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(1.) The other projects assessed to date include the Kenya Sexually Transmitted Infections Project, the Zimbabwe Sexually Transmitted Infections Prevention and Care Project, the First India National AIDS Control Project, the first and second Brazil AIDS and Sexually Transmitted Disease Control Projects, and the Kingdom of Cambodia Disease Control and Health Development Project.

(2.) The first Multi-Country HIV/AIDS Program (MAP), a horizontal Adaptable Program Loan (APL) for Africa Region's intensified assistance to the fight against HIV/AIDS, in the amount of US$500 million, was approved on September 12, 2000. MAP II for an additional US$500 million was approved on December 20, 2001.

(3.) Data and information cited in this section are drawn from Chad's Poverty Reduction Strategy Paper (PRSP) of October 7, 2003, and from the World Bank's Country Assistance Strategy (CAS) for Chad of November 12, 2003.

(4.) Ministere de la Sante et des Affaires Sociales et Banque Mondiale, March 2004.

(5.) Priority sectors include: health, social affairs, education, infrastructure, rural development, and environment and water resources.

(6.) Ministry of Health statistics.

(7.) Direction de la Statistique des Etudes Sconomiques et Demographiques--DSEED.

(8.) Weak capacity was due both to a lack of qualified health personnel and to a lack of prioritization of family planning information and services within the minimum package of services.

(9.) Diarrhea, tuberculosis, malaria, trypanosomiaisis, onchocerciaisis, meningitis, cholera, measles, STDs/AIDS.

(10.) The percent of adults infected with HIV at a given time.

(11.) In 1993, 88 percent of all reported cases came from Ndjamena and Moundou.

(12.) Mother-to-child transmission was also acknowledged as a means of infection, with some 4,800 children estimated to be infected in 1994, along with the transfusion of unsafe blood supplies (World Bank 1995).

(13.) Consisting of: (a) the National AIDS Committee (Comite National de Lutte contre le SIDA, CNLS), chaired by the Minister of Health and composed of six ministers, responsible for oversight of all HIV/AIDS control activities, (b) the Technical Committee for AIDS Control (Comite Technique de Lutte Contre le SIDA, CTLS), chaired by the Director General of Health, and (c) the National AIDS Control Program (Programme National de Lutte Contre le SIDA, PNLS) within MoPH, responsible for day-to-day implementation and follow-up of AIDS activities.

(14.) Surveillance activities included seroprevalence surveys in selected prefectures (Abeche, Sarh, Moundou, Bongor and Ndjamena) and limited surveillance of pregnant women, blood donors and TB patients.

(15.) Credit 2156-CD in the amount of SDR 10.4 million (US$13.4 million equivalent) was approved on June 14,1990, and made effective on April 14,1991. A supplemental credit (Credit No. 21561-CD) in the amount of SDR 6.8 million (US$9.8 million equivalent) was approved on November 10, 1994, and made effective on September 6, 1995. Both credits were closed on April 30, 1998.

(16.) The Bank's final evaluation report (World Bank 1998) acknowledged this component's success in improving utilization of health facilities, but also noted that the project did not fully achieve its objectives to expand infrastructure and to develop sustainable institutional capacity.

(17.) World Bank Report No. IDP-122, "Population, Health and Nutrition Sector Report," December 1992.

(18.) It called for action to slow down population growth through: (a) the establishment of a government coordinating body for population policy development and the creation of a population unit for program development and coordination; (b) the development of a national family planning strategy and action plan to increase access to family planning services, with an emphasis on child spacing; and (c) intensified information, education and communication (IEC) by promoting a multi-media approach and involving NGOs.

(19.) This report noted that the scale and urgency of HIV/AIDS were growing rapidly and were possibly grossly underestimated. At that time the rates of infection of HIV, according to sentinel site data, were 1.6% in Moundou, 0.5% in Sarh and 0.2% in N'djamena. Low awareness, inadequate skills of health personnel and shortage of resources and logistical support all were cited as important impediments to program effectiveness.

