Document of The World Bank Report No: ICR2708 IMPLEMENTATION COMPLETION AND RESULTS REPORT (IDA) ON CREDITS IN THE AMOUNTS OF SDR 19.6 MILLION (US$24.56 MILLION EQUIVALENT) AND SDR 13.3 MILLION (US$20.0 MILLION EQUIVALENT) TO THE REPUBLIC OF CHAD FOR A SECOND POPULATION AND AIDS PROJECT DECEMBER 23, 2013 Human Development Sector Health, Nutrition and Population (AFTHE) Country Department AFCW3 Africa Region CURRENCY EQUIVALENTS (Exchange Rate Effective December 2013) Currency Unit = Franc CFA (FCFA) 481.41 FCFA = US$1.00 US$1.54 = SDR 1 ABBREVIATIONS AND ACRONYMS AF Additional Financing AIDS Acquired Immuno-Deficiency Syndrome AM Aide-mémoire AMASOT/MASOCOT Chadian social marketing program ASTBEF Association Tchadienne de Bien-Etre Familial (Chadian Family Planning Association ARV Anti Retroviral BCC Behavioral change communication CAS Country Assistance Strategy CBO Community-based Organizations CFAF Central African Franc CNLS National AIDS Committee CNSEE Centre National de la Statistique et des Etudes Economiques (National Center for Statistics and Economic Studies) CNTS Centre National de Transfusion de Sang (National Center for Blood Transfusion) CPN Consultation Pré-Natale (Prenatal consultation) CPPA Central Pharmaceutical Procurement Agency CPS Country Partnership Strategy CSN Cadre Stratégique National (National Strategic Framework) CSO Civil Society Organization CSW Commercial Sex Worker CTA Centre de Traitement Ambulatoire (Treatment Center for Ambulatory Patients) DGA Development Grant Agreement DHS Demographic and Health Survey DO Development Objective DTC Vaccination against diphtheria, tetanus, and whooping cough EA Environmental Assessment ESMF Environmental and Social Management Framework EU European Union FED European Development Fund FM Financial Management FMA Fiduciary Management Agency FMR Financial Management Report FOSAP Fond de Soutien aux Activités de Population (Support Fund for Population Activities) GDP Gross Domestic Product GFATM/GF Global Fund to Fight AIDS, TB and Malaria HIPC Highly Indebted Poor Country HIV Human Immunodeficiency Virus HMIS Health Management Information System HPI Human Poverty Index HSSP Health Sector Support Project ICB International Competitive Bidding ICRR Implementation Completion and Results Report IDA International Development Association IEC Information, Education, and Communication IEG Independent Evaluation Group IOI Intermediate Outcome Indicator IP Implementation Progress IPP Incidence and Prevalence Study (2001) IPPF International Planned Parenthood Federation ISR Implementation Status Report KAP Knowledge/Attitudes/Practices KfW Kreditanstalt Fur Wiederaufbau (German Development Bank) KPI Key Performance Indicators MAP Multi-Sectoral HIV/AIDS Program MCH Maternal and Child Health MDG Millennium Development Objectives M&E Monitoring and Evaluation MICS Multi-indicator cluster study (UNICEF) MOH Ministry of Public Health MoU Memorandum of Understanding MSM Men who have sex with men MTR Mid-Term Review MWMP Medical Waste Management Plan NAC National AIDS Commission NACP National AIDS Control Program NCB National Competitive Bidding NGO Non-Governmental Organization NPP National Population Policy OI Opportunistic Infection OI Outcome Indicator OVC Orphans and Vulnerable Children PACP Population and AIDS Control Project PAD Project Appraisal Document PAIP Priority Action Investment Plan PCN Project Concept Note PCT Project Coordination Team PDO Project Development Objective PHRD Policy and Human Resources Development Fund PIM Project Implementation PLWHA People Living with HIV and AIDS PMTCT Prevention of Mother-to-Child Transmission PNLS National AIDS Program of the Ministry of Health PPAR Project Performance Assessment Report PPF Project Preparation Facility PRSP Poverty Reduction Strategy Paper QAG Quality Assurance Group QEA Quality at Entry Assessment QALP Quality Assessment of the Loan Portfolio RBF Results-based Financing RGA Revenue generating activities SECBO Board Operations SIL Specific Investment Loan SOE Statement of Expenditure STI Sexually transmitted infection TF Trust Fund TFR Total Fertility Rate TOMPRO Dedicated accounting system TT/TTL Task Team/Task Team Leader UN United Nations UNAIDS Joint United Nations Program on HIV/AIDS UNDP UN Development Program UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special UNICEF United Nations Children's Fund USD/US$ US Dollar VAT Anti-tetanus vaccine VCT Voluntary Counseling and Testing WHO World Health Organization XDR Standard Drawing Rights Vice President : Makhtar Diop Country Director : Ousmane Diagana Sector Manager : Trina Haque Project Team Leader : Aissatou Diack ICR Team Leader : Aissatou Diack CHAD SECOND POPULATION AND AIDS PROJECT Table of Contents A. Basic Information ___________________________________________________________________________ i B. Key Dates _________________________________________________________________________________ i C. Ratings Summary ___________________________________________________________________________ i D. Sector and Theme Codes _____________________________________________________________________ ii E. Bank Staff _________________________________________________________________________________ ii F. Results Framework Analysis __________________________________________________________________ ii G. Ratings of Project Performance in ISRs _________________________________________________________ ix H. Restructuring ______________________________________________________________________________ ix I. Disbursement Profile ________________________________________________________________________ x 1. Project Context, Development Objectives and Design ___________________________________________ 11 1.1 Context at Appraisal _____________________________________________________________________ 11 1.2 Original Project Development Objectives (PDO) and Key Indicators (as approved) ___________________ 12 1.5 Original Components ____________________________________________________________________ 13 1.6 Revised Components _____________________________________________________________________ 14 1.7 Other significant changes _________________________________________________________________ 15 2. Key Factors Affecting Implementation and Outcomes___________________________________________ 15 2.1 Project Preparation, Design and Quality at Entry ______________________________________________ 15 2.2 Implementation _________________________________________________________________________ 16 2.3 Monitoring and Evaluation Design, Implementation and Utilization ________________________________ 19 2.4 Safeguard and Fiduciary Compliance _______________________________________________________ 21 2.5 Post-completion Operation/Next Phase ______________________________________________________ 23 3.1 Relevance of Objectives, Design and Implementation ___________________________________________ 24 3.2 Achievement of Project Development Objectives _______________________________________________ 25 3.3 Efficiency ______________________________________________________________________________ 30 3.4 Justification of Overall Outcome Rating ______________________________________________________ 31 3.5 Overarching Themes, Other Outcomes and Impacts_____________________________________________ 31 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops __________________________ 34 4. Assessment of Risk to Development Outcome __________________________________________________ 34 5. Assessment of Bank and Borrower Performance _______________________________________________ 35 5.1 Bank Performance_______________________________________________________________________ 35 (a) Bank Performance in Ensuring Quality at Entry _________________________________________________ 35 5.2 Borrower Performance ___________________________________________________________________ 37 6. Lessons Learned __________________________________________________________________________ 38 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners _________________________ 39 Annex 1: Project Costs and Financing_____________________________________________________________ 41 Annex 3: Economic and Financial Analysis ________________________________________________________ 45 Annex 4: Bank Lending and Implementation Support/Supervision Processes ____________________________ 52 Annex 5: Beneficiary Survey Results _____________________________________________________________ 54 Annex 6: Stakeholder Workshop Report and Results ________________________________________________ 55 Annex 7: Summary of Borrower's ICR and/or Comments on Draft ICR ________________________________ 56 Annex 8: Comments of Co-financing partners and Other Partners/Stakeholders _________________________ 61 Annex 9: List of Supporting Documents ___________________________________________________________ 62 MAP A. Basic Information Country: Chad Project Name: Second Population and AIDS Project P072226 (Orig.) IDA 35480 (Orig.) Project ID: L/C/TF Number: P105724 (AF) IDA H5980 (AF) ICR Date: December 30, 2013 ICR Type: Core ICR Lending Instrument: SIL Borrower: Government of Chad Original Total Original: 19.6 million) Disbursed Original: 19.58 million Commitment (XDR) Additional: 13.3 million Amount (XFR): Additional: 13.14 million Environmental Category: B Implementing Agency: Co-financiers and Other External Partners: N/A B. Key Dates Process Date Process Original Date Revised / Actual Date(s) Concept Review: Dec. 20, 2000 Effectiveness: Original: Dec. 11, 2001 Apr. 11, 2002 Additional financing: Oct. 27, 2010 Appraisal: Apr. 16, 2001 Restructuring: February 2008 1 August 25, 2010 Approval: July 12, 2001 Mid-term Review: June 1, 2004 Nov. 25, 2005 Closing: Original: Sept. 30, 2006 July 31, 2008 Additional financing: June 30, 2012 June 30, 2013 C. Ratings Summary C.1 Performance Rating by ICR Outcomes: Moderately Unsatisfactory Risk to Development Outcome: Substantial Bank Performance: Moderately Unsatisfactory Borrower Performance: Moderately Unsatisfactory C.2 Detailed Ratings of Bank and Borrower Performance (by ICR) Bank Ratings Borrower Ratings Quality at Entry: Moderately Unsatisfactory Government: Moderately Unsatisfactory Quality of Supervision: Moderately Satisfactory Implementing Agency Moderately Satisfactory Overall Bank Moderately Overall Borrower Moderately Unsatisfactory Performance: Unsatisfactory Performance: 1 The proposed Additional Financing for the Chad Second Population and HIV/AIDS project was formally negotiated on December 11, 2007, and scheduled for presentation to the Board in February 2008. While the project package was delivered to SECBO in December 2007, it was subsequently pulled from Board consideration due to conflict in Chad. C.3 Quality at Entry and Implementation Performance Indicators Implementation Performance Indicators QAG Assessments (if any) Rating Potential Problem Project at any time (Yes/No): Yes Quality at Entry (QEA): n/a Problem Project at any time (Yes/No): Yes Quality of Supervision n/a Assessment (QALP): DO rating before Closing/Inactive status: MS D. Sector and Theme Codes Original Actual (AF) Sector Code (as % of total Bank financing) Central government administration 15% 20% Health 67% 60% Other social services 18% 20% Theme Code (as % of total Bank financing) HIV/AIDS 25% 22% Population and reproductive health 25% 22% Participation and civic engagement 24% 22% Child health 13% Gender 13% 11% Other communicable diseases 23% E. Bank Staff Positions At ICR At Approval Vice President: Makhtar Diop Callisto Madavo Country Director: Ousmane Diagana Robert Calderisi Sector Manager: Trina Haque Alexander Abrantes Project Team Leader: Aissatou Diack Michèle L. Lioy ICR Team Leader: Aissatou Diack ICR Primary Author: Peter Bachrach F. Results Framework Analysis Project Development Objectives The development objective of the project will be to contribute to changing the behavior of the Chadian populations so that they will adopt behaviors which will reduce the risk: (i) of infection from HIV; and (ii) of too closely spaced and/or unwanted pregnancies Revised Project Development Objectives (as approved by original approving authority) The PDO was not revised. (a) PDO Indicator(s) Original credit 2 Original Target Actual Value Achieved at Values (from Formally Revised Indicator Baseline Value Completion or Target approval Target Values Years documents) Indicator 1: By the end of the project, 95% of all men and 90% of all women aged 15-49 years are aware of HIV/AIDS. Value (Quantitative Men: 88% Men: 95% Revised Men: 90% or Qualitative) Women: 60% Women: 90% (see Indicator 7) Women: 80% Date achieved 1996-97: DHS 2010: AF, Annex 3 2004-05: DHS Comments (incl. % Partially achieved. Awareness among men increased by only 2% from 1997 to 2005, but the achievement) target was achieved at 95%; awareness among women increased by 20% between 1997 and 2005 but the target was achieved at 89%. Indicator 2: By the end of the project, 50% of young people aged 15-24 will have used a condom at last non- union sexual contact which took place in the last 12 months. Value (Quantitative Men: 8.1% Men: 50% Revised Men: 25.4% or Qualitative) Women: 5.8% Women: 50% (See Indicator 8) Women: 17.2% Date achieved 2001: IPP 2010: AF, Annex 3 2004-05: DHS Comments (incl. % Not achieved. Though significant progress was made, the targets were not achieved either for men achievement) (51% of the target was achieved) or for women (34% of the target was achieved). Indicator 3: By the end of the project, 75% of military personnel will have used a condom at last non-union sexual contact which took place in the last 12 months. Value (Quantitative 15% 75% Dropped 67.6% or Qualitative) Date achieved Not known 2010: AF, Annex 3 2006: Bank AM (June 2009) Comments (incl. % Partially achieved. A significant increase was realized, and the target was achieved at 90%. achievement) Indicator 4: By the end of project, prevalence of HIV among pregnant women aged 15-24 will be reduced by 25 % Value (Quantitative 7.0% 5.25% Dropped 3.90% or Qualitative) Date achieved 2000: Sentinel data 2006: Sentinel data Comments (incl. % Achieved. Based on sentinel site data, HIV prevalence was reduced by more than 25%. achievement) Indicator 5 : By the end of the project, women in union using modern contraceptive methods will have increased to 10% in urban areas and to 3% for rural areas. Value (Quantitative Urban: 4.2% Urban: 10.0% Revised Urban: 7.1% or Qualitative) Rural: 0.3% Rural: 3.0% (See Indicator 9) Rural: 0.4% Date achieved 1996-97: DHS 2010: AF, Annex 3 2004-05: DHS Comments (incl. % Not achieved. While some progress was made in urban areas (71% of the target was achieved), achievement) there was virtually no change in rural areas (13% of the target was achieved). Indicator 6: By the end of the project, 60% of women 15-49 in union will wish to space their next birth by at least 2 years. Value (Quantitative 39% 60% Dropped 38% 2 The PDO indicators are taken from the PAD text (p. 3-4) rather than Annex 1. While identical in substance, they are more clearly stated in the PAD text. or Qualitative) Date achieved 2000: M&E report 2010: AF, Annex 3 2004: M&E report Comments (incl. % Not achieved. Based on project data, the target remained unchanged from the baseline indicator. achievement) Additional financing 3 Original Target Actual Value Achieved at Formally Revised Indicator Baseline Value Values (from Completion or Target Target Values approval documents) Years Indicator 7: By the end of the project, 70% and 50% respectively of men and women aged 15 to 24 will both correctly identify ways of preventing the sexual transition of HIV and reject major misconceptions about HIV (% by gender). Value (Quantitative Men: 31.4% Men: 70% Men: 55.5% or Qualitative) Women: 24.3% ) Women: 50% Women: 57.8% Date achieved 2012: Baseline 2013: Final evaluation Comments (incl. % Results for Indicator 7 relied on a survey conducted in the project area in mid-2012 (baseline) and achievement) in May 2013 (follow-up evaluation). The ICR team reports the result above but was unable to verify the information independently. Indicator 8: By the end of the project, 65% of men and 35% of women (aged 15-24) will have used a condom during their last act of sexual intercourse with a non-regular partner in the last 12 months Value (Quantitative Men: 16.0% Men: 65% Men: 18.6% or Qualitative) Women: 11.5% Women: 35% Women: 11.0% Date achieved 2012: Baseline 2013: Final evaluation Comments (incl. % Results for Indicator 8 relied on a survey conducted in the project area in mid-2012 (baseline) achievement) and in May 2013 (follow-up evaluation). The ICR team reports the result above but was unable to verify the information independently. Indicator 9: By the end of the project, women using modern contraceptive methods will have increased to 10% in urban areas and to 3% in rural areas for the project intervention areas Value (Quantitative Urban: 10.3% Urban: 10.0 Urban: 45.0% or Qualitative) Rural: 7.4% Rural: 3.0% Rural: 26.5% Date achieved 2012: Baseline 2013: Final evaluation Comments (incl. % Results for Indicator 9 relied on a survey conducted in the project area in mid-2012 (baseline) achievement) and in May 2013 (follow-up evaluation). The ICR team reports the result above but was unable to verify the information independently. 3 The ICR team reports the results for Indicators 7-9 above (and in a more extensive comparison in the Borrower’s ICR in Annex 7) but was unable to verify the information independently. (b) Intermediate Outcome Indicator(s) Original credit 4 Component 1: Original Target Actual Value Achieved at Formally Revised Indicator Baseline Value Values (from Completion or Target Target Values approval documents) Years Indicator 1 : The National AIDS/STD Control Program fully functional, i.e., its six units are functional, and implementing the National Strategic HIV/AIDS Prevention Plan at the end of 2002. Value (Quantitative 0 6 Dropped 2 or Qualitative) Date achieved 2002: M&E report 2010: AF, Annex 3 2006: M&E report Comments (incl. % Not achieved. achievement) Indicator 2 : Annually, six selected key-ministries develop annually an action plan including prevention and care priority activities and report on the activities they have carried out during the previous year. Value (Quantitative 6 6 Dropped 6 or Qualitative) Date achieved 2002: M&E report 2010: AF, Annex 3 2006: M&E report Comments (incl. % Achieved. achievement) Indicator 3 : Annually, 14 Regional Health Councils develop an action plan including the prevention and care priority activities to be carried out to support PLWHAs and their families and report on the activities they have carried out during the previous year. Value (Quantitative 0 14 (18 after 2006) Dropped 0 or Qualitative) Date achieved 2002: M&E report 2010: AF, Annex 3 2006: M&E report Comments (incl. % Not achieved. achievement) Component 2: Component 3: Original Target Actual Value Achieved at Formally Revised Indicator Baseline Value Values (from Completion or Target Target Values approval documents) Years Indicator 4 : Set up the social marketing program for oral contraceptives by the end of the first 2004 quarter. Value (Quantitative No Yes No or Qualitative) Date achieved 2002: M&E report 2006: M&E report Comments (incl. % Not achieved. achievement) Indicator 5: Set up the social marketing program for impregnated bed nets in the five southern prefectures where malaria is very prevalent by the beginning of 2002 Value (Quantitative No Yes Yes or Qualitative) Date achieved 2002: M&E report 2004: M&E report 4 The intermediate objective indicators are taken from the PAD text (p. 3-4) and not from Annex 1. While identical in substance, they are more clearly stated in the PAD text. Comments (incl. % Achieved. The program was established late but had marketed almost 40,000 nets during the achievement) period 2004-07. In 2006, more than 90% of the nets were distributed in N’Djamena. Component 4: Original Target Actual Value Achieved at Formally Revised Indicator Baseline Value Values (from Completion or Target Target Values approval documents) Years Indicator 6: Annually, 14 Regional Population Commissions develop an action plan including the prevention and care priority activities related to increasing knowledge and underlining the need for behavior change in the areas of reproductive health and HIV/AIDS and report on the activities they have carried out during the previous year Value (Quantitative 0 14 Dropped 18 or Qualitative) Date achieved 2002: M&E report 2010: AF, Annex 3 2006: M&E report Comments (incl. % Achieved. Administrative reorganization increased the number of regions resulting in an achievement) increased number of Population Commissions. Additional financing Component 1: Original Target Actual Value Achieved at Formally Revised Indicator Baseline Value Values (from Completion or Target Target Values approval documents) Years Persons aged 15-49 who received counseling and testing for HIV and received their test results Indicator 7: (by gender) Value (Quantitative Nd 88,189 160,227 or Qualitative) Date achieved Project Paper 2012: Project data Comments (incl. % Achieved. Data by gender are not available, but the average number of persons counseled and achievement) tested over the period 2010-12 was 136,891 (or 155% of the target). Indicator 8: Military personnel tested for HIV Value (Quantitative 2,517 6,400 7,915 or Qualitative) Date achieved 2007: Project Paper 2012: Project data Comments (incl. % Achieved. The number of military personnel tested increased from 2,414 in 2010 to 7,915 in achievement) 2012 (or 124% of the