Dominican Republic - Population and Family Health Project

Document of FILE COPY The World Bank FOR OFFICIAL USE ONLY Report No. P-1905-DO REPORT AND RECOMMENDATION OF THE PRESIDENT OF THE INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT TO THE EXECUTIVE DIRECTORS ON A PROPOSED LOAN TO THE DOMINICAN REPUBLIC FOR A POPULATION AND FAMILY HEALTH PROJECT August 31, 1976 This document has a restricted ditribution and may be used by recipients only In the performance of | their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  Currency Equivalents Currency Unit = Dominican Peso (RD$) us$ 1.00 = RD$ 1.00 Fiscal Yaar January 1 - December 31 Abbreviations ADPBF Asociacion Dominicana Pro-Bienestar de la Familia (Dominican Association for Family Welfare) CEA Consejo Estatal del Azucar (State Sugar Council) CONAPOFA Consejo Nacional de Poblacion y Familia (National Council for Family Planning) ENE Escuela Nacional de Enfermeria (National Nursing School) IDSS Instituto Dominicano de Seguros Sociales (Dominican Social Security Institute) ODC Oficina de Desarrollo de la Comunidad (Office of Community Development) PAHO Pan American Health Organization SESPAS Secretaria de Estado de Salud Publica y Asistencia Social (Secretariat of State of Public Health and Social Assistance) UNDP United Nations Development Programme UNFPA United Nations Fund for Population Activities USAID United States Agency for International Development  FOR OFFICIAL USE ONLY Definitions Birth Rate Annual births per 1,000 population. Death Rate Annual deaths per 1,000 population. Total Fertility Rate It is interpreted as births per woman of child bearing age. Rate of Natural Increase Difference between the crude birth and death rates. Dependency Ratio Persons of "dependent" ages (those under 15 years of age and age 65 and over) per person of "working ages" (15-64). Graduate Nurse Nurses who have completed 3 or 4 years of nursing education after completion of secondary school. Technical Nurse A new category of nursing personnel (who will graduate from secondary schools); the course will consist of two years of nursing training after four years of secondary studies. Nursing Auxiliary Health worker with 6-9 months of nursing training after completion of the eight years of education. Practical Nurse Nurses without formal training. Rural Clinics Health facilities located in a rural area covering an estimated population of 2,500 - 3,000 staffed by one or two nursing auxiliaries and/or practical nurses and visited by a physician once a week. Health Sub-Centers Health facilities with both outpatient and inpatient services; they have 10 to 30 beds mainly for deliveries and pediatric cases. Health Centers Health facilities located in provincial capitals, providing mainly outpatient services. Thb document has a restricted distribution and may be used by recipients only in the performance of their oMcial duties. Its contents may not otherwise be disclosed without World Bank authorization.   INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT REPORT AND RECOMMENDATION OF THE PRESIDENT TO THE EXECUTIVE DIRECTORS ON A PROPOSED LOAN TO THE DOMINICAN REPUBLIC FOR A POPULATION AND FAMILY HEALTH PROJECT 1. I submit the following report and recommendation on a proposed loan to the Dominican Republic for the equivalent of US$5.0 million to help finance a Population and Family Health Project. The loan would be made on standard Third Window terms of 25 years, including 7 years of grace, with interest at 4.9 percent per annum. PART I - THE ECONOMY 2. An economic mission visited the Dominican Republic in August/September 1974. Its report, "Updating Report on the Economy of the Dominican Republic" (611-DO), was distributed to the Executive Directors on April 18, 1975. Relevant social and economic data are presented in Annex I. 3. In 1970-74, the Dominican economy expanded rapidly, stimulated by large inflows of private capital into key sectors such as mining, agriculture, and manufacturing, by rapid export growth and by a dynamic public investment program. The rate of real GDP growth averaged almost 11 percent. 4. Mining, industry (including sugar refining), construction, and services accounted for the bulk of output growth. Industrial incentive laws, although offering a high degree of protection and encouraging capital-intensive activi- ties, did stimulate private investment in manufacturing, mostly in import sub- stitution industries. Construction activity was stimulated by the high level of public investment outlays for infrastructure and by private residential construction. Much of the increase in mining output came from the Falconbridge ferronickel plant (partly financed by Loan 646-DO), which started production in 1972. Urban services and tourism also expanded rapidly. The total volume of agricultural production increased at a slower rate, as increases in export crops were partly offset by slow growth in food crops. 5. Responding to political stability and a favorable business climate, gross investment increased from 19 percent to 25 percent of GDP between 1970 and 1974, an annual increase of nearly 20 percent in real terms. Much of the investment was financed out of internal savings. Domestic savings increased from just under 12 percent of GDP in 1970 to about 18 percent of GDP in 1974. Prudent fiscal policies contributed to the growth of savings. Consolidated public sector savings financed over three-fourths of public capital expendi- tures and contributed over one-half of total gross domestic savings in 1970-74. However, the restraint on current expenditure involved some cost in the neglect  of needed public services. The ratio of taxes to GNP is in excess of 16 percent, reflecting a substantial public resource mobilization effort. 6. Exports have been the most dynamic element in the economy. Merchand- ise exports increased from US$213 million in 1970 to an estimated US$634 million in 1974. The Dominican Republic was one of the few countries able to increase its volume of sugar exports in a period of rising world prices. Raw sugar exports amounted to 764,000 tons in 1970 and 1,016,000 tons in 1974. Other exports have also been buoyant. The combined export value of cocoa, coffee, and tobacco reached US$134 million in 1974 as compared to US$63 million in 1970. Ferronickel exports, which began in 1972, reached US$93 million in 1974. Although tourism has only recently become a significant source of foreign exchange, gross tourism earnings came close to US$50 million in 1974, up from about US$20 million in 1970. 7. The economic expansion of 1970-74 was accompanied by liberal credit policies. In this period, the stock of bank credit to the private sector increased at an average annual rate of over 33 percent and bank credit to the public sector increased at an average annual rate of 14 percent. The infla- tionary potential of the fast credit expansion was partly compensated by an increased willingness on the part of the private sector to hold time and savings deposits, even though low yields are paid to savers. Nevertheless, the Santo Domingo Consumer Price Index, which rose at an average annual rate of 4 percent in 1970-71, accelerated to 14 percent in 1973-74. Part of this increase was the result of the sharp increase that import prices experienced in 1974. It is probable, moreover, that the cost of living in Santo Domingo understates inflationary pressures because prices of staples and rents, which weigh heavily in the index, are controlled. In any event, the liberal credit policy of 1970-74 would have led to even greater price rises, had not imports been allowed to rise from US$278 million in 1970 to US$673 million in 1974, an annual nominal rate of nearly 25 percent and a real rate of 14 percent. 