Report No. PID9849
Project Name                   Chad-Population and AIDS II
Region                         Africa Regional Office
Sector                         HIV/AIDS; Primary Health; Including
Reproductive Health; Chi
Project ID                     TDPE72226
Borrower(s)                    REP. OF CHAD
Implementing Agency
Address MINISTRY OF ECON. PROMOTION AND DEV.
N'Djam6na, Chad
Contact Person: Mr. Mahamat Saleh Idriss
Tel: 235-52-65-16 or 52-47-64
Fax: 235-52-65-14
Email: ims@intnet.td
Environment Category           C
Date PID Prepared              March 28, 2001
Projected Appraisal Date       April 16, 2001
Projected Board Date           July 5, 2001
1. Country and Sector Background
a. The Health Sector in ChadThe main weaknesses identified in the health
sector are : (i) Severe shortage of qualified human resources. Because of
the lack of qualified staff, many of the country's health facilities and
most health centers cannot provide all the services included in the
minimum package of activities (MPA), and they have to limit their services
to priorities in prevention such as vaccination, oral dehydration therapy
(ORT), pre-natal consultation (PNC), and curative care; (ii) Inefficacy of
basic health services in reducing maternal and child mortality which
remain at an unacceptable levels. This situation is caused by factors
inside and outside of the health sector. However, specific interventions
in the health sector must be designed to improve access to, and the
performance of, the health system. These interventions are needed to
improve the health status of the mother-child target group and facilitate
the fertility decline, but also to improve the socio-economic status of
women, change attitudes towards family size, etc.; (iii) Partnership with
the private sector still in its infancy. While the principle of
partnership is accepted both within the Ministry of Public Health (MOPH)
and among the great majority of stakeholders in the health sector,
achievements to date are few; and (iv) Mechanisms to control epidemics and
endemic diseases are still inadequate. Repeated outbreaks of meningitis
and cholera are still frequent occurrences in the country. The
improvements that are needed in the health sector encompass the following
areas: (i) Central Administration. In the past, development partners
tended to overlook the central level in favor of direct interventions in
the field. Steps have been taken by the MOPH, with the assistance of its
partners, to develop at the General Directorate level a "management team"
approach in order to coordinate financial and human resources -- both
domestic and foreign -- to steer reforms, hold annual activity reviews,
and establish ad hoc working groups with clear operational goals; (ii)
Fees for services. Fees for services and cost-recovery for


pharmaceuticals are accepted in principle and are in place in many parts
of the country, but methods for implementing them are haphazard. Progress
in this area will require both greater harmonization of practices and a
better way of dealing with inability to pay and risk-sharing. Community
involvement is very important in this area; (iii) AIDS prevention and
mitigation. The STI/HIV/AIDS multi-sectoral approach has been successful
in increasing HIV/AIDS knowledge. Today, most Chadians know about
HIV/AIDS and the majority know how HIV is transmitted. Many sectors and
communities are involved in HIV/AIDS prevention and mitigation activities.
However, this approach needs to be reinforced and be more focused in
order to stop the progression of the epidemic; and (iv) Coordination among
development partners is not strong enough. While there has been a notable
improvement in recent years in terms of coordination, particularly through
the use of sectoral round tables, the MOPH and the Ministry of Economic
Promotion and Development (MEPD) needs to develop more periodic and
systematic mechanisms (annual coordination reviews) that will involve to a
greater degree all of the various private sector stakeholders and
partners.The MOPH has started to address the weaknesses as urgent
priorities, because they will in effect block progress in the sector, be
a constant source of frustration for development efforts, and jeopardize
future efforts on all fronts (i.e., population, reproductive health, and
HIV/AIDS). As for the areas where improvement is needed, the MOPH, which
had taken steps for action and reform in certain areas, is starting a
sustained action to develop the health sector and put these improvements
on a sustainable footing with the assistance of its partners, including
IDA (see section of the PAD on Project Rationale, D.1.b.).b. The HIV/AIDS
Situation in ChadSince 1986, when the first case of AIDS was reported, the
epidemic has been spreading rapidly in Chad. According to the last
figures (1st quarter of 2000), the cumulated number of AIDS cases in Chad
was 11,681 and there are currently about 200,000 sero-positive persons.
