for the “table ronde 2008” but from key donors (MOP with UNFPA) minister advocates with funding agencies Organization of inter-sector meetings (MOP) Project Outcome Indicators At the end of the project Annual Work Plans (AWPs) are designed, including M&E indicators, adopted through consultations Completed through steering committee (annual reviews) with stakeholders and donors, and implemented under monthly supervision of the MOP Intermediate Outcome Indicators Annual Work Plans (AWPs) and the M&E Guide, including performance indicators, are in 5 annual work plans done place by the end of 2008 At the end of 2008 8 regional coordination 8 regional coordination (CORAPO) installed units for population and RH issues are but not fully functional/ duplication of established and operational activities with health regional directions. Partially Completed. At the end of 2008 36 departmental 36 departmental coordination (CODEPO) coordination cells for population and RH issues installed but not fully functional. Partially are established and operational completed. Output Indicators Coordination meetings take place at monthly (department level), quarterly (regional level) Put in place but didn’t function and biannual (central level) intervals on project activities Quarterly supervision missions to department level by regional personnel and biannual same supervision missions at regional level by central level personnel take place Joint field visits by the project coordination and the development partners take place each year 1 joint visit by year + world bank supervision (Target: 2 per year) Project annual reviews are carried out (Target: Partially Completed 1 per year) Component 4: Capacity Building and Monitoring and Evaluation (Total Estimated Baseline Cost: US$4.08 million) Note: This Component Scaled Back for a Project vs. Program-wide Focus Key to successful program approach for Pop/RH To help MOP establish its authority to influence the broader decision-making and resources allocation framework in Niger To address the challenges of decentralization, which requires the strengthening of sub-national public institutions and increased attention to training and supervision of service providers at the periphery? Subcomponent (a): Data Collection, Analysis, Dissemination and Utilization (Total Estimated Baseline Cost: US$1.08 million) Establishment of statistical database to keep 1 data base put in place in2011 but not track of population activities (Census, surveys, functioning well etc.) Financing of small-scale KAP survey and focus Not completed 32 group discussions to support project MTR Financing of follow-up DHS survey in 2010 Completed (Project Year 4) Set up of GIS to map project activities Not done because the data base was not operational Assessment of baseline values of all Project Completed indicators through M&E situation analysis, as an effort to obtain baseline values from the first year of implementation, over and above baseline (2006) DHS data Development of an M&E guide for the project, completed which will provide the specifications and data collection tool for each project indicator Regular monitoring and communication of project process indicators by M&E structure within MOP, in close collaboration with M&E completed units of other relevant public sector agencies Contractual requirements of sub-contracted service delivery organizations to provide periodic activity monitoring reports showing completed the level of attainment of agreed indicators. Disbursement to sub-contracted service delivery organizations will be results-based, i.e., conditional upon satisfactory reporting Result based contract signed with organ compliance and the attainment of financial and technical targets. Use of data management system to provide Completed/ Didn’t function well important information to decision-making policy-makers. Recruitment of consultant to create the data completed management system Establishment of contracts with INS on data completed collection and analysis Subcomponent (b): Capacity Building of Key Personnel in MOP and Institution Building (Total Estimated Baseline Cost: US$3.00 million) Provision to new MOP with human and Completed Done but not sufficiently; main material capacities /training recruited staff was not sufficiently integrated into the ministry. They remained project centered and left at the closure: accountant, procurement, M&E and admin assistant Technical assistance and consulting services completed UNFPA-financed international population completed After the development of communication expert for 10 months communication materials, Capacity transfer to project was not done at the satisfaction of the consultant/UNFPA Extensive training of MOP staff completed Institutional strengthening activities, drawing Completed for human resources, MPs and on several studies financed under the PPF, others ministries (health, education, justice) including a study on institutional capacity. Dissemination of institutional capacity study completed 33 Creation of PRODEM Steering Committee completed and is functional (Comite de Pilotage) and its Sub-Committee. PPF-financed strengthening of MOP fiduciary All experts recruited and remained on board till expertise the end of the project. The level of capacity transfer was very weak as there was no functional link between Ministry’s fiduciary staff and project’s fiduciary staff Purchase of vehicles: 9 SUVs; 3 sedans completed Purchase of 4 motorcycles at the central level completed for liaison activities Purchase of office equipment for information completed systems units Purchase of office furniture and supplies completed Recruitment of new staff: 1 financial specialist; Completed All recruited staff left the Ministry 1 procurement specialist; 1 accountant; 10 after the project. There was no integration drivers; 1 office assistant; 1 information effort done to retain capacities. assistant; 1 janitor, among others. Intermediate Outcome Indicators At the end of 2008 a national multi-sectoral An M&E system have been established M&E system is operational with a population database centralizing M&E data and spatial data from all sectors and regions At the end of 2008 a study about migration has completed but results not used by the project been carried out and the migration balance is and not disseminated estimated Output Indicators At the end of 2008 a multi-sectoral national 1 M&E system is in place since 2008 M&E system, along with a socio-demographic and special (GIS) database, is operational An M&E Guide for the project is validated and 1 M&E guide validated and disseminated disseminated by 2008 A data dashboard of project indicators is disseminated semi-annually At least one operational research study or 6 research done and published action research on population, development and RH/FP issues is published every year. New Component: Reproductive Health Services Note: Added through Amendment to the Financing Agreement of May 12, 2011 To strengthen the capacity of the Recipient’s ministry responsible for health for the provision of reproductive health services Development of guidelines and material Completed Provision of training material and equipment Completed Training of nurses, midwives and community Completed health workers Provision of contraceptive products Completed along with MoH and other partners such as KFW and UNFPA. 