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5. Ratings.

5.1 Outcome. The outcome of the Population and AIDS Control Project is rated moderately satisfactory overall, based on an unsatisfactory outcome of the population objective and a satisfactory outcome of the HIV/AIDS objective (see Table 1). The final rating was derived from a heavier weighting of the outcome of the HIV/AIDS objective, commensurate with its high relevance and its share of the total project cost (about two-thirds).

Population Outcome

5.2 Based on assessments of its relevance, efficacy and efficiency, the overall rating of the outcome of the population objective is unsatisfactory. The fundamental objectives of reducing fertility and reducing population growth are not articulated in the Government's PRSP (October 2003), nor does it mention family planning for birth spacing and family well-being. The document's treatment of population is to note that demographic factors (including population growth) call for strong economic growth to ensure sufficient jobs and access to services for a growing population, and a redistribution of the fruits of economic growth to those most in need. Neither are the control of population growth or the reduction of fertility specified among the Bank's CAS objectives (November 2003). Under the umbrella of the MDGs, however, a number of determinants of fertility are highlighted in the CAS, including: reduction in the poverty and vulnerability of women, increased girls' enrollment in school, and reductions in maternal and child mortality. Relevance of the population objective is thus rated as modest.

5.3 Efficacy in achieving the objective of raising the modern contraceptive prevalence rate to 10 percent by the year 2000 is negligible. Population-related behavior change is progressing slowly, at best, with only very modest increases in contraceptive prevalence rates documented between 1996 and 2000. Efficiency of efforts to reach the population objectives is modest. Because of staffing shortages, a shortfall in UNFPA financing, and upheaval caused by a reorganization of CERPOD, (62) the Department of Population was late in producing major research and studies, although the quality of these studies is high. Absence of effective coordination of the multiplicity of IEC initiatives and IEC units across have caused efforts to be fragmented and uncoordinated. The institutional framework for population policy approval and oversight was highly inefficient. At the decentralized level initial efficiency of the newly established CRPRH was low, but improved over time.

HIV/AIDS Outcome

5.4 The overall outcome of the HIV/AIDS objective is satisfactory, based on the following ratings of its relevance, efficacy and efficiency. The relevance of the

HIV/AIDS objective is high. Both the PRSP and CAS are articulated around the MDGs, which specify the goal of controlling the spread of HIV and a three-year outcome indicator of reductions in high-risk behavior for HIV/AIDS prevention. The project's efficacy in achieving the HIV/AIDS objective is substantial. Overall, good progress has been made in increasing levels of, and decreasing inequities in, awareness and knowledge of the population about HIV/AIDS. The social marketing program has significantly increased the availability of condoms throughout Chad at an affordable price. Taboos associated with the purchase and use of condoms have decreased considerably. Available data indicate modest, but positive, changes in behavior, a trend which is likely to continue, and which contributes directly to reductions in infection. There is inadequate evidence available on trends in the number of new infections (incidence) in the general population and among high-risk groups.

5.5 The efficiency in achieving HIV/ADDS objectives is judged to be substantial overall. More than half the project resources were ultimately channeled through the nongovernmental sector to two autonomous agencies, which proved to be efficient in their operations. First, FOSAP (responsible for the social fund) disbursed 133 percent of funds initially allocated for civil society and decentralized subprojects. The microfinance subcomponent achieved a reimbursement rate that exceeded 90 percent, in spite of the fact that it relied on the few microfinance organizations that existed in Chad, whose capacity was weak. Challenges remain to improve the coordination of subprojects so as to minimize duplication or gaps in essential interventions. Second, AMASOT, in charge of the social marketing component, was efficient in its organization and its operations, especially after the initial technical assistance was replaced at the mid-term by new technical assistance that was more geared to the transfer of skills.

5.6 The PNLS has not been fully efficient in leading and coordinating MoPH's response to the HIV/AIDS epidemic. By design, the PCT in the MoPC carried out the role of inter-sectoral coordination of HIV/AIDS actors and activities. The PCT was highly efficient in managing and overseeing project implementation and was proactive in communicating with the multiplicity of actors and beneficiaries, both through frequent field visits (63) and through regular (monthly) meetings with key actors on each of the four components.

5.7 Institutional Development. The project's support to the development of institutions for population and HIV/AIDS is substantial. The establishment of a social fund has (a) significantly strengthened incentives of a range of public and nongovernmental stakeholders to become involved in population and AIDS; (b) supported the decentralization of population and HIV/AIDS activities; (c) incited a new dynamic of inter-sectoral and public-private partnerships in the planning and implementation of activities, especially at the local level; and (d) fostered the strengthening and expansion of civil society organizations. FOSAP is a well-established agency, with substantial reach throughout the country made possible by its contractual arrangements with field-based, intermediary NGOs. It evolved from a temporary agency set up under the auspices of the PCT into a fully autonomous agency with a permanent legal status. Likewise, the social marketing entity set up under the project evolved from a temporary project entity (MASACOT) into a fully autonomous agency (AMASOT) with a permanent legal status. AMASOT's performance is strong, with growing sales in condoms and oral rehydration packets and an expanding portfolio (64) and it is staffed with capable staff both in the areas of social research and marketing/sales. The creation and successful operation of these two legally autonomous entities has reformed the way population and HIV/AIDS activities are carried out. A significant portion of the population and HIV/AIDS agenda is in essence subcontracted out to the nongovernmental sector.

