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6. Findings and lessons.

6.1 The Bank can be instrumental in stimulating government commitment with regard to population and HIV/AIDS through policy dialogue, advocacy, technical support and lending, but such support is insufficient to consolidate and sustain that commitment. Through policy dialogue and technical assistance provided in the context of project preparation, the Bank supported the development and approval by Government of policy and strategic documents for addressing population issues and for fighting HIV/AIDS. Government's agreement to borrow for HIV/AIDS was in considerable part attributable to the Bank's persistence in highlighting the risks and consequences of not addressing HIV/AIDS during the preparation of the health operation in 1994. The Bank's persistence and candor helped open a national discussion on HIV/AIDS.

6.2 Other factors that are critical to raising and sustaining Government commitment are (i) the relevance of the objective, determined in part by the availability of local evidence and data; and (ii) the degree of mobilization of civil society. The support of HIV/AIDS research, data collection and analysis, studies and the strengthening of a sentinel surveillance system have provided concrete, country-specific (and region-specific) information to sensitize officials on the progression of the epidemic, and its socioeconomic consequences. Over and above these data, the fight against HIV/ArDS became more relevant (especially in the south) as the epidemic progressed and more people observed first-hand and were affected by the disease and its consequences. (67) The objectives of the second medium-term plan (to prevent further infection, to care for those infected and to mitigate the social and economic impact of the disease), thus have immediate and growing relevance. As civil society mobilized itself to undertake its own action, as new local associations of vulnerable and affected groups were formed, and as public-private partnerships were formalized, civil society advocacy has raised pressure for public sector engagement and accountability (associations of PLWHA at the local level, and national NGOs of women ministers and parliamentarians are two cases in point).

6.3 Data was also generated on population size, growth and dynamics in Chad and projections were available as early as 1994, assessing the consequences of rapid population growth on the socio-economic development prospects of the country. While there was general consensus in Chad about the desirability of implementing the population policy components aimed at improving the rights, opportunities, services and well-being of mothers and children, the notion of limiting family size was met with some reticence. High infant and child mortality and poverty have propelled couples to have more children for social security in their old age and for supplemental household income and labor. As opposed to HIV/AIDS, the relevance and immediacy of objectives to reduce the rate of population growth were not nearly as apparent. Even the use of modern contraception for child spacing--which can lower child mortality and improve maternal and child health--has not been fully embraced. As a consequence, civil society advocacy around the objective of increasing the modern contraception rate has not happened.

6.4 Successful achievement of population and HIV/AIDS objectives requires the conviction and commitment of public sector and nongovernmental leaders and decision-makers in all layers of Chadian administration and society. The stimulation and nurturing of national commitment requires continuous and multiple efforts, given population mobility and turnover in leadership and public sector positions.

6.5 Capacity building of public sector institutions will not be successful if efforts are not aligned with the official mandates of these institutions. The institutional framework for the fight against HIV/AIDS had already been established at the project's outset. By government arrete (68) the PNLS was given the responsibility for the coordination and management of HIV/AIDS/STD activities in the country, including the provision of technical oversight and support to national partners in their fight against HIV/AIDS/STDs, and for epidemiological surveillance and other relevant data collection and analysis. However, because the PNLS in effect was so weak, and because the other components of the institutional framework for HIV/AIDS were not considered to be sufficiently functional, (69) the project was set up to give the PCT/MoPC the de facto responsibility for inter-sectoral coordination.

6.6 Because PNLS's mandate was never changed, there was confusion and frustration about its role. Tracking and coordination of financial and technical assistance to the fight against HIV/AIDS, as well as strategic program coordination and oversight, have not been effectively carried out to date. (70) An institutional audit has recently been carried out that has launched a reflection within Government and between Government and its partners about a realignment of responsibilities in line with comparative advantages, on which basis adequate staffing and capacity building can be envisioned.

6.7 By the same token, an institutional framework for the coordination and implementation of population policy had been established before the project, but an institutional assessment was not undertaken to inform the design of the project's capacity building efforts. Efforts to amend this framework during implementation were unsuccessful.

6.8 The channeling of funds to inter-sectoral committees responsible for population and HIV/AIDS at the regional level stimulated decentralized, multi-sectoral action. However, the absence of full-time staff at the regional level to undertake HIV/AIDS program management and coordination has undermined the effectiveness and efficiency of regional level operations.