34 Annex 3. Economic and Financial Analysis 1. Background Niger is one of the poorest countries in the world with a per capita gross national income (GNI) of US$360 as of 2011. Current development conditions in Niger are far from favorable, and its ability to achieve the MDGs and PRS II goals is severely limited by the lack of abundant natural resources, the low productivity of its traditional agricultural systems, and its harsh climatic conditions. Fertility is still very high and is estimated at 7.6 births per woman in 2012/DHS-MICS. Persistent high fertility, combined with some improvements in child mortality, contributes to both high population growth and a very young age structure. Niger has the highest proportion of young people in the world, and due in part to improvements in child mortality, the proportion has been increasing. This implies an unfavorable effect on the dependency ratio – Niger has the highest youth dependency ratio globally (105 people below age 15 for every 100 working age adults). Niger’s demographics have substantial implications for economic growth and poverty alleviation, and the Project was designed to address some of the key challenges by: (i) enabling the Ministry of Population (and Social Reform) (MOPSA) to design and implement a nationwide multi-sector population program; and (ii) increasing general awareness on population and reproductive health issues. While an analysis was conducted analyzing Niger’s demographic situation for the preparation of the project (Annex 11 in PAD), an economic analysis was not conducted. In March 2010, a review conducted by QAG indicated that “given the project’s institution-building and technical assistance nature, an economic and financial analysis was not applicable.” As such, no economic analysis exists with which to compare results at the end of the project. Nor can we replicate the analysis with the latest data. However, to the extent possible, we use the data available to conduct an analysis to highlight (a) the development impact of the Project, and (b) the efficiency of the completed activities. 2. Development Impact of the Project: Costs, benefits and efficiency The project investments created both direct and indirect benefits for the population. In this section, we assess the project costs, the direct and indirect benefits, and Project efficiency. 2.1. Project Costs A wide range of economic, health and social costs and obstacles are associated with the use of family planning: lack of knowledge; availability of family planning methods; health concerns and side effects; objections from husbands or other family members; and concerns about moral and social acceptability.i Compared to other settings, these issues are particularly challenging in Niger and the Project was designed to comprehensively address these costs and barriers on both the supply- and demand-sides to ultimately 35 increase the utilization of family planning. As indicated in the table below, 44 percent of project costs went toward implementation of Component 1, 9 percent for Component 2 and 47 percent for Component 3 (components as per the 2011 restructuring). Table A.1 Project Costs Component US$ Component 1 Advocacy, Communication and Coordination 4,420,314 Strengthening the Supply of Reproductive Health Component 2 Services 924,601 Component 3 Capacity Building and Monitoring & Evaluation 4,769,700 Total 10,114,615 Component 1 supported IEC/BCC activities to raise awareness of population and reproductive health issues, including fertility, links between family planning and investments in children’s education, family planning methods, and exclusive breastfeeding. Target audiences included women, traditional and religious leaders, journalists, parliamentarians, youth and researchers. Component 2 supported supply-side activities to improve the quality of reproductive health service provision. Health providers at facilities as well as health workers in the community were trained. Additionally, contraceptive supplies were financed to address supply shortages and smooth distribution flows. Component 3 supported capacity building; data collection, analysis and dissemination; partial financing of the 2012 DHS; training of NGOs in project and financial management; and supervision of sub-contracts to NGOs. This component was dropped during the 2011 restructuring of the Project. While we can estimate some of the impacts of Components 1 and 2 of the Project, no direct evidence is available to corroborate the impact resulting from Component 3. Therefore, in line with previous assessments of the economic impact of this type of project (i.e. TA for capacity building and institutional strengthening), the scope of this economic analysis will be limited to the areas where there is relatively more measurable information. Since we cannot reasonably estimate the economic benefit of all project activities, the analysis will be restricted to Components 1 and 2, totaling US$5.3 million (53 percent of Project costs). Thus, the following sections only reflect the costs, benefits and efficiency associated with only Components 1 and 2. 