Documentof The WorldBank ReportNo.: 31746 PROJECTPERFORMANCE ASSESSMENTREPORT CHAD POPULATIONAND AIDS CONTROL PROJECT (CREDIT NO. 2692) March7,2005 Sector, Tlzematicand Global Evaluation Group Operations Evaluation Department Currency Equivalents(annual averages) Currency Unit = FCFA ExchangeRateEffectiveAugust ExchangeRate Effective Exchange Rate EffectiveMarch 2004 December 31,2001 lst,1995 53 1CFA Francs = U S 1.OO 744 CFA Francs= US$l.OO 5 14 CFA Francs= USSl.OO US$0.1883= 100CFA Francs US$O.1344= 100CFA Francs USSO. 1946= 100 CFA Francs Abbreviations and Acronyms AIDS Acquired ImmuneDeficiency IEC information, education, and Syndrome communication AMASOT Association pour le Marketing KAP knowledge, attitudes, and practices Social au Tchad (Social Marketing KfW KreditanstaltFur Wiederaufbau Association o f Chad M&E monitoring and evaluation ARV anti-retroviral MASACOT Project Social Marketing Unit ASTBEF Association Tchadiennepour le M C H Maternal and child health Bien-Etre Familiale (Chadian MoPC MinistryofPlanningand Association for FamilyWell-being) Cooperation CERPOD Centre de Recherche sur la MoPH MinistryofPublic Health Populationpour le Ddveloppement MTR Mid-termreview (Center for Researchon Population NGO nongovernmental organization and Development) OED Operations EvaluationDepartment CNLS ComitdNational deLutte contre le PAIP Programme d 'Action et SIDA (National AIDS Committee) d 'InvestissementPrioritaire en CNPRH CommissionNationale de mati8re de Population (Program for Population et des Ressources Priority Actions and Investmentin Humaines (National Population and Population) HumanResources Commission) PCT project coordinationteam CPR contraceptive prevalence rate PLWHA people living with HIV/AIDS CPPRH Commission Preyectorale de PNLS ProgrammeNational deLutte Population et des Ressources Contre le SIDA (National Program Humaines (Prefectoral Commission ofAIDS Control) on Populationand Human PPAR Project Perfonnance Assessment Resources) Report CTLS Comite' Technique deLutte Contre PPLS Projetpopulation et Lutte contre le le SIDA (Technical Committee for SIDA (Population and AIDS AIDS Control) Control Project) DHS demographic and healthsurvey PRSP Poverty Reduction Strategy Paper FOSAP Fonds de Soutien aux Activitis en STD sexually transmitted disease mati2re de Population (Social Fund) TB tuberculosis HCPRH Haut Conseil de la Population et TOR terms o freference des RessourcesHumaines (High UNFPA UnitedNations PopulationFund Council on Populationand Human UNICEF UnitedNations Children's Fund Resources) USAID UnitedStates Agency for HIV HumanImmunodeficiency Virus InternationalDevelopment ICR ImplementationCompletion Report VCT Voluntary counseling and testing FiscalYear: Government: January 1-December 3I Director-General, Operations Evaluation : Mr.GregoryK.Ingram Director, Operations Evaluation Department : Mr.Ajay Chlxbber Manager, Sector, Thematic and Global EvaluationGroup : Mr.AlainBarbu Task Manager : MsDenise Vaillancourt i OED Mission: Enhancing developmenteffectiveness through excellence and independence in evaluation. About this Report The Operations EvaluationDepartmentassessesthe programs and activities of the World Bankfor two purposes:first,to ensurethe integrityof the Bank'sself-evaluationprocessandto verify that the Bank's work is producingthe expected results,andsecond, to helpdevelopimproveddirections, policies,and proceduresthrough the disseminationof lessonsdrawnfrom experience.As part of this work, OED annually assesses about 25 percentof the Bank's lendingoperations. Inselectingoperationsfor assessment,preferenceis givento those that are innovative,large, or complex; those that are relevantto upcomingstudies or country evaluations;those for which ExecutiveDirectorsor Bank managementhaverequestedassessments; and those that are likely to generate importantlessons.The projects,topics, and analyticalapproachesselectedfor assessmentsupport largerevaluation studies. A ProjectPerformanceAssessment Report (PPAR) is basedon a review of the ImplementationCompletion Report (a self-evaluationby the responsibleBank department)and fieldwork conducted by OED. To prepare PPARs, OED staff examine projectfiles and other documents, interviewoperationalstaff, and in most cases visit the borrowing countryfor onsitediscussions with project staff and beneficiaries.The PPARthereby seeks to validateand augment the informationprovided in the ICR, as well as examine issuesof special interestto broader OED studies. Each PPAR is subjectto a peer review process and OED managementapproval. Once cleared internally, the PPAR is reviewed by the responsibleBank department and amended as necessary.The completedPPAR is then sent to the borrower for review;the borrowers' commentsare attached to the document that is sent to the Bank's Board of ExecutiveDirectors.After an assessment reporthas beensent to the Board, it is disclosedto the public. About the OED Rating System The time-testedevaluationmethods used by OED are suited to the broad rangeof the World Bank's work. The methods offer bothrigorand a necessary levelof flexibilityto adapt to lendinginstrument, projectdesign, or sectoralapproach. OED evaluators all apply the same basic methodto arrive at their project ratings. Following is the definitionand ratingscale usedfor each evaluation criterion (more informationis availableon the OED website: http://worldbank.org/oed/eta-mainpage.html). Relevance of Objectives: The extent to which the project's objectivesare consistentwith the country's currentdevelopment prioritiesandwith current Bank countryand sectoralassistancestrategiesand corporate goals (expressedin PovertyReduction Strategy Papers, CountryAssistance Strategies,SectorStrategy Papers, OperationalPolicies).Possibleratings: High, Substantial, Modest, Negligible. Efficacy: The extent to which the project's objectives were achieved, or expectedto be achieved,taking into account their relativeimportance.Possibleratings: High, Substantial,Modest, Negligible. Efficiency: The extentto which the projectachieved, or is expectedto achieve,a return higherthan the opportunitycost of capitaland benefits at leastcost compared to alternatives.Possibleratings: High, Substantial, Modest, Negligible.This rating is not generallyapplied to adjustmentoperations. Sustainability: The resilienceto risk of net benefitsflows over time. Possibleratings: Highly Likely, Likely, Unlikely, HighlyUnlikely, Not Evaluable. lnstitutional Development Impact: The extent to which a project improvesthe abilityof a countryor region to make more efficient,equitableand sustainableuse of its human, financial, and natural resourcesthrough: (a) betterdefinition,stability,transparency, enforceability,and predictabilityof institutionalarrangementsand/or (b) better alignment of the missionand capacityof an organizationwith its mandate, which derivesfrom these institutionalarrangements.InstitutionalDevelopment Impactincludesbothintendedand unintendedeffects of a project.Possibleratings: High, Substantial, Modest, Negligible. Outcome: The extent to which the project's major relevantobjectiveswere achieved,or are expectedto be achieved, efficiently.Possibleratings: HighlySatisfactory, Satisfactory,ModeratelySatisfactory,Moderately Unsatisfactory,Unsatisfactory,Highly Unsatisfactory. BankPerformance: The extent to which services providedby the Bank ensured quality at entry and supportedimplementationthrough appropriatesupervision(includingensuringadequatetransitionarrangements for regularoperationof the project).Possibleratings: HighlySatisfactory,Satisfactory, Unsatisfactory,Highly Unsatisfactory. Borrower Performance: The extent to which the borrowerassumedownershipand responsibilityto ensure quality of preparationand implementation,and complied with covenants and agreements,towards the achievement of development objectivesand sustainability.Possibleratings: HighlySatisfactory.Satisfactory, Unsatisfactory,Highly Unsatisfactory. ... 111 Contents Principal Ratings ................................................................................................................ v Key Staff Responsible ........................................................................................................ v Preface .............................................................................................................................. .. vi1 Summary ........................................................................................................................... ix 1 BackgroundandContext . ............................................................................................ 1 2 . Objectives and Design .................................................................................................. 7 3 Implementation and Costs . .......................................................................................... 9 Implementation Experience ..................................................................................... 9 Planned VersusActual Costs and Financing......................................................... 13 4 Outputs and Outcomes by Objective . ........................... ........................................... 14 Population.............................................................................................................. 14 HIV/AIDS............................................................................................................... 17 5. Ratings ............................................................. .......................................................... , 25 6 Findings and Lessons . ................................................................................................. 30 References ......................................................................................................................... 37 Annex A .Basic Data Sheet .............................................................................................. 41 Annex B .Personsand Organizations Consulted .......................................................... 43 Annex C .Population and AIDS Control Project (Credit No 2692) ..Presentation of Project Components ................................................................................................... . 51 Annex D Program and Project Data . ............................................................................. 54 Annex E .Key Targets and Indicators Supported UnderPopulation and AIDS Project ......................................................................................................................... 64 Annex F .Borrower's Comments .................................................................................... 67 Ths reportwas preparedbyDenise Vaillancourt. who assessedthe project inFebruary 2004.The report was edited by William B.Hurlbut. and Pilar Barquero provided admmistrative support. iv Boxes Box 1. 1994 PopulationPolicy Objectives: ........................................................................ 2 Box 2. Second Medium-TermPlanfor AIDS Control- Strategic Orientations (1995- 1999) ........................................................................................................................... 4 Tables Table 1.Summary OED Ratings by Objective................................................................. 25 Figures Figure 1.ReportedAIDS Cases 1986. ..................................................................... 2002 3 Figure2.Useo fcontraception amongmarriedwomen andthose inconsensual union, 1996 and2000........................................................................................................... 16 Figure3.Condom Sales. 1996-2002................................................................................. 19 Figure4.Percent ofmenandwomen surveyed declaring they have heardofAIDS.......22 Figure5 Percent ofmen andwomenwho know condoms are ameans ofprotection.....22 . Figure 6.Percent o fmenand women who know that fidelity i s a means ofprotection...22 Figure7.EvolutioninLevels o fKnowledgeofWomen by Socioeconomic Group. 1996- 2000........................................................................................................................... 23 Figure 8.Ever-Use o f Condoms (percent). 1996 and 2003 .............................................. 23 Figure9.Trends inAdult PrevalenceinThree Cities ...................................................... 24 Figure 10.HIVPrevalenceAmong Women UsingPrenatal Services inFour Urban Sites. 1999-2002 ................................................................................................................. 25 V PrincipalRatings ICR * PPAR ~- Outcome Satisfactory ModeratelySatisfactory Sustainability Likely Likely InstitutionalDevelopment Modest Substantial Impact Bank Performance Satisfactory Satisfactory Borrower Performance Satisfactory Satisfactory * The ImplementationCompletion Report (ICR) is a self-evaluation by the responsibleoperational division of the Bank. Key StaffResponsible -Project Task Manager/Leader SectorManager CountryDirector --I Appraisal Eva Jarawan David Berk FranciscoAguirre- Sacasa Completion MicheleL. Lioy Arvil Van Adams RobertCalderisi vii Preface This is theProject Performance Assessment Report (PPAR) for the First Population andAIDS Control Project inChad. This project was financed through IDA Credit No. 2692 inthe amount o fUS$20.4 millionequivalent (13.9 million SDR) with a plannedgovernment and community contributions o fUS$1.3 million andUS$l.O million, respectively, andprojected cofinancingby KfW and UNFPA inthe respective amounts o fUS$4.4 million andUS$O. 1million for a total cost o fUS$27.2 million. The credit was approved on March 23, 1995, became effective on September 8, 1995, and closed on December 31,2001, after a six-month extension. The credit was fully disbursed. The findings o fthis assessmentare basedon an Operations Evaluation Department(OED) missionto ChadinFebruary 2004. Themissionmet inN'Djamena with: authorities andstaffo fthe Ministryo fPlan, Developmentand Cooperation (including the Project CoordinationTeam); the Ministryo fPublic Health; other public sector agencies implementing population andHIV/AIDSactivities; the Social Marketing Association (AMASOT); the Social Fund(FOSAP); representatives o f civil society; and keydonors supporting population andHW/AIDS activities inChad. The mission also visitedthe cities (andprefectures) o fMongo (Guera), Mao (Kanem), Bongor (Mayo- Kebbi), andMoundou(Logone Occidental), interviewingpublic sector andcivil society actors andbeneficiaries and visiting selected facilities, researcwacademic institutions, andcommunity-based projects. Keydocumentary sources consultedinclude: (a) World Bankproject files; and(b) project-related reporting andevaluation, epidemiological data, studies andresearch on populationandHIV/AIDS, much o fit generated inChad. This PPARis one o f six conducted on the "first generation" o fthe Bank's HIV/AIDS projects, as background for a larger OED evaluation of the development effectiveness of World Bank's assistance for fighting the AIDS epidemic. Inlight o fthat purpose, relatively more material has beenpresented inthis "enhanced" PPARthan i s the OED standard. The OED mission gratefully acknowledges all those who made time for interviews andprovided documents and information. Following standard OED procedures, copies o fthe draft PPARwill be sent to the relevant government officials andagencies for their review and comments. Comments received are incorporated into the PPAR andpresented inAnnex F. i x Summary The objectives o fthe PopulationandAIDS Control Project (Credit No. 2692 of 13.9 million SDR) were to advance the onset o f fertility decline by increasing the modern contraceptive prevalence rate (CPR) from 1percent in 1990to 10percent by 2000, andto slow the spread o f HlV infectionbypromotingbehavioral change. The project was managed and implementedefficiently overall; and the credit was fully disbursed. Implementation, however, was constrained bythe lack o f Government counterpart financing andweak capacity o fpublic sector implementing agencies. In1992 Chadwas oneofthe few Saheliancountries that didnothave a populationpolicy. However, deteriorating socioeconomic conditions and analysis o f populationissues, supported bythe World Bank, prompted in 1994the preparation o f a nationalpopulationpolicy and the repeal o f the 1920law which prohibited contraceptives. Populationprogram efforts were constrainedbypoor coverage and quality o f family planning andweak capacity for the coordination o f activities and for the collectionand analysis o f data. Strong disincentives for decreasing fertility includedhigh levels o fpoverty and highdependence on childrento supplement family income and provide old age social security, and very highinfant and child mortality. The first cases o f AIDS were reported in 1986, with a total accumulation o f2,866 reported cases by 1994, 97 percent o fwhich were attributed to heterosexual transmission. Government's earliest response under its short-term plan(1988-89) and first medium- term plan(1990-93) for AIDS control focused onprogram start-up, capacity-building, surveillance andpreventionactivities. Denial and stigmawithin the Government and in society at large were pervasive. Population. Project assistancedidnot succeedinraisingthe modernCPR to 10 percent. Bythe project's end, CPR was estimated at 2 percent. Available data indicate that the total fertility rate inChad has remained constant over the life o fthe project at around 6.6 children. At the time o fthe project's mid-term review, the Bank and the Borrower acknowledged that the objectives were, inretrospect, not realistic andwould not be achieved. UNFPA hiredconsultants to set new targets on the basis o fthe DHS data, but their work progressed slowly andthe project objectives were not amended. HIV/AIDS. Epidemiologicalandbehavioralsurveillance was improvedunder the project and helpeddocument the seriousness and scope o fthe epidemic. The project was successful inestablishing a social marketingprogram that has increased the availability o f condoms inChad at an affordable price. Against a target o f 14 million, a total o f 19.9 million condoms were sold, o fwhich about 3 million are estimated to have been sold in neighboring countries. While condoms were taboo at the start o fthe project, they are now sold openly inshops, market stands, inns and hotels across the country. There i s considerably less stigma today associatedwith the purchase and use o f condoms. The project has mobilized and financed a wide response from civil society organizations, and a response from various sectors inthe public sector at central and decentralized levels. X Theproject has succeededinincreasing awarenessandknowledge o fHIV/AIDS andininciting safer behavior. The most significant improvements inawarenessand behavior are found among women, rural residents, and the poorest income quintiles with consequent reductions indisparities between men andwomen, urbanandrural residents andthepoorest andrichest segments o fthe population. Condomusehas increased among menandwomen, although levels are still relatively low. Inthe absence o f baseline data, it i s difficult to evaluate the extent to which the project has slowed the spread o f HIVinfection. Available data revealthat HIVprevalence has risenover the past decade inthe general populationand that it may have stabilized amongpregnant women usingprenatal services inurbanareas. However, the HIVprevalence rate does not yield insights into the change inthe rate o fnew