Malawi - Second Family Health Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No. 6471-MAI STAFF APPRAISAL REPORT MALAWI SECOND FAMILY HEALTH PROJECT February 26, 1987 Population, Health and Nutrition Department This document his a rewricled distribution and nmJ! he used b! recipienis onl in the performance of their official duties Its conltent mae not otherwiwe be di%clo%ed without World Bonk authoriiation.  CURRENCY EQUIVALENTS Currency Unit = Malavian Kwacha (K) US$1.00 = K2.00 K1.00 = US$0.50 SDR1.00 = US$1.27 METRIC EQUIVALENTS 1 meter (m) = 3.28 feet 1 square meter (sq.m.) = 10.76 square feet 1 kilometer (km) = 0.62 miles 1 square kilometer (sq.km) = 0.386 square miles GOVERNMENT FISCAL YEAR April 1 - March 31 This report is based on the findings of an appraisal mission that visited Malawi in December 1985 and comprised Dr. V. Jagdish and Ms. F. Plunkett (IDA). and Messrs. S. Ayalew. B. Jacobson. P. C. Mohan, and M. Tayback (consultants), and on a donor coordination meeting that took place in September 1986.  FOR OFFICIAL USK ONLY MALAWI SECOND FAMILY HZALTH PRDJBCT CREDIT AND PROJECT SUMMARY Borrower: Republic of Malawi Beneficiaries: Ministry of Health. Department of Economic Planning and Development Credit Amount: SDR 8.7 million (US$11.0 million equivalent) Terms: Standard IDA Terms Project The project objectives are to: (a) improve health status of Description: families. particularly of mothers and children through expansion and strengthening of primary health care programs; (b) increase the availability and accessibility of chi.d spacing services within the maternal and child health program; (c) further strengthen the Ministry of Health's (MOH) capacity to plan. manage and evaluate health services in the framework of a decentralized health system; and (d) design and implement a multi-sectoral family health program through other government agercies. The project is comprised of two parts: The first part consists of activities to be undertaken by the MOH and includes (a) the building of health centers, replacement of a district hospital and the training of and provision of equipment and supplies to village health committee members and health care workers to extend coverage of the primary health care system; (b) technical assistance. training, and provision of computer equipment to reorganize the MOH and to strengthen drug production and supply. health service management and manpower development; and (c) the production of Information. Education and Communications (IEC) materials, health worker training, and the provision of vehicles, drugs, and facilitied to strengthen maternal and child health, child spacing and nutrition prograss. The second part of the project consists of activities to be coordinated by the Department of Economic Planning and Development (BP and D) and includes (a) training of women's welfare workers and youth progra instructors and the production of educational materials on family health to be introduced into functional literacy and youth programs; and (b) the production of IEC materials on family health and child spacing concepts to be introduced into the mses media. Benefits The project would directly benefit about 2 million people and Risks: throughout the country tbrough strengthening and expanding primary health care and family health progrms and through increased accessibility of child spacing services. In the medium term, health status is expected to be improved by a significant reduction in the incidence of infant and maternal mortality and morbidity. Population increase would be slowed This document hu a restricted dtstribution 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.  - ii - through a significant increame in women using modern contraceptives. The main project risk relates to weak implementation capacity. The project minimises thi$ risk by (a) strengthening with additioal staffing and technical assistance the units involved in carrying out the civil works component; (b) coordination of *ulti-sectoral family health activities through the BP and D. which is being ctrengthened with technical assistance; (c) implemeotation of multi- sectoral family health activities through ministries with demonstrated adequate implementation capacity; and (d) support for a comprehensive management review to support the Ministry' s reorganization. Estiaated Cost: Local Foreign Total Copq oneut - -(US$ Million)-- A. Primary Health Care 4.4 3.2 7.6 D. Management. Manpower and Support Systems 1.8 1.5 3.3 C. Family Health 3.0 2.8 5.8 D. Project Management 0.2 1.3 1.5 E. Health Through Other Ministries 2.7 1.6 4.3 Total Baseline Costs 12.1 10.4 22.5 Physical Contingencies 0.7 0.8 1.5 Price Contingencies 0.5 0.4 0.9 TOTAL PROJECT COSTS a/ 13.3 11.6 24.9 Financing Plan: Local Foreign Total ------- (US$ Million)- IDA 4.7 6.3 11.0 UIN!CU 1.2 1.4 2.6 EDP 2.4 1.1 3.5 KfW 2.2 1.9 4.1 Government of the Netherlands .3 .6 .9 UNYPA .9 - .9 Government of Malawi (including taxes) 1.6 0.3 1.9 TOTAL 13.3 11.6 24.9 Estimated Disbursement of IDA Credit: IDA n 88 89 90 91 92 93 ------------US$ Millions------ Annual 0.6 2.4 3.0 2.7 1.7 0.6 Cumulative 0.6 3.0 6.0 8.7 10.4 11.0 Rate of Return: N.A. ^ p IBRD 20099 a/ Includes US$0.4 million for taxes and duties.  -iii- tALAWI S8COND FAMILY IMALTH PAJ3CT STAFF APPRAISAL RWORT TABLE OF CONTETS Credit an Project Summary Table of Contents asic Data v Definitions vi Abbreviationo vii I INTDUCTION I II POPULATION AM HEALTH SECTOR STATUS AND ISSUS 2 A. Population 2 B. Health 5 C. Sectoral Issues 17 D. Role of the Bank 19 I. The First Phase of the National Health Plan 20 III THE PROJECT 22 A. Objectives and Design 22 B. Smary Description 23 C. Detailed Description 24 IV PRJCT COSTS N FINANCING 33 A. Costs 33 B. Financing 36 C. Procurement 39 D. Disbursemnts 41 K. Accounts and Audit 42 V PROJCT IMPLDIATION 43 A. Status of Project Preparation 43 B. Organization and Management 43 C. Monitoring. Reporting and Evaluation 44  VI PROJECT BENEFITS, JUSTIFICATION AM RISKS 47 A. Benefits and Justification 47 B. Risks 49 VII ASSURANCES AND RECOMbM)ATIONS 51 TABLES: 1. Pr-ject Costs by kzpenditure Category 33 2. Project Costs by Functional Component 35 3. Project Costs by Financing Source 38 4. Procurement Table 40 ANNIOS: 1. Statistical Annez 53 2. Documents Available in Project File 68 3. Det&iled Cost Tables (Sumary Accounts) 69 CHARTS: 1. Current Organizational Structure of the Ministry of He,lth 77 2. Proposed Organizational Structure of the Ministry of Health 78 MAP IBRD 20099 - Malawi. Primary Health Care Project  Mlv MALAWUI SECOND FAMILY HEALTH PROJECT Basic Data (All figures apply to 1985 unless otherwise indicated) General: Ares 118.500 sq. km. Area (land only) 94.300 sq.ka Population 7,154,000 Population Density 74 per km2 Rural population as a proportion of total population 91.5X (1977) Crude birth rate 54/1000 population Crude death rate 23/1000 population Rate of population growth 3.2S Infant mortality rate 151/1000 live births GNP per capita (US$) 170 Health: Population per physician 52,893 Population per nurse 2,978 Population per hospital bed 7,127 Proportion of births attended by trained personnel 601 (1984) Proportion of woven receiving antenatal care by trained personnel 701 (1984) Proportion of children between 1 and 2 years of age fully immunized 55X Governmsent ezpenditure on Ministry of Health as proportion of total budget 4.81  _vi- Definitions Contraceptive Prevalence Rate: The percentage cf married women of reproductive age who are using (or whome husbands are using) any form of contraception. Crude Birth Rate: The number of births per 1.000 population in a given year. Crude Death Rate: The number of deaths per 1.000 population in a given year. Dependency Ratio: The ratio of the economically dependent part of the population to the productive part, arbitrarily defined as the ratio of the young (those under 15 years of age) plus the elderly (those 65 years of age and over) to the population in the "working ages" (those 15 to 64 years of age). Infant Mortality Rate: The number of deaths of infants under one year old in a given year per 1.000 live births in that year. Life Upoctancy at Birth: The average number of years a newborn would live if current age-specific mortality rate trends prevailing at the time of birth were to continue. Rate of Natural Increase: The rate at which a population is increasing (or decreasing) in a given year due to surplus (or deficit) of births over deaths expressed as a percentage of the base population. Rate of Population Growth: The rate at vhich a population is increasing (or decreasing) in a given year due to natural increase and net migration, expressed as a percentage of the base population. Total Fertility Rate: The average number of children that would be born alive to a woman (or group of women) during her lifetime if during her child-bearing years she were to bear children at each age in accord with prevailing age-specific fertility rates.  -vii- U BR8VIATIONS ACMO Assistant Chief Medical Officer CBR Crude Birth Rate M3A Comunity Development Assistant M)R Crude Death Rate CHSU Community Health Sciences Unit CHS Chief of Health Services CMS Central Medical Stores CO Clinical Officer DMO District Medical Officer IN Enrolled Nurse SP and D Department of Economic Planning and Development SPT Expanded Program of Immunization FFS Family Formation Survey GDP Gross Dowestic Product HA Health Assistant HI Health Inspector HSA Health Surveillance Assistont INC Information. Education and Comunication IMR Infant Mortality Rate IUD Intrauterine Device KfW Kreditanstalt fur Wiederaufbau MA Medical Assistant MCH Maternal and Child Health MDT Multiple Drug Therapy MOCS Ministry of Comunity Services MOH Ministry of Health MowS Mit Axtry of Works and Supplies MWRA Married Women of Reproductive Age MYP Malawi Young Pioneers NSO National Statistical Office OPC Office of the President and Cabinet PHAM Private Hospitals' Association of Malawi PHC Primary Health Care RNI Rate of Natural Increase SCO Senior Clinical Officer TBA Traditional Birth Attendants TFR Total Fertility Rate UNFPA United Nations Fund for Population Activities UNICEF United Nations Children's Fund USAID United States Agency for International Development VHC Village Health Comittee WHO World Health Organization  MALAWI SECOND FAMILY HEALTH PROJECT I. INTRODUCTION 1.01 Malawi is a land-locked country located in east central Africa. It has a total land area of approximately 118.500 km2 of vhich Ekpproximately 36.200 km2 is considered arable. Geographical:y, Malavi is bordered to the north by Tanzania; to the east, south and southwest by Mozambique; and to the west by Zambia. 1.02 Malawi in divided into three administrative regions which vary significantly in topography and climate. The Northern Region consists largely of plateausi ranging from about 1,500 to. 2,500 meters high and with temperature ranges between 15OC and 18oc. The Central Region has low lying terrain along Lake Malawi rising to highland plateaus ranging from about 1,000 to 1.200 meters and with a temperature range similar to the Northern Region. The Southern Region iS distinguished by widely varying climatic and topological areas: the Shire Valley. in the extreme south, is very hot with an average annual temperature of 27oc; and the highest mountain, Mount Mulanje and the Shire highlands which have generally cool temperatures. 1.03 Between 1967 and 1979 Malawi's Gross Domestic Product (GDP) grew at an annual average rate of 6.8%. In 1979-1981 the economy of Malawi fell upon hard times. As a result of deteriorating terms of trade, drought and disruptions on external transport routes the GDP fell by 2.7 percent; deficit on the current account and in the Government budget ballooned to unsustainable levels, and investment and savings rates fell sharply. 1.04 The Government launched a two-pronged effort to deal with the problems of the economy: a stabilization program designed to reduce short- term fiscal and balance of payments disequilibria and a structural adjustment progrua designed to improve efficiency of resource use and to ensure that positive growth of per capita income could be re-established and maintained over the medium and long-term, within the context of a manageable balance of payments current account deficit. These programs have been supported by three structural adjustment operations from the World Bank and a series of standbys and an Extended Financing Facility from the International Monetary Fund. As a result of the improved policy environment, more favorable climatic conditions and better export prices, the Malawian economy began to recover and in 1983-84 GDP grew at about 4.1 percent with expainsion occurring in most sectors. The balance of payments deficit on the current account was reduced and the budget deficit as a percentage of GDP was also reduced significantly. Despite continued implementation of these programs, Malawi's economic recovery has slowed in 1985. It is estimated that GDP growth fell from 4.1 percent in 1984 to less than 2.5 percent in 1985. This was the result of exogenous factors. It is believed that the recent setbacks are temporary and that, with continued implementation of the Government's program, growth of per capita income can resume and financial equilibrium can be restored. Despite the progress made in the past twenty years, Malawi is still ote of the poorest countries in the world.  - 2 - II. POPULATION AND HRALTH SECTOR STATUS AND ISSUES A. Population Demogri phic Situation 2.01 The popul4tion of Malawi was enumerated as 5.55 million in Septemler 1977. It had increased by 37 percent since 1966. when the enumerited population was 4.04 million, thus implying an average annual rate of intor-censal growth of 2.9 percent. The population in 1985 was estimated to be .15 million and the growth rate 3.2 pertent. Malawi is one of the most d4!nsely populated countries in Sub-Saharan Africa. equalled or surpasoied only by Rwanda, Burundi, Nigeria and Uganda. The national density accord ng to the 1977 census was 59 inhabitants per ka2, and this may now have r sen to 74 per km2. There is considerable variation within the countr, however, vith 1977 regional densities ranging from 24 in the Northe:n Region. 60 in the Central Region, 87 in the Southern Region, and distri :t densities varying from 11 to 230 persons per k2. The level of urbani! ation in Malawi is low by any standard. If urban is defined as locali:ies with a minimum of 2000 inhabitants. 8.5 percent of the population in 197' lived in urban areas, and only 5 percent in 196t. The urban growth rate bhls been high, however, averaging 7.6 percent between 1966 and 1977. 2.02 Between 1966 and 1977 rural-to-urban moves made up about 35 to 45 perceri: of all internal migration. Otber important migration streams were into a reas of commercial agricultural development or new agricultural bettlElaents and out of areas with population pressure on limited land resouices (such as the Shire highlands) or areas lacking in general economic devel(pment (such as most of the Northern Region). External migration. imporiant in past decades, has undoubtedly fallen and is expected to contitue to diminish. 2.03 The level of mortality in Malawi from the 1950. to the mid 1970s was e ceptionally high by any standard, and declined only very slowly during this period. According to Bank estimates, life expectancy stood at only 37 years in the late 1950s, then rose to 39 years by the mid-1960. and to 41 years by the early 1970.. Theme low levels of life expectancy are due prima.ily to extremely heavy mortality in childhood. Even in tne early 1970s, the national infant mortality rate (IMR) was as high as 190 per thousind live births, with 36 percent of all children dying before reaching their fifth birthday. The IMR is estima^ed currently to be 151/1000 live birtbh ranging from about 70/1000 in part,, of the Southern Region to about over ZOO/1000 in parts of the Central Region. A Family Formation Survey (FPS) undertaken in 1984 whose results are currently being analyzed, may provide some information into the causes of childhood mortality. By contiast, adult mortality appears to be unremarkable by Eastern African standards. The level of fertility is high. In the mid 1970s, the total fertility rate (TFR) was estimated at between 7.5 and 8.0 and is unlikely to  have changed since. Regionally the TFR is highest in the Central Region at around 8.5 and lowest in the Southern Region between 7 and 7.5. The TPR in the Northern Region is close to the national average. Population Prolections 2.04 Rapid population growth in Malawi is all but inevitable over the next two decades though a decline in fertility would reduce the rate of population growth. Thus, if fertility remains constant, the population would grow from 7.15 million in 1985 to 11.95 million in 2000 and 21.31 million in 2015. If there is standard decline in fertility, the population would grow to 11.44 million in 2000 and 17.09 million in 2015. If there is accelercted decline in fertility, the population would reach 10.63 million in 2000 and 13.29 million in 2015. MALAWI: POPULATION PROJECTIONS 1985-2015 Ratio of Population Population to Base 1985 (in millions) population in 1985 2000 2015 2000 2015 A. Constant Fertility 7.15 11.95 21.31 167 298 B. Standard Decline 7.15 11.44 17.09 160 239 C. Accelerated Decline 7.15 10.63 13.29 149 186 Socio-economic Implications of Population Growth 2.05 Malawi faces the prospect of a 50 to 702 increase in population size over the coming 15 years. and a doubling or tripling witbin the next 30 years. Such rapid population growth would have significant socio-economic consequences. During the 1970s economic growth averaged 6.8S annually. while the population growth rate during the same period was 2.8 to 2.9S. This resulted in a continued increase in per capitn income. Between 1979 and 1983 GDP growth fell to 2.82 per annum and has failed to match population growth, with a consequent slight decline in average income. Much of the economic growth is due to estate and s'allholder agriculture. However, the growth of the agriculture sector is constrained by shortage of land. The following table ehows the land required to support the population at present nutritional levels and land productivity under three fertility assumptions.  - 4 - TABLE Land Needed to Support Percent of Total Land Fertility Assumption Population (km2) Resources* Required for Cultivat,on 2000 2015 2000 2015 Constant Fertility 24,054 42,888 63 113 (deficit) Standard Decline 23,018 34.389 61 91 Accelerated Decline 21.259 26,749 56 71 *not including land under estate cultivation in 1985. Source: Malavi Population Sector Review: March 1986. Table 7. 2.06 If fertility remains constant, there are major implications for primary education expenditures. To achieve current enrollment targets for primary education, annual costs would have to rise from K24.4 million in 1985 to K68.2 million in 2000 and to K159.3 million in 2015 (a 553S increase froo 1985 to 2015). With accelerated fertility decline, annual costs would rise from K24.4 million in 1985 to K61.2 million in 2000 and to K66.1 million in 2015 (a 1712 increase). Thus rapid fertility decline could result in annual savings of K93 million by 2015. Similarly, a decline in fertility could cut annual secondary education expenditure within 30 years by 17X if fertility declines moderately, and by 43S if rapid fertility decline occurs. The need for expanded Maternal and Child Health (MCH) services will also increase substantially. If no fertility decline occurs, the number of children under 5 years of age would increase by 70S in 15 years and would more than triple within 30 years to 4.5 million. In order to maintain present levels of services, MCH expenditures would have to grow by 3.8 percent annually. Since coverage is still very incomplete, much larger cost increases would be necessary to achieve an adequate standard of MCH care. Reduction in fertility would not only reduce health costs, but enable the country to increase the quality and scope of the health services. Population Policy 2.07 Although until recently population growth has not been considtered a problem by the Governsent of Malavi, child spacing has come to be recognized as a valuable component of MCH services on the grounds that unregulated pregnancies endanger the health of both mothers and children. In 1982 the Govermnent decided to include child spacing services as part of the MCH program. The overall goal of the child spacing program is 'to reduce maternal morbidity and mortality by allowing the mother to rest between pregnancies and to reduce infant and chiAd morbidity and mortality". The Government further stated that the introduction of child spacing  - 5 - services left intact the right of the family to have as many children as desired, and that the child spacing program was not a tool of population control. These statements reflected deeply rooted attitudes in Malawian society favoring large numbers of children. 2.08 The last two years have seen significant changes in attitudes at all levels. There is increasing concern over the consequences of current rates of population growth, and there is awareness that rapid growth may be a constraint to developsent. At the 1984 International Population Conference in Mexico, the Government expressed its support for the concept of educating the public about the benefits of small families. At the request of the Government. IDA undertook a Population Sector Review in nctober 1984. Two major recommendations emerged from the review. The first was that the Government should establish a formal capacity for population policy formulation and planning. The second was that the MCH program and its child spacing component should be further developed and strengthened. For planning it was recommended that the Government establish a population planning capacity in the Economic Planning Division, Office of the President and Cabinet, to develop a multi-sectoral population program. Population related activities should be started in priority ministries, such as Education, Community Services, Health, Agriculture, and the Information Department of the Office of the President and Cabinet. For MCH and child spacing services it was recommended that the Child Spacing Program should be revised for incorporation into the five-year National Health Plan then under preparation. A seminar vas held in June 1985 to discuss the report and the major recommendations were accepted by the Government. The introduction of the child spacing program has generated interest among the public, despite the limited availability of services. Though no systematic surveys have yet been undertaken, it is increasingly evident that demand is growing rapidly. Random record checks at child spacing clinics show that an increasing proportion of clients come from outside the catchment areas. People are willing to travel long distances to obtain contraceptives. This phenomenon has been observed in hospitals, in urban and rural areas alike. Demand for services has led the MOH to develop plans for a nationwide child spacing program. The results of the 1984 Family Formation Survey financed under the first IDA-supported health project are expected shortly and will contribute to a better understanding of the determinants of fertility in Malawi. B. Health Health and Nutrition Status 2.09 Mortality is high, particularly amongst infants and children. The Crude Death Rate (CDR) is estimated to be 23 and the Infant Mortality Rate (IMR) 151. While mortality has declined from its high levels in the 1950s and 1960s (CDR 30, IKR 200), compared to neighboring countries. Malavi's infant and child mortality are very high. Infant mortality in rural areas is reported to be twice that in urban areas. The leading causes  - 6 - of death (inpatient data) in children 0-4 years are: measles (16.21). pneumonia (13.02). nutritional deficiency (11.2Z). malaria (10.1). nemia (9.1) and diarrheal diseases (8.41) (Annez 1. Table 1). These data show that 57 percent of all deaths in Malawi occur in children under five years of age. and that malnutrition directly or indirectly accounts for at least one-third of all deaths in the country. 2.10 Data on morbidity is obtained from outpatient facilities only. The leading causes of morbidity are: malaria, respiratory infections, diarrheal diseases, skin diseases, inflamatory eye diseases, traumas venereal diseases, and hookworm and other helminthic infestations. Among children 0-4 yeare. malaria (35.6%). respiratory infections (19.81). diarrheal diseases (8M7), inflanmatory eye diseases (7.91) and skin diseases (5.6S) (Annez 1 Table 2) are the five leading causes of outpatient morbidity. These account for 77.6Z of morbidity of children and vould be relatively easily preventable. 2.11 Nutritional information is sparse and generally outdated. The 1981 National Sample Survey of Agriculture revealed that Malawian infants have a very high level of stunting. A distinct growth fUltering begins at 6 months of age, possibly due to insufficient food intake and the onset of infectious diseases. The prevalence of underweight and wasting was found to be higher between 6-24 months, coinciding with the nutritionally critical period of weaning. Prevalence of stunting increases r"ith age through the first three years when it reaches a peak of 652 and levels off at 601 for the remaining two years. This shows that most children get stunted during the weaning period, a time of aximal growth. The survey found over 502 of preschool children to be chronically malnourished (below 2 standard deviations weight for age - ranging from 472 to 651) in different parts of the country. This compares with 371 in Kenya and 282 in Zimbabwe. This is the highest in Eastern and Southern Africa (except for Ethiopia). A more recent survey (in one district only) has highlighted the problem of food availability. Sixty-nine percent of women interviewed said they had insufficient food for their families. Taking April as the first month of the harvest, 301 of women reported they had exhausted food supplies by September and 602 by December. The EP and D has recently begun work on formulating a food and nutrition policy. This is being supported through an MDA-financed agricultural project. Since the nutrition problem in Halawi is primarily one of shortage of food, changes in agricultural policy are likely to have a greater impact on nutrition than specific nutrition program interventions. Nevertheless, other necessary nutrition activities are included in the proposed project. Health Plans 2.12 Shortly after independence, the Government launched its first five-year plan (1965-69). Resources were devoted prinmrily to curative services and development of nursing manpower. Evaluations of plan isplementation showed that these interventions, though important, were unlikely by themselves to improve health status. With assistance from the  - 7 - World Health Organization (WHO). the Government produced a 15-year health plan (1973-1988) whose priorities yere: development of basic health services; control of comunicable diseases; manpower development; construction of new hospitals and improvement of mzisting ones; and reorganization of the MOH. In 1975 emphsis was placed on the expansion of maternal and child health services and in 1978 the MOH introduced a primary health care (PHC) program on a pilot basis. Implementation of the 15-year health plan was hampered by: lack of adequate financial resources, scarcity of trained manpower and inexperienced health administrators. Recognizing that the 15-year plan covered too long a tise period and was outdated, the MOH began preparation of a 10-year National Health Plan in 1983 through the first L1A-supported health project. 