Tunisia - Population Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No. 5135 PROJECT PERFORMANCE AUDIT REPORT TUNISIA FIRST POPULATION PROJECT (CREDIT 238-TUJN) June 21, 1984 Operations Evaluation 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. ABBREVIATIONS MCH/FP - Maternal and Child Health/Family Planning GOT - Government of Tunisia INPF - National Institute of Family Planning MOPH - Ministry of Public Health MWRA - Married Women of Reproductive Age NORAD - Norwegian Agency for Development ONPFP - National Office for Family Planning and Population SIDA - Swedish International Development Agency UNFT - National Union of Tunisian Women UNFPA - United Nations Fund for Population Activities USAID - United States Agency for International Development CURRENCY EXCHANGE RATES Name of Currency (abbreviation) Tunisian Dinar (TD) Year: Exchange Rate: Appraisal Year Average US$1 = TD 0.5208 Intervening Year's Averages: 1971 US$1 = TD 0.5157 1972 US$1 = TD 0.4772 1973 US$1 = TD 0.4200 1974 US$1 = TD 0.4365 1975 US$1 = TD 0.4023 1976 US$1 = TD 0.4288 1977 US$1 = TD 0.4290 1978 US$1 = TD 0.4162 1979 US$1 = TD 0.4065 1980 US$1 = TD 0.4050 Completion Year Average US$1 = TD 0.4000 FOR OFFICIAL USE ONLY PROJECT PERFORMANCE AUDIT REPORT TUNISIA FIRST POPULATION PROJECT (CREDIT 238-TUN) TABLE OF CONTENTS Page No. Preface .............................................................. Basic Data Sheet ................................................... iii Highlights ........................................................... v PROJECT PERFORMANCE AUDIT MEMORANDUM I. PROJECT SUMMARY .......................................... I II. MAIN ISSUES .............................................. 3 A. Problems in Project Concept and Design ............... 3 B. Socio-Medical Issues ................................. 5 C. Physical Structures and Functions of Space ........... 7 D. Performance and Responsibility of Consultants ........ 10 E. Role of Supervision Missions ......................... 11 F. Impact of the Project: Institution-building and Project Continuity ................................. 12 G. Lessons Learned and Conclusion ....................... 17 Addendum ............................................. 19 PROJECT COMPLETION REPORT I. Introduction ............................................... 23 II. Project Identification and Preparation ..................... 25 III. Project Implementation ..................................... 30 IV. Project Performance ...................................... 39 V. Covenants and Their Fulfillment .......................... 44 VI. The Role of The Bank Group ................................. 46 VII. Lessons Learnt ............................................. 47 Annexes: 1. Trend Analysis of Family Planning Activities 1973-80 49 2. Acceptors of Family Planning by Method 1972-81 ........... 50 3. 1981 Family Planning Indicators .......................... 51 4. Family Planning Activities in 23 Project MCH Centers 52 5. Schedule of Disbursements ................................ 53 6. Revised Expenditures and Percentage of Total Costs to be Financed from the Credit ......................... 54 Map: TBRD No. 3151R1 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. PROJECT PERFORMANCE AUDIT REPORT TUNISIA FIRST POPULATION PROJECT (CREDIT 238-TUN) PREFACE This is a performance audit of the First Population Project in Tunisia, for which a credit of US$4.8 million was approved in March 1971, and to which a Norwegian Agency for Development (NORAD) grant of US$4.8 million was subsequently added, by an Amendment to the Credit Agreement in October 1976, bringing the total amount of external financing to US$9.6 million. The closing date of the Credit Agreement Amendment was December 31, 1981, but US$110,450 remained undisbursed and was cancelled March 31, 1982. The report consists of a Project Completion Report (PCR), dated April 1983, prepared by the Population, Health and Nutrition Department (PHN), and an audit memorandum, prepared by the Operations Evaluation Depart- ment (OED), following a visit to the country (February 14-28, 1983). The audit memorandum is based on both a review of a number of docu- ments and on discussions with PHN staff and Tunisian officials concerned with the project. In Tunis, discussions were held with officials in the Ministry of Health, Ministry of Equipment, the Office National de Planning Familial et de Population (ONPFP), and former officials of the Directorate of Family Planning (predecessor of ONPFP) and of the ONPFP. Field trips were made to three Maternity Hospitals (Tunis, Sousse, Sfax) and three Maternal and Child Health Centers (Somaa, Bir Ali Ben Khalifa, Matmata). Visits were also made to regional delegates of the ONPFP in Sousse, Sfax, Gabes, Gafsa, and to the director of the Hospital at Kasserine, formerly an official of ONPFP. Other visits to donor organizations were made: United Nations Fund for Population Activities (UNFPA) in Tunis, United States Agency for International Develop- ment (USAID) in Tunis and Washington, D.C., and the Population Council in New York. A number of documents were used for reference, as well as the cor- respondence with the Borrower, internal Bank memoranda, supervision mission reports and other sources. The most important of these were the Appraisal Report of 1971, the Credit Agreement of 1971 and its Amendment of 1976, the Sector Review of the Population Program in Tunisia of 1975, the UNFPA Report on Needs Assessment for Population Assistance in Tunisia of 1981, the UNFPA Evaluation Report on its Assistance to Family Planning and Population in Tunisia, of 1982, and the ONPFP's own final evaluation of the Population Project (Credit 238-TUN), of 1982. A number of other documents and scholarly articles relating to the program were also reviewed. - ii - The audit memorandum addresses a number of issues which were not fully covered in the PCR, particularly those relating to project design, implementation delays, cost overruns, social issues, functionality of struc- tures constructed, performance of consultants and role of supervision missions. It also gives particular attention to the redirection of the initial goal of institution-building of the project and highlights the impor- tance of project continuity in view of the 1981 Health and Population Project underway. The draft report was sent to the Borrower for comment on January 18, 1984; however none have been received. The assistance provided by Government during the audit mission in Tunisia and in the preparation of the report is gratefully acknowledged. - 111 - PEilIECT PERFORJANCE ADDIT KEPORT TuNSIA FIMST POPULATION PRDJECT (CEMIT 235-TN. BASIC DaTA Sm ET PaOJECT DATA Appraiwal Actual or Actual ab Z of Expectationa Current Emtiate Appraisal Eationte Total Project Costa (US$ aillion) 7.7 34.0 340 IA Cradit (USS Million) 4.8 4.8 100 IDA (0=a) Aead A Credit (USS million)a - 4.8 99 Final Disbur= m 3/2 <USS milloa) - 9.5/c 9 Date Physical Componeuts Completad Avicenne Parn=d=cal Tråning School 1972 1974/5 1 rural =aternity hompital 1972 deleted (1975) 9 ICm/FP centers 1972 1976 (8) 1 wateruity boapital (140 beds) Tunis 1973 1979 12 NCK/MP centers 1973 07/77 (5) - 1 aternity hospital (140 beds) Souese 1974 1979 - 1 rura materaity hospital 1974 delated (1975) - 8 KCWIP centers/b 1974 06/79 (8). 06/80 (4) - 1 waternity honpital (140 beds) Sfax 1975 1979 - 1 mternity hospital (80 bada) aizerte 1975 1983 - PRJECT DATES Actual or Original Plan Ravialons Eatiastad Actual virat Keation la Filea 12/68 Covernument' Applicatio - 06/03/69 enotlations 02/71 Board Approal - - 03/23/71 Board Approval Azmdnt - - 08/10/76 Credit Agreent Date - - 04/05/71 Credit A=a~d. Agr~nt Date - - 10/13/76 Effectivaen Date 06/30/71 08/31/71; 11/11/71 12/29/71 Effectiveness Date Auenduent 11/11/77 03/11/77 03/31/77 Cloaing Date 06/30/76 06/30/78 Clowing Date Amend~ent 06/30/78 12/31/79 03/31/82 12/31/80 12/31/81 CUMILAT= DISBURSEH TS IDA Piacal Year: Ff72 7173 Ff74 FY75 F76 F77 778 FY79 Ff8O Fy81 _782 Appralsal Eetieate (USS 000.) 855 2.244 3.669 4.402 4.742 9.600/a 2evised Entleate (USS 000.) 4.500 7.900 9.600 Actuel (USS 000.) 217 964 2.842 4.808 6.103 6.378 7.339 8.295 9.490/C Actual as percenta~a of Appralaal or Revised Eutieate 5.9 21.9 59.9 106.8 27.3 66.4 76.4 86.4 98.8 Date of Pinal Disbureement: 01/31/82 Klim DATA Sent Date No. of Nandaya Specializationa Performance Typen of mission b ÇNoth/Year) Perana in Field Repreneuted /d Rating e Trend f Problems L& Identification PmN 11/69 2 31 e,ph - - Appratsal PER 05-06/70 4 55 e,^,ph,ar - - Poll-W PEN 07-08/70 1 12 e - - - Pre-BegotiatIons PEN 12/70 4 [? e.e,e,1 - - Total 9 Sapervision I PEN 08/71 2 - ar,d - - N.F,T Supervision 11 PEN 11/71 2 6 e,d - - 0 Supervialon III PEN 12/71 1 5 e - - ",0 Supervision IV PEM 04/72 2 12 ar,d - - H.T Superveion V PH 05/72 1 5 e - - 0 Superviion VI PHm 07/72 3 15 ,ar,d - - N,F,T Superviion VII PH 11/72 1 5 d - - K Superviaion VIII PEN 01/73 1 3 e - - n, Supervision IX pen 05/73 4 36 e,,ar,d - -,T Sectnr Review PmN 11/73 6 106 - - F,T Supervi.ion X PmN 02/74 1 4 ar 3 2 N.,T Supervision XI PEG 06/74 2 20 p.ar 3 2 K,T Superviion XII/b Pen 09/74 4 20 p.ar.e,ph * 3 2 F..T Supervision XIII PHN 11/74 1 5 ar 3 2 F.T Superviaion XIV PH 03/75 2 8 ar.p 3 1 P,T Superviaion XT PH 06/75 3 26 p,ar,ph 2 1 F,T Supervision XVI PmN 12/75 1 5 ar 2 1 T Superviaion XVII PHm 04/76 2 12 p.pb 2 1 F,T Su~epriion XVIII PHN 06/76 1 12 ar - - Saperviion XIX PHN 11/76 4 36 p,pb.ar,as 2 1 F,7 Suparvision Xz PRN 06/77 4 37 p,ph.ar.a 2 2 X,7 Supervision XLI PmN 11/77 4 32 p,ar,ar, sa 2 2 ä,T Supervision xuII/1 PHN 06/79 2 22 ar,.e 2 2 B,T Supervision X uIIi PHm 05/80 1 1 ar 2 2 X,T Supervision XXIVTE PE 10/80 2 4 p,ddc 2 2 X,T Total 425L *Footnotes on folloaing page- - iv - OTHER PROJECT DATA Borrower Government of the Republic of Tunisia Executing Agencies Ministry of Public Health initially; later ONPFP Fiscal Year of Borrower January 1 - December 31 Follow-on Project Name Health and Population Project Loan Number 2005-TUN Amount US$12.5 million Date Board Approval 05/28/81 la Amendment to Credit Agreement signed October 13, 1976. lb One MCH/FP center (Tunis) was deleted from the project with IDA consent. /c An amount of $1'.0,450 was cancelled at closing date, 03/31/82. /d e = Economist; p = Project Officer (generalist); 1 = legal counselor; ph = physician; he = health educator; ar = architect; ddc = deputy division chief; ss = social scientist; d - demographer. /e 1 = Problem-free or minor; 2 = moderate; 3 = major. If 1 = Improving; 2 = Stationary; 3 = Deteriorating. /g M = Managerial; T = Technical; F = Financial; 0 = Other. /h Including Sector Review draft discussion. /i As part of the Identification Mission. /j Total without Sector Review Mandays: 319. - v - PROJECT PERFORMANCE AUDIT REPORT TUNISIA FIRST POPULATION PROJECT (CREDIT 238-TUN) HIGHLIGHTS The goal of the project was to strengthen the family planning program of Tunisia by means of two major activities: construction and tech- nical assistance. The original physical infrastructure component included the construction of 4 urban maternity hospitals, 29 rural MCH/FP centers, 2 rural maternity centers and the extension of the Avicenne Paramedical School, all of which involved the assistance of expatriate consultant architects. The technical assistance component originally comprised the management con- sultants who were to design and recommend a system to ensure optimum use of FP services and training experts for the Avicenne Paramedical School. Both components were amended in 1974, and as a result the paysical infrastructure component was to include 4 urban maternity hospitals, 28 rural MCH/FP units and the extension of the Avicenne Paramedical School, while keeping the con- sultant architects as experts for the component. The technical assistance comprised only the management consultants. The contract of the latter team was terminated by the Borrower that same year, in 1974, within two years after their arrival, because of difficulties of rapport with their counter- parts and lack of understanding of the social environment. Initially, the project was crucial to the other donors involved in the FP program because of its potential impact on policy-making. A great deal of emphasis was therefore placed, during appraisal, on the institution- building aspect of the project. From the start, however, the project was perceived by the participants as mainly construction-oriented. Two shortcomings in the project design restricted the imple- mentation process: (a) an underestimation of costs (repeated at re- estimation after appraisal), and (b) a dichotomy in project conceptualization whereby no link was established between physical infrastructure and institu- tion building. The intended institutional and program goals of the project were thus never achieved because both IDA and the Government of Tunisia focussed on the numerous construction delays, cost escalation and lack of local supervision, labor and construction materials. Total project costs rose from the initial estimate of US$7.7 million to over US$34.0 million to date. Numerous socio-medical and institutional issues were raised before and during the implementation of the project. There is no evidence that they were given serious consideration. - vi - The preoccupation with financial aspects and the delayed schedule of the construction component of the project distracted the supervision mis- sions from their technical advisory role: evaluation of the performance and technical expertise of the consultants was lacking throughout the project. Moreover, there was little technical feedback to the working-level project staff, although the normal follow-up letters were sent to the Government after each mission. The negligible institution-building input of the First Population Project resulted in a lack of continuity with the 1981 Health and Population Project presently underway. The integration of health and FP activities and institutions is a basic premise of this latter project. Nonetheless, issues unresolved in the first project hampered the design of the 1981 project and still need to be more fully addressed, particularly those related to the implications of integratton and to the management capacity of the institu- tions involved. Several lessons can be derived from the experience of the First Population Project (PCR, paras. 7.01 to 7.08; PPAM, paras. 51-58). Those of special interest are the following: - consideration of sociological factors for the sake of better institution-buildirg, more functional construction, and an under- standing of the complexity of population programs should be part of project identification and design and pursued throughout project implementation; - supervision missions should have been multidisciplinary and more technically-oriented and should have fully involved the national technical staff, so as to strengthen the dialogue between Bank staff and Government and create greater monitoring capacity among the national technical staff; and - ability to reset priorities during project implementation is essen- tial to ensure greater technical efficiency and a more positive project impact at completion. - 1 - PROJECT PERFORMANCE AUDIT MEMORANDUM TUNISIA FIRST POPULATION PROJECT (CREDIT 238-TUN) I. PROJECT SUMMARY 1. Ever since the early 1960s, Tunisia has had a strong political cor- mitment to family planning, viewing it as an essential tool for economic development. This commitment is still strong today. It was in this atmo- sphere of political support to a family planning program--exceptional in North Africa or in any other Arab country-that the credit for the First Population Project was approved by IDA in March 1971. An Amendment to the Credit Agreement was signed in October 1976 to include a NORAD grant and extend the closing date of the credit to June 1978. The actual closing date was March 1982. 2. The project's objective was to strengthen the family planning pro- gram in Tunisia by means of two distinct components, construction and tech- nical assistance. This implied a strong institution-building emphasis in the Project, and, indeed, much importance in the Credit was placed initially on the management studies to be undertaken. The project funds, however, were directed primarily to the construction component which, after amendment in 1974, consisted of 4 urban maternity hospitals, the extension of the Avicenne Paramedical School, 28 rural maternity and child health/family planning (MCH/FP) centers as well as furnishings and equipment. Two rural maternities and one urban MCH/FP center and the technical assistance in paramedical teaching and fellowships were deleted in 1974. The Management consultants' contract was terminated two years after starting (1972-74). Two sector review missions were planned, but only one was undertaken (1974). 3. Actual project construction started in 1974. Numerous factors caused this initial delay, as well as all subsequent delays: an initial underestimation of costs, a revision of estimates which only included the costs of maternity hospitals, delays in the hiring of both consultant archi- tects and management consultants, unfamiliarity of the Government with the Bank's bidding procedures, problems in the construction industry in the country (exacerbated by shortage of labor due to migration and a construction boom leading to pressures on contractors), and an increase of costs of con- struction material. Project costs skyrocketed. Initially estimated at US$7.7 million, then US$22 million in 1973, they are currently estimated at over US$34 million, with the Bizerte Maternity Hospital still under con- struction. Total IDA/NORAD contribution was US$9.6 million. 4. While the PCR and the Government agree that most of the construc- tion units were adequate and served the purpose for which they were designed, they are all characterized as -overdesigned", or more precisely, "misde- signed. Delays in the completion of the structures were a result of problems with contractors, lack of staff and inadequate supervision by the Ministry of Equipment, as well as an unrealistic timetable and insufficient -2- in-country presence of the hospital consultants. The credit was closed in December 1981 more than three years behind schedule. 5. The management consultants completed three of the four reports they had planned to undertake. The purpose of the studies outlined in the Terms of Reference was to recommend a management system which would ensure optimum use of the resources available in the family planning program. Except for a partially-implemented pilot study, none of their recommendations was adopted. Rapport between consultants and the Government was strained from the outset. When a new director of the Office National de Planning Familial et de Population (ONPFP) took over in 1973, a decision was made to discon- tinue their services. 6. The ONPFP was the executing agency for the project. It became an "Office" in 1973, having been preceded by a Directorate (1968), then by a National Institute of Family Planning (1971). While all three were under the tutelage of the Ministry of Public Health (MOPH), the Office acquired the legal status of a parastatal organization. The management of the prede- cessors of the ONPFP was in constant upheaval, and it was only in 1973 that the newly created ONPFP began to acquire stability through a strong and politically powerful leadership. Relations with the MOPH, however, were never smooth because of an unclear institutional division of labor in the population sector and the equally unclear status of FP personnel borrowed from the MOPH. These problems still persist. The program of the ONPFP developed, however, with financial and technical support from various donors. The lack of impact of IDA's First Population Project on management and policy was due not only to the termination of the contract of the manage- ment consultants, but also to inadequate appreciation on the part of both the Bank and the Government, of the need to establish a relationship between con- struction, management and social factors. As a result, the ONPFP became a mere conduit for construction financing of the project. 