infection. Ratings. This project i sjudgedto have had a moderately satisfactory outcome overall, based on an unsatisfactory outcome o fthe population objective and a satisfactory outcome o f the HN/AIDS objective. Institutionaldevelopment is rated as substantial; andsustainability o fproject efforts is likely. BothBankandBorrowerperformance was satisfactory. LESSONS The Bankcan be instrumental instimulating government commitment with regardto populationand HIVIAIDSthrough policy dialogue, advocacy, technical support and lending,butthat support is insufficientto consolidate and sustain the commitment. Other factors that are critical to raisingand sustaining Government commitment are the relevance o fthe objective (determined by the availability o f local evidence and data) andthe degree o fmobilization o f civil society. The stimulation and nurturingo f broad-based nationalcommitment requires continuous andmultiple efforts, givenpopulationmobility and turnover inpublic sector positions. Eveninthe context o f a multisectoral approach to the achievement o fHIV/AIDS and populationobjectives, the role o f the health sector i s pivotal. The absence o fbaseline data for keyindicators and o f a monitoring and evaluation planundermines opportunities to track and fine-tune the performance andimpact o f national populationandHIVIAIDS efforts. Intensiveinformation campaigns inthe early years o fthe project followed by the recruitment o f intermediaryNGOsto build capacity onsite andto stimulate the formation o fnew associations, provedto be very effective inengaging civil society in populationand HIVIAIDS activities. Gregory K.Ingram Director-General Operations Evaluation 1 1. Backgroundand Context 1.1 This is the sixth o fa series o fPPARsthat are beingundertaken onthe "first generation" o f completed Bank-financed HIV/AIDSprojects, as background for a larger OED evaluation o f the development effectiveness o fthe World Bank's AIDS assistance.' Inlight ofthat purpose, relativelymorematerialhasbeenpresentedinthis "enhanced" PPAR thanis the OED standard. Thisproject was chosen for assessment to provide the main study with lessons and insight on the experience o fthe Bank's HIV/AIDS assistanceto a West African country, prior to the design and approval o fthe MAP.2 1.2 GeneralContext3Chad is one ofthe poorest countries inthe world with an estimated four-fifths o f its population o f 8.1 million livingon less than a dollar a day, and halfo fthe populationlivingon less than 50 cents per day. More than 50 percent o f Chadians over the age o f 15 are illiterate and only about 30 percent o f the populationhas access to potable water. Epidemic and endemic diseases are prevalent inall regions o f the country andthere i s only one doctor for every 29,000 inhabitants. Infant and child mortality were estimated at 102.6 and 194.3, respectively, andmaternalmortality was estimated at 827 per 100,000 live birthsin2000.4 Life expectancy i s estimated at 50 years. Genderdisparities are acute andhighlycorrelated to poverty inChad. 1.3 Chad is a vast territory (over 1.2million squarehlometers) with only about 550 kilometers o fpaved road. Geographc isolationandhtghtransport costs undermine the viability o feconomic activity andconstrain accessto basic social services andinformation. Development efforts are further challengedbythe broadcultural diversity o fthe country with about 200 ethnic groups and 120distinct languages. Followingdecadeso fcivil war, a democratization process has taken hold since the mid-1990s, butpolitical stability remains fragile. 1.4 Chad's recent macroeconomic performance has been satisfactory with an increase inthe rate ofrealgrowthofGDP from anaverageof3.1 percent for theperiod 1997- 2000 to 8.5 percent in2001, 9.7 percent in2002 and 11.2 percent in2003, largely due to investments inthe Chad-Cameroon pipeline, completed inearly 2003. With full productionachieved in2004, it i s estimated that some US$lOO millioninoil revenues 1. The other projectsassessedto date includethe Kenya SexuallyTransmitted Infections Project,the Zimbabwe Sexually Transmitted InfectionsPrevention and Care Project, the First India NationalAIDS ControlProject, the first and second BrazilAIDS and SexuallyTransmitted DiseaseControl Projects,and the Kingdom of Cambodia Disease Control and Health DevelopmentProject. 2. The first Multi-CountryHlVlAlDS Program(MAP), a horizontalAdaptable ProgramLoan (APL)for Africa Region's intensifiedassistanceto the fight against HIV/AIDS, in the amountof US$500 million, was approvedon September 12,2000. MAP I1for an additionalUS$500millionwas approvedon December 20, 2001. 3. Data and informationcited inthis section are drawn from Chad's Poverty ReductionStrategy Paper (PRSP)of October 7,2003, andfrom the World Bank's CountryAssistance Strategy (CAS)for Chadof November 12,2003. ' 4. Ministerede la Sante et des Affaires Socialeset Banque Mondiale, March2004. 2 will be generated this year, aportionofwhich is supposedto be earmarked for expenditures inpriority sector~.~ 1.5 Population.The first populationcensusestimated Chad's populationto be about 6.2 million inApril 1993 and growing at an annual rate o f2.5 percent. The total fertility rate was estimated at 5.7 live birthsper women, lower than the average o f 6.6 for Sub- SaharanAfrica. The population o fN'Djamena increased fivefold between 1960 and 1990. 1.6 In1992Chadwas one o fthe Box 1.1994 Population Policy Objectives: few Sahelian countries that didnot have a populationpolicy, inpart A Summary because o f the large size o fthe 1 Improve coverage and access to basic health and nutrition country and low population density. services (including reproductivehealth services) and education services However, deteriorating 1 Decrease annual population growth from 2.5 percent to 2 socioeconomic conditions and percentby 2005 analysis o fpopulationissues m Strengthenunderstanding of the relationship between popula- tion anddevelopment increased Government awareness o f m Promote women's rights, social status and participation in population growth as a development development issue, andpromptedtwo key actions: m Promote and ensure the rights and well-being o f children and vouth. (a) the preparationo f a national populationpolicy andthe creation o f institutions for its oversight andmanagement; and (b) the repeal ofthe 1920law whichprohibitedthe importation, distribution anduse of contraceptives. In 1994,the Government o f Chad adopted its Declarationo fPopulation Policy (DPP), which outlined nationalpriorities and strategies inpopulation and family planning(see Box 1). 1.7 Receptivityto the notiono fcontrolling family size was very weak inChad. First, extremely highlevels o fpovertyinChadpromptedcouples to have manychildren as a means o f supplementing family income andproviding social security intheir old age. Second, civil conflict was another deterrent to limitingfamily size inthe face o fcontinued tensions among ethnic groups. Third, infant andchildmortalitywere very high(estimated, respectively, at 132and222 per thousand in 19936),incitinghghfertility levels as women triedto compensatefor the loss o f children. Furthermore, religious leadershavehad a very strong influenceon Chadian society andmanytook aposition against the use o fmodern contraception. 1.8 At thetimeofproject preparationthe MinistryofPlanandCooperation (MoPC) was responsible for populationpolicy implementationandoversight, with the Ministry o f Public Health (MoPH) havingprimaryresponsibilityfor family planning.Within MoPC a Population Division (Division de la Population) was created to facilitate the coordination o fpopulationpolicy implementation and a Directorate o f Statistics ando fEconomic 5. Prioritysectors include: health,social affairs, education, infrastructure,ruraldevelopment,and environmentand water resources. 6. Ministryof Healthstatistics. Studies' was responsible for demographc researchandanalysis. Giventhe multi-sectoral nature o fthe populationagenda, ahgh-level council onpopulation(Haut Conseil de la Population et des Ressources Humaines ,HCPRII),chairedbythe President o fthe Republic, was set up to define the general orientations o fpopulationpolicy andto adopt recommendations o f aninter-ministerial populationcommittee (Comission Nationalepour la Population et les RessourcesHumaines, CNPRH,),chaired bythe Minister o fPlanand Cooperation. Themandate o fthe CNPRIIwas to preparepolicy andcoordinate its implementation. The mainissues constraining population programefforts in 1994were (a) poor coverage andquality o f familyplanninginformationand services'; (b) limiteddemand for these services; and (c) weak capacity for the planningandcoordination o fpopulation activities and for the collection and analysis o fsocia1and demographc data through research, studies and surveys (World Bank 1995). 1.9 Health andHIV/AIDS.The leading causes o f illness and death inChad (infectious andparasitic diseases,' pregnancy-related conditions, andmalnutrition) are all preventable and amenable to the effective delivery o f a basic package o fhealth services (including communicable disease control and family planning). Health system performance inthe early 1990s suffered from low coverage, poor access, limited and inefficiently allocated resources, lack o f qualified health personnel, lack o f strategic management capacity and an overly centralized organization, An indicator o fthe health sector's inadequateperformance inChad i s the extremely low child immunization coverage o f 3 percent inthe early 1990s(World Bank 1992). Figure 1.ReportedAIDS Cases 1986-2002 3000 2748 2500 I s5t @ 2000 1500 v) 1000 It 500 0 Source: MoPH/PNLS EpidemiologicalData 7. Directionde la Statistiquedes Etudes konomiques et Demographiques - DSEED. 8. Weak capacity was due bothto a lack of qualified health personnelandto a lack of prioritizationof family planninginformationand serviceswithin the minimumpackage of services. 9. Diarrhea,tuberculosis,malaria, trypanosomiaisis,onchocerciaisis,meningitis,cholera, measles, STDs/AIDS. 4 1.10 The first cases o fAIDS were reported in 1986, with a total accumulationo f 2,866 reported cases by 1994 (Figure 1). At the time o fproject preparation, adult prevalence for HWOwas estimatedbyMoPHat 3percentwiththehighestratesinthe south andwest of the country." Ninety-sevenpercent o freported AIDS cases were estimated to have been causedby sexual transmission, a result o fmultiplepartners, lack o f education and information, and difficult accessto condoms.l2Poverty, conflict, and successive droughts have contributedto this phenomenon by encouraging significant migration and commercial sex. 1.11 In1988, the Box 2. Second Medium-Term Plan for AIDS Control- Government set up an Strategic Orientations (1995-1999) institutional framework for Prevention of: the fight against a. sexual transmission HIVIAIDS,13andprepared b. transmission through unsafeblood c. mother-to-child transmission and launched a short-term Mitigation of: planfor AIDS control a. the health impact of sero-positive patients with or without AIDS coveringthe period 1988- b. the social impact ofAIDS on patientsand their families 89, followed by the first c. the impact on public expenditure, especially for the health sector medium-termplancovering d. the impoverishing effects o f the disease through income- -generation activities. the period 1990-93. Early I I activities focused on program start-up, capacity building, early surveillance activitie~,'~ andpreventionfor the general public, and for prostitutes, youth, andthe military.A second medium-termplan, prepared duringproject preparation, accorded highest priority to prevention (see Box 2), at a cost o f about US$9 million(excluding social marketingand social fund). 1.12 Despitethe institutional andpolicy framework established for HIV/AIDS by the Government o f Chad, there was still widespread denial and stigmawithin Government andinsociety at large. Manyinterviewsrevealthat HIV/AIDS was not referredto byits name, but instead referredto as "the sickness" or "the syndrome." There was reported to be widespread denial among Government officials at central and decentralized levels o f administration, many stating that this was a creation o f donors. Religious leaders were also reported to be strongly resistant inthe early 1990s to the promotion o f condoms and 10. The percentof adults infectedwith HIV at a given time. 11. In 1993,88 percentof all reportedcases camefrom Ndjamenaand Moundou. 12. Mother-to-childtransmissionwas also acknowledged as a means of infection,with some4,800 children estimatedto be infected in 1994, alongwith the transfusionof unsafe blood supplies (WorldBank 1995). 13. Consisting of: (a)the NationalAIDS Committee (ComiteNationalde Lutte contre le SIDA, CNLS), chairedby the Ministerof Health and composedof six ministers,responsiblefor oversight of all HIWAIDS controlactivities,(b) the TechnicalCommittee for AIDS Control (ComiteTechniquede Lutte Contrele SIDA, CTLS), chaired by the DirectorGeneralof Health, and (c) the NationalAIDS Control Program(Programme Nationalde Lutte Contre le SIDA, PNLS)within MoPH, responsiblefor day-to-day implementationand follow-upof AIDS activities. 14. Surveillanceactivities includedseroprevalencesurveys in selected prefectures(Abeche,Sarh, Moundou, Bongor and Ndjamena) and limitedsurveillanceof pregnantwomen, blood donors and TB patients. 5 interventions with commercial sex workers, whch they considered to be inconflict with religious principles. Strongly influencedbyreligious and traditional leaders, and lacking basic facts about HIV/AIDS andhow to prevent its transmission, Chadian society at large exhibited great discomfort with discussion o f the disease itself andwithways andmeans o f controlling it. Societal resistance to early HIVIAIDS control efforts was reportedby many o fthose interviewed, who cited billboards set up inmajor cities beingtorn down and destruction o f equipment after informationand social marketingcampaigns. 1.13 PreviousBank Support. The Bank's first support to Chad's health sector was through a US$7 millionhealthcomponent under the Social DevelopmentAction Project, approved inJune 1991,15w h c h sought to improve basic social services inthe city of N'Djamena andinthe southern regiono f Tandjilk (the only regionnot covered by donor t up port).'^ The Bank's engagement inhumandevelopment inChad was intensifiedin 1992 with the preparation and discussion o f an in-depth analysis o fthe population, health and nutrition sectors." This report highlightedthe negative consequenceso f highfertility on the healtho fmothers and children, on poverty at the household level, and on the socio-economic development prospects o fthe country at large." With regard to health, the report recommended steps to improve the quality, coverage and cost-effectiveness of healthservices through decentralization, capacity buildingandthe control o f key diseases, highlightingAIDS, inparticular." 1.14 This dialogue culminatedinthe preparation o f a proposedHealth and Population project, which was ultimately split into two projects: (a) the Healthand Safe Motherhood Project, approved inJune 1994, the Bank's first freestandinghealth sector investment;" and (b) the PopulationandAIDS Controlproject, the subject o fthis review. The decision to split support into two projects was based on a number o f factors. First, the population component was not sufficiently prepared inrelationto the rest o fthe original project 15. Credit2156-CD in the amount of SDR 10.4 million (USfi13.4 million equivalent)was approvedon June 14, 1990, and madeeffectiveon April 14, 1991.A supplementalcredit (Credit No. 21561-CD) in the amount of SDR 6.8 million(US9.8 millionequivalent)was approved on November IO, 1994,and made effective on September 6, 1995.Both creditswere closed on April 30, 1998. 16. The Bank's final evaluation report(WorldBank 1998)acknowledgedthis component`s success in improvingutilizationof health facilities, but also notedthat the projectdid notfully achieve its objectivesto expand infrastructureand to develop sustainableinstitutionalcapacity. 17. World Bank Report No. IDP-122,"Population, Healthand NutritionSector Report," December 1992. 18. Itcalledfor actionto slow down populationgrowth through: (a) the establishmentof a government coordinatingbodyfor populationpolicydevelopment and the creationof a populationunitfor program development and coordination; (b) the development of a nationalfamily planningstrategy and action planto increaseaccess to family planningservices, with an emphasis on childspacing;and (c) intensified information,educationand communication (IEC) by promoting a multi-mediaapproachand involving NGOs. 19. This report notedthat the scale and urgency of HIV/AIDSwere growing rapidlyand were possibly grossly underestimated.At that time the ratesof infectionof HIV, accordingto sentinel site data, were 1.6% in Moundou, 0.5% in Sarh and 0.2% in N'djamena. Low awareness,inadequateskills of health personnel and shortageof resources and logisticalsupport all were cited as importantimpedimentsto program effectiveness. 20. Credit2626-CD in the amount of SDR 31.Imillion (US$18.5 millionequivalent),providedsupportto three componentsaimed at: (a) strengthening central MoPHcapapcityto support regional healthservices: (b) improvinghealth, nutritionandfamily planningservices in Guera and Tandjile regions;and (c) developing and implementinga nationaldrug policy. 2/24/95, closing 6/30/01. 6 concept at the time o fits appraisal," andthere was incentiveboth not to delay the health operation and not to compromise on the quality o f the populationcomponent. Second, it was considered critical to address the spread o fHIV/AIDS, which was recognizedas a threat to Chad's economic and social development prospects.22The rationale for combiningpopulationandAIDS efforts under one operation was to exploit synergies o f efforts inthe provision o f family planning andHIV/AIDS services and information for behavior change, and inthe social marketingo f commodities. Third, a combined health andpopulationproject was thought to be too complex for the limitedmanagement capacity o f MoPH. Given the multi-sectoralapproach o fpopulation andHIV/AIDS, the management o fthis project was placedunder the auspices o fthe MoPC. 1.15 Support by Other Donors to populationandAIDS inthe early 1990s fell short o fneeds. Populationsupport was providedprimarilyby UNFPA (US$3.5 million for the population census, policy formulation, and family planningprogrammanagement) and USAID (USS8.5 million for maternal and child health andfamily planning [MCHDP] service delivery intwo regions, andprovision o f contraceptives). Other support to M C H F P was providedby donors inthe context o fbasic health services support23.A major gap inthe financing o fcontraceptives was imminent with the plannedwithdrawal o fUSAIDfrom Chad in 1995. Donorsprovided about US$4.3 millionto support implementationo f Chad's first short-term (1988-89) andmedium-term (1990-93) HIVIAIDS plans. WHO'SGlobal Programme on AIDS (GPA) was the main source o f financial and technical assistance, with support also beingprovidedbyUNDP, USAID, France andthe EuropeanUnion(World Bank 1995). 21. Slow progressin the preparationof the populationcomponent is largelyattributableto the weak capacity of the demographic unitwithin MoPC. 22. Buildingon the analysisof the Population,Health and Nutrition Report(World Bank 1992),the Regional AIDS Strategyfor the Sahel (World Bank January 1995)providedupdates on the progressionof the HIV/AIDS epidemicin Chad and guidancefor Bank support, most notably: strengtheningand expansionof communication; expanding clinical management, epidemiologicalsurveillanceand laboratorycapacity; support for NGO and community initiatives:supportfor multisectoralinterventions;and policy analysis, research, monitoringand evaluation. 