Senegal - Endemic Disease Control Project

Document of The World Bank Report No. 16459 - SE STAFF APPRAISAL REPORT REPUBLIC OF SENEGAL ENDEMIC DISEASE CONTROL PROJECT April 11, 1997 Iluman Development 2 Africa Region  CURRENCY EQUIVALENTS Currency Unit: CFA Franc (CFAF) US$1 = CFAF500 (March 1997) ABBREVIATIONS AND ACRONYMS AGETIP Agence d'Execution des Travaux d'Inter6t Public contre le Sous-en7ploi (Contract Management Agency) AIDS Acquired Immune Deficiency Syndrome BRH Brigade Regionale d'Hygiene (Regional Hygiene Unit) CFA Comnmunaute Financiere Africaine (African Financial Community) DAGE Direction de I 'Administration et de I 'Equipement (Administration and Equipment Directorate) DALYs Disability-Adjusted Life Years DSTAT Division des Statistiques (Statistics Division) DHSP Direction de l'llygiene et de la Sante Publique (Hygiene and Public Health Directorate) EU European Union FAC Fonds d'Aide cr la C'oop&ration (French Cooperation) GDP Gross domestic product IDA International Development Association IEC Information, Education and Communication ICB International Competitive Bidding MRA Medical Region Administration MSPAS Ministere de Ia Sante Publique et de I 'Action Sociale (Ministry of Public Health and Social Affairs) OCP Onchocerciasis Control Program OMVS Organisation pour la Mise en Valeur du Fleuve Senegal (Organization for the Development of the Senegal River) PNA Pharmacie Nationale d'Approvisionnement (Central Pharmaceutical Procurement Agency) SA Special Account SSA Sub-Saharan Africa SGE Secteur des Grandes Endemies (Regional Endemic Disease Control Unit) SIG Systeme d'Information ai desfins de Gestion (Health Information System) SIP Health Sector Investment Project SNGE Service National des (Grandes Endemies (National Endemic Disease Service) STD Sexually Transmitted Disease UNICEF United Nations Children Fund USAID U.S. Agency for International Development VHW Village Health Worker WHO World Health Organization FISCAL YEAR January 1 - December 31 Vice President : Jean-Louis Sarbib Director : Mahmood A. Ayub Technical Manager : Ok Pannenborg Task Team Leader : Yves Genevier  REPUBLIC OF SENEGAL ENDEMIC DISEASE CONTROL PROJECT CONTENTS BASIC DATA AND COMPARATIVE INDICATORS CREDIT AND PROJECT SUMMARY ...................................................... i 1. INTRODUCTION .......................................................1 2. THE CONTEXT ...................................................... .I A. DEVELOPMENT CONTEXT .......................................................1 B. SECTORAL CONTEXT .......................................................3 C. ISSUES .......................................................7 D. GOVERNMENT POLICIES AND ACTIONS AND THE BANK'S EXPERIENCE ...................................................8 3. THE PROJECT ...................................................... . 10 A. PROJECT OBJECTIVES AND STRATEGY ...................................................... 10 B. PROJECT DESCRIPTION ...................................................... I I C. PROJECT COST AND FINANCING ...................................................... 19 4. PROJECT IMPLEMENTATION ...................................................... 20 A. STATU1S OF PROJECT PREPARATION AND READINESS ...................................................... 20 B. PROJECT COORDINATION AND MANAGEMENT ...................................................... 20 C. MONITORING AND EVALUATION ...................................................... 21 D. PROCUREMENT AND DISBURSEMENT ...................................................... 22 E. ACCOUNTING, AUDITING AND REPORTING ...................................................... 25 5. PROJECT BENEFITS AND RISKS ...................................................... 26 6. AGREEMENTS REACHED AND RECOMMENDATION ...................................................... 27 ANNEX I PROJECT LOGICAL FRAMEWORK & INDICATORS ANNEX 2 LETTER OF SUB-SECTOR POLICY ANNEX 3 MALARIA ANNEX 4 SCHISTOSOMIASIS ANNEX 5 ONCHOCERCIASIS ANNEX 6 HEALTH MANAGEMENT INFORMATION SYSTEM (SIG) ANNEX 7 NATIONAL ENDEMIC DISEASE SERVICE (SNGE) ANNEX 8 ECONOMIC ANALYSIS ANNEX 9 SUPERVISION PLAN ANNEX 10 PROCUREMENT PLAN ANNEX 11 PROJECT COSTS ANNEX 12 SELECTED DOCUMENTS & DATA IN PROJECT FILE This report is based on the findings of an appraisal mission carried out in Senegal in December 1996 by Mr. Yves Genevier (Task Manager), Mr. Alassane Diawara (Resident Mission), Slaheddine Ben-Halima (Procurement specialist), and Dr. Jose Najera (Consultant) and has been the object of a Decision Meeting, chaired by Mr. Mahmood Ayub on January 30, 1997. The project preparation has also benefitted from consultation, review, and technical work from Dr. Bemard Liese, Lead Advisor; Mr. Armin Fidler, Peer Reviewer; Mr. Florent Agueh; Mr. Bernard Abeille, Procurement Specialist; Ms. Myrina McCullough, Program Assistant, and Ms. Bronagh Murphy, Editor.   REPUBLIC OF SENEGAL ENDEMIC DISEASE CONTROL PROJECT BASIC DATA AND COMPARATIVE INDICATORS Sub-Saharan POVERTY and SOCLAL Senegal Africa Low-income Population mid-1995 (millions) 8.5 589 3,188 GNP per capita 1995 (US$) 570 490 460 GNP 1995 (billions US$) 4.8 289 1,466 Average annual growth, 1990-1995 Population (%) 2.7 2.8 1.8 Labor force (%) 2.6 2.8 1.9 Most recent estimate (latest year available since 1989) Poverty: headcount index (% of population) Urban population (% of total population) 42 31 29 Life expectancy at birth (years) 50 52 63 Infant mortality (per 1,000 live births) 62 92 58 Child malnutrition (% of children under 5) 20 .. 38 Access to safe water (% of population) 51 47 75 Illiteracy (% of population 15+) 67 43 34 Gross primary enrollment (% of school-age population) 56 71 105 Male 67 77 112 Female 50 64 98 Development dlamond' Life expectancy GNP Gross per - - primary capita enrollment Access to safe water Senegal Low-income group   REPUBLIC OF SENEGAL ENDEMIC DISEASE CONTROL PROJECT CREDIT AND PROJECT SUMMARY Borrower: Republic of Senegal Implementing Agency: Ministry of Public Health and Social Affairs (MSPAS) Beneficiaries: Not applicable Poverty Category: Not directly applicable Amount: SDR10.8 million (US$14.9 million equivalent) Terms: Standard IDA terms with 40 years maturity Financing Plan: IDA :US$14.9 million EU :US$0.3 million FAC :US$0.7 million WHO :US$0.1 million UNICEF :US$0.l million Government :US$0.9 million Staff Appraisal Report: Report No. 16459 Map: IBRD No. 28634 Project lID: SN-PE-41567 Project Description 1. For every population cohort in Senegal, infectious diseases are the main cause of mortality and morbidity, with malaria, respiratory infections and diarrhea being most prevalent. In recent years, there has been a recrudescence of epidemic diseases such as cholera, a steady increase of endemic diseases such as malaria, schistosomiasis, onchocerciasis and hepatitis B, and the emergence of new viral diseases such as AIDS. 2. The organization of endemic and epidemic diseases surveillance and control is the responsibility of the Endemic Disease Control sub-DirectorateService National des Grandes Endemies (SNGE). Over the past 20 years, the resources allocated to the SNGE have steadily decreased to 1 percent of the Ministerial budget. Surveillance and control activities have been mainly supported by the donor community, with a project-by-project and donor-by-donor approach. The capability and organization of the SNGE as a team have progressively deteriorated, undermining the effectiveness and motivation of its staff. Furthermore, knowledge of the epidemiological situation in the country has decreased in the absence of an effective and communicative health management information system, leaving no opportunity for prevention or proactive measures. 3. The project was born from the dialogue between Government and IDA about the New Orientations of the Health and Social Sector Policy (Nouvelles Orientations de la Politique de  ii Sante et d'Action Sociale) defined in June 1995, and was developed during a series of consultative meetings organized by the Government over an 18-month period. Participants in these meetings were drawn from all stakeholder groups, including district and regional medical staff, from the medical university, and partners in development for Senegal. 4. The long-term objective of the project is to strengthen national capacity to control endemic and epidemic diseases, with greater concern for rationalization in the use of resources and cost-effectiveness in the choice of control stategy. Project strategy consists in institutionally strengthening the SNGE, supporting its efforts to control, in particular, three diseases of public health importance, i.e. malaria, schistosomiasis and onchocerciasis, and implementing a computerized health management information system. The project design includes three main components: (a) support to malaria, schistosomiasis and onchocerciasis control activities, (b) development of a computerized health management information system; and (c) institutional strengthening of the SNGE. Project Benefits 5. By reducing the burden of malaria, schistosomiasis and onchocerciasis, the project will directly benefit the populations in rural areas where these diseases are most prevalent. As a result of the reinforcement of national capacities to control endemic and epidemic diseases, the project will also significantly benefit people in poor urban areas who have been severely hit by recent epidemics of cholera, and who are still at high risk from other epidemics such as cerebral meningitis. The social and economic development of the Senegalese population will strongly benefit from the success of the project as endemic disease control activities are pure public goods with important externalities. For example, the project's global objective to reduce malaria morbidity by 20 percent would save an equivalent of 0.2 percent of GDP. Finally, the implementation of a computerized network supporting the national health information system will allow a better planification of resources, a improved communication between staff, and also with international partners, as well as a new work culture towards partnership and cross- fertilization. Project Risks 6. The first risk relates to the acceptance by health staff of the new mission for the SNGE and its integration within the general health services. This risk would be reduced by: (a) a clear definition of the breakdown of the SNGE's responsibilities in the control of each disease; (b) the SNGE's demonstration of high professionalism and expertise; and (c) the development of a strong team spirit. The second risk relates to the non-sustainability of crucial activities at peripheral levels, such as continuous in-service training, regular supervision of the staff, and education of the population on public health issues. These activities will be included and budgeted for within the Regional and District Health and Social Plans, and regional and district health teams would be accountable for implementing these activities. The last risk would be the failure of the donor community to fully coordinate its efforts to support the surveillance and control of endemic and epidemic diseases. The Bank would assist the Government in minimizing this potential risk during project implementation through coordination mechanisms to be established under both this project and the Health Sector Investment Project under preparation.  iii ESTIMATED COSTS AND FINANCING PLAN ESTIMATED PROJECT COSTS (US$ million equivalent, including taxes and duties) ff Foreign if Local if Total ][ % of Total l_ ft II Base Cost 1. Malaria, Schistosomiasis and Onchocerciasis Control 2.4 2.2 4.6 30% 2. Health Information System 2.5 0.8 3.3 22% 3. Institutional Strengthening 3.9 3.4 7.3 48% TOTAL BASE COSTS: 8.8 6.4 15.2 100% Physical Contingencies: 0.6 0.4 1.0 7% Price Contingencies: 0.4 0.4 0.8 5% I1 I l1 TOTAL PROJECT COST: F[ 9.8 || 7.2 17.0 11 112% FINANCING PLAN (US$ million equivalent, including taxes and duties) L Foreign || Local Taxes & Duties Total IDA 8.6 6.3 0.0 14.9 Government 0.0 0.4 0.5 0.9 UNICEF 0.1 0.0 0.0 0.1 WHO 0.1 0,0 0.0 0.1 EU 0.3 0,0 0.0 0.3 FAC 0.7 0,0 j 0.0 0.7 TOTAL if 9.8 || 6.7 if 0.5 17.0 ESTIMATED IDA DISBURSEMENTS (US$ million equivalent) FY98 FY99 FY00 FY01 FY02 Annual 2.0 4.5 3.5 2.6 2.0 Cumulative 2.0 6.5 10.3 12.9 14.9 Slight differences in amount may occur due to rounding of figures.   REPUBLIC OF SENEGAL ENDEMIC DISEASE CONTROL PROJECT 1. INTRODUCTION 1.1 The Government of Senegal has requested International Development Aid (IDA) financing over 5 years for a credit to develop its national capacity for epidemiological surveillance and control of endemic and epidemic diseases. Total project costs are estimated at US$17.0 million. The Government would contribute about US$0.9 million. The remaining US$16.1 million would be financed by the International Development Agency (IDA), European Union (EU), French Cooperation (FAC), United Nations Children's Fund (UNICEF) and World Health Organization (WHO). 1.2 The project would be IDA's first free-standing endemic disease control project in Senegal and the first project of its kind in sub-Saharan Africa. It is an intervention which focuses on the revitalization of the Service National des Grandes Endemies (SNGE), on the development of a computerized network-based health management information system (SIG), and on the reinforcement of the control of malaria, schistosomiasis and onchocerciasis, three diseases which impede the productivity of the human capital base. The project would precede and complement the Senegalese Health Sector Investment Project (SIP) which is under preparation and will be appraised in FY97. The early implementation of the project will give a headstart to the development of the SIG, thus facilitating the SIP implementation. 1.3 The project would be IDA's third contribution to the development of health services in Senegal. The first two projects did not include any significant investment in the control of endemic diseases. Policy measures and investments included in this project have been developed through extensive dialogue with Senegalese authorities based on a ten-year National Health and Social Development Plan and a five-year investment program, both completed in March 1997 with the support of multilateral and bilateral donors. 1.4 The following partners of the Senegal Government who are involved in the health sector, the EU, FAC, UNICEF and WHO, have participated actively in project preparation and would cofinance the project. Given the importance they attach to the achievement of the project objectives, they would adjust the agendas of their bilateral programs in order to maximize the synergy with the project, in particular in the domain of the development of the SIG. 2. THE CONTEXT A. DEVELOPMENT CONTEXT 2.1 Geography and Climate. Senegal is a medium-sized country (196,722 km 2) with 550 km of Atlantic coastline. It is located at the westernmost point of the African Continent. Senegal is generally flat and lies in the Senegal-Mauritanian Depression. Three-fourths of the country lies in the Sahel, which has suffered from a lower-than-normal average rainfall for the last 40 years. The country itself has a tropical sub-desert climate. The rainy season is limited to  2 a seasonal monsoon, wetter in the south (more than 1000 mm from May to October) than in the north (greater than 300 mm from June to September). The duration, intensity, and seasonal distribution of the rains at any location varies considerably from year to year, particularly in areas of lowest rainfall. 2.2 Population and Economy. Senegal population is estimated around 8.5 million inhabitants. Half is under the age of 16, and the majority (58 percent) lives in rural areas. Senegal has a per capita income of US$621 (1996). One-third of the population lives below the poverty line, estimated at US$150 in 1992. Population growth rate is substantially above the real GDP growth rate (2.5 percent vs. 1.7 percent, 1986-93). This decline in real per capita product was due to Senegal's inability to adjust to falling terms of trade for its main exports (groundnuts and phosphates). Senegal shares with many Sub-Saharan African (SSA) countries a lack of export differentiation that makes it particularly vulnerable to changes in the world prices of its main exports. The three major exports of Senegal, i.e. phosphates, groundnuts and fish, represent 77 percent of total exports. 2.3 Since Senegal belongs to the African Financial Community (CFA) franc zone, adjustment of the nominal exchange rate was, until the end of 1993, out of reach because it requires unanimous agreement by all CFA zone members and France. A devaluation of the real exchange rate, which is the crucial variable for competitiveness, was prevented by rigid nominal wages and by an expansive fiscal policy. The over-evaluation of the exchange rate compounded the Senegalese economy's loss of competitiveness, owing to the rigid regulation of labor and widespread monopolies in the industry and service sectors. 2.4 Macroeconomic Performance. Since early 1994, Senegal has been implementing a medium-term adjustment and reform strategy aimed at taking full advantage of the gain in competitiveness brought about by the devaluation of the CFA franc (January 12, 1997) and creating the conditions for strong and sustainable economic growth. This strategy is based on fiscal and monetary stability and structural reforms. It aims at liberalizing the economy, reducing the size of the public sector, and fostering private sector development. 2.5 This strategy has resulted in a marked recovery of economic activity and a significant improvement in Senegal's macroeconomic performance. Real per capita growth became positive in 1995 and it is estimated at 2.4 percent in 1996. Inflation has been lower than expected: the CPI fell from 37 percent in 1994 to 5.5 percent in 1995 and is estimated at 3.3 percent in 1996. Fiscal performance has also improved: revenue rose as a percentage of GDP due to strengthened tax administration, but a failure to adjust petroleum prices to increased world prices created a shortfall in revenue in 1996. There was no expenditure overrun, while increased resources were allocated to basic health and education. 2.6 Poverty. Although recent indicators of poverty or income distribution are not available, the CFA franc devaluation and the resulting shift in internal terms of trade appear to have boosted incomes in rural areas by 40 percent. Given that the agricultural sector in Senegal is dominated by small landholders, the large increase in the real value of agricultural output suggests a substantial improvement in the real living standards of Senegal's rural poor during the last three years. 2.7 Social Indicators. In spite of real improvements over the last decade, health indicators show that Senegal's living standards remain below those of other lower-middle income countries. Infant and child mortality account for 60 percent of all deaths; life expectancy and  3 primary school enrollment are estimated at 50 years and 56 percent respectively as compared to the Sub-Saharan Africa (SSA) averages of 52 years and 70 percent. In education, efforts continue toward raising the primary enrollment ratio and improving the quality and efficiency of higher education. The primary enrollment ratio declined from 58 percent in 1989 to about 54.3 percent in 1993, before rising to the current level of 56 percent, with female enrollment growing faster than male enrollment. The Government has a goal of universal basic education and intends to raise the primary enrollment ratio to 65 percent by 1998. 2.8 In the health sector, infant mortality declined from 159 (per thousand live births) to 68 between 1975 and 1992 (Demography Health Survey 2, 1992-93). The Government will reinforce its policy to further improve the quality and efficiency of health care delivery at all levels. A three-year Public Investment Program - Programme Triennal d 'Investissement Public (PTIP) - covering the period 1997-99 will give priority to projects that support human resources development and the fight against poverty. Primary health care has been recently expanded nationwide with IDA support, and with a better allocation of resources for health services provided by district health centers and health posts, the budget share of the hospital sector and urban services decreasing in the mean time from 45 percent during the period 1981 - 1985 to 34 percent during the period 1986 - 1995). 2.9 The Country Assistance Strategy, discussed by the Board on February 16, 1995, aims to assist Senegal in reducing poverty by restoring growth in per capita income and fostering a more equitable distribution of the benefits of growth. To relaunch economic growth, the strategy focuses on increasing opportunities for private sector expansion and improving productivity in agriculture--particularly in the production of the traditional export (groundnuts), food, and non- traditional and high value-added crops. To support this growth, the Government should provide a more efficient and cost-effective provision of public goods such as power, water and transportation, and an improvement in the human capital base. To foster a more equitable distribution of benefits, the strategy focuses on improving public resource mobilization and the efficiency and cost-effectiveness of public expenditures-particularly in basic education and health. B. SECTORAL CONTEXT 2.10 Introduction. For every population cohort in Senegal, infectious diseases are still the main cause of mortality and morbidity, with malaria, respiratory infections and diarrhea being most prevalent. In the past ten years, there has been a recrudescence of epidemic diseases such as cholera, a steady increase of endemic diseases such as malaria, tuberculosis, schistosomiasis and hepatitis B, and the emergence of new viral diseases such as AIDS. Lastly, the threat of the development of deadly epidemics such as the cerebral meningitis outbreak, which affected more than 200,000 persons and killed around 20,000 of them in the sub-region in 1996, became a high public health concern for the MSPAS and its partners in development. 2.11 Malaria. In Senegal, malaria is the main cause of morbidity, representing between 40 and 50 percent of all consultations (approximately 450,000 reported cases in 1994), one of the main causes of mortality, and a major burden on society. Based on the sub-regional average cost of a case of malaria, the economic burden of malaria represents 1 percent of GDP in Senegal (around US$6 million). 2.12 The parasite is Plasmodiumfalciparum which can cause severe symptoms and lead rapidly to death. The chief symptom of malaria is fever but the characteristics of the disease  4 vary with the intensity of the infection and the host's level of immunity. The risk of severe malaria is almost exclusively limited to those who have not acquired a certain level of immunity. The level of immunity depends on the level of transmission of the disease. Malaria is responsible for high mortality in children from six months to five years of age (about 25 percent of all deaths in these groups) who have not yet developed an immunity. Malaria also represents a serious risk for pregnant women in a first or second pregnancy by causing low birth weight and high neonatal mortality in first- and second-bom children. A more detailed description of malaria issues in Senegal is attached in annex 3. 2.13 Human impact due to the disease varies with the great diversity in epidemiological context and is considered close to the African average, i. e. five to six days' incapacity per acute attack with an attack rate of 1.5 to 3 per year for children under five and 0.25 per year for older children and adults. The burden of illness is compounded when affecting mothers of young children, income-generating members of the family (particularly during outbreaks in the agricultural season), and young children (which places heavy demands on mothers, affecting the whole family). Based on sub-regional studies, malaria would account for about I I percent of all disability adjusted years (DALYs) in Senegal, as in the rest of SSA. 2.14 Schistosomiasis. Schistosomiasis results from a heavy infection with schistosome trematode worms. Infection follows contact with water bodies contaminated with infected water snails, which are the intermediate hosts of the parasite. Populations at risk are those who are in frequent contact with contaminated water bodies, i.e. school-age children, rice-culture workers, and to a lesser extent, women. The disease kills few people but has sapping chronic effects. Depending on the type of schistosomiasis, the clinical manifestations of the disease involve intestinal or urinary complications resulting from reactions to schistosome eggs lodged in these tissues. Since the risk of complications is related to the intensity of infection, severe pathology tends to be concentrated in the communities where prevalence is highest. A more detailed description of the disease and related issues is attached in annex 4. 2.15 Statistically, the relative importance of schistosomiasis in the burden of infectious diseases is still low in Senegal - 5,300 notified cases in 1994. But the development of agricultural and irrigation projects which started in the 1980s have led to environmental changes which favor the spread of schistosomiasis and the emergence of outbreaks such as the epidemic of intestinal schistosomiasis in the St. Louis region. A prevalence map is attached in annex 4. The rapid development of the epidemic of intestinal schistosomiasis in the St. Louis region and the increase in prevalence and intensity rates of urinary schistosomiasis in the rest of the country have rightly raised Govemment and Donor concem. 