2.2. Development Impact: Direct Benefits The project benefits comprised several measures of direct impact, which included greater awareness of population and reproductive health issues, greater knowledge of contraceptive methods, higher utilization of modern contraceptive methods, increased 36 prevalence of exclusive breastfeeding, improved capacity of health service providers to address issues of reproductive health and family planning, and enhanced capacity of the MOP to design multi-sector population programs. Table A.2 Summary of Achievements Indicators 2006 2012 Comments Data source Number of annual work programs prepared, including the indicators, adopted and implemented each year 0 5 C Project records PDO level Contraceptive prevalence rate indicators (modern method for women in DHS 2006 and union aged 15-49) 5% 8,3% C 2012 Proportion of women aged from 15 to 49 who know at least one DHS 2006 and contraceptive prevalence method 72% 90% C 2012 Percentage of children aged 0- DHS 2006 and 5months exclusively breast-fed 14% 23% C 2012 Former PDO- level Percentage of the population over indicators the age of 15 years that has been sensitized on population and reproductive health issues 0% 95% D Project records Health personnel receiving training on Family planning and Reproductive health issues 0 682 D Project records Intermediate outcome “Femmes-Relais” (community indicators health workers) receiving training on Family planning and Reproductive health issues 0 270 D Project records Note : C : Contribution of the Project; D: Directly attributed to the Project On the contraceptive prevalence rate, Component 2 of the project (reproductive health services after restructuring) was specifically targeting 5 regions that have higher fertility rates. Contraception prevalence rates (for women in union aged 15-49) show in some of the targeted regions significant increase, as detailed in the table below: Table A.3 Improvements in CPR in Targeted Regions Percentage point CPR 2006 CPR 2012 increase Dosso 5.8% 10.8% 5.0 Maradi 1.9% 4.6% 2.7 Touha 5.1% 5.6% 0.5 Tillaberi 4.3% 10.9% 6.6 Zinder 2.5% 6.1% 3.6 National 5.0% 8.3% 3.3 Source: DHS 2006 and DHS 2012 preliminary results 37 On the raising awareness impact of the project, women’s knowledge of contraception increased from 72 percent to 90 percent. Other aspects of BCC and IEC activities were assessed in 2013 through a Beneficiaries Assessment. ii Data from this assessment provide a sense of the knowledge gained by the population through the Project’s IEC and BCC activities and also the thoughts of the population about changes entailed by the communication strategies: Table A.4 Summary of Findings of Beneficiaries Assessment Themes Proportion of people who Proportion of people who benefited and understood thought that some changes the message related to the happened after the BCC theme activities (community level) Use of contraception methods 91.0 70.9 Needs for birth spacing 80.6 80.0 Benefits of birth spacing on the mother and child health 72.6 79.1 Exclusive breastfeeding until 6 months 89.7 77.3 Link between population and education 93.6 80.3 Source: Beneficiary assessment of the Project, 2013 2.3. Development Impact: Indirect Benefits While the indirect benefits of this project are difficult to quantify, the development impact is potentially substantial. Evidence suggests that when childhood mortality decline is followed by fertility decline, there is an impact on a population’s size and structureiii:  Population momentum: an initial increase in population growth due to improving mortality rates.  Population structure: the period of time between the declines in mortality and fertility creates a population bulge as more children are born and fewer die. Age structure will be affected because as mortality rates decline, a large cohort of infants and children will survive to their productive working years, resulting in a lower dependency ratio.  If accompanied by appropriate policies, countries may be able to harness this demographic transition in the form of the demographic dividend that leads to economic growth and poverty alleviation. As described in the PAD, the Project intended to induce this fertility decline. In order for fertility to decline, there needs to be knowledge about family planning methods and utilization of these methods, both of which increased during the implementation of the 38 Project as discussed in section 2.2 on direct benefits. The established literature indicates that family planning has numerous effects on health including preventing unintended pregnancies, high-risk pregnancies and the number of unsafe abortions. In addition, a number of non-health benefits of family planning have been identified at both the micro- and macro-levels. These indirect benefits are summarized in the table belowiv: Table A.5 Indirect benefits of family planning Non-health benefits Health benefits Micro-level Macro-level Higher private health, nutrition Reduced public expenditures Reduced maternal deaths & and education expenditures per in education, healthcare and disability child other social services Lower newborn, infant and A woman’s improved ability to Higher productivity child mortality participate in the labor force Less societal burden of More time to breastfeed Higher household earnings caring for neglected children Better health and nutrition of More attention and parental care Higher savings and mothers for each child investment Economic growth Most of these indirect benefits are not short-term effects – in other words, the returns on investment will take longer than the Project implementation period to emerge. For example, smaller family size means that families can invest more in each child’s education. Measuring this requires the children to grow to age of enrollment in school and then attend school. While it is difficult to quantify the economic benefit of the indirect health and non-health effects listed above, we use data from existing literature to assess overall efficiency of the Project based on direct benefits. 2.4. Measures of Economic Efficiency and Cost-Effectiveness Analysis The previous sections discussed the direct and indirect benefits of the project on health and non-health factors. In the following paragraphs, we assess the efficiency of the project considering its costs and health benefits. Efficiency of a project can be assessed along several dimensions – allocative efficiency, productive efficiency, implementation efficiency and technical efficiency (definitions provided in the table below) – and each of these is discussed below with respect to the Project. 39 Table A.6 Dimensions of Efficiency Analyzed Efficiency Definition Allocative efficiency Allocative efficiency could be defined as the use of resources to meet strategic development priorities and improve welfare of population. Productive efficiency Productive efficiency is concerned with producing services with the optimal combination of inputs to produce maximum output for the minimum cost. Implementation efficiency Implementation efficiency could be defined as the effectiveness of implementation arrangements to achieve project’s activities. Technical efficiency Technical efficiency can be thought of as the effectiveness with which a given set of inputs is used to produce an output.  