(20.) Credit 2626-CD in the amount of SDR 31.1 million (US$18.5 million equivalent), provided support to three components aimed at: (a) strengthening central MoPH capapcity to support regional health services; (b) improving health, nutrition and family planning services in Guera and Tandjile regions; and (c) developing and implementing a national drug policy. 2/24/95, closing 6/30/01.

(21.) Slow progress in the preparation of the population component is largely attributable to the weak capacity of the demographic unit within MoPC.

(22.) Building on the analysis of the Population, Health and Nutrition Report (World Bank 1992), the Regional AIDS Strategy for the Sahel (World Bank January 1995) provided updates on the progression of the HIV/AIDS epidemic in Chad and guidance for Bank support, most notably: strengthening and expansion of communication; expanding clinical management, epidemiological surveillance and laboratory capacity; support for NGO and community initiatives; support for multisectoral interventions; and policy analysis, research, monitoring and evaluation.

(23.) WHO, UNICEF, Swiss Tropical Institute, European Union, France, Switzerland. In addition, the International Planned Parenthood Federation (IPPF) provided support to its local affiliate in Chad, the Association for Family Well-being (ASTBEF).

(24.) All US$ amounts represent the US$ equivalent of SDRs or other currencies.

(25.) Regional Commissions for Population and Human Resources, created in 1994; and Prefectoral Health Councils, created in the late 1980s.

(26.) During negotiations the Government gave assurances that it would maintain in the budget of the ministries involved in AIDS control a separate budgetary item for AIDS activities to meet their counterpart obligations.

(27.) While it provided critical information on both population and HIV/AIDS, the 1996 DHS did not provide needed data on many of the project targets and indicators.

(28.) Project effectiveness slipped from July to September 1995 because of extra time taken for the Conseil Superieur de la Transition to ratify the credit.

(29.) The project was extended to bridge a financing gap pending the delayed start of the follow-on project.

(30.) The 1999 approved budget did provide for this counterpart funding, thus permitting implementation of sectoral activities that year.

(31.) The Bank's internal supervision reporting downgraded its rating of counterpart funding from "unsatisfactory" to "highly unsatisfactory" during the latter years of implementation.

(32.) HCPRH (Haut Conseil de la Population et des Ressources Humaines) is the High Council on Population and Human Resources, chaired by the Head of State, with membership comprised of Ministers, responsible for setting and enforcing population policy. CNPRH (Commission Nationale de la Population et des Ressources Humaines) is the National Commission on Population and Human Resources), chaired by the MoPC with membership comprised of representatives of public sector and civil society, responsible for coordination and oversight of policy implementation. CRPRH (Commission Regionale de la Population et des Ressources Humaines) is the Regional Commission on Population and Human Resources, chaired by the Governor, with membership comprised of regional representatives of the public sector and civil society, responsible for regional-level policy implementation.

(33.) Five demographers have died since the start of the project, including one who was trained overseas under the project. A number of other staff trained under the project were hired by multilateral agencies (e.g., UNDP and UNICEF).

(34.) It is interesting to note that this project was designed during a time when the Bank sought to reduce long-term technical assistance financed under projects, given client countries' expressed resistance to the high cost of such assistance as well as to the idea of borrowing for this purpose. Project files do provide evidence of the need to strongly justify the inclusion of technical assistance. Some interviewed indicated that, in retrospect, the TOR for this assistance were too broad and ambitious for one person to fulfill.

(35.) A 10th site in Faya-Largeau was established with project support, but its operations were limited to notification of AIDS cases and not HIV surveillance at the end of the project.

(36.) Sero-prevalence studies focused on: prostitutes and military in Ndjamena (1995), military in N'djamena (1997), military in Moundou (1997), prostitutes in Sarh (1997), migrants in Logone Occidental (1997).

(37.) In the prefectures of Abeche and Amtiman.

(38.) Study completed was on the management of STDs and AIDS patients. Planned studies not carried out focused on: referral protocols for AIDS patients and families; evaluation of the clinical definition of AIDS; relationship of HIV and TB; and accessibility and utilization of health centers and district hospitals.

