Morocco - Social Priorities Program : Basic Health Project

Document of The World Bank Report No. 15073-MOR STAFF APPRAISAL REPORT KINGDOM OF MOROCCO SOCIAL PRIORITIES PROGRAM (BARNAMAJ AL AOULAOUIYAT AL IJTIMAIYA) BASIC HEALTH PROJECT May 9, 1996 Human Resources Division Maghreb and Iran Department Middle East and North Africa Region CURRENCY EQUIVALENTS Currency Unit: Dirham (DH) US$1.00 = DH8.3 (as of April 1996) FISCAL YEAR January 1 to December 31 (until 1995) July 1 to June 30 (as of 1996) ABBREVIATIONS AND ACRONYMS AfDB African Development Bank BAJ Barnamaj al-Aoulaouaiyat al-Ijtimaiya (Social Priorities Program) CAS Country Assistance Strategy CNSS Caisse Nationale de Securit Sociale CSSS Comitg de Suivi de la Strategie Sociale (Social Strategy Steering Committee) DALYs Disability-Adjusted Life Years EPI Expanded Program of Immunization ESSB Etablissements de Soins de Santd de Base EU European Union ICB International Competitive Bidding HIV Human Immuno-deficiency Virus IEC Information, Education, Communication LSMS Living Standards Measurement Survey MSP Minist&re de la Sant Publique NCB National Competitive Bidding PAS Programme d'Action Sectoriel (Sectoral Action Program) PDP Programme de Depenses Publiques (Public Expenditure Program) PECS Plan d'extension de la couverture sanitaire PMIS Program Management Information System PPS Programme de Priorites Sociales (Social Priorities Program) SAP Sectoral Action Plan SDS Strategie de Developpement Social (Social Development Strategy) SEGMA Service g6r6 de mani re autonome SPP Social Priorities Program STD Sexually Transmitted Disease TB Tuberculosis TFR Total Fertility Rate UNFPA United Nations Fund for Population Activities UNICEF United Nations Children's Fund USAID United States Agency for International Development ZIP Zone d'intervention prioritaire (Priority intervention area) KINGDOM OF MOROCCO SOCIAL PRIORITIES PROGRAM BASIC HEALTH PROJECT STAFF APPRAISAL REPORT Project and Loan Summary Borrower: Kingdom of Morocco Implementing Agency: The Ministry of Public Health (MSP) Poverty: Program of Targeted Interventions Amount: US$68.0 million equivalent Terms: Twenty years, including a five-year grace period, at the IBRD standard variable interest rate Commitment Fee: 0.75% on undisbursed loan balances, beginning 60 days after signing Financing Plan: (US$ million) Foreign Local Total IBRD 68.0 - 68.0 Government 0.2 50.6 50.8 Total 68.2 50.6 118.8 Net Present Value: N\A (cost-effectiveness calculations) Environmental Rating: C Staff Appraisal Report: No. 15073 Map No.: IBRD 27639 Project ID No.: 42415 BASIC DATA Indicators Measure Date National Wealth GNP per capita (US$) 1040 1993 Population Total population (million) 26,073 1994 Rural population (% of total) 48.6 1994 Population growth rate (%) 2.1 1982-94 Poverty Head-count Index poor (%) 13.1 1990-91 very poor (%) 7.0 1990-91 Poverty line (annual DH per person) very poor (rural) 2,040 1990-91 poor (urban) 2,730 1990-91 Education Adult literacy (% of population, age 15+) Total 45 1991 Female 32 1991 Net School enrollment (% of total) Primary 58 1991-92 Secondary 28 1992 Health Life expectancy at birth (years) 62 1992 Infant Mortality Rate (per thousand) 62 1995 General malnutrition (%) 15 1992 People per physician (number) 2,760 1995 Married women using contraceptives (%age) 42 1995 Employment Minimum wage for nonagricultural sectors (DH per day) 50 1995 Minimum wage for agricultural sector (DH per day) 38 1995 TABLE OF CONTENTS I. SOCIAL SECTOR BACKGROUND AND ISSUES ..................................................1 A . Econom ic C ontext............................................................................... B . P overty............................................................................................ C. Population, Health, and Nutrition.............................................................2 II. GOVERNMENT STRATEGY AND BANK RESPONSE...........................................7 A . G overnm ent Strategy............................................................................7 B. Rationale for Bank Involvement...............................................................8 C. Bank Experience and Lessons Learned .......................................................9 III. T H E PR O JE C T ......................................................................................... 10 A. The Social Priorities Program ............................................................... 10 B . Project O bjectives ............................................................................. 11 C . Project D escription ............................................................................ 12 IV. COSTS, FINANCING, AND MANAGEMENT .................................................. 15 A. Summary of Project Costs ................................................................... 15 B . F inancing ....................................................................................... 16 C . Econom ic A nalysis............................................................................ 17 D. Management and Implementation ........................................................... 19 V. PROJECT BENEFITS AND RISKS.................................................................. 25 A . B enefits ........................................................................................ 25 B . R isks............................................................................................. 26 C. Stakeholders' Participation................................................................... 26 D . Poverty C ategory .............................................................................. 27 E. Environmental Assessment ................................................................... 27 VI. AGREEMENTS AND RECOMMENDATIONS .................................................. 27 This report, prepared by Mrs. Maryse Pierre-Louis (MN1HR), is based on the findings of an appraisal mission that visited Morocco in June 1995, led by Mr. Benoit Millot (MNIHR), and comprising Mrs. Maryse Pierre-Louis and Mr. Jean Christophe Laederach (MN1HR). Mrs. Dung-Kim Pham, (MNIHR) assisted in preparing the project costs and financing tables. Ms. Elizabeth Sherman edited project documents. Peer reviewers are Mr. Alexandre Marc (EC4MS), Mrs. Dominique Van de Walle (PRDPE). Mr. Jean Francois Dupuy is the lawyer for Morocco, Mrs. Roslyn Hees is MN1HR Division Chief and Mr. Daniel Ritchie is MN1 Department Director. ANNEXES 1. Basic Sector Information 2. SPP/BAJ: Organizational Structure 3. Provinces Selected for the Program 4. Selected Project Data 5. Summary Cost Tables 6. Procurement and Disbursement Data 7. Project Implementation Monitoring: Key Indicators 8. Selected Information in the Project File MAP Map No. IBRD 27639 KINGDOM OF MOROCCO SOCIAL PRIORITIES PROGRAM BASIC HEALTH PROJECT STAFF APPRAISAL REPORT I. SOCIAL SECTOR BACKGROUND AND ISSUES A. Economic Context 1.01 Over the past decade, Morocco has instituted reforms designed to achieve macroeconomic stability and to liberalise the economy. Wide-reaching and comprehensive, the reforms have gradually moved Morocco away from a predominantly state-administered economy towards one that is more market-driven and outward-oriented. Yet, progress achieved on the macroeconomic front remains fragile, as demonstrated by the continued indebtedness, and the deterioration in the fiscal and external accounts which were exarcerbated by the 1995 drought. 1.02 Morocco's growth rate, which averaged about 4% annually during the last decade, fell well below expectations and was too low to absorb the country's growing labor force. Private investment and domestic saving rates remain modest; labor productivity is not increasing; and international competitiveness has recently eroded. The situation has been further exacerbated by the recent drought, but prospects for 1996 are brighter. Despite significant recent progress, performance has also been disappointing in the social sectors. Morocco's indicators in health, education, literacy, and access to safe water continue to lag behind those of economically comparable countries. A fifth of the population still lives in poverty or near-poverty, urban unemployment rates have reached 20%, and rural women are still economically and socially marginalized. 1.03 Morocco's low social performance and its relative economic success are intimately related. For even with constructive political and economic reforms in place, the country cannot reach and sustain higher economic growth rates without a substantial accumulation of human capital. To achieve such a reserve, it must boost its investment in the provision of basic social services. Conversely, without sustained economic growth, it will be extremely difficult to improve substantially employment opportunities and living conditions of its population, which already stands at 26 million and is growing apace. B. Poverty 1.04 Data gathered from the 1985 Household Consumption Survey and the 1991 Living Standards Measurement Survey (LSMS) showed that the share of Morocco's population living below the poverty line fell from 21 to 13% in those six years, while the GNP per capita rose by about 30% (and presently hovers at around US$ 1,100). This performance was achieved during the period of structural adjustment. Adding the number of those whose expenditure levels are just above the poverty line to the number of those who live below it, more than 3.3 million Moroccans are poor enough to be isolated from the mainstream economy. -2- 1.05 Urban, rural, and regional variations are also striking, and the gap dividing them is deepening. In 1991, 72% of all poor lived in rural areas as compared to 70% six years earlier. Likewise, while a quarter of the population lived in poverty in the Center-North, East, and Center- South regions, the poverty rate was below 5% in coastal areas. In rural areas, the poor are typically either seasonally underemployed wage-earners or small-scale farmers. In urban areas they are mostly self-employed people who work in the informal sector, underpaid (often temporary) wage- earners, or are unemployed. If access to basic social services is taken into account, still more differences between urban and rural areas come to light. 1.06 Along with low pay, unemployment and underemployment are major determinants of poverty. In the early 1990s, the aggregate unemployment rate in urban areas was estimated at 16 to 20%, but among the urban poor the unemployment rate reached 30%. Unemployment rates are much lower in rural areas, but these areas suffer substantial, chronic underemployment. Not surprisingly unemployment is most widespread among those with little or no education, but neither are those with a secondary education immune. Unemployment rates are higher for women overall. 1.07 The growing importance of the informal sector--although a sign of the economy's dynamism and ability to absorb excess labor supply and react to demand--reflects an increase in the reservoir of persons prone to fall below the poverty threshold. The poverty assessment report (World Bank 1994) found a strong link between poverty in economic terms and such social ills as low literacy, education, health, and nutrition levels and high fertility rates. That report, and other studies, also found a strong correlation between income levels and degree of access to basic social services. In light of these findings, the report strongly recommends the rehabilitation of basic social services as a necessary prerequisite for the durable alleviation of poverty. Yet, until recently the various social policies and programs were not strongly coordinated, and the link between this disparate set of sectoral actions and the macroeconomic framework was loose. There was, moreover, no visible political will to address the problem of lagging social sector performance. C. Population, Health and Nutrition Population and health 1.08 As the other countries of the Maghreb, Morocco is in the midst of a demographic, epidemiologic, and social transition resulting from the diminution of the mortality rate from 19 per 1,000 in the 1960s to 7.3 per 1,000 in 1992 and a diminution in birth rates to 28.1 per 1,000. The annual population growth rate slowed from 2.8% for 1955-60 to 2.06% in 1982-1994. On the health front, transmissible diseases and maternal and child-related health problems are coming increasingly under control but still represent an important burden of disease ("the unfinished agenda" as it is referred to in the epidemiologic transition), while the impact of chronic diseases is rising. In 1989, for instance, cardiovascular diseases caused one out of five deaths in Morocco. The country's successful priority health programs and improved lifestyles are responsible for these significant health gains. Over the last thirty years infant mortality has decreased from 119 to 61.6 per 1,000 and life expectancy at birth has increased from 45 to 65 years. 1.09 But despite these significant achievements, key indicators remain low. The maternal mortality rate is among the highest in Africa, averaging 332 per 100,000 as compared to 50 in Tunisia and 140 in Algeria. Inadequate handling of complicated deliveries is the main cause of death--not surprisingly, since only 40% of all deliveries take place in a medical setting (compared to 76% in Tunisia). Access to health facilities, evacuation procedures, and the medical referral system are deficient. Survey results also suggest that the prevalence of male health personnel is a possible -3- factor in Morocco's low use rates of maternal medical services. In addition, the fact that early neonatal deaths account for half of the infant mortality rate reflects the poor quality of services offered. Such potentially controllable infectious diseases as acute respiratory infections, diarrhea, measles, and meningitis are also among the leading causes of mortality and morbidity in children aged one to five. Tuberculosis, malaria and schistosomiasis are still non-negligeable features of morbidity, and poor hygiene and sanitation in the rural areas are a cause of serious concern. Although acquired immunodeficiency syndrome ( HIV/AIDS) is not yet a major problem, sexually transmitted diseases (which increase the risk of HIV infection) affect more than 7% of the population, according to a recent survey. 1.10 Morocco's population is expected to grow from 26 million currently to 33 million by 2007. At that time, the natural rate of increase will be 1.30%. The population under 15 would then represent a quarter of the population as against 38% now. Since 1968, family planning has been integrated into all development plans. In 1976 a division was created within the Ministry of Public Health (Minist&re de la Santg Publique, MSP) to launch the VDMS program (visite a domicile de motivation systmatique)--a major community outreach effort that subsequently led to the rapid development of family planning activities. This program and the increase of age at marriage, from 17.3 years in 1960 to 24 years in 1987, are responsible for the decrease in the total fertility rate (TFR) in Morocco from 7.4 to 3.6 children per woman. The modern contraceptive prevalence rate is now estimated at approximately 43%, with the pill being the most widely used method. The Government's objective for the year 2000 is to decrease the TFR to 2.6 children per woman. 