Senegal - Rural Health Project

Document of The World Bank M C P FOR OFFICIAL USE ONLY Report No. 4003-SE STAFF APPRAISAL REPORT SENEGAL RURAL HEALTH PROJECT November 29, 1982 Population, Health and Nutrition Department This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  Currency Equivalents: Currency Unit = CFAF US$1.00 = CFAF 340 GOVERNMENT OF THE REPUBLIC OF SENEGAL FISCAL YEAR: July 1 - June 30 ,,  FOR OFFICIAL USE ONLY REPUBLIC OF SENEGAL Rural Health Project Table of Contents Page No. Basic Data. . . . . . . . . . . .i Definitions.. . . . . . . . . ii Abbreviations . ............. .. iv I. THE HEALTH SECTOR.. . . . . . . . . . 1 A. Introduction. . . . . . . . . . . . . . . . . . . 1 B. Health Status . . . . . . . . . . . . . . . . . . 2 C. Structure and Performance of Health Services. . . . . . . . . . . . . . . . . . . . 3 D. Health Sector Financing . . . . . . . . . . . . . 8 II. HEALTH SECTOR STRATEGY AND CONSTRAINTS. . . . . . . . 10 A. Strategy . . . . . . . . . . . . . . . . . . . . 10 B. Key Constraints . . .... .. . . . . 11 C. Need for the Project. . . . . . . .. . . . . . . 14 III. THE PROJECT .15 A. Project Objectives. . . . . . . . . . . . . . . . 15 B. Project Composition . . ....... . . . . 15 C. Detailed Project Features . . . . . . . . . . . . 17 IV. PROJECT COST AND FINANCIAL PLAN . . . . . . . . . . . 23 V. PROJECT IMPLEMENTATION, PROCUREMENT, DISBURSEMENT AND AUDITING . . . . . . . . . . . . . . . . . . . . 27 VI. PROJECT BENEFITS AND RISKS . . . . . . . . . . . . . . 31 A. Benefits . . . . . . . . . . . . . . . . . . . . . 31 B. Risks ..... . . . . . . . . . . . . . . . . . 32 VII. RECOMMENDATIONS . . . . . . . . . . . . . . . . . . 33 This report is based on the findings of an IDA mission which visited Senegal in June/July 1981 comprising Messrs. A. Williams (Mission Leader), V. Kumar (Public Health Specialist), J. Pillet (Public Health Specialist), G. Sinclair (Architect), Mrs. K. L. Hall (Health Planner), Ms. A. Mashayekhi (Economist) and Ms. D. Vaillancourt (Research Assistant). The project was further reviewed in December 1981 by Messrs. A. Williams, U. Mbanefo (Financial Analyst), J. Pillet, G. Sinclair and M. El Fekih (Consultant, Pharmaceutical Specialist). This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  Table of Contents (cont.) Page No. TABLES IN MAIN TEXT 4.1 Estimated Project Cost by Expenditure Categories . . . . . . . . . . . . . . . . . . 24 4.2 Estimated Price Escalation Rates . . . . . . . . 25 4.3 Financing Plan . . . . . . . . . . . . . . . . . 26 5.1 Disbursement Schedule. . . . . . . . . . . . . . 29 ANNEXES 1. Disease Priorities by Type of Intervention. . . . . . 35 2. Supporting Tables, Charts and Maps. . . . . . . . . . 37 Tables T-1 Comparative Health Status Indicators . . . . 37 T-2 Mortality Indicators . . . . . . . . . . . . 38 T-3 Geographic Distribution of Ministry of Health Personnel by Regions, 1981. . . . . . . . 39 T-4 Functional Distribution of Health Manpower by Type of Facility or Service, 1981 . . . . . 40 T-5 SIPOA: Performance and Financial Indicators . . 41 T-6 Total Recurrent Expenditure on Health. . . . . . 42 T-7 Financial Situation of Health Committees . . . . 43 T-8 Total External Contribution to the Health Sector .. . . . . . . . . . . . . . . . 44 T-9 Evaluation Criteria and Major Indicators . . . . 45 T-10 Estimated Annual Project Cost. . . . . . . . . 46 T-11 Project Component Costs. . . . . . . . . . . . 47 T-12 Estimated Project Cost by Expenditure Category . . . . . . . . . . .. . . 49 T-13 Implementation Schedule: Civil Works. . . . . . 50 T-14 Implementation Schedule: Training Component . . 51 T-15 Project Preparation Facility Advances. . . . . . 52 T-16 Estimted Schedule of Disbursements . . . . . . . 54 Charts C-1 Ministry of Public Health Organizational Chart . 55 C-2 Structure of the Public Health System. . . . . . 56 C-3 Project Management Organization Chart. . . . . . 57 Maps M-1 IBRD 16182 M-2 IBRD 16326 3. Selected Documents and Data Available in the Project File. . . . . . . . . . . . . . . . . . . . . . . . 58  - i - SENEGAL HEALTH PROJECT Basic Data Total Area. . . . . . . . . . . . . . . . . . . . . . . 197,000 km2 Total Population (mid-1981) . . . . . . . . . . . . . . 5.8 million Density per km2 (mid-1981). . . . . . . . . . . . . . . 29 Rate of Natural Increase of the Population (1980) . . . 2.7% Crude Birth Rate (1979) . . . . . . . . . . . . . . . . 48/1,000 Crude Death Rate (1979) . . . . . . . . . . . . . . . . 21/1,000 Life Expectancy at Birth (1979) . . . . . . . . . . . . 43 Infant Mortality Rate (1979). . . . . . . . . . . . . . 114/1,000 Urban Population as Percent of Total Population (1979). 25 Adult Literacy Rate (1976). . . . . . . . . . . . . . . 10% Primary School Enrollment (1978). . . . . . . . 41% Age Structure 0-4 .. .. . .. . 18.4% 5 - 14 .............. . 26.3% 15 - 49 .... . . . . ...... . . . . . . . . . 45.3% 50+ ......................... . 10.0% Population per Physician (1977) . . . . . . . . . . . . 15,710 Population per Nurse (1977) . . . . . . . . . . . . . . 1,660 Percentage of Married Women of Reproductive Age using a Modern Contraceptive Method (1978). . . . . . 1% Per Capita Gross National Product (1979). . . . . . . . US$430  - ii - DEFINITIONS Adult Literacy Rate : The percentage of persons aged 15 and over who can read and write. Case Fatality Rate : The proportion of persons contracting a disease who die of that disease; usually expressed as a percentage. Child Mortality Rate : Annual deaths of children 1-4 years per 1000 children in the same age group. Crude Birth Rate : Number of live births per year per 1000 people. Crude Death Rate : Number of deaths per year per 1000 people. Dependency Ratio : Ratio of population 14 years or under and 65 or over, to population aged 15 to 64 years, multiplied by 100. Indicates proportion of population that needs to be economically supported. Incidence Rate : The number of persons contracting a disease as a proportion of the population at risk, per unit of time usually expressed per 1000 persons per year. Infant Mortality Rate : Annual deaths of infants under 1 year per 1000 live births during the same year. Life Expectancy at Birth : Indicates the number of years a newborn child would live if subject to the mortality risks prevailing for the cross-section of population at time of birth. Maternal Mortality Rate : Number of maternal deaths per 1000 births in a given year attributable to pregnancy, childbirth or puerperal complications.  - iii - DEFINITIONS (cont.) Morbidity : The frequency of disease and illness in a population. Mortality : Deaths as a component of population change. Neo-Natal Mortality Rate : The number of deaths of infants under 28 days of age in a given year per 1000 live births that year. Peri-Natal Mortality Rate : The number of fetal deaths after 28 weeks of pregnancy (late fetal deaths) plus the number of deaths to infants under 7 days of age per 1000 live births. Prevalence Rate : The number of persons having a particular disease at a given point in time per population at risk. Usually expressed per 1000 persons per year. Rate of Natural Increase : Difference between crude birth and crude death rate; usually expresed as a percentage. Total Fertility Rate : The average number of children a woman will have if she experiences a given set of age-specific fertility rates throughout her lifetime. Serves as an estimate of average number of children per family.  -iv- ABBREVIATIONS CESSI Centre d'Enseignment Supgrieur Center for Advanced Nursing en Soins Infirmiers Education DAGE Direction de l'Administration Directorate of General Generale et de l'Equipement Administration and Equipment DHPS Direction de l'Hygiene et de la Directorage of Hygiene and Protection Sanitaire Health Protection DRPF Direction de la Recherche, de Directorate of Research, la Planification et de la Planning and Training Formation EPI Programme Elargi de Vaccinations Expanded program of immunization. MCH Protection Maternelle et Maternal and Child Health Infantile MOPH Ministare de la Sante Publique Ministry of Public Health MUHE Ministere de l'Urbanisme, Ministry of Urbanism, Housing de l'Habitat et de and Environment 1'Environnement PMU Unite de Gestion du Projet Project Management Unit PNA Pharmacie Nationale National Drug Supply d'Approvisionnement Department PPF Fonds de preparation du projet Project Preparation Facility PPNS Programme pour la protection Nutritional and Health nutritionnelle et sanitaire Protection Program SIPOA Societe Industrielle Industrial Pharmaceutical Pharmaceutique de l'Ouest Company of West Africa Africain SOFFIN Societe Financiare France Ingelheim UNFPA Fonds des Nations Unies pour United Nations Fund for l'Assistance en Matiare de Population Activities Population USAID Agence Americaine de United States Agency for Developpement International International Development WHO Organisation Mondiale de la Santg World Health Organization  I. THE HEALTH SECTOR A. Introduction 1.01 Senegal's population was estimated at 5.8 million in mid-1981, at which time the natural rate of population increase averaged 2.7% annually. Economic growth, which averaged 2.3% per year between 1971 and 1979, has not kept pace with population growth. Periodic droughts, price fluctuations, unsatisfactory economic management, and disproportionately heavy investment in favor of urban areas have contributed in the past to a bleak macro- economic situation. About 70% of the population derive their livelihood from agriculture. Their health status is poorer than other countries elsewhere in Africa (Annex 2, T-1). The infant mortality rate is as high as 204 per 1,000 live births in some rural areas; only two-thirds of all children survive through age five. This loss of life contributes to a persistent pattern of high fertility; the average woman bears seven children which, in turn, is harzardous to maternal health. 1.02 Aware of the health and economic consequences of high fertility and infant mortality, the Government recognizes the need to: (a) develop integrated maternal, child health (MCH) and family planning programs; (b) upgrade the existing network of basic health services so that they might become strategic points in Senegal's public health system; and (c) promote village-level primary health care programs whereby minimal care, vaccinations, elementary health education, sanitation and, above all, MCH activities might be developed and managed by the communities themselves. 1.03 Since 1978, there has been an impressive response by the inter- national/external donor community in pursuit of these objectives. UNICEF supported rural MCH services; UNFPA and USAID have followed in developing population programs with an emphasis on family planning. Switzerland and the U.S.A. are assisting local government authorities to upgrade health posts in greatest need of repair. UNICEF, Canada, the Netherlands, Belgium, France and the United States have assisted in structuring community-level primary health care programs (involving the selection and training of community health workers, the establishment of village health huts or pharmacies, rural maternities, and vaccination programs). The World Health Organization and France are supporting an expanded program of immunization--a key component of the primary health care strategy. 1.04 These inputs are major contributions to the development of a comprehensive health system incorporating maternal and child health, family planning, and community-level primary health care programs. But the present system is under strain because basic pre-conditions have been insufficiently addressed to date. Most health centers have insufficient technical capabili- ty and have lost their credibility among the rural population (para. 1.12), a situation which must be reversed if they are to play a strategic role in the near future. Under the current (sixth) Development Plan, the Government is attempting to re-establish this credibility by improving the quality of services at health centers where curative, preventive, MCH, family planning  - 2 - and health education services are being integrated. While responding more efficiently to an immediate demand for services, the health centers are required to support and guide primary health care programs being targeted toward the community. Community-level health care has, in addition, created urgent new demands or accentuated other needs to which the health centers and the rest of the system must respond. In particular, there is a need to improve the availability and distribution of basic drugs, and to develop health education programs in support of community-level efforts. IDA assistance is being sought in these areas, which are the focus of the proposed project. Furthermore, given the large number of primary health care projects financed by different external donors which require coordination, the project would as well assist the Government to strengthen its capability in health sector planning, project implementation and evaluation. B. Health Status 1.05 Mortality. Data on morbidity and mortality patterns in Senegal rely mainly on hospital and health center records and are therefore incomplete. Nevertheless, key indicators show that the health status of the population has improved little over the past decade. Between the early 1950s and the late 1970s, life expectancy at birth increased from 33 to 42 years. More recent gains in life expectancy have slowed to half the rate achieved between 1955 and 1965. Current life expectancy (43 years) is lower than the average for sub-Saharan Africa (47) and is at the same level as Senegal's poorer Sahelian neighbors. This reflects high infant mortality, estimated to range by geographic area from 114 to 204 per 1,000 live births. Infant mortality (Annex 2, T-2) dominates all reported deaths; most infant deaths are due to various combinations of interrelated causes, chiefly diarrhea, malnutrition, malaria and measles. Maternal mortality, directly and indirectly associated with childbearing, is estimated at 500 maternal deaths per 100,000 live births (compared with about 820 in Ghana, 300 in Algeria and Peru, and 22 in the United States). High neonatal and maternal mortality underscores the substandard quality of prenatal and obstetric care in Senegal. It also reflects the adverse impact of frequent, closely spaced pregnancies on the health and nutrition status and survival chances of pregnant women and infants. Fertility remains at very high levels; the crude birth rate is currently estimated at 48 per 1,000 population. Average age at marriage is 15.6 for rural women. Only 1% of married women of reproductive age in Senegal are estimated to have ever used a modern method of contraception. Child spacing and the promotion of fertility moderation (para. 2.08) together with improved maternal and child health services, are important factors in improving the health status of the population. 