Sierra Leone - Health and Population Sector Support Project

Do_uen of The World Bank FOR OFFICIAL USE ONLY C t /69o~0L Report No. 5995-SL STAFF APPRAISAL REPORT SIERRA LEONE HEALTH AND POPULATION SECTOR SUPPORT PROJECT April 22, 1986 Population, Health and Nutrition Department 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 Currency Unit = Leone (Le) US$1.00 Le 5.26 !i Le 1.00 = US$ 0.19 SDR 1.00 US$1.16 GOVERNMENT OF SIERRA LEONE FISCAL YEAR July 1 - June 30 ACRONYMS AND INITIALS ACHO : Assistant Community Health Officer CHEN Council for Health Education and Nutrition CR0 : Community Health Officer CMO : Chief Medical Officer DM0 * District Medical Cfficer EPI Expanded Program for Immunization GTZ German Agency for Technical Cooperation IEC Information, Education, Communication MCH/FP Maternal and Child Health/Family Planning MODEP . Ministry of Development and Economic Planning MOH * Ministry of Health NNS * National Nutrition Survey NPC . National Population Commission PCM Protein-Calorie Malnutrition PHC : Primary Health Care PIC . Project Implementation Committee PHU : Peripheral Health Unit PMISU : Planning, Management Information and Statistics Unit PMO Principal Medical Officer PPF Project Preparation Facility PSC Project Steering Committee SECHN : State-Enrolled Community Health Nurse TBA : Traditional Birth Attendant 1 The official exchange rate in Sierra Leone has been fluctuating since it is based on a basket of currencies. The rate used in this report is US$1 = Le 6.  FOR OFFICIAL USE ONLY STAFF APPPAISAL REPORT SIERRA LEONE HEALTH AND POPULATION PROJECT Table of Contents Pare No. Credit and Project Summary .. .............. iii Basic Data ...... .......................... vi Definitions ............................... vii I. INTRODUCTION ......................................... 1 II. SECTOR ISSUES AND STRATEGY .......................... I A. Sector Status ..................1................ Population ................................ 1 Health ....... ............................. 2 Nutrition ................................. 3 B. The Health Sector .............................. 4 Health Services Organization and Performance 4 Health Expenditure and Financing ........ .. 6 Health Policy and Strategy ................ 7 C. Population Initiatives ..... .................... 8 D. External Assistance ...... ...................... 10 E. Issues and Constraints ..... .................... 10 F. The Bank Group's Role and Assistance Strategy .. 13 III. THE PROJECT . . . ......... 14 A. Project Objectives ............. .. .............. 14 B. Project Composition ............. .. ............. 14 C. Detailed Project Description ................. .. 15 Health Policy Reforms ......... .. .......... 15 Institutional Development for MOB ........ . 17 Strengthening of Basic Health Care and Family Planning Services ................. . 20 Population Activities ......... .. .......... 24 rTh documnt has a restricted distribution and may be used by recipients only in the peforumae of their oflcial dutis. It contents may not otherwi be disdaosnd without Wrld Dank autnorokn  I .L - ii - IV. PROJECT COSTS AND FINANCING .. ......... 27 A. Cost Estimate .... 27 B. Financing Plan .............28 C. Procurement ....... 30 D. Disbursements .. . . .. 31 E. Accounts and Audit ..... .. . . 32 V. PROJECT ORGANIZATION, NANAGEMENT AND IMPLEMENTATION ........ 32 A. Project Organization and Management ... 32 B. Project Implementation and Monitoring ....... 33 VI. PROJECT BENEFITS AND RISKS E ............ 35 VII. AGREEUENTS REACHED AND RECOMMENDATION .............. 35 ANNEXES Annex 1 Tables 2.1 Comparative Health and Population Related Indicators ... 39 2.2 Percentage Distribution of Communicable Diseases,1979 as 40 2.3 Main Causes of Rospitalization Among Adults, 1980 ...... 41 2.4 Distribution of Health Facilities ........6660* ...... 42 2.5 Comparison of Drug Prices Paid Locally vith World Market Generic Prices 4.... a ....* ... . 43 3.1 List of Project Preparation Studies and Dates of Completion ....................................... . . 44 3.2 List of Incremental Staff ...... 45 4.1 Detailed Project Cost Estimate (by Components and Years) 46 4.2 Financing Plan . 53 4.3 Post-Project Annual Recurrent Cost ..................... 54 4.4 Procurement Method ........ ............ ........ 55 4.5 Estimated Schedule of Disbursement ....s.....e ....... 56 5.1 Implementation Schedule of Project Activities .......... 57 5.2 List of Technical Assistance and Fellowships ...-....... 61 Annex 2 Primary Health Care Strategv in Sierra Leone ........... 63 Annex 3 Illustrative Drui Revolving Fund System ................ 67 Annex 4 Selected Documents and Dats Available in the Proiect File 75 Annex 5 Charts ...........*.*.. .......... De ........ 76 C-1 Organigram of the Ministry of Health C-2 Organigram of the Project Map .. ... .. ..................... 