7. By 1977, the ONPFP had developed a network of linkages with a mul- titude of ministries and organizations for educational and promotional acti- vities. It also had begun to redirect the program away from its urban bias toward more rural outreach. The most critical problem hampering FP activi- ties, from the start, has been a shortage of paramedical personnel and doctors in rural areas, the urban centers remaining more attractive for most. 8. Between 1971 and 1977, the number of new acceptors of contra- ceptives had been on a steady rise. Since 1977, this number has levelled off. It is not clear, however, whether and to what extent this is due to more realistic statistical data gathering, to socio-medical factors or to in- adequate service deliveries. In any case, the need for a greater under- standing of prevalence is a present concern of the ONPFP as well as the need for an approach adjusted to different target populations. All this will require greater feedback, both from and to the field. - 3 - II. MAIN ISSUES A. Problems in Project Concept and Design: 9. This section will deal with a series of interrelated issues perti- nent to these problems. Pressures to produce a "bankable" project led to undue haste in project appraisal. As a result of this, and of the oil price rise of 1973, serious underestimation of project cost ensued. The lack of consideration of the interrelationships between construction, access, person- nel and social issues was a result of the dichotomy in project conceptualiza- tion and design. 10. In part, "the weaknesses in project formulation reflected the states (sic) of the art in the 1970s and, in part, the nature of the family planning program in Tunisia at a time when emphass was on immediate action..."./ This statement can be wholly applied to the Bank's First Population Project in Tunisia, if not to all the other projects in that sector which started up at the same time. 11. The statement should not, however, be used to rationalize loopholes in the project design of the First Population Project in Tunisia. Unlike the other population projects current at the time, it had the advantage of receiving early warnings from a variety of internal and external sources during preappraisal, appraisal and after appraisal (see paras. 17 to 20). It appears that the Bank staff, in the early 70s, "were under tremendous pres- sure to produce a bankable project,"2/ and had no time to devise a methodology appropriate to the population sector. However, the question as to what constitutes a "bankable" project may have been asked even then. Surely, regardless of methodology, a project's program strategy and infra- structure component should fit appropriately so as to beneficially affect (socially and financially) institution and population alike (paras. 18, 21 and 22). 12. The initial pressure on IDA's staff for immediate action has re- sulted in hasty project design and implementation and has led to the relaxa- tion of technical standards. The PCR describes one of the major problems which plagued the life of the project. An initial underestimation of costs, plus inflation and an increase of costs of construction materials, led to a 316% increase in actual costs by the end of the project (PCR, para. 2.23), currently estimated at a 340% increase. From an initial estimate of US$7.7 million, reestimated at USq22 million, the project cost today exceeds US$34.0 I/ UNFPA, Evaluation Report of UNFPA Assistance to the Family Planning and Population Education Programmes in Tunisia - 1974 - 1982, UNFPA, N.Y. December 1982, p.7. 2/ Kenya - First Population Project, OED Report No. 3536, dated June 28, 1981. million (PCR, para. 2.23), and the Maternity Hospital of Bizerte is still under construction after a delay due to serious technical (foundation) prob- lems. This underestimation of cost was a major flaw in the project design and reflects both on the competence of the consultants and the trust the Bank exhibited in accepting these figures. Though not so acknowledged in the PCR, internal Bank memos3/ did recognize the fact that an "oversight- on the part of the consultants as well as the appraisal team had led to the initial underestimation. While underestimation is also due to the figures provided by the Government, the failure to examine technical specifications and to check details during the appraisal missions (partially because of lack of time) as well as the lack of precision of consulting architects, clearly indicate that the Bank relaxed its technical standards and monitoring mechanisms in the rush of project design and appraisal. As a result, the sharing of project costs was reversed: the Government's share went from 38% to 72% of total costs, 4hile IDA's and NORAD's combined share was 28%, instead of the initial 62% (PCR, para. 3.39). 13. While doubt on the availability of personnel was expressed in an internal Bank memo (July 7, 1970), it was not reflected in the pre-appraisal (December 18, 1970) nor in the Appraisal Report. Government assurances were accepted that staffing would be secured by the time of construction com- pletion. A few years later, the supervision mission of April 19, 1974, con- firmed the initial Bank concern and raised the problem of lack of personnel affecting the schedule of construction of the M37 centers. This was never pursued. Indeed, the PCR (para. 2.05) notes that the identification mission found that many of the existing facilities and personnel were underutilized and ascertains that -the geographic expansion of the program was hindered by acute shortage of qualified medical personnel..." (PCR, para. 2.15). More importantly, no consideration was given in the design stage of the project or during its implementation, to the fundamental problem of the relationship between access, construction and personnel nor to the possibility of rehabil- itation versus new construction. 14. A reluctance to redefine the project4/ during implementation may have been the result of administrative pressures on both IDA and Government project staff. Yet, rethinking of priorities at an early stage, when delays were apparent, might well have benefitted the project.51 The PCR confirms, in fact, that the "real take-off" of the construction program was only in 31 July 25, 1973 and November 26, 1974. 4/ Project redefinition resulted in deletion of two rural maternities (PCR, para. 2.25) and of the training component (both for cost considerations) (PCR, para. 3.28) and the discontinuation of the Management Technical Assistance. 5/ More "step-by-step- flexibility in project development has been recow- mended by B. Berelson and R. Freeman in A Review of the Implementation of the Recommendations of the External Advisory Panel on Population, Sec.M79-114, March 2, 1979, p.5. - 5- 1974 (PCR, para. 3.09) while the management component was dropped from the project that very year. The overwhelming concern with cost escalation overshadowed a-ad eventually dominated both the ultimate functionality of structures (paras. 22 to 29) and the main institutional goal of the project. That goal was to -strengthen the Government's program through a series of measures (Appraisal Report, para. ii), of which construction was but one component. 15. Was the project design too ambitious in view of the managerial and institutional capacity of the country, as well as the Bank's own lack of experience in population lending? The overall outcome of the project (see section F) proves it to have been so. Indeed, the earliest project pre- identification by the Government envisioned 100 man-years of professional gynecological services, medical equipment and supplies, and the construction and equipment of 25 MCH centers, including approximately 12 small operating theaters (internal Bank memo, July 8, 1969). During project identification, the project concept gradually expanded. The Minister of Health at the time had objected to this expansion, which he felt might hamper the effectiveness of the project (letter from identification mission to IDA, December 22, 1969). 16. The consultants and staff of the First Population Project in Tunisia were committed to an approach which led to a dualism in project design and, eventually, implementation: one section, construction, and another section, program management. The same was true of other Bank-assisted population projects at the time.6/ More tangible and obviously more costly, the -hardware- component was the most serious concern throughout the project, as the technical orientation of the supervision missions between 1971 and 1976 indicates (para. 35). 3. Socio-Medical Issues 17. Socio-medical issues were raised before and during the implementa- tion of the project. In view of the complexity of family planning, the relative lack of emphasis on these issues not only weakened the initial im- portance given to the management component of the project but also had a negative impact on the ultimate design.and optimum use of the buildings cow- structed. 18. The complexity of population programs was clearly spelled out during the presentation of the Project to the Extcutive Directors of the Bank and IDA, March 23, 1971: -The problem of slowing population growth is one of the most complex of all development problems because its solution touches upon a greater number of fields than is the case with almost any other prob- lem: cultural and private attitudes, urban and rural.sociology, psychology, medicine, public administration, politics, and religion." This was true in 61 First Population Project of Trinidad and Tobago, Loan 943-TR; First Population Project of Jamaica, Loan 690-JM; First Population Project of Egypt, Credit 437-UAR. -6- the 1970s and still holds true today. One of the hardest of wares to sell is "software". Yet, it is also one of the most critical to address in project design and during the project cycle. The comprehension of the social ew- vironment, in this case that particular to family planning and health in general, is a sine qua non to the function of management. A management information system is meaningless without this background of understanding if its purpose is to render political priorities administratively and socially feasible. 19. Substantial social issues relating to the project were raised before, during and after the Appraisal Report.7/ While supporting the PCR's conclusion that the "project consisting of coherent components was designed, based (on what)... was the leading philosophy of those days..." i.e. the post-partum approach (PCR, para. 6.01), the audit maintains that these issues,8/ if administratively impossible to include as an addendum to the Appraisal Report, should at least have been covered by understandings between IDA and Government and periodically reassessed.9/ 20. The PCR does not raise many of the above concerns but states (PCR, para. 3.37 and 4.19) that the level of new acceptors has reached a plateau since 1977. The audit strongly supports the recommendation made by the PCR (para. 4.22) to "reassume (sic) the study of continuation rates..." and that "any inclination in the curves of family planning acceptance should be studied in detail...". 21. An underlying question, still relevant today, could well have been asked by the designers of the Project: does a physical structure suffice? Indeed, what matters is the meaning given the structure by the population 71 Letters and comments from the UNFPA (April 25, 1969) and the Population Council (March 18 and 19, 1971) were received at the Bank in response to its request for an informal assessment of the project. Numerous issues were also raised during the lengthy discussion of the project by the Executive Directors of the Bank and IDA on March 23, 1971 to whom it was assured that the issues would be resolved by "associating ourselves with the management study ...". Liter the Sector Review of 1975 (p. iv, para. 56) had also raised numerous social and institutionally-related issues. B/ Some of the issues raised in these lettersand discussions: need for an in-depth socio-anthropological study; need to reassess the "showplace buildings and sophisticated equipment" planned in the project; criticism of the post-partum and "simplistic approach of the program"; need to address the male's role in FP; importance of attitude surveys; defini- tion of linkages between hospitals and MCR centers, etc.... 9/ This could have been immensely useful given the fact that the appraisal had set high expectations by stating, Annex 6, p.4: "The project alone would make the population and the labor force 3.2% and 1.6% smaller, respectively, by the year 2000." (Audit underlining). - 7 - which will use it. This will be based on their needs, their logic and their understanding of it. The unidimensional bias in financial and construction concernsl0/ predominated throughout the project and allowed little time for such issues. C. Physical Structures and Functions of Space 22. Construction of hospitals and MCHIFP centers were new to the Bank in the early 1970s, though the Bank had a wealth of expertise in construction projects in other sectors. However, criticism in the PPAR of Jamaica's First Population Project (Loan 690-JM, PPAR, p. v) applies equally to Tunisia's First Population Project: "serious problems were encountered in implemen- tation of the construction program; the Bank's wealth of experience and long- established policies and procedures in dealing with construction projects were never fully brought to bear on these problems". The same phenomenon was also noted in the First Population Project in Trinidad and Tobago (Loan 743-TR, PCR, paras. 3.06-3.14). At the start of the Tunisia project, an internal Bank memo foresaw the situation very differently and identified "no technical problems regarding the bidding procedures and the construction schedule" (June 17, 1970). 23. While it is accepted that the Bank had no experience in construe- tion of hospitals and MCH centers at the time, it should be remembered that the hospital consultants suggested (internal Bank memo, May 18, 1971) and approved by the Bank (though not the Bank's first choice) were chosen precisely because of that particular kind of expertise (internal Bank memo, October 17, 1971). Several Government officials are of the opinion that these consultants were experimenting with ideas while not taking into account the conditions of the country.11f 24. A reconsideration of the construction designs would have been appropriate. The audit does not support the PCR's assertion that the Bor- rower considers the "buildings constructed under the project... of good qual- ity responding well to their functions" (PCR, para. 4.15). That they are used for what they were designed to be, is correct. That they "respond well to that function" is debatable. Moreover, the Government officials met do not support the PCR's statement that "the wishes of the client ... led to the overdesign" (PCR, para. 3.17). An internal Bank memo (Feb. 15, 1973) noted that the Government found the MCH designs "too luxurious", but were unsure of whether elimination of the "luxury items" would reduce cost overruns. 10/ In the words of a Government health official: "The World Bank concen- trates too much on financial issues. In such a project, it should not only have considered the social context within the project but also its administrative linkages (i.e., management relationships) to better de- fine its goals". 11/ This is supported by the ONPFP Report, ibid., p. 34, which states that the project appraisal did not take into account the fluctuations In de- lays, the nature of the terrain nor the "realities" of the country. -8- 25. While the most repeated criticism of the structures is that they are "luxurious" or "overdesigned" (PCR, para. 3.17), the audit considers them as simply misdesigned, reflecting a lack of consideration of the optimum use of the buildings as functional units and an equal lack of consideration of maintenance problems and needs. Luxury and overdesign reflect a certain functionality, albeit with unnecessary frills. Though this can also be applied to the maternity hospitals (e.g., the presently unused "bfb&-tiroirs" and complicated corridors),_2/ the most obvious observation, for all the buildings is the awkward and unused-or misused--space of entrances, offices, corridors and consultation rooms, and the lack of any room at all in mater- nity hospitals for external visitors. In the Wassila Bourguiba Maternity Hospital of Tunis, a corridor has been used as "the waiting room" for the external patients. In the MCH center of Matmata, the midwife had to squeeze her office into the consultation room, for there was no link between neigh- boring rooms.13/ Because of the dual purpose of MCHIFP centers, the waiting room at the entrance of the buildings is enormous in relation to the building as a whole, under the assumption that the different types of clients would sit at opposite ends and that audio-visual presentations would be made there. Such presentations never materialized. The cavernous entrances of the Maternity Hospitals reflect not luxury but oppression.14/ The Government technicians met during the Audit Mission felt that, had the poten- tial users of the buildings (i.e., doctors, nurses, midwives) been consulted, the spatial function could have differed. The consultation of a doctor was only done for the Maternity Hospital of Tunis.15/ 26. Lack of consideration of the optimum use and potential function of physical structures diminished the effectiveness of the units constructed. 12/ These "bb-tiroirs" and corridors were said to have been imposed against the desire of the Government (information gathered from Audit field mission). 13/ In that small village of Matmata, another building had to be built be- hind the MCR to house 10 beds, for no room was big enough to place a number of beds, even though consideration was given to pulling down walls to make space. 14/ While the frequent excuse is that the architects were Westerners (French and American) and therefore applied Western norms to their design, the Audit takes exception with such an assumption. A Western hospital or dispensary would not be conceived of with such unused and misdesigned space nor such a waste of money. 15/ At first, several doctors had been approached for consultation but no consensus was reached among them. As a result, only the opinion of the director of the Maternity Hospital of Tunis was retained. It appears, however, that the architects-consultants did not succeed in projecting the importance of functionality as based on technical needs. - 9 - The technical problems of the strucituresl6/ designed are numerous. They range from inadequate plumbing7-because of inadequate local supervision--to initial underestimation of equipment and materials. The ONPFP evaluation report (pp. 23 and 34) pointedly imputes the responsibility to the consultant architects for several of the following problems: not taking into account the need of services for premature infants In the hospitals; not anticipating the function of operating rooms in the maternity hospitals as teaching rooms for medical students and midwives; not allowing for heating in MCH centers, etc. While these functions did not appear in the Appraisal Report (PCR, para. 3.23), they were part of the terms of reference of the architects.17/ 27. The PCR mentions the problem of maintenance of the mechanical installations of the three maternity hospitals (PCR, para. 3.18). The lack of maintenance in equipment and buildings, is one of the most critical prob- lems in developing countries and often leads to greater underdevelopment.18/ This was not considered in either project design or project implementation. International bidding for equipment and materials encouraged a proliferation of different brands for the sane equipment, rendering maintenance more diffi- cult in some cases.19/ The Audit strongly supports the PCR's recommendation that in "the case of ICB for equipment, the need for standardization should be endorsed..." (PCR, para. 7.04). Indeed, the Revised Sixth Plan of Tunisia has budgeted 20.8% of its overall health expenditures for major repairs, 16/ Many of these problems, from construction delays to unused space, are strikingly similar to the ones noted in the PCR of the First Population Project of Trinidad and Tobago, Loan 743-TR (paras. 