Rwanda - Family Health Project

Document of The World Bank FOR OMCIUL USE ONLY Report No. P-4255-RW REPORT AND RECOMMENDATION OF THE PRESIDENT OF THE INTERNATIONAL DEVELOPMENT ASSOCIATION TO THE EXECUTIVE DIRECTORS ON A PROPOSED DEVELOPMENT CREDIT IN AN AMOUNT EQUIVALENT TO SDR 9.8 MILLION TO THE RWANDESE REPUBLIC FOR A FAMILY HEALTH PROJECT March 6, 1986 This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  CURRENCY EQUIVALENTS (November 1985) Currency Unit = Franc Rwandese (RwF) US $1.00 = RwF 110 RwF 100 = $ .91 (Project data are based on the exchange rate of US$1.00= RwF 99) (August 1985) ME,ASURES 1 meter 3.28 feet I kilometer 0.62 mile I square kilometer = 0.39 square mile I hectare 2.47 acres GLOSSARY OF ABBREVIATIONS BUFMAR - Bureau des Formations 4idicales Agreees du Rwanda CCCI) - Combatting Childhood Communicable Diseases CRS - Catholic Relief Services CUSP - Centre Universitaire de Sante Publique EDF - European Development Fund E.C - European Economic Community EPI - Expanded Program on Immunization FP - Family Planning HC - Health Center IWC - Information, Education and Communication INTRAH - International Training in Health (Chapel Hill University) IPFF - International Planned Parenthood Federation IUD - Intra-Uterine Device JHPIEGO - Johns Hopkins Program for International Edtucation in Gynecology and ObsteLrics MCH - Maternal and Child Health MOHSA - Ministry of Health and Social Affairs KINEPRISEC - Ministry of Primary and Secondary Education MINIFINECO - Ministry of Finance and Economic Planning NC - Nutrition Center NGO - Non-governmental Organization ONAPO - Office National de la Population OPHAR - Office Pharmaceutique du Rwanda SFCS - Service de Financement et de Constructions Scolaires UNFPA - United Nations Fund for Population Activities UNICKF - United Nations Children's Fund USAID - United States Agency for International Development WHO - WJorld Health Organization GOVERNMENT OF RWANDA-FISCAL YEAR Government - January 1 to December 31  FOR OFFICLAL USE ONLY (i, RWMADA: FAHILY HEALTH PROJECT Credit and Project Summary Borrower: Rwandese Republic Beneficiary: Ministry of Health and Social Affairs (MORSA), including National Office of Population (ONAPO); and Ministry of Education (MINEPRISEC). Amount: SDR 9.8 million (US$10.8 million equivalent) Terms: Standard IDA terms. Project Description: (i) Objectives: (a) make family planning (FP) services available in all health facilitieg as part of the maternal and child health (MCH) program; (b) improve the quality and increase the coverage of MCH services; (c) target and integrate nutrition activities into NCR services: (d) strengthen the institutional capacity of MOHSA at the central and regional levels; (e) increase the output and improve the quality of basic paramedical training programs; and (f) improve ONAPO' s data base for population policy formulation. Cii) Components: The project would provide for: (a) strengthening of Family Health Services through support to restructuring the MCH program, including the addition of an FP component nationwide, provision of essential medical supplies and upgrading/reequipping of 30 Health Centers (HCs); (b) institutional strengthening of MOHSA at the central and regional levels; (e) assistance to staff development through in-service MCH/PP/Nutrition training for 1400 HC staff, with particular emphasis on 200 nurses aides and construction of two new nursing schools; (d) financing of two studies intended to lead to the strengthening of population policy; and (e) project management services. (iii) Benefits and Risks: MOHSA will be considerably strengthened in terms of more and better qualified staff as well as the improvement of its infrastructure, particularly locally. The main beneficiaries as a result would be the most vulnerable population groups - fertile women, and children under five. The introduction of a new weaning food is a specific benefit. The major risk is MOHSA's limited administrative capacity, which this project seeks to help overcome. Ths document ha restitd distbution and may be used by reipients only in fte perfomnae of ther ocial duties Its contents may not otberwis be dicosed without World Bak autbhozto.  (ti) Local Foreign Total Estimated Project Costs: US$ thousand I. Strengthening Family Health Services: 1,559 2,099 3,658 II. Institutional Strengthening 916 2,268 3,184 III. Human Resource Development 2,066 1,211 3,277 IV. Population Policy Studies 113 119 232 V. Project Management 368 555 923 VI. Refunding of PPF 176 264 440 Total Base Cost 5,199 6,517 11,715 Contingencies Physical 79 114 193 Price 1,292 1,251 2,543 Total Project Cost 6,569 7,882 14,451 (net of taxes and duties) Project Financing Plan Local Foreign Total - US$ thousand Proposed IDA Credit 3,740 7.063 10,803 World Health Organization 725 725 Government: Recurrent Budget 2,829 2,829 Development Budget 93 93 6,569 7,882 14,451 Estimated Disbursements FY87 FY88 FY89 FY90 FY91 FY92 (US$ million) Annual 0.6 2.0 2.8 2.9 1.9 0.6 Cumulative 0.6 2.6 5.4 8.3 10.2 10.8 Economic Rate of Return: N/A Appraisal Report: No.6024-RW of March 6, 1986 Map: IBRD 19455  INTERNATIONAL DEVELOPMENT ASSOCIATION REPORT AND RECOMMENDATION OF THE PRESIDENT TO THE EXECUTIVE DIRECTORS ON A PROPOSED CREDIT TO THE RWANDESE REPUBLIC FOR A FAMILY HEALTH PROJECT 1. I submit the following report and recommendation on a proposed development credit to the Rwandese Republic in a total amount of SDR 9.8 million (US$10.8 million equivalent) on standard IDA terms to finance a family health project. The Project will be co-financed by the World Health Organiza- tion on a grant basis in the amount of US$725,000 equivalent. PART I - THE ECONOMY 2. A Country Economic Memorandum (Report No. 4059-RW) was distributed to the Executive Directors on May 20, 1983 which discussed economic develp- ments in Rwanda until that date. An economic mission visited Rwanda in September 1985. Its report is under preparation. Its findings are incorporated below. Country data are provided in Annex I. 3. Rwanda's salient characteristics include its small size, an annual population growth rate of 3.7 percent (ranking among the highest in Africa), a population density (in terms of agricultural land) of about 500 per square km (ranking among the highest in the world), hilly terrain and high average altitude, a landlocked position, lack of natural resources (including a serious shortage of arable land), underdeveloped physical and institutional infrastructure, and a very low level of development as measured by a variety of social as well as economic indicators. These indicators include a per capita income of about US$270 (1983), among the lowest in the world; an average life expectancy of 47 years; and an adult literacy rate of 37 percent. 4. The country is heavily dependent on agricultural exports (coffee, tea, pyrethrum, cinchona), which provide 75 percent of its foreign exchange earnings. Rwanda' s manufacturing base is narrow, and the growth of modern manufacturing is limited by the small size of the market and the lack of raw materials, marketing facilities, entrepreneurial skills, and skilled manpower. The country, consequently, imports capital goods, steel, petroleum products, cement and other construction materials, and virtually every modern consumer product. Its merchandise trade is hampered by high transportation costs and dependence on neighboring countries for access to the sea ports of Mombasa and Dar-es-Salaam. 5. Despite these constraints, Rwanda has made a creditable effort toward economic and social development. During the 1976-80 period, the country managed to satisfy its subsistence needs and to make Important advances not only in agriculture but in other fields such as education, health, water supply, and small-scale industry. It succeeded in building  basic transport and communication infrastructure, and set in place a state administrative apparatus serious about development. These dchievements reflect the Government's commitment to economic and social progress, as well as its prudent fiscal, balance of payments ard debt management policies. At the same time, Rwanda has been able to attract substantial volumes of external aid from a great diversity of sources, confirming donor perceptions that Government is indeed development-oriented and is pursuing generally appropriate objectives. The Government's efforts during this period were significantly helped by favorable weather conditions and the coffee boom of the late 1970's. 6. Achievement and good fortune notwithstanding, development efforts in Rwanda have not alleviated the fundamental problems which cortinue to compromise development prospects: population growth, increasingly at odds with land availability, an undiversified economic structure, Government's limited capacity to provide social services, and the economy's inability to generate jobs either outside or within the rural sector. Though foodcrop output has, at least, kept pace with populai'on growth, it has apparently done so at a cost to the land's long-term fertil'ty. Agricultural land use in Rwanda has reached a point where there is little fallow or grazing area left. The rapidly growing population has resulted in serious deforestation, accompanying erosion, and has required the cultivation of marginal lands with a fragile ecology. Concomitant wl.ch these adverse trends has been a deterioration of nutritional stan"lards induced by the shift to traditional high-yield, high-calorie, but low-protein crops. The limited success of Government's efforts has been largely due to the country's structural constraints (among them the critical population problem), institutional weaknesses (stemming largely from a shortage of skilled personnel), and insufficiency of domestic financial resources. At the same time, the shortage of skilled personnel, fragmentation of institutional responsibilities, and poor interagency coordination have limited the country's capacity to absorb external resources. 7. The Rwandese authorities have taken steps to address these problems. Of particular importance have been actions concerned with the extremely rapid population growth, and the lack of education and training. The project presented in this Report is our first full-scale effort to assist the Government to respond to its pressing population realities. To address the problem of lack of education and training, the Government introduced an education reform in 1979 which - after subsequent adjustment - was responsive to the country's needs, but whose implementation has been hampered by financial constraints and the lack of teachers. 