At the national level, although the latest UNAIDS figures set
sero-prevalence at 2.7% on the basis of the 9 functional sentinel sites,
actual sero-prevalence is estimated at about 5% of adult population and
even at more than 10% in some areas (e.g. Logones and Tandjil6
prefectures). Heterosexual transmission is the predominant mode of
transmission and some socio-cultural characteristics of Chad (migration to
other countries where the prevalence rate is higher, frequent conflicts,
extreme poverty of some segments of the population, the status of women,
activities linked to the oil field development in the South) explain the
existence of high risks groups such as: women, youth, commercial sex
workers, and migrants within the country and to neighboring countries.
Quantified projections will be estimated during the appraisal mission and
included in the PAD during the appraisal mission. They will be calculated
using the last version of WHO/UNAIDS EPIMODEL. Government AIDS Control
StrategyChad's response to AIDS has been rapid and determined even at a
time HIV prevalence was very low. As early as 1988, the Government
established a National AIDS Control Commission (NACC), a multi-sectoral
body of six ministers presided by the Prime Minister, an AIDS Control
Technical Committee (ACTC) including the Directeurs G6n6raux of the key
ministries to be involved in the fight against HIV/AIDS and a National
AIDS Control Program (NACP). All strategies and interventions were the
responsibility of a Technical Committee for AIDS Control (TCAC), chaired
by the Director General of Health. Day-to day implementation and
follow-up of AIDS activities were entrusted to the National AIDS Control
Program (NACP), a Unit of the MOPH, which reports directly to the
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Directeur G6n6ral of Health. Surveillance and IEC activities started in
1998 with the launching of a short-term plan for 1988-1989. This was
followed by the first Mid-term Plan (MTP) 1990-1994 for AIDS Control.In
1994, it was recognized that HIV/AIDS had ramifications beyond the health
sector. This became apparent during the preparation of the second MTP
(1995-1999). The Population and AIDS Control Project (PACP - Cr. 2692
CD), which was being prepared at that time, incorporated in its design, in
agreement with the MTP2, a multi-sectoral approach also involving the
civil society. In addition, the project was placed under the Ministry of
Planning (now the MEPD), with the MOPH as the technical ministry, in
charge of coordinating the HIV/AIDS health-related activities. From that
time on, Chad's response to HIV/AIDS has been characterized by a broad
partnership involving the Government, NGOs, religious groups, civil
society organizations (CSOs), communities, people living with HIV/AIDS
(PLWHAs), local and international donors. The main axes of the fight were
preventive actions including STI treatment. With the assistance of the
first IDA-financed project, Chad strengthened the existing Government
entities responsible for implementing the MTP2. In this context, it
established a social funds to finance HIV/AIDS prevention and population
activities to be carried out at the community level by local NGOs, as well
as a condom social marketing program. After the project mid-term review,
the project designed, established, and financed a micro-credit component
for women and women's associations.The project also assisted Chad in
developing, on the basis of the analyses of the situation and of the
response to HIV/AIDS, the National AIDS Control Strategic Plan in 1999
which was endorsed by the donor community at the meeting on HIV/AIDS which
followed the Sectoral Meeting on health (Geneva IV Round Table). This
strategic plan, which is presently being implemented, builds upon the
previous AIDS programs and places the HIV/AIDS in the broader context of
social and economic development. This plan is based on a decentralized
approach and an active involvement of the civil society and calls for a
greater emphasis on: (i) behavior change; (ii) decentralization of the
various interventions; (iii) community involvement; (iv) promotion of
voluntary testing and counseling; (v) blood safety; (vi) integration of
care in the health system; and (vii) prevention of mother-to-child
transmission. In addition, the plan addressed the issue of care which had