(39.) KfW's technical and financial continues today in the context of the follow-on project.

(40.) Many of these agencies were NGOs that did not necessarily have microfinance experience, as this was very rare on the ground. They were chosen for their overall experience in working with communities and for their management and organizational skills. The operational manual was a means of guiding these agencies in carrying out microfinance activities and in developing microfinance capacity in the country.

(41.) Opinion and religious leaders, women, NGOs, journalists, youth, union workers and local leaders.

(42.) Created in September 1997, almost two years after the initial target date.

(43.) While it was acknowledged at the MTR that the program's (and project's) original objectives and targets were, in retrospect, unrealistic and would not be met, there was no formal revision of objectives. UNFPA was working on revising the objectives, but their consultants are reported to have worked very slowly and realistic data were available only for the 2nd project.

(44.) Source: Directorate of Coordination of Population-Related Activities, Ministry of Planning, Development and Cooperation (MPDC), 2004 data.

(45.) At the time of the project's closing, a tenth site (Faya) is only reporting AIDS cases (and not HIV prevalence) for the moment.

(46.) At the time of the mission's visit, four annual statistical reports had been produced, providing a series of data for the years 1999, 2000, 2001, and 2002. While the project financed training and other support to the functioning of the surveillance sites, the quality and completeness of the data are still in need of improvement.

(47.) PNLS staff person responsible for epidemiological surveillance at the project's outset received training in epidemiology, but was transferred to another post upon his return to Chad. He was replaced by a non-specialist who received no technical training in epidemiology.

(48.) The long-term international technical assistant, who is an epidemiologist, did not provide full-time support to this effort, because his terms of reference were very broad. In addition to epidemiological technical support, his terms of reference also included the provision of technical/managerial support to the PCT/MoPC in coordinating HIV/AIDS activities and to the social fund entity, FOSAP.

(49.) The syndromic approach to STD patient management bases diagnosis and treatment on the presence of symptoms, generally without resort to confirmatory laboratory tests. This approach is recommended by WHO in developing country settings as it allows treatment with a single visit and away from a laboratory setting.

(50.) The project did not finance the purchase of ARVs. In 1994 when the project was designed ARVs were very expensive and not widely available; and Chad's second medium-term plan for HIV/AIDS placed highest priority on prevention activities.

(51.) In October 2003, AMASOT doubled the price of condoms (from 50 to 100 CFA francs for a packet of 4) to discourage their cross-border sales, still keeping the price affordable for most Chadians. Sales data in late 2003 and early 2004 reveal a decline in overall sales, attributable by AMASOT both to a reduction in cross-border sales and to a temporary decline in in-country sales because of the price increase.

(52.) Unfortunately available data is inadequate to document this trend.

(53.) Social Action and Family; National Education; Defense; Finance; Justice; Communication; Health; and Interior.

(54.) This evaluation focused more on the process and efficiency of the microfinance scheme than on the impact of this investment. Nevertheless, the methodology did include interviews with beneficiaries in five prefectures to assess the impact of this investment on their lives and on the lives of their families. While the report provides useful insights on impact, the authors note that their evaluation of impact was not sufficiently systematic or rigorous, and recommend that an in-depth evaluation be undertaken.

(55.) Trends on awareness and knowledge presented in this report are derived from three national studies: (a) the 1996/97 Demographic and Health Survey; (b) the 2001 UNICEF Multiple Indicator Survey; and (c) a 2003 KAP survey commissioned by Government. All three surveys are national in coverage and based on the zones defined during the 1993 population census. All three cover women in the same (15-49 year) age group; and the first and third surveys also include men in the same (15-59 year) age group. DHS questions related to knowledge and awareness were open-ended, whereas the UNICEF and KAP survey questions were prompted. All three surveys covered both urban and rural populations and properly weighted the data to reflect the urban/rural population distribution. Sample size for the DHS included 7,454 women and 2,320 men. UNICEF's sample size covered 5,865 women; and the KAP sample was comprised of 1,148 women and 1,332 men. Different questions were posed across the three surveys with regard to condom utilization, thus limiting the possibility of deriving trends on behavior.