8. A quantitative assessment of Rwanda's recent economic performance can only be tentative, as the national account statistics have serious shortcomings. These estimates suggest that, compared to the period of 1978-1980, during which the GDP grew by about 6 percent annually, economic growth in Rwanda slowed down during 1983-1984 -- GDP grew on average by about 1 percent p.a. - mainly on account of a downswing in tertiary sector activities. Balance of payments and budgetary constraints impinged heavily upon trade and transport activities whose rapid growth in the past had been facilitated by greatly enlarged availabilities of foreign exchange and budgetary revenues. Budgetary austerity measures introduced since 1983  -3- resulted in stagnation of Government's expenditures in real terms during 1983 and 1984. Notwithstanding this domestic recession, the manufacturing sector expanded its productive c*acity and improved its capacity utilization due, in part, to the import restrictions which limited foreign competition. Mining continued the decline that started in 1980 due to persistent financial and management problems of the major mixed-ownership company (SOMIRWA), which has been recently declared bankrupt and ceased its operations. In agriculture, the sluggish performance of food crop production due to drought has been partially offset by the rise in production of export crops. Preliminary data suggest that 1985 witnessed moderate growth after the economic slump of the preceding 3 years. This renewed growth occurred mainly on account of an increase in agricultural production and despite a precipitous decline in the price of tea and the virtual cessation of all mining activities. 9. Rwanda's external position came under strong pressure, as the volume of imports continued to expand at a time when export earnings were declining. Since 1981, the total value of exports has been consistently below their 1977-80 levels, reflecting the decline in world coffee prices rather than a shortfall in export volume. The terms of trade deteriorated by about 24 percent between 1979 and 1984. In an attempt to arrest the deterioration of the balance of payments, the Government adoptVed - beginning in 1983 - what they expected would be temporary measures, including licensing, prior deposit requirements and increased import tariffs. The restrictions aimed mainly at curtailing imports of non-essential consumption goods as well as those of locally produced commodities. The Rwandese authorities also shifted the peg of the Rwandese franc (in September 1983) from the US dollar to the SDR, entailing a 5.2 percent depreciation vis-a-vis the US dollar. These measures, coupled with some improvement in the terms of trade in 1984 and 1985 (with respect to the 1981-1983 period) helped to reduce the current acco-unt deficit to about 9 percent of GDP both in 1984 and in 1985 as compared to 12 and 11 percent, respectively, in 1982 and 1983. 10. On the budgetary side, the authorities did not realize that the high level of tax revenues recorded in 1979 and 1980 was a temporary phenomenon not justifying a permanent increase in expenditures. As a result, the sharp decline in revenues from coffee export taxes beginning in 1981, together with increases in current outlays (in order to achieve the social objectives of the Plan), resulted in an overall budgetary deficit equivalent to about 2 percent of GDP in both 1982 and 1983 (as compared to a surplus of 0.9 percent in 1980.) Concern over the worsening budgetary situation led Government to introduce corrective fiscal measures. In 1984, the growth of current expenditures (in nominal terms) was limited to 2.3 percent. The growth of public sector employment was held under 0.5 percent - the education sector' was exempted in order to achieve the revised targets of the 1979 Education Reform. This represented a major break from Government's past policy of practically "guaranteeing employment to every secondary-school graduate. Large reductions were also decided in net transfers to parastatals. Thanks to the austerity measures and increased revenues from taxes on international trade both in 1984 and 1985, the Government has been successful in reducing the budgetary deficit to about 1 percent of GDP. The Government is likely to face an even more favorable budgetary situation in 1986 because of an anticipated increase in coffee prices and the introduction of a new sales tax.  -4- 11. Government has been traditionally conservative in its monetary and credit policies. Inflat :onary pressures have arisen mainly from supply shortages caused by frequent disruptions of supply routes through neighboring countries, bigh international transport costs, and increased prices of imports and seasonal fluctuations in the price of domestic foodstuffs. Inflation averaged 10.6 percent per annum during 1977-82, it peaked at 12.6 percent in 1982, reflecting mainly the substantial increases in electricity and water tariffs and educational fees. In 1983 and 1984 inflation was down to 6.6 and 5.4 percent, respectively. In 1985, inflation appears to have further declined to about 4 percent. 12. Rwanda has been one of the most favored beneficiaries of foreign aid in recent years. Per capita disbursements of net official development assistance (ODA) have been above US$30, much larger than the average for Africa. During the period 1981-84, grants comprised about 80 percent of total external aid flows, and were provided mainly by Belgium, the Federal Republic of Germany, and France. In view of its level of development, Rwanda will need external assistance for a long time to come. While the anticipated coffee price increases for the next two years may provide temporary balance-of- payments relief, this is unlikely to continue beyond 1987. To help the Rwandese to implement their economic growth program (Programme de Relance), foreign assistance would have to continue at least at the current level, given population growth and export constraints. 13. Rwanda's medium- and long-term external public debt is relatively small, estimated at US$304 million at end-1985, equivalent to about 16 percent of GDP. Most of Rwanda's external debt was contracted on highly concessionary terms; the grant element was over 70 percent on average during the 1972-84 period. Due to the concessionary nature of these loans, the debt service payments on mediumr and long-term debt are relatively low: about 8 percent of exports of goods and nonfactor services in 1985. Hence, there remains scope for further borrowing. However, given the poverty of the country, its overwhelming constraints and vulnerability, and its long-term unfavorable terms of trade prospects, external funds should continue to be provided in the form of grants or loans at highly concessionary terms, and include a high proportion of local cost financing and non-project assistance. PART II - THE BANK GROUP ASSISTANCE 14. Bank Group assistance to Rwanda started in 1970, and was initially focused on the improvement of the road network and the strengthening of agricultural production. As of January 20, 1986, Rwanda has received twenty-six IDA credits totalling US$267.2 million: eight for agriculture (34 percent); six for roads (30 percent); four for DFC's (10 percent); two for power (9 percent); two for education (6 percent); one for water supply (5 percent); two for technical assistance (4 percent); and one for telecomr munications (3 percent). In addition, Rwanda has also received a Special African Facility Credit of US$15.0 million for the Sixth Highway project. There have been no Bank loans. Three IFC investments (one of US$535,000 for a tea factory; a second of US$226,000 with contingent equity commitment of up to US$60,000 to expand the tea factory; a third of US$249,000 also to expand the  -5- tea factory) were signed in 1976, 1980 and 1985, respectively. Annex II contains a summary statement of IDA credits and IFC investments as of September 30, 1985. 15. In fiscal years 1982-84, disbursements for Rwanda totalled US$49.1 million, compared to new commitments of US$86.2 million. The annual disbursement rate increased steadily over this period, to reach about 25 percent in FY85 which is above the average for countries of the Eastern and Southern Africa Region. There are no problem projects in Rwanda. 16. The Bank Group lending has been based on a country strategy which has emphasized: (i) agriculture and rural development, the main objective being to increase food production as well as export crops, while maintaining soil fertility; (ii) human resources development, focusing on support to basic education and skills training to improve agricultural productivity, provide skilled manpower, and influence attitudes on the population issue, and, more recently, on family planning programs per se; (i.i) infrastructure development, particularly roads, to reduce the country's isolation and to provide incentives to further intensification of agriculture as well as increased specialization and diversification through better marketing; (iv) energy, to lessen the country's demand for fuel imports; and (v) development of small and medium-size enterprises in manufacturing and other sectors. 17. One of the major constraints to Rwanda's development is the shortage of administrative and technical/managerial capacity. his affects all sectors and inhibits project preparation and implementation. Institutional and human resource development through intensive technical assistance and on-the-job training of Rwandese staff have, therefore, been a salient feature of the Bank Group program for Rwanda, both under individual projects in various sectors, and through free-standing technical assistance projects (a second Credit 1565-RW became effective January 10, 1986). These projects have helped strengthen inter-ministerial coordination, provided t-aining to staff in the studies units of concerned agencies, and contributed to improve the preparation of the next five-year plan. 18. The Bank Group program has been pursued in a climate of good relations with the Government. In all sectors in which we are active, there exists a general receptivity to our advice and willingness to take action where required. In agriculture, improved sector management as well as more rigorous project planning and financial controls have been attained, with a shift away from integrated rural development schemes towards more directly productive projects. In the highway sector, our active dialogue with the Ministry of Public Works and Energy is now focusing on the ways to reduce reliance upon expatriate expertise. In industrial development, we have gained Government's commitment to promote small-scale enterprises. In the education sector, we had difficulties due to two misprocurements (some six years ago) and an overly ambitious education reform proposal at the primary level. However, a positive dialogue with the Ministry of Primary and Secondary Education (MINIPRISEC) has emerged in the past three years; the Ministry has since adopted a less costly and lengthy primary cycle. On population, our initially cautious approach to Government has developed into cooperative efforts to promote suitable family health and planning programs.  - 6 - 19. The Bank Group strategy continues to center on the five sectors mentioned above (para. 16), with special emphasis on agriculture and population. For the former, we give priority to: (i) promote intensification by developing and strengthening Rwanda's agricultural research and extension capabilities; and (ii) reinforce the key sector institutions - the Rwandese Research Institute and the Ministry of Agriculture. In the population sector, our program and proposals are described below. 20. Finally, our dialogue with the Government has also had a macroeconomic dimension. Rwandese authorities have recently indicated readiness to proceed with the preparation of an economic recovery program ("Programme de Relance"), and asked the Bank's assistance in its formulation. A Bank economic mission recently visited Rwanda in response to this request. The mission's work, which extended in particular over agriculture and mining sectors and public enterprises, will help further strengthen the cooperation between Rwanda and the Bank at the macroeconomic level. PART III. POPULATION AND HEALTH SECTOR Introduction Population, Health and Nutrition Status 21. With a population density of about 230 people per km2, Rwanda is the most densely populated country in Africa. The 1985 population is estimated at 6 million. The total fertility rate (8.4) and the population growth rate (3.7 percent p.a.) are among the highest in the world. Thus, major population growth is inevitable for Rwanda. Under the most optimistic assumptions (rapid fertility decline and emigration of about half a million people), the population will double by 2015. Under the worst (with the current rate of population growth prevailing and no emigration), it will more than triple and reach 22.3 million. Moreover, growth rates will remain high enough at the end of the project period to permit a further doubling of the population within the following 20 to 25 years. Rwanda's agricultural performance over the past decade has been sufficient to allow local food production to keep pace with population growth. Sustaining this performance will prove harder in future, however, because the intensification of cultivation has led to deforestation, erosion and a decrease in soil productivity. As land reserves vanish, it will be a difficult challenge for Rwanda to develop and apply, within 30 years' time, agricultural technology and methods adequate to support the projected 800 people per km2 of agricultural land. The effect of population growth on consumption needs will be most strongly felt in the area of food availability. Population growth will also increase the demand for jobs, housing, water, electricity, schooling and health care. This increasing pressure on the country's social and economic systems makes the need for large-scale efforts to reduce fertility more urgent. 22. As in most sub-Saharan African countries, health conditions are poor. Life expectancy is about 47 years, and the infant mortality rate is at 115-125 per 1000. About 25 percent of the children die before age 5. Mothers and young children account for the bulk of Rwanda's morbidity and mortality. The leading causes of death among children are malaria, diarrheal diseases and measles; for women in reproductive age, most of the deaths are related to  pregnancies. Many of these deaths can be prevented with an effective MCH/FP/Nutrition program. Several nutrition studies found about one third of Rwandese children to be suffering from some degree of protein-calorie malnutrition. There are considerable differences in nutritional status among sub-groups of the population and among regions. The network of 167 locally-financed nutrition centers (NCs), many of which are operated by religious organizations, represents Rwanda' s main intervention for nutriti=n. Sector Development Objectives and Organization: Population 23. Realizing the extent and the detrimental effect of rapid population growth on the country, the Government of Rwanda's policy on population evolved from analysis of the demographic situation to development of specific objectives and action programs. This evolution led to the creation, in 1981, of a parastatal agency under the umbrella of Ministry of Health and Social Affairs (MOHSA) and the formulation of the Third Five-Year Plan (1982-1986), reflecting the Government's policy on population. The policy is to 'st oilize demographic growth at 3.7% per year and to put in place the conditions necessary for the eventual reduction in growth, which is indispensable." Measures envisaged to meet this objective are to raise the legal minimum age of marriage; provide family planning services; carry out socio-economic studies, and organize motivational campaigns on family planning. ONAPO's mandate, in this process, is to carry out educational and informational programs, research and evaluation, and staff training. While ONAPO is the lead agency in planning and coordinating the program, FP services are delivered by MOI!SA staff in Government health facilities. That is, ONAPO does not intend to operate a separate service delivery network. Government support of the population program and ONAPO's effective approach are the major strengths within this sector. Nevertheless, the Government is still cautious about setting up specific targets for reducing fertility in this heavily Catholic country. The Catholic Church is aware of the population problem, however, and promotes natural FP methods. 24. In September 1982, ONAPO organized a national colloquium on "Family, Population and Development," which was attended by about 200 persons including deputies, community leaders, civil servants, physicians, religious leaders and other influential people. Having been favorably received and widely publicized, it represented a breakthrough in public awareness of the issues. IEC (Information, Education and Communication) pregrams are now being targetted at several ministries and groups specifically concerned with development. These multi-sectoral activities are funded by USAID and other donors. In addition, numerous population education seminars have been held with key administrative officials (sous-prgfets, bourgmestres and chefs de service) throughout the country since 1983. Most Government officials and politically active citizens are now clearly aware of the Government decision to deal effectively with the population problem. Since January 1983, ONAPO has also used the radio for disseminating FP messages. Radio is Rwanda's most important mass medium and reaches at least 80% of homes. ONAPO has produced a popular weekly 15-minute radio program about the impact of rapid population growth and large family size.At present, the equipment and expertise of the ONAPO radio team are limited, but a USAID project will provide adequate funds to  -8- meet its needs. Information activities using other media are still at an early stage: a few newspaper articles and brochures have been published, and a film and a play have been prepared. At the community level, ONAPO strategy is to sensitize local officials and community workers at the prefecture level through three-day seminars conducted by ONAPO staff. Local officials and community workers then conduct shorter informational sessions for the general public. These gatherings are proving an effective way of promoting the subject of fertility reduction because they are easy to organize, take place in an informal setting, and include men and women of all ages. The participation of local political leaders adds credibility and underlines Government support for the population program. 25. Since the late 1960s, FP services have been available in Rwanda on a limited scale as part of gynecological services at the Government central and prefectoral hospitals. Presently, FP services are provided in only one third of peripheral health facilities. Whereas public hospitals recruit more acceptors than private hospitals, private health centers (HCs) (Protestant and Catholic) recruit more acceptors than public HCs. Various contraceptive methods are available. Sterilization and abortion are not offered as part of the FP program, but are permitted for medical reasons only. According to the 1983 National Fertility Survey (NFS), contraceptive prevalence for modern methods was estimated at 0.9 percent of women ages 15-45 years who were in union, not pregnant and fertile. Traditional or nnatural' methods were used by 10.1 percent of women but with no measurable positive effect. Contraceptive methods mix was as follows: injectables 45%, oral contraceptives 44%, IUDs 8% and barriers (mostly condoms) 3%. Data from the 1983 NFS suggest that a substantial demand for contraceptive services already exists in Rwanda. Of the women ages 15-49 years in the sample, 31% (representing 223,200 women in the country) said they intended to use contraception in the future. An additional 20% of the women of the same age group (representing 144,000 women) did not want an additional child. Thus, the unmet demand for FP services was much greater than service delivery capacity in 1983 and has probably now increased even further. Consequently, it is now important to find ways of meeting the current and increasing demand for FP services. Improving the MOHSA FP service delivery system is the best way of doing this. MOHSA and ONAPO have already approved, in December 1984, a document describing the division of tasks between the two institutions. A high-level 3eminar held in May 1985 brought together MOHSA's central staff, regional health and hospital directors, and ONAPO representatives to expand and further develop the strategy to extend FP services nationwide. Health and Nutrition Programs 26. The Government health policy and strategy for the Third Five-Year Plan (1982-86) is sound, giving priority to the main elements of primary health care as defined by WHO, and include: (i) reorganization of MORSA, based on the implementation requirements of a policy of -Sant& pour les masses"; (ii) development of the health infrastructure by providing at least one HC per commune (there are 143 communes in Rwanda) and two rural hospitals in each of the ten prefectures; (iii) an increase in hospital beds to keep up with popul:ition growth; and (iv) staff development by strengthening present and planned facilities. To implement these general  - 9 - goals, MORSA, with the support of WHO, held a workshop in May 1983 to formulate a specific health plan. Priority was given to improving existing facilities (rather than building new ones), to converting dispensaries into HCs and to expanding nationwide the Expanded Program on Immunization (EPI). MOHSA is presently preparing its Fourth Development Plan. The preliminary draft reflects serious efforts to enhance quality of care and to develop priority service programs that go beyond numerical targets for buildings and personnel. The proposed Bank supported family health project would be the major investment in the sector and would constitute support to the core of the integrated national MCK/FP/Nutrition program. 