23. WHO, UNICEF,Swiss Tropical Institute,EuropeanUnion, France, Switzerland. In addition,the InternationalPlanned ParenthoodFederation(IPPF) provided supportto its local affiliate in Chad, the Association for FamilyWell-being (ASTBEF). 7 2. Objectives and Design 2.1 The Populationand AIDS ControlProject was financed through an IDA credit o f US$20.4 million equivalentz4,approved on March 23, 1995, and a plannedgovernment contributiono f US$1.3 million. Inaddition, cofinancingbyKfW andUNFPA inthe respective amounts o fUS$4.4 million andUS$O.l million, brought the total estimated project cost to US$27.2million. This first free-standing population and AIDS project in Chad became effective on September 8, 1995. 2.2 ObjectivesandComponents.The projectwas designed to assist the Government inimplementingits long-term strategy inpopulationandfamily planningandits medium- term plan 1995-99 (MPT 2) for AIDS control. Its overall objectives were to advance the onset o f fertility decline by increasing the use o f modernmethods o f contraception (from 1percent in 1990to 10percent by2000), andslow the spreado fHIV infectionby promotingbehavioral change. Project assistancewas channeled through four components aimed at: (a) strengthening o fnational capacity to implement the populationpolicy; (b) strengthening o fnational capacity to contain the spread o f HIV/AIDS/STDs; (c) establishment o f a social marketingprogram for condoms; and (d) promoting the participationo f the nongovernmental sector inpopulation, family planning, and HIV/AIDS/STD programs. See Annex C for a presentation o f project components. 2.3 ImplementationArrangements.The MoPCwas responsible for overallproject coordination, management and oversight. To this end a project coordination team (PCT) was established andplacedunder the direct supervision o fthe General Directorate o fthe MoPC. The PCT was responsible for the day-to-day coordination ofproject activities, administrative and financial matters, and for the coordination o fmonitoring and evaluation. Itwas also responsible for maintaining an effective dialoguewith key donors and agencies inthe population andhealth sectors. The PCT consisted o fa project coordinator appointed by Government, local contractual staff (including aproject administrator, anaccountant, the FOSAPadministrator, and support staff), and a long- term international specialist inepidemiology andprogram management. Inaddition to the cost o fthese staff, the project financed short-term technical assistance inprocurement, accounting and audits, training, logistical support, and operational costs. 2.4 The management ofproject activities was assigned to institutional structures with respect to their traditional mandates. The populationpolicy component was to be managedby the Division o fPopulationat the MoPC; andthe HIVlAIDS component was assigned to the PNLS within the MoPH. Management and implementation arrangements for the social marketing and social fund components are presented below. 2.5 Social Marketing. Responsibility for the management and implementation o fthe social marketingcomponent was givento ASTBEF and (initially to) an internationalfirm specialized insocial marketing, together underthe general supervisiono fMoPC and in collaborationwith the PNLS/MoPH (for technical aspects). Transfer o f skills was the main objective o ft h s technical assistance, which was to beprovided on apermanent 24. All US$amounts representthe US$equivalentof SDRs or other currencies. 8 basis duringthe first three years o fthe project, andthrough short-term assistancefor the remainingtwo years o fthe project. The Government, World Bank, and KfW signed an agreement to support this program. KfW was to finance the first three years o f the program and IDA the remaining two years; they sharedthe expenses o f an auditor. 2.6 Social Fund. The PCT was given responsibility for management o fthe social fund, with a social fund administrator includedamong its core staff. Fundswere to be made available for subprojects prepared and implementedby: (a) NGOs and civil society organizations; (b) selected sector ministries (health, education, defense, justice, social affairs, communications, and interior); and (c) decentralized, multisectoral entities responsible for populationand HIV/AIDS.'' The social fundwas designed to finance 80 percent o fthe subproject costs, the remaining20 percent to beprovided as counterpart from the implementing organizations.26A procedures manual and contract prototypes were developed and agreedbythe borrower and IDA, providing for IDA review of contracts larger than CFAF 30 million (about US$60,000) before signature. Under the "resource projects" experienced NGOswere given a geographical zone to operate in, withinwhich they would (a) provide capacity-building support to local associations that would preparelimplement subprojects; and (b) stimulate the development o fnew associations and additional subprojects to further strengthen civil society. The role o f these experienced NGOs was limitedto technical assistance and capacity building; they neither signed contracts with the implementingagencies nor disbursed funds, these tasks beingthe responsibilityo fthe social fund. 2.7 MonitoringandEvaluationo fproject performance was the responsibilityo fthe implementingunits, inline with indicators specified innational policies and strategic documents onpopulationandHIV/AIDS, under the overallcoordination o f the PCT. Baselines didnot exist for most HIV/AIDS indicators andmanytargets were not quantified before effectiveness. Research, studies andother data collectionactivities were expected to refine and complete baseline data andtargets.27There was no monitoring and evaluation planother thanthe expectationthat indicatorswouldbereviewedasrequired bythe second medium-term planreview process (not defined). Standard Bankreportingrequirements on implementation included: (a) semi-annual progress reports to IDA; (b) annualjoint (IDA/Government) reviews; and(c) a mid-termreview. 25. RegionalCommissionsfor Population and Human Resources,created in 1994;and PrefectoralHealth Councils,created inthe late 1980s. 26. Duringnegotiationsthe Government gave assurancesthat it would maintainin the budgetof the ministriesinvolvedinAIDS control a separatebudgetaryitemfor AIDS activitiesto meettheir counterpart obligations. 27. While it providedcriticalinformationon both populationand HIVIAIDS,the 1996 DHS did not provide neededdata on many of the projecttargets and indicators. 9 3. Implementationand Costs ImplementationExperience 3.1 After an initial three-month delay ineffectiveness,28the project was implemented over six years and three months (including a six-month extension*') and closed on December 31,2001, with the credit fully disbursed. 3.2 CounterpartFinancing.At the start oftheproject Government made its counterpart funds available, although frequently later thanthe agreedschedule. However, Government's failure to budget the 20 percent counterpart funding for key sectoral ministries in 1998 causedtheir activities to come to ahalt3' Chronic unavailability o f counterpart financing duringthe secondhalfo fthe project life causedthe working relationship and trust between the project andits suppliersto deteriorate seriously, because the latter werebeingpaidonly 80percent oftheir invoices (the Bank's share). Support staffwere only receiving 80 percent o ftheir salaries andtelephone andelectricity were cut. The Bankwaspersistent inraisingthis issue with Ministers o fFinance and o fPlan, Development and Cooperation, but this issue was not resolved prior to the project's closing. 3.3 Population.The two major studies startedwith some delays but were eventually completed. The Demographic andHealth Survey was delayed by elections andthe initial unavailabilityo f logistics to support field work. The Migration andUrbanization Survey was delayed because UNFPA was unable to provide all o fthe fbnds it had initially committed and CERPODrestructuringcaused a disruption inits technical support. IDA agreedto finance the gap andcost overruns given the importance o fthis study. 3.4 Lack o f government commitment and heavybureaucratic processes causedmajor delays inkeyproject activities. The Government decree creatingthree key population entities -- the HCPRH, CiVPRHand C P P W -- was signed on November 23,1995, and the legal texts definingthe composition andoperations o f these entities were signed on April 10, 1996. The preparation andapproval o fthe Programfor Priority Actions and ~ ~ 28. Projecteffectivenessslippedfrom July to September 1995 because of extra time taken for the Conseil Superieurde la Transitionto ratifythe credit. 29. The projectwas extendedto bridge a financinggap pending the delayed start of the follow-onproject. 30. The 1999approved budgetdid providefor this counterpartfunding, thus permitting implementationof sectoralactivitiesthat year. 31. The Bank's internalsupervisionreportingdowngraded its ratingof counterpartfunding from "unsatisfactory" to "highly unsatisfactory"duringthe latter years of implementation. 32. HCPRH (Haut Conseilde la Populationet des RessourcesHumaines)is the High Councilon Population and Human Resources,chaired by the Headof State, with membershipcomprisedof Ministers, responsible for setting and enforcingpopulationpolicy. CNPRH (CommissionNationalede la Populationet des Ressources Humaines) is the NationalCommission on Populationand Human Resources),chaired by the MoPCwith membership comprisedof representativesof public sector and civil society, responsiblefor coordinationand oversightof policy implementation.CRPRH (CommissionRegionalede la Populationet des Ressources Humaines) isthe RegionalCommission on Populationand Human Resources,chairedby the Governor, with membershipcomprisedof regionalrepresentativesof the publicsector and civil society, responsiblefor regional-levelpolicyimplementation. 10 Investments (Programmed'Actionet d'InvestissementsPrioritaire, PAIP), which was the framework for populationpolicy implementation, was delayed as a consequence. It was transmitted to the HCPRHfor its review and approval on January 23, 1998,nearly three years later thanplanned. Furthermore, the HCPRHmet for the first and only time on November 17,2000 to approve the PAIP almost three years after it was received. A draft decree was prepared in 1998 proposingthat the HCPRHbe chairedby the Prime Minister, rather than the Heado f State, to make it more operational, but the decree was never signed. Ina meeting o f September 7,2001,the CNPRHinsisted that the President continue to chair the HCPRH. 3.5 Six seminars for journalists, NGOs, opinion leaders, and leaders o fwomen's organizations were carriedout as planned. Some 140unionleaders (against 100planned) were trained inpopulationinformationworkshops and the majority o fprefects and subprefects were trained inpopulation, as planned. The messageso fthese seminars and training sessionswere tailored to the specific target groups, but by and large included dissemination o f the Declarationo fPopulationPolicy andthe social and economic consequences o frapidpopulation growth and highfertility for the country at large, the local level, the family, as well as individuals. Themes discussed included: poverty, allocation o f scarce resources, the status androle o fwomen indevelopment, andmaternal and child health and the benefits o f child spacing. 3.6 W h l e the PopulationUnitwas given a higher profile inMoPC -promoted first to the level o f a division and subsequentlyto the level o f a full directorate -the number o f populationprofessionals was diminishing due to death and attrition.33Some o f them were replacedwith contractual staff and others not at all. Capacity-building efforts were also undermined by the reorganization o f CERPOD in2000, with whom the Division of Populationhad signed a contract for technical assistance and capacity building. With manystaffleavingCERPODafter thereorganization, the quality andquantityo fsupport fell short o f levels providedinthe initial years o f the project. 3.7 HIVIAIDS.Implementationofthis component was constrainedbyweak capacity within the PNLSinthe MoPHthroughout the life o ftheproject. Attemptsto strengthen PNLSwere made inthe early years ofthe project with the appointment ofa new coordinator and a few other qualified staff However, inadequacies innumbers and skills o f staffhave persisted. Difficulties ineliminating shortages o f qualified personnel were due both to paucity o f available qualified staff andto the reluctance o f decision-makers to dismissweak, non-performing staff. 3.8 There were tensions betweenthe PNLS coordinator and the long-term technical assistant, hired to buildPNLS capacity inepidemiology andprogrammanagement. One source o ftension was the extent to which the technical assistant was perceivedto have substituted for PNLS skills gaps instead o f developing the capacity o fPNLS. Interviews revealed many strong and divergent opinions, some expressing that the technical-assistant 33. Five demographershave died sincethe start of the project, includingone who was trained overseas under the project. A numberof other staff trainedunderthe projectwere hired by multilateralagencies (e.g., UNDP and UNICEF). 11 encroached on the responsibilities o fthe PNLS coordinator, while others notingthat management andtechnical skills were so scarce and demands so great onPNLSthat there was no other alternative andthat support at the technical level was appreciated. Additionally, the terms o freference o f this technical assistant included significant, additional responsibilities that extendedbeyondthe support to PNLS:technical assistance andguidance to the PCT inproject management andinthe set-up, launch and oversight of the social fund. These resp~nsibilities,~~ combined with the fact that his office was located with the PCT, reduced his availability to the PNLS.A final evaluationo f this technical assistance was not undertakenby the Borrower. 3.9 Despite these constraints, most planned activities were implemented. Progressively, A I D S planswere developed and implemented at the prefecture levelby prefectoral health councils. Byproject close, prevention activities were beingundertaken inall 14 prefectures, as planned.Two hundredeighty three healthpersonnel (against 300 planned) were givenHN/STD-related training. The project providedtechnical and financial support to five existingsentinel surveillance sites already existing at the project's outset and established four additional sentinel sites (versus two planned) bringingthe total o f hlly functional sites to nine (versus seven~lanned).~'FiveHlVsero-prevalence studies focusing on specific groups were carried out as planned;36andtwo population-based HIV sero- prevalence studies were carried out in 199737(versus none planned). Inaddition, three KAP studieswere carried out (versus two planned); and aplanned study on the socio-economic impact o fHIV/AIDS was also carried out. However, ofthe five plannedoperational studies to improve health servicesquality, only one was carried 3.10 Social Marketing. At the project design stage KfW cofinancing was slated to cover the costs o fthe first three years ofimplementation o fthis component (including the cost o f condoms), and IDA the remaining two. However, duringimplementationKfW decided to extend its support, includingthe social marketingtechnical assistance, through 2001 (the end of the pr~ject).~' 3.11 Despite initial delays instart-up activities, implementation o fthis component was highlysuccessful. Earlier activities focused onthe setting up o fMASACOT (the project social marketingunit),promotional activities, professional training, and networking. 34. It is interestingto note that this projectwas designedduring a time when the Bank sought to reduce long-termtechnicalassistancefinanced underprojects,given client countries'expressed resistanceto the highcost of such assistanceas well as to the idea of borrowingfor this purpose. Projectfiles do provide evidenceof the needto stronglyjustiQ the inclusionof technicalassistance.Some interviewedindicated that, in retrospect, the TOR for this assistancewere too broad and ambitiousfor one personto fulfill. 35. A 10thsite in Faya-Largeau was establishedwith projectsupport, but its operationswere limitedto notificationof AIDS cases and not HIV surveillanceat the end of the project. 36. Sero-prevalencestudiesfocusedon: prostitutesand militaryin Ndjamena(1995), militaryin N'djamena (1997), militaryin Moundou (1997), prostitutesin Sarh (1997), migrantsin Logone Occidental (1997). 37. Inthe prefectures of Abeche and Amtiman. 38. Study completed was on the managementof STDs and AIDS patients. Plannedstudies not carriedout focused on: referralprotocolsfor AIDS patientsand families: evaluationof the clinicaldefinitionof AIDS; relationshipof HIV and TB; and accessibilityand utilizationof healthcenters and district hospitals. 39. KfW'stechnicalandfinancial continuestoday inthe contextof the follow-onproject. 12 Condom sales soon exceededproject targets and increased duringthe first years o f the project untilthe year 2000. Inthat year it was decided to replace the technical assistant for this component, who was not considered bythe Bank, KfW, or the borrower to be fulfillingcapacity buildingresponsibilities specified inthe terms o freference. The time anddisruption ofreplacingthis expert hadanegative effect oncondom sales. Also, at the end o f 1999the Government and its partners decided to transform MASACOT, which had a temporary (or project) legal status, into a permanent NGO, the Association for Social Marketing o f Chad (I'Associationpour le Marketing Social au Tchad,AMASOT). Time and effort were thus spent onthe preparation anddiscussion o fdraft legaltexts. The first General Assembly for this new entity met on October 17,2001. AMASOT was formally recognized bythe Ministryo f Interior and Security inJanuary 2002 andthe following month regional branches o fAMASOT were established inAbkch6, Mongo, Moundou, N'Djamena, Pala, and Sarh. The dip inthe sale o f condoms was only temporary and continued to climb thereafter. 3.12 Around the time ofthe M T R itwas decided to diversifj social marketingefforts to include oral rehydrationsalts for home treatment o fdiarrhea anddehydration. The rationale for this decision was to contribute to reductions inchildmortality, which is recognized to bea strong determinant o ffertility. The financingofthis initiativeunder the project was madepossible after KfW financing of socially marketedcondoms was extended to the end o fthe project, thus liberatingIDA funds for this newcommodity. The first packets were ordered andmarketed in2000 with great success and increasing sales over time. 3.13 Social Fund. This component was slow to start becauseo t (a) the weakness o f civil society organizations; (b) Government mistrust o f civil society organizations inthe wake o f civil conflicts; and (c) a general lack o f informationand discomfort about population issues and HIVlAIDSacross civil society. The preparationand approval o f a social fund procedures manual havingbeen a condition o f effectiveness, the first two years o f activity were devoted primarilyto informationand outreach with potential partners (NGOs, associations, key sector ministries) to informthem o fthe availability o f h d s and the projectpreparation andapproval cycle. 