Document of The World Bank FOR OFFICIAL USE ONLY Report No: 41320-TD PROJECT PAPER ON A PROPOSED ADDITIONAL FINANCING GRANT IN THE AMOUNT OF SDR 13.3 MILLION (US$20.0 MILLION EQUIVALENT) TO THE REPUBLIC OF CHAD FOR A SECOND POPULATION AND AIDS PROJECT May 28, 2010 Human Development Health, Nutrition and Population Africa Region This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS (Exchange Rate Effective January 1, 2010) Currency Unit = Franc CFA CFA 450.89 = US$1 US$1. = SDR . 66176081 FISCAL YEAR January 1 ­ December 31 ABBREVIATIONS AND ACRONYMS AIDS Acquired Immune Deficiency Syndrome MOPH Ministry of Public Health AAP Africa Action Plan MoU Memorandum of Understanding AMASOT National Social Marketing Agency MTEF Medium Term Expenditure Framework ARV Anti Retro Virals MTR Mid-Term Review BCG Bacille Calmette-Guérin (Tuberculosis MWMP Medical Waste Management Plan vaccine) CBO Community-Based Organization NGO Non Governmental Organization CFPs Country Financing Parameters PAD Project Appraisal Document CPPA Central Pharmaceutical Purchasing PCT Project Coordination Team Agency DHS Demographic and Health Survey PEPFAR President's Emergency Plan for AIDS Relief DPT DiphteriaTetanus Pertussis Vaccine PLWHA People Living With HIV/AIDS ECOSIT Household Consumption Survey PMTCT Prevention of Mother to Child Transmission EU European Union PPA Performance Purchase Agency FFG Fund for Future Generations PPLS2 Second Population and AIDS Project FOSAP Fund for Population and HIV/AIDS PRSP Poverty Reduction Strategy Paper Activities HIV Human Immunodeficiency Virus RBF Results Based Financing IBRD International Bank for Reconstruction SDR Standard Drawing Rights and Development IDA International Development Association STI Sexually Transmitted Infections IMF International Monetary Fund UNAIDS United Nations Program on HIV/AIDS ISN Interim Strategy Note UNICEF United Nations Children's Fund MAP Multi-country HIV/AIDS Program for Africa MDG Millennium Development Goal UNGASS United National General Assembly Special Session on HIV/AIDS M&E Monitoring and Evaluation WHO World Health Organization MEP Ministry of Economy and Planning VCT Voluntary Counseling and Testing Vice President: Obiageli Katryn Ezekwesili Country Director: Mary Barton-Dock Sector Director/Manager: Tawhid Nawaz/Eva Jarawan Task Team Leader: Boubou Cissé CHAD SECOND POPULATION AND AIDS PROJECT ADDITIONAL FINANCING CONTENTS Project Paper Data Sheet........................................................... i I. Introduction ........................................................................................ 1 II. Project Performance and Country Background ............................. 1 III. Rationale for Additional Financing .................................................. 5 IV. Proposed Changes .............................................................................. 7 V. Consistency with PRSP, MDG and AAP .......................................... 9 VI. Appraisal of Restructured or Scaled-up Project Activities ............ 9 VII. Expected Outcomes ............................................................................10 VIII. Benefits and Risks .............................................................................10 IX. Financial Terms and Conditions .....................................................11 Annex 1: Results Based Financing (RBF) Approach ....................... 12 Annex 2: Revised Results Framework and Project Indicators ........... 15 Annex 3: Results Arrangement ................................................. 18 Annex 4: Evaluation of Original Results Framework and Indicators of the PAD ................................................... 21 Annex 5: Project Implementation, Financial Management, Disbursement and Procurement Arrangements ................... 26 Annex 6: Project Costs and Financing Plan of the Additional Financing .................................................... 31 Map No. IBRD 3385 PROJECT PAPER DATA SHEET Date: May 28, 2010 Team Leader: Boubou Cissé Country: Chad Sector Director/Manager: Tawhid Nawaz / Project Name: Second Population and Eva Jarawan AIDS Project Country Director: Mary Barton-Dock Original Project ID: P072226 Environmental Category: B AF Project ID: P105724 Borrower: Government of Chad Responsible agency: Ministry of Economy and Planning Revised estimated disbursements (Bank FY/US$m) (Original project + AF) FY 11 12 13 Annual 7.0 7.0 6.0 Cumulative 7.0 14.0 20.0 Current closing date: July 31, 2008 Revised closing date: June 30, 2012 Does the restructured or scaled-up project require any exceptions from Yes No Bank policies? Based on exceptional country circumstances and in accordance with paragraph 5 of BP l3.20, there was an authorization request addressed to OPCS to process an Additional Financing for the Chad Second Population and HIV/AIDS project ("PPLS2") which closed on July 31, 2008. Have these been approved by Bank management? Yes No The Approval was granted by VP OPCS Is approval for any policy exception sought from the Board? Yes No Revised project development objectives/outcomes The development objectives of the project have not been revised. Does the project trigger any new safeguard policies? Yes, a Medical Waste Management Plan was prepared(OP/BP 4.01) The original project was given a "C" rating since it was not expected to generate any adverse environmental effects. The proposed additional financing project is rated "B" - as is the case for all HIV/AIDS projects. This is due to the risks associated with the handling and disposal of medical waste. As a result, the only safeguard triggered is the environmental assessment, because a Medical Waste Management Plan (MWMP) is required. No construction and/or rehabilitation of facilities will take place under the proposed additional financing operation. A MWMP was prepared and disclosed in the Infoshop and in-country in August 2007. For Additional Financing i [] Loan [ ] Credit [X] Grant For Loans/Credits/Grants: Total Bank financing (US$m.): US$20.0 million Proposed terms: IDA Grant Financing Financing Plan (US$m.) (AF) Source Total Borrower/Recipient 0.0 IBRD 0.0 IDA 20.0 -New 20.0 -Recommitted 0.0 Others 0.0 Total 20.0 Financing Plan (US$m.) (Original project + AF) ii REPUBLIC OF CHAD SECOND POPULATION AND AIDS PROJECT ADDITIONAL FINANCING PROJECT PAPER I. INTRODUCTION 1. This Project Paper seeks the approval of the Executive Directors to provide additional financing in the amount of SDR13.3million (US$20.0 million equivalent) to the Republic of Chad for the Second Population and AIDS Project or PPLS2 (P105724). 2. The proposed additional financing will extend the new integrated and decentralized approach to HIV/AIDS and maternal and child health services in ten health districts in five regions, in addition to the capital city, Ndjamena. This approach decentralizes oversight to local governments, involves community-based organization in service delivery, and expands the use of mobile teams to reach isolated villages. It will also introduce a results-based financing (RBF) approach to improve maternal and child health outcomes that would be piloted in two additional regions. Lastly, the additional financing will strengthen monitoring and evaluation, including data collection, analysis, and the use of national household based surveys, and medical waste management. The project's development objective will remain unchanged; however, project components will be modified to introduce the new RBF approach and better reflect the integrated and decentralized approach to maternal and child health and the fight against HIV/AIDS. Project indicators will also be modified to reflect the current international thinking in HIV/AIDS and be line with UNGASS indicators as well as integrate the lessons learned during implementation and define more precisely the expected outcomes of the original project. 3. The original project closed July 31, 2008 despite a request from Government for an extension of the closing date. The project was not extended given the nature of the dialogue between the Bank and the Government at the time and that it was also almost fully disbursed. Despite the lack of IDA funds, the Government provided the necessary financing to continue to support the most critical project activities on the ground while waiting for approval of the additional financing. Based on exceptional country circumstances and in accordance with paragraph 5 of BP l3.20, there was an authorization request addressed to OPCS VP to process an Additional Financing for the Chad Second Population and HIV/AIDS project ("PPLS2") which closed on July 31, 2008. The approval was granted by VP OPCS. II. PROJECT PERFORMANCE AND COUNTRY CONTEXT 4. Project Background: The PPLS2 was approved on July 12, 2001 and became effective on April 11, 2002. The amount of the credit was SDR 19.6 million (US$24.56 million equivalent). The development objective of the project is to contribute to changing the behavior of the Chadian population in order to reduce the risk of infection from HIV and too closely spaced and/or unwanted pregnancies. To this end, the project financed five main components: (i) multi- sectoral activities at the central and local levels of key ministries; (ii) community interventions and local response initiatives through a social fund mechanism (FOSAP); (iii) social marketing of key health-related products; (iv) support to implementation of the national population policy; and (v) project coordination and monitoring and evaluation (M&E). 