27. MOHSA has recently been reorganized. The former Ministry (now Department) of Social Affairs has become part of the Ministry of Health. ONAPO is under the umbrella of MOHSA but retains its essential character as a parastatal. MOHSA itself comprises three Departments: General Services, Public Health, and Social Affairs, all under the Secretary General. Three much-needed technical divisions have been created recently: one for MCH, a second for Studies and Evaluation, and a third for Training. The Studies and Evaluation Division is responsible for statistics, documentation, studies and project monitoring. The Training Division is in charge of organizing a systematic in-service training program and developing curricula for auxiliary staff. The MCH Division is setting up standards and procedures for priority programs (immunizations, nutrition activities, prenatal care, etc.); and its FP and Nutrition Bureaux are responsible for the development of family planning and nutrition activities in health facilities. Decentralization of health services management to the regional level has been initiated, although the extent of decentralization in the different health regions is quite uneven. Formally, the regional health directors have full control over personnel and services in their regions, and their administrative and financial authority could allow them to effectively run health services and to adapt them to local needs. In practice, however, most regional directors are constrained by the limited facilities and staff available to them, and also need more tecbnical guidance and logistical support from the central level, particularly in the key areas of in-service training and program monitoring. 28. The network of hospitals, HCs, and dispensaries is evenly distributed throughout the country and health coverage is high by African standards. About 60% of Rwandats health facilities are operated by the MOHSA, with the remainder belonging to the missions. Operation of each facility is the subject of a legal agreement between the Government and the sponsoring church. Government policies on health services apply to the missions, and their facilities are supervised by MOHSA regional directors. MOHSA pays 80% of the salaries of Rwandese staff working in the missions and approves the mission fee schedules. The missions have a coordinating body called, -Bureau des Formations Medicales Agreees du Rwanda (BUFMAR).- It represents the missions in negotiations with MOHSA and provides services for its members, including drug supply, maintenance of equipment and production of educational materials. There is a need to upgrade health facilities in selected locations, but a wide-scale expansion of the service network is not presently required. MOHSA completed, during project preparation, a systematic assessment of selected health facilities, geographical accessibility and utilization patterns. Staffing of HCs is inadequate to serve the heavy load of outpatients. The shortage is particularly acute for enrolled nurses and nurses aides.  -10 - 29. General out-patient services in hospitals and peripheral facilities are heavily utilized, and out-patient facilities are almost invariably crowded. The level of utilization of in-patient services varies, depending on their ',pe and location. The average bed occupancy rate for hospitals is 70X, which is relatively high. The occupancy rate for HC beds is 30X, which is typical for this type of facility. Some hospitals and wards have occupancy rates over 100%. This suggests that future planning of capital investments should be based on a careful analysis of each facility's needs. MCEH services are provided in lCs and hospitals. The Expanded Program on Immunization (EPI) has been underway since 1980 with financing from WHO, UNICEF and USAID and is managed by a Rwandese national. The program is implemented in all of Rwanda's hospitals and HCs. Coverage of children is presently approaching 50%, a respectable achievement as shown by the decrease in incidence of measles and pertussis. A new program, Combatting Children's Communicable Diseases (CCCD), financed by the same donors, has been launched to complement the EPI. It is presently imple.mented in three pilot zones and will be expanded nationwide within five years. Prenatal care is provided for 80% of pregnant women, but the average of two visits per woman is insufficient for the proper monitoring of a pregnancy. Most women deliver at home. It is estimated that only 10Z of all deliveries take place in health facilities. Postnatal care is almost non-existent and theare is no promotion of FP during this particularly receptive period. A national program is needed to establish standards, procedures, and skill requirements for delivery of MCH services. 30. The Nutrition Center (NC) network is the cornerstone of the national nutrition effort. The 167 centers are distributed throughout the country, close to HCs, averaging one center for every 35,000 persons. Their operation is financed by beneficiary families (who pay a monthly fee), the communes (which are responsible for staff salaries) and external donors (who mostly finance food and equipment). The Governmwent undertakes planning and supervision by MOHSA's Nutrition Bureau, and staff training is provided through the National Training Center at Ruhengeri. About two- thirds of the NCs are privately operated, mostly by the missions. The Catholic Relief Services (CRS) provide food for about 95 centers. Utilization of NCs by the public is high, on average a center serves 500 mothers per month. Major activities include growth monitoring of children, nutrition rehabilitation of malnourished children, educational talks on weaning practices, development of family gardens, and food distribution. The present Government policy is to integrate the NC activities with the HC MCH activities, i.e., no new NCs will be built. Some space will be devoted to nutrition activities in new or upgraded HCs. Due to the absence of strict enrollment criteria, such as malnourished children or poor families, the NC staff are presently spending much of their time taking care of well-nourished children. The weaning mixtures presently suggested to the parents are also inappropriate. 31. Drugs come from four main sources: the G3vernment pharmaceutical office (OPHAR), the mission-operated office (BUFMAR), private commercial pharmacies and bilateral aid. In recent years, OPHAR has been increasingly less able to meet the needs of the health system and coimercial pharmacies have steadily increased their role. In 1984, OPHAR purchased only 25% of drugs available in Rwanda. An essential drugs list of 286 items was  - 11 - established in 1980, but only applies to the Government health system, since BUFMAR and the commercial pharmacies import freely. Also, there is no control over direct donations of drugs to the facilities supported by missions, and over French and Belgian assistance. Commercial pharmacies specialize in items not on the essential drugs list because they tend to generate higher profits. OPHAR is facing increasing difficulties in sup- plying drugs to health facilities. Its budget for drug purchases has not increased for the past five years, and management procedures and storage facilities need to be improved. As a result, in some Government facilities quarterly stocks run out after two months. The Government is aware of this problem, which reduces the quality of health services provided, and is taking steps to improve the situation. OPHAR will be reorganized as a parastatal agency. WHO will provide technical assistance to implement the reorganization, and the African Development Bank is financing a new warehouse and is likely to provide technical assistance. Health Expenditures and Financing 32. Total private and public outlays for health care amounted to about 3.5% of GNP in 1984, or an equivalent of US$5 per capita, which is close to the average figure for sub-Saharan African countries with a similar low income level. The major sources of finance for recurrent expenditures are the Government, bilateral aid and the missions. More than 80% of the capital expenditure is financed by external donors. About half of the capital expenditures during the past five years was funded by Belgium and was used for purchase of equipment, renovation of hospitals and for a new drug production unit. MOHSA's budgeted capital expenditure for 1984 is about 6% of the total Government investment budget. The composition of capital expenditure seems in general to be well balanced between central and peripheral facilities. The public contributes to the construction and rehabilitation of facilities through the system of cooperative labor (umuganda). For the past 10 years, MOH's recurrent expenditures have averaged 6% of the annual recurrent budget. The two major categories of expenditure, as per the 1985 budget, are personnel (57%) and drugs (13%). The proportion of the MOHSA budget devoted to personnel is much lower and more balanced than in most countries of the region. Annual spending on drugs (in current RwF) was cut back in 1982 to its 1977 level which resulted in a 35 Z reduction in real per capita terms. External Assistance 33. External assistance to the health sector has been provided by a variety of agencies, particularly by the missions and philanthropic organizations. External assistance to MOHSA itself has been limited. USAID is co-financing the CCCD project with WHO, UNICEF and the Center for Disease Control. UNICEF is supporting training activities in MCH and nutrition and some activities in water supply. The EEC is supporting the development of a nutrition surveillance system through EDF. French and Belgian aid supports hospitals in the Kigali and Ruhengeri regions. For the population program, the Government is receiving substantial external assistance, almost all of which is being channelled through ONAPO. USAID, with a US$6.25 million project for 1982-88, is presently the largest donor. UNFPA is financing some technical assistance and construction of  - 12 - health facilities. Various training activities are provided by JHPIEGO, INTRAH and the University of Chicago. In all, an estimated US$9 million in external assistance will have been provided for population programs in the 1982-1986 Plan. The