2.16 Intestinal schistosomiasis was not significant in Senegal until 1986. Since the start of the Diama dam on the Senegal river in 1986, an epidemic has spread rapidly in the western part of the St. Louis region (west to Podor) with a serious risk of extension to the rest of the Senegal river valley. The epidemic has been characterized by an unceasing transmission, an extremely rapid re-infestation rate, and high prevalence and intensity rates. Urinary schistosomiasis has always been endemic in Senegal with a highly focal distribution. High prevalence rates were found in scattered villages in the Tambacounda, Kolda, Kaolack and Diourbel regions. In the St. Louis region, with the irrigation and rice development projects, it too has become epidemic, though at a lower rate than intestinal shistosomiasis. 2.17 Onchocerciasis. Since 1986, the regional Onchocerciasis Control Program (OCP), with MSPAS support, has been responsible for controlling the morbidity due to onchocerciasis in  5 Senegal through an annual large-scale distribution of ivermectin. According to the devolution process, i.e. process for transferring the responsibility of control activities to Participating Countries, the Government of Senegal should take over this responsibility progressively and has requested IDA support during the transition period. The endemic area covers 456 villages, distributed in six counties of the Tambacounda region and one county of the Kolda region; 200,000 inhabitants are exposed. Demonstrated to be the most cost-effective and sustainable ivermectin distribution system, community-based distribution has been implemented in 299 villages and should be extended over the next five years to the other 157 endemic villages. A detailed description of the situation is attached in annex 5. 2.18 National Endemic Disease Service. Both before and since independence, the organization of the surveillance and control of endemic and epidemic diseases has been under the administration of the National Endemic Disease Serviceervice National des Grandes Endemies (SNGE). The SNGE is one of the three National Services and four sub-Directorates within the Hygiene and Public Health Directorate-Direction de l 'Hygiene et de la Sante Publique (DHSP}-which is responsible for implementing the health policies adopted by the Government. The SNGE includes a central unit with 6 high level staff, and 10 regional endemic disease control units - Secteurs des Grandes Endemies (SGE) - with 4 medical doctors and 60 nurses and health assistants. An organizational chart of the MSPAS and the present distribution of the SNGE personnel are described in annex 7. 2.19 Over the past 20 years, Senegal, like many Sub-Saharan African countries, did not develop its capacities to control endemic and epidemic diseases. Resources allocated to the SNGE steadily decreased to I percent of the MSPAS budget in 1995. Expensive epidemiological surveillance and control activities could not be financed either by the meager Government allocation of US$2 per capita/per year for the health sector, or by the population which has no demand for these services. 2.20 Surveillance and control activities were mainly supported by the donor community with a disease-by-disease and donor-by-donor approach. Although credited with some successes, this approach was too costly to be sustainable due to the absence of rationalization in resource utilization. In the 80s, donors' financial constraints imposed an arbitration between diseases for financial support. Only a few diseases were accorded the benefit of a well-financed national control program: leprosy, dracunculosis, onchocerciasis and the diseases of the Expanded Program for Immunization (EPI). Human, material, and logistical resources were attributed to these well-supported programs, but with no coordination or rationalization in their utilization and management. As a consequence, some major diseases, such as malaria, schistosomiasis, cerebral meningitis and hepatitis B, were not accorded effective surveillance and control activities, leading to their recrudescence. 2.21 Epidemiological Surveillance System. The national epidemiological surveillance system has been developed within the SIG but confined to passive surveillance indicators, i.e. morbidity and mortality, based on health facilities reports. These indicators are generally non- pertinent and unavailable for the decision-making process. In addition, the system does not record risk indicators which could be used to prevent epidemics or recrudescence of endemics. As a consequence, several national programs, such as the National Tuberculosis Control Program, the National Leprosy Control Program, the Onchocerciasis Control Program, the STD/AIDS Program, the EPI, and the Nutrition Program, developed their own information systems. These information systems are centrally managed by the supervisor of the Program. None of the existing information systems gives practically feedback to the staff at the periphery.  6 2.22 The Health Information System (SIG). The SIG is under the responsibility of the Statistics Division-Division des Statistiques (DSTAT)- within the DHSP. In 1986 the first reform of the SIG was initiated. It focused on the management of health services with data concerning demography, morbidity, mortality, financing, and activities. From 1986 to 1993, efforts were directed towards the standardization of forms and health indicators. In 1994, supported by different partners, the MSPAS started computerizing the SIG with the development of several types of software: (i) GESIB, monitoring the Bamako Initiative activities; (ii) Logiciel Sante, monitoring data collected from health posts, including mortality and morbidity data; (iii) SIGeo, background mapping and monitoring of malaria and schistosomiasis indicators in the St. Louis region, and of dracunculosis in endemic areas; and (iv) the Family Planning information system. Although promising, these efforts have suffered from a lack of coordination and expertise in software development, and from the absence of a global plan for the SIG development. A detailed analysis of issues related to the SIG are attached in Annex 6. 2.23 General Health Services. Since the mid-70s, the Government's policy in the health sector has emphasized primary health care and preventive medicine and has accorded priority to the delivery of basic health services to rural areas, where the great majority of the population lives. A network of 750 health posts and around 8,000 village health workers (VHWs) form the base of the health care system, serving as its first entry point. The key health providers are the nurses who staff the health posts. They are responsible for a variety of curative and preventive services, supervision and in-service training of the VHWs, health and nutrition education, and record-keeping. Health problems that cannot be resolved at the village or health post level are referred to the 52 health centers, which constitute the first level of referral and are usually located in the district capital (department level). These centers are managed by one or two medical doctors and are designed to provide out-patient and limited in-patient services and laboratory services, as well as to supervise the health posts. In addition, the 45 health districts have a Hygiene sub-unit. 2.24 The Country is divided into ten Medical Regions which correspond to the administrative regions; each Medical Region is constituted of: a) a regional medical team located in the regional capital and headed by the regional medical officer, b) a regional endemic disease control unit-Secteur des Grandes Endemies (SGE), and c) a regional hygiene unit-Brigade Regionale d 'Hygiene (BRH). With the exception of the Kolda and Fatick regions, each region has a regional hospital located in the regional capital which constitutes the second referral level. The St Louis region has, in addition, two hospitals in Dioum and Ouorossogui. Three national hospitals, one university hospital, and a National Center for Tuberculosis located in Dakar complete the national referral system. Drug procurement and distribution to the regions are handled by the Pharmacie Nationale d'Approvisionnement (PNA)-a entity under the jurisdiction of the MSPAS. PNA operates a network of five regional pharmacies-Pharmacie Regionale d'Approvisionnement. 2.25 Following the Alma-Ata conference in 1978, the Government of Senegal undertook a major reform to decentralize health services with community participation and to develop primary health care with the definition of an integrated minimum package of activities. But activities such as the surveillance and control of endemic and epidemic diseases, though recognized as essential and with strong externalities, could not be integrated and were practically left out of the reform process.  7 C. ISSUES 2.26 The global issue relates to the institutional weakness of the MSPAS in mobilizing and managing its resources to control endemic and epidemic diseases of public health concern. Few of these diseases are subjected to control activities and even so the management and financing of these control programs stay out of MSPAS control. As a result, endemic diseases of high public health importance such as malaria and schistosomiasis are only subject to limited control activities. 2.27 The first specific issue relates to the SNGE's personnel. The fragmentation of the SNGE organization has led to the loss of the SNGE mission, the deterioration of the team spirit, and the degradation of the institutional capacity to tackle global and specific problems posed by endemic and epidemic diseases. In fact, the SNGE mission is reduced to the management of the few well- financed control programs without any search for rationalization and cost-effectiveness. 2.28 At the central level, the national coordinators are mostly involved in operational activities of the control programs for which they are individually responsible and receive donor financial and logistical support. As individual or as a group, there is no time given to the conceptualization, monitoring and supervision of non-financed control programs. In addition, the scattering of the SNGE offices in Dakar contributes to independent (non-cohesive or duplicate) work and to a loss of cross-fertilization and team work. 2.29 At the peripheral levels, the personnel receives training for, and implement, only well- funded control activities; and few of them are exposed to integrated training and supervision programs. None of them are trained for non-funded disease control programs. For example, training on malaria and schistosomiasis (with the exception of the St Louis region) control activities is not provided at the peripheral levels. Moreover, there is no incentive for the staff to promote flexibility and rational management in the utilization of logistic and financial resources. 2.30 The second specific issue is the lack of epidemiological intelligence due to the under- development of the existing epidemiological surveillance system, and more generally of the Health Management Information System (SIG). The utilization of the SIG as an alert system, and in the programming, management, and monitoring of health activities is still very low for the following reasons: (a) there are at least seven different forms to fill out and more than one thousand data to report at the health post level each month; (b) many indicators are either redundant or irrelevant; (c) the system does not allow rapid circulation and consultation of the collected information; (d) there is no feedback information; and (e) there is no cross-circulation of information allowing neighboring districts to have access to each other's data and consequently benefit from each other's experience. 2.31 The third specific issue is the need to maintain a balance between the decentralization process and the need for quality. Quality often requires technical expertise found mainly at the regional and national levels. This issue relates not only to the frequency of the activities but also to the evaluation of the staff capabilities, the relevance of training programs, as well as the effectiveness of supervisions and support.  8 D. GOVERNMENT POLICIES AND ACTIONS AND THE BANK'S EXPERIENCE Government Policy and Actions 2.32 The Government's commitment to the development of the health services is embodied in the National Health Policy statement adopted in June 1989, and in the recently developed document entitled "Nouvelles Orientations de la Politique de Sante et de l 'Action Sociale, juin 1995." This approach is consistent with the strategy outlined in the 1993 World Development Report published by the World Bank, and the World Bank Africa Region policy paper, Better Health in Africa, and constitutes a good framework for the development of the health sector. Preparation of a ten-year National Health Development Plan and a five-year investment program to implement this framework was completed in March 1997, with the support of multilateral and bilateral donors. 2.33 In these documents the Government reaffirms its commitment to the reinforcement of endemic disease control through the development and implementation of: (i) epidemiological surveillance and control activities for endemic and epidemic diseases; (ii) a National Training Policy which would be effective and integrated; and (iii) a computerized and integrated health information system. 2.34 With regard to malaria control, the Republic of Senegal participated in the Ministerial Conference on Malaria in Amsterdam in 1992 and co-signed the final Declaration, reaffirming its commitment to pursuing malaria control as an essential element of the health development of the country. A National Malaria Control Program was finalized in September 1995 based on the strategy recommended by the Ministerial Conference. The strategy relies on the improvement of case management at household and health facility levels, vector control with impregnated bednets, and development of an epidemiological information system. 2.35 With regard to schistosomiasis control, in 1991 the Government created in the St. Louis region the program ESPOIR to coordinate schistosomiasis-related research and control activities, with the financial and technical support of the EU, the FAC, the Pasteur Institute and different European universities. The World Bank's Experience in Senegal 2.36 The World Bank Group's involvement in the health sector in Senegal includes the Rural Health Project (Cr. 13 10-SEN), signed on February 2, 1983, and closed in 1989, whose objective was to support the improvement of primary health care in rural areas, and the Human Resources Development Project (Cr. 9180-SEN), closed in March 1997, whose health objectives were to support the extension of primary health care services in three regions, the decentralization nationwide of health planning and management, and the promotion of essential generic drugs. 2.37 The Rural Health Project had mixed success in attaining its objectives. Project activities contributed to completing coverage nationwide with respect to health centers. However, the accompanying improvements in service quality that were expected through the training have been less satisfactory due principally to the lack of an integrated and well-defined training strategy. Progress was made in the development of a pharmaceutical sector strategy, including improvements in the official list of essential drugs, preparation of practical recommendations for the reform of the National Pharmacy, and recommendations for improvements in the drug cost recovery system.  9 2.38 The Human Resources Development Project has successfully tested the acceptability of generic drugs and has demonstrated the willingness and ability of communities to pay for health services as well as manage cost-recovery schemes. On the other hand, the project highlighted: (a) the difficulties in dealing with human resource management reforms in the absence of greater decentralization of health system management and broader civil service reform; (b) the limited capacity of central administrative structures to redefine their roles away from direct control and management toward strategic and support functions; and (c) the need for major legislative and regulatory reform of the pharmaceutical sub-sector to achieve a meaningful shift to generic drug procurement and distribution. 2.39 Upon Government request, a SIP is under preparation and will be appraised during FY97. This program would contribute to provide the administrative structure for monitoring all government and donor activities within the health sector and its sub-sectors, i. e. peripheral, regional and central facilities, health finance, health insurance, human resource development. The SIP would encompass the project. 2.40 The project would be launched approximately 12 months before SIP effectiveness. Although the project was designed according to the National Health and Social Development Plan, and developed in the context of the SIP preparation, the Government decided (with IDA tacit agreement) to bring forward its implementation for two reasons. First, for the SIP to be effective in developing and coordinating MSPAS and donor activities in the area of endemic diseases control, the SNGE must be reformed and strengthened. Second, the SIP implementation will require the development of a reliable health management information system. It will be a great advantage for these elements to be well advanced when the SIP becomes effective. The management of the proposed project will be merged with the SIP management when the latter is in place. Rationale for IDA Involvement 2.41 The Country Assistance Strategy aims to assist Senegal in reducing poverty by restoring growth in per capita income. Part of the Government's strategy consists of improving the human capital base through the provision of basic education and health services. To improve the health of the population, health services should be able to control infectious diseases which are the main cause of mortality and morbidity for every population cohort. By strengthening the MSPAS capacity to control infectious diseases, the project would be an important mean of the Bank's assistance strategy. 2.42 In recent years, through different initiatives worldwide, the Bank, in collaboration with the Donor community, has been seeking to reduce the burden of malaria, schistosomiasis and onchocerciasis, particularly with regard to women and children. It has been proven that these three endemic diseases hamper human development in Sub-Saharan Africa. Controlling them would thus have a strong economic rate of return. Given the fragmented donors' support in the area of surveillance and control of endemic disease, with the current program-by-program and donor-by-donor approach, IDA is the only possible support to Government efforts in designing and implementing a comprehensive institutional reform in this area. The traditional role the Bank has played in promoting supportive and effective donor coordination will be crucial in this area, as well as in that of the SIG development.  10 2.43 In addition, many components of the project have financial requirements that are beyond the capacity of local resources or those available through existing or planned donor programs. The IDA Credit sought by the Government would complement these resources. 2.44 The proposed project is the first IDA credit aiming specifically to strengthen the surveillance and control of endemic disease in Senegal, as well as throughout the West-African sub-region. However, the Bank has supported similar projects in Brazil and Egypt. Project preparation and design have benefited from the experience gained through these projects. 3. THE PROJECT A. PROJECT OBJECTIVES AND STRATEGY 3.1 Project Objectives. The global objective of the project is to support the Government in its efforts to alleviate the burden of endemic and epidemic diseases on the Senegalese populations, with, in particular, a reduction of the burden of malaria, schistosomiasis and onchocerciasis. In its Letter of Sub-Sector Policy (Annex 2), Government has established the following benchmarks for the year 2002: (a) reduce by 25 percent the infant mortality attributable to malaria; (b) reduce by 90 percent the school-age children morbidity attributable to urinary schistosomiasis; and (c) eliminate the risk of blindness due to onchocerciasis. Progress toward these objectives would be assessed with a Burden of Disease Analysis and an economic analysis based on data twice collected by the SIG--once after two years of SIG implementation, and again at project completion. During negotiations, Governmentfurnished the Letter of Sub-Sector Policy, including the project monitoring indicators (para. 6.1 (a)). 3.2 Project Strategy. The project strategy is two-fold. First, the project aims to demonstrate, with the example of the management of malaria, schistosomiasis and onchocerciasis surveillance and control activities, the feasibility, effectiveness and efficiency of developing the concept of integration within the peripheral health services, in conjunction with the community. By project completion, it would be desirable that control activities for the endemic and epidemic diseases of public health importance be fully integrated. Second, the project aims to reinforce the national capacity in conceptualizing, managing and conducting endemic and epidemic disease control activities by reforming the SNGE at central and peripheral levels and implementing nationwide a computerized health management information system, including an epidemiological surveillance system. 3.3 Project Scope. The project would be implemented nationwide, with the exception of the schistosomiasis control activities in the St. Louis region. These control activities will not be subjected to a specific support from the project for the following reasons: (a) they are subjected to several donor's supports, particularly to an important EU's support; (b) the EU is considering to increase its financial support; and (c) an additional support in controlling the epidemic will be forthcoming from the proposed World Bank Regional Hydropower Development Project (scheduled for May 1997 Board consideration), with the financing of feasibility studies for reducing the man-vector contacts in infected villages. However, the project will contribute to the global effort against the epidemic through the national and local reinforcement of the SNGE. The execution of the pilot projects would be coordinated by the Organization for the Development of the Senegal River (OMVS) which will work closely with the St. Louis Medical Region staff, the Program ESPOIR, and the SNGE.  I1 B. PROJECT DESCRIPTION 3.4 Project Components. To help achieve these objectives, the project would support policy measures and investments designed to: (a) improve the management and implementation of malaria, schistosomiasis and onchocerciasis control activities at central and peripheral levels; (b) develop an integrated and computerized health management information system (SIG) and its use; and c) strengthen the SNGE capabilities at central and peripheral levels and the DHSP ability in project management. The composition of the investment program is summarized below. 3.5 Progress in achieving sectoral development and project implementation objectives would be measured against a set of monitoring indicators, developed by and agreed upon with the Government. They would form an integral part of the Government's Letter of Sub-Sector Policy. Measurable indicators are listed in Annex 1. Recurrent cost implications and resulting budget shares are given in Annex 11. Proiect Summarv -US$ illjan i. Malaria, Schistosomiasis and Onchocerciasis Control 4.61 - Operational Activities (3.64) - Monitoring and Evaluation Activities (0.97) 2. Health Managernent Information System 126 - System Development (2.48) - Monitoring and Evaluation Activities (0.78) 3. Institutional Strengthening of the SNGE and DHSP 211 - Central Level of the SNGE (3.81) - Peripheral and Regional Capacities (3.31) - Project Administration (0.19) L. Support to Malaria, Schistosomiasis and Onchocerciasis Control Activities (US$4.61 million) 3.6 The overall objective of this component is to initiate and develop at the peripheral levels an operational and managerial organization in the area of surveillance and control of endemic and epidemic diseases. The project would specifically support this effort for three endemic diseases, i.e. malaria, schistosomiasis and onchocerciasis, expecting this approach could then be extended to all endemic and epidemic diseases. Surveillance and control activities would be included in the five-year District and Regional Health Development Plans to be adjusted each year according to the decentralization process. The budget allocation process, including allocations provided for under this project, would be based on these plans after revision and adjustments by the MSPAS and Donors, once the SIP becomes effective. Central and regional SNGE staff would support medical districts and regions in the elaboration of these plans. (a) Operational Activities (US$3.64 million) 3.7 Scope and Objectives. The objective of this sub-component is to implement malaria, schistosomiasis and onchocerciasis control activities at peripheral levels with an eye to rationalization and sustainability. Control of endemic diseases, in particular malaria, schistosomiasis and onchocerciasis, ensues from the disease-specific adjustment of the following generic activities: (a) the improvement of the quality of case management at health facilities through training of care providers in diagnosis, treatment, referral practices, counseling and  12 interpersonal communication; (b) the improvement of the case management and prevention at the household level through information and education campaigns covering recognition of signs and symptoms of illness, appropriate treatment and proper health-seeking behaviors; (c) the implementation of large-scale treatment or prevention campaigns for targeted populations; and (d) the use of selective measures against vectors. Specific guidelines pertaining to each of the three diseases targeted by the project are developed below. Improvement of Case Management at Health Facilities. 