8. In 1974, world sugar prices rose to record levels. The world price, which had averaged 8.5 cents/lb in 1972/73, peaked at over 60 cents/lb in November and averaged 30 cents/lb for the year. The Dominican Republic, because it had followed the practice of selling forward most of its crop, did not fully benefit from these high prices in 1974, as the average price obtained was 14.7 cents/lb. In early 1975, it was expected on the basis of future sales already contracted at that time that Dominican sugar exports in 1975 would sell at an average of 33 cents/lb. The actual average export price received in 1975 was 25.4 cents/lb. While still a very high price, it did not allow for the reserve build-up that had been envisaged (see Economic Report 611-DO). 9. The potential for a reserve build-up in 1975 was further affected by a severe drought, causing low sugar exports and higher food imports than in 1974. The volume of bauxite and ferronickel exports also dropped in 1975, owing to weak foreign demand. On the other hand, the Rosario gold and silver mine started operations in 1975, with exports of US$28.6 million. The  - 3 - authorities were able to sterilize in 1975 about US$60 million of tax revenues and US$20 million of sugar exporters' revenues in special reserve accounts. These measures helped prevent excessive expansion of domestic credit and imports, making it possible for banking system external reserves to increase by US$60 million in 1975. As a consequence of the poor weather and world recession, GDP growth in constant prices was only 4.7 percent in 1975. 10. Prospects for 1976 are mixed. Good weather in late 1975 and early 1976 is expected to lead to a recovery in agricultural output. Recent expan- sions in installed electric power capacity should facilitate some growth in industrial production. The ongoing economic recovery in OECD countries could result in larger volumes of bauxite and ferronickel exports, as well as in higher earnings from tourism. Further expansions in gold mining capacity are under way. On the other hand, with world sugar prices running at about one-half the prices obtained by the country in 1975, total 1976 export earnings may be some US$200 million below the 1975 levels and a sub- stantial balance-of-payments deficit is expected to re-emerge. Because the Government feels that the Dominican Republic failed to benefit fully from th& high sugar prices prevailing in 1974 and 1975, it has been reassessing its marketing strategy. This reassessment has led to a marked slowdown in marketing the current sugar crop. As a result, in early 1976 domestic liquidity continued to be tight, and the authorities were again pursuing cautious fiscal and incomes policies so that overall growth is likely to be quite modest. 11. Because much of the recent economic growth was concentrated in the main urban centers, it did not materially improve the living standards of the rural majority. Although the official accounts show a GNP per capita of between US$460 and US$480 in 1972, most non-financial indicators of the level of economic development show the Dominican Republic at par with other Latin American countries in the US$320 to US$360 GNP per capita range (see Annex I, p. 5), and suggest that poverty is far more widespread than suggested by GNP per capita figures. A recent health sector assessment found that the food intake of almost 70 percent of the population is below the minimum nutritional standards established for Central America and Panama and that over threefourths of pre-school children suffer from protein-calorie malnutrition. Malnutrition in the Dominican Republic is probably more severe than in any Central American country. 12. The Government is acting to correct the disparity between rural and urban incomes. It has taken action to redistribute land, to redirect public credit to small scale farmers, and to extend the benefits of public education to rural areas. Since 1972, the land reform institute has acquired over 225,000 hectares (almost 10 percent of the country's arable land). Much of this land has been distributed to individuals -- in farms of under 7 hectares -- or to "asentamientos", state farms in which the members work the land together and share the proceeds. To ensure that subsidized credit reaches small-scale farmers, the lending ceiling of the State Agricultural Bank was lowered from US$250,00 to US$50,000. The average size of new  loans made in 1975 was about U SSI , 50(3 in the case of the AgricultuIral Bank and even smaller in the case of the two other official agricultural credit agencies. The Government also intends to broaden the opportunity for chiildren to have at least four vears of primary schooling, especially in rural areas. With Bank Group assistance, the Government is beginning to emphasize nonformal vocational training for agricultural activities and industrial trades. 13. The Government is also continuing its efforts to provide new employ- ment opportunities by pursuing growth-oriented policies and carrying out a large public investment program. Nonetheless, despite recent increases in output, the overall urban unemployment rate has not been significantly reduced, mainly because the urban labor force has increased by more than 6 percent per annum, reflecting migration to the cities and an increase in the economic participation of women. A recent ILO study suggests that in early 1973, 20 percent of the Santo Domingo labor force was unemployed and 60 percent of the remainder were partially unemployed. In spite of extensive rural migra- tion, underemployment in agriculture is still widespread. Nationwide, un- employment and underemployment are equivalent to about 40 percent of the labor force. Because of the fast growth of population (over 3.3 percent annual natural increase), the economy would need to expand by 6.5 percent per vear merely to maintain unemployment at its present high rate. 14. The United States Agency for International Development (USAID), the Inter-American Development Bank (IDB), and IDA have provided the bulk of external assistance since 1960. Because of its income level, the country is no Longer eligible for IDA credits. USAID's budget has been significantly reduced in recent vears and U.S. government assistance to the Dominican Republic has gone down from over USS100 million per year in the mid-1960's to about US$17 miLlion per year. IDB lending has averaged USS30 million per year. The Dominican Government has also been able to borrow modest amounts from foreign commercial banks. 