Government's main financial contribution is the personnel and administrative costs of ONAPO. These amount to US$0.6 million in 1984 or about O.5Z of the Government's total operating budget. Cost Recovery 34. Both Government and mission facilities levy fees for health services. In Government facilities, drugs are included in the consultation fee, but in the missions they are charged separately. In 1984, Government revenues from health services represented about 7% of the total costs of services provided by its health facilities. Complete information about fees charged by the missions is not available. Since most mission facilities rely heavily on fees for their financing, it can be inferred that their fees are higher and the collection more rigorous than in Government facilities. MOHSA is not adverse in principle to raising its fees, but is currently focusing on the possibilities of charging for drugs as the most effective approach to cost recovery. MORSA is presently reviewing an operational research project on drug financing at the community level including preliminary studies on community willingness and ability to pay and managerial capabilities needed which would be financed under PPF. MOHSA is also undertaking with WHO support a comprehensive health financing study. It was also agreed during negotiations that MORSA would present the findings of the study and a proposal to implement the recommendatlons to the Association by April 31, 1987 at the latest. Bank Group Strategy in the Sector 35. IDA's principal objective in the PEN sector is to assist the Government to reduce the rate of population growth and improve maternal and child health. The Government's strategy of developing a comprehensive family health program is sound, and is the key feature of the Bank strategy in the sector. The five-pronged approach envisaged is to: (i) improve family health services to adequately meet the increased demand for FP and MCH services; (ii) provide assistance for imnproving the effectiveness of the nutrition programs, and for integrating them with the MCH/FP activities in the HCs; (iii) strengthen MOUSA further, so that the Ministry could discharge its responsibilities more effectively; (iv) help train the additional staff needed to overcome shortages; and (v) develop a data base for improving policy formulation. This approach complements the assistance being provided by other donors. 36. Bank Group lending for population-related activities in Rwanda has hitherto been confined to a population component in the IDA-financed BGM II rural development project (Credit No. 1283-RW), and a component in the Second Education project (Credit No. 1263-RW). The rural development  - 13 - project will be completed at the end of 1988. The population objective was to develop on an experimental basis community-based FP services. ONAPO was responsible for implementation, which included IEC and training activities, rehabilitation and equipping of a few health centers, and improved supervision from the central level. The component was limited to the prefecture of Kibungo (about 500,000 people). While ONAPO was successful in raising awareness of the population problem, it was unable to increase significantly the number of contraceptive acceptors. The major constraint was the lack of involvement of MOHSA in FP services provision at the HCs. Other constraints were ONAPO's reluctance to use technical assistance as planned and its limited planning and managerial capacities. However, this effort gave IDA the opportunity to learn about the sector, and to identify the need for r nproved collaboration and coordination between ONAPO and MOHSA. The Second Education project includes support for the construction of a nursing school in Gisenyi. PART IV - THE PROJECT 37. A PPF advance of US$440,000 was approved by IDA on November 15, 1984. Project preparation was handled by MOHSA, assisted by a task force of four external consultants (in FP, nutrition, architecture and preparation coordination), who worked in close coordination with seven staff members from MOHSA and ONAPO, under the chairmanship of MOHSA's Director of Administrative and Financial Affairs. In April 1985, a detailed draft report was made available to the pre-appraisal mission, and in late June 1985 a proposal was submitted to IDA. The proposed project was appraised by an IDA mission in July-August 1985. During the two years of project preparation and appraisal, the proposed project has changed from a hardware (buildings, equipment, vehicles) orientation to one focused on delivery of comprehensive family health services. As a result of the dialogue between Government and Bank staff, the working relationships between MOHSA and ONAPO staff have been defined, and the overall strategy of implementing an integrated MCH/FP/Nutrition program has been developed. The proposed project now constitutes a key element of the Government action plan for providing more effective health and FP services to the general population and on the longer term reducing the national fertility rate. Project Objectives 38. The proposed project would, in the context of the national primary health care strategy, improve maternal and child health status, and, more specifically, develop family planning. These objectives would be achieved through: (a) improving the quality and increasing the coverage of FP and MCH services; (b) improving the focus of nutrition activities and integrating them into MCi services; (c) strengthening the institutional capacity of MOHSA at the central and regional levels; and (d) increasing the output and improving the quality of basic paramedical training programs. The proposed project would be an integral part of the Fourth Development Plan (1987-91). It would complement other donor assistance in health and population. To this end it was agreed during negotiations that Government would transmit to the Association for comment by September 30 each year its proposed health sector investment program for the coning year, including the family health project budget.  - 14 - Project Description 39. Strengthening Family Health Services. Through specific in-service training, essential medical supplies and intensified supervision, FP services will be made widely available by 1991: (i) all HCs (public and private) would be providing FP services (three times as many as in 1983); (ii) each HC would be recruiting 20 new acceptors per month (five times as many as in 1983); (iii) about two hours would be spent daily on FP services in each EC, including clinical and non-clinical activities (O to 30 minutes daily in 1983); and (iv) all the NCs (162) would promote family planning thrcugi health education. The latter point is particularly innovative and should generate more demand for FP since 'Cs, whose clients are numerous, could refer these patients to health centers for contraceptives. Other MCH activities would benefit from the in-service training/supervision program: (i) pre-natal care will improve quantitatively and qualitatively; (ii) post-natal care, which is presently almost non-existent, will be progressively developed; (iii) the control of sexually transmitted diseases, a problem of growing importance, will be introduced through use of condoms and standardized treatments as and when appropriate; and (iv) NC activities will be targetted towards high-risk groups, and the nutrition workers will learn how to use the new weaning food developed during project preparation. 40. In service training in FP and MCH service delivery would be provided for: medical assistants (in charge of the MCs), certified and enrolled (A2, A3 level) nurses, nurses aides (A4 level), and social workers/nutritionists. The training would include non-clinical techniques, so as to enable staff to work more closely with the community and develop interpersonal communication skills. Nutrition and social workers would receive instructions for integrating their work with HC activities, delivering FP messages to clients of NCs and preparing and promoting the new weaning food. Over the five year period, the project is expected to train about 1400 staff. An average of about 7-10 training days per staff per year are planned. By project completion, the in-service training program would be a well-established on-going activity. To ensure this, the project would provide 7 staff-months of local and 3 months of foreign consultancies for curriculum development and operating costs for training sessions. Training sessions would be organized at the regional level by a joint MOHSA/ONAPO team led by the regional health director. The MOHSA Training Division would develop a specific curriculum for each category of health worker. According to the training program under preparation, staff support would be provided by the TOHSA Training Division and ONAPO, and a detailed implementation plan for the first year of the project. 41. The project would provide for some of the contraceptives required by an accelerated FP program as part of on-going donor assistance. MOHSA/ONAPO have agreed on a target of 10% contraceptive prevalence rate (modern methods only) for women in the fertile age (15-49) to be reached in 1991. The target, though modest in absolute terms, implies increases in acceptor rates equal to or greater than those achieved elsewhere in the world under voluntary programs. It implies that: (i) in 1991 more than 100,000 women will be using a modern contraception method (excluding natural family planning methods), 10 times more than in 1983; (ii) during the 1987-1991 period more than 200,000 new acceptors would be recruited  - 15 - (recognizing that during that period not all 'acceptors' become regular "users"). It also implies that ONAPO would sustain its IEC efforts in estimacing and responding to contraceptive requirements. Presently, the limited contraceptive needs are met by donations from various international organizations. IDA funds would be used to supplement these free supplies and to purchase injectable contraceptives for meeting 30X of the expected needs at the health centers. 42. The Government's two major objectives regarding the RC network are: (i) to cake each RC capable of delivering key services, including MCH/FP/Nutritlon services, short-term in-patient care and community outreach activities; and (ii) to provide an average of one BC per 30,000 population (presently 43,000). In order to reach these objectives, MORSA has been gradually increasing the number of HCs with the financial support of various donors. It is now planning to upgrade and rehabilitate about half of the existing HCs and dispensaries, which are in poor condition and do not meet the standard required for adequate service delivery. Project support of this effort by financing the first phase of an BC rehabilitation program would benefit about one million people. During project preparation, MOHSA undertook a functional analysis of RC requirements, including services to be provided, staff, equipment and space needed for each type of activity. MOHSA then established a priority list of 30 HCs to be upgraded and rehabilitated. The appraisal mission reviewed this work and accepted 25 facilities. Five further locations remain to be selected. It was agreed during negotiations that by December 31, 1986, Government would provide to the Association the locations of these five health centers proposed for rehabilitation during the third year of the project. 