target). Indicator 9: Pregnant women tested for HIV during prenatal consultations Value (Quantitative 16,096 28,038 27,671 or Qualitative) Date achieved Project data 2012: Project data Comments (incl. % Achieved. The average number of pregnant women tested for HIV during prenatal consultations achievement) over the period 2010-12 was 27,671 (or 99% of the target). Component 2: Original Target Actual Value Achieved at Formally Revised Indicator Baseline Value Values (from Completion or Target Target Values approval documents) Years Indicator 10: Condoms distributed (number) Value (Quantitative 4.1 million 5.05 million 4.5 million or Qualitative) Date achieved 2009: Project data 2012: Project data Partially achieved. Results from 2012 are 89% of the target; the average number of condoms Comments (incl. % distributed over the period 2010-12 was 4.0 million but the annual results improved over the achievement) period from 3.4 million (2010) to 4.1 million (2011) to 4.5 million (2012). Orphaned and vulnerable children aged 0-17 whose households received free basic external Indicator 11: support in caring for the child (number) Value (Quantitative 6,872 8,872 9,102 or Qualitative) Date achieved 2008: FOSAP data 2012: Project data Comments (incl. % Achieved. Results from 2012 are 103% of the target. achievement) Indicator 12: Women of child-bearing age reached by CBO interventions Value (Quantitative 29,089 393,600 410,538 or Qualitative) Date achieved 2005: FOSAP data 2012: Project data Comments (incl. % Achieved. The results from 2012 are 104% of the target. achievement) Component 3 (RBF Approach): Original Target Actual Value Achieved at Formally Revised Indicator Baseline Value Values (from Completion or Target Target Values approval documents) Years Indicator 13: Children immunized (DTC 3)(cumulative) Value (Quantitative 34,420 46,732 Declared: 62,194 or Qualitative) Validated: 51,339 Date achieved 2010: HMIS 2013: FBR evaluation, p20. Comments (incl. % Achieved. The cumulative, validated results over the period 2011-March 2013 are 110% of the achievement) target. Indicator 14: Pregnant women receiving antenatal care during a visit to a health provider (CPN 3) (cumulative) Value (Quantitative 27,817 45,912 Declared: 31,438 or Qualitative) Validated: 24,113 Date achieved 2010: HMIS 2013: FBR evaluation, p20. Comments (incl. % Not achieved. The cumulative, validated results over the period 2011-March 2013 are 53% of the achievement) target. Indicator 15: Assisted deliveries in public and private health centers (cumulative) Value (Quantitative 11,086 16,807 Declared: 17,853 or Qualitative) Validated: 17,031 Date achieved 2010: HMIS 2013: FBR evaluation, p20. Comments (incl. % Achieved. The cumulative, validated results over the period 2011-March 2013 are 101% of the achievement) target. Indicator 16: Pregnant women vaccinated (VAT 2)(cumulative) Value (Quantitative 34,726 45,912 Declared: 44,651 or Qualitative) Validated: 37,387 Date achieved 2010: HMIS 2013: FBR evaluation, p20. Comments (incl. % Partially achieved. The cumulative, validated results over the period 2011-March 2013 are 81% achievement) of the target. Indicator 17: Women attending post natal care consultations during a visit to a health provider (cumulative) Value (Quantitative 34,726 45,912 Nd or Qualitative) Date achieved 2010: HMIS Comments (incl. % Not measured. No data are available in the FBR reports. achievement) Component 4 (Integrated Approach): Original Target Actual Value Achieved at Formally Revised Indicator Baseline Value Values (from Completion or Target Target Values approval documents) Years Indicator 18: Children immunized (DTC 3)(cumulative) Value (Quantitative 59,367 71,620 116,522 or Qualitative) Date achieved 2010: HMIS 2013: Project data Comments (incl. % Achieved. The cumulative results over the period 2011-13 were 163% of the target. achievement) Indicator 19: Pregnant women receiving antenatal care during a visit to a health provider (CPN1 / New consultations)(cumulative) Value (Quantitative 50,928 70,094 131,583 or Qualitative) Date achieved 2010: HMIS 2013: Project data Comments (incl. % Achieved. The cumulative results over the period 2011-13 were 188% of the target. achievement) Indicator 20: Assisted deliveries in public and private health centers (cumulative) Value (Quantitative 16,321 25,659 27,638 or Qualitative) Date achieved 2010: HMIS 2013: Project data Comments (incl. % Achieved. The cumulative results over the period 2011-13 were 108% of the target. achievement) Indicator 21: Pregnant women vaccinated (VAT 2)(cumulative) Value (Quantitative 51,305 70,094 111,361 or Qualitative) Date achieved 2010: HMIS 2013: Project data Comments (incl. % Achieved. The cumulative results over the period 2011-13 were 159% of the target. achievement) Indicator 22 : Women attending post natal care consultations during a visit to a health provider (cumulative) Value (Quantitative 3,389 7,698 36,944 or Qualitative) Date achieved 2010: HMIS 2013: Project data Comments (incl. % Achieved. The cumulative results over the period 2011-13 were 480% of the target. achievement) G. Ratings of Project Performance in ISRs Date ISR Actual Disbursements No. DO IP Archived (USD millions) 1 26-Nov-01 S S 0.00 2 19-Dec-01 S S 0.00 3 30-May-02 S S 0.79 4 17-December - 02 S S 1.79 5 19 June 2003 S S 3.75 6 22 December 03 S S 7.99 7 23 June 2004 S S 10.60 8 16 December 2004 S S 13.56 9 31 May 2005 S S 17.31 10 22 December 2005 MS S 22.66 11 31 May 2006 U U 23.11 12 21 August 2006 MS MS 25.24 13 22 May 2007 MS S 27.26 14 19 December 2007 S S 28.48 15 25 June 2008 S S 28.49 16 10 January 2011 S S 32.18 17 12 October 2011 S S 37.97 18 25 April 2012 S S 40.34 19 11 December 2012 S S 42.58 20 5 June 2013 MS S 47.84 H. Restructuring Board ISR Ratings at Amount Restructuring Approved Restructuring Disbursed at Reason for Restructuring & Key Changes Date(s) PDO Restructuring in Made Change DO IP USD millions Conformity with 2010-12 Bank Interim Strategy Continuing high rates of HIV prevalence Poor reproductive and child health outcomes but 6/24/10 No S S 28.49 demonstrated measures for improving them (integrated decentralized response and RBF) Limited external support I. Disbursement Profile 1. Project Context, Development Objectives and Design 1.1 Context at Appraisal 1. Country context. Chad ranked among Africa’s least developed countries in 2000. The World Bank estimated per capita GDP at US$200, the UN Human Development Indicator ranked Chad 167th out of 174 countries, and the Human Poverty Index (HPI) was 57 percent. Health and nutrition indicators were precarious with life expectancy estimated at 47 years, the infant-child mortality rate at 222 per 1,000 and the maternal mortality rate at 827 per 100,000 births. 5 2. The 1999 CAS identified diverse sources for this extreme level of poverty: geographical characteristics; political instability; inadequate economic policies; and rapid population growth. These factors had sharply curtailed economic growth and left the country with little physical infrastructure, poor provision of social services, and weak institutions. 3. Population and HIV/AIDS. From 1990, Government policies and strategies recognized the implications of population growth and HIV/AIDS for the country’s future economic and social well-being: 4. Population. Chad adopted a National Population Policy (NPP) in 1994. Subsequently, the country began to: (i) develop IEC and sensitization (particularly among political, religious, and trade union leaders); (ii) expand reproductive health (RH) services; and (iii) initiate a condom social marketing program to reach specific target groups (e.g., men, teenagers, and single women). These efforts were accompanied by the creation of the Association Tchadienne de Bien-Etre Familial (ASTBEF), an affiliate of the International Planned Parenthood Federation (IPPF). 5. The implementation of the NPP was challenged by widespread attitudes opposing the notion of promoting family size 6 as well as the influence of religious leaders taking a position against the use of modern contraceptives. The 1996-97 demographic and health survey (DHS) estimated the total fertility rate (TFR) at 6.6 live births, demographic growth at 3.3 percent, modern contraceptive use at 4.1 percent in urban areas and 0.3 percent in rural areas. 6. HIV/AIDS. After 1995, the HIV/AIDS epidemic evolved towards a generalized epidemic: (i) prevalence among pregnant women rapidly increased from 2 percent in 1995 to 6 percent in 1999 in N'Djamena; and (ii) overall prevalence was estimated by UNAIDS to be 3 percent in 1999 and between 5-12 percent in subsequent years. As of early 2000, the cumulative number of AIDS cases was 11,681 with about 200,000 sero-positive persons. There was also concern about future infections, particularly in the south around the oil exploration sites. By 2000, HIV/AIDS was already having a significant impact on the health system in general and on 5 WHO, UNICEF and UNFPA data at the time estimated the maternal mortality rate between 1,000 and 1,500 per 100,000 inhabitants, which was later confirmed by the 2004 DHS. 6 Due in large measure to: (i) high levels of poverty inciting couples to have many children as a means of supplementing family income and providing social security in their old age; (ii) high infant and child mortality prompting women to compensate for the loss of children; and (iii) civil conflict. See World Bank, PACP1-PPAR, p. 2. households in particular. 7. Despite difficult circumstances (insufficient human resources, inadequate infrastructure, etc.) and highly unfavorable conditions among communities, Chad made progress in the fight against HIV/AIDS: (i) a strategic plan for 1999-2003 was adopted and accompanied by high level appeals for action; (ii) voluntary testing and counseling was introduced in 1999 (but essentially limited to N’Djamena); (iii) piloting of Prevention of Mother to Child Transmission (PMTCT) strategies and case management of Opportunistic Infections (OI) began; and (iv) blood transfusion capabilities were strengthened. 8. Country Assistance Strategy and Rationale for Bank Involvement. With two existing projects, the first Population and AIDS Control Project (PACP1) and the Safe Motherhood Project, the Bank was very active in the health sector in Chad in the late 1990’s. The 1999 CAS identified the "Demographic Challenge" as a priority. In 2000, the Government urged IDA to make the fight against HIV/AIDS a key development objective in the Bank's country assistance strategy, and an addendum to the CAS identified the need to prevent the epidemic from spiraling out of control as in neighboring countries. This addendum also indicated that a follow-on multi- sectoral HIV/AIDS project was planned. Simultaneously, a Health Sector Support Project was approved in April 2000. 9. In support of the National Poverty Reduction Strategy and the Highly Indebted Poor Country (HIPC), the proposed project was considered a key operation since it addressed both human development and socio-economic challenges. Furthermore, the Bank’s previous support to Chad (through PACP1 and other operations), the positive effect of Bank assistance on HIV/AIDS and population awareness, and the lack of sufficient resources (from Government and other sources) put IDA in a unique strategic position to finance the scaling-up of activities and to contribute to the mobilization of additional funding. 1.2 Original Project Development Objectives (PDO) and Key Indicators (as approved) 10. The development objective of the second Population and AIDS Control Project (PACP2) was “to contribute to changing the behavior of the Chadian populations so that they will adopt behaviors which will reduce the risk: (i) of infection from the HIV; and (ii) of too closely spaced and/or unwanted pregnancies.” 7 This PDO complemented the companion Health Sector Support Project’s PDO, which was “to support the extension of basic quality health services in Chad through the implementation of a National Health Policy as defined by the Ministry of Public Health (MOH) and a specific objective of addressing health-related HIV/AIDS activities. 1.3 Revised PDO (as approved by original approving authority) and Key Indicators, and reasons/ justification 11. The PDO was not revised. During the mid-term review (December 2005), project activities were reoriented without a change in the PDO or the key indicators. A formal restructuring in 2010 for the additional financing (AF) modified the project’s components in 7 The objectives of PACP1 were similar: to advance the onset of fertility decline by increasing the use of modern methods of contraception, and slow the spread of HIV infection by promoting behavioral change. order to: (i) introduce the new Results Based Financing (RBF) approach; and (ii) better reflect the integrated and decentralized approach to maternal and child health and the fight against HIV/AIDS. Project indicators were also modified to reflect the current international thinking in HIV/AIDS, be in line with UNGASS indicators, integrate the lessons learned during implementation, and define more precisely the expected outcomes of the original project. 1.4 Main Beneficiaries and Benefits 12. The HIV/AIDS component of the project was intended to benefit: (i) women and youths generally; (ii) key ministries (Health, Education, Social Affairs, Communication, etc.); (iii) groups at increased risk of HIV infection including: commercial sex workers (CSWs), long- distance drivers, members of the defense forces and others in uniform, prisoners and prison guards; and (iv) workers in key sectors of the economy such as agriculture, power and energy, and construction. The population component of the project was intended to benefit mothers and children through birth spacing, the use of chemo-prophylaxis for sero-positive pregnant women, and bednets. 13. Project benefits included: (i) a reduced number of new HIV/AIDS cases and deaths; (ii) better care for people living with HIV/AIDS; (iii) an improved community response to the epidemic and particularly the ability of households and individuals to prevent or cope with HIV/AIDS (particularly among orphans in urban areas); and (iv) changes attitudes towards family size combined with increased accessibility to modern contraceptives and condoms. 1.5 Original Components 14. Component 1: Strengthening the Capacities of the Key Ministries (US$6.57 million). To strengthen the capacity of those ministries most likely to have an impact on the evolution of the HIV/AIDS epidemic, the project focused on six ministries (Communication, Justice, National Defense and Reinsertion, Interior, National Education, and Social Action and Family) to develop and implement HIV/AIDS prevention, care and support strategies adapted to the local conditions. The component was expected to improve capacity for program coordination, resource management, and implementation at all levels by supporting: (i) the Ministry of Health (MOH) to complement the support provided to HIV/AIDS prevention and care by the HSSP; and (ii) HIV/AIDS units established in key ministries and their activities at central and regional levels. 15. Component 2: Strengthening of the Social Fund (FOSAP) and its two-sub- components (Grants and Micro-credits) (US$8.87 million). The component was expected to continue and expand support for: (i) grants to local non-governmental organizations (NGO) for HIV/AIDS prevention and population activities; (ii) micro-credits for income generating activities for women and women's associations; and (iii) supervision of these groups by NGOs with strong proven capacities. Under this component, HIV/AIDS activities were considered either as essential are as secondary: • Essential activities targeting priority vulnerable groups included: (i) information, education, and communication (IEC) for behavior change in the areas of population, reproductive health (RH), and HIV/AIDS prevention and care; (ii) promotion and accessibility of voluntary HIV testing and counseling for the general population, for prevention of mother to child transmission of HIV; and for at risk and/or vulnerable groups; (iii) psycho-medico-social support for persons living with HIV/AIDS (PLWHA) as well as economic support for HIV/AIDS infected and affected persons and comprehensive support and care for HIV/AIDS orphans; (iv) interventions to increase the status and the autonomy of women (e.g., income generating activities); and (v) promotion and distribution of condoms and other modern contraceptive methods. • Secondary activities comprised: (i) advocacy for HIV/AIDS and population interventions; (ii) development of national guidelines to implement essential activities; (iii) training and capacity building for local NGOs and Community-Based Organizations (CBO); and (iv) social mobilization of traditional leaders. 16. Population activities were expected to focus on linkages between reproductive health interventions and the spread of the HIV/AIDS epidemic, specifically: (i) IEC and behavior change messages; (ii) promotion and distribution of condoms to supplement the social marketing channels (e.g., in health centers, within the communities, and to persons in uniform); and (iii) adolescent needs to address early pregnancies and the transmission of HIV/AIDS among this vulnerable population. Interventions pertaining to screening and treatment of sexually transmitted infections (STI) were to be complemented by the IDA-financed HSSP. 17. Component 3: Support to the Social Marketing Program (MASOCOT) (US$4.03 million). Established under the initial project (with support from the Bank and KfW), MASOCOT developed a social marketing program for condoms (and for oral rehydration salts). This component was expected to provide support to MASOCOT for: (i) its transition to an autonomous NGO (AMASOT); (ii) the ongoing marketing of condoms and rehydration salts; and (iii) the addition of new products (e.g., oral contraceptives, impregnated bed nets, etc.). 18. Component 4: Support for the implementation of the National Population Policy (NPP) (US$3.45 million). This component was expected to continue support to Government entities dealing with population issues, in particular the Ministry of Economic Promotion and Development and its Population Division. Project support to the Division of Population was intended to: (i) strengthen its managerial capabilities, especially its strategic planning capabilities and management of decentralized programs, in order to prioritize the population activities; (ii) mainstream IEC and behavioral change communication (BCC) interventions using existing structures such as local and regional radios stations, public and private written press, prefectoral population commissions, etc.; and (iii) carry out, disseminate and promote results of operational research in the area of population, in collaboration with other specialized organizations 19. Component 5: Project management (US$1.64 million). To coordinate and manage the project, the project was expected to finance new personnel, vehicles, training and consultant services (in particular for the financial audits) for the Project Coordination Team (PCT). In particular, a Population Specialist was to be recruited for 24 months to assist in the implementation of the National Population Policy Component. 1.6 Revised Components 20. While the project’s components were maintained throughout the original and AF, there were two important changes. First, after the 2005 mid-term review (MTR), Component 2 was substantially modified by: (i) introducing two mobile teams covering 40 sites in two regions in order to improve access to quality health services promote RH interventions and family planning; and (ii) revising the micro-credit approach (which was subsequently eliminated in 2007). Second, after the 2010 AF, the project’s components were modified by: (i) reducing the number of assisted ministries under Component 1 to receive financing to only 3 key ministries, namely Education, Health, and Defense/Security and increasing financing to MOH; (ii) replacing the support for social marketing under Component 3 (funded by KfW and the Global Fund) with activities addressing results-based financing (RBF); (iii) reorienting the activities of Components 2 and 4 to support mobile teams and the implementation of the decentralized and integrated approach adopted in 2005 and tested during the period 2007-09; and (iv) expanding Component 5 to strengthen monitoring and evaluation (M&E) efforts as well as medical waste management. 1.7 Other significant changes 21. A series of amendments to the financing agreement were approved in order to restructure, provide AF, reallocate funds and extend the project closing date. 2. Key Factors Affecting Implementation and Outcomes 2.1 Project Preparation, Design and Quality at Entry 22. Soundness of the background analysis. Four major sources of information informed the preparation of the project and provided a sound basis for project preparation: (i) the sectoral analyses carried out in the context of the preparation the HSSP emphasized the poor quality of health human resources and the inability of basic health services to improve maternal and child health services; (ii) the HIV/AIDS strategic plan 1999-2003 (amended in 2001 to provide for access to ARVs and to delegate specific operational tasks to selected regional decentralize) provided the socio-economic context and institutional structure for the national response as well as proposed priority actions in some eighteen different areas (including behavior change, VCT, PMTCT, blood safety, etc.); (iii) the assessment of progress achieved in implementing the 1994 NPP, particularly in view of the results of the 1996-97 DHS which confirmed the country’s accelerating demographic growth; and (iv) the experience of the first project 8, which highlighted the country’s decision to use a multi-sectoral and civil society response, focus on HIV/AIDS prevention and population (using a social fund to finance NGOs and community level activities) and innovative condom social marketing program and micro-credit sub-components for women and women's association. 