6.9 Financing and technical support alone will not optimize the individual and collective efforts of the various sectors. The project stimulated and supported the preparation and implementation of HIV/AIDS proposals from seven sector Ministries, and elicited Government co-financing of 20 percent of the costs of these activities. The stimulus was the availability of supplemental funds (both those provided by the project and those provided through budget supplements). A number of ministries did not (fully) include in their proposals key activities for which they have the comparative advantage. For example, the Ministry of Justice supported targeted activities for prisoners, but has an important role to play in defining and defending a legal framework for the fight against HIV/AIDS, including the protection of rights of people living with HIV/AIDS. Another example cited is the potential role of Ministry of Social Affairs and Family to expand its role beyond the care of orphans to encompass ways and means of reducing vulnerabilities. A definition of roles, comparative advantages and target groups might have elicited the most critical responses from respective sector ministries for higher impact results, more fully responsive to national objectives. Currently there is little rigor in the specification and monitoring of accountabilities for results. For the most part HIV/AIDS activities are designed and implemented by HIV/AIDS focal persons or designated units, with little involvement of the rest of the Ministry; and inter-sectoral coordination has not fully exploited potential synergies across sectoral responses.

6.10 Absence of a strategy on communications for behavior change and the lack of clarity of roles and responsibilities across the multiple institutions that carry out IEC, have undermined the quality and effectiveness of public sector and nongovernmental action. Virtually all sector ministries and non-public partners design their own prevention messages and campaigns. There is no one entity responsible for coordination and oversight. Ministry of Communication has a full-time person responsible for HIV/AIDS activities (training of journalists and radio and television media campaigns), the IEC unit within PNLS has developed some IEC material and carries out an ongoing HIV/AIDS campaign carried out by and for youth, but does not have the capacity for oversight and coordination of all communications efforts for prevention. Some sector ministries have an IEC unit. The Population IEC unit, responsible for coordinating and overseeing all population-related IEC has remarked that they have great difficulty in mobilizing various IEC experts from different ministries for discussion and coordination because they are not sufficiently elevated in the public sector hierarchy or have sufficient authority to oversee IEC activities in other ministries. The project missed an opportunity to clarify roles and responsibilities and strengthen coordination capacity in this regard.

6.11 Even in the context of a multi-sectoral approach to the achievement of HIV/AIDS and population objectives, the role of the health sector is pivotal. The health sector's ability to carry out its potential role effectively was undermined. First, its mandate is not fully or clearly defined in the health policy document, nor are accountabilities of relevant departments and divisions of MoPH specified; (71) Second, the health sector response is limited by very weak health sector capacity overall. (72) Project support has made headway in strengthening epidemiological surveillance, but this capacity must be mainstreamed into the MoH, beyond the PNLS. However, the health sector is very behind in taking on other core activities that are public goods. Technical experts interviewed have estimated that the blood supply is still unsafe. Training, guidelines and protocols and the provision of drugs have started to build capacity of health services to diagnose and treat STIs and opportunistic infections, but the quality and coverage and reliability of these services are lacking. Testing capacity is far below what is needed, especially now that the Government is subsidizing ARVs, which will stimulate increased demand for tests. Prevention of transmission within health facilities is inadequate. It was mentioned numerous times during field visits and exchanges with actors at the national level that health sector personnel are among the least mobilized of all civil servants working on HIV/AIDS and that more effort is needed to inform and involve them in the fight and to relieve them of the fear and stigma with which they tend to be associated.

6.12 The absence of baseline data for many of the key indicators and of a monitoring and evaluation plan has undermined opportunities to track the performance and impact of national population and HIV/AIDS efforts and to refine approaches and increase effectiveness in light of experience. Information on trends is limited thus far to HIV among pregnant women, which is not particularly useful for gauging trends in new infections. Some trends on knowledge, awareness and behavior can be derived from the DHS (1996/97), the UNICEF multiple indicator survey (2000) and the 2003 KAP, but questions and indicators vary across surveys making them non-comparable. Furthermore, data collection activities were not designed to measure many of the indicators identified at project appraisal. Informants have pointed out the absence of denominators of key target groups such as number of orphans, schools, etc. and of current coverage of these groups (numerators) that make it impossible to set viable targets for coverage of services. Implementation of the civil society projects has been evaluated and audited by the Social Fund, but program effectiveness would benefit from results-focused evaluations. The functional relationship between the M&E unit of PPLS and the PNLS/MoH is weak.