1.06 Morbidity. Preventable and treatable diseases--malaria, measles, whooping cough, tuberculosis, and acute respiratory infections--account for much of the high morbidity (Annex 1). Malaria is the leading cause of illness; over 80% of the population are at risk. In the 0-4 age group, the prevalence of malaria parasites at the end of the rainy season is as high as 90%. In addition, intestinal parasites reduce the absorption rates from food consumed and thereby contribute significantly to malnutrition and associated  3 complications. Through baseline surveys conducted with IDA assistance in 1979/80 (para. 2.07), there is now substantial information available on nutritional status, food intakes, the prevalence of parasitic diseases among the rural poor, child weaning practices, and the adequacy of energy intake by women and male workers during periods of highest energy expenditure on pro- ductive activities. The data show: (i) significant seasonal undernutrition, particularly during the May-September preharvest or "hungry" season, resulting from low energy (calorie) intake; (ii) protein/calorie mal- nutrition, deriving from inadequate protein/calorie balance in the diet and exacerbated by infections; and (iii) specific nutrient deficiencies, particularly of iron, Vitamin B, and iodine. Of these problems, that of anemia (caused mainly by low iron intake or absorption) is the most wide- spread, with debilitating effects on stamina and worker productivity. Up to 70% of the population in Diourbel region and 45% in southern Casamance are affected. In southern Casamance, close to 30% of children aged 1-5 show signs of chronic malnutrition. Under these conditions, other infectious diseases such as malaria and measles become extremely dangerous and often fatal (para. 2.07). C. Structure and Performance of Health Services 1.07 The stagnation in health status, particularly in the countryside, is associated with low purchasing power, adverse environmental conditions, inadequate and unsanitary water supplies, and low public awareness of disease causation and prevention. But the structure and performance of the public health system is a central feature of the problem. The worsening economic situation after the 1968-74 drought led to a marked deterioration of health services. The Government then readily endorsed the principles of primary health care (para. 2.01) drawn up at the Primary Health Care Conference held in Alma-Ata (U.S.S.R.) in 1978 in order to improve health and nutrition status among the most vulnerable groups--mothers and children-- particularly in peri-urban and outlying rural areas. 1.08 Past Policy. Until then, the approach to Senegal's health problems was conducted entirely through pre-independence structures with the following characteristics: urban based curative medicine, often sophisticated and unadapted to local patterns of pathology and morbidity; mobile and military control of transmissible disease; limited attention to hygiene and health education; indifference to general nutritional status and opposition to contraception and abortion; limited national health planning, with health sector investments persistently favoring the national capital area; health administration dominated by physicians and pharmacists; and cumbersore central administration, often compartmentalized, with minimal ties between the central Ministry and regional health authorities. The mobile endemic disease program, which, in colonial times, penetrated deeply into rural areas, fell into relative neglect due to the diversion of resources to curative services.  1.09 The Ministry of Public Health. Most health services and facilities in Senegal are operated and financed by the national Government, although there has been a steady increase in local and private contributions (para. 1.20). The Ministry of Public Health (MOPH) is the principal organ responsible for health services. Prior to the adoption of its primary health care policy, the MOPH was organized around three departments: Equipment and Administration; Public Health Inspection; and Central Services (Public Health and Social Affairs). The central Ministry, with limited staff and even more limited staff skills in planning and management, found it increasingly difficult to coordinate various programs outside the capital. In 1979, the MOPH was reorganized in an attempt to help it better support the Government's primary health care policies by integrating curative and preventive health care; decentralizing technical support functions within the Ministry; creating an inservice training capability; and improving the coordination and planning of the entire system with a view toward ultimately strengthening local level services. (A MOPH organization chart is shown as Annex 2, C-1.) Curative and preventive health care, excepting national and regional hospitals, are the responsibility of a Directorate of Hygiene and Health Protection (DHPS) in charge of supervision of health services in the country's eight medical regions, regulation of private medical practitioners, endemic disease control, public hygiene and sanitation, MCH, family planning and nutrition services, health education and primary health care develop- ment. The remaining Directorates are General Administration and Equipment (DAGE); Research, Planning and Training (DRPF); Hospitals; Pharmacy; and Procurement Drug Supplies and Medical Equipment. Several national health institutes and paramedical training institutions are controlled directly by the MOPH. 1.10 The DRPF was an entirely new entity which was expected to improve MOPH internal operations, external coordination and planning. But its immediate development has been constrained principally by three factors: the lack of qualified staff, particularly in health sector planning; the inability of the DAGE to provide ready, reliable information for planning purposes; and, the inappropriateness of epidemiological surveillance and health service reporting (para. 3.16) both at the health center level and between health centers and the central MOPH. Short and long-term training already is being provided to new staff. Additional support is being sought for staff training to render the DRPF, DAGE and DHPS more effective instruments of planning and coordination. 1.11 Hospital Services. There are 11 national and regional hospitals in Senegal, of which four, including a university hospital center and a psychiatric hospital, serve principally Dakar and the Cap-Vert Region (Annex 2, C-2). Of the seven remaining medical regions, Fleuve is served by three regional hospitals, whereas Louga and Senegal Oriental have no regional hospital. Most hospitals are equipped to handle major surgery, and have pediatric and maternity wards. Hospital utilization rates are high: the average reported occupancy rate for hospital beds is about 85%. Access to hospital-based services varies greatly between regions because of the uneven distribution of hospitals. In 1978, for example, the ratio of population served per hospital bed ranged from 426:1 in Cap-Vert to 7,254:1 in Casamance. Despite the concentration of qualified physicians, nursing staff  - 5 - and medical equipment available in national and regional hospitals, they do not serve effectively as referral facilities. Much of their services is for technically simple care to patients who have by-passed health centers because of the low quality of care provided at the peripheral level. 1.12 Regional Services. The organization of rural medical services follows the administrative division of the country into eight regions. Medical regions are headed by a physician, who, as Regional Chief Medical Officer, is in charge of supervising the health care delivery system in the region. Each regional system consists at the apex of regional hospitals and/or endemic disease control centers; at the mid-level, of health centers, MCH centers and maternities; and, at the periphery, of satellite health posts and rural maternities. On average, each regional system serves a population of 600,000 covered by four health centers (serving an area within an average radius of about 64 km) and 45 satellite health posts (serving an average of 12,000 persons within a radius of about 12 km). Within their immediate catchment areas, health centers are (along with many mission owned facilities) major providers of primary health care. In addition, health centers are assigned an important function of programming, supervising and providing technical and patient referral support to village-level primary health care based on health posts and community health workers. The physical conditions of health centers and their quality of care are generally substandard to the extent that many are little more than large health posts. Out of 36 health centers in 1980, only 24 were considered operational and 17 were currently in need of repair. About half of Senegal's 492 health posts are also in poor operating condition. Many health centers are 30 to 50 years old. Basic commodities, such as water, latrines and electricity are unavailable. Technical equipment is missing or in disrepair; laboratory facilities are poor or non-existent. The Government's meagre yearly allocations of essential drugs are often exhausted within six months (para. 1.18), requiring patients to purchase drugs over the counter, thus reducing health centers and health posts to ineffectual dispensaries. In short, Senegal's basic health service network has lost credibility in many parts of the country; it is inefficient and wasteful. Until this situation is rectified, basic health services will be incapable of contributing toward more rapid improvement of the health status of the population at risk. 1.13 Village-level services. As shown in Annex 2, C-2, a new level of care is emerging comprised of rural maternities, village pharmacies, and health huts, owned by village health committees and operated by community health workers. This is a result of the gradual implementation of the Government's Administrative Reform measures adopted in 1972, and its primary health care policy. The 1972 Reform Law decentralized the civil administration, granted greater powers to the regions, fostered the creation of regional and local participatory structures, and created a new peripheral administrative rung called the "rural community." These rural communities, which group several villages within a maximum radius of 10 km., offer an institutional framework for extending the health system to the village level. Governed by Rural Councils, rural communities decide what local development projects would be undertaken with the proceeds of rural taxes, as well as how the community's share of the National Solidarity Fund would be used. A significant portion of these proceeds to date has gone toward supporting community health activities (para. 1.20). From 1974 through 1979,  - 6 - rural communities built and equipped about 190 rural maternities and 170 village pharmacies, and trained rural matrones (midwives) and community health workers with the help of UNICEF. Although they are locally self-managed, the promotion and maintenance of village-level services requires supervisory linkages and logistical support at the regional level, as envisioned under the MOPH decentralization reform. These linkages are weak, and unless they are strengthened --particularly at the health center level--the future of village-level primary health care is seriously in doubt (paras. 2.03 - 2.05). 1.14 Health Personnel. With over 7,000 persons employed in the health sector, and a manpower/population ratio of 1/800, there is no overall short- age of health manpower in Senegal. The geographic distribution and qualita- tive deficiencies in health manpower, however, are key impediments. In the Dakar/Cap-Vert capital area are concentrated 70% of Senegal's physicians, two-thirds of its pharmacists, 62% of its midwives, 44% of nurses and virtually all of its dentists. Annexes 2, T-3 and T-4 show the geographic and functional distribution of health personnel. Mandatory rural service of seventh year medical students and assignment of military physicians to unserved regions have been effective mechanisms to redress physician shortages in rural areas. Throughout the country, there exists a core staff for health centers which includes 1 physician, 1 certified nurse, 1 nurse- midwife and 4 auxiliaries. Core staff for health posts comprises I registered nurse and 1 sanitation aide. There has been a general increase in student enrollment in the Dakar University Medical School even as the Government is attempting to control the size of the public service, particularly in manpower intensive sectors such as health. The MOPH, in addition, has begun to place more emphasis on improved monitoring of its staff, particularly in the outlying regions, and on incentives to attract current and future personnel to rural areas. The provision of staff housing at the health center level, and improved working conditions at health centers and health posts are important steps in this direction. 