3.8 Regarding malaria, the project aims to improve, via training of health care providers, the management of patients with fever illness, primarily among children under five, and the prevention or management of malaria and anemia in pregnant women. Regarding schistosomiasis, the project aims to improve, via training of health post nurses, the diagnosis by developing the utilization of chemical reagent strips, and the treatment by promoting the prescription of praziquantel. The SGEs would organize with the support of trainers, i.e. medical district officers, hospital medical doctors lab assistants, the training of 1,100 nurses and midwives and 160 private practitioners. Trainers would be trained through regular programs to be organized in the context of the strengthening of the SNGE. 3.9 Project Support. The project would finance: (a) the training of nurses, midwives and practitioners; and (b) the supplying of an initial stock of praziquantel and chemical reagent strips (approximately 2,000 tablets and 1,000 strips for each of the 320 health centers and posts) whose replenishment would be covered by the health post income. Population Information and Education 3.10. Regarding malaria, the project aims to improve at the household level the management of fever in children under five through information an education of household caretakers, and raise the awareness of pregnant women in order to develop their demand for health services and prevention measures. Regarding schistosomiasis, the project aims to increase, via information and education, the population awareness, in particular the high-risk schoolchildren population, to improve their knowledge about: (a) the disease cycle, symptoms and risks; (b) the prevention measures; and (c) the personal and community hygiene and sanitation. 3.11 The SNGE would contract out the design of IEC campaigns and the production of posters, leaflets, batiks and boites a images. Household caretakers would be reached with the help of the national federation of women's association (La Federation Nationale des Groupements Feminins). In each region, district and village, the association would organize regular talks and chats with the support of the information tools mentioned above. UNICEF would technically support the training of opinion leaders and the organization of the talks and chats. These activities would be done on an integrated basis whenever warranted. School children would receive public health instruction, particularly regarding schistosomiasis, from their school teachers who will have been properly trained by the SGE staff with UNICEF support. 3.12 Project Support. The project would finance: (i) consultant services for the design and production of national IEC campaigns; (ii) the education of opinion leaders and school teachers; and (iii) the organization of monthly talks and chats by the national federation of women's association for the benefit of household caretakers.  13 Large Scale Treatment and Selective Measures Against Vectors 3.13 Malaria. The project aims to support selective vector control through the development of the nighttime utilization of bednets impregnated with insecticide-Niclosamide. Experience in Gambia has shown that the use of bednets can produce an important reduction in childhood mortality and morbidity, when it is accepted by the population. But the Gambian experience was successful only as long as the impregnation was provided free of charge. As a lesson from the Gambian experience, it would be premature and risky in Senegal to determine up-front the strategy for bednet distribution and impregnation. 3.14 The project strategy is to employ a sequential approach. The SNGE, with the technical support of WHO, would conduct: (a) during the first year, operational research projects and studies of the opportunities and modalities for support to local production and commercialization of bednets, of different options for the organization of impregnation, and of possible implementation of a cost recovery system; (b) during the second year, the testing of one or two alternatives of organization and functioning of the system and their articulation within the health services; and (c) during the last three years, the full incorporation of the assessed strategy into the health services. Given the financial constraints of both the population and the Government, the project has anticipated, for financing, the results of the operation research and has considered to support the implementation of a private production of bednets, and a Government-supported impregnation system. The BRHs would be responsible for the bednet impregnation, and their staff would receive appropriate training, organized by the SNGE. 3.15 Schistosomiasis. The project aims to control the transmission in highly focal transmission villages through the concomitant use of molluscicides-niclosamide-against vectors and the large-scale distribution of praziquantel to schoolchildren. During the first year of the project, it is planed to treat the 60 villages identified during the prevalence study in March 1996 with an initial prevalence rate among school children of over 50 percent. During the following years, high-transmission villages and hamlets would be identified by local infection and re-infection rates in humans to be evaluated by rapid epidemiological assessment to be jointly conducted by SGE and district teams. 3.16 School teachers would carry out the distribution of praziquantel to the schoolchildren population of identified villages, under the supervision of medical district teams and SGEs with UNICEF technical support. The project has estimated that approximately 3,000 school children would be treated the first year; the number of children to be treated decreasing the following years. Appropriate treatment of infected ponds and water bodies with niclosamide in identified villages would be carried out by the BRHs' staff who would have received an appropriate training to be organized by the SNGE. At the end of the first three years of this operation, the SNGE would conduct an assessment study to evaluate the feasibility, effectiveness and cost of focal mollusciciding, concentrating on the reduction of incidence and re-infection rates in treated villages and research results. 3.17 Onchocerciasis. The project aims to generalize and consolidate the ivermectin community-distribution system in the onchocerciasis areas. The strategy consists of: (a) the training of health post nurses in supervision of the distribution of ivermectin by VHWs; (b) the identification and training of 314 VHWs by the regional and district teams in the remaining 157 villages; (c) the provision of ivermectin from the district to the village via the health post; and (d) the information and education of the population of the 456 exposed villages. Ivermectin will  14 be given free of charge by the pharmaceutical company Merck, Sharp & Dohme for as long as necessary. 3.18 Project Support. The project would finance: (a) the procurement and distribution of 150,000 bednets and 18.000 liters of deltamethrine in the context of the operational research, of 2 tons of niclosamid and 5.000 tablets of praziquantel for urinary schistosomiasis vector control and large-scale treatment of the schoolchildren population respectively, of ivermectin; and of consumables; (b) the supervision missions; (c) assessment studies of the different options to implement a sustainable market of impregnated bednets; (d) malacological and sociological studies in highly infected areas with schistosomiasis; (e) an evaluation study at the end of the three years of schistosomiasis control activities; (f) training of BRHs staff in the utilization of deltamethrine and niclosamide; (g) training of approximately 400 health post nurses and VHW in ivermectin community distribution; and (h) the organization of yearly information and education campaigns in the 456 villages exposed to onchocerciasis. WHO-Afro would technically support the operational research related to the development of the utilization of impregnated bednets. 3.19 Implementation Arrangements. The SNGE and SGEs would be responsible for the implementation of this sub-component jointly with medical district and regional teams. Activities related to the treatment with niclosamide, and to the bednet impregnation with deltamethrine would be carried out by the BRHs. Activities related to the education and information of the household caretakers would be carried out by the national federation of women's associations (La Feidration Nationale des Groupements Fiminins) with the technical assistance of UNICEF. Operational research and studies relating to the development of the utilization of impregnated bednets, to be conducted during the first two years, would be entrusted to the WHO resident mission in Senegal under the general responsibility of the SNGE. Procurement, stocking, and distribution of bednets, deltamethrine, niclosamide, praziquantel and ivermectin would be the responsibility of the PNA at the central and regional levels, and of the medical districts from the regional level to villages. (b) Monitoring and Evaluation (US$0.97 million) 3.20 Scope and Objectives. The objective of this sub-component is to develop capacity not only at central level but also at regional and district levels to monitor and analyze data relevant to the surveillance and control of malaria, schistosomiasis and onchocerciasis. The empowerment of peripheral staff in the management of surveillance and control activities would strongly implement the concept of integration and rationalization in the domain of endemic and epidemic disease control. Using the analytic and connecting capabilities of the computerized SIG, the SNGE would develop a malaria outbreak prevention system, to be extended to other diseases later on. It would also conduct operational research and evaluation studies related to malaria, schistosomiasis and onchocerciasis. As onchocerciasis is concerned, the OCP would provide technical assistance to the SNGE in the area of operational research, and in ivermectin donation applications. 3.21 Outbreak Prevention System. The development of forecasting and prevention strategies for malaria outbreaks will be undertaken in the area along the Senegal river valley, i.e. the St. Louis Region and the Bakel district of the Tambacounda Region. These areas of unstable malaria transmission are affected by periodic local outbreaks which may produce serious increases of mortality and incapacity. The SNGE and the St. Louis SGE with the support of WHO and short-term technical assistance would undertake:  15 (a) during the first year: (i) the study of potential determinants of epidemic risk in the area; (ii) the mapping of the areas affected by each major determinant and the identification of localities at risk; (iii) the definition of indicators with predictive value; and (iv) the negotiation for the acquisition of timely information on their variation; (b) during the second year: (i) the validation and incorporation of indicators into the SIG; (ii) the organization of alarm mechanisms, emergency preparedness and response capabilities; and (iii) the evaluation of the system; and (c) during the last three years, the operationalization of the system and the extension to other epidemic diseases. 3.22 Operational Research and Evaluation. The SNGE and SGEs with the support of short-term technical assistance would undertake regular studies and operational research to assess: (a) with regard to malaria, (i) the validity of regular malaria morbidity and mortality reporting; (ii) drug resistance; (iii) mosquito resistance to insecticide; (iv) malaria case containment at the community level; (v) chemoprophylaxis for pregnant women; and (vi) the acceptability of impregnated bednets; (b) with regard to schistosomiasis, (i) the prevalence of urinary schistosomiasis in the treated population in the context of the project; (ii) the quality of field management and program management; (iii) the snail control techniques; and (iv) the development of new health education, management, monitoring and evaluation and surveillance approaches. Priority topics for the operational program are presented in Annex 4; and (c) with regard to onchocerciasis, the quality of information and education activities. 3.23 Project Support. The project would finance: (i) consultant services for the studies and operational research; (ii) equipment and furniture; and (iii) operating costs. II. Health Management Information System (US$3.26 million) 3.24 The objectives of this component are: (i) to implement a national computerized network between the district, regional and central levels of the MSPAS to support an integrated, flexible and communicative SIG, and develop its management and utilization by the health staff at each level of the health pyramid; and (ii) to build the capacity within the MSPAS to monitor, evaluate and improve the utilization of the SIG. The opportunity of live communication offered by the network between district, regional and central health facilities would benefit the development of feedback information which has been demonstrated to be a major incentive for peripheral health staff to comply with policies and strategies. A description of the computerized network supporting the SIG is detailed in annex 6. 3.25 In the specific context of control of endemic and epidemic diseases, the SIG with its epidemiological surveillance and alert system would be of the highest importance because fast reaction and control strategy adjustment depend on the capacities to be informed as early as  16 possible with relevant indicators and analysis. The computerization of the SIG would also allow the integration of environmental and geographical data in the analysis process and its instantaneous distribution nationwide. This capacity would be particularly relevant to the suiveillance of severe Sahelian malaria outbreaks which are often linked to the pluviometry and ocod levels. 3.26 A Health Information Council would be created to regulate and monitor the use of the SIG, and evaluate the impact on the MSPAS work culture. During its first years of existence, it is expected that the SIG would not only evolve but also initiate an evolution within the MSPAS. As mentioned earlier, the new internal connectivity would bring about a major culture change within the MSPAS services, which should be carefully assessed and taken into account in the reflection about future reforms and global programs in the sector. This Council would include as a rtinimum the heads of the MSPAS Directorates and Services, university and research experts, and the MSPAS partners in development. A permanent secretariat would be held by the DSTAT. (a) System Development and Implementation (US$2.48 million) 3.27 Scope and Objectives. The objective of the sub-component is the implementation and utilization of a national computerized network which would support and integrate all present and future health information systems. The DHSP, with the assistance of the consulting firm Mazars & Guerard acting as contract manager, would: (a) analyze the existing specific health information systems; (b) rationalize and structure the computerized SIG data collection and analysis (cahier des charges); (c) establish the specifications and procedures for the procurement of 12 servers (one in each region and two at the center), 141 computers (50 at the center, three per MR, and one per medical district), and server software and consumables as necessary to allow network implementation; (d) elaborate terms of reference and selection processes for specialist services in charge of developing the network software, testing the system in one pilot area, extending it nationwide and training staff in network utilization; and (e) r onitor the contract execution and establish certification of services rendered until full completion. The DHSP via its sub-Directorates and Services would undertake, with the assistance of USAID, UNICEF and EU, the organization of training programs in the utilization of the SIG in the following components: epidemiological surveillance, Family Planning, and more generally health district activities management. 3.28 Project Support. The project would finance: (a) the procurement of servers, computers, server's software and consumables; (b) the specialist services for the contract management, and the development of the software; and (c) the training of district and regional officers, as well as the SNGE staff, in the utilization of the SIG for epidemiological surveillance purposes. The EU would finance temporary technical assistance to support training in the utilization of this software. 3.29 Implementation Arrangements. Contract management for the development of the computerized network will be contracted on a single-source selection basis to Mazars & Guerard for continuity purpose since the firm has designed the system to the satisfaction of Government and the donors during project preparation. Two package sets would be subjected to ICB. The first would relate to goods and include the hardware equipment, the second would relate to consultant services and include the software programming, network implementation, training and skill transfer.  17 (b) Monitoring and Evaluation (US$0.78 million) 3.30 Scope and Objectives. The objective of this sub-component is to reinforce the capacities of the MSPAS to manage the SIG by: (i) strengthening the DSTAT-Service des Statistiques-in maintenance, monitoring and evaluation of the SIG; and (ii) creating the Health Information Council. To guarantee a high sustainability level for the network technical maintenance by the DSTAT, the MSPAS would contract, on a two year basis, a local private computer maintenance firm to provide two computer engineers as long term technical assistants to the DSTAT. 3.31 Project Support. The project would finance: (i) consultant services of the local private firm to provide the two computer engineers; (ii) consultant services to assist the Health Information Council in conducting studies and organizing regular conferences and workshops; and (iii) on a declining basis, incremental recurrent costs incurred by the network utilization, such as consumables, maintenance equipment and telephone communication. 3.32 Implementation Arrangements. The implementation of the sub-component would be the responsibility of the Head of the DSTAT. The project management will be responsible for the recruitment and monitoring of the local firm to provide two computer scientist engineers. lII. Institutional Strengthening of the SNGE (US$ 7.31 million) 3.33 The global objective of this component is to rebuild the institutional capacity of the SNGE to efficiently survey and control endemic and epidemic diseases. The mandate and organization of the SNGE would be redefined in the context of the decentralization of the health services and the search for better rationalization in resources utilization. As a condition for Credit effectiveness, the Government will adopt a new organizational and administrative structure of the SNGE, satisfactory to IDA (para 6.3 (a)). The strategy would consist in first developing the capacity to conceptualize and manage surveillance and control programs at the central level; and second in reinforcing the capacity to adjust and implement these programs at the regional and district levels. (a) Strengthening the Central Level of the SNGE (US$ 3.81 million) 3.34 Scope and Objectives. The objective of this sub-component is to develop at the central level a highly competent team of civil servants with a strong team spirit and public health interest. The strategy would consist of: (a) regrouping the SNGE scattered staff within a renovated state-owned building, accommodating the other DHSP services and directorates, and the other MSPAS Services as well; (b) building up the team spirit among the staff, with the support of consultant services; (c) developing staff capacities through training courses; and (d) providing SNGE with resources to achieve its mission. In the particular context of the project, and in line with its mandate, the SNGE would: (a) organize annual refresher courses for its staff; (b) revise and/or design national control programs for endemic and epidemic diseases, with consecutive training modules and guidelines; (c) organize national information campaigns; (d) hold regular and frequent meetings with the decentralized staff during the first years to implement the new culture and mission of the SNGE; and (e) undertake Burden of Disease Analysis and sound economic analysis. 3.35 Project Support. The project would finance: a) the civil works to rehabilitate the state- owned building; b) equipment and furniture to the DHSP and DAGE; c) five vehicles for the  18 SNGE central unit; d) the local and international consultant services for: (i) the design and supervision of the civil works, (ii) the build-up of teamwork and esprit de corps, (iii) the design of national control programs, (iv) the preparation of two burden of diseases analysis and economic analysis, and (v) the design and implementation of national information campaigns; e) the training and study tours for the staff; and f) the recurrent costs incurred by the regular operations, maintenance and supervision activities such as vehicle operation and maintenance, and staff travel allowances. 3.36 During negotiations, the Government submitted to IDA the documents showing that the building to be rehabilitated is state-owned and has been officially earmarkedfor the MSPAS (para. 6.1 (b)). 3.37 Implementation Arrangements. The civil works component including the procurement of furniture and equipment for office rehabilitation, will be given to the executing agency AGETIP which will be in charge of contract management (Maitre d'Ouvrage Delegue), consultant services, and suppliers and contractors. (b) Strengthening District and Regional Capacities (US$ 3.31 million) 3.38 Scope and Objectives. The objective of this sub-component is to build capacity at regional and district levels to implement and manage activities related to the surveillance and control of endemic and epidemic diseases. In line with the decentralization process and development of Regional Health Development Plans, SGEs staff would be responsible for adjusting to local situations (even conceptualizing to a certain extent), implementing, and supervising these national control programs. SGEs'staff would participate to the preparation of Regional and District Health Plans. A plan would be developed to integrate SGE activities with the Medical Region activities and to rationalize the human, material, and financial resources of both teams. The strategy would consist of: a) bringing the SGE and Medical Region teams closer together through the relocation of SGE facilities onto the Medical Region premises, whenever necessary and feasible; b) upgrading through training the capacity of SGE and district staff to execute their mission; and c) providing facilities and budget for supervision and IEC activities, focal studies and surveys. 3.39 Training would be available for district and regional medical officers, and for hospital and district laboratory assistants. The training program would consist of annual refresher courses and opportunities for short-term training in Centres d 'excellence in countries within the sub-region. Training will be crucial for medical officers and staff of the SGEs to successfully carry out the responsibilities resulting from the decentralization process. Due to the project-by- project approach it has always been difficult to integrate the training activities for the different disease control programs. First, a pilot course of integrated training would be provided for lab assistants. Second, SGE and district medical staff would receive an integrated training on the surveillance and control activities of malaria, schistosomiasis and onchocerciasis. To design these training courses the SNGE would contract experts from local universities, hospitals, and scientific institutions. Eventually, these courses would become part of the national training program after a review and evaluation process. 