15. The Covernment's prudent financial management is reflected in a rela- tively small and well-structured external public debt. As of year-end 1975, the disbursed total external public debt of USS437 million was equivalent to 11.5 percent of GDP. The Government has taken the position that the economy cannot afford to service more than a quite limited amount of debt on conventional terms, because of its lasting structural weakness. Therefore, only one-third of the debt had been contracted at commercial terms (commercial banks and suppliers' credits) and the debt service ratio is relatively low. The Govern- ment, in its assessment of terms that the country can afford, is mindful of the fact that until only a few years ago official external lenders like the Bank considered that the economy's creditworthiness was so fragile as to warrant lending only on highly concessionary terms such as those provided by IDA. 16. Despite progress achieved in recent years towards diversifying exports, sugar still represents more than half of export earnings. Sugar prices, traditionally highly volatile, are expected to remain depressed for several years, whiLe other traditional exports (ferronickel, coffee, cocoa, tobacco, and bauxite) are expected to grow slowly in the medium term. While  - 5 - gold and silver exports are expected to expand, as well as tourism earnings, and the country could develop new exports, such as agro-industrial products, the balance of payments outlook is not likely to change significantly until the mid-1980's. On balance, export earnings over the next decade are likely to fluctuate considerably and can be expected to lag behind import growth if an effort to improve social conditions is to be sustained. Therefore, the country will continue to need a substantial resource transfer over the medium term. 17. The urgently required improvement of social conditions is expected to lead to a shift in the composition of public development outlays towards agriculture and the social sectors, i.e., towards sectors with a relatively high local cost component. It may not be possible, therefore, to achieve the necessary transfer of development assistance if the latter is limited to the foreign exchange component of development projects. Given this situation, it is desirable to Include some local cost financing in external official loans. 18. Because the authorities have pursued prudent debt management policies, they have some untapped borrowing capacity from private sources. But they could draw from these sources only in moderate amounts, if overall debt terms are to remain sufficiently soft in the face of poor prospects in the world sugar market. To the extent that new commercial borrowing is kept at moderate levels and a suitable balance is maintained between conventional and concessionary loans, the Dominican Republic can be considered creditworthy for some Bank lending. Eligibility for Third Window Lending 19. The foregoing paragraphs (11 through 18) present material which is relevant to the consideration of Third Window financing for the Dominican Republic. In summary, the country is considered eligible for this type of financing on the basLs of the following criteria: (a) Poverty: Although the GNP per capita is shown at about US$460 in 1972 (Bank Atlas figure), most non-financial indicators of the level of economic and social development show the Dominican Republic at par with other Latin American countries in the US$320 to US$360 per capita income level (see Annex I, p. 5). (b) Performance: The Dominican Republic is making a substantial development effort in relation to its resource base and economic potential. The Government is pursuing growth-oriented policies designed to provide new employment opportunities, attempting to correct the imbalances between the urban and rural population and promoting the diversification of the country's foreign exchange earnings. (c) Creditworthiness: The Dominican Republic is creditworthy for limited amounts of Bank lending. Its external debt and debt ser- vice are at moderate levels, although its overall borrowing should  - 6 - continue to be on relatively soft terms given the critical dependence of the balance of payments on sugar exports and the depressed out- look for world sugar prices. (d) Alternative sources of finance: In the past, the bulk of the Dominican Republic's borrowings has come from IDA, USAID, and IDB. The country is no longer eligible for IDA financing, USAID has sharply reduced its lending program, while IDB lending is expected to remain at recent levels. As indicated in paragraph 15, the Government is prudently limiting its recourse to borrowing on commercial terms. PART II - BANK GROUP OPERATIONS IN THE DOMINICAN REPUBLIC 20. Since the Bank Group began operations in the Dominican Republic in 1969, the country has received three IDA credits totalling US$22 million and four Bank loans totalling US$59 million, making a total for the Bank Group of US$81 million. At the end of June 1976, the Bank and IDA held about US$70 million, including about US$40 million not yet disbursed. One loan of $25 million, made in 1969 for the Falconbridge ferronickel project, has been fully disbursed. 21. Two IDA credits were made in FY71: US$4 million for an Education Project and US$5 million for a Livestock Development Project. A third IDA credit for US$13 million was approved in FY73 for an irrigation project (Yaque del Norte) which is being jointly financed with IDB. Two Bank loans were made in FY75: one for US$21 million to finance a tourism project and another one for US$8 million to finance a Second Education Project. The latest loan, US$5 million on Third Window terms for a Road Maintenance and Reconstruction Proj- ect, was approved by the Executive Directors in July 1976. IFC has made one investment in the Dominican Republic: a loan and an equity commitment for US$7.4 million in FY74 for a cement project, which has been fully disbursed. Execution of Bank Group-financed projects has been, on the whole, satisfactory. Annex II contains a summary statement of Bank loans, IDA credits, and IFC investments as of June 30, 1976, and notes on the execution of ongoing projects. 22. When the Bank Group began to lend to the Dominican Republic in the late sixties, the country's precarious economic and financial situation required that all external assistance be on highly concessionary terms. Therefore, with the exception of the Falconbridge ferronickel project, an enclave export project, all lending up to fiscal year 1973 was on IDA terms. In view of the considerable economic progress achieved by the country in recent years, the Dominican Republic is no longer eligible for lending on IDA terms. However, for the reasons explained in Part I, the Dominican Republic will continue to require some external financing on concessionary terms.  23. Bank Group lending to the Dominican Republic has been primarily directed at redressing the three major obstacles to economic and social develop- ment: the vulnerability of the balance of payments, higlh rates of rural under- employment and urban unemployment, and weakness of the institutions respon- sible for sectoral policies, project preparation, and project execution. The ferronickel, livestock, and tourism projects are aimed at strengthening the Dominican Republic's balance of payments. The livestock and tourism projects have at the same time strengthened sectoral institutions; the Road Maintenance and Reconstruction Project is expected to improve the national road maintenance capability. The education projects are directed at upgrading the capabilities of the labor force, thus helping to resolve the underemployment and unemploy- ment problems. The Yaque del Norte Irrigation Project will assist both to improve the standards of living of the rural population as well as to increase production in a potentially rich agricultural area. 24. The Dominican Republic's population density ranks among the highest in the hemisphere, and the net population growth rate would also be among the highest were it not for substantial emigration to the United States and Puerto Rico. The Government has begun an active, though limited, family planning program with the support of the United Nations Fund for Population Activities and USAID, and has requested Bank assistance to complement the activities of these agencies. The Project is designed to improve the efficiencv of the Dominican Republic's family planning program through the strengthening of the public health system. 