been mostly overlooked in previous plans. Prefectoral Health Councils
(Conseils de sant6 pr6fectoraux) have developed HIV/AIDS prevention plans
which they are starting to implement. The health-related aspects are
included in the IDA-financed Health Sector Support project which was
approved by the Board in April 2000 (see section D.1.b. of the PAD for
details on HIV/AIDS activities included in the Health Sector Support
Project.c. Population IssuesIn 1993, the average annual demographic growth
was 2.5%, leading to a doubling time of the population in less than 28
years. The country's birth rate, which had remained the same since 1965,
was 45 per thousand, while the crude death rate had decreased from 28 to
19 during the same period causing an acceleration of the population growth
rate which is consistent with the first stage of the demographic
transition. The estimated total fertility rate at 5.7 live births per
women was at the time one of the lowest in the region where the average
was 6.6.In 1993, Chad recognized the problem of rapid population growth
and established an inter-ministerial Committee to prepare, under the
chairmanship of the Ministry of Plan and Cooperation, a National
Population Policy (NPP) which was adopted in 1994. The major goal of the
NPP was to improve the well being of the population through specific
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strategic objectives that focused mainly on maternal and child health
activities; the promotion of childhood and youth; the promotion of women;
and Information, Education and Communication (IEC) programs. Despite
considerable progress, main challenges remain, namely: (a) to prioritize
the numerous actions proposed in the NPP; (b) to focus on the key elements
that will have an impact on population outcomes; and (c) to implement the
priority interventions nationwide.Two major government institutions had,
and still have, responsibility for population activities. The MOPH is
responsible for family planning policy-making and programming and for
coordinating, supervising and evaluating all family planning activities.
The Ministry of Economic Promotion and Development, which created in 1993
the Division of Population, is responsible to coordinate the
implementation of the NPP. The Direction of Statistics and Demographic
Studies, also located in the Ministry of Plan and Cooperation, had the
primary responsibility for demographic research and analysis. A High
Committee for Population (Haut Comit6 de la Population), chaired by the
President of the Republic and including all the Ministers involved in the
implementation of the Population Policy and programs, was created at that
time. The challenges to implement the National Population Policies remain
important. First, the delivery of reproductive health (RH) services
remains weak and so is the dissemination of proper information on RH and
population issues. Second, in addition to severe supply constraints,
there is a low demand for RH services. Third, the institutional
capacities for management, planning, and coordination of population
activities are still weak, especially at the decentralized level, with the
emphasis usually put on inputs and processes rather than outcomes.The
first Population and AIDS Control Project has helped to begin address
these issues. However, although the project has been implemented
satisfactorily, progress have been slow and the expected demographic
increase or "population upsurge" has become a reality. In 2000, it is
estimated that the average annual demographic growth is over 3%. In
addition, the estimated total fertility rate has increased to 6.6 live
births per woman (as evidenced in the 1996-97 Demographic and Health
Survey). Such an increase in fertility is to be expected in situations
like in Chad where the traditional factors (e.g., breastfeeding and
postpartum abstinence) no longer fully inhibit fertility whereas modern
contraception and birth spacing are not yet fully in place. Nevertheless,
the trend feared at the time the project was prepared has confirmed itself
and demographic growth, which was already a problem in 1994, has further
accelerated and is more acute. Given the poor economic and social
indicators of the country, it is therefore important to continue and
expand the efforts to lower the total fertility rate, to get over the
temporary fertility peak and accelerate the demographic transition.