2.13 National Health Plan (1986-1995) and Health Policy. The National Health Plan has met the following medium-term goals: ...to achieve a drop in early childhood mortality of 33.32 over a fiveyear period; to achieve an improvesent in maternal health; and to impact on the extent and severity of illness due to major causes of morbidity 5 years of age and over through the Primary Health Care approach and/or core health service*s. To accomplish these goals, six specific objectives have been formulated: (1) improv' access to a rational network of available and acceptable facilities by extending the peripheral services. especially comunity based services and by modestly strengthening hospital facilities and staffing; (2) establish effective mechanisms for the MOH manpower development and the monitoring of deployment; (3) improve the management support of the enhanced health delivery system; (4) improve child survival of the under five age group; (5) improve health status generally by strengthening relevant programs; and (6) improve the nutritional status of mothers and children. 2.14 For the first five years (1986-1990) the plan assumes that there will be no real growth in the MOH s recurrent budget. Recognizing the budgetary constraints, emphasis is placed on improved cost recovery and cost effectiveness. At the same time emphasis is placed on consolidation of existing services and expansion of prioritv health programs which have loi. recurrent cost or manpower isplications. Recognizing the seriousness of the nutrition problem. the Plan has highlighted nutrition activities. Given the resource constraints the MOH faces on the one hand, and the need for priority health programs on the other. the plati is sodest in its resource requirements and in its expectations. Organization of Health Services 2.15 MOH has primary responsibility for the development of policies. strategies and programs for health care in Halawi. Public health services are provided mainly by the MOH. The Private Hospitals Association of Malawi (PHAM) made up of church-related and other private voluntary agency facilities is the largest non-governsent provider of health services.  - 8 - 2.16 MOH services are provided at five levels: comunity, health centers and rural hospitals, district hospitals. e ntral hospitals and special hospitals. Services at the comunity level consist of an eztensive network of outreach activities through mobile clinics and the PHC program. (paras. 2.33-34). Comunity level services strese activities and interventions associated with under fives care (health education. environmental sanitation. diarrheal disease control, immunizations, pre- and post-natal care, and growth monitoring). The MOH runs 162 bealth centers and 19 rural hospitals which offer similar services: curative care, pre- natal, natal ard post-natal care, infant and child care, and comaunity services. Many health centers also run nutrition clinics (nutrition education, food preparation demonstrations and free food supplements). There are 21 district hospitals run by the MOH which serve as referral facilities for health centers. In addition, they offer all preventive services available at the health center. The two central hospitals function as referral hospitals for their respective regions. They are also used as training facilities for various training institutions. There is one general bospital. Special hospitals offer specialized services, including mental health services and inpatient care for leprosy and tuberculosis cases. There are considerable regional variations with regard to the distribution and coverage of facilities. Twenty percent of all health facilities are situated in the northern region. 332 in the central region and 471 in the southern region for populations of 860,000. 2.785.000. and 3.432.000 respectively. The percentage of population within 8ka of a health facility is 57, 70, and 100 for the northern, central, and southern regions respectively. There are a total of 17.664 beds in the country of which 6.017 are in MOH facilities. Utilization of hospital services (both inpatient and outpatient) is very high (Annex 1. Table 3). The same is the case with services provided at health centers and sub-centers, where daily patient loads range between 100 and 150. 2.17 PHAM operates 20 district hospitals. 19 rural hospitals, and 97 health centers in the country. PHAM hospitals account for just over one- third of all adcissions. PHAM facilities see about 142 of total outpatient first attendances. Services offered by PHAM are similar to those of the MOH. At PRAM facilities fees are charged for curative services though most preventive services are available free of charge. Despite efforts by the MOH and the PHAM secretariat the quality of services provided at individual PHAM facilities varies enormously. 2.18 PHAM provides about 451 of the country's health services and its training institutions produce nearly 701 of Malawi's enrolled nurses. Due to severe financial constraints however, a number of PHAM units have been asking the MOH to take over operations of these units. The MOH, which provides an annual subsidy to PHAM, is not considering any take-over. Instead plans have been formulated to ensure close cooperation and coordination between PHAM and MOH. These plans would enable the MOH to: establisb peripheral health staff positions in PHAM facilities; utilize the training capacity of PHAM for its training needs; integrate district level supervision and in-service training for PHAM and MOH programs; adopt  standardized preventive and curative interventions at PHAJ and MOH health facilities; and standardize job descriptions and training for health staff. 2.19 Local government authorities and other agencies such as the army. police, estates and industries provide curative and preventive services for their employees. Private medical practice is limited to about 35 physicians in urban areas. There are about 5,000 traditional healers and 5.000 traditional birth attendants (TBAs) scattered throughout the country. By July 1985 about 800 TBAs had been trained by the MOH. Formal links between the MOH and traditional practitioners do not exist. Management and Administration 2.20 The Principal Secretary is the senior manager in the MOH vho is responsible for both its technical and administrative branch (Chart I). The Chief of Health Services (CHS) has overall responsibility for all technical services. He is assisted by senior technical staff. On the administrative side. the Deputy Secretary is responsible for the Planning Unit and for the administrative units such as finance. personnel, administration and internal audit. Below the MOH. the health care delivery system has three levels. viz, regional, district and peripheral. Each of the country's three regions has a Regional Health Team comprising of a Regional Public Health Inspector and a Regional MCH Coordinator who report directly to their respective units at the MOH. The District Medical Officer (DMO) is responsible for all health services in the district and reports directly to the CHS. Peripheral health services are managed by the medical assistant in charge of the health center. Together with the health assistant he is responsible for supporting primary health care activities at the village level. 2.21 With increasing emphasis on preventive and rural h..slth services, ad hoc organizational and management changes have been made periodically in the structure of the MOH. However, the organization structure is cumbersome. Recognizing these problems, the Malawi Civil Service Review Comission undertook a comprehensive study of the MOH in 1984. The study highlighted the MOH's major management problems. First, the objectives of the MCH and the individual departments were no longer appropriate to the changing health needs of Malawi. Second. lines of authority were often unclear. Accountability followed professional rather than functional lines. Third. individual roles vere inadequately defined and often there were no job descriptions. This led to ad hoc allocation of responsibilities and often resulted in reduced efficiency. Fourth, there were too many levels of authority in the administrative branch of the MOH. At the same time, the reverse occurred at the district level where a sanager was expected to sanage too large working groups. Fifth, the decision making process was over-centralized. Routine operational issues were referred to the CHS which should have been dealt with lover down the hierarchy. Sixth, management support systems were inadequate. There was no firm control or monitoring of expenditures particularly with regard to vehicles and supplies. This may have been due to the fact that a number of positions in the establishment  - 10 - list could not be filled because of budgetary constraints. Seventh, the Regional Health Teams and District Health Teams typically lacked experience in planning and evaluation. Finally, there was inadequate supervision of peripheral health workers due largely to poorly developed supervisory systems, lack of training in supervision, lack of delegation of authority and transport shortages. 2.22 The recommendations of the Civil Service Review Commission have been studied by the MOH and a new organizational structure has been proposed (Chart II). The recommendations of the Commission together with the MOH's proposals have been reviewed by an inter-ministerial committee chaired by the Secretary to the Office of the President and Cabinet. Additional studies are being carried out through the IDA health project. During negotiations assurances were obtained that the Government will submit to IDA for its review and coments, a revised organization chart for MOH by September 1, 1987, and formally adopt such revised organization chart by October 1, 1987 (para. 7.Ola). Pharmaceutical Procurement and Distribution 2.23 Pharmaceuticals for the health sector are supplied by the Central Medical Stores (CMS), a self-financing and self-accounting body since April 1984. In 1983-84 its annual turnover was around K4 million. Pricing of drugs is currently fixed at CIF value plus 12.5X to cover all operating costs (up from 31 before April 1984). The CMS is responsible for procurement, inventory control and store keeping, drug assembly, repackaging and distribution, and manufacture of simple products. Since 1983, a program of continued upgrading of its operating procedures has beer underway. Facilities for formulation and manufacture of simple drugs have been established in Blantyre. Regional stores are being con*tructed in Lilongwe and Mzuzu. Implementation of plans to improve drug procurement and monitoring has begun. These activities when fully operational are expected to result in cost savings of K900,000 annually. Most of the key elements in an essential drugs policy are either already implemented or are under discussion. Thus, an Essential Drugs List was drawn up in 1985 and is being revised; procurement for the public sector is under generic names through ICB, and legislation on pharmaceutical matters has been drafted. The development of a district level network, equipping of a quality control laboratory, and further training of staff constitute the next phase of development of the pharmaceutical system. Manpower and Training 2.24 T ere were 4,962 established positions in the MOH in June 1984. Nearly 151 of these positions were vacant (Annex 1, Table 4). A considerable amount of manpower development activities have been undertaken during the past 5 years. Annex 1, Table 5 presents the growth of health staff between 1978 and 1983 by category. From this table it is clear that some categories of staff are particularly affected--the number of medical officers and dentists declined during this period whereas the number of  - it - clinical officers. enrolled nurses. laboratory technicians and health educator. (manpower pril_rily staffing rural health facilities) rose substantially. The NO has concentrated upon the develoyeant of health auziliaries ed has been able to post soot staff to rural hcalth facilities. Staffing patterns are being reviewed and the MOH plans to add one health ssistant and comnalty health nurse at each health center. With low attrition rates (about 5S per annua) it Lo likely that the MOH will be able to produce adequate numbers of health auxiliaries to staff its facilities during the plan period (Annex 1. Table 6). Furthermore, PHAN training facilties produce more enrolled nurses than they can absorb but the MMB can utilise the surplus. The proposed project does not require significant additional manpower. The NOR's training facilities are expected to be able to supply all required health auxiliaries. Tho project itself would * phasise continuing education at this stage. 