23. In addition, a PHRD grant was approved in March 2001 to prepare viable work plans for key ministries involved in HIV/AIDS prevention and care activities and assess the contribution of on-going micro-credit activities and modalities for strengthening and decentralizing the grant sub-component of the social fund (FOSAP). Support was also provided to establish sound monitoring and evaluation systems and management mechanisms. 24. Government’s commitment. Commitment to reverse the spread of the epidemic was reflected by the Government’s early decision to finance PACP1 and by urging IDA to make HIV/AIDS a key development objective in the Bank's CAS of May 2000. Government 8 The lessons learned in the ICR for PACP1 were only available in June 2002 after the approval of the project. commitment was further reinforced by: (i) its recognition of the linkages between HIV/AIDS and health services development; (ii) its development of a comprehensive National Strategic Framework for HIV/AIDS activities (1999-2003); and (iii) its intention to use anticipated oil revenues as the means for reducing poverty and improving the living conditions of the Chadian population. This commitment was explicitly presented in the June 2001 Letter of Sector Policy. Government commitment to address demographic growth through the implementation of the NPP was less clear as reflected in its lack of support for the high level body it created and action on the priority action investment plan (PAIP) that was to translate the NPP into more concrete interventions. 25. Assessment of project design. Given the establishment under PACP1 of the key institutions and the widespread awareness of HIV/AIDS and its means of transmission, PACP2 was designed in accordance with the Bank's regional HIV/AIDS strategy9 as a second generation HIV/AIDS project and was expected to intensify action to motivate Chadians to change their behavior. As with PACP1, PACP2 comprised three "MAP-like" components (sectoral responses, community interventions, and social marketing) but did not include the full range of health- related activities as they were included in the ongoing HSSP. The project was not financed by the MAP because of the population component, which was especially requested by the Chadian Government in view of the high fertility rate and the appropriateness of building on the results of the first project. The project also included a management component to support the PCT’s role of coordinating the various partners and acting as the relay between the Government of Chad and the Bank. 26. In most respects, the project design was very thorough: (i) institutional arrangements were clearly established for all the components, except for the population component; (ii) project implementation arrangements were defined in manuals and based on previous experience; (iii) the PCT’s management responsibilities were made explicit and their capabilities strengthened; and (iv) a two-year procurement plan was prepared to ensure project readiness. However, there were some weaknesses: (i) lack of baseline data; (ii) very ambitious targets for project indicators; and (iii) optimistic assessment of the Government’s commitment to the project, particularly with respect to the population component. Also, some ministries and many districts had insufficient experience with multi-sectoral initiatives and limited experience in HIV/AIDS control at the start of the project. 27. Risk assessment and mitigation. The overall risk rating was Moderate, but the assessment did not identify certain key risk factors: (i) potential political and financial risks (counterpart funding); (ii) institutional concerns with respect to the population component; and (iii) monitoring and evaluation concerns. The proposed risk mitigation measures were somewhat generic. 28. Quality at Entry. No Quality at Entry Assessment was carried out. 2.2 Implementation 29. Because of concerns about a potential gap in funding between PACP1 and PACP2, 9 Intensifying Action against HIV/AIDS in Africa: Responding to a Development Crisis. PACP2 was approved quickly, but with three conditions of effectiveness. 10 The time needed to meet these conditions delayed project effectiveness until April 2002. Disbursements were somewhat slower than planned over the first couple of years due to protracted procurement processes. The resulting disbursement lag was mostly eliminated by 2004, though inadequate counterpart financing (from effectiveness through mid-2005) posed significant problems for paying suppliers. 30. Despite these difficulties, reasonable progress was achieved during the 2002-2003 period: (i) the capacity of key ministries was strengthened; (ii) testing was expanded; and (iii) FOSAP had adopted appropriate procedures, recruited CBOs, and begun approving sub-projects and micro-credits for implementation. By the end of 2004, 701 sub-projects had been approved (instead of the 83 envisioned) accounting for 56 percent of the total project budget; the Social Marketing Program (AMASOT) increased sales for condoms (supported as well by KfW), oral rehydration salts, and mosquito nets and was considering new products (e.g., oral contraceptives); and the Population Division became the Population Directorate, produced several key analyses (analysis of the implementation of the National Population Policy, population projections for Chad through 2050, etc.), and provided support to the 18 Regional Population Commissions. 31. Beginning in late 2003 and continuing through 2005, problems became apparent: (i) the Central Pharmaceutical Procurement Agency (CPPA) was unable to supply sufficient quantities of STI treatment kits and reagents for HIV/AIDS thus affecting the quality of STI/HIV/AIDS treatment 11; (ii) the lack of coordination between the National AIDS Council and the National HIV/AIDS Program; (iii) the Global Fund’s selection of FOSAP as the Country Coordination Mechanism (CCM) raised the risk of overburdening the institution with additional responsibilities 12; and (iv) the remaining project components (involving condom sales, micro- credits, and population) were not performing adequately (with condom sales declining, reimbursement problems with the micro-credits, and insufficient progress on the population component’s activities). The Bank succeeded in resolving some of these issues by: (i) promoting institutional changes and a refinancing of the CPPA by the Government; (ii) financing a technical audit of the institutions involved in the fight against HIV/AIDS; and (iii) working with FOSAP and the Global Fund to define FOSAP’s responsibilities with respect to PACP2 and the Global Fund. Recommendations for strengthening condom distribution, micro-credit reimbursements, and population activities were not followed. 32. By the MTR, with the exception of the public sector support component, substantial changes were needed for the other components since (i) there were weaknesses in FOSAP’s 10 Conditions of effectiveness: (i) adoption of three implementation manuals (for the project as a whole and for the FOSAP grant and micro-credit procedures); (ii) recruitment of an acceptable PCT and FOSAP management unit; (iii) establishment of a project steering committee; and (iv) adoption of an action plan for implementing the population policy. 11 The project did not finance ARV, but CPPA was responsible for managing them. 12 This became a significant issue in 2006 and was resolved by separating management of the two activities. community grants related to the selection and administration of the sub-projects, performance of the NGOs providing TA to the CBOs and lack of information on sub-project quality and impact on their intended populations; (ii) the micro-credits faced significant problems with the reimbursement rates 13; and (iii) AMASOT experienced cash flow problems with the project and its suppliers and therefore was asked to focus on contraceptives and mosquito nets (and particularly promotional campaigns), solve its supply problems (with the assistance of its partner KFW), and improve collaboration with the priority ministries and FOSAP. In addition, the 2004 Demographic and Health Survey showed little impact in terms of fertility rate and there was limited progress on policy issues (e.g., continued blockage of the Family Code, High Population Commission’s failure to adopt the revised NPP). To strengthen the link between IEC activities and RH/family planning services, the establishment of mobile health teams was proposed on a pilot basis in two regions where contraceptive prevalence was among the lowest in the country under the population component. 33. The studies prepared for the MTR, the decisions reached at the MTR (in December 2005), and the suspension of the Bank’s portfolio during the first half of 2006 provided the basis for three significant changes in the project over the final years of implementation: (i) decreasing support for AMASOT as a result of some CFAF20 million of ineligible expenditures; (ii) suspension of new micro-credit grants; (iii) increased emphasis on quality and results on the ground, especially behavior and practice rather than knowledge and attitudes; and (iv) reorientation of the population component’s funds to establish mobile teams in two regions of the country. 14 34. During the 2006-10 period, project implementation suffered from a series of stops and starts due to: (i) contentious oil negotiations with the Bank which resulted in the project suspension from January to June 2006; (ii) a national general strike from February to August 2007 which slowed down the implementation of project activities; (iii) rebel conflict which reached the capital in 2008 leading to another project suspension from February to July 2008; and (iv) delayed approval of the AF. Results during the short 2007-08 period showed the potential for the decentralized local response to accelerate counseling and testing activities 15 and to increase the use of modern contraceptive methods in the project areas. The project closed end of July 2008 (despite a request from the Government for an extension of its closing date) given the nature of the dialogue between the Bank and the Government at the time and that it was almost fully disbursed. The Government provided the necessary financing to continue to support the most critical project activities, at a reduced scale, while waiting for approval of the AF. 35. In March 2010, based on exceptional country circumstances and in accordance with 13 Only 45 percent of the outstanding amounts had been collected by the oversight agencies, and legal assistance had been recruited to reduce the amounts (which totaled more than US$ 600,000). 14 The proposed pilot experience was based on the successful experience of Tunisia (and to a more limited extent Niger). Mobile teams were expected to focus on prevention and treatment of STIs, a complementary package of services for PLWHAs, and population activities, including contraceptive prevalence. It was expected that the lessons learned could be used to scale up the experience at a later date. 15 For instance, between 2006 and 2007, the number of people tested for HIV in the project area increased by 38% and the proportion of those testing positive was greater than 20%. The increases in testing as well as the high rate of HIV positive cases among those tested demonstrated both a large unmet demand and the relevance of this targeted strategy. paragraph 5 of BP13.20, the Operational Policy and Country Services (OPCS) authorized the processing of an AF for the project. The AF’s objectives remained consistent with the original project with two modifications: (i) the introduction of a results-based financing approach; and (ii) the strengthening of monitoring and evaluation (M&E) to prepare a sound evidentiary basis for a new project. 36. Components and activities for the AF were simplified: (i) only the three best performing ministries continued to implement activities at central and local levels (Component 1); (ii) FOSAP oversaw the decentralized local response using mobile teams (Components 2 and 4); and (iii) a consortium of local and international expertise was recruited to implement the RBF pilot. Project management and M&E (Component 5) were continued by the PCT in place throughout project implementation. With a reduced volume of activities and an experienced set of implementers, implementation was smooth over the period 2010-13. 2.3 Monitoring and Evaluation Design, Implementation and Utilization 37. M&E design. The M&E design was based on: (i) physical and financial monitoring in accordance with the requirement for quarterly financial and management reporting (FMR); (ii) project monitoring based on the agreed-upon M&E plan; and (iii) surveys and studies, including Demographic and Health Surveys (DHS), sentinel sites, and specific surveys (on knowledge, attitudes, beliefs and practices, etc.). More specifically, the M&E design proposed physical and financial indicators to be monitored on a bi-annual basis for the first 18 months of the project and on a quarterly basis thereafter, in agreement with the FMR requirements; defined key indicators to be monitored on a yearly basis; and relied on a DHS to be conducted 2002 (with support from HSSP) to provide demographic, RH and child, and HIV/AIDS baseline data. 38. In addition, the M&E design included the following measures to ensure the effective, and evidence-based supervision of the project: (i) adoption of a M&E plan; (ii) selection of indicators on the quality, effectiveness and impact of sub-project grants and micro credits included in the procedures manuals; and a MTR preceded by evaluation of project activities, a beneficiary assessment, and an HIV sero-prevalence survey. 16 Finally, an M&E specialist was recruited to provide M&E assistance the ministries and of the Population Division. 39. At the time of the AF, the overall M&E approach was maintained but more resources were included to strengthen the M&E subcomponent, in particular at the regional levels. In addition: (i) the key performance indicators (KPI) and component output indicators were modified in accordance with the HIV/AIDS Results Scorecard 17; and (ii) non-DHS baseline and final evaluations were organized with sample surveys in the project areas and complemented by the collection and analysis of secondary information. 40. Implementation. Each of the planned M&E measures for the initial credit encountered difficulties. First, while the FMR generally provided timely and accurate information, they 16 The PAD noted that support for sentinel surveillance and the DHS had been included in the HSSP. 17 An assessment of the original indicators identified excluded those which were regarded as too difficult to measure, unrealistic or more strictly related to activities funded by the Health Sector Support Project rather than by the PACP2 (e.g. the incidence of STI within the general population, the incidence of HIV/AIDS among truck drivers). tended to emphasize the financial aspects more than the physical aspects of monitoring and thus did not sufficiently link expenditures to outputs, thereby diminishing discussion of potential efficiencies overall and from region to region. The internal audit function was established and reports were regularly available, but like the FMR emphasized financial and accounting issues. The transfer to the PCT (and strengthening) of the internal audit function resolved a number of these weaknesses. 41. Second, project monitoring was based on the definition of twenty-four indicators and external consultants were recruited to prepare semi-annual M&E reports based on these indicators. 18 These reports were systematically prepared but provided mostly process information and did not adequately address the issue of the quality of the interventions. At the MTR, substantial changes were proposed, but these were not followed up with a formal amendment to the Financing Agreement. Ultimately, each component developed its own data collection tools, but delays in the receipt of the data hindered their use for real time adaptation of program activities. 42. Ratings of project monitoring were generally satisfactory or moderately satisfactory, except for the period from December 2005 to December 2007, when they varied sharply due both to the suspension and to the Bank’s dissatisfaction with the collection and reporting of data on the local integrated response. Subsequently, the M&E specialist was replaced and new reporting forms and guidelines developed and linked to continuation of funding for the entities supported by the project. Ratings over the period of the AF were uniformly moderately satisfactory. 43. Third, the DHS was not conducted until 2004 (and not released until September 2005) which deprived the project of much of the baseline data it had anticipated. 19 Sentinel data was collected, periodic UNGASS reports were prepared, and an evaluation of the status of the national strategic framework was carried out. No follow up DHS was organized though a Multi Indicator Cluster Survey (MICS) was conducted in 2010. 44. For the AF, an initial survey (October 2012) served as the baseline data, and a follow-up evaluation was conducted (May 2013) using the same methodology. While the two surveys might have provided some comparisons (albeit over a short period of time), the ICR team was unable to independently verify the results of the follow up survey. 45. Utilization. Although the PAD adequately described the project’s institutional arrangements for M&E, it did not sufficiently detail the prospective use of M&E results for decision-making and program management. The issue of utilization arose after the 2006 suspension, when it was noted that, while the components received reports, the implementing agencies at national and regional levels were not included. Afterwards, the PCT and FOSAP 18 Early supervision reports noted that baseline data was not available or relied on estimations from unpublished sources, and it was agreed that the necessary studies would be carried out and all data would be based on published sources. 19 Both the ICR (2002) and the PPAR (2005) for the first project emphasized the extent to which the absence of baseline data for key indicators undermines opportunities to track and fine-tune the performance and impact of the project. were expected to systematically provide official presentations to all of the partners and implementing agencies at national and regional levels. By the 2009 appraisal for the AF, quarterly meetings were being held in all regions and the different implementers were required to present a report of the last quarter and an action plan for the next quarter. Subsequently, under the AF, the information available was adequate and there are indications that the use of the information by the regional and national structures progressively improved and that joint annual reviews were carried out. 46. M&E is rated Modest for the initial credit, due primarily to: (i) the lack of baseline and follow-up information; (ii) the overly ambitious and poorly measurable indicators; and (iii) the insufficient use of the M&E data for management purposes. M&E is rated Substantial for the AF, since adequate information was regularly available to assess the financial situation and the technical implementation (particularly for the mobile teams and RBF pilots). In addition, separate evaluations of the mobile teams and the RBF were conducted. Finally, Bank supervision missions systematically charted project responses to past recommendations with indications of how information was used to improve project performance. 47. Because the ICR mission was unable to independently verify the data from baseline and follow-up evaluations, this information was not used in the ICR but is reported in the Borrower’s ICR. 2.4 Safeguard and Fiduciary Compliance 48. Environment. The project was originally given a “C” rating since it was not expected to generate any adverse environmental effects and could even have some positive environmental effects through the population component’s potential long term impact on fertility reduction and a decline in the population growth rate. 20 In 2004, the rating was retroactively changed in the system to a B (along with all HIV/AIDS projects). Safeguard compliance was not rated throughout the initial project. The “B” rating was maintained for the AF due to the risks associated with the handling and disposal of medical waste, and a Medical Waste Management Plan (MWMP) was prepared in August 2007. 