43. Institutional Strengthening of MOHSA. The project will strengthen the institutional capacity of MOHSA to: ti) better plan and manage centralized activities, particularly in the three new Divisions (MCH, Training, Studies and Evaluation); and (ii) implement, at the regional level,, the new strategy of integrated MCH/FP/Nutrition service delivery, using a decentralized administrative system. The project would enable the MCH Division, including the FP and Nutrition Bureaux, to better manage and supervise field activities by providing equipment, supplies, two vehicles and fellowships. A long-term MCH/FP/Nutrition adviser is being recruited under WHO contract for five years to assist in the planning and implementation of the family health program. The terms of reference and scope of work for this expert have been agreed. The project would also support overseas fellowships in public health for the MCH Division chief, to be appointed by MOHSA by September 30, 1986 (agreed during negotiations), and for the FP Bureau deputy, along with fifteen study tours. 44. The project would also strengthen the MCH Nutrition Bureau. It would help the Bureau in: (i) introducing a new weaning food; (ii) targeting nutrition activities towards priority groups; and (iii) collaborating with the FP Bureau by integrating FP activities into the NC program. The Bureau, with the guidance of the Nutrition Training Center, will be strengthened through the provision of teaching materials, equipment and a vehicle each. The project would also finance study tours in appropriate countries where nutrition programs have been successfully integrated into MCR activities.  - 16 - 45. The Training Division would develop the in-service training program for HC personnel. The project would provide for about 20 staff-months of advisory assistance to help the Division develop an in-service training curriculum, and a plan for its implementation, supervision and evaluation procedures. It was agreed during negotiations that in order to accommodate the increased workload, MOHSA would appoint, by December 31, 1986, an additional training specialist in this division. The project would also provide equipment, teaching materials and a vehicle. The Studies and Evaluation Division, created to develop planning and evaluation capacities of MOHSA, needs a more effective health information system (vital and service statistics) to fulfill its functions. The project would finance seven staff-months of foreign consultancies to analyze the present system and to propose and introduce improvements. At negotiations it was also agreed that by December 31, 1987, MOHSA would present, for approval by IDA, its proposal to improve its health information system. The project would also provide two fellowships for statisticians, office equipment and a vehicle. To monitor the impact of the family health program, the project would also finance operating costs to undertake two surveys on fertility and MCH status. 46. Presently, only two out of ten health regions have adequate offices for the regional health director and his staff, including the ONAPO physician, nurse and social worker. In the other regions, staff is poorly housed at scattered locations and cannot effectively undertake its supervision responsibilities. The project would, therefore, finance the construction, equipment and one vehicle each for eight regional offices, including 13 staff houses. Each regional office would include administrative space, storage facilities and residential quarters. 47. The regional director and his staff would play an important role in developing a supervision system for the family health program and in implementing the in-service training program for BC personnel. To strengthen supervision of the HC network, MOHSA and ONAPO have agreed on a work program which familiarizes the regional staff with planning, managing and supervising the restructured MCH program. Staff from five regions have already been trained with funds from the PPF. To continue this effort additional workshops will be held in Kigali with participation from senior staff from MOHSA, ONAPO and MINEPRISEC, including the training consultants. Supervision will also be improved quantitatively, with each HC visited by the regional medical director (or his deputy) at least once every two months. The project will also support the salaries of 10 additional regional MCH supervisors and their operating costs. These supervisors will be social workers in charge of monthly monitoring of the integration of FP activities within. the daily activities of H/NCs. 48. Human Resource Development. This component would have two parts (i) pre-service training and deployment of nursing aides (A4 level), undertaken by MOHSA; and (ii) construction, staffing, and management of two new nursing schools for A3-level nurses, undertaken by the MINEPRISEC. To address the critical manpower shortage and to deal effectively with the needs generated by the intensified and restructured MCH/FP/Nutrition program, the project would support the pre-service training of about 200 nurses aides. The training would be done in the existing schools, which  - 17 - can accomodate additional students. The project would provide for training of trainers, incremental operating costs and monitoring and evaluation by the HOHSA Training Division. The curriculum was reviewed by Bank staff and found appropriate. The additional yearly output would be about 40 nurses aides, who would work in HCs to ensure adequate staffing of primary health care facilities. The 200 new nurses aides would help introduce the restructured MCH program, and to make FP services widely available. The project simultaneouly provides for training of enrolled A3 nurses (para. 49), who would be ready for deployment in 1992. At that time, the question of career opportunities and professional future of nursee aides would arise since the A3 nurses will progressively replace them. To facilitate eventual absorption of the nurses aides into the cadre of enrolled nurses, MOHSA is presently reviewing the mechanism whereby a career path for A4 staff could be established. It was agreed during negotiations that by December 31, 1987, a career path for nurses aides would be agreed upon between MOHSA and MINEPRISEC. 49. Nursing Schools. Training of additional paramedical personnel, particularly enrolled nurses (A3 level), is an urgent need recognized by the Government since 1982. Substantial shortages of nurses would remain until mid-1990 unless additional training facilities are provided. The project would finance the construction of two new nursing schools in Byumba and Kaduha for A3 nurses comprising five classrooms, a laboratory, a preparation room and a library each. The project would as well provide for construction of two houses for teaching staff at each school. Professional and architectural services would be provided by the construction agency (SFCS) of the MINEPRISEC, which is presently supervising the constrdction of a virtually identical nursing school in Gisenyi, financed by the Second Education Project. The new nursing schools, with a capacity of 120 students each, would be established adjacent to the Government hospitals in Byumba and Kaduha. The schools would, in line with Government policy, provide a four-year training course for selected primary school graduates with a yearly output of about 25 nurses each, starting in 1992. The curriculum has been reviewed by Bank staff and found to be satisfactory. Upon successful completion of training, graduates would be awarded a MINEPRISEC diploma and assigned to HCs and hospitals. When in full operation, each new school would require four full-time teachers, seven part-time teachers and an administrative staff of about 22. A specialist recruited under Project would conduct training of nurse teachers. 50. Population Policy. The project would strengthen ONAPO's capacity to formulate population policy by funding two key operational research studies. One would focus on factors influencing the acceptance and continuation of modern contraception, while the other would analyse the causes of mother/child deaths. Overall guidaneo would be provided by the ONAPO Studies Division, and would closely involve MOHSA field staff and The University Public Health Center in Butare. The project would provide equipment, six months of consultancies, and operating costs for the studies.  - 18 - Project Implementation 51. The project would be implemented through existing Government departments and staff, managed by two separate entities: the MOHSA Secretary General would have responsibility for implementing the MOHSA part through a Project Coordination Office and its line directorates, in collaboration with ONAPO; and the MINEPRISEC would implement its part through the SFCS. A project Coordinating Committee, chaired by the MOHSA Secretary General, and consisting of the Directrice of ONAPO and the Director of SFCS, along with officials from the Ministries of Finance and Planning, would be responsible for overall project coordination. A condition of credit effectiveness agreed during negotiations is that MOHSA will appoint a Project Coordinator, an accountant and an architect with qualifications and experience satisfactory to IDA. The Project Coordinator and his staff would report directly to the MOHSA Secretary General, and would maintain close liaison with the other MHSA Departments. The Project Coordinator would serve as secretary to the Coordinating Committee, and manage the project implementation and periodic reporting. Monitoring and Evaluation 52. The MORSA Studies and Evaluation Division would monitor the progress of project implementation. Particular attention would be paid to the number and quality of health staff retrained, additional nurses aides (A4) trained and deployed, health facilities up-graded/rehabilitated and health facilities delivering FP servicee. Among outcome indicators, contraception prevalence would be of particular importance and would be monitored jointly with ONAPO. An evaluation of the specific impact of the project on population and health status is not possible due to the variety of external factors (including other projects) influencing morbidity, mortality and fertility. However, the Government has requested project support for collecting baseline data on MCH status and for documenting changes in fertility, maternal and infant mortal.ty and nutritional status. A baseline survey will be undertaken during the first year of the project, and a second survey (using the same sample) is planned during the last years of the project. Survey design has been reviewed by the Bank and found satisfactory. Project Costs and Financing 53. The total cost of the proposed project is estimated at US$14.5 million equivalent, net of taxes. Items imported for the project would be exempt from taxes and duties. Project costs are expressed in August, 1985 prices. The foreign exchange component amounts to US$7.9 million, or 55Z of total project costs. Cost estimates for civil works are based on a review of cost data of recent construction work in Rwanda, including construction financed under the Second Education Project. For physical contingencies, on average five percent has been added to the base cost for civil works, furniture and equipment. Price contingencies are estimated on the basis of annual price increases for local costs of 72 per annum during the project period. For the foreign exchange component, contingencies of 7X for 1986/1987, 7.5% for 1988, 7.7% for 1989, 7.6% for 1990, and 4.5Z for 1991 have been used.  - 19 - 54. The proposed IDA Credit of US$10.8 million equivalent would finance about 75% of total project costs, including all foreign exchange costs and 44% of local costs. The Government would allocate US$2.9 million to the project (20Z of total cost). A grant of US$725,000 will be provided by WHO for technical assistance for MCi/FP/Nutrition (5% of total cost). The project's main recurrent cost is for salaries of the additional paramedical staff trained under the project-financed staff development program, and other incremental operating costs associated with supervision, and in-service training. The estimated incremental recurrent costs generated by the project at completion represent only about 3.5% of the estimated MORSA operating budget for 1992, assuming a GNP growth rate of 3% annually and constant share of 6.0% of MORSA in the Government budget allocation. As such the project is clearly affordable. The Ministry of Finance shares this assessment and does not see any difficulty fo- the Government to absorb this increase. Procurement and Disbursement 55. Annex IV details the breakdown and manner in which items would be procured under the project. 56. The proceeds of the IDA credit would be disbursed against: 1OOZ of cost of civil works; 100l of foreign expenditure and 80% of local expenditure for furniture, equipment, medical supplies and vehicles; 100% of consultant services, fellowships, studies and training, except consultant services funded by WHO; 70X of operating costs for project administration, except salaries, vehicle operating costs and per diem of supervisory staff. 57. All disbursements will be fully documented except those for training and operating costs and for contracts below US$10,000 equivalent. These would be made against statements of expenditures (SOEs), documentation for which would not be submitted for review but would be retained by the Borrower. It would be subject to an annual audit by auditors acceptable to the Association. In addition, the documentation would be readily available for review by the Association representatives during project supervision. The Borrower would not submit applications for reimbursement valued below US$20,000 equivalent. Based on expenditures in previous IDA-financed projects, the SFCS has satisfactory institutional capacity to use SOEs, and to assist the NOHSA Project Coordination Office to use the procedure. The project would be completed in five and one-half years. Based on experience of on-going IDA education projects and because of the unusually advanced state of preparation particularly for civil works, a disbursement profile of six years (as against eight years standard) is considered reasonable. 58. In order to ensure that funds for project implementation would be available when required, a special account would be established at the National Bank of Rwanda. The account would be replenished by IDA on the basis of documentary evidence of payments made for goods and services. Opening of the special account, into which an initial deposit of US$0.6 million would be made by IDA, is recognized to be a condition of credit effectiveness.  - 20 - Project Benefits and Risks 59. The project would have a substantial impact on the FP and health situation in Rwanda. Family planning services would be made available at 200 HCs, and over one million couples would have access to modern methods of contraception. The project objective of reaching a contraceptive prevalence of 10% by 1991 (up from 0.9% in 1983) is modest in absolute terms, but equals or exceeds acceptance rates achieved in other developing countries under voluntary programs. It would set in motion a process that should gain momentum in subsequent years, eventually leading to a reduction of fertility by year 2000. The two research studies would provide the basic data needed for developing new strategies for the population program. 60. The thirty upgraded/rehabilitated HCs would allow about one million people from underserved areas to have better access to health care, including nutrition and family planning. The project would strengthen the Ministry's administrative capacity to plan, implement, monitor and evaluate the MCHlFP/Nutrition program. Improvements would be made at all levels-central, regional, and local-using technical assistance, training, equipment and logistical support. The introduction of a new weaning food will be a real benefit. The development of a better health data base would improve decision-making in key areas of resource allocation and evaluation of program effectiveness. This institutional strengthening would enable MOHSA to sustain its MCH/FP/Nutrition program efforts after the project is completed. 61. Finally, the project would assist the Government in solving one of the health system's most severe constraints: the shortage of paramedical personnel. In-service training and pre-service training would help improve the quality of para-medical staff nationwide. The nursing schools for A3 nurses would train primary health care staff. New curricula and teaching methodologies, developed with technical assistance financed by the Project, would improve the professional competence of nursing school graduates. 62. Tne main risk is that due to MOHSA's limited administrative capacity, proiect implementation could be delayed or otherwise hindered. As a first time borrower, MOHSA has little experience or appreciation of the management challenge inherent in implementing a major IDA-funded project. This constraint can be eased by providing suitable technical assistance, but thus far MOHSA has mainly utilized free technical assistance from other agencies. To minimize this risk, key long-term advisory positions will be financed by IDA. In addition, Bank and Government supervision will focus on active donor coordination and closely monitor the technical assistance inputs. 63. The second risk is that delays in implementing MOHSA's decentralization strategy could easily cause shortfalls in pro,ect achievement. Although the roles and tasks of various categories of staff have been recently clarified, and extensive in-service training and supervision is envisaged, intensified efforts might be needed as project  - 21 - implementation proceeds. Bank missions would need to continuously monitor the nature, extent, and effectiveness of decentralized administration, and its impact on the restructured family health program. PART V - RECOMMENDATION 64. I am satisfied that the proposed IDA credit would comply with the Articles of Agreement of the Association, and I recommend that the Executive Directors approve the proposed Credit. A. W. Clausen President Attachments Washington, D. C. March 6, 1986  -22 Annex r TABLE s a Page 1 of 6 *wa - SOUIA IHIC^sa eXISS) /a No"r (NUT uiCac ISTIATh) /b n.ok 1970t1 Ul o LOW IW aU 0 NtoS S.0t s XITKNAI3a SOMim Or iANARA AFRICAL S. OP S*5*3A aa(misa5m MR. no TOTAL 26.3 26.1 26.1 SUIOL71URL 15.0 15.2 14.8 Cw m cr () .. .. 270.0 23A 1063.8 CKILQ 7A Or OIL UwUThLUhuI 10.0 1I.0 18.0 62.2 5S1.5 Pmus Me us STL ASIIX MILuxxouz.U (traum) 2525.0 3165.0 .5674.0 umam POPUIA CZS (3r ToTArI 2.6 3.2 4. 20. 1 32.0 OULATIU11 US 2000 CHMIL 10.2 I UULtIC (IW) A0.0 POPULATIW ICIWlIENT 2.0 roris osm e SQ. M. 04.5 140.3 215.4 13.2 45.1 FMSq. a. WI. UlA 136.1 262.9 370.9 112.J 124 POMAIno AE SsCnUn (Z) 0-14 us ".2 :.S.6 464 46.0 65.6 15-4 us 53.0 51.5 50.5 50.8 31.5 63 AM 0AI 2.1 2.7 2.3 2.9 2.7 MPUOLATO CEOUtS mAn9 (3) ToT7L 2.4 2.9 3.3 2.8 2.9 UNm 5.5 34a 6.2 6.4 5.1 own ism umn (M ) 51.1 5.1 51.9 47.2 *7.0 Cmon ca mra (M c Ta n) 19.2 17.6 19.4 17.3 15.0 GSM WXRUOUCUIOH aTE 3.5 3.8 4.1 3.3 3.2 IranlI PLAHNTh wAnC , su. s (as) ..... UA CZ or KARRs Maul) .. .. 1 33 6 . reawm mutEM uns or rOW "M. Mi CaFnT C 19-71'-LO) 31.0 102.0 107.0 63.3 62.9 M ci SUFPL: or C aLUS CZ o? itqUUhiinS) 31.0 S3.0 3.0 *7.7 93.5 PWoUs (GRAN M ) 49.0 56.0 50.0 51.9 55.4 or UNCE HINL AMD M S 26.0 330 29.0 I 16.7 16.5 CHIL (C 1-4) 05M %T 37.5 32.5 26.0 23.1 IGA LIPg usPEC. AX aUm (mZsS) 46.2 48.0 46.5 47a 52.0 131ANT W. am CPU tWOS) 166.5 149.5 125A. 119.5 10OS4 TaL .. .. 4.0 It 27.1 42.4 OuRB"3 a. .. 48.0 63.5 67.3 Rom .. .. 35.0 19.3 5sa A0053 TO n&V DISPOSWL. (ta OFWIOILATIO) TOML .. 33.0 31.0 id 26.5 28.9 033 63.. 6.0 6O.o071 65.4 57.7 IDEAL .. 52.0 50.0 20.8 20.7 POPULATICU FM P3LCXAu 139050.0 5960.0 31360.0 1 27901.7 t17t.7 PP. PU MRUS mP0 11270.0 U20.0 9790.0 320. 2434A Par. PUS SPITAL - 7OTAL 70.0 450.0 id 1273.6 981.1 0. se o 50.0 5o.a7 42.2 346.8 ZIUaL .. 3100.0 1600.07; 3292.3 4311.9 amSs mm mOsQ. Sm .. 21.2 *- *- 27.Z Ainsa SIl or UDsOW TOTAL .. .. sue .~ ~ ~~~~~~~~~~~. .. IDEL .. .. . .. west mW. or Pl3SO/noM TOTAL .. .. D *m .. .. . .. IDUL .. .. IPRRDILU W OlALUSS 1tT SL. TTL .. .. . .. umme.. .. . .. Tom . .*  -23 - 23 - '. ~~~~Annex I TA * L * 14 Page 2 of 6 A - SCIAL tDkCt DT U 311*11A .35103 CSw%PS (IGN AMVERAS) /a NOR CHOW SCEN ZffhA /b wed! 701k ESGEIT LOU tINGE AflCA "IDDLE Ncm LoGal rpm usrmnL4k SOUTF0 SAHARA *9310 S. Olr SANARtA ADJUSTS, 101 1W , RATIOS PaUDA:s TOL 49.0 74.0 70.0 87.4 95.7 MIALI 08.0 83a 72.0 77.0 1.0 PnuAL 30.0 o 3.0 07.0 34.9 03.2 2CCIIDART: TAL 2.0 2.0 2.0 13-5 17.3 mALE 2.0 3.0 3.0 17.9 25.0 13305 1.0 1.0 2.0 9.1 14I VOCATSL (I 0W SW ) 39.9 12.2 24.0 13.2 5.9 IWIL-SCACn 3810 P33MM 39.0 00.0 33.0 44.9 01.1 uuaaNr 14.0 13.0 14.0 27.4 25.3 PASSUIKR CAESWIOUSAU MPO 0.4 0.9 ..3.4 2 ItDO 1 vat .. 