Allocative efficiency: Allocative efficiency of the project is considered as substantial as increasing awareness of population and RH issues (and increasing use of modern contraception to reduce fertility) are a key strategic priority for the development of the country. Moreover, decreasing the high fertility rate has a global positive impact on development of the country, through decreasing the demand for social services (health and education), pressure on natural resources and poverty rates (as detailed in the 2.3 section). Population issues are sensitive in Niger, with important cultural and social opposition. The design of the project was adequately allocating a large part of the funding (44 percent of the Project: US$ 4.4 million) to advocacy, communication and coordination. The Project sensitized 95 percent of the population, exceeding the target of 85 percent. Cost per beneficiary of sensitization on population and reproductive health issues (population over 15 years old) are calculated in Table A.7. Table A.7 Cost per Beneficiary Sensitized Share of 15 years and Population Niger older in the Cost of Population Cost per 2012 population component 1 reached beneficiary 17,6 million 50,80% 4,4 $US million 95% of 15+ US$0.53  Productive efficiency: In the Project, productive efficiency is considered as adequate (after restructuring in 2011). For component 1, to reach awareness on population and reproductive health issues, an exhaustive study to develop a national communication strategy to behavioral change on 40 reproductive health was conducted to assess the best strategies to implement (through a perception study and an inventory of past communication strategies). The IEC/BCC activities were contracted to NGOs (selected through competitive process) and religious leaders: they have a comparative advantage to implement communication activities as they were already implementing activities in the communities, and this was the most cost- effective way to achieve the desired output. Additionally, contracting local NGOs also aimed at increasing appropriation of the project and activities. Communication supports were selected from an inventory of existing communication supports and the most powerful communication tools were distributed to local associations for support their local activities. Finally, mass media were used to convey RH messages which helped to further reach a wider audience (75 community radios and 5 commercial radios). For component 2 related to supply of health services, significant saving was achieved through the competitive bidding process for training materials procured by the project (for health personnel and “femmes-relais”). The support from the project was also complemented by UNFPA which provided support to the Government to improve the expansion of reproductive health activities at the community level.  Implementation efficiency: Project implementation was affected by some institutional instability with the implementing agency, the MOP being changed twice and later on merged to become the Ministry of Population and Social Reform and Women’s Promotion and Child Protection. After weak implementation during the first half of the project (delays in activities implementation due partly to the weak capacity of the implementation unit), a restructuring of the Project in May 2011 led to intensive implementation for the 2 last years. Disbursement rate was at 100 percent by the end of the Project. The restructuring largely contributed to improve the implementation efficiency, which could be considered as satisfactory by the end of the project (latest ISR rating). Indeed, the restructuring of the project aimed at strengthening and simplifying the project design, with intensifying the demand-creation for reproductive health services and strengthening the supply-side of health services. Expanding contracting to NGOs for demand-side activities and increasing the investments in supply-side initiatives substantially contributed to improving efficiency of Project implementation.  Technical efficiency: Evidence from both controlled and “natural” experiments indicate that family planning programs have successfully not only increased knowledge and use of contraceptives but also decreased fertility and improved maternal and child health, household earnings and use of preventive health care – examples include Bangladesh, Iran and Kenyav . A vital part of successful family planning programs is communicating and promoting the benefits of contraception to all stakeholders to increase awareness and acceptance of contraception. By providing factual information and dispelling myths about family planning, these efforts can motivate individuals to change behaviors. Of course, the supply-side also has to be able to provide quality services to keep pace with growing demand. 41 The interventions included in the Project are technically sound and consistent with a series of articles in The Lancet which recommended priority, high-impact interventions to reduce child and maternal mortality rates. Components 1 and 2 together can be considered a packaged family planning program, addressing both demand- and supply- side constraints to the utilization of family planning. This type of family planning program has been identified as one of the most cost-effective development interventions to date.vi By convention, due to data availability and methodological constraints, cost-effectiveness has been assessed based only on direct health benefits from increased birth spacing and reduced adolescent pregnancies. These estimates do not take into account any of the indirect health and non-health benefits discussed above. However, based on the direct health benefits alone, Table A.3 displays regional estimates of costs of family planning programs per benefit for the following health benefits: birth, infant death, and maternal death averted as well as disability-adjusted life year (DALY 8 ) gained. Health interventions that cost less than $100 per DALY are considered highly cost-effective by international standards.vii Thus, family planning programs can be considered highly cost- effective at $34 per DALY gained. Table A.8 Average Costs of Family Planning Programs per Benefit by Region (in US$2001) Maternal Disability- Birth Infant death death adjusted life Region averted averted averted year gained East Asia and Pacific $163 $4,907 $12,880 $60 Latin America and the Caribbean $87 $2,316 $34,564 $53 Middle East/North Africa $97 $1,989 $18,917 $49 South Asia $113 $1,577 $5,172 $30 Sub-Saharan Africa $131 $1,367 $10,231 $34 Source:Levine et al, 2006. As discussed above, the efficiency assessment is limited to the Project Components 1 and 2 which together is a technically sound family planning program. Based on the cost- effectiveness estimates of family planning programs documented above, this analysis uses the overall estimate for Sub-Saharan Africa and the Project costs to calculate the DALYs gained in Niger. (This assessment focuses on DALYs gained as it is the most comprehensive measure of health benefit available). As indicated in Table A.4, an estimated 157,203 DALYs were gained from implementation of Components 1 and 2 of the Project. 