3.08, 3.14, 3.16 and 3.17). 17/ Lack of heating is a controversial topic and is not accepted by all Bank staff as being reasonable, for it is pointed out that Tunisian homes do not have heating. The Audit believes, however, that although this is partially true (for even the poorest home will have a -kanoun - a charcoal-burning mud stove to heat a room), the external patients are sitting immobile in a cold MCH center, while there is greater mobility inside a home. Moreover, the sick need minimal heating. In view of the so-called "luxury" of the buildings, such a detail may well have fit within the design. 18/ The MCK centers have windows close to the ceiling, which do not allow easy cleaning nor the possibility of opening them during hot weather. The enormity of the Maternity Hospitals adds to their expensive upkeep. Moreover, the lack of use of natural light in all the designs has made the use of electricity a necessity at all times, summer and winter, thereby increasing upkeep costs. 19/ The relationship of physical structure, function and maintenance is relevant. At the Maternity Hospital of Sfax, the operating rooms are on a different level from the patients' rooms. In 1982, the elevator was out of order during four months because of a missing bolt, and the women operated upon had to be carried up or walk up to their rooms. - 10 - maintenance and renewable equipment with the specific concern of reducing the diversity of sources of equipment. 28. The design of the project buildings highlights three important issues: (a) the need for preliminary studies in order to understand the interrelationships between climate, terrain, people, function, optimum use and maintenance problems; (b) the importance for the Bank to assume an ob- jective advisory and supervisory role in view of its technical expertise; and (c) the necessity to establish a rational, time-phased implementation plan.20/ 29. The PCR objectively outlines the delays and technical problems of the construction component chronologically (PCR, paras. 3.05-3.21), but suar- marizes in two paragraphs the ONPFP's lengthy critical evaluation of the project (PCR, paras. 3.22-3.23).21/ D. Performance and Responsibility of Consultants 30. This section highlights two problems which were particular to both sets of consultants: they both lacked an understanding of the environment they were to function in, and they both misunderstood the extent of their role vis-a-vis their counterparts. This had a negative impact on the outcome of their respective work, particularly harmful to the management team which was dismissed before the end of its contract. 31. It is pertinent to note that at no time during the project cycle, in the supervision mission reports or in the PCR, was any evaluation made of the performance or expertise of the consultants, reinforcing the effect of the "hardware" orientation of the project. The extent of the impact of a project is not only due to its original design. Much of it relies on what the consultants do with the design and on their expertise, performance, per- sonality and rapport established aith the host country. Management Specialists 32. Great importance was given to the choice of the management con- sultants (internal Bank memo, June 3, 1971) and emphasis was placed on a "continuing management study" (meeting of Executive Directors, March 23, 1971). So significant was this component to the Bank that the appraisal re- port specified (para. 4.13): "An evaluation of the study undertaken by the Consultant-Group may be asked by the Association at various time intervals in 20/ The same issues were raised in the following audits of population proj- ects: Egypt, Credit 437-UAR, PPAR, Highlights; Trinidad and Tobago, Loan 743-TR, PCR, para. 3.05; Jamaica, Loan 690-JM, PPAR, Highlights; India, Credit 312-IN, PPAR, Highlights. 21/ ONPFP, Projet Dfmographique (Accord TU 238) Rapport Final, 1982, pp. 14-23,33-36,58-60. - 11 - the course of the study. Reorientation steps may be taken at that time if deemed necessary." There is no evidence that such an evaluation was ever made. 33. The PCR (para. 4.09) states that the competence of the consultants was never questioned although it appeared that they had "lost rapport" with their client at an early stage. This led to their dismissal in June 1974. The supervision missions barely comment on this problem in the field except in one instance, February 15, 1973. Ironically, on July 19, 1974, a month after dismissal, the supervision mission noted that the consultants appeared to be appreciated by the Borrower. The Tunisian officials interviewed felt, however, that the consultants were young, inexperienced and socially insen- sitive, and could not possibly have made an impact on policy-making, a particularly difficult task, because of the numerous changes and instability of leadership in the INPF, the predecessor of the ONPFP. It was not until 1974 that the new director of the ONPFP finally took action. 34. Was this the result of a lack of understanding of the situation on the part of the Bank or of a lack of interest in the overall institutional component? This is not clear. The supervision missions, however, made no expliLit analysis of the situation for the records. The audit fully supports the recommendation of the PCR (para. 7.05) regarding the "imposition" of technical assistance on borrowers. It dces not feel, however, that it was the management component as such which was rejected or misunderstood by the Borrower. Indeed, the ONPFP subsequently obtained a management advisor, funded by USAID, in 1975 (internal Bank memo, June 3, 1975). What is at issue here is the lack of understanding of their role by the consultants. E. Role of Supervision Missions 35. The family planning orientation of the supervision missions was lacking. In the nine years between 1971 and 1980, there were 24 supervision missions, of which more than half (16) had taken place during the first four years, usually comprising an architect and an economist, who participated in the missions throughout the project cycle, while a demographer was involved only during the first two years of supervision. At first glance, the specialization composition of the supervision missions (see Basic Data Sheet) may appear satisfactory. However, the technical input was uneven because of the immense financial and construction problems which dominated the project. The early presence of a demographer did not allow for the consideration of socio-medical issues, and the subsequent involvement of a health educator- project officer, as of 1974, followed the termination of the contract of the management team. Similarly, apart from his participation in the Sector Review, it was only as of the fifteenth mission, June 1975, that a medical doctor accompanied the missions and only as of the twentieth mission that a social scientist became part of four successive missions, one of which involved the identification of the 1981 Project. These missions took place after the termination of the management contract. Between 1978 and 1979, no mission took place because of postponements requested by the Borrower (PCR, para. 3.41), but no explanation is given for this. It appears, however, that the Bank-and the Government--had lost interest in the project and had - 12 - already been thinking of another project since 1975 (internal Bank memo, March 4, 1975). Unexplained, as well, was the elimination of a second Sector Review (PCR, para. 5.14), though such a review would have been worthwhile for the design of the new project and for the better continuation of the efforts of the first into the subsequent project (paras. 44-45), even though the latter widened its concerns to include Primary Health Care. 36. These missions were unanimously considered one-sided by the Tunisian officials, particularly the technicians. While one of the most important functions of the supervision missions is to pursue a dialogue with the borrowers and establish "personal and working relrtionships", it was felt that, although exchange of ideas took place, there was rarely a feedback of the issues to the technicians.22/ The mission reports, therefore, were considered merely as "a review of progress" for the benefit of the Bank. Moreover, the primary corcerns of the supervision missions were felt to be timing, financial estimates and Bank regulations and not technical issues. Not only was the need expressed for more direct involvement and interaction of the Tunisians in the progress reports-a group effort-but the feeling was that their involvement would help them in their own continuous monitoring of the projects and achieve a greater "meeting of the minds". F. Impact of the Project: Institution-building and Project Continuity 37. The project had one goal: to strengthen the Government's family planning program through physical construction together with the provision of consulting services for a management study and paramedical teaching, as well as fellowships for paramedical personnel (Appraisal Report, 1971). There- fore, much emphasis was placed at appraisal on the institution building aspect of the project as a means of reinforcing the overall FP program (PPAM, para. 32). Some of the construction and the three last components -management, paramedical teaching and fellowships--were dropped early on in the project (PCR, paras. 2.25, 3.28 and 4.09). Despite this, the original project description was left unchanged through the last supervision report in 1981 and was repeated verbatim in a recent UNFPA report 23/ as well as in the Amendment to the Credit Agreement (October 13, 1976, Schedule 2). 22/ This very issue was raised in the PPAR of Egypt's First Population Proj- ect (Highlights): the need to deal directly with technical personnel and to give them responsibility as they are the ones involved in the daily running of programs. 23/ "The project is desigaed to support the population control program of the Borrower and consists of the construction and equipment of 4 new maternity hospitals, 2 new rural maternity centers, 29 maternal and child health centers and an extension to the paramedical training school; management consultants for family planning services, assistance for teaching of medical personnel and two external missions." Report of Mission on Needs Assessment for Population Assistance, Report No. 45, UNFPA, New York, 1981, p.82. - 13 - 38. The implied goal of institution-building was not achieved. This, however, was differently perceived by the Government and the PCR. While the former viewed it as the development of physical infrastructure for the FP program, the la.tter highlighted the attainment of the original goal. In reality, the Bank abandoned its institutional interest in the ONPFP. This has resulted in a break in continuity between the First Population Project and the population component of the 1981 Health and Population Project. The latter still faces unresolved issues of institutional-and programmatic- integration. Differences in Perception of Project Goal 39. After 1974, with the deletion of the management component, the project began to be viewed differently by both parties: the Government per- ceived the purpose of the project as a strengthening of physical infrastruc- ture for MCH/FP centers while the Bank kept on describing the activities of the ONPFP in its supervision reports, essentially for internal recordkeeping. 40. The question needs to be asked: Has the institution concerned, the ONPFP, developed because of or in spite of the project? The PCR (para. 4.14) is most accurate in its evaluation of the project impact by stating that it cannot be measured in precise terms, and that the project was only one input into the FP program. 41. There is absolutely no doubt that at the very inception of the idea of the project and during project negotiations, the leadership role of the Bank vis-a-vis the Government was considered crucial by the other donors (PCR, para. 2.07) particularly in the role of impressing upon the Government the importance of the relationship between FP and economic growth.24/ But the political commitment to the idea, at the highest level of the Government, was already important since 1962, when President Bourguiba made the relation- ship part of his political ideology in a speech to the UNFT.25/ The commit- ment is still strong and is explicit in the GOT's Sixth Plan (pp. 65-77). 42. The PCR, paras. 1.05 to 1.10, outlines the evolution of the family planning program in Tunisia from 1964 to 1973 with the creation of an Office National de Planning Familial et de Population (ONPFP). It also points to the impact of the First Project in helping develop a parallel structure (PCR, para. 6.03) and to the 1981 Project in rectifying this development by pur- suing an approach of institutional integration (PCR, para. 6.01). There is need to briefly discuss these two concepts--parallel structure and integra- tion-within the Tunisian context. 24/ The Agreement between the GOT and USAID for their Family Planning Program Grant (No. 664-GOI), dated May 26, 1972, had stated as one of its Conditions PrEc'dents (Article 2, Section 2.1d): "evidence that all major convenants, requirements and conditions of the IDA credit agree- ment are being met...". 25/ ONPFP, Le Planning Familial dans le Gouvernorat de Jendouba, Tunis, June 1981, p.3. - 14 - ONPFP: Issues in Institutionalization of Integration 43. From the earliest days in 1968, the activities of FP were within the MOPH, first as a Directorate, then as an Institute in 1971 (INPF) and finally as an Office (ONPFP) in 1973, when ONPFP was established as a para- statal crganization, although still under the tutelage of the MOPH. It is important to realize that the creation of ONPFP was part of a national trend. Various "offices" had already been established under other minis- tries. 44. An important reason for the creation of an "office" was to allow greater budgetary flexibility for programs within the particular sector, a flexibility which the bureaucratic procedures within ministries themselves did not-and still do not-allow. That enabled the ONPFP to take initiatives and pursue actions. On the other hand, while all of the "offices" had their own budget and a nucleus of personnel, they had to rely on their ministries' personnel, particularly for extension work (midwives and nurses for the ONPFP). There arises the confusion. In the case of the ONPFP, the status of personnel remained unclear while efforts were made outside the project to integrate the FP program, through a "promotional network".26/ The malaise was based on the difference in salary scales between office and ministry personnel (PCR, para. 3.33).27/ In other words, the creation of ONPFP allowed it, through its specialization, to reinforce an activity within the ministry. However, although its legal status provided it an independent bud- get, it was not enabled to have control over personnel it fully relied upon for the functioning of its activities. A confusion of verticality and horizontality of structure ensued. 45. The "prestigious and energetic Director General" (PCR, para. 1.10) of the ONPFP set Plans of Action for 1974-76 and 1977-81 which he summarized in a document in 1979.28/ In it he outlined the philosophy and desired approach of FP: FP is an essential component of the basic health needs of the family; the actions of the Office, favoring maternal and child health 26/ The Supervision Mission Report of January 7, 1977, includes (Annex IV, p. 1) a diagram of the "promotional network" of the ONPFP: its organi- zational ties with a multitude of institutions, from the General Union of Tunisian Workers to Regional Commissions for Agricultural Develop- ment. 27/ Problems of verticality, parallelism and subsequent jealousies, a result of differences in salary scales, also appear regarding Jamaica's National Family Planning Board (Jamaica First Population Project, PPAM, para. 27), the NFWC in Kenya (Kenya First Population Project, PPAM, paras. 18-20) and the Trinidad and Tobago First Population Project, (PPAM, paras. 5.27-5.28). 28/ ONPFP, L'Action de l'Office du Planning Familial et de la Population 1974-78 - Objectifs, Rfalisations, R6sultats, Tunis, Mars 1979. - 15 - care, are within the context of a medecine intigrfe; this integrated approach has had favorable results in several regions of the country. However, the void created by the inability of the MOPH to take actions in FP, and its reluctance to release its personnel for FP duties, left the ONPFP, by means of a multitude of donor grants and loans, to pursue independent outreach pro- grams (mobile teams and FP clinics) where MCH centers and dispensaries did not exist and to create its own linkages with various other ministries and groups (Sector Review, para. 1.28). Weakness in institutional linkages between ONPFP and the MOPH still persist, and "integration" remains based on personal relationships already noted by the Sector Review in 1975 (PCR, para. 3.31). 46. While it is undeniable that the Bank had a role in helping mold the status of the ONPFP, through its recommendations in the Credit Agreement and in a letter of June 23, 1972 to the INPF, what is unclear is the Bank's real input in the process of institution-building within the First Population Project, i.e., strengthening the FP program through institutional linkages, actions and development beyond the mere erection of physical structures. 47. Schedule 4, para. 3, of the Credit Agreement did indeed encourage the specificity of the Directorate in 1971, while promoting its involvement and support mechanism, i.e., integration in MCH centers, hospitals and other groups for educational and FP activities (Credit Agreement, Schedule 4). The recommendations of the Bank to the INPF reinforced this trend and it similar- ly requested clarification on hierarchical administrative linkages and on the administrative procedures for control of operations on the local and national level. Finally, the law of March 23, 1973 (No. 73-17), creating the vertical institutional structure of the ONPFP, not only specified (article 2) the research and planning functions of ONPFP but also gave it the responsibility of establishing and executing programs and plans of action in conjunction with all public and private organizations interested in FP (article 2.b), i.e., encouraging a horizontal support mechanism. 