3.14 Early efforts also focused, as planned, onthe recruitment o f experienced NGOs to carry out capacity buildingandoutreach with civil society groups to guide them in subproject preparation and implementation, incite the development o fnew subprojects andcontribute to the strengthening ofpublic-private partnershipsat decentralized levels. The social fundfinanced six NGOsto carry out these technical support capacity-building initiatives, two more thanplanned. 3.15 Inresponseto acall duringthe MTRfor microfinance for women as ameans of fightingHIV/AIDS andaddressing determinants o freproductivebehavior andfamily well-being, the Development Credit Agreement was amended and funds reallocated to support this initiative. Duringthe secondhalfo fthe project this new subcomponent 13 providedUS$800,000 to 12 field-based agencie~,~'which providedmicrocredit to women's groupsthroughout the country. 3.16 Despite successes inexceeding implementationtargets, lack of FOSAP capacity inmicrofinance causedadifferentiationinthe quality andappropriateness ofapproaches andresults across the 12field-based agencies. Implementationo fthe populationand HIV/AIDSsubprojects was constrainedbothby slow disbursements (caused inpartby failure to replenishthe Special Account due to delays instatements o f expenses submission) andby the fact that someNGOsresponsible for capacity buildingand outreach had a growing clientele that was exceeding their budgets and staff capacity. 3.17 FOSAP carried out independent evaluations and audits o f all subprojects. Many o f the local associations interviewed duringfield visits notedthat FOSAP andPCT staff and senior NGOs (underthe capacity buildingprojects) provided critical technical guidance andsupport. 3.18 Originally FOSAP was conceived as an organ o f the project with no life anticipated after the project's closing. However, it was later acknowledged that an important dynamic hadbeen initiatedthat should continue beyondthe project's closing. In1998, the legalstatusofFOSAPwas revisedto giveitapermanent legalstatus. As such, its management was detached from the project and given full autonomy. Two management committees, eachmade up ofpublic sector and civil society representatives, oversee, respectively, the subproject grant andmicrofinance components. Since FOSAP achieved this autonomy, co-signature of projects by PCT was no longernecessary; and FOSAP acquired its own Special Account, which greatly facilitated disbursements. PlannedVersusActual Costs andFinancing 3.19 The total project cost was US$26.1 million equivalent, or 96 percent o fthe cost estimated at appraisal (US$27.2 million, see Annex D). While the IDA credit o f 13.9 million SDR was fully disbursed, its dollar value decreasedover the life of the project from US$20.4 millionto US$18.7 million at closing (see Annex D). KfW financing was greater thaninitially plannedbecause o fits decisionto extend its support o fthe social marketing component. Government counterpart financing fell short o f its commitments and the actual contribution bycivil society (under the social fund) was inline with appraisal estimates. 3.20 Annex Dpresentsplannedversus actual disbursements. While grants under the social fund were initially estimated at 2.70 million SDR or 19percent ofthe total credit amount, actual disbursements under the social fund amounted to 3.55 million SDR or 25 percent ofthe total credit. An additional 5 percent o f the credit (0.8 million SDR) was disbursed to support microcredit for women. 40. Many of these agencies were NGOsthat did not necessarilyhave microfinanceexperience,as this was very rareon the ground. They were chosenfor their overall experienceinworkingwith communitiesand for their managementand organizationalskills.The operationalmanualwas a means of guidingthese agencies in carrying out microfinanceactivitiesand in developingmicrofinancecapacityin the country. 14 4. Outputsand OutcomesbyObjective 4.1 Annex Eprovides an overview o fkey targets andindicators for population and HIV/AIDS supported under the project. It shows that for most o f these indicators baseline data were not established, targets were not quantified, data as o fthe end o f the project were not compiled. This beingsaid, progress against a few ofthese indicatorshas been measured. In addition, the project supported the generation o fuseful demographic, social, epidemiologicalandbehavioraldata that provide additional indication o f the outcomes o f this investment. This chapter highlightsthe major achievements ofthe project andthe outcome for eachpopulationand HN/AIDS. Population 4.2 The capacity of theDivision of Population was strengthened with overseas training, study tours, and on-the-job technical assistance, but this Department remains understaffed relative to the scope of its mandate. Technical training was providedin demography, the use o f demographic data indevelopment planning andthe implementation, management, andmonitoringand evaluation o f the population policy andprogram. However, the amount o fdemographic training (both innumbers o fpeople trained and lengtho ftraining) was inadequate for the needs (Wakam 2001). The effectiveness o ftraining delivered was not evaluated. Participationat the 1994 Cairo Conference on Population and study tours to BurkinaFaso, Mali, Senegal, and Tunisia increased the exposure o f staff to intemational goodpractices. Training was also providedto over 60 public sector officials inthe use o f demographic data indevelopment planningbyall ministries, bututilizationofdemographic datahasremainedweak (Wakam 2001). 4.3 Theproject wasgenerally successful in raising community awareness and disseminating thepopulation policy, but attitudes are slow to change. At the MTRand again at the close o fthe project it was acknowledged that it takes considerable time to change attitudes. Nevertheless, duringits field visits the mission was told about and also observed evolutioninknowledge and attitudes across a wide range o f groups.41For example, religious leaders (Muslimand Christian) are involved members o f local-level population commissions and are highlycommitted to populationpolicy objectives that aim to improve mother and child healthandwellbeing and girls'schooling. National and international informants noted that some (initially resistant) imams are now sufficiently convinced about the benefits o fbirthspacing that they are promoting this practice inrural populations. This being said, there i s still ambivalence andeven resistance to the idea o f limitingfamily size, whereas other components o fthe populationpolicy (child spacingto promote ofmatemal and child health, improvement o f women's status, and expansion o f women's economic opportunities) are more widely supported. m l e the coverage targets o fpopulationIEC were essentially met, the efficiency o f efforts was compromisedby the 41. Opinion and religiousleaders,women, NGOs,journalists, youth, unionworkers and localleaders. 15 delay inthe creationo f a technical coordinationcommittee for IEC4*andthe failure of this committee to meet regularly. 4.4 Theproject was successful in generating relevant socio-demographicdata and information in Chad, but it is notfully exploited. The three mainresearch outputs o fthe project were: (a) the first Demographic andHealth Survey (1996197); (b) a study on migration and urbanization; and (c) the preparation o f 15 monographs that provide for eachprefecture regional-leveldata drawn from the 1993 census, five in-depth analyses o f census data, and seven regional-levelanalyses ofDHS data. The extent to which this data i s used indevelopment planning and evaluation has beenreviewed andjudged to be very weak (Wakam2001). Inaddition, delays inthe publicationo fcompleted studies undermine efforts to disseminate anduse them. A case inpoint was the migration and urbanizationstudy, which was publishedthree years after its completion. 4.5 Theproject strengthenedMCWfamily well-being services at all levels of the public health system, most notably through the supply of contraceptivesfor these services throughout the life of theproject. As a complement to the ongoingHealthand Safe MotherhoodProject, which sought to strengthen basic health services, the project averted a major gap incontraceptive supplies when USAIDwithdrew support to Chad in 1995. USAIDhadbeenthe main supplier o f contraceptives inChad; inthe absence o f project support, there would likely have beena severe shortage o f contraceptives inthe country. Close coordinationbetween these two projects, includingjoint supervision, ensured a coherence inthe provision o f inputs for M C H and family well-being. Other supports to M C H and family well-being included: (a) subprojects supported bythe social fundto improveM C Handfamily well-being; (b) the productionofcriticalbaseline data on M C Hand family well-being (DHS 1996197); and (c) the improved availability and affordability o f oral rehydrationtherapy throughout the country. 4.6 Thesocialfund was successful in mobilizing andfinancing a responsefrom civil society organizations in addressingpopulation issues and in inciting and supporting an integratedpublic sector responseat decentralized levels of the administration. Forty-five population subprojects (against 20 planned) were carried out. Ofthese, 30 were executedby local associations supporting a variety o f activities (maternal and child healthand family well-being, promotiono fwomen and youth, and studies), and 15 integrated projects (addressing direct andindirect determinants of population andreproductivehealth) were implementedby the 15 CRPRH. 4.7 Evaluations o f subprojects commissioned by the social fund focused more on implementationrates than onresults. However, field discussions highlighted results reported by implementers andbeneficiaries, including an increase inthe use o fprenatal services, improved economic opportunities for youth, increased enrollment o f girls in school, increases inexclusive breastfeeding, and a reduction insevere cases o f malnutritionamong children. 42. Createdin September 1997, almost two years afterthe initialtarget date. 16 4.8 Theprovision of microfinancefor poor women achievedpositive changes in important, inter-related determinantsof fertility: (a) increased incomegeneration and economic opportunitiesfor women; (b) increased investmentsin the health, nutrition and education of their children; (c) improved social and economic status of women; and (d) improved information on reproductivehealth andfamily health. These achievements, relative to the counterfactual o f no support, are documentedboth inthe final evaluation o fthe microfinance component (Miller2001) andindiscussions with about 50 beneficiaries o f this support the cities o fMao, Bongor, Moundou andMongo. Informed questions posedby these women about the relative safety andrisks o f different methods o fcontraception provided an indication o ftheir basic knowledge and internalizationo fmessages about reproductive health and family planningchoices. However, as i s documented later inthis chapter, these achievements have not yet translated into increases inthe CPR. 4.9 Theintroduction of oral rehydrationpackets into the social marketingportfolio of AMASOT tofight diarrhea in children underfive addressedyet another critical determinant of fertility -that of high child mortality. Sales thus far have exceeded initial expectations due to a very highdemand for this product. The potentialimpact o f this activityon childmortalityis significant, but ithasnot yet beenevaluated. 4.10 Project Figure 2. Use of contraception among married women and assistance did not those in consensualunion, 1996 and 2000 succeed in increasing the modern 9 contraceptive 8 prevalence rate (CPR) 7 6 from an estimated 1 5 percent in 1990 to the ae 4 target of 10 percent by 3 2000.43As illustratedin : I 2 Figure 2, Chad achieved 1 a modem CPR Any method Modern method prevalence rate o f 2.0 percent in2000 (UNICEF Note:The differences between 1996and 2000, are statisticallysignificant 2001), a statistically at p~ .05. Source: DHS 1996197and UNICEF Multiple IndicatorSurvey 2001; Reproduced significant increase over from Country Status Report (World Bank 2004). the 1996 level o f 1.2percent (DHS 1996/97),but, nevertheless, considerably lower than the target. The figure also shows that the CPR for modemandtraditionalcontraception combined increased fiom 4.2 percent to 7.9 percent over the same period. Table 3 in Annex Dshows a breakdownincontraceptive use by level o f education andplace of residence in2000. The modem CPR i s significantly higher amongwomen with secondary school education (12.3 percent) as opposed to those with primary education 43. While it was acknowledgedat the MTRthat the program's (and project's) originalobjectives and targets were, in retrospect,unrealisticand would not be met,there was no formal revisionof objectives. UNFPA was working on revisingthe objectives,buttheir consultantsare reportedto haveworked very slowly and realistic data were availableonly for the 2nd project. 17 (2.8 percent) or some education (1.4 percent); and modem CPR i s also higher among women livinginurbanareas (6.6 percent), especially inN'Djamena (9.0 percent), as opposed to their m a l counterparts (0.8 percent). 4.11 Available data indicatethat the total fertility rate (TFR) inChadhas remained constant over the life o fthe project. The DHS revealed a TFR o f 6.6 children in 1996/97; recent analytic work suggests this same rate for 2000 (CSR 2004). 4.12 The population strategy also aimed, through an anticipated increase inthe CPR, to reducethe annual rate o fpopulationgrowth from 2.4 percent in 1990to 2 percent by 1999. According to the most recent Government estimates, the actual rate o fpopulationgrowthi s about 3.1 percent.44 4.13 Itis important to note that at the time ofthe MTR(1997), whenthe results ofthe first-ever DHS inChad became available, it was acknowledged bythe Bank andthe borrower that the objectives o f increasingthe use o fmoderncontraceptives anddecreasing fertility andthe populationgrowthratewere, inretrospect, not realistic andwould not be achieved. They expressedthe intentiono f setting new targets on the basis ofthe DHS data. UNFPAhiredconsultants to this end, but the work o fthese consultants progressed slowly; andthe Development Credit Agreement was not formally amendedto set morerealistic objectives against which the projectwouldbemeasured. HIVIAIDS 4.14 Epidemiological and behavioral surveillancewas improved under theproject and documentedthe seriousness and scope of the epidemic. The project supported the strengthening and functioning ofthe epidemiological surveillance system for HIV, comprised o fnine fully functional sentinel bythe endo fthe project (versus seven planned), two o fwhich were set upwithproject assistance (see list inAnnex D).This systemcollects andreports annual dataonHIVprevalence amongpregnantwomenusing prenatal services, blooddonors, STD patients, andTB patients.46Sentinel sites also monitor andreport onprevalence ofsyphilis amongwomen usingprenatal services. Techmcal supervision and support o f sentinel sites was somewhat constrained by staff t~mover,~' but compensated inpartbythe support ofthe long-term technical assistants4* 44. Source: Directorateof Coordinationof Population-RelatedActivities, Ministryof Planning, Development and Cooperation (MPDC), 2004 data. 45. At the time of the project`s closing, a tenth site (Faya) is only reportingAIDS cases (and not HIV prevalence)for the moment. 46. At the time of the mission's visit, four annual statistical reportshad been produced, providinga series of data for the years 1999,2000, 2001, and2002. While the projectfinanced training and other support to the functioningof the surveillancesites, the quality and completenessof the data are still in need of improvement. 47. PNLSstaff personresponsiblefor epidemiologicalsurveillanceat the project`soutset receivedtraining in epidemiology,but was transferredto another postupon his returnto Chad. Hewas replacedby a non- specialistwho receivednotechnicaltraining in epidemiology. 48. The long-terminternationaltechnical assistant, who is an epidemiologist,did not providefull-time supportto this effort, becausehis terms of referencewere very broad. Inadditionto epidemiological 18 4.15 HIVprevalenceandbehavioralstudieshavesupportedthe documentation of trends, issues, and consequenceso f the epidemic andthe development o f strategies on how best to fight it. HIV seroprevalence studies indifferent geographical regions, some focusing onthe general populationothers focusing on specific high-riskgroups, have permittedinsome cases an assessment o ftrends inthe epidemic (see Annex D). Sentinel sites and studies data were often cited byregional authorities and actors andmaywell be motivatinglocalcommitment and, to a lesser extent, the design andtargeting o f activities. Also contributing to improvedknowledge and insightwere: knowledge, attitude and practice (KAP) surveys and sociological studies on high-risk groups (such as prostitutes) anda studyto assessthe economic and social impacto fthe epidemic. 4.16 The IECUnitwithinPNLSproducedmaterials andcarried out campaigns to inform the general population andtarget groups and enhancetheir ability to protect themselves. These efforts were complemented bythe numerous andwidespread IEC efforts carried out by other nationalpartners (such as the Ministryo f Communication, the IEC division o fMoPH, andpublic andnon-public actors at the local level) targeting many groups across the country. Many actors encountered during field visits acknowledged the good quality andutility o f IEC material produced by the IEC unit in PNLS.Manyalso calledfor more locally appropriate material inlocal languages, better coordinationo f IEC, and moreresearch for adjusting interventions andtarget groups. There was consensus among the majority o f informants that evolutionhas occurred inthe knowledge and attitudes o f a range o f actors and stakeholders. HIV/AIDS i s no longer taboo, but rather recognized for what it is: a threat to the development o f Chad andthe well-being o fits populationthat requires urgent andpersistent action. While IEC efforts do seem to have had some impact, their coordination and efficiency are inneed o f improvement. 4.17 Theproject supported the strengthening of thepublic health system's capacity in: the diagnosis of H I V infection (including equipment of laboratories), thepsycho- medico-social care of HIV/AIDSpatients, the diagnosis and treatment of opportunistic infections, and STD syndromic treatment.49The project providedtechnicaltraining and consumables for laboratories and established a national laboratory referral center for HIVlAIDS diagnosis. It also financed a CD4 count instrument andthe establishment o f Enzyme-LinkedImmuno Sorbent Assay (ELISA) chains infive hospitals. Support for improved STD services includedthe training o f over 2000 service providers andthe preparation o f STD treatment guidelines. Some training on the use o f anti-retroviral drugs (ARV) and triple therapy was also provided." No evaluationhasbeen carriedout technical support, his terms of referencealso includedthe provisionof technicallmanagerialsupportto the PCT/MoPC in coordinating HIV/AIDS activitiesand to the socialfund entity, FOSAP. 49. The syndromic approachto STD patient management bases diagnosisand treatmenton the presenceof symptoms, generallywithout resortto confirmatorylaboratorytests. This approach is recommendedby WHO in developing countrysettings as it allows treatmentwith a single visit and away from a laboratory setting. 