8 DALYs are a measure of overall burden of disease, expressed as the number of years lost due to ill-health, disability or early death. 42 Table A.9 DALYs gained through implementation of Components 1 and 2 of the Project Costs (US$) Benefit (DALYs) Cost of Components 1 & 2 Cost per DALY gained DALYs gained $5,344,915 $34 157,203 It is important to note that the estimate of DALYs gained is based only on direct health benefits, and the calculation excludes any indirect benefits to the population in both the short-and long-term (e.g. public and private expenditures for health, nutrition and education; women’s labor force participation; higher household earnings; higher productivity; etc.). The estimate also does not include any improvements in quality of service provision resulting from training provided to health providers. Thus, this estimate can be considered an underestimate of benefits gained from Components 1 and 2. In the Project, technical efficiency is rated high. ------------------------- i Bongaarts et al. 2012. Family Planning Programs for the 21st Century: Rationale and Design. New York: The Population Council. ii  Rapport d’enquête auprès des bénéficiaires dans le cadre de l’évaluation finale du projet démographique multisectoriel (PRODEM), Bureau Africain de Suivi et Evaluation « Development Consult » (BASE/DC), 2013. Sampling for the survey: 48 villages were surveyed and 15 households interviewed per village (in each of the 8 regions of Niger, 3 “communes” were selected and 2 villages per “commune” were surveyed). iii Bloom, Canning, and Sevilla, 2002; Bloom and Canning, 2007 iv Smith et al. 20 v  Bongaarts et al. 2012. Family Planning Programs for the 21st Century: Rationale and Design. New York: The Population Council. vi Levine et al. 2006. Disease Control Priorities in Developing Countries. vii  Ibid 43 Annex 4. Bank Lending and Implementation Support/Supervision Processes (a) Task Team members Responsibility/ Names Title Unit Specialty Lending C. Mark Blackden Consultant AFCC2 AFTH2 - Jean-Pierre Guengant Consultant HIS Djibrilla Karamoko Sr Health Spec. AFTHE Rama Lakshminarayanan Sr Health Spec. HDNHE Karima Laouali Ladjo Program Assistant AFMNE John F. May Lead Population Specialist AFTHE Anne M. Pierre-Louis Lead Health Specialist AFTHE Khama Odera Rogo Lead Health Specialist CICHE Abdoul-Wahab Seyni Senior Social Development Spec AFTCS Serge Theunynck Consultant AFTED Yao Wottor Senior Procurement Specialist LCSPT Mamadou Yaro Sr Financial Management Specialist AFTFM Supervision/ICR Pia Axemo Consultant HDNHE Jean J. De St Antoine Lead Operations Officer AFTHE Mohamed I. Diaw Operations Assistant CFPPM Ibrahim Cheik Diop Communications Officer AFRSC Rachidatou Idrissa Temporary AFMNE Madougou Djibrilla Karamoko Sr Health Spec. AFTHE Karima Laouali Ladjo Program Assistant AFMNE John F. May Lead Population Specialist AFTHE Ibrah Rahamane Sanoussi Procurement Specialist AFTPC Madjiguene Seck Communications Associate PRMVP Mona Sharan Consultant HDNHE Nko Etesin Umoren Resource Management Analyst AFTRM Mamadou Yaro Sr Financial Management Specialist AFTFM 44 (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 FY06 27.48 114.39 Total: 27.48 358.76 Supervision/ICR FY07 48.97 244.37 FY08 39.00 177.02 FY09 47.35 235.7 FY10 32.33 178.55 FY11 32.81 182.41 FY12 29.15 126.19 FY13 23.59 62.6 FY14 1.45 7.6 Total: 254.65 1,214.44 45 Annex 5. Beneficiary Survey Results In February 2013, a beneficiary assessment was conducted by the Project through a consultant service (Bureau Africain de Suivi et Evaluation « Development Consult » - BASE/DC. The survey covered all eight regions of Niger. In each region, three zones were selected and two villages within these zones were covered; the survey also included a reference zone. The survey team visited a total of 48 villages/sites. The survey results show that most people recognize the impact of population growth on health, education and agriculture. However, the impact on the environment and employment is not as well understood. Changes attributable to the Project:  Population - Development Interrelation: A general awareness of local stakeholders about the effects of uncontrolled population growth was observed. Respondents cited famine, poverty and the lack of socio-economic infrastructure as consequences of population explosion. This awareness is reflected on the spot through the adoption of family planning by communities for responsible parenthood. In general, the leaders expressed their commitment to the desired changes through the awareness of the consequences of population explosion and the adverse effects of drought, famine, poverty, diseases and lack of socio-economic infrastructure.  Reproductive Health: In all regions, there is a positive attitude towards the use of modern contraceptive methods, even if these behavioral changes are not due solely to the Project activities. Indeed, women have a better understanding of the benefits of RH and they use the two main modern contraceptive methods that are pills and injections.  Breastfeeding only: Significant progress has been made in this area. Understanding the importance of breastfeeding-only, many women have adopted the practice and are expressing their satisfaction with it. This is mainly the result of health workers’ endeavor, as they explain to women the importance of breastfeeding during prenatal consultations, as planned under the Project.  Education of girls: Survey results show that, in project areas, there is a very positive attitude towards girl’s education within the communities. As a result many girls are enrolled in schools. However, there is still some resistance by some who believe that girls learn bad behaviors in school.  Women Empowerment: The Project’s support is appreciated as very significant, although support was minimal. However, it is considered that support to women to assist them materially with their domestic chores gives them opportunities to send their daughters to school. Others confirm that women who received wheel cart and motorized pumps were able to support their husbands in the buying of clothes for the 46 family. Still some say that when women have more means to live by, they are more difficult to “manage”.  