49. Because the Borrower's experience and ability to implement safeguards were limited, capacity building on safeguards, particularly medical waste management, was built into the AF. In addition, critical materials and equipment for medical waste management as well as safeguards supervision was included to address weaknesses and enhance the implementation and systematic monitoring of the MWMP by the MOH. Safeguards compliance was rated Satisfactory throughout the AF. 50. In July 2012, an assessment and update of the MWMP was conducted. Among the issues identified were: (i) insufficient political support and legislative gaps; (ii) inadequate organization of plan implementation including a lack of material support and appropriate behavior among 20 Three risks were cited: (i) the inappropriate or poor disposal of condoms which would be mitigated by information provided at the time of sale; (ii) disposal of chemicals for re-impregnating mosquito nets which would be mitigated by ensuring a life span of 5-8 years; and (iii) the effects of the sub-projects, for which the project implementation would include guidelines for taking environmental considerations into account. health personnel; and (iii) very limited financial resources from the Government and virtually no collaboration with the private sector. The updated MWMP proposed a comprehensive strategy, an estimated budget, institutional responsibilities, and monitoring measures. 51. In addition, an environmental audit of the project was conducted (October 2012) by the Direction for Environmental Evaluations of the Ministry of the Environment and Water Resources for each of the ten health facilities supported by the project. The audit found that waste management capabilities remained limited and cited in particular a lack of documentation to guide the disposal of bio-medical waste and insufficient and inadequately trained staff. A remedial plan and budget was proposed along with formats for monitoring waste management. Key recommendations had been implemented through national budget and donor funding, including IDA. 52. Procurement, Disbursement, and Financial Management. 53. Procurement. Early missions noted the difficult overall country procurement context, the time-consuming national procedures, and the persistent delays which had reduced disbursement. Though generally satisfied with the PCT’s capacity, the June 2003 audit recommended recruiting a procurement specialist, which was done in February 2004. Post reviews of contracts under the review ceiling were carried out on several occasions, and no major irregularities were found. 54. The lengthy procurement delays continued to be a problem throughout the project, particularly with respect to the approval, signature, and obtaining of the required visas. In addition, during the initial project there were minor problems linked to procedures for local shopping and NCB) and an issue with respect to AMASOT’s conformity with IDA procedures. During the AF period, the principal recommendations concerned: (i) keeping the procurement plan current; (ii) publishing the announcements and results of procurements in a timely manner; and (iii) improving the organization and archiving of procurement documents. Subsequent missions continued to emphasize these problems as well as that of contract management. 55. Financial management. Financial management (FM) was complicated by the number and relative independence of the implementing agencies. The computerized accounting and reporting system was determined to be adequate and though shortcomings in FM were identified, they did not prevent the timely and reliable provision of information required to manage and monitor the implementation of the project. After initial delays, the FMRs were submitted on time and were deemed to be of acceptable quality. Annual project audits and bi-annual FOSAP audits indicated that project management was acceptable; supervision missions noted that recurrent costs, in particular those linked to vehicles were particularly high and attributed these high recurrent costs to requests from Government officials for vehicles, fuel, and spare parts. Consequently, it was agreed to put in place, as in the Health Project, a system to monitor expenses by vehicle. 56. There were, however, repeated lapses in FM: (i) in 2003, the project audit was qualified because some of the assets of the first project were not accounted for in the inventory of the second project; (ii) in 2004, both AMASOT and the PCT incurred certain ineligible expenditures (which were subsequently reimbursed); (iii) in 2006, the audit report was qualified and the external auditors raised issues related to ineligible expenditures and internal controls which required an action plan (along with refunding the ineligible expenditures and inactive special accounts; (iv) in 2005, 2007, and 2008, the auditors refused to certify the financial situation (due in part to the destruction of financial records); (v) in 2009, there were ineligible expenditures (related to funding the project coordination staff after project closing were identified and subsequently refunded); and (vi) in 2011 and 2012, the audits were qualified. 57. A recurrent problem throughout implementation of the project was the delay in providing counterpart financing in a timely fashion, which strained FM and probably contributed to some of the lapses noted above. Successive Bank missions (from 2006 to 2010) followed the counterpart financing issue closely and identified CFAF160 million outstanding as of January 2010. 21 As the AF was 100 percent IDA grant funded, there were no counterpart financing issues. 2.5 Post-completion Operation/Next Phase 58. All the National Strategic Frameworks clearly define the institutional arrangements between the Permanent Secretariat to the Offices of the President and the Prime Minister as well as between the implementing structures and the external partners; these steps should ensure an adequate institutional framework after project closing. In addition, the Government adopted Law 19/PR/2007 (2007) to protect people living with HIV/AIDS. While the analysis of the evolving epidemiological situation could have focused more on the concentrated nature of the epidemic, the strategies and operational directives for implementing the National Strategic Frameworks were prepared in a participatory manner and adopted by consensus. With further examination, these guidelines (e.g., protocols and standards around screening, PMTCT, management of HIV and STIs, etc.) should serve as the basis for the future planning and implementation of the different interventions. 59. The project contributed to the capacities of its key implementing agencies, and c ertain sectoral ministries (MOH and the Ministry of Defense) and FOSAP made significant progress and can be expected to continue their work. The other participating institutions (the other sectoral ministries, the Population Divisions/Directorates, and AMASOT) made slower progressand, though they may continue to carry out their mandates, the quality of their work may suffer. 60. Future planning and implementation of population interventions raises somewhat different issues. The project made reasonable progress in conducting analytical work but an effective program of priority population-related activities was not developed. Though the AF significantly reoriented the interventions to address RH and FP, the broader population policy issues remain to be addressed. 61. The post-completion phase must confront two key issues. First, inadequate human resources remain an issue and constrain both the provision of services and the management of the implementation of the NPP and the National Strategic Framework. Second, insufficient financing of the national response remains a key constraint, especially given the budgeted needs expressed in the National Strategic Framework. In the immediate term, for the period July- December 2013, the Government allocated CFAF1.324 billion to continue the integrated local response and the RBF in their current zonesbut as of December 1st, no funds had been disbursed. 21 A subsequent supervision mission noted that Chad had deposited its outstanding counterpart obligations. Similarly, none of the three non-health ministries hadreceived a budget line item for combating HIV/AIDS. 62. In the longer term, the problem is more acute. The Global Fund proposal for Round 10 estimates the funding gap for 2014 at 74 percent of need and it is expected to rise again in 2015. The approval of new Bank financing (of US$15 million to finance the scale up of the RBF/Mobile team pilots) will reduce the gap by about 25 percent of need. 22 3. Assessment of Outcomes 3.1 Relevance of Objectives, Design and Implementation 63. The overall relevance of the project is rated Substantial for both the initial credit and the AF. While the objectives were (and remain) highly relevant to the existing political orientations and technical considerations, the relevance of the project design was relatively modest early and has become more substantial over time. 64. Relevance of the project objectives. The relevance of the project's development objectives, components, and specific activities is rated Substantial for both the original credit and the AF. The project’s objectives: (i) support the country’s international (e.g., the Millennium Development Goals, the declarations of Abuja and Brazzaville, universal access, etc.) and regional (Lake Chad Basin initiative) obligations; (ii) are consistent with the country’s overall socio-economic development objectives; and (iii) contribute to the prevention and mitigation of the effects of HIV/AIDS and the consequences of rapid the demographic growth. 65. In April 2008, Chad moved to a second generation national poverty reduction strategy (PRSP 2), prioritizing five axes, including human resource development and protection of vulnerable populations. Throughout implementation, the project was consistent with the Bank’s country assistance strategies and objectives of achieving a sustainable reduction in poverty and building capacity for delivering basic social services. The 2010-2012 Bank Interim Strategy Note (ISN) confirmed the Bank’s continued engagement in the social sectors and their direct impact on population and poverty. The project’s objectives continue to reflect the Population Policy (adopted in 1994 and most recently revised in 2007), the National Strategic Frameworks to fight HIV/AIDS (and most recently the National AIDS Strategy for 2012-15), and specific strategies (e.g., the national roadmap for reducing maternal mortality), which have guided the national response. 66. Relevance of the project design and implementation. The relevance of the project design and implementation is rated Modest for the original credit and Substantial for the AF. Though 22 The Global Fund proposal for Round 8 (2008) estimated funding needs from 2008-13 at approximately US$57.49 million annually of which domestic resources were estimated at US$ 1.96 million (or 3.4 percent). The Government included ARV, reagents, and drugs to combat opportunistic infections on the list of essential medicines, and about 50 percent of the Government’s contribution was allocated to a budget line for purchasing of medicines and reagents. Other external sources (excluding the Bank, which was not operational at the time the estimates were made) accounted for some US$1.58 million annually and the Global Fund for US$ 3.61 million annually. the project’s original PDO remained constant throughout implementation, its components evolved significantly to correct weaknesses which became apparent to respond to past implementation experience and current program priorities. 67. The original design did not adequately address four issues: (i) inadequate information to determine the impact of the project, particularly on at-risk groups; (ii) weak links between PACP2 and the companion IDA-financed health sector support project; (iii) insufficient coordination of HIV/AIDS financing and activities through the National AIDS Commission (NAC); and (iv) ineffective decentralization of HIV activities through the priority ministries and NGOs to address drivers of the epidemic and particularly vulnerable groups. 68. The AF significantly modified the original and emphasized implementation based on the strengths of the previous design by: (i) allocating funding only to the four successful public sector ministries (Component 1); (ii) reallocating resources away from the ineffective social marketing intervention (Component 3); and (iii) merging FOSAP’s community-based initiatives (Component 2) and population activities (Component 4) to focus on the integrated decentralized approach and RBF. While implementation of the integrated approach using mobile health teams benefited from experience since 2007, the RBF design was developed as a pilot and did not fully benefit from a feasibility analysis. The overall assessment of risk as High was accurate, but the project proposed no risk mitigation measures. 3.2 Achievement of Project Development Objectives 69. The project’s efficacy rating is based on: (i) the project's results as summarized in Section F of the Data Sheet; (ii) the quantitative results by year for the OI, IOI, and outputs in Annex 2; and (iii) the project's weighted results as a proportion of actual disbursements at the time of the AF and at closing. The following table provides an overview of the results for the numbered outcome and intermediate outcome targets in the data sheet and shows that 57 percent of the project’s targets were fully achieved: Table 1: Summary of the achievement of project targets Outcomes Intermediate Outcomes Total Initial Additional Initial Additional Level of Achievement credit financing No. credit financing No. No. % Achieved (95%+) 4, 1 2, 5, 6 7, 8, 9, 11, 12, 13, 15, 15 16 57% 18, 19, 20, 21, 22 Partially achieved (75-94%) 1, 3 2 10, 16 2 4 14% Not achieved 2, 5, 6 3 1, 3, 4, 14, 1 4 14% Data not verified 7, 8, 9 3 17, 1 4 14% Total 9 19 28 100% NB. The numbers in the outcome and intermediate outcome columns correspond to the numbered targets in the data sheet. The table shows, for example, that 57% of the targets were fully achieved. 70. PDO 1: Adopt behaviors which will reduce the risk of infection from HIV. Of the six outcome indicators for PDO 1, one was fully achieved, two were partially achieved, three were not achieved, and three were measured but the data was not verifiable. During both the initial credit and the AF, awareness/knowledge of HIV/AIDS was partially achieved: • OI 1: Based on a comparison of DHS results for the awareness of HIV/AIDS, men’s awareness increased from 88 percent (1997) to 90 percent (2005) (or 95 percent of the target); women’s awareness increased from 60 percent (1997) to 80 percent (2005) (or 89 percent of the target. The MICS (2010) found that women’s awareness of HIV/AIDS was 64 percent. 71. During the initial credit, there were significant increases in condom use by persons aged 15-24 and by military personnel, though the ambitious targets resulted in mixed results: • OI 3: There was a significant increase (from 15 percent to 67.6 percent) in the use of condoms by military personnel, and the target was achieved at 90 percent. • OI 2: Significant progress was made in the use of condoms by persons aged 15-24: from 8.1 percent to 25.4 percent for men and from 5.8 percent to 17.2 percent for women. However, the targets were not achieved either for men (51 percent of the target was achieved) or for women (34 percent of the target was achieved). 72. HIV prevalence during the initial credit decreased considerably, but was not measured during the AF: • OI 4: Based on sentinel site data, HIV prevalence among pregnant women aged 15-24 was reduced by more than 25 percent (in fact, by more than 55 percent from 7.0 percent to 3.9 percent). 73. Components 1 and 2 of the initial credit and of the AF contributed to these results. 74. Component 1: Strengthening the Capacities of the Key Ministries. The initial credit comprised three intermediate outcome indicators, of which one was achieved: • IOI 1: Of the six units of the National AIDS/STD Control Program expected to be functional by the end of 2002, none were; by 2006, two of six were considered functional. • IOI 2: Of the six selected key-ministries expected to develop annually an action plan including the prevention and care priority activities, all six did so. • IOI 3: Of the 14 Regional Health Councils (18 after 2006) expected to develop an action plan including the prevention and care priority activities, none did so. 75. In addition, the project achieved the output target of assuring voluntary counseling and testing (VCT) services are available in 25 percent of the 54 existing health districts by the end of 2003 (41 percent of districts had VCT services), and 75 percent by the end of the project (96 percent of districts had VCT services by the end of the project). 76. Component 1 (AF): Strengthening the Capacities of the Key Ministries. The AF focused on counseling and testing with positive results: • IOI 7: The average number of persons counseled and tested over the period 2010-12 was 136,891 (or 155 percent of the target); • IOI 8: The number of military personnel tested increased from 2,414 in 2010 to 7,915 in 2012 (or 124 percent of the target); • IOI 9: The average number of pregnant women tested for HIV during prenatal consultations over the period 2010-12 was 27,671 (or 99 percent of the target). The result is almost double (172 percent) the baseline which is the average number of women tested over the period 2007-09. 77. Component 2 (Initial credit): Strengthening of the Social Fund (FOSAP) and its two-sub-components (Grants and Micro-credits). During the initial credit, the PAD did not establish any intermediate outcome indicators for this component; there were, however, three important outputs: • The project far surpassed the target of 170 community-based sub-projects, approving more than 1500 between 2003 and 2007. • Data on the number and amounts of the sub-projects by target group suggest that youths were the principal beneficiary group. • Overall, micro-credit sub-projects reached almost half (47 percent) of the departments by the end of the first phase. 78. Component 2 (AF): Strengthening of the Social Fund (FOSAP). FOSAP made reasonable progress on condom distribution and significant progress in two other areas during the AF phase: • IOI 10: In 2012, 4.5 million condoms were distributed (or 89 percent of the target), but the average number of condoms distributed annually over the period 2010-12 improved from 3.4 million (2010) to 4.1 million (2011) to 4.5 million (2012). • IOI 11: The households of 9,102 orphaned and vulnerable children (aged 0-17) received free basic external support in caring for the child. This constitutes 103 percent of the target. • IOI 12: Some 410,538 women of child-bearing age were reached by interventions provided by community-based organizations. 79. PDO 2: Adopt behaviors which will reduce the risk of too closely spaced and/or unwanted pregnancies. During the initial credit, the target for women using modern contraceptive methods was not achieved: • OI 5: While some progress on the use of modern contraceptives was made in urban areas (71 percent of the target was achieved), there was virtually no change in rural areas (13 percent of the target was achieved). 80. During the initial credit, the project aimed to increase the proportion of women aged 15- 49 in union who wish to space their next birth by at least two years. This target was not achieved. 81. OI 6: Based on project data, the target remained unchanged: from 39 percent in 2000 to 38 percent in 2004. The indicator was dropped for the AF. Components 1 and 2 of the initial credit contributed to these results; 82. Components 3 and 4 of the initial credit contributed to these results as shown below; components 3 and 4 of the AF contributed more broadly to reproductive and child health, which are determinants of pregnancy. 83. Component 3 (Initial credit): Support to the Social Marketing Program. During the initial credit, AMASOT did not achieved its targets under this component: • IOI 4: The social marketing program for oral contraceptives was not established. • IOI 5: The social marketing program for impregnated bed nets in the five southern prefectures where malaria is very prevalent was established in 2005 (rather than at the beginning of 2002) and more than 90 percent of the nets were sold in N’Djamena. 84. Among the outputs, the targets for condoms and oral rehydration salts were not achieved. At the end of the initial credit, the component and its targets were dropped. 85. Component 4 (Initial credit): Support to the implementation of the Declaration of Population Policy. The single intermediate outcome target was achieved: • IOI 6: the 14 Regional Population Commissions were established and later increased to 18 after the administrative organization of the country. 86. All of the planned outputs were achieved: Workshops for religious leaders and traditional leaders were organized, as were the IEC activities. There was no assessment of the results of this component, and the component and its targets were dropped for the second phase. 87. Component 3 (AF): Implementation of RBF. The results of the implementation of the RBF approach are presented in the table below: Table 2: Cumulative, declared results of the results-based financing approach (RBF) Baseline Target Results 2010 2013 2011 2012 2013 % Children immunized (DTC 3) 34 420 46 732 5 059 49 795 62 194 133% Pregnant women receiving antenatal care during a 27 817 45 912 2 720 25 688 31 438 68% visit to a health provider (CPN 3) Assisted deliveries/public & private health centers 11 086 16 807 0 16 761 22 056 131% Pregnant women vaccinated (VAT 2) 34 726 45 912 4 566 31 941 46 651 102% Women attending post natal care consultations 34 726 nd nd nd nd during a visit to a health provider Sources: Rapports FBR; Capitalisation de l'expérience FBR, p. 20. 