1.11 Seven separate surveys have been carried out over a twenty-year period regarding the nutritional status of the population and Morocco has made significant efforts to deal with problems of food insecurity. The typical Moroccan diet's daily supply of calories (essentially from sugar, cereals, oils and other fats) would be adequate if food were equitably distributed. But as it now stands approximately 17% of children are wasted, stunted, or both. Children in the rural areas are at a clear disadvantage, and acute and chronic malnutrition are most prevalent in the South and Tensift regions. A 1989 infant mortality survey showed that malnutrition, associated with diarrhea, was the leading cause of death for children aged twenty-eight days to five years. It also showed significant gaps in the nutritional status of the urban versus the rural population, and men versus women. A 1994 national survey on iron and iodine deficiency found that 22% of children aged six to twelve were iodine deficient. Even more strikingly, 35.5% of children aged six months to five years and 45.5% of all pregnant women suffered from iron-deficiency anemia. A strategy to deal with iodine deficiency is presently being implemented with the assistance of the United Nations Children's Fund (UNICEF) and the African Development Bank (AfDB), and a strategy to address the problem of iron deficiency is being discussed (Annex 4). Organization of the health system 1.12 The national health system is organized around three sectors: public (MSP and Royal Army structures), semiprivate (mutuals and the CNSS, Caisse nationale de s9curit6 sociale, a network of twenty-three hospitals and clinics for government employees and their dependents) and private (about 2,550 private doctor's offices and 110 clinics). The private sector tends to be concentrated in major urban areas. The rural population relies almost entirely on the public sector for the provision of health care. 1.13 The MSP was reorganized in December 1994 and now includes seven directorates at the central level and sixty provincial delegations headed by physicians (Annex 1). Each provincial delegation includes an ambulatory unit staffed by a physician and nurses. This structure is -4- responsible for all preventive and ambulatory care. But given the fact that MSP has until now been a highly centralized organization, the provincial level's actual contribution to planning has been quite limited so far, with the exception of some pilot experiences. 1.14 The public sector network includes about 1,650 basic health facilities (-0tablissements de Soins de Santg de Base, ESSBs), and 98 hospitals (provincial, regional, and university). The ESSBs include urban and rural dispensaries and health centers and represent the first interface of the population with the fixed facility system. They provide primary health care and handle deliveries, and all services are free of charge. In addition to the ESSBs, service coverage is provided by mobile clinics, outreach health workers, and in some remote areas, by traditional birth attendants (kablats). Major sector issues 1.15 Major sector issues include the inequity and inefficiency of the health system; the insufficient coverage of the rural population; the poor performance of the public health system, especially at the basic level; the situation in the pharmaceutical industry; insufficient financing to cover the rising cost of health care; and the centralization of management. 1.16 Inequity and inefficiency of the health system. Discrepancies between urban and rural areas and among regions are striking. The infant mortality rate is 65 per thousand in rural areas as opposed to 44 per thousand in urban areas; total fertility is 4.9 children per woman in rural areas compared to 2.2 in urban areas; and the under five mortality rate is 160 per thousand in the south, the poorest region of the country, as opposed to 66 per thousand in the center. Three-quarters of health personnel are concentrated in Rabat and Casablanca, where their services are underused. Morocco's better off citizens receive 40% of the MSP budget, the poorest receive less than 20% of this budget--translating into a per capita health expenditure which is 2.6 times greater in urban areas. The former therefore benefit more from the system. The hospital network, moreover, is mostly concentrated in the northeastern and central regions, and while all categories of health care personnel have significantly increased since 1960, 63% of physicians in the public sector are assigned to hospitals, with only 30% working in the ESSBs. The sector as a whole is poorly managed (as can be seen from its record of poor maintenance of equipment and infrastructure, waste, inadequate management and deployment of human resources, and poor logistics). By targeting Morocco's needy, the project would address the issue of inequity. It would also address the problem of inefficiency at the basic health level, since the hospital level is being dealt with by a separate Bank-funded project, under preparation (Health Management and Financing Project, FY97). 1.17 Insufficient coverage of the rural population. It is estimated that 37% of Moroccans use fixed public sector health facilities, and this number reaches 79% in lower-income groups and rural areas. By comparison, 52% of consultations are handled by private sector physicians. Data from the 1991 LSMS show that health care consumption is income elastic: the use rate is 64% among the 20% richest of the sample, as against 32% for the 20% lowest income group. While the coverage provided by the basic health network has significantly improved during the last decade, only 47% of the rural population now has access within six kilometers to fixed primary care facilities provided by the public sector, and no private facilities exist in the rural areas. Fourteen percent of rural people have no coverage, even in theory. This situation is not only caused by the inadequate distribution of health facilities and manpower between regions and in rural areas but also by their insufficient number overall. Approximately 53% of the rural population, moreover, lives more than six kilometers away from an existing health care facility, which represents a major constraint to -5- access, especially that the private sector is not likely to expand significantly into the rural areas. The coverage provided by the mobile teams and outreach health workers (infirmiers itingrants) is not functioning well, and the number of such workers has been diminishing significantly. The project would address these issues in the provinces targeted. 1.18 Poor quality within the basic health care system. The low credibility of the public health system largely explains its low rate of use. Curative care is virtually nonexistent, and visible and sustainable improvements in essential service delivery would be necessary to build the public's confidence in the ESSBs. During project preparation, a beneficiary assessment carried out in a sample of five of the provinces targeted under the project indicated that approximately half of the sample population was unhappy with the overall performance of public health facilities because of the lack of drugs, long waiting time, and poor staff attitude. As confirmed by surveys undertaken during project preparation, many facilities lack basic equipment and are poorly maintained. This accounts mainly for the low utilization of these services. Two-third of all public facility medical equipment have not been replaced in the last fifteen years. As confirmed by surveys undertaken during project preparation, the mobile clinics, too, are poorly equipped and organized, are not supervised, are poorly maintained, and resources to supervise and keep them functioning properly are lacking. 1.19 Health personnel, moreover, are not adequately deployed, are poorly motivated, and are not properly trained to deliver services. Because of lack of support from the MSP at the central and provincial levels, the number of outreach health workers is decreasing rapidly (there are barely a thousand left in the country). Mobile clinics and outreach workers, moreover, are not well integrated in the system and deliver in fact only a small portion of the essential services they are supposed to provide. Morocco's priority health programs are suffering from this situation. To give a few examples, the safe motherhood program is clearly lagging behind with only 45% (as opposed to almost 60% in Tunisia) of pregnant women seeking prenatal care. Immunization coverage in rural areas has improved (to around 78%) but is still very insufficient. Emergency evacuations still do not exist, a situation which contributes to unacceptable levels of maternal, neonatal and infant mortality rates for a middle-income country such as Morocco. 1.20 Insufficient financing and rising cost of health care. Public sector financing accounts for 34% of total health expenditures in Morocco, NGOs and international aid for 4% and the private sector for 62%. Total health expenditures represent 3.8% of GDP (as compared to 4.9% in Tunisia and 7% in Algeria). Approximately 92% of public sector financing comes from MSP budget, which grew in real terms by 3.7% annually from 1960 to 1994. But if the effect of population growth is added to inflation, MSP's budget has been virtually stagnant during that period, averaging increases of only 1.3% a year. The MSP's share of government expenditures, moreover, decreased from 7.8% in 1960 to 2.9% in 1975, then rose again to 4.6 in 1994. About 75% of the MSP recurrent budget, moreover, goes to hospitals, which have no mechanisms to ensure better targeting of the needy population, which is eligible for free care. Expenditure on personnel represent 55% of the MSP total budget. Health costs are defrayed by households, which contribute up to 50% of expenditures 1.21 Per capita health expenditure (less than US$40) is relatively low in Morocco when compared with that in other countries of similar economic development (such as Tunisia's US$100). Public expenditure is also distributed poorly within the sector and across regions and milieus. As Morocco enters an epidemiologic, demographic, and social transition, and as income increases, the demand for health care will be even greater. An aging population will demand more sophisticated medical technology and long-term care, both of which are costly. It will therefore be even more -6- difficult for the Government to sustain the rising cost of health care. The MSP is presently conducting a study to analyze the changing situation in the sector (Maghreb Health Priorities Study FY96). At the same time a Health Management and Financing Project is being prepared in collaboration with the World Bank which will address financial as well as managerial issues. 1.22 The situation in the pharmaceutical sector. Morocco has a thriving pharmaceutical industry that produces a large quantity of drugs, covers over 80% of the country's pharmaceutical consumption and has started to export to other countries in the Region. The Moroccan industry, however, has been partly protected from international competition by high tariffs that have increased the cost of drugs to the population, and some firms have not achieved the level of quality of production that should be expected. Most of the pharmaceutical market is in the private sector, and serves wealthy and middle-class populations, as essential drugs often prove too expensive for the poor. The small public sector takes care of drug supply to primary care facilities and hospitals. Because of severe budget under-funding for essential drugs, Morocco has relied on external financing, including Bank loans, to finance a large share of public sector drug provision. This policy of financing basic operating costs through external assistance has proved a major disincentive for exploring other financing avenues, such as cost recovery, and has created a serious issue of sustainability in the medium and long term. 1.23 Morocco does not have a comprehensive pharmaceutical policy which guarantees reasonable access to essential drugs to the poor. Quality control and inspection have not performed adequately, and the drug pricing policy has favored the distribution of relatively expensive drugs in the private sector over that of cheap products. The recent reorganization of what used to be the Pharmacie Centrale (Central Pharmacy), under the umbrella of the MSP, has improved the overall management of stocks and MSP is committed to pursue this effort. However, logistics is still deficient and delays in the delivery of drugs to hospitals and the peripheral level are still more than a month, except for emergencies. Despite noticeable improvement in the procurement of drugs, the annual unique bidding process limits the possibilities to negotiate interesting prices. Because of these shortcomings, health facilities often face shortages and have to buy directly from local suppliers at a high price. The most serious problems in the public sector are the insufficient funding allocated through the budget and the inadequate intrasectoral allocation of resources for drugs among the different levels of health care, with hospitals taking the lion's share of drug allocations. In the early 1990's, the annual budget allocated to drugs and consumables was approximately 200 million of dirhams. This number has been decreasing recently, and hospitals use 36% of this budget. Per capita expenditures on drugs is estimated to US$23 of which US$1 comes from the public sector. During project preparation, the Bank funded a major pharmaceutical study. Agreement on actions to be taken in the sector was reached at negotiations [para.6.03 a(ii)]. 1.24 Centralization of management. An effective partnership between the central and provincial administrations does not currently exist. The provincial level, perceived as the implementing arm, has traditionally enjoyed little decisionmaking power, leaving little room for the initiatives and local adjustments necessary for the development of programs. Key aspects of personnel management are also centralized, an issue that will need to be dealt with if peripheral units are to manage their own personnel. The performance of rural health programs and services is also hampered by the lack of a locus for managing local health systems. Under the current arrangements, districts are widely dispersed and no intermediate level between province and district exists. With the recent reorganization (December 1994), the MSP is in the process of redefining the respective mandates of the central and provincial administrations, and defining the role of the MSP at each level of health care would be an important outcome of the Sectoral Action Plan. During negotiations, agreement was reached that mechanisms to strengthen provincial participation to planning of and decision- -7- making for sector activities would be identified, submitted to the Bank and implemented by December 31, 1997 [para 6.03a (iii)]. II. GOVERNMENT STRATEGY AND BANK RESPONSE A. Government Strategy 2.01 For a long time in Morocco, spending to promote human capital was not considered an investment that would ultimately lead to greater and more sustainable economic growth, and instead, economic growth was perceived as the only engine of social progress. Therefore, social concerns were not a top Government priority, and--despite indisputable sectoral improvement during the 1980s and 1990s--there was no comprehensive, long-term plan for the social welfare of the country. 