Family Planning: The survey highlighted the acceptance of birth spacing with the use of modern contraceptive methods. Women feel more comfortable about the issue and do visit health centers more frequently for prenatal consultations. Behavior change occurs gradually despite the reluctance of some religious leaders. CIP at health centers and programs previously carried out contributed significantly to change the habits of people.  Early Marriage: Most people interviewed indicated that they learned the negative impact of the early marriage such as fistulas and still born babies. If this trend is maintained, the rate of early marriages should be reduced, thereby delaying the age of first marriage and allowing girls to remain in school until the end of the primary cycle.  Literacy of women: Women leaders and religious leaders are unanimous on the necessity to educate women. Some people mentioned that the Project did not provide support to activities to create and support literacy centers. However, outreach financed by the Project had a positive impact on the number of women going to the existing centers. Other partners have financed new centers, and some new Koranic schools have opened. Assessment of the Project approach: The evaluation showed generally very positive findings regarding the results reached by the Project and changes observed in the populations. The main strengths cited by stakeholders are: (i) increased use of health facilities by women; this has improved the use of modern contraceptive methods, as well as mother and child health services, the improvement of girls’ level of education; (ii) reduction of early marriages in villages; (iii) qualitative change in civil registration; (iv) reduction of risks associated with pregnancy and childbirth; (v) awareness of opinion leaders on population-development link; and (vi) Improvement of geography and biology lessons. However, the Project shows some weaknesses regarding:  Late start of IEC/CCC communication campaigns on the ground and the delay in the implementation of activities due to the slow disbursement which are essentially due to the time taken by the departments of the Ministry and the various stakeholders to master the procedures;  Inadequate involvement of decentralized technical departments in the implementation of the activities of NGOs for the first contracts;  All stakeholders underlined the insufficient monitoring of activities;  Lack of supporting measures for women (low funding of IGA that should favor poverty reduction or women empowerment);  Shortcomings in the programming of activities which in some cases overestimated the capacity of stakeholders; 47  The short duration of the project (which did not allow the implementation of certain activities); and  Lack of financial resources, which did not allow for greater coverage in the 8 regions of the country. Beneficiaries’ expectations are as follows: (i) increase of resources allocated to stakeholders; (ii) support to the village committee in its management of the case de santé (community health center); (iii) financing of IGA and house work relief (fattening, mill, etc.); (iv) greater involvement of local actors in the field; (v)support activities of the PDC; (vi) Provision of adequate resources for raising awareness; (v) better adapt awareness of themes and tools to match the different social and cultural contexts; and (vi) civic awareness with regards to payment of income taxes so that the municipalities can invest in areas such as education. Recommendations are:  Changes that were attained during the project life could be lost if the momentum is not maintained. In other words, the main risk is the Project closure and no follow up project. The achievements as of today are too fragile to be sustained on their own. The sustainability of these results could only be obtained with in-depth work for their strengthening; this requires means, time and a good strategy.  The evaluation team recommends the continuation of the Project interventions in all eight regions so as to consolidate and strengthened achievements obtained so far. The mission suggests that the basic principles of the project be maintained and continued, particularly the involvement of exiting expertise in the country (NGOs, associations, local leaders);  There is a need to include capacity building for them as well as for all stakeholders/actors in the implementation of the project at the local level; and  Particularly it is important to include measure for the sustainability of the Project achievements, so that the decentralized technical services may take over. Particular attention should also be given to building the capacity of beneficiaries, including women for house work relief and practice of income-generating activities, and accompanying measures to consolidate the achievements. There is also a need to plan measures ensuring sustainability of the achievements of the Project. 48 Annex 6. Summary of Borrower's ICR and/or Comments on Draft ICR 1. Background Since the first general population census in 1997, all successive governments have had to face the problem of the country’s demographic explosion and its consequences. The Nigerien population grew from three millions in 1960 to about 17 million in 2012. This represents a quintupling of the population in a timeframe of 52 years. Between 1990 and 2006 the average rate of population growth was 3.1 percent. It grew to 3.9 percent in 2012 which, coupled with the rapid degradation of the country’s limited natural resources, contributed to worsening the gap between economic and population growth. Project initiation and preparation evolved in the framework of structural adjustments, implementation of the first phase of the PRSP (which third pillar was the control of the population growth), a general population census, demographic and housing surveys, demographic projections for 2005-2050, a Bank-financed study with a demographic perspective on food safety, provision of health services and education for all Nigeriens, as well as an evaluation of the existing national population policy. Awareness of major challenges related to the rapid population growth led government to take action and implement new initiatives including the adoption of the Déclaration du Gouvernement en matière de Politique de Population (DGPP) in 2007 which has for objectives to: • increase utilization of birth spacing method from 15 to 20 percent amongst Nigerien couples; • reduce by one third the proportion of early marriages; • promote the extension of the period of breastfeeding; • reduce the number of mother/child ratio from seven to five; and • reduce the population growth from 3.3 percent to 2.5 percent. In order to support the implementation of the national program and attain expected results, the Ministry of Population developed and implemented the Multi-sector Demographic Project (PRODEM) financed through an IDA grant of US$10 million signed between the Government of Niger and the World Bank in June 2007. 