Tunisia - Health and Population Project

Document of FILE CoPY The World Bank FOR OFFICIAL USE ONLY Report No. 3204-TUN TUNISIA STAFF APPRAISAL OF A HEALTH AND POPULATION PROJECT May 6, 1981 This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  CURRENCY EQUIVALENTS US$1.00 = DO.4 D1.0O = US$2.50 D I million = $2,500,000 GOVERNMENT OF THE REPUBLIC OF TUNISIA FISCAL YEAR January 1 to December 31 ABBREVIATIONS BHC - Basic Health Care CARE - Cooperative for American Relief Everywhere CNI - National Computing Center CRFP - Center for Pedagogical Research and Training CRS - Catholic Relief Services DBHS - Director of Basic Health Services DGPH - Director General of Public Health EBU - Equipment and Building Unit (NOPH) GDP - Gross Domestic Product INE - National Institute of Child Health INNTA - National Institute of Nutrition and Food Technology MCH - Maternal and Child Health MIS - Management Information System MOE - Ministry of Equipment MOPH - Ministry of Public Health MWRA - Married Women of Reproductive Age NORAD - Norwegian Agency for International Development ONPFP - National Office of Family Planning and Population RDHs - Regional Directors of Health SIDA - Swedish International Development Authority SPD - Studies and Planning Directorate (MOPH) UTNFPA - United Nations Fund for Population Activities USAID - United States Agency for International Development WHO - World Health Organization  FOR OFFICIAL USE ONLY TUNISIA STAFF APPRAISAL REPORT HEALTH AND POPULATION PROJECT Table of Contents Page No. INTRODUCTION ......... . 1 I. HEALTH, POPULATION AND NUTRITION IN TUNISIA ........... . 2 A. Health, Population and Nutrition Conditions and Programs ...................................... 2 - Health ....................................... 2 - Population and Family Planning ............... 3 - Nutrition ...... .............................. 7 B. Financing of Health, Population and Nutrition Activities ........................................ 8 - External Assistance ..... ................. 9 - IDA Population Project ....................... 9 II. INTEGRATION OF HEALTH, POPULATION AND NUTRITION POLICIES AND SERVICES .................................. 11 A. Development Planning and Objectives ............. .. 11 B. Integration of Services ..... ...................... 12 C. MOPH Service Delivery System, Organization and Management .................. .................. 15 - Health Personnel ............ .. ............... 16 - Education and Training Programs .............. 16 - Drugs and Medications ..... ................... 18 - Need for the Project .......... .. ............. 18 III. THE PROJECT ..9.......................................... 9 A. -Project Concept and Objectives ................. ... 19 B. Summary of Project ...... .......................... 21 C. Project Description ............. .. ................ 22 - Management Improvement ........................ 23 - Strengthening of Basic Health Care Services 24 - Health, Population and Nutrition Communications ....... ........................ 26 - Training .......... ........................... 27 - Technical Assistance ...... ................... 29 IV. PROJECT COSTS, FINANCING, PROCUREMENT, DISBURSE14ENT AND AUDITS .30 A. Costs and Financing ............. 30 B. Procurement .32 C. Disbursement .33 D. Audit .34 This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  - ii - Page No. V. PROJECT ORGANIZATION AND MANAGEMENT ................... 34 A. Coordination .... .................................. 