Government Population strategyThe NPP, adopted in 1994, seeks to improve
the overall well-being of the population of Chad and has four main
strategic objectives: (i) Improving Maternal and Child Health by reducing
infant mortality levels; (ii) Promotion of Childhood and Youth; (iii)
Promotion of Women; and (iv) Information, Education and Communication
(IEC).The Government of Chad had made important efforts toward the
implementation of its NPP. The most important successes so far have been:
the collection and analysis of demographic and health data (Chad has
conducted in 1996-97 its first Demographic and Health Survey (DHS) ever);
the more open discussion of population and RH issues; massive efforts in
the areas of IEC and sensitization, particularly among parliamentarians
and political and religious leaders; and a modest expansion of
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reproductive health services. The Government of Chad has also launched a
condom social marketing program targeted at specific groups (e.g., men,
teenagers, and single women) and has also approved in 1992 the creation of
the Association Tchadienne de Bien-Etre Familial (ASTBEF), an affiliate of
the International Planned Parenthood Federation (IPPF). However, the
objectives and strategies of the NPP are very ambitious and far from being
met. Their effective implementation will require two major challenges
being met: (a) prioritization of numerous actions proposed in the NPP; and
(b) focusing on the key elements that will impact on reproductive behavior
changes and population outcomes. It will also be necessary to implement
priority interventions nationwide to obtain measurable impacts.
2. Objectives
The project will support the goals of the National Strategic AIDS
Prevention Plan which was endorsed by the donors at the HIV/AIDS Meeting
held at the time of the Sectoral Consultation on Health (Geneva Round
Table IV). In addition, the project will assist the Government in further
implementing its NPP adopted in 1994. The development objective of the
project are to contribute to changing the behavior of the Chadian
populations so that they will adopt behaviors which will reduce the risk:
(i) to be infected, or to infect others, with the HIV; and (ii) to have
too closely spaced and/or unwanted pregnancies. The project specific
objectives are : (i) scaling up the HIV/AIDS and population multi-sectoral
and decentralized activities presently carried out by the Government, the
civil society and the private sector and expanding the local response to
the HIV/AIDS epidemic; (ii) designing and implementing specific and
targeted IEC/behavior change communication BCC) interventions aimed at
changing behavior; (iii) increasing HIV voluntary testing and counseling
activities in particular for priority vulnerable groups; (iv) reducing the
vulnerability factors, the transmission co-factors and the socio-economic
impact of the HIV/AIDS epidemic and of high fertility, in particular by
supporting income generating activities, women's education, and setting up
mechanisms for caring for HIV-infected people and PLWHAs; and (v)
providing the means to comply with new behavior, in particular increasing
the availability (at the lowest costs possible) and use of condoms and
modern contraceptives.
3. Rationale for Bank's Involvement
IDA has been directly supporting the effort to fight the HIV/AIDS epidemic
in Chad through the current Population and AIDS Control Project (Cr. 2692
CD), and through other operations. Progress has been made in increasing
awareness, increasing prevention and treatment for STIs. As a result,
awareness of AIDS and knowledge of its means of transmission is now very
high. Condom use has increased. This is a cause of satisfaction, but it
should by no means be a reason for complacency: HIV prevalence, at more
than 5 percent and rising, is already an horrendous burden of disease.
The program has to be scaled up by mainstreaming program activities
through line ministries and other non-health government agencies at
national, regional and local levels, and by making better use of the
capacity of community-based and civil society organizations. It is clear
that the Government alone cannot possibly provide for such effort and that
additional of resources and technical assistance from the international
community are required to reinforce and expand current activities. IDA is
in a unique strategic position to support the GoC HIV/AIDS program
including the mobilization of external resources. This project allows IDA
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to provide continued support to the implementation of Chad HIV/AIDS
strategy following up on the PACP, which will be closed on December 31,
2001. The project will also bring to Chad knowledge and lessons learned
from international experiences in HIV/AIDS programs.The continued support
of IDA in the area of population and development issues is important.
First, efforts to slow the rapid rate of population growth are very much
in line with the overall objective of poverty reduction spelled out in the
Country Assistance Strategy (CAS). Second, this new project will help
continue and expand previous efforts funded by IDA, namely those
undertaken under the PACP. Third, IDA plays an important role as a
catalyst in the population sector and IDA's involvement will permit to
leverage much needed resources from other partners to development.