48. The management study did not deal with the problem of linkages clearly but rather recommended that the Directorate limit itself to planning, evaluation and research (PCR, para. 6.03). None of the supervision missions addressed the problem with concrete puggestions. In the atmosphere of ten- sion that gradually developed between the MOPH and ONPFP, the Bank was caught in the middle and was unable to overcome the personality and political cor- straints which ensued. The supervision mission of July 11, 1979, summed up a situation which still prevails today: "The option to integrate services fully has elicited a wait-and-see response among the ONPFP and other relevant bodies within the MOPH- (Annex 8, para. 2), and it adds that both bodies would gain from working together. Yet, the mechanism of how to work together or the meaning of integration is not spelled out: at what point is there a division of labor? What are the priorities common and separate to both agen- cies? What is the respective administrative capacity of the divisions and institutions involved in defining roles and in coordinating activities? Does integration imply a single, polyvalent health worker or several people with specific functions supporting a global action? At what level is there inte- gration? How are incentives to be maintained without monetary gains? How is - 16 - the duality of PP (with its emphasis on discretion for the client) to be maintained in the process of integration? Most of all, no written evidence appears regarding the real prerequisite of institutional and programmatic integration on such a large scale: i.e., the existence of a highly co- ordinated and smoothly-run administrative structure. If this condition is not met, then risk of mediocritization of all services may result.291 The questions are numerous. They reflect, however, on an obvious weakness in the design implications of the First Population Project.30/ Differences in the Perception of Project Impact 49. A difference in the evaluation of the impact of the project appears between the PCR and the Government's own evaluation report. The PCR's over- all assessment (PCR, para. 4.23 and PPAM, para. 37) is expressed in more measured terms by the Government (para. 38), while acknowledging that the new facilities allowed greater penetration of services in rural areas.31/ 50. Based on all the documents relevant to the project and on the numerous frank discussions which took place during the audit mission in Tunisia, the audit cannot support the PCR's claims. Indeed, it feels that the project ended up by using the ONPFP merely as a conduit or financing mechanism for the construction component of the projedt. The project missed the opportunity of having an impact either on policy or on institution- building, a fundamental requirement for achieving the original program- strengthening goal of the project (para. 37). Furthermore, the importance of the management component was neither clarified nor redefined by the Bank or the Borrower. The project consequently lost a valuable opportunity to assist in the development of the ONPFP, which evolved, with all its weaknesses and strengths, more or less independently of it. 51. While the project cannot be considered a success, it did have generally positive aspects which should be noted as part of an effort made by several donors to support the family planning program. Together the donors added to the trend and effort of highlighting the importance of reaching out to rural areas instead of only concentrating on the urban areas (PCR, para. 291 Golladay and Liese, (Health Problems and Policies in the DevelopingCoun- tries, World Bank Staff Working Paper No. 412, August 1980, p. 44,) state under "Project Concepts": "Projects should conserve admini- strative capacity. Wholesale introduction of inncvations ... only over- whelms the implementation capabilities of the Ministry of Health o... a strategy for change should be devised that gradually develops operating capacities." (See also the audit of the Kenya First Population Project, para. 34.) 30/ Similar questions were also raised in the PCR of the First Population Project of Trinidad and Tobago (note 5 of para. 5.28) and the PPAM of the First Population Project of Jamaica (paras. 25-39). 31/ ONPFP, Projet Dfmographigue, 1982, p. 63. - 17 - 6.06). The interaction between donors and the ONPFP also helped refine respective thinking regarding the general approach of family planning: the importance of the preventive versus the curative; the reconsideration of the post-partum approach for a broader-based educational approach and for a greater insistence on spacing of children. G. Lessons Learned and Conclusion 52. An outstanding characteristic of this project is the need for more effective institutional memory. Consideration of opinions and questions raised concerning project design and goal was not given; similar experiences of projects in the same sector in other countries were not reviewed; aware- ness of other projects implemented in the same country (in industrial and agricultural sectors), with the same problems of management and construction, was not apparent. Institutional memory implies written reflection and analy- sis of project process, of documents, events, and other relevant projects. There is need for such an effort to be made to avoid the constant repetition of the "first-time" syndrome. It is particularly important to be aware of projects in the area so as to better comprehend the problems and process of the project in question. 53. Need for stricter and more program-oriented supervision missions which would also more closely involve the national technical staff. The project was burdened by numerous mishaps: a sketchy project appraisal report, underestimation of costs, numerous delays in project components, mis- designed construction, difficulties with international bidding procedures, elimination of the technical assistance components, personality and admini- strative ir-fighting and, last but not least, consultants with little under- standing of the Tunisian environment. Many of the problems could have been resolved by more program-oriented supervision missions, i.e., multidisci- plinary, and a more critical appraisal of technical issues. The supervision missions could also have benefited from a combined Bank/Borrower supervision-monitoring exercise reflecting a collaborative effort. It appears, however, that efforts for such a collaboration have already taken place in the implementation of the 1981 Health and Population Project. 54. Commitment to the study of the complexity of social issues in popu- lation and health projects should be acted upon. The project fell into the "bricks and mortar- category in spite of early warnings and the initial importance placed on the outcome of its "software" component. Institution- building was minimal because of the lack of int.errelationships between "hard- ware" and "software" and the lack of understanding of the relevance of socio-economic and socio-medical issues to institution-building. Projects would greatly benefit in this respect by addressing these issues in project identification and design, and during project implementation and monitoring. 55. Maintenance problems create greater dependence, greater under- development and exacerbate recurrent costs of structures. They also diminish management efficiency. Maintenance issues and their repercussions were not considered in this design either by the local or the foreign consultant- architects. Concern with such issues should be part of all implementation schedules. - 18 - 56. Flexibility should not only be limited to Bank regulations and procedures vis-a--vis the Borrower (PCR, para. 7.04). The flexibility in implementation of project design, allowing for resetting of priorities, would have greatly benefited the overall -,utcome of the project in view of the multitude of problems resulting in numerous delays. 57. A project design should consider the administration's capacity to manage (on a national, regional and local level) the complex interrelatior- ships of a project to these structures and, simultaneously, the availability of personnel necessary at different stages of the project. The audit sup- ports, in principle, the PCR's recommendation (para. 7.02) that placing a project administrator in "a high enough level in public administration" will facilitate project implementation and coordination. However, this will not assure the project's smooth implementation or success unless administrative capacity and availability and expertise of personnel on the lower levels are also assured. 58. Conti2uity between projects adds to the development of a program, if not to the development process in general. The continuity between proj- ects is a measure by which both IDA and the Borrower can improve the extent of lessons learned. The 1981 Health and Population Project of Tunisia had the advantage of having been preceded by a project with many lessons to learn. Yet, an identification of the new project was made before the evalua- tion of the first. 59. It is pertinent to briefly highlight lessons learned by the Borrower, as expressed to the audit mission, though yet to be internalized (see also para. 52): - need for better coordinated planning between different divisions and between ministries and related organisms; - need for greater efficiency in management; - projects should fit within overall program goals; - need to adjust a program to better assessed needs; - study different approaches for di.ferent population targets; - need for greater technical interaction between the Ministry of Public Works, the MOPH and the Ministry of Plan; - need to better address relationships between structure and func- tion; and - concern with maintenance problems has already been highlighted in the Health Plan within the current Sixth Plan. - 19 - Addendum 60. According to data gathered by the audit mission, rectification is proposed in some of the Demographic Indicators of the PCR's Key Indicators. Table: 1981 /a 1981 /b Demographic Indicator GOT Objectives (PCR Data) GOT Estimates (PCR Data) Crude birth rate 32.3% ( 33.6%) 34.6% ( 32.8%) Crude death rate - - 7.8% ( 7.6%) General fertility rate 133.8% (135.3%) 148.0% (133.8%) Rate of natural increase 2.3% - 2.7% ( 2.52%) Annual rate of popula- 2.6% ( 2.5%) tion growth /a Source: Objectives of Fifth Development Plan of Tunisia, ef. Sixth Development Plan, p. 67. /b Source: Estimates in Sixth Development Plan of Tunisia, pp. 71-72. - 2e0 - - 21 - PROJECT COMPLETION REPORT TUNISIA POPULATION I PROJECT Credit 238-TUN April 12, 1983 Population, Health and Nutrition Department -� � г - �s ���� �`��� � � 23 I .114TRODUCTION 1.01 In March 1971 the International Development Association granted a credit to the Government of the Republic of Tunisia for the execution of a population project. The credit was the Bank Group's second operation in the field of population and the first to be financed by the Association. 1.02 A strong commitment of President Bourguiba. to family planning and social development in generall-/ made Tunisia one of the most indicated countries for the Bank Group to start these new activities. At the request of the Government a population specialist joined an Economic Review Mission which visited Tunisia in Harch/April 1969, to review the national efforts in family planning- 1.03 At the time, Tunisia's population stood at a little over 5 million people distributed over an area of 164,000 km2, yielding a population density of 31 inhabitants per km2; however only half of the area is suitable for agriculture and grazing. Cultivable land represents only about one third of the total area. The annual demographic growth rate was estimated at 2.8 percent (1965-1970). At that rate the country would double its population in less than 26 years. Birth and death rates were estimated respectively at 44 and 16 per thousaud2/. Still some 60% of the population of 10 years and over was illiterale. life expectancy was around 53 years and infant mortality was high: twelve out of each hundred newborn infants were dying before they could reach their first anniversary. 1.o4 About 61% of the population was living in rural areas. Of the employed labor force 43%was in agriculture which represented a 14.3% of the GDP (1966 prices); the GDP per capita was the equivalent of US$205- During the period 1965-1970, GDP showed an annual rate of growth of 3-62. Unemployment was a serious problem (15% of the labor force), somewhat alleviated in the late sixties and early seventies by economic growth and out-migration of mostly male laborers estimated at some 30,000 p.a. to France and other West-European countries. Also Libya received at times some important contingents of Tunisian laborers, but there was not-a constant outward flow to that country. a 1.05 in 1964 a Government-sponsored experimental program of family planning activities was launched through the Ministry of Public Health. This pilot program was preceded by a national survey on knowledge, attitude and practice of family planning (KAP study) which indicated a*large demand for family planning 1/ It will be remembered that President Bourguiba Also strongly advocated for the emancipation of women. Shortly after independence he banished the veil. and pushed other legislation to improve the status of women. As early as 1962 he declared that -a race against the clock is going on between our economic development and our demographic increase-. 2/ The latest estimates for birth and death rates are respectively 34 per thousand and 8 per thousand which mean an annual rate of natural growth of 2.6% (doubling time: less than 27 years); migration has become negligible. services. Two years later this experiment was expanded into a national program. Tunisia's third Four-Year plan (1969-1972) explicitly called for a reduction in the rate of population growth3/ in order to improve the economic and social prospects of the country. The National program received the active support of President Bourguiba, seconded by his Socialist Destour Party and the National Union of Tunisian Women. 1.06 The National Family Planning Program offered free contraceptive advice and services and included provision for sterilization (tubal ligations) and social abortions for women with at least 5 living children. Considering the time and the social and cultural setting of the country this policy was most notable. 1.07 Under the national program, the Ministry of Health established 30 centers within its service delivery network. Initial deficiencies in the services and inadequate follow-up created a popular backlash which caused the Government to temporarily withdraw its unqualified political support for the program. However by the end of 1967 the Government had renewed its full support and restated its conviction that population growth at prevailing rates was a hindrance for social and economic development. By early 1968, family planning services together with the services for mother and child, were brought under a separate Directorate within the Ministry of Public Health. 1.08 The following year brought a complete reorganization of the health services; a large part of the administrative and financial control of the health services was decentralized from the Ministry of Public Health to the authority of the 16 regional health administrators. The Directorate for Family Planning and Mother and Child Health was reorganized in 1970; it retained the responsibility for recruitment, training and assignment of personnel but lost its control over the utilization of this personnel once it was assigned to a region. Not surprisingly, the health administrators faced with a constant lack of para-medical personnel were inclined to give higher priority to Immediate curative services than to family planning activities. 1.09 Performance of the National.Family Planning Program for the first years was very modest. The early service statistics show a number of new acceptors of not more than ten thousand per year (up to 1968). The division of responsibilities between the central Directorate and the regions weakened family planning activities. 1.10 With the unexpected windfall of oil money and increasing phosphate prices, Government commitment to family planning seems to have slackened, as it was felt that population pressure was less stringent.. In spite of the creation in 1971 of an independent Office for Family Planning and Population with a prestigious and energetic Director General, the problems of delivering family planning services at the roots of society was never quite solved. There were mixed feelings in the country as well as in the Bank about the desirability of 3/ The Government also had changed legislation to increase the minimum legal age for marriage to 20 for men and to 17 for women. - 25 - integrating family planning services with basic general health services; many feared that such an integration would lead to neglecting or abandoning of family planning services; those in favor of integration argued that without also offering other basic health services, family planning by itself would not be accepted. In the early 1970's, there was little concern for real out-reach programs as services were concentrated, according to the prevailing philosophy of the time, mainly on post-partum programs. 1.11 The Tunisian government had expressed its interest in Bank Group's assistance in assessing the needs of the National Family Planning Program, which was the first in an Arab country, and the first in Africa. In June 1969 the Minister of Planning confirmed to the Bank Group the interest of his Government in Bank's assistance in expanding and improving the activities of the program. Identification took place late that year and in 1970 the project was appraised. Total project costs were estimated at $7.7 million. In March 1971 the Board of Directors approved an IDA Credit in the amount of US$4.8 million. 1.12 The project was to contribute to the strengthening of the Government's program through a series of measures designed to increase the number of acceptors of family planning and to retain more of them as practitioners for longer periods of time. It is difficult to measure this contribution in solid figures but it is felt that iti reviewing family planning programs which operate through health delivery systems more attention should be paid to the improvement of general health conditions indirectly resulting from these programs. 1.13 Several years ago a Bank Working paper4/ pointed to the importance of a drop in infant mortality levels to a threshold beyond which people would start to realize that to be assured of care in one's old age, a larger number of children was no longer a necessity. The improvement in the health of infants and young children might even lead to a temporary increase of the growth rate and interested authorities should be made aware of this. Even a temporary increase in fertility might be the result of improved health conditions. 1.14 The preparation and implementation of this project started a dialogue with the Government which led to a second project directed at improvement of health and family planning servicesC, especially in rural areas. The implementation of this second project will undoubtedly benefit from the experiences gained through the first project. II. PROJECT IDENTIFICATION AND PREPARATION 2.01 Project Origin. At the 1968 Annual IMP/Bank Meeting, Mr. McNamara announced the Bank's interest in assisting developing countries to overcome their population problems. At the request of the Ministry of Planning, it was decided to include a population specialist in the Economic Review Mission which 4/ Zachariah, K.C. Fertility, Mortality and Population Growth: Interrelations and Policy Implications, Washington, D.C., IBRD, 1973. - 26 - visited Tunisia in March and April, 1969. In discussions with the mission, the Minister of Planning requested the Bank for a team of experts to advise the Government on the likely success of the activities of the family planning program and the need for possible improvements. By letter of June 3, 1969, he confirmed this request. At the Annual Meeting in September of the same year, the Governor for Tunisia reiterated his Government's interest in Bank assistance. 