Niger - Health Project

DI__met of The World Bank FOR OMCIL USE ONLY Rk,t N.5937-NIR STAFF APPRAISAL REPORT NIGER HEALTH PROJECT February 26, 1986 Population, Health & Nutrition Department Thh d0cM=n ho a mblcf.d di1ntlkm may be _d by m*ens ony in the -eufwmme of 1er OdEl igleg. cs kgt my met uehuiwe be disdhd thw lWod Duk awiz.dzi.  CURRENCY EQUIVALENTS Currency Unit = CFA Franc (CFAF) US$1.00 = CFAF 385 CFAF 1 = US$.0026 CFAF 1 Million = US$2,597 WEIGHTS AND MEASURES Metric System FISCAL YEAR October 1 - September 30 GLOSSARY OF ACRONYMS EPI Expanded Program of Immunization FP Family Planning FED European Development Fund (Fonds Europeen de Developpement) MCH: Maternal and Child Health MOPHSA Ministry of Public Health and Social Affairs ONPPC National Pharmaceutical Company (Office National des Produits Pharmaceutiques et Chimiques). PMU Project Management Unit WHO World Health Organization UNFPA United Nations Fund for Population Activities UNICEF United Nations Children's Fund USAID United States Agency for International Development  FOR OFFICIAL USE ONLY STAFF APPRAISAL REPORT NIGER HEALTH PROJECT TABLE OF CONTENTS Page No. Credit and Project Summary . . . . . . . . . . . . . . . . . iii Definitions .vii I. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . 1 II. THE POPULATION, HEALTH AND NUTRITION SECTOR . . . . . . . 2 A. Population, Health and Nutrition Status . . . . . . 2 B. The Health System . . . . . . . . . . . . . . . . . 3 C. Health System Performance . . . . . . . . . . . . . 3 D. Health Expenditures . . . . . . . . . . . . . . . . 5 E. Health Policy . . . . . . . . . . . . . . . . . . . 5 F. Nutrition Policy . . . . . . . . . . . . . . . . . . 6 G. Population Policy . . . . . . . . . . . . . . . . . 6 H. External Assistance. . . . . . . . . . . . . . . 7 I. Bank's Role in the Health Sector . . . . . . . . . . 8 III. THE PROJECT . . . . . . . . . . . . . . . . . . . . . . 8 A. Project Objectives . . . . . . . . . . . . . . . . . 8 B. Project Composition . . . . . . . . . . . . . . . . 8 C. Detailed Features . . . . . . . . . . . . . . . . . 9 A. Policy Reform . . . . . . . . . . . . . . . 9 B. Basic Health and Family Planning Services . . . 12 1. Strengthening of Existing Services . . . . 12 2. Development of Health Education and Community Initiative in Health and Nutrition. . . . 16 3. Health Manpower Development . . . . . . . 17 IV. PROJECT COST AND FINANCING PLAN . . . . . . . . . . . . . 18 V. PROJECT IMPLEMENTATION . . . . . . . . . . . . . . . . . . 19 VI. PROJECT BENEFITS AND RISKS . . . . . . . . . . . . . . . . 22 VII. AGREEMENTS REACHED AND RECOMMENDATION . . . . . . . . . . 23 This report is based on the findings of an IDA mission that visited Niger in June 1985. The mission consisted of H. Sederlof (Mission Leader); D. Vaillancourt (Operations Analyst); S. Foster (Consultant Economist); R. Meloni (Consultant Public Health Specialist); A. Shaw (Consultant Health Education and Communications Specialist); and J. Waechter (Consultant Archi- tect). rThis document his a restricted distributon and may be used by recipients only in thepormane of their official duties. Its contents may not otherwise be discloed without World ank authoiation  - ii - ANNEXES Page No. 1 Basic Data . . . . . . . . . . . . . . . . . . . . . . . . . 26 2-1 Comparative Health-Related Indicators . . . . . . . . . . 27 2-2 Ranking of Reported Diseases . . . . . .. . . . . . . . . . 28 2-3 Principal Health Facilities by Department . . . . . . . . . 29 2-4 Functions and Training of Health Personnel 30 2-5 Health Staff Allocated by Major Category and Type of Facility, 1984 . . . . . . . . . . . . . . . . . . . . . 32 2-6 Organization Chart of the Ministry of Public Health and Social Affairs . . . . . . . . . . . . . . . . . . . . . . 33 2-7 Health Coverage . . . . . . . . . . . . . . . . . . . . . . . 34 2-8 Village Health Worker System . . . . . . . . . . . . . . . . 35 2-9 Health Expenditures, 1984 . . . . . . . . . . . . . . . . 36 2-10 Recurrent Budget for Health, 1984 . . . . . . . . . . 37 2-11 Two Scenarios for Personnel/Materials Composition of MOPHSA Recurrent Budget for the Period 1986-90 . . . . . . . . . . 38 2-12 Health Sector Investment Program, 1979-1988 . . . . . . . . . 39 2-13 Structural Adjustment Program: Health Sector Synthesis . . . 40 3-1 Supply of and Demand for Nurses, 1984-1990 . . . . . . . . . 42 3-2 Implementation Schedule for Policy Reform Component . 43 3-3 Sunmuary of Studies to be Financed under the Project . . . . . 44 3-4 Organization Chart for Nutrition Program . . . . . . . . . . 45 3-5 Summary of Fellowships . . . . . . . . . . . . . . . . . . 46 4-1 Project Cost Summary . . . . . . . . . . . . . . . . . . . 47 4-2 Summary Account by Project Component . . . . . . . . . . . . 