1 5. Results of the Mid-Term Review (MTR): The MTR was held in December 2005 and, to ensure better results on the ground, recommended (i) further decentralization and better integration of the response to HIV/AIDS at the local level; (ii) delivery of a complementary package of services for People living with HIV/AIDS (PLWHAs); (iii) emphasis on the prevention and treatment of STIs; and (iv) renewed focus on behavioral change, through high quality peer education programs. Box 1 outlines the new decentralized approach to HIV/AIDS introduced to respond to the issues raised during the MTR. Box 1: Introduction of Decentralized Local Response to HIV/AIDS after MTR In response to MTR recommendations, the project piloted an integrated decentralized response to HIV/AIDS in two regions, Ndjamena and Logone Occidental. Through the financing of activities of Community Based Organizations (CBO) by the FOSAP, the project sought to stimulate demand for STI and Voluntary Counseling and Testing (VCT) services. CBO interventions included peer education, social mobilization, and condom promotion and sales. FOSAP also financed social centers to provide social and nutritional support to the most vulnerable PLWHAs as well as educational support to orphans. Given the expected increase in demand, the project also sought to improve the access and quality of these services. As such, PPLS2 supported the strengthening of existing health and VCT centers and put in place two mobile units to cover 40 sites within the two regions. Support included training of public and private health personnel to ensure a certain level of knowledge and skill and provision of vehicles, equipment, drugs, STI kits, reagents, and medical supplies to all partners. Anti-retroviral (ARV) treatment is provided by the Government with financial support from the Global Fund. Results from 2007 and 2008 of the decentralized local response showed an acceleration of counseling and testing activities, as well as a high rate of HIV positive cases among those tested, demonstrating both a large unmet demand and the relevance of this targeted strategy. In 2007, 22,761 people were tested in the intervention areas (38 percent increase from 2006) of which 22 percent tested positive; and in 2008, 25,102 people were tested (10 percent increase) of which 22 percent tested positive. Out of those infected in both regions, 8,434 are being followed by health facilities of which 4,805 are under ARV treatment. Furthermore, 4,459 cases of STI were treated (a 107 percent increase from 2006). 6. The MTR showed that the project was not as successful in meeting its population objectives. The latter were secondary objectives of the project as only 14 percent of the total credit amount was allocated to these activities. To try to redress the dismal results, and following the successful experience of Tunisia, the MTR recommended reorienting the population activities and putting in place mobile teams focused on reproductive health and family planning services in a region with very low contraceptive usage (see Box 2). An international technical assistance program was structured to support this process and ensure a transfer of skills and knowledge. 7. Both approaches are overseen by the Governor of the respective region, in close collaboration with the regional health delegates, and are managed by de facto regional committees comprised of regional representatives of the ministries of education, security, 2 defense, social affairs, and communication as well as civil society. The PPLS2 facilitates the preparation of regional action plans integrating the activities of all stakeholders, the implementation of which are then jointly supervised by the Governor, the regional health delegate, the Ministry of Public Health (MOPH), certain Ministry partners and the FOSAP on a quarterly basis. A major strength of this approach is the close involvement and commitment of the local authorities to these activities, which has facilitated the behavior change of the communities given that they are seen as role models. Box 2: New Approach to Population Activities: Mobile Teams To improve the results of the population activities, a mobile team approach was piloted in 2007 with support from Tunisian experts in Mayo Kebbi Ouest, a region with the lowest reproductive health indicators in the country. Two mobile teams were put in place to provide a comprehensive package of reproductive and child health services in 40 sites (located in both existing health centers and in villages without access to health centers) in the sub-prefects of Torrock and Lamé and part of Pala for 120,000 inhabitants of 103 villages within a five kilometer radius of the intervention sites, resulting in coverage of around 80 percent of the population. On the demand side, FOSAP financed community mobilization, social communication and peer education activities by theme, such as family planning, maternal behavior during pregnancy and prevention of childhood illnesses. These activities are implemented by CBOs under the supervision of facilitating organizations responsible for quality control of the activities. This new approach had very encouraging results in 2007: ·Number of prenatal consultations: 17,794 (276 percent increase from 2006) ·Number of assisted deliveries assisted by qualified personnel: 434 (132 percent from 2006) ·Number of women using modern methods of contraception: 2,883 ·Number of children (0-11 months) vaccinated: 37,814 (188 percent increase from 2006) ·Number of women vaccinated: 10,538 (266 percent from 2006) Despite the suspension of activities in Pala from March to September 2008 as a result of lack of financing, this positive trend continued in 2008 and 2009. Activities resumed in September 2008 with partial Government financing. 8. Country Context and Impact on Project Implementation: The last four years have been difficult for project implementation given the challenging country context. In January 2006, the IDA portfolio in Chad was suspended (see Box 3). The development objective and implementation progress ratings of all IDA-financed projects in the country were downgraded to unsatisfactory during this period. Following the lifting of the suspension in June 2006, a mission was undertaken to re-launch project activities and address the procurement and financial difficulties experienced by the project implementing agencies. However, considerable momentum had been lost during the six-month suspension and it took an additional six months to effectively regain this momentum. Moreover, a national general strike from February to August 2007 significantly hampered service delivery and project activities. 9. Rebel Attack in February 2008: In 2008, severe civil unrest broke out again. The capital, Ndjamena was attacked by rebels in February and a period of major insecurity followed. During 3 this time, project buildings and materials, including vehicles, furniture and files, were set on fire and destroyed by rebel factions. Project staff remained at home for safety reasons and work at the regional and district level was stopped. The country office was closed and World Bank staff evacuated. The office was partially re-opened in January 2009. Box 3: Suspension of IDA Portfolio in Chad and Memorandum of Understanding In December 2005, the Government of Chad, unilaterally revised the Petroleum Revenue Management Program that was the contractual basis for the Bank's financial support to the Chad-Cameroon Pipeline Project, by (i) revising the Petroleum Revenue Management Law, (ii) abolishing the Fund for Future Generations (FFG) and providing for the repatriation of its balance by decree; (iii) expanding the list of priority sectors financed by earmarked oil revenue to include energy, justice, territorial administration, and domestic security; and (iv) increasing the share of oil revenue allocated to the general budget from 13½ percent (the original 15 percent net of the FFG) to 30 percent. In response, the World Bank suspended its portfolio in Chad from January to June 2006. In July 2006, a Memorandum of Understanding (MoU) was agreed upon as an interim solution to the dispute between the World Bank and Chadian authorities over petroleum revenue management. The MoU was expected to remain in force until the Poverty Reduction Strategy Paper (PRSP), the basis for the 2008 budget, was updated. It committed the Chadian authorities to: (i) allocate 70 percent of its total budgetary resources to specified priority sectors in 2007; (ii) develop a Medium-Term Expenditure Framework (MTEF) in coordination with the World Bank and the International Monetary Fund (IMF) to guide annual budgetary expenditures; (iii) develop a mechanism by end-2006 to manage oil resources in excess of annual expenditures in the MTEF; (iv) strengthen the oversight role of the Collège de Contrôle et de Surveillance des Ressources Pétrolières; and (v) implement the Action Plan for the Modernization of Public Finances. 10. Results of the Project: Despite these extraordinarily difficult conditions, the project made progress on meeting its development objectives related to HIV/AIDS. Knowledge about HIV/AIDS has increased in both men and women, the use of condoms has increased for both men and women during non-union sexual contacts, the use of condoms among military personnel has greatly increased and the number of VCT centers and number of community based interventions have surpassed the target. Less progress though has been made on meeting the population targets, especially prior to the reorientation of the activities of the population component following the MTR in December 2005. Since the introduction of the new approach in 2007 in pilot areas, there has been an increase in basic mother and child health care indicators as well as HIV/AIDS related indicators, including use of contraceptives and HIV testing. 11. Project Performance: At the time of project closing, implementation progress was satisfactory as was progress towards the attainment of the project development objectives, despite the turbulent country circumstances. Implementation progress and project management had been upgraded due to the significant improvements in the management of FOSAP as well as the solid results produced by the field activities, especially in terms of VCT testing rates among the target groups. M&E, rated unsatisfactory in 2006, was upgraded to satisfactory as a result of 4 significant restructuring within the M&E team and the development and dissemination of new streamlined M&E tools for implementing agencies. Financial management, counterpart funding and procurement were all rated moderately satisfactory. Table 1: Progress on Selected Indicators of the Original PAD Indicator Base-line* End 2006** Target Increase in the use of condoms by young people Men: 1.8% Men: 25% 50% (aged 15 to 24) during non-union sexual contact in Women: 2.6% Women: 18% the last 12 months Increase in the use of condoms by military personnel 15% 68% 75% during sexual contact over the last 12 months Increase in knowledge of men and women aged 15- Men: 88% Men: 90% Men: 95% 24 years regarding HIV/AIDS Women: 60% Women: 80% Women: 90% Increase in the use of modern contraceptive methods Urban: 4.1% Urban: 7.2% Urban: 10% by women in union Rural: 0.3% Rural: 0.4% Rural: 3% Increased number of public VCT centers throughout 6 50 41 the country Number of condoms distributed -- 3.9 million 4 million Number of units of oral rehydration salts distributed -- 1.5 million 2 million * Demographic and Health Survey (DHS), 1996/1997; ** DHS 2004/2005 (fieldwork completed end 2005) III. RATIONALE FOR ADDITIONAL FINANCING 12. Renewed Bank Engagement in Social Sectors: A 2010-2012 Bank Interim Strategy Note (ISN, forthcoming) confirms the Bank's continued engagement in social sectors which can have a direct impact on the population and poverty. This includes work in the health sector. The ISN is forthcoming in June 2010. 