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1. Background and context.

1.1 This is the sixth of a series of PPARs that are being undertaken on the "first generation" of completed Bank-financed HIV/AIDS projects, as background for a larger OED evaluation of the development effectiveness of the World Bank's AIDS assistance. (1) In light of that purpose, relatively more material has been presented in this "enhanced" PPAR than is the OED standard. This project was chosen for assessment to provide the main study with lessons and insight on the experience of the Bank's HTV/AIDS assistance to a West African country, prior to the design and approval of the MAP. (2)

1.2 General Context. (3) Chad is one of the poorest countries in the world with an estimated four-fifths of its population of 8.1 million living on less than a dollar a day, and half of the population living on less than 50 cents per day. More than 50 percent of Chadians over the age of 15 are illiterate and only about 30 percent of the population has access to potable water. Epidemic and endemic diseases are prevalent in all regions of the country and there is only one doctor for every 29,000 inhabitants. Infant and child mortality were estimated at 102.6 and 194.3, respectively, and maternal mortality was estimated at 827 per 100,000 live births in 2000. (4) Life expectancy is estimated at 50 years. Gender disparities are acute and highly correlated to poverty in Chad.

1.3 Chad is a vast territory (over 1.2 million square kilometers) with only about 550 kilometers of paved road. Geographic isolation and high transport costs undermine the viability of economic activity and constrain access to basic social services and information. Development efforts are further challenged by the broad cultural diversity of the country with about 200 ethnic groups and 120 distinct languages. Following decades of civil war, a democratization process has taken hold since the mid-1990s, but political stability remains fragile.

1.4 Chad's recent macroeconomic performance has been satisfactory with an increase in the rate of real growth of GDP from an average of 3.1 percent for the period 19972000 to 8.5 percent in 2001, 9.7 percent in 2002 and 11.2 percent in 2003, largely due to investments in the Chad-Cameroon pipeline, completed in early 2003. With full production achieved in 2004, it is estimated that some US$100 million in oil revenues will be generated this year, a portion of which is supposed to be earmarked for expenditures in priority sectors. (5)

1.5 Population. The first population census estimated Chad's population to be about 6.2 million in April 1993 and growing at an annual rate of 2.5 percent. The total fertility rate was estimated at 5.7 live births per women, lower than the average of 6.6 for Sub-Saharan Africa. The population of N'Djamena increased fivefold between 1960 and 1990.

1.6 In 1992 Chad was one of the few Sahelian countries that did not have a population policy, in part because of the large size of the country and low population density. However, deteriorating socioeconomic conditions and analysis of population issues increased Government awareness of population growth as a development issue, and prompted two key actions: (a) the preparation of a national population policy and the creation of institutions for its oversight and management; and (b) the repeal of the 1920 law which prohibited the importation, distribution and use of contraceptives. In 1994, the Government of Chad adopted its Declaration of Population Policy (DPP), which outlined national priorities and strategies in population and family planning (see Box 1).
Box 1.1994 Population Policy Objectives:

A Summary

* Improve coverage and access to basic health and nutrition
services (including reproductive health services) and education

* Decrease annual population growth from 2.5 percent to 2
percent by 2005

* Strengthen understanding of the relationship between population
and development

* Promote women's rights, social status and participation in

* Promote and ensure the rights and well-being of children and

1.7 Receptivity to the notion of controlling family size was very weak in Chad. First, extremely high levels of poverty in Chad prompted couples to have many children as a means of supplementing family income and providing social security in their old age. Second, civil conflict was another deterrent to limiting family size in the face of continued tensions among ethnic groups. Third, infant and child mortality were very high (estimated, respectively, at 132 and 222 per thousand in 1993 (6)), inciting high fertility levels as women tried to compensate for the loss of children. Furthermore, religious leaders have had a very strong influence on Chadian society and many took a position against the use of modern contraception.

1.8 At the time of project preparation the Ministry of Plan and Cooperation (MoPC) was responsible for population policy implementation and oversight, with the Ministry of Public Health (MoPH) having primary responsibility for family planning. Within MoPC a Population Division {Division de la Population) was created to facilitate the coordination of population policy implementation and a Directorate of Statistics and of Economic Studies (7) was responsible for demographic research and analysis. Given the multi-sectoral nature of the population agenda, a high-level council on population (Haut Conseil de la Population et des Ressources Humaines, HCPRH), chaired by the President of the Republic, was set up to define the general orientations of population policy and to adopt recommendations of an inter-ministerial population committee (Comission Nationale pour la Population et les Ressources Humaines, CNPRH), chaired by the Minister of Plan and Cooperation. The mandate of the CNPRH was to prepare policy and coordinate its implementation. The main issues constraining population program efforts in 1994 were (a) poor coverage and quality of family planning information and services (8); (b) limited demand for these services; and (c) weak capacity for the planning and coordination of population activities and for the collection and analysis of social and demographic data through research, studies and surveys (World Bank 1995).

1.9 Health and HIV/AIDS. The leading causes of illness and death in Chad (infectious and parasitic diseases, (9) pregnancy-related conditions, and malnutrition) are all preventable and amenable to the effective delivery of a basic package of health services (including communicable disease control and family planning). Health system performance in the early 1990s suffered from low coverage, poor access, limited and inefficiently allocated resources, lack of qualified health personnel, lack of strategic management capacity and an overly centralized organization. An indicator of the health sector's inadequate performance in Chad is the extremely low child immunization coverage of 3 percent in the early 1990s (World Bank 1992).