2.02 A comprehensive population census had been carried out in 1966, followed by three demographic surveys. Results indicated an annual growth rate of approximately 2.8 per cent, much higher than many Government officials had expected. The demographic objectives of the 1969-1972 development plan were based on three alternative projections yielding by 1986 a total population of 8.5 million (no change in fertility level), of 7.8 million or 7.4 million (moderate or pronounced change). The plan stated that it should be possible to reduce the annual growth rate from 2.8 per cent to 2.0 per cent by 1986. On the other hand, the Ministry of Public Health expected the decline in fertility to be compensated by a reduction in mortality and was anticipating only a slight decrease in the rate of natural growth to 2.7, over the following ten years. (At that time the birth rate was estimated at 46 per thousand and the death rate at 18 per thousand). There were obviously important discrepancies between the objectives of the ministries of Health and Planning. 2.03 The demographic surveys indicated a great interest in family planning among Tunisian women. According to the findings of the Economic Mission, the Ministry of Public Health could not cope with the demand for services despite generous contributions of outside donors as USAID, the Ford Foundation, the Population Council and SIDA. Family planning activities appeared to suffer from a substantial lack of medical and para-medical personnel, a lack of training facilities and considerable flaw in the administration of the program. Contributions from donor agencies were kept outside the regular budget of the Ministry of Health and were not well administrated. A need for more coordination among the donors was already keenly felt. 2.04 Project Identification. In November 1969 an Identification mission consisting of a staff member and a medical consultant was sent to Tunisia. The mission was to: a) review the family planning program in all its aspects and b) ascertain the manner in which the pank could provide assistance in developing and improving Tunisia's family planning activities. The mission's terms of reference also included a review of the targets for the family planning program during the 1969-72 plan period and beyond; an analysis of the administration of the program; an assessment of personnel, supplies and equipment needed to achieve the targets set for the program; an analysis of the extent of foreign assistance received, its effectiveness and the need for further external assistance. 2.05 The Identification Mission found that much of the existing facilities and personnel were actually underutilized. Although family planning was said to be an integral part of the health delivery system, it was only provided by doctors specially designated for that purpose. In the larger cities gynecologists at MCR centers carried out family planning services on a part-time basis for which they received a supplementary salary. - 27 - 2.06 In spite of the presumably favorable conditions in Tunisia, the mission was disappointed by the number of new accepLors. which was not going to exceed 17,000 that year. The Government seemed unaware of the total cost of the national family planning program. The mission estimated that these costs were extraordinarily high in comparison with results obtained. 2.07 Between the time of the Economic Review Mission to Tunisia and the visit of the Identification Mission, major changes in the Tunisian Government had come about. The new Secretary of Planning initially felt that the Tunisian economic development might be accelerated by more investment in the conventional sectors rather than in family planning. The new Minister of Health requested that concessionary terms be considered as he felt that almost unlimited amounts of grant funds from other foreign sources were available. The mission felt it was imperative for the Minister to agree that performance of the national family planning program should improve in order to achieve the national objectives; the Government should recognize expenditures for family planning as a necessary factor in stimulating economic growth. The Bank's role in this respect was considered crucial as none of the bi-lateral agencies involved in family planning was in a better position to discuss these qu; stions with the Government. 2.08 Appraisal. A four member appraisal mission consisting of two staff members, a medical and an architectural consultant "visited Tunisia from May 19 - June 2, 1970. One staff member re-visited Tunisia from July 25 - August 7 and a pre-negotiations mission consisting of four staff members including a member of the Legal Department was sent for a week in December 1970. The appointment of a high level technical Director for Family Planning, directly responsible to the Minister of Health with centralized functions was promised to the mission but there remained the difficulty concerning the direct control over the personnel and facilities of the family planning program in the regions. Effectively, in the following month of July the Minister of Health issued an internal memorandum whereby he reorganized the Directorate for Family Planning and Maternal and Child Health more or less according to the lines discussed with the Appraisal Mission. (The day-to-day control of MCH and family planning personnel remained however with the Regional Health Administrators). 2.09 Extensive discussions took place within the Association while the Appraisal Report went through its different stages of preparation. The economic justification of the project and the measuring of its demographic benefits were topics of great consideration. In the end it was decided that in the appraisal document all estimates of economic benefits of the project would be left out while preserving estimates of demographic beliefits expected from the project. It was also discussed whether the cost of the proposed external review missions should be financed by the credit or whether the Association should assume these costs since an external review could also be seen as an in-depth supervision by the Ass-ciation. 2.10 The pre-negotiation missioT presented an aide-memoire to the Governmt-nt describing the proposed contents of the project. The mission ascertained the Government's willingness and capability to finance the non-foreign exchange component of the project and put forward several conditions to be fulfilled by the Government. These conditions concerned mainly the organisation and administration of the national family planning program, the provision of the necessary persovnel for the expanded activities and the employment of consultants. - 28 - 2.11 Negotiations took place at the Bank's headquarters from 4 to 12 February 1971. The appointment of management-consultants and a project administrator was a condition of credit effectiveness. 2.12 Project Description. The project was presented to the Board of Directors of the International Development Association, which approved the proposed credit in March 1971. The total cost of the project was estimated at $7.7 million towards which IDA granted a credit of $4.8 million equivalent in various currencies. The purpose of the project was to assist in expanding and improving Tunisia's national family plenning program through the construction of maternity hospitals and maternal and child health centers and the provision of consulting services. 2.13 The construction-equipment component of the project included: (1) Medical Facilities (a) Construction of four new maternity hospitals (in Tunis, Sousse, Sfax and Bizerte) with a total of approximately 500 beds; (b) Construction of twenty-nine maternal and child health centers; (c) Construction of two new rural maternity centers with a total of approximately 25 beds (in Djerba and Sedjenane). (2) Educational Facilities Extension of the Avicenne Paramedical Training School in Tunis including its Postgradaate Training Section. 2.14 The technical assistance component comprised (a) provision of consultants to design and recommend a system which would ensure an optimum use of the resources at the disposal of the family planning services and to help the Government of Tunisia to implement the system; (b) provision of experts to assist in teaching at the Avicenne Paramedical Training School and its Postgraduate Training Section and provision of fellowships for training key paramedical personnel; (c) provision of two external review missions of two to three experts scheduled for the fall of 1972 and 1974 to assess the progress and efficiency of the national family planning program. The project was expected to be completed by December 31, 1975. 2.15 Results expected from the project. At the time of project identification, the National Family Planning Program had lost its momentum after an enthusiastic start in 1964. The annual number of new acceptors of contraception or birth control was far below the natural increase of women of fecund age and was even decreasing in absolute figures. Geographic expansion of the program was hindered by an acute shortage of qualified medical and above all para-medical personnel and serious flaws in program management were apparent. In 1970, after six years of operations, only about 2.5% of the eligible MWRA were estimated to be reached by the program. 2.16 In order to achieve its purpose, the project was designed with a number of coherent components. The provision of 29 additional MCK centers (with midwife residence) would enhance the possibilities of more women asking for family planning consultations and services. However, some MCR activities require supporting gynecological services which are dispensed by maternity hospitals. Because the existing facilities were overcrowded, the project was adding four new maternity hospitals in the four main cities of Tunisia: Tunis, - 29 - Sousse, Sfax and Bizerte; with the same objectives in mind the project envisaged to expand the facilities in the rural areas by constructing two rural maternity hospitals. The expansion of MCH services would require an important increase in the already too low output of the paramedical training institutions. Therefore, the project allowed for the addition of a wing consisting of classrooms and a hostel to the existing Avicenne Paramedical Training School, enhancing its training capacity from 190 to 200. The project also foresaw the provision of experts to assist in teaching at the Avicenne School and some fellowships for training key para-medical personnel. 2.17 In order to help the national program in solving its administrative problems the project provided for the services of management consultants. The project also called for the reorganization of the Maternal and Child Health/Family Planning Directorate of the Ministry of Public Health, centralizing and strengthening its authority over ongoing and future family planning activities. One of the conditions of effectiveness, requested the implementation of a series of administrative arrangements concerning the salaries and work conditions of midaives and the involvement of an increasing number of physicians in MCH/FP activities. 2.18 To ensure performance monitoring of the national program on a regular basis, the project included the provision for two external review missions by a small team of international experts to evaluate overall progress and make recommendations for further expansion of the program. The first mission was planned for 1972, the second for 1974. 2.19 As a result of the project, the number of consultations with potential acceptors was expected to rise from 125,000 p.a. in 1970 to more than 400,000 p.a. and the number of acceptors from just over 21,000 p.a. to well over 76,000 p.a. This would.increase the number of births averted from about 6,000 p.a. in 1970 to more than 21,000 p.a. in 1975. 2.20 In addition, by improving the conditions under which deliveries were performed and family planning was practiced the project was to make an important contribution towards better health for mothers and children. Revised Costs and Financing % 2.21 By the end of 1973, it was already becoming clear that the project would have important cost overruns. In 1974 it was proposed to drop the construction of two rural maternity hospitals from the project when it was realized that the total cost of the project would be more than twice the initial estimates. As stated in the final report of the Tunisian Project Administrator, even that sum was underestimated as it did not comprise a revision of costs of the twenty nine MCK centers. In effect, the revised estimate seem to have been based only on a reassessment of the costs of the maternity hospitals to be built in Sousse, Sfax and Tunis and the expansion of the Avicenne Paramedical School, while, at the sa time it was suggested to delete also the maternity hospital for Bizerte from the project. As a result, total project costs were estimated by the Association at $22 million. 2.22 The Government of Tunisia requested the Association's help in finding additional external financing for the project. In general, the Association is reluctant to grant additional financing for project implementation, but was - 30 - prepared to reconsider this case, provided that a considerable improvement in program performance would show shortly. 2.23 By 1976 project costs at completion were expected to increase by 316%, from an initial $7.7 million to $32.0 million. The Governent of Tunisia's share in financing the project would increase more than eightfold. At present total costs at completion are estimated at close to $34 million despite the delition of two rural maternities, one MCR Center and adivisory services for training schools. Project Cost Estimates (US$ million equivalent) Appraisal estimates Revised estimates (1971) (1976)1/ Construction and Equipment 6.4 24.4 Technical Assistance 0.3 0.4 Contingencies 1.0 7.2 Total: 7.7 32.0 1/ Excluding two maternity hospitals (see para. 2.25) 2.24 In the meantime the Norwegian Government had expressed its interest in co-financing certain IDA projects. The Association found the Government of Norway willing to participate in financing the project. On October 13, 1976 an Amendment to the Credit Agreement was signed whereby the Association, through the co-financing by the Kingdom of Norway, granted an additional credit of $4.8 million to the Government of Tunisia, thus bringing the total credit to $9.6 million. The completion date of the project was brought forward to December 31, 1977. 2.25 It was agreed that the two rural maternities would be dropped from the project but that the maternity hospital for Bizerte would not be deleted. From the technical assistance component, the experts and fellowships for the Avicenne Paramedical Training School were deleted. III. PROJECT IMPLEMENTATION A. Effectiveness and Start-up 3.01 Conditions of effectiveness. The credit agreement stipulated the folowing conditions for the credit to become effective: (a) the employment by the Government of management consultants to (i) help design and implement a system of program planning, budget- - 31 - ing and statistical reporting appropriate to the family planning program and (ii) to design a plan for further expansion of the program; (b) the employment of architect consultants to help: (i) prepare schematic designs and tender documents and evaluate bids for and to supervise the construction of buildings and facilities included in the project and (ii) prepare specifications and evaluate tenders for the furniture and equipment for the buildings and facilities; (c) the appointment of the Project Administrator. 3.02 The credit became effective on December 29, 1971 after the date of effectiveness had been postponed twice. The reasons of the six month delay were initial difficulties in the selection and hiring of the architect consultants and the management consultants. The Ministry of Health was not familiar with the contracting of external consultants and needed more time than was foreseen to complete the process. There were some initial difficulties concerning pre-selection and the interpretation of the terms of reference and also with final selection of consultants (language problems). 3.03 The postponement by six months of the dateL on which the project became effective evidently caused a delay in the initial activities of the consultants. With the assistance of the Association the architect consultants and the Government came to an agreement in December. The contract with the management consultants was also signed in December. Inviting consulting firms for both major components of the project and then later selecting and negotiating with these firms, took more time than suggested by the date of effectiveness in the Credit Agreemeat. 3.04 The Government o, Tunisia consulted the Association on the appointments of the Director of the Family Planning Directorate, of the Family Planning Administrator and of the Project Administrator. The Association approved the candidates for the post of Director for family planning and of Project Administrator; however the candidate proposed as administrator for the family planning program was not acceptable to the Association. In view of the dearth of suitable candidates the Association suggested that for the initial period of project execution, (a maximum of six months) bot functions, those of Project Administrator and those of Family Planning Administrator would be combined in one person. This was subsequently agreed. B. Implementation of the Civil Works Component 3.05 The implementation of the civil works component had a slow start. In the first place there were some initial problems of.comunications between the Ministry of Health and the architect consultants which resulted in delays in the first payment of fees which were due upon signing of their contracts. Coordination among the Ministry of Public Works, the Ministry of Health, the consultants and the executing architects posed its problems, which a frequent change of staff in the participating national institutions only exacerbated. The-e was also the fact that at an early stage in the Implemertation process, the wnthorities expressed their desire that changes be introduced in some of the construction components. This was the case with the maternity hospitals which were to be redesigned to include also teaching facilities. - 32 - 3.06 All in all, it was almost a year after the date of effectiveness that the first contracts to local architects were awarded. The first contract for construction - the extension of the Avicenne Paramedical Training School - was awarded in October 1973; there was very little progress in other project components. The delay had already accrued to two years. 3.07 From 1974 onwards unexpected problems appeared of shortages in the construction industry. The oil crisis, started in 1973, benefitted Tunisia, whose modest oil production nevertheless gave a significant boost to the national income, once prices began to soar. The private construction sector became much more active while Libya attracted a major number of skilled construction laborers. All this contributed to an escalation of prices and scarcity of material and labor in this sector and consequently, to further increases in project costs. Earlier, the Tunisian authorities had already pointed out to the Association that fees for local architects and engineers seemed to be underestimated. 3.08 The anticipated substantial cost overruns lead to a mutual agreement between the Association and the Borrower to delete the two rural maternity hospitals from the project; the Association also propoued to delete the maternity hospital for Bizerte reasoning that the nearby hospital in Menzel-Bourguiba (the hospital of the former French military base) could absorb for several years the increased needs in maternity beds of Bizerte. The Tunisian Authorities never quite agreed with that proposal and suggested at that time to defer a definitive decision on this matter. 