3.40 The financial ability to carry out regular and frequent supervision, focal studies and surveys would be essential to the SGE and medical district teams. Facilities and budget would be provided by the project for two years; future budget needs should be assessed in the context of the Regional and District Health Development Plans prepared in the context of the SIP.  19 3.41 Project Support. The project would finance: (a) renovation costs to integrate the SGE offices within the medical Region premises and prepare one apartment for the SGE medical chief; (b) equipment and furniture for each SGE office and the laboratory equipment for each medical district lab; (c) two vehicles per SGE; (d) consultant services for the design and supervision of civil works, and for the design and organization of regional IEC campaign on endemic and epidemic disease control; (e) the training component for annual refresher courses for regional and district staff and supervisors, as well as for laboratory assistants and short-term training in the sub-region; and (f) the recurrent costs incurred by the supervision activities by SGEs and medical district staff, including the operation and maintenance of office equipment and vehicles. (c) Project Management (US$0.19 million) 3.42 Scope and Objectives. Until the SIP is in place, the financial and technical management of the project would be the responsibility of the Deputy-Director of DHSP. He would be assisted by a project officer whose assignment would be on a bi-annual assignment basis, renewable with satisfactory performance, and whose terms of reference and qualifications would be acceptable to IDA. In addition, support would be provided by the accountant of the DHSP whose qualifications are acceptable to IDA, and one secretary hired on a contractual basis. Audits, paid for by the Project, would be done every year. To enable the DHSP to carry out the project-related activities upon project start, a limited quantity of equipment will be provided early on. Facilities and non-incremental recurrent budget expenditures would be provided by the Government to allow effective project implementation. 3.43 When the SIP is in place, the financial management of the project would be merged into the SIP management within the DAGE. Management of project technical activities would continue to be the responsibility of the DHSP. 3.44 Project Support. The project would finance: (i) office equipment and furniture; (ii) 2 vehicles; (iii) consultant services for audit, accountant and short-term support services; and (iv) the recurrent costs incurred by the operation and maintenance of office equipment and vehicles. C. PROJECT COST AND FINANCING 3.45 Project Cost. The total cost of the project, including taxes, is estimated at about US$17.0 million, with a base cost of US$15.2 million and a foreign exchange component of US$9.8 million. Price contingencies estimated at US$0.8 million, assume an annual domestic inflation of 3 percent and a foreign inflation rate of 3 percent. Physical contingencies are estimated at about US$1.0 million (6 percent of base cost). IDA would finance about 87.6 percent of total project costs (US$14.9 million). The Government would contribute US$0.9 million equivalent. The European Union (EU) would finance US$0.3 million equivalent. The French Government would finance US$0.7 million equivalent. UNICEF would finance US$0.1 million equivalent. WHO would finance US$0.1 million equivalent. Detailed project costs are provided in Annex 11. 3.46 Recurrent Costs Implications. Total recurrent costs generated by the project are estimated at around US$2.46 million for the life of the project, with an annual average of US$0.49 million. During the implementation phase of the project, the Government's share of the expenditures is estimated at 10 percent for administrative costs, cost of goods and works, or  20 approximately US$0.4 million. At project closing, for proceeding with different activities, the Government will allocate to US$1.66 million, corresponding to the project's supervision costs as well as the additional costs associated with its activities, including the purchase of consumable goods, vehicle maintenance, equipment and materials, and contracts for the maintenance of the computer information network by a private sector operator. Pharmaceutical acquisitions will be assured by the beneficiaries. Throughout the duration of the project, additional expenditures should correspond to 13.8 percent of actual investments, of which US$0.4 million will form part of the Government's budget and shall represent 0.6 percent of the MSPAS budget, following the hypothesis of evolution as described above and projected for the year 2000. 3.47 Cost-effectiveness Analysis. Strategies adopted by the MSPAS in the control of malaria, schistosomiasis and onchocerciasis have been proven on several occasions to be cost- effective, in particular in countries within the sub-region. Nevertheless, it would be necessary to assess the cost-effectiveness of each strategy in the global context of the cost of control activities for all diseases. As a prerequisite for such evaluation, a valid health management information system is essential. Given the scope and precedence of the proposed project, a Burden of Disease Analysis and an economic analysis based on data collected by the SIG would be done twice--once after two years of SIG implementation and once at project completion. 4. PROJECT IMPLEMENTATION A. STATUS OF PROJECT PREPARATION AND READINESS 4.1 History and Development of the Project. Financial requests made by the Republic of Senegal to IDA for the National Malaria Control Program and the Onchocerciasis Devolution Plan initiated a dialogue with the MSPAS on the merits and potential for the proposed project. A project identification mission in October 1995 assessed the overall rationale and feasibility of strengthening the national capacity for surveillance and control of endemic diseases. During the project identification mission, the DHSP held a seminar to define the framework of the proposed project. Preparation missions in February and April 1996 were able to make considerable progress in project preparation and in coordination between all different programs and donors. Revision of the project proposals as agreed with the preparatory missions was accomplished smoothly by the Government and the project was appraised in December 1996. 4.2 With regards to the malaria sub-component, the implementation manual of the control program was finalized during the preparation stage. The project preparation stage was used to develop a constituency around the National Malaria Control Program. Eighteen operational research papers were produced through a joint-venture between the MSPAS staff and the Dakar Medical University staff and students. There has been an agreement between all actors on the key issues, the strategy to solve them and the implementing agency. At the same time, training activities for field staff were launched to try to curb the impact of the malarial season in October and November 1996. B. PROJECT COORDINATION AND MANAGEMENT 4.3 Until the SIP is in place, management and coordination of project activities will be carried out by the DHSP of the Ministry of Health. The Deputy-Director of the DHSP will be appointed as the project Director and receive the responsibility of facilitating the coordination of  21 activities among different departments of the MSPAS involved in the project implementation. The organigramme of the DHSP is in annex 7. Day-to-day activities will be carried out by a project manager who will be assisted by the DHSP accountant and a secretary. The project manager who is also a DHSP staff has been designated during project preparation and has received training sponsored by the Bank in disbursement and procurement procedures. During negotiations, the Government appointed. the Deputy-Director of DHSP as the Project Director, the project manager and DHSP accountant whose qualifications and terms of reference are acceptable to IDA (para. 6.1 (c)). When the SIP is in place, the financial management of the project would be merged into the SIP management within the DAF. Management of project technical activities would continue to be the responsibility of the DHSP. 4.4 Coordination and consolidation of financial accounts and monitoring of project implementation outcomes will be under the responsibility of the project manager who will ensure that the following tasks are oarried out: (a) coordination of the preparation of annual work programs and budget for all project components; (b) procurement of goods and services, and recruitment of consultants; (c) maintaining and consolidating all project accounts, including the special account; (d) preparation of necessary documentation for withdrawal of proceeds from the Credit account; (e) making arrangements for the audit of project accounts and Statement of Expenses; and (f) organization of annual and mid-term reviews of project implementation. C. MONITORING AND EVALUATION 4.5 The monitoring and evaluation of project performance and outcomes are an integral part of each component and will be carried out by the respective component implementation units over the life of the project, with the DHSP playing a coordinating role. Key monitoring indicators are shown in Annex 1. In its role as project coordinator, the DHSP will organize in November of each year, beginning in 1997, a joint IDA-Government review of project implementation with the participation of other development partners, based on the progress reports and expenditure statements of the past year, and annual work programs and budgets for the following year. In addition, the DHSP will prepare a mid-term review of project implementation, to be conducted jointly by IDA and the Government in November 1999. Details of the Bank's supervision plan and of the annual and mid-term reviews, are provided in Annex 9. The results of the mid-term review will be incorporated in an action plan, acceptable to IDA, for further implementation of the project. In addition, the Government will, within six months of the Credit closing, submit an implementation completion report (ICR), in accordance with the guidelines for the preparation of a completion report applicable at that time. During negotiations, the Government gave assurance to this effect (para. 6.2 (a)).  22 Table 4.1: Summary of Proposed Procurement Arrangements (in US$ million) International National Other\2 NBF/3 Total Project Element Competitive Competitive Bidding Bidding 1. Works 1.67 1.17 2.84 (1.55) (1.00)/1 (2.55) 2. Goods - Equipment,Vehicles, materials 2.71 0.19 2.90 (2.71) (0.19) (2.90) - Drugs, Chemicals 0.98 0.98 (0.98) (0.98) - Fumiture 0.19 0.19 (0.17) (0.17) 3. Training 2.01 0.29 2.30 (2.01) (2.01) 4. IEC 0.37 0.37 (0.37) (0.37) S. Consultant Services 3.99 0.93 4.92 (3.99) (3.99) 6. Recurrent Expenditures - Incremental Recurrent Costs 1.23 1.23 (I. I 1) (I. I 1) - Project Operating Costs 0.80 0.43 1.23 (0.80) (0.80) TOTAL 5.36 1.36 8.59 1.46 16.96 (5.24) (1.17) (8.47) (14.88) Note: 1. The figures in parentheses are the amounts to be financed by IDA. 2. "Other" is Limited Intemational Bidding, international and local shopping, and consultants services 3. Not financed by IDA D. PROCUREMENT AND DISBURSEMENT 4.6 Table 4.1 summarizes the project cost by disbursement category and proposed procurement method. A detailed procurement plan and timetable are given in Annex 10. Procurement and decision-making will follow the World Bank's official guidelines on procurement of works and goods (Procurement under IBRD Loans and IDA Credits, January 1995, Revised January andAugust 1996), and services (Selection and Employment of Consultants by World Bank Borrowers, January 1997) in all respects. Senegal's procurement laws and regulations conform to IDA procurement guidelines. No special exemptions, permits, or licenses need to be specified in Credit documents for international competitive bidding (ICB), as Senegal's procurement regulations allow IDA procedures to take precedence over any contrary provisions in local regulations. 4.7 Civil Works. The civil works program financed by IDA (US$1.5 million) concerns the rehabilitation of an existing state-owned building to accommodate offices for DHSP, the DAGE and MSPAS cabinet at the central level, and the rehabilitation of regional offices as well as the construction of one staff house for each of the 9 SGE regional medical officers. Civil works will be grouped into packages of at least US$500,000 each and procured through ICB in accordance with the Bank's Guidelines for Procurement under IBRD Loans and IDA Credits (January 1995 revised 1996). Standard bidding documents developed by the Bank will be used. Civil works contracts financed under the credit for contracts not exceeding US$500,000 will be awarded through NCB procedures up to an aggregate amount of US$1.2 million. Due to spread and high transportation costs, these civil works contracts are unlikely to attract foreign or large firns that use modem equipment. Foreign bidders, however, would not be precluded from submitting bids. Civil works contract management will be delegated to AGETIP, an autonomous local  23 construction management entity closely supervised by Bank staff and auditors under another IDA-financed project, whose efficiency has been proven in this area since 1992. 4.8 Goods. Goods financed under the credit (US$4.1 million) include: (a) drugs, laboratory supplies and consumable chemicals; and (b) office equipment and supplies, office furniture for the DHSP and DAGE, and vehicles for the SNGE central unit and project coordination. Procurement of drugs, laboratory supplies and consumable chemicals will be procured through Limited International Bidding (LIB) up to an aggregate amount of US$1 million because contracts values will be small and quality requirements with regard to the products and their delivery are important factors. Other goods will be grouped into packages of at least US$100,000 each and procured through ICB in accordance with the Bank's Guidelines for Procurement under IBRD Loans and IDA Credits (January 1995, revised 1996). Standard bidding documents developed by the Bank will be used. A preferential margin of 15 percent or the applicable customs duty, whichever is less, over the c.i.f. prices of competing goods for all ICB procurement will be given to domestic firms in accordance with the Bank's guidelines. Contracts for goods not exceeding US$100,000 will be awarded through NCB procedures up to an aggregate amount of US$200,000. Small quantities of goods such as office supplies and equipment, vehicles, consumable materials and spare parts, which are available off-the-shelf and cannot be grouped into bidding packages of at least US$50,000 may be procured through prudent international shopping for an aggregate amount of US$90,000 and national shopping for an aggregate amount of US$ 100,000, based on price quotations of at least three reliable suppliers. All bids will be submitted on a c.i.f. basis for imported goods and on ex-factory basis for locally manufactured goods. 4.9 Consultant Services. The project does not provide for long-term resident technical assistance. International and local consultants providing specialist services financed by IDA (US$4.0 million) would be contracted in accordance with the Bank's Guidelinesfor the Selection and Employment of Consultants (January 1997). Selection of consultants will be addressed through competition among qualified short-listed firms in which the selection will be based both on the quality of the proposal and on the cost of the services to be provided except for audits of a standard- nature which will use the least-cost selection. Short-lists for contracts estimated under US$200,000 may be comprised entirely of national consultants if a sufficient number of qualified firms (at least three) are available at competitive costs. However, if foreign firms have expressed interest, they will not be excluded from consideration. The standard Letter of Invitation and Form of Contract as developed by the Bank will be used for appointment of consultants. Simplified contracts will be used for short-term assignments, i.e. those not exceeding six months, carried out by individual consultants. The Government will be briefed during negotiations about the special features of the new guidelines, in particular with regards to advertisement, requirements for short lists and specific notice in the United Nations Development Business (UNDB) publication for contract above US$200,000, and public bid opening. Services to be contracted include technical consultants, training, contract management services for building rehabilitation, and auditing and assistance in the area of accounting and procurement. Contract management for the development of the Health Management Information System (SIG) will be contracted on a single-source selection basis to Mazars & Guerard for continuity purpose since the firm has designed the system to the satisfaction of Government and the donors during project preparation. Construction management will be delegated to AGETIP using the standard contract developed by the Africa Region for AGETIP-type agencies acting as a contract management agency. AGETIP will recruit the necessary consultants' services for design and supervision in accordance with procedures described in its manual of procedures which are consistent with Bank's procurement Guidelines.  24 4.10 Review by IDA. IDA-financed contracts above the threshold value of US$500,00 and of US$100,000 equivalent for works and goods respectively will be subject to IDA's prior review procedures. The review process would cover 80 percent of the total value of the amount contracted for goods and 56 percent of the amount contracted for civil works. Selective post- review of contracts awarded below the threshold levels will apply to about one in three contracts. Draft standard bidding documents for NCB will be reviewed by and agreed upon with IDA. The Bank will review the selection process for the hiring of consultants proposed by the Borrower. The Borrower will be reminded that opening of the financial envelopes will not take place before receiving the Bank's no-objection to the technical evaluation. Prior IDA review will not apply to contracts for the recruitment of consulting firms and individuals estimated to cost less than US$100,000 and US$50,000 equivalent respectively. However, the exception to prior IDA review will not apply to the Terms of Reference of such contracts, regardless of value, to single- source hiring, to assignments of a critical nature as determined by IDA or to amendments of contracts raising the contract value above the prior review threshold. 4.11 Procurement Status and Proposed Arrangements. During negotiations, the Government submitted to IDA, discussed and finalized the following documents: (a) procurement plan; (b) Operational Manual for Project Management and Implementation; and (c) bidding documents for the civil works and major equipment, as well as letters of invitation for consultants services, financed by IDA (para. 6.1 (d)). During negotiations, the Government gave assurance that it would apply the procurement procedures and arrangements outlined in the Bank's Standard Bidding Documents for ICB, NCB, and in the operational manual (para. 6.2 (b)). 4.12 Disbursements. The project is expected to be completed over a five-year period, with the IDA Credit disbursed over six years, according to the categories shown in Table 4.2 below. The estimated disbursement profile is shown in Annex 11. Disbursement of the Credit will be fully documented, except for expenditures for works and goods under contracts costing less than US$500,000 and US$100,000 respectively, and services under contracts with consulting firms not exceeding US$100,000, and with individual consultants not exceeding US$50,000, which would be made against Statements of Expenditure. Documentation for withdrawals under Statement of Expenses would be retained for review by IDA supervision missions and for audits. Table 4.2: Allocation and Disbursement of the IDA Credit Amount of Credit Allocated % of Expenditures to be Category (US$ million) Financed 1. Civil Works 2.3 90 2. Goods - Equipment, drugs, vehicles 3.4 100 of foreign & - Fumiture 0.2 90 of local expenditure 3. Training 2.2 100 4. Consultant Services - for part with IEC 1.2 100 - for other parts 2.4 100 5. Operating Costs - forproject management parts 0.6 90 - for other parts 1.0 90 6. Unallocated 1.6 TOTAL CREDIT AMOUNT 14.9  25 E. ACCOUNTING, AUDITING AND REPORTING 4.13 Special Account. To facilitate disbursements, the Government will open a Special Account (SA) in a commercial bank in Dakar to cover IDA's share of eligible expenditures, managed by the DSPH. The authorized allocation for the SA would be US$1 million equivalent. IDA will make an initial deposit of US$600,000 equivalent into the SA upon Credit effectiveness and will replenish the SA upon receipt of satisfactory proof of incurred eligible expenditures. Replenishment will be accompanied by up-to-date bank statements and reconciliation of the SA. To expedite the implementation of day-to-day activities and effect small payments for local training programs involving frequent expenditures in local currency at the district level, Medical Regions will be provided from the special account with petty cash equivalent to two months of expenditures to be incurred in carrying out the activities planned and agreed upon between the Medical Region and the DSPH. Justifications of the use of cash, together with the request for replenishment if necessary, will be prepared monthly by the Medical Region Administration accountant. All documentation regarding the use of the funds by the Medical Region Administration accountant will be kept at the level of the Medical Region for supervision missions and audits. Medical Regions will open accounts operated by the accountant of the Medical Region Administration under the supervision of the Regional Medical Officer. The Medical Region Administration accountant is a staff member qualified in accounting and administrative procedures and is subject to regular government monitoring and scrutiny. Each district medical officer will be responsible for establishing an annual budget for the activities to be carried out, and the Medical Region Administration accountant would regularly provide the necessary funds on the basis of justification established with the assistance of the district administrative accountant. Justifications of expenditure eligibility will be handed over to the project accountant and kept as supporting documents for the use of the Statement of Expenditures procedure. 4.14 A detailed proposal on the accounting system and procedures to be followed, as well as a profile of personnel needed and equipment required, would be prepared by consultants. During negotiations the Government furnished the terms of reference for the consultants to be recruited to establish the accounting andfinancial management system of the project, the terms of reference, the short list offirms and the selection procedures for audit contracts, to be reviewed by IDA and agreed upon (para. 6.1 (e)). As a condition for Credit effectiveness, the Government will establish afinancial management and accounting system for the project, acceptable to IDA (para. 6.3 (b)). The DHSP Deputy-Director would at all times keep project financial records in accordance with sound internal accounting practices to reflect project operations and financial position. These records would be made available to visiting Bank missions and independent auditors. The project accounts, including the SA, will be audited annually, in accordance with International Standard of Auditing, by independent external auditors acceptable to IDA. The audited accounts and the auditor's report, including the Management Letter (Long Form) and a statement as to whether or not IDA funds had been used for their intended purpose, and a separate opinion with respect to statement of expenditures and the Special Account would be submitted to IDA within six months of the end of the fiscal year for the Project. Assurances to this effect were reached at negotiations (para. 6.2 (c)). As a condition for Credit effectiveness, the Government will sign a multi-year contract awardfor auditing the Project accounts, acceptable to the Association (para. 6.3 (e)).  26 5. PROJECT BENEFITS AND RISKS 5.1 Project Benefits. By reducing the burden of malaria, schistosomiasis and onchocerciasis, the project will directly benefit the rural populations where these diseases are most prevalent. As a result of the reinforcement of national capacities to control endemic and epidemic diseases, the project will also significantly benefit people in poor urban areas who have been severely hit by recent epidemics of cholera, and who are still at high risk from other epidemics such as cerebral meningitis. 5.2 The social and economic development of the entire Senegalese population will strongly benefit from the success of the project as endemic disease control activities are pure public goods with important externalities. All activities have been proven to have a high cost- effectiveness (less than US$50 per DALYs) and an important economic retum. Based on the sub-regional average cost of a case of malaria, the burden of malaria in Senegal represents one percent of GDP, i.e. around US$6 million in 1995. The project's global objective to reduce malaria morbidity by 20 percent would save an equivalent of 0.2 percent of GDP. 5.3 Finally, the implementation of a computerized network supporting the national health information system would: (a) help decision-makers to better program and rationalize the use of resources allocated to the health sector, in particular through the achievement of the SIP's objectives, currently under preparation; (b) develop the connectivity not only between health staff with the electronic mail, but also with intemational partners with a possible link to the intemet network; and (c) create within the MSPAS a new work culture towards partnership and cross-fertilization with external actors. 5.4 Project Risks. The first risk relates to the integration of a reinforced SNGE within the general health services, and its acceptance by the staff in general. This risk would be reduced by: (a) a clear definition of the breakdown of responsibilities between the SNGE and the general health services in the control of each of the endemic and epidemic diseases; (b) the SNGE's demonstration of high professionalism and expertise in the area of infectious diseases; and (c) the development of a strong team spirit. 