50. The projectdid not financethe purchaseof ARVs. In 1994when the projectwas designedARVs were very expensiveand notwidely available;and Chad's second medium-termplanfor HIV/AIDSplaced highest priority on preventionactivities. 19 to assess the extent to which these investments culminated inmore andhigher-quality services. A number o fthose interviewednotedthat HIV/AIDS and STD patients are still not well managed andthat there are still considerable gaps between facility-based and community-based care. Datawere not available to check progress against the project target o f 12,000 AIDS patients beingtreated bythe healthsystem. The project also invested inthe strengthening and expansion o f counseling andtesting services; at the end o f the project some 13 centers were functioning (target not specified inproject documentation), with more slated to be established. 4.18 Thesocial Figure 3. CondomSales, 1996-2002 marketingprogram has significantly increasedthe availability of condoms in 7 Chad at an affordable 6 price. A total o f 19.9 4.0 million condoms were sold duringthe lifeoftheproject (1996-2001) througha network o fover 1,200 points o f sale throughout the country, against the 1996 1997 1998 1999 2000 2001 2002 initialtarget o f 14million. Project Implementation The annual salestarget set for the last year o fthe Source: AMASOT statistics,2004 project (4.8 millioncondoms) was exceededinthe third full year o fthe project (6.5 million in1999). ForreasonsexplainedinChapter 3, annualsales declinedtemporarily in2000, then steadily increasedover the following two years, achieving 4.0 millionin2002. Figure 3 shows trends inannual sales over the life o fthe project andduringthe first year after the close o fthe project (2002). Annex Dshows a further breakdowno fthese sales bymonth andaveragemonthlysales for eachyear (just under 300,000 condoms). 4.19 The very low price o f less thanUS$0.02 per unit (50 CFA fi-ancs for a packet o f four) has made condoms widely accessible to the general population. It has also promptedthe sale o fthese condoms inneighboring countries o f Cameroon and Central African Republic, where the price o f condoms i s higher. A study o f social marketing programs inthe three countries estimated that up to 20 percent o fAMASOT condoms (about 4 millionunits) may have beenresoldinthese countries (Lehmann et al. 2003). Net o f estimated sales inneighboring countries, the total number o f condoms sold in Chadover the life o fthe project (15.9 million) still exceeded the project target o f 14 million. InOctober 2003, AMASOTincreased the price o f condoms to 100 CFA 51, In October 2003, AMASOT doubledthe priceof condoms (from 50 to 100CFA francs for a packetof 4) to discourage their cross-bordersales, still keepingthe priceaffordablefor most Chadians. Sales data in late2003 and early 2004 reveal a decline in overall sales, attributableby AMASOT both to a reductionin cross-bordersales andto a temporary declinein in-countrysales becauseof the price increase. 20 4.20 While condoms were taboo at the start o f the project, they are now sold openly in shops, market stands, inns, andhotels across the country. The Bank evaluation mission was told by the majority o f those interviewedthat condoms are usedmore frequently duringcasual sexual enco~nters.~~ There are now some 25 billboardswithHIV/AIDS messagesprominently displayed inmajor cities. Messages abound as well innewspapers and onposters placedinmanypublic venues: workplace, stadium, restaurants, hotels, and public transport. Religious institutions and leaderswho were vehemently against condom promotion at the project's outset have tempered their opinions andhave a laissez-faire demeanor, with some tacitly promotingtheir use as a means o fpreserving family health andwell-being. As a consequence, there seems to beconsiderably less stigma associated withthe purchase o fcondoms. 4.21 Thesocialfund has been complementary toAIDS interventions carried out by Government. A total o f 97 HIV/AIDS subprojects were prepared and implemented throughout the country (against 40 planned), o fwhich 68 by local associations (prevention targeted at youth, prostitutes, andpsycho-social-medical care), three by regionalIslamic associations (inthree prefectures), 15 integrated projectsunder the coordinationo fPrefecture Health Councils, and 11by eight sector ministries.53 The impact o f these efforts has not beenevaluated, but the social fimdhas achieved an expansion o fnationalcapacity to respond to HIV/AIDS andhas broadened the rangeo f actors and scope o f activities. 4.22 Thesocialfund has nurtured and supported a responsefrom civil society organizations in addressingHIV/AIDS: Civil society projects covered a range o f advocacy, IEC, behavior change interventions, and community-based efforts to provide care and social support to people livingwith HIV/AIDS (PLWHA). Fielddiscussions withimplementers andbeneficiaries pointedto improvedawareness andknowledge, better quality o f life for PLWHA andtheir families, and greater civil society pressure on public sector leaders to be accountable for addressing HIV/AIDS. 4.23 Thesocialfund has also strengthened the capacity of civil society to conceive and implement activities in support of HIV/AIDS. Six experienced NGOs carried out capacity development activities, basedin, andcovering, different geographical zones across the territory o f Chad. Assistance included subproject design, proposalwriting, implementation, andmonitoring and evaluation. Thrs approach putneeded technical assistance and support within immediate access o f a relativelyinexperiencedandweak civil society. A significant majority o f the numerous local associations interviewed duringthe evaluation missionconsideredthis assistanceto bepivotal intheir ability to access funds and implement subprojects successfully. Another outcome o fthe efforts o f the capacity buildingefforts i s the development o f new local associations, inparticular associations o fprostitutes and associations o f PLWHA. This is an important accomplishment, given taboos prevalent at the project's outset and given the great potential o fthese two groups to contribute to HIV/AIDS preventionefforts. A number o f 52. Unfortunatelyavailabledata is inadequate to document this trend. 53. SocialAction and Family; NationalEducation; Defense; Finance;Justice; Communiation;Health:and Interior. 21 experienced NGOsraised concern about the limits o ftheir ability to provide effective support to the increasing numbero f local associations with limitsinfinancial andhuman resources defined intheir contracts. 4.24 Improved capacity ofpoor women to earn income under the microfinance component, combined with theprovision of practical information on HIV/AIDS decreasedthe vulnerability of women toHIV infection. An evaluation o f this subcomponent was undertaken (Miller 2001)s4and corroborates the findings o fthe mission, derivedthrough interviewswith microfinance agencies and about 50 women beneficiaries infour prefectures. The large majority o fwomen's groups succeeded in usingmicrofinanceresources to start or expand economic activities that resultedin increased income used for investmentsinfamily well-being. Together, the extra income andthe informationonHIV/AIDS were reported to have givenwomen an equal partnershipwith their husbands, higher self esteem and dignity, andthe knowledgeto protect themselves from HIVinfection. Women benefiting from this assistancereported that it protected them informalprostitution for income and equippedthemto reduce vulnerabilities o ftheir daughters and other women. Inshort, they expressed a strong sense o f economic, socia1andpersonal empowerment. 4.25 Thesocialfund mobilized andfinanced the involvement of key sector ministries in HIV/AIDS efforts. The social fundhas supported HIV/AIDS activities o f eight key ministries, who have designated a focal person and, insome cases HIV/AIDS units, to addressHIVIAIDS issues, targeted at staff and clients. Among activities supported are: HIVlAIDS training and IEC inschools (Ministryo fEducation), social support o f PLWHA andtheir families (Ministryo fSocialAction andFamily), medical andsocial support o f HIV/AIDS patients (Ministry o f Public Health), training ofjournalists, and radio andtelevision media campaigns (Ministry of Communications), sensitization o f militaryandpreventiono fcontamination inhealthfacilities (MinistryofDefense), protection o fprisoners (Ministryo fJustice), informationandmobilization o f local officials andtraditional leaders (Ministry o f Interior). However, the effectiveness o f these activities has not been evaluated. 4.26 The socialfund launched and supported the decentralization of HIV/AIDS activitiesin all 14prefectures. Carried out under the auspices o f inter-sectoral Prefecture HealthCouncils, the effectiveness o fthe subprojects, focusing on a range o f prevention, care, andmitigation activities, has not beenevaluated. Over and above the financing o fthese activities at the regional and subregional level, project support provided a dynamic for local-level, inter-sectoral deliberationand action on HIV/AIDS. 54. This evaluationfocused more on the processand efficiency of the microfinancescheme than on the impact of this investment. Nevertheless, the methodologydid includeinterviewswith beneficiariesinfive prefecturesto assess the impactof this investmenton their lives and on the lives of their families. While the reportprovides usefulinsightson impact, the authors notethat their evaluationof impactwas not sufficiently systematic or rigorous,and recommend that an in-depthevaluation be undertaken. 22 4.27 Awareness and knowledge of - . Figure 4. Percent of men andwomen surveyed HIUAIDS, among men and women, declaring they have heardof AIDS both urban and rural, have increased during the life of theproje~t.~' The 1 10O%l 88.1.-I most significantimprovements found 80% amongwomen, ruralresidentsandthe 60% poorestincomequintiles (see text Women 1 40% Figures4, 5,6, and7; andAnnex D). Improvementshavethus reduced 20% importantdisparities inknowledgeand I awarenessbetweenmenandwomen, 1996197 2000 2003 urbanandruralresidents, andthe Source: DHS 1996/97; UNICEF2001; KAP 2003 poorest andrichest segments ofthe population. Trends inknowledgeofhighrisk groups are not Figure 5. Percent of men and women who Figure 6. Percent of men andwomen who know condoms are a means of protection know that fidelity is a means of protection 100% 80% 80% j..enl BOY0 ClWomen 40% 20% 0% 1996197 2000 2003 199WS7 2000 2003 Source: DHS 1996/97; UNICEF2001; KAP 2003. 55. Trends on awareness and knowledge presentedin this reportare derivedfrom three nationalstudies: (a) the 1996/97 Demographic and HealthSurvey; (b) the 2001 UNICEF MultipleIndicator Survey: and (c) a 2003 KAP survey commissioned by Government. All three surveys are national in coverageand based on the zones definedduring the 1993populationcensus. All three coverwomen in the same (15-49 year) age group; and the first and third surveys also include men in the same (15-59 year) age group. DHSquestions relatedto knowledge and awarenesswere open-ended,whereas the UNICEF and KAP survey questions were prompted. All three surveys coveredboth urbanand rural populationsand properlyweighted the data to reflectthe urbanlruralpopulationdistribution. Sample size for the DHS included 7,454women and 2,320 men. UNICEF's sample size covered5,865 women; and the KAP samplewas comprisedof 1,148 women and 1,332 men. Differentquestionswere posedacross the three surveyswith regardto condom utilization, thus limitingthe possibilityof derivingtrends on behavior. 56. A nationwidestudy of prostitutesin Chad found that 96 percentof prostitutesliving in urban areas and 74 percent in ruralareas were aware of HIVIAIDSand possessedthe knowledgeof sexualtransmission and howto protectthemselves (Ngoniri2001). No baselinedata on knowledgeof prostituteswas established, against whichthese levelscan be compared. Prostituteswere a prioritytarget group for HIV awarenessand prevention of the first medium-termHIV/AIDSplan (1990-1993). 23 Figure 7. Evolution inLevels of Knowledge of Women by Socioeconomic Group, 1996-2000 100 , HKnowledgeofAIDS 1996 HKnowledgeofAIDS 2000 Poorest RichestQuintile Quintile Source: DHS 1996-97 and Unicef Multiple IndicatorSurvey. Reproducedfrom CountryStatus Report (WorldBank2004). 4.28 The proportiono f adults reporting that they have ever used a condoms has risen over the period 1996-2003,with the most significant increase amongwomen (Figure 8). While urban-rural and gender differentials are still evident in2003, they have been reduced since 1996197. 4.29 In2003,6.6 percent ofwomen surveyedreported usingcondoms regularly and another 6.5 percent o f women reported usingthem occasionally. higher than in 1996/97, when 0.7 percent o fwomenhavingknowledgeo fAIDS andhaving sexual relations withinthe last 12monthsreported usinga condom intheir most recent sexual encounter Figure 8. Ever-Use of Condoms (percent), 1996 and 2003 (DHS 1997).Menalso reportedhigher levels o f condom use thanwomen in2003 than in 1996/97:8.7 percent reported regular use and9.1 percent reported occasional use in2003, up fiom 2.2 'percent o fmenknowing about AIDS and having sexual relations within the past 12 months reportedusing a condom intheir most recent sexual encounter (DHS 1997). Trends incondom use by high-riskgroups All Urban Rural A11 Urban Rum1 All Urbm R U I ~ Ail Urban Rural R96197 2009 have not been systematically tracked, but Source: DHS 1996197: KAP2003 a recent study reveals highrates of condom use by prostitute^.^^ 57. The Ngoniristudy ( 2001) revealsthat use of condoms by prostitutes is highest in urbanareas, where 82 percentof professional prostitutes and 52 percentof those engaged in clandestine prostitution report that they regularlyusethem. In ruralareas an estimated 55 percentof professional prostitutesreport regular useof condoms, while regular use among clandestine prostitutes is much lower at 20 percent.While there is no baseline against which to comparethesefindings, discussionswith a wide rangeof actors and stakeholders, and consultation of project designdocumentation,revealthat condomswere both unavailableandtaboo inthe early 1990s. 24 4.30 I n the absence of incidence data, it is difficult to evaluate the extent to which theproject has slowed the spread of HIVinfe~tion.'~ At the time ofproject design 2,865 AIDS cases hadbeenreported over the 9-year period 1986-1994. Duringthe following eight-year period (1995-2002) an additional 14,108 cases were reported, a fivefold increase. However, even the most recentlyreported cases were most likely the result o f infections which occurred before the start o fthe project andAIDS cases are underreported. 4.3 1 A series ofpopulation-based Figure9. Trends inAdult Prevalencein surveys o f general and specific Three Cities populations reveal HIVprevalence rates for different geographical regions, 10 different population groups, and different :: 8 periods (Annex D). These data for the 8 6 a 4 0) most part show snapshots o f rates o f h z B certain groups andor regions at a certain 0 time. The only trends that these datashow 1989 2000 I989 1997 1989 2000 are (a) an increase inthe prevalence rates Sarh Abechb Bongor inthe cities ofSarh, AbechCandBongor Source: Populationbased studycovering6 cities (N'Djamena, (see Figure 9), and (b) a slight decline in Moundou, Sarh, BongorandAbechB. (Organizationfor the Coordinationof Epidemics of CentralAfrica, OCEAC, 1989); and the prevalence among militarypersonnel populationbasedsurveys onAbBche, Bongor, and Sarh (PNLS) 1997and2000 inN'Djamena (from 10.2 percent in1995 to 8.40 percent in 1997).59 58. The objectiveof the projectwas to slow the spread of HIV,which means reducingthe numberof new infections. Prevalence is affectedby the numberof new infections,the numberof past infectionsand the AIDS mortalityrate and therefore masks the rate of new infections (incidence). Becauseof the delay in the onsetof AIDS of 10 years or more, HIV prevalencecan rise quicklyearly in an epidemic, beforeAIDS mortalityaffects HIV prevalence. Subsequentdeclinesin prevalencewill be attributablein partto AIDS mortalityand may not necessarilyreflectdeclines in new infections. 59. The samplesize of these studies is not known. 25 4.32 Figure 10shows Figure 10. HIV PrevalenceAmong Women Using Prenatal that prevalence among Services inFour UrbanSites, 1999-2002 women usingprenatal services infour urban 10% sites6"has increased from 4.0 percent in 1999to 7.5 8C 8% percent in2001 andthen f> 6% decreasedto 6.4 percent in2002.61While I! 4% available data reveal that =1 2% HIVprevalence hasrisen 0% over the past decade in 1999 2000 2001 2002 the general population I andthat itmayhave stabilized among Source:MOPH 1999-2002 sentinel site data from: Bol,N'Djamena, Bongor, and pregnant women using Sarh. prenatal services inurbanareas, these data do not reveal the extent to which changes in prevalence are due, on the one hand, to risingmortality due to AIDS, and, on the other hand, to reductions innewinfections. 5. Ratings 5.1 Outcome. The outcome of the Populationand AIDS Control Project i s rated moderately satisfactory overall, basedon an unsatisfactory outcome o fthe population objective and a satisfactory outcome o fthe HIV/AIDS objective (see Table 1). The final ratingwas derived from a heavier weighting o fthe outcome o fthe HIV/AIDS objective, commensurate with its highrelevance and its share o fthe total project cost (about two- thirds). Table 1. Summary OEDRatings" by Objective ~ -Relevance - Efieacy Efficiency Outcome - To advance the onset o f fertility decline by increasing the use o fmodern methods of contraception Modest Negligible Modest Unsatisfactory To slow the spreadof HIVinfection bypromoting behavioral change High Substantial Substantial Satisfactory * See insidecover of this report for definitionsof relevance,efficacy, efficiency and outcome. 60. The only four sentinel sites for which data is availableevery year during the period 1999-2002are the urbansites of Bol, N'djambna,Bongorand Sarh. Two other urbansites (Abecheand Moundou)did not have complete data sets over this time periodand so were eliminatedfrom this trend analysis. 61. Data from all 11sentinel sites reporting in 2002 (ofwhich seven classifiedas urban and four classified as rural) indicatean overallprevalencerate among pregnantwomen usingprenatalservices of 5.82 percent (seeAnnex Dfor details). Given that seven of the 11sites are urban, national prevalenceamong this group is likely to be lower when weightedfor the urbanhuralpopulationdistribution.These data should be interpretedwith caution as capacitiesfor the collectionand analysisof epidemiologicaldata are still consideredto beweak; and ruraldata are too recent to revealtrends. Furthermorethe representativityof these data is notsure as less than halfof all women utilize prenatalservices (AnnexD). 