3.09 The real take-off of the construction program should be set at 1974. (Probably, for this very reason, the final report of the Project Administrator starts with the activities referring to this year). The contracts for the construction of the maternity hospitals in Tunis, Sousse and Sfax were awarded and by the end of 1974 all three were under construction. However the international tendering for the MCH centers had run into difficulties. Under then prevailing circumstances of increased demand, the bigger firms were not interested in the tendering of relatively small projects and the smaller firms according to the regulations in force in Tunisia, did not qualify to participate. As a result, not one single offer was received on the first date of submission for the first batch of nineteen XCH buildings (October 1974). New invitations resulted in the awarding of six contracts on the basis of competitive tendering and four additional contracts were negotiated with qualified contractors on the basis of agreed rates (marchfs de grf A grf). The first construction initiated under the project was the extension of the Avicenne Paramedical Training School which was completed before the start of the academic year in October 1974. 3.10 In 1975 construction costs continued to rise. The situation was aggravated not only by serious shortages in materials but also by a shortage in qualified staff at the Ministry of Equipment (Public Works) as a result of the booming construction activities in the private industry sector. Supervision of works was more and more difficult to provide for by the Ministry. The Association advised the 'Service des batiments' to call more frequently on the architect consultants to remedy the situation. Coordination between the Ministry of Health, the Ministry of Equipment, the local architects and the consultants remained a problem throughout the execution of the project. - 33 - 3.11 The supervision mission which visited Tunisia in December 1975 found that the construction of the three maternity hospitals in Tunis, Sousse and Sfax proceeded well. Of the 29 MCH centers the first three were scheduled to be completed the following month. In the meantime building costs had escalated even more. For the first time no timetable slippage was reported since the previous supervision mission six months before. The total project costs were estimated by the Tunisian authorities to have now reached the $30 million mark. 3.12 As reflected by the state of actual disbursements, progress with the construction program went well during FY 1976. From a total sun of under one million dollars at the end of FY 1975, disbursements had risen to close to three million dollars at the end of FY 1976. Twelve months later, by the end of FY 1977 the total of the initial credit of $4.8 million was disbursed. IDA granted an additional credit of $4.8 million through co-financing by NORAD, in October 1976. Activities then came to a virtual halt in the first half of FY 1978: no disbursements were made until the second half of that fiscal year. However, the situation grew worse in the following years. No disbursements were made throughout fiscal '79 or during the first half of FY 1980. (Annex 5) 3.13 The explanation for an apparent lack of activities in the implementation of the constructionlequipment component during a period of 18 months must be sought in a series of circumstances like the insufficient coordination between subcontractors; delays on site resulting in claims from contractors; failures of contractors to complete their contracts; inadequate documentation by executive engineers and inadequate follow-up by the Ministry of Equipment; delays in requests for importation of equipment with subsequent delays in delivery. Some of the bidding documents for equipment did not follow the Guidelines of the Association and contributed to further delay. 3.14 Acquisition of sites was no problem since most of the sites were already owned by the Government. A special case arose from the maternity hospital of Bizerte where unexpected difficulties resulted from the conditions of the site. Costly piled foundation proved necessary before starting construction. This caused additional problems which took many months to be decided upon and solved. Problems with the sites were also encountered in the construction of the MCH centers in Zahret Medien, and Melassine, and la Bafsia situated in the Medina of Tunis, a historical site. As neither the Municipality of Tunis nor the Association for the Preservation of the Medina could find another suitable site for the la Rafsia center, it was finally deleted from the project. 3.15 By the end of 1980 the situation was as follows: the construction of the maternity hospitals of Tunis, Sousse and Sf ax was completed but none of these maternities were yet commissioned; of the twenty nine MCH centers, twenty four were in operation. The Bizerte maternity hospital continued to be haunted by technical problems resulting in increasing delays: Tendering and awarding of equipment contracts went also through great difficulties with the resulting delays in delivery and installation. All these factors plus little familiarity with withdrawal appliations on the side of the project executing agency made disbursements slow. 3.16 Three maternity hospitals became fully operational during 1981: Tunis and Sfax in the first trimester, Sousse in the second trimester. By the end of the year all MCH centers constructed under the project were in operation. - 34 - However the opening of the Bizerte Maternity Hospital was not expected to take place before December 1982. 3,17 Design and Construction Quality. With the exception of the extension of the Avicenne Paramedical Training School and the urban MCR centers, the other project facilities could be considered as overdesigned. In the maternity hospitals this ua however largely compensated by putting more beds to each room than foreseen in the original plans. Most of the project facilities were described with too little detail at the time of appraisal; the possibility exists also that the wishes of the client as reflected in the schedules of accomodations, led to this overdesign. This was also the case with the MCH centers where the client insisted upon separate rooms for family planning treatment and for MCR services. Evidently, the centers would have been more functional with multi-purpose rooms and more rational waiting rooms. 3.18 The maternity hospitals of Tunis, Sousse and Sfax (para. 3.05) are generally well constructed, but the mechanical installations are far from perfect and will need careful and frequent maintenance work. The extension of the Avicenne School and the urban MCH centers are well built; the quality of the rural centers is variable: the most isolated being generally poorly built due to a lack of fully competent contractors combined with insufficient supervision (para. 3.10). Moreover, some contracts had to be terminated due to poor performance of the contractor. 3.19 Equipment and Furnishing of Project Facilities. Hospital equipment is generally adequate but the more sophisticated equipment will cause maintenance problems. Equipment for the XCH centers is adequate and so are the furniture and equipment for the Avicenne School. 3.20 Summary of Problems during Construction. The main problems were: . late selection and appointment of executing architects/engineers; . lack of specialists (architect, engineer) in the Ministry of Public Health and later in the National Office for Family Planning as executing agencies; . inadequate preselection of contractors; . lengthy procurement procedures; frequent changes in the Public Work Ministry's management; . poor capacity of the building industry (particularly with regard to mechanical installations); . poor coordination among specialized contractors; . insufficient supervision; and . steep escalation of prices and scarcity of materials. 3.21 The construction of the maternity hospital in Sousse was delayed by almost two years because of the bankrupcy of the main contractor who had to be replaced after new tendering. The construction of the maternity hospital in Bizerte was delayed because the executing architect received inadequate information regarding the proper foundation conditions of the site, which later appeared to require piling; the only contractor specialized in pile foundations was overloaded with work. 3.22 Some Opinions of the Executing Agency on Construction Problems. In the final report prepared-by the Project administrator it is explained how the - 35 - Executing Agency went through great pains to comply with the guidelines of the Bank Group concerning the process of international competitive bidding and the awarding of contracts. Because of the complexity of the procedures, the ONPFP constituted technical advisory commissions and hired the services of specialists (bureau d'ftudes) to prepare the necessary documents. The results were not completely satisfactory, however. For example: certain instruments and materials were not included in the tender documents for the equipment of the maternity hospitals and later arrangements had to be made for additional tendering. Existing national requirements and regulations further complicated the tendering process, especially in the case of equipment. 3.23 The executing agency feels that the Bank Group's procedures and regulations for the awarding of contracts should be more flexible and finds the conditions posed by the Bank Group for project preparation and execution rigoreuses et rigides". It also claims that timetables set up by the Association for preparation and construction of the physical facilities were not realistic. On the other hand, the final report admonishes the project administrators of future similar projects to keep a bet:er control of the project's timetable to avoid cost increases. There are further some remarks about design details and the architect consultants are said to have overlooked the teaching functions of the maternity hospitals, especially with regard to the operating theaters. (However, those functions did not appear in the original project design). C. Implementation of the Technical Assistance Component 3.24 The first of the technical assistance provisions made in the project concerns the consultants to design and recommend a system which would ensure an optimum use of the resources at the disposal of the family planning services and to help the Government implementing the system. The engagement of a management consulting firm was necessary to remedy the serious administrative weaknesses found in the family planning program at that time. There were no systematic procedures to evaluate the various components of the program in terms of their contribution to the desired objectives; for determining the operating costs; for projecting activities and resources over an adequate time horizon and for designing a further expansion of the program, zevising objectives, program activities and budgets in the light of experience and changing circumstances. Given the relatively high cost per acceptor there was a great need for a system to monitor accounting procedures. 3.25 The selection and appointment of the consultants took a considerable time partially because the MDPH had no experience in similar procedures and partially because the desire of the authorities that the National Institute of Productivity participate in the studies to be carried out by the (foreign) management consultants. Some financial administrative delays caused the management consultants, appointed by the end of 1971, not to start their activities until February 1972. 3.26 After an exhaustive analysis, the consultants presented proposals for the restructuring of the national family planning program. In the second phase of their mission (September 1972-January 1973) the consultants examined the - 36 - overall organization of family planning activities paying special attention to the relations between the services of the MOPR and those of the National Institute for Family Planning and Maternal and Child Health (later the ONPFP). They proposed the creation of the functions of assistant-administrator in family planning (to assist the regional health administrators) and prepared guidelines for a proper budgetary organization; for the internal organization of the headquarters of the national family planning program; for a training program in family planning education; for a management control system at central and regional levels and a design for a pilot program to be tested in one of the governorates of Tunisia. The pilot study would address the expansion of family planning acceptance through: a) incentive payments; b) face-to-face promotion activities among women and men; c) improvement of continuation rates through follow-up visits and d) setting of objectives for each MCR/FP center. 3.27 Except for the pilot study, none of the specific proposals presented by the consultants were subsequently implemented by the client. The Minister of Public Health was agreeable however to the idea of carrying out the proposed pilot program. During the major part of the third phase (1973) the consultants dedicated themselves to organizing, supervising and analyzing the results of the pilot program which had been scaled down, thus preventing to attain many of the objectives. Over time, relations between the consultants and their client had suffered and by the end of the pilot program relations were seriously severed. In June 1974, the consultant services were discontinued. The pilot program was not extended to other governorates, as was planned for the fourth and final phase of the consultants' activities. 3.28 The second element of the technical assistance component was not implemented. The Borrower did not really want to use credit funds for the services of teaching consultants and fellowships for the Avicenne Paramedical Training School (para. 2.21). 3.29 The slow start of project activities led to the postponement of the first external review of the national program, originally scheduled for the fall of 1972. The review mission visited Tunisia in November/December 1973 and consisted of a Bank staff member, a staff member of each UNFPA, UNESCO, USAID and the Population Council, Inc., as well as a medical consultant. The mission's main terms of reference were: "to write a comprehensive report that will enable the Goverment to draft a detailed four-year plan of action." The mission analyzed the activities of the National Office for Family Planning and Population (ONPFP), and formulated recommendations for each of the following sectors: Organization and Policy; Delivery of Servces; Manpower and Training; Information, Education and Communications; Evaluation and Research; Personnel, Supplies and Transport. 3.30 Soon after the visit of the review mission a ney President Director General was appointed to the ONPFP, who introduced profound changes in the organization, staff and program of the Office. Consequently, a second mission comprised of two Bank staff members and a medical consultant was sent to Tunisia in September 1974 to review the draft report with the Government. Several recommendations made by the review mission coincided with the reorganization and were omitted from the report. 3.31 The report stresses the importance of the relations between the MOPH and the ONPFP which were found to be excellent but based on personal relationships. The mission pointed to the necessity of formalizing the working - 37 - relations between both institutions with a view in the future. It was recommended that within the MOPE a unit would be set up to coordinate MCR, basic health and family planning activities. 3.32 In the field of education and information, the Office was encouraged to establish formal relations with other ministries such as the Ministries of Information, Education and Agriculture to jointly execute extension programs in family planning. The need was emphasized for a home visiting program to be carried out by paramedical personnel and community health workers, recruited from the same areas where they would serve. One of the major problems in recruiting acceptors in rural areas is that services tend to be center based, i.e., the services will not reach the women who do not have any need or desire to visit the centers. An out-reach program through locally recruited home-visitors could - it was thought - bring greater numbers of MWRA's into the program. The attitude of the staff serving the centers should be improved so as to attract rural women to the centers. 3.33 It was further suggested that the paramedical staff be up-graded so that they could carry out family planning activities in the absence of a physician (a very common phenomenon in rural Tunisia of the time). In hindsight the implications of this recommendation were perhaps underestimated: there was first the traditional opposition of the medical profession against such extension of (medical) responsabilities to nurses and auxiliaries but there was (and proves to be) the sociological consequence of also upgrading the status of the paramedicals which makes them even less willing to work and live in the rural areas (where among other things the opportunity to find a spouse of comparable status is very limited). It seems that the recent decision to replace the midwife training for a training as "obstetrical technician" has produced precisely that pheaomenon. 3.34 The review mission saw clearly the importance of the Regional Health Administrator as the pivot of the health delivery system in Tunisia, since 1969. In order not to burden these Administrators with extra family planning tasks, the addition of a medical doctor and a regional secretary for family planning, already started by the Office, was strongly endorsed. 3.35 The overall shortages in phyiicians, nurses, midwifes and auxiliaries made an efficient manpower planning a necessity. Therefore, the creation of a special unit for manpower planning in the MOPH was recommended. In the same context it was suggested that medical students would be trained to practice in MCR centers and dispensaries. (In the meantime the dearth of physicians in Tunisia is much less; the number of doctors more than doubled between 1973 and 1980). 3.36 The Office had started with a progressive policy of promotion and education and the mission made recommendations towards the strengthening of the Office as the coordinating point of all such activities in the country. Finally, the need for evaluation of the national family planning program for reasons of feedback and policy/strategy formulation was underlined. 3.37 The report was well received by both the MDPH and the office and most tf its recommendations were taken into consideration. The office was strengthened and in particular its family planning education and information program was a success. A population statistical unit was created within the - 38 - office. The MPH never set up the coordinating unit recommended by the report (p. 3.31) and many problems occurred between regional health administrators and the office in the Implementation of the MCH/FP program. The office, however, made great progress during the following years, resulting in a remarkable yearly increase in new acceptors until the program seemed to start losing momentum; new acceptors per year reached 86,000 in 1977 (para. 4.19-4.20) but declined somewhat to 73,000 in 1979 rising again to 81,000 in 1981 (see Anner 2). D. Project Costs, Funding and Disbursements 3.38 Within two years from the date of effectiveness (December 29, 1971), it became clear that total project costs would exceed by far the total estimated costs at appraisal. By the end of 1975 the total project costs were estimated at $32 million (para. 2.24). According to the President's Report presenting the proposal for a supplementary credit (July 29, 1976), the increase was attributable to physical and other adjustments introduced subsequently to improve on initial project design, accounting for $4.3 million or 18% of the total increase, and price adjustments (including the declined value of the dollar relative to the Tunisian dinar) accounting for-another $20.0 million or 82% of the cost increases. 