5.5 The second risk relates to the non-sustainability of crucial activities at peripheral levels, such as continuous in-service training, regular supervision of the staff, and education of the population on public health issues. In recognition of this risk, the proposed SIP, would support the development of Regional and District Health Plans which will include these activities and ensure their budgetary allocations. Regional and district health teams would be accountable for the implementation of these activities. 5.6 The last risk would be the failure of the donor community to fully coordinate its efforts to support the surveillance and control of endemic and epidemic diseases. The Bank would assist the Govemment in minimizing this potential risk during project implementation through coordination mechanisms, to be established under both this project and the SIP.  27 6. AGREEMENTS REACHED AND RECOMMENDATION 6.1 During negotiations, the Government furnished the following documents: (a) the Letter of Sub-Sector Policy, including the project monitoring indicators (para. 3.1); (b) the document showing that the building to be rehabilitated is state-owned and has officially been earmarked for the MSPAS (para. 3.36); (c) the appointment of the Deputy-Director of the DHSP as the project director, and the appointment of the project manager and DHSP accountant, whose qualifications and terms of reference are satisfactory for IDA (para. 4.3); (d) the procurement plan, the Operational Manual for Project Management and Implementation, and the bidding document for the civil works and major equipment, as well as the letters of invitation for consultants services, financed by IDA (para. 4.1 1); and (e) the terms of reference for the consultants to be recruited to establish the accounting and financial management system of the project; and (ii) the terms of reference, the short list of firms and the selection procedures for audit contracts (para. 4.14). 6.2 During negotiations, the Government gave assurance that it would: (a) submit an Implementation Completion Report (ICR) within six months of the Credit closing (para. 4.5); (b) apply the procurement procedures and arrangements outlined in the Bank's Standard Bidding Documents for ICB, NCB, and in the operational manual (para. 4.11); and (c) submit to IDA within six months of the end of each fiscal year, audited accounts and the auditor's report, including the Management Letter (Long Form) and a statement as to whether or not IDA funds had been used for their intended purpose, and a separate opinion with respect to statement of expenditures and the Special Account (para 4.14). 6.3 As conditions for Credit effectiveness, the Government will: (a) adopt the new organizational and administrative structure of the Endemic Disease sub-Directorate acceptable to IDA (para. 3.33); (b) establish a financial management and accounting system for the project, acceptable to IDA (para. 4.14); and (c) sign a multi-year contract award for auditing the Project accounts, acceptable to the Association (para. 4.14).  28 6.4 Recommendation. Subject to the above terms and conditions, the proposed project would be suitable for an IDA Credit of SDR10.8 million (US$14.9 million equivalent) to the Republic of Senegal on standard IDA termns.  29 Annex I Page I of 3 REPUBLIC OF SENEGAL ENDEMIC DISEASE CONTROL PROJECT PROJECT LOGICAL FRAMEWORK AND INDICATORS Narrative Summary (NS) |MIeasurable Indicators Means of Verification I ImportantAssumptions Goal: Alleviate the burden of Decrease of the burden of endemic and I Burden of Disease Analysis I No baseline data today. endemic and epidemic epidemic diseases, in particular through the in 1999 and 2002 Effectiveness of the diseases reduction of the infant mortality attributable to SIG in the malaria (by 10% by PY3, by 15% by PY4, and 2 SIG establishment of by 25% by PY5), the reduction of school-age baseline data in 1999. children morbidity attributable to urinary 3 Schistosomiasis prevalence schistosomiasis (by 20% by PY2, by 40% by studies every two years PY3, by 70% by PY4 and by 90% by PY5), and no new case of riverblindness in the 4 Onchocerciasis Program area. entomological studies Purpose: To reinforce national 1 20% of suspected cases of malaria, schisto. or I Health district supervision I That there regular capacities to control oncho. received good quality care by PY2, reports, KAP surveys and supervisions by endemic and epidemic 40% by PY3, 50% by PY4 and 60% by PY5 UNICEF reports medical and regional diseases district teams 2 10% of households with mosquito nets for 2 KAP surveys 2 That operational children under 5 by PY3, 30% by PY4, 40% research on bednets be by PYS conducted and a solution be found on the impregnated bednet affordability issue 3 % of highly schisto. infected villages with no 3 BRH Unit reports and 3 That there is a good transmission malacological studies coordination between the SNGE and BRH 4 by PY3 30% of health facilities with on-time 4 DSTAT reports 4 That the training has complete SIG monthly mortality and been effective morbidity reports and feedback, 50% by PY4 and 60% by PY5 5 Number of communications exchanged over 5 DSTAT reports the electronic message system included in the network 6 Effectiveness of the SNGE in its efforts to 6 Capacity Building 6 Willingness of staff to develop team work and resource Assessment in PY3 and develop teamwork rationalization in implementing its activities PYS at central and regional levels  30 Annex 1 Page 2 of 3 Outputs: I Demonstration of 1.1 The proportion of health facilities with at 1.1 Health District 1.1 Regular supervisions feasibility of integrating least one practicing clinical health worker Supervision Reports, by medical and surveillance and control trained in integrated management of KAP surveys and regional district teams activities of endemic malaria, schistosomiasis and onchocerciasis UNICEF reports diseases such as and who: a) can correctly state standards for malaria, schistosomiasis diagnosis, treatment and referral, & onchocerciasis within particularly with suspected cases of malaria the peripheral health and schistosomiasis services and community activities 1.2 The proportion of caretakers having 1.2 KAP surveys received IEC messages who can correctly recognize signs and symptoms of fever and state that fever in child requires prompt treatment, state an appropriate treatment protocol for uncomplicated malaria, and know where to seek appropriate additional care when the condition does not improve or worsens 1.3 The proportion of pregnant women who 1.3 BRH Unit Reports and know that they can and should prevent and malacological studies treat malaria and anemia during pregnancy 1.4 Effective outbreak prevention system 1.5 Operational research and prevalence studies 1.5 That operational on: a) bednets, b) organization of research on bednets be impregnation and possible system for cost conducted and a recovery, c) identification of villages and solution be found on hamlets with high transmission of urinary the impregnated schistosomiasis, and d) proportion of bednet affordability endemic villages with identified and trained issue CHWs responsible for ivermectin 1.5 That there is a good distribution. coordination between the SNGE and BRH 2 Integrated, flexible and 2.1 Implementation of the computerized 2.1 Monitoring and highly communicative network and development of the revised supervision reports and SIG SIG certification of services rendered to full completion of specialist services contracts by the maitre d'ouvrage delegue 2.2 Proponion of health workers, supervisors 2.2 DSTAT reports 2.2 Continuous training and planners who have received training in and supervision of the use of the revised SIG and information health staff to improve for decision making the diagnosis and reporting systems 2.3 Setting up and number of effective meetings 2.3 Cabinet conclusion of the Health Information Council 3 Institutional 3.1 SNGE Functional Organizational chart 3.1 Cabinet conclusion 3.1 Thatthe Strengthening of the developed and approved by Cabinet by reorganization of the SNGE September 1997 MSPAS has been completed and approved 3.2 Personnel functioning according to 3.2 Capacity building approved organizational chart by March 98 assessment studies in PY3 and PY5 3.3 Facilities renovated according to 3.3 AGETIP reports 3.3 Renovation and specifications by PY 2 equipment will be provided on time  31 Annex I Page 3 of 3 3.4 National Control Programs revised or 3.4 Document published and 3.4 That the SNGE with developed for all endemic diseases. distributed the support of Guidelines or "Conduits a Tenir" before technical assistance diseases with high risk of epidemics will be able to organize a work program 3.5 Training and supervision programs in 3.5 SNGE activity reports 3.5 Real commitment for surveillance and control activities designed, integration and piloted, reviewed and implemented by PY2 rationalization of training programs  32 Annex 2 Page 1 of 10 REPUBLIC OF SENEGAL ENDEMIC DISEASE CONTROL PROJECT SUB-SECTOR POLICY LETTER Mr. James D. Wolfensohn President, World Bank 1818 H Street N.W. Washington, D.C. 20433 Dear Mr. President i . I have the honor, in connection with the negotiations now under way with your institution concerning the Endemic Diseases Control Project, to be carried out within the framework of the Nouvelles Orientations de la Politique de Sante et d'Action Sociale, to send you the following letter on behalf of the Head of State and Government of Senegal. 2 While the health of a country's population at any given time is largely determined by that country's current level of development, health is also a decisive factor in determining future growth, particularly when, as in Senegal's case, that growth rests upon the development of human resources. This same health-development nexus underlies all the international recommendations to which Senegal has subscribed since adopting the Primary Health Care Strategy at Alma-Ata in 1978. Even before the Alma-Ata conference, indeed from the early days of independence, Senegal has been implementing a basic health care policy, which was strengthened in 1972 by a reform based on decentralization and community participation, with the additional element of regionalization. 3. Regrettably, after two decades (1960-1980) of growth, and of considerable improvement in the national health indicators, Senegal found itself faced in the nineteen-eighties with an economic crisis and a severe tightening on the volume of resources allocated to the social sectors. This lack of resources led to a qualitative and quantitative decline in the services provided in those sectors, and a deterioration in the living conditions of the vulnerable population cohorts, specifically, the rural communities, low-income urban households, and women. Moreover, Senegal's heavy population growth was resulting in increasingly heavy pressure on the demand for health services; a demand the country's health system was simply unable to meet. 4. It was within this context, which, while fraught with difficulties, proved conducive to debate and to change, that the Head of State, following the country's tradition of viewing the development of human resources as the key to growth, approved the Population Policy Statement in April 1988, as well as the Health Policy Statement in June 1989. The basic objective was to improve the standards of living and well-being of the population by achieving a better  33 Annex 2 Page 2 of 10 quantitative and qualitative balance between supply and demand in the areas of health, education, and employment. 5. In August 1991, the Health and Social Action Sector Policy Letter was adopted, serving as a framework for the Human Resources Development Project (PDRH 1) supported financially by IDA. The objectives of the National Health Policy were to: (a) improve health coverage, particularly in rural and peripheral urban areas; (b) improve maternal and child health; (c) develop preventive and educational activities; (d) rationalize curative care; (e) rationalize and develop the utilization of human, material, and financial resources; and (f) keep check on democratic variables. 6. In 1995, based on the results obtained, medium- and long-term guidelines, as well as priority spheres of action for the Ministry of Public Health and Social Action (MSPAS) and for the development partners were defined. These consisted of: (a) rationalization of human resource utilization through the development of personnel hiring, training, and redeployment policies; (b) improvements in health and social action services, focusing in particular on infectious disease control, establishment of an information system, and actions to inform and educate the communities; (c) development of a national pharmaceutical policy; and (d) redefinition of the role to be played, particularly on the financial scene, by the various actors in the health field, namely the Government, the communities, the local authorities, and the development partners. 7. The present statement clarifies those guidelines as they relate to the control of endemic and potentially epidemic diseases. They are set out under three main headings: (a) the evolution of the health situation; (b) the key issues in the control of endemic and epidemic diseases; and (c) the Government's medium- and long-term objectives. 1. THE EVOLUTION OF THE HEALTH SITUATION 1.1 Evolution of Health service Supply 1.1.1 Historical Overview 8. A legacy of the colonial era, the control of endemic and potentially epidemic diseases has continued to be the territory of the National Endemic Disease Service [Service National des Grandes Endcmies - SNGE] and of its regional units, the Secteurs des Grandes Endcmies (SGEs). Despite some attempts to achieve administrative decentralization and integration in peripheral health services, the SNGE remains profoundly independent and centralized. The economic crisis of the last fifteen years has revealed the disastrous consequences of the SNGE's failure to evolve: it has practically no resources left of its own and is dependent upon external support. 1.1.2 Organization and Operation of the Present System 9. The National Endemic Disease Service is one of three national services operated by the Directorate of Hygiene and Public Health [Direction de l'Hygiene et de la Sante Publique - DHSP]. It comprises a central unit, the Service Central des Grandes Endemies, and the nine regional Secteurs (SGEs). At the regional level, the SGEs come under the administrative  34 Annex 2 Page 3 of 10 authority of the Medical Regions. The DHSP also includes seven Divisions, including the Statistical Division, which is responsible for the health information system -- Systeme d'Information a des fins de Gestion (SIG). 10. SNGE's operating budget is extremely tight and does not cover its recurrent expenditures. Its activities are virtually restricted to those financed by the donors within the framework of the National Disease Control Programs, targeting specific diseases such as malaria, leprosy, tuberculosis, dracunculosis, onchocerciasis, and diseases covered by the Expanded Program of Immunization [Programme Elargi de Vaccination - PEV]. Each program is managed independently, with its own logistical and material resources. II. SNGE's central unit has few employees. In addition to the unit's director [Directeur du Service], there are five physicians and three senior health technicians, with each responsible for one of the national programs. Although they all belong to the same service, each member of the team works completely independently of the others. Compounding this isolation is the fact that, for lack of space at the DHSP, the programs are all housed in different locations scattered throughout the city of Dakar. 12. At the regional level, only four of the ten existing SGEs are headed by a physician (Kaolack, Thies, St. Louis and Ziguinchor). The staff of the SGEs chiefly comprises health "agents," or technicians, who are attached to one of the national programs. The number of agents attached to a program depends on the extent of that program's funding. In practice, staffers are attached either to leprosy control programs, onchocerciasis control programs, or the PEV. The total number of agents in the SGEs varies from two in the Diourbel region to twenty- one in the Tambacounda region, where the onchocerciasis program alone has a staff of ten. 13. Although administratively dependent on the Medical Regions, the offices of the SGEs, except for those of Fatick and Diourbel, are not located at the headquarters of the Medical Regions but scattered among different cities, making it all the more difficult for their staffs to communicate or exchange information. 1.2 Evolution of Demand 14. Three key elements have influenced the general state of health of the Senegalese population: (i) an overburdened and highly varied epidemiological picture; (ii) the high fertility levels, which represent a serious threat to maternal and child health; and (iii) the persistently dubious conditions of public hygiene and pervasive malnutrition. 1.2.1 An Over-burdened Epidemiological Picture 15. An analysis of the epidemiological situation demonstrates the persistence, or even the recrudescence, of the major tropical endemic diseases, sexually transmissible diseases, tuberculosis, and childhood diseases. This picture is compounded by recent threats of epidemics of diseases such as cholera or cerebro-spinal meningitis, and the appearance of new endemic diseases such as AIDS. 16. Overall, mortality rates have declined substantially over the past 30 years, falling from 26 per million to 18 per million in 1995. Nevertheless, child and maternal mortality rates are still too high, respectively 68 per million and 5 10 per 100,000 live births.  35 Annex 2 Page 4 of 10 17. In Senegal, the chief causes of death in children of 0-5 years are diarrheal diseases, respiratory diseases, and malaria. These three pathologies are also the chief causes of morbidity, malaria being the principal motivation for a medical consultation. 1.2.2 High Fertility Levels 18. The overall fertility level is high, with a gross birth rate of 47 per million, and a synthetic measure of fertility of 6.0 per woman. This high fertility level, remaining more or less stable over the period 1978-1995, has resulted a very young population: over 45% of the country's population is under 15 years of age. 1.2.3 Inadequate Hygiene and Malnutrition 19. Rapid urban development, as well as inadequately monitored flight from the land, has led to the establishment of housing settlements where there is little respect for the basic rules of public and domestic hygiene. The shantytowns and squatter settlements that have sprung up both on the urban peripheries and in the inner cities are all foci of epidemic diseases. The lower income level of their occupants is yet another factor contributing to the often appalling health conditions found in these areas, resulting in veritable breeding grounds for all types of socio- health scourges, such as childhood diseases, malaria, schistosomiasis, cholera, sexually transmissible diseases, malnutrition, etc. II. THE KEY ISSUES IN THE CONTROL OF ENDEMIC AND EPIDEMIC DISEASES 20. The epidemiological situation continues to be dominated by infectious diseases and represents a major challenge for any health policy. Despite this, national capacities for combating these diseases have gradually diminished over the past twenty years as SNGE's organization and operation have deteriorated. 2.1 Organizational Dysfunctions 21. The serious dysfunctions affecting the system's organization cannot fail to have an adverse impact on its results and performance. 2.1.1 Dysfunctions on theActivities Side 22. For lack of the necessary resources, a large number of endemic and epidemic diseases are subject to virtually no surveillance or control. SNGE's activities in the area of endemic disease control are restricted to diseases targeted by the national programs and financed by a development partner. 23. The epidemiological surveillance system is extremely rudimentary and consists mainly of passive surveillance based on the activities reports submitted by the health services. There is no epidemic alert system, and, with a few exceptions, no active epidemiological surveillance. 24. There is no systematic feedback for the health workers.  36 Annex 2 Page 5 of 10 25. In the area of control, specific activities have been defined for a few diseases such as tuberculosis, malaria, dracunculosis, and leprosy. However, these activities are rarely linked to a monitoring indicator. There are no specific control programs for any of the potentially epidemic diseases. 26. In the case of the SGEs, regular activities, apart from those connected with the PEV, commonly take the form of general medical consultations. With the substantial decline in the leprosy prevalence rate, the activities of the national leprosy control program have been scaled down. The few activities relating to the surveillance and control of other endemic and potentially epidemic diseases still occur only very sporadically, and without any form of planning. 2.1.2 Staffing Dysfunctions 27. Administratively speaking, SNGE's employees all belong to the same government department. In practice, however, they belong first and foremost to the national disease control programs. Their training and retraining, and sometimes their career path itself, are covered exclusively by the national program to which they belong. Their benefits and pay are linked to those programs. 28. The fact that there are practically no inter-program staff transfers adds to the lack of rationalization in staff utilization. For example, although the activities of the leprosy control program have been scaled down in view of the program's success, members of the program's team have not received other assignments and are substantially under-employed. At the same time, the tuberculosis control program has no staff specifically assigned to it in the SGEs, and can thus perform only a limited range of activities. 29. The disparities in health service delivery are heightened by the uneven distribution of personnel among the SGEs, Diourbel, for instance, having two workers and Tambacounda twenty-two. 2.1.3 Dysfunctions in Terms of Workspace 30. The DHSP is located in a tumble-down building that cannot house all of its Services and Divisions. What little equipment it has is often out of service. The SGEs operate in extremely old, if not virtually uninhabitable, premises and suffer from a lack of equipment and logistic facilities. In most cases, their premises are a long way away from the Medical Regions, compounding the lack of rationalization in the use of equipment, communications equipment in particular, and of logistic facilities. 2.2 Operational Disorders 31. The decision to subdivide SNGE's organization and operations into different programs has considerably weakened the potential for strengthening institutional capacities in the field of control of endemic and potentially epidemic diseases. This negative impact has been particularly detrimental to the control of "old" endemic diseases such as malaria. For example, the expertise and practical skills acquired by SNGE in the areas of entomology and epidemiology during the malaria eradication campaigns of the sixties have virtually disappeared.  37 Annex 2 Page 6 of 10 m THE OBJECTIVES IN THE SUB-SECTOR 32. To address all the constraints and issues identified in the area of endemic and epidemic diseases, the Govemment intends to focus on national capacity building in the area of infectious disease control, with the aim of seeking a better quantitative and qualitative balance between service delivery and the essential needs of the communities. Its strategy will be based on a cohesive set of actions geared to redefinition of SNGE's mission, reorganization and decentralization of MSPAS, and efforts to improve demand and supply. 3.1 SNGE's Mission 33. SNGE's mission is to organize and coordinate the surveillance, prevention, as well as the control of endemic and potentially epidemic diseases and of infectious diseases detrimental to public health. 34. This mission falls within the framework of the decentralization of health services and the redefinition of the role of MSPAS' central services, and is restricted to the design of policies and strategies, and the contracting-out of the actual implementation of those same strategies. 3.2 SNGE's Organizational Chart 35. To enable SNGE to accomplish its objectives, a reform will be initiated within the general framework of the MSPAS reorganization. The pertinent legislation should receive final approval during 1997. 36. The philosophy of SNGE's reorganization falls within the framework of decentralization of the health services and is geared to greater rationalization in the utilization of human, logistical, physical, and financial resources, as well as to the provision of better quality and more evenly distributed services. 37. At the central level, SNGE will be expected to concentrate on the design of surveillance and control strategies to combat endemic and potentially epidemic diseases, definition of objectives and monitoring indicators, and supervision of the SGEs' performance in implementing the Regional Health Plans. The central unit will also enter into all necessary contracts for disease control activities, either with the regions, within the framework of the Regional Health Plans, or with other govemment, parastatal, or private agencies, both for profit and non-profit. 38. The work of the central unit will be carried out by a multi-disciplinary team headed by a Chef de Service. Task allocation within the unit will be based on team spirit and flexibility. 