13. HIV Prevalence Remains High: Although the official HIV prevalence rate appears to have stabilized at around 3.3 percent according to the 2005 HIV prevalence survey, high rates of STIs coupled with high-risk sexual behavior could translate into a rapid increase in the number of new HIV infections. Heterosexual transmission is the predominant mode of transmission with high-risk groups emerging as a result of certain socio-cultural characteristics of Chad (i.e. frequent conflicts, the status of women, activities linked to the oil field development in the South). High risk groups include commercial sex workers (with a prevalence rate of 20 percent in 20091), truckers (10 percent2) and the military (7 percent3). Women still remain at a higher risk of infection and prevalence rates tend to be higher among women than men. In a country where a large share of the population is not aware of their HIV status and where the capacity of health services nationwide is overstretched, targeted interventions (such as those expected under the additional financing) are critical to prevent the epidemic from spreading further. 1 2009 UNAIDS survey among commercial sex workers. 2 2005 national HIV prevalence survey. 3 Idem. 5 14. Very Poor Reproductive and Child Health Outcomes: Even though antenatal care and skilled attendance at delivery has increased, maternal mortality in Chad remains high at 1,009 deaths per 100,000 live births. The risk of maternal mortality is heightened by precocious and intense fertility (6.3 children on average per women and 15-19 years old girls contributing to 15 percent of national pregnancies). Contraceptive use remains very low: in 2004, the contraceptive prevalence rate was 2 percent4. This is not only due to cultural barriers but is also the result of frequent shortages in family planning supplies at the health center level. Under-five mortality, which is 209 deaths per 1,000 live births, is among the third highest in the world. 15. Limited External Support: Continued World Bank support through the additional financing is critical as the Bank is one of the few donors supporting reproductive health and child health and HIV/AIDS activities in the country. The additional financing will provide an opportunity for continued policy dialogue and support high-impact, priority interventions. 16. Building on Successful Approaches: The project will help achieve better results on the ground by extending the integrated decentralized response to HIV/AIDS and maternal and child health activities to districts with the poorest indicators. Thus far this approach has resulted in positive trends in key health indicators. With the appropriate reinforcement of quality and scaling up, the approach would complement activities of other development partners. 17. Going beyond Input Financing: The Government has made enormous investments in constructing new health facilities. However, results on the ground have been disappointing, mostly due to the poor performance of the health service providers. Health workers are poorly motivated, one major demotivating factor mentioned by all cadres of health workers being low salaries. Other demotivating factors mentioned were lack of supportive supervision by the Ministry of Health and poor human resource management practices, including lack of continuing education. In addition, poor infrastructure, equipment and the absence of basic amenities such as water and electricity were considered to negatively affect work performance. The focus on inputs has limited the focus on results. Given this situation, to ensure Chad makes progress towards achieving the health Millennium Development Goals (MDGs), it is critical that the health sector develop innovative financing mechanisms, such as results based financing (RBF), to motivate health service providers. RBF provides health facilities with payments based on the amount of services they provide which means a greater focus on results rather than inputs. This approach has been successful in a number of low income countries such as DRC, Rwanda, and Burundi. (Annex 1 has further details on this approach). 18. Measuring Results: Chad, across all sectors, needs to do a better job of tracking the results of its development activities. The project will help ensure the systematic collection of epidemiological data which will provide a better understanding of the HIV epidemic (thus addressing the changing epidemiological and HIV vulnerability scenario through more tailored activities). The project will also introduce new techniques, such as health facility surveys that will strengthen service delivery and help in the design of a possible future population and basic service delivery project for Chad. 4 DHS 2004. 6 19. The Additional Financing instrument was deemed the appropriate Bank instrument to address the financial needs of the sector rather than preparing a new investment project at this time because: (i) more time is needed to allow for consolidation of the results of the new integrated local response approach to HIV/AIDS and population activities; (ii) strengthened monitoring and evaluation will be required to prepare a new phase of financing; and (iii) the IDA envelope available for Chad at this time would not allow for a full population and basic health service delivery project. Based on exceptional country circumstances and in accordance with paragraph 5 of BP l3.20, there was an authorization request addressed to OPCS VP to process an Additional Financing for the Chad Second Population and HIV/AIDS project ("PPLS2") which closed on July 31, 2008. The approval was granted by VP OPCS and given the exceptional country conditions, Regional management, has endorsed the additional financing, to be implemented within two years, closing on June 30, 2012. IV. PROPOSED CHANGES 20. PDO and Indicators: Although the project's development objectives would remain unchanged, indicators would be revised to reflect the current international thinking in HIV/AIDS and be aligned with UNGASS indicators as well as integrate the lessons learned during implementation. The number of indicators has been reduced to facilitate data collection and analysis. Given that both incidence and prevalence were originally used as indicators, an assessment of the original indicators was undertaken to ensure the indicators used were those that were directly linked to measuring progress in HIV-related awareness and behavior change, such as condom use among at-risk groups. The assessment identified those indicators that were difficult to measure, unrealistic or more strictly related to activities funded by the Second Health Sector Support Project rather than by the PPLS2. A revised set of indicators was agreed upon with Government and is presented in Annex 2. The table outlining the results of the assessment of the original PAD indicators is in Annex 3. 21. Project Components: The project's components for this Additional Financing are the same as those of the Original Project, with the following modifications: (i) Component A (multi-sectoral response) would increase support to the health sector, given the important role of the sector, and provide financing to only three additional key Ministries, namely education, defense and security. (ii) Component C (social marketing) will be removed since activities under Component C are now being financed by Global Fund and KfW. This component will be replaced by the new RBF component. (iii) Activities under Component B (community interventions) and Component D (population activities) will be re-oriented to support the implementation of the decentralized and integrated approach. (iv) Finally, Component E would be expanded to strengthen monitoring and evaluation efforts as well as medical waste management. 22. Within the above framework, in the ten health districts5 employing the decentralized, integrated approach to HIV/AIDS, the additional financing will finance: (i) the supply of a comprehensive package of basic maternal and child health services through mobile teams; 5 The population of the ten health districts is around 1.96 million inhabitants. 7 (ii) strengthening of the existing public and private health centers and voluntary counseling and testing centers, including for medical waste management; and (iii) promotion of demand for services through social mobilization, communication and peer education activities implemented by civil society. Activities focused on HIV/AIDS prevention include, among others, testing and treatment of STIs, HIV testing and counseling, and psycho-social, medical and nutritional support to PLWHAs. Maternal and child health activities include, among others, family planning, pre-natal care, referral for assisted deliveries, and vaccination. HIV/AIDS activities would also be implemented in Ndjamena. 23. Component A: Strengthening the Capacity of the MOPH, Ministry of National Education, Ministry of Defense and Interior, and Ministry of Public Security (Multi- Sectoral Response). This component would finance scaled-up activities of the health sector as well as the education, defense and security sectors. The bulk of the financing for this component will go to front-line service delivery with a small amount of financing for supervision by the central level (resulting in an overall reduction of number of activities). Component B: Strengthening of FOSAP would continue to finance civil society interventions to stimulate demand. However, these interventions have also been restructured and their number reduced to improve the quality of their interventions and maximize the impact of those activities that will continue to be financed over the next two years. Moreover, performance-based contracting will be introduced for NGO contracts. Micro-credit activities under this component will be dropped given the lack of results and the resulting cost-savings will be allocated to other project components. Activities under Component D: Support to the Implementation of the National Population Policy would be scaled up to cover a greater number of districts under the integrated approach. 