8.1 2u.s S5L 107.8 TV rSifluA p .. .. .. 2.4 20.8 HW (bAn aD hH!EUSV CZISLATOU nt 719 ro .. ..M O.t * . 1 o .a CDu An L ..I 0.5 A TOTAL 801 VOIE (TOOS) 1538. W 2W.0 2915.0 nowz (PnIED) 49.1 484 46.4 34.2 3S.2 a'lImUs (C 93.0 *A 91.0 ld 77.3 54.5 IDDsTI C 1.0 2.0 2.077 9.7 18.3 PA .TICWATIOU RE (flCmw TOL 54.0 534.3 31.4 39.3 30.8 Au 53.9 34.9 54.5 30.9 47.1 P30 34.4 51.9 49.1 28.1 27.2 IcoUONiC DC ! 38110 0.8 0.9 0.9 1.3 1.3 Ieeror ntis - zmmm sx r oses 3191? W r OF H.OSoLS. ... LON? OP 1 1_ .. .. . .. LoWS? 40 or0 o_.. .. LUVL (1SP S CAVA) DAM .0 .. 18.0 /e 10653 390.7 mu - .. . .. 95.0 27J3 a nDIT SZATIVE taVE amma LImL (OU P CUMA UUU ,, .. .. 113.1 5434 RAL .. .. 43.0 Ic 074 201.1 an t. so. UCU tOWSR? nim LEM CZ) RAM .. .. 30.0 /c 3.04 RURAL~~ .. .. .. 814a . aunt GIZCUL Ea ~ /a Us. sroP annw for each tadtester ar p-r-' - 4tS otdl ettec ams. Coerae af cotrli amonng cbe lailcatnr. dipeada -n &waIZlty of data end Ja not aVero.. lb DAleos otbezeets ace "Dat for 1IW refer teom yaea e 1959 ad 1981; "Data for 1970" l190 and 1971: nd dat for 9eoe Mces gstlet" batrn 1381 at 1963. It 1977; /d 190; la 182. .-. -  ; - 24- Anitezx I -24- .1a T of 6 DOFNmMONS OF SOCIAL NDICATORS Notm Athoug the damn drmwn ro survisapmanyJudl the most aushhtive and reiable. t oUl albo be noted dat thy may not be Int omly compmable bmcw or thek lack of asaddimd dduluon mg -ut-ps ud by diNems cmain. collelk-tg the data The damsn a oahel d o dribe order orniapktd IdI tronds. an dwacm an __mao d ncea bten counte The se up ae (1) the mum country group of the mabdect couy and (2) a conuny grup wkh mewhat Ig avemae Inwom than de country srpf at hesbjea am" (except for "High Incme Oil espe" group w_e MWddle Income Nort Afam nd Middle is draen bauom rtauron sacl al a a)~ bn the reference group data the vapa popu n wn ed athmetic _mes mor cindcatr andown nly whe majorkty ofthecounlIan c roup h dan for that indicuor. Sine he d e ofcounriam the inditon depends on the availability ofdsta and ia not uniform. carutionmtbee iedareatiavesofoineidic too another.Tbeearageoreonlyuulincompnngtevalueofoneinaordatathimeang the country and reea grup AEA (thota sq.knL) Cd Brth Rote (per thonwad)-Number of live births in the year Toif-Total surface area comprising land area amd inland waters per thousad of nid-year population; 1960. 1970. and 1983 data. 1960. 1970 amd 1983 data CrG Deat Rate (,wr thimNad)-Number of deuhs in the year Agritf-Es timate of agrultwal ar used temporarily or p r thousand of amid-ysar population; 1960. 1970. and 1983 data. pemanendy for crops. pasture market and kitchen pakns or to Gre Rep qdudo Rare-Average number of daughters a woman ie fsallow, 1960. 1970 and 1982 datL will bear in her nor.al reroductive period if she expericrs present age-specfic fertility rates usualy five-year avas ening GNP PER CAPITA (USS)-GNP per capita estimates at current in 1960. 1970. and 1983. market prices calculated by same convarsion method as World & A Ani (dmiss -Annual num- lask Atns (1981-83 basisk 1983 dta. ber of accepwrs of birth-control devices under auspics of naional ENERGY CONSUMPIION PER CAPITA-Annual appart family planning prgamL consumptko of commercal primary energy (coal and lgnite. Family Pluiq.-lsers (percgtq of mniwed awmer)-The percen- petroleum. natural gas and hydro-. nuclear and geothermal elec- tage of mared vomen of child-bearing age who are piacticing or tncity) in kilogamms of oil equivalent per capita; 1960. 1970. and whose husbands ae practicng any form of contraception. Women 1982 data of child-bearing age are genally women aged 15-49. although for some countres conaptive usage is measured for odier age POPULATION AND VITAL STATnSTCS groupL Tned tP9p11 ro3 MII-Yw (dhewainds)-As of July 1; 1960. 1970. FOOD AND NUTRIMON and 1983 data. Yrim Pepadi (pere i of tv)-Ratio of urban to total IALe of FoodPedagosPerCapa(196-71- JN)-indexofper poplaton;diferet dfintios o uran rea ma afectcapita annual production of all food commodities Production population; different defimuons of urban areas may affect compar- excludes anma feed and seed for agricultur Food commoditis ability of data among coutries 19601970. and 1983 daI include pnmay comodite (eg. sugarcane instead of sugar) P.phade.Prejcuiu which are edible and contain nutrients (eg. coffee and tea are Popdaom in year 2000-The projetion of populaton for 2000. eduded); tdey comprie cereals. root crops. pulses oil seds. made for each economy scparately. Strtig with informaton on vetables, fruits. nuts. supnare and sugar beets. ivestoc and total popuation by age and sex etlity rats mortality rats and lives products. Aggagte production ofeach country is based iternational migration in the bwse year 1980 these paammet on natidoal erge producer price weights 1961-6S. 1970. and were projected at five-year intervals on the basis of generlized 1982 data. assumptions until the population became stationary. Per Capita Supy efCalwis (pecent afreq w j-Comput- Starinary popuatin-Is one in which age- and se-specific mor- ed from caloone equivalent tonet food supplies available in country tality rates have not changed over a long period. while age-specific per capita per day. Available supplies comprise domsic produc- fertilty rates have simultaneousy remained at replmet level tion. imports less exports and changes in stock. Net supplies (net reproduction rate-1). In such a population, the birth rate is exclude animal eed. secds for use in agriculture, quantities used in constant and equal to the death rate, the age stuture is also food processing, and losses in distribution. Requirements were constant, and the growth rate is zero. The stationary population esmated by FAO based on physiological needs for normal activity size was estimated on the basis of the prjected charactmistis of and health considering environmental temperatur body weights. the population in the year 2000. and the rate of decine of ferility age and sex distribution of population. and allowing 10 percent for rate to replacement level. waste at household kvel: 1961. 1970 and 1982 daum. Popadion Mo lena-Is the tendency for populaton growth to Per Cra Su y of Proie (gran per y-Protein content of contiue beyond the tune that replcmet-level fertility has bet per capita net supply of food per day. r4et supply of food is defined achieve; tha is. even after the net reproduction rate has reached as above. Requrements for all countries estabished by USDA unity. Ihe momentum ofa population in the year t is measured as provide for minimum allowances of 60 grams of total protein per a ratio of the ultimate stationary population to the polion m day and 20 grams of animal and pulse protein. of which 10 gram the year t. given the assumption that fertiity remains at replac- should be animal protein. Tbese standards.are lower than those of ment level from year t onward. 1985 data 75 grms of total protein and 23 grans of animal protein as an FOP.Sdm Deniry avere for the world. proposed by FAO in the Third Wodd Food Per sqAnL-Mid-year population per square kilmetr (100 hec- Supply. 1961. 1970 and 1982 data tares) of total area; 1960. 1970. and 1983 data. Per Capa heted Supply Fomi Anilan dh -Protein supply Per sq.kn. agrmkuW LAnd-Computed as above for agricultural offood derived from animals and pulses in grams per day; 1961-65. land only. 1960. 1970. and 1982 data. 1970 and 1977 da. Paptiaa. Age Structre (percent)-Childreu (0-14 years). work- CNN (ie 1-4) Deat Rate (per thomsud)-Numberol'deat of ing ag(S-64yea).andmired(65yaandover)aspecentage childwi aged 1-4 years per thousand children in the same age of mid-year population; 1960,1970, and 1983 daL group in a given year. For most devdoping countries data derived Popultka.C;reuth Rat (perc nr)-tol-Annual growth rates of from lfe tabes 1960. 1970 and 1983 data. total mid-year population for 1950-60. 1960-70. and 1970-83. HE ACpeado Groh* RAe (pent),whop-Annual growth rat L4* Expectny at " (yeaw)-Namber of yemas a newborn of urban popuation for 1950-60. 1960-70. and 197083 data. infant would live if prevailing patterns of mortality for al people  -25 - Annex I Page 4 of 6 at the dmc of of its birth were to stay the mm throughout its life; Pupl-teawher Ratio - primay, and secondary-Total students en- 1960, 1970 aNd 1933 data. rolled in primary and econdary lvel divided by numbers of bow Mwalt Awe (per rthmsmN)-bnumber of infants who die teachrs in the corresponding kvels. before reag one yea of age per thouand live births in a given year 1960.1970 and 1983 datL CONSUMPTION Ac,e to S* Wowr (prce of pPU ii)-t-o4 whii d Paunge Cas (per thousad pop*kr)-Passengcr cars com- rwn5-Nwnber of people (totaL urb and runa) with reaonable prisc motor cars scating less than eight persons: excludes ambul- accre to safe war supply (includes trated surfsce waters or anon, hearses and military vehicles. untrad but uncontmnted water such as that from protrecd RAo Receiwers (pr thowand pepuedirn)-All types of receivers boreholes spanps and smnitary waes) as percentage of thir respw- for radio broadcasts to general public per thousand of population; tve populdo. In an urban area a public fountain or stndpost exlude un-licnsed receivers in counetrie and in years when located not more than 200 met _ ro a bouse may be cosidered registration of radio sets was in elfect; data for recent years may as being withna reasonble access of that house. In rural Areas o ecmabesnemotcutisaoiWI rasonable access would imply that the housewfec or members of the not be com trpml sincemos countrie ablihe bcensin st houselolsd do not have to spend a disproportonate part of the day Rvr ppa -Tr reci forbroadt in fetching the family's water needs to nerd public per thousand populadion excludes unlicensed TV *e,eives in countries and in yeas when rgistikon of TV set was Accus to Exuma DiNJO5a (pJvgwN ofppddon-o4 arm in effect. and una-Number of pcople (totaL urba and rural) served by eacreta disposal as percentages of thir respectve populations. Newsp_pw CwCulm (per rhownidpapakeop)-Shows the aver- Excta disposal may include the collection and disposal with or age circulation of "dady gneal interest newspaper defined as a without treatnt of human excreta and wast-water by water- perioil pubficaion devoted primarily to recording general news. borne systems or the use of pit pivies and sinilar instaltions. It is considerd to be 'daily" if it appea at least four times a week. Pbpdu per Php uihn-Population divided by number of prac- C2imeon Amu. Attendncer per Capia per ar-Based on the dsing physicians qualified from a medical school at university levl. number of tickets sold during the year. including admisions to Pbpdap i per NnPAn nersm-FPopulatio divided by aum ber of dinve-in cinems and mobile units. practicing male and female grduate nurses. assistant nurses. practcal nurses and nuorsig aumhares LOR FORCE _