1.15 Training. Senegal's medical and paramedical training institutions (many of which are accredited under the French system) have not adapted to the epidemiological, social and technical conditions of the country. Inadequacies lie not only in the content of basic and clinical sciences, but also in the transmission of practical skills, insufficient exposure to laboratory sciences, management, reporting, clinical and community work. With the notable exception of the MOPH's School of Advanced Nursing Education (CESSI), the medical and paramedical teaching process transmits professional attitudes and expectations that become sources of frustration when graduates confront field conditions. Qualitative improvements in health manpower are an important adjunct to efforts to improve health status. As a consequence of the deterioration of the basic health service network, many public health personnel in rural areas lack sufficient competence in important skills which they have used infrequently or under poor supervision over the years. These cadres include civilian physicians in rural service, midwives, nurses, technicians and auxiliary personnel. The proliferation of community health workers under Senegal's primary health care policy requires that they be trained by the MOPH at the rural community level, even though they are not employed by the Government. Likewise, physicians, midwives and nurses  -7- operating out of district-level health centers and community-level health posts must receive pre-assignment and inservice training in primary health care. These needs, taken altogether, have caused the MOPH to create its own training capability for conducting inservice training and programs of continuing education. The DRPF (para. 1.10) is in charge of these functions. To date, the training division of the DRPF has acquired a small capable staff, but not the resources for a full-fledged inservice training program aimed at improving the quality and performance level of health center, health post and community-level health workers. UNICEF assistance is being directed principally at initial training of community health workers; other donors, notably American and Belgian, are helping at the health post nursing personnel level. IDA assistance has been sought at the health center level and inservice training of community health workers. 1.16 Drug Supply. The private and public health systems together utilize an extraordinary range of about 6,000 different pharmaceutical products, with a corresponding foreign exchange import bill of CFAF 5 billion (US$18 million). This list contrasts sharply with countries such as Tunisia (with less than 3,000 products). The wide range of imported products attests to the importance of the private drug retail market in urban areas, and the high profit earned by wholesalers and retailers who dominate the urban market. The availability of imported brand-name drugs at the peripheral levels of health care contrasts with persistent shortages of basic drugs such as chloroquine. In an attempt to redress this situation in the public sector, the MOPH has drawn up an essential drug list based on World Health Organization recommendations, and intends to prepare a new vademecum (prescribers' manual) to accompany the list. 1.17 Senegal is fortunate in having its own local drug manufacturing capability that is also expanding into the West and Central African markets. The Socift6 Industrielle Pharmaceutique de l'Ouest Africain (SIPOA) is a joint enterprise with 78% shareholding by the Socifte Financiare France Ingelheim; the remainder is held by the Senegalese Government and a few private Senegalese pharmacists. Its financial position (shown in Annex 2, T-5) is satisfactory, but there is room for improvement which could be stimulated if the Government became more active in encouraging the expansion of private drug manufacturing and distribution. The private drug retail market is dominated by 87 locally owned pharmacies concentrated in Dakar and large towns. About 200 smaller retail depots supply outlying areas; they are authorized to sell only non-injectible basic drugs, but, in fact, also sell a wide range of more profitable items. It is often noted that private sector stocks of basic drug items needed at the rural community level are deficient, possibly due to the small profit margin for these items. Consequently, village health committees have begun to procure drugs directly from the central MOPH which supplies its own public health network with essential drugs at low cost. However, the MOPH has difficulty coping with the supply of both the public health system and the village pharmacies. The solution lies in granting these committees access to the private sector. 1.18 The MOPH manages its drug supplies and the provision of medical material to public health facilities through its Pharmacie Nationale d'Approvisionnement (PNA). Aside from that portion of basic drugs which it  procures locally (mainly from SIPOA), the PNA relies chiefly on a limited number of foreign suppliers. Unfortunately, in the recent past, the PNA was poorly managed and not financially viable. Payment by public health facilities for goods received from the PNA have not been accounted for; many foreign suppliers have gone unpaid. The result has been nonsettlement of PNA accounts with the Treasury, and greater reliance on fewer suppliers at higher cost. Simple laboratory facilities for testing generic and cheaper brand- name drugs from new supply sources are urgently needed. Existing PNA warehouses suffer from a lack of maintenance, equipment and poor ventilation resulting in a loss of stock due to spoilage. PNA inventory management and accounting are inadequate resulting often in insufficient stocks to cover the supply needs of health centers and health posts. Furthermore, annual budget allocations to these facilities are inadequate to cover their needs. Their annual drug allotment is often used up within six months (para. 1.12). Shortfalls are increasingly covered by community health associations (para. 1.21); otherwise, patients are given prescriptions which are filled through over-the-counter purchases at prices many of the urban and rural poor find unaffordable. D. Health Sector Financing 1.19 Recurrent Expenditure. The health sector's share of the recurrent budget has steadily decreased from 9% of the total national operating budget in 1971/72 to only 5.8% in 1981/82. The current budget totals CFAF 6.7 billion (US$20 million), representing about 24% of total estimated national expenditures in the health sector (Annex 2, T-6). About half of the budget is spent on hospital services. Recognizing the need to increase funding for rural services, the National Assembly adopted a resolution in 1981 recommending that the MOPH budget be increased to 9%. However, the Government is unable currently and in the foreseeable future to commit any substantial increase. 1.20 Local Participation. The Government has relied increasingly on local government taxes, user fees, and the financial contributions of community level health associations to increase resources for public health services in rural areas. The 1972 Administrative Reform Act granted each region a greater degree of financial decision making authority. The newly created "rural communities" (para. 1.13) have allocated a significant proportion of their revenue to supporting health services at the village level. In 1980, 33 rural communities in Thies region spent 13% of total tax receipts on health and sanitation; in Casamance, health expenditure was as high as 25%. 1.21 In addition, under the Government's primary health care policy, health associations are being organized with notable success. These voluntary associations represent groups of villages located in the catchment area of health posts and health centers. Each association appoints its own management committee, treasurer and fee collector who collects payment daily from patients when they arrive at these facilities for services. The association's treasurer banks these funds which are drawn upon only with the  -9-_ authorization of the association's executive in consultation with the local public health official. Funds typically are spent on drug purchases, minor repairs and maintenance of health posts and health centers, incentive payments to health volunteers and remuneration of fee collectors. Annex 2, T-7 shows that the scheme is already generating substantial resources. Associations' subsidies now represent on average 38% of the recurrent expen- diture of health posts, and about 15% of the cost of operating health centers. Cofinancing by the State, urban communes, rural communities and village health associations can therefore be relied upon to finance an increasing portion of the recurrent cost of local health services. Once again, the Government recognizes that it must rapidly improve the technical performance and efficiency of health centers and health posts--to make them more credible service providers--in order to assure continued support by the population. 1.22 Investment Budget. The MOPH investment budget earmarked in the Fifth Plan (1977-81) was CFAF 8.8 billion (US$26 million) representing about 2.3% of the Government's total investment budget. Weaknesses in the MOPH's capacity to prepare and implement investment projects, however, resulted in actual expenditures of only CFAF 4.1 billion, or about 47% of the target budget. About 80% of these investments were financed and carried out by external assistance or through supplier credits, and concentrated on the construction of national and regional hospitals. Forty-six percent of the Fifth Plan projects were based in the Dakar/Cap-Vert capital region, 10% in neighboring Thies, and the remainder divided among the other six regions with an average of 5% per region. The 1982-87 national health development plan's emphasis on upgrading the basic health service network, and on the development of an expanded program of immunization at the community level represents an important shift of emphasis in favor of rural areas. 1.23 External Assistance. French aid has since Independence represented about one-half of total aid in the health sector (Annex 2, T-8). Over 75% of French aid in the past has been in the form of technical assistance to the hospital and endemic disease control centers. France is now, however, the major contributor to an expanded immunization program. Canada pioneered in supporting primary health care activities at the community level in Sine Saloum region. UNICEF, Belgium, the United States and the French Volontaires du Progress have since followed in expanding Senegal's primary health care program. The United States and UNFPA are also supporting Senegal's family planning program. The World Health Organization has played a major advisory and technical assistance role to date, and is considering supporting the creation of a regional health development (training) center in Senegal. German aid has concentrated in the hospital sector but is expected to support health service maintenance in the future. Brazil and Italy are providing lines of credit for medical equipment at the health center level; Switzerland is doing the same to upgrade and re-equip 234 health posts. These are important, well-chosen investments aimed at testing the feasibility of primary health care on a pilot scale in urban and rural areas. However, there has been very little aid coordination to date, in part due to the piecemeal, sub-regional nature of many projects as well as the weak planning and coordination capability of the central MOPH. In the past, most aid has flowed to the two extremes of the system - hospitals and the urban commune or  - 10 - village levels - thereby leaving the middle tier of health centers and health posts seriously neglected prior to the current Plan period. II. HEALTH SECTOR STRATEGY AND CONSTRAINTS A. Strategy 2.01 It is evident that there has been a rising demand, and willingness to pay, for health services in Senegal. The Government's health sector policy and Sixth Development Plan reflect this situation and are based on the primary health care strategy (para. 1.07). The major components of the Government's strategy are as follows: (a) To give renewed priority to preventive measures, by strengthening programs in environmental sanitation, nutrition surveillance and rehabilitation, health education, maternal and child health care and family planning, and malaria prevention; and by introducing an expanded program of immunization (EPI), designed to achieve 75% immunization coverage of children 0-2 years of age against seven diseases. (b) To cover all villages by the year 2000 with a framework of village health volunteers under the supervision of the public health system (nurses and physicians) and supported by a referral system of health posts and health centers. (c) To develop and expand cost recovery mechanisms throughout the health system, while strengthening community participation and control over financial, resources generated at the village level. (d) To improve the management and distribution of basic drugs to public health facilities and local communities in accordance with a restricted list of essential drugs for each level of care. (e) To upgrade the entire network of health centers and health posts so that they are able to serve as (i) fixed-points from which to manage the EPI, environmental sanitation, health education, family planning, nutrition and other outreach programs, (ii) primary levels of care for surrounding communities, and (iii) centers for patient referral. (f) To improve the performance of all categories of health personnel working in rural areas through refresher courses, in-service training, and continuous education. (g) To develop an appropriate planning, implementation, management information and evaluation capability within the MOPH.  - 11 - B. Key Constraints 2.02 This strategy is an appropriate response to current health condi- tions in Senegal. With its emphasis on prevention, MCH services, family planning, nutrition, health education and improved curative services for the rural poor, it is both comprehensive and ambitious. For example, to achieve 75% immunization coverage of eligible children at current birth rates would mean reaching approximately 200,000 children each year. Maximum coverage attained to date has been 50%; effective coverage in terms of delivery of efficacious vaccines to children at the appropriate ages has been only about 20%. 