2.02 But following an era of thorough macroeconomic adjustment and worrisome decline in social conditions throughout the Kingdom, the Government has started to focus on social issues in a more concerted manner. In 1993 it issued the Social Development Strategy (Stratigie de Dgveloppement Social pour la DOcennie 1990, SDS), which sets forth clear directives aimed at reversing past trends and establishing the framework for a sound social policy. Based on the 1991 Living Standards Measurement Survey, the Government strategy made extending basic social services to the poor and increasing their participation in economically productive activities its highest social goals. Such extended coverage would include access to safe water, sewage facilities, health care, family planning services, nutrition, primary education, literacy programs, and subsidized public housing. But recognizing prevailing budgetary constraints, the strategy stresses the inter- and intra-reallocation of resources and introduction of cost-recovery mechanisms. It also advocates action to promote employment and bolster social protection. Finally, the SDS emphasizes that a strong and appropriate administrative vehicle and reliable statistical monitoring system are required for the implementation of its recommendations. 2.03 The Government gave the first version of the Stratigie de Diveloppement Social pour la D6cennie 1990 to the Bank in the context of the second adjustment program. Following the appraisal of the Social Priorities Program, the strategy was updated, formally reendorsed by the new Government, and officially conveyed to the Bank [para. 6.01b]. Its internalization throughout the relevant agencies is now underway. Specific Sectoral Action Plans (SAPs) are being developed for the education and health sectors as part of the preparation of the Social Priorities Program. The recent creation of the Ministry of Population, which has the responsibilities of a ministry of planning, and should be able to coordinate actions throughout the social sectors within a unifying framework, is another signal that the Government is taking social concerns seriously and is adapting its institutions accordingly. Finally, the King's address to the Parliament of Morocco in October 1995 shows that concerns for the social situation now emanate from the highest levels of the power hierarchy. 2.04 Public resources for health are limited, and competition with other sectors for these resources is great. Moreover, considerable deficits have accumulated in the sector, and projected growing needs in the future (given population and demographic trends) will have to be addressed, while at the same time promoting efficiency and equity. -8- 2.05 The Government has already taken a number of strategic measures to deal with these challenges: (a) resources will be targeted toward priority rural areas. The latest investment program already reflects this new policy, and the MSP's Programme de Midicalisation du Monde Rural is staffing rural health centers with physicians. Four-hundred physicians have already been deployed to priority districts; (b) the Government is also working on a health financing reform plan that would introduce compulsory health insurance. Discussions on establishing a fund to subsidize health care for the needy are also under way, but no agreement has as yet been reached on this important issue. At the same time, greater efficiency is being sought by reorganizing hospitals, granting them autonomy (SEGMA) and integrating priority health programs. These measures should also make it possible to channel more resources to the primary health level, as required in the SAP; (c) priority health programs will be strengthened, with special emphasis on programs in maternal and child health; and (d) roles and functions of the central and provincial levels will be redefined in the context of the recent reorganization of the MSP in order to give more autonomy to the provinces. The submission of the SAP was a condition of negotiations [para.6.02a]. B. Rationale for Bank Involvement 2.06 The severe state of degradation of Morocco's social sectors underscores the urgent need for intensive, durable action. Bank support for such action is called for both by the present climate of support in the Government and by the Bank's own Country Assistance Strategy (CAS), currently under preparation, which puts investing in people as its first priority. Bank support for the social sector would also accord with its parallel efforts to strengthen macroeconomic performance and encourage growth through private investment. Other donors have viewed the goals of the Stratigie de Dveloppement Social pour la D6cennie 1990 (based on the Living Standards Measurement Survey and confirmed by the World Bank poverty assessment) as a rallying point, and support for SDS policies is fully in line with the Bank's strategy of poverty alleviation and Morocco's overall plan to develop its human resources. Since the Bank has already financed several projects in Morocco's social sectors--especially in health and education--the proposed project would be an extension of earlier Bank involvement. The Country Economic Memorandum (World Bank 1995a) provides a solid body of evidence that programs whose aim is to improve Morocco's human capital base and to increase labor efficiency and productivity warrant reinforcement of present Bank support. Finally, a recent study of the region's present situation and long-term prospects (World Bank 1995b) shows that Morocco, along with its neighbors, is experiencing high unemployment and now feels an especially urgent need for bold programs aiming for both economic growth and poverty alleviation. The Bank's role in promoting the Government's social strategy and marshaling international and bilateral support for social programs will be critical if Morocco is to succeed in the fight it is waging against poverty, both in terms of equity and of economic growth. 2.07 In its SDS, the Government of Morocco identified inequity in the health 3ector as a major impediment to socioeconomic development and committed itself to channel more resources to rural areas, especially for the priority health programs (basic curative and preventive care, safe motherhood, transmissible diseases, nutrition). The proposed project would help the Government to -9- close the gap between rural and urban health indicators by better targeting of the needy population. The project fits into the Bank's human resources development strategy, which supports efforts to improve the quality and relevance of social services, to increase public spending on basic services and improve targeting to underserved groups and areas and to increase internal efficiency overall within the human resources sector. Project preparation was instrumental in getting the MSP to develop its Sector Action Plan, which will provide a framework for all interventions in the health sector, facilitate coordination, and stimulate additional grant funding from other donors. C. Bank Experience and Lessons Learned 2.08 In the past, the Bank has supported several operations in Morocco's social sectors, and three such projects are currently being implemented (Rural Primary Education Project, Loan 3026- MOR; Rural Basic Education Development Project, Loan 3295-MOR; and Health Sector Investment Project, Loan 3171-MOR). The main general lessons to be drawn from these operations are as follows: (a) reforms in the social sectors should not be overly ambitious because of their immense impact on large groups and the political risks attached to them; (b) a good management information system and simple and transparent management, procurement, and disbursement procedures must be in place for all Bank-financed activities. Such measures are also meant to offset cumbersome local financing circuits, which tend to delay execution and slow down disbursements, especially for decentralized project activities. A study is currently being conducted by the Government to identify precisely the bottlenecks and the sources of delays; (c) to ensure full acceptance of the project, it is critical to seek the early involvement of all constituents--in particular, employees of line ministries at the provincial and local level who will play a crucial role during project implementation. It is equally important to involve other government constituencies (such as the Ministry of Finance) and other donors early enough in the process to guarantee successful future collaboration; (d) finally, realistic budgetary envelopes have to be projected (and committed) to ensure the sustainability of sectoral programs and actions. 2.09 The Health Development Project (HDP, Loan 2572-MOR, US$28.8 million, 1986-93), was the first major Bank loan in the sector. Prior to this loan, Bank involvement in the sector was limited to a component of an agricultural project (Loan 1201-MOR) and to a health worker training component in the Third Education Project (Loan 1220-MOR). The HDP was designed to support the MSP primary health care program in three provinces on a pilot basis, to improve the drug supply system, and to enhance the MSP's management capacity. The primary health care component was fully implemented and had a significant impact on access to health care. Some aspects of MSP management capacity have improved, but others (program budgeting, resource allocation, availability of drugs) remain serious concerns. 2.10 The second Bank supported operation in the sector was the Health Sector Investment Project (HSIP, Loan 3171-MOR, US$104.0 million, 1990-96) which is still being implemented. Its objectives are to reestablish sustainable health programs nationwide and strengthen the administration and management of services. Given its slow start, and although its disbursement profile has significantly improved, the project may not achieve all of its stated objectives. Its closing date has been extended to December 1997. - 10 - Lessons learned in the health sector 2.11 Evaluations of the Health Development Project (ICR) and of the ongoing Health Sector Investment Project have underscored the importance of taking certain key areas into account during project preparation and design: (a) The question of the financial sustainability of the system must be addressed. An agreement with the Government is already in place for the preparation of the Health Management and Financing Project which would address the question of health financing, sector efficiency, and hospital management. (b) The provision of drugs to the public sector need to be reviewed. In May 1995, during project preparation, the Bank's Human Development Department sponsored a major study of the pharmaceutical sector whose conclusions have been integrated into the proposed project [para. 1.23 ]. (c) The different strategies for delivering services need to be analyzed carefully and adapted for each region. During project preparation, the National Institute of Health Management (INAS) conducted such an analysis in a sample of the provinces where the project would be implemented (Annex 8). The provincial medical officers of these provinces have also been involved in the selection of districts within their provinces that would benefit from various different types of coverage (such as health centers, mobile teams, outreach health workers). (d) Provincial health officials should be accorded more power to make decisions so as to ensure that project activities are suited to local conditions. During project preparation the medical officers of the targeted provinces attended three workshops to discuss project objectives and agree on which priority activities needed to be developed. The MSP is also reviewing its provincial organization plan [para. 1.24] to ensure that activities are tailored to local needs and to stimulate initiative at the local level. III. THE PROJECT A. The Social Priorities Program 3.01 The proposed project is part of the Social Priorities Program I (SPP I; Barnamaj al- Aoualaouiyat al-Ijtimaiya, or BAJ I, in Arabic; Programme Priorits Sociales, or PPS I, in French), initiated to assist the Government in the implementation of its strategy to increase the poor's access to basic social services, enhance basic social protections, and create new opportunities for the unemployed to participate in economically productive activities. The program would also bolster Government awareness of poverty-related and social issues and catalyze efforts to rehabilitate Morocco's social sectors. While the SPP would entail a series of consecutive programs following one another at a rapid pace, SPP/BAJ I was conceived as a set of three complementary projects to be negotiated and implemented simultaneously (Annex 2). All three share the same broad objectives, were developed within the same framework, and would be implemented independently within the same geographical area. 3.02 By using a multisectoral approach--which is expected to yield more significant and durable results than serial, strictly sectoral projects--this tripartite program would help to guarantee - 11 - flexibility in execution and should therefore be a more efficient way to channel energies and resources. The SPP/BAJ would target Morocco's thirteen poorest and least urbanized provinces, where 27% of the total population, or 7,054 million people, currently live (provinces and selection criteria are listed in Annex 3). By involving provincial authorities in project monitoring, moreover, the SPP/BAJ should achieve the integration needed to reinforce its impact. The objectives of the three projects are: (a) to increase the quality and quantity of basic education while at the same time making the education system more efficient and equitable; (b) to improve access to basic health services and improve their quality while bolstering performance and managerial capacities within the health care system; (c) to enhance basic rural infrastructure through labor-intensive techniques; and (d) to establish a permanent apparatus for data collection and analysis that would strengthen the government's ability to galvanize support for SDS activities and monitor their impact. B. Project Objectives 3.03 Specific objectives of this project are: (a) to provide better access to essential preventive and curative care from 47% (population currently living within 6 kms of an ESSB) to 60% of the targeted population, including equitable access to essential drugs; (b) to reduce maternal and neonatal mortality in the targeted areas by increasing the coverage of prenatal visits from 28 to 50% and assisted deliveries in a medical setting from 18.5 to 30%, and by making available modern family planning methods; and (c) to maintain the performance of priority public health programs at the national level. For key project indicators, see Annex 7. 3.04 The innovative aspect of this project in Morocco stems from the fact that: (a) it will target the poorest population in the country; (b) the project was designed and prepared in closed collaboration with the local staff who would be involved in its monitoring and implementation; (c) it would be a major support for the development of the MSP Sectoral Action Plan and would stimulate the implementation of many activities with pay-offs in the medium-term; (d) it would be flexible enough to allow for adjustment to the local situation; (e) it would hold provincial health officials responsible for the planning, implementation, and monitoring of project activities in the thirteen provinces; and (f) it would require providing drugs while implementing important actions in the pharmaceutical sector. 