25. Sugar exports are likely to remain the Dominican Republic's principal source of foreign exchange earnings in the foreseeable future. The State Sugar Council, which is responsible for some 60 percent of the countrv's sugar output, is considering, with the assistance of Bank staff, a project designed to increase field and factory productivity. Implementaton of this project would assist the Dominican Republic to maintain its competitive posi- tion in the world sugar market and to make more effective use of its limited land resources. 26. The U.S. Government has in the past been the Dominican Republic's major source of external financing, mainly for budget support and for projects in agriculture, education, health, and for industrial credit. However, as noted above, this support has been declining sharply. The IDB has been active in power, irrigation, water and sewerage, industrial and agricultural credit, and higher education, and has made one loan for ports development. Future lending by the USAID is expected to be concentrated in health, agricul- ture and rural development, while IDB expects to continue lending in the sectors in which it has been active in the past.  - 8 - Table i: External Assistance to the Dominican Republic, 1953-1976 (USS million; commitments, net of cancellations) U.S. IBRD/IDA /a IDB Government /b Lending '953-65 - 12.0 47.7 Lend.ng 1966-76 76.0 174.0 245.8 Lend ing by Sector: Power - 67.0 16.6 Education, HeaLth, and Housing 12.0 3.4 9.3 Agrictulture, Livestock, and Fishing 18.0 45.2 26.5 Industry and Tourism 46.0 7.0 27.9 Water and Sewerage - 27.5 - Transportation - 35.5 _ Other - 0.4 213.2 /c Total 76.0 186.0 293.5 /a A US$5 million loan for a Road Maintenance and Reconstruction Project was made in July 1976; the loan has been signed but is not yet effective. /b USAID and PL480; excludes PL480 grant funds. /c Mainly budget support. 27. The Bank Group's share in che Dominican Republic's publicly guaran- teed external debt outstanding and disbursed amounted to 11 percent at the end of 1975. The Bank Group's share of public external debt service was 11 percent. Its share in the Dominican Republic's external debt and debt service is likely to remain below 15 percent by the end of the 1970's. The service of public external debt in 1975 was equivalent to about 3.6 percent of foreign exchange earnings, i.e., exports of goods and non-factor services plus transfer receipts. Though some increase in this ratio can be expected, it should not exceed 10 percent in the early 1980's, provided the Government's present policy of restricting its borrowing on commercial terms is continued. PART III - THE POPULATION PROBLEM1 28. The population of the Dominican Republic almost doubled in the 20 years preceding the 1970 census; at 3.3 percent, its rate of natural increase in 1970 was one of the highest in the world. Emigration, mainlv to North America, has reduced population growth to 2.8 percent annuallv. However, tile still high rate of population increase requires that substantial government funds be devoted to finance the needed social services. At the present time, an estimated 49 percent of the population is illiterate, with illiteracv in rural areas reachiing 60 percent. Health and nutrition standards are low and the administrative machinerv for services to improve them .s inadequate. Although the Government has undertaken ambitious hoisirng, water supply and sewerage programs, these have been insiiffic ient to meet Ieeds, especially in rural and semi-rtirli areas.  - 9 - 29. Social stability as well as economic growth are jeopardized by high rates of population growth. Despite recent economic expansion, unemployment and underemployment persist. Tentative estimates suggest that for the country as a whole up to one-quarter of the labor force may be unemployed and a recently concluded ILO study indicates that in 1973, 20 percent of the Santo Domingo labor force was unemployed. The labor force, on the other hand, con- tinues to grow at about 3 percent annually. 30. Demographic trends in the Dominican Republic do not portend a significant decline in population growth rates. The population's age struc- ture (48 percent was under age 15 in 1970) provides a built-in momentum for continued high birth rates and improvements in health standards can be expected to result in a decline in death rates. Urgent steps are therefore required to bring about a decline in fertility rates by extending family plan- ning assistance, particularly in rural areas where 60 percent of the popula- tion lives and where family planning assistance is most deficient. Government Policies 31. The Government has encouraged several voluntary agencies to provide family planning assistance since the early 1960's. In 1968, it established the National Council for Family Planning (CONAPOFA), the official agency responsible for planning population programs, coordinating the activities of all public and private agencies in the field and organizing family planning services within the official health delivery system. Family planning receives firm and open support from the Government; several of its agencies provide advice and assistance in this field. Among these are the main agencies responsible for health services and social welfare, including the Secretariat for Public Health and Social Assistance (SESPAS), the Social Security Institute, and the Office of Community Development. The State Sugar Council, which employs a large labor force, and the armed forces also provide family planning assistance. Family Planning Programs to Date 32. Five Government organizations and one privately sponsored agency offer family planning services through clinics. Currently, CONAPOFA operates, in SESPAS facilities, 205 of the 237 clinics providing family planning assist- ance. The remaining clinics are operated by the armed forces, the State Sugar Council, the Social Security Institute, the national police, and the Dominican Association for Family Welfare, a private agency. In addition, four clinics are operated by doctors in private practice. The effectiveness of these clinics varies considerably, depending on the availability of trained staff, the caseload and staff motivation. 