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The objectives of the Population and AIDS Control Project (Credit No. 2692 of 13.9 million SDR) were to advance the onset of fertility decline by increasing the modern contraceptive prevalence rate (CPR) from 1 percent in 1990 to 10 percent by 2000, and to slow the spread of HIV infection by promoting behavioral change. The project was managed and implemented efficiently overall; and the credit was fully disbursed. Implementation, however, was constrained by the lack of Government counterpart financing and weak capacity of public sector implementing agencies.

In 1992 Chad was one of the few Sahelian countries that did not have a population policy. However, deteriorating socioeconomic conditions and analysis of population issues, supported by the World Bank, prompted in 1994 the preparation of a national population policy and the repeal of the 1920 law which prohibited contraceptives. Population program efforts were constrained by poor coverage and quality of family planning and weak capacity for the coordination of activities and for the collection and analysis of data. Strong disincentives for decreasing fertility included high levels of poverty and high dependence on children to supplement family income and provide old age social security, and very high infant and child mortality.

The first cases of AIDS were reported in 1986, with a total accumulation of 2,866 reported cases by 1994, 97 percent of which were attributed to heterosexual transmission. Government's earliest response under its short-term plan (1988-89) and first medium-term plan (1990-93) for AIDS control focused on program start-up, capacity-building, surveillance and prevention activities. Denial and stigma within the Government and in society at large were pervasive.

Population. Project assistance did not succeed in raising the modern CPR to 10 percent. By the project's end, CPR was estimated at 2 percent. Available data indicate that the total fertility rate in Chad has remained constant over the life of the project at around 6.6 children. At the time of the project's mid-term review, the Bank and the Borrower acknowledged that the objectives were, in retrospect, not realistic and would not be achieved. UNFPA hired consultants to set new targets on the basis of the DHS data, but their work progressed slowly and the project objectives were not amended.

HIV/AIDS. Epidemiological and behavioral surveillance was improved under the project and helped document the seriousness and scope of the epidemic. The project was successful in establishing a social marketing program that has increased the availability of condoms in Chad at an affordable price. Against a target of 14 million, a total of 19.9 million condoms were sold, of which about 3 million are estimated to have been sold in neighboring countries. While condoms were taboo at the start of the project, they are now sold openly in shops, market stands, inns and hotels across the country. There is considerably less stigma today associated with the purchase and use of condoms. The project has mobilized and financed a wide response from civil society organizations, and a response from various sectors in the public sector at central and decentralized levels.

The project has succeeded in increasing awareness and knowledge of HIV/AIDS and in inciting safer behavior. The most significant improvements in awareness and behavior are found among women, rural residents, and the poorest income quintiles with consequent reductions in disparities between men and women, urban and rural residents and the poorest and richest segments of the population. Condom use has increased among men and women, although levels are still relatively low. In the absence of baseline data, it is difficult to evaluate the extent to which the project has slowed the spread of HIV infection. Available data reveal that HIV prevalence has risen over the past decade in the general population and that it may have stabilized among pregnant women using prenatal services in urban areas. However, the HIV prevalence rate does not yield insights into the change in the rate of new infection.

Ratings. This project is judged to have had a moderately satisfactory outcome overall, based on an unsatisfactory outcome of the population objective and a satisfactory outcome of the HIV/AIDS objective. Institutional development is rated as substantial; and sustainability of project efforts is likely. Both Bank and Borrower performance was satisfactory.


* 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 that support is insufficient to consolidate and sustain the commitment. Other factors that are critical to raising and sustaining Government commitment are the relevance of the objective (determined by the availability of local evidence and data) and the degree of mobilization of civil society.

* The stimulation and nurturing of broad-based national commitment requires continuous and multiple efforts, given population mobility and turnover in public sector positions.

* Even in the context of a multisectoral approach to the achievement of HIV/AIDS and population objectives, the role of the health sector is pivotal.

* The absence of baseline data for key indicators and of a monitoring and evaluation plan undermines opportunities to track and fine-tune the performance and impact of national population and HIV/AIDS efforts.

* Intensive information campaigns in the early years of the project followed by the recruitment of intermediary NGOs to build capacity onsite and to stimulate the formation of new associations, proved to be very effective in engaging civil society in population and HIV/AIDS activities.

Gregory K. Ingram


Operations Evaluation
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Author:Ingram, Gregory K.
Publication:Chad - Population and AIDS Control Project
Date:Mar 7, 2005
Previous Article:Preface.
Next Article:1. Background and context.

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