(56.) A nationwide study of prostitutes in Chad found that 96 percent of prostitutes living in urban areas and 74 percent in rural areas were aware of HIV/AIDS and possessed the knowledge of sexual transmission and how to protect themselves (Ngoniri 2001). No baseline data on knowledge of prostitutes was established, against which these levels can be compared. Prostitutes were a priority target group for HIV awareness and prevention of the first medium-term HIV/AIDS plan (1990-1993).

(57.) The Ngoniri study (2001) reveals that use of condoms by prostitutes is highest in urban areas, where 82 percent of professional prostitutes and 52 percent of those engaged in clandestine prostitution report that they regularly use them. In rural areas an estimated 55 percent of professional prostitutes report regular use of condoms, while regular use among clandestine prostitutes is much lower at 20 percent. While there is no baseline against which to compare these findings, discussions with a wide range of actors and stakeholders, and consultation of project design documentation, reveal that condoms were both unavailable and taboo in the early 1990s.

(58.) The objective of the project was to slow the spread of HIV, which means reducing the number of new infections. Prevalence is affected by the number of new infections, the number of past infections and the AIDS mortality rate and therefore masks the rate of new infections (incidence). Because of the delay in the onset of AIDS of 10 years or more, HIV prevalence can rise quickly early in an epidemic, before AIDS mortality affects HIV prevalence. Subsequent declines in prevalence will be attributable in part to AIDS mortality and may not necessarily reflect declines in new infections.

(59.) The sample size of these studies is not known.

(60.) The only four sentinel sites for which data is available every year during the period 1999-2002 are the urban sites of Bol, N'djamena, Bongor and Sarh. Two other urban sites (Abeche and Moundou) did not have complete data sets over this time period and so were eliminated from this trend analysis.

(61.) Data from all 11 sentinel sites reporting in 2002 (of which seven classified as urban and four classified as rural) indicate an overall prevalence rate among pregnant women using prenatal services of 5.82 percent (see Annex D for details). Given that seven of the 11 sites are urban, national prevalence among this group is likely to be lower when weighted for the urban/rural population distribution. These data should be interpreted with caution as capacities for the collection and analysis of epidemiological data are still considered to be weak; and rural data are too recent to reveal trends. Furthermore the representativity of these data is not sure as less than half of all women utilize prenatal services (Annex D).

(62.) With whom a major contract was signed to provide technical assistance and capacity building.

(63.) Most field visits undertaken were carried out jointly with the management/team of the ongoing health operation.

(64.) Other commodities are being added to its portfolio under the follow-on operation, including impregnated mosquito nets, female condoms and hormonal contraceptives for women.

(65.) The MoPC was chosen as implementing agency given the multi-sectoral nature of population and HIV/AIDS activities. The PCT was responsible for the management, supervision and financing of HIV/AIDS activities.

(66.) The task manager remained the same from effectiveness through the to the close of the project (and continues with the implementation of the follow-on operation).

(67.) Informants at the local level frequently referred to the infection or death of a family member or close friend.

(68.) Arrete No. 577/MSP/DG/98 of April 28, 1998, modifying arrete No. 59/MSPAS/SE/DG/PNLS/91 of May 13, 1991, modifying Arrete No. 31/MSP/SE/DG/013/DAFM/DILA/88.

(69.) The National Committee for the fight against HIV/AIDS (CNLS), created in 1988 by government decree No. 035/PR/PSP/88 of March 19, 1988, and the Technical Commission for the Fight Against HIV/AIDS (CTLS), created by government arrete No. 012/PMT/95 of February 12, 1995.

(70.) As a consequence, this evaluation was unable to provide an overview of the nature, levels and impacts of other partners' contributions to HIV/AIDS control efforts during the life of this project.

(71.) The 2000 health policy makes reference to the PNLS as the responsible department for HIV/AIDS activities, making no reference to any responsibilities of other departments. It also highlights the importance of multisectoral collaboration without clearly distinguishing MoPH's role and comparative advantages.