33. Shortly after it was created, CONAPOFA established that a reduction of birth rates from 47 per thousand to 38 per thousand should be a national target for 1973. It was estimated that, in order to achieve this goal, some 20 percent of women of fertile age would have to be reached with family plan- ning assistance and advice by 1973. The chosen objective has proved difficult to attain: birth rates were still at about 45 per thousand by 1973 and recent  - 10 - estimates indicate that only about 6.5 percent of fertile women were prac- ticing contraception in 1975, too small a proportion to have a significant impact on the fertility rate. 34. There are many obstacles to a wider use of family planning methods in the Dominican Republic. Sixty percent of the population is rural, educa- tion levels are low and marriages take place at an early age. The great majority of women of child-bearing age live in areas where family planning services are either not available or are inadequate because clinics open at inconvenient hours and/or do not have trained staff. Though an extension of family planning will require a concerted effort on many fronts to increase motivation and knowledge of techniques, the most promising strategy under present circumstances is to strengthen family planning assistance through the Government's general health services and, in particular, to offer family plan- ning advice and services to mothers of child-bearing age together with maternal and child health care. This strategy would help couples limit the number of their children while improving their nutrition and health standards. Health Services 35. To put such a strategy into effect, steps must be taken to improve the quality of health services. Much greater emphasis should be given to services in rural areas and to preventive (rather than curative) services; severe manpower constraints should be reduced by expanding the use of auxiliary medical personnel, and SESPAS' management should be reorganized and strength- ened. The Government is developing plans to carry out these improvements with the technical assistance of the Pan American Health Organization and USAID. The Project, as well as a recently initiated Health Sector Project which is being financed by USAID, will further assist in carrying out needed reforms. 36. With the assistance of the Pan American Health Organization, a program to decentralize the administration of health services was initiated in the 1960s; its objectives are to improve administration at the field level and extend services to rural areas. This system has proved successful in other countries, but decentralization through regionalization has proceeded slowly in the Dominican Republic, mainly due to insufficient delegation of responsi- bility and lack of adequately trained staff. 37. There are serious health manpower problems which directly affect the provision of family planning services. They include severe shortages of nurses and auxiliaries, over-production of doctors in relation to the absorptive capacity of the present health care system and a marked geographic maldistribution of all health personnel. The main consequences are a heavy "brain drain" of doctors that wastes educational investment, and lack of health services in rural areas. 38. The availability of trained nurses and nursing auxiliaries is essen- tial to the delivery of low cost health services and to the expansion of the family planning program. Of the 2,436 nursing staff in the health care system  - 11 - of the country only 15 percent are graduate nurses with 3 or 4 years of pro- fessional training after completing high school. The rest are nursing auxil- iaries with 9 months of training after primary school. About half of those auxiliaries were, until recently, "practical" (untrained) staff serving in rural clinics and hospitals. Only 25-30 nurses graduate annually from the two nursing schools; this is mainly due to the relatively high cost of studies and the rather poor potential which the career has offered until now. The Govern- ment, however, increased the salaries of health personnel in 1975, and has agreed to review pay scales from time to time to ensure that they provide sufficient incentive for people to enter and remain in the nursing profession and to serve in rural areas (Section 3.12 of the Draft Loan Agreement). 39. To improve the availability of health personnel, the Government has developed plans to train nursing instructors, increase the output of trained nursing personnel of all categories, establish an intermediate category of nurses (technical nurses) which could be quickly trained, provide better health facilities in rural areas in order to encourage trained personnel to serve in such areas, and require medical and nursing students to serve in rural areas as part of their training. The number of graduate nurses should be doubled by 1980 in order to fill the supervisory and administrative posi- tions required for expanded health and family planning services. The Govern- ment proposes to establish a fellowship program as part of the Project to train graduate nurses, technical nurses and auxiliaries in existing schools, and it will provide those institutions with teaching equipment and material and vehicles. Twenty tutors were already trained in pedagogical methods In a semester course, completed in November 1975, conducted as part of the pre- paration of this Project. The Government has agreed that in granting fellow- ships under the Project it will require each fellowship beneficiary to sign a contract with SESPAS to ensure that upon completion of the fellowship the beneficiary will work for SESPAS, in the location set forth in such contract, for a period of at least two years; repayment of the cost of the fellowship would be required if the contract were not fulfilled (Section 3.08 of the Draft Loan Agreement). 40. Recognizing the impracticability of requiring that all nursing personnel in supervisory positions be graduate nurses, a new level has been established by the Government: the technical nurse will be granted a diploma after completing four years of basic secondary studies and two years of nursing studies at the secondary level. This program is being carried out by the Secretariat of Education as part of the secondary education curriculum reform introduced under the IDA-financed First Education Project and extended under the Second Education Project. The first technical nurses will graduate in 1978, and it is expected that about 315 will have graduated by 1980. 41. The Government has also begun an intensive program to train auxilia- ries and to upgrade the "practical" (untrained) nurses to at least the auxiliary level. Auxiliaries will be trained to provide elementary health care, including first aid, pre-natal and pediatric check-ups, vaccinations and family planning services. Training of auxiliaries who would work in rural health clinics and health sub-centers would include IUD insertion and the detection of oral con- traceptive contra-indications. It is intended that about 1,250 such auxiliaries  - 12 - should be trained at four existing and two future Nursing Auxiliary Training Centers over the period 1975-80. To make the training target possible, the Government intends to shorten the training period for nursing auxiliaries from 9 months to 6 months, enabling training centers to provide two courses a year. 42. In order to increase the relevance of medical and nursing training to the Republic's health needs, the Government intends to reach agreement with four universities, three with medical programs and one with a school of nursing. The agreement will provide that the universities (i) assign medical and nursing students to field service in rural areas including those in Regions I and V and (ii) modify their curricula to emphasize preventive and community health services, including family planning. In addition, the agreements with the medical universities will have provisions to the effect that these would help train SESPAS' staff in community health services. The government has agreed to conclude such agreements within six months of loan effectiveness. Assur- ances were also obtained that the Government will cause the nursing school run by SESPAS to carry out a program similar to that of the university (Section 3.07 of the Draft Loan Agreement). 