26 PopulationOutcome 5.2 Based on assessments of its relevance, efficacy and efficiency, the overall rating of the outcome of thepopulation objective is unsatisfactory. The fundamental objectives o freducing fertility andreducingpopulationgrowth are not articulated inthe Government's PRSP (October 2003), nor does it mention family planningfor birth spacing andfamily well-being. The document's treatment o fpopulationi s to note that demographic factors (including population growth) call for strong economic growth to ensure sufficientjobs and access to services for a growing population, and a redistribution o fthe h i t s o f economic growth to those most inneed. Neither are the control o f populationgrowth or the reduction o f fertility specified among the Bank's CAS objectives (November 2003). Under the umbrella o f the MDGs, however, a number o f determinants o f fertility are highlightedinthe CAS, including: reductioninthe poverty andvulnerability o fwomen, increased girls' enrollment inschool, and reductions in maternal and child mortality. Relevance o f the population objective i s thus ratedas modest. 5.3 Efficacy inachieving the objective o fraisingthe moderncontraceptive prevalence rate to 10percent by the year 2000 is negligible. Population-related behavior change is progressing slowly, at best, with only very modest increases incontraceptive prevalence rates documented between 1996and2000. Efficiency o f efforts to reach the populationobjectives is modest. Because o f staffing shortages, a shortfall inUNFPA financing, andupheaval causedby a reorganization o f CERPOD,62the Department o f Populationwas late inproducingmajor research and studies, althoughthe quality o fthese studies i s high.Absence o f effective coordination o fthe multiplicity o f IEC initiatives andIEC unitsacrosshave causedeffortsto be fragmented anduncoordinated. The institutional framework for populationpolicy approval and oversight was highly inefficient. At the decentralized level initial efficiency o fthe newly established CRPRH was low, but improved over time. HIV/AIDSOutcome 5.4 Theoverall outcomeof theHIV/AIDS objective is satisfactory, based on the following ratings of its relevance, efficacy and efficiency. The relevance ofthe HIVlAJDSobjectiveis high. BoththePRSP andCAS are articulated around the MDGs, which specify the goal o f controlling the spread o f HIVand a three-year outcome indicator o freductions inhigh-riskbehavior for HIV/AIDS prevention. The project's efficacy inachievingthe HIV/AIDSobjective i s substantial. Overall, goodprogress has beenmade inincreasing levels of, and decreasing inequities in, awareness andknowledge o fthe population about HIV/AIDS. The social marketingprogramhas significantly increasedthe availability o fcondoms throughout Chad at an affordable price. Taboos associatedwith the purchase anduse o f condoms have decreasedconsiderably. Available data indicatemodest, butpositive, changes inbehavior, a trend which is likely to continue, and which contributes directly to reductions ininfection. There i s inadequate 62. With whom a majorcontract was signedto providetechnical assistanceand capacitybuilding. 27 evidence available on trends inthe number o fnew infections (incidence) inthe general population and among high-riskgroups. 5.5 The efficiency inachieving HIV/AIDS objectives isjudged to be substantial overall. Morethanhalfthe project resources were ultimately channeled through the nongovernmental sector to two autonomous agencies, which provedto be efficient in their operations. First, FOSAP (responsible for the social fund) disbursed 133 percent o f funds initially allocated for civil society and decentralized subprojects. The microfinance subcomponent achieved a reimbursement rate that exceeded90 percent, inspite o fthe fact that itrelied onthe few microfinance organizations that existed inChad, whose capacity was weak. Challenges remainto improvethe coordinationo f subprojects so as to minimize duplicationor gaps inessential interventions. Second, MASOT, incharge o f the social marketingcomponent, was efficient inits organization andits operations, especially after the initial technical assistancewas replaced at the mid-termby new technical assistance that was more gearedto the transfer o f skills. 5.6 ThePNLShasnot been fully efficient inleadingand coordinating MoPH's responseto the HIV/AIDS epidemic. By design, the PCT inthe MoPC carried out the role o f inter-sectoral coordinationo f HIV/AIDSactors andactivities. The PCT was highlyefficient inmanagingandoverseeingproject implementationandwas proactivein communicatingwith the multiplicity o f actors andbeneficiaries, boththrough frequent field andthroughregular (monthly) meetings with key actors on each o fthe four components. 5.7 InstitutionalDevelopment. The project's support to the development o f institutions for population andHIV/AIDS is substantial. The establishment o f a social fimdhas (a) significantly strengthened incentives ofarangeofpublic and nongovernmental stakeholders to become involved inpopulationandAIDS; (b) supported the decentralization o fpopulation andHIV/AIDS activities; (c) incited a new dynamic o f inter-sectoral andpublic-private partnershipsinthe planning and implementationof activities, especially at the local level; and (d) fostered the strengthening and expansion o f civil society organizations. FOSAP is a well-established agency, with substantial reach throughout the country made possible byits contractual arrangements with field-based, intermediaryNGOs. It evolved from a temporary agency set upunder the auspices o fthe PCT into a fully autonomous agency with a permanent legal status. Likewise, the social marketing entity set up under the project evolved from a temporary project entity (MASACOT) into a fully autonomous agency (AMASOT) with a permanent legal status. AMASOT's performance i s strong, with growing sales in condoms and oral rehydrationpackets and an expanding portfolio64and it is staffed with capable staffbothinthe areas o f social research andmarketindsales. The creation and successful operation o f these two legally autonomous entities has reformed the way populationandHIVIAIDS activities are carried out. A significant portion o fthe 63. Mostfield visits undertaken were carriedoutjointly with the managementlteamof the ongoing health operation. 64. Other commodities are beingaddedto its portfolio under the follow-on operation, including impregnated mosquitonets, female condoms and hormonal contraceptivesfor women. 28 population andHIV/AIDS agendais inessence subcontracted out to the nongovernmental sector. 5.8 Public sector institutionbuildingfor populationhasbeenmodest. The numbers and qualifications o f staffinthe Directorate o fPopulation fall short o fthose neededto fulfill its mandate, particularly inthe disciplines o fdemography andsociology. Regional-level capacity inthe planningandimplementation o fpopulationactivities was strengthened through the technical and financial support o fthe inter-sectoral CRPRff which conceived andoversaw local-levelpopulationactivities. 5.9 SomeHIV/AIDS institutionaldevelopment has also been achieved inthe public sector, although considerably more i s needed. By designPNLSwas relievedo f inter- sectoral coordination responsibilities underthe to enable it to focus its limited capacity on mobilizing and guidingMoPHinfulfilling its critical mandate inthe fight against HIV/AIDS. Progresswas made instrengtheningcapacity for epidemiological surveillance andinthe provisiono fcriticalinputs for keyHIV/AIDS and STD services delivered throughthe public health system. Inaddition, regionallevel capacity for the planningandimplementationofHIV/AIDS activities was developed throughtheprovision o ftechcal and financial assistancechanneledthrough inter-sectoral RegionalHealth Councils insupport o f local levelHIV/AIDS initiatives. These Councils existedprior to the project, but informants havereported that they were not functional untilthey benefited from project support. 5.10 Sustainability.The sustainability o fproject efforts is likely.BothFOSAP and AMASOT havepermanent legal statusthat providethemwith autonomy intheir functioning, an independent andcompetitively recruited staffo fprofessionals andviable mechanisms for public-privateoversight andcontrol. Furthermore, their strong and improvingperformances are attracting the financingo fother partners indevelopment wishmg to contribute to the fight against HIV/AIDS. Revenues from the sale o f commodities are usedto finance the operational costs o fAMASOT. The strong demand for the services o fboth entities underpinsustainability fkom a social perspective. There i s also evidence that the strengthening andinvolvement o fcivil society has achieved momentumat the local levelthat will last beyondany one investment. Empowerment and self-reliance was observed inthe input anddemeanor o f localassociations, some o fwhich were formed and functioning without direct (continued) project support. Civil society i s also carryingout an advocacy role from the local level (e.g., prostitutes, PLWHA) to the national level (e.g., national-level NGOso fwomen, ministers, parliamentarians, retired civil servants). 5.11 The sustainability o f efforts to establish, disseminate andeffectively use demographic and socio-economic data will depend heavily on Government's success in the recruitment o fanadequatenumber o fprofessional staff, continued efforts to generate demand for these products, andthe relevance o fthe population messages. 65. The MoPCwas chosen as implementingagency giventhe multi-sectoral natureof populationand HIV/AIDS activities. The PCTwas responsiblefor the management, supervision and financing of HlViAIDS activities. 29 5.12 Bank Performance. Theperformance o f the Bank isjudgedto be satisfactory overall: satisfactory duringprojectpreparation and highly satisfactory duringproject implementation. 5.13 Duringpreparation, the Bankhelpedacceleratethedevelopment andofficial adoption o f the populationpolicy as well as the second medium-termplanfor AIDS control. A participatory approach to project preparation helped to engender understanding andcommitment among abroadrange of stakeholders. The Bank also deserves credit for aproject design that emphasizespublic goods that have often been neglected inother projects. However, for the majority o fproject indicators baseline data were not established, some project targets (notably the populationobjective) were not realistic, and others were never quantified. 5.14 DuringimplementationtheBank was persistent, candid, andvigilant incarrying out advocacy at all levels o f government about the risks and consequenceso f the HIV/AIDS epidemic andincited govemment officials to visit the field to observe the realities o fthe HIV/AIDSepidemic andpopulationissues. The Bank i s credited with contributingto breakingthe taboo o fHIV/AIDSwith frank and open discussions about highlysensitive issues (e.g., condoms, prostitution). The Bank's advocacy about population, especially the promotion o f family planning for matemal and child healthand familywell-being, was met with great discomfort and evenresistance onthe part o f Chadian leaders and authorities; and so a tactical decisionwas made to focus Bank advocacy where there was morereceptivity and opportunity for achieving goals. The frequency, staffing and duration o fBank missions andthe continuity o fthe task team managemenPhave enhancedBank effectiveness duringimplementation. The Bankwas considered bymany interviewedto bevery client-oriented, with good listening and response skills. A case inpoint i s the task team's success inintroducingthe microfinance for women subcomponent following the MTR, which was initially resistedby some Bank experts. 5.15 Borrower Performancewas satisfactory overall. Its most notable accomplishments duringpreparation were the preparation and approval o fthe national populationpolicy andthe second medium-term plan for the fight against HIV/AIDS. Failure to deposit the initial counterpart fimds as originally agreed ledto delays inproject effectiveness. 5.16 During implementation the Government's failure to provide counterpart funds in adequate amounts and on time impeded the efficiency andtimeliness o fproject implementation. Furthermore, the failure o fthe high-level population commissionto meet and approve the plan o f action andpriority investments for population (PAP) was an important cause o fdelay inthe populationcomponent andan indicator of lack o f Government commitment. Health-related activities and epidemiological surveillance were implemented, albeit with some difficulty, attributable to very weak capacity o f PNLS. Despitedifficult countrycircumstances, andweak Governmentcapacityoverall, 66. The task manager remainedthe samefrom effectivenessthrough the to the close of the project(and continueswith the implementationof the follow-on operation). 30 the other two components were well implementedwith very good performances bythe implementing agencies, AMASOT andFOSAP.The performance o f the PCT was highly satisfactory withregardto management, coordination, and oversight o fproject implementation, good quality andregular communications with the key actors and implementers o f each component, and fulfillment o f all fiduciary andreporting requirements o fthe Bank. Synergies established with the project management o fthe ongoinghealthoperation permitted good coordination andcomplementarityo fthe two operations. 6. Findings andLessons 6.1 TheBank can be instrumental in stimulating government commitment with regard topopulation and HIV/AIDS throughpolicy dialogue, advocacy, technical support and lending, but such support is insufficient to consolidateand sustain that commitment. Throughpolicy dialogue andtechnical assistanceprovidedinthe context o f project preparation, the Bank supported the development and approvalby Government o f policy and strategic documents for addressing population issues and for fighting HIV/AIDS. Government's agreement to borrow for HIV/AIDS was inconsiderable part attributable to the Bank's persistence inhighlightingthe risks andconsequences o fnot addressing HIV/AIDS duringthe preparation o f the healthoperation in 1994. The Bank's persistence and candor helpedopen a national discussion on HIV/AIDS. 6.2 Otherfactors that are critical to raising and sustaining Government commitment are (i) the relevance of the objective, determined inpart by the availability of local evidenceand data; and (ii) the degreeof mobilization of civil society. The support o f HIVlAIDS research, data collection and analysis, studies andthe strengthening o f a sentinel surveillance system have providedconcrete, country-specific (and region- specific) information to sensitize officials onthe progression o f the epidemic, and its socioeconomic consequences. Over and above these data, the fight against HIV/AIDS becamemore relevant (especially inthe south) as the epidemic progressed andmore people observed first-hand andwere affected bythe disease and its consequence^.^' The objectives o f the second medium-term plan(to prevent fwther infection, to care for those infectedandto mitigate the social and economic impact o f the disease), thus have immediate andgrowing relevance. As civil society mobilized itselfto undertake its own action, as new local associations o f vulnerable and affected groups were formed, and as public-private partnerships were formalized, civil society advocacy has raisedpressure for public sector engagement and accountability (associations o fPLWHA at the local level, andnationalNGOs o fwomen ministers andparliamentarians are two cases in point). 6.3 Datawas also generated on populationsize, growth and dynamics inChad and projections were available as early as 1994, assessingthe consequences o frapid population growth on the socio-economic development prospects o fthe country. While 67. Informantsat the local levelfrequently referredto the infectionor death of a family memberor close friend. 31 there was general consensusinChad about the desirability o f implementingthe populationpolicy components aimed at improving the rights, opportunities, services and well-being of mothers and children, the notion o f limitingfamily size was met with some reticence. Highinfant andchild mortality andpoverty have propelledcouples to have more children for social security intheir old age and for supplemental householdincome andlabor. As opposed to HIV/AIDS, the relevance andimmediacyo fobjectives to reduce the rate o fpopulation growth were not nearly as apparent. Eventhe use o fmodern contraception for child spacing -which can lower child mortality and improvematernal andchildhealth-- has not beenfully embraced.As a consequence, civil society advocacy around the objective o fincreasing the modem contraception rate has not happened. 6.4 Successful achievementofpopulation and HIEAIDS objectivesrequires the conviction and commitment of public sector and nongovernmental leaders and decision-makers in all layers of Chadian administration and society. Thestimulation and nurturing of national commitmentrequires continuous and multiple efforts, given population mobility and turnover in leadershipandpublic sectorpositions. 6.5 Capacity building of public sector institutions will not be successful if efforts are not aligned with the official mandates of these institutions. The institutional framework for the fight against HIV/AIDS had already beenestablished at the project's outset. By government m6te6*the PNLS was giventhe responsibilityfor the coordination andmanagement o fHIV/AIDS/STD activities inthe country, including the provisiono f technical oversight and support to nationalpartnersintheir fight against HIV/AIDS/STDs, and for epidemiologicalsurveillance andother relevant data collection and analysis. However, becausethe PNLSineffect was so weak, andbecausethe other components o fthe institutional framework for HIVIAIDS were not considered to be sufficiently ftlll~tional,~~ the project was set up to give the PCTMoPC the defacto responsibility for inter-sectoral coordination. 6.6 Because PNLS's mandate was never changed, there was confksion and frustration about its role. Tracking and coordinationo ffinancial and technical assistanceto the fight against HIV/AIDS, as well as strategic programcoordination andoversight, have not been effectively carried out to date.70An institutionalaudit has recentlybeen carried out that has launched a reflection within Government andbetweenGovernment and its partners about a realignment o fresponsibilities inline with comparative advantages, on which basis adequate staffing and capacity buildingcan be envisioned. 68. Arr6te No. 5771MSPIDGl98of April 28, 1998, modifyingarr6te No. 59IMSPASISE/DG/PNLS/91of May 13, 1991, modifyingArrete No. 31IMSPISEIDG/O131DAFM/DIW88. 69. The NationalCommittee for the fight against HIVIAIDS (CNLS),created in 1988 by governmentdecree No. 035lPWPSPl88of March 19, 1988, and the TechnicalCommissionfor the FightAgainst HIVIAIDS (CTLS), created by governmentarrete No. 012lPMT195 of February 12, 1995. 70. As a consequence, this evaluationwas unableto provide an overviewof the nature,levelsand impacts of other partners'contributionsto HlVlAlDScontroleffortsduring the life of this project. 32 6.7 Bythe sametoken, aninstitutionalframework for the coordinationand implementation o fpopulationpolicy hadbeen established before the project, but an institutional assessmentwas not undertaken to inform the design o f the project's capacity buildingefforts. Effortsto amendthis framework duringimplementationwere unsuccessful. 6.8 The channeling of funds to inter-sectoral committeesresponsiblefor population and HIV/AIDS at the regional level stimulated decentralized, multi-sectoral action. However, the absenceof full-time staff at the regional level to undertakeHIV/AIDS program management and coordination has undermined the effectiveness and efficiency of regional level operations. 