2.25 The question of shortage of doctors is. however, another matter. Malwi does not have a mdical school. In the past, the country hba sent candidates abroad to pursue medical studies. However, difficulties in securing admissions to overseas universities and problems in persuading doctors to return has led to a chronic and serious shortage. The MOB is tborefore considering establishing a medical school in the country. Feasibility studies have been carried out. These studios have highlighted the bigh cost of establishing a separate medical school and a teaching hospital. A review of optiono to establish a medical school has recently been completed by the NOR with support from the Overseas Development Adainistration and the Federal Republic of Germany. The emphasis on 'comnity bealth in the proposed curriculum is particularly attractive and could be tbh basis for the developaent of appropriate medical education in Malawi. The use of mxisting hospitals for the proposed medical school would significantly reduce the coot of such a project. Preparatory work on a project proposal has begun. A medical school proposal has been included in the Public Sector lnvestment Programs it is possible in our view for Malawi to consider establishing such a medical school. 2.26 Ifforts to establish continuing education programs for health worikers began in 1964. However, few facilities eoist and continuing education prograas are hold at hotels at high costs and at infrequent intervals. The other major problo with continuing education programs is the lack of coordination aaong major service prograns resulting in duplication and wastage of scarce resources. These problems underline the inability of the NMM to plan and imploemnt continuing education progrms. Maternal and Child Health (MCI) 2.27 Tbh objectives of the MCH program are to: strengthen and expand MCM services throughout the countrys strengthen the training of health woikercs increase immunisation coverage of all children to 802 by 1990; improve nutritional status of children and decrease the incidence of undermeLght children through growth monitoring with nutrition education and  - 12 - food supplementation where neeeseary; use Traditional Birth Attendants (TBAs) to deliver MCH services; and, promote child spacing. The MCH program wao initiated in 1973 under the Assistant Chief Medical Officer (ACMD), MCH. At the regional level, an MCH supervisor oversee MCH activities in each of the three regions. At the district level, a member of the ezisting district health staff, usually a nurse. is appointed as MCH coordinator. 2.28 Child care services are provided through 1,075 static and outreach under-five clinics throughout the country. There were about 600,000 first attendances of children under one year of age in 1983. Immunizations are provided as part of the MCR program. Despite an impressive beginning. shortage of equipment and suppliex, weak cold chain and poorly trained staff have resulted in the proportion of fully immunized c1ildren to decrease by about 202 since 1982. Present coverage levels are about 352. Nutritional surveillance and education activities are undertaken at health clinics. The quality and impact of these activities have not been evaluated. 2.29 In 1984. an evaluation of MCH activities was undertaken. The evaluation confirmed earlier field observations that the quality of services is consistently high and the people attending appeared to have confidence in the staff providing the services. However, coverage appears to be far from adequate; about 60Z of women have at least one antenatal visit, some 402 of all pregnant women deliver at home, and over 502 of children aged four years and under are not being reached by MCH services. Services are constrained by lack of transport, drugs and IEC materials. Mothers with young babies under two years do not seem to use the services as much as mothers with older children. Also, use of facilities for post-partum services is virtually non-existent. This. together with low immunization coverage and poor nutrition, may be significant reasons for Malavi's high IMR. Unregulated fertility, often resulting in short birth intervals and early weaning, is another factor associated with continued high infant and child mortality rates. Child Spacing 2.30 In light of the continuing problems of infant and child mortality, the MOH organized a workshop on Health and the Family .n 1981 which recommended the introduction of child spacing services. In 1983 an initial two-year plan to initiate child spacing was prepared. The main objectives of the plan were to: orient health staff on child spacing; provide technical training to providers of child spacing services; develop the capability of the MOH to implement the child spacing program; organize seminars to acquaint community leaders and the public about child spacing; provide child spacing services as an integral part of MCH services at various levels of the health care delivery syotem; and develop a simple system for monitoring and evaluation of child spacing activities. 2.31 In 1983, child spacing services were introduced in the two central hospitals at Blantyre end Lilongwe and the Zomba General Hospital. Initially, theme services were provided by doctors alone. Shortly after the  - 13 - program was initiated, nurse-midwives were trained in child spacing, and currently they too provide service. The participation of midwives has resulted in a steady rise in the number of acceptors. As a result, child xpacing clinics are now held every working day rather than once a week. In 1984 the total number of attendances at the Queen Elizabeth Hospital's child spacing clinic were 8,281, of which 2.138 were new client. Demand for services at the hospitals in Lilongwe and Zomba has also been growing steadily. Child spacing services are now available at all district hospitals and preliminary indications are very encouraging. No estimates of contraceptive prevalence rates are currently available. Training of trainers and service providers has exceeded the targets. The MOH has begun to use mass media to provide general information on family health. Comunity seminars have not yet been organized but are planned during this year. Contraceptives are available through public and private health facilities. While no social marketing programs have yet been developed. contraceptives are increasingly becoming available through pharmacies and a range of other commercial channels. 2.32 Despite a promising start, the program is experiencing problems which have important implications for future child spacing plans. They relate to inadequacy of facilities, supplies and logistics constraints and lack of a good reporting system. Lilongwe lacks facilitiea to provide child spacing services; services Are provided at a run down clinic that is heavily overcrowded. The rapid and unforeseen growth in demand has resulted in a severe shortage of contraceptive supplies. There is still limited knowledge of potential demand and a lack of coordination between MOH headquarters in Lilongwe. which orders commodities, and the CMS (CMS), which handles customs clearance, storage, and distribution of contraceptives. Demand has been difficult to estimate since child spacing services have only recently become available and the MOH has no survey mechanism or other means of obtaining necessary information. Forms for information on child spacing users are now being designed. The program urgently needs a simple data collection and record system supplemented by periodic sample surveys that can be used by both Government and PHAM hospitals. Primary Health Care (PHC) 2.33 Following naLional seminars in 1978 the MOH began implementation of PHC on a pilot basis in three districts. The PHC approach adopted by Malawi consists of training district area and health center staff in concepts, community sensitization, and the establishment of village health comittees (VHC). VHCs art responsible for initiating PHC activities at the community level, PHC activities were introduced through the IDA-supported first health project. Details of the program are available in the project file. An evaluation of these activities undertaken in 1982 revealed a number of weaknesses in the approach. In 1983 the program was revised significantly and PHC activities were begun in a phased manner through the first project. PHC activities were started in the three districts, Mzimba, Dowa and Mwanze; at the same time the health infrastructure in these  - 14 - districts was strengthened by upgrading six facilities to primary health centers. In mid-1985, PHC activities were extended to iz more districts (namely: Mulange. Dodma, Ntcheu, Karongea Nsaage ad Chikvwa), where supporting health infrastructure was adequate. 2.34 Soon thereafter, in October 1985. the MOB undertock a program evaluation in the three districts in which PRC was first starteds it concluded that PRC approach in Malawi is appropriately cautious Ma education intensive. PRC activities are introduced into an area only after VICa have been formed and trained. The evaluation found that VICs interacted well with health vorkers in their respective areas. Health workers visited VHCs on a sonthly basis and the quality of the supervision was good; the provision of bicycles at the health center level considerably facilitated supervisory activities. The NOR has concluded that one health worker can effectively supervise 3 VTCs. Participation of communities was good and an understanding and acceptance of the concept of self reliane was developing. The evaluation concluded that the education intensive approach adopted by Malawi is providing a solid base for nationwide expansions it could not. however, assess the impact on health status because of the ahort implementation period. Though the PHC program is making gains the evaluation identified three major probles areas: scarce transport; pressure of work; and the need for continuing education. Area team and VRCs felt that there was poor supervision from the district level because district teams lacked transport. In adlition to strengthening the nobility of district team, the evaluatiot recommended continued use of bicycles and motorcycles at the area and village levels to facilitate further the implemnntation of field activities. Area teams were expected to cover large area and hence the pressure of work was significant. Steps needtd to be taken to reduce the work load of area teams through perhaps introduction of extension assistants or part time workers at the village level. The evaluation recomended strengthening continuing education program for district PHC teams, area teams, health workers and village health comittees. Community Health Sciences Unit (CRSU): Disease Control and Prevention 2.35 Health planning and evaluation is made difficult by the scarcity of valid epidemiological data. The capacity of the MOR to collect and snalyse health status information is very limited. Various diseao control progras (bilharzia, tuberculosis. sexually transmitted diseases. onchocerciasis, malaria, and leprosy control programs) historically have been developed with little coordination between each other and with the health system as a whole. There are no laboratory facilities to provide the support for field surveys and analyses. Diaposis and treat met cf cses at health centers is unsatisfactory prim-rily due to inadequate training of health staff and lack of equipment and supplies for field surveys and analyses. Under the ongoing IDA-assisted health project, the CHSU with the necessary laboratory services is being established. The cHsU will also be used to provide services normally required of a national public health laboratory which Malawi currently lacks.  - 15 - 2.36 The CESU is being established as part of the ten-year health plan. The main goal is to improve managemnt and routine health information system. coordinate and aonitor all disease control program activities and promote applied research and the use of epidemiological skills and revive euvirozmental health activities Some of theme activities have already started. e.g.. coordination and monitoring disease control program. The construction of the CHSU is now under way and will be completed by nd April. 1987. Equipment and vehicles used by existing programs will be absorbed by the unit and is being supplemented under the first health project. 2.37 The controller (Community Health Services) will head CGSU which would have two sections. A field activities section, headed by an epidemiologist, would be responsible for malaria, diarrhoea, achistosomiasis, iodine deficiency. onchocerciasis, Vitamin A deficiency. sezually tranmitted diseases, leprosy, tuberculosis, envirommental health program and epidemiology. This section will also be responsible for the collection and evaluation of health statistics, providing the evaluated output to the MOH Planning Unit. The pattologist of the Kasuzu Central Hospital in Lilongwe would head the laboratory services section covering microbiology, biochemistry and parasitology. 2.38 Although the staff of existing programs vill form part of the new unit. training will be required for staff with skills not now available. The unit head hs been identified, and a pathologist and a parasitologist are available. An epidemiologist, sociologist, and biochemist are in training and two laboratory technologists will need external training. The six persons required to staff the field activities unit will be drawn from the health inspectors, registered community health nurses, and clinical officers, some of whom are now employed under ezisting disease control program which will be subsumed under the CH8U. They will receive training in Malawi in survey methodology from the epidemiologist recruited to assist in PEC activities. Two years will be needed to establish the facilities and train staff. from January. 