1.10 The first cases of AIDS were reported in 1986, with a total accumulation of 2,866 reported cases by 1994 (Figure 1). At the time of project preparation, adult prevalence for HIV (10) was estimated by MoPH at 3 percent with the highest rates in the south and west of the country. (11) Ninety-seven percent of reported AIDS cases were estimated to have been caused by sexual transmission, a result of multiple partners, lack of education and information, and difficult access to condoms. (12) Poverty, conflict, and successive droughts have contributed to this phenomenon by encouraging significant migration and commercial sex.

1.11 In 1988, the Government set up an institutional framework for the fight against HIV/AIDS, (13) and prepared and launched a short-term plan for AIDS control covering the period 198889, followed by the first medium-term plan covering the period 1990-93. Early activities focused on program start-up, capacity building, early surveillance activities, (14) and prevention for the general public, and for prostitutes, youth, and the military. A second medium-term plan, prepared during project preparation, accorded highest priority to prevention (see Box 2), at a cost of about US$9 million (excluding social marketing and social fund).
Box 2. Second Medium-Term Plan for AIDS Control--Strategic
Orientations (1995-1999)

Prevention of:

a. sexual transmission

b. transmission through unsafe blood

c. mother-to-child transmission

Mitigation of:

a. the health impact of sero-positive patients with or without AIDS

b. the social impact of AIDS on patients and their families

c. the impact on public expenditure, especially for the health sector

d. the impoverishing effects of the disease through income-generation

1.12 Despite the institutional and policy framework established for HIV/AIDS by the Government of Chad, there was still widespread denial and stigma within Government and in society at large. Many interviews reveal that HIV/AIDS was not referred to by its name, but instead referred to as "the sickness" or "the syndrome." There was reported to be widespread denial among Government officials at central and decentralized levels of administration, many stating that this was a creation of donors. Religious leaders were also reported to be strongly resistant in the early 1990s to the promotion of condoms and interventions with commercial sex workers, which they considered to be in conflict with religious principles. Strongly influenced by religious and traditional leaders, and lacking basic facts about HIV/AIDS and how to prevent its transmission, Chadian society at large exhibited great discomfort with discussion of the disease itself and with ways and means of controlling it. Societal resistance to early HIV/AIDS control efforts was reported by many of those interviewed, who cited billboards set up in major cities being torn down and destruction of equipment after information and social marketing campaigns.

1.13 Previous Bank Support. The Bank's first support to Chad's health sector was through a US$7 million health component under the Social Development Action Project, approved in June 1991, (15) which sought to improve basic social services in the city of N'Djamena and in the southern region of Tandjile (the only region not covered by donor support). (16) The Bank's engagement in human development in Chad was intensified in 1992 with the preparation and discussion of an in-depth analysis of the population, health and nutrition sectors. (17) This report highlighted the negative consequences of high fertility on the health of mothers and children, on poverty at the household level, and on the socio-economic development prospects of the country at large. (18) With regard to health, the report recommended steps to improve the quality, coverage and cost-effectiveness of health services through decentralization, capacity building and the control of key diseases, highlighting AIDS, in particular. (19)

1.14 This dialogue culminated in the preparation of a proposed Health and Population project, which was ultimately split into two projects: (a) the Health and Safe Motherhood Project, approved in June 1994, the Bank's first freestanding health sector investment; (20) and (b) the Population and AIDS Control project, the subject of this review. The decision to split support into two projects was based on a number of factors. First, the population component was not sufficiently prepared in relation to the rest of the original project concept at the time of its appraisal, (21) and there was incentive both not to delay the health operation and not to compromise on the quality of the population component. Second, it was considered critical to address the spread of HIV/AIDS, which was recognized as a threat to Chad's economic and social development prospects. (22) The rationale for combining population and AIDS efforts under one operation was to exploit synergies of efforts in the provision of family planning and HIV/AIDS services and information for behavior change, and in the social marketing of commodities. Third, a combined health and population project was thought to be too complex for the limited management capacity of MoPH. Given the multi-sectoral approach of population and HIV/AIDS, the management of this project was placed under the auspices of the MoPC.

1.15 Support by Other Donors to population and AIDS in the early 1990s fell short of needs. Population support was provided primarily by UNFPA (US$3.5 million for the population census, policy formulation, and family planning program management) and USAJD (US$8.5 million for maternal and child health and family planning [MCH/FP] service delivery in two regions, and provision of contraceptives). Other support to MCH/FP was provided by donors in the context of basic health services support (23). A major gap in the financing of contraceptives was imminent with the planned withdrawal of US ADD from Chad in 1995. Donors provided about US$4.3 million to support implementation of Chad's first short-term (1988-89) and medium-term (1990-93) HIV/AIDS plans. WHO's Global Programme on AIDS (GPA) was the main source of financial and technical assistance, with support also being provided by UNDP, US AID, France and the European Union (World Bank 1995).
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Publication:Chad - Population and AIDS Control Project
Date:Mar 7, 2005
Previous Article:Summary.
Next Article:2. Objectives and design.

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