3.05 The project would concentrate on specific districts in the targeted provinces. These districts were selected as priority intervention areas (Zones d'Intervention Prioritaires, ZIP) in collaboration with provincial medical officers according to the following criteria: demographic data, existing access to health services, coverage, epidemiologic profile, and use of services. Most of the districts chosen were rural. 3.06 Infant mortality and maternal and neonatal mortality are well above national averages in these districts, and the health infrastructure there is both quantitatively and qualitatively inadequate. The mortality and morbidity pattern is dominated by infectious diseases (measles, diarrhea, typhoid fever, tuberculosis). Access to safe water is a major issue, and in some areas, literacy rates only reach 20%. In addition to health coverage being insufficient in those areas, the people rarely use the services that are available, mainly because of their poor quality. While the project would focus most of its activities on these selected areas, moreover, certain interventions would be carried out nationally (such as the transmissible disease control programs already being supported under the PRISS project). In fact, most of these activities, under the third component, will concentrate primarily on the thirteen provinces, given their mortality and morbidity patterns. - 12 - C. Project Description 3.07 The proposed project would be implemented over a five-year period plus one year to complete disbursements, at an approximate total cost of US$118.8 million equivalent and would complement donor intervention in the sector (Annex 1). It would consist of three components: (a) Improving access to essential curative and preventive health care in the thirteen provinces targeted under the project. (b) Strengthening the safe motherhood program in all its aspects within the thirteen provinces. (c) Maintaining support for priority health programs nationwide. Improving access to essential curative and preventive health care services (US$45.1 million) 3.08 The project would strengthen the capacity of the ESSBs, mobile clinics, and outreach workers to deliver effective basic curative and preventive care. Special emphasis would be placed on rehabilitating curative services to restore public confidence in the services offered and in the efficacy of preventive care. This component would finance activities aimed at strengthening the physical infrastructure, the specific technical functions, the overall organization and delivery of services within health centers and the mobile clinics and the availability of drugs in health facilities. 3.09 During project preparation, the functions of each type of ESSB were reviewed so that the technical capacity and personnel requirements could be accurately estimated. The functions of mobile clinics and outreach workers were also assessed. It was also agreed during project preparation that--during the first phase of the project--resources should be used first to improve existing health care facilities. Once these facilities were fully operational the system would be expanded. This decision was taken to avoid another situation such as that which arose under the Health Development Project, when twenty health centers built and equipped in 1992 and 1993 had to remain closed until June 1995 for lack of personnel . During negotiations, agreement was reached that a human resources development plan would be discussed and agreed upon by December 31, 1997 [para 6.03 (a)i]. This plan will take into account the mobile strategy. It will include redeployment mechanisms, the profile of personnel to be trained, training strategies, and staffing plans for new health centers under the project. The standards for infrastructure expansion and rehabilitation prepared by MSP in 1994 (PECS, Plan d'extension de la couverture sanitaire) would apply under the proposed project. The conclusions of an analysis of the mobile strategy (clinics and outreach health workers) carried out during preparation have been taken into account in the project design. The provincial health administration and the physician in charge of the health center would have primary responsibility for ensuring that the different types of ESSBs deliver the relevant package of services agreed upon. The central Directorate of Hospitals and Ambulatory Care would coordinate the effort. In the public pharmaceutical sector, activities proposed are based on the conclusions of a major sector study carried out during project preparation. 3.10 This component would finance the following elements: (a) The construction of about 80 communal health centers and the renovation rehabilitation/reconstruction of 160 health centers, 25 rural dispensaries, and 15 rural hospitals; - 13 - (b) The purchase of about 340 motorcycles for outreach health workers (to complement the USAID intervention, which would provide the mobile clinics in the selected areas); (c) The provision of medical and non-medical materials and equipment necessary for the delivery of essential curative and preventive services at the clinic, by the mobile team, and by the outreach worker. (The in-country training of health personnel in technical matters related to service delivery, as well as in management and planning of activities, would be financed primarily by USAID and UNFPA); (e) The reorganization of services to be delivered by health centers, mobile clinics, and outreach workers would necessitate the organization of workshops at the local level and additional recurrent costs for follow-up, supervision, and the strengthening of the capacity of provincial health care workers. Provincial officers would be given more flexibility to plan and organize their work in order to tailor services, including outreach activities, to local needs; and (f) a set of activities aimed at improving the access of the rural population to basic curative drugs, including: (a) the purchase of drugs according to a list agreed upon by type of health facility; (b) the strengthening of the information system and the purchase of 6 vehicles at the procurement unit of Berrechid in an effort to improve the management and the distribution of drugs; and (c) the strengthening of the national laboratory for quality control (Laboratoire National de contr6le de M6dicaments/ LNCM), mainly through the improvement of its infrastructure, the purchase of technical materials and equipment. Unlike what was done under the HDS and the HSIP projects, the financing of drugs by the Bank under this project will be linked to the implementation of these above-mentioned actions in the public pharmaceutical sector on which agreement was reached at negotiations [(para.6.03 a(ii)]. Strengthening the Safe Motherhood Program (US$30.8 million) 3.11 This program will be one of the highest priorities of MSP over the next five years. A strategic document on the subject being prepared will outline several specific actions the MSP is planning, both at the national level and in targeted regions where the need is great. There is already agreement that in the proposed project's targeted districts, all aspects of the safe motherhood program would be addressed (except information, education, and communication (IEC) financed by USAID [US$6 million]): the availability of modern FP methods, the reorganization of prenatal services including support to the iron-deficiency anemia program, the improvement of maternity wards, the use of community health workers (such as traditional birth attendants/Kablat) where needed, and the establishment of a sound evacuation and referral system to transfer women in danger from communities and ESSBs to the maternity wards of provincial hospitals. Maximizing the impact of these activities would require a high degree of initiative and commitment by competent provincial officials, who would have to organize and monitor service delivery. 3.12 Available resources (human, material, and financial) in the thirteen provinces would also have to be concentrated in strategic areas, which would be chosen according to specific criteria. Some maternity units would therefore be closed, while other delivery units in strategic areas (health centers with maternity beds, rural maternity wards) would be reinforced. Equipment and personnel would be redistributed and redeployed in these reinforced units. But this approach will necessitate the implementation of a performing emergency referral system and well-trained personnel. These activities would complement EU and UNFPA Safe Motherhood interventions. Provincial health - 14 - officials would have the primary responsibility for the implementation of this component, which would be coordinated by the MSP's Directorate of Hospitals and Ambulatory Care and the Directorate of Population. 3.13 This component would finance the following interventions: (a) The purchase of contraceptives. USAID has officially informed the Government that, beginning 1999, it will no longer finance these purchases. The MSP has therefore requested that the proposed project bear these considerable costs toward the end of the project, given contraceptives proven effectiveness for reducing rates of fertility and maternal and infant mortality. (b) Reorganizing the provision of prenatal services to increase the coverage of pregnant women. This reorganization would require greater physician involvement at the health center level, improved waiting areas (an aspect already taken into account under the first project component), and trained personnel able to detect high-risk pregnancies and to make the necessary referrals'; the provision of iron in the context of the iron-deficiency anemia program; (c) Renovating and rehabilitating 55 rural maternity wards (health centers with maternity wards), and 13 obstetric wards within selected provincial hospitals in the priority zones. (d) Purchasing materials, equipment, and drugs to meet the minimum requirements needed to handle basic obstetrical emergencies. (e) Setting up a medical evacuation system, including defining referral norms and purchasing 126 ambulances. (f) Training, where needed, of traditional birth attendants (Kablats) to handle home deliveries better. Maintaining support for selected priority health programs nationwide (Base cost US$ 41.9 million) 3.14 The project would support Morocco's Transmissible Disease Program, including efforts to control those diseases targeted under the Expanded Program of Immunization (EPI). This support was initiated under the Health Sector Investment Project (HSIP) project. At the time of the mid- term review of this project (May 1994), the Government formally requested Bank support to maintain the performance of these priority health programs nationwide. Given their public health implications, the Bank felt that it was appropriate to provide such support to these programs and not only to the thirteen provinces. This decision was also based on the fact that in the Middle East/North Africa crescent, transmissible diseases account for 51% of the burden of diseases. The EPI--along with the Tuberculosis Control Program--would be the major beneficiary of this support. Other programs would include the Acute Respiratory Infections Program (ARI) in the areas not supported by AfDB as well as programs to combat schistosomiasis, infectious ocular diseases, I The recruitment and training of midwives and obstetrician-gynecologists will be part of the human resources strategy MSP will develop. These categories of personnel are in very short supply in Morocco and are concentrated in major urban areas. Most of the targeted provinces have fewer than one obstetrician-gynecologist for every 10,000 expected births. - 15 - sexually transmitted diseases (STDs), leprosy, malaria, and hygiene and sanitation programs. As mentioned in para. 3.06, it is expected that approximately half of the resources under this component would be concentrated in the targeted provinces, given their mortality and morbidity patterns. (For objectives of these various health programs, see Annex 4). The MSP directorate of Epidemiology and Prevention of Diseases, in collaboration with provincial health officials, would have the responsibility for implementing this component. The high cost of drugs for these programs, especially the tuberculosis control program, EPI, ARI and STDs partly explains the high cost of this component. 3.15 Under this component, the proposed project would finance: (a) The provision of drugs and vaccines, essential materials and equipment relevant to the different programs. The financing of drugs and vaccines under this component will also be linked to the implementation of the set of activities described in para.3. 10(f). (b) The purchase of 7 vehicles and 32 motorcycles which will replace partly the deficient logistic system and will strengthen supervision and monitoring of programs. (c) IEC activities to motivate the population, enroll their support and induce behavioral changes. (c) Additional recurrent costs for the integrated monitoring, supervision, on-the-job training necessary to carry out these programs, improving their performance, and for their evaluation. These resources will help strengthen the provincial level which depends on them to implement these programs successfully. IV. COSTS, FINANCING AND MANAGEMENT A. Summary of Project Costs 4.01 Total costs of the three projects which, together, constitute the SPP/BAJ are estimated at US$266.0 million. Total project costs are estimated at US$118.8 million equivalent, including US$20.8 million for contingencies (17.5%) and US$10.4 million for taxes (9%). The foreign exchange component is equivalent to US$68.2 million, representing 63% of total project costs excluding taxes. A summary of project costs appears in Table 4.1 and in Annex 5. 4.02 Contingency allowances. Project costs include a contingency allowance--for unforeseen physical variations--equal to US$9.7 million (9% of total project cost excluding taxes). Price contingencies between negotiations and project completion are estimated at US$11.1 million (10% of total project costs excluding taxes). The following annual rates have been applied: 5% per year for local costs, 2.6% per year for foreign costs. 4.03 Foreign exchange component. The foreign exchange component is estimated as follows: construction: 25%; medical supplies, equipment, computers and vehicles: 70%; furniture: 25%; foreign specialists and training abroad: 90%; locally recruited specialists, local training, local seminars: 10%. The resulting foreign exchange component is estimated at US$68.2 million. - 16 - Table 4. 1. Project cost summary by component Cost (DH million) (US$ million) Local Foreign Total Local Foreign Total Component Access 142.7 164.3 307.0 17.2 19.8 37.0 Safe Motherhood 80.7 127.7 208.4 9.7 15.4 25.1 Priority Health Program 107.4 183.4 290.8 12.9 22.1 35.0 Management 3.8 2.8 6.6 0.5 0.3 0.8 TOTAL BASE COSTS 334.6 478.3 812.9 40.3 57.6 97.9 Physical 32.8 47.8 80.6 3.9 5.8 9.7 Price 52.5 39.9 92.4 6.3 4.8 11.1 TOTAL PROJECT COSTS* 419.9 565.9 985.8 50.6 68.2 118.8 * Figures have been rounded off and may not add up to totals shown. 