2.03 Nevertheless, the primary health care program is moving forward in Senegal with political commitment and with a mixture of successes and disappointments. The most impressive achievements to date are the development of cost recovery mechanisms through community participation, together with the promotion of a new service stratum of village health huts, pharmacies and community health workers all managed by the rural communities concerned. The structuring of community level services is most evident in the peri-urban suburb of Dakar (Pikine), and in the Sine Saloum, Casamance and Senegal Oriental regions which have benefitted from external donor support and field level technical assistance. Evaluation of the major pilot schemes range from the unqualified success of the Pikine experiment, to the initially disappointing experience of the USAID funded village level primary health care project in Sine Saloum. The Sine Saloum project was designed to build, equip and provide an initial stock of drugs for 600 village health huts, each staffed by a health worker, a birth assistant and a sanitary worker. Villagers were expected to pay for the medicines and services of the health team who were to have been supervised by the health post, and trained by appropriate staff from the health post and health center. 2.04 In 1980, a joint Government of Senegal-USAID evaluation team found that one-third of the huts constructed in one area of the project zone had closed within 9 months after construction. The evaluation identified three vital elements which must function effectively for the project to survive: (i) huts must be financially viable; (ii) the Government must deliver adequate support and supervision; and (iii) an efficient medicine resupply system must be organized. In addition, matters such as the selection of health workers, location of huts, drug procurement procedures, transportation, and project management style were identified as major constraints. It was recommended that the project be scaled down, and its design reassessed particularly with respect to location and size. Other successful experiments elsewhere in the Sine Saloum have emphasized payment for services, information campaigns and logistics over the creation of community level infrastructure. 2.05 Primary Health Care Pre-Conditions. Primary health care is a system of health services, not a string of health outposts nor a proliferation of unsupported community health volunteers, village health huts and pharmacies. The Government has thus correctly identified a major constraint surrounding the implementation of its primary health care policy:  - 12 - community and external donor investments at the rural periphery can be sustained only if, as a pre-condition, resources are directed toward developing a credible basic health service network in rural areas. The growth of community participation and village health services are increasing demand and pressure on a poorly equipped, weakly managed public health system. At the same time, the health centers are increasingly being identified as strategic fixed points for integrating and coordinating key preventive and curative programs, including the expanded program of immunization. Their viability is a clear prerequisite for purposes of: (a) providing effective primary health care to the population immediately surrounding them; (b) serving as receiving points for patients, particularly mothers and children, who have been identified at the village level as being at risk and in need of immediate outpatient or hospital care; and (c) guiding and coordinating village level primary health care programs. 2.06 Emphasis on Health Education. The current curative emphasis of the primary health care program reflects a strongly felt need for quality care; this, however, must be used as a vehicle that leads to greater awareness of disease causation and prevention. The Government recognizes that the community health associations provide a new opportunity for promoting health, nutrition and family planning education by using committee representatives as educators known to and respected by their communities. The MOPH's health education service has rudimentary resources which do not permit it to produce, test, evaluate, commission and disseminate appropriate information. To overcome these constraints, the MOPH has taken an important initiative by planning to create a small national health education center whose activities would concentrate initially on programming, training, and light production of information aids. 2.07 Appropriate Nutrition Interventions. Because they increase susceptibility to disease, alleviation of the seasonal nutrition problem (para. 1.06), malnutrition and anemia, is an important preventive aspect of the primary health care strategy. In the wake of the 1968-74 Sahelian drought, the Government placed increasing emphasis on the prevention of malnutrition through nutrition surveillance and rehabilitation, accompanied by the promotion of more nutritious local weaning foods, vegetable gardens, and nutrition education. The primary mechanism for redressing malnutrition has been the Nutritional and Health Protection (PPNS) Program's nutrition surveillance, education and feeding activities under the Ministry of Human Promotion. However, the value of supplementary feeding has been increasingly challenged in terms of its effect on improving child growth. Vegetable gardens have met with very limited success. In an initial attempt to obtain IDA support for a nutrition project which included a primary health care component, the Government received an IDA project preparation facility (PPF) advance to conduct scientific field surveys and to draw up more viable nutrition interventions. These surveys have provided important health sector baseline data of potential use in evaluating future changes of health status. However, following a review of the preparation studies, it was decided that an Integrated Food and Nutrition project was not appropriate at present given the complexity of proposed village-level interventions and the degree of institution-building that would be required. The Bank is helping to draw up administratively feasible nutrition interventions on the basis of these studies, which can be used by the Bank to incorporate certain  - 13 - activities in its projects in relevant sectors and by the Government to mobilize external assistance from other sources. The disbursed portion of the Food and Nutrition PPF advance would be refinanced under the proposed Health project (para. 4.07). 2.08 Family Planning. Constraints to a rapid increase in family planning acceptance include the strong social value placed on children, the high probability of infant deaths, and cultural reticence or opposition to matters related to contraception. As part of its efforts to create a constituency for family planning, the Government has taken important steps since 1979 by: (a) establishing a National Population Commission to develop population policy recommendations for incorporation into the Sixth National Development Plan; (b) creating in the Ministry of Planning and Cooperation a population unit, with UNFPA technical assistance, to integrate demographic variables into national economic development planning; and (c) assigning family planning education to the Secretariat of the Human Promotion, and the delivery of family planning services to the MOPH. The Government's approval in 1979 of its first officially sanctioned family planning project (to be implemented first in the main Dakar MCH center, then in MCH centers in four regions, and finally on a pilot basis through the primary health care facilities under development in the Sine Saloum) stands out as a key expression of commitment. 2.09 However, achievements have fallen short of expectations. The National Population Commission is still in the process of developing a population policy. The first USAID family planning project is just getting underway in part because of past confusion (since clarified) about the respective roles and responsibilities of the MOPH and the Secretariat of Human Promotion. It is expected that, in regaining initiative and making up for lost time, the USAID-financed project will set the stage over the next three years for introducing family planning services into rural areas at the MCH and health center levels (para. 3.03). 2.10 Emphasis on Improved Drug Supply. The provision of basic drugs to peripheral levels of care and rural consumers is unreliable and, as such, is a major impediment to the development of primary health care. This contrasts sharply with the unusually wide range of available imported non-essential drugs. To redress this situation, the Government has begun to reassess the needs of the pharmaceutical sector with a view toward developing a national drug policy which strengthens the role of both the private and public sec- tors. Such a policy would favor the private sector in part by reassessing the profit margin for the sale of basic drugs at rural drug retail outlets, and by enlarging the range and distribution of locally manufactured drugs. With regard to the public sector, the Government intends progressively to improve the organization and management of the PNA. The MOPH has already obtained IDA assistance, through a PPF advance, to (a) examine the management needs of the PNA, and (b) to undertake an external audit of the PNA's assets and liabilities. The audit will assist the Government in determining the magnitude of unpaid accounts, prior to drawing up a program for settling past accounts and improving the PNA's accounting, payment and management procedures (para. 3.14). 2.11 Cost of Primary Health Care. The key issue confronting the health sector at this time is, without doubt, the growing need to estimate the total  - 14 - cost (capital and recurrent) of expanding the primary health care program on a nationwide basis. This needs to be assessed against the availability of resources through the national budget, the rural community contributions and external assistance in order to design a phased program to match the resources. Furthermore, the cost burden on peri-urban and rural communities for supporting basic health services is not shared by urban residents, who continue to receive free outpatient care in most hospitals. Equity considerations, and the need to begin shifting greater Government resources toward satisfying basic pre-conditions for primary health care, have already prompted the Government to extend the principle of fees for service experimentally to two hospitals in the Fleuve region. This experiment will be evaluated as a part of the project (para. 3.16 (b)). C. Need for the Project 2.12 Despite the Government's initial success in attracting widespread local and external support for its primary health care policy, several important problems continue to affect the quality, efficiency and coverage of Senegal's health, family planning and nutrition programs. To redress past emphasis on urban health services, particularly hospitals, there has been a dramatic shift of political emphasis toward the promotion of services at the village level where, by all indications, there is a widespread felt need for improved, accessible health services. This swing of emphasis, however, has preceded and far outstripped the Government's ability to put in place some basic pre-conditions for supporting its new policy. Although the central MOPH was restructured and decentralized to facilitate the integration of preventive, curative, MCH and family planning services, it is still a long way from acquiring adequate technical capability in planning, coordinating and implementing the Government's policy. Likewise, few resources have been made available to improve the training of central and regional MOH administrators as well as physicians, nurses, midwives and technicians in rural areas--all of whom are critical inputs in developing primary health care programs. Past curative emphasis associated with urban hospital services is likely to persist unless health education programs are developed around preventive, MCH, family planning and nutrition themes. Most importantly, the circumvention of Senegal's basic network of health centers and health posts in an attempt to develop services at the grassroots level has been shown to lead to failure. But, to make health centers and health posts strategic fixed-points from which to guide and coordinate programs close to the community, it is necessary first to re-establish their credibility by upgrading their performance. In addition to efforts currently underway by local municipalities and rural communities to upgrade the network of health posts, the Government has obtained assistance from Switzerland and the United States to renovate a total of about 250 health posts in greatest need of repair. Current United States' aid to improve the quality of trained health post nurses is expected to expand. With regard to its health centers, the Government seeks IDA assistance in helping to transform them first into viable centers of integrated health care with a view toward reaching out and managing primary health care programs at the rural community level.  -15 - III. THE PROJECT A. Project Objectives 3.01 To provide adequate technical, logistical and management support for Senegal's primary health care, nutrition and family planning efforts, the proposed project would: (a) strengthen the basic health services at the health center level; (b) improve the training of health service providers; (c) improve the supply and utilization of basic drugs; (d) develop health education services; and (e) strengthen the capability of the MOPH to plan, implement and evaluate activities in support of primary health care. As such, the project would strengthen institutional and health service capability. The project was prepared by the MOPH during 1981, with the support of consultants and advances through IDA's project preparation facility (para. 4.07). The project marks IDA's first operation in the population, health and nutrition sector in Senegal, and consequently was prepared with a view toward keeping the project as simple as possible, without expanding the sector at a time of severe economic constraint, and without intervening directly at the village level during this initial, nationwide health project effort. Because of the difficulties of the health sector in Senegal, emphasis has been placed in this project first on setting up credible primary and secondary health services and support systems capable of subsequently moving on to manage outreach programs at the village level. This capability barely exists at the present time. B. Project Composition 3.02 In summary, the project would: (a) Strengthen Basic Health Services: (i) The construction and equipment of new facilities to replace 5 functionally inadequate health centers; and the renovation and re-equipment of 4 existing centers; (b) Upgrade the Training of Health Personnel: (i) Three years of specialist services, teaching materials, equipment and incremental operating costs for field training of medical and paramedical students; refresher/inservice training for health center staff, as well as community  - 16 - health workers; and the design of a long-term national inservice training program for health center and health post personnel and community health workers. (c) Improve the Supply and Utilization of Basic Drugs: (i) Minor upgrading/renovation and equipping of the central Pharmacie Nationale d'Approvisionnement (PNA) and three regional pharmacies; together with vehicles for the national PNA; (ii) Equipment to develop a PNA drug testing and quality control laboratory; (iii) Specialist services, teaching and research materials and incremental operating costs for preparation of an essential prescription manual, and for orientation of doctors, nurses and midwives in its use; and (iv) Three years of specialist services to audit the PNA accounts; improve PNA's management and distribution capability; train PNA staff; and develop a national pharmaceutical policy. (d) Improve Health Education Services: (i) The construction and equipment of a national health education center, including the provision of educational materials for the center; (ii) Audiovisual equipment, furniture, educational materials and vehicles for regional health education services; together with audiovisual equipment and educational materials for 36 health centers; (iii) Four fellowships and local training for MOPH health education personnel; and (iv) Two manyears of specialist services to assist in developing program material and inservice training activities in health education. (e) Strengthen MOPH's Planning, Implementation and Evaluation Capability: (i) Equipment and furniture for the central MOPH Directorates of Research, Planning and Training (DRPF), General Administration and Equipment (DAGE), and Hygiene and Health Protection (DHPS), Directorate of Pharmacy, and the Public Health Inspectorate; (ii) Provide the DRPF, DAGE and DHPS with 8 fellowships, and with about six manyears of specialist services to assist in developing a capability in health sector planning, personnel monitoring, improved financial monitoring and reporting, and  - 17 - pre-investment studies; and (iii) Support of a project management unit (PMU) within the MOPH including office materials, operating costs and specialist services in procurement, architectural design, the supervision of construction and external auditing. (f) Support activities undertaken for the preparation of an integrated food and nutrition project, as well as the proposed health project (para. 2.07 and Annex 2, T-15). C. Detailed Project Features Strengthening Basic Health Services 3.03 As mentioned in paras. 2.05 and 2.12, Senegal's 36 health centers are key elements of the basic health service network and important for the establishment of primary health care. The project, as designed, provides a package of services to be conducted on a standardized basis in all health centers in accordance with the following functions: (a) Family planning and MCH Services (prenatal care, routine and complicated deliveries, postnatal care, child care); (b) Immunizations (children 0-2 years; others); (c) Health, Family Planning and Nutrition Education (within and outside the health center); (d) Endemic/Epidemic Disease Surveillance and Reporting (liaison with special disease control programs against malaria, tuberculosis, leprosy, and sexually transmissible diseases); (e) General Outpatient Services; (f) Sanitation Inspection; (g) Emergency Care; (h) Administration, Training, Referral of Patients to Hospitals; and (i) Supervision of Health Posts and Community Health Workers. 3.04 The development and standardization of these activities--most of which already comprise the official functions of existing health centers-- would be the responsibility of the MOPH's Directorate of Hygiene and Health Protection (DHPS) supported by the proposed project management unit (PMU) (para. 3.17). The PMU (for which an organization chart is shown as Annex 2, C-3) would be staffed in part by a medical officer, planner, trainer and family planning advisor whose responsibilities would include frequent tours to the health centers to guide the implementation and conduct the evaluation of this component.  - 18 - 3.05 In view of their poor physical condition and the importance of their catchment area, the project would reconstruct, equip and furnish dilapidated health centers at Dagana, Dahra, Bakel, Guinguineo and Koungheul. The existing centers at Fatick, Goudiry, Kolda and Kedougou would be renovated, re-equipped and furnished. Their catchment areas are estimated to cover a total of 660,000 beneficiaries, many of whom are in high density or outlying areas where the health center is the major available medical facility (see Map 16326). 3.06 These facilities and services determined the standards for the scheduled upgrading of 8 additional health centers to be financed by the Government (thereby upgrading a total of 17 facilities most urgently in need of physical improvement), and the design standards adopted minimize costs for the level of services required. The health centers would have on average of 40 beds, depending on actual and projected catchment. On-site housing would be provided for the resident physician and midwife. Space would be provided for sanitation services and for inservice training and health education. 3.07 Design and supervision of construction of the five new health centers would be the responsibility of the Ministry of Urbanism, Habitat and Environment (MUHE), in accordance with an architectural program drawn up by the MOPH, and in liaison with the MOPH staff architect assigned to the pro- posed PMU. Renovation of four additional centers would be supervised by consultant architects to be appointed by MUHE (paras. 5.02, 5.03). The upgrading and re-equipping of 234 out of Senegal's 472 health posts with Swiss Government support, together with the proposed uprading of health centers, will cover most of the immediate infrastructure needs at the peri- phery of the public health system. The Government has provided a list of those health posts (in the catchment areas of the 9 health centers financed under the proposed project) which have been upgraded or are scheduled to be upgraded during the life of the project. Training 3.08 Objectives. In attempting to strengthen basic health services, the project would: (a) support field training in public health; and (b) develop the inservice training of health center staff and community health workers. 3.09 Categories and Targets. The project would improve the practical training of an estimated 50 final-year or recently graduated medical and nursing students who are expected to serve the health centers over the life of the project. Each medical student is expected after graduation to serve for two years in a rural health center. The project would also provide priority inservice training to about 60 midwives, 60 certified nurses and 36 head nurses at the health center level. The remaining staff of the health centers--registered nurses (25), practical nurses (165), auxiliaries (290), technicians (70), maintenance workers (105) and administrative/secretarial staff (72) would receive inservice training on site at the health center. Finally, about 2,000 community health workers would be eligible for training under the project.  - 19 - 3.10 Implementation. Field work in public health, primary care, family planning and management would be conducted in the Mbour, Joal and Fatick health centers under the direction of the Dakar University Medical School. Pre-assignment and inservice training courses would be organized by the MOPH and delivered at select regional medical headquarters (St. Louis, Kaolack and Ziguinchor). All other courses would be conducted at the health center level or satellite health post(s). The MOPH is already assessing the training needs with the use of PPF funds. The project would provide about three years of technical assistance to help the MOPH to: (i) plan, prepare materials and implement the training; (ii) evaluate the project training program; and (iii) on the basis of this evaluation, develop a long-term national MOPH inservice training program and assess how the training programs of other donor-financed projects could be integrated. During negotiations, the Government provided assurances that, by the end of the third year of the project, it would prepare and submit to IDA for review the proposed continual inservice training program for health center and health post personnel as well as for community health workers, and subsequently take steps to implement this pro- gram. Improved Drug Supply and Prescription 3.11 Supplies. Drugs are the life-line of the primary health care sys- tem and, as mentioned in paras. 1.18 and 2.10, inefficiencies in public sector drug procurement, storage, inventory control, transport, usage and financing have been constant problems. The project would assist with modest renovations of the existing central PNA in Dakar, particularly improved warehouse ventilation, and provide basic equipment (shelves, fork-lifts). Similar assistance would be provided to the only existing regional PNA pharmacy in St. Louis. To assist in developing other regional PNA facilities, the project would convert two regional hospital drug depots at Kaolack and Ziguinchor to serve as regional pharmacies. The central PNA would be provided with two vehicles to supply the network of regional pharmacies. As the PNA lacks the capability to test the quality of imported drugs and their ability to withstand climatic conditions in Senegal, (thus discouraging attempts to procure generic and other brand-name drugs more cheaply), the project would provide equipment to the PNA's central laboratory to develop a more appropriate drug testing capability. During negotiations, the Government provided assurances that, by the end of the second year of the project, it would undertake drug testing at the PNA laboratory for which purpose adequate PNA laboratory staff would be promptly selected and given training to upgrade their skills. 3.12 Prescription. To guide doctors, midwives, and nurses in using the new MOPH essential drug list (para. 1.16), the project would prepare, publish and disseminate a new prescribers' manual. The project would provide two manmonths of consultant services to assist in preparing the manual and organizing brief orientation sessions for about 260 practicing physicians, 350 midwives and 1,400 nurses. 3.13 PNA Management and Development of National Drug Policy. In res- ponse to the need to strengthen the PNA's procurement, inventory, accounting  - 20 - and distribution capability, and to develop a national pharmaceutical policy which strengthens the role of the private and public sectors, the project would provide about three manyears of technical assistance to assist in: (a) improving the PNA's distribution and administrative procedures; (b) establishing an appropriate PNA accounting system; (c) training PNA staff in inventory management and laboratory techniques; and (d) developing a national pharmaceutical policy, which would inter alia ensure a more active role for the private sector in the marketing of basic drugs. 3.14 To these ends, assurances were obtained during negotiations that the Government of Senegal would undertake the following specific actions: A. Measures in respect of MOPH 1. Assure that for its fiscal year 1983/84 and for all fiscal years thereafter, the budget allocation for drugs will be separately specified for each health facility, in particular health centers and health posts. B. Measures in respect of PNA's accounts 1. Assure that the initial audit of the PNA shall be completed before the end of the fiscal year ending June 30, 1983, and that annual audits shall identify all operations of PNA. 2. Undertake all necessary measures to settle all amounts due in respect of PNA's activities promptly and not later than six months after completion of the initial audit referred to in B. 1 above. C. Measures for the purpose of strengthening PNA's management capability 1. On the basis of the findings and recommendations of the its PNA management study, promptly take appropriate measures in consultation with IDA for strengthening the management of PNA. Subsequently, in consultation with the Association, (i) take such further measures for strengthening PNA's management capability and operations as shall be appropriate in view of the recommendations of technical assistance teams financed under the project; and (ii) review the effects of such measures annually.  - 21 - D. Measures in respect of PNA's drug supply system 1. Develop and implement an appropriate policy for drug pricing, procurement and distribution which shall, inter alia: (a) ensure that all expenses incurred on account of PNA's drug distribution operations shall be covered by revenues from the sale of drugs; (b) ensure a more active role for the private sector in the marketing of basic drugs in Senegal; and (c) allow private non-profit organizations, including community health associations, to procure drugs directly from domestic pharmaceutical manufacturers on the basis of arrangements between PNA and any such manufacturers. This policy is expected to be developed in consultation with the Association and implemented by December 31, 1983 and its adequacy shall be reviewed annually in consultation with the Association. 2. Take all measures necessary to induce domestic pharmaceutical manufacturers to enlarge their production range, and distribution capability. 3. Prepare and publish by March 31, 1983 a list of approved basic drugs for hospitals, health centers, health posts and village health associations. Health Education 3.15 As the present ability of the MOPH is weak with regard to producing and disseminating appropriate public health information in support of primary health care, maternal and child health services, and family planning (para.2.06), the project would construct, equip, furnish and provide materials for a small national health education facility in Dakar. The proposed center (360 m2) would limit production initially to simple printed material. It would store and circulate film material produced by the Ministry of Information or obtained from overseas. It would serve as the central office of the MOPH health education division and as a venue for seminars regrouping regional health educators. Two manyears of specialist services would be provided to help set up the national center, to develop program material and inservice training activities, and to undertake a performance evaluation at the end of the fourth year of the project. The project would provide fellowships for training one national level cadre (future Director of the Health Education Center) in public health and health education, and for training four regional health educators. At the regional level, the project would provide furniture, equipment and vehicles for regional health education services, and light audiovisual equipment for all of Senegal's 36 health centers. This component is expected to benefit the population served by health centers and health posts.  - 22 - Strengthening MOPH's Planning, Implementation and Evaluation Capability 3.16 Planning. Since the MOPH's planning directorate (DRPF) was created in 1979, staff have been receiving training overseas and are expected to take up their positions during the course of implementation of the proposed project. The project would strengthen the MOPH planning capability by providing eight fellowships for training central MOPH staff in health personnel planning, public health, and health statistics. The project would provide about six manmonths of specialist services in physical planning of health facilities, and one manyear in personnel planning. In addition, office furniture and equipment would be made available for the DRPF, DAGE, DHPS, the Directorate of Pharmacy, and the Public Health Inspectorate which make inputs into the planning process. To permit the DRPF to develop further the project identification and formulation process begun during the preparation of this project, the project would finance consultant services provided to the DRPF for pre-investment studies with a view toward the: (a) preparation of proposals for setting up an improved MOPH financial planning, monitoring, reporting and evaluation system; (b) preparation of a cost and feasibility analysis of a nationwide primary health care program; (c) improvement of monitoring of personnel; and (d) establishment of outreach programs and projects for strengthening primary health care activities including nutrition at the community leve' These studies should be completed by the end of the fourth year of the project with a view toward possible preparation of a second health project which will be contingent upon satisfactory performance of the first project as indicated by the midterm evaluation of the project (para. 5.11). 3.17 Implementation. To strengthen the MOPH's project implementation and coordination process, the project would support a project management unit (PMU) within the MOPH (organizational details are given in para. 5.02, and an organization chart is provided in Annex 2, C-3). The PMU would be responsible for coordinating implementation of the proposed project and would authorize all project related expenditures. To ensure that the PMU liaises closely with key MOPH directorates involved in the project (DRPF, DHPS, DAGE, the Directorate of Pharmacy and the Directorate of Procurement of Drug Supplies and Medical Equipment), the PMU director would participate in the weekly MOPH coordination meeting of Directorate heads and technical advisors which is conducted by the Minister of Public Health. The Directors of the DRPF, DHPS and the PMU would also organize periodic meetings to review the implementation progress of primary health care projects. Donor representatives would be expected to participate from time to time. To set up the PMU, the Government has received an IDA project preparation facility advance (para. 4.07) to provide office furniture, equipment and vehicles, and  - 23 - to enter into contract with an accounting firm which would: (a) design a PMU accounting system prior to credit effectiveness; (b) audit PMU accounts; and (c) conduct an initial audit of the PNA. The project would provide two manyears of specialist services in procurement to assist the PMU in acquiring equipment financed under the project. In addition, the project would provide operating expenses for the PMU including office supplies, vehicle operation and maintenance, salary supplements for MOPH staff seconded to the PMU, salaries for contract staff, fees and travel allowances. The MOPH's Inspector of Administrative and Financial Affairs would be responsible for monitoring and evaluating the performance of the PMU. 3.18 Evaluation. To strengthen the MOPH evaluation capability, the project would provide office equipment, materials and operating costs, including transportation, to design an appropriate statistical/information system. Two manyears of specialist services would be provided to assist in the design. Short-term local training for seven statisticians is also included. The evaluation system would be designed to provide a small data base for evaluating the impact of the health center component of the project. Annex 2, T-9 shows the key evaluation indicators envisioned. DRPF would take the lead in conducting the evaluation as well as the midterm review of the project and in coordinating the health education and training evaluation. In addition to monitoring and evaluating the performance of the PMU, the MOPH's Inspector of Administrative and Financial Affairs would review all proposals for improving the management of the PNA and evaluate their implementation. IV. PROJECT COST AND FINANCIAL PLAN 4.01 The total project cost including contingencies is estimated at US$16.7 million equivalent net of taxes. The estimated costs and foreign exchange components, given in Annexes 2, T-10, T-11 and T-12 are summarized as follows:  - 24 - TABLE 4.1 SFNF1DA HEALTH PROJFCT PRaJECT 0(ST SUR4RY (CFA Million) (US$ Million) % of Foreign % of Total Local Foreign Total Local Foreign Total Exchange Base Costs A. HEALTH SERVICE STRENGTHENING AND TRAINING a. Health Center Infrastructure 1,250.3 818.1 2,068.4 3.7 2.4 6.1 39.6 49.7 b. Trainiag Health Personnel 132.4 135.7 268.1 0.4 0.4 0.8 50.6 6.4 Sub-Total Healtlh Services 1,382.7 953.8 2,336.5 4.1 2.8 6.9 40.8 56.2 B. BASIC DRUGS a. Depot Construction/Renovation 92.5 259.6 352.1 0.3 0.8 1.0 73.7 8.5 b. Training of Prescriptors 1.1 9.8 10.8 0.0 0.0 0.0 90.2 0.3 Sub-Total Basic Drugs 93.5 269.4 362.9 0.3 0.8 1.1 74.2 8.7 C. HEALTH EDUCATION a. Physical Facilities 77.1 156.4 233.5 0.2 0.5 0.7 67.0 5.6 b. Health Fducation Training 5.0 5.2 10.2 0.0 0.0 0.0 51.2 0.2 Sub-Total Hiealth Education 82.1 161.7 243.8 0.2 0.5 0.7 66.3 5.9 D. CENTRAL MOPH a. DAGE/DRPF/DHPS 19.8 77.5 97.3 0.1 0.2 0.3 79.6 2.3 b. Staff Training 13.9 44.1 58.0 0.0 0.1 0.2 76.0 1.4 c. Project Management UJnit 496.6 217.2 713.8 1.5 0.6 2.1 30.4 17.2 d. Information & Evaluation 21.8 60.6 82.5 0.1 0.2 0.2 73.5 2.0 Sub-Total Central MOPH 552.2 399.4 951.6 1.6 1.2 2.8 42.0 22.9 E. REPAYMENT PPF 92.0 173.7 265.7 0.3 0.5 0.8 65.4 6.4 Total BASELINE CMSTS 2,202.5 1,958.0 4,160.5 6.5 5.8 12.2 47.1 100.0 Physical Contingencies 139.7 119.1 258.8 0.4 0.4 0.8 46.0 6.2 Price Contingencies 858.8 395.6 1,254.4 2.5 1.2 3.7 31.5 30.2 TOUML PROJECT OO'TS 3,21D.0 2,472.7 5,673.8 9.4 7.3 16.7 43.6 136.4  - 25 - 4.02 The cost estimates for civil works and furniture are based on con- tracts awarded in Senegal during the period 1979-81 and on MUHE cost estimates. The September 1982 Dakar base construction cost for health center facilities is estimated at about US$299/m2 and this relatively low cost reflects the simple facilities proposed by the MOPH. In-patient accommodation, including maternity facilities, accounts for 33% of new center construction costs or about $4,190 equivalent per bed place. About 26% of the health center construction cost is for staff housing and simple shelter for visiting relatives. The facilities to be provided will be functional but also the minimum necessary to achieve the basic objectives of the project. The cost of local architectural and engineering consultants is estimated at about US$40,000 per staff year. The base cost of expatriate specialists based on recent recruitment experiences of international organizations and the Government is about US$100,000 per year including travel and housing. 4.03 For unforeseen physicial conditions, 10% has been added to the base cost for civil works and for architectural/engineering services; 10% has been added to the base costs for furniture and equipment. Estimated price increases are based upon the application of the following annual percentage rates of price escalation from the base cost date (September 1982) in accordance with the implementation schedule (Annexes 2, T-12 and T-13). Table 4.2 Construction 1983 1984 1985 1986 1986 Foreign 8.0 7.5 7.0 6.0 6.0 Local 15.0 12.0 10.0 10.0 10.0 Other Local and Foreign 8.0 7.5 7.0 6.0 6.0 The estimated local price increases for construction are based on recent trends and forecasts by the Ministry of Equipment. These have been reviewed by Bank Group Staff and found appropriate. 4.04 Foreign Exchange Component. The foreign exchange component of US$7.3 million equivalent or 44% of total project costs has been calculated as follows: (a) civil works: 25%; (b) furniture: 60%; (d) equipment, vehicles and materials: 90%; (e) architectural/engineering services: 50%; (f) specialist services: 80%; (g) auditing and accounting expenditures: 60%; (h) fellowships: 70%; (i) Project Preparation Facility advance: 60%; (j) preinvestment studies: 34%; and (k) operating costs: nil. In line with Government policies and practices, goods and services financed from the credit will be excempt from customs and duties and taxes. 4.05 Financing Plan. An IDA credit of SDR 14.2 million (US$15.0 million equivalent) would represent 90% of the total project cost net of taxes. The credit would finance the foreign exchange costs and 82% of local costs. The overall financing plan would be as follows:  - 26 - Table 4.3 Financing Plan US$ Million Equivalent Category Govt. IDA TOTAL 1. Construction - 6.76 6.76 2. Furniture, Equipment, Vehicles & Materials 0.17 2.26 2.43 3. Architectural/Engineering, Technical and Fellowships - 2.23 2.23 4. Project Preparation Facility - 0.78 0.78 5. Pre-Investment Studies - 0.78 0.78 6. Operating Costs 1.43 - 1.43 7. Initial Deposit IDA Special Account - 0.60 0.60 8 Initial Deposit in Local Revolving Fund 0.10 - 0.10 9. Unallocated - 1.59 1.59 TOTAL 1.70 15.00 16.70 4.06 In any year during project implementation, the maximum Government contribution would be US$0.67 million equivalent. Additional annual recurrent costs generated by the project when it is fully operational in 1988 are estimated at about US$0.26 million equivalent per annum or about 1.3% of the estimated total recurrent expenditures of MOPH for 1981/82. Project generated incremental costs are low principally because all facilities would replace or upgrade existing buildings. Except for a few temporary (contract) PMU staff, the project would not require new personnel to be posted. Rising demand for services at the health center level would be partly supported by user charges and the financial contributions of local communities (para. 1.21). Nevertheless, during negotiations the Government provided specific assurances that health centers will be adequately staffed, that it will operate all facilities appropriately, and ensure adequate maintenance of all buildings, furniture and equipment provided by the project. 4.07 Project Preparation Facility (PPF). An advance ($400,000) was made for preliminary nutrition studies, (para. 2.07). Of this, about $351,500 has been disbursed so far and the remaining funds will be cancelled. Advances of up to $430,000 were made for pharmaceutical, health center and training studies; site surveys; preliminary architectural design work; the initial costs of technical assistance specialists and the procurement of miscellaneous furniture and equipment. These expenditures are included in the overall cost of the project. Annex 2, T-15 provides a summary of these PPF authorized expenditures.  - 27 - V. PROJECT 1iMPLEl 0, .OUcLR&iS DISBURSE)CMT AND AUDITING Implementation 5.01 The project would be implemented over a period of six years including one year for completion of payments and withdrawals. The project is expected to be completed by December 31, 1987 with a closing date of December 31, 19E8. Construction of the main element of the program, health centers, is expected to start before the end of 1983. Preliminary project implementation work is well underway: training needs are currently being reviewed; equipment lists were drawn up as a part of the Government preparation document; MOPH and MUHE have prepared designs for the five new health center facilities; and consultant architects for the renovation of four existing health centers have been selected. Administration 5.02 The MOPH has identified the following principal positions as needed for coordinating the administration of project implementation: a director, who is a senior MOPH official, a technical director/medical officer, a MOPH staff architect, office administrator/procurement officer, and an accountant. Staff to fill all positions have been selected. The team would be supported part-time by a planner, a training coordinator, a drug advisor, a family planning advisor, by 4 years of specialist services to strengthen planning and project organization, and by clerical staff. The project would pay the salaries and allowances of the administrative/procurement officer, accountant. and support staff (1 secretary, 1 typist, 3 chauffeurs, 1 maintenancen <:A ` : ;,achman, and 1 messenger). As the prevailing Government travel and subsistence allowances are insufficient to permit effective field work, the project would finance field trip expenses for key project staff, including the di-rector and medical officer. This would enable them to travel frequentl, 7: - nloect zcnes in an effort to evaluate implementation performanc: a, organizational structure of the proposed project management unit is shown in Annex 2, C-3. The formal establishment of the PMU is a condition of effectiveness of the IDA credit. 5.03 Ard,-itectuiral/E-ngineering Services. The Ministry of Urbanism, Habitat and Environment (MUHE) will have general oversight responsibility for the civil works component of the project. In addition, MUHE has agreed to undertake the design and supervision of the five new health centers, the National Health Education Center and the drug warehouse renovation. To this e d, MUTE hasstabiished a design team of four architects. Additional engineering, surveying and drafting personnel will be recruited by MUHE on short-term contracts as required and subject to approval by IDA. MUHE, in cooperation -with the MOPH, will prepare all necessary contract documents, p,itblic ancciiPsoments for construction tenders, and will participate in the normal cos-, sat bid-award committee. MUHE field staff will be responsible tor verification of consultants' certificates of payment to contractors.  a 28 - With respect to the upgrading of four additional health centers in the project, two consulting firms have been selected by the MOPH and MURE on the basis of their experience and ability to design appropriate, economical faci- lities. The MOPH has its own coordinating architect who has drawn up the overall architectural program in conjunction with MUHE. Architectural/ engineering firms have been selected on terms and conditions acceptable to IDA to undertake the design and supervision of the four health centers to be upgraded under the project. The Government has also submitted to IDA design proposals for the five new health centers. 5.04 Site Selection. Sites for all physical facilities have been selected and surveyed and are appropriate. 5.05 Procurement. Contracts for furniture and equipment (expected to amount to about US$2.3 million equivalent including contingencies) would be awarded on the basis of international competitive bidding (ICB) in accordance with IDA's guidelines for procurement. Exempted from ICB would be: (a) construction contracts (total value $6.8 million equivalent including contingencies). These contracts are all small ($50,000 - $500,000 equivalent each) and distributed throughout the country, and are unlikely to interest contracting firms from outside Senegal; (b) furniture and equipment contracts costing less than US$50,000 equivalent each (total value including contin- gencies US$0.5 million equivalent). Such contracts would be awarded following competitive bidding advertised locally and in accordance with procedures acceptable to IDA. Purchases of medical equipment using UNICEF's international procurement procedures would be permitted where feasible as a recognized means of limiting costs. 5.06 Architectural sketch designs, draft tender documents, and master lists of furniture, equipment and materials, would be reviewed by IDA. Items would be grouped to the extent practicable to encourage competitive bidding and to permit bulk procurement. Construction contracts costing more than $250,000 equivalent, and furniture, equipment and materials costing more than $50,000 equivalent would be subject to IDA review of procurement documenta- tion prior to award. This is expected to result in coverage of about 90% of the total estimated value of works contracts and about 85% of goods contracts. 5.07 Where ICB procedures are used, domestic manufacturers of furniture and equipment would be allowed a margin of preference of 15% of the existing applicable rate of duties, whichever is lower, over the c.i.f. prices of competing foreign suppliers. 5.08 Disbursements. Funds from the credit account would be disbursed according to the following schedule:  - 29 - Table 5.1 Amount of Credit % of Allocated Expenditure Category (US$ equiv.) to be Financed (a) Civil Works, including construction/ 6,760,000 100% renovation of 9 Health Centers, upgrading of 4 PNA warehouses, and construction of new National Health Education Center. (b) Furniture, equipment, vehicles and 2,260,000 100% of foreign materials. expenditures; 50% of local expenditures. (c) Professional Fees for consulting archi- 2,230,000 100% tects and MUHE to undertake civil works; technical assistance; consulting services; fellowships. (d) Preinvestment Studies 780,000 100% (e) Repayment of Nutrition and Health Project 780,000 100% of amounts Facility advances, disbursed under the advance. (f) Initial deposit in Special Account 600,000 (g) Unallocated 1,590,000 TOTAL 15,000,000  - 30 - Disbursements would be fully documented. The disbursement schedule is shown in Annex 2, T-16; it is based on the implementation schedule shown in Annexes 2, T-13 and 14, and assumes a six month lag in disbursement time. The project management unit would operate under government financial procedures and its staff would include an accountant (para. 5.02) who would maintain the necessary accounts and records according to procedures acceptable to IDA (para. 5.10). 5.09 Revolving Funds. Because the Government is expected to have diffi- culty in pre-financing expenditures to be reimbursed under the IDA Credit, an IDA financed special account of $600,000 equivalent would be established for all items eligible for IDA disbursements except those which IDA would disburse directly. The Bank Group would replenish the account upon receipt of evidence of disbursements from the fund for eligible expenditures. The Government would be responsible for replenishing the account resulting from any payment being unacceptable to IDA. An account would be opened in a local commercial bank for the purpose of establishing the proposed IDA-financed revolving fund under terms and conditions acceptable to IDA. The Government is expected, as well, to open a local revolving fund of CFA 25 million ($75,000 equivalent) to finance Government counterpart expenditures. This would be replenished every quarter and would be established under terms and conditions acceptable to IDA. The opening of both these accounts would be a condition of effectiveness of the IDA credit. 5.10 Accounting and Auditing. The Project Unit would establish and maintain account records, in accordance with accepted accounting practices, of all expenditures under the project. Unaudited financial statements for all project accounts should be submitted to IDA within three months of the end of the fiscal year. During negotiations, the Government provided assurances that it would carry out for all project accounts an annual audit by independent auditors appointed on terms and conditions acceptable to IDA, and submit these accounts to IDA no later than nine months after the end of each fiscal year. The estimated cost of such auditing is US$35,000 equivalent and is included in the credit. 5.11 Reporting and Project Review. Semi-annual implementation progress reports should be submitted to the Bank for review within one month of the periods ending March 31 and September 30. A joint mid-term project review conducted by the Government (DRPF) and IDA would also be undertaken. Not later than six months after the Project Closing Date, the MOPH should provide to IDA a report evaluating the execution, initial operations, costs and benefits of the proposed project, and the performance of the Government and IDA as well as the lessons learned during project implementation.  - 31 - VI. PROJECT BENEFITS AND RISKS A. Benefits 6.01 The proposed project is in line with health sector priority needs, and would support the Government's attempt to improve the health status of the population by developing primary health care at the community level. It would yield significant health service delivery and institutional benefits by improving the provision of basic health services to a large segment of the underserved rural population; establishing basic conditions for current and future attempts to lessen severe illness and, consequently, death, particularly among women and children; developing the quality of locally trained health manpower; and strengthening the planning and implementation capability of the MOPH. Specifically, the project is expected to yield significant benefits by 1987 in the following ways: (a) providing improved basic services, including family planning, to about 660,000 persons served by the nine proposed project health centers, 100,000 of whom are expected to be recipients of primary care close to the health centers; (b) by improving the supply of drugs, health programs, staff quality and performance at the remaining 27 health centers, the benefits of improved basic health services would be extended to an additional 2.8 million persons; (c) improving the use of basic health services and supporting community level activities through health education/promotion and better referral services at the health center level; (d) providing the health center level with a capability from which to manage key preventive programs (such as an expanded immunization program, malaria control, and maternal and child health), the health benefits of which are very high; (e) improving the skill and performance levels of about 530 MOPE medical and paramedical staff and about 2,000 community health workers; (f) improving the relevance and content of basic training in support of primary health care, and strengthening the MOPH's inservice training capability at the central and regional levels; (g) supporting the Government's attempt to promote cost recovery in the health sector, by offering the population better services in return for their participation and financial contributions; and, (h) strengthening the MOPH's capability in management, planning, implementation and evaluation with a view toward more efficient use of resources.  32 - 6.02 Because adequate baseline health data are unavailable, it is diffi- cult to predict and quantify the expected health impact of the project. The health center evaluation component will provide baseline data during the first two years of the project, thus providing a basis for discerning trends. Nevertheless, it is expected that the health centers will have a direct, primary impact on reducing infant mortality below the current estimated level of 204 per 1,000 in many rural areas, and maternal mortality below the current estimated level of 500 maternal deaths per 100,000 live births. The number of family planning acceptors at health centers is expected to rise significantly for the simple reason that no such services are currently being provided. B. Risks 6.03 First, past MOPH performance in execution of its health investment program (para. 1.22) has been less than satisfactory, resulting in its inability to implement all projects as planned during the Fifth Plan period. Such a risk to this project would be minimized by the creation of a MOPH project management unit comprising key staff who have participated in project preparation and start-up activities. While current management realities have strongly suggested the need for a project management unit, every effort is being made to minimize its isolation; the PMU is, for example, wholly within the MOPH and represents no real increase in staff or funds. The use of the PPF to undertake architectural designs prior to project effectiveness, the simplicity of these designs, and the assignment of a full-time MOPH coordinating architect to the PMU would reduce the risk of undue delay in executing the major civil works component. Likewise, the recruitment of specialist services to assist in the implementation of the training component would lend substantial support to the MOPH in another area of implementation where the MOPH has had limited experience to date. 6.04 Secondly, success in developing family planning services at the health center level would depend on continued Government commitment and more rapid progress in the implementation of USAID and UNFPA supported projects in population and family planning. These projects have been designed to set up pre-conditions for extending services to the health center level. The inclu- sion of a family planning advisor within the PMU is expected to assure close liaison between the IDA-financed health project and other project efforts in family planning. Future IDA missions will continue to monitor their progress and, if necessary, assist in identifying and circumventing obstacles. 