48 4-3 Project Components by Year . . . . . . . . . . . . . . . . . 49 4-4 Breakdown of Summary Accounts . . . . . . . . . . . . . . . . 50 4-5 Financing Plan . . . . . . . . . . . . . . . . . . . . . . . 51 4-6 Bases for Estimating Project Costs . . . . . . . . . . . . . 52 4-7 Incremental Recurrent Cost Summary . . . . . . . . . . . . . 53 4-8 Incremental Recurrent Costs for Year 6 . . . . . . . . . . . 54 4-9 Annual Incremental Recurrent Costs and Financing at Full Project Development . . . . . . . . . . . . . . . . . . . . 58 5-1 Project Coordination Chart . . . . . . . . . . . . . . . . . 59 5-2 Summary of Technical Assistance . . . . . . . . . . . . . . . 60 5-3 Implementation Schedule for Strengthening of Basic Health and Family Planning Services . . . . . . . . . . . . . . . 61 5-4 Procurement . . . . . . . . . . . . . . . . . . . . . . . . . 62 5-5 Disbursement Plan . . . . . . . . . . . . . . . . . . . . . . 63 5-6 Estimated Schedule of Disbursements . . . . . . . . . . . . . 64 Selected Documents and Data Available in the Project File . . . . 65 MAP: IBRD 19460R  -iii- NIGER HEALTH PROJECT CREDIT AND PROJECT SUMMAURY Borrower: Republic of Niger Beneficiary: Ministry of Public Health and Social Affairs Ahount: SDR 25.1 million (US$27.8 million equivalent) Terms: Standard Project Objectives: The proposed project will assist the Government in introducing structural reform in the health sector. It will do so through studies and reform programs aimed at improvements in investment planning, the allocation of recurrent expenditures, cost recovery, the availability of essential drugs, sector management and aid coordination. It will also assist the Governrment to define policies relating to population and family planning and nutrition. Moreover, in support of the sectoral reform program, the project will improve the efficiency of priority health programs: (i) maternal and child health care including family planning, control of malaria, diarrhea and other communicable diseases, (ii) health education and community initiatives in health and nutrition, and (iii) training of health personnel. Benefits: Through its support of the Government's reform program, the project will help correct imbalances that have appeared in recent years in the allocation of resources in the health sector, ease financial constraints, increase the availability of essential drugs, reinforce planning and program execution in MOPHSA and improve donor coordination. Also, the project will strengthen priority health programs and services with particular emphasis on women and young children, the highest risk group in the population, and on rural services. It will improve the quality of health services available to about 3.4 million people. Under the expanded program of immunization, an estimated 1.2 million children under five years of age will be vaccinated against the major childhood diseases by the end of the project implementation period.  - iv - Risks: The project will be the first IDA-financed operation in the sector. There is, therefore, a risk of delays in implementation. However, the Government is strongly committed to the reform program and anxious to move ahead with project implementation. Local staff responsible for project implementation is well qualified. Moreover, with financing from two PPF advances, a number of steps have been taken to ensure expeditious project start-up, and a project implementation workshop is planned prior to credit effectiveness.  v Estimated Project Costs: Local Foreign Total USS Million A. POLICY REFORM 1. Policy Development Studies - 0.3 0.3 2. Funds for Implementing Sub-projects 1.5 1.8 3.3 Sub-Total A. 1.5 2.1 3.6 B. STRENGTHENING OF BASIC HEALTH AND FAMILY PLANNING SERVICES 1. Strengthening of Existing Services 5.3 7.9 13.1 2. Development of Health Education and Conmmunity Initiative in Health and Nutrition 0.7 0.9 1.6 3. Health Manpower Development 1.0 2.3 3.3 Sub-Total B. 7.0 11.1 18.1 C. PROJECT MANAGEMENT AND ADMINISTRATION 0.4 1.0 1.4 D. REPAYMENT OF PPF 0.3 0.7 1.0 Total BASELINE COSTS 9.2 14.9 24.1 Physical Contingencies 0.5 0.9 1.4 Price Contingencies 1.5 2.4 3.8 TOTAL PROJECT COSTS 11.2 18.2 29.3 Note: Totals may not add up due to rounding. Estimated project costs are net of taxes and duties from which the project would be exempt.  - vi - Financing Plan: Local Foreign Total US$ MillioJ IDA 9.6 18.2 27.8 Government 1.5 - 1.5 TOTAL 11.1 18.2 29.3 Estimated Disbursements: FY87 FY88 FY89 FY90 FY91 FY92 FY93 US$ Million Annual 2.5 3.9 5.0 5.8 4.8 3.6 2.2 Cumulative 2.5 6.4 11.4 17.2 22.0 25.6 27.8 Rate of Return. Not applicable Project Completion Date: December 31, 1992 Map: IBED 19460R  - 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 among children 1-4 years of age per 1,000 children in the same age group in a given year. Crude Birth Rate: The number of live births per year per 1,000 people in a given year. Crude Death Rate: The number of deaths per year per 1,000 people in a given year. Incidence Rate: The number of persons contracting a disease 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 1 year of age in a given year per 1,000 live births during the same year. Life Expectancy at Birth: Number of years a newborn child would live if subject to the mortality risks prevailing for the cross-section of population at time of birth. Maternal Mortality Rate: The number of maternal deaths per 100,000 live births in a given year attributable to pregnancy and childbearing complications. Morbidity: The frequency of disease and illness in a population. Rate of Natural Increase: Difference between crude birth and crude death rates; usually 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 wonan during her lifetime if she were to pass through her childbearing years conforming to the age-specific fertility rates of a given year; serves as an estimate of average number of children per family.  I. INTRODUCTION 1.01 Niger is one of the poorest countries in the world with only modest physical and human resources at its disposal. The environment is harsh: the population lives in persistent poverty steming from low and erratic rainfall, poor soils, underdeveloped human resources, population pressures on limited agricultural lands and sparse infrastructure, especially a severe lack of safe water. Social indicators are low even by African standards: life expectancy at birth is only 45 years, the adult literacy rate is 8%, and the primary school enrollment rate is 23X. Subsistence farming is the mainstay of the population, 85X of which live in the countryside, but uranium mining remains the main revenue-earning activity in the econoWy. For a brief period in the late 1970s, favorable climatic conditions and a worldwide uranium boom ushered in a period of strong economic growth. However, the boom cone to an abrupt end in 1980, heralding a fundamental change towards the worse in the economic prospects of the country. At the same time, climatic conditions again began to deteriorate, culminating in the drought that has afflicted the country over the past two years. A basic data sheet is at Annex 1. 1.02 Due to its severely constrained resources, Niger faces limited prospects for longer-term growth. Poor budget policies implemented during the uranium boom have left in their wake structural deficiencies in the economy such as too rapid growth of personnel expenditures and increasing imbalances between outlays for personnel and supplies. Financing constraints, exacerbated by overspending during the uranium boom, highlight the need to address the underlying structural issues of the economy including the weak resource base and distorted policies for economic activity. 1.03 In order to address the economic difficulties, the Government has, with assistance from the Bank, prepared a structural adjustment program aimed at restoring and subsequently maintaining minimr acceptable growth levels in the medium and longer term. The program will include policy reforms to increase the efficiency of existing investments, improve resource allocation and develop the resource base of the country. More specifically, it will require that increased attention be given to efficient use of the existing capital stock, strict control over the growth and composition of public expenditures, better mobilization of revenues through increased cost recovery, and an improved institutional framework for management at all levels of the economy. This applies to pro-luctive and social sectors alike. The proposed health project supports structural adjustment at the sectoral level with the dual objective of more efficient use of resources and policy reform to increase effectiveness of services. However, while adjustment policies can be expected to reduce impediments to higher and more efficient production, they will not by themselves be sufficient to achieve sustainable long-term growth. That will require a concerted development effort to reduce the country's severe real resource constraints and expand the productive base of the economy, including in particular an accelerated effort to develop the country's human resources, combined with an active program to slow population growth. Here again, the proposed project will provide support to tackle longer term issues of  - 2 - improving the human resource base through appropriate health programs and improved maternal and child health and family planning services. II. THE POPULATION HEALTH AND NUTRITION SECTOR A. Population, Health and Nutrition Status 2.01 Niger's population was estimated at 6.1 million in mid-1983. With