4. Description
This operation will build on the lessons learned in the PACP, financed by
IDA which has been extended to December 31, 2001, in order to ensure
continuity and smooth transition between the two projects. This new
operation would involve HIV/AIDS-related activities with a Population
Component capitalizing on the progresses achieved in the first project and
would further operationalize the NPP. The country's high fertility rate
and accelerating demographic growth is the rationale behind this
component. As underlined in the World Bank publication Intensifying
action against HIV/AIDS in Africa, "high fertility and rapid population
growth impede efforts to reduce poverty", and thereby contribute to the
spread of HIV/AIDS. The HIV/AIDS components of the project will be
complementary to the health-related HIV/AIDS activities of the
IDA-financed Health Sector Support Project and where of other donor
activities in the areas of population and HIV/AIDS prevention and care.
Finally, the proposed project will support multi-sectoral activities and
also provide resources to the civil society. The project will have four
components: Strengthening of the capacities of the Key Ministries. This
component is designed to reinforce the capacity of the Government of Chad,
the private sector, and the civil society at the central, regional and
prefectoral levels, to develop and implement HIV/AIDS prevention, care,
and support strategies adapted to the local conditions. Strengthening of
the two sub-components of the FOSAP: Grants and Micro-credits.     In the
context of the PACP, a social fund -- the FOSAP -- was established to
finance, through grants to local NGOs, HIV/AIDS prevention and population
activities, and through micro-credits, income generating activities for
women and women's associations. These activities are supervised by NGOs
with proven capacities. The objective of this component would be to
strengthen the assistance provided by FOSAP to the civil society
intervening in the areas of HIV/AIDS and population, and in some cases, to
government entities, so that all priority vulnerable groups are covered.
The following activities will be supported and encouraged: (i) promotion
and distribution of condoms; (ii) targeted IEC for behavior change in the
areas of population and HIV/AIDS; (iii) intervention aiming at increasing
the autonomy of women, such as income generating activities; (iv)
psycho-medico-social support for people living with HIV/AIDS; (v) economic
support for HIV/AIDS infected and affected persons; (vi) comprehensive
support and care for HIV/AIDS orphans; (vii) promotion of voluntary HIV
counseling and testing; (viii) mitigation of HIV mother to child
transmission for pregnant women; and (ix) promotion and distribution of
modern methods of contraception. Support to the existing program of
Social Marketing (MASOCOT). The objective of this sub-component will be
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to provide support to MASOCOT for: (i) marketing of condoms, (ii)
marketing activities of rehydration salts and mainly to expand the program
to new products that would have an impact on child mortality and fertility
(i.e., oral contraceptives, impregnated bed nets).Support to the
implementation of the NPP. This component will provide support to the
Division of Population in order to: (a) help prioritize the numerous
actions proposed in the NPP; and (b) focus on the key elements that will
have an impact on reproductive behavior and population growth outcomes, so
that it will be priority interventions that are implemented nationwide to
obtain measurable impacts.
5. Financing
Total ( US$m)
Total Project Cost 31.37
6. Implementation
Implementation period: 5 years, from October 2001 to September
2006Executing agencies: The MEPD, through its Direction G6n6rale will be
responsible for the planning, management, and coordination of project
activities through a Steering Committee to be presided by the Directeur
G6n6ral of the MEPD. The Assistant President will be the Directeur
G6n6ral of the MOPH (see the role of the Committee in section on Project
Management and Coordination the role of the Committee). The
implementation arrangements for the key-ministries will be similar to
those used for the ongoing PACP. Each participating line ministry and
government agency will manage its own HIV/AIDS subproject through its own
HIV/AIDS unit (which in most instances already exists), reporting
regularly to the NACP and PPLS/FOSAP team on agreed input and output
performance indicators. For the FOSAP, the Coordination Bureau will be
independent from the PCT. It will manage community-led and civil society
organization led sub-projects and micro-credit programs. The Management
Committee of the grant sub-component and the Credit Committee for the
micro-credit will include representative of the GoC and of the civil
society (e.g., associations of PLWHA and NGOs). These committees will
inter alia have the responsibility to select, on the basis of priorities
established annually and quality criteria specified, among the eligible
sub-projects/programs submitted to them. The Bureau of the FOSAP II will
be under the supervision of the PCT which will ensure that activities are
carried out in agreement with the annual priorities and budget. The FOSAP
will be audited bi-annually and financial expost reviews and evaluations
of a sample of subprojects will be conducted by the internal auditors and
IDA supervision missions. In addition, the FOSAP will finance external
audits of all project of more than 15 million Francs CFA and its internal
auditor will ensure the respect of procedures at all the levels. The
National AIDS Control Program (NACP) will coordinate the IEC HIV/AIDS
Project activities and review monitoring and evaluation reports. In
addition, it will be a member of the FOSAP Management and Credit
Committees. The Division of Population will have the responsibility to
coordinate all activities related to the implementation of the NPP.