1988, four consultants pravided by VHO with UNDP funding, an epidemiologist, microbiologist. biochemist and laboratory technologist, will be made available for two years to assist in establishing the unit's work program and the smooth functioning of laboratory services. Trom that date, the unit will be able to: (a) undertake epidemiological studies and surveyas (b) coordinate, monitor and periodically evaluate all disease control programs; and (c) coordinate ongoing research prograns in, for example, malaria, diarrhoea, schistomomiasis, trypanosomiasis and leprosy. Health Expenditures and External Assistance 2.39 Government resources finance a large proportion of the MOH's recurrent budget. The MOH's recurrent budget rose from K18.7 million in 1981/82 to n estimated K36.7 million in 1985/86 (Annex 1, Table 7). It accounts for about 6.72 of the overall Government recurrent budget. About  - 16 - 1,82 or K19.3 million cam from the Treaury. The remaining 252 is expected Iao come from fees and eaternal sources. Betveen 1981/82 and 1985/86 non- t reasury support for the recurrent budget has ranged between 192 and 32S. 1lupport for drugs and medical personnel cover a large proportion of external tupport. Annez 1. Table 8 shows that revenue from fees have not kept pace with the growth of health expenditure. Between 1975/76 and 1984/85 revenue from fees as a percent of gross MOH expenditure declined from 4.32 to 3.62. Fee schedules have been revised, and it is expected thiat revenue from fees would rise to 4.32 of gross MOR expenditure in 1985/86. Approximately 262 of the recurrent budget is spent on salaries and wages. 2,40 Health expenditures cannot be broken down easily by programs. Arnex 1, Table 9 shows actual MOH expenditure by activity category in 1985/86. Eighty-one percent of the budget is expected to be spent on hospitals and only 62 on preventive activitiez. Since hospitals do support some preventive activities, it is probable that the percentage spent on preventive activities is somewhat higher. Between 1976/77 and 1985/86 total HOA expenditure has increased about four-fold with an average growth of 16 82 (Annex 1, Table 10). When expenditures are adjusted for inflation. the MOR's budget has still increased by about two-fold with an average anuiual growth of 6.42. The MOH's share of the overall governaent recurrent budget has ranged between 7.62 in 1975/76 and 6.72 in 1984/85. Despite this growth, the NOH's recurrent budget position is difficult and expenditures have consistently exceeded approved budgets by about 352. This has been due, in part, to inadequate budgeting for pipeline projects and to lack of 8 coq)rehensive health plan and budgetary controls. On a per capita basis, hea;.th expenditures grew from K1.2 in 1975/76 to K4.3 in 1985/86 in current prices and from K1.6 to K2.2 in constant prices. 2.41 The preparation of the national health plan (parss 2.13-2.14) has resulted in a more realistic projection of incremental recurrent costs. For the first five years of the plan costs are expected to be K4.0 million at const:ant prices. Activities begiining in the first three years of the five- year program would have incremntal recurrent costs of K2.5 million at const ant prices. The MOR would need an additional K2.03 maillion in the recurrent budget in order to adequately fund all ongoing and proposed activities during this period. A significant increase in Treasury allocations is unlikely during the plan's first five years. In view of the diffie,ult financial situation, the MOH has explored carefully for sources of finan,ing of bealth services. Fees charged for private patients and several fee schedules for general patients were revised in 1984. As a result fee collec:tion is expected to rise from K570,000 in 1982/83 (3.32 of gross NOR ezpenciture) to K1.6 million in 1985/86. or 4.32 of gross MOH expenditure. It is projected that in 1990 income from fees will, rise to K5.3 million (6.82 of MOH expenditure). Although important from the point of view of increrised service use rationalization, this source will continue to be limited. The other major area being pursued is improvement of the operational efficiency of the MOh. With restructuring of the CMS and the strengthening of the pharmaceutical sector, annual savings of K910,000 are expected. Other cost saving measures, particularly with regard to houpital  - 17 - management, *re being introduced. The MOB expects to save [1.2 million in 1986 rising to K4.3 million by 1990 through improved efficieucy of its operations. 2.42 The approved capital budget of the MNO, as a percent of total Government budget, increaced from about 1.22 in 1977/78 to 4.82 in 1985/86. Actual expendituren in constcat price. per capita increased from [0.19 in 1977/78 to KO.56 in 1983/84. The capital budget of the MOH for 1985/86 is estimated to be [7.5 million. Of thic, K6.3 million is ezternally financed (Annex 1. Table 11). Only 5l of the capital budget in financed from Government resources. Alth4ugh under-utilization had been a prominent feature of the capital budget in the post, the situation has improved in recent years. From 1976/77 to 1983/84 under-implementation averaged 282 ranging from 42S in 1981/82 to 62 in 1983/84. Limitations of the recurrent budget and delays in construction were the main constraints. 2.43 Income to PHAM is derived from Governmsent allocations. ftee and overseas donotions. MOE contributions account for about 35S, fees 34S and overseas donations for about 302 of its income. The total Government assistance to PRAM in 1984/85 was abwat 11 of MOR expenditure. In 1985/86 [2.5 million (or 112) of the MOR budget has been allocated. The MOR grant supports: (a) cost of Malawian staff employed by PRAM, and (b) cost of drugs for TB, leprocy, sexually transmitted diseases and bilharzia. In addition. vaccines for immunization of the under-five population are provided free. On the development side. PRAM units have been built with funds from agricultural development projects and external financing. C. Sectoral Issues 2.44 The implications of rapid population growth have been discussed earlier (paras 2.05-2.06). The rate of growth would slow in primarily two ways: (a) by mass emigration; or, (b) by a significant fall in fertility. Large-scale emigration to neighboring countries, all of which are experiencing high rates of population growth and economic problems themselves, is no longer an option. Though reducing fertility is the only practical and important solution, analysis of population problems extetds beyond fertility or migration. Population programs must address issues such as women's development and literacy, health and education. 2.45 Fertility reduction on the scale required to alleviate the problems of population growth can only be achieved through undervtanding of these problems by both the Government and the public, followed by the development of appropriate population policies by the Government and their implementaition through a multi-sectoral family health program. The Governumvt does not support any direct reference to limiting family mire. and informs fasilies to preserve the right to have as many children as they desire. The present policy consists of providing child specing services to those who want it, and establishing soxcial and educational programs wbich  - to - will develop awareness of the problem of rapid population growth. 2.46 The Governmet has mae signif icant offorts to reduce the infant and child mortality rates through increaed access to and improved quality of health services. These efforts have been successful in parts of the Southern Region where the DM has dropped to aroun 75. In other parts of the country, however, the 0Govrnmet's efforts have hd limited impact. To bring down infant and child mortality, selective targeting of interventions would have a significant impact. However, this approach has not been followed and hs resulted in a lack of focus on priority activities. Many family health and dis*ase control programs are still new and have not yet covered the whole country. Health services are still not readily accessible in many rural areas of the country. Shortages of drug supplies in remote health facilities are ecomon. As mew health programs have been implemented over the years. the saagmnot of the MOE has not evolved to respond to the changing environments decision-making is still over-centralized. There is little coordination among health progrm units at the central level, and consequently the effeetiveness of service delivery suffers at operational levels. The roles of the regional and district levels need to be more clearly efied. linally, are such as financial plannig, budgeting and manpower ca.ag"eat are poorly staffed and managed. Rospital anagment is weak.. The absenc of trained bospital administrators and the sevre overcrowding make hospitals inefficient institutions often providing bsic services at higher unit costs. 2.47 Concerted attepts 'o addreuu ItiAwil? minutririon problem nve not yet been made althogh nutrition activities are undertaken an part of the MCI progrm. In July 1986 the Gvenment held a seminar on the nutrition problem for Pricipal Secretaries. A decision to establish a Food and Nutrition Unit in the *P and D has been token. The unit is expocted to coordinate end maintain an overview of activities related to food security and nutritiou in Maiawi, estimte the nutrition effects of selected policies ato programs, help develop early warning and nutritional surveillanee system and determine cost-effective ways to reach nutrition goals. 2.48 Three major needs merge fron the proceeding sectoral analysis: (a) development oad strengthening of a decentralized health systems (b) institution buildinj fox health and populations and (c) expansion of population activities. The development and strengthening of a decentralized health systm (with a strong focus on pri$ary bealth care) would make basic kealth care accessible in the more re ote rural areas. This emphasis oe village and comraity health given Malawi's stage of development would be appropriate. It would also belp focus diseas prevention, nutrition and family health activities. In the MM and the largse hospicals there is a need for strngtbening organizational manageent, financial managemet and controls (including efficiency improvements, cost saving aesures and cost recovery), planning and budgeting and manpower developomnt. ectoral planing through strongthening of the 3P and D is part of the institution development objective. Information on child spacing would be disseminated to a larger audience and would belp stimulate demoad for services.  - 19 - D. Role of the ank 2.49 IDA ha been involved in the bealth sector in Malawi since 1971 whe the first Karongs Rral Developmt Project included a health component. In all, ten agricultural projects have included health components with e total investment of about US$4.5 million. Inputs have ranged from enlarging and modernizing the Karonga Hospitals to the bilhar.ia control programs. and the development of sub-centers and health posts. In 1980 IDA undertook a health sector review. In late 1982 the GOvernmeat decided that, for purposes of facilitating child spacing on health grounds. child spacing services would be available as an integral part of the MM program. A child spacing component was therefore included in the flrst health project. Since this very cautious beginning, child spacing services have expanded steadily. and dmand has been rising. As evid-ace of the changing official environment. the Government requested IDA to undertake a population sector review in 1984. The results of the review were dilcucsed at a seminar held in LilonVu. attended by senior Government officials. 2.50 The first MDA-assisted health project began in 1983 and focused on health planning and financing. The project's objective is to make the health system more responsive to the health needs of Malawians. Zach of the five components deals with major pr',blems identified in the 1980 Health Sector Review: a comprehensive National Health Plan; an improved ploaning. monitoring and evaluation capacity, and improved systems of financial accounting and health and service statistics; an epidemiological survey capacity; an efficient, cost-effective system of pharoaceutical procurement and distributioun the first phese of a natiaonl priary health care program; and the introduction of child spacing activities. The National Health Plan has been completed. A Co mnity Health Sciences Unit (CHSU) to improve monitoring capacity, undertake epidemiological surveys and strengthen health statistics collection is being established. Training of staff in biochemistry, microbiology, and laboratory techbology has been delayed because of difficulties in obtainiug admission into oversea universities. Substantial progress ha been made in the pbhrmaceutical component. The CRS was established as a distinct self-accounting unit with effect from April 1. 1984. Facilities for anufacture of drugs at Blantyre are in use. Most prioary bhalth care activities have been completed abead of seb dule, and in most caes agrod targets have been meoeded. The sac situation prevails with regard to child spacing activities under the project. The ongoing project ba emphasised cost-effectiveness (through strengtbening the CXM), cost recovery (with the introduction of fees for some categories of services (pares. 2.39-41). strooger comnity involve mt (through the PlC program (paras. 