2. Implementation The project was implemented mainly by the MOP (DEP, DAF, General Population Department, and other technical departments of the MOP) and by the MOH which received a substantial portion of the funding for implementation of activities for strengthening the supply of reproductive health and family planning services through the deployment of community-based distribution points for contraceptives. Main activities implemented under the project and main achievements, by component: 49 Advocacy and Communication:  large awareness campaigns covering the whole territory through contracts with NGOs and CBOs and involving various media organizations, religious leaders and village local leaders. Themes that were covered under these campaigns included (i) the relationship between population and development, (ii) birth spacing ; (iii) early marriages ; (iv) girls education and women literacy; and (v) breastfeeding only. Strengthening the Supply of Reproductive Health Services:  creation of distribution points for contraceptives  staff training for field supervision;  distribution of training and awareness materials and equipment;  procurement of contraceptives was cancelled due to their availability in the country;  training of local health center staff and femmes-relais in five regions; and  financing of equipment for women associations to (85 motorized water pumps, 145 wheel carts) to makes their domestic tasks easier and motivate them to support girls education. These activities were implemented by all partners, including the MOP. The MOP and other partners activities resulted in an increase of breastfeeding-only rate (from birth to 5 months) of 13.5 percent in 2006 to 23 percent in 2013, surpassing the end-of-project target of 20 percent The gross rate of contraceptive prevalence in married women (age 20-24) increased from 4.4 percent in 2006 to 12.6 percent in 2012, also surpassing the target of 7 percent. Capacity Building and Monitoring & Evaluation:  a population migration survey;  a general population and health survey in 2012; the establishment of a socio- demographic database (not operational as of project closing due to lack of current data);  the creation of several committees responsible for population issues at the national and regional levels; and  Capacity strengthening of Parliament and Regional Representatives. These activities contributed to the timely production of the projects monitoring and evaluation reports as well as planning and implementation reports as listed in the financing agreement. 50 Project performance: All key performance indicators, with the exception of the most important one related to increase of the legal age at first marriage, have either reached or exceeded the target value at the end of the Project. Major decisions that have favored the Project:  The appointment of a project manager based in Niamey greatly facilitated the implementation of the Project.  During the mid-term review, the Bank’s readiness to adapt the Project to the national context contributed to the reorientation of the Project by further promoting a multi – sectoral approach and greater involvement of partners including the Ministry of Public Health, NGOs, religious organizations and traditional leaders for a more effective implementation of planned project activities.  The agreement by the Bank to experiment accompanying actions such as the procurement of wheel carts and motor pumps which have led to the massive participation of women in various outreach activities in the villages.  The government’s willingness to ensure that existing staff in technical departments involved in the implementation of the project were not only available but also committed, and dedicated to the achievement of project results; and  The establishment of the Inter-ministerial Committee for monitoring indicators. Key decisions (or lack of) having hindered the project implementation: 1. The formalization by contract with NGOs / AD took more than a year because of the options recommended changes by the Bank as part of the procurement; and 2. The lack of resources and the lack of management of coordinating bodies established at national, regional, departmental, and communal level have seriously hampered implementation of several decentralized activities. Among the lessons learned, it was noted that:  The more frequent visits to health facilities by women has improved the use of modern contraceptive methods, the health of mother and child, and girls’ schooling; and  The involvement of NGOs to organize outreach campaigns have been effective and should be continued especially in rural areas targeting young people at schools and university level. Assessment of Bank performance and implementing partners: Despite difficulties and delay with regards to Bank procedures, relations between the Bank and the MOP were cordial and respectful. Assessment of implementing agents: Overall, the efficiency of the various project implementing partners was satisfactory. 51 Perspectives beyond the Project: The good experience of the Project deserves to be maintained and strengthened over a relatively long period taking into account the very slow process that the mechanism of behavioral change takes, especially in the particular context of Niger. It is therefore critical to consolidate the achievements of the project with increased resources for a better coverage of target areas, including support to massive awareness campaigns more particularly with regards to rural associations and the distribution of equipment to ease women’s domestic chores, especially in rural areas. 52 Annex 7. Comments of Co-financiers and Other Partners/Stakeholders N/A 53 Annex 8. List of Supporting Documents 1. Aide-mémoires, Bureau du Niger, World Bank, Niamey, 2008-2013 ; 2. Bilan 2010 du PRODEM, Ministère de la Population et de l’action sociale ; Niamey, Niger 3. Bilan annuel d’activités 2011, Ministère de la Population et de l’action sociale ; Niamey, Niger 4. Liste des membres du CTSI du PRODEM, Ministère de la Population et de l’action sociale ; Niamey, Niger 5. Enquête Démographique de Santé-MICS du Niger; EDSN-MICS IV 2011-2012 Rapport Préliminaire; Mai 2012; Institut National de la Statistique (INSA, Niger) et ISF International (Calverton, Maryland); 6. Enquête Démographique de Santé-MICS du Niger; EDSN-MICS IV 2005-2006 Rapport; Institut National de la Statistique (INSA, Niger) et ISF International (Calverton, Maryland); 7. Financing Agreement -Multi-Sector Demographic Project- between republic of Niger and international development association Dated June 29, 2007, The World Bank; 8. Implementation Completion and Results Report on a grant number h309-nir Multi- Sector Demographic Project- between republic of Niger and international development association to the Republic of; 2008-2013 World Bank; 9. Liste des copies de rapport d’activités et supports de communication 2011-2013 ; 10. Project Appraisal Document of the Multi-sector demographic project on a Proposed Grant o in the amount of SDR 6.700 million to the Republic of Niger; May 17, 2007; World Bank; 11. Quality Assessment of lending portfolio; March 2010; World Bank. Revue a mi- parcours du PRODEM, mars 2012, MOP, Niamey, Niger. 