78 19459 Existing and Proposed PHC Areas  - iii - SIEan LEONE mATH AND POPULATION PROJEC CREDIT AND PROJECT SUIDART Borrower: Sierra Leone Beneficiaries: Ministry of Health and National Population Commission Amount: SDR 4.6 million (US$ 5.3 million equivalent) Terma: Standard Proiect Obiectives: The major objectives of the project are to: (a) support necessary adjustments in the health sector through policy reforms and strengthening of the Ministry of Health's capacity for program planning, managing, coordinating, and monitoring; (b) strengthen basic health services with emphasis on the Primary Health Care approach and inclusion of family planning in health services; and (c) help develop population policy and strengthen family planning demand-generation activities. Benefits: The project will help reorient health and population program efforts away from their current urban bias and towards improving the availability and quality of services in rural areas. By stimulating policy reforms and improving financial management including the adoption of cost-recovery and cost-containment measures, the project would enable the Government (in the long run) to finance broad-based health and population programs. It is estimated that by the end of the project period, about Le 5.1 million of the cost of service delivery would be recovered through cost recovery measures and about Le. 2.4 million would be saved through cost containment measures. The project will extend primary health care services in three presently underserved districts with a total population of about 1.2 million. Through its support for population efforts, the project will help lay the foundation for the development of a national population program and increase awareness of and access to services.  - iv - Through institution building activities in both health and population, it vill contribute to improved planning. policy implementation and coordination. Risks: As the project would be the first Bank-financed operatLn in the sector, there is a risk of delays in implementation. To minimize these risks, the project provides for additional higher-level staff at key units of the implementing agencies and for technical assis- tance in organizational development and management. In addition, a project launch workshop would be held following IDA approval of the project to fully familiarize all concerned staff with project goals and implementation requirements.  -v - A. Proiect C0st 5 _ry 1. Sectoral Adiustment in USS million ( i) Policy Reforms 0.5 (ii) Institutional Development 1.0 2. Strentthenina of Basic Health and Family Planning Services ( i) Facilities and Drug Supply 1.6 (ii) Training. Health Education, 1.0 Monitoring and Evaluation 3. Population Activities 0.4 4. Proiect PreDaration Facility 0.3 5. Base Cost 4.8 6. ContinRencies C i) Physical 0.3 Qii) Price 0.6 Total Proiect Cost 5.7 S. FinJncint Plan Local Foreizn Total IDA 1.2 4.1 5.3 Government 0.4 - 0.4 Total 1.6 4.1 5.7 C. Kutiunted Disbursements FY87 FY88 FY89 FY90 Annual 1.30 1.35 1.50 1.15 Cumulative 1.30 2.65 4.15 5.30 Rate of Return: not applicable Proiect Completion Date: June 30, 1989.  - vi - SIERRA LEONE HEALTH AND POPULATION PROJECT BASIC DATA Total Area (km2. thousands) . . .............................. 72 Total Population (mid-1983, millions) ... 3.6 GNP per capita (1983, U.S.$) ... 330 Life expectancy at birth (1983, years) .................... . 38 Crude birth rate (1983, per 1000 population) . . . 49 Crude death rate (1983, per 1000 population) . . . 27 Infant mortality rate (1983, per 1000 live births) . ..... 198 Child death rate (1983, per 1000 children of 1-4 years) .... 54 Population growth rate (1983%) ............................. 2.3 Maternal mortality rate (1983, per 100 deliveries) ......... 4.5 Population per physician (1980) ............................ 17,520 Population per nurse (1980) .................. 2,040 Daily calorie supply per capita (1981) . ............ 2,049 Daily calorie supply as Z of requirement (1982) . . 85 Working age population (1983, %) .. 55 Urban population as x of total (1983) . . 23 Source: 1985 World Development Report and World Bank Social Indicators Data Sheets (June 1985).  - vii - DEFINITIONS Adult Literacy Rate: The percentage of persons aged 15 and over who can read and write. Child Death Rate: The number of deaths of children one to four years of age per 1,000 children in that age group in a given year. Crude Birth Rate: Number of births per 1,000 population in a given year. Crude Death Rate: Number of deaths per 1,000 population in a given year. Dependency Ratio: Population 14 years or under and 65 years and over as a percentage of population aged 15 to 64 years. Incidence Rate: The number of new cases of a disease which occur in a population during a specified period of time. Usually expressed as the number of cases per 1,000 persons. Infant Mortality Rate: The number of deaths of infants under one year of age per 1,000 live births in a given year. Maternal Mortality Rate: The number of deaths to women who die due to pregnancy, childbearing complications in a given year per 1,000 live births in that year. Morbidity: The frequency of disease and illness in a population. Prevalence Rate: The total number of people affected by a disease estimated either at a specific time (point prevalence) or over a stated period (period prevalence) expressed per 1,000 population (in case of low figures, prevalence is expressed per 100,000 population). Rate of Natural Increase: The rate at whicb a population is increasing (or decreasing) in a given year due to a surplus (or deficit) of births  - viii - over deaths, expressed as a percentage of the total population. Rate of Population Growth: Rate of natural increased adjusted for (net) migration, expressed as a percentage of the total population in a given year. Total Fertility Rate: The average number of children that would be born alive to a woman (or group of women) during her lifetime if she were to pass through her child-bearing years conforming to the age-specific fertility rates of a given year.  SIERRA LEONE HEALTH AND POPUIATION PROJECT I. INTRODUCTION 1.01 With an annual per capita income of about US$ 330 (mid-1983), Sierra Leone is among the 25 poorest nations in the world. Throughout the 1970s and early 1980. the country suffered from a prolonged period of economic stagnation brought on by a combination of factors including: con- tracting output in the predominant mineral sector and a resulting decline in domestic income; unfavorable external factors such as worldwide inflation, particularly the sharp increases in oil prices; and continuing over-reliance on a narrowly-based development strategy which focused on the mineral sector (primarily diamonds) to the detriment of agriculture and other renewable resources. In consequence, by the start of the 1980s, real per capita income was nearly 20% lower than it bad been a decade earlier. Moreover, the prevailing incentive structure, which was biased towards minerals and against agriculture, has led to serious inequities in income distribution -- with the about 2.6 million Sierra Leoneaus engaged in agriculture (65Z of the population) earning far lower incomes and having much poorer access to social services than their urban counterparts. 1.02 Faced with limited prospects for longer-term growth and an increasingly constrained resource position, the Government has, with assistance from the Bank, begun to develop a structural adjustment program to help rehabilitate the economy and set it on a growth path. The program would include measures to increase control over the growth and composition of public expenditures, broaden the revenue base, promote greater efficiency in investment and improve the institutional framework for effective manage- ment. By placing major emphasis on achieving such adjustment in the health sector, the project proposed later in this report would further this national structural adjustment process. In addition, through support for health and family planning services in rural areas, the proposed project would also increase access to improved health and family planning services. II. SECTOR ISSUES AND STRATEGY A. Sector Status PoDulation 2.01 Sierra Leone's mid-1983 population was estimated at 3.6 million,1 representing an increase of about 30% over the population size of 2.7 million recorded by the 1974 census. With a crude birth rate of 49 per thousand population and a total fertility rate of about 6.5, fertility in Sierra Leone remains extremely high. While mortality has shown some decline in the past 10-15 years, Sierra Leone's current crude death rate of 27 per thousand is considerably higher than the average for Sub-Saharan Africa (18 lAll data in this section are from World Develoument Report 1985, unless specified otherwise.  - 2 - per thousand). Thus, Sierra Leone remains at a very early stage of demographic transition, and as a result, the rate of population growth (2.3Z per annum) is somewhat lower than the regional average of about 2.8x. If, as is expected, mortality were to decline rapidly in the short term to levels commensurate with those in other Sub-Saharan countries, the rate of population growth would rise substantially, particularly as declines in fertility are likely to be relatively slower. 