Finally, marketing social activities will be carried out by MASOCOT, which
will become an NGO (draft statutes have been submitted to IDA for
review).Project management and coordination: The project activities will
be managed by a "Steering Committee" chaired by the Directeur G6ndral of
the MEPD and coordinated by a small Project Coordination Team (PCT),
patterned after the team coordinating the on-going PACP project, which
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will serve as a Secretariat to the Steering Committee. The MEPD Steering
Committee will include representatives of the General Directions of the
Key-Ministries, of NGOs, of agences d'encadrement (AE), and of the PNAC.
The PCT will act as a Secretariat to this Committee, which will be
responsible for planning, managing and monitoring project activities and
for coordinating them with activities financed by other donors. The
Steering Committee will hold regular meetings (prepared with the
assistance of the PCT) to which development partners involved in the
sectors may be invited, in accordance with procedures to be defined. The
Steering Committee will also have the authority to make recommendations
for improving project implementation. Lastly, it will be responsible for
organizing consultations with the different partners, in particular
through bi-annual activity reviews. The day-to-day coordination of project
activities will be done by the PCT as it is done with the present PCT.
This PCT has fulfilled its mandate satisfactorily and has acquired
valuable experience in IDA-financed activity management, coordination
implementing agencies and the various entities involved in the project at
the prefectoral level. The role of the PCT will be to prepare the annual
reviews, draft and submit to IDA the bi-annual progress reports, procure
goods and services for the project, prepare and forward to IDA
disbursement requests and assist the committee to supervise project
activities.The PPLS II Coordination Team will modify its operations to
build on lessons learned during the previous project during which it
discharged its responsibilities satisfactorily and acquired good
experience in: (i) managing IDA-financed activities; and (ii) coordinating
the work of implementing agencies and key ministries. The Program
Implementation Manual (PIM) will delineate processes and responsibilities
for general management, procurement activities, and financial management
and control, including Terms of Reference for internal and external audits
acceptable to the Bank, and it will further elaborate on reporting
requirements. The PIM will reflect the lessons learned from previous
experiences in project implementation. A project launch workshop will be
held within two month of Credit signing. All parties managing the
implementation of the different components of the project will participate
in the workshop. The Manuals of Procedures of the FOSAP, one for each of
the two sub-components, (including two parts, one on administrative
procedures and the other on accounting and financial procedures) is being
revised to take into account the lessons learned and the new features of
each sub-component.Procurement procedures: Procurement for all
IDA-financed activities will be carried out in accordance with the Bank's
Guidelines: Procurement under IBRD Loans and IDA Credits (January 1995 and
revised in January and August 1996, September 1997, and January 1999), in
particular Section 3.15, Community Participation in Procurement.
Consulting services by firms, organizations, or individuals financed by
IDA will be contracted in accordance with the Bank's Guidelines: Selection
and Employment of Consultants by World Bank Borrowers (January 1997,
revised in September 1997 and January 1999). With respect to the FOSAP,
the Bank's simplified Procurement and Disbursement Procedures for
Community-Based Investments will be used. Pharmaceutical and medical
products may be procured directly from the Central Pharmaceutical
Procurement Agency (CPPA), which was established in the context of the
IDA-financed Health and Safe Motherhood Project (see Appendix to Annex 6
for details on the CPPA and its procurement procedures) because: (i) it is
the only institution in Chad which provide generic essential drugs and
medical products; and (ii) its procurement procedures are found acceptable
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and efficient by IDA and the other donors intervening in the health
sector.A Procurement Plan for the Project will be prepared during project
preparation. It will be updated every quarter and reviewed by IDA.