24. Component C: Support to a Pilot Performance-Based Approach to Improving Maternal and Child Health Outcomes would support a pilot RBF implementation through the provision of Performance-Based payments to eligible health centers in the pilot regions to improve critical maternal and child health outcomes. This approach will be piloted in selected districts of two regions, namely Guera and Tandjilé. The component will finance the RBF payments and provide support for the design, implementation and supervision of the RBF pilot, through contracting of a performance purchase agency (PPA). The PPA will contract with RBF health facilities in the selected districts based on payments for a defined set of services. The amount of services provided and the quality of care would be evaluated by the PPA (in collaboration with external reviewers) every three months. Based on the final verified results, the health facility would receive an agreed payment (linked to the results achieved), made by the Project Coordination Unit. The PPA will be responsible for undertaking an assessment of the capacity of health facilities, calculating the unit cost of the services, contracting with health centers, and verifying achievement of results. In each district, technical assistants of the PPA will check the consistency between reported results and health facility records. In addition, NGOs and CBOs will be contracted to undertake external verification through random household checks to confirm that beneficiaries actually received services. 25. Component E: Support to Project Management and Monitoring and Evaluation will support project management costs and strengthening medical waste management of health centers supported by the project, through provision of equipment, materials and incinerators 8 (where needed). Moreover, monitoring and evaluation capacity will be strengthened, including routine monitoring of project results and data collection, in particular at the regional and district levels, and use of evaluation tools and studies, including household and health facility surveys to assess the use and quality of services. It is proposed not only to implement "periodic household surveys" using rapid assessment techniques, but complementing them with "limited facility surveys" which will provide a comprehensive picture of both "demand and supply" side bottlenecks. Carrying out such surveys at a more decentralized level on a regular basis will immensely support development of appropriate strategies to address any bottlenecks. A baseline household survey will be undertaken after effectiveness by September 2010 to validate and update existing data and after the first year of project implementation to determine progress in the last quarter of 2011. An evaluation of the results of the project will be undertaken at the end of the implementation by the end of 2012. Data from these studies will be complemented by data from Multiple Indicator Cluster Surveys (MICS), a Demographic and Health Survey and a HIV prevalence survey. The project--under this component--will also finance a third Household Poverty and Consumption Study (ECOSIT3). This will be a follow-up to a 2003 household study (ECOSIT2), which provides a baseline for poverty levels in Chad prior to the emergence of oil revenues. ECOSIT3 will provide up-to-date and reliable poverty data for Chad and allow for an assessment and analysis of progress on key health sector indicators and the reduction of poverty since 2003. ECOSIT3 will have a particular focus on gender issues. 26. Project implementation, financial management, disbursement and procurement arrangements would generally remain the same as under the original project. However, under the Additional Financing, the percentages of eligible expenditures will be increased to 100 percent for IDA financing of all grant expenditures, as allowed by the Country Financing Parameters (CFPs) for Chad, given the problems faced by the project in mobilizing counterpart funding. An overview of these is provided in Annex 4. The total project cost, including taxes and duties, is estimated at US$20 million. The project costs, allocation and disbursements of the additional financing are shown in Annex 5. V. CONSISTENCY WITH PRSP, MDG AND AFRICAN ACTION PLAN 27. The Government adopted a second generation PRSP in 2008. The proposed project is fully aligned with this PRSP, specifically to the objectives of improving: (i) the social, judicial, political and economic environment through building institutional capacity and promoting good governance at the local level; and (ii) human capital by training and reinforcing the capacity of staff at various levels of government. The proposed project includes activities that are central to achieving the MDG 4 (reduce the child mortality rate), MDG 5 (reduce the maternal mortality rate) and MDG 6 (halt and reverse the spread of HIV/AIDS and malaria by 2015). Finally, the proposed project supports the objectives laid out in the Africa Action Plan, including with respect to the results framework for achieving impact and the development of national capacity and management of STI/HIV/AIDS and Population programs. VI. APPRAISAL OF SCALED-UP PROJECT ACTIVITIES 28. Although the project is being scaled-up, the program and economic, financial, technical, institutional, fiduciary, and social aspects of the activities to be undertaken with the additional 9 financing remain the same as in the original project. 29. Environmental analysis: The original project was given a "C" rating since it was not expected to generate any adverse environmental effects. The proposed additional financing project is rated "B" - as is the case for all HIV/AIDS projects. This is due to the risks associated with the handling and disposal of medical waste. As a result, the only safeguard triggered is the environmental assessment (OP/BP 4.01), because a Medical Waste Management Plan (MWMP) is required. No construction and/or rehabilitation of facilities will take place under the proposed additional financing operation. A MWMP was prepared and disclosed in the Infoshop and in- country in August 2007. The Borrower's institutional capacity for implementing safeguard is somewhat weak as they have little experience in this area and implementation of the Plan is uneven. Provision of critical materials and equipment for medical waste management, capacity building and supervision of safeguards is included in the additional financing under Component E to address weaknesses and enhance the implementation and systematic monitoring of the MWMP. VII. EXPECTED OUTCOMES 30. Key outcome indicators to measure behavior change include the following: (i) increased percentage of young people (aged 15 to 24 years) reporting the use of condom in their last act of sexual intercourse with a non-regular partner in the last 12 months (by gender); (ii) increased percentage of persons aged 15 to 49 who both correctly identify ways of preventing the sexual transition of HIV and who reject major misconceptions about HIV (by gender); and (iii) increased percentage of women using modern methods of contraceptives in project intervention areas. VIII. BENEFITS AND RISKS 31. Benefits. The additional financing will help ensure increased awareness of the importance of maternal and child health and of STI and HIV/AIDS through community and social mobilization. It will also increase the availability and provision of services through existing health centers and mobile teams. Renewed emphasis on counseling and testing and STI prevention and treatment should generate greater results in terms of changing HIV related behavior. In addition, on the health side, behavior change among women of child-bearing age, especially in remote areas, is expected to gradually­but substantially--improve family planning and antenatal and postnatal care indicators. The project would contribute to improving family welfare by providing contraceptive and essential medicines related to child survival. Finally, health workers in the project interventions areas will benefit from capacity strengthening related to reproductive health. 32. Risks. Most of the risks mentioned in the original PAD with respect to the achievement of the project development objectives remain valid especially with respect to inability to ensure continuous supply in medical products, misuse of funding, and deteriorating political environment and instability. 10 Inability of the Central Pharmaceutical Procurement Agency (CPPA) to regularly supply the necessary drugs, medical supplies and reagents (high risk). The CPPA continues to have problems with assuring a regularly supply of the necessary drugs, reagents and medical supplies throughout the country and specifically to the project. This has repeatedly resulted in delays in the implementation of project activities. As a result, the Bank has accepted that the project procure the necessary supplies through competitive methods until such time as the CPPA is reorganized. In parallel, other donors, such as the EU and the French, are working closely with the MOPH on restructuring the CPPA, including providing a new legal framework, putting in place a new management team and reviewing distribution mechanisms for the regions. Grant proceeds may not be used for their intended purposes, financial transactions may not be properly accounted for, and control and procurement procedures may not be properly applied (high risk). Mitigation measures have been taken, including the recruitment of independent external auditors and strengthening of the internal auditor function. Moreover, monitoring of the beneficiary compliance with the new financial management and procurement guidelines will take place on a more regular basis. Close supervision of financial management and accounting practices of the project by the IDA team will continue. Health workers may manipulate results data to increase RBF payments (high risk). This risk is significantly reduced by contracting a