4.04 Customs duties and taxes. Directly imported goods and goods procured locally average an import duty and taxes of 20%. Indirect taxes on civil works are estimated at 15%. B. Financing 4.05 The financing of the project would consist of (a) a Bank loan of US$68.0 million equivalent (63% of total project costs excluding taxes), and (b) a Government contribution of US$50.8 million equivalent, which includes US$10.4 million in taxes (see table 4.2). The Bank loan would cover 100% of foreign expenditures. The Government would finance the small balance of foreign costs, the local costs, taxes and operating costs associated with the implementation, administration, and supervision of the project, including staff salaries and architectural and engineering services. During negotiations, assurances were given that the Government take all necessary measures to ensure that adequate and timely financial arrangements were in place at all times for the continued and successful operation of the project. These would include provision for counterpart funds and the establishment of individual project line in the MSP budget of July 1st, 1996 [para. 6.03b(ii)]. During negotiations, retroactive financing up to 10% of the loan amount was agreed upon, excluding drugs [para. 6.036 (iii)J. 4.06 Although UNFPA, EU. USAID and UNICEF have expressed their interest in participating in BAJ I Health, no formal cofinancing has been secured at this stage. However, the project design has taken into account actions already undertaken by these agencies in the targeted provinces. - 17 - Table 4.2. Project Financing Plan (US$ million) % of Total Project Costs Funding Source Total excl. taxes IBRD 68.0 63 Government 40.4 37 taxes 10.4 - Total 118.8 - C. Economic Analysis Alternatives and effectiveness 4.07 The project is part of a major social program which is the backbone of the latest country assistance strategy (CAS). It involves the provision of essential public goods, and addresses equity issues in the distribution of these goods. In the rural areas of Morocco, the public sector is in a better position to deliver these goods since the private sector is basically concentrated in major urban areas and given the fact that no incentive system has been created to encourage its involvement in the rural areas. The decision was made by the Government to target the poorest areas of the country, in an effort to maximize the impact of project inputs on vulnerable groups. The benefits and the number of beneficiaries are stated in para. 5.01. In the absence of this project, health indicators would only worsen in the targeted where infant mortality already peaks at 145 per 1,000 in some districts (more than twice the national average). Cost recovery at the basic level is being envisaged and MSP is about to implement actions over the next five years, to improve the overall sector efficiency, in order to protect core programs which will be implemented under the project and the PAS. The increase in the MSP budget for basic services will be monitored annually through the PEP process, [para. 4.111. 4.08 The study being carried out in Morocco and other Maghreb countries in collaboration with the Bank to determine the burden of diseases of a broad variety of health problems will permit cost- effective packages of health interventions to be defined for these countries. Such studies have been carried out in other similar countries and give some order of magnitude of the expected benefits of the project: (a) The prevention of one case of tuberculosis (TB) prevents 20-28 new infections over the approximate two-year course of infectious TB. TB tends to burden one of the most productive age groups of society and these deaths affect the family unit significantly. In Morocco, the incidence of TB per year is still high (30,000 new cases per year). The unit cost of adding BCG vaccine to an immunization program is estimated to be under US$10 as opposed to US$160-217 for the treatment for a TB case. It should be noted however, that BCG vaccine is effective mostly for the 0-15 years of age. Therefore, short-course chemotherapy needs also to be considered and has one-third greater benefit in term of cost-effectiveness as compared to standard chemotherapy. (b) An integrated antenatal/delivery care program can induce a reduction of 25-50% in maternal mortality, of 12.5-25% in perinatal mortality and 1 % in low birth weight. - 18 - (c) In addition to maternal morbidity and mortality, FP programs have economic and welfare gains from improved control of level and timing of fertility. (d) It was estimated that iron deficiency anemia (the most prevalent nutrition problem in Morocco) costs the economy well over $200 million per year in lost work productivity and in excess health and education expenditures. The cost of a national iron supplementation program (fortification of wheat and iron pills for pregnant women) would be about US$5 million per year. The payoff is clearly high. (e) Preliminary results of the Maghreb Health Priorities Study for Morocco (based on mortality data only) show that infectious diseases represent 45% of the Burden of disease. These data reinforce the decision taken by MSP to give priority to these diseases under the project. The project is also expected to improve access to basic care (defined as less than 5 kilometers from an ESSB) from 47 to 60% --currently more than half of the targeted population live at more than 6 kilometers from an ESSB and 43% at more than 10 kilometers.) The number of visits to an ESSB would grow from 0.32 to 0.97 in those provinces. Incremental recurrent costs 4.09 Incremental recurrent costs. The proposed project would generate additional recurrent costs for the recruitment of medical and administrative staff for the proposed new facilities. But the redeployment of existing staff and other cost-saving measures would reduce the cost of new recruitment substantially. Other incremental recurrent costs would include additional health related materials (drugs, vaccines, medical materials), the maintenance of the new facilities, and costs associated with operating medical equipment, vehicles, and ambulances. The total additional recurrent base costs generated by these items would reach by the end of the project an estimated US$16 million equivalent (or 3% of the Ministry of Public Health's recurrent budget projected for year 2000). Detailed incremental costs are presented in the project implementation manual. Cost recovery 4.10 Until recently, cost recovery schemes were not officially envisaged at the basic health care level. However, given the insufficient amount allocated to drugs in the rural areas and the budgetary constraints, MSP officials have agreed to launch a cost recovery study for drugs at the basic level, and to integrate the conclusions of such a study in the project [(6.03a(ii)]. UNICEF will participate in the implementation of this study. Sustainability 4.11 The project is part of the SAP which be monitored through the PEP process. Recurrent costs induced by the project [para. 4.09] will have to be addressed by the corresponding annual increase in expenditures at the end of the project. During negotiations, agreement was reached on the undertaking and updating each year a multiyear rolling public expenditure program for the health sector and transmittal of the program to the Bank by July 31st of each year beginning in 1997 [para. 6. 03b(i)]. It is therefore unlikely that project activities will stop at the end of project implementation. In addition, agreement on a set of dated covenants regarding the pharmaceutical sector were reached at negotiations [para 6.03a(ii)]. - 19 - D. Management and Implementation Program implementation 4.12 The national Social Development Strategy (SDS) and the SPP/BAJ would be monitored by a steering committee made up of all concerned ministers. Such a committee, the Comite de Suivi de la Strategie Sociale (CSSS), already exists; it is assisted by a Secretariat. which is housed in the Ministry of Population's Department of Planning, and is already in place. The Secretariat would be responsible for monitoring the objectives of the SPP/BAJ and would also be the liaison between technical ministries, the CSSS, and the donor community (Annex 2). In parallel, an Observatory for Monitoring Living Conditions was created to monitor social conditions in the Kingdom. The formal establishment, within the Ministry of Population, of the Observatory was a condition of Board presentation [para. 6.04a]. 4.13 To simplify implementation and avoid the creation of an overall project implementation and coordination unit, program activities would be implemented under three distinct projects and financed by three distinct loans. The first loan, for the Basic Education Project, would comprise the activities to be implemented by the Ministries of Education, and Employment and Social Affairs. The second loan, for the proposed Basic Health Project, would comprise the activities to be implemented by the Ministry of Public Health. The third loan, for the Coordination and Monitoring of Social Programs and Labor Promotion Project, would comprise the activities to be implemented by the Ministries of Interior (Promotion Nationale), and Population. 4.14 The multiple activities included under the SPP/BAJ will require careful programming and coordination of inputs from the various implementation agencies at the central, provincial and community levels. The individual impact of the three projects, too, could only be measured if implementation were sufficiently well-coordinated for each to build on the efforts of the others. To ensure that SPP/BAJ activities were implemented in a coordinated manner, both at the grass-roots level and in the central ministries, the Government would be asked to commit itself to the setting up of a Program Management Information System (PMIS) by the Secretariat, and to the implementation of the PMIS by the line ministries. The staff needed to run the PMIS in the Secrtariat and in the MSP should be in place in time so that the PMIS could be launched in place no later than December 31, 1997 [para. 6.03c(i)J. The data input would be performed by the implementation staff at the provincial level and at the departmental and division levels in the ministries. Proiect implementation 4.15 Project activities would be implemented at two different levels: (i) at a central level, by the ministry's departments, and (ii) at the provincial level by Provincial Medical Officers. Implementation coordination would be performed by a Project Coordination Unit (PCU) located within the Ministry of Health's Planning and Financial Resources department. The Project Coordinator would be appointed by December 31, 1996 [para. 6.03c(ii)]. While the implementation record of the MSP is mixed, a reorganization of the ministry and a change in key staff improved its implementation capability. Moreover, various departments within the Ministry of Health have developed expertise with procurement and disbursement procedures related to Bank-financed projects. As experienced with previous Bank financed projects, implementation of the proposed project would also be hampered by generic, country-wide problems such as cumbersome administrative procedures and the requirement that all documents pertaining to contracts and payments be reviewed in advance. An ongoing study of reasons for delays in the payment of - 20 - suppliers should help to improve some of these generic problems [para. 6.01c]. The Government would ensure that an action plan to improve the management of the proposed project, based on results of the study be presented to the Bank for discussions before March 31, 1997, and that implementation of the recommendations be launched no later than October 31, 1997 [para. 6.03(c(iii)]. A project implementation volume has been prepared, which will be used as a reference during the project's execution. 4.16 Project Coordination Unit (PCU). A PCU, located within the Planning and Financial Resources Department of the Ministry of Health, would be responsible for overall project programming, coordination, and reporting. While implementation would be carried out by the line departments, the PCU would oversee the performance of such specific administrative tasks as programming, accounting, and monitoring. By December 1996, therefore, the PCU would need at least two additional persons to make sure that project programming and monitoring tools are being properly used, plus a qualified accountant to monitor the accounting records procedures in use in various implementing departments [para. 6.03c(ii)]. 4.17 Department of Equipment (DEM). This department would delegate the procurement of civil works contracts to the MSP's provincial officers. To oversee civil works implementation and to coordinate the delegated activities, the DEM would need at least three technical staff members. This staff would need to have experience in monitoring such type of contracts and to be well-acquainted with both the technical and financial aspects of Bank procurement and disbursement procedures. The technical team would be headed by a senior implementation specialist with experience in handling complex projects. The project's technical team would have to be established by December 1996. Most equipment would be procured directly by the DEM, with only a few items being procured at the provincial level. The DEM already has sufficient know-how and expertise to manage the procurement of equipment. 4.18 Concerned line departments would handle procurement for all project activities related to health programs (immunization, tuberculosis control, acute respiratory infections, leprosy, etc.). These departments have implemented similar activities under earlier Bank-financed projects and have the necessary procurement expertise. But like the DEM, they lack systematic planning skills. The PCU, using the PMIS tool, would help line ministry departments to set up adequate programming, accounting, and monitoring tools and would recommend corrective measures where needed to ensure that project programming, accounting, and monitoring were up to standard. 4. 19 Activities delegated to Provincial Officers of the Ministry of Health. Provincial MSP officers would be responsible for the implementation of smaller scale civil works, such as the building of rural clinics, for which procedures are well known and decentralized services are sufficiently staffed. 