34 B. Implementation .....0......... ............................. 35 C. Programming and Budgeting .................. 37 D. Project Monitoring and Evaluation ................. 37 VI. JUSTIFICATION AND RISKS ........... .................... . 39 A. Justification ................................... o.............. 39 B. Risks ...................................... .......... ..o.. 40 VII. RECOMMENDATIONS ........................ ..... 41 ANNEXES 1. Demographic Data A. Demographic Profile: 1966-1978 44 B. Incidence of Notifiable Diseases 45 C. Infant Mortality in Hospitals by Major Cause, 1972 45 D. Age-Specific Fertility Rates, 1976 and 2000 46 E. Total Births to be Averted, 1980-1987 46 F. Family Planning Indicators 47 G. Impact of the Family Planning Program 48 2. Organization of the MOPH A. Organigram: Ministry of Health - Tunis, May 1980 49 B. Organization of Regional Services 50 3. Medical Services A. Estimates of Total and Communal Population in Areas Covered by the Project 51 B. Doctors and Hospital Beds in the Project Area (1980) 52 C. Regional Distribution of Health Facilities 1980 53 D. Effective Protection Prevalence (EPP) for Married Wonen of Reproductive Age (MWRA) Aged 15-49, in 1979 54 E. Regional and Skill Distribution of Paramedical Personnel 55 F. Estimated Number of Paramedicals Assigned Outside Hospitals in the Project Area (1980) 56 G. Graduates from Para-medical Schools 57 4. Health Financing A. Distribution of Annual Allocation, by Type of Institutions 58 B. Distribution of Health Capital Expenditure 59 C. Evolution and Functional Distribution of Recurrent Public 60 Health Expenditure  - iii - ANNEXES (cont'd) 5. Health Objectives of the Project 61 6. Manpower Requirements A. Staffing Patterns and Functions in the Integrated Health Delivery System 62 B. Classification of Services Provided Through the Integrated Health Delivery System 6 C. Additional Manpower Requirements Generated by the Project 64 7. Health, Population and Nutrition Indicators 65 8. The MIS A. Proposed MIS for Tunisian Health System 66 B. Management and Information System for Peripheral Structures 67 9. Schedule of Implementation A. Project Implementation Flow Chart 68 B. Quarterly Implementation Schedule of Project Activities 69 C. Schedule of Implementation for Civil-Works and Procurement 70 of Equipment and Vehicles 10. Schedule of Accomodation for Project Facilities 71 11. Location and Type of Health Facilities to be Constructed, Extended or Remodeled per Governorates and Districts 72 12. Cost Estimates A. Cost Estimates per Category of Expenditure 83 B. Summary of Base Cost Estimates per Type of Activity and Expenditure 92 C. Summary of Base Cost Estimates per Category of Expenditure per Year 93 D. Estimates of Physical Contingencies and Price Escalations per Category of Expenditure 94 E. Estimated Schedule of Disbursements 95 13. Organization of Project Administration 96 TABLES 1. Estimated Project Cost by Component 2. Estimated Project Cost by Category MAP IBRD 15368 This report is based on the findings of an appraisal mission which visited Tunisia in May 1980. The members of the mission were: Messrs. B. Hubert, A. Shaw, L. Vassiliou, IBRD, and Dr. P. Coudray, Dr. P. Cronin, Mr. F. Hachette, and Dr. J. Montague Consultants. This report was prepared by Mr. B. Hubert and Mr. L. Vassiliou with contributions from the other mission members.   