Rwanda - First Population Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No. 9233-RW STAFF APPRAISAL REPORT RWANDA FIRST POPULATION PROJECT MAY 15, 1991 Africa Region South Central & Indian Ocean Department Population & Human Resources Division This documenl has a restricted distsbunton and may be used by recipients orly in the performance of their officia duties. Its contents may not otherwise be disclosedwihuWolBakutrzton Rai wihu Wol Ban authorization  RWANDA: FIRST POPULATION PROJECT CURRENCY EQUIVALENTS Currency Unit - Rwandan Franc (FRW) US$1.00 m FRW 118 (February 1991) MEASUREMENTS 1 meter - 3.28 feet 1 kilometer - 0.62 mile 1 square kilometer 0.39 square mile 1 hectare - 2.47 acres GOVERNMENT OF RWANDA - FISCAL YEAR January lst - December 31st This report is based on the findings of an appraisal mission which visited Kigali in October 1990, comprising of Dr. J. Baudouy, Mission Leader; Dr. A. M. Pierre-Louis, Deputy Mission leader and Task Manager; Mmes M. Schneidman, Economist, and E. Murray, Financial Analyst. Mr. B. CarLson is the lead advisor for this operation. Mmes V. Fauconnier, F. Duchesne. F. Ryckebusch and V. Vaselopoulos provided secretarial support in the preparation of this report. Messrs. A. Colliou aa'd F. Aguirre-Sacasa are the Managing Division Chief and the Department Director, respectively for this operation.  FOR OFICIAL USE ONLY RWANDA: FIRST POPULATION PROJECT ABBREVIATIONS AIDS Acquired Immunodeficiency Syndrome ARBEF Association Rwandaise pour le Bien-Etre Familial (Rwandese Association for family welfare) BUFHAR Bureau des Formations Mddicales Agr6des du Rwanda (Association of religious NGOs involved in the health sector in Rwanda) CBD Community Based Distribution CBR Crude Birth Rate CCDFP Centre Communal de Developpement et de Formation Permanente (Community Center for Developpement and Continuing Education) CERAI Centre d'Enseignement Rural et Artisanal Integr6 (Post- primary Rural Centers of MINEPRISEC) CND Conseil National de Developpement (National Development Council) CPS Contraceptive Prevalence Survey DHS Demographic and Health Survey GTZ Gesellschaft fUr Technische Zusammenarbeit (German Cooperation agency) HC Health Center HCR Haut Co=missariat aux Rafugi6s (United Nations Agency) HIV Human Immunodeficiency Virus IEC Information, Education and Communication INTRAH International Training in Health EPPF International Planned Parenthood Federation IUD Intra Uterine Device JOC Jeunesse Ouvri$re Catholique (Catholic youth workers) MCH Maternal and Child Health MEDIRESA Medecin Directeur de la Region Sanitaire (Regional Medical. Officer) MINIPRESEC Ministbre de l'Enseignement Primaire et Secondaire (Ministry of Primary and Secondary Education) MOH Ministry of Health MRND Mouvement R6volutionnaire National pour le D4veloppement (National Revolutionary Organization for Development) MIS Management Information System NFP Natural Family Planning NFS National Fertility Survey NGO Non Governmental Organization ONAPO Office National de la Population ORINFOR Office Rwandais d'Information (Rwandese Office of Information) PAU Project Administrative Unit PHC Primary Health Care PHN Populat ion-Health-Nutrition TFR Total Fertility Rate UNDP United Nations Development Program UNFPA United Nations Fund for Population Activities UNR Universit4 Nationale du Rwanda LILMAM Rwandese Women Xssociation (Association des Femmes Rwandaises pour le Developpement) USAID United States Agency for International Development This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  RWANDA: FIRST POPULATION PROJECT BASIC DATA I/ Population (1990) 7.3 million Rural 2 942 Urban Z 6S Population growth rate 3.6Z 21 Population density (per km2) 279 2/ Crude birth rate 53 per 1000 births 3/ Crude death rate 18 per 1000 deaths 3/ Infant mortality rate 122 per 1000 Total fertility rate 8.5 2/ Contraceptive prevalence rate (1989, all modern methods) 9? 2/ GNP per capita (1990) US$310 Access to primary health care 4O0 of the population 2/ Number of physicians 272 Number of nurses and medical assistants 1271 2/ Health expenditures as a percentage of budget about 6S 2/ I/ Population and demographic indicators are taken from Population Reference Bureau, 1990, except where noted. 2/ Data are from 1987 and 1989 ONAPO reports and 1990 HOH annual report 3/ World Develop Report 1990.  RUANDA: FIRST POPULATION PROJECT DEFINITIONS Age Specific Fertility Rates Number of live births to women in a given age group per 1.000 women in the same age group, in a given year. Contraceptive Prevalence Rates The percentage of married women of reproductive age who are using (or whose 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 Expectancy 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. Net Reproduction Rates The average number of daughters that would be born to a woman (or group of women) if during her lifetime she were to conform to the age specific fertility and mortality rates of a given year. A net reproduction rate of 1.00 means that each generation of mothers is having exactly enough daughters to replace itself in the population.  Definitions (Continued) 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 which a population is increaring (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 accordance with prevailing age-specific fertility rates.  FOR OFFICIAL USE ONLY RWANDA: FIRST POPULATION PROJECT TABLE OF CONTENTS Page No. CREDIT AND PROJECT SUMMARY ........................... i-ii I. BACKGROUND A. Socioeconomic context ..... ................... 