12. Rapport d’achèvement du projet, Ministère de la population et de l’action sociale, République du Niger, Septembre 2013 ; Rapport Préliminaire de l’Enquête Démographique de Sante-MICS 2012, INS, Niger. 13. Rapport d’évaluation interne du PRODEM, 20 janvier-4 février 2013 ; Niamey, Niger. Rapport final d’enquête auprès des bénéficiaires du PRODEM, février 2013, BASE ; Niamey, Niger. Revised Financial agreement; République of Niger: Grant No. H309-NIR (Multi-Sector Demographic Project) Amendment to the Financing Agreement; 14. Rapport d’activités du PRODEM 2008-2013; Ministère de la population et de l’Action Sociale ; 15. Restructuring paper on a proposed project restructuring of multi-sector demographic project (credit No H309-NIR) to the Republic of Niger, March 2011. World Bank. 16. Situation de la planification au Niger, Dr ABDOUL KARIM Adama Kemou ; Chef de Division Planification Familiale ; Direction de la Santé de la Mère et de l’Enfant ; Direction Générale de la Sante de la Reproduction, Ministère de la Santé Publique ; février 2013, Niamey, Niger. 54 Annex 9. Restructuring Changes Table 1. Changes in PDO and Intermediate Outcome Indicators Original Indicators Proposed Change Comments Original performance indicators Annual work programs are Replaced by: designed, including monitoring Number of annual work and evaluation indicators, programs prepared, including adopted after annual consultation the indicators, adopted and with stakeholders and donors, implemented each year and implemented under monthly supervision of the Ministry of Population 85 percent of the population over Replaced by: The new indicator will age 15 has been sensitized on Proportion of women aged better capture the efforts population and reproductive from 15 to 49 who know at made by the project in the health issues least one contraceptive sensitization of the prevalence method population The median age at first marriage Moved to intermediate among women aged 25-49 has outcomes increased from 15.5 years to 16.5 years Percentage of children aged 0-5 Dropped To simplify the results months exclusively breast-fed framework has increased from 13.5 percent to 20 percent Prevalence of modern Clarified to: contraceptive use among women Contraceptive prevalence rate in union aged 20-24 has (modern methods for women increased from 4.4 to 7 percent aged 15 to 49) Intermediate Outcome Indicators At the mid-term review of the Dropped Project, 50 percent of the population over age 15 has been sensitized on population and RH issues At the end of 2012, 85% of the Replaced by: members of religious At the end of the Project, 300 associations at central, regional sermons have been completed and community level are on “Parenté responsible” by sensitized on population and RH preaching religious leaders in issues 6 regions At the end of 2012, 100 percent Replaced by: of the members of networks At the end of the Project, 100 (journalists, government, journalists have been trained researchers and youth) are on population and RH issues sensitized on population and RH 55 issues Measures to increase the legal Clarified by: age at marriage are taken by Government has prepared the Project Year 4 (2012) legal text and measures to increase the minimum age of marriage Gross enrollment for girls Dropped To simplify the results increases from 11 percent in framework 2004/5 to 18 percent in 2011/12 Annual Work Plans and the Changed by: M&E guide, including - At the end of the Project, Performance Indicators are in the M&E system is in place place by the end of 2008 and the demographic data had been collected and are available for all sub-sectors and regions - The M&E report has been prepared and distributed for all stakeholders and implementers At the end of 2008, regional Dropped Completed coordination units for population and RH issues are established and operational A the end of 2008, departmental Dropped Completed coordination cells for population and RH issues are established and operational At the end of 2008, a national Dropped Under construction and multi-sectoral M&E system is expected to be completed operational with a population soon database centralizing M&E data, and spatial data from all sectors and regions At the end of 2008, a study about Dropped The survey is ongoing migration has been carried out, and the migration balance estimated New indicator: At the end of the Project, all members of Parliament have been trained on population and RH issues New indicator: At the end of the Project, three main political parties have been trained on population and RH issues 56 New indicator: Health personnel receiving training on family planning and RH issues New indicator: “Femmes-Relais” receiving training on family planning and RH issues Table 2. Description of Responsibilities COMPONENTS FIRST SECOND IMPLEMENTATION IMPLEMENTATION AGENCY AGENCIES Advocacy, Communication Ministry of Population (MOP) - MOP/Directions and Coordination - Ministry of Education - Ministry of Justice - NGOs/CSO Strengthening the supply of Ministry of Health (MOH) Child and Maternal health Reproductive Health Services Direction – MOH Capacity Building and Ministry of Population - Directions of the MOP Monitoring & - National Institute of Statistics Evaluation (NIS) - NGOs/CSO Table 3. Reallocation of grant proceeds Difference Revised Revised (+/-) Allocation Original Difference Allocation Category (D) as of Allocation (+/-) As of May Description March (A) (B) 2011 2012 (A+B=C) (C+D) Goods & Consultant services including 1a 4,700,000 -400,000 4,300,000 + 320,000 4,620,000 audit and training (Parts A and C) Goods & Consultant services including 1b 1,400,000 1,400,000 - 800,000 600,000 audit and training (Part B) 2 Operating Costs 650,000 70,000 720,000 + 480,000 1,200,000 3 PPF Refund 660,000 -380,000 280,000.00 0 280,000 4 Unallocated 690,000 -690,000 0 0 0 TOTAL 6,700,000 6,700,000 6,700,000 57   58