TABLE 3A TUNISIA SOCIAL INDICATORS DATA SHEET TUNISIA REFERENCE GROUPS (WEIGHTED AVER4CZS LAND AREA (THOUSAND SQ - MOST RECENT ESTIMATE)- TOTAL 164.0 MIDDLE INCOME AGRICULTURAL 76.6 MOST RECENT NORTH AFRICA 4 MIDDLE INCOME 1960 lb 1970 /b ESTIMATE /b MIDDLE EAST LATIN AMERICA & CARIBBEAN GNP PER CAPITA (US$) .. 360.0 1120.0 818.5 1562.9 ENERGY CONSUMPTION PER CAPITA (KILOGRAMS OF COAL EUIlVACANT) 190.0 261.0 543.0 545.0 1055.9 POPULATION AND VITAL STATISTICS POPULATION, MID-YEAR (MILLIONS) 4.2 5.1 6.0 URBAN POPULATION (PERCENT OP TOTAL) 36.0 43.5 50.1 45.7 63.4 POPULALTION PROJECTIONS POPULATION IN YEAR 2000 (MILLIONS) 9.0 STATIONARY POPULATION (MILLIONS) 14.0 YEAR STATIONARY POPULATION IS REACHED 2075 POPULATION DENSITY PER SQ. KM. 26.0 31.0 37.0 40.7 28.1 PER SQ. KM. AGRICULTURAL LAND 55.0 67.0 78.0 598.6 81.7 POPULATION AGE STRUCTURE (PERCENT) 0-14 YRS. 43.3 46.2 42.6 44.0 41.4 15-64 YRS. 52.5 50.0 53.8 52.5 54.7 65 YRS. AND ABOVE 4.2 3.8 3.6 3.5 3.9 POPULATION GROWTH RATE (PERCENT) TOTAL 1.8 /c 1.9/c 2.0 2.6 2.7 URBAN .. 3.8 3.9 4.5 4.1 CRUDE BIRTH RATE (PER THOUSAND) 49.0 42.0 32.0 41.6 34.8 CRUDE DEATH RATE (PER THOUSAND) 21.0 15.0 12.0 13.7 8.9 GROSS REPRODUCTION RATE 3.1 3.4 2.2 2.9 2.5 FAMILY PLANNING ACCEPTORS, ANNUAL (THOUSANDS) .. 29.2 73.5 PSERS (PERCENT OF MARRIED WOMEN) .. 8.0 18.0 16.2 FOOD AND NUTRITION INDEX OF FOOD PRODUCTION PER CAPITA (1969-71-100) 97.0 98.0 126.0 93.5 106.9 PER CAPITA SUPPLY OF CALORIES (PERCENT OF REQUIREMENTS) 80.0 88.0 112.0 103.6 107.4 PROTEINS (GRAMS PER DAY) 50.0 57.0 73.0 69.8 65.6 OF WHICH ANIMAL AND PULSE 12.0 14.0 22.0 17.5 33.7 CHILD (AGES 1-4) MORTALITY RATE 29.0 20.0 15.0 17.5 8.4 HEALTH LIFE EXPECTANCY AT BIRTH (YEARS) 48.0 54.0 57.0 54.4 63.1 INFANT MORTALITY RATE (PER THOUSAND) 148.0/d 135.0 .. .. 66.5 ACCESS TO SAFE WATER (PERCENT OF POPULATION) TOTAL .. 49.0 70.0 62.5 65.9 URBAN .. .. .. 82.9 80.4 RURAL .. .. .. 45.1 44.0 ACCESS TO EXCRETA DISPOSAL (PERCENT OF POPULATION) TOTAL .. .. .. .. 62.3 URBAN .. .. 30.0 .. 79.4 RURAL .. .. .. .. 29.6 POPULATION PER PHYSICIAN 10000.0 5950.0 4800.0 4688.7 1849.2 POPULATION PER NURSING PERSON .. 730.0 1070.0 1751.5 1227.5 POPULATION PER HOSPITAL BED TOTAL 373.0/e 410.0 439.0 635.5 480.3 URBAN .. 280.0 RURAL .. 930.0 ADMISSIONS PER HOSPITAL BED .. 24.1 HOUSING AVERAGE SIZE OP HOUSEHOLD TOTAL .. 5.1 /f 6.0 URBAN .. 5.1 7? 5.8 RURAL .. 5.1 7? 6.1 AVERAGE NUMBER OF PERSONS PER ROOM TOTAL .. 3.2 /f URBAN .. 2.7 7 ** RURAL .. 3.6 7 .. ACCESS TO ELECTRICITY (PERCENT OF DWELLINGS) TOTAL .. 24.0 /f URBAN .. RURAL ..  Page 2 TABLE 3A TUNISIA - SOCIAL INDICATORS DATA SHEET TUNISIA REFERENCE GROUPS (WEIGHTED AVEAGES - HOST RECENT ESTIMATE)- MIDDLE INCOME MOST RECENT NDRTH AFRICA A HIDDLE INCOME 1960 /b 1970 /b ESTIMATE /b MIDDLE EAST LATIN AHERICA 6 CARIBBEAN EDUCATION ADJUSTED ENROLLMENT RATIOS PRIMARY: TOTAL 66.0 100.0 100.0 76.4 99.7 MALE 88.0 120.0 118.0 92.2 101.0 FEMALE 43.0 79.0 81.0 59.9 99.4 SECONDARY: TOTAL 12.0 23.0 22.0 33.3 34.4 MALE 19.0 33.0 28.0 41.9 33.5 FEMALE 5.0 13.0 15.0 24.2 34.7 VOCATIONAL ENROL. (2 OF SECONDARY) 24.0 12.0 17.0 9.8 38.2 PUPIL-TEACHER RATIO PRIMARY 61.0 48.0 40.0 39.2 30.5 SECONDARY 16.0 28.0 23.0 25.1 14.5 ADULT LITERACY RATE (PERCENT) 15.5 24.0/f 55.0 39.7 76.3 CONSUMPTION PASSENGER CARS PER THOUSAND POPULATION 11.0 13.0 18.3 15.3 43.0 RADIO RECEIVERS PER THOUSAND POPULATION 40.0 74.0 138.0 139.6 245.3 TV RECEIVERS PER THOUSAND POPULATION 0.1 10.0 35.0 29.0 84.2 NEWSPAPER ("DAILY GENERAL INTEREST") CIRCULATION PER THOUSAND POPULATION 19.0 16.0 33.0 22.2 63.3 CINEMA ANNUAL ATTENDANCE PER CAPITA 2.0 .. 