third party and by using field surveys to measure and verify results. Suspension of activities due to political instability or general strikes (high risk). Project activities may be impacted due to political instability in the country, or as a result of internal strikes. However, given that the project directly finances activities on the ground, such as the mobile teams, ensuring that staff receive their salaries and the necessary drugs and reagents, the potential impact of instability of strikes will be reduced (as evidenced during the general strike in 2007 during which the mobile teams continued to operate). IX. FINANCIAL TERMS AND CONDITIONS 33. The proposed Additional Financing Grant will be provided on standard IDA terms. Other than submission of a satisfactory legal opinion on the Financing Agreement, there are two conditions of effectiveness as the project's implementation and Administrative and Financial Manuals have been updated recently and reflect the new indicators: (i) the Recipient has recruited a procurement specialist for the Project implementation Unit, (ii) the Recipient has installed a financial management system for the Project satisfactory to the Association. Covenants to be included are standard and pertain to financial management, including the auditing of project financial statements by independent auditors acceptable to IDA. 11 ANNEX 1: RESULTS BASED FINANCING (RBF) APPROACH 1. The project will adopt a highly targeted approach to improving the existing health service delivery by introducing a RBF approach. The Government's investment in health structures has shown little results on the ground. In the context of Chad, it is believed that the greatest impact in increasing the use of services will need to come from: (i) improving the motivation of health workers; (ii) reducing financial barriers to patient access; (iii) increasing the amount of financing at the health facility level to improve the quality of the services provided; (iv) using internal and external controls to verify what services are actually provided by facilities; and (v) involving the community in increasing demand for services. While improving the quality of service through better equipment and infrastructure, experience suggests that, even with existing capacity, it should be possible to pilot a RBF mechanism, if it is well implemented. 2. Given these constraints the pilot seeks to: (i) Strengthen internal control and verification mechanisms and introduce external verification mechanisms that involve civil society; (ii) Prioritize high-impact, cost-effective maternal and child health interventions; (iii) Increase the amount of financing available to health facilities (and health providers) and ensure that they have sufficient autonomy to adapt to their local circumstances and are able to innovate; (iv) Ensure sufficient flexibility to be able to respond and adapt to lessons learned during implementation and to harmonize with other donors' efforts; (v) Build the capacity of communities (as the pilot develops) to stimulate demand for services and promote health behaviors among the population; and (vi) Increase the capacity of the MOPH to plan, manage, and oversee its programs and measure effectiveness. 3. To implement the pilot, a Performance Purchase Agent (PPA), generally a highly experienced NGO, will be contracted to provide technical support and external monitoring and will be accountable, along with other actors, to ensure that the performance of service providers improves and that tangible results are achieved. It will have the managerial autonomy to develop and implement diverse RBF mechanisms adapted to the local context. The PPA will introduce innovations aimed at achieving the stated RBF objectives, and be held accountable for the results in its region of intervention. 4. The transfers under the RBF will reimburse facilities for the provision of services already provided. The services to be paid for through the RBF mechanism include, among others, primary health care and preventive services for pregnant women, delivery and post-partum care, care for children under the age of five, family planning, and HIV/AIDS services. Although the final list of services/outputs to be related to RBF has to be defined and confirmed, a preliminary list was drafted based typical activities of health centers and is outlined in Table 2 below. The RBF payments obtained from these quantitative outputs will be adjusted with the quality of care. The final list of items for measuring quality of care will be included in the RBF operational manual. For each of the RBF outputs defined above, the RBF operational manual will define the unit costs to be used for calculating RBF payments to facilities. A study on unit costs will be 12 undertaken accordingly and these unit costs will be estimated more precisely before the start of the RBF process. They will also be updated annually. Table 2: RBF Services/Outputs (indicative list) MATERNAL CARE SERVICES 1. Antenatal care visit 2. Antenatal care visit for a woman identified as poor 3. Family planning visit 4. Assisted delivery 5. Assisted delivery for a woman identified as poor OTHER HEALTH CARE SERVICES 6. Antenatal care visit for a woman with fever and having been tested for malaria (rapid test) 7. Antenatal care visit for a woman with malaria and having received CTA 8. Outpatient visit for a child with diarrhea 9. Outpatient visit for a child with fever and having being tested for malaria (rapid test) 10. Outpatient visit for a child with malaria and having received CTA 11. Distributed Insecticide-Treated mosquito Net (ITN) 12. Fully immunized children 13. Hospital care for medicine case 14. Hospital care for surgery case 15. Voluntary counseling and Testing for HIV/AIDS 5. There will be a standard tariff for key services. Front-line health facilities will be paid a standard tariff for each type of high impact service. The tariff reflects an estimate of the incremental recurrent cost of providing the service and the priority that the MOH attaches to it. Tariffs would be modified based on experience. Table 3 below provides an example of how the payment for a given health facility will be calculated. Table 3: Calculating a Health Facility's RBF Payment - Example Type of Service Provided Tariff Number of Services Provided Total Amount Earned by ($) in Previous Quarter the Health Facility Voluntary counseling and $3.00 100 $300 testing for HIV New or Continuing user of $2.00 150 $300 family planning Antenatal visit $1.00 200 $200 Child becomes fully $1.50 300 $450 immunized Birth in the health facility $5.00 25 $250 Total $1,500 6. Equity will be taken into consideration in the tariffs. Because remote health facilities have a harder time attracting staff, these centers will receive an additional equity bonus that will be a specified percentage of how much they have earned during the month. The criteria for selecting the facilities to receive this higher tariff will include the current availability of staff at the facility and its physical remoteness. These criteria will be reflected in the RBF Manual of Procedures. 13 7. The quality of care will be reflected in three monthly transfers. In order to ensure that facilities are focusing on the quality of the care that they provide, the payments given to the facility will be adjusted according to a quality score during the quarter. The quality score will be given following an assessment carried out in health centers and hospitals, based on a broad variety of indicators such as the availability of staff and medicines, cleanliness, and the quality of recordkeeping. The payment to the health facility will be adjusted according to the given quality score. For example, if the health facility depicted in Table 3 scored 80 percent on its quality assessment it would receive $1,200 (i.e., $1,500 x 80%). 8. Facilities will have considerable autonomy in spending RBF payments. The facility will have substantial autonomy over how to use the funds they receive, although the Project Coordination Team (in collaboration with the RBF Steering Committee) and the PPA will set some general guidelines in the RBF manual. For example, the RBF payments cannot be use for construction and the percentage of its funds a health facility can spend on performance incentives to staff will be limited. However, the facilities can spend these funds on buying equipment and medicines, maintaining the facility, and supporting community-based activities. 9. Implementation Manual: The PPA will develop an implementation manual for the RBF model with details including: (i) institutional arrangements; (ii) roles and responsibilities for the verification and control of results for payment and auditing purposes; (iii) indicators and targets to be met; (iv) penalties and sanctions for exaggeration or fraud in the amount billed; (v) management and data collection tools; (vi) rules for the use of funds; and (vii) reporting mechanisms. The manual will be a working document that will be regularly updated on the basis of agreements reached between the PPA and the health facilities but subject to the non-objection of the Bank. The non objection of the Bank to the manual is a disbursement condition for this activity. 10. Evidence Supporting RBF: A recently reported randomized trial from Rwanda has demonstrated the effectiveness of RBF even when controlling for the amount of funds provided to the facilities. In Burundi, a controlled, before and after study conducted between 2006 and 2008 compared two provinces in which RBF was introduced with two control provinces where NGOs were also active but provided only input-based financing. For 22 out of 27 indicators, the RBF provinces experienced significantly larger improvements than the control provinces, including a 12 percentage point increase in coverage of insecticide-treated bed nets and a 39 percentage point increase in births taking place in health institutions. Similar results have been reported for an RBF scheme in the Democratic Republic of Congo. 