2.02 Population projections for Sierra Leone indicate that the country's population will nearly double over the next 30 years (assuming reasonable declines in both fertility and mortality), and that total population size will grow to over 17 million before it becomes stationary. Under this scenario, and assuming constant labor force participation rates, Sierra Leone's labor force would grow from its present size of slightly over 1 million to just under 2 million by 2009. Thus, in 2009, about 60,000 jobs would have to be created to accommodate new labor entrants, versus only about 20,000 in 1984. Since future labor entrants, i.e. for the next 15 or so years, have already been born, and the bulk of them are likely to continue to be absorbed by agriculture, this situation will reduce agricul- tural land per capita. Moreover, annual food import requirements (which already more than doubled in the last decade) would increase further. Even with reasonable increase in annual food production, the food import requirement will double again by the year 2009. Thus, there is an urgent need to improve agricultural productivity and simultaneously pursue policies and programs to reduce fertility in the near-term if pressure on unemployment is to be relieved, and food imports are to be kept within reasonable bounds, in the long-term. 2.03 Fertility decline in the short-term would also have immediate beneficial implications for the economy. Currently, Sierra Leone's child- dependency ratio (the proportion of children under 15 years to working-age adults) is extremely high at about 80 per 100 adults, implying lower capacity for saving, greater pressure on limited food supplies, and the need for substantial expenditures on social services such as education and health. If fertility were to fall, however, there would be an immediate lessening of this dependency burden, freeing up additional public and private resources for more intensive investment in human resource development and for other priority investments and consumption. Health 2.04 Despite improvements in the past two decades, health and nutrition conditions in Sierra Leone remain precarious. In 1983, life expectancy at birth was approximately 38 years (well below the Sub-Saharan average of 49 years), and infant and child mortality levels were about 198 and 54 per thousand respectively. This implies that over one-quarter of all babies fail to reach their fifth birthday. While studies show that there is wide regional variation in the mortality levels in the country, Sierra Leone, as a whole, however, has one of the highest infant and child mortality levels and lowest life expectancy in the world. These indicators nonetheless  - 3 - reflect some improvement since 1965 when infant and child mortality rates were 230 and 69 per thousand respectively (Annex 1, Table 21 ). 2.05 Sierra Leone's epidemiological profile is typical of the region, with infectious and parasitic diseases and gastro-intestinal illnesses accounting for most morbidity and mortality (Annex 1, Tables 2.2 and 2.3). Over one-half of total mortality occurs among children below five years of age; the leading causes of death in this age group include new-natal tetanus, whooping cough, polio, measles, diarrheal diseases, respiratory infections, malaria, anemia and nutritional deficiencies, most of which are preventable or treatable. Maternal mortality is also high, estimated at about 4.5 deaths per thousand deliveries. These deaths are for the most part attributable to the fact that under 20% of births are institutionalized and that traditional birth attendants MTBAs), lacking training, often employ unsafe practices in handling deliveries. Moreover, high fertility means that Sierra Leonean women have frequent and closely-spaced deliveries, making them (and their infants) more susceptible to the risk of complica- tions. Other important causes of illness or death among adults include malaria, pneumonia, gastroenteritis and tuberculosis, which, like diseases affecting children, can largely be avoided or treated through simple, sow-cost primary health care (PHC) interventions (Annex 1, Table 2.3). Hence, strengthened PHC efforts, particularly improved maternal and child health (MCH) services, are an obvious priority in the Sierra Leonean context. Nutrition 2.06 The daily supply of calories per capita in Sierra Leone is only 85Z of estimated requirements, and, as a result, protein calorie malnutrition remains widesp-ead. According to the 1978 National Nutrition Survey (NNS), the nutritional status of the "vulnerable group', i.e. young children and pregnant and lactating women, is very poor and an important contributor to the high levels of maternal, infant and child morbidity and mortality. Although conducted in January-March which is the annual period of high food supplies, the NNS found that about one-quarter of all children under 5 years were chronically undernourished or stunted2 and that about 3-5% suffered from acute undernutrition3. Moreover, the prevalence of undernutrition was found to be nearly 2 1/2 times higher in the rural areas than in the largest city, Freetown, and 1 112 times higher than in urban areas in general. 