2.33-34). consolidation rather than expansion of bealtk facilities, ad institution building (through strengthening the planning process and establisbeet of improved systems of financial accounting). These strategies are comprehensively reflected ln the National Health Pln (par"s. 2.13-2.14). A review of financial system bs been completed. laplementation of rccinendations in this review will continue in the  - 20 - proposed project. Despite these achievement the project has lagged behind with regard to civil works and has been extended by two years. S. The First Phase of the National Health Plan 2.51 Following approval of tho National Health Plan (1986-1995), the KOH prepared a comprehensive implementation program for the period 1986- 1990. The progran was appraised by MA in December 1985. It wa agreed with the Government that a phaed approach would be followed. The first phase will cover new activities initiated during the first thre years and the second phase will include activities to be initiated during and beyond the subsequent two years of the proposd progrm. The investment costs for three years activities would be US$ 43.0 million. Out of this plan activities amounting to US$ 22.9 million are to be finaneed by the proposed IDA-financed project. Using tbh Bank's standard disbursement profile for Malawi this works out to US$ 24.9 million. Details of the investment plan are provided in Annex 1 Table 12. During negotiations assurances were obtained that should the Borrower propose to make any investment in the health sector which is not included in the first five years of the Borrower's National Health Plan (1986-1995), such investment shall be made by mutual agreement between the Borrower and the Association (par&. 7Olb). 2.52 During the first phase of the Plan the following components will be implemented in the MOH: (a) increased coverage of peripheral and district health services; (b) manpower development; (c) management and support systems; (d) fasily bealth; (e) disease prevention; and (f) nutrition activities. A sulti$ectoral family health program comprising the following components will be implemented through other ministries: (a) functional literacy and women's programs; (b) youth programs; (c) informotion, education and communication activities; (d) census support; and (e) establishment of a population planning capability. 2.53 The Governmnwt invited donors and IDA to participate in the financing of the first phase of the Plan and organized a donor conference in Malawi in September 1986. Donor agencies supported the principles and strategy of the plan and a number of them indicated strong interest in supporting specific activities or program. inncing for over 502 of the firot phase has been agreed to. UNICUP has formally agreed to finance the ezpmaded program for imunization in its entirety. The Federal Republic of Germay indicated strong interest in financing the Zomba General Hospitals the Iachinga district hospital and the bilhar$ia control program. UNPA indicated its interest in financing the component on the establishmont of a population planning capability in the IP and D. USAID hs boen supporting environmental bealth activities and has funding coiitted until 1989. For its next round of assistance USAID ozpects to continue support for envlronmentsl health and diarrheal disease progra s. USAID has beon providing contraceptives required since the inception of the child spacing program. A satisfactory system for ensuring continuity of adequate supplies has boen developed. The complete range of contraceptive supplies (except  - 21 - injectablec) is being provided by USAT. Injectables are provided by UNYPA. Arrangements for the supply of contreceptives for the envisaged expansion of the child spacing prograa are considerd satisfactory in the foreseeable future. In addition to these free standing activities/components, EDY, UNICU. UNFPA. KfW and the Government of the Netherlands are planning to finance activities which are inter-linked and are described as part of the proposed IDA-financed project.  - 22 - III. THE PROJUCT A. Objectives and Desmig 3.01 The proposed project is an integral part of the first phase of the National Uealth Plan. It will complemnt activities finaced separately by donor agencies (per". 2.51-2.53). The objectives of the project are to: (i) improve health status of f$milies particularly of nothers and children through expansion and strengthening of ezisting health programs ($i) increase the availability and accessibility of a complete range of child spacing services within the MOM's MCR program; MOii) strengthen the NOR's capacity to plan. mange nd evaluate health services in the framwork of a d centralized health system a nd (iv) design and implement a multi-sectoral fanily health program through other government agencies. 3.02 The proposed project is a logical follow-up to the IDA-assisted first health project. It is designed to continue institution building activities, to consolidate and ezpand PHC and cbild spacing begun under the first project, and, to introduce fasily health activities through a multi- secteoral approach. The project would support activitieos implemented through the NOE and otber ministries. Through MOR it would finance activities at the national, regional, district and peripheral levels. At the peripheral level, it would improve coverage of health services. At the district level, activities would comprise: MOR management and support system strengthening, provision of surgical contraception services, and strengthening of district level referral services. At the regional level, activities would focus on management strengthening; at the national level activities would includet management and support system strengthening, manpower development, training and IIC in primary health core, child spacing and nutrition programs, and urban family health services. To promote family health multi-sectorally using other goavrnmnt ageicies, the project would support IZC snd training activities in functional literacy, women's and youth programs; and the development of INC campaigns on femily health. 3.03 The Government has established the following targets for the five- year period: (i) reduction of IMR from a national average of 151/1.000 to 100/1000 live births; ($i) reduction of 0-4 cumulative mortality from 330/1000 to 210/1000 live births; ($ii) reduction of maternal mortality from 16/1000 to 10/1000 births; and (iv) achieve a contraceptive prevalence rate of 102.  - 23 - These targets are ambitious and the mortality reductions are unlikely to be achieved in the short space of 5 years. although substantial progress should be possible. onitoring and evaluation studies are plannd (see below pars. 5.07 and 5.08). S. Suomary Description 3.04 The project, designed to be impleaented over a three-year period starting April 1, 1987. eonsists of two parts: Part A. to be implemented by the MM, and Part B, which comprises multi-sectoral family health activities to be impleeonted by various government agencies and coordinated by BP and D. 3.05 Part A includes the following three components: (a) Primary Realth Care (US$7.6-)1, The expansion of the primry health care program from nine districts at present to cover six more districts including training, provision of equipment and supplies for village health comittee; construction. furnishing and equipping of 19 new health ceters and upgrading of six existing health sub-ceoters; and replacement of one mzisting district hospital. (b) HMaaemnt, Manpower and Support Systms (U!43.3a). The strengthening of the management of NOM through technical assistance, workshops and training at all levels of the health system; the replacment of an existing enrolled nurses school; construction, furnishing and equipping of three regional level training facilities, and of pharmaceutical depots at eight district hospitals; equipping the NOR and major hospitals with computers for budget management; equipping of a quality control laboratory; baseline, monitoring and evaluation studies, and a study of the potential of health insurance. tc) Family Health (US$5.8a). Strengthening the MCR program through tecbnical assistance, training, provision of Information. Iducation a*d Comunications (IZC) vaterials, vehicles and equipment. Strengthening of the child spacing program by orienting all health staff and training 900 service providers, construction of surgical contraception units at seven district hospitals, construction, equipping and furnishing of three new urban health centers and replacing a family health unit in Lilongwe. Strengthening nutrition activities in the MOR through technical assistance, development of ric materials and training bealth workers. (d) Project Management for Part A (US$1.5n). Salaries of a project coordinator, technical advisor, clerk of works, procurement officer, sceountant, support staff of administrative assistants 1 Costs excluding contingencies.  - 24 - and secretaries, and office equipment and supplies; and preparation of a third project. 3.06 Part B includes the following three components: (a) Functional Literacy. Nutrition and Women's Proutrms (US$3.3m). Under the Ministry of Community Services (MOCS), introduction of fanily health topics into ongoing functional literacy and women's prograas and expansion of these prograns to the Northern Region; construction, equipment and furnishing of a regional training center, production of IEC materials and overseas and local training; the establishment of nutrition activities in the MOCS through training women's groups and community development assistants (CDAs), strengthening nutrition-related activities through surveillance, and nutrition education, and construction of fish ponds. (b) Youth Programs (US$0.4.). Under the Departsent of Youth. introduction of faaily health aimed at young audiences through training, educational programs, equipment. IEC materials and innovative activities. (c) Information, Education and Communicgtion (US$0.6a). Development of notionvide IEC programs by the Information Department through production of IEC materials, overseas training and surveys and evaluation activities. C. Detailed Description Part A Primary Health Care 3.07 This component would aim at increasing coverage of peripheral health services and strengthening district health services. The project would support the expansion of the PHC program from nine districts at present to 15 districts. The pilot PHC approach dteveloped and tested partly under the MDA-supported first bealth project and adopted by Malaiw has been evaluated (parsa. 2.33-2.34) and, with suitable modifications, will be expanded in this second phase to cover six more districts. Training Village Health Committees (VHC) and bealth staff, provision of equipment and supplies, increased supervision by health staff, and establishment of a referral network are the elements of Malawi's PHC program. Village Health Committees (VHC) will continue to undertake activities in sanitation and water supply, maternal and child core and treatuent of common diseases. In addition, the MOB has recently decided to provide child spacing services through VHCs. 3.08 The project would support training activities for V8Cs and health staff including workshops and seminars for senior district officers, *mebers of District Development Committees (DDC). district and area PHC tea" members a*d TICs annually. A sajor effort would be initiated through the project to  - 25 - have refresher training for VHCa and health staff on a regular basis. Details of training activities are presented in Annez 1, Table 14. The project would also aupport visits by health workers from project area to study the success and difficulties being faced in the implementation of PHC in other areas. Area level PHC staff would visit other areas within the same district (three visits per district annually). District level PHC staff would visit other districts where PEC activities are being isplemented (one visit in each region annually). Such training activities will be taken up in two districts every year and thus in siz districts during the project period. In addition, intensive retraining is proposed for three of the first phase districts over the project period; each year. based on an evaluation of the PHC program, out of the nine districts in the first phase. one district will be selected for retraining. Training activities for PHC were first developed under the IDA-supported first health project. Following an evaluation, these courees have been suitably modified. The course content is appropriate, and training methods are considered effective. Details of the training activities to be undertaken under the project are available in the project file. Also, the project would finance about 400 drug kits for VHCs, at the rate of one kit per VHC annually. To improve the ability of health staff to supervise VHCs the project would provide 48 motorcycles and 300 bicycles, financed in parallel by UNICEF. 3.09 In each area where the PHC program is implesented a health center capable of providing support for village level activities and for acting as a referral facility is required. Six ezisting health sub-centers need upgrading to health centers. Nineteen new health centers also need to be built during the project period. Nine of these centers are to be located in the six districts (namely Nkhata bay, Lilongwe. Chiradxulu, Rumphi, Kasungu and Kangochi) where the program is being extended into its second phase. The other ten centers are to be located in the nine first phase districts (namly Mzimba, Dowa, M?anza, Mulanje, Dedza, Ntcheu, Karonga, Chikwawa and Nsanje; see map for details). The need in the first phase area is to consolidate the health infrastructure, based upon the experience of the last few years of the PHC program. Each health center of approimately 400m2 would serve 10,000 persons. In each new center the project would finance three houses for two enrolled nurses and one medical assistant, and one bouse would be added at each upgraded health center. During negotiations assurances were obtained from the Government that the health centers, once completed, would be adequately staffed by at least one medical assistant and two enrolled nurses (par&. 