2.3 2.8 LABOR FORCE TOTAL LABOR FORCE (THOUSANDS) 1137.9 1214.8 1533.5 FEMALE (PERCENT) 6.1 7.7 8.0 9.6 22.2 AGRICULTURE (PERCENT) 56.0 49.8 45.0 47.0 37.1 INDUSTRY (PERCENT) 17.6 21.0 24.0 23.8 23.5 PARTICIPATION RATE (PERCENT) TOTAL 27.0 23.7 23.7 26.1 31.5 MALE 50.2 44.2 44.0 47.4 48.9 FEMALE 3.3 3.6 4.0 4.7 14.0 ECONO1IC DEPENDENCY RATIO 1.4 1.8 1.8 1.9 1.4 INCOME DISTRIBUTION PERCENT OF PRIVATE INCOME RECEIVED BY HIGNEST 5 PERCENT OF HOUSEHOLDS .. .. 17.0 HIGHEST 20 PERCENT OF HOUSEHOLDS .. .. 42.0 LOWEST 20 PERCENT OF HOUSEHOLDS .. .. 6.0 LOWEST 40 PERCENT OF HOUSEHOLDS .. .. 15.0 POVERTY TARGET GROUPS ESTIMATED ABSOLUTE POVERTY INCOME LEVEL (US$ PER CAPITA) URBAN .. .. 204.0 262.5 RURAL .. .. 97.0 140.4 190.8 ESTIMATED RELATIVE POVERTY INCOME LEVEL (US$ PER CAPITA) URBAN .. .. 193.0 202.1 474.0 RURAL .. .. 193.0 122.2 332.5 ESTIMATED POPULATION BELOW ABSOLUTE POVERTY INCOME LEVEL (PERCENT) URBAN .. .. 20.0 22.1 RURAL .. .. 15.0 33.1 Not available Not applicable. NOTES /a The group averages for each indicator are population-weighted arithmetic means. Coverage of cunntriea among the indicators depends on availability of data and is not uniform. /b Unless otherwise noted, data for 1960 refer to any year between 1959 and 1961; for 1970. between 1969 and 1971; and for Most Recent Estimate, between 1974 and 1978. /c Due to emigration population growth rate is lower than rate of natural increase; /d 1960-65 average; /e 1962. /f 1966. Most recent estimate of GNP per capita is for 1979, all other data are as of April, 1980. October, 1980  Page 3 DEFINITIONS OF SOCIAL INDICATORS Notes: Although the data are drawn from nuroes genre ally jodged the most athoritative and reliable, it should also be noted that they nay net be inter- natiooally compaehbl be.auue of the lock of sendardiznd defisitions and concepte used by different coontries in collecting the data. The data are, snoe- theless, useful to describe orders of nagnitude, indicote trends, and characterio certain major differences h .etween .coanties. The reference groops ace (1) the aeCe .ca.nty group of the -ubject country and (2) a country group with so-enh-e high-er average Idc. e tha the canntry grnup of the subjecnt coutry (eacept foe "Copital Surplus Oil Eporters" group here "Middle Ico=e North Africa cad Middle East" is chases becau-e of ste.grg- soic-o-ultural affinities). Is the reference g-op data the averages are population weighted arith=etic means fee each indicator and shovn aply when et lease half of thbe o..tries In a group has data for that indicator. Sieee oh corerage of countries among the indicators depends on the evaieability of data end in nun upifera, ceution rust beexercised in relating averages of ne indicator so u-other. Theus averages are only useful in cunpar.ig the value of one indicator at a time anong the -otcry and -eference g..ups. LAND AREA (th.o.a.d sqiku.) Fopulation pcr Physician - spupltien divided by runber ot practncing phy- Ttotl - Tftal surfaone area coprisiig land area and inland stees. siioans qualified frue a adital school at onivernity level. Agrdo-l2trol - Estipate of agricultural area aced teaporarily or pe-naently Popalatfon per Narsing Per-so - Population divided by neber of practiciag fc crops, pastures, market and kitchen gardens no to lie fallow; 1977 data, mle and female graduate nrses pruetital unens, and assistant nurse.