1 B. The PHN situation ....... ................ 2 II. POPULATION SECTOR STATUS AND ISSIES A. Demographic status ....................... 2 B. Impact of population growth on socioeconomic development ........................................... 3 C. Population policy and family planning activities ........ 6 D. Major sector issues .......................................... 10 E. Sectoral strategy and Bank's role ....................... 13 III. THE PROJECT A. Project objectives and design .................. 15 B. Detailed project description ................. ........... 16 IV. PROJECT COSTS AND FINANCING A. Costs ............................ 25 B. Incremental Recurrent Costs and Projec; Sustainability .. 26 C. Financing ................................................. 28 D. Procurement .... . . .... . ... . ............. . 29 E. Disbursement .................. 31 V. PROJECT IMPLEDNTATION A. Status of project preparation ........................... 32 B. Organizacion and management ..... ....................... 32 C. Honitoring and Reporting .... ................... ............ 34 VI. PROJECT JUSTIFICATION, BENEFITS AND RISKS A. Justification and Benefits .............................. 35 B. Risks .......... ......................................... 36 VII, ................................................... 37  RWANDA: FIRST POPULATION PROJECT Table of Contents (Continued) Page No. List of Tables in Text 2.1 Projected population size and growth .................. 3 4.1 Summary accounts cost summary .............. .................... 25 4.2 Project casts summary by component ............................. 26 4.3 Financing plan by disbursement category ..... ................... 28 4.4 Procurement arrangements ................... .................... 29 4.5 Disbursement schedule ........ .................................. 31 ANNEXES 1 - TABLES Table 1: Rwanda - Population estimates by region Table 2: Evolution of population of Rwanda, 1940-1985 Table 3: Rwanda - Population distribution by age Table 4: Rwanda - Estimated population density by region Table 5: Number of new accepturs per method and number of health facilities delivering FP services, 1981-1989 Table 5a: Total number of users and contraceptive mix by method, 1985-90 Table Sb: Total number of users and contraceptive mix, by region and by method (december 1989) Table 6: Distribution of new acceptors per method, 1981-2011 Table 7: Estimation of contraceptive prevalence required to reach different fertility targets, 1990-2015 Application of the simplified version of Bongaarts Model Table SA: Ministry of Health and ONAPO recurrent budget Table 8B: Donors contributions to ONAPO (in RF), 1981-1987 2 - FIGURES Fig. 1A: Organization chart: Ministry of Health Fig. 1B: Organization chart: ONAPO Fig. 2 : Population projections, Rwanda 1990-2015 Fig. 3 : Projection of land availability, 1990-2015 Fig. 4 : Population Program in Rwanda: The effects of a reduction of the total fertility rate Fig. 5 : Contraceptive prevalence and total fertility rate in Africa's seolected countries 3 - Key Project Indicators 4 - Summary Account by Project Component Table 1: Improving quality and efficiency of FP services Table 2s FP post-- equipment and supplies Table 3: Support to IEC Strategy Table 4: Volontaires Abegangurambaba  RWANDAt FIRST POPULATION PROJECT Table of Contents (Continued) Table 5 Research/development of multisectoral populatien activities Table 6: Project management unit SAP Table 7: Summary Account by Year Table 7a: Base Costs (thousand of US $) Table 7b: Totals Including Contingencies (thousand of US $) Table 7c: Totals Including Contingencies (thousand of FRW) 5 - Research carried out by ONAPO since 1982 6 - Targeted donors intervention in Rwanda 7 - Official declarations on population issues in Rwanda 8 - Project Management: project organizational chart; TOR's of project coordinator, project advisor, project accountant and procurement specialist 9 - Terms of reference for the PP posts, the Volunteers and the Health Canter 10 - Supervision plan 11 - Detailed training plan 12 - Implementation schedule by project component 13 - Estimated schedule of disbursement 14 - Technical assistsnce requirements 15 - Procurement schedule 16 - References MAP  RWANDA: FIRST POPULATION PROJECT CREDIT AND PROJECT SUMMARY Borrower : Republic of Rwanda Beneficiaries Ministry of Health (MOH) and National Office of Population (Office National de ls Population - ONAPO) Amount . SDR 14.5 million (US$19.6 millic' equivalent) Terms Standard IDA terms, with 40 years maturity Project Description: (a) Objectives: The project will support the implementation of the National Population Policy and will contribute to: (a) reducing the total fertility rate (TFR); (b) improving maternal and child health (MCH); and (c) integrating the demographic dimension in cross-sectoral development activities. These objectives will be reached by: (a) improving the quality and efficiency of Family Planning (FP) service delivery; (b) increasing demand for and access to FP services; (c) carrying out a set of population studies and strengthening the FP information system; and (d) supporting multisectoral ectivities within the framework of the national population policy. Selected demographic targets for 1997 (last year of project implementation) include (figures for 1990 are in parenthesis): TFR at 7.2(8.5); modern contraceptive prevalence rate (CPR) at 20.0 (9.0) and 276,000 FP users (100,000). (b' CoMponents: The project will provide for: (a) improvement in quality and