5.8 Public sector institution building for population has been modest. The numbers and qualifications of staff in the Directorate of Population fall short of those needed to fulfill its mandate, particularly in the disciplines of demography and sociology. Regional-level capacity in the planning and implementation of population activities was strengthened through the technical and financial support of the inter-sectoral CRPRH, which conceived and oversaw local-level population activities.

5.9 Some HIV/AIDS institutional development has also been achieved in the public sector, although considerably more is needed. By design PNLS was relieved of inter-sectoral coordination responsibilities under the project (65) to enable it to focus its limited capacity on mobilizing and guiding MoPH in fulfilling its critical mandate in the fight against HIV/AIDS. Progress was made in strengthening capacity for epidemiological surveillance and in the provision of critical inputs for key HIV/AIDS and STD services delivered through the public health system. In addition, regional level capacity for the planning and implementation of HIV/AIDS activities was developed through the provision of technical and financial assistance channeled through inter-sectoral Regional Health Councils in support of local level HIV/AIDS initiatives. These Councils existed prior to the project, but informants have reported that they were not functional until they benefited from project support.

5.10 Sustainability. The sustainability of project efforts is likely. Both FOSAP and AMASOT have permanent legal status that provide them with autonomy in their functioning, an independent and competitively recruited staff of professionals and viable mechanisms for public-private oversight and control. Furthermore, their strong and improving performances are attracting the financing of other partners in development wishing to contribute to the fight against HIV/AIDS. Revenues from the sale of commodities are used to finance the operational costs of AMASOT. The strong demand for the services of both entities underpin sustainability from a social perspective. There is also evidence that the strengthening and involvement of civil society has achieved momentum at the local level that will last beyond any one investment. Empowerment and self-reliance was observed in the input and demeanor of local associations, some of which were formed and functioning without direct (continued) project support. Civil society is also carrying out an advocacy role from the local level (e.g., prostitutes, PLWHA) to the national level (e.g., national-level NGOs of women, ministers, parliamentarians, retired civil servants).

5.11 The sustainability of efforts to establish, disseminate and effectively use demographic and socio-economic data will depend heavily on Government's success in the recruitment of an adequate number of professional staff, continued efforts to generate demand for these products, and the relevance of the population messages.

5.12 Bank Performance. The performance of the Bank is judged to be satisfactory overall: satisfactory during project preparation and highly satisfactory during project implementation.

5.13 During preparation, the Bank helped accelerate the development and official adoption of the population policy as well as the second medium-term plan for AIDS control. A participatory approach to project preparation helped to engender understanding and commitment among a broad range of stakeholders. The Bank also deserves credit for a project design that emphasizes public goods that have often been neglected in other projects. However, for the majority of project indicators baseline data were not established, some project targets (notably the population objective) were not realistic, and others were never quantified.

5.14 During implementation the Bank was persistent, candid, and vigilant in carrying out advocacy at all levels of government about the risks and consequences of the HIV/AIDS epidemic and incited government officials to visit the field to observe the realities of the HIV/AIDS epidemic and population issues. The Bank is credited with contributing to breaking the taboo of HIV/AIDS with frank and open discussions about highly sensitive issues (e.g., condoms, prostitution). The Bank's advocacy about population, especially the promotion of family planning for maternal and child health and family well-being, was met with great discomfort and even resistance on the part of Chadian leaders and authorities; and so a tactical decision was made to focus Bank advocacy where there was more receptivity and opportunity for achieving goals. The frequency, staffing and duration of Bank missions and the continuity of the task team management (66) have enhanced Bank effectiveness during implementation. The Bank was considered by many interviewed to be very client-oriented, with good listening and response skills. A case in point is the task team's success in introducing the microfinance for women subcomponent following the MTR, which was initially resisted by some Bank experts.

5.15 Borrower Performance was satisfactory overall. Its most notable accomplishments during preparation were the preparation and approval of the national population policy and the second medium-term plan for the fight against HIV/AIDS. Failure to deposit the initial counterpart funds as originally agreed led to delays in project effectiveness.

5.16 During implementation the Government's failure to provide counterpart funds in adequate amounts and on time impeded the efficiency and timeliness of project implementation. Furthermore, the failure of the high-level population commission to meet and approve the plan of action and priority investments for population (PAIP) was an important cause of delay in the population component and an indicator of lack of Government commitment. Health-related activities and epidemiological surveillance were implemented, albeit with some difficulty, attributable to very weak capacity of PNLS. Despite difficult country circumstances, and weak Government capacity overall, the other two components were well implemented with very good performances by the implementing agencies, AMASOT and FOSAP. The performance of the PCT was highly satisfactory with regard to management, coordination, and oversight of project implementation, good quality and regular communications with the key actors and implementers of each component, and fulfillment of all fiduciary and reporting requirements of the Bank. Synergies established with the project management of the ongoing health operation permitted good coordination and complementarity of the two operations.
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Publication:Chad - Population and AIDS Control Project
Date:Mar 7, 2005
Previous Article:4. Outputs and outcomes by objective.
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