Procurement performance (including sub-project procurement activities)
will be assessed on an annual basis. In addition to the formal annual
audits, ad-hoc procurement reviews will be conducted periodically.
Further details of procurement arrangements will be provided in Annex 6 of
the Project Appraisal Document (PAD).Accounting, financial reporting and
auditing arrangements: Accounting, financial reporting and auditing
arrangements have been satisfactory under the existing project (according
to IDA Financial Management Specialist mission) and will continue under
the proposed project. The Accountant's responsibility will be to oversee
the accounting and the financial management system and staff and to
transfer funds, with clearance by the PCT Coordinator, to suppliers and
implementing agencies responsible for implementing the project
components. Given that the project will be using Bank statement of
expenses (SOE) procedures, the Bank Resident Mission will verify SOE
reliability.Monitoring and Evaluation: The overall project will be
monitored against process and output indicators on a bi-annual basis for
the first 18 months of the project and on a quarterly basis thereafter, in
agreement with the requirements for Project Management Report (PMR)
production. Outcome indicators defined for the development objective and
for each of the components (on Key Indicators, see Section A2 above and
Annex 1 of the PAD) will be monitored on a yearly basis. During project
preparation, a monitoring and evaluation plan will be prepared to finalize
the project indicators and ensure that mechanisms are in place to collect
the data necessary to monitor and evaluate the project performance and
impact. In addition, a DHS, that is scheduled to be carried out in 2002,
with financing from the HSSP, will provide demographic and child and
reproductive health and HIV/AIDS baseline data. The Mid-Term Review, to
be carried out in the second half of 2003, will be preceded by an
evaluation of project activities which will include a beneficiary
assessment. During the review, the objectives of the project will be
examined and adjustments to the implementation plan may be made. A final
beneficiary assessment will be carried out as part of the final evaluation
of the project.
7. Sustainability
The project is built upon strong government ownership and supports the
on-going HIV/AIDS national program and NPP. The project will scale up
existing programs by mainstreaming activities into several Government
sector and civil society, and by tapping into community organizations
resources. The emphasis on institutional capacity building at the
national and local level would enhance the sustainability of the project
and its local sub-projects.An analysis of the sustainability and of the
equity of the proposed strategies will be included in the economic
analysis which is under preparation and will be completed during
appraisal.
8. Lessons learned from past operations in the country/sector
Lessons learned from both national and global experiences with HIV/AIDS
epidemic and population have been incorporated in project design, as
follows: a) Postponing the age of first sexual intercourse and reducing
the number of sexual partners are key for successful HIV control as well
as for reducing fertility. The project will focus not only on the social
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marketing of condoms, but also on delaying the age of first intercourse
and in reducing multiple sexual partnership; b) Prevention of mother to
child ("vertical") HIV transmission and chemo-prophylaxis of opportunistic
infections may reduce the incidence of the disease and delay the
progression from HIV infection to clinical AIDS. The project will support
such interventions, but will carry out the careful evaluation of each type
of intervention to determine their effectiveness in the Chadian
environment;c) Community participation in planning and the inclusion of
non-government sectors such as community-led organizations and civil
society organizations (i.e., religious organizations, trade unions, women
and student associations) and private businesses in project
implementation, will increase coverage of HIV/AIDS-related activities and
widen the scope of services to be provided. In Chad, this approach has
been used successfully and more than 80 sub-projects, financed by the
project, have been implemented by communities throughout the country. The
second project will build on the achievements of the first project and
finance community-led and civil society organization-led HIV/AIDS
prevention and mitigation sub-projects using mechanisms similar to those
developed in the PACP. d) Mainstreaming HIV/AIDS control activities into
different line ministries and empowering districts and communities for