43. At present, SESPAS has limited capability for design of health services, resource planning and organization of programs. The Secretariat has competent staff, but it is overburdened, and the staff's capability to carry out new tasks is limited. The Government has undertaken to reorganize the Secretariat so as to permit a more efficient utilization of the available professional expertise, and to strengthen the professional staff. An impor- tant component of the Health Sector Project being financed by USAID provides technical assistance to bring about the necessary organizational improvements. The Government has agreed to take the necessary steps to reorganize and strengthen SESPAS within 12 months of loan effectiveness (Section 4.05 of the Draft Loan Agreement). Training in Family Planning 44. Little training in family planning has been provided up to the present time to personnel in the health care system and people working in agencies concerned with social affairs. CONAPOFA has recently provided limited courses for nurses and doctors, but coverage has fallen far short of requirements. In order to improve the ability of social workers and paramedical personnel to counsel and assist in family planning, the Govern- ment intends to extend such training as part of the Project. PART IV - THE PROJECT 45. Initial discussions with the Government on a possible population project were held in 1973. Preparation missions visited the Dominican Republic in mid-1974 and the Project was appraised in November 1974. The Government deferred further action until early 1976 when it requested the Bank to send a Mission to update the Project and to consider certain changes introduced by the Government. An updating mission was in the Dominican  - 13 - Republic from February 17 to 27, 1976. Negotiations were held in Washington from August 2 to 4, 1976. The Dominican delegation was headed by Mr. Carlos Rojas Badia, Secretary of Public Health and Social Assistance. Annex III of this report summarizes the proposed Loan and Project. An appraisal report (No. 752b-DO) is being circulated separately to the Executive Directors. Objectives and Strategy 46. The Project is designed to assist the Government develop a compre- hensive program, to be carried out through its health service system, aimed at reducing fertility rates while enhancing the health of the population, parti- cularly of mothers and children in rural areas. Because of the constraints imposed by the acute shortage of trained personnel, improvement in clinical facilities and services would be concentrated in two of the six Health Regions of the Republic initially (Region I in the West and V in the East), and would be extended to other Regions at a later stage as trained health personnel become available and experience is gained in the comprehensive approach to family planning and health. Regions I and V have been selected for this purpose because they are currently the most deficient in adequate health services. Furthermore, the extension of health services in those Regions would complement current Governmental regional development plans. 47. In order to prepare for an extension of family planning and pre- ventive health services throughout the health care system, the Project would help increase the number and quality of nursing personnel nationwide through training and technical assistance programs benefitting SESPAS, CONAPOFA, the universities and nursing schools. 48. The Project is consistent with the Government's overall strategy for Improving health and family planning services and with related ongoing projects in the health sector. Its main components are described below. Project Description 49. The Project would include the construction and equipping of 26 rural health clinics in Regions I and V and one health sub-center in Region V, in locations strategically selected to provide services to the rural and semi- rural population which now have only minimal access to health and family planning services. In addition, radio-communication equipment and vehicles would be financed to ensure rapid referral of emergency cases from the rural clinics to major hospitals. The Project would also finance travel and other allowances for medical and nursing supervisory staff in Regions I and V and advisory services to the two regional health directors and respective medical and nursing supervisors. These components would enable the establishment of a comprehensive health delivery system in those Regions, with due emphasis on preventive care and family planning activities. In additon, several national universities would field medical and nursing students in the rural areas including Regions I and V to render basic health services along with the regular SESPAS staff (see para. 42 above).  - 14 - 50. The Project's training and technical assistance components would emphasize programs to strengthen the national health and family planning systems. The training component would include fellowships for auxiliary, technical and graduate nurses, and for planning and programming staff of SESPAS/CONAPOFA; equipment, teaching materials and vehicles for nursing schools and for CONAPOFA; and tutors and lecturers' travel allowances and fees for courses and seminars given by SESPAS, CONAPOFA and other partici- pating agencies (see paras. 40-42 above). Technical assistance financed under the Project would include advisory services to universities, CONAPOFA and to SESPAS on health services delivery, information systems and statistics; on design, management and operation of re-oriented community health care and family planning services; on research on family planning programs; for curri- culum reform so that community health care and family planning are adequately covered at the university level; and for project preparation and implementa- tion, including travel allowances for six family planning training coordi- nators and support staff (one team for each of the six Health Regions). Operating costs for a program of community-based distribution of contraceptives in rural areas and urban slums would also be financed under the Project. Project Implementation 51. The Government has given assurances that it will acquire the right to use all sites for project construction, in locations acceptable to the Bank, within three months of loan effectiveness (Section 3.05 of the Draft Loan Agreement). Responsibility for construction of the physical facilities included in the Project and for coordinating all technical assistance and training activities will rest with a Project Implementation Unit which has been established within SESPAS. The Regional Health Directors will be res- ponsible for Project execution in their respective Regions. The Project Implementation Unit is composed of a Director, who is also the Director of the International Assistance Division of SESPAS and who reports directly to the Secretary of Health; a Deputy Director; a Training Coordinator, and an Architect. Salary support for Project Unit officers would be financed up to 50 percent by the proposed loan over a period of three years. To plan the execution of the Project and review its progress, the Secretary of Health will call a meeting at least every four months of the senior officials of SESPAS, CONAPOFA, other Government agencies dealing with social affairs and represent- atives of universities (Section 3.01 of the Draft Loan Agreement). 