6.9 Financing and technical support alone will not optimize the individual and collectiveefforts of the various sectors. Theproject stimulated and supported the preparation andimplementationo fHIV/AIDSproposals from seven sector Ministries, andelicited Government co-financingo f20 percent o fthe costs o fthese activities. The stimulus was the availability o f supplemental funds (both those providedby the project andthose providedthroughbudget supplements). A number o fministries didnot (fully) include intheir proposals key activities for which they have the comparative advantage. For example, the Ministry o fJustice supported targeted activities for prisoners, but has an important role to play indefining and defendinga legal framework for the fight against HIV/AIDS, includingthe protectionofrights ofpeople livingwith HIV/AIDS. Another example cited i s the potentialrole o fMinistryo f Social Affairs and Family to expand its role beyond the care o f orphans to encompass ways andmeans o freducing vulnerabilities. A definition o froles, comparative advantages and target groups might have elicited the most critical responsesfrom respective sector ministries for higher impact results, more fully responsive to national objectives. Currently there is little rigor inthe specification andmonitoringofaccountabilities for results. Forthe mostpart HIV/AIDS activities are designedand implementedbyHIV/AIDS focal persons or designated units, with little involvement o f the rest o fthe Ministry; andinter-sectoral coordinationhas not fully exploitedpotentialsynergies across sectoral responses. 6.10 Absence of a strategy on communicationsfor behavior change and the lack of clarity of roles and responsibilities across the multiple institutions that carry out IEC, have undermined the quality and effectiveness of public sector and nongovernmental action. Virtually all sector ministries andnon-publicpartners design their ownprevention messages and campaigns. There i s no one entity responsible for coordinationand oversight. Ministryo f Communicationhas a full-time personresponsible for HIV/ALDS activities (training o fjoumalists and radio andtelevisionmedia campaigns), the IEC unit within PNLShas developed some IECmaterial and carries out an ongoingHIV/AIDS campaign carried out by and for youth, but does not have the capacity for oversight and coordinationo f all communications efforts for prevention. Some sector ministries have an IEC unit. The Population IEC unit, responsible for coordinating and overseeing all population-related IEC has remarked that they have great difficulty inmobilizing various IEC experts from different ministries for discussion andcoordination because they are not sufficiently elevated inthe public sector hierarchy or have sufficient authority to 33 oversee IEC activities inother ministries. The project missed an opportunity to clarify roles and responsibilities and strengthen coordinationcapacity inthis regard. 6.11 Even in the context of a multi-sectoral approach to the achievement of HIV/AIDS andpopulation objectives,the role of the health sector ispivotal. The health sector's ability to carry out its potential role effectively was undermined. First, its mandate is not fully or clearly defined inthe healthpolicy document, nor are accountabilities o frelevant departments and divisions o f MoPH specified; Second, the healthsector response i s limitedbyvery weak health sector capacpity Project support has made headway instrengthening epidemiologicalsurveillance, but this capacity must bemainstreamed into the MoH, beyondthe PNLS. However, the health sector i s very behindintakingon other core activities that are public goods. Technical experts interviewedhave estimated that the blood supply is still unsafe. Training, guidelines andprotocols andthe provisiono f drugs have started to buildcapacity o f health services to diagnose andtreat STIs and opportunistic infections, but the quality and coverage and reliability o f these services are lacking. Testing capacity i s far below what i s needed, especially now that the Government i s subsidizing ARVs, which will stimulate increased demand for tests. Preventiono f transmission within healthfacilities i s inadequate. Itwas mentionednumerous times duringfield visits and exchanges with actors at the national level that health sectorpersonnel are amongthe least mobilized o f all civil servants working on HIV/AIDS andthat more effort is neededto informand involve them inthe fight and to relieve them o f the fear and stigma with which they tend to be associated. 6.12 The absence of baseline datafor many of the key indicators and of a monitoring and evaluationplan has undermined opportunities to track theperformance and impact of nationalpopulation and HIUAIDS efforts and to refine approaches and increase effectiveness in light of experience. Informationon trends i s limitedthus far to HIV among pregnant women, which isnotparticularlyuseful for gaugingtrends innew infections. Some trends on knowledge, awareness andbehavior canbe derived from the DHS(1996/97),the UNICEFmultipleindicatorsurvey (2000) andthe2003 KAP, but questions andindicators vary across surveys makingthem non-comparable. Furthermore, data collection activities were not designed to measure many o fthe indicators identified at project appraisal. Informants have pointedout the absence o f denominators o fkey target groups such as number o f orphans, schools, etc. and ofcurrent coverage o fthese groups (numerators) that make it impossibleto set viable targets for coverage o f services. Implementationo fthe civil society projects has been evaluated and auditedby the Social Fund, butprogram effectiveness would benefit from results-focused evaluations. The hctional relationship between the M&Eunit o fPPLS andthe PNLS/MoH i s weak. 71. The 2000 health policy makes referenceto the PNLS as the responsibledepartmentfor HlVlAlDS activities, makingno referenceto any responsibilitiesof other departments.It also highlightsthe importance of multisectoralcollaborationwithout clearly distinguishingMoPH's role and comparativeadvantages. 72. Overallweaknesses in healthsystem capacity, include: humanandfinancialresourcesconstraints,low service quality and utilization rates (seeAnnex D),sporadicavailabilityof drugs and supplies, and many competing priorities. 34 6.13 TheBank can be effective in influencing theBorrower to supportpublic goods and high-impact interventions. Withinthe overall context o fpopulationpolicy andthe second medium-termplanfor HIV/AIDS, the Bank supported the productiono fpublic goods, interms o f collection andmaintenance o fbasic epidemiological, behavioraland populationdata, that most likely would not have enjoyed such highpriority inthe absence o f Bank assistance. 6.14 The inclusiono f a well-designed component on social marketingo f condoms channeled resources to a potentiallyhigh-impact intervention. The social fund supplemented the borrower's implementationcapacity with that o f civil society and established partnerships with civil society and across development sectors. Within those partnerships the Bank encouraged the targetingo fhigh-risk groups, and (as experience was gained) the definitiono fmandates o fpublic and civil society actors inline with in line with their comparative advantages. The Bank's support o f intermediaryNGOs for capacity buildingo f local associations was also a good strategic choice. As ARVs became more affordable and Parliament passeda billto subsidize their costs, the Bank continuedstrong advocacy for maintaining a priority on prevention. The Bank was less successful inencouraging targeted behavior change interventions, as opposed to IEC. 6.15 The strategy o f intensive IEC inthe early years o f the project to inform civil society about the social fund, followed bythe recruitment o fintermediary NGOs to build capacity insubproject proposal writing and implementation andto stimulate the formation o f additional relevant local associations, provedto be very effective in gradually engaging civil society inpopulationand HIVlAIDS while providingthem with needed support and guidance. This experience also points to the need for improved coordination andmonitoringand evaluation o fNGOactivity. 6.16 Government financing o f NGOssupported not only a complement to public- sector activities, but also strengthenedadvocacy role o f civil society. The creation o f associations o fPLWHA andprostitutes give legitimacy to these groups and contribute for humanrightsandequity advocacy. The support of associations ofParliamentarians, high- level civil servants, the business sector andretiredtechnicians has created an important force indemandingthe involvement and accountability o fpublic officials inaddressing HIV/AIDS. 6.17 A second Population andAIDSproject" continuesBank support to Chad's population policy and HIV/AIDS strategicplan. Its development objective i s to contributeto the behavior change o f different populations inan effort to reduce the risks o fHlV infection, closely spacedbirths, andunwantedpregnancie~.'~ 73. Credit No. 3548 was approved on July 12,2001, and became effective on April 11,2002. 74. To this end it supports: (i) scaling up multi-sectoraland decentralizedactivitiescarried out by publicand privatesector agenciesand civil society; (ii) targeted behaviorchange interventions;(iii) an increasein voluntarytesting and counseling:(iv) reductionin vulnerabilityfactors through incomegeneration,women's education,and care of those infectedand affectedby the epidemic:and (v) an increase in the availabilityof condomsand contraceptivesto enable adoption of healthy behaviors.Support is channeledthroughfour components: (a) strengtheningof the capacitiesof the key ministries; (b) strengtheningof grants and micro- 35 6.18 Inaddition, the HealthSector Support Project (HSSP)75supports the strengthening o fbasic health services, includingreproductive health, and includes an HN/AIDS component to support epidemiological surveillance andhealthcare practices for limiting the risks o fHIV transmission (enhanced blood safety, improved STItreatment and control, andreduction o f risks o f clinical infection). 6.19 The Government is currently financing ARV treatment for about 80 AIDS patients and the Global Fundwill support expansion o f this program. Additional patients are accessing ARV through a Government subsidyprogram.76While HSSP does not finance the purchase o f ARV drugs, it haspositioneditselfto support needed strengthening o ftreatment and referral services. The second Population and AIDS Project i s financing a consultant to help MoPHdevelop a global care and treatment framework, a management system for ARVs, and a national reference guide. 6.20 Current Bank support to populationandHIV/AIDS remains strong andreflects manylessons learned duringthe implementationofthe first operation, corroborated by other relevant OED reports, 77notably: (a) continuedemphasis on prevention; (b) the development o f a communications strategy for behavior change and definition o froles andresponsibilities for its coordination, management andimplementation; (c) continued efforts to address vulnerabilities, buildingon the experience and outcome o fmicrofinance for women and expanding to other vulnerable groups (such as prisoners); (d) review and revision o fthe institutionalframeworks for population andHN/AIDS for greater efficiency; (e) intensified support to MoPH capacity; and (f) improvementsto program monitoring and evaluation. 6.2 1 The importance o f sound andrigorousmonitoringandevaluationcannot be overemphasized. With the ongoing Bank support a project monitoring and evaluation planwas developed andagreedthat defines 24 indicators and specifies data collection methodologies and responsibilities. Impact indicators focus on behaviors, HN prevalence, and measures o f STDs among keypopulations. A second DHS i s planned, along with the first nationalHNsero-prevalence survey and a beneficiary assessment. A full-time M&Eexpert has been recruitedinto the PCT, However, there i s scope for intensifying efforts on a number o f fronts, notably: establishment o fbaseline data for all program indicators; greater consistency inthe type and frequency o fdata collection to enable the tracking o f trends over time; and inclusion o fmeasures o f incidenceto track rates o fnew infections among the general populations and among high-risk groups. credits underthe social fund; (c) supportto the social marketingprogram; and (d) populationpolicy implementation. 75. Credit No. 3342 was approved on April 27,2000, and became effectiveon February28,2001. 76. The monthly costof ARV is 20,000 CFAfrancs, or about US$40 (price at which the Central Procurement Agency buys the drugs): underthe Government`s ARV subsidy program,Parliamentvoted a budgetwhich finances 15,000 CFA francs of the monthly costsof ARV and the patientco-paysthe balanceof 5,000 CFA francs. 77. "NongovernmentalOrganizationsinWorld Bank-SupportedProjects," 1999:"Social Funds:Assessing Effectiveness,"2002; and "OED Reviewof Bank Lendingfor Linesof Credit," 2004. 37 References Ahmat, Bongo. 2001. ((Evaluation duprogramme de crCdit de l'association d'appui a m initiatives a la base (APIBASE).))Novembre 2001. Assemblee Nationale, RCseaudes Parlementaires Tchadiens, Population et le Developpement, Coordination, Secretariat Executif. ((Propositionde Loi portant lutte contre le V W S I D M I S T en Republique duTchad.)) Fevrier 2001. Banque Mondiale, Region Afrique, Departement duDeveloppement Humain. ((Le secteur de la SantC au Tchad: Analyse et Perspectives dans le cadre de la strategie de reduction de la pauvretk: Raport analytique SantC et Pauvretk. Serie Documents de Travail No. 48. March 2004. "Big OilandHealth: Lessons fi-om the Chad-Cameroon Pipeline Project." Princeton University, Woodrow Wilson School o f Public Healthand International Affairs. May 2004. Bilan de l'exercise 2001, PPLS (internal project report). 2001. EpiSida Tchad :Bulletin semestriel d'infonnation epidemiologique duPNLS/IST Gbenyon, Dr Kuakuvi. 2001. "Analyse des organs et mechanisms de mise en oeuvre de la declaration de lapolitiquede population du Tchad et assistance technique :Rapport d'evaluation 2eme partie, N'Djamena, 24 avril2001. Greindl, Dr.Isaline. 1997. Evaluation externe du volet lutte contre le SIDA duprojet population (( et lutte contre le SIDA au Tchad, ))17 septembre - 10 octobre 1997. Guengant, Jean-Pierre. 2001. ((Rapport de Mission `Plan de suivi et evaluation'.))12juillet 2001. ((Le FOSAP dans la perspective duPPLS 2.)) Decembre 2000. Lehmann, L.and A. Lemel. 2003. ((Ventes transfi-ontalikesde prdservatifs des programmes de marketing social en Afhque Central. )) KfW. Mars2003. Kayaye, Adam Abakar. "Projet de Promotion de la JeunesseDescolariseepar la couture et la menuiserie; MaOKanem, 1999-2001:Rapport Final des ActivitCs." 2001. Miller, Hillary A. et John Jespen. 2001. ((EvaluationduFond de Soutien aux activitCs en mati&-e de population (FOSAP): le Rapport Final.)) Mars/Avril2001. Ministitre de la Promotion Economique et duDeveloppement, Direction de la Statistique, des Ctudes Cconomiques et demographiques, bureau central durecensement. ((Enquete par grappes a indicateurs multiples: Rapport complet.)) janvier 2001. Minist2re de la Promotion Economique et duDeveloppement. 2000. ((Le FOSAP:CinqAnnCes d'Appuia la Lutte Contre le SIDA et a la Politique de Population au Tchad.)) Decembre 2000. Ministkre de la SantC Publique, DirectionGeneral, Programme National de Lutte Contre le SIDA, Divisiondu Systkme d'hformation Sanitaire, ((Systkme de Surveillance Epidemiologique duVIH/SIDA/MST: Reformulation.)) Decembre 1995. Ministibe de la SantC Publique, DirectionGCnCrale, Programme Nationale de Lutte Contre le SIDA. ((Rapport annuel d'activitks 1997.)) Janvier 1998 Ministere de la Santk Publique, Secretariat d'Etat, Direction Gknerale, Programme Nationale de Lutte Contre le SIDA. (> RCgionAfrique, DCpartement duDCveloppement Humain, SCrie documents dutravail, No. 48, Mars2004. Ministkre duPlan, duDeveloppement et de la Cooperation, Secretariat General, Direction General, ProgrammeNationale de Lutte Contre le SIDMST. (ailan Analyse et evaluation des activitCs de la caravane desjeunes anti-SIDA duPNLS?IST (1999-2001).>) Decembre 2001. Moto, Dr.DauglaDoumagoum, Dr.Yemadji N'Diekhor, Dr.Deoudje Noe, NathanNaibei. 2000. 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Impacts socio-CconomiquesduVIH/SIDA au (( Tchad :Rapport Final d'Etude, Tome B. )) Swiss Tropical Institute, Centre de Support en SantC Intemationale au Tchad. Juin 2001. World Bank. Development Credit Agreement (Population andAIDS ControlProject) between Republic of Chad and Intemational Development Association. CreditNumber 2602 CD. April 14, 1995. World Bank. 2000. Project Appraisal Document: Health Sector Support Project. Report No. 20189-CD. World Bank. 2001. Project Appraisal Document: SecondPopulation and AIDS Project. Report NO.22003-CD 40 World Bank, 1995. Staff Appraisal Report: Population and AIDS Control Project. Report No. 13869-CD. March 3, 1995. WorldBank: Internal Documents. 41 Annex A. BasicData Sheet POPULATION AND AIDS CONTROL PROJECT (CREDIT 2692) Government Communities Cofinancing Cancellation Original Actual Boardapproval 03/23/95 Signing 04/14/95 Effectiveness 7/14/95 09/08/95 Closingdate 06/30/2001 12/31I2001 ActuaIlLatest Estimate W Staff weeks us$us$(`ooo~ Identification/Preparationa 23.3 63.7 AppraisalINegotiations 16.6 66.6 Supervision 101.8 418.5 ICR 7.2 33.1 Total 148.9 581.9 ______ - ._ a. The low number of staffweeks for projectpreparationand appraisalis relatedto the fact that mostof the projectwas preparedas partof a "Health and Population"operation.However, duringthe appraisalmissionof the Healthand Populationproject(November 1993), itwas decidedto divide the projectintotwo separateprojectsand to add AIDS mitigationactivitiesto the Populationactivities.The Healthand Safe Motherhood Projectincludedall the health aspectsof the preparedprojectand was to be implemented by the MOPH.The Populationand AIDS Projectwas to be implemented by the then Ministryof Planning(nowthe MEPD). Infact there was only one projectpreparationmissionin May 1994 when the AIDS component was prepared. The projectappraisalwas carriedout in November 1994,at the same time as the first supervisionmissionfor the Healthand Safe Motherhood Project.With regardto supervision,the numberof staff weeks is also low in comparison with similar projectsbecause the supervisionalways took placeat the same time as the supervisionof the Health and Safe Motherhood project. 42 Mission Data No. of Specializationsrepresented Performance Rating trend persons rating Identification/Preoarationa 6 1 DivisionChief/Economist, 1 PopulationSpec., FY1994 1 Community-DevelopmentSpec., 1 Public HealthSpec., 1 IEC/Pop. Spec., 1 Consultant FY1995 4 1 PopulationSpec., 1 Community-DevelopmentSpec., IPublic HealthSpec., 1 IECIPop.Spec. AppraisalINegotiation 7 1 Sr. Pop. Spec., 1Architect, 1 Pharmacist, 1 FY1995 STD Spec. 1 ImplementationSpec., 1 Community Dev., Spec., 1 Public Health Spec. Supervision FY1995 4 1 Sr. Pop. Spec., 1 PublicHealthIAIDS S S ControlSpec., 1 Division Chief, 1 Sr. Staff Assist. FY1996 3 1 IECIPop. Spec., 1 ImplementationSpec., 1 Proc.Spec. FY1997 4 1 AIDS Control Spec., 1 IECIPop. Spec., 1 Sr. ProcurementSpec., 1consultant 10 1IEC/Pop. Spec., 1Sr.ProcurementSpec., 1 FY1998 Architect, 1Sr. ImplementationSpec., 1PublicHealth/STDSpec., 1AIDScontrol Spec., 1Pop. Spec., 1Economist/Social Fund Spec., 1Senior AIDS Adviser, 1Consultant. FY1999 11 1IEC/Pop.Spec., 2Sr. ProcurementSpec., 1 s S Sr. ImplementationSpec., 1PopulationSpec., 1Sr. PublicHealthSpec., 1AIDSControl Spec., 1social ProtectionSpec., Sr. AIDS Control Adviser, 1Economist/Social Fund Spec., 1Financialanalyst, 1Spec. in Community Participation. FY2000 5 1IECSpec., 1ImplementationSpec., 1Public S Health Spec., 1Demographer & Economist, 1 FinancialManagementSpecialist. 