6.05 Thirdly, if the Government fails to meet incremental recurrent costs incurred by the project, the level of health center activity will be less than envisaged, which will adversely affect the health benefits. This risk has been reduced by the fact that the project health centers include a minimal level of incremental recurrent cost and focus more on better utiliza- tion of existing resources. A success in this respect will improve the utilization of existing resources in other health centers (outside the project) and thus help in minimizing the overall additional recurrent cost burden. It is expected that health associations will continue to contribute financially toward the maintenance of health centers (para. 1.21), such  - 33 - maintenance having been neglected in the past. Nevertheless, adequate maintenance will also depend on the Government's ability to improve building maintenance supervision, a function which is currently being developed within the MOPH. 6.06 Fourthly, there is a risk that the health centers will fail to develop the requisite outreach capability (in the form of supervision and technical support) to the posts in the catchment area of each health center. This risk stems from the fact that the functional components of primary health care are still insufficiently defined. Consequently, training and supervision requirements linking health centers and health posts are still being thought through. The high cost of vehicle operation is an overriding impediment in primary health care program development and supervision. Since many of the rural primary health care programs are likely to continue to be financed by external sources, donor coordination within Senegal needs improvement in order to reduce the risk of insufficient linkages between health centers, health posts and village level services. The project would improve coordination by strengthening the DRPF and through the evaluation/ coordination role of the PMU. However, even if the health centers failed to develop effective outreach, the project would make a signficant immediate contribtution by restoring their credibility and allowing them to provide effective primary and secondary care to their immediate catchment areas. VII. RECOMMENDATIONS 7.01 During negotiations, the Government of Senegal gave assurances that it would: (a) by the end of the third year of the project, prepare a national inservice training program which would be submitted to IDA for its review and subsequently implemented (para. 3.10); (b) by the end of the second year of the project, undertake drug testing at the PNA laboratory for which purpose adequate PNA laboratory staff would be promptly selected and given training to upgrade their skills (para. 3.11); (c) undertake appropriate measures including those specified in para. 3.14 (A-D) to improve the financial status and management capability of the PNA, and assist in developing a national pharmaceutical policy; (d) maintain adequate staffing of all project health centers, operate all facilities appropriately, and ensure adequate maintenance of all buildings, furniture and equipment provided by the project (para. 4.06); and  - 34 - (e) carry out for all project accounts an annual audit by independent auditors appointed on terms and conditions acceptable to IDA and submit these accounts to IDA no later than nine months after the end of each fiscal year (para. 5.10). 7.02 As conditions of effectiveness of the IDA credit, the Government should: (a) formally establish the project management unit (PMU) (para. 5.02); (b) open an account in a local commercial bank for the establishment of the IDA-financed special account (para. 5.09); and (c) open an account for the establishment of a local revolving fund for Government counterpart financing (para. 5.09). 7.03 With these assurances, the project constitutes a suitable basis for an IDA credit of US$15.0 million on standard IDA terms.  - 35 - ANNEX 1 SENEGAL DISEASE PRIORITIES BY TYPE OF INTERVENTION Diseases Impact Intervention A. Diseases preventable by immunization: 1. Measles High incidence, highest Highly effective low-cost specific mortality, 20-25% vaccine. lethality, important biological damage in complications. 2. Whooping cough High incidence; high in- Immunization against cidence of complications. whooping cough, tetanus Important contributing and diphteria is usually factor in other causes of given in an effective low- mortality/morbidity. cost triple vaccine. Tetanus Moderate incidence but 50 to 75% lethality. Diphteria Low incidence but important residual biological damage. Poliomyelitis High incidence, low Highly effective low-cost morbidity but still high vaccine. residual incapacity in Senegal. 3. Meningitis Low incidence in endemi- Partially effective vac- city, high lethality. cine. Risk of periodic epidemics. 4. Tuberculosis High prevalence and Value of mass BCG immuni- disability. zation in children and adolescents is being questioned. BCG to new- born remains unquest- tioned. B. Diseases controllable by service delivery 1. Diarrheas Highest incidence; high Mortality and, to a lesser mortality. extent morbidity can be a- bated by rehydration and education. 2. Maternal Unacceptably high in Risk approach to pregnancy mortality and Senegal. and delivery . Perinatal mor- The hLghest mortality hv Soacing of preanancies/ tality group cauises. family planning.  - 36 - ANNEX 1 Page 2 SENEGAL DISEASE PRIORITIES BY TYPE OF INTERVENTION Diseases Impact Intervention 3. Malaria Highly prevalent. High Seasonal chloroquinisation mortality. High morbidity. of groups at risk. Early treatment of attacks. 4. Acute respira- High incidence; high Early treatment and educa- tory infections mortality. tion. 5. Intestinal para- Both highly prevalent with Periodic deworming. Iron sitosis and low morbidity but impor- and vitamin supplementa- specific nutri- tant contributing factor tion. tional deficien- in other causes of cies morbidity/mortality. 6. General Patho- Varying incidences. As an Screening, or early diag- logy aggregate, high temporary nosis and treatment. incapacity, undue residual damage and incapacity, i.e. rheumatic fever, eye infec- tions, trachoma, tubercu- losis, leprosy, typhoid. 7. Schistosomiasis Varying incidences, low Periodic treatment with mortality and varying new drugs now permit a- morbidity. batement of morbidity. C. Diseases controllable by large-scale programs 1. Malaria High prevalence, high Effective control of these morbidity. major endemic diseases re- 2. Schistosomiasis Scattered foci, varying quires massive resources morbidity. and combination of inter- 3. Onchocerciasis Prevalent in southeast. ventions for vector con- .4. Trypanosomiasis Scattered foci, high trol and treatment of mortality. carriers. D. Diseases that will recess with improvement of general life conditions Water-borne Highly prevalent, varying Domiciliary piped water diseases mortality and morbidity. supply; sanitation; educa- tion. Malnutrition Highly prevalent, high Raising income in rural morbidity, important areas. Development of contributing factor in food crops. Education. other causes of mortality! morbidity.  ANNEX 2 T-1 SENEGAL COMPARATIVE HEALTH STATUS INDICATORS Low- Middle- Income Income Developing Developing Year Countries Tanzania Kenya Senegal Countries GNP per Capita (US$) 1979 240 260 380 430 1,420 Infant Mortality Rate 1979 160 n.a. 91 147 94 Life Expectancy at Birth 1979 51 52 55 43 61 Access to Safe Water (%) 1975 25 39 17 37 58 Daily per Capita Calorie Supply as % of Require- ment 1977 96 89 88 95 109 Source: World Development Report, 1981.  - 38 - ANNEX 2 T-2 MORTALITY--SENEGAL 1978 A. Causes of Death by Major Groups of Diseases Neonatal mortality 29.8 adrA parasitic diseases 25.9 Cardiovascular diseases 5.0 Malnutrition 4.4 Accidents and injuries 4.2 Respiratory diseases 3.9 Gastrointestinal diseases 3.0 Delivery and complications 2.0 Other causes defined 5.3 Other causes ill-defined or unknown 16.5 100.0 B. Mortality by Age Group Age Group No. of Deaths X 0-1 year 6,593 41.2 1-4 " 2,542 15.9 5-14 " 1,313 8.2 15-54 3,608 22.5 .-<. t.u;7rI 1,960 12.2 TOTAL 16,016 100.0 Source: Ministry of Public Health, Dakar, 1980.  - 39 - ANNEX 2 T-3 GEXNA C DISEMTMI(CN OF MINIStY OF HEALIH PESSL BY REIN, 1981 Dacar & Senegal Sine Category Cap-Vert Casamnce Diourbe FleFle Oriental Saloum Thies Itug 1TTAL Professionals Physiciais 80 8 8 14 3 8 11 4 137 Pharmacists 6 2 2 1 - 1 - - 12 Dentists 7 - - 1 - 1 1 - 10 Techzlogists Technicien superieur in rwrsing 15 2 2 2 - - 2 1 24 Certifiedmrrses 168 96 45 54 34 57 57 21 532 Midwives 113 16 15 20 6 27 36 10 243 Tebhnicien suFrieur In dentistry - - - - - - - - - Technicien sueperieur In sanitaticm 4 8 5 4 6 26 3 3 59 Techdtciams Registered nrses 339 123 51 111 64 107 85 52 1,136 Social workers 63 - - - - - 2 - 65 Sanitation tecmiciarw Lab tecmicians 20 - - 1 - 4 2 - 27 X-Ray technician 17 - - - - 1 1 - 19 Amdliary Personrl Practitioners 238 28 20 32 10 56 58 14 456 Orderlies 210 10 10 35 4 23 33 4 329 Practical midwives 5 16 6 2 6 32 5 7 89 Services Workers 290 35 21 26 11 43 25 16 337 Drivers 55 - 3 11 - - 7 1 77 1,630 344 188 284 144 386 328 133 Source: Ministry of Public Health.  - 40 - ANIEX 2 T-4 SENRDAL FUNCMI4AL DISJYON OF HEALTH MA R BY TYPE OF FACILIY (R SEICE, 1981 Public Service Teachirg National Regional Private or Hospitals Hospitals Health Health Practice IDH & Services & Services Centers Posts TLt Professionals Physicians 130 77 73 33 36 - 349 Pharmacists 70 8 6 4 - - 88 Dentists 19 1 1 - - - 21 Technologists Technicien superieur in tirsing - 10 7 8 - - 25 Certified nurses - - 192 89 63 212 556 Midwives - 8 320 69 61 - 458 Technicien superieur in dentistry - - - - - - Technicien superieur i saritation - 4 8 19 31 - 63 Technicians Registered nurses 83 - 377 302 151 274 1,187 Social workers - 1 61 4 2 - 68 Sanitation technicians - - - - - - - Lab tecnicians 17 - 45 19 8 - 89 X-ray technicians - - 16 7 1 - 24 Adzliary Persormel Practical nurses - - 209 180 144 142 675 Orderlies - - 191 62 10B 70 431 Practical midwives - - - 36 22 57 115 Services Workers - - 183 111 53 12) 467 Chauffeurs - - 67 45 32 - 144 319 109 1,756 988 712 875 4,759 Source: Ministry of Public Health regional reports.  - 41 - ANNEX 2 T-5 SENEGAL SOCIETE INDUSTRIELLE PEARMACEflTIQUE DE L'OEUST AFRICAIN (SIPOA) Performance and Financial Indicators 1976 1977 1978 1979 1980 Ratio of Gross Profit to Turnover 47 52 51 48 49 Ratio of Inventory to Turnover X 39 49 53 34 54 Ratio of Export to Total Turnover % 34 45 45 47 41 Ratio of Net Profit to Turnover % -5 -0.2 9 4 6 1 / Ratio of Net Profit to Equity % NJE - N,'E N/E 26 15 Term Debt/Equity Ratio X NWE N/E N/E 26/18 25/22 1/ N/E - Negative Equity. Net equity was negative in the first 5 years due to early losses and a low initial share capital of only CPAF 60 million. Source: Government of Senegal  42 - ANNEX 2 T-6 EMCAL fotdl Recurrent Expenditure on Health (in thousands of CFAF) 19" 1978 1979 1960 198l Cestral Governent !xnenditure iflastry of Realch Budget 5,369,908 6,133.799 6,572,014 6,698,202 6,890,380 Special ludget for Civil 1,040,000 1,240,200 1,240,200 1,240,242 1,201,240 State Contribution to Rousing and ItAdn Lties of Foreign Techuical Assistants 352,890 352,840 541,320 541,320 601,200 Ulitary Forces 276,000 276,000 278,000 124,000 220,000 Pftstions Rumain* - 2,108 2,808 S,019 8,019 Osivirsity of Dakar, Faculry of Medicine and raaxmacy ~ ~ ~ ~ ~ ~ - - - 160,000o164,431 S ecal Security S9,146 102,427 166,158 1752748 _1315 - - - 50,000 _ 50,000 Total 7,127,944 8,008,074 8,800,600 9,093,528 10,115,270 Local Government Ezienditure irbas Comunes 6",571 9,3851 1,107,557 1,143,498 954,073 Rural Ceoiunes - - 225.000 225.000 Total 699,571 944,851 1,107,557 1,368,496 1,179,073 PaspublIc Enrterises Exvenditure Total - 1,112,454 1,575,625 1,525,061 1,525,061 ftivate Exnenditure mpoet.of P?arzaceuticals 2,812,799 3,251,989 ',726,471 5,238,.i4 6,494,920 11.Dpital Prlncipal - - 2,074,000 2.294,000 ftivate Doctors - _ _ 562,800 562,800 Private Clinics - - - 1,300,000 1,300,000 4'-.m1xy Participation - - - 350,000 425,000 Total 2,812,799 3,251,989 4,726,471 9,425,424 11,076,720 External Contributions Rilateral Funds 3,383,833 3,727,095 3.169,330 3,144,133 3,563,328 !oltilateral Funds 173,230 lM3,%5 1e&,ee 260,077 222,483 Other 580,000. 606,097 696.297 696.297 745.068 Total 4,137,063 4,486,757 4,050,511 4,070,507 4.530,879 Total Expenditure 14,477,377 20,804,125 20,980,765 25,483,018 28,427,003 Source: Government of Senegal  SENEGAL FINANCTAL SITIIAT'ION OF IIEAI.TII COtMtEKS 19B00a1 (in thousands of CFAF) 31 3/ benegal Sline Cap Veit C. Ciwassiance Diourbel Fleuve Oriental Saloum Thloa LOURa Total Receipts 53,734 14,145 9,241 6.359 5,945 18,666 20.086 3,678 131,854 Expendtture 50,240. 7,551 4,958 2,058 - 8,859 11,186 1.798 86,650 Treasury Account 3,514 6,694 4,283 4,301 - 9,811 8,900 1,880 45,204 Starting Ditte Jan 1981 Aug-Oct 80 Asg 80 Pec 50 Nnv 80 Nov 80 Aug 80 Oct 80 Audit Date Hiar 1981 t1ar 81 Nov 80 May 81 Apr 81 Feb 81 Dec 80 Jai) 81 Receipts Extralated to itle Wlbole Year 96,952 27,526 21,276 13,407 11,631 74,664 60,258 14,712 245,762 4 Source; (1) 11nstlaLere do le Seiote Pibtlique, D11PSg (11) Consultatlon uith, adicins Chefs of Casawance, Tusei, and Fietive. 1/ Note that there is a great diversity in reporting of data accuracy between regions. Most figures used are expected to be takenurder estimated actual receipts. / Eikine circonscription started in 1978. 3/ In Casamance, actual receipts are believed to be much higher and increasing; the probable yearly receipts are expected to be CFAF 10 million. It3l  - 44 - ANNEX 2 T-8 SENEGAL TOTAL EXTERNAL CONTRIBUTION TO THE HEALTH SECTOR (in thousand of CFAF) M77 1978 1979 1980 1981 1982 ~Francw b/ 2,597,900 2,764,500 2,452,000 2,639,000 2,333,775 2,290,000 Belgium-/ 257,484 324,581 319,652 533,032 270,871 c/Kand- 45,090 4,S71 45,360 14,855 13,582 VWA- 92,433 56,521 71,436 75,121 326,666 205,306 ;iad,/ a 563,500 563,500 241,742 - - - Switz land 113,000 113,000 ItalyIh/ 270,000 70,COQ 8razil-3 180,000 180,00c Cermany- 90,000 404,000 40,000 35,000 35,000 35,000 35,000 Sub-Total 3,383,833 3,7Z7,095 3,169,330 3,114,133 3,563,328 3,377,759 Xultilateral Fonds Europeam de Developpament 57,000 41,000 264,000 WHO 70,980 77,740 86,500 99,964 80,557 106,110 UNICEF 102.250 76,82 98384 103.13 100,926 69.293 Sub-Total 173,230 1.53,S65 184,884 260,077 222,483 439,20_ Others-/ Catholic MIssions 580,000 600,000 684,000 684,000 720,000 744,000 Follereaau 6_07 12,297 12,297 25,068 58.078 Total 4,137,063 4,486,757 4,050,511 4,070,507 4,;30,879 4,619,040 Government of Same- gal s contscbution to housing and in- deazit