- Papplatien fer H.spital fed - total. urbn. a-nd rural - Populatiop (trtel, GIP PER CAPITA (US$) - GNP pet capit.a estiates se coroent market prices, cl- urban, and rural) divided by their renpective umuber of hospital beds ouloted by nane converni.o methed an tenld Bank Atlas (1977-79 busts); 1960, available in public and private general and specialiaed hbepital -nd re- 1970, and 1979data. habilinaciont cenrsra Hospitols are eatablidhafteea pere ttly staffed by at least sue physician. Etablishnents providing principally osatedim1 ENfRGY CONSUMPTION PER CAPITA - Anual c onsumpsieu cf cennercil energy (coal care are net included, Rfal henpitels, however, inclode heith and edical and lignite, petrole.., natural gas and hydra-, nuclear asd geothernal elec- centers sac pareaneotly staffed by a phynicias (but by a -edidal -asiata-t, reisity) in kilogeas of coal equivalent per capita; 1960, 1970, and 1978 nurse, midwife, etc.) which offer in-patioet roosedatini and penvide I data. liited range of medical facilities For statisticsl puepeses urban heapi- talm include WHO. prisnipsi ges-1a and spectalerd haspitais, and rura POPDLATION AfD VIPTA STATISTICS hospitals IaCa1 or ruralh.pitels ted medical nd aternity teeters. Total Papulation, Mid-Ybea (nillisn- ) - An of July 1; 1960, 1973 and 1978 Admissions per foshaitL fed - Total noehr of edeisnis.n ta se dianbarse- data. from hospitals divided by the nunber of beds. Urban Populatios toercene of tntal) - Ratio of urban to tot-l apoplation; different definitione of urban areus nay af fact conpPrshilty of data hOUSING among cosunries; 1960, 1970 and 917 data. Avrraae fine of fauneheld (pePsame er hss.ehold) - toal, urban, and newel- Popalotion Projections A househeld consists of a group of irdividuals sho share living quarters Peopultion in year l20i - Current pepalaidos pr-jectiose aTe ba.ed on 1980 and their main -.ls. A boarder ot ledger nay at nay net be inaluded in teal popolation by age sod sea and their mortality and fernility rates, the household for utatinticl purposes. Projection pacanotens foe mortality rates neaprise of three levels annum- Average number of persons per rm - total, arbas, and rural - Averge nu- ing lir expectancy et birth increasing with coantry's per capita lacuna her of parsons pee roan In all urban, end rural occnpied cemventiseal level, snd fermle life expeocnscy stabilieing at 77.5 years. The pata- dwellings, respectively. DSellings enclude nn-pereanest etenetore- and sneers for fertility cato tlim have three levels assuing decline in nnccupied patns. fertility accrotdig to incane imeel and past fatily plea-isg perforuosce. ccess to Electricity (vercetC of dow-li,ss) - tntal. abean and rural - lath country is thes assigned sue of the ss nine cobinations of artality tanveutlanal dwellings with electricity in living quwtarter s P- .e.etge and fertiliuy trends for prjenetin psrposes. of tstal, ub=, and rural dwellings raspectivly. Statiosary prualati-n - In a stationary populattin there in ne growth sisce the birth rate is equal en the death nate, end alto the age trtuctort re- EDUCATION mains crsennt. This is auhieved only after fertility rntes decline ta Adjusted Etnoli=ent Ratiom the repla_esest level of unit ret nepnduntion rats, ghns each genre rties Pri=aty schnol - totalr, le wed fale - Grss. totl, male and femal of gores replaces itself eactly. The stationary popul..in. si_e wan ne.olleest of all ages at the primary level as percantages of reepantira entimated en the bain of the projected charatertics of the population primary