5 1IECSpec., 1ImplementationSpec., 1Public S FY2001 HealthSpec., 1Demographer & Economist, 1 Finanaal ManagementSpeaalist. FY2002 5 1IECSpec., 1ImplementationSpec., 1Public S HealthSpec., 1Demographer & Economist, 1 FinancialManagementSpecialist ICR FY2002 3 1Sr.PopulationSpec., 1PublicHealthSpec., 1ImplementationSpec. a. Mostof the preparationwas doneas partof a "Healthand PopulationProject"whichwas split intwo. 43 Annex B. Personsand OrganizationsConsulted CHAD N'Djamena Ministry ofPlan, Development and Cooperation Mahamat Ali Hassan, Minister o f Plan, Development and Cooperation Saradimadji Mingabaye, Secretary General Djourbe Taiki Zeune, Director o fPopulationActivities Coordination, Ninoam Ngakoutu, National Expert, PopulationandDevelopment NodjimbantemNgoniri Joel, Statistical Demographer/Consultant, Population and Development Mahamat Saleh Idriss, Coordinator, Populationand AIDS Control Project (PPLS) Caman BedaouOumar, M&EOfficer, PPLS Ministry ofPublic Health Madame Aziza Baroud, Minister o f Public Health Dr.Mahamat Saleh Younouss, Secretary General ofHealth Dr.HamidDjabar, Coordinator ofthe NationalAIDS andSTD ControlProgram (PNLS/IS T) Abdoulwahab Sani, Youth Leader, PNLS Ahmat Idriss Rozi, AdministratorlManager, PNLS Dr.Donato Koyalta, Assistant Coordinator, PNLS/STDs Dr.NoueDeoudje, EpidemiologicalSurveillance Service, PNLS Moussa Issaye, Administrator o f PlanningDepartment, Health Information Systems Youssouf A. Kadjangaba, Chief, Information, Education and Communications Unit, PNLS Mme NalgaKatir, Information, Educationand CommunicationsUnit Rangar Ndjenadjim, Responsible for Oversight o fNGOs, PNLS Dr.NoelDjemadji, ChiefofSexuallyTransmitted DiseasesDivision Other Public SectorAgencies/Actors Implementing HIV/MDS Activities Mahamat Galli Mallah, Secretary General, MSPI Dr.andColonelAdrinkaye Allao Dounia, Director ofHealthandHIV/AIDS Coordinator, Ministry of Defense Kouladingar Kaha Dakor, Coordinator ofAIDS andPopulationUnit,Ministry o f Communication 44 Mbaindingatoloum Rawei Elise, Coordinator o fA I D S Unit,Ministryo f Social Action andFamilyAffairs Moulkogue Boulo Felix, Coordinator o f AIDS Unit,Ministryo fNational Education Non-GovernmentalSector/CivilSociety A. NGOSubprojects: NGOincharge o fcivil society capacity building: Mr.Piquet, SONGES Nateguingar Franco-Joseph, Researcher andNGO Support Officer,Health and Environment Support Office (BASE) NGOImplement~rs'~: Mme CarmelNgarmbatinan, President, Network o f Women Parlementarians and Ministers andPresident o f the Board o fAMASOT Pastor DjibC, Network o f Evangelist Missions and Churches inChad MmeDjikoloumKesias Garba, CCEVF MbaiguedemDjai Daniel, CCEVF Pastor Mbaiadoum Obed, JACT Nassaradoumadji Mathieu, JACT Mahamat BCchir, ITS Mahamat Amine Abdel-Mazid, C.S.A.I. Corinne Bali, Coordinator, Support for Eastern European andAfrican NGOs (SONGES) Arsene Mayangar, SONGES LoumHinansou Laina, CONALUS M m e Zenaba Borgoto ASFEA Dr.MbeurnodjiLucien, UCCT NodjitoloumJustin, UCCT B. Microfirzance: FOSAP(Fonds de soutien aux activitCs enmatikre de Population et de Lutte contre le SIDA) ; Nodjikwambaye Enock, Deputy Administrator-Manager Ache Djidda, Accountant NgarbaroumModobe, Microcredit Officer 78. These NGOs representeda rangeof constituencies,themes and missions,including: health of nomads, Islam,Christianreligions,community developmentand empowerment, youth movements,coalitionof public sector leaders, women and children's health and well-being,among others. 45 C.SocialMarketing: Social Marketing Association o f Chad (Association our le Marketing Social au Tchad- AMASOT): DokblamaKadah, Director o f Service Center Rino GuyMeyers, TechnicalAdviser Bilateral andInternationalPartners Marie-Paule Fargier, Pharmacist, European Union Dr.Abdelmajid, HealthProgramOfficer, Swiss Cooperation Dr.FariaIbrahim, TechnicalAdviser, HIV/AIDS Project, UNDP Dr.KekouraKourouma, CountryProgramCoordinator, UNAIDS Keumaye Ignegongba, Assistant to the ResidentRepresentative, Poverty Alleviation Unit,UNDP MouenonDenis, Technical Adviser, FrenchCooperation Dr.GrangaDaouya, UNICEF WorldBank Office,NWjamena Gregor Binkert, Country Manager Mahamat Goadi Louani, Senior HumanDevelopment Specialist Joel Tokindang, Economist, World Bank Fridolin Ondobo, FinancialManagement Specialist Moundou/DepartmentofLacWeylRegionof LogoneOccidental Mahamat Bechir Cherif, Governor, Regiono f Logone Occidental RegionalCommissiononPopulationandHumanResourcesandHealth Advisory CommitteeMembers Mbaikeboum Kagao, Prefect, D.Lac Weg Malangso Souleymane, Secretary General o f Commission, Ministryo fPlan, Development and Cooperation PassehDavid, Assistant Secretary GeneraVCFW, Civil Society Dingamtoudji Ngana Esaie, First Vice President, Chadian Association ofFamily Wellbeing (ASTBEF) Miambaye Rando, Treasurer, DRCJS Mme NdingambayeRomian, TGA, DRASL NdingambayePascal, Logistics Officer Weigue Laoundodji, RegionalDelegate for National Education, Ministryo fEducation Vissia Bouranga, Regional Delegate for Economic Affairs for the 2 Logones and Tandjile Districts Mbairareou Yanlingar, Logistics, Ministry o f Commerce 46 Dr.MbaintissemMbuitotouvas, ChiefMedicalOfficer, MoundouDistrict Non-GovernmentalSector/CiviISociety NGOincharge ofcivil society capacity building: 0 World Vision Microfinance Agency: CEPRIC 0 KagdomMagourna, Coordinator 0 MmeTamissengar Evelyne, Manager 0 Mme Nadingar Ndjilarlem Odile, staff 0 BendodjimBenjamin, Accountant 0 Koulangar Ngartoubam, Trainer 0 Keimbaye Mbailemdana, Trainer Beneficiaries: 0 Representatives o f Women's Groups and Women's Cooperatives (names not obtained) Regional Branch o f AMASOT Bongor/Department of Mayo-Boneyemegion of Mayo-Kebbi Est Governor o fthe Region RegionalCommissiononPopulationandHumanResourcesand RegionalHealthAdvisory CommitteeMembers Goundou1Vikama, Director o fPlan, Secretary o fthe Commission Mor Victor, Mayor o f Bongor city Nodji Wassem Gerard, SGRMKE Mme MoussaCharlotte Ouagadijio, RegionalDelegate o fwomen's associations o f Mayo-Kebbi/Tandjile Dr.BopanTekemet, RegionalDelegate for Public Health, Mayo-Kebbi Bakreo Dakssala, RegionalDelegate for Social Action andFamilyAffairs, Mayo- Kebbi/Tandjile Dingatoloum Barack, Animator, CLACA3ongor Gnavourbe Tao, RegionalDelegate for Public Works Seibana Daniel, DDCJSMayo-Boneye Loubata Jean, RegionalDelegate o fPolicelMayo-Kebbi Est Dosso Bessoum, Adviser to the Minister o fPlan 47 Non-GovernmentaISectorKiviISociety NGO incharge o f civil society capacity building: SONGES Local Associations: 0 ADSEC Guidawa Microfinance Agency: APIBASE (Association d'Appui aux Initiatives de Base - Association for the Support of Community-Based Initiatives) 0 Mana Malgueteng, Chief 0 Andrews Yoh Pudens, Animator 0 MharyMournor Jean, Animator 0 Jurs Clement, Animator 0 Tocsouma Houmaizou, Accountant Beneficiary Women's Groups: Iya Gama ElHadji Oumar, Member, Tamidja 0 Falmatou Sidi, Secretary, Udjekusarenove 0 Yoma Rosalie, Member, Udjekusarenove 0 Yawada Marie, Secretary, Minaituya 0 Zen0 Marcelline, Secretary, Udjekusa 0 DoudouMoksia, President, Minaituya 0 SambaRigale, President, Takasna 1 0 DeniseVayanga, President, Takasna 1 0 Ndiguimal Rebecca, President, Komna le Denedje 0 Modjimariya Nahomie, President, Takasna I1 0 Largoto Martine, Member, Takasna I1 0 Mianda Falla, Cashier, Minaituya 0 Delao Marthe, Cashier, Takasna I1 Mao/Region of Kanem Govemor o fKanem RegionaICommissiononPopulationandHumanResources andRegionalHeaIthAdvisory CommitteeMembers IssenBenMoussaye, RegionalDelegate for National Education, Ministry o fNational Education Malloum Abakar Kaya, Association to FightMalnutritioninKanem HeriataMoussa, Association Femink DohMallah, Coordinator, ETMS/Mao KedelaBatran, Chief, Forestry Inspection, Kanem 48 Dr.Oumar Abdelhadi, RegionalDelegate for Health, MinistryofPublic Health Barka Tambour, RegionalDelegate for Social Action and FamilyAffairs Ahmad Moustapha, P. Com. Su. Affairs, DKM k i n a 0110 Japhet, Pastor, Evangelist Churcho f Chad Adoum Goulgue, Representative, Catholic Church Representative o f Islam Non-Governmental Sector/Civil Society NGOincharge o f civil society capacity building: e Dr.BrumaMasumbuko, Technical Advisor, GTZ e Ahamat Mahamat Abdou, Trainer, GTZ LocalAssociations : e MallaBatran, HealthAgent andPresident, ADESK e MoustaphaNgartorangal, Representative, ARNUT e Achta Bintou Moustapha, Women's Group Loelle, Social Center o fGFB e Ache Bougoudi, staff, AFAT e FatimeMahamat Seid, Women's Group o f Matoboko e Ahmat Moustapha Outman, ASUDEK 0 Abdallah Moustapha, Secretary General, APLFT e Hisseine Issa, Red Cross o fKanem e Ali Abakar, President, ADEK e Malloum Abakar, Representative, ALCMK e Ali Lanne, Secretary General, AJACKanem 0 Choukou El-Hadj Mahamat, Head, ADIS Microfinance Agency : ADIS (Agence d'Encadrement pour les Credits) e Choukou El-Hadj Rahamata, Head e Haoua Sedik, Credit Agent e Achta Bouguidi, Credit Agent Mitoissi Kossadoum, Manager, FOSAP Beneficiaries of MicrocreditdRepresentatives o f Women's Groups: e HadjeAchta Oumar e Bintou Batran e Zara Laye MongoPRegion of G d r a Secretary General o f GutraDepartment 49 Regional CommissiononPopulationandHuman Resourcesand RegionalHealthAdvisory CommitteeMembers IbrahimHassanBargouley, RegionalDelegatefor Finance, MinistryofFinance Ramat Mangue, RegionalDelegate for Social Action, Ministryo f Social Action and Family Affairs Yadia Banserne Pierre, RegionalDelegate for Economic Affairs, Ministryo f Commerce Nossor Doungous, Regional Delegate for NationalEducation, Ministryo fNational Education Souk Kangoutoum, RegionalDelegate for Culture, Youth and Sports, Ministryo f Culture, Youth and Sports Ganda Nabia Koutou, Chief o fBureau, Customs and Taxes Adoum Vamalia Abakar, RegionalDelegate for Plan and Development, Ministryo fPlan Daniela Stirpe, Public HealthDoctor, SECADEV HassanaAnguimi, Subprefect o f Mongo Dr.Ali SoumaineBaggar, RegionalDelegate for Health, Ministry ofPublic Health MmeMahazalneeMankassia Tchere, member Yacoub Hassan, IFC Officer Non-GovernmentalSector/CivilSociety NGOincharge o fcivil society capacity building: ITS/SwissInternationalOrganization Mahamat Abbo, Officer, ITS/CSSI Abdel-Madjid Hanan,Assistant Officer, ITSlCSSI Akaye Albert Mustapha, Animator, ITS/CSSI DjimyeWeletna, Animator, ITS/CSSI Local Associations: Fatime Sorom, Presidente, AFGDR MaimounaMoussa, Treasurer, AFGDR Maimouna Tassigot, AFGDR MariamMahamat Saleh, AFGDR Amsakine Outman, Adviser, AFGDR KadidjaAyoub, Adviser, AFGDR Younous Dris, ADECAB HamdanIbet, ADECAB Hassan Souleymane, Financial Secretary, ADECAB AllamineMoussa, Secretary General, ADESCAMO Ali Chachate, ADESCAMO Mahamat Chaltout, ADESCAMO Mahamat Madri, ADESCAMO Asan Souleymane Al-Nidal Abdel-Aziz Abbas, Administrative Secretary, Al-Nidal (association of combatants) 50 MoussaFayaDouzet, President, Al-Nidal Makaye Elie, Assistant Secretary General, APLD B r ~ Dabara, President, PROJAET m DjimetDarap, Treasurer, PROJMT HisseinDagasche, Adviser, PROJAET Caleb Deodere, Secretary, PROJAET AssociationofFree Women, various members Microfinance agency : ACCORD Seid Gaye Alexis, Head Idriss A. Foudoussia, Supervisor Kilabe MbaitoloumAbel, Regionalbrancho f AMASOT WASHINGTON,D.C. LauraFrigenti, Sector Manager, HumanDevelopment, AFTH3, World Bank Michele Lioy, Senior Population Specialist, AFTH3, World Bank 51 Annex C. Population and AIDS ControlProject (Credit No. 2692) -- Presentation of ProjectComponents The project was designedto assist the Government inimplementingits long-term strategy inpopulation and family planningand its medium-term plan 1995-99 (MPT 2) for AIDS control. Its overall objectives were to advance the onset o f fertility decline by increasing the use o fmodemmethods o f contraception (from 1percent in 1990 to 10 percent by 2000), and slow the spreado fHIV infectionbypromoting behavioral change. Project assistance was channeled through four components: (a) Strengthening of national capacity to implement thepopulation policy (US$8.0 million). This component sought to strengthen capacity o f the newly created Division o f Populationwithin MoPC to undertake population-related activities, particularly: (a) the dissemination and coordinationo fthe implementation o fpopulationpolicy; (b) the planning, management, and evaluation ofpopulation-related activities; (c) the planning, coordination, and implementationo f donor-financed projects; and (d) the integration o f demographic variables into sector plans. Project support included office rehabilitation, equipment, logistical support, participation inintemationalmeetings, contractual staff, training, technical assistance, includinga twinningarrangement with the Center for Research on Population and Development (CERPOD), inBamakoMali.79The project also financed IEC activities and radio and TV programs inan effort to disseminate the populationpolicy andto promote awareness o f the relationshipbetween population and development, especially among identifiedtarget groups such as opinion andreligious leaders, women, NGOs, reporters, youth (12-25 years), andmembers o f trade unions and associations. This component also supported collectionand analysis o fbasic demographic data to improve knowledge o f socio-demographic indicators. To this end, it financed a national studyonmigrationandurbanizationandanalysis o fthe 1993 censusdata andthe first demographic and health survey (DHS).Project assistance also includedcontraceptive supplies for matemal andchild healthservices providedthrough the public health system to fill the gap created bythe withdrawal o fUSAID support in 1995.The total estimated cost o f contraceptives to beprovidedunderthe project was US$3.0 million(38 percent of the component cost). (b) Strengthening of national capacity to contain the spread of HIV/AIDS/STDs (US$6.6million). This component sought to strengthen the capacity o fthe Ministryo f Public Health(MoPH) to manage and coordinate the AIDS Control Program andto carry out epidemiological surveillance and operational research. Project support consisted primarilyof (a) long- andshort-term technical assistance inkeydisciplines, notably epidemiology andprogrammanagement; and (b) long- and short-term training in 79. A Sahelianinstitution of the Inter-CountryCommittee on the Fightagainst Desertification(Comiteinter- etats de lutte contre la secheresse dans le Sahel,CILSS). 52 epidemiology, management, IEC, and health information systems. Support was directed at the PNLS, CNLS, CTLS, and the MoPH division incharge o fhealthmanagement informationsystems. Inaddition, this component financed epidemiological, operational, andsocio-economic researchunderthe supervision o fthe General Directorateo f Planningo fthe MoPC. Plannedactivities includedthe development o ftwo additional sentinel sites (for a total o f seven); five studies o f HIV/STD prevalence among target groups; two knowledge, attitude, practice (KAP) studies; and a study on the priority indicators o fpreventionto permit assessment o f impact o f interventions. Other studies plannedto improve healthservices response included: the development o f algorithms for the management o f STDs andAIDS patients; the preparation o f a referralprotocol for people with HIVlAIDS and their families; the evaluation o fthe clinical definition of AIDS; a study on the relationship o fHIV andtuberculosis (TB) to improve the treatment o f TB and a study on the socioeconomic impact o f AIDS at the individual, family, community, and macroeconomic levels. (c) Establishment of a social marketingprogram for condoms (US$7.1million). This component aimedto increase the availability andpromote the use o f condoms for AIDS prevention. The main benefit envisaged was reduced transmission ofHIV and other sexually transmitteddiseases (STDs), a secondary benefit beingprotection against unwantedpregnancies. Targets were to increase the useo fcondoms fiom an anticipated 2 millioninthe first year o fthe project to about 4.8 million inthe last year o f the project, reachinga cumulativetotal o f about 14millioncondoms sold during five years. Project support included: technical expertise insocial marketing and auditing, contractual professional stafc training and study tours to develop capacities insocial marketing and IEC; condoms; equipment and logistical support; and rehabilitation works. The condom social marketingprogramwas managedinanautonomous manner by a social marketingunit establishedwith project assistance, under the general direction and guidance o fASTBEF'O with the technical support o f a social marketing firm, inclose coordination withPNLS andincollaboration withpublic sector andcivil society. Project support envisagedincludedspecialist services, localprofessional staff, training, logistical support and office equipment, studies, andoperating costs. (d) Promoting theparticipation of the nongovernmentalsector inpopulation, family planning, andHIV/AIDS/STDsprograms (US$5.5 million). T l s component supported the establishment o f a social h d (Fonds deSoutien aux Activitks en mati2re de Population, FOSAP) to provide grant financing to civil society for populationandAIDS control activities inorder to complement and enhancethe interventions o f government and the social marketingprogram. A minimumo f40 A I D S control subprojects would be supported encompassing (a) preventionaimed at key target gro~ps;'~and (b) mitigation through theprovisiono fpsychosocial support for HIVIAIDSpersons and their families in 80. ChadianAssociationfor FamilyWell-being (AssociationTchadiennepour le Bien-EtreFamiliale),an affiliateof the InternationalPlannedParenthoodFederation. 81. Target groups identifiedfor preventionactivities includedyouth, prostitutesand their clients, civil servantsof key ministries,migrantworkers, and truck drivers on major migrationand transport routesto Cameroon and Nigeria. 53 five prefectures. The project also envisagedsupport to a minimumof20population subprojects including (a) targeted IEC;" (b) activities to improve women's income-eaming capacities and status; and (c) studies andoperational researchon the acceptability o fnew contraceptive methods. In addition, giventhe weak capacity o fpotentialbeneficiaries o fthe grants (national NGOs, local associationsand individualhealth service providers) FOSAP would support several "resource projects" (projets dynamisateurs) bywell-established NGOsto buildcapacity amongpotential beneficiaries inthepreparation, implementation, andevaluation oftheir subprojects 82. Targetgroups identifiedfor populationIECincludedmen, teenagers,workers, agriculturalextension workers, community developmentworkers, women's associations,ruraldevelopmentcooperatives,and privateemployers. 54 Annex D. Programand ProjectData 1. HIV/AIDS/STDandBehavioralSurveillanceData (Source: PNLSMoPH Surveillance Data) Table D-1.Evolutionof PrevalenceRates in Generaland Specific Populations derived from Seroprevalence Surveys 1997 - 2000 Prevalence Rates Year GeographicArea General Specific Prevalence Population Populations Rate 1989 Abeche 0% Sarh 0.5% Moundou 1.6% Bongor 0.6% N'Djamena 1.02% 1995 N'Djamena Prostitutes 14% N'Djamena Pregnantwomen using prenatalservices 2.1% N'Djamena Militarypersonnel 10.2% 1997 Abeche 2.1% Am-Timan 6.1% Sarh Prostitutes 26.4% Logone Occidental/ Migrants 7.93% Moundou Moundou Military personnel 8.48% N'Djamena Military personnel 8.40% 2000 Sarh 8.84%