7.01 c). 3.10 Health centers refer patients to district bospitals. In Malawi, a number of district hospitals function in inadequate, old buildings. Bed occupancy rates, however, are very high (Annex 1, Table 3). Overcrowding is comon. With the implementation of PEC prograas and the introduction of child spacing services at the district level and below, the role of the district hospital hc become even more crucial. The project would support the replacement of one existing 102 bed hospital at Mzimba. The new facility with a total area of about 4500W 2 would have 40 additional beds and space for surgical contraception. The hospital is now heavily utilized and its current bed strength is inadequate for the demand it faces. Preliminary drawings have been reviewed by IDA and recomendations for nodifications have been made (par&. 5.01). In addition to replacement of the existing  - 26 - hospital, provision is made for 20 staff houses for key staff who need to live near the hospitals. Mzimba hospital and housing would be constructed on a nw site which has been acquired. The existing facility would be turntd over to the 'istrict authorities. The hospital would be provided with two ambulances and one station wagon. Management, Manpower and Support Systems 3.11 Management. This component would aim at strengthening the managesent of health services at the national, regional, and district levels by restructuring the MOH and improving systems and procedures. At the natiopal level a study of the MOH by the Malawi Civil Service Review Commission has revealed the need to revise the organizational structure to make it more responsive to the changing needs of the health sector (paras. 2.21-2.22). Restructuring of the MOH headquarters would require functional realigmnent of departments, creation of a manpower coordination unit, and review of the layers of authority in the administrative branch (Chart 2). A time bound plan for reorganization of the MOH is being developed and will be adopted by the Fall of 1987 (para. 2.22). 3.12 Detailed management studies of each unit of the health care delivery system have been completed by the Malawi Civil Service Review Comission. Additional studies are being undertaken by the MOH with funding from the first IDA-supported health project. The project would continue the process of strengthening the management of MOH by developing unit and job descriptions, and a short-term consultant would be provided to assist with these studies. After finalizing unit and job functions, national, regional. and district workshops would be held to train health staff in management and new procedures. A national five-day workshop for 25 unit heads and program smangers would take place annually. A four-month consultancy would be provided to develop curricula and plan the seminars. The project would also finance three one-month study tours to neighboring countries for senior and middle-level MOH officials annually. 3.13 The project would finance the establishment of a regional health team in each of the country's three regions, which would back up and supervise the health services of the region. Each regional health team would comprise a Regional Health Officer (team leader), a regional nursing officer, a regional public health nurse, and a regional public health inspector. The project would finance three regional health officers and three regional nursing officers, three drivers, and would provide three vehicles (one per regional health team). During negotiations, assurances were obtained from the Government that posts of three regional health officers and three regional nursing officers would be created and filled by October 1, 1987 (para. 7.01 d). 3.14 A major area of concern is the management and administration of hospitals. Detailed studies of the two central hospitals have been carried out by consultants financed under the first IDA-supported health project and recommendations have been made to improve overall efficiency. According to these studies up to 40t of non-personnel costs at the hospitals could be saved through better management. The project would support annual workshops in hospital management and administration for all hospital secretaries and  - 27 - administrators in Malawi. During negotiations the Government submitted an implementation plan for cost reduction measures satisfactory to IDA. The Government has agreed: (a) to establish within MOH, not later than July 31. 1987, a committee with the Deputy Secretary of the MOH as chairman with representatives from the Queen Elizabeth Central Hospital. the Kamuzu Central Hospital and the Zomba General Hospital to monitor the implementation of cost reduction measures; (b) to implement cost reduction measures at MOH and at the Queen Elizabeth Hospital by December 31. 1987; (c) to submit to IDA by March 31. 1988 for its review and comments, an evaluation of the cost reduction measures implemented by MOH; (d) to implement cost reduction measures at the Kamuzu Central Hospital and the Zomba General Hospital by April 30, 1988 and at all district hospitals by December 31. 19881 and (e) to decentralize finance and accounting functions of the three major hospitals from MOH to the Queen Elizabeth Central Hospital, the Kaauzu Central Hospital and the Zomba General Hospital by not later than April 30, 1988 (para. 7.01 e). 3.15 The Planning Unit was expanded and six new posts were established through the first IDA-assisted project. With the development of a National Health Plan (para. 2.13) and training in planning of senior Planning Unit officials, the MOH has developed an increased ability to plan and evaluate programs. The Planning Unit has evolved into an effective organization. The project would support the MOH's efforts to further improve its planning capability, through increased emphasis on decentralization of the MOH and by strengthening district level planning capability. A senior internationally recruited health planner was appointed in 1986 and has begun training district level staff. The project will provide for one long-term and one short-term training course in health planning and one five-day workshop annually for 20 senior officials to assess implementation of the plan and to recommend modifications in strategy. A study of the impact of fees charged on utilization of services and on the potential for health insurance would be undertaken by the Planning Unit with assistance of a short-term consultant. 3.16 The project would finance an expenditure control accountant at the central budget section, three regional level accountants and one accountant at each of the three main hospitals. Also four computers needed to improve financial accounting would be financed (one computer for the MOH headquarters and the remaining three for the main hospitals in Blantyre. Lilongwe and Zomba). During negotiations assurances were obtained from the Government that the positions of one expenditure control accountant at the MOE, three regional accountants, and one accountant at each of the major three hospitals would be filled by October 1, 1987; in order to carry out cost reduction measures at district-level hospitals, the Government has provided assurances that it would hire assistant accountants for each of the 21 district hospitals by August 31, 1988 (para. 7.01 f). 3.17 Manpower. The project would provide for: (a) strengthening the capacity of the MOH to train enrolled nurses; (b) establishing an in-service training capacity; and (c) developing MOH's capability to undertake manpower planning and analysis. Project assistance would include construction, furnishing and equipping of one school for enrolled nurses, hostel and  - 28 - warden's flat at Zomba, with a capacity for 140 students (about 4000m2), to be built near the Zomba General Hospital at a mite already acquired. IDA has reviewed sketch drawings and suggested modifications (para. 5.01). The project would improve in-service training by MOR of about 1.000 health workers annually by financing construction, furnishing and equipping of three regional level training facilities (each of about 400sq.m area and including one house for the resident caretaker). Courses to be offered at these facilities are described under the respective MOH programs. Utilization rates are expected to be 952 during the first three years and 852 in subsequent years. Sites have been identified and are being acquired. Sketch drawings have been reviewed and considered satisfactory. To ensure satisfactory scheduling of training, the appointment of a Training Officer would be essential. The project would also finance the overseas training of a middle level officer in manpower planning for one year. During negotiations assurances were obtained from the Government that a Training Officer would be appointed by September 1. 1987, to coordinate in-service training activities; and that in-service training plans for the GOM fiscal year beginning April 1988 would be submitted to IDA for review and comment by December 31. 1987. with annual plans for succeeding fiscal years submitted by December 31 of the previous year (par. 7.01 g). 3.18 Support Systems. With the establishment of a Community Health Sciences Unt in 1984 the MOH began to develop a capacity to undertake survey and evaluation activities. The project would support the MOH's efforts to further strengthen its monitoring and evaluation capability. A baseline health status and utilization study would be undertaken in the first year of the project, with a survey planned in the third yea-. The project would provide a short-term consultant for one month in the first and third years to assist with study design and field work. In addition, there would be annual impact studies of specific programs. 3.19 Efforts to improve the effectiveness and efficiency of the pharmaceutical system were begun in 1983 (para. 2.23). The MOH proposes to further strengthen the pharmaceutical system by decentralization down to the district level. The project would finance the renovation of pharmaceutical depots at eight district hospitals including furniture and equipment, and the establishment of a quality control laboratory. Through 28 man-months of consultant services the project would support the drafting of drug legislation, review production procedures at CMS, review quality control procedures and computerize CMS operations. There would be two seminars of one-week duration for 20 pharmacy assistants in the scope and functions of the revised CMS and two five-day annual seminars each for 30 drug pre- scribers. The project would also finance 25-1/2 months of overseas training in drug inspection, drug administration, quality control and drug manufacture. Family Health 3.20 This component would include: (a) maternal and child health (antenatal, natal and postnatal services, and health services for under fives); (b) child spacing; and (c) nutrition. 3.21 MCH. The progrum is hampered by poor and inadequate transport, lack of IEC materials and shortage of drugs, and has weak postnatal services  - 29 - (part. 2.29). The project would finance the replacement of 27 vehicles for the regions and districts, for service supervision and for the provision of mobile services. Maintenance facilities at the regional and district levels are considered satisfactory. Two boats to provide MCH services to island and lakeshore communities would be financed. The project include one month consultancy for the development of an integrated course in family health for 200 health workers annually; annual in-service training in priority diseases (diarrhea, malaria, respiratory illness, measles, and nutritional deficiency) for 900 health workers; an MCH manual for use by health workers in MOH and PHAM units; printing of IEC and training materials developed for the MCH program; and annual supplies of drugs for 1.100 MCH centers and 639 antenatal clinics. Through the proposed training activities emphasis would be placed on the development of postnatal services (pars. 3.22). The proposed content of courses has been reviewed by IDA and is considered appropriate. Details of the training activities are available in the project file. 3.22 Child Spacing. The enhanced receptivity towards child spacing has led MOR to increase the range of services offered and to make services available more widely (paras. 