88. An evaluation of the RBF pilot identified several weaknesses: (i) the underfunding of the RBF budget (at approximately US$1.5 per capita); (ii) the contents and remuneration of the minimum (health center) and complementary (hospital) packages of services; (iii) the inability to manage drugs independently of Central Medical Stores and personnel independently of MOH; and (iv) the unfamiliarity with planning and with data collection and analysis. Despite these difficulties, available data show substantial progress on both the quantity and quality of services offered in the facilities as shown below: Table 3: Evolution of the quantity and quality of services in health facilities using RBF Oct-11 Dec-11 Mar-12 Jun-12 Sep-12 Dec-12 May-13 Utilization of services Pre natal consultation 1 5.1% 5.5% 7.2% 5.6% 5.9% 5.2% 7.3% Pre natal consultation 3 1.6% 1.6% 2.9% 1.5% 1.7% 1.4% 3.6% VAT 3 0.9% 1.1% 1.6% 1.0% 4.0% 4.6% 6.5% Assisted delivery 0.6% 0.9% 1.4% 1.4% 1.6% 1.6% 2.5% Family planning 0.1% 0.1% 0.3% 0.4% 0.6% 0.3% 0.6% Measles vaccination 3.5% 4.1% 5.4% 4.2% 4.8% 5.3% 7.0% Pentavalent 3 3.5% 4.0% 5.3% 4.3% 4.4% 5.2% 7.8% Quality assessment Health centers 41.5% 55.8% 63.1% 65.1% 66.3% 66.5% Hospitals 54.3% 63.1% 63.1% Source: Project data 89. All of the key services demonstrate significantly increased utilization: (i) child immunization (measles and Pentavalent 3) more than doubled; (ii) both first and third pre-natal consultation have increased, the latter more than doubled; (iii) assisted delivery quadrupled; and (iv) family planning increased six-fold. 90. By comparing services delivered with prescribed, protocols, the evaluation determined that quality has also improved in RBF health centers and hospitals; in both cases, rapid early increases were followed by consistent measures of 63-66 percent. 23 The RBF pilot also contributed to other aspects of quality, both physical (infrastructure and equipment) and non- physical (improvement in the quality of the information collected by the RBF facilities. Unfortunately, the poor quality of the data in the non-RBF zones precluded a comparison of RBF zones with non-RBF zones. 91. Component 4 (AF): Support for implementation of the decentralized and integrated approach. As shown below, the project’s targets were met and, in most instances, exceeded: Table 4: Cumulative results of the decentralized and integrated approach (Mobile Health Teams) Baseline Target Results 2010 2013 2011 2012 2013 % Children immunized (DTC 3) 59 367 71 620 39 441 89 578 116 522 163% Pregnant women receiving antenatal care during a 50 928 70 094 42 562 92 946 131 583 188% visit to a health provider (CPN1 / NC) Assisted deliveries/public & private health centers 16 321 25 659 11 564 20 733 27 638 108% Pregnant women vaccinated (VAT 2) 51 305 70 094 31 623 83 354 111 361 159% Women attending post natal care consultations 3 389 7 698 2 470 15 050 36 944 480% during a visit to a health provider Source: Project data. 23 The final RBF evaluation recommended further study to understand the plateauing of quality in the RBF hospitals and health centers. See Rapport de l’évaluation de l’expérience pilote du financement basé sur les résultats au Tchad, p. 21. 92. The contribution of the mobile teams varied considerably from district to district and particularly from service to service. However, two of the essential services delivered through the mobile health teams were VTC for pregnant women and post natal consultations. The mobile teams did not perform assisted delivery. Formal baseline data for before/after comparisons are not available, but the project collected data to evaluate zones with/without the mobile health teams; these data show important gains in service delivery in districts with mobile teams, ranging from 50 percent to several hundred percent depending on the service provided. 93. Overall achievement result. Based on ICR guidelines, the project's initial and revised indicators, and disbursement during the initial credit and the AF, project efficacy is rated Modest for the original grant, Substantial for the AF (due largely to the results on the Intermediate Outcomes), and Modest overall. Table 5: Combined overall project achievement ratings Against Original Against Restructured Considerations PDO/Targets PDO/Targets Overall Rating value 1.93 2.64 Amount disbursed 19.34 13.30 32.64 Weight (% disbursed) 59% 41% 100% Weighted value (1 x 3) 1.14 1.08 2.22 Final rating (rounded) Modest Guidance: ICRR Guidelines, Appendix B; Data Sheet, Section H. 3.3 Efficiency 94. Technical efficiency. Annex 4 of the PAD 24 relied on the general finding that both high HIV prevalence and high fertility had been shown to negatively affect the economic wellbeing at the household level and for the country as a whole but that there were synergies in addressing the two issues together. 25 Annex 4 recommended a specific set of Population and HIV/AIDS interventions. For Population, it proposed that the project focus on implementing proven interventions to: promote the control of family size; increase the use of modern contraceptive methods; and adopt technologies contributing to child survival. To this end, Annex 4 proposed synergies between an expanded family planning program and the use of vaccination, impregnated bed nets, oral rehydration salts, etc. to reduce infant mortality. For HIV/AIDS, Annex 4 proposed interventions which would provide value for money, including specifically to: (i) increase condom use and reduce the prevalence of STIs among female sex workers and their male clients; and (ii) to increase condom use and reduce the number of sex partners among males and females in union. 95. Project interventions are technically sound and recognized as high impact interventions to reduce the risk of infection by HIV and child and maternal mortality rates. There is evidence that some of the project’s benefits were considerable, as the project succeeded in: (i) supporting the development of policies, strategies, and operational guidelines; (ii) strengthening the capacity of key stakeholders within Government (at national and local levels) and community groups to 24 See Annex 3 of the ICR for a more detailed summary of the PAD’s arguments. 25 See Annex 4 of the ICR for the complete discussion. collaborate in organizing and implementing HIV/AIDS prevention and care activities; and (iii) preventing the rapid spread of the disease among the most productive (and sexually active) elements of the population as well as providing support to groups infected and affected by HIV/AIDS. Moreover, both innovative interventions (the decentralized and integrated approach and the RBF pilot) contributed to significant increases of health-related indicators (project evaluation reports) with a limited cost: US$2.6/person/year for the integrated and decentralized approach and US$1.8/person/year for the RBF pilot. 96. Management efficiency. From a management perspective, the project had mixed results. First, while it may not have been able to measure the efficiency of its interventions, it was able to identify and act on underperformance: (i) the number of ministries supported was limited to those demonstrating results; (ii) the number of sub-projects financed by FOSAP was reduced (and then halted) when results were not evident, and the micro-credit program was halted; and (iii) financial resources for the social marketing component and for population activities were reduced and then eliminated. In place of this range of activities, the project focused on specific ministries (at national and regional levels) and on specific interventions at the health district level (with the mobile teams and RBF). 97. Second, the PCT successfully managed project implementation while operating within an administrative environment which handicapped efficiency: (i) counterpart funding (during the initial credit) was not timely; (ii) procurement was slow and difficult; (iii) financial management was weak (and audits often qualified); and (iv) evidence-based results (from either the monitoring and evaluation system or associated studies) for decision-making was not sufficient. Finally, the PCT’s resilience in confronting the constant implementation challenges resulting from the socio-political situation should be noted. 98. Despite the measures taken to improve efficiency and the efforts to improve operations in the complex Chadian environment, project efficiency is rated Modest for the initial credit and Modest for the AF. 3.4 Justification of Overall Outcome Rating 99. A summary of the individual and overall project ratings by criterion and by phase of the project financing is presented in the following table: Table 6: Summary of project ratings Additional Initial credit financing Rating criteria 2002-08 2010-13 Overall Relevance Substantial Substantial Substantial Objectives Substantial Substantial Design/Implementation Modest Substantial Efficacy Modest Substantial Modest Efficiency Modest Modest Modest Overall MU MS MU Based on OPCS and IEG guidance and the previous ratings of Substantial for relevance, Modest for efficacy, and Modest for efficiency, the overall outcome rating for the project is Moderately Unsatisfactory. 3.5 Overarching Themes, Other Outcomes and Impacts (a) Poverty Impacts, Gender Aspects, and Social Development 100. Poverty. As highlighted in the strategy to combat HIV/AIDS, "high fertility and rapid population growth impede efforts to reduce poverty", and thereby contribute to the spread of HIV/AIDS. 26 Thus, by slowing down demographic growth, reducing pressures on the need for services, and empowering people and institutions to deal more effectively with the epidemic, the project components addressed the issue of poverty. Further, reducing the number of HIV infections and AIDS deaths would decrease life years lost, the costs of treatment, and the loss of productivity27 and thus contribute to the reduction of poverty. Because the burden of HIV/AIDS falls disproportionately on poor and vulnerable groups, who are at increased risk of being infected, the project sought to fund micro-credits to generate revenue among vulnerable groups and support for PLWHA and families providing for orphans. The Government’s contribution to free periodic clinical follow-up and ARV has also reduced the risk of poverty resulting from catastrophic illness. 101. Gender. PACP2 expected to finance research on RH behavior, family structure and function, gender issues, and the causes and consequences of population growth. A study of these population issues concluded that the direct determinants of population growth had not changed significantly since 1964 28, which confirmed other findings that change is virtually impossible without long-term efforts to change attitudes and improve the socio-economic status of women. The project addressed knowledge needs (to empower women to decide on their fertility), service delivery needs (through the promotion, inter alia, of birth spacing, the use of bednets, testing and prevention of mother to child transmission, etc.), and economic needs (through the micro-credit window of the FOSAP grants). The project also included gender specific targets and indicators among the project performance indicators, but did not explicitly address the feminization of the epidemic. 29 102. Social development. The project contributed to the country’s overall social development by addressing the need to: (i) adopt a legislative context to promote RH and the protection of PLWHA; (ii) identify the importance of socially marginal groups in the spread of HIV; (iii) discuss culturally sensitive issues (including family size, sexual behavior, sexually transmitted diseases and HIV infection, etc.); and (iv) develop an overarching programmatic response to the 26 World Bank, Intensifying action against HIV/AIDS in Africa (2001). 27 Annex 4 of the PAD provided estimates and with/without project scenarios. 28 Ministère de l’Economie et du Plan/Direction de la Population, Dynamique de la Population (décembre 2009), p. 28. 29 UNICEF’s PMTCT Fact Sheet for 2010 noted that HIV prevalence has remained relatively stable among adults (15-49 years), but that levels of infection are much higher among young women (2.5%) than among young men (1%) (15-24 years). epidemic. Specifically, the project: (i) strengthened the participation of regional health institutions; and (ii) supported NGOs capable of providing technical assistance to the community-based organizations as well as the organizations themselves. Most importantly, through the mobile health teams, the project reduced the physical, cultural, and financial barriers for utilizing health services by populations with little previous access to these services. (b) Institutional Change and Strengthening 103. Population. At the outset of PACP2, the Government adopted the Law No. 6 (2002) promoting RH, and during project implementation the NPP was revised and adopted by the National Assembly in 2007. Prior to the MTR, the contributions of the project to institutional change were mixed: (i) Regional Population Commissions were established in all regions (though their achievements were not evaluated); (ii) certain operational research was conducted (though dissemination was inadequate); (iii) key groups (religious leaders, traditional chiefs, etc.) were sensitized (but attitude change was not assessed and seems not to have been significant); and (iv) numerous IEC activities were carried out (though not with significant impact on key indicators such as use of modern contraceptive methods). After the MTR, population activities were reoriented to focus on the establishment of mobile health teams to deliver basic health services, including RH services, family planning, HIV, IEC, etc. Though the scale of this intervention has been limited to selected districts in two regions, the success of the approach has been recognized by the Government and carefully followed by the Regional Governors involved. 104. HIV/AIDS. The project contributed to strengthening national and regional institutions capable of formulating and coordinating the national response: (i) at central level with the National AIDS Committee (NAC), the National AIDS Control Program (NACP), and the PCT; and (ii) at regional level through the Regional Health Councils and the Regional Population Committees and the Regional Permanent Secretariats. Combined with the series of national strategic frameworks to combat AIDS and the adoption of an MCH strategy for 2008-15, the project has contributed to the adoption of the requisite instruments for implementing the national response. Within this framework, the project has effectively maintained the Government’s multi- sectoral response to the epidemic by: (i) mainstreaming HIV/AIDS activities into the action plans of key sector ministries (with particularly good results for the Ministry of Health); (ii) decentralizing resources and responsibility for implementing these activities (especially through the mobile health teams); and (iii) strengthening the management capabilities and financing a range of civil society organizations to improve results at local levels. 30 105. By delegating responsibility for component implementation to specific entities (ministries, FOSAP, AMASOT, etc.), the project contributed to the development of capacity at the national level. In the end, the ministries of health and defense performed adequately but the others less so, FOSAP increased its financial and program management skills and established itself as a viable non-governmental entity with follow-up financing from the Global Fund, but AMASOT encountered organizational and societal problems and was subsequently dropped 30 A number of these improvements followed the recommendations of the institutional audit, which was partly funded by the project. See Dr. Idrissa Ouedraogo, et al., Audit technique des organes d’encadrement de la lutte contre le VIH/SIDA au Tchad (septembre 2004). during the AF phase. 31 106. In addition to national level strategies and institutions, regional and district authorities, the project also financed the involvement of non-governmental organizations (NGOs) and civil society organizations (CSOs) to implement sub-projects, which responded to community-led initiatives and contributed to strengthening the capabilities of these community institutions (including Priority Vulnerable Groups and associations of PLWHA). 107. Finally, during the implementation of the PACP2, the Government adopted the Law No. 19 (2007) promoting the fight against HIV/AIDS and the rights of persons living with HIV/AIDS and with sexually transmitted diseases. The law provides a basis for protecting the rights of PLWHA. (c) Other Unintended Outcomes and Impacts (positive or negative) 108. Though unintended, the difficulties (political, financial, etc.) confronting the PCT contributed to the development of a resilient and resourceful unit, capable of adapting the project to the changing conditions for its implementation. In addition, unlike many other similar projects, the project team demonstrated the potential for coordinating a multisectoral approach and collaborating with the Ministry of Health rather than assuming implementation responsibilities. 3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops 109. Though a beneficiary assessment was completed for the MTR, it was destroyed when the project offices were burned in 2008. As part of the final evaluation in 2013, an analysis of the project’s “penetration” and interviews with some beneficiaries were carried out and showed that some 70 percent of the target population in the project zones knew of the project, and of these 60 percent had had experience with the project implementing agencies. Among the communications channels cited most frequently by the population were: (i) the mobile health teams (83.6 percent); (ii) the community-based organizations (67.7 percent); (iii) local radio (66.5 percent); and (iv) other members of the community (51.3 percent). In addition, the ICR mission met with many of the stakeholders, both within their institutions for thorough discussions of the way in which the project strengthened their responses to HIV/AIDS issues and during the final project evaluation workshop (June 2013). 4. Assessment of Risk to Development Outcome Rating: Substantial 110. Several elements should contribute to the reduction of risks to development outcomes; these include the current legal structure, strategic measures (as well as oil revenues) for implementing a national population policy, and a series of frameworks to combat HIV/AIDS. However, a number of risks identified in the PAD are still pertinent and in particular: (i) intersectoral collaboration; and (ii) coordination and implementation capacity at all levels. Other 31 AMASOT had financial support from other donors, mainly KfW, during both phases of the project. risks have become more apparent over time and include: (i) inadequate human resources; (ii) weak capabilities for supplying the requisite drugs and consumables to avoid service interruptions; and (iii) the likelihood of insufficient financing, particularly for community-based prevention activities. 111. Despite Government promises, the lack of follow-up funding since project closing is particularly worrisome and may even raise questions about the Government’s continuing commitment to the project’s objectives. Given such concerns, the risk to development outcome would be considered high, except that a follow up IDA operation is being prepared to build on the experiences of the pilots initiated during the additional financing period. 112. Within the framework of these innovative service delivery mechanisms, priorities for improving RH have been identified, and adequate progress for fighting HIV has been made, including the adoption of program policies and procedures (for testing, care and support, and treatment), enhanced surveillance and knowledge of the most vulnerable populations, expanded testing and counseling, formal protection of PLWHA, and provision of MTCT prevention and ARV treatment. The follow-on IDA financing will support these services and strengthen the mechanisms for delivering these services. 5. Assessment of Bank and Borrower Performance 5.1 Bank Performance (a) Bank Performance in Ensuring Quality at Entry Rating: Moderately Unsatisfactory 113. Preparation of the PACP2 relied on the experiences of the first operation, but was not able to take advantage of the findings of the ICR. 32 As a result, preparation of the second project was relatively easy and predictable but perhaps missed opportunities to re-think important aspects of the project. Specifically, the second project repeated a number of the design weaknesses identified by the ICR for the first project, namely that: (i) baseline data were insufficient and contributed to the establishment of overly ambitious targets (and expectations) which were reflected in the M&E plan subsequently adopted by the Government; and (ii) assessment of the Government’s capacity to implement the objectives outlined in the National Population Policy was overly optimistic. Somewhat surprisingly, given the first project’s contribution to the preparation of the National AIDS Control Strategic Plan for the period 1999- 2003, there is little reference to the integration of project financing in support of the implementation of the plan. Finally, as noted previously, the identification of risks and proposed risk mitigation measures were weak and did not envision the possibility of civil strife. 