4.20 Program Management Information System (PMIS). The responsibilities for administering the PMIS would be divided as follows: (a) Provincial level. By December 31, 1996, a SPP/BAJ focal point would be appointed in each province to coordinate and monitor the implementation of all of the SPP/BAJ activities delegated by the various line ministries and to ensure that the PMIS data and information was kept up to date [para. 6.03c(ii)]. The various provincial delegates would provide the provincial SPP/BAJ focal point with all pertinent information about project activities. The provincial focal point would ensure that the data was entered into the system and would--with the assistance of this tool--prepare the annual provincial implementation - 21 - program. The PMIS would generate implementation progress reports and reports on various indicators and financial benchmarks. The PMIS would be linked to a Geographical Information System. The PMIS would be designed in such a manner as to allow for the gradual expansion of the system to include other data required by the Governor or other users. (b) Ministry department or division level. Each department involved with the SPP/BAJ would be responsible for managing the implementation of its respective project activities using the PMIS. To that end, each concerned department would appoint a staff-member to manage the PMIS. Several different departments and divisions within the Ministry of Health would be responsible for project activities under a ministry-appointed SPP/BAJ coordinator. This ministry-level health coordinator would oversee and coordinate the work of the departmental and divisional SPP/BAJ coordinators and would be expected to ensure the proper use of the PMIS. Procurement 4.21 All goods and services to be financed by the loan would be procured in accordance with the Bank's guidelines. For ICB procedures, the Government would use the Bank standard bidding documents, available in French at the time of project negotiations (March9s de travaux--Taille Moyenne et Marchs de Fournitures). Procurement of goods and services would be undertaken by the concerned line ministries at the central level, by provincial representatives delegated by the line ministries, and by the communities themselves. NCB procedures at these three levels have been reviewed by the Bank. The procedures agreed upon are in conformity with general Bank procurement guidelines with respect to economy, efficiency, equal opportunity to all eligible bidders, development of local industry, and transparency (Table 4.3 below summarizes the procurement arrangements for goods and services). Table 4.3. Procurement arrangements (total including contingencies in US$ million equivalent) Procurement Method Goods and Services ICB NCB Other NBF Total Civil Works - 17.8 -- -- 17.8 (7.0) (7.0) Equipment 24.8 8.8 1.8 -- 35.4 (17.0) (5.0) (1.0) (23.0) Drugs 46.8 2.8 5.5 55.1 (32.0) (2.0) (3.3) (37.3) Technical assistance -- -- 0.2 0.9 1.1 (0.2) (0.2) Training -- -- 1.0 -- 1.0 (0.5) (0.5) Operating costs -- -- -- 8.4 8.4 Total financed costs 71.6 29.4 8.5 9.3 118.8 IBRD financing (49.0) (14.0) (5.0) - (68.0) Note: Figures in parenthesis represent amounts to be financed by the loan. - 22 - 4.22 Civil works. The project would include the construction and rehabilitation of over 400 facilities (health centers, dispensaries and rural hospitals). Works contracts would be of small value (from US$8,000 to US$100,000 equivalent per facility), and would be distributed over a large rural area. As demonstrated under previous and ongoing loans, such contracts do not normally attract foreign firms or local funds. The implementation of those small works would be delegated to provincial delegations and all civil works would be carried out in accordance with NCB procedures. NCB procedures at the central (ministry), and provincial levels have been reviewed by the Bank and found acceptable. Civil works contracts of less than US$20.000, up to an aggregate of US$500.000 equivalent, for the remodeling of small health facilities in remote areas may be carried out by force account with the Bank's prior approval. 4.23 Goods. (a) Contracts for goods estimated to cost more than US$500,000 equivalent each would be procured through ICB (US$24.8 million plus US$46.8 million for drugs), with the exception of furniture which could be procured through NCB. Such furniture, manufactured by local suppliers, is of excellent quality, below international prices, and delivery and supply would be appropriate for this project. (b) Contracts for goods costing US$100,000-500,000 equivalent would be procured through NCB. (US$11.6 million). (c) Contracts for goods that the Bank agrees to be of proprietary nature (such as computer software, books, and reference materials) could be awarded through direct contracting after negotiations with proprietors or publishers in accordance with procedures acceptable to the Bank. (US$6.2 million). (d) Contracts for goods costing less than US$100,000 equivalent each could be awarded through shopping procedures on the basis of three price quotations from suppliers. (US$1.1 million) 4.24 Consultant services. Consultants financed under the project would be selected in accordance with the Bank's guidelines for consultants. Consultant services would consist of foreign or local specialized services to conduct specific studies or to offer short-term advice. The project would also finance local seminars. A large number of consultant contracts would be related to civil works (architectural and engineering services). The procedures under which such services are engaged are well-known and efficient. 4.25 Contracts and contract review (a) Items to be disbursed on the basis of proof of services would be subject to Bank review as described in Annex 6. (b) Works. Contracts exceeding US$500,000 equivalent would be subject to prior Bank review. Contracts below US$500,000 equivalent, exept for activities subject to lump sum disbursement, would be subject to ex post Bank review. (c) Goods. To ensure compliance with Bank procurement guidelines, procurement documentation for all contracts for goods estimated to cost the equivalent of US$500,000 or more - 23 - would be subject to prior review by the Bank. Contracts below US$500,000 in value would be subject to ex post review by Bank missions. (d) Consultant services and training. Procurement documentation for all contracts for consulting firms, estimated to exceed the equivalent of US$100,000 would be subject to prior review by the Bank. Procurement documentation for all contracts for the employment of individuals or single source selection of firms estimated to exceed the equivalent of US$50,000 would also be subject to prior review by the Bank. Procurement documentation for all contracts for consulting firms estimated to cost less than US$100,000 equivalent and US$50,000 for all contracts for the employment of individuals or single source selection of firms estimated to cost less than the equivalent of US$50,000 would be limited to terms of references only. (e) Contracts and financial data related to activities subject to lump sum disbursement procedures will not be subject to post review but will be subject to technical audit (para. 4.29). 4.26 Disbursement. The project would be implemented over a period of five years. Including a 12-month disbursement lag, the closing date would be December 31, 2003. The loan would disburse according to the categories and schedule shown in Tables 4.4, 4.5 and 4.6. Table 4.4. Disbursement by category Category Schedule Category 1 Civil Works (a) lump-sum for items listed in table 4.5; (b)100% of foreign expenditures and 70% of local expenditures for items not listed. Category 2 Equipment 100% of foreign expenditures and 70% of local expenditures. Category 3 Drugs 100% of foreign expenditures and 60% of local expenditures. Category 4 Consultants 100% Services and Training - 24 - Table 4.5. Disbursement by lump sum:. Lum sum disbursement amounts by activities (DH). Activities lump sum disbursement CSC (rehab.) 200 000 Rural Dispensary (rehab.) 50 000 Table 4.6. Proposed disbursement schedule (US$ million) Disbursement Plan Project Year 1 2 3 4 5 6 Annual 3.0 10.0 15.0 15.0 15.0 10.0 Cumulative 3.0 13.0 28.0 43.0 58.0 68.0 4.27 Documentation. In accordance with regular Government procedures, the required supporting documents would be retained by the implementing agencies for at least one year after the Bank received the audit report for the year in which the last disbursement was made. This documentation would be made available for review by auditors and visiting staff upon request. Documentation for contracts subject to lump sum disbursement would consist of a "proof of services". This is a certificate established by the borrower, confirming that the specific activity has been implemented in accordance with agreed standards and criteria. (Annex 6). The content and procedure to establish a proof of service was presented in a format agreed upon during negotiations [para. 6.03c(iv)]. Both the disbursement by lump sum and the documentation by proof of services are innovative, result oriented methods aiming at simplifying procedures and accelerating project disbursement, while giving more initiative to the beneficiaries (especially communities); they concur with the directions set in the new Guidelines for Procurement under IBRD Loans and IDA Credits. For expenditures under contracts above the prior review thresholds, full documentation would be required. All other expenditures would be disbursed based on statement of expenditures (SOE). 4.28 Special Account. To reduce the number of claims submitted to the Bank, the Government may establish, maintain, and operate--under terms and conditions satisfactory to the Bank--a Special Account, in which the Bank would make an initial deposit of up to US$5.0 million. This special account would be located in the General Treasury of the Ministry of Finance and would be replenished every month, or whenever the undisbursed balance of the account would fall below an amount equal to one third or less of the amount of the initial deposit, whichever came first. 4.29 Accounts and audits. Each department responsible for the implementation of the project in the Ministry of Health would maintain separate accounts for all project activities in conformance with international accounting practices. Project accounts would be audited in accordance with the Guidelines for Financial Reporting and Auditing of Projects Financed by the World Bank (World Bank, March 1982). Activities subject to reimbursement on the basis of proof of services rendered would be audited in accordance with OD 10.60, para. 48. For technical audits, both - 25 - reimbursement claims using SOEs and applications for replenishment of special expenditures from the Special Account would be required to be certified by an independent expert rather than by an independent auditor. The Bank would be provided with an audit report of such scope and detail as the Bank might reasonably request (including a separate opinion by the auditor on disbursement against a certified statement of expenditures and a certified statement of proof of service rendered) within the six months following the end of each fiscal year. Supervision, monitoring, and evaluation 4.30 Project preparation. The Secretariat has de facto taken over the responsibility for coordinating the preparation of the three projects. The Secretariat has convened a number of meetings with other concerned ministries, and has organized a workshop on monitoring the implementation of the SDS. Bids would be launched as soon as the corresponding budgets were available. Provincial delegations would start preparing bid documents as soon as the ministries delegated the implementation of those activities and provided corresponding budgets. But because of budgetary planning, payment, and disbursement lags, during the first year of implementation the loan would disburse only the amount corresponding to the initial deposit to the Special Account. 4.31 Project implementation review. The Ministry of Health would prepare an annual implementation progress report of a scope and in the detail agreed upon by the Government and the Bank and including (a) a review of progress achieved in the implementation of the project based on selected monitoring indicators agreed upon, (b) projected sector and project expenditures for the year, and (c) programs for project activities in the selected provinces. The report would be submitted to the Bank not later than September 30 of each year, beginning in 1997 [para. 6.03d(ii)] and reviewed jointly. The Secrtariat would collect and review sectoral reports issued for each of the three BAJ projects, and incorporates them in an annual program implementation report. A midterm project implementation review would be conducted by December 31, 1999 [para. 6.03d(i)]. This midterm review would not only assess the project's implementation progress in greater detail but would also assess the extent to which project activities might need to be redirected to achieve the objectives of the program. The review would also include a discussion of the follow-up to the study on cost recovery for drugs [para. 4. 10]. 4.32 Monitoring indicators. The Government has developed, in coordination with the Bank, a list of program and project indicators to follow both the process and the impact of the operations. This list of indicators was agreed upon before negotiations [para. 6.02b], and a final agreement on baseline values and target values was reached during negotiations [para. 6.03d(iii)]. The list of indicators is presented in Annex 7. The value of these indicators would be updated each year and incorporated in the annual implementation report submitted to the Bank each year by the Secrtariat. V. PROJECT BENEFITS AND RISKS A. Benefits 5.01 This project specifically targets the needy--especially women and children--and should therefore help transfer resources to those who need them most. Improving primary health care services in the target areas would benefit some 27% of Morocco's population, including 1.4 million - 26 - children under five and 1.05 million women of childbearing age. In addition, the overall population would benefit from the improved implementation of public health programs to control tuberculosis, malaria, cholera, leprosy, STDs, infectious ocular diseases as well as to improve hygiene and nutrition and to expand immunization coverage. Basic curative and preventive health coverage will increase from 47 to 60% in targeted areas. If adequately implemented, the project would significantly reduce the burden of disease in Morocco and would help reduce the number of maternal and child deaths and ensure more equity throughout the health system. 