a total fertility rate of 7.0 and a crude birth rate of 51 per thousand, fertility is the highest in West Africa. Mortality is also high: the crude death rate is estimated at 21 per thousand. The annual rate of population growth is estimated at 3.0X. As fertility is expected to decrease only slightly, to 6.4 by the year 2000 in the absence of effective population programs, Niger's population should almost double by that time. This is likely to maintain GNP per capita growth at its current negative rate while increasing the costs of human resource development and compromising attempts at food self-sufficiency. It will be increasingly difficult for Niger to absorb the entire working age population into its labor force, which will accelerate urban migration and emigration. Moreover, high fertility and closely spaced births are serious contributors to Niger's high infant and maternal mortality rates; and large family size tends to perpetuate poverty within families. 2.02 The health status of the population in Niger is among the poorest in West Africa. Life expectancy at birth is a low 45 years. Infant and child mortality rates are both high at 139 and 28 deaths per 1,000 live births, respectively, and account for 60% of all deaths in the country (Annex 2-1). Maternal mortality is also high: nearly 1,000 out of 100,000 pregnancies result in the death of the mother. Preventable and treatable diseases such as malaria, diarrheal disease, measles, meningitis, tuberculosis, pneumonia, hepatitis, poliomyelitis and tetanus, combined with inaccessibility to potable water, poor sanitation and malnutrition, are responsible for high mortality, especially of infants and children, as well as for high morbidity (Annex 2-2). Malaria, diarrheal disease and measles alone account for 60X of recorded deaths, and are particularly severe among children under five, where they are responsible for 80X of deaths. Malnutrition, especially of children and nursing mothers, is a serious problem in spite of theoretical availability of sufficient food in normal rainfall years, and has gotten worse as a result of the recent drought. A pre-drought study in Niamey department indicated that 40% of all children under five suffered from some degree of malnutrition. In the same study, over 50X of pre-school children and 60% of pregnant mothers were found to be anemic. 2.03 The reasons for poor health status are numerous: (a) the environment is difficult, providing only meager subsistence to a majority of the population; (b) coverage of health services remains low despite efforts to expand health infrastructure and a village health worker program; (c) there is little access to health education and information, and literacy is low; (d) nutrition and family planning concerns have been inadequately  addressed in public policy and through the health services; and (e) financial constraints, inadequately trained manpower, and the low absorptive capacity of the health sector limit the scope for rapid improvements. B. The Health System 2.04 Since independence in 1960, Government policy in the health sector has emphasized primary health care and preventive medicine, and precedence has been given to the delivery of basic health services to rural areas, where the great majority of the population lives. Consequently, a network of rural dispensaries and village health worker teams has evolved to form the base of the system while also serving as its first entry point. The key health providers are the nurses that staff the rural dispensaries. They are responsible for a variety of curative and preventive services, supervision and in-service training of village health teams, health and nutrition education, and recordkeeping. Where maternal and child health services are not available, the dispensary nurse also is responsible for pre- and post-natal care. Health problems that cannot be resolved at the village or dispensary level are referred to medical centers, usually located in provincial capitals, and designed to provide dispensary, maternity and maternal and child health services and limited in-patient facilities, as well as supervision of dispensaries. These centers are directed by higher- level nurses. There is also a separate network of maternities and maternal and child health care centers, located primarily in urban areas. Two national hospitals and five departmental hospitals complete the national referral system (Annex 2-3). Details on the functions and training of health personnel and their allocation within the public health system may be found in Annexes 2-4 and 2-5, respectively. Drug procurement and distribution is handled by the Office National des Produits Pharmaceutiques et Chimiques (ONPPC), a state-owned company, under the jurisdiction of the Health Ministry, that runs its own network of pharmacies and produces some drugs. An informal network of ambulatory private drug merchants complements the ONPPC network. A small private sector operates six clinics, four maternities and two pharmacies in Niamey. 