114. Preparation of the second project did have a number of strengths: (i) formal documentation by recognized international experts was satisfactory; (ii) the PAD was clear and 32 The ICR for the first project was prepared a year after the Second Project was approved. For the discussion of design weaknesses, see the ICR for the first Population and Aids Control Project (Report No. 24344) (June 2002), pp. 6ff. concise; (iii) an extensive economic analysis of high fertility and HIV/AIDS was done; and (iv) implementation manuals were prepared as a condition of effectiveness. Discussion of these elements with the Government and participation of various groups (at least before the national consensus building workshop after effectiveness) seems to have been fairly minimal. From the Bank’s perspective, there do not appear to have been many concerns expressed during the PCN review, the Decision Meeting, and the negotiations. A QEA was not prepared. 115. The major consideration in rating quality at entry as moderately unsatisfactory is that within two years of effectiveness, there was already consideration that there were important problems for the implementation of the project components. (b) Quality of Supervision Rating: Moderately satisfactory 116. Two TTLs assured continuity during project implementation over the period 2002-2009 as well as the preparation of the AF (in 2007). Their performance under often difficult circumstances punctuated by extended periods of civil strife was laudable. 33 Supervision missions were conducted regularly, often by sizeable Bank teams (generally six or more specialists). Informative aide-mémoires with detailed component results and lists of observations and recommendations were submitted in a timely manner. Fiduciary management was particularly systematic. 117. The task team’s contributions to the project were especially useful (and valued by the Borrower) for: (i) the systematic analysis of progress (accompanied by very comprehensive action tables); and (ii) the identification of implementation issues where progress was inadequate. Despite the recommendations, action plans, and management letters, the missions were less successful in resolving a number of chronic problems, including poor implementation of the population component, slow formulation of certain strategies necessary to organize financing, and insufficient counterpart funding. There was a tendency to identify the need for a study, for which terms of reference were eventually proposed but which rarely reached a concrete conclusion. 118. During the initial credit, the ISRs had several weaknesses: (i) some of the ratings seem to have been too generous, notably for achievement of the PDO and financial management; and (ii) the component ratings tended to lag about a year after the findings of the supervision missions. The supervision reports did not include many observations about how the IDA financing reinforced other financing in the sector (e.g., EU, GFATM, etc.) or the contributions of other agencies (e.g., UNAIDS for the REDES, UNICEF for the MICS, etc.). During the AF, the ISRs tended to emphasize the positive findings rather than the observed implementation challenges. 34 In addition, discussion of measures to promote the future sustainability of the project’s benefits was insufficient. 33 Two other TTL assumed responsibility for the additional financing (the last for only the final six months before project closing). 34 Compare, for example, ISR 18 (December 2012) with the TA report on project progress (November 2012) where the former rates the PDO and the IP as satisfactory and the latter identifies an urgent need to reinvigorate all of the project’s activities (p. 7, and especially Annexes 5 and 6). (c) Justification of Rating for Overall Bank Performance Rating: Moderately Unsatisfactory 119. Following ICR guidance that when ratings for the two dimensions are in different ranges (moderately unsatisfactory for quality at entry and moderately satisfactory for supervision), the rating for overall Bank performance depends on the outcome rating. Bank performance is therefore rated Moderately Unsatisfactory. 5.2 Borrower Performance (a) Government Performance Rating: Moderately Unsatisfactory 120. Government performance is rated as moderately unsatisfactory, based on an assessment of its moderately satisfactory performance on HIV/AIDS and its unsatisfactory performance on population. From a statutory perspective, the promulgation of a national population policy and laws on RH and protection of the rights of PLWHA constitute significant accomplishments. The implementation of these laws through the adoption and application of the necessary judicial texts has not followed. 121. The Government also provided satisfactory project oversight, including: (i) participation of the prime minister in the steering committees; (ii) support for the project implementation unit (including their retention during the period 2009-10); and (iii) its contribution to the development of a common enabling environment (politico-legal, institutional, technical, financial, and administrative) facilitating the national response by public and private actors. 122. Performance of Government entities at the regional levels (regional health councils and regional population commissions) was less successful, though the participation of the regional governors in the efforts of the mobile health teams was positive. Though the project envisioned funds for both entities, only the population commissions took advantage of them. Disbursement tended to be slow and justification of expenditures even slower. Also, while timely counterpart funding was weak, the amounts were eventually paid and served to carry out project activities during the 2008-09 period (particularly for the mobile teams). The Government’s relationships with donors, partners, and other stakeholders were not always productive. (b) Implementing Agency or Agencies Performance Rating: Moderately Satisfactory 123. The PCT’s performance is rated Moderately Satisfactory. Though confronted with a succession of intractable problems (ranging from complicated Government procurement regulations to the destruction of their offices), the PCU provided both an effective environment for project implementation and a positive channel for communication between the project and the Bank. The PCU showed tremendous resilience during project implementation, responding to changing circumstances and adapting program interventions as required. The PCU was recognized as an effective coordinating unit (and not viewed, as in many other similar projects, as an implementing unit). The PCT effectively handled the period from 2008-2010 by maintaining core staff and ensuring the continuation of key activities (notably, the mobile health teams). The PCT also effectively managed the start-up and implementation of the AF as well as the oversight of the RBF initiative. 124. Neither procurement nor financial management was ever rated lower than moderately satisfactory, but: (i) the aides-mémoires noted procurement problems related to conformity with the procurement procedures, delays, contract management, and procurement documentation; and (as noted previously) there were problems with virtually all of the external audits. Finally, the MTR was carried out with considerable delay and without all of the planned documentation, but the borrower’s completion report was completed on time. 125. Several other entities assumed responsibility for the implementation of the project’s components; an assessment of their performance is presented in Annex 10. (c) Justification of Rating for Overall Borrower Performance Rating: Moderately Unsatisfactory 126. Following ICR guidance that when ratings for the two dimensions are in different ranges (moderately unsatisfactory for Government performance and moderately satisfactory for implementing agency), the rating for overall Borrower performance depends on the outcome rating. Borrower performance is therefore rated Moderately Unsatisfactory. 6. Lessons Learned 127. Combining components for HIV/AIDS and population (and RH) in a single project is challenging. While the Bank can be instrumental in stimulating Government commitment for both HIV/AIDS and population, commitment is perhaps more easily sustained for HIV/AIDS than for population. Though both address sensitive cultural issues, mobilizing support is easier to achieve when personal interests (e.g. avoidance of HIV) are at stake 35 and more difficult to obtain with respect to changing long-standing traditional attitudes and practices (e.g. the demand for large families and high fertility). The case of religious leaders in Chad offers the example of where their support for HIV/AIDS prevention strengthened the project’s actions but (despite project efforts to raise awareness) their opposition to family planning and population weakened the project’s achievements. 128. The advantages and disadvantages of building on previous projects need to be carefully examined during project preparation. Continuing interventions which had been successful during PACP1 was an attractive option for PACP2, but by the mid-term review it was clear that many of these “inside” approaches needed substantial modification or elimination. Instead, the interventions which succeeded in the late stages of the initial credit and throughout the additional financing were innovations based on “outside” ideas adapted to the Chadian context. For the follow-on project to PACP2, evaluations of past performance and studies of future improvements are in progress to ensure that the two innovations initiated during the 35 The PPAR for PACP1 cites informant comments indicating that “the fight against HIV/AIDS became more relevant (especially in the south) as the epidemic progressed and more people observed first-hand and were affected by the disease and its consequences”. (p. 30). additional financing period (results-based financing and mobile health teams) remain pertinent for the foreseeable future in Chad. 129. Risk assessment is an essential aspect of project design. A more rigorous risk assessment of PACP2 might have concluded that: (i) significant risks (political, socio-cultural, technical, and financial) existed; (ii) potential mitigation measures would likely be insufficient; and (iii) the feasibility of completing the project as designed was questionable. In addition, it should also have comprised risk assessments for institutional arrangements and financing, both of which underlie potential commitment to the project’s objectives. Where roles and responsibilities are insufficiently defined and/or overlap, implementation will suffer; where future financing is uncertain, sustainability will suffer (even with adequate institutional arrangements). While the introduction of the mobile health teams and the RBF contradicted this lesson, this was justified by the fact that when the existing delivery of services is so poor and the need for services so great, important risks are warranted, even without adequate feasibility studies. For the follow-on project, more “due diligence” is in progress to assess accurately the risks of the operation with a view to build stronger government ownership. 130. The importance of efficiency as a criterion for assessing health and social development projects must be seen in a broader context. Multi-sectoral responses to sensitive socio-cultural issues, a comprehensive range of interventions involving health and non-health actors (at national, regional and local levels), and the participation of organizations, associations, and communities with varying capabilities have all been shown to be essential but not predictably efficient components of success. This is especially true when these various aspects are considered in the context of Chad’s ongoing civil strife. What is important in these circumstances is: (i) focusing on sectors with the greatest potential impact on the epidemic (health, defense, education, etc.); (ii) clearly distinguishing the potential contributions (political mobilization, technical expertise) of community organizations; and (iii) initiating and sustaining a series of priority actions. 131. There is no substitute for timely baseline data and an operational M&E system. Though often ignored by task teams, these elements are needed by projects: (i) at the beginning to ensure that targets (and the expectations raised by them) are reasonable; (ii) during to assess financial and technical accountability and provide the means for evidenced-based project management; and (iii) at the end to determine whether (and to what extent) the results can be attributed to the project. 7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners 132. (a) Borrower/implementing agencies: The task team and the Borrower reviewed and agreed on the results of the indicators reported in the Data Sheet. 36 The Borrower has prepared a comprehensive final evaluation report in French and an English summary, which is presented in Annex 7. The Borrower’s final evaluation report is available from the Project Files. 36 A technical note was prepared at the completion of the ICR mission and is available in the project file. In addition , the Executive Secretariat has prepared final project evaluation. (b) Co-financing: Not applicable (c) Other partners and stakeholders: Not applicable Annex 1: Project Costs and Financing (a) Project Cost by Component Appraisal Estimate Additional Actual/Latest Original credit financing (USD Estimate (USD Percentage of Components (USD millions) millions) millions) * Appraisal 1. Strengthening of the capacities of key ministries 6.42 1.4 8.49 91.9% 2. Strengthening of the Social Fund (FOSAP) 9.56 7.5 16.40 93.0% 3a. Support to the existing program of social marketing (MASOCOT) 3.35 3.88 94.9% 3b. Piloting of performance-based financing 5.0 3.84 76.8% 4. Support to the implementation of the National Population Policy 2.94 0.1 3.13 84.4% 5. Project management 1.41 6.0 7.18 93.6% Estimated Total Baseline Cost 23.68 20.0 Physical Contingencies 0.58 0.0 Price Contingencies 3.07 0.0 Total Project Cost 27.33 20.0 42.92 90.7% Sources: Annex 3 of the PAD and Annex 5 of the AF FPP for cost by component; Project for actual estimate. (b) Financing Appraisal Additional Actual/Latest Type of Co- Estimate Percentage of Source of Funds financing (USD Estimate (USD financing (USD Appraisal millions) millions) millions) International Development 24.56 20.0 40.37 90.6% Association (IDA) Borrower 2.77 0 2.55 92.1% Total Project Financing 27.33 20.00 42.92 90.7% PAD, p.12; Annex 2a: Project perform ance / Outcom es Baseline Targets Results Value Year 2001 2008 2010 2003 2004 2005 2006 2008 2009 2010 2011 2012 2013 Original credit (2001) 1 By the end of the project, 95% of all men and 90% of all w omen aged 15-49 years are aw are of HIV/AIDS Men 88.1% 1996-97 95.0% 95.0% 89.8% Women 60.0% 1996-97 90.0% 90.0% 79.9% 63.9% Men 81.0% 2001 Women 79.0% 2001 2 By the end of the project, 50% of young people aged 15-24 w ill have used a condom at last non-union sexual contact w hich took place in the last 12 months Men 8.1% 2001 50.0% 25.4% 24.6% Women 5.8% 2001 50.0% 17.2% 17.0% 3 By the end of the project, 75% of military personnel w ill have used a 15.0% 75.0% 75.0% 67.6% condom at last non-union sexual contact w hich took place in the last 12 months 4 By the end of project, prevalence of HIV among pregnant w omen aged 7.0% 2000 5.25% 5.8% 5.2% 3.90% 15-24 w ill be reduced by 25 % 5 By the end of the project, w omen in union using modern contraceptive methods w ill have increased to 10% in urban areas and to 3% for rural areas Urban 4.2% 1996-97 10.0% 7.1% 5.7% Rural 0.3% 1996-97 3.0% 0.4% 0.5% Urban 6.6% 2000 Rural 0.8% 2000 6 By the end of the project, 60% of w omen 15-49 in union w ill w ish to 39.0% 2000 60.0% 38.0% Dropped space their next birth by at least 2 years Additional financing (2010) 7 By the end of the project, 70% and 50% respectively of men and w omen aged 15 to 24 w ill both correctly identify w ays of preventing the sexual transition of HIV and reject major misconceptions about HIV (% by gender) Men 20.2% 2004-05 70.0% 20.2% Women 8.1% 2004-05 50.0% 8.1% 10.1% 8 By the end of the project, 65% and 35% respectively of men and w omen (aged 15-24 yrs) w ill have used a condom during their last act of sexual intercourse w ith a non-regular partner in the last 12 months Men 25.4% 2004-05 50.0% 65.0% 25.4% Women 17.2% 2004-05 50.0% 35.0% 17.2% 9 By the end of the project, w omen using modern contraceptive methods w ill have increased to 10% in urban areas and to 3% in rural areas for the project intervention areas Urban 7.1% 2004-05 10.0% 10.0% 7.1% 5.7% Rural 0.4% 2004-05 3.0% 3.0% 0.4% 0.5% Annex 2b: Project perform ance / Interm ediate outcom es Baseline Target Results Value Year 2001 2008 2010 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Original credit (2001) Component 1: Strengthen capacities of key ministries 1 The National Control AIDS/STD Program fully functional, i.e., its six units 0 2002 Op. prog. 0 of 6 2 of 6 2 of 6 2 of 6 2 of 6 Dropped are functional, and implementing the National Strategic HIV/AIDS plans & Prevention Plan at the end of 2002 éval 2 Annually, the six selected key-ministries develop annually an action plan 0 2002 6 of 6 6 of 6 6 of 6 6 of 6 6 of 6 Dropped including prevention and care priority activities and report on the activities they have carried out during the previous year 3 Annually, the 14 Regional Health Councils develop an action plan 0 2002 14 of 14 0 of 14 0 of 14 0 of 14 0 of 14 0 of 18 Dropped including the prevention and care priority activities to be carnied out to (100%) support PLWHAs and their families and report on the activities they have carried out during the previous year Component 2: Strengthen FOSAP (Grants and Micro-credits) Component 3: Support for the Social Marketing program 4 Set up the social marketing program for oral contraceptives by the end 0 2002 No No No Dropped of the first 2004 quarter and ensure sales of 500,000 cycles a year by the end of the project 5 Set up the social marketing program for impregnated bed nets in the five 0 2002 No No Start 11205 14321 13 178 Dropped southern prefectures w here malaria is very prevalent by the beginning of 2002 Component 4: Support for implementation of the Nat'l Population Policy 6 Annually, the 14 Regional Population Commissions develop an action 0 2002 14 of 14 0 of 14 18 of 18 18 of 18 18 of 18 18 of 18 Dropped plan including the prevention and care priority activities related to (100%) increasing know ledge and underlining the need for behavior change in the areas of reproductive health and HIV/AIDS and report on the activities they have carried out during the previous year Additional financing (2010) Component 1: 7 Persons aged 15-49 w ho received counseling and testing for HIV and 88 189 1 703 6 493 24 462 7632 72111 19 431 62 589 80 646 169 799 160 227 136 645 received their test results (by gender) Men / Number 40 625 943 13 560 Men / % 3.7% 2004-05 12.5% Women / Number 47 564 760 10 902 Women / % 0.9% 2004-05 10.0% 8 Military personnel tested for HIV Number 2 517 2007 6 400 2414 4955 7 951 % 13.8% 35.0% 9 Pregnant w omen tested for HIV during prenatal consultations Number 173 2004-05 28 038 4 031 5 587 5 401 4 676 10 831 32 780 13 364 48 265 21 383 % 7.7% 2004-05 40.0% Component 2: 10 Condoms distributed (number) 4.1 5.05 4.1 million 4.1 million 3.4 million 4.1 million 4.5 million 11 Orphaned and vulnerable children aged 0-17 w hose households 6 872 2008 8 872 7 098 9 102 received free basic external support in caring for the child (number) 12 Women of child-bearing age reached by CBO interventions Number 29 082 2004-05 393 600 177 975 410 538 % 39.0% 2004-05 50.0% 45.2% 104.3% Components 3 and 4: Children immunized (DTC 3) Integrated approach / Annual number 59 367 71 620 2392 9706 39 441 50 137 26 944 13 Integrated approach / Cumulative number 39 441 89 578 116 522 Integrated approach / Coverage (%) 80.0% 95.0% 301.2% 129.6% 124.3% RBF approach / Number 34 420 46 732 5 059 44 736 12 399 14 RBF approach / Cumulative number 57.0% 95.0% 5 059 49 795 62 194 RBF approach / Coverage (%) 4.0% 5.2% 7.8% Pregnant w omen receiving antenatal care during a visit to a health provider (CPN1 / New consultations) Integrated approach / Annual number 50 928 70 094 1990 8859 42 562 50 384 38 637 15 Integrated approach / Cumulative number 42 562 92 946 131 583 Integrated approach / Coverage (%) 52.0% 80.0% 276.7% 110.9% 151.7% 55.0% 2010 RBF approach / Number 27 817 45 912 2 476 65 743 18 686 16 RBF approach / Cumulative number 80.0% 2 476 68 219 86 905 RBF approach / Coverage (%) 40.0% 5.5% 5.2% 7.3% Assisted deliveries in public and private health centers Integrated approach / Annual number 16 321 25 659 187 342 11 564 9 169 6 905 17 Integrated approach / Cumulative number 11 564 20 733 27 638 Integrated approach / Coverage (%) 20.0% 30.0% 75.2% 20.2% 27.1% RBF approach / Number 11 086 16 807 0 16 761 5 295 18 RBF approach / Cumulative number 18.0% 30.0% 0 16 761 22 056 RBF approach / Coverage (%) 0.9% 1.6% 2.5% Pregnant w omen vaccinated (VAT 2) Integrated approach / Annual number 51 305 70 094 871 2734 31 623 51 731 28 007 19 Integrated approach / Cumulative number 31 623 83 354 111 361 Integrated approach / Coverage (%) 58.0% 80.0% 205.6% 113.8% 110.0% RBF approach / Number 34 726 45 912 4 349 27 375 14 710 20 RBF approach / Cumulative number 49.1% 80.0% 4 349 31 724 46 434 RBF approach / Coverage (%) 1.1% 4.6% 6.5% Women attending post natal care consultations during a visit to a health provider Integrated approach / Annual number 3 389 7 698 20 1533 2 470 12 580 21 894 21 Integrated approach / Cumulative number 2 470 15 050 36 944 Integrated approach / Coverage (%) 3.1% 30.0% 18.9% 32.5% 31.6% RBF approach / Number 34 726 45 912 nd nd nd 22 RBF approach / Cumulative number 49.1% 80.0% nd nd nd RBF approach / Coverage (%) nd nd nd Annex 2c: Project perform ance / Outputs Baseline Targets Results Value Year 2001 2008 2010 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Original credit (2001) Component 1: Strengthen capacities of key ministries 1 Voluntary counseling and testing (VCT) services are available in 25% of Revised the 54 existing health districts by the end of 2003, and 75% by the end of the project Number 2 2002 41 2 20 36 45 52 52 72 Percentage 5% 2002 75% 3.7% 40.7% 66.7% 83.3% 96.3% 96.3% Component 2: Strengthen FOSAP (Grants and Micro-credits) 2 At the end of the project, FOSAP w ill have implemented at least 170 0 2002 170 projects Annual number 264 438 695 128 17 Specific vulnerable groups Jeunes 146 264 Femmes 57 84 Prostitués 11 17 Mossos 4 2 PVVS 9 12 Migrants 4 17 Autres 33 42 Cumulative number of sub-projects 0 264 702 1 397 1 525 1 542 Dropped 3 Sub-projects implementation and funds allocated to each category of nd nd nd nd nd Dropped grant sub-projects financed by FOSAP Grants w ill be at least 90% consistent w ith annual plan Specific vulnerable groups Jeunes 145 921 1 859 584 92 500 Femmes 92 905 0 72 000 Prostitués 27 890 107 496 19 000 Mossos 5 495 0 500 PVVS 1 210 113 649 0 Migrants 2 895 119 636 0 Autres 5 630 9 211 753 1 000 9 896 0 4 Micro-credit programs are available in 50% of the new departments by Dropped the end of 2003 and in all departments by the end of the project Departments (created in 1999) Cumulative number 2 19 27 27 27 27 Percentage (57 departments) 3.7% 32.8% 46.6% 44.8% 46.6% 46.6% Component 3: Support for the Social Marketing program 5 Increase the number of condoms available nationally through social marketing by at least 10% a year to reach 3 million by end of 2003 and at least 4 million by the end of the project Number 3.0 million 4.7 million 3.7 million 2.1 million 2.8 million 2.1 million 3.0 million Dropped 4.0 million 6 Increase the number of oral rehydration therapy (ORT) packets sold by 15% a year to reach 1.3 million by the end of 2003 and at least 2 million by the end of the project Number 1.3 million 1.9 million 0.9 million 1.4 million 0.8 million 1.2 million 1.1 million Dropped 2.0 million Component 4: Support for implementation of the National Population Policy 7 Betw een 2003-2005, 18 w orkshops/seminars (6 per year) designed for Dropped 1,000 religious leaders by AMASOT to raise aw areness on HIV/AIDS, STIs and risks associated w ith frequent & numerous pregnancies Cumulative number of w orkshops 18 5 11 27 Cumulative number of religious leaders 1000 250 750 1630 8 (DCA 2001): Betw een 2003-2005, 28 w orkshops/seminars (7 per year) Dropped designed for 1000 traditional leaders by AMASOT to raise aw areness on reproductive health issues. Cumulative number of w orkshops 28 2 14 32 Cumulative number of traditional chiefs 1000 144 672 1552 9 (DCA 2001): 75 IEC activities (15 per year) designed to modify Dropped reproductive health behavior are implemented using radio as media Cumulative number of IEC activities 75 14 35 35 Additional financing (2010) Component 1: Component 2: Components 3 and 4: Annex 3: Economic and Financial Analysis A. Summary of the original Economic Analysis (PAD 2001) 1. Initial situation. Annex 4 of the PAD noted that both high fertility and high HIV prevalence had been shown to negatively affect economic wellbeing and had been identified by the Government of Chad as major priorities to be addressed as part of its development and poverty reduction strategy. The first part of the annex addresses HIV/AIDS while the second treats high fertility; in both cases, an analysis of the cost of inaction will be related to the cost of action. 37 2. HIV/AIDS. Annex 4 assumed that HIV/AIDS was on the rise in Chad and “seemed” to have moved towards a generalized epidemic. Prevalence was estimated by UNAIDS at 3 percent in 1999, but cross-sectional studies conducted in four cities in 2000 showed prevalence among adults at 9-15 percent. Based on the 2000 results, the annex estimated the number of PLWHA in 2000 at between 160,000 and 360,000 and projected that this number could reach between 260,000 and 700, 000 by 2005, that is, double between 2002 and 2005. 3. Population. Annex 4 estimated that population size would grow at an annual rate of some 3 percent, based on an expected decrease in child mortality and a slight rise in fertility. This would reflect a classic demographic transition pattern resulting from decreasing use of traditional birth spacing methods but not yet accompanied by an equivalent increasing use of modem contraceptive methods. Assuming a constant level of fertility, Annex 4 projected that the population was likely to almost double within the next 20 years with an explosion of the number of people less than 20 years of age. Annex 4 concluded that significant changes were needed to modify the economic environment and encourage the use of family planning methods but noted that family planning services benefit only a small proportion of the population, mainly the richest and most educated. 4. As in a number of instances under MAP 1 and MAP 2, assessment of HIV/AIDS prevalence was overestimated; the number of PLWHA in 2005 was estimated at 193,000 and at 206,000 in 2010. Similarly, the projected population growth rate was overestimated, as World Bank data showed a downward trend from 3.23 percent in 2005 to 2.62 percent in 2011. 5. Projected costs of inaction and benefits of action. Annex 4 attempted to estimate the costs of inaction and action in intervening to reduce the spread of HIV/AIDS and slow population growth. 6. HIV/AIDS. Based on 2001 data, the projected costs of the epidemic comprised: • direct costs (for Government financing of hospitals and for outpatient care), which were estimated at US$560 per year per case of AIDS care, financed by the public sector (20 percent) and households (80 percent); and • indirect costs linked to losses in productivity and revenue from labor, which were estimated 37 The PAD referred to the “Economic Analysis of HIV/AIDS” in the Multi-Country HIV/AIDS Program for the Africa Region (MAP) Project Appraisal Document (Report No. 20727 AFT, Annex 5) and the Second Multi-Country HIV/AIDS Program (MAP2) (APL) for the Africa Region (Report No. P7497 AFR). It did not, however, cite the six volume study of the Swiss Tropical Institute (2001). 45 (based on the results of a case control study in 2001) at about US$800 per AIDS case per year. 7. Annex 4 then estimated the combined cost of AIDS in 2010 at almost US$200 million or 14 percent of GDP and the cumulative costs over the period 2000-2010 at between US$180 million to over US$1 billion overall, extremely high amounts suggesting that the epidemic was likely to have a substantial impact, not only on the welfare of households, but potentially on the pace of economic growth. 8. Given the costs of the project and the costs of inaction, Annex 4 concluded that the project should focus on implementing proven interventions to: (i) reduce the estimated number of new HIV/AIDS cases in targeted groups; (ii) reduce the estimated number of HIV/AIDS deaths resulting in a reduced number of years of life lost due to HIV/AID; and (iii) increase productivity and significant savings in public and private health care and expenditure. Specifically, Annex 4 estimated impact on incidence: • for female sex workers and male clients of: (i) increasing condom use; (ii) reducing the prevalence of STIs; and (ii) jointly increasing condom use and reducing STD prevalence; and • for males and females in union: (i) increasing condom use; (ii) reducing the number of sex partners; and (iii) jointly increasing condom use and reducing the number of sex partners. 9. According to the model used, a gradual change in condom use (2 percent increase per year) and an accompanying decline in STIs (1 percent per year) would, after 4 years, reduce the number of new infections among female sex workers and their male clients by 40 percent. Similarly, a gradual change in condom use (2 percent increase per year) and an accompanying decline in sex partners (of 0.1 per year) would, after 4 years, reduce the number of new HIV infections among couples by almost 40 percent and the number by almost 700 per 100,000 couples. Based on these changes, Annex 4 projected that, by 2010, the anticipated level of behavior change would represent a savings of US$5 to 30 million per year, or a cumulative savings of between US$17-$97 million. 10. These findings conform, for the most part, with the general findings in the literature, as shown in the following table 38 and with the proposals recommended by the preparation studies in 2000 39: 38 World Bank (2008) The World Bank’s Commitment to HIV/AIDS in Africa: Our Agenda for Action, 2007-2011, March, citing Bollinger and Stover (2007). 39 See Swiss Tropical Institute, Impacts socio-économiques du VIH/SIDA/MST au Tchad (June 2001), Table 6. 46 Central and West Africa (lower prevalence) Impact (% of Infections Averted) Cost per Low Medium High infection averted (0-10%) (10-20%) (> 20%) Low MSM Sex Workers (< US$ 1,000) Medium Blood safety PMTCT (US$ 1,000- Condom distribution VCT 3,000) Workplace programs High Community (> US$ 3,000) mobilization Mass media STI treatment Peer education 11. Population. Based on evidence of the impact of demographic changes on economic growth, poverty and inequality, Annex 4 identified the costs of inaction on fertility and population growth, comprising: • direct costs resulting from the continuing strain on social services as a consequence of rapid population growth; and • indirect costs emphasize the negative impact of population growth on the pace of aggregate economic growth and on the lost contribution of declining fertility to contribute to the reduced incidence and severity of poverty. 12. Given the costs of the project and the costs of inaction, Annex 4 concluded that the project should focus on implementing proven interventions to: promote the control of family size; increase the use of modern contraceptive methods; and adopt technologies contributing to child survival. To this end, Annex 4 proposed synergies between an expanded family planning program and the use of vaccination, impregnated bed nets, oral rehydration salts, etc. to reduce infant mortality. B. Development impact of the Second Population and AIDS Project: cost, benefits and efficiency 13. The development objective of the Project was to contribute to changing the behavior of the Chadian population so that they would adopt behaviors which would reduce the risk of: (i) infection from HIV; and (ii) too closely spaced and/ or unwanted pregnancies. Thus, the project was designed, then restructured, to comprehensively address supply and demand side issues related to costs and barriers to access HIV/AIDS and population information and health services. Costs, benefits and efficiency of the project are assessed in this section. 47 B.1 Project cost Table B1 : Project costs (in $US) Initial Additional Components Total financing financing (as disbursed) 2001 2010 8.49 6.42 1.4 Component 1:Strengthening the capacities of key Ministries Component 2:Strengthening of the Social Fund 16.4 9.56 7.5 (FOSAP) Component 3a: Support to the existing program 3.88 3.35 of social marketing (MASOCOT) Component 3b: Piloting of Performance-Based 3.84 5.0 Financing Component 4: Support to the implementation of 3.13 2.94 0.1 the National Population Policy Component 5 : Project Management 7.18 1.41 6.0 42.92 23.68 20.0 14. As no direct evidence is available to assess the direct impact on population of capacity building activities of component 1 and as activities under component 3a were funded by other partners after 2010, the economic analysis would be limited to the components 2, 3b and 4 (specifically with the additional financing). Indeed, more measurable information is available for these components and after 2010 (63 percent of AF costs; and 26 percent of the total project costs). 15. Components 2 (reoriented with the additional financing) and 4 supported the implementation of the decentralized and integrated approach. The integrated approach consisted in (i) the supply of a comprehensive package of basic maternal and child health services through mobile health teams; (ii) strengthening of the existing public and private health centers and voluntary counseling and testing centers, including for medical waste management; and (iii) promotion of demand for services through social mobilization, communication and peer education activities implemented by civil society. This approach was implemented in 10 health districts after 2010. 16. Component 3b financed a Performance-Based Financing (PBF) approach to improve maternal and child health outcomes in 8 pilot health districts (different from the 10 districts targeted by the integrated approach). This component supported the design, implementation and supervision of the PBF approach. 48 B.2 Direct benefits and cost efficiency 17. The project led to several impacts, including a greater awareness of HIV/AIDS issues, better availability and quality of HIV/AIDS and maternal and child health services, and an increase in utilization of these services. 18. The decentralized and integrated approach contributed to significant increases of health related indicators according to data from project surveys. Covering a population of 2.2 million in ten health districts, the cost of this intervention represented only US$2.6/hab/year: Table B2 : Achievement through the decentralized and integrated approach Indicators 2011 2013 % of youth (15-24) correctly identifying means of transmission and rejecting false ideas (PDO level indicator) 27,4 56,8 % of youth (15-24)using a condom with a non-regular partner during the last 12 months (PDO level indicator) 13,3 14,3 % of persons tested over the last 12 months who know the results 25,3 95,2 % of pregnant women with at least 3 antenatal visits 72,6 87,8 % of assisted deliveries 18,5 35,3 % of children vaccinated with Penta 3 14,3 62,7 Source: Project evaluations reports 19. The Performance-Based Financing pilot was implemented in eight health districts (different from the ones covered by the decentralized approach) from October 2011 to June 2013. Even after such a short period of implementation and limited funding (US$1.8/capita/year) for a PBF scheme, the intervention generated promising results: Table B3 : Achievement through the Result-Based Financing approach % of increase Oct. 2011 May 2012 May 2013 Oct 2011- May 2013 % of pregnant women having a Antenatal Care visit 5,10% 6,50% 7,30% 43% % of pregnant women having a 3rd Antenatal Care visit 1,60% 1,80% 3,60% 125% % of women (15-49) using modern contraceptive methods 0,10% 0,40% 0,60% 500 % % of children immunized with Penta3 3,50% 4,90% 7,80% 123% Quality score of the FBR health facilities 41,47% 63,14% 66,51% 60,38% Source: Project evaluations reports B.3 Cost effectiveness analysis 20. Project interventions are technically sound and recognized as high impact interventions to 49 reduce the risk of infection by HIV40 and child and maternal mortality rates 41. Both innovative interventions funded through the Project (additional financing) had a limited cost: US$2.6 /hab/year for the integrated and decentralized approach and US$1.8/hab/year for the RBF pilot. 21. Due to data availability and methodological constraints, an estimation of Disability-Adjusted Life Year (DALYs 42 ) gained from the project is not proposed. However, implementation of components 2, 3b and 4 could be compared to similar interventions related to HIV/AIDS prevention and family planning programs in other Sub-Saharan countries. As stated in the table below, these interventions cost between US$12 and US$34 per DALY gained. By international standards, health interventions that cost less than US$100 per DALY are considered highly cost-effective. Thus, the integrated and decentralized approach and the RBF pilot can be considered as highly cost-effective as they both contributed to HIV/AIDS prevention and family planning activities. Table B4 : Average cost of HIV/AIDS and family planning interventions per DALY gained (US$) Intervention Cost per DALY gained (US$) Diagnosis and treatment of STIs 12 Voluntary counseling and testing 18–22 Family Planning Program 34 Source : Cost-effectiveness of HIV/AIDS interventions in Africa: a systematic review of the evidence, The Lancet, Vol 359 May 11, 2002 and Levine et al, 2006 for family planning intervention (data for Sub-Saharan Africa). Financial Analysis 22. According to Annex 4, the fiscal impact of the project was likely to be small, as: (i) less than US$ 6 million was expected to be disbursed annually; and (ii) counterpart funds (mostly for operational costs) were not expected to be unduly heavy (particularly given current HIPC and future oil revenues). The actual fiscal impact would be somewhat diminished by the fact that much of the project would be directly channeled to CSOs, NGOs, and communities, which were required to generate their own counterpart contributions equivalent to 20 percent of the cost of their proposals. Despite the difficulties with counterpart financing under the initial credit, these assumptions were (and remain) valid. Other 23. IEG suggests other criteria for assessing the benefits of MAPs, 43 including: (i) enhanced political commitment to controlling the epidemic; (ii) expanded and strengthened national and sub- 40 Cost-effectiveness of HIV/AIDS interventions in Africa: a systematic review of the evidence, Andrew Creese, Katherine Floyd, Anita Alban, Lorna Guinness, The Lancet, Vol 359 May 11, 2002. 41 Disease Control Priorities in Developing countries, Levine et al., 2006. 42 DALYs are a measure of overall burden of disease, expressed as the number of years lost due to ill-health, disability or early death. 43 Committing to Results: Improving the Effectiveness of HIV/AIDS Assistance (Washington, 2005). 50 national AIDS institutions for the long-run response; (iii) mobilization of NGOs in the national response and reinforcement of their capacity to provide access to prevention and care among the high-risk groups most likely to contract and spread the infection; and (iv) enhanced the efficiency of national AIDS programs. These were also all positive. 51 Annex 4: Bank Lending and Implementation Support/Supervision Processes (a) Task Team members Names Specialty Lending Michele Lioy Task Team Leader T Agnes Soucat Health Economist, AFTH2 Daniel Dupety Implementation Specialist, Consultant Magaye Gaye Financial Specialist, Consultant Oliver Weil Public Health Specialist, Consultant Morsen Farza Specialist in Community-Led Initiatives, Consultant S Negoa Jahanshashi Social Fund Specialist, Consultant S Supervision/ICR Responsibility/ Names Title Unit Specialty Maryanne Sharp Operations Officer AFTH2 Hughes Agossou Financial Management Specialist AFTFM Charles Donang Procurement Specialist AFTPC Etienne Nkoa Financial Management Specialist AFTPC Ando Raobelison Public Health Specialist Maryanne Sharp Task Team Leader AFTH2 Boubou Cissé Task Team Leader AFTH2 Benjamin Loevinsohn Lead Public Health Specialist AFTH2 Gaston Sorgho Sr. Technical Specialist AFTH2 Lanciné Dorso Financial Management Specialist AFTFM Berthe Tayelim Program Assistant AFMTD Enias Baganizi Sr. Health Specialist AFTH2 Sekou Keita Financial Management Specialist AFTFM Aissatou Diack Task Team Leader AFTHW Peter Bachrach Consultant in Health Administration AFTH2 Beth Wanjeri Mwangi Financial Management Specialist AFTFM Papa Aynina Diop Financial Analyst CTRLA Alain-Désiré Karibwami Health Specialist AFTHW Paul Jacob Robyn Health Specialist, Consultant AFTHW Paulette Zoua Program Assistant AFMTD Arci Djerkane Consultant (Financial Management) Celestin Niamen Financial Management Specialist AFTFM Diane Steele Survey Coordinator DECPi Olivier Beguy ETC AFTP3 Valerie Evans Consultant Sylke von Thadden Public Finance Consultant Daniele Jaekel Operations Analysit AFTHW Nicole Hamon Language Program Assistant AFTHW 52 (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 2000 Not available 2001 20.82 157,457.76 2002 2.98 5,701.03 Total: 23.80 Note: Breakdown by fiscal year is not available. Supervision/ICR 2002 17.06 93,596.97 2003 18.88 94,837.39 2004 29.38 120,252.86 2005 16.38 152,273.23 2006 39.06 161,539.85 2007 25.09 7,560.00 2008 11.48 75,674.32 2009 3.03 78,057.97 2010 13.78 133,383.35 2011 17.36 128,712.59 2012 1.50 2,130.60 2013 13.20 127,403.48 2014 2.35 11,408.27 Total: 218.55 1,186,830.88 53 Annex 5: Beneficiary Survey Results Though a beneficiary assessment was completed for the MTR, it was destroyed when the project offices were burned in 2008. An analysis of the project’s “penetration” and interviews with some beneficiaries were undertaken as part of the final evaluation, and showed that some 70 percent of the target population in the project zones knew (connaissance) with the project, and of these, 60 percent had had experience with the project implementing agencies. Among the communication channels cited most frequently by the population were: (i) the mobile health teams (83.6 percent); (ii) the community-based organizations (67.7 percent); (iii) local radio (66.5 percent); and (iv) other members of the community (51.3 percent). 54 Annex 6: Stakeholder Workshop Report and Results Not applicable 55 Annex 7: Summary of Borrower's ICR and/or Comments on Draft ICR 1. The Population and AIDS Control Project (PACP 2) has been implemented since April 2002 by the Ministry of Planning, Economy and International Cooperation (MPECI) and managed by the PCT under the aegis of a Steering Committee, chaired by the Secretary General of the said Ministry. It was designed to enhance the achievements of PACP 1 by focusing on changing people's behavior with respect to STI, HIV/AIDS, RH, and family planning. Initiated by the Government of Chad with technical and financial support from the World Bank, it supports implementation of the National Population Policy (NPP) and the National Strategic Framework to Fight AIDS (CSNLS). 