14 ANNEX 2: REVISED RESULTS FRAMEWORK AND PROJECT INDICATORS Project Development Project Outcome Indicators Use of Project Objective Outcome Information Contribute to changing 1. Persons aged 15 to 24 who both correctly identify To track progress the behavior of the ways of preventing the sexual transition of HIV and who on a major project Chadian population so reject major misconceptions about HIV (% by gender) objective and to that they will adopt [UNGASS] contribute to global behaviors which will reporting on reduce the risk of: (i) HIV/AIDS HIV infection; and (ii) 2. Young people aged 15 to 24 years reporting the use To track progress too closely spaced of condoms in their last act of sexual intercourse with a on a major project and/or unwanted non-regular partner in the last 12 months (% by gender) objective and to pregnancies. [UNGASS] contribute to global reporting on HIV/AIDS 3. Women using modern methods of contraception in To track progress project intervention areas (% & number) and service uptake for contraception in project areas Results for each Results indicators component 1. Availability and 1. Direct project beneficiaries (number), of which In order to track quality of female (percentage) whether the project STI/HIV/AIDS [CORE INDICATOR] is contributing to services improved in one of the overall project interventions objectives, and to areas. contribute to global IDA reporting In order to track 2. People with access to a basic package of health, whether the project nutrition, or population services (percent increase) is contributing to [CORE INDICATOR] one of the overall objectives, and to contribute to global IDA reporting 3. Persons aged 15-49 who received counseling and To track service testing for HIV and received their test results (by gender uptake for VCT and age) (number/%) among the general [AFRICA HIV/AIDS CORE INDICATOR] population and to contribute to global IDA reporting 4. Military personnel tested for HIV (number/%) To track VCT uptake among high risk group 5. Pregnant women tested for HIV during prenatal To track progress consultations (number/%) in service uptake for VCT among pregnant women, in 15 support of PMTCT activities 2. Demand for 6. Condoms distributed (number) To track progress STI/HIV/AIDS and [ AFRICA HIV/AIDS CORE INDICATOR] on condom reproductive health distribution and services increased in will contribute to project intervention global IDA areas. reporting 7. Orphaned and vulnerable children aged 0-17 whose This is a core households received free basic external support in caring indicator for the for the child (number) Africa region and [AFRICA HIV/AIDS CORE INDICATOR] will provide information on service provision and support for vulnerable children 8. Women of child-bearing age reached by CBO To track progress interventions (number/%) in CBO activities and service reach among the target population and project sites 3 & 4. Utilization of 9. Children immunized (number/%) Immunization maternal and child [CORE INDICATOR] status is a health services in fundamental project interventions indicator of the areas. performance of the health system. 3. RBF Approach (in 10. Pregnant women receiving antenatal care during a To track service two pilot regions) visit to a health provider (number/%) uptake for ANC [ CORE INDICATOR ] 4. Integrated approach 11. Assisted deliveries in public and private health This is a major (in five regions) centers (number/%) indicator of improvement in MCH operations and will serve as a proxy indicator for reduction in maternal and child death 12. Pregnant women vaccinated (number/%) To track progress in vaccination 13. Women attending post natal care consultations To track progress during a visit to a health provider (number/%) in service uptake for antenatal care 14. Health personnel receiving training (number) To improve the [CORE INDICATOR] adequacy of competence in service delivery and other areas 16 15. Long-lasting insecticide ­treated malaria nets To track progress purchased and/or distributed (number) on purchase and/or [CORE INDICATOR] distribution of LLTNs 16. Health facilities constructed, renovated, and/or To track IDA equipped (number) contribution to [CORE INDICATOR] health system strengthening 17 ANNEX 2: RESULTS ARRANGEMENT Outcome Indicators Latest Target Data Source Frequency Persons Progress End project Responsible 1. Persons aged 15 to 24 who both correctly identify M : 57,3% M : 70% Household 2010 (HS),2011 Project ways of preventing the sexual transition of HIV and F : 28,7% F : 50% Survey/DHS/MICS (MICS) and 2012 PPLS2, who reject major misconceptions about HIV (% by EDST2 (HS) UNICEF gender) (2004/056) 2. Young people aged 15 to 24 years reporting the M : 25% M : 65% Household 2010 (HS),2011 Project use of condoms in their last act of sexual intercourse F : 18% F : 35% Survey/DHS/MICS (MICS) and 2012 PPLS2, with a non-regular partner in the last 12 months (% EDST2 (HS) UNICEF by gender) (2004/05) 3. Women using modern methods of contraception Urban : 7,1% ( Urban : 10% Household 2010 (HS),2011 Project in project intervention areas (% by zone) Rural : 0,4% Rural : 3% Survey/DHS/MICS (MICS) and 2012 PPLS2, EDST2 (HS) UNICEF (2004/05) Results indicators Latest Target Data Source Progress End project COMPONENT 1 4. Persons aged 15-49 who received counseling and M : 3,7% (62) M : 12,5% Project Reports Every 6 months Project testing for HIV and received their test results (by F : 0,9% (55) (40625) PPLS2 gender ) (number%) EDST2 F : 10% (2004/05) (47564) 5. Military personnel tested for HIV (number/%) 2,517 (13,8%) 6,400 (35%) Project Reports Every 6 months Project 2007 PPLS2 6. Pregnant women tested for HIV during prenatal (173) 7,7% (28038) 40% Project Reports Every 6 months Project consultations (number/%) EDST2 PPLS2 (2004/05) COMPONENT 2 7. Condoms distributed (number) 3,900,000 5,050,000 FOSAP / MEN, Every quarter FOSAP (2007) MISP / MDN/ VCT Reports 8. Orphaned and vulnerable children aged 0-17 6,872 8,872 FOSAP Reports Every quarter FOSAP 6 Field work was completed end 2005. 18 whose households received free basic external 2008 FOSAP (2,000 new support in caring for the child (number) FM report OVC) 9. Women of child-bearing age reached by CBO 29,082 393,600 FOSAP Reports Every quarter FOSAP interventions (number/%) (39%) (50%) Pala Project intervention areas COMPONENTS 3 AND 4 10. Children immunized (number/%) a. 59,367 a. 71,620 PPA Reports Every quarter MoH, a. Integrated Approach (80%) (95%) HMIS / Facility Project b. RBF Approach7 surveys PPLS2 b. 34,420 b. 46,732 Household surveys Every quarter PPA and (57%) (95%) Project PPLS2 11. Pregnant women receiving antenatal care during a a. 50,928 a. 70,094 PPA Reports Every quarter MoH, visit to a health provider (number/%) (52%) (80%) HMIS / Facility Project a. Integrated Approach surveys PPLS2 b. RBF Approach b. 27,817 b. 45,912 Household surveys Every quarter PPA and (40%) (80%) Project PPLS2 12. Assisted deliveries in public and private health a. 16,321 a. 25,659 PPA Reports Every quarter MoH, centers (number/%) (20%) (30%) HMIS / Facility Project a. Integrated Approach surveys PPLS2 b. RBF Approach b. 11,086 b. 16,807 Household surveys Every quarter PPA and (18%) (30%) Project PPLS2 13. Pregnant women vaccinated (number/%) a. 51,305 a. 70,094 Project Reports Every quarter MoH, a. Integrated Approach (58%) (80%) HMIS / Facility Project b. RBF Approach surveys PPLS2 b. 34,726 b. 45,912 Household surveys Every quarter PPA and (49,1%) (80%) Project PPLS2 7 Data for the RBF component is an average of the regional data from the two pilot regions. The base line data and targets will be validated and refined after the selection of the specific project intervention districts. 19 14. Women attending post natal care consultations a. 3,389 a. 7,698 (30% Project Reports Every quarter MoH, during a visit to a health provider (number/%) (3.1%) of assisted HMIS / Facility Project a. Integrated Approach deliveries) surveys PPLS2 b. RBF Approach b. N/A b. 11,765 Household surveys Every quarter PPA and (household (70% of Project survey to assisted PPLS2 provide) deliveries) b. 898 b. 15,577 (0,31%) (5%) 20 ANNEX 3: EVALUATION OF ORIGINAL RESULTS FRAMEWORK AND INDICATORS OF THE PAD Project Development Outcome / Impact Indicators Baseline Achievements Status of Comments Objective (end 2006) Indicator for additional financing The development Use of condoms by young people Men: 1.8% Men: 25% Revised Indicator revised (Cf. Indicator objective of the (aged 15 to 24 years) during non- Women: Women: 18% Outcome n0 2) to reflect the project is to contribute union sexual contact in the last 12 2.6% current international thinking in to changing the months will have increased to 50% HIV/AIDS and be aligned with behavior of the UNGASS indicators Chadian populations The prevalence of STIs within 15- Dropped Support to STI initially financed so that they will adopt 49 years of age population will be by Second Health Sector behaviors which will reduced Support Project. Although reduce the risk of: (i) PPLS2 is financing STI HIV infection; and (ii) activities as of 2007, outcome too closely spaced cannot be achieved within 2 and/or unwanted years. pregnancies. Incidence of STI, syphilis, and Dropped. Support to STI originally HIV/AIDS among truck drivers, financed by Second Health and prevalence of HIV/AIDS and Sector Support Project. HIV syphilis among truck drivers with prevalence no longer used as STIs outcome indicator. Incidence of STI, syphilis, and Dropped Support to STI initially financed HIV/AIDS among CSWs, and by Second Health Sector prevalence of HIV/AIDS and Support Project. Although syphilis among CSWs with STIs PPLS2 is financing STI activities as of 2007, outcome cannot be achieved within 2 years. Condom use by in the last non- Dropped The number of military union sexual contact among personnel testing for HIV will military personnel will increase to be measured under Component 75% by the end of the project 1. 