(72.) Overall weaknesses in health system capacity, include: human and financial resources constraints, low service quality and utilization rates (see Annex D), sporadic availability of drugs and supplies, and many competing priorities.

(73.) Credit No. 3548 was approved on July 12, 2001, and became effective on April 11, 2002.

(74.) To this end it supports: (i) scaling up multi-sectoral and decentralized activities carried out by public and private sector agencies and civil society; (ii) targeted behavior change interventions; (iii) an increase in voluntary testing and counseling; (iv) reduction in vulnerability factors through income generation, women's education, and care of those infected and affected by the epidemic; and (v) an increase in the availability of condoms and contraceptives to enable adoption of healthy behaviors. Support is channeled through four components: (a) strengthening of the capacities of the key ministries; (b) strengthening of grants and micro

credits under the social fund; (c) support to the social marketing program; and (d) population policy implementation.

(75.) Credit No. 3342 was approved on April 27, 2000, and became effective on February 28, 2001.

(76.) The monthly cost of ARV is 20,000 CFA francs, or about US$40 (price at which the Central Procurement Agency buys the drugs); under the Government's ARV subsidy program, Parliament voted a budget which finances 15,000 CFA francs of the monthly costs of ARV and the patient co-pays the balance of 5,000 CFA francs.

(77.) "Nongovernmental Organizations in World Bank-Supported Projects," 1999; "Social Funds: Assessing Effectiveness," 2002; and "OED Review of Bank Lending for Lines of Credit," 2004.

(78.) These NGOs represented a range of constituencies, themes and missions, including: health of nomads, Islam, Christian religions, community development and empowerment, youth movements, coalition of public sector leaders, women and children's health and well-being, among others.

(79.) A Sahelian institution of the Inter-Country Committee on the Fight against Desertification (Comite interetats de lutte contre la secheresse dans le Sahel, CILSS).

(80.) Chadian Association for Family Well-being (Association Tchadienne pour le Bien-Etre Familiale), an affiliate of the International Planned Parenthood Federation.

(81.) Target groups identified for prevention activities included youth, prostitutes and their clients, civil servants of key ministries, migrant workers, and truck drivers on major migration and transport routes to Cameroon and Nigeria.

(82.) Target groups identified for population IEC included men, teenagers, workers, agricultural extension workers, community development workers, women's associations, rural development cooperatives, and private employers.

(83.) Directorate of Coordination of Population-Related Activities, Ministry of Planning, Development and Cooperation (MPDC), 2004 data.

(84.) DHS 1996/97.

(85.) Government of ChadA/Vorld Bank Country Status Report 2003.

(86.) UNICEF 2001.

(87.) UNICEF 2001.

(88.) 1996/97 DHS.

(89.) PPLS 2001.

(90.) 1999 sentinel surveillance data for: Abeche, Bol, Bongor, Moundou, N'djamena, Sarh.

(91.) 1999 sentinel surveillance data for: Abeche, Bol, Bongor, Moundou, N'djamena, Sarh.

(92.) 2002 sentinel surveillance data for: Abeche, Bol, Bongor, Moundou, N'djamena, Sarh.

(93.) Final Evaluation Report (Ngarmig-Nig 2002).
Table 1. Summary OED Ratings * by Objective

 Relevance Efficacy

To advance the onset of fertility Modest Negligible
decline by increasing the use of
modern methods of contraception

To slow the spread of HIV infection High Substantial
by promoting behavioral change

 Efficiency Outcome

To advance the onset of fertility Modest Unsatisfactory
decline by increasing the use of
modern methods of contraception

To slow the spread of HIV infection Substantial Satisfactory
by promoting behavioral change

* See inside cover of this report for definitions of relevance,
efficacy, efficiency and outcome.

Figure 1. Reported AIDS Cases 1986-2002

 # AIDS Cases

Year

1986 2
1987 2
1988 7
1989 10
1990 38
1991 165
1992 363
1993 1010
1994 1268
1995 1132
1996 1242
1997 2748
1998 2030
1999 1664
2000 1704
2001 1661
2002 1927

Source: MoPH/PNLS Epidemiological Data

Note: Table made from bar graph.