52. It is envisaged that family planning services would be offered within the context of a comprehensive community health care program. In Regions I and V, the Project would implement a delivery system representing a shift from the present emphasis on expensive curative services, to preven- tive, community-based health services, including family planning. To ensure the participation of social workers in the Project, the Government has given assurances that, within three months of loan effectiveness, it will cause the Office of Community Development, State Sugar Council, the Dominican Agrarian Institute, and the Department of Agricultural Extension of the Secretariat of Agriculture to assist in the implementation of the Project. The Government has also agreed to enter into an agreement with the Social Service of Dominican  - 15 - Churches, so that the Service will assist the Government in the distribution of contraceptives and in carrying out family planning education programs (Section 3.10 of the Draft Loan Agreement). 53. SESPAS would be responsible for operating the rural health clinics and the Regional Health Sub-Center. In order to ensure that health service administration in Regions I and V is improved as part of the decentralization policy which the Government has adopted, the Government has given assurances that it will consult the respective Health Directors before appointing, trans- ferring and dismissing staff, and that the Health Directors will be provided with an adequate budget and be given autonomy on day-to-day financial matters. Assurances were also given that new positions will be created to operate the new facilities in Regions I and V, and that qualified staff will be appointed to such positions (Section 3.06 of the Draft Loan Agreement). 54. To ensure that graduates of the Nursing Auxiliary Training Centers (see para. 41) and other nursing training facilities will be suitably employed, especially in rural areas, the Government has agreed that, beginning in 1977, it will create the necessary positions within SESPAS (Section 3.09 of the Draft Loan Agreement). 55. In order to assess the impact of the Project on family planning, it is essential that program evaluation be carried out continuously and systema- tically. The Government has agreed to continue to carry out an evaluation of its family planning program (Section 3.11 of the Draft Loan Agreement). Project Costs and Financing Plan 56. Total project costs are estimated at US$7.5 million, including con- tingencies of US$1.4 million (a breakdown of project costs is given in Annex III). Foreign exchange costs are estimated at US$2.4 million, or about 32 percent of total costs. The proposed loan of US$5.0 million would cover the foreign exchange costs and US$2.6 million of local costs, including $0.4 million of operating costs (50 percent of Project Unit administrative costs, travel allowances for supervisory health personnel and 80 percent of the operating expenditures of the community-based program for distribution of contraceptives). Local currency financing is justified by the country's economic situation (see para. 17). Other project costs, estimated at US$2.5 million, would be financed by the Government. 57. The proposed loan would include retroactive financing not to exceed US$83,000, to cover expenses incurred by the Government since March 1, 1976 to start project preparation and train staff. SESPAS would establish a separate Project Account which would be audited annually by independent auditors acceptable to the Bank and to which the Government would make monthly advance deposits (Sections 3.01 and 4.03 of the Draft Loan Agreement). Establish ment of the Project Account and deposit by the Government in the account of US$300,000 equivalent would be a condition of loan effectiveness (Section 5.01 of the Draft Loan Agreement).  - 16 - 58. The Project includes 92 man-months of consulting services to pro- vide technical assistance. Of this total, 68 man-months will be for senior advisors at a total cost of about US$198 thousand, or US$2,900 per man-month. Twenty-four man-months of associate advisors (who could be graduate students in a health field) are also contemplated. The total cost of these advisors is estimated at about US$40 thousand, or US$1,700 per man-month. The cost of these consultants is in line with the prevailing cost of the type of expertise required. 59. Recurrent costs related to the Project after the third year of operation, when the Government would have assumed full responsibility for salary and Project Implementation Unit operation expenses, are estimated at RD$400,000 per annum, or approximately 2 percent of SESPAS' projected recurrent expenses. These additional expenses would not adversely affect the Govern- ment's fiscal position. The Government would undertake to finance the cost of medical and nursing staff in rural health facilities in Regions I and V and the services of CONAPOFA's regional training coordinators and their staff for at least 15 years from the date of the Loan Agreement (Section 4.04 of the Draft Loan Agreement). Procurement and Disbursements 60. Contracts for over US$200,000 or equivalent for civil works and over US$80,000 for furniture and equipment for the clinics and the sub-center, special equipment (audio-visual and radio-communication equipment and teaching aids) and vehicles, would be awarded on the basis of international competitive bidding according to Bank guidelines. Contracts for civil works of less than US$200,000 but not exceeding US$400,000 in the aggregate, and for furniture and equipment, special equipment, and vehicles of less than US$80,000 but not exceeding US$200,000 in the aggregate, would be awarded on the basis of competitive bidding advertised locally and in accordance with procedures acceptable to the Bank. Contractors for civil works would be prequalified. Domestic manufacturers of furniture and equipment would be allowed a prefer- ential margin of 15 percent of the CIF cost of competing imports, or the current applicable import duty, whichever is lower. 61. Disbursements would be made on the basis of 100 percent of the cost of technical assistance, research, professional fees, and project preparation costs; 100 percent of the foreign exchange cost of imported vehicles and special equipment; 80 percent of total costs of training and seminars, the community-based distribution program, and supervision travel allowances; 60 percent of the total cost of furniture and equipment; 30 percent of the cost of civil works which represents the foreign exchange component of such works; and 50 percent of Project Administration costs during project execution. Project Justification 62. Reduced population growth will make it more feasible for the Govern- ment to achieve development goals, in particular to increase educational levels, improve health and nutrition and lower unemployment. The Project would be part of a national family planning effort aimed at reducing the  - 17 - total fertility rates, from 7.1 in 1970 to 3.4 in the year 2000, so that total population would be 8.8 million by the year 2000, instead of 12.3 mil- lion which would result if fertility remained constant. The family planning effort is expected to account for over 80 percent of the desired fertility reduction and socio-economic development would account for the remainder. The Project, through the improvements it would make to health and family planning service delivery, and creation of demand for family planning, would be expected to contribute directly to over one-fourth of the fertility reduction resulting from the family planning program. In the short run, if the assumptions about the number of family planning acceptors and contraceptive mix are fulfilled, it is estimated that, as a result of the measures introduced by the Project, the combined crude birth rate in Regions I and V could be as low as 41 per 1,000 in 1980, down from 47 per 1,000 in 1970. 