2.07 With regard to micronutrients, iron-deficiency anemia is the most important, with two-thirds of pregnant women and 58' of all children (70.6% rural) found to be anemic. Malaria, worm infestations, and the common practice of not feeding supplemental foods to infants until they have 2Height for age less than 90 percent of reference median. 3Weight-for-height less than 80 percent of refences median.  - 4 - reached the age of one, together with food shortages, have contributed significantly to undernutrition. Given the worsening of economic conditions and the concomitant sharp increases in food prices and occasional scarcity of basic foodstuffs since the NNS was conducted in 1978, it is likely that Sierra Leone's nutritional situation has deteriorated in the past few years, as indicated by the anecdotal evidence of health and nutrition professionals. B. The Health Sector Health Services Organization and Performance 2.08 Organization. The Ministry of Health (MOB) is responsible for the formulation and implementation of national health policy and for the overall administration, coordination and management of the health system. It is headed by the Minister, responsible to the President, and comprises two arms: an administrative arm supervised by the Permanent Secretary, and a professional arm supervised by the Chief Medical Officer. As the attached organizational chart (Annex 5, __1) shows, the Permanent Secretary, assisted by a Deputy, is responsible for overall administration, including personnel, accounts and audit, budget preparation, supplies and logistics, public relations and health p'Lanning. The Chief Medical Officer (CMO), as principal advisor to the Government on medical and health matters, oversees all technical aspects of public health services delivery, including: hospital and basic health services; specialized programs (e.g., the expanded program for immunization (EPI) or leprosy control); and support services (e.g. medical statistics reporting, health manpower development or medical supplies procurement/distribution). The CML is assisted by the Deputy CMO, the Chief Nursing and Dental Officers, and supported by a number of professional staff with more specific functions, sucb as the Primary Health Care (PHC) Coordinator, the Maternal Child Health (NCR) Director, the EPI Director, the Chief Pharmacist and the Chief Statistician, among others. 2.09 In each of the country's three provinces (Northern, Eastern and Southern) and the Western Area, health services are directed and coordinated by Principal Medical Officers (PMOs) who report directly to the CMO. Distric,, sub-district and chiefdom-level health services are managed by District Medical Officers (DMOs). Overall, however the administrative .'ructure remains essentially centralized, with senior MOB officials in Freetown holding most decision-making and management authority. 2.10 Health services in Sierra Leone are provided by the Government (principally MOH), by many, uncoordinated noa-governmental organizations (NGOs), and by private practitioners and industry. The basic health care infrastructure consists of referral and general hospitals, and peripheral health units (PHUs). In mid-1984 there were 25 government hospitals, with a total of about 2,772 available beds; 8 church-related hospitals, with some 920 beds; and 4 industrial (mining) and 12 privately-owned hospitals, providing an additional 932 beds.  2.11 Government and private hospitals, together accounting for about two-thirds of available beds, are concentrated in urban centers, while mission and mining hospitals are generally located in rural areas. PHUs located primarily at the Chiefdom and village levels, numbered 237 in 1984. They are intended to provide crucial preventive, promotive and curative services including: MCH services, immunization and treatment of common diseases aid injuries. About 75% of PHUs are government-run, and in theory, are linked to the district hospitals for supervision, technical support and referral. The precise distribution of hospitals and PHUs by province and district is given in Annex 1, Table 2.4. 2.12 Performance. Since the mid-1970s, there has been growing recognition in Sierra Leone that any substantial improvement in national health status would require significantly-improved health conditions and services at the periphery (i.e., district level and below). Consequently, the Government, with assistance from WHO, UNICEF, and the Federal Republic of Germany has initiated pilot PHC programs focused on: strengthening service delivery at PEUs (through improved staffing, in-service training, equipping and supplies, and better supervision and referral); revitalizing eutreach efforts; and increasing community involvement through training of village health workers and TBAs, and formation of health committees at the village, chiefdom and district levels. 