Figure 2. Use of contraception among married women and
those in consensual union, 1996 and 2000

 1966 2000

Any method 4.2 7.9

Modern method 1.2 2

Note: The differences between 1996 and 2000, are statistically
significant at p[less than or equal to].05.

Source: DHS 1996/97 and UNICEF Multiple Indicator Survey 2001;
Reproduced from Country Status Report (World Bank 2004).

Note: Table made from bar graph.

Figure 3. Condom Sales, 1996-2002

Project Implementation Millions of condoms

1996 0,8
1997 3,2
1998 4,0
1999 6,5
2000 2,2
2001 3,2
2002 4,7

Source: AMASOT statistics, 2004

Note: Table made from bar graph.

Figure 4. Percent of men and women surveyed
declaring they have heard of AIDS

 Women Men

1996/97 60.0 88.1
2000 70.6
2003 76.0 76.8

Source: DHS 1996/97; UNICEF 2001; KAP 2003

Note: Table made from bar graph.

Figure 5. Percent of men and women who
know condoms are a means of protection

 Women Men

1996/97 11.1 22.3
2000 20.9
2003 60.1 65.1

Figure 6. Percent of men and women who
know that fidelity is a means of protection

 Women Men

1996/97 27.9 17.7
2000 34.8
2003 81.9 81.8

Source: DHS 1996/97; UNICEF 2001; KAP 2003

Note: Table made from bar graph.

Figure 8. Ever-Use of Condoms (percent),
1996 and 2003

 Women Men

1996/97
All 2.9 13.2
Urban 6.6 30.4
Rural 1.1 6.0

2003
All 15.2 19.6
Urban 24.3 29.3
Rural 12.2 16.3

Source: DHS 1996/97; KAP 2003

Note: Table made from bar graph.

Figure 9. Trends in Adult Prevalence in
Three Cities

 Prevalence %
Sarh

1989 0.5
2000 8.84

Abeche

1989 0
1997 2.1

Bongor

1989 0.6
2000 6.5

Source: Population based study covering 6 cities (N'Djamena,
Moundou, Sarh, Bongor and Abeche. (Organization for the
Coordination of Epidemics of Central Africa, OCEAC, 1989); and
population based surveys on Abeche, Bongor, and Sarh (PNLS)
1997 and 2000

Note: Table made from bar graph.

Figure 10. HIV Prevalence Among Women Using Prenatal
Services in Four Urban Sites, 1999-2002

 HIV Prevalence

1999 4.0
2000 6.9
2001 7.5
2002 6.4

Source: MOPH 1999-2002 sentinel site data from: Bol, N'Djamena,
Bongor, and Sarh.

Note: Table made from bar graph.

Table D-14. Planned vs. Actual Use of IDA Credit by
Disbursement Category (millions of SDR)

 Initial Reallocation
Disbursement Category Allocation (byDCA Actual
 amendment)
(1) Goods:
 (a) Contraceptives 2.40 0.65 0.64
 (b) Other Items 0.50 1.31 1.22
(2) Rehabilitation of Offices 0.01 0.08 0.07
(3) Consultants' Services 1.70 1.93 2.02
(4) Training 0.70 1.40 1.44
(5) Studies 2.70 1.90 2.04
(6) FOSAP Grants 2.70 3.23 3.55
(7) Incremental Operating Costs 1.50 1.90 1.75
(8) Refunding of PPF 0.24 0.24 0.23
(9) Unallocated 1.45 0.05 0
FOSAP microcredits 0 1.17 0.80
Reconciliation of Special Account 0.09
Total (rounded) 13.9 13.9 13.9
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Title Annotation:PROJECT PERFORMANCE ASSESSMENT REPORT CHAD POPULATION AND AIDS CONTROL PROJECT (CREDIT NO. 2692) MARCH 7, 2005
Publication:Chad - Population and AIDS Control Project
Date:Mar 7, 2005
Words:5434
Previous Article:Annex F. Borrower's comments.

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