39. At the regional level, the SGEs will conform to the guiding principles and policies laid down at the central level. Within this framework, the SGEs will be responsible for adapting the endemic and epidemic disease control strategies to local constraints, and for implementing those strategies, which they will incorporate into activity plans specifying objectives, activities, costs, and sources of financing. 40. The SGEs will submit annual performance reports, and while it is on these reports that their evaluation will primarily depend, account will also be taken of the degree of satisfaction expressed by the regional medical teams and district teams they support.  38 Annex 2 Page 7 of 10 41. As at the central level, the dominant characteristics required of SGE personnel will be flexibility and demonstration of team spirit. 3.3 Actions in the Areas of Demand and Supply 42. In the area of demand, the focus will be on actions to inform and educate the different population cohorts, in particular mothers, pregnant women, and school children. Steps will also be taken to obtain a better knowledge of their demand for services, so that this information may rapidly be used to guide, if not actually drive, supply. 43. On the health service supply side, actions in the area of surveillance and control of endemic and epidemic diseases will focus on making better use of existing resources by improving the distribution of personnel and the allocation of available resources, and by enhancing the services' cost-efficiency ratios (internal efficiency). New linkages will be forged with non-governmental entities so as to increase the participation of civil society, and establish a cohesive nationwide health system based on both the public and private supply of health services. 44. The specific goals the Government aims to achieve over the medium term in order to accomplish this general objective are: (a) a reduction of morbidity and mortality rates linked to malaria, schistosomiasis, and onchocerciasis; (b) a greater efficiency of health system performance in the control of endemic and epidemic diseases; (c) improvements in health care utilization; and (d) an improved quality of health services. 45. The strategies for achieving this overall package of objectives are: (a) an improvement and rationalization of activities to control malaria, schistosomiasis, and onchocerciasis, thereby paving the way for those activities to be extended to other endemic and epidemic diseases; (b) a development of the review and computerization of the SIG to make this into a flexible and efficient system of communication which can provide rapid feedback to the health workers; and (c) a capacity building at SNGE and the SGEs. IV. CONCLUSION 46. I take this opportunity to reiterate the Government of Senegal's commitment to the program described in the present health policy letter. It is the Government's firm conviction that this program will help to bring about a substantial improvement in the development of Senegal's health and social sectors.  39 Annex 2 Page 8 of 10 47. Based on the reforms already undertaken, and in light of the above mentioned program, the Government urges you to give favorable consideration to the grant of a credit to develop our national capacities in the field of endemic and potentially epidemic disease control. Dakar, April 1, 1997 His Excellency Ousman NGOM Minister of Public Health and Social Action Annex: Monitoring Indicators  40 Annex 2 Page 9 of 10 PROJECT MONITORING INDICATORS 1. Project Purpose. Regarding the overall project objective to support endemic and epidemic diseases control, the following monitoring indicators are accepted: (a) Reduction of infant mortality attributable to malaria by 10 percent by the Project Year 3 (PY3), by 15 percent by PY4, and by 25 percent by the end of the project. (b) Reduction of school-age children morbidity attributable to urinary schistosomiasis, by 20 percent by PY2, by 40 percent by PY3, by 70 percent by PY4 and by 90 percent by the end of the project. (c) No new case of riverblindness in the Program area. 2. These indicators will be measured on the basis of the Health management Information System (SIG), the two Burden of Disease Analysis conducted in PY3 and PY5, and schistosomiasis prevalence studies conducted every two years. 3. Outcomes. Regarding the project outcomes, the following four indicators are accepted: (a) Number of suspected cases of malaria, schistosomiasis and onchocerciasis which received good quality care at the health facility and household levels. The benchmarks are: 20 percent by PY2, 50 percent by PY3, 50 percent by PY4, and 60 percent by the end of the project. This indicator will be measured on the basis of supervision reports from districts and medical regions, of UNICEF reports and KAP surveys. (b) Number of health facilities with on-time complete SIG monthly mortality and morbidity reports and feedback. The benchmarks are: 30 percent by PY3, 50 percent by PY4 and by 60 percent by the end of the project. This indicator will be measured on the basis of the DSTAT reports. (c) Number of communications exchanged over the electronic message system included in the network. This indicator will be measured on the basis of the DSTAT reports. (d) Effectiveness of the SNGE in its effort to develop team work and resource rationalization in implementing its activities at central and regional levels. This indicator will assessed on the basis of external evaluations undertaken at PY3, and at the end of the project. 4. Inputs. Regarding the project inputs, the following indicators are accepted: (a) Progress made in civil works implementation, according to time schedule. This indicator will me assessed on the basis of AGETIP reports.  41 Annex 2 Page 10 of 10 (b) Progress made in the implementation of the computerized Health Information System, according to a time schedule. This indicator will be assessed on the basis of the MSPAS reports. (c) Number of training sessions organized for health staff, and number of IEC sessions for household caretakers in the context of malaria, schisotosomiasis and onchocerciasis. (d) Number of health staff who have received training on malaria, schisotosomiasis and onchocerciasis control.  42 Annex 3 Page 1 of 18 REPUBLIC OF SENEGAL ENDEMIC DISEASE CONTROL PROJECT MALARIA I. INTRODUCTION 1. Both the study and control of malaria has a long history in Senegal, at least since the mid- 19th century but, as in all other countries of tropical Africa, the disproportion between the meager resources available and the magnitude of the problem, has not permitted important and durable impact on the epidemiological situation. Malaria continues to be the main cause of morbidity and mortality, representing between 40 and 50% of all consultations. A. HISTORICAL BACKGROUND 2. The use of quinine for individual prophylaxis was introduced in Senegal by the mid-19th century, and limited efforts of environmental sanitation and larviciding were undertaken in Saint Louis and Dakar during the first half of the XX century. The introduction of DDT, after World War II, led to the establishment of a national anti-malaria service (Service de Lutte Antipaludique, SLAP) in 1952, with the collaboration of WHO and UNICEF, starting a Malaria Control Pilot Project in the Thies region. The failure to interrupt malaria transmission with only insecticide spraying, led te the introduction of mass chemoprophylaxis in 1957, on a pilot project scale comparing chloroqu,ne and pyrimethamine. 3. In 1961, the recognition by WHO that malaria eradication could not be sustained in the absence of solid general health services resulted in the progressive transformation of malaria control programs into so-called Pre-eradication Programs aimed at the development of basic health services and, therefore, to the abandonment of specific malaria control activities throughout tropical Africa. 4. Malaria chemoprophylaxis for the protection of children under 5 years of age continued to be promoted, but coverage was always irregular and never achieved the level required to control malaria morbidity, although it undoubtedly contributed to the general availability of chloroquine and, therefore, to the decline of malaria mortality. Since the mid-1980's, mass chemoprophylaxis of children has been discouraged by WHO because of its selection pressure for drug resistant parasites. 5. Vector control activities, no longer demanded as a basic component of the malaria control strategy, and in 1981 became the responsibility of a newly-created militarized Hygiene Service, which attempted to undertake and coordinate larviciding and spraying activities, limited in most cases to point actions based on empirical considerations, such as complaints of mosquito nuisance or stagnant water. An evaluation of their activities, carried out in April 1996, indicated severe insufficiencies in material and human resources, leading to a lack of technical guidance in the field, and a failure to evaluate activities and results.  43 Annex 3 Page 2 of 18 B. RATIONALE FOR INTERVENTION 6. The successive failure in Senegal, as in most tropical countries, of the different attempts to achieve sustainable interruption of transmission, and the final elimination of the disease, created a feeling of disappointment about malaria, and did not allow the focusing of attention on the possibilities to alleviate the burden of the disease. Meanwhile, malaria continued claiming lives throughout the tropics, its toll of death and incapacity remaining a major obstacle to socioeconomic development, and demanding ever more costly treatment, as parasite resistance continued to spread. 7. Between 1990 and 1992, WHO, with the assistance of most international development agencies, coordinated the development of regional malaria control strategies, culminating with the adoption of a global strategy at the Ministerial Conference on Malaria Control in Amsterdam in October 1992. This strategy gives the highest priority to the prevention of death and the reduction of incapacity by making appropriate case management accessible where ever necessary, through the development of primary health care and health information, through the education of the population, and concentrating vector control wherever it can achieve sustainable results. The strategy also gives a high priority to the development of an epidemiological information system, to early detection and control, and, if possible, to the prevention of epidemics. 8. Conscious of the importance of the malaria problem, the Government of Senegal, in its Declaration of National Health Policy of June 1989, had made malaria control one of the highest priorities of its health policy. Senegal was an active participant in the Ministerial Conference and co-signatory of the declaration of Amsterdam in October 1992. The political will to pursue this goal, according to the global malaria control strategy, has been shown by the formulation of a National Program for Malaria Control (1996-2000), issued in Dakar in August 1995. II. SITUATION ANALYSIS A. VECTOR DISTRIBUTION AND ECOLOGY 9. Within the last twenty years, twelve Anopheles species have been found in Senegal, either biting man or resting in human dwellings; by far the most important vectors are the two main members of the A. gambiae complex, A. gambiae s.s. and A. arabiensis; A. funestus is mainly limited to the South; A. melas, a third member of the A. gambiae complex, is limited to the coastal areas, and A. pharoensis may play a very limited role in transmission in the Senegal delta. B. EPIDEMIOLOGY 10. Epidemiological Patterns. The great ecological diversity in Senegal is reflected in a similar diversity in malaria epidemiology. A general stratification has been made into two main epidemiological patterns (facies epidemiologiques): (a) sahelian malaria with a short transmission season, generally less than 4 months. The main vector is A. arabiensis with A. gambiae and/or A. funestus, as occasional  44 Annex 3 Page 3 of 18 vectors in some places. It corresponds to the Saloumian, Ferlian, and Capvertian geographical regions; (b) tropical malaria, with a long period of transmission, during the 4-6 months of the rains and the beginning of the dry season. It corresponds to the region of Boundou and the Basse Casamance, inland from the mangrove. The main vector is A. gambiae s.s. with the addition, in some places, of A. arabiensis and/or A. funestus, giving a high inoculation rate (>100 infectious bites/man/year). 11. Malaria transmission shows important seasonal fluctuations and generally increases from North to South and from West to East, both in intensity and in the duration of the transmission season. The two main patterns are modified by ecological variations and human activities, the two most important being the general drought, which has affected most of the country since the 1970's, and urbanization which continues to increase. Irrigation projects in Sahelian areas have, so far, not resulted in important changes in the pattern of malaria transmission, perhaps due to their relatively small scale. There is, nevertheless, some anecdotal evidence that the revitalization of the Ferlo valley and the Guiers lake are extending the transmission season in this northern area. 12. Therefore, thus far, only two focal patterns are important enough to deserve attention: (a) urban malaria, corresponding to the main urban areas, particularly the Dakar area; in general, the intensity of transmission decreases from the periphery towards the center of town, although, within the perimeter of the city, there are water collections and even agricultural areas which may represent important foci of transmission, and (b) mangrove malaria, corresponding to the mangrove swamps on the deltas of the main rivers Senegal, Saloum, and Casamance. 13. Malaria Parasites. P. falciparum is by far the predominant species, representing over 97% of the infections detected throughout the country, mainly found alone, although, in between one to four percent of the cases it has been found associated with P. malariae and P. ovale. Parasite rates, found in general population surveys, varied from 3% in 1991 in the Senegal river valley (Dagana & Podor), to 28% (1979) in Diourbel region, 28-31% (1992 & 1995) in Tambacounda region, and over 60% (1986) in the Ziguinchor region, confirming the North South gradient in the intensity of transmission. 14. Morbidity and Mortality. As mentioned above, all health statistics place malaria as the main cause of morbidity and mortality in the country. The statistical compilation made in 1995 for the preparation of the National Program of Malaria Control gave a proportional morbidity for the whole country for 1993 of 35.3%, followed by diarrheal diseases with 12.2%, and intestinal parasitoses with 10.9%. In urban areas, surveys carried out in October-November 1992, showed that malaria represented 13.7% of all fevers in Dakar and 12.4% in Pikine; infections in adults were as frequent (55.6%) as in children (44.1 %) in these areas. 15. Mortality has been traditionally under-evaluated, particularly in rural areas. Data collected in 1993 from health centers and health posts, gave a national case fatality rate of 0.1%, and a rate of only 5.7% for neuropaludisme, which indicates obvious under-reporting .  45 Annex 3 Page 4 of 18 16. In the Dakar area, hospital statistics show great variability in the epidemiological indicators, with proportional morbidity in the range 1-3% for general services and 11% in the department of infectious diseases. Case fatality is rather indicative of case selection, being in the range of 4-8% in general services, 10.8% in the department of infectious diseases, and 32.9% in the intensive care service of the Principal Hospital of Dakar. 17. In spite of the paucity of available information, as well as the lack of continuity of existing data, regional hospital statistics reflect the endemicity of the different areas. Proportional morbidity, which in Thies remains similar to the Dakar area, reaches 5-12% in Louga and well over 30% in Fatick, Kaolack and Tambacounda. The 1996 survey also showed in hospital statistics the general intensification of malaria transmission in 1994-1995. 18. Parasite Susceptibility to Anti-malarial Drugs. The first cases of resistance reported from Senegal were infections with P. falciparum resistant to pyrimethamine, discovered in Thies in 1961. Chloroquine resistance was found in vitro in 1985 in Kaolack. The first cases of P. falciparum resistant in vivo were reported in Dakar and its suburbs in 1988. Since 1988, a system of surveillance has been established in selected areas, with the collaboration of the Faculty of Medicine and O.R.S.T.O.M. III. ISSUES 19. As in other endemic countries, malaria control in Senegal suffers from the fact that the realistic strategy now being adopted has much less spectacular objectives than the eradication proposed in the past, and does not match the expectations of the general population. During the past decade, efforts to change these perceptions have succeeded in convincing the authorities, but have not penetrated to the educated general public who often view the new strategy as a disappointing surrogate. There is therefore a need for intensifying the information and education efforts on the perception of the malaria problem and the strategy of control. In the past, the absence of a National Control Program and a coordinating mechanism for the different agencies involved in malaria control also created some confusion about basic elements such as case definitions and treatment, and laboratory practices. 20. There are specific problems in each of the main areas of possible intervention: diagnosis and treatment, chemoprophylaxis, selective vector control, epidemiological information system and epidemic prevention or control. A. DIAGNOSIS AND TREATMENT 21. It has traditionally been considered a purely medical problem, outside the scope of public health. Nevertheless, inadequate case management of a disease as prevalent as malaria is a major health problem, and making proper diagnosis and treatment accessible to the whole population, both physically and socio-culturally, is one of the most useful and sustainable public health activities, particularly when backed-up by an epidemiological information system capable of guiding necessary adjustments. The development of a health infrastructure was the main factor which contributed to the elimination of malaria from southern Europe and the U.S.A. and was recognized, as early as 1961, as a prerequisite for the effectiveness of control programs based on transmission control. In Senegal, current treatment practices are rather anarchic and, to a certain degree, contribute to the deterioration of the malaria problem.  46 Annex 3 Page 5 of 18 22. Case Containment at the Community Level. Self-medication of fever is the normal practice in rural areas, where it could be expected, as in other countries of West Africa, to be the only therapeutic resource in around 80% of the cases. Even in Dakar, self-medication has been recognized in 20% of the cases. Chloroquine is the drug most used and may be the only one available in many rural markets. In Dakar, in 1992, quinine, amodiaquine and sulfadoxin/ pyrimethamine were also widely used in self-treatment, often several drugs at a time. 23. Dosage, as in other countries, is generally inadequate, as knowledge about doses and duration of treatment is almost always lacking, possible sources of information are unclear and often contradictory, and tablets with different drug content are widely available without guidance. 24. Delayed and inadequate treatment are among the main causes of severity and death; a study of hospitalized patients in the Infectious Diseases Department of Fann Hospital in Dakar in 1990, indicated that 51% of severe cases had received inadequate treatment before attending the hospital; mortality in health posts serving areas with poor communications and scattered villages seems to be much more frequent than in those serving more compact areas. 25. There is an urgent need to improve early treatment, and particularly to enable mothers to recognize signs of severity, requiring immediate referral to health services, while improving the quality of care in the latter. 26. Case Containment at the Health Facilities. At health facilities, the increasing deficit of health personnel, the lack of motivation of health workers, the absence of supervision, and the breaks in stock of antimalarials and other essential drugs, contribute to the poor quality of peripheral care. These factors are compounded by: a) almost complete disregard of microscopy as a diagnostic aid, even for severe and complicated cases, in hospitals with well equipped laboratories and trained technicians; b) inadequate management of severe cases, which do not benefit from a parasitological monitoring of treatment; c) excessive prestige of injections, which is often encouraged by health staff, leading to an abuse of parenteral quinine; d) tendency to use the latest drugs without consideration to relative effectiveness, side effects or cost; and e) ignorance of appropriate dosages. 27. Confusing Sources of Information. Many media messages to the general public and the number of circulating guidelines for health professionals are contradictory in recommending different drugs and dosages. 28. Confusing Tablet Formulations. Adding to the confusion, there is in circulation within the health services, tablets with 100 and 150 mg of chloroquine base, some even with 250 mg. Similarly, chloroquine syrup may be dosed at 25 or 50 mg per coffee spoon. This may be very confusing, particularly for lay treatment providers for whom doses will continue to be expressed in numbers of tablets in lieu of mg/kg. These problems are further complicated by the existence of an illicit parallel market where all sorts of drugs, including counterfeits, are available. 29. No Active Participation in Monitoring Drug Resistance. Health services neither record nor report treatment failures. 30. Excessive Use of Anti-malarial Drugs. It is due not only to excessive prescriptions for the treatment of malaria, but also because an anti-malarial treatment, particularly the use of  47 Annex 3 Page 6 of 18 chloroquine, is included in the recommended treatment of all fever episodes, even if a clear cause of the fever can be identified. The excessive use of anti-malarials is not only wasteful but, more importantly, contributes to the selection of drug resistance. An April 1996 inquiry into the consumption of anti-malarials, gave figures, for chloroquine only, of 2 to 5 times higher than necessary to treat the malaria cases reported. B. CHEMOPROPHYLAXIS 31. As mentioned above, it continues to be used, with the intention of protecting young children, in many areas, despite contrary recommendations from the center. It should be reserved for the protection of pregnant women, particularly primigravidae, as it is the best way of preventing low birth weight, and they do not constitute such an important parasite reservoir as young children. C. SELECTIVE VECTOR CONTROL 32. Endemic malaria represents a certain equilibrium between the human, vector and parasite populations. High endemicity is equivalent to very stable epidemiological equilibrium, both vector and parasite populations are many times higher than required for species survival. Very important reductions in the parasite reservoir or in the vector population, by mass treatment or by vector control, are rapidly compensated and the population returns to their original levels, once the control activity is interrupted. Malaria parasites are well tolerated by people surviving early childhood, most people becoming asymptomatic carriers thereafter. The higher the endemicity, the lower the age of immunity development. This solid herd immunity is achieved at a cost of high childhood mortality. In areas of low endemicity, such as the Dakar area, severe malaria and mortality is relatively frequent in older children and young adults, as mentioned above. 33. By contrast, in areas of very low malaria endemicity, under normal conditions, transmission does not occur, generally because vectors cannot survive the sufficient time for parasite development, either because of low relative humidity or low temperatures. Nevertheless, most of these areas are periodically subject to abnormal rains or floods, which not only provide extensive vector breeding, but also relatively long periods of humidity/temperature conditions favorable to malaria transmission with epidemic outbreaks. Observations in Congo, Tanzania, Kenya and Senegal indicate that merely reducing transmission in endemic areas, may reduce severe morbidity and mortality in young children but place them at higher risk at older ages, without a net cohort benefit. 