schooi-age populatias; unenally igoludee children aged 6-11 in thc year I f20, and the rate cf delise of fertility rate tn replace- ye-rs bht adjasted for differeet lengths of primary eduantien; feo met level. notei-s with univnr.nl education entailment may esteed 100 perent Year stationary population if reached - Th. ye-c when tsttienany ppoplation since sane pupils ace being at ub-ve the effiia1 schosl age. sian has hot reached. Si.cndary school -t toal, n1e and female - Cueputed an habve; .ecnddry Populatin Dety eduootinn orqoires at least four yeers of approved primary inetmsnirm; Pee us. bn - Mid-year pypulatina per squats kilceeter (1ff hectrare) of provides generaf,vccnnitnal, or teacher training festrtten f-r pspLb erotl ares stualyi of into 17 yearn of age; correspondencey cures are generally Pee s han agrioultural lard - Computed an abuve foe agniultural land excluded nly. V.oatinal enrollent n(pocent of ec.ndaryj - VPo..tinal iseftiteti.n Peulation Are ftructuCe (pec.ent) - Children (f-l4 years), waking-age (15- include technical, industrial, or other progr-es which apteate indepes- 64 yeace), end eticed (65 yearn end nver) as pecestages of rid-year popn- dently or an departments of secondary in-tit-tins. latint; 19f6, 197D, and 1918 data. Psul-ceocte- ratio - primary,sand seonedary - Intel studests eseolled in Puoulacion Grovth late (onroent) - total - Adoral grovth eaten of totas mid- primary and secowdary levels divided by maniacs of tneahers in the yee, populstions foe 195D-6D 19i0-70, end 1970-78. -creepondifg levels. Ppulatiun Grovth Raco (percent) - urb= - Annual grovth rateu of urhanb pop- Adult literacy rate (nerCent) - Literate t dults (rble te rend and grits) altions fo- 1950-60, 196f-7, and 1970-78. s a percentage nf total adult populatinn aged 15 years and o.ve Crude firth tate (oar thousand) - Annual live births per theusand of mid-year populacion; 19ff, 191f, and 1918 dana CON8UMPIOiN Crude Deathlate (net thousand) - A.n.al deaths per thousend of mid-year Passenger lets (per thnuuand Poulati-n) - Passesge ers en prite mater population; 19f6, 1917, and 1978 datac. os snaring lesn than eight persona; anclades nebalascas. heersam med icons Reproduccian Ratn -Averge sunier of danghtersas I an will bear in rilitaCy vehicles. hee tna. l reprndu-tive period if she esperiences present age-specific C en- Rldin teceivecs (per eth-and populatise) - All types af reneivere feor ed tility rates; usually fivn-yar aveages ending in 1960, 197D, and 19771. hbodasen no general public per thopeand of populaniun; esnlades unnl- Panily Planning - Acceptors, Adrsal (Idounueds) - A.nuol nI bber of acorptine cesed receivers in c-toiries ad in yearn vhan regietrati.a of radi- see f bircth-control devicss under auspices of _ational family planning program. ws in effe-t; date fae reaent yeses may not be .ospseable since mast Partly Planninn-gnatser (percent of married wanes) - Ptrcentage of macrind countries abolishrd licensing. waose of child-hearing age (15-i4 years) whi use birth-onstrol devices to TV Receivers (oo tinneand peoplation) - TV receivers for brndoaCst t all married vo=en in same age grnp. gener=l paublc per thousand populatino; ancluden anliceesed TV receivers fin osnCtrien nd in years when neglnttor at T7 nets was in effeot. F'OOD AND NUTRITION NCite~~~~~~oesape irolao (rev thnusand upulaItlan) - Sbsw the -veag tieal-1 Iudma on Ford P-oduction per Capita (19h9-llt off) - 1ndex nf par capita na=nael of Cira ( t