2.30-2.32). The project would assist in development of surgical contraception services and expansion of urban and rural family health services by training of health staff. TBAs and VHCs in child spacing and printing of IEC materials for child spacing. The project would finance the building, furnishing and equipping surgical contraception units at seven district hospitals. Designs for the units have been approved by IDA and the list of furniture ard equipment finalized. The project would provide a one month consultancy to review training and quality control plans. With increasing demand for child spacing services in urban areas there is a need to provide adequate facilities (pars. 2.32). The project would finance construction, furnishing and equipping of an urban family health unit in Lilongwe, three health centers in Blbntyre and Lilongwe, and upgrading two existing health centers in Blantyre and Lilongwe. Designs have been reviewed and modifications suggested for the family health unit in Lilongwe (para. 5.01). The project would finance the training in child spacing of 20 trainers, 10 tutors, 675 nurse midwives and enrolled nurses, 225 clinical officers and medical assistants; the orientation of 1,440 health personnel and 1,500 DDCs and VHC members in child spacing. These training activities were introduced initially under the first IDA-supported health project, and are considered appropriate. Details of the training activities are available in the project file. The importance of the postnatal period both for better mother and child care and for provision of child spacing services would be emphasized in these courses (para. 3.21). IEC materials would be financed by the project as would the appointment of six clinical officers and 16 enrolled nurses for the urban family health clinics. During negotiations assurances were obtained that six clinical officers and 16 enrolled nurses would be appointed to the urban clinics once completed (para. 7.01 h). 3.23 TBAs would be trained in child spacing under the project. Four courses, each for 15 TBA trainers, would be undertaken during the first two years of the project. (A TBA trainer is an enrolled nurse posted at a health center and trains about five TBAs in her area annually.) About 250 TBAs would be trained per year in child spacing.  - 30 - 3.24 Nutrition. New initiatives in nutrition are being proposed by the MOH with the participation of the MOCS to deal with the problem of malnutrition and the consequent impact on infant and child mortality. The project would promote nutrition education through MOM and growth surveillance at health clinics. These activities would be undertaken in conjunction with the MOCS (para. 3.27). The project would include the development and production of flip charts, posters and post literacy booklets for use by the MOH through health clinics. Health workers would be trainied in nutrition as part of the family health training program (para. 3.26). To develop nutrition activities further, particularly with the EP and D, the project will provide two man-months of consultancy. Proiect Management 3.25 The project would provide for a project coordinator, technical advisor, clerk of works, procurement officer, accountant, support staff of administrative assistants and secretaries, and office equipment, supplies and a vehicle. Funds for the preparation of a third project would also be provided. The project coordinator would report directly to the Chief of Health Services, MOH. A project coordinator has been appointed under terms of reference approved by IDA. Part B 3.26 Part B of the project would finance family health activities to be undertaken by government agencies other than the MOH, including nutrition activities to be undertaken by MOCS, complementary to the nutrition activities to be undertaken by MOH (para. 3.24). These activities would be coordinated by the EP and D. Functional Literacy, Nutrition and Women's Programs 3.27 The 1977 Population Census revealed that 82.2% of the population of all ages was still illiterate. Of these, 77.5% were in the economically productive age of 15 and above. The widespread illiteracy in rural areas has constituted one of the major limitations in enhancing the pace of rural development. The Government has therefore set the target of achieving two million literate by 1990. The strategy is being carried out largely through adult literacy classes held at the various functional literacy centers. The program is well managed, and evaluations have shown that it is effective. However, up to now, this program has not dealt directly with matters of population education or family health. Through the Functional Literacy component the proposed project would introduce family health into the curricula and would finance designs and production of written/pictorial materials. 3.28 This component would aim at rapid dissemination of messages regarding family health to both the rural and urban population. Though child spacing topics would have priority, nutrition and maternal and child health services would also be covered. Through this approach, it is  - 31 - ezpected that the demand for child spacing and family health services would be stimulated. tll adult literacy centers would receive information relating to family health. The target audience will be the large and growing number of illiterates, both men and women, field workers and youth. in both urban and rural areas. Materials to be produced would include literacy booklets, family health booklets, posters, and flip charts. The MOH would review all materials produced by the MOCS. which has the capability to undertake these tasks. Training activities under the project would include: courses on family health for Members of Parliament (MPH), Home Craft Workers (HCWs) and their supervisors the Community Development Assistants (CDAs). The basic function of the latter two cadres is the promotion of women's welfare; they are controlled by MOCS. Refresher courses on family health would be held for HCWs, local women's leaders, functional literacy educators and literacy supervisors. Details of these courses are presented in Annex I, Table 14. The project would finance the construction, furnishing and equipping of a training center for the Northern Region to enable the courses discussed above to be carried out regionally. This center would serve the needs of the MOCS. The project would finance 10 study tours of one-month duration by planners and program managers from MOCS to study the operational aspects of similar successful programs in adult functional literacy and women's activities in neighboring developing be undertaken through MOCS: training women's groups to undertake nutrition surveillance and related nutrition education and introduction of fish ponds to provide protein for mothers and children at the village level. The project would finance the development and production of IEC materials, training CDAs and the construction of fish ponds iD 150 village communities. Fish froa the ponds would provide much needed protein for mothers and children. Technical assistance for construction and maintaining the fish ponds would be pro-vided by the Department of Fisheries, which has had considerable success in smi 1 scale fish farming in Southern Malawi. During negotiations assurances were obtained from the Government that the MOM would establish by September 1, 1987 a health information, education and comMunLation review committee to approve IEC measages prepared by non-MOR agencies chaired. by the Chief of Health Services with members fro* the Ministries of Health and Community Services end the Secretary for Youth and the Malawi Pioneers (pars. 7.01 i). Youth Programs 3.29 Youth between 13 to 19 years of age are an important target group for family health education activities. The Malawi Young Pioneers (MP?) program trains yout! in this age group in a number of activities both technical and non-technical. However, issues related to tamily health education are not included. Malawi youth in this age group are not adequately provided with information needed for their fertility regulation. This contributes to unplanned pregnancies and very often an increase in the dropout rate from school. 3.30 The objectives of the youth program component would be to: provide MYP matron/instructors/instructresses with knowledge related to family health education, to be in turn imparted to MYP youth; provide female MYP graduates with knowledge related to family health education so as to prepare them for responsible adulthood; and equip MYP graduates with  - 32 - sufficient knowledge and skills that will enable them to informally educcte families and fellow youth in their respective communities. 3.31 The project would provide training programs in family health for 100 MYP matrons, instructors and instructresses. basic training courses for female adolescents (13-19) and young women (20 and over). Details of the training activities are presented in Aunsx 1 Table 14. The project would also include the construction of 10 simple shelters attached to existing dispenaaries to be used by MYP volunteers to educate women coming to the dispensaries. The project would support the provision of one sewing sachine to each of the 49 MYP youth clubs and one fish pond in each of the sevERn MYP bases in the country for demonstration of potential income generating activities to village comunitieu. The introduction of income jeneratiug activities, particularly to women, has been demonstrated to reduce morbidity, mortality and fertility. Information, Education and Communication 3.32 The objectives of the ISC component would be to enhance receptivity among the people of Malawi to the concept of fasily health and to update knowledge regarding family health among service providers. The primary target audience would be: the rural population, men, women and youth; local leaders and traditional authorities; urban population, men and women and youth; and health service providers. 3.33 The IEC component would be primarilv concerned with the expanded use of ass *edia in support of fsaily health activities and bolding training/refresher workshops to further sensitize existing health mervice providers and others associated with the content of media messages and multi-media use. The activities would be implemented by the Information Department, Office of the President and Cabinet. The project would enable widespread use of the mass media through introduction of family health mesoages into the Chichewa paper, Bona Lathu, to reach a monthly audience of ebout 500,000; family health boards on long distance buses; family health labels on match boxes; radio programs on family health; and production of two 20 minute films annually. The project would include overleas training of three Infornation Department staff in graphics, audio-visual techniques and development c%mmunications. The MOR would review the content of fasily health messages developed for use by other ministries (pars. 7.01h).  - 33 - IV. PROJICT COSTS AND FINANCING A. Costs 4.01 Although the project has been designed to be impleewnted over a three-year period, it has been cated over a five-year period, to have a disbursement profile corresponding to the standard profile for Malawi. Total costs of the proposed project are estimated at K56.1 million (US$24.9 sillion equivalent). Base costs are calculated at US$22.5 million equivalent (902) and contingencies .t US$2.4 million equivalent (102). foreign exchange costs account for US$11.6 million or 47Z of total project costs. Taxes and duties have been calculated at US$0.4 million for civil works, design fees, furniture, materials, equipment and vehicles. Projeet costs by expenditure category are summarized in Table I below, and details are provided in Annex 3. Capital costs for civil woris account for 432 of beae costs; furniture, equipment, vehicles, supplies and saterials for 22Z; monitoring and research activities 1; technical assistance for 72; training for 152; and incremn tal recurrent costs (salaries and allowances, building. equipment and vebicle operation and maintenance) for 92. atoe 1: ProJoct Coot. by Expenditure Cataliry ., 411 ~SE FIWILY "XIN ""CT SIT ACfOiL MT MalC a.il C.r , or , (u 459 OR, ;-~~~~~~~~ ;.;. 3 . .3"s 9.,. : For,na.l S.,, * J j.4iIe,z 'AL, E^e* Sar =.id su'Iak '4ti,d E.cftMi* 3.411 ...... ..;.,; . ... .. .... . ............,,;..---........ .. . . . ..A$14EN1 C05TS .. ..... ..... *@6.... A. CIVIL MS .'1'. 1 '743.0 19,442,6 40 43 5.4.S ;31..5 9.7:; S. FUM3T 302 3 405.0 4,217:3 3 402 :4: 5 ,3.* ; i 7 M A0TERIALS Il ? . ,* 5.948. '0 43 M9 2 '@.S ''070.3 I '' D ENUPIM 47I 1,3 ,39.3 I 334 , 99 3 8. 844,7 a?3. n E. 4AICLS 13.9 i.394.3 1- .: 3 ,.9 01 *04. i r. TEhlEliL WSIsTU 3y ,1:9.1 379.1 0 - 10379,. W 4Mt 6. KOIS FEES 1,217.3 1,17.0 1 1 .43. 043.' 3 .. 4131135 , l J . EJIllIlR 47.E - 4754 - 237.7 :3 i. ATIVITIES - * 71 - 4.4 4.0 TRAWN .:,14.: 5 - 0142.1 14 3.071.4 3.80,1.4 a, Mfl1W 1040IMIN - 453.3 453.3 4O4 4 - 2.A 2i.' : : Toll INKSM!T WiATS A,..2 M13.6 41,043.i 4 71 II,I3.I ..3' 20,30, 4, '3 z,ca4 ~.t4rwud,,, s,434.2 1,510.3 7'4.5 51 '11. 7S3.: :Z413.3 Price Cobt&t swn 43743.2 3W .1 .3111.0 44 33 414.' 341.7 '43.4 4. ........ ..... ... . _...... ... .... . .... ... _...... .. .... ...... ....... .. .. .... ... .. .... .... ?@UI ligL.lilS CWITIES 7440.5 23,171.1 50,539 3 44 111 12,270.t 10,471, 22742.3 4 ,,,,,,,,,,...... ........ ......... ...... ........ .,...... ,........ ...........,.i 43 410W colS . ....... . . _... A. IS.WIE 1.44.' - .4444. 3 723,2 - '23. I., I 9X t I 2Ii e tliTtiw aA. 1,i. 322.: 40 3 154.0 40'.4 'w1 10 ; C. lSIl M1U?Ul O 44.4 334.) 499,7 Z 0 20.2 7., 94 i : S. N L8Z4SIN its" is 12 f iln, 3W.2 4t591 'S .. .... .... ...._... . ... .. ._... .._. _ .... .. .._ ..... .... ... . .. ............... ....... Toel mt C1tS I'M.$ 24.9 4.t 177' 52 '15.41-0'53.5 2,043.T 5I P9.s,e,4 C.tier_4.1 47 4 64.7 Si, I K 1.' 34.4 43.1 0 ; Fn C.1&r_ Hin 493.3 1 42.9 1,056.' 53 2 52.13 59,4 il:.8 53 o Ytill SS.0C51ttl1E IS 249,2.0 2-''.3 5-2333, 52 12 14045.3 I,147.2 .:91, S; 5 .1.3 .LMS TITS 24257.0 ......2.. 4309 4 4 .. . 2. 21.3.0.424,3 22 .4... ... .W 'fewat,c Un -<in3. 1-45 3 ,0 3,032.4 52 '26eO 'Ps.3 :4514.3 5S Prien C.t0 _ema , $,442.0 3-,95.7 7,M.' 4? I 467.0 403 , I'S,: I ' 4 l1,4A ISfT CWITS 2q,932.* 24,447.3 540-9.1 47 :24 1-3Zl,3 1-,11.7 4,14.94, 4* il; -3 lff* -A...a