21 Reduction in the prevalence of Dropped Support to STI initially financed STIs, syphilis and HIV/AIDS by Second Health Sector among military personnel Support Project. Although PPLS2 is financing STI activities as of 2007, outcome cannot be achieved within 2 years. By the end of the project, at least Urban: 4.1% Urban: 7.2% Revised Indicator revised to measure 10% of Chadian women in urban Rural: 0.3% Rural: 0.4% progress in project intervention areas, and 3% in rural areas use a areas and not nationally. modern method of contraception By the end of the project, 60% of Dropped Indicator is not measurable. women aged 15-49 wish to space Problem with DHS. next pregnancy by at least 2 yrs 22 Project Development Outcome / Impact Indicators Revised Comments Objective Indicator By the end of the project, 95% of all men and Revised Indicator revised (cf. indicator Outcome n0 90% of all women aged 15-24 years are aware of 1), to reflect the current international thinking HIV/AIDS, and 90% of them know at least two in HIV/AIDS and be aligned with UNGASS means of prevention indicators Increase the number of condoms available Revised Indicator is a results indicator, not outcome nationally through social marketing by at least and is already captured in the results of 10% a year to reach 3 million by end of 2003 and component 3. at least 4 million by the end of the project Intermediate Results Results Indicators for Each Component Revised Comments One per Component Indicator 1. Strengthened capacity of National HIV/AIDS program is operational and Dropped. Indicator is a process indicator, not results the Government, the private implements the national strategic plan. The 6 indicator. sector and civil society, at technical services of the program prepare annual the national, regional and work plans that are evaluated each year. local level to formulate and The 6 key ministries implement an annual Dropped. Indicator is no longer relevant. adopt HIV/AIDS HIV/AIDS action plan and report on the activities prevention strategies carried out the previous year. tailored to the local context. VCT are available in 75% of the 54 existing Revised. Replace with a Scorecard indicator, namely: health districts persons aged 15 or older who received an HIV/AIDS test in the last 12 months and received their test results (by gender and by age) (number and percentage) 2. Strengthened capacity of FOSAP has implemented at least 170 sub- Dropped indicator not relevant FOSAP projects. The implementation of sub-projects and allocation Dropped Indicator is a process indicator, not results of funds for each category of sub-projects will be indicator at least 90% consistent with the annual plan. Micro-credit programs are developed in all of the Dropped. Indicator remains relevant and measurable. Departments (created in 1999) However, project stopped financing micro- credit programs following the MTR. 23 Intermediate Results Results Indicators for Each Component Revised Comments One per Component Indicator At the end of each year, the Regional Population Dropped. Indicator is no longer relevant as the project Commissions prepare an annual activity report has stopped financing these Commissions and identify a list of priority activities for the given the lack of results. following year for behavior change in the areas of HIV/AIDS and reproductive health. The Regional Health Councils develop annually Dropped Indicator is no longer relevant. an action plan including prevention and care activities and report on the activities of the previous year. 3. Support to the Social The number of condoms available through the Dropped. Indicator is no longer relevant. marketing Program social marketing program reaches 4 million by the end of the project The number of oral re-hydration salt packets Dropped. Indicator is no longer relevant. distributed by AMASOT reaches 2 million by the end of the project. Between 2003 and 2005, 18 workshops/seminars Dropped Indicator is no longer relevant. (6 per year) designed for 1,000 religious leaders by AMASOT to raise awareness on HIV/AIDS, STIs and risks associated with frequent & numerous pregnancies Between 2002 and 2005, 28 workshops/seminars Dropped Indicator is no longer relevant. (7 per year) designed for 1000 traditional leaders by AMASOT to raise awareness on reproductive health issues. 75 IEC activities (15 per year) designed to modify Dropped Indicator is not measurable. reproductive health behavior are implemented using radio as media. A marketing program for oral contraceptives is Dropped. Indicator is no longer relevant. established in 2004 and ensure the sales of 500,000 cycles a year by the end of the project 24 Intermediate Results Results Indicators for Each Component Revised Comments One per Component Indicator A marketing program for impregnated bednets is Dropped Indicator is no longer relevant. 4. Support to the established in 2002 and is active in least 5 of the Dropped Indicator is no longer relevant as the project implementation of the southern prefectures. has stopped financing these Commissions National Population Policy All 14 Population Commissions implement and given the lack of results. update an annual action plan Dropped Indicator is not measurable. Problem with The percentage of women wishing to space their DHS. birth by at least 2 years will have increased to Dropped Indicator is no longer relevant as the project is 60% no longer financing this activity under this Number of religious leaders trained in population component, rather under component 2. and development issues. 25 ANNEX 4: PROJECT IMPLEMENTATION, FINANCIAL MANAGEMENT, DISBURSEMENT AND PROCUREMENT ARRANGEMENTS 1. Implementation mechanisms. The implementation arrangements under the additional financing would be the same as for the original project, as they are working well. The Ministry of Economy and Plan (MEP) is responsible for the planning, implementation and supervision of project activities through a Steering Committee presided by the Permanent Secretary (Secrétaire Général ­ SG) of the MEP. The day-to-day coordination of project activities is undertaken by the Project Coordination Team (PCT), headed by a Project Coordinator under the direct supervision of the SG of the MEP. The team also includes an administrator, a procurement specialist, a monitoring and evaluation officer, two internal auditors, an accountant and a program officer in charge of component C of the project. The MOPH will continue to be responsible for the coordination and technical supervision of the health sector related activities as well as provision of qualified medical personnel and vaccines. The MEP is responsible for the provision of the contraceptives and general implementation supervision. Local response and community interventions are coordinated by FOSAP, a national fund that has been responsible for the selection, procurement, financial management, and monitoring of community sub-projects all over the country for over ten years. FOSAP will include a management with the following staff: an administrator, an assistant administrator, two program officers, a monitoring and evaluation specialist, and an accountant. Implementation arrangements, including procurement, financial management and monitoring and evaluation, are detailed in the PPLS2 Project Execution Manual, the FOSAP Grant Operational Manual and the FOSAP Administrative and Financial Manual. These manuals were reviewed again and approved in February, 2010. 2. The RBF component will be managed by a technical unit to be created within the PCT. A Purchase Performance Agency (PPA), generally a highly experienced international NGO, will be contracted to provide technical assistance to the PCT (through the provision of one technical assistant at the central level and four technical assistants at the district level), assess the capacity of health facilities, calculate the unit cost of the services, contract with health centers, verify achievement of results, and strengthen the capacity of the Government and project team in collecting, analyzing and using data from different sources. Household and facility surveys would be used to evaluate the quality of services, the knowledge skills and practices of health workers, utilization of services and the opinions and attitudes of communities regarding availability and quality of health services. Technical assistance provided by the PPA will include on-the-job training and other knowledge transfer activities so that the national teams are technically autonomous by the end of the project and support to carry out controlled (before and after) evaluation of the RBF pilot. 3. The PPA will be accountable, along with other actors, to ensure that the performance of service providers improves and that tangible results are achieved. It will have the managerial autonomy to develop and implement diverse RBF mechanisms adapted to the local context. The terms of reference (ToRs) will be prepared and an expression of interest will be published to identify interested candidates. A request for proposal will then be tendered out, and both technical and financial proposals will be requested before selecting the appropriate candidate. Selection criteria for the PPA include demonstrated project and financial management capacity. The development of an implementation manual for this component and the modalities of 26 verification will be included in the tasks outlined in the ToRs and is a disbursement condition for this activity. 4. Careful and independent monitoring and evaluation of this Component will be carried out by the PCT. 5. Financial management and disbursement arrangements. In accordance with Bank policy and procedures, the financial management arrangements of the project were reviewed in October 2009 to determine whether they are acceptable to the Bank. This review is rather an update since the financial management system of this project was already assessed during the implementation period of the original project. The overall conclusion from this review is that the project financial management is acceptable. Fiduciary risk remains substantial as is the case for all IDA-financed projects in Chad. Following the civil unrest in February 2008 and the looting of the project, the computerized accounting and reporting system (TOMPRO) to be maintained for the timely production of financial information required for managing and monitoring project activities as defined in the PPLS2 Project Execution Manual, is no longer in place given the lack of equipment. The Government will finance the purchase of the necessary equipment and TOMPRO software (which is an effectiveness condition) as soon as possible to avoid any delay in project implementation to ensure that the system is operational prior to the launch of the project. To ensure efficient use of grant funds for the purposes intended and consistent application of policies and procedures and in response to weakness in auditing, the internal auditor that was recruited for the FOSAP will be transferred to the PCT to cover all project components and will be assisted by an assistant internal auditor. Independent auditors acceptable to IDA will audit the project accounts annually as well as the FOSAP account under the Additional Financing. 