5.02 Following the burden-of-disease approach recommended in the World Development Report 1993: Investing in Health, a study is now being carried out in Morocco to assess the number of disability-adjusted life years (DALYs) that could be saved by the implementation of priority health programs [para. 4.08] and to identify cost-effective interventions. Rehabilitation of the primary health care system would also improve its quality, which would help to restore public confidence in the system. In the medium term this would stimulate demand for preventive care services. In addition, the reorganization of health administration and services already agreed upon [para. 6.01a] would improve the efficiency of the MSP and maximize the impact of the proposed project's health activities. The implementation of the Sector Action Plan initiated during project preparation would further help to ensure better coordination of aid, and would provide a planning and monitoring tool for the MSP. Finally, the integration of health with education and other basic services would result in cross sectoral synergy. B. Risks 5.03 The first risk relates to the potentially weak implementing capacity of MSP, especially at the provincial level, given the fact that, under the proposed project, provincial health officials would have the primary responsibility for planning, implementing and monitoring activities in the targeted provinces. To address this risk, MSP is currently in the process of reorganizing the provincial level in order to strengthen its managerial capabilities. In addition, during negotiations, agreement wa reached on identification and implementation of mechanisms which will strengthen provincial participation to planning and decision-making [para. 6.03a(iii)]. The second risk relates to the possibility that Morocco may fail to implement the hospital reforms and the financing strategy being developed under the Health Management Project, to reorganize at the provincial level and to implement the actions proposed for the public pharmaceutical sector. Such situation would threaten the sustainability of the entire health system over the long term, since it would effectively prevent adequate shifting of resources to the needy, rural population and to more cost-effective interventions. These activities are well underway and unlikely to be stopped. In addition, financing of drugs under the project is linked to a set of dated covenants [para.6.03a(ii)]. The third risk is linked to the lack of adequate counterpart funding, especially for recurrent costs. Discussions and agreement with the Ministry of Finance on the Sectoral Action Plan, the flow of funds study and the preparation of sectoral public expenditures programs, however, should reduce this risk, which is of a generic nature. C. Stakeholders' Participation 5.04 Project preparation has drawn directly or indirectly on the input of final beneficiaries and users, including the results of the Bank participatory study on rural women which has suggested that maternity related and preventive health care programs should be part of the first cluster of actions to improve the daily life of women (World Bank 1995c). During project preparation, provincial medical officers of the targeted provinces were involved in the definition and planning of activities to be financed under the project. Three regional workshops were organized between November 1994 - 27 - and January 1995 to discuss with them the project objectives and the priority activities it should address. Different surveys were carried out in five of the targeted provinces, including a beneficiary assessment and a survey of the concerns of medical and paramedical personnel (see Annex 8 for list of studies carried out). They were financed under a Japanese Grant. The conclusions of these surveys have been integrated into project design. Finally, the other two projects of the SPP/BAJ Program have also been prepared with the participation of actual actors and potential beneficiaries, thus ensuring that the integrated activities envisaged under the program would coincide with real needs perceived by the targeted population, and would mobilize those in charge of implementing the measures aimed at meeting these needs. D. Poverty Category 5.05 The proposed project is part of the SPP program whose entire justification and overarching objective is poverty alleviation. Because the proposed Project would target the poorest population of the country, especially women and children, it falls squarely in the "Program of Targeted Interventions". It would also contribute significantly to the reduction in the global burden of disease in vulnerable populations and would help close the gap between urban and rural areas, thereby addressing the issue of equity. It is therefore part of the programs of targeted interventions. E. Environmental Assessment 5.06 The proposed project was determined to be in screening category C and would therefore not normally result in significant environmental impact. No Environmental Assessment (EA) is expected to be conducted for this project. VI. AGREEMENTS AND RECOMMENDATIONS 6.01 During preparation of the project, the following actions were taken: (a) A commitment was made for the operationalization of the new MSP organizational chart [para. 5.02]; (b) The Strategie de Developpement Social was reendorsed [para. 2.03]; (c) The contract for the study on financial circuits was signed [para 4.15]; (d) The Secr&tariat was informally installed [para 4.12]; 6.02 Before negotiations: (a) The health sector SAP was officially transmitted to the Bank [para. 2.05d]; (b) The final list of selected project indicators was officially transmitted to the Bank [para. 4.32]; - 28 - 6.03 During negotiations, agreement was reached regarding: (a) Sector specific actions (i) A human resources development plan to be reviewed by December 31, 1997 [para. 3.09]; (ii) Actions to be taken and activities to be implemented in the pharmaceutical sector during project implementation [paras. 1.23, 3.10, 4.10 and 5.03]; (iii) The mechanisms to strengthen provincial participation in planning and decision-making for sector activities to be identified, submitted to the Bank and implemented by December 31, 1997 [paras. 1.24 and 5.03]. (b) Financing (i) Undertaking and updating each year a multiyear rolling public expenditure program for the health sector and transmittal of the program to the Bank by July 31st of each year, beginning in 1997 [para. 4.11]; (ii) Provision of counterpart funds, and establishment of individualized project lines in the budget of the MSP, starting July 1st, 1996 [para. 4.05]; (iii) Retroactive financing within the limit of 10% of the loan amount, and excluding expenditures on drugs [para. 4.05]. (c) Project implementation (i) Setting up by the Secr9tariat of a Program Management Information System, and staffing the MSP for implementation of such a system by December 31, 1997 [para. 4.14]; (ii) Appointment of a SPP/BAJ health coordinator in the MSP and of the project technical team, and appointment of a SPP/BAJ focal point in each target province by December 31, 1996 [paras. 4.15, 4.16 and 4.20]; (iii) Presentation to the Bank of an action plan to improve procurement, payment, and disbursements, based on the results of the study on fund flows, before March 31, 1997, and launching implementation of the plan after discussion with the Bank, no later than October 31, 1997 [para. 4.15]; (iv) Procedures to establish a proof of service, and format of such a certificate [para. 4.27]. (d) Project review (i) Organization of a joint project midterm review by December 31, 1999 [para. 4.31]; - 29 - (ii) Submission to the Bank of an annual implementation report that would include a review of project implementation progress based on selected project indicators, projected sector and project expenditures for the year, and programs for the project activities in the selected provinces by September 30 of each year, beginning in 1997 [para. 4.31]; (iii) Baseline and target values of the project indicators [para. 4.32]; 6.04 The Observatory for Monitoring Living Conditions has been formally established, as a condition of Board presentation [para. 4.12]. KINGDOM OF MOROCCO SOCIAL PRIORITIES PROGRAM BASIC HEALTH PROJECT DEFINITIONS Contraceptive Prevalence -- Percentage of married women of reproductive age using, or whose husbands use, any form of contraceptive. Crude Birth Rate -- Number of live births per year per 1,000 people. Infant Mortality Rate -- Annual deaths of infants younger than 1 year old per 1,000 live births during the same year. Life Expectancy at Birth -- The number of years a newborn child would live if subject to the age-specific mortality rates prevailing at time of birth. Low Birth Weight -- Infants whose weight at birth is less than 2,500 grams. Maternal Mortality Rate -- Number of maternal deaths per 100,000 live births in a given year attributable to pregnancy, chilbirth, or post- pactum. Neonatal Mortality Rate -- The number of deaths to infants under 28 days of age in a given year per 1,000 live births in that year. 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 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 a woman will have if she experiences a given set of age-specific fertility rates throughout her lifetime. Serves as an estimate of the number lof children per family. Disability Adjusted Life Years -- Is an indicator of the time lived with a disability and (DALYS) the time lost due to premature death. Annex 1 Page 1 of3 KINDGOM OF MOROCCO SOCIAL PRIORITIES PROGRAM BASIC HEALTH PROJECT SECTOR DATA SHEET A. DEMOGRAPHIC 1. Crude Birth Rate (per 1000) 28.1 1991-1992 2. Crude Death Rate (per 1000) 7.3 1991-1992 3. Population Growth Rate (%) 2.06 1994 4. Population in Age Groups (%) 0 - 14 34.8 1994 15-64 55.6 1990 65+ 4.5 1990 5. Population Projection (million) 32.918.000 2007 6. Mean Female Marital Age (years) 24 1987 7. Total Fertility Rate Average No. of Children per Woman 3.6 1995 8. Women of Chilbearing Age Using Modem Contraceptives (%) 42.4 1995 9. Pharmacies per inhabitants 1/12.031 1995 B. HEALTH AND NUTRITION DATA 1. Public Health Care Expenditures as % of 3.8 1994 GDP 2. Health Expenditures as % of Total Government Budget 4.6 1994 3. Population of Physician 1/2756 1995 4. Total number of physicians Generalists - Private sector (56%). 2462 1995 - Public sector (44%) 2088 1995 5. Population per Hospital Bed 1/889 1995 6. Access to Health Care (% of pop.) 47 1993 7. Maternal Mortality (per 100.000 live births) 332 1992 8. Infant Mortality Rate Both Sexes (per 1000) 61.6 1995 9. Under Five Mortality (per 1000) 80.4 1995 10. Births Attended by Health Staff (%) 40 1995 11. Immunized--Under five 88 1992 Annex 1 Page 2 of 3 MSP ORGANIZATIONAL CHART General Inspection [. Minister Cabinet General Secretariat ........ . ....... . ....ou at o Procurement Division.D i r e c t o r a t e of -[:: Population Division of General Direct. ofEpidemiology Services Administratior and Disease Prevention Provinces D (medial officers) Direct. of Hospitals and D ivision of lnformatics 1 __________ muaoyCr Ambulatory Care National Institute Directorate of Drugs Health Management and Pharmacy Direct. ofEquipment and Maintenance Directorate of Human Resources Directorate of Legal Matters Direct. of Planning ind Financial Rresources Annex 1 Page 3 of 3 DONOR INTERVENTION IN THE HEALTH SECTOR* DONORS AREAS PERIOD AMOUNT AfDB Basic Health 1993-1997 430 million DH USAID MCHIFP 1993-1999 US$ 52 million UNFPA Population MCHIFP 1992-1996 US$ 7 million UNICEF Women and Children survival 1992-1996 US$ 5 million EU MCH - neonatal 1994-1997 5 million ecu FP - Northern Provinces 1995-1998 9 million ecu FRENCH Training, documents, technical Annually Non quantifiable COOPERATION assistance WHO Technical Assistance 1994-1995 US$ 3 million UNDP Maintenance 1992-1996 US$ 1.5 million * Source: MSP, 1995 I Annex 2 Page 1 of 2 SPP/BAJ: ORGANIZATIONAL STRUCTURE Table 1. Ministry-Level Responsibilities for the Three SPP Projects MEN MSP MEAS MI MP (3) Primary 1. BASIC EDUCATION (1)cPrima* (2) Literacy School Education* Cntcin Construction** (4) Basic II. BASIC HEALTH Heath Health 111. COORDINATION (6) Statistical AND MONITORING Monitoring OF SOCIAL (5omlon (7) Program PROGRAMS, AND Coordination LABOR PROMOTION (Secrtarat) MEN: Minist6re de I'Education Nationale (Ministry of National Education) MSP: Minist6re de la Sant6 Publique (Ministry of Public Health) MEAS: Minist6re de I'Emploi et des Affaires Sociales (Ministry of Labor and of Social Affairs) MI: Ministbre de l'Int6rieur (Ministry of the Interior) MP: Minist6re de la Population (Ministry of Population) * school construction not included ** supervised by local collectivities Table 2. SPP/BAJ Organizational Chart CSSS Secritariat Basic Education Basic Health Employment Promotion and Project Project Poverty Monitoring Project MEN MEAS MSP MP MI SSP Technical SSP SSP SSP SSP U Coordinator Committee Coordinator Coordinator Coordinator Coordinator I _ _ _ _ _ I Dt PProvincial I Focal point 0 Annex 3 Page 1 of 1 PROVINCES SELECTED FOR THE SPP PROGRAM Rural Share in Total Share in population, total rural population, total 1994 population 1994 population Ratio Rank Province (000) (%) (000) (%) rural/total Saharan provinces 1. Ouarzazate 553 4.4% 695 2.7% 80% 2. Taroudant 560 4.4% 694 2.7% 81% 3. Tiznit 278 2.2% 348 1.3% 80% Wilaya of Marrakech 4. Ai Haouz 402 3.2% 435 1.7% 92% 5. Chichaoua 280 2.2% 312 1.2% 90% 6. El Kelaa Sraghna 551 4.4% 682 2.6% 81% 7. Essaouira 358 2.8% 434 1.7% 82% 8. Safi 447 3.5% 823 3.2% 54% Wilaya Grand Casablanca 9. Azilal 393 3.1% 455 1.7% 86% Wilaya of Tetouan 10. Chefchaouen 396 3.1% 439 1.7% 90% 11. Sidi Kacem 471 3.7% 646 2.5% 73% Wilaya of Fes 12. Al Hoceima 270 2.1% 383 1.5% 70% 13. Taza 502 4.0% 708 2.7% 71% Total, selected provinces 5,461 43.1% 7,054 27.1% 77% Total Morocco 12,659 100.0% 26,074 100.0% 49% Source: Minist6re de l'Incitation de I'Economie - Direction de la Statistique. R6sultats provisoires du Recensement G6ndral de la Population. February 1995. Note: Criteria for the selection of provinces 1. Living standards indicators 1.1 Annual per capita expenditures 1.2 Urbanization rate 2. Education sector indicators 2.1 Illiteracy rate 2.2 Admission rate in first year of primary education (children aged 7) 3. Health sector indicators 3.1 Under-5 mortality rate 3.2 Population per physician 3.3 Population per paramedical staff 3.4 Population per health center Annex 4a Page 1 of 2 SELECTED PROJECT DATA Specific Objectives of Selected Priority Health Programs (Third component), by year 2000. 1. - Tuberculosis: - Decrease incidence of Tuberculosis by 10% a year. - Cure 90% of identified cases. - Identify every year 80% of infections sources in the community. 2. - Leprosy - Identify 90% of leprosy cases. - Examine 70% of the population living in areas where the prevalence is between 0.5 and 1%o. - Examine, once a year, 90% of family contacts. 3. - Acute Respiratory Infections (ARI) - Decrease the mortality rate due to ARI by 25%. - Implement the program national. - 80% of health facilities will be able to manage adequately ARI cases. 4. - Infections Ocular diseases: - Decrease the prevalence rate of blindness to <0.5% of the population. 5. - Malaria: - Decrease incidence rate in high risk areas to <10 cases for 1 million inhabitants. 6. - Schistosomiasis - Eradicate schistosomiasis in Agadir, Assa Zag, Beni Mellal, Essaouira, Figuig, Kenitra, Larache, Marrakech, Nador, Ovarzazate, Tanger and Tiznit. 7. - Hygi6ne and sanitation - Surveillance of 659 of "water points" identified. - Achieve 70% of control of recommended desinfection. - Achieve 100% of bacteriological analysis, according to the norms. - To prevent food intoxication, ensure 80% of analysis of some type of goods ("denr6es p6rissables"). - Decrease the incidence rate of cholera cases to <5 per 100,000 inhabitants. - Decrease the incidence of Typhoid fever to <10 per 100,000 cases. - Decrease the fatality rate: for cholera to <1% and typhoid fever to <0.5%. 9. - STDs (Sexually Transmitted Diseases) Decrease the incidence of STDs in the country. Annex 4a Page 2 of 2 10. - EPI - Increase and maintain coverage to >90% of <1 year old children for the diseases targeted under the program: Tetanus, Poliomyelitis, Measles, Diphteria, Whooping cough. 11. - Nutrition - Prevention of non-deficiency anemia in pregnant women and <5 year old children. - Decrease by 50% the number of acute malnutrition and by 10% the number of chronic malnutration 12. - Oral Rehydration Therapy: (ORT) - Increase and maintain the utilization rate of ORT to 80%. - Improve case-management of diarrhea in health facilities. Annex 4b Page 1 of 2 SELECTED PROJECT DATA Pharmaceutical Sector: Main Recommendations based on the conclusions of the major study: Main features 1. Improvement of the operation of the Central Medical Stores (Pharmacie Centrale) 2. Improvement of budgetary mechanisms for drugs (weaning out of Bank funds) 3. Study of a cost recovery scheme for essential drugs in primary care facilities 4. Upgrading of the National Control Laboratory 5. Pharmacie Centrale (PC) 6. Procurement: The Procurement Unit (PU) would modify its procurement and distribution practices to increase their productivity: The PU would start tendering for essential drugs with contracts expected to cover two years of consumption, with staged deliveries to Berechid (preferably on a monthly basis). The PU will also determine a list of products for which deliveries would be undertaken directly by the suppliers to the regional warehouses and the SEGMAS. Finally, the PU would experiment a system by which the PU would determine the level of prices of drugs for the CHUs through tenders, but would leave the purchasing and organization of deliveries to the CHUs (i.e. the drugs would not physically enter the PU at any time. These various new mechanisms are expected to (a) improve the lead time between procurement and distribution of drugs, (b) improve the lead time between procurement and distribution of drugs, (b) improve the logistics of drug distribution in the public sector, (c) reduce the level of stocks (and the drugs reaching their shelf-life) in public sector facilities and (d) improve the adequacy of procurement to actual needs. 