2.05 The Ministry of Public Health and Social Affairs (MOPESA) is responsible for the formulation and implementation of national health policy and for overall administration, coordination and management of the country's health system. Operations are decentralized at the departmental level, where medical officers head the seven departmental directorates of health, and at the provincial level, where medical centers are located. An organization chart of MOPHSA is at Annex 2-6. C. Health System Performance 2.06 The health system has not responded adequately to the needs of the population. While hospitals tend to be reasonably well provided for in terms of staff and supplies, this has not been the case with local level facilities, which have suffered from relative neglect in recent years, when they have borne the brunt of budget cuts. As a result, buildings and technical equipment have deteriorated, drugs are scarce, facilities are insufficiently staffed, and medical services are limited. Rural dispensary nurses are only able to fulfill some of their responsibilities; lack of  -4- supplies and drugs seriously compromise their effectiveness and consequently the population's confidence in their services. Medical centers, intended to serve as referral centers for rural dispensaries, are hardly more than oversized dispensaries themselves from lack of equipment and supplies. Furthermore, easy access to these facilities is limited to those living within a 10-km radius (about half the population) (Annex 2-7). The population beyond this catchment area relies on occasional services, mainly immunization, provided by a small team of mobile units, and on traditional practitioners. Until recently, there has been an almost total lack of in-service training and technical supervision of middle- and lower-level personnel. 2.07 Drugs are expensive and scarce. ONPPC imports over 4,000 drugs, mostly in brand name form and in small quantities, and, consequently, in many instances, at unnecessarily high prices. Drugs are sold through the ONPPC network to private middlemen and cor.sumers, and to MOPHSA, which provides them free of charge in its facilities. However, the drug budget of MOPHSA has barely increased over the past five years and is no longer able to supply its facilities adequately. As a result, private expenditures on drugs at ONPPC outlets have risen sharply as patients often have to buy their own medicine in order to be treated in public facilities. 2.08 The impact on health status of the village health worker system is unclear. Village health teams were introduced in Niger as early as 1964, but it is only recently that coverage has attained some significance, reaching 46% of villages in 1984 (Annex 2-8). The teams consist of two to four villagers, including traditional birth attendants, trained in personal hygiene, the treating of wounds, the distribution of simple medicines according to specific symptoms, and referral of more serious problems to the nearest medical facility. In practice, many village health teams limit their activities to acting as village pharmacists. The system has suffered from a lack of supervision, which is essential to its success; and, recently, the displacement of whole villages due to the drought may have effectively dissolved many health teams. Moreover, unless village health teams are allowed to provide more complex services, the system is in danger of becoming redundant as information on health, hygieine and nutrition becomes more widespread. USAID, which has been providing the bulk of the funding for the system, is at present conducting a review of it. 2.09 Major health problems, particularly those affecting women and children, are addressed through special health programs whose performance falls short of desirable. Before its recent revision, the malaria control program strategy of chemoprophylaxis of women and children was neither sustainable nor cost effective given resource constraints and poor outreach capacity. Despite the financial support of various aid donors, the diarrheal disease control program suffers from a lack of proper coordination and management. Immunization coverage is low (20% at best) and until recently no design for a national program of immumization existed. Implementation of the matemnal and child health services is impeded by lack of equipment and logistical support. Family planning services are not presently provided by the MCH inetwork. 