34. These observations support the abandonment of vector control as the main element of malaria control, in accordance with the global strategy adopted in Amsterdam in 1992. Vector control has, nevertheless, a place in malaria control as a complement of a strategy based on the development of health services, particularly if it concentrates on interventions which do not require the repeated implementation of strictly organized activities and a high level of coverage to be effective. This is the reason why large scale campaigns of indoor insecticide spraying are hardly ever recommended. In contrast, the followings may be very useful: (a) the promotion and support of the use of bednets in areas where their use is considered desirable, or the introduction of insecticide impregnation, in areas where  48 Annex 3 Page 7 of 18 bednets are in use; such actions could be sustainable complements of the general improvement of case management. Individuals using bednets are protected, even if coverage is very low, and coverage may progressively spread as bednets become more widely accessible. (b) a point intervention, with re-impregnation of existing bednets, with indoor insecticide spraying, or with well timed space spraying, when an information system has detected the occurrence of an epidemic risk. (c) the organization of timed interventions, like the re-impregnation of bednets, to decrease the peak of seasonal epidemics in areas subject to short intense transmission periods. D. EPIDEMIOLOGICAL INFORMATION SYSTEM AND EPIDEMIC PREVENTION OR CONTROL .3 S It should be the backbone of any disease control activity, but it cannot be limited to a isingie disease even as important as malaria. It should be incorporated in the functioning of the gerneral health services and not viewed as an external imposition. Regional epidemiologists, particularly in areas subject to periodic increases of epidemic risk, should be provided with the e~apacity of analysis to monitor the epidemiological situation of malaria, and to investigate local abnoormalities, organize local response and/or request assistance from the center. In order to drovelop such capacity, it will be necessary: a) to determine the major determinants of epidemic sk which should be monitored regularly, e.g. rainfall, floods or humidity/temperature, to dtter7mine levels indicative of epidemic risk, and to identify the sources of information and .&, ganize monitoring mechanisms; b) to organize the immediate reporting by telephone, fax or e- nMaii of suspected epidemiological emergencies; and c) to prepare emergency plans to be imnplemented in response to risk situations or detected emergencies. -3 V. OPERATIONAL TOOLS FOR MALARIA CONTROL ACTIVITIES A. ORGANIZATION OF DIAGNOSIS AND TREATMENT FACILITIES 36. The provision of prompt diagnosis and opportune treatment to the sick constitutes the mnost elementary intervention in the Global Malaria Control Strategy, being considered as a basic human right. The number and type of services required for the adequate management of malaria disease will vary in relation to the prevalence of the disease and the risk of severity and death. The feasibility of providing the required services will depend on the stage of development of the ;gent-eral health services and their use by the population, the human and material resources, and the degree of community collaboration. *i1 First Line Care: Health Posts. Because it normally responds to a simple, safe and cheap treatment, malaria has been traditionally managed by the most peripheral health services aid their projections into communities, using rather loose diagnostic criteria with very low specificity. On the other hand, treatment of severe and complicated malaria is a medical emergency requiring intensive care and presenting a high risk of death. It is therefore essential chneit peripheral services should be able to recognize signs of severity, and be backed by adequate refeiTal services.  49 Anneo 'M Page 8 of it 38. The preparation of diagnosis, and treatment guidelines for the training and use of peripheral health workers, is indispensable for the recognition of conditions which could be handled by the first line care services and those that would require referral. Such guidelines should include the steps to be taken in initiating treatment of severe cases in their way to referral, and would be prepared in consultation with local health authorities, clinicians and consultants, and be adapted to the local pathology, the competencies and the resources available or potentially available. 39. Both the prevalence of resistant P. falciparum and the risk of severity should guide the development of laboratory facilities for microscopical diagnosis. In areas of high resistance, microscopic diagnosis in health centers of severe fevers would permit the differential diagnosis of severe P. falciparum malaria which should be immediately referred to hospital, and negatives which will require further search for diagnostic clues or be referred. Similarly, the differential diagnosis of peripheral treatment failures could permit the detection of drug resistant infections. 40. Maternal and child care may be provided in organized MCH clinics. Any such sern icc- should be used to educate mothers on the risk of delaying diagnosis and treatment of fevers in young children. If there is any form of prenatal care, it should be used to provide chemoprophylaxis, or intermittent preventive treatments to primigravidae. 41. Referral Services. They would normally be provided by ensuring a working liaison between peripheral health posts and health centers and hospitals in the area for the referral of severe fever cases and treatment failures. In any case, it should be ensured that diagnostic and treatment practices at all levels are adequate to the local problems. B. TRANSMISSION CONTROL MEASURES 42. The selection and use of preventive measures should be guided by considerations of feasibility, effectiveness and sustainability, as defined in the Global Malaria Control Strategy. i n principle, all malarial interventions could be considered for possible application, if suited to tht local problem and human material resources. A classification of these measures is presented in table 2. Table 2. Transmission control Measures Expected efect For individual and family protection For community protection Reduction of man-mosquito contact Bednets, repellents, protective clothing Site selection, zooprophylaxis screening of houses Destruction of adult mosquitoes Use of domestic space spraying (aerosols) Residual indoor insecticides, space spTaying ultra-low volume sprays Destruction of mosquito larvae Peridomestic sanitation, intermittent drying of Larviciding of water surfaces, intermixtenm water containers irrigation, biological control Source reduction Peridomestic sanitation, small scale drainage Environmental sanitation, provision of pined water, water management Social participation Motivation for personal and family protection Health education. community pat.;cisatlon m  50 Annex 3 Page 9 of 18 Peridomestic sanitation would not be effective unless it forms part of a participatory collective action of the whole community (Bruce-Chwatt., 1985.) Reduction of Man-mosquito Contact 43. The use of bednets, particularly pyrethroid impregnated bednets, is a very effective method of personal protection when vector activity occurs at the time when people have retired under the net. In most circumstances, the effect of bednets is more evident in the protection of infants and young children who are put to bed while adults remain exposed in the early hours of the night. Nevertheless, many of the most serious malaria vectors have their peak activity in the central hours of the night, and bednets therefore can considerably reduce man vector contact and cause great mortality among mosquitoes attracted to man, when bednets are used by a large proportion of the population. Measures Against Adult Vectors 44. Indoor insecticide spraying has been the traditional transmission control measure for mass application, and its implementation has been thoroughly standardized. In Senegal, only very small scale application was ever made, and the basic material and human resources to begin or expand its application in a cost-effective manner are very limited. 45. Indoor spraying of residual insecticides, even if it does not have the predominant role given in the past, is one of the most effective ways of reducing malaria transmission, and still has an important role in malaria control, particularly in the prevention and control of epidemic outbreaks. It should be indicated in situations where its use could be clearly targeted, and limited in time and place where the effectiveness and quality of the spraying could be maintained, even if periodic applications may be required. Insecticide toxicity and the hazard they may represent for spraymen and the inhabitants of sprayed houses, as well as for the environment, should be major concerns when contemplating their use. 46. Traditionally, DDT has been considered the insecticide of first choice, because of its low toxicity to man, its relatively long residual effect, the slow development of resistance, as well as the fact that the most common mechanism of DDT resistance does not confer a cross resistance to other insecticides. Its long persistence in the environment proscribes its use outdoors, particularly as larvicide. Nevertheless, its use as an indoor spray has been maintained due to the low probability that spayed surfaces, even of demolished houses, will become agricultural land or otherwise enter the environmental food chain. New synthetic pyrethroids with long residual effect, such as deltamethrin and lambda-cyalothrin which are effective at very low doses (25-50 mg/m2) with a very low toxicity, are also relatively competitive with DDT regarding the cost of applications for malaria control. 47. Space spraying of insecticides was the first adulticiding method used to control malaria transmission, based on the attack of adult mosquitoes resting indoors with pyrethrum extracts dissolved in kerosene (Park Ross, 1936). In general, it is considered that space spraying has very few indications for malaria control.  51 Annex 3 Page 10 of 18 Measures Aiming at the Destruction of Mosquitoe Larvae 48. Domestic and peridomestic sanitation has a general value in improving the quality of life. The impact on malaria transmission of destroying mosquito breeding places depends on the bionomics of the particular vector species. The elimination of peridomestic mosquito breeding places, including the protection of domestic water containers, and the maintenance of clean surroundings would have a general health interest but the specific measure, which may affect malaria transmission, would vary from area to area. It should be considered that, as an antimalarial measure, peridomestic sanitation requires a high coverage in order to be effective; a single remaining active breeding place may suffice to maintain an important focus of transmission. 49. Larviciding, as an antimalarial measure, has limited applicability as it affects only vector density and requires a very high coverage for effectiveness, without the advantages of sustainability and socioeconomic benefits that sanitation may have. 50. Biological control includes the use of mosquito pathogens and predators. Although there are a number of known mosquito pathogens (viruses, bacteria, protozoa, fungi and nematodes), few have been for mosquito control, and none have reached operational use for malaria control. Source Reduction 51. Environmental sanitation constitutes the most effective and sustainable measure for the protection of dense human settlements and urban areas. The effectiveness of environmental sanitation on malaria transmission was recognized for a long time before its biological basis was understood. Implementation of community-wide environmental sanitation requires the mobilization and commitment of important community resources, not only for promoting, supporting and coordinating individual action, but, in most situations, for the undertaking of engineering works. It is therefore essential that such actions would be carefully planned, based on the appropriate knowledge of local epidemiology and the bionomics of the vectors it is intended to control. It is necessary to ensure the continuous availability of professional entomological and engineering competence for the planning and execution of sanitation projects, the evaluation of which has to be determined not only for malaria control but from the point of view of their general health and socioeconomic impact. 52. Environmental sanitation would consist of the selection of appropriate measures among the followings. (a) Drainage, filling and prevention of unnecessary surface water collection which are among the most traditional antimosquito measures, although they have been mainly undertaken in response to economic incentives. Unfortunately, drainage of unwanted water seldom has the economic interest of the introduction of water for irrigation, so that a large proportion of major irrigation projects have not completed the construction of appropriate drainage systems, or, if constructed, are seldom properly maintained. Similarly, leakage of irrigation canals, overflows and misuse of irrigation water often produces extensive breeding places ,and, eventually, water logging, which is not only a major cause of malaria but also of land degradation, leading to salinization and eventual desertification.  52 Annex 3 Page 11 of 18 (b) Artificial shading or clearing of river or canal banks, changes in plant-water-air interface, changes in salinity, desalinization of coastal swamps, increase of the organic content of breeding places have very limited local applicability. Community Participation 53. The global malaria control strategy places the greatest emphasis on the building of local capabilities to understand and solve problems in the hope of reaching every home or every patient, more than in the massive use of drugs or insecticides. The strategy promotes the establishment of all possible intersectoral linkages, as well as community involvement. The main aim of public information and education should be: to improve peripheral management of fevers, particularly in young children in highly endemic areas, to improve the utilization of health care facilities, and to obtain the actual participation of individuals and communities instead of the passive acceptance of antimalarial drugs or spraying. School should play a key role as an instrument of education, not only for children, but also using all forms of adult education, as well as making all efforts to engage the collaboration of existing community organizations. 54. This participatory antimalaria strategy gives a prominent role to the development of malaria safe habits, including the use of personal protection measures and chemoprophylaxis during pregnancy. It appears obvious that the development of such habits cannot only be a function of the school. Women could be essential partners, if their social status would permit their incorporation into the education process. Early Detection and Containment, or Prevention of Epidemics 55. Ideally, malaria epidemics should be forecast and prevented rather than detected and controlled. Such forecasting may be possible if based on a dynamic information system capable of identifying high risk periods, areas and populations, and of designing and implementing appropriate measures of control. As the most relevant information for such identification is of an ecological, meteorological, social or economic nature, it is necessary to establish linkages and obtain information on these variables, as well as on plans and status of implementation of economic development projects. 56. nevertheless, epidemics are most frequently recognized only when well advanced in their evolution and, many times, either the epidemic is subsiding or it has resulted in a well established higher level of endemicity. Under these circumstances, not much benefit may be expected from the mobilization of extraordinary control measures, particularly if they are not ready for immediate implementation. 57. In general, the most urgently needed control measures, in the face of a detected epidemic, consist in strengthening disease management. If the epidemic has been detected at the beginning of a potentially long transmission season, residual insecticide spraying should be considered, particularly if it has been included in emergency preparedness plans, and it is possible to have the required resources immediately available. Unfortunately, in most cases, spraying is recommended as the main response without having the capacity to do so in time, so that spraying is done after transmission has occurred, and thus totally wasted. If preventive measures cannot be mobilized in time, consideration should be given to mass fever treatment or  53 Annex 3 Page 12 of 18 even mass drug administration. Residual insecticide spraying should be supplemented with the strengthening of the epidemiological information system and the diagnostic and treatment facilities, public information and education, the promotion and support of personal protection measures, and the mobilization of intersectoral collaboration. V. MALARIA CONTROL STRATEGY A. GENERAL OBJECTIVES 58. The national malaria control strategy has established the reduction of malaria mortality and morbidity in the general population, particularly in children and pregnant women, as a general objective of the program. It has set the following targets for the first five years: (a) Reduce by 50% the malaria specific mortality in the general population, and particularly in children less than 5 years old; (b) Reduce by 20% malaria morbidity in the general population; and (c) Reduce by 50% the incidence of severe malaria among pregnant women. B. APPROACHES First Objective 59. The technical approach to achieve a sustainable reduction of malaria specific mortality, according to the WHO global malaria control strategy, is to improve case management throughout the country by making adequate diagnosis and prompt treatment accessible to everybody, and by improving the utilization of this facility by the population. As shown in the situation analysis, a number of serious problems hamper the quality of case management, ranging from poor accessibility of health facilities, negative population attitudes, and cultural barriers, to poor quality of care due to a lack of appropriate training for health staff, or insufficient supplies of medicaments and materials. It is obvious that the solutions to these problems will require action addressed at the communities, as well as at several levels of the health services. The following approaches are therefore considered essential. 60. To standardize first line antimalarial treatment. It will be necessary to support and strengthen the normative function of the central level in order to ensure that it: (a) develops national guidelines for diagnosis and treatment of uncomplicated malaria, within the concept of managing common fevers in a peripheral setting; its main purpose is to guide health posts and health committees, these guidelines should include a clear statement of the first line drug, which remains oral chloroquine at a dose of 25 mg of cloroquine base per kg of body weight, divided in three days, taking at least 10 mg/kg the first day; (b) establishes a clinical definition of cases requiring an antimalarial treatment;  54 Annex 3 Page 13 of 18 (c) translates the dosages of first line drugs from milligrams per kg of body weight into number of tablets per age group, according to local conditions; and (d) defines signs of severity, which demand immediate referral to a health center or hospital; the recognition of these signs should be a major component of the program of health education of the population. The development of these national guidelines will require the set up of an expert group with the participation of the University, health professional associations, selected regional and district medical officers and health post staff, WHO, ORSTOM and Institut Pasteur. This group should review all existing recommendations, particularly the WHO guidelines for management of a sick child, in order to adapt them to local conditions. 61. It will be also necessary to: (i) reproduce and distribute to all treatment providers, distribution should be reinforced with introductory and subsequent supervisory visits by health personnel; (ii) review the National Clinical Guidelines to remove recommendations for excessive use of antimalarials, and to incorporate into these guidelines the clinical criteria established; and (iii) review all information, as it is generated, on drug susceptibility in order to consider whether a change of first line treatment is needed. 62. To standardize anti-malarial drugs, particularly those used at the periphery. It will be necessary to: a) select a single tablet formulation of chloroquine for all government purchases; this is particularly important to permit adequate dosage by lay treatment providers, for whom doses will continue to be expressed in numbers of tablets, in lieu of mg/kg (the current common availability of chloroquine tablets of 100 and of 150 mg may be a cause of serious under-dosage); b) ensure that all drugs donated to the country conform to that requirement; and c) require the same restrictions for all drug imports. 63. To improve public awareness on opportunity of treatment, and home management. Although it is recognized that home treatment is seldom adequate, it is also realized that it will continue to be the most frequent form of management of common diseases such as malaria. The strategy should therefore concentrate in strengthening the positive aspects of case management at home, whilst continuing efforts to prevent the more serious negative ones. Public information and education will be one of the most important lines of action to reduce malaria mortality, and will concentrate on: (a) stressing the importance of immediately initiating treatment with chloroquine of any fever with chills, particularly in children; children unable to swallow or to retain the tablets, and those not responding to the treatment should be referred to the health posts; (b) enabling mothers to recognize signs of severity (e.g. loss of conscience, abnormal behavior, convulsions, intense pallor, little or no urine, jaundice), requiring immediate referral to a health center or hospital, and to convince them that they constitute a severe evolution of the disease, and not due to an independent spiritual cause; (c) convincing mothers of the dangers of delaying treatment of severe fever cases, and the effectiveness of timely medical treatment.  55 Annex 3 Page 14 of 18 64. A subgroup of the expert group with a broad representation of peripheral health workers and local health committees should develop the technical messages to be included in the public information and education program to achieve these objectives. All forms of illustrated and written materials should be developed, but emphasis should be placed on persistent verbal communication to obtain full understanding. 65. To improve accessibility to diagnosis and treatment facilities. Particularly in large areas with poor communications and small and rather scattered villages. It should be noted that deaths due to malaria have been recorded in health posts serving such areas, and not in smaller districts with denser distribution of villages. It will be necessary to: a) promote the establishment of new health posts and local health committees in malaria-infested areas still too far from existing ones; and b) support the establishment of antimalarial drug depots, during the rainy season, in villages which may become isolated from the nearest health post during the peak of the transmission season, or where the distances to the health post are too great. 