63. The Project would also assist in bringing about improvements in the delivery of health services by improving the quality and increasing the number of health personnel. It is estimated that in Regions I and V the Project would make it possible to provide effective health and family planning services to about 800,000 people by 1981, compared with 115,000 that could be expected without the Project. Institutional improvements in health services, initially concentrated in Health Regions I and V, would serve as a useful model to extend such benefits to other rural areas at a later stage. Risks 64. The major risk to the success of the Project is the institutional weakness of SESPAS. A previous USAID-funded family welfare project encountered serious difficulties mainly with respect to the staffing of the physical facili- ties provided thereunder. 65. This risk should be substantially reduced as a result of the Govern- ment's decisions to strengthen SESPAS' organization and management (para. 43), increase salaries of nurses (para. 38), expand nurse training courses (para. 39-41) and require that medical and nursing students undertake field service (para. 42). 66. Recognizing that the Project constitutes a new approach to health delivery and family planning in the Dominican Republic, and that there is an acute shortage of health personnel in the Dominican Republic, the Project is concentrating, as an initial stage, in two Health Regions. As SESPAS's capabi- lities are strengthened, the Project approach will be replicated in other parts of the country. PART V - LEGAL INSTRUMENTS AND AUTHORITY 67. The Draft Loan Agreement between the Dominican Republic anld the Bank, the Report of the Committee provided for in Article T11, Section 4 (iii) of the Articles of Agreement and the text of the draft resolution approv'ing  - 18 - the proposed loan are being distributed to the Executive Directors separately. Features of the Loan Agreement of special interest are referred to in paras. 38-39, 42-43, 51-55, 57 and 59 above. A special condition of effective- ness is the establishment by the Government of the Project Account with an initial balance of US$300,000 equivalent (Draft Loan Agreement, Section 5.01). 68. I am satisfied that the proposed loan would comply with the Articles of Agreement of the Bank and with the established criteria for Third Window loans. PART VI - RECOMMENDATION 69. I recommend that the Executive Directors approve the proposed loan. Robert S. McNamara President by I.P.M. Cargill Attachments August 31, 1976  Page 3. of 5 TABLE 34k ODMINICAN REP - SOCIAL INDICATORS DATA SHEET LAND AREA (THOU KRZ)------------------------- --------------- D~~~~ODMINICAN REP REFERENCE COUNTRIES (1970) TOTAL 48.7 MOST RECENT AGRIC. 214.1 19 60 1 970 ESTIMATE NICARAGUA JAMAICA SPAIN'- GNP PER CAPITA (USS) 2 ---0.0 3,80.0 720.0 L~160.0 770.0 1560.0 POPULATION AND VITAL STATIStIZ-S POPULATION (MID-TR. MILLION) 3.0 14.1 14.7 / 1.8 1 .9 3 3. 6 POPULATION DE-NSITY PER SQUARE KR. 63.0 83.0 96.0 /t 1 '.0 170.0 67.0 PER SQ. KM. AGRICULTURAL LAND 158.0 1714.0 97.0 VITAL STATISTICS CRUDC ABIRTH RATE PER THOUSAND 149.9 147.3 45.8 149.3 38.5 21.0 CRUDE DEATH RATE -ER THOUSAND 18.7 13.4& 11.0 16.8 8.6 8.8 INFANT MORTALITY RATE 0/TIGO) 1.0 103.0 /a 1o6.0 S 4. 32.2 2 7.9 LIVE EXPECTANCY AT BIRTH 1 YRS) 1491 55.14 57.8 50.6 67.8 70.8 GROSS REPRODUCTION RATE . 3. 5 3. 5 3.3 2 .7 1. 4 POPULATION GROWTH RATE (Z3 TOTAL 3.6 /b 29 /9 2.V9/af, 2.7 /a 1.6 /a 1.1I URBAN 6.:1 5.6 6.7 6.:0 6. 2 2. 0 UR989N POPULATI1ON I(1 OF TO TAL) 00.0 4 0. 0 4 2 .0 4 5.0 37 .0 5 9. 1 AGE STRUCTURE (PERCENT) 0 10) 14 YCARS 67 .3 47T.5 ..47.0 45. 9 2 7.A8 LS TO 64 TEARS 49 .7 4 9.4 .5 0 .0 48. 5 6 2. 5 65 TCARS AND OVEN 3 .0 3. 1 3. 0 5.46 9. 7 AGE DEPENDENCY RATIO 1.0 1.0 . 1.0 1.1 0.6 ECONOMIC DEPENOE'SCY RATIO 1 .9 /c 1. 9/S. 2 .1 1 .71. FAMILY PLANNINZ ACCEPTORS (CUMULATI YE. THOU) . 36.8 . 18.9 6:9.8 USERS (Z OIF RARRIED WOMEN) . 6.5 /b EMPLOY MENT TOTAL LABOR FORCE (THOUSAND) 8020.0 1100.0 50 0.0 40 0.0/ I 119 00. 0 LAROR FORCE IN AGPICJLTURE It) 61 .0 55 .5 5 1.0 3 3. 0 2 4. N UNEMPLOTED (C OF LAROR FORCE) . 1 4. 0/d 20.0 Lc 16 .O/c 1 4.0 2. 0/ INCOME DISTRIBUTION O OF PRIVATE INCOME REC-D R1- HIONEST 5% OP HDUSOOLOS . 2 6. 3 /t 42.4 /d )UWST 20% OF WUSHMW .. 54.36 ..4.47 LODdE 20% 07 HOUSES= . 4. 34t 3. 1 LOWET 140% OF BD)SETJ . 12.4 I .81/ DISTKB3IfOR OF LAND CMIIESNIF Z OWINED AT TOP 101 OF OWNERS . 62. 7 O OWNED AT SMALLEST 10X OWNERS .. 1.8. .. HEALTH AND NUTRITION POPULATION PCR PHYSICIAN 1600.0 /, 2100.0 9V4O1. C 2060.0 2 630 .0 7 90. 0/b POPULATION PER NURSING PERSON 61 9007C 39.0 1872.0 /d 4 860.0 1720O.0/b 14 30. 0 POPULATION PER HOSPITAL AED 440.07W8 350.0 360.0 410.0 240.0 220.0 PER CAPITA 3UP'LT OF- CALORIES (0 OF REQUIREMENTS) 92.0 91.0 94.0 106.0 103.0 107.0 PROTEIN (GRAMS PER DAY) 64.0 50.0 48.0 70.0 56.0 01.0 -OF WHICH ANIMAL AND PLLS, . 2 9.0 .3 3 .0 29.0/2 40. 0 CEATA RATE C/tHOJ) AGES 1-4 17.0... 0. 9 EDUCATION AD.JUSTED ENROLLMENT RATIO PRIMARY SCHOOL 99.0 /g 107. 0/ 108 8.0 /a ooI 101.0 131.0 /c SECCNOART SCHVIOL 13.0 Z 19.O0 20.00j 18.oj7- 214.0 57.o07 TEARS OF SCMOD..ING PPOVIDEO (FIRST AND SECOND LEVEL) 12 .0 1 2. 0 1 2. 0 12.0 1 2. 0 1 3. 0 VOCATIONAL ENROLLMENT EZ OF SECONDART) 44.0 5.0 3.0 9.0 9.0 20.0 ROULT LITERACT RATE (II . 50.0 51.0 5 3.0 86.0/d 94. 0 HOUSING PERSO;NS PER ROOMo (AVERAGE) 1 .6 ... OCCUPIED DWELLINGS WITHOUT PIPED WATER (1) 9 0/ .o/ ACCESS TO ELECTRICITY 20S .... iaog (1 O7 ALL DWELLINGS) 20 .0 ... 27.0 RURAL OWELLINGS CONNECtED TO ELECTRICITY (0) 3 .0 ... CONSUMPT ION RADIO RECEIVERS (PER THOU POP) 34.0 38.0 40.0 55.0 376.3 214.0 PASSENGER CARS (PER THOU Po,) 4.0 10.0 11.0 17.0 38.0 70.0 ELECTRICItyT (KWH/YR PER CAP) 113.0 227.0 331 .0 Li 3143.0 8 25. 0 1 6 27. 0 NEWSPRINT (KG/TM PER CAP) 0 .6 1.0 0.6 1.8 4 .3 5. 8 .-- - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - SEE 4OTES AND DEFINITIONS ON RE-VERSE  0 D }tl'':: t i;2tT: ji0ii ' lliifr~~~83} a~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~: O T S X D | O E ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~~4 ~ F ez O o u r <> X %, a , s, E < E < : > * LA _ _ 1 W E - O _ ~ ~~~ O O 6 S @ < > ffi C v w M |X C C cC >, no W ; bAH 0 e O z > H ~ *IoR 3 7 f _= e * W a - - u > W-,~~~~~~~~ . . .' .g .1 M:.; .'t '  ANN EC I Page 3 of 5 pages ECONOMIC INDICATORS GROSS NATIONAL PRODUCT IN 1975 ANNUAL RATE OF GRO'rH (%, constant prices) US$ Mln. % 1960 -66 19614 -70 197CL75 GNP at Market Prices 3,704.1 100.0 14.3 3.8 Gross Domestic Investment 917.5 214.8 10.8 5.7 16.e Gross National Saving 821.L 22.2 -15.2 C.1 17.5 Current Account Balance -6C.2 -1.6 Exports of Goods, NFS 1,003.2 27.1 -4.7 5.C 12.0 Imports of Goods, NFS -1,007.0 -27.2 11.i 2.6 12.6 OUTPUT, LABOR FORCE AND PRODUCTIVITY IN 1975 Value Added Labor Force/ V. A. Per Worker US$ Mln. M3n. % us $ % Agriculture 691.0 18.2 0.66 52.8 1,017 34.5 Industry 884.7 23.3 0.18 1L.14 14,s15 i6T.8 Services 2,221.1 58.5 0.1,1 32.8 5,0117 178.14 Unallocated Total/Average 379 10