2.13 Initial evaluations have been conducted at the two largest PHC pilots -- in Bombali district in Northern Province and Bo and Pujehun districts in Southern Province -- which indicate that the PUC approach has resulted in better utilization of health facilities, improved coverage of deliveries, more widespread and quicker treatment of malaria and diarrheal diseases, and improved health and nutrition knowledge and practices in the communities themselves. Moreover, both programs have been largely success- ful in mobilizing incremental resources for the health system, through the introduction of user fees to support drug and medical supply costs and through community involvement in the construction and renovation of health facilities. The Bo-Pujehun project (assisted by the German Agency for Technical Cooperation) has succeeded in recovering about 78% of the cost of drugs while the Bombali project (assisted by UNICEF) recovered about 40%. This is a remarkable achievement particularly when compared to other districts where no costs are recovered. A description of these projects is available in the project file. Cost recovery measures are also being tested by small church-related health programs. A comparative analysis of these various efforts is being undertaken by the Government with Bank assistance. 2.14 Nutrition. Nutrition activities are pursued as part of MOH's PHC activities. Various NGOs are also implementing small nutrition projects. No national organization is promoting and monitoring nutrition policy and programs. Although in principle, the Council on Health Education and Nutrition (CHEN) could perform this role, its effectiveness is limited owing to lack of staff and financial support.  - 6 - 2.15 Among the priority actions recommended by the 1978 National Nutrition Survey Report are strengthening CHEN, conducting intensified nutrition education and incorporating nutrition activities into PHC. Meals for Millions (a California-based NGO) is encouraging food production, providing supplementary feeding to malnourished children, and promoting sanitation. Health Expenditure and Financing 2.16 Total private and public health expenditures in 1983/84 were estimated at Le 160 million (US$26.7 million equivalent) or about Le 44.4 (US$7.4 equivalent) per capita, and about 3% of GDP. This total figure includes actual recurrent and development expenditure of about Le 29.1 million and Le 0.9 million respectively by the NOR, and estimated health expenditures of nearly Le 3.0 million by other governmental agencies (e.g., the Ministry of Defense, the Civilian Police and the Ministry of Social Welfare) -- implying per capita public health expenditure of Le 9.2 or US$1.5 equivalent. This compares favorably with expenditures in other West African countries. Public financial resources for health are virtually all derived from general government revenues, with only nominal sums generated through user fees or pension schemes. 2.17 Over the past five years, health expenditures have averaged about 9-10% of total government expenditures, substantially lower than allocations for education (24% in 1983/84), but higher than public expenditures in most other sectors, including agriculture, social welfare, industry and defense. Health's share of total government expenditure is thus relatively large, and given sectoral expenditure ceilings set by the Ministry of Finance (in consultation with the IMF), unlikely to increase significantly in the foreseeable future. It is, therefore, critical that available resources be utilized efficiently, if adequate health system coverage is to be achieved and services effectively delivered. 2.18 Since 1978/79, current expenditures have been incred- singly dominated by personnel costs, and by 1983/84 these accounted for nearly 60% of expenditures. The gr-aatest increase occurred in the wages subcategory, reflecting unchecked -.ecruitment of daily wage workers (most of whom are underemployed) in an effort to ease employment pressures brought on by recession. In parallel, spending on salaries/training for skilled health personnel, essential drugs and supplies, supervision costs and maintenance has had to be reduccd, impeding effectivp service delivery and causing rapid deterioration of existing infrastructure. In 1983/84, the Government allocated Le. 5.1 million for drugs; an amount which covered only about one-quarter of estimated drug requirements under prevailing drug procurement practices, (Annex 1, lable 2,5). 2.19 Despite policies e:ressing the need for improved PEC services in rural areas, nearly three-quarters of the current budget has supported urban health programs (primarily hospitals), with under 20% devoted to rural health activities. As a result, per capita public bealth expenditure in the  - 7 - Western Area (comprising greater Freetown) remains nearly 5 times as high as the average for the predominantly rural Northern, Southern and East'