66. To improve malaria case management at the health services. Besides accessibility and acceptance, health services need to improve the quality of care provided, particularly regarding diagnostic and treatment practices. The strategy, therefore, calls for the followings. (a) The improvement of the competence of health staff by: (i) developing the malaria component of training courses of all categories of health staff and of general refresher training activities; (ii) organizing, when necessary, specific refresher training; (iii) stressing the importance of microscopical diagnosis, particularly for differential diagnosis of severe fever cases and treatment failures, as well as the uncertainty of clinical diagnosis, particularly of P. falciparum infections, hardly ever better than 40%, under the best conditions; and (iv) organizing, in collaboration with University, ORSTOM, Pasteur Institute and WHO, national and regional seminars; (b) The improvement of laboratory diagnosis and its actual use by: (i) contributing to the strengthening of laboratory services, prioritizing the development of appropriate malaria microscopy in all regional hospitals; for the diagnosis of severe fever cases and the follow-up of treatment of severe malaria, and in health centers located in areas where parasite resistance is prevalent; for the differential diagnosis of treatment failures of clinically diagnosed cases; and (ii) training and retraining laboratory technicians in malaria microscopy; (c) The improvement in the management of severe malaria, by: (i) including the WHO Guidelines on the Management of Severe and Complicated Malaria in all training and retraining activities for medical staff, (ii) acquiring and distributing to all health centers and hospital services the WHO manual and the computer self-training program on the management of severe malaria; (d) The strengthening in the monitoring of drug sensitivity, by: (i) supporting the existing capabilities for conducting surveys by ensuring the continued collaboration of the health services with the University, ORSTOM and Pasteur Institute; (ii) reporting treatment failures from the periphery; and (iii) developing, in health centers with performing laboratory services, the capacity for conducting simplified sensitivity tests, and eventually developing a network of sentinel posts for monitoring drug resistance with the collaboration of currently involved institutions;  56 Annex 3 Page 15 of 18 (e) The incorporation of malaria requirements into the development of a national drug policy incorporating: (i) a clear definition of first and second line drugs, and the procedures for their updating; and (ii) the inclusion of second line drugs, currently sulfadoxin-pyrimethamine, in the national list of essential drugs; (f) The development and support of a formative supervision system at district, regional and national levels, stressing reinforcement of local capabilities, retraining and strengthening support over the mere policing of activities. Such a system should be based on the full utilization of the epidemiological information system, by: (i) strengthening the capacity of analysis of the epidemiological situation at the regional level to monitor trends, identify lacunae, recognize and delimit problems and initiate epidemiological investigation, request central support if necessary and, eventually, organize emergency control; (ii) avoiding the consolidation of heterogeneous data, such as malaria cases diagnosed by medical and non-medical treatment providers, or clinical and microscopically diagnosed cases; (iii) ensuring the immediate reporting by telephone, FAX or e-mail of any suspected epidemiological emergency situation; and (iv) maintaining, through the epidemiological information system, an updated analysis of the epidemiological situation, including the results of drug sensitivity testing, and communicating directly to any district medical officer, any epidemiological information of particular interest to their district. Second Objective 67. The main effect of improved case management will be a reduction of malaria mortality, severity and duration of incapacity; it may therefore include a reduction of prevalence of symptomatic malaria, but it should not be expected to result in a reduction of incidence. The full achievement of the second objective will require the implementation of some form of transmission control. There exist a number of well known methods to reduce malaria transmission which fall into the following categories: (a) source reduction, including all forms of larval control, only useful when breeding places are few in relation to the population; they are therefore inapplicable to the conditions of rural tropical Africa. These methods require a high level of coverage to have any effect, being, therefore, not suitable for individual protection; (b) chemoprophylaxis, which is basically a method of individual protection; when used as a public health control method, it shows rapidly a marked effect when first introduced, but it is very difficult to maintain for long periods and often results in local epidemics when interrupted; its continuous use is recognized as one of the main factors in selecting resistant parasite strains; (c) indoor insecticide spraying requires a high coverage to be effective and, therefore, requires organized disciplined spray teams; its continued use is likely to select vector resistance and has resulted in local epidemics when discontinued; it is not suitable for individual protection; (d) bednets, particularly insecticide impregnated bednets; a method of individual protection, which can extend into widespread use and be very effective particularly  57 Annex 3 Page 16 of 18 for vectors biting predominantly in the middle of the night; generally most effective for the protection of young children and infants. 68. It is recognized that in areas of high stable endemicity, any form of vector control is likely to result only in a relatively small delay in the age of occurrence of morbidity and mortality. 69. The only control methods suitable for large scale implementation are, therefore, the use of impregnated bednets and, on very focal applications, indoor residual spraying for the prevention of malaria epidemics of short expected duration, when they can act as a fore-caster with reasonable accuracy. 70. Impregnated bednets. As mentioned above this method is fully additive, i.e. it does not require a high coverage threshold to be effective, it can begin by being used by a small proportion of the population, who will be protected, and progressively spread into large scale use. It nevertheless requires, in order to be effective, that vector biting habits and people activities after dusk do not coincide to produce important disease transmission before retiring under the net. A. gambiae and A. arabiensis, the main vectors in Senegal, bite predominantly in the central hours of the night so that the method is potentially effective and, experience in The Gambia has shown that it can produce an important reduction in childhood mortality and morbidity, when the use of bednets is accepted by the population (much greater impact in the western and central districts than the East of the country, in relation to people's acceptability of bednets). 71. It therefore requires a basic acceptability by the population; this is commonly assured in areas with high density of nuisance mosquitoes, particularly early biters which interfere with people's sleep. Many people object to using bednets in areas of high humidity and little air circulation. There are also many cultural factors which may or may not favor the acceptability of bednets. 72. Another essential factor to take into consideration is the problem of affordability; bednets, and their impregnation, are generally too expensive for most people. In The Gambia, a very successful project, when impregnation was provided free of charge, failed when a charge of about US$0.50 was claimed for bednet impregnation. 73. In Senegal, non-impregnated bednets are in wide use in the North, along the river Senegal (the St. Louis Region), and in similar areas of Louga and part of Tambacounda; these are also areas with very unstable malaria transmission, with great variation of rainfall from year to year and, in some areas, periodic risk of floods. Under these conditions, they appear as suitable areas for the implementation of an impregnated bednet program, based on the promotion and support of bednet production and impregnation. Production and sale could be based on local cooperatives or women associations, who could also undertake the impregnation and re- impregnation under the supervision of the health post 74. The project strategy, therefore, will consist of: (a) during the first year: study the opportunities and modalities for local production and commercialization of bednets, the organization of impregnation and possible system of cost recovery;  58 Annex 3 Page 17 of 18 (b) during the second year: test one or two alternatives of organization and functioning of the system and their articulation with the health services; (c) last three years: full incorporation into the health services and health information system. 75. Forecasting and prevention of epidemic outbreaks. Malaria endemicity in Senegal decreases, in general from south to north and from east to west and, although the country does not suffer the classical devastating regional epidemics of malaria of densely populated subtropical dry areas, it has large areas affected by periodic local outbreaks, which may produce serious increases of mortality and incapacity; these areas of unstable malaria transmission coincide with the Sahelian eco-epidemiological zone described in the situation analysis; the most densely populated part of this area lays along the Senegal river valley, and it is constituted by the St. Louis Region and the Bakel district of the Tambacounda Region. 76. Epidemic outbreaks appear to be triggered by particular combinations of extensive floods and high local rainfall, which will produce massive anopheline breeding and the necessary humidity/temperature to allow sufficient vector survival for the development of the parasite. Historical data indicates that these situations may last one or two years and be repeated with a periodicity of approximately five years, which may relate to the paraquinquenial cycle described elsewhere. It also seems that the main determinant, at least in the lower half of the river may be the floods, which could be predicted by receiving information of the level of river raising upstream. 77. increased vector breeding due to high rainfall will produce a malaria outbreak about a month later, while the effect of floods will be seen a month after the floods have subsided and left pools of stagnant water. These periods give the time necessary for the implementation of preventive measures. Historical records also indicate that the peak of rainfall occurs in August- September, while the river swelling occurs in September-October. If the area were protected by bednet impregnation, which normally would have been done before the rainy season in June, the detection of an epidemic risk would require the emergency re-impregnation of bednets in the areas at risk. 78. The prediction of an incoming flood, and the knowledge of how villages might be affected will, therefore, permit the implementation of certain preventive measures, such as: a) restocking of health posts, and high risk villages, with anti-malarial drugs for the emergency period; b) re-impregnation of bednets, and c) eventually, emergency indoor insecticide spraying. 79. The implementation of the Health Information System will permit the analysis of the local significance of the factors mentioned above, as well as, in certain areas, more detailed analysis of the influence of temperature and humidity, in the production of local epidemic outbreaks. Such studies will permit the definition of indicators of epidemic risk which could be incorporated into the epidemiological information system. 80. The project strategy consists of: (a) studying, during the first year, potential determinants of epidemic risk in areas of unstable malaria transmission; mapping of the areas affected by each major  59 Annex 3 Page 18 of 18 determinant and identification of localities at risk; defining indicators with predictive value, and negotiation for the acquisition of timely information on their variation; (b) during the second year, incorporating of indicators into the health information system at the level of regional epidemiological analysis; organization of alarm mechanisms, emergency preparedness and response capabilities; evaluation. (c) during the last three years, operationalizing the system. Third Objective 81. The current technical recommendation for preventing severe malaria in pregnant women, as well as for preventing low birth weight in areas of high endemicity, is the implementation of a program of chemoprophylaxis for pregnant women, particularly during their first pregnancy. This strategy has confronted, practically everywhere, serious problems of compliance and coverage and different evaluations have suggested, as a possible alternative, periodic treatment courses (e.g. once a month, or at each attendance at a prenatal consultation) and immediate treatment of any clinical manifestation. 82. The project strategy will be: (i) the continued promotion and support of chemoprophylaxis during pregnancy; (ii) the continued evaluation of severe manifestations during pregnancy; (iii) the follow-up of field research on possible alternatives for the protection of pregnant women, and consideration of their possible adoption.  60 Annex 4 Page I of 17 REPUBLIQUE DU SENEGAL PROJET DE LUTTE CONTRE LES MALADIES ENDEMIQUES LES BILHARZIOSES I. INTRODUCTION Historique 1. DejA citee dans le papyrus d'Eber (1,500 avant J.-C.), l'existence de bilharzioses A S. haematobium a e etablie par la d6couverte d'oeufs calcifies dans la vessie d'une momie egyptienne de la XXeme dynastie (plus de 1,000 ans avant J.-C.). Au Moyen-Age, les medecins arabes parlent de "pissements de sang" des caravaniers revenant de Tombouctou. En 1852, Theodor Bilharz d6couvre et decrit S. haematobium. En 1904, Manson decrit les oeufs de S. mansoni. Definition 2. Les bilharzioses sont des affections parasitaires dues A des vers plats, les bilharzies ou schistosomes, hematophages vivant dans le systeme circulatoire. Cinq especes sont pathogenes pour l'homme, mais deux seulement sont presentes au Senegal. Shistosoma haematobium est I'agent de la bilharziose uro-genitale; Shistosoma mansoni est responsable de la bilharziose intestinale. 3. S'il a toujours exist6 des foyers diss6mines de bilharzioses a S. haematobium au Senegal, la bilharziose A S. mansoni est un phenomene recent qui est lid aux modifications ecologiques dues aux projets d'irrigation et a la construction de barrages sur le fleuve Senegal et en Casamance. En particulier dans la region de St Louis, la construction du barrage de Diama en 1986 a ete A l'origine d'une epidemie foudroyante de bilharziose a S mansoni qui est toujours en phase d'expansion. Cycle parasitaire 4. Les oeufs de S. haematobium ou de S mansoni excretes par l'homme dans les canaux ou les mares d'eau douce liberent des miracidiums qui infestent l'h6te intermediaire, qui est un mollusque d'eau douce. Le developpement de ces miracidiums dans l'h6te intermediaire aboutit A la formation de larves qui s'echappent pour passer dans 1'eau avant de penetrer chez l'h6te definitif, I'homme. L'infestation de I'homme s'effectue lors des bains dans des eaux douces, contamin6es par les mollusques. 5. Les bilharzioses humaines sont liees A la presence des mollusques h6tes intermediaires dont 1'existence est conditionnee a des facteurs 6co-bio-climatiques bien definis. L'etude de ces facteurs permet d'evaluer les risques d'apparition de la maladie bilharzienne. Enfin, il existe une dynamique dans la distribution geographique des mollusques et une evolution dans leur r6le  61 Annex 4 Page 2 of 17 epidemiologique. C'est pourquoi une surveillance malacologique constante et reguliere est necessaire surtout dans les zones oui les conditions ecologiques changent. 6. Les h6tes intermrdiaires des bilharzioses sont des petits mollusques d'eau douce. L'hote intennediaire de la bilharziose humaine a S. mansoni au Senegal est Biomphalariapfeifferi. Les h6tes intermrdiaires de la bilharziose humaine A S. haematobium sont au Senegal B. globosus, B. senegalensis et B. umbilicatus. B. truncatus a toujours e le bulin le plus frequent dans la region de St Louis, probablement en raison de sa tolerance de la salinite, mais il n'intervient pas actuellement dans la transmission de la bilharziose humaine dans cette region. 7. Les gites de ces mollusques se trouvent toujours dans des eaux peu profondes, stagnantes ou faiblement courantes, riches en matieres organiques et comportant une vegetation aquatique qui sert de support et de nourriture aux mollusques. La temperature de l'eau doit etre comprise entre 25 et 30 degres Celsius; par contre le pH et la salinite peuvent varier dans de larges proportions; les mollusques preferent les zones ombragees, ils vivent en general a 20 ou 30 cm de profondeur sur les tiges des plantes, les feuilles mortes ou la boue du fond. Enfin, il a b remarque que ces mollusques etaient plus abondant dans la periode allant de mai A aouit, oil les temperatures sont plus elevees (23 A 30 degres Celsius). 8. B. pfeifferi est tres sensible A la dessiccation et ne vit que dans des gi^tes A eau perrnanente et souillee. II n'est tolerant ni A la salinite de 1'eau ni au pH acide. Les bulins, tres resistants A la secheresse a l'exception de B. globosus, peuvent vivre dans des mares temporaires et etre transportes A grande distance par des boues sechees, les sabots des animaux, les oiseaux. En saison seche, les densites de mollusques sont elevees dans les gites permanents. H. SYMPTOMATOLOGIE DES INFECTIONS A SCHISTOSOMES Phase de penetration et phase d'invasion 9. La symptomatologie est commune aux deux bilharzioses A S. haematobium et A S. mansoni lors de la phase de penetration et de la phase d'invasion. La phase de penetration correspond A la penetration transcutanee des furcocercaires et se traduit par une dermatite tres discrete voire inapparente. La phase d'invasion correspond aux reactions de l'organisme mis en contact avec les substances antigeniques et toxiques des vers et se traduit par des phenomenes allergiques avec de la fievre, des sueurs et des cephalees. Cette phase n'est marquee que lors des primo-infections; elle est discrete lors des reinfestations successives. Enfin, cette phase est plus fr6quente et plus grave pour S. mansoni. Phase d'etat 10. C'est souvent la periode oui le patient decouvre sa maladie. Dans le cas de la bilharziose a S. haematobium, cette periode correspond A la ponte de nombreux oeufs dans la vessie et l'uretere. Les principaux sympt6mes sont l'hematurie, pratiquement toujours presentes, et des troubles de la miction urinaire. Des complications apparaissent chez un faible pourcentage de personnes infect6es, telles que des infections de la vessie et des st6noses ureterales qui peuvent conduire A des atteintes graves des reins. Enfin, des signes cutanes (papules non prurigineuses) peuvent etre observes sur les zones peri-ombilicales ou thoraciques.  62 Annex 4 Page 3 of 17 11. Dans le cas de la bilharziose a S. mansoni, cette periode apparait trois mois environ apres le bain infestant et se traduit par une diarrhee et des douleurs abdominales. L'evolution de cette atteinte intestinale est gen6ralement favorable, meme sans traitement. Le risque majeur de cette maladie est la complication au niveau du foie qui peut entrainer la mort (emboles ovulaires dans le foie--thrombose des veinules du foie--hepato-splenomegalie--hypertension portale->h6morragies digestives-*ruptures de varices oesophagiennes-*mort). D'autres complications peuvent &re observees avec S. mansoni dues A des migrations des oeufs dans le systeme cardio-pulmonaire et dans le systeme nerveux. A l'echelle communautaire 12. Il semble exister: (i) une correlation entre l'intensite de l'infection et le developpement de complications graves ; (ii) une correlation entre la prevalence de la maladie et l'intensite de l'infection; et (iii) une correlation entre la prevalence et le developpement de complications graves. III. CARACTERISTIQuEs DES DIFFERENTES ZONES D'ENDEMIE La Region de St Louis 13. Ecologiquement, la region peut etre divisee en deux parties: le Walo qui correspond a la plaine alluviale s'etendant sur une vingtaine de kms de part et d'autre du lit principal du fleuve et dans laquelle on pratique des cultures de decrues, et le Dieri, zone semi-aride situee en bordure du Walo ou se pratiquent les cultures pluviales; il inclut les vallees fossiles, en particulier, la vallee du Ferlo. 14. La vallee du fleuve Senegal est divisee en trois parties: la haute vallee qui se situe presque entierement en territoire malien, la moyenne vallee qui s'etend sur pres de 500 km et qui va de Matam A Richard-Toll, et le Delta qui s'6tend sur 170 km et qui va de Richard-Toll A St Louis. 15. Le Delta est lui-meme subdivise en cinq zones: le bas Delta du fleuve S6negal, le moyen Delta du fleuve Senegal oiu se trouve la riviere Lampsar, le haut Delta du fleuve Senegal, le lac de Guiers, et le Dieri situe au sud de la route principale St Louis- Matam. (a) Le bas Delta (Walo). Cette region est situee entre St Louis et Debi et entre le fleuve Senegal et la riviere Djeuss. Avant la construction du barrage, il y avait peu d'agriculture dans la zone A cause de l'intrusion de l'eau salke. Apres la construction du barrage de Diama (1986), des projets d'irrigation furent developpes. (b) Le moyen Delta (Walo). Cette region a et depuis longtemps protegee de l'intrusion de l'eau salee par de petits barrages pour fournir de l'eau douce A St Louis. (c) Le haut Delta (Walo). Cette region etait envahie par les eaux salkes avant la construction du barrage Diama; elle est maintenant une zone importante pour la culture du riz et de la canne A sucre. Cette zone est situee entre le fleuve Senegal et  63 Annex 4 Page 4 of 17 la route principale, entre Debi et Dagana. Elle inclut les villes de Ross-Bethio et Richard-Toll. (d) Le lac de Guiers. Un canal relie le fleuve Sen6gal et le lac de Guiers qui est la principale source d'eau de Dakar. Les activites agricoles sont importantes et comprennent les cultures du riz et de la canne a sucre. (e) Le Dieri. Le Dieri s'etend des deux bords du lac de Guiers et est limite au nord par la route principale St Louis- Matam et au sud par la region de Louga. La population est principalement nomade, Peul et Maure. 16. La moyenne vallee s'etend dans une plaine alluviale de 20 km de large et peut etre divisee en deux zones: le Walo ou est pratiquee la culture irriguee de riz, et le Di&ri, sec, au sud de la route principale. Dans la moyenne vallee, le Dieri inclut les vallees fossiles, en particulier la vallee fossile du Ferlo. Les vallees fossiles font l'objet d'un projet de revitalisation grace a un projet d'irrigation a partir des crues du fleuve Senegal. Au sud de Matam, la vallee se retrecit et se creusejusqu'a la haute vallee. Les autres regions 17. Suite a l'enquete de prevalence effectuee dans le cadre de la preparation du projet en avril 96, les zones touchees par les bilharzioses se distinguent en deux groupes. Le premier groupe correspond aux zones endemiques riveraines du fleuve Faleme, et de la riviere Anambe, qui font l'objet de programmes d'irrigation et de developpement agricole; le deuxieme groupe correspond aux zones endemiques qui ne peuvent etre rattachees a des bassins fluviaux, telles que celles situees dans les regions de Diourbel, Kaolack, Fatick, Tambacounda et Thies et qui sont liees a des mares temporaires. 18. Dans le bassin de la Faleme, la region endemique se situe autour de Bakel ou les perimetres irrigues sont tres nombreux. Le bassin compte environ 150 villages pour une population approximative de 25,000 habitants. Dans cette region, l'emigration est tres importante. Dans le bassin de l'Anambe, la zone endemique est liee au programmme de developpement de riziculture irriguee. Le bassin compte environ 200 villages peuplds par pres de 30,000 habitants dont la majorite est impliquee dans le projet rizicole. 19. Dans les regions endemiques qui ne peuvent etre rattachees a des bassins fluviaux, la bilharziose urinaire se developpe en foyers a proximite de mares temporaires infestees par des mollusques-vecteurs. Ces mares temporaires sont assechees de mars ajuillet. Pendant cette periode les mollusques s'enfoncent dans la terre pour ressortir a la saison des pluies lors de la reconstitution des mares. II est estimd qu'au moins 200 villages (population approximative de 100,000 habitants) sont endemiques a cause de la proximite de mares temporaires infestees, dont au minimum 1 00 villages dans la region de Tambacounda. 20. La rdgion de Ziguinchor, qui n'a pas ete incluse dans l'enquete, comprend des zones endemiques liees aux barrages anti-sel d'Affiniam (departement de Bignona) et de Guidel (ddpartement de Ziguinchor) et des foyers endemiques liNs a des mares temporaires. II est estime qu'environ une centaine de villages sont endemiques pour une population approximative 50,000 habitants.  64 Annex 4 Page 5 of 17 IV. LA SITUATION EPIDEMIQUE ACTUELLE DES BILHARZIOSES HUMAINES La region de St Louis 21. Bilharziose a S. haematobium. Le detail des resultats par village montre des differences importantes dans la prevalence et l'intensite de la bilharziose A S. haematobium et reflete des niveaux variables de transmission dans les differentes zones du bassin du fleuve Senegal. Le plus grand nombre de villages infectes et les villages ayant les plus fortes prevalences et les plus fortes infestations ont ete observes dans le bas Delta dans l'aire de la riviere Lampsar, et a un niveau moindre dans la zone Walo de la moyenne vallee. Dans la zone du Dieri, seulement 6 villages sont infectes bien que les conditions de vie soient les memes. Ces resultats soulignent la nature extremement localisee de la transmission de la bilharziose. 22. Bilharziose a S. mansoni. Les prevalences sont les plus hautes dans le haut Delta avec une prevalence moyenne de 95.6% et dans tous les villages autour du Lac de Guiers ou l'on trouve une prevalence moyenne de 71.8%. Les prevalence sont moyennes dans la zone du Bas Delta / riviere de Lampsar avec une prevalence moyenne de 22.8%. Par contre les prevalences sont encore basses dans le bas Delta du fleuve Senegal. Les autres regions 23. Les resultats d'une enquete de prevalence realisee en avril 1996 dans le cadre de la preparation de ce projet montre les resultats suivants. (a) a) II n'a pas et trouve de cas de bilharziose intestinale (S. mansoni) en dehors de la region de St Louis, A part quelques cas importes dans la region de Kolda. (b) b) II existe des foyers de bilharzioses urinaires dans pratiquement toutes les regions du Senegal, A l'exception de celle de Dakar. Les details de l'enquete sont donnees plus loin sous forme de carte. Les tendances 6pid6miotogiques recentes dans la region de St Louis 24. Depuis la construction du barrage de Diama, en 1986, les bilharzioses humaines A S. haematobium et S. mansoni sont en expansion dans la region de St Louis. Avant la construction du barrage, it n'existait pas de bilharzioses A S. mansoni. Seule la bilharziose A S. haematobium etait presente A des taux de prevalence faible et dans des foyers tres localises. 25. L'evolution de l'epidemie de bilharziose a S. mansoni est liee A l'evolution de l'h6te intermediaire Biomphalaria pfeifferi. Avant la construction du barrage, Biomphalaria pfeifferi n'etait present que dans la partie la plus douce du Lac de Guiers, et il n'y avait pas de cas de bilharziose A S. mansoni. Depuis la construction du barrage, sa multiplication a e foudroyante aussi bien vers l'ouest qu'a l'est. Grace aux nouvelles conditions ecologiques, en particulier la diminution de la salinite et l'alcalinisation de l'eau, Biomphalariapfeifferi a envahi de proche en proche le Lac de Guiers, puis le Canal principal, les canaux d'irrigation, A Mbodienne et A Podor, le canal et le marigot de Taouey, la riviere Lampsar et le fleuve Senegal.  IBRD 2863A IB- I7' - 15 I 14 13 13'I S tN 4GA L KA A n I 1' I ~~~~~~~~~~~~~~~~~~MWn" fy oP P6bI H.oith ..d Sooi. Aoti..SNEA M A U R I TI I A MW',OI. r.d.IS-t Pobliqo..t.6I'Aoli- S-io. 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