6. Two new designated accounts (one for the PCT and one for the FOSAP) will be opened in a commercial bank acceptable to IDA. The ceiling of each DA has been set at 750,000,000 Francs CFA which is equivalent to around US$1.5 million for each account. For the purpose of Performance Based (PB) payments under Part C 1, bank accounts will be opened by eligible health centers in a bank acceptable to IDA or at the post office in the prefectures where there are no banks. Funds withdrawn from IDA are advanced to the DAs from which payments for eligible expenditures are made; PB payments to eligible health centers will be transferred from the [DA- PCT] to their bank accounts (cf. Table below). 27 Grant Account (Washington) IDA Designated Account Designated Account DA-FOSAP DA-PCT Financial Bank Ndjamena Financial Bank Ndjamena FOSAP Beneficiaries Performance based payments to eligible Health Centers Accounts Goods, Consultants Services, audits, training and operations costs 7. An initial advance up to the ceiling of the DA will be disbursed upon request and after effectiveness. Subsequent advances will be made against submission of Statement of Expenditures (or records as the case may be) documenting the use of the previous advance. Disbursements for the Results Based component will be made against submission of a withdrawal application supported with a Customized Statement of Expenditures (Attachment 5 to the Disbursement Letter) providing a list of health service packages billed by the health centers. Other disbursements methods (reimbursement, direct payments and special comments) will also be available and these are described in detail in the Disbursement Guidelines for World Bank projects of May 2006 (Annex 1 to the Disbursement Letter). 8. Disbursement percentages for the additional financing will be increased to 100 percent IDA financing of all grant expenditures, as allowed by the Country Financing Parameters (CFPs) for Chad, given the problems faced by the project in mobilizing counterpart funding. This should facilitate implementation of project activities in a timely manner and prevent delays in provision of equipment, medicines and medical supplies. 28 9. Disbursement under Component C.1 would be subject to the following disbursement conditions: (i) recruitment and signature of the contract with the PPA; and (ii) a satisfactory implementation plan (the "PB Plan") outlining the work plan and budget for the first 12 months of implementation of Part C.1 of the Project, and (ii) a satisfactory operational manual (the "PB Manual"), outlining implementation, organizational, administrative, monitoring and evaluation, environmental and social monitoring and mitigation, financial management, disbursement, and procurement arrangements for purposes of implementation of results-based financing in the health sector under Part C.1 of the Project, as well as a detailed assessment of the estimated unit costs of the Health Services Packages to be provided by the Eligible Health Centers; and (iii) the recruitment of the external consultants to carry out quarterly verifications of the health services packages. 10. Procurement arrangements. Under the proposed additional financing, the general procurement arrangements would be the same as the arrangements under the Second Population and HIV/AIDS Project; however, the updated "Guidelines for Procurement under IBRD Loans and IDA Credit" published by the Bank in May 2004, and as revised in 2006 and in May 2010, will apply to all contracts financed under the additional financing. Procurement of consultants' services shall be governed by the "Guidelines for the Selection and Employment of Consultants by World Bank Borrowers" published by the Bank in May 2004 and revised in October 2006 ad in May 2010. No works will be financed under the additional financing. To ensure cost efficiency, all contracts should be grouped to the extent possible and the project should avoid launching small bids. 11. The same procurement methods for goods used under the ongoing project will be applied to the additional financing, namely: international competitive bidding, national competitive bidding procedures acceptable to the Bank, shopping, and direct contracting. In addition, procurement from United Nations specialized agencies, acting as suppliers, pursuant to their own procedures consistent with para 3.9 of the Bank Procurement Guidelines, may include IAPSO, United Nations Development Program, UNICEF and WHO. The form of contract between the Government and the UN agency will be prior reviewed by the Bank. The items to be procured from UN agencies would be agreed on in the procurement plan if and when to be used. 12. Procurement methods for consultants include Quality and Cost-based Selection, Least- Cost Selection, Selection Based on Consultant Qualifications, Single Source Selection and Individual Consultants. For each contract to be financed by the Grant, the different procurement methods or consultant selection methods, the need for pre-qualification, estimated costs, prior review requirements, and the time frame are outlined in the Financing Agreement, the Implementation Manuals and the Procurement Plan. 13. Prior review will be required for contracts for goods and vehicles costing US$500,000 or more, contracts for medical supplies costing US$300,000 or more, contracts with consultant firms costing US$200,000 or more, contracts with individual consultants costing more than US$100,000 and all single source contracts. 14. A Procurement Plan for the full implementation period of the additional financing was evaluated on May 12, 2010 and found satisfactory. As per Bank policies, the Procurement Plan 29 will be disclosed on the Bank's website upon approval of the additional financing. The Procurement Plan will be reviewed and updated regularly and at least once a year. Compliance with procurement procedures has generally been satisfactory in the past; however, delays systematically occurred during implementation in the past, due to the overall country context, weak capacity, and the cumbersome national procurement procedures. 15. To address these issues, all procurement undertaken by national bidding will be carried out in conformity with paragraph 3.3 of the Procurement Guidelines of May 2004, revised in October 2006 and May 2010 and considered to be acceptable by the Bank. Furthermore, a new procurement specialist is being recruited prior to effectiveness based on experience with Bank procedures. To mitigate the risk of project implementation delays, several measures have been put into place to strengthen procurement. Firstly, to simplify and accelerate procurement, FOSAP has been given some responsibility for certain procurement under Component B. In general, the PCT is responsible for implementation and supervision of procurement matters related to Components A, C and D. For Component B, FOSAP will be assisted as needed by the PCT's procurement specialist for contracts of amounts less than or equal to 3 million Francs CFA. 16. A further measure to facilitate project implementation and raise any potential procurement issue is the organization of quarterly meetings by the project procurement specialist with each implementing agency to review the implementation of the procurement plan. Finally, close supervision of the project and its procurement will continue to be undertaken by the Bank team as under the original project. In addition to the prior review supervision to be carried out from Bank offices, the capacity assessment of the implementing agency has recommended bi- annual supervision missions to visit the field to carry out post review of procurement actions. 30 ANNEX 5: PROJECT COSTS AND FINANCING PLAN OF THE ADDITIONAL FINANCING ESTIMATED PROJECT COSTS (in US$ million equivalent) Total (expressed in Category millions of USD) % of expenditures to be financed (inclusive of taxes) 1. Goods, Consultants' services, including 13.8 100% audits, Training and operating costs 2. FOSAP Grants 3.2 100% of amounts disbursed 3. Performance Based Payments under Part 3.0 100% of amounts disbursed C1 of the project Total Project Costs 20.0 FINANCING PLAN (BY PROJECT COMPONENT) (in US$ million equivalent) Local Foreign Total Project Cost By Component and/or Activity Component A: Multisectoral response to 1.2 0.2 1.4 HIV/AIDS Component B: Support to the Social Fund 6.6 0.9 7.5 (FOSAP) and community interventions Component C: Piloting of Performance Based 4.1 0.9 5.0 Financing Component D: Support to the implementation 0.1 0.0 0.1 of the National Population Policy Component E: Project management and M&E 4.0 2.0 6.0 Total Financing 16.0 4.0 20.0 31 IBRD 33385 15°E 20°E 25°E To 0 100 200 300 Kilometers Akhaltsikhe 0 100 200 Miles CHAD LIBYA Aozou Tarso Emisou Pic Touside (3,376 m) (3,315 m) sti be Ti Zouar 20°N To 20°N Séguédine Emi Koussi (3,415 m) S a h a r a D e s e r t kou Bor N IG E R BORKOU - ENNEDI - TIBESTI Faya-Largeau Fada a r En ow lé ne iH é ad d di W o B Koro Toro Toro Oum-Chalouba ma o) O Fa or 15°N KANEM al (S BILTINE 15°N h az G el Biltine hr Ba Mao Salal LAC B AT H A SUDA N Abéché Abéché Abéché Bol Moussoro Oum Hadjer To Mouzarak Ati Nyala 1963 Level 1973 Level Batha 2001 Level Lake Chad Massaguet Bokoro Mongo Mangalmé Mangalmé OUADDAÏ N´DJAMENA N´DJAMENA N IG E RIA To Fotokol Beïda Beï Goz Beïda This map was produced by the Map Design Unit of The CHARI- Masalasef World Bank. The boundaries, colors, denominations and BAGUIRMI Deïa Deï Abou Deïa any other information shown on this map do not imply, on Massenya the part of The World Bank To Group, any judgment on the Timan Am Timan Maroua Gélengdeng Gélengdeng Melfi GUERA legal status of any territory, at or any endorsement or S A L A M AT m acceptance of such ala ha C Bousso ri boundaries. hr S To Bongor Maroua Ba 10°N Harazé Harazé MAYO- MAYO- KEBBI Kélo Kélo TANDJILE TANDJILE Lai MOYEN- CHARI Mangueigne To Birao CH A D Pala L Koumra Sarh SELECTED CITIES AND TOWNS og on LOGONE e Moundou Ba PREFECTURE CAPITALS OCC. Doba ng r an NATIONAL CAPITAL o C AM E RO O N ORIENTAL LOGONE ORIENTAL Gribingui am RIVERS Vina To B i Kaga Bandoro ng MAIN ROADS ui To To RAILROADS Bozoum Bossangoa CENT RA L A FRICA N PREFECTURE BOUNDARIES REPUBLIC Mbakaou INTERNATIONAL BOUNDARIES Res. 15°E 20°E SEPTEMBER 2004