3.39 Through a grant from NORAD the Association made an additional credit of $4.8 million available to the Government of Tunisia. The original and revised financing plans for the project are shown below: Original Plan Revised Plan 1/ Local Foreign Local Foreign Currency Currency Total Currency Currency Total ( US$ Million- -) Sources of funds - IDA Credit - 4.8 4.8 - 4.8 4.8 - Government contribution 2.9 - 2.9 12.2 10.2 22.4 - NORAD grant - - - - 4.8 4.8 Total: 2.9 4.8 7.7 12.2 19.8 32.0 1/ Excluding the two rural maternity hospitals. Within the Association it is estimated that upon completion, the project will have cost a total of around $34 million. Data on final costs have not yet become available. Assuming IDA's estimate of total costs to be correct, the credit granted by the Association and NORAD would represent 28% of total expenditure against 62% envisaged as the time of Appraisal. (Annex 6) 3.40 Disbursements (Annex 5) were slow in the first four years of project implementation for reasons which were described earlier (para 3.13). At the end - 39 - of FY 1975 less than $1 million was disbursed which represented only 21% of appraisal estimates. In the following two years the total initial amount of the credit ($4.8 million) was disbursed but after the credit was raised to $9.6 million, an additional $1.6 million was disbursed between January and December 1978; there was no disbursement at all during the whole calendar 1979, reflecting the delays in construction and equipment of project facilities (para. 3.21). 3.41 Supervision. From 1971 through 1977 a total of 21 supervision missions were sent to Tunisia at intervals of 2-6 months (Annex 2). The supervision mission scheduled for June 1978 was postponed twice at the request of the Borrower so that during 1978 no supervision mission could visit Tunisia. Four more supervision missions were carried out in combination with missions to prepare a second project. IV. PROJECT PERFORMANCE 4.01 The project was expected to -strengthen the Goverment's program through a series of measures designed to increase substantially the number of acceptors of family planning and to retain more of them as practitioners for longer periods of time-5/. In the appraisal of this project which was the second ever designed by the Bank Group in this sector, it was from the onset admitted that "although economic and social benefits cannot be measured precisely, they are substantial and can be described in specific terms". This still holds true today. 4.02 The project contributed to the expansion of the Tunisian national family planning program in various ways, including some improvement in management and organization and some increase in the annual number of new acceptors. The physical facilities built under this project have not only contributed to better services for the population in want of family planning but also to an expansion of the health services at large specially in the field of the health of mothers and children. Birth and death rates have steadily declined over the last ten years and so have the infant mortality rates, although in the rural areas they still are high. 4.03 The concerted efforts to expand family planning acceptance throughout the country, endorsed by the Bank Group and several international donors have certainly contributed to focussing attention to the needs of the rural population and the lower echelons of the urban population. The Goverment is at present changing the emphasis from a curative to a preventive health approach in which family planning activities are incorporated.. The Bank has developed a second project to assist the Government in carrying out this new health policy. 4.04 Physical Facilities and their Utilization. Almost all buildings were constructed as foreseen in the project design. Two rural maternity hospitals 5/ Appraisal of a Population Project, TUNISIA, March 3, 1971. - 40 - were deleted from the project.O10t-Db 29 MCH centers one was deleted. Three maternity hospitals are in function, th ommissioning of the Bizerte maternity hospital was expected for December 1982 bbut v confirmation of its inauguration has been received. The MCH centers are all in peration. The expansion of the Avicenne Paramedical Training School was completedin-time for the beginning of the academic year in October 1974. 4.05 No complete data on the utilization of the project facilities are available. The final report of the Project Administrator contains information on family planning activities in the 23 MCH centers active in 1981. The number of visits varies widely from well over 3,000 in some to around 400 in others (Annex 4). The size of the population to be served by each center determines partially of course the number of visits to be expected, but less than 350 per year seems low by any standard. This seems to reinforce the arguments for the need of out-reach activities in the form of a home-visiting program. 4.06 The maternity hospitals of Tunis and Sfax opened both in November 1980. Both show considerable family planning activities through the service statistics of 1981 (16,700 and 10,500 visits respectively). Visits to the maternity hospitals in Tunis and Sfax showed full utilization;all wards have more beds than originally assigned numbers. Information on utilization of the Sousse maternity is not yet available.; the hospital opened in May 1981. 4.07 As indicated, the only building which was constructed with little delay was the addition to the Avicenne Paramedical Training School, which could start the academic year of 1974-75 with the new class rooms; the equipment and inauguration of the auditorium for that school took however much longer. In 1976 the school gave diplomas to 35 midwifes and 62 nurses. In 1977 the training of mid-wifes was discontinued and replaced by the training of high level obstetric technicians carried out at the Tunis School of Medicine. Since 1978 the Avicenne school has been used for the training of nurses at nearly full capacity thus contributing to the expansion of health training facilities in the country. In this sense this project component responded also to the project objectives. The second project now under implementation will remodel six paramedical training schools and provide them with additional equipment. 4.08 The construction of maternity hGospitals, MCK centers and additional facilities for the Avicenne paramedical school were considered necessary for the expansion of the national family.planning program. This objective was attained while indirectly a contribution was made to the expansion of much needed health facilities. 4.09 Outcome of the Technical Assistance Component. The implementation of the management component proved to be difficult. The consultants analysed the organizational problems of the national family planning irogram and made a series of proposals to improve management and the organizational set up of the Institute, later Office. For a variety of reasons, their recommendations were not followed. The most important reason was probably that at an early stage the consultants lost "rapport" with their client and from then on lost virtually their usefulness as management counselors. The competence of the consultants is not questioned although neither they ncr many others, in the early 70s had much experience in specific "family planning" management. However, it is likely that the idea of the need for management consultants originated on the side of the project designers in the Bank and not precisely from the authorities In the - 41 - MOPH or in the Directorate for FP/MCH. The latter were probably never very much convinced of the need for this part of the technical assistance component. 4.10 The situation was aggravated by frequent changes, of incumbents at the helm of the national program and almost as frequent changes of the institutional set up. These changes, much of which coincided with the recommendations of the consultants, were not brought about as a direct result of the intervention of the consultants. It is not clear how much their analysis and their discussions had to do with a gradual but undeniable improvement of the national program. 4.11 The first Family Planning Director with whom the consultants had to work was himself appointed after the signing of the Credit Agreement and thus had not been part in any of the discussions on the subject of management consultants during project preparation. If the first director already felt that the consultants were imposed on him, so much more must the second or third directors have had that feeling. Correspondence received in the Bank from both parties indicated from the very beginning that the necessary relationship for making an optimum use of the consultants' services, was not present. This only grew worse as corroborated by later supervision missions. 4.12 After almost a year, the consultants' work was confined to conceiving and testing an experimental project in one of the Governorates. When the time came to implement the new approach to the rest of the country, the Office opted for putting and end to the services of the consultants. In conclusion, no matter how obvious it was, at the time of projet preparation, that poor management was one of the major obstacles for setting an efficient program in motion, the frequent changes in national directors prevented the consultants from having a fair start. 4.13 The external review missions carried out under-the leadership of a Bank staff member and comprising experts from various fields, had their impact on organizational and operational Improvements in the program. Many of the recommendations contained in the sector review report were introduced, some immediately, others gradually. A recommendation to create multipurpose health units, serving appropriate populations and connected to hospitals as a means for an efficient and effective system of fertility control presented at that time, is now under a modified form being applied in Tunisia. 4.14 In discussing the impact of the project on various aspects of the national family planning program one has to admit in the first place that such an impact cannot be measured in precise terms and in the second place that the project was not the only input of the program. Such is a fortiori the case in Tunisia where many external donors all make substantial financial contributions (most in the form of grants) to the national family.planning program. Undoubtedly, these too have an important Impact on program performance, equally impossible to express in neat figures or clear-cut facts. These considerations call for optimum contact and cooperation between the various agencies involved and the leadership of the national family planning program. Fortunately this contact and cooperation have generally prevailed throughout the implementation of the first project as well as during the preparation and present implementation of the second project. 4.15 Opinion of the Borrower. The construction of four materniy hospitals and 28 MCRi centers is viewed in Tunisia as a welcome reinforcement of the health - 42 - infrastructure which still cannot meet the ever increasing demand for health services, especially outside the principal cities. A qualitative and quantitative Improvement of the health infrastructure is seen as the principal achievement of the project. As such,the Borrower considers the project a success. The increased capacity of the infrastructure has already given cause to a greater penetration of the health services into the rural areas. The buildings constructed under the project are considered of good quality and responding well to their functions. Program Performance 4.16 The Tunisian family planning program has been relatively successful. The support of the Government which had demographic targets incorporated in its development plans during the last decade, has encouraged ONPFP and the MOPH seek for new and better ways to increase the numbers of new acceptors and to encourage them to continue contraceptive practice for a longer time. Supplies are readily available and sold at subsidized prices through pharmacies. 4,17 As in all programs designed to bring about social change, the family plKnning program in Tunisia has caught on much quicker in the urban than in the rural areas. The progress shown in the urban areas stands in sharp contrast with t..at in the rural areas: of all new acceptors of family planning two-thitAs are recruited from the cities. This should not be surprising as family planning activities rely heavily on existing health infrastructure. The urban bias found in the family planning program of Tunisia is a mere reflection of the urban bias in the development of its health services delivery system. This bias is not only apparent from the more abundant availability of health facilities per thousand inhabitants in the cities but also from the tendency of medical and paramedical professionals to exercise their functions rather in the urban surroundings than in areas remote from the advantages of urban life. The tendency, already prevailing for a long time, to increase the level of paramedical training in Tunisia (and reaching levels of overqualification for a number of jobs, certainly those required most in rural areas) unfortunately strengthens the urban bias. In addition, many young girls having a diploma from one-of the higher paramedical training programs, show little desire to establish themselves in rural areas. 4 4.18 At regular intervals, special efforts have been made for a new drive to recruit acceptors from rural areas. A recent experimental program sponsored by USAID has proven that a home-visiting program can yield results6/, although at a relatively high cost per acceptor. At this moment Tunisia has not the means and much less the manpower required to implement such a system on a wide scale. The solution of the problem seems to lie in the expansion of the basic and integrated health services to all villages while using paramedical personnel and non-professional personnel of rather modest training, recruited to the extent possible from the same environments as where they work. This is what is being done presently by the Ministry of Public Health, assisted by a second 6/ PFAD, Household Distribution of Contraceptives in Bir Ali Ben Khalifa, Tunisia. International Tacility Research Program, Research Triangle Park, NC, 1979. -43 - health/population project of the Bank. The extension of medical services to the rural areas will also create better avenues for family planning activities and closer coordination between the MOPH and the ONPFP would facilitate even further strengthening of services. 4.19 Since the start of the project, numbers of family planning acceptors increased year after year. From a little over 40,000 new acceptors in 1971 the number of annual new acceptors doubled in six years: in 1977; 86,000 new acceptors entered the program. The following years have been less successful: while naturally the number of women in fecund age kept rising, the number of new acceptors through the national program started to decline: 81,000 in 1978 only 72,700 in 1979. The last years show a tendency for increase but the level of 1977 has not been reached (Annex 2). 4.20 The reasons for the plateauing in the statistics of family planning acceptance are various but no definite analysis of these reasons has become available yet. Of course, it is true that many women prefer to practice contraception privately and once they know how to obta .n the means, disappear from the state program. But, fluctuations in the number of new acceptors per year are too considerable for this being a sufficient explanation. This seems to be corroborated by the comparison of statistics on new acceptors for one year and those on regular users of contraception the next year. For example: in 1979 the number of regular users in the program was about 303,000 and that same year close to 73,000 new acceptors entered the program; nevertheless, the statistics for the following year show only 308,000 regular users, an increase of 5,000. It is hardly likely that almost all of the new acceptors of 1979 went to the private sector. If that were true one wonders why they did not get started in the private sector in the first place. 4.21 According to other sources7/ the Central Pharmacy, through which all drugs are distributed in Tunisia, sold in 1979 a total of 500,000 pill cycles. This would represent a total of about 38,400 woman-years of protection: a far cry from the 97,000 regular users reported for that year by the official service statistics. In spite of the great efforts deployed by the ONPFP, the reporting system seems to have its weaknesses. A bi-lateral USAID-ONPFP evaluation study (1979/80) refutes two easy explanations for the plateauing of acceptance figures and shows that private sector recruitment remains negligible and that the reservoir of unprotected eligible couples remains very large. Although the reasons for the apparent stagnation of the national program after 1977 are not analyzed, the study shows clearly that there exist large regional disparities in acceptance, in numbers and by method. (Annex 1.) 4.22 This is no intention to belittle the considerable efforts and the achievements of the Tunisian family planning program. The impact of much of the activities of the ONPFP on the acceptance of family planning cannot be better measured than the impact of IDA's population project. The 1978 National Fertility Surveys showed that over 90% of Tunisian women knew of family planning. Much of the spread of this knowledge must be attributed to the education and motivation activities of the Office. The population started aging because fertility has constantly declined over the last fifteen years but this 7/ Population Council Support to the Tunisian Family Planning Program, Washington, D.C., USAID, June 1981 (unpublished). -44 - decline was not enough to meet the long-run demographic targets of the Government (para. 2.02). Therefore, any inclination in the curves of family planning acceptance should be studied in detail and strategy implications should be fed back to the field. In this context, it might prove very useful to reassume the study of continuation rates and to carry out, on a regular basis, small surveys among a sample of MWRA (i.e. acceptors and non acceptors). This could also lead to a greater cost-benefit awareness which will become so much more urgent if the considerable foreign assistance which the national program has enjoyed since 1966, should start to phase out. The program would then have to show what it can achieve on its own. 4.23 During the life of the first population project, the national family planning program was several times reorganized until in 1973 the ONPFP emerged as a semi-autonomous institution. Since then the Office has developed into an organization which has attracted important international assistance for its program. The Office is receiving trainees from francophone Africa and is sharing its knowledge and experience with various family planning organizations in other countries. The IDA project has contributed to the institution-building process, as well as to the expansion of facilities and services and throughthem to some increase in family planning acceptance. Since the completion of the project the exact division of responsibilities between the MDPH and the ONPF has become a matter of controversy in Tunisia: a resolution of this isdue will be a critical element in further improvements in provision of family planning services. V. COVENANTS AND THEIR FULFILLMENT 5.01 This report describes a series of difficulties which arose during the different stages of project implementation leading to considerable delays and cost overruns. Nevertheless it must be concluded that the Borrower made every effort to carry out the project with due dilligence and efficiency and in conformity with sound administrative financial, health and family planning practices as are demanded by Section 3.0; of the Development Credit Agreement. In general, the specific convenants were also fulfilled. 