effective local response in the fight against the epidemic will also
increase coverage. Chad has demonstrated that it could carry out such a
program, using Projets dynamisateurs, contracting out sub-project
development and supervision. In addition, the project preparation team
has organized a multi-sector consensus building workshop in January 2001
to reach an agreement on overall project objectives and design and
regional workshops. The project will have a component to support HIV/AIDS
prevention and mitigation sub-projects in different line ministries, as
well as prefecture-based sub-projects. Finally, the project will invest
substantial resources in building the necessary capacity in non-health
sector government agencies;e) Adequate HIV/AIDS surveillance systems must
be strengthened for effective monitoring and evaluation of the impact of
HIV/AIDS interventions. Although it is conscious of this fact, the
project does not include support to the surveillance system, because it is
already included the HSSP which supports the strengthening of the HIV/AIDS
surveillance system;f) Prioritizing and implementing population, RH, and
HIV/AIDS activities is crucial to ensure that proposed interventions have
an impact and help change population and HIV/AIDS outcomes. The project
will help the Division of Population and its partners to focus on key
population and HIV/AIDS activities with an emphasis on building of
managerial capacity as well as a built-in system of performance
indicators; andg) Changing RH and intimate personal behavior is always
difficult, although it is key to the ultimate success of population and
HIV/AIDS interventions. The project will promote innovative approaches to
overcome traditional barriers, such as, peer counseling, itinerant
"information and education campaign" etc. e.g. "Youth Caravan" -- a video
van with facilitators who spend a whole day in a village and shows videos
on HIV/AIDS and RH. These shows are followed by debates and condom
distribution. This inter-personal approach is successful in informing and
educating youth and their parents. It is hoped that, as condoms become
available, behavior change will also take place. The on-going project is
not presently able to measure behavior change impact. This variable will
be monitored in the project being prepared; andh) The multi-sectoral
approach taken by the MEPD for both HIV/AIDS prevention and mitigation and
population policy implementation calls for close cooperation among
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development partners. Throughout the preparation of this project, joint
and complementary actions have been discussed with all partners -- AfDB,
8th EDF, WHO, UNDP, UNICEF, UNFPA, the French cooperation, NGOs,
community-based organizations and regional authorities-- to ensure that
there will be no duplication and that all priorities are covered. This
cooperation will result : (i) in better coordination among partners under
the aegis of the General Directorate of MEPD; and (ii), in joint support
for a more comprehensive government program.
9. Program of Targeted Intervention (PTI)   N
10. Environment Aspects (including any public consultation)
Issues        The long term impact on fertility reduction and the
possible slowing down in the rate of population growth would have some
positive implications for the environment. It is expected that the other
project activities would not generate any adverse environmental effects,
although possible environmental risk might include the inappropriate
disposal of condoms. In order to minimize this risk, information (which
is understandable even by illiterate persons) is given at the time of sale
and of distribution, a practice which will be continued. If the social
marketing program sells impregnated bed nets, particular attention will be
given to the handling and disposal of the left over chemicals used. If
this option is selected, World Health Organization (WHO) protocols will be
used and all involved in the re-impregnation of the bed nets will be
trained to use WHO recommended practices. In addition, the project
implementation manual (PIM) will include guidelines to ensure that
environmental considerations are taken into account in the selection and
design of subproject activities.
11. Contact Point:
Task Manager
Michele L. Lioy
The World Bank
1818 H Street, NW
Washington D.C. 20433
Telephone: 202-473-4810
Fax: 202-473-8216
12. For information on other project related documents contact:
The InfoShop
The World Bank
1818 H Street, NW
Washington, D.C. 20433
Telephone: (202) 458-5454
Fax:       (202)  522-1500
Web: http:// www.worldbank.org/infoshop
Note: This is information on an evolving project. Certain components may
not be necessarily included in the final project.
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