efficiency of FP services through In-service training of approximatively 1,100 health workers, intensification of supervisl and management procedures and the provision of contraceptives and FF equipment; (b) expansion and promotion of FP services through the strengthening of 39 existing FP posts and the establishment of 44 new posts as satellites of the health center network, the mobilization of about 17,500 community volunteers and the support of a targeted Information, Education and Communication (IEC) strategy; and (c) implementation of population studies and promotion of multisectoral population activities through technical assistance, seminars and operational support. (c) Benefits and Risks: By rapidly increasing the contraceptive prevalence rate, the project will provide micro and macro benefits. At the individual level, reduced family size and increased birth spacing will have positive health effects on women and children and will diminish family expenses on schooling, health care and food. At the national level, the reduction in population pressure on scarce land resources, fraaile eco systems, limited savings and employment/ investment capacities will contribute to economic growth. The first risk is linked to the limited meanagerial capabilities of ONAPO. To address this risk, a project management structure will be put in place before credit effectiveness. The second risk is a lack of coordination between ONAPO and MOI. To address this risk agreement was reached during project negotiations, on the implementation of the collaboration mechanisms  ii - between MOH and ONAPO which have been developed during project preparation. The third risk relates to the capacity of Rwanda to find appropriate solutions to the lingering problems of Rwandese refugees in neighboring countries. Reinsertion of these refugees in Rwanda requires careful planning and a major support from the international community. PROJECT COST ESTIMATES Local Foreign Total -US$ million - Improvement of quality & efficiency FP services 0.59 5.38 5.97 - Expansion & promotion of FP services 7.18 4.52 11.70 - Studies and multi- sectoral activities 0.84 0.81 1.65 - Project management 0.45 1.22 1.67 Total base costs 9.06 11.93 20.99 Physical contingencies 0.10 1.05 1.15 Price contingencies 2.50 1.46 3.96 Total project costs 11.66 14.44 26.10 Financing Rlan - IDA 8.3 11.3 19.6 - Th.AID 1/ -- 1.9 1.9 - UNFPA 1/ -- 1.2 1.2 - Government 2/ 3.4 -- 3.4 Total 11.7 14.4 26.1 ESTIMATED IDA DISBURSEMENTS (US$ million) FY92 FY93 FY94 FY95 FY96 FY97 PY98 Annual 1.00 6.00 4.00 5.00 2.00 1.20 0.40 Cumulative 1.00 7.00 11.00 16.00 18.00 19.20 19.60 Vi The figures represent estimates of the contributions of these agencies to the activities undertaken under this project. Their total support to population and FP activities in Rwanda is more substantial than the figures indicated in this table. 2/ Including $64,000 equivalent for taxes.  FIRtST P0PLA&TIO_K0PROECT STAFF APPRAISAL REOR I. BACKGROUND A. Socioeconomic context 1.01 With a GNP per capita estimated at US$310 in 1989, Rwanda belongs to the group of the world's least developed countries. As common to poor nations, social conditions are bleaks malnutrition affects many women and children, maternal and infant mortality are high, illiteracy is high (60 percent of women are illiterate) and unemployment is a serioas problem (less than 10 percent of those entering annually the labor maLket will find formal employmant). What is particular to Rwanda as compared to other Sub-Saharan African countries (with the exception of neighboring Burundi which faces a similar situation) is the extremely high population density and the explosive rate of population growth. With a total population estimated at 7.3 million in 1989, this small landlocked country has a population density of 279 people per square kilometer, the highest in Africa. Such a density puts a heavy pressure on land availability and agricultural production in this essentially rural economy, where people live on small farms scattered across the hilly countryside. Population pressure will increase rapidly as a result of the current population growth rate of 3.6 percent per year (the fastest growth rate in Africa). At this rate, the total population will double in twenty years. While trying to avoid prediction of a doomsday scenario, it is difficult not to be apprehensive about Rwanda's situation in the year 2010. At that time, with 2 to 3 million job-seekers and landless farmers and a heavily deteriorated environment, Rwanda could be facing severe internal social unrest and external tension with neighboring countries unable or unwilling to absorb large numbers of illegal migrants. The potential resettlement in Rwanda of thousands of refugees as a result of recent political events will worsen the population pressure in certain parts of the country. 1.02 On the economic side, the situation is also worrisome. Rwanda is essentially an agricultural country, with agriculture accounting for half of GDP and 75 percent of total export earnings. The nation's balance of payment situation is heavily dependent upon a single export, coffee. During the 19709, thanks to high coffee prices o0 the world's market and prudent government management, Rwanda's economic performance was good, particularly in comparison with other SSA countries. However, in the 19809 the situation progressively deteriorated for several reasons. The price of coffee fell and is not likely to rise in the near future. The government, by keeping a tight control on