5.02 Architect consultants and management consultants were appointed acceptable to and upon terms and conditions satisfactory to the Association, (Section 3.02 (a)). 5.03 The hardware component of the project was carried out by contractors acceptable to, and employed under contracts acceptable to, the Association. (Section 3.02 (b)). 5.04 The Borrower obtained the Association's approval for designs, plans specifications, contracts and work schedules and the lists of equipment and furniture for Part A of the Project. (Section 3.02 (c)). 5.05 All lands necessary for the construction and operation of the buildings were selected promptly. (Section 3.02 (d)). Many were already the property of the Ministry of Public Health; the purchase of the remaining sites did not delay the construction program. Because of problems of site acquisition - 45 - for the Haifsa MCH center, this center was deleted from the project (para. 3.14). 5.06 The regulations concerning international competitive bidding (Section 3.03) were observed by the Borrower except in a few cases where this was virtually not feasible as for examaple, in the case of some MNC centers para. 3.09). 5.07 The Directorate referred to in Section 3.04, was transformed in an Institute for Family Planning and Mother and Child Health in August 1971, which in turn was changed into the National Office for Family Planning and Population (March 1973). The consecutive changes of the family planning organization were for the better. In accordance with the new decentralization of the Ministry of Public Health, all MCH/FP centers became integrated basic health centers under the authority of the Regional Medical Directors. The Association had no objec- tions to this policy evolution which supersedes para. 2(a) of Schedule 4. 5.08 Section 3.04(c) required the Borrower to provide funds through annual budgetary appropriations and other facilities, services and resources, needed for the national family planning program. This was done. 5.09 Generally speaking all family planning facilities are provided with adequate competent and experienced staff (Section 3.65). However, staffing problems especially of paramedical personnel for rural areas, remain. 5.10 The administrative arrangements set forth in Schedule 5 of the Agreement referring to FP/MCH services were implemented. 5.11 Part B(2) of the Project referring to the provision of experts and fellowships for the Avicenne Paramedical Training School and its Postgraduate Training Section, was deleted from the project with the approval of the Associa- tion. Therefore the covenant in Section 3.07 no longer applies. 5.12 The Borrower did employ at all times a Director and an Administrator for the national family planning program as well as an Administrator for the project. The first officials in these posts and their successors were appointed in consultation with the Associationjuring the first five years from the date of the Agreement. (Section 3.08). 5.13 Location and bed capacities of the project facilities follow Schedule 5 guidelines (Section 3.09). Changes introduced in the Schedule met with the approval of the Association. 5.14 An external Review Mission was carried out respecting the stipulations under Section 4.03. The second review did not materialize. 5.15 All other covenants in the Credit Agreement were complied with. - 46 - VI. THE ROLE OF THE BANK GROUP 6.01 The Bank Group responded quickly to the Government's request for assistance in its efforts to reconcile the demographic growth of the population with the adopted objectives for social and economic development. Given the fact that the Bank Group had only limited experience in the field of population before the development of this project, the time it took between identification, appraisal and the approval by the Board of Directors must be considered as very reasonable. A project consisting of coherent components was designed, based - as was the leading philosophy of those days - on a post-partum approach to family planning. In later years it was recognized that this approach could make only a limited contribution to family planning goals and the strategy shifted to out-reach programs through integrated health services and with the experience gained by the Government and the Bank Group the second health/population project reflects this new approach. 6.02 The Bank Group identified the weakness of management and administration of the national family planning program at that time. In the light of these deficiencies several arrangements and conditions were built into the project design to guarantee a strong centralized authority of the family planning administration. It was correct to request the Directorate (or any successor thereof) to have full responsibility for education and information programs, for research, evaluation and promotion of MC/FP programs and that the Bank be consulted in the appointment of the Director and the administrator of the national program as well as of the Project administrator. 6.03 The Credit Agreement however also requested the Directorate to have full responsibility for existing and future MCR centers and for personnel assigned to hospitals for the purpose of family planning activities. It is now easier to see that this arrangement fostered a service delivery system parallel to the existing health delivery services. In spite of official endorsement of the authority of the Directorate over family planning personnel and HMC centers, the reorganization of the health services in 1969 had made the Regional Health Administrators directly responsible for all health operations in their region. In fact, the Directorate could never exercise its assigned authority over the day-to-day activities of the family planning personnel and the powerful position of the Regional Health Administrators was insufficiently recognized in this part of the project design. The management consultants, right from the beginning suggested that the role of the Directorate (Institute later) be confined to policy formulation, promotion, training, evaluation and logistic and financial support, while specifically excluding direct responsibility for the family planning services in the field. 6.04 The implementation of the civil works component took much longer than foreseen. Undoubtedly, the initial estimates of construction costs were deficient and problems such as lack of expertise and coordination at the local level were apparently underestimated in determining the time schedules for implementation. The Yinistry of Public Health and later the Office (OIFP) as executing agency had to liaise with the Ministry of Public Works (later Equipment), the Ministry of Finance, local architects, contractors and the consultants. National regulations, bidding operations and construction did not coincide with the regulations of the Bank Group and the lack of coordination between all parties involved was a constant problem. The Project Administrator - 47 - in the first years of implementation was an official of middle level and had certainly not enough authority to bring about the desired coordinatior between various ministries and other partners in the execution of the project. Frequent supervision by the Bank Group played a role in reducing these problems of coordination. The second health/population project has upgraded the level of project administration which now is attached directly to the Cabinet of the Minister of Public Health. 6.05 The continuous contact between the Bank and the Tunisian authorities not only helped to solve many problems during the implementation of the project but also induced the MDPH and the ONPFP into a learning-by-doing process of project execution. This has prepared the grounds for the preparation and implementation of the second project. On the basis of the experience gained by the Tunisians and the Bank Group, the second project seeks to assist the Government in spreading the integrated basic health care services with special attention being paid to preventive health and through it, family planning; it reinforces several aspects of institution building initiated under the first project and in particular the extension of the health system to the rural population. 6.06 Experience also taught the Tunisians and the Bank Group that the post-partum approach is costly and does not reach enough eligible women in countries were the vast majority of deliveries still take place at home. Consequently in Tunisia, in spite of the results obtained by the national family planning program, rural women constitute only one third of the total acceptors of family planning or birth control (sterilzations, abortions). The Authorities have become aware of the urban bias in the health delivery system and the family planning services, and of the need to decentralize services reaching out to a large proportion of the population which is not yet accustomed to visit health service points for the purpose of preventive health. 6.07 Since 1977 a new health policy is under way in Tunisia emphasizing this new trend. The Bank's second health/population project focusses on eight project areas and comprises: the improvement of management and management information systems for basic health care; the training of middle level administrators and technicians; the extension of health and family planning services to under-served rural areas.by reinforcing the health infrastructure of the project areas and the development and strengthening of the population, health and nutrition communications activities of the Ministry of Public Health, the Ministry of Education, the National Office for Family Planning and the National Institute for Nutrition and Food Technology. VII. IESSONS LEARNT 7.01 In July 1981 the Bank made a loan to the Government of Tunisia for the development of a second project in health and population. The design of this second project reflects the experience gained with the first population project and the lessons learned during the ten years of regular contact with the health and family planning activities of the country. Neveatheless it seems useful to recapitulate here the most important points. - 48 - 7.02 Project administration should be established at a high enough level in the public administration to carry out efficiently its functions and have the effective strength to coordinate the various govermental institutions, executing architects, contractors and consultants involved in the execution of the public works component. In the second project, a Project Coordinating Unit is attached to the Ministerial Cabinet. 7.03 Schedules of accommodation should be laid down in some detail in the project documents so as to avoid cases of "over design" or "oversight", which may be due to changes at the request of the borrower introduced after project implementation has started. The Staff Appraisal of the Second Health/Population project contains such a schedule. 7.04 During project preparation the Bank and the Borrower should study in more detail how and where governmental regulations fail to coincide with the Bank's regulations and procedures, especially with regard to international competitive bidding and explore where flexibility could be applied. In Tunisia ICB proved impractible In the case of small constructions like the MCH centers and contracts had to be awarded on the basis of agreed rates. In the case of ICB for equipment the need for standardization should be endorsed and taken into account in successive tendering. 7.05 "Consultants are useful only if the client is convinced they are necessary"/. The management consultants were not successful because from the beginning there were strong indications that the beneficiary-to-be felt them as an imposition and sometimes as an intervention in his affairs. During project preparation, more attention should be paid to discussing with the Borrower the possible needs for management assistance. 7.06 Disparities in salaries and benefits of family -planning workers and those of health personnel should be discouraged. Extra payments do not necessarily conduct to extra efforts and the different rewards for comparable services only create a situation of jealously if not obstruction which will seriously hamper the integration of services which is now pursued. 7.07 The wealth of detailed statistics now available from the national family planning program should not prevent a careful examination of their operational value and the price at which these are collected at the grass-root level. There remain serious inconsistencies in the data and not enough is known about the (probable) high drop-out rates. On the other hand overburdening paramedical personnel of dispensaries and health posts with administrative chores would deter attention from their basic functions. Regular prevalence sample surveys could prove to be more efficient and less costly. 7.08 Although all international aid agencies pursue the same ultimate population objectives, important differences in emphasis as to the strategy to achieve those objectives appear from time to time. In a country where considerable external assistance for population is available, a special effort should be made to coordinate Bank/IDA activities with other external donors in order to assure that assistance from various sources points in the same direction. n I' inI f A(A ..c u.n. O , 7 I. mov a '.$ s p..4k y..r. Te.'. 19a0 parforronce proctedb at 1 rate 1yLng between 1973 and 1976. (2) T(rin Venent.ration Hathodolony enables to Atucy proCrn elynaicn coneonitnnt with poroSrm occurranco. JANVIOR / JAJUARY 1973 1974 1915 1976 1377 1970 1919 1960 80/77(X) 80/79(3) FHARI 725500 748950 77.181 790264 824203 851033 878/95 907513 I.U.D. Fr. 790 . 1371 1484 1512 1914 2017 230l 2285 T.1I. 1.009 1.831 1.919 1.894 2.322 2.370 2.618 2.518 T.A. 13.067 21.957 23.032 22.729 27.061 20.441 31.420 30.214 48.41 -3.84 Pills Fr. 940 757 1071 1900 2345 239 2111 1807 T.1. 1.296 1.011 1.305 2.300 2.005 2.772 2.402 1.991 T.A 15.540 12.129 16.622 20.562 34.142 33.263 20.026 23,894 -30.87 -17.11 Sec. Fr. 844 926 810 1205 1665 1332 .1339 1201 Method T.1H. 3.163 1.23 * 1.125 1.310 2.021 I.565 1.524 1.412 T.A. .13.960 14.837 13.500 10.114 24.256 18.702 10.284 16.939 -30.17 -7.36 Tubal Fr. 227. 963 855 77'i 000 691 064 651 Ligation T.H. 0.113 1.206 1.106 0.970 0.980 0.012 0.903 0.717 T.A. 3.755 15,430 13.210 II,635 II.764 9.743 I3.790 0.608 -26.03 -27.04 Four Fr. 2801 4017 4200 3391 6733 . 6399 6615 6024 Categories T.1, 3.861 5.364 5.536 6.753 8.169 7.519 7.527 6.638 T.A. 46.3%9 64.362 66.426 81.0411 90.029 90.229 90.328 79.653 -38.74 -11.62 Social Fr.. * fll a52 II1I 1537 1047 1752 1769 1406 Abortions T.H. 0.s67 1.130 1.437 1.925 2.241 2.059 2.013 1.637 T.A. 6.798 13.65I 17.243 23.105 26.091 24.706 2415S6 19.649 -26.93 -18.66 All Fr. 3212 6869 5391 6920 6580 8151 8304 7510 Categories r.H. 4.427 6.501 6.972 0.679 10.410 9.578 9.540 8.275 T.A. 53.127 78.013 83.669 104.146 124.921 1t4.933 114.484 99.304 -20.51 -13.26 Fr.s Frquence/Frequancyl T.H., Taux enmuel/Honthly Rate. Taux/Hatet pour 1000 FMAR/per 1000 HU'RA. T.A.: Taux annuel/ Anauat Rdta. Toutes CntdAooess IHDEX d'ACTIVITF. NOUVELLE DR F / fRIMARY Fp ACTIVITY 1NDEX. TU-CB rb/ch 4 80 Source: Roger P. Bernard and A. Charffedine:- "Family Planning Monitoring in Tunisia (1973-1979): Findings and Implications for the Next Five-Yeai Plan (1982-1986)" TUNISIA, NATIONAL FAMILY PLANNING PROGRAM 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 Total No. Visits - 273,156 302,015 351,322 429,891 500,957 527,501 521,933 566,207 627,151 Contraceptive Users 246,675 241,335 256,984 289,973 346,351 397,834 397,682 303,034 307,970 337,166 Estimated No. of now Acceptors 43,665 43,840 50,901 58,052 75,323 86,021 81,149 72,700 76,799 80,854 Registered Now Accep- tors: - IUD 13,250 16,790 19,084 17,307 20,830 23,879 26,273 25,735 31,792 40,597 - Pills 12,026 11,194 10,795 16,310 25,987 27,567 27,017 23,608 21,768 20,137 - Tubal Ligation 2,453 4,964 10,757 9,896 8,269 7,987 8,832 8,141 8,460 8,719 - Abortions 4,621 6,547 12,427 16,000 20,341 21,162 20,999 19,248 20,482 20,718 Sources ONPFP 1981 FAMILY PLANNING INDICATORS National PROJECT FINANCED FACILITIES (1981) FP Project Program 23 MCH/FP Tunis SFAX Total Tunisia 1981 Centers Maternity Maternity Project (%) - Total Number visits 627,151 31,479 16,700 10,493 58,672 9.4 - Contraceptive users 337,166 N.A. 6,554 4,991 (11,545) (3.4) - New acceptors 80,854 N.A. 2,885 1,972 (4,857) (6.0) - I.U.D. insertions 40,597 2,351 1,446 615 4,412 10,9 I.1 - I.U.D. removals 14,937 N.A. 344 358 (702) (4.7) - Pills users 73,897 N.A. 161 334 (495) (0.7) - New Pills acceptors 20,137 1,291 415 158 1,864 9.3 - Pills distribution (cycles) 152,436 N.A. 987 1,441 2,428 1.6 - Condoms users 7,167 N.A. 48 250 (298) (4.2) - New condoms acceptors 9,694 586 184 552 1,322 13.6 - Gel users 2,104 N.A. 63 14 (77) (3.7) - New Gel acceptors 5,968 298 272 99 669 11.2 - Tubal Ligations 8,719 N.A. 294 262 (556) (6.4) - Abortions 20,718 NeA. 2,312 690 (3,002) (14.5) NOTE: In parenthesis, incomplete information Source: ONPP AN! 4 - 52 - FAMILY PLANNING ACTIVITIES IN 23 PROJECT MCH CENTR~S 1981 -------------------------------------7-.--- NCH Centers 1-osigDm 1 New pill ]ew Acceptors 1 Insertions I Acceptors Condom La Marsa 1 1.296 168 l 14 3 12 1 M ellassine J.537 341 52 2 20 Ez-Zouhour 1 3.-116 i -321 1 127 25 29 - . I Kalaat Landalous 1.1216 113 36 38 6* Sers 1 3.222 i 196 1 87 7 • 2 * 10 Regueb 947 73 64 10 10 B.Aoun 1 1220 1 49 1 69 1 18 16 El Guetar 1.'478 8 127 6 1 Ghomrassen 458 24 1 71 10 2 B.Guerden 1.195 161 64 4 Tataouine 418 73 1 41 1 1 Matmata 1.158 16 38 2 5 Menzel Chaker 1.'-775 62 1 32 59 1 32 Bir Ai 2.'-275 - 73 35 97 18 Hajeb 1 343 1 47 1 27 ! 15 1 0 Nasrallah 402 16 31 0 0 Sbikha 1,;.270 1 162 10 1 10 1 4 Haffouz 888 69 23 12 0 E1Alia • 678 i 87 1 10 1 14 1 3 Ksour Essef 1.623 59 88 105 29 Jemmal 1 2."312 1 201 1 148 ! 100 1 97 Somaa 586 25 28 - 23 9 Haouaria 1·.066 7 69 16 8 -- - - - - - - - 69--- - - -- - - -- -1-- - - -- - - -- - -8-- - AIE 5 - 53 - TUNISIA: (:r. 238-TUN) FIRST POPULATION PROJECT SCHEDULE OF DISBURSEMENTS IDA Fiscal Year Appraisal Revised and Semester Estimate Estimate Actual $(000s) in Z $(000s) in % $(000s) in Z As of Appr#isa or Revised Estimate FY 72 1st 196 4.1 2nd 855 17.8 FY 73 1st 1.700 35.4 2nd 2.244 46.8 FY 74 let 3.007 62.6 187 3.9 6.2 2nd 3.669 76.4 217 4.5 5.9 FY 75 1st 4.172 86.9 344 7.2 8.2 2nd 4.402 91.7 964 20.1 21.9 FY 76 1st 4.698 97.9 1.876 39.1 39.9 2nd 4.742 98.8 2.842 59.2 59.9 FY 77 1st 4.800 100.0 3.815 79.5 79.5 2nd 9.600 1/ 4.500 46.9 4.808 50.1 1/ 106.8 FTY 78 1st 7.500 78.1 4.828 50.3 64.4 2nd 7.900 82.3 6.103 63.6 77.3 FTY 79 let 8.700 90.6 6.378 66.4 73.3 2nd 9.600 100.0 6.378 66.4 66.4 EL.an 1st 6.378 66.4 66.4 2nd 7.339 76.4 76.4 FY 81 1st 7.339 76.4 76.4 2nd 8.295 86.4 86.4 FY 82 1st 9.490 98.8 98.8 ( 110)V I1 Credit amended as of October 13, 1976. 2/ Cancelled at closing date (3/31/82) ANNEX 6 - 54 - Revised Expenditures and Percentage of Total Costs to be Financed from the Credit Cred±t 238-TUN Amendment (000's) (000's) I. Civil Works $1,950 55% $6,076 20% II. Equipment and Furniture 1,730 100% 2,224 35% III. Technical Assistance 230 80% 270 80% IV. Consulting Services for schematic and final designs 160 75% 160 75% V. Professional Services of architects/ engineers for project execution 120 60% 260 60% VI. Unallocated 610 610 $4,800 $9,600 (62.3% of 7.7 m) (28.2% of 34.0 m) ILJNISIA PROPORTIONA. DISTRIBUTION Mediterranean Sea OF THE POPULATION BY PROVINCE Urban papulat ion B l Z E R T E Dens.ly popiled.re.s SDorsely poplulated ares JhPOPULATIN DENSITY, 1966 CENSUS - Less thon 20 T UJN IS 2o-39.9 80-99.9 '~ B E J A00 Nr ABlErU 1% \f \ . jProvincial boundaries LE KEF >- Inte-..- nalow.b.neries ?. JTunisio 3 1 SsousSE AF R I C A KA5RUAN 0 lp2 3p 40p 50 -- MILES ZOOT7 EL OJERfD-1-2- MEDENINE LWBYA 19700IBRD-3i5i