2. Additional funding for PACP 2 was provided for the period from June 2010 to June 2013. This evaluation was designed to assess the results of the project, both immediate (output) and intermediate (effects and outcome), in the context of the ten health districts supported by the project (Kanem, Salamat, Logone Occidental, Logone Oriental, Mayo Kebbi West region, and N'Djamena). A survey was conducted of a representative sample of households in areas covered by PACP 2 and of the Priority Vulnerable Groups (GVP) to determine the effects and results of the key activities, the penetration of the Project, and the satisfaction of those members of vulnerable groups and people living in the priority service areas. In addition to the survey, interviews and discussions were also conducted with officials of the project and partners involved in its implementation (e.g. FOSAP); documents were also made available to the evaluation team. 3. The evaluation addressed project relevance, effectiveness/impact, efficiency, sustainability, and visibility. 4. Relevance. The project was consistent with the National Strategy for Growth and Reduction of Poverty (NPRS2) adopted in April 2008; the Declaration of Population Policy adopted in January 1994 and revised in July 2007; the National Strategic Framework for the Fight against STIs/HIV/AIDS (2007-11); and the national roadmap for accelerating the reduction of maternal and child mortality (2009-2015). 5. The project’s three development objectives (PDO) were appropriate, consistent, and clearly related to the problems identified. PACP 2 was designed to consolidate the achievements and experience of PACP 1 through: (i) actions focused on changing people's behavior with respect to STI/HIV/AIDS, RH, and family planning; and (ii) initiation of an additional component “RBF” to improve outcomes of maternal and child health in four other pilot regions. Each of the four components addressed an aspect of the problem and was also relevant. 6. Effectiveness/Impact. With respect to the PDO, all the deliverables have been fully met or are on track to be. Results from the survey for the various indicators are presented in Attachment 1. 44 The impact of the project’s peer education (on awareness of HIV/AIDS) and social communication sessions (on RH/FP) have been very noticeable despite the relatively high attrition in attendance. 44 Though not included in the Borrower’s final report, results for comparable indicators from the 2011 and 2013 surveys are presented in Attachment 2 for the reader’s convenience. Data in the report from project sources has been included in the text of the ICR. 56 7. Efficiency. Regarding project management and the relationship between cost-effectiveness and efficiency, the procedures developed and implemented by the project contributed to effective daily management. The project monitoring and evaluation established by the PCT and FOSAP was especially valuable. 8. Collaboration with the administrative authorities was very good, and their involvement in the project activities was very noticeable. The local authorities were particularly pleased with the mobile health teams and their ability to bring services to the populations in rural, underserved areas. They were concerned about the continuation of the project’s benefits. 9. With the community-based associations and their support groups, there were misunderstandings from time to time, especially related to delays in in the transmission of supporting documents of funds and activity reports by the CBA and DP and disbursements by FOSAP. 10. The social centers also complained of inadequate support for vulnerable people. Relations between the social centers and the associations of PPLW were not always smooth, and the PPLW associations found it very difficult to provide home visits for patients, especially for patients living in rural areas. 11. Sustainability. The selection of districts for project implementation did not sufficiently take into account either local perceptions and needs or status systems and beliefs; this was particularly noticeable in the Kanem and Salamat Districts. 12. The project’s financial viability, including peer education and social communication services, which entirely relied on the use of local dialects, were well-considered and welcomed by communities, and there is no doubt that these elements will continue in some form. Funding for the CBA were only sufficient to cover the activities planned, and it is doubtful these activities will continue beyond the life of the project. The situation is almost identical in the social centers, where the sustainability of the the project’s achievements is not yet on their agenda. Supplies of inputs for systematic screening and treatment of STIs as well as all the benefits of mobile teams to the development of maternal and child health will need to rely on Government assistance. 13. Visibility. The project was well-known and received throughout the project areas and affected communities: about 70 percent of respondents knew of the project, and among these, 60 percent were also familiar with key partners’ developing activities in the field. In the regions of Logone Occidental, Logone Oriental, and Salamat, the proportion of the population aware of the project was highest; in the Kanem Region and even in the capital, only 40 percent of the population knew of the project. 14. The project’s strong popularity resulted from the implementation approach adopted by the project, and particularly: • The range of service providers involved at various levels in the implementation of activities. These included: NGOs and Community-Based Associations, community and public radio, theater troops, health services (Voluntary Testing Centers, Health Centers), Social Centers, Legal Clinics, and Associations of PLWHA; and 57 • The high mobility in districts of the mobile health teams, and especially the indication "Mobile Team, PPLS2/FOSAP” on all vehicles. 58 Results of the 2013 Survey of PACP 2 zones Logone-Occidental Mayo Kebbi Ouest Logone-Oriental N'Djamena Salamat Kanem Total OUTCOMES % of youths (15-24 years) correctly identifying means of transmission and rejecting false ideas Males 30.3% 41.3% 80.7% 70.2% 73.0% 46.3% 55.5% Females 27.8% 51.1% 64.3% 77.8% 48.7% 60.4% 57.8% Total 29.2% 46.7% 71.1% 74.7% 57.4% 54.5% 56.8% % of youths (15-24 years) using a condom w ith a non-regular partner during the last 12 months Males 3.4% 33.3% 18.7% 12.6% 15.9% 25.0% 18.6% Females 4.3% 11.6% 16.7% 3.2% 2.7% 29.7% 11.0% Total 3.8% 21.3% 17.5% 7.0% 7.4% 27.7% 14.3% % of w omen using modern contraceptive methods Urban 22.7% 56.3% 52.3% 25.4% 44.7% 59.1% 45.0% Rural 1.9% 39.3% 48.9% 9.3% 29.0% 0.0% 26.5% Total 7.4% 44.1% 49.9% 15.4% 34.0% 59.1% 33.5% RESULTS Voluntary counseling and testing (VCT) % of persons tested over the past 12 mos. 10.7% 51.8% 40.7% 31.4% 29.8% 28.6% 34.0% % of persons tested over the past 12 mos. know ing results 95.9% 97.0% 97.1% 91.2% 92.1% 94.9% 95.2% % of military personnel tested over the past 12 mos. 96.8% 65.8% 71.1% 76.8% 66.7% 54.4% 70.2% % of pregnant w omen tested during antenatal care 68.4% 85.0% 73.3% 70.5% 95.4% 71.7% 77.2% Maternal health % of w omen of child-bearing age benefiting from IEC on RH/FP 21.7% 34.3% 43.0% 33.1% 73.8% 6.8% 35.6% % of pregnant w omen w ith at least 3 antenatal visits 83.2% 93.6% 87.2% 92.5% 78.2% 93.6% 87.8% % of pregnant w omen w ith at least VAT 2 92.6% 82.3% 74.2% 42.5% 80.9% 63.0% 70.1% % of assisted deliveries 14.2% 42.6% 38.5% 20.6% 52.1% 61.4% 35.3% % of w omen benefiting from post natal consultation before 1 mo. 29.3% 84.0% 76.3% 82.9% 60.7% 100.0% 66.3% Child health % of children vaccinated w ith Penta 3 79.2% 24.4% 55.9% 69.6% 67.9% 42.9% 62.7% % of children (0-2 years) w ith a vaccination card 97.0% 96.1% 72.7% 97.9% 94.9% 95.1% 91.2% % of children (0-2 years) w ith an up-to-date vaccination card 0.0% 0.0% 3.3% 26.2% 20.8% 0.0% 11.9% Sexually transm itted infections (STI) % of men and w omen know ing means of transmission of STI 30.7% 81.9% 93.2% 86.3% 90.2% 81.2% 77.7% % of persons w ith signs of STI during the last 12 mos. 10.9% 19.3% 25.1% 8.6% 9.5% 17.1% 16.4% Social com m unication % of population w ith know ledge of PACP 2 34.2% 72.1% 85.9% 62.7% 84.5% 39.3% 65.2% % of households w ith at least one member benefiting from a project service 89.2% 90.3% 62.5% 91.9% 77.2% 59.3% 76.2% % of w omen of child-bearing age participating in at least 1 social communication session 0.152 35.0% 43.0% 34.9% 75.0% 3.8% 35.9% % of vulnerable groups participating in the full cycle of social communication 21.3% 27.7% 35.7% 11.4% 36.3% 40.0% 27.0% 59 Com parison of the 2011 and 2013 Survey Results of PACP 2 zones Logone-Occidental Mayo Kebbi Ouest Logone-Oriental N'Djamena Salamat Kanem Total OUTCOMES % of youths (15-24 years) correctly identifying m eans of transm ission and rejecting false ideas 2011 Males 32.5% 18.0% 30.6% 55.9% 14.0% 21.7% 31.4% Females 4.7% 31.6% 14.5% 27.9% 10.5% 50.0% 24.3% Total 17.8% 25.6% 21.7% 40.4% 11.8% 38.0% 27.4% 2013 Males 30.3% 41.3% 80.7% 70.2% 73.0% 46.3% 55.5% Females 27.8% 51.1% 64.3% 77.8% 48.7% 60.4% 57.8% Total 29.2% 46.7% 71.1% 74.7% 57.4% 54.5% 56.8% % of youths (15-24 years) using a condom w ith a non-regular partner during the last 12 m onths 2011 Males 12.5% 17.2% 14.0% 15.7% 5.4% 32.2% 16.0% Females 6.6% 18.1% 5.6% 11.0% 3.1% 20.2% 11.5% Total 9.2% 17.7% 9.2% 13.0% 3.9% 24.5% 13.3% 2013 Males 3.4% 33.3% 18.7% 12.6% 15.9% 25.0% 18.6% Females 4.3% 11.6% 16.7% 3.2% 2.7% 29.7% 11.0% Total 3.8% 21.3% 17.5% 7.0% 7.4% 27.7% 14.3% % of w om en using m odern contraceptive m ethods 2011 Urban 5.5% 13.8% 7.0% 7.9% 4.1% 16.6% 10.3% Rural 3.8% 16.5% 1.2% 3.6% 7.6% 0.0% 7.4% Total 4.6% 15.8% 2.4% 5.2% 6.2% 16.6% 8.5% 2013 Urban 22.7% 56.3% 52.3% 25.4% 44.7% 59.1% 45.0% Rural 1.9% 39.3% 48.9% 9.3% 29.0% 0.0% 26.5% Total 7.4% 44.1% 49.9% 15.4% 34.0% 59.1% 33.5% RESULTS Voluntary counseling and testing (VCT) % of persons tested over the past 12 months w ho know the results 2011 23.6% 29.6% 20.3% 30.3% 16.5% 26.9% 25.3% 2013 95.9% 97.0% 97.1% 91.2% 92.1% 94.9% 95.2% % of military personnel tested over the past 12 months 2011 13.8% 67.6% 52.6% 43.8% 19.2% 27.9% 35.6% 2013 96.8% 65.8% 71.1% 76.8% 66.7% 54.4% 70.2% Maternal and child health % of pregnant w omen w ith at least 3 antenatal visits 2011 68.1% 61.3% 72.9% 85.9% 44.4% 89.7% 72.6% 2013 83.2% 93.6% 87.2% 92.5% 78.2% 93.6% 87.8% % of pregnant w omen tested during antenatal care 2011 64.0% 44.0% 100.0% 80.0% - 100.0% 63.0% 2013 68.4% 85.0% 73.3% 70.5% 95.4% 71.7% 77.2% % of assisted deliveries 2011 - 17.9% 28.9% 11.2% 3.1% 48.3% 18.5% 2013 14.2% 42.6% 38.5% 20.6% 52.1% 61.4% 35.3% % of w omen benefiting from post natal consultation before 1 month 2011 20.4% 5.0% 6.7% 6.7% 2.1% 5.8% 7.5% 2013 29.3% 84.0% 76.3% 82.9% 60.7% 100.0% 66.3% Child health % of children vaccinated w ith Penta 3 2011 6.5% 18.6% 3.1% 14.0% 14.3% 60.0% 14.3% 2013 79.2% 24.4% 55.9% 69.6% 67.9% 42.9% 62.7% 60 Annex 8: Comments of Co-financing partners and Other Partners/Stakeholders Not applicable 61 Annex 9: List of Supporting Documents Enquêtes Tchad Enquête Démographique et de Santé 1996-1997 (1997) Impacts socio-économiques du VIH/SIDA/MST au Tchad (2001) Multi-Indicator Cluster Survey (MICS) (2001) Tchad Enquête Démographique et de Santé 2004 (2005) INSEED et PNLS, Rapport de l’enquête nationale de séroprévalence du VIH/SIDA au Tchad (2005) Multi-Indicator Cluster Survey (MICS) (2010) UNGASS Reports (2004, 2006, 2008, 2010 and 2012) Evaluations Rapport d’évaluation de l’approche communautaire de renforcement des capacités pour une réponse efficace au VIH/SIDA (2012). Mahamat Hami Koua, Analyse du système de suivi évaluation du Programme National la Lutte contre le VIH/SIDA (PNLS) au Tchad (2007) Plan Stratégique de Lutte contre le SIDA au Tchad (2003) Plan National Multisectoriel de lutte contre le VIH/SIDA et LES IST - 2006-2008 (2006) Cadre Stratégique National de lutte contre le VIH/SIDA et les IST 2007-2011 (2007) Plan National de Développement Sanitaire du Tchad 2009-2012 : Tome 1/Analyse situationnelle, objectifs, orientations stratégiques (2008). Tome 2 : Programmation, suivi et évaluation (2008) Feuille de route pour l’accélération de la réduction de la mortalité maternelle et néonatale au Tchad 2008-2015 (2008) Plan stratégique de développement des ressources humaines pour la sante au Tchad 2011- 2020 (2010) Cadre stratégique national de Riposte au SIDA 2012-2015 (2011) Annuaire des statistiques sanitaires du Tchad (Années 2004-2009) PPLS, Rapport Annuel 2007 (2008) PPLS, Rapport Annuel 2011 (2012) PPLS, Rapport Annuel 2012 (2013) Indicateurs de suivi et évaluation : Rapports semestriel N°1-9 (2002-2006) Audit technique des organes d’encadrement de la lutte contre le VIH/SIDA au Tchad (2004) Rapport de mission de l’évaluation externe par les pairs de la mise en œuvre et des résultats initiaux du financement base sur la performance au Tchad (2012) Caractéristiques de la cartographie de séro-prévalence chez les travailleuses de sexe dans 15 villes du Tchad (2009) Evaluation à mi-parcours du PPLS 2 (2012) Troisième Enquête sur la Consommation et le Secteur Informel au Tchad (ECOSIT3) (2012) 62 Estimation des ressources et dépenses relatives au SIDA (REDES) au Tchad 2009-2010 (2011) Estimation des ressources et dépenses relatives au SIDA (REDES) au Tchad 2011-2012 (2012) Rapport Plan de Gestion des déchets bio médicaux (2007) Plan de gestion des déchets bio médicaux : Rapport Final (2012) Audit environnemental des infrastructures sanitaires appuyées par le deuxième projet de population et de lutte contre le SIDA (PPLS2) (2012) Projet de manuel d’exécution : Vol. 1 and 2 (2001) PAD, Second Population and AIDS Project (2001) Project Paper, Second Population and AIDS Project (2010) Misc. PPLS documents : Annual audits, FMR, etc Misc. Bank documents : Aides-mémoire, ISR, etc ICR, Population & AIDS Control Project (2002) PPAR, Project Performance Assessment Report (2005) ICR, Health Sector Support Project (2007) 63 Annex 10: Assessment of the Additional Project Implementing Agencies 133. As with the first project implementation, responsibilities were established for each component: (i) line ministries for Component 1; (ii) FOSAP for Component 2; (iii) AMASOT for Component 3; and the Ministry of Economic Planning and Development for Component 4. After the AF, AMASOT was dropped, and the MEPD assumed responsibility for oversight of the mobile teams. Finally, a consortium comprising an international NGO (AEDES) and a national NGO (CSSI) managed the RBF pilot program. Overall, the performance of the project implementing units is rated Moderately Unsatisfactory. 134. Line ministries. Six line ministries received assistance under the initial project and four under AF. Implementation started slowly (due in large measure to procurement delays), but the ISRs assessed performance as satisfactory through the Mid-Term Review and moderately satisfactory thereafter. The Ministry of Health performed well, and progress was made on: (i) expanding testing in regional and district hospitals and using mobile screening units to reach people living in rural and remote areas; and introducing free ARV treatment and biological/radiological check-ups which have markedly improved access to care and explain the rapid increase in the number of patients under medical supervision. The Ministry suffered from insufficient supplies of reagents and other consumables, difficulties coordinating with the mobile teams, and inadequate human resources to ensure the smooth implementation of the FBR sub-component. The performance of the Ministry of Defense was considered satisfactory, but the performance of the other ministries during both phases was variable. The overall performance of the line ministries is rated Moderately Satisfactory. 135. FOSAP. Though the ISRs judged FOSAP’s performance as satisfactory (except for the period around the Mid-Term Review), the ICR rates its performance as Moderately Unsatisfactory. FOSAP’s financial management would seem to have had significant problems; virtually all annual audits were qualified, and the auditor refused to certify FOSAP’s accounts in 2005, 2007, and 2008 (due in part to the civil strife which destroyed the financial records). The audits in 2011 and 2012 were approved, but not without a number of questions raised. 136. The results of the sub-projects were Moderately Satisfactory. With a manual describing the sub- project procedures, a pre-approved set of priority activities aimed at specific vulnerable groups, and the recruitment of oversight NGOs (projets dynamisateurs), FOSAP rapidly surpassed the project’s objective for the number of sub-projects to be financed. However, supervision missions noted that: (i) the sub-projects were not always targeted in line with the project’s objectives 45; and (ii) there were issues related to the actual performance of the sub-projects, particularly insufficient data collection and inadequate quality control. After the Mid-Term Review, the number of sub-projects was reduced and the selection and implementation guidelines modified significantly. Beginning in 2007, new sub-projects were suspended, and attention was focused on FOSAP’s role in implementing the integrated local response. 137. Micro-credits were Unsatisfactory. There were significant problems linked to the design (too few beneficiaries could actually be reached by the approach) and to the implementation by the oversight organizations (agences d’encadrement). The oversight organizations failed to ensure adequate management and reimbursement of the loans, and FOSAP was obliged to sue them (over the period 2006-08) to recover unpaid loans. 138. AMASOT. The ISRs rated the social marketing component satisfactory or moderately satisfactory through mid-2007 before dropping the rating to moderately unsatisfactory in late 2007 and dropping it entirely for the AF. Initial issues with AMASOT’s NGO status were followed by condom pricing issues with respect to neighboring countries and, then, the organization of oral contraceptive and bed net distribution campaigns. The 2006 audit highlighted a number of fiduciary issues, including more than 20 million FCFA 45 The December 2004 supervision mission concluded that all of the vulnerable groups benefited from the sub-projects, but the distribution among groups did not conform to the project’s objectives: e.g. only 3% PLWHA objective was achieved while 157% of the sub-project objective for youths and 588% of the target for other groups were achieved. 64 of ineligible expenditures. Based on poor management and a lack of achievement on almost all objectives, the ICR rates AMASOT’s performance as Unsatisfactory. 139. Ministry of Economic Planning and Development. ISR ratings for this component varied markedly over the life of the project: (i) from satisfactory through the end of 2004 (when the Population Division/Direction produced several important documents); (ii) to unsatisfactory through mid-2007 (when planned activities were implemented with difficulty, and there were questions about the Government’s commitment to the NPP); and (iii) except for the last ISR, to satisfactory through the end of the initial credit and the AF (based on the supervision of the integrated local response). Overall, as a result of the reorientation of the component, the ICR rates its performance as Moderately Satisfactory. 140. AEDES/CSSI. According to the final evaluation, there were minor shortcoming in the consortium’s performance, but, overall, it successfully carried out its contractual obligations. The ICR rates its performance as Moderately Satisfactory. 65 IBRD 33385 15°E 20°E 25°E To 0 100 200 300 Kilometers Akhaltsikhe 0 100 200 Miles CHAD LIBYA Aozou Tarso Emisou Pic Touside (3,376 m) (3,315 m) sti be Ti Zouar 20°N To 20°N Séguédine Emi Koussi (3,415 m) S a h a r a D e s e r t kou Bor N IG E R BORKOU - ENNEDI - TIBESTI Faya-Largeau Fada a r En ow lé ne iH é ad d di W o B Koro Toro Toro Oum-Chalouba ma ro) O Fa So BILTINE 15°N l( 15°N KANEM az a h G el Biltine hr Ba Mao Salal LAC B AT H A SUDA N Abéch Abé ché Abéchéé Bol Moussoro Oum Hadjer To Mouzarak Ati Nyala 1963 Level 1973 Level Batha 2001 Level Lake Chad Massaguet Bokoro Mongo Mangalmé Mangalmé OUADDAÏ N´DJAMENA N´DJAMENA N IG E RIA To Fotokol Beïda Beïda Goz Beï This map was produced by the Map Design Unit of The CHARI- Masalasef World Bank. The boundaries, colors, denominations and BAGUIRMI Deïa De Abou Deïïa any other information shown on this map do not imply, on Massenya the part of The World Bank To Group, any judgment on the Timan Am Timan Maroua Gélengdeng G élengdeng Melfi GUERA legal status of any territory, at or any endorsement or S A L A M AT m acceptance of such ala ha C Bousso ri boundaries. hr S To Bongor Maroua Ba 10°N Harazé Haraz é MAYO- MAYO- KEBBI Kélo K élo TANDJILE TANDJILE Lai MOYEN- CHARI Mangueigne To Birao CH A D Pala L Koumra Sarh SELECTED CITIES AND TOWNS og on LOGONE e Moundou Ba PREFECTURE CAPITALS OCC. Doba ng r an NATIONAL CAPITAL o C AM E RO O N ORIENTAL LOGONE ORIENTAL Gribingui am RIVERS Vina To B i Kaga Bandoro ng MAIN ROADS ui To To RAILROADS Bozoum Bossangoa CENT RA L A FRICA N PREFECTURE BOUNDARIES REPUBLIC Mbakaou INTERNATIONAL BOUNDARIES Res. 15°E 20°E SEPTEMBER 2004