7. Improvement of budgetary mechanisms for pharmaceuticals. The Ministry of Public Health would increase the budget allocated for drugs over the duration of the project, to make sure that public sector financing for pharmaceuticals becomes sustainable once Bank financing is over. The Ministry of Health would undertake a study of actual needs for essential drugs (including contraceptives and micro-nutrients), based on actual consumption rather than historical procurement, using the methodology developed by WHO to assess pharmaceutical requirements. This study woudl also take private sector supply and logistics in consideration to determine the adequate level of budget necessary to finance these requirements. The services of Moroccan and international consultants to undertake this study would be needed and the Ministry of Public Annex 4b Page 2 of 2 Health would submit detailed tables to the Ministry of Finance to improve financial mechanisms for essential drugs. 8. Study of cost recovery in primary care facilities It is agreed that the availability of drugs in primary and secondary care facilities is low, and that many patients who receive a prescription in these facilities actually have to purchase drugs from private pharmacies. These patients, who are usually the less well-off cannot take advantage of the cheap procurement prices of the PC and have to pay a much higher price for equivalent products, or to remain without a treatment. Although it is not possible for the moment to envisage full cost recovery of drugs in Moroccan public health facilities at the peripheral elvel, the issue of the financial sustainability of pharmaceutical supplies at this level requires that a study be conducted on the feasability of partial cost recovery of pharmaceuticals. The study would explore the willingness to pay of the population, the level of actual expenditures incurred at present in poor rural and urban areas, the level of drug budgets likely to be available in the future, and the technical feasibility (including the legal conditions) of charging for drugs in public sector health facilities. The study would also review the conditions for a participation of the private sector of pharmaceutical distribution in a scheme that would involve partial cost recovery for drugs, and the implications that the implementation of the national health insurance have would have on a cost recovery scheme. The services of an international consulting firm would be neded and would participate with the Government of Morocco in the analysis of the results of the study. 9. Upgrading the National Drug Control Laboratory The Laboratoire National de Sant6 Publique (LNSO) is in charge of the quality control of drugs, in particular drugs in the public sector. The LNSP needs to be upgraded to take care of the growing needs for quality control of both imported and locally produced drugs, and to meet international quality requirements for exports (equipment), reagents and basic supplies and training of personnel. By the end of the project, the LNSP would be expected to perform high quality controls and batches of imported drugs and before release of exports, supervise and control the QC laboratories of all Moroccan pharmaceutical manufacturers, and to participate in international networks of quality control laboratories. Annex 4c Page 1 of I SELECTED PROJECT DATA Strategy Proposed for the Prevention of Iron Deficiency and Anemia (being reviewed by MSP) PHASE ONE: Nutritional Supplements * Target population: all pregnant women * Prescription: 1 tablet per day, starting in the fourth month of pregnancy. Each pill contains 60 mg of iron and 250 mg of folates. * Coverage discount for pregnant women = fifty percent IEC * Study the acceptance of iron tablets among the local population * Increase awareness of the problems of iron deficiency and anemia among the population * Educate the public about solutions to the problems of iron deficiency and anemia * Develop and test educational support * Marketing/ Choice of iron to be distributed * Identify limitations of the program Training of Personnel * Seminars for the benefit of MCH nurses and doctors Follow-up and Evaluation * Implementation of information system Logistics and Mobility * Improvement of the distribution of medication PHASE TWO: Fortification offood stuffs * Chosen food: national flour * Feasibility study (technical) * Feasibility study (industrial) * Regulatory study * Impact study Annex 5 Page 1 of 1 Expenditure Accounts by Components - Base Costs (US$ Million) II. BASIC HEALTH IIA IIB IIC lID Acces Maternity Priority Follow-up - - Program Manag. Total Investment Costs WORKS New Construction 5.3 - - - 5.3 Extension - 0.6 - - 0.6 Development/Rehabilitation 7.1 1.2 - - 8.3 Subtotal 12.4 1.8 - - 14.2 EQUIPEMENTS Machinery/Tools 8.7 5.6 8.9 - 23.2 Vehicules 1.3 2.9 0.3 0.1 4.6 Data Processing 0.1 - 0.0 0.3 0.4 Pharm. Products 13.8 11.7 20.3 - 45.8 Office Supplies - 0.3 1.1 - 1.4 Subtotal 23.9 20.6 30.6 0.4 75.3 EXPERTISE Studies - - 0.1 - 0.1 Local Consultants 0.7 - - - 0.7 Subtotal 0.7 - 0.1 - 0.9 FORMATION Local/a - - 0.9 - 0.9 Total Investment Costs 37.0 22.3 31.6 0.4 91.3 Recurrent Costs Operating Costs - 2.8 3.0 0.4 6.2 Salaries - - 0.5 - 0.5 Total Recurrent Costs - 2.8 3.4 0.4 6.7 Total BASELINE COSTS 37.0 25.1 35.0 0.8 97.9 Physical Contingencies 3.7 2.5 3.5 0.1 9.7 Price Contingencies 4.5 3.2 3.4 0.1 11.1 Total PROJECT COSTS 45.1 30.8 41.9 0.9 118.8 Taxes 4.0 2.7 3.7 0.0 10.4 Foreign Exchange 23.5 18.4 26.0 0.4 68.2 \a Including information and awareness campaigns Annex 6 Page 1 of 1 PROCUREMENT AND DISBURSEMENT UNDER PROOF OF SERVICE A "proof of service" is a certificate established by the Government confirming that the specific operation, service or activity has been implemented in accordance with agreed standards, criteria or terms of references which have been reviewed by the Bank at priori. For a "certificate of proof of service" (Certificate) to be conform the following procedures would have to be followed: (a) By June of each year, a yearly program of activities planned to be implemented during the next fiscal year, will need to be established for each of the concerned communities. This program will be established by the delegates at the provincial levels, submitted for review and clearance to the respective line ministries and for approval to the Bank. (b) Budgets, corresponding to the approved list of activities will be made available by the line ministries to the provincial delegations. For the construction of primary school facilities, each community will include the necessary funds in its annual budget. (c) Activities subject to lump sum disbursement procedures will be procured: (i) in accordance with National Procurement Procedures (ii) for civil works: in accordance with agreed standards or architectural drawings reviewed at priori by the Bank; and; (iii) for training and seminars in accordance with agreed terms of references established for each type of training or seminar, and reviewed by the Bank at priori. (iv) Contracts and financial data related to activities subject to lump sum disbursement procedures will not be subject to post review. (d) Upon completion of the activity, the ministry's representative, accompanied by a technical staff (architect or engineer for civil works, medical doctor for health related activities, etc.) will inspect the completed facility or review the training/seminar, and issue a Certificate of completion and/or a Certificate confirming that the training/seminar took place and was delivered as planned. This technical Certificate will certify that the described activity has been implemented in accordance with the agreed standards, criteria or terms of references, and will be established in a format and content acceptable to the Bank. Because the disbursement amount is not a percentage of a contract amount, and because the item has been procured in accordance with National Procurement Procedures, it will not be required that the certificate mention the cost of the operation, nor the procurement procedure. (e) This certificate will be forwarded to the concerned Ministry which will prepare a monthly Statement of Expenditures (SOE), listing all completed activities. The cost of each activity will be the average cost as defined in Table 4.5 of the SAR. The amount to be reimbursed will be the lump sum amount per activity, as listed in Table 4.5 and in Schedule 1 of the Loan Agreement. The certificate of completion may also trigger other activities such as providing staff for health related facilities. (f) The annual audit will include an audit (at random) of some of the Certificates. The audit will also include a technical audit (at random) of the implemented activities. Annex 7 Page 1 of 2 Project Implementation Monitoring: Key Project Indicators Licator Geographic Content Base Value Source (1) Target Value Data unit collection (2) A. Basic hIdicatora 13 Pmovinces 1. Non-ealary - Ratio to non-targcted 20% Savice du Budget, 1995 25% R xpoenditures (%) in the provinces twenty provinces as compared to the other province. 2. Medical and - number of MD, nar, MD: 148 500 R Paramedical personnel audliairy nurses Nuraca: 438 SCS, 1995 750 deployed in Health deployed in the 13 auxiliary-nurses: 1040 infiastructmea. provinces. 1350 3. Basic Health coverage - % of population 47% SCS, 1995 60% E provided in the twenty covered by ESSB. 4. Deliveries in health % of deliverics 18.5% EnqutEt Panel 1995 30% E facilities. B. Proces Indicators L Component: Imprving acce to curative and prevention health care services. * Health Provinces - number of ESSB built 80 R infantructure - number of easbs renovatedAransformed/ 200 R rebuilt. * Medical equipment Provinces - number of ESSB fully iden R equipped according to their specific functions * Essential drugs National/rural - Budgetary allocations 90 milions DH D.A. 1995 105 millions DH R to assential dugas for ESSBL * Vehicles Provinces - Number of operating 117 R ambulances in ESSBs. - Number of oprating 600 SCS, 1995 864 R motorcycles. - Number of operating 69 SCS, 1995 vehicles. * Medical Personael - Number of 0.3 SCS, 1995 0.6 R & Paramedical physicians/10,000. Capacity deployed - Number of 0.8 SCS, 1995 1.3 R in ESSBs nurses/10,000. - Number of auxiliary 1.9 SCS, 1995 2.3 R nuracs/10,000. Annex 7 Page 2 of 2 Indicator Geographic Content Base Value Source (1) Target Value Data Unit collection (2) * Client satisfaction - Beneficiary Baseline in 5 provinces - E assessments II. Safe Motherhood * Proportion of 45% - National Survey Panel 1995 N = 60% R pregnant women 28%- Rural R=50% who made 2-3 prenatal visits to ESSBs. * Health - Number of maternity 13 provincial R infrastructure wards. rehabilitated maternity wards 55 rural maternity R - Number of midwives wards recruited 20 200 R * Availability of - Number of referral system ambulances. 31 SCS 1995 157 * FP - Contraceptive N = 42% Survey Panel 1995 50% E Prevalence R = 35.6% (13 provinces) * Anemia Program - % of pregnant women 0% 45% R receiving iron supplementation III. Priority Health National Programs. * EPI - Coverage for diseases N = 85% Survey Panel 1995 >90% E targeted under the EPI. R= 78% * Tuberculosis -Incidence 116 DELM 1994 Reduction of 10% E rate per 100,000 per year >90% R * Hygibne du milieu - Percentage of analysis 21% DELM 1994 80% R of perishable goods. - Percentage of 53% 80% R surveillance of vector breeding areas. C. Impact indicators of the SAP (National) * Crude Birth Rate 26% M. pop. 1992 E (per 1000) * Total fertility rate 3.6 Survey Panel 1995 2.6 E * Crude death rate 6.7 Survey Panel 1995 - E (per 1000) * Infant mortality 61 Survey Panel 1995 41 E rate by sex (per 1000) * Child <5 mortality 80 Survey panel 1995 54 E Rate by sex * Life expectancy at mas. 63,8 ENDR 1988 Birth by sex fem. 67,1 * maternal mortality 332 Survey Panel 1995 rate * neonatal mortality 37 per thousand Survey Panel 1995 25 rate (1) SCS: Service de la carte sanitaire DELM: Direction de 1'6pid6miologie et de lutte contre les maladies M. pop: Minist6re de Ia Population ENDR: enquete d6mographique i passages rdp6tds D.A.: Division de l'approvisionnement (2) E = enquete/survey R = routine Annex 8 Page 1 of 1 Selected Information Available in the Project File: 1.- BAJ - Government and consultant documents preappraisal and appraisal mission - February and June 1995. 2 - INAS - December 1994 - February 1995: surveys in samples of the twenty provinces. (5 of them) - Le Profil Epid6miologique dans les zones d6favoris6es (ZIP) - La mortalit6 infanto-juv6nile dans les zones d6favoris6es. - Les strat6gies mobiles de couverture sanitaire: 6valuation dans cinq provinces. - Les services de sant6 de base: analyse de fonctionnement. - La perception des prestations sanitaires par la population. - Les structures hospitalires: analyse de l'utilisation. - Perception du personnel de sant6 sur les services de sante de base. 3. - Detailed Tables on the civil works aspects of the project - February 1995. 4. - SAP - Preliminary document - July 1995. 5. - Staff report on Nutrition - November 1995. 6. - Pharmaceutical sector: reports of the three consultants on quality control, inspection, Pricing Policies and availability of drugs - May 1995. 7. - Detailed description of programs financed under the project. 8. - Specific functions of different types of ESSBs - February 1995. 9. - Strat6gie de Developpement Social pour la D6cennie 1990 - April 1995. BRD 27639 MOROCCO T-nerO - MAROC TANGER.J f Tetouanl SOCIAL PRIORITIES PROGRAM TETOUA PROGRAMME PRIORITES SOCIALES oue Hocemø BASIC HEALTH PROJECT CHECHAUEN L HOCEIMA N PROJET SANTE DE BASE SELECTED PROGRAM PROVINCES IiTAOUNATE PROVINCES SELECTIONNEES POUR LE PROGRAMME I KACEM Toun Jerado Ken,r Koc mTAZ OUJDA Rob.a T - KHEMiSSET Mk FES RABAT , \ht' @ s- Cosbl.nc- BENI SLIMANE - - CASABLANCA0 Be l ) i ~ FRANE,, uemn EbI.od,do - ..,\ MEKNE'\, BOULEMANE - 0 | KHOURIBGA EL JADIDA SETTAT KhounbqO ooued Z. Kh-n r FIGUiG - -KHENIFRA BENI-MELLAL \ -3°SAFie e 32'- 32' 3 - Erroch,d, a) E RRACHIDIA Ag.d.0 SHARE OF RURAL POPULATION OF A PROVINCE IN THE TOTAL POPULATION OF THE PROVINCE PROPORTION DE LA POPULATION RURALE DUNE PROVINCE AGADIR PAR RAPPORT A LA POPULATION TOTALE DE LA PROVINCE ) BETWEEN 50% AND 7A' ENTRE 50 ET 74% O 75% AND MORE 75% ET PLUS RIVERS COURS D EAU PROVINCE CAPITALS CAPITALES PROVINCIALES -.NATIONAL CAPITAL - CAPITALE NATIONALE G _ PROVINCE BOUNDARIES 0 50 00 150 LIMITES PROVINCIALES KILOMETERS INTERNATIONAL BOUNDARIES GUELMIME FRONTIERES INTERNATIONALES T n " ------Te boundres. color, dn m n andayoherm o ron NTERN TIONAL BOUNDARIES -hono , np d. -o1-rpi,, - Ih. p.,,. ol ý TO. ,IdS.no G-,op - APPROX IMATE) -howyi.dg-M tI,, mp f-y -y- w d- FRONTIERES INTERNATIONALES TAN-TAN ,p0bdar- (APPROXIMATiON) MARCH 1090 IMAGING Report No: 15073 MOR Type: SAR