6.13 The Bank can be effective in influencing the Borrower to support public goods and high-impact interventions. Within the overall context of population policy and the second medium-term plan for HIV/AIDS, the Bank supported the production of public goods, in terms of collection and maintenance of basic epidemiological, behavioral and population data, that most likely would not have enjoyed such high priority in the absence of Bank assistance.

6.14 The inclusion of a well-designed component on social marketing of condoms channeled resources to a potentially high-impact intervention. The social fund supplemented the borrower's implementation capacity with that of civil society and established partnerships with civil society and across development sectors. Within those partnerships the Bank encouraged the targeting of high-risk groups, and (as experience was gained) the definition of mandates of public and civil society actors in line with in line with their comparative advantages. The Bank's support of intermediary NGOs for capacity building of local associations was also a good strategic choice. As ARVs became more affordable and Parliament passed a bill to subsidize their costs, the Bank continued strong advocacy for maintaining a priority on prevention. The Bank was less successful in encouraging targeted behavior change interventions, as opposed to IEC.

6.15 The strategy of intensive IEC in the early years of the project to inform civil society about the social fund, followed by the recruitment of intermediary NGOs to build capacity in subproject proposal writing and implementation and to stimulate the formation of additional relevant local associations, proved to be very effective in gradually engaging civil society in population and HIV/AIDS while providing them with needed support and guidance. This experience also points to the need for improved coordination and monitoring and evaluation of NGO activity.

6.16 Government financing of NGOs supported not only a complement to public-sector activities, but also strengthened advocacy role of civil society. The creation of associations of PLWHA and prostitutes give legitimacy to these groups and contribute for human rights and equity advocacy. The support of associations of Parliamentarians, high-level civil servants, the business sector and retired technicians has created an important force in demanding the involvement and accountability of public officials in addressing HIV/AIDS.

6.17 A second Population and AIDS project (73) continues Bank support to Chad's population policy and HIV/AIDS strategic plan. Its development objective is to contribute to the behavior change of different populations in an effort to reduce the risks of HIV infection, closely spaced births, and unwanted pregnancies. (74)

6.18 In addition, the Health Sector Support Project (HSSP) (75) supports the strengthening of basic health services, including reproductive health, and includes an HIV/AIDS component to support epidemiological surveillance and health care practices for limiting the risks of HIV transmission (enhanced blood safety, improved STI treatment and control, and reduction of risks of clinical infection).

6.19 The Government is currently financing ARV treatment for about 80 AIDS patients and the Global Fund will support expansion of this program. Additional patients are accessing ARV through a Government subsidy program. (76) While HSSP does not finance the purchase of ARV drugs, it has positioned itself to support needed strengthening of treatment and referral services. The second Population and AIDS Project is financing a consultant to help MoPH develop a global care and treatment framework, a management system for ARVs, and a national reference guide.

6.20 Current Bank support to population and HIV/AIDS remains strong and reflects many lessons learned during the implementation of the first operation, corroborated by other relevant OED reports, (77) notably: (a) continued emphasis on prevention; (b) the development of a communications strategy for behavior change and definition of roles and responsibilities for its coordination, management and implementation; (c) continued efforts to address vulnerabilities, building on the experience and outcome of microfinance for women and expanding to other vulnerable groups (such as prisoners); (d) review and revision of the institutional frameworks for population and HIV/AIDS for greater efficiency; (e) intensified support to MoPH capacity; and (f) improvements to program monitoring and evaluation.

6.21 The importance of sound and rigorous monitoring and evaluation cannot be overemphasized. With the ongoing Bank support a project monitoring and evaluation plan was developed and agreed that defines 24 indicators and specifies data collection methodologies and responsibilities. Impact indicators focus on behaviors, HIV prevalence, and measures of STDs among key populations. A second DHS is planned, along with the first national HIV sero-prevalence survey and a beneficiary assessment. A full-time M&E expert has been recruited into the PCT. However, there is scope for intensifying efforts on a number of fronts, notably: establishment of baseline data for all program indicators; greater consistency in the type and frequency of data collection to enable the tracking of trends over time; and inclusion of measures of incidence to track rates of new infections among the general populations and among high-risk groups.
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Publication:Chad - Population and AIDS Control Project
Date:Mar 7, 2005
Previous Article:5. Ratings.
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