2.10 The inefficiencies in the health system highlight crit ical weaknesses in MOPHSA. While higher and middle-level staff in MOPHSA are  -5- technically competent, administrative and management skills are lacking at all levels. Moreover, MOPHSA suffers from weak planning, programming and project analysis, poor information and an ineffective system of monitoring and evaluation. Consequently, investment decisions often seem to bear little relationship to sectoral development objectives; also, manpower needs and recurrent costs have not been considered when planning investments, and investment and recurrent expenditure budgeting have not reflected MOPHSA policies. D. Health Expenditures 2.11 Recurrent public expenditures on health totalled CFAF 6.0 billion, or 7.5% of total recurrent budget outlays, in 1984 (Annex 2-9). The MOPHSA recurrent budget accounted for CFAF 4.5 billion, while the remainder, mainly for medical evacuations and training of doctors, came out of other titles of the government budget (Annex 2-10). 2.12 Personnei costs have beei. steadily increasing over the past few years, reflecting the effects of ambitious training programs for paramedical staff and of a policy of Government guaranteed employment for all graduates into the health system. To accommodate the growth in personnel expenditures, spending on supplies has been curtailed, adversely affecting the efficient delivery of services and causing rapid deterioration in existing infrastructure. Personnel costs represented 45% of MOPHSA recurrent expenditure in 1979 as compared with 52% of the 1985 budget, and would consume 64% of the projected 1990 budget if Government policy were to remain unchanged (Annex 2-11). At the same time, private expenditures for health services have been increasing, as the mainly free-of-charge public facilities have not been able to provide the necessary services. Private expenditures now total about half of public recurrent expenditures; they are mostly for drugs and services purchased from ONPPC and the private facilities. 2.13 Despite stated Government policy to the contrary, the balance of recurrent health expenditures has in recent years g:adually shifted towards urban hospitals and medical evacuations, resulting in an undesirably strong emphasis on curative, rather than preventive, health care, catering to a small urban minority. Some 50% of the budget allocation for personnel and supplies are for hospitals, 40% for provincial-level medical facilities, and only 10% for rural dispensaries. This is despite the fact that over 10 million consultations are held every year in dispensaries and provincial level facilities, compared with 350,000 hospital admissions. The investment budget has also shown a marked trend towards the urban and hospital sector, while the major "investment" in the rural sector has cnsisted of financing the operating costs of village health worker tes (Annex 2-12). A major share of health expenditures in Niger, including recurrent expenditures, is financed by external assistance (para. 2.1-). E. Health Policy 2.14 The Government remains committed to a policy of primary health care and preventive medicine, primarily aimed at rural areas. Emphasis is given to expanding coverage and improving the quality of health services, in general, and to serving the most vulnerable segments of the population, in  - 6 - particular. The maternal and child health strategy extends beyond the provision of typical MCH services to include social and economic activities such as literacy program, income generating opportunities for women, home economics instruction and other health and nutrition education activities. The Government is aware of the imbalances that have appeared in the sector over the past few years, in particular between (i) curative and preventive health care; (ii) urban and rural health services; and (iii) outlays for personnel and supplies (see paras. 2.11 - 2.13), and the need to correct them if the sector is to contribute to the country's development effort in an efficient and effective manner. Moreover, as budget resources can be expected to remain severely constrained for the foreseable future, successful adjustment in the sector will depend on the Government's ability to control growth in expenditures and to match more appropriately objectives witn cost effective use of resources in the choice, design and implementation of projects and programs. Under the structural adjustment program that the Government is implementing with the assistance of the Bank, a health sector strategy that begins to address these imbalances has been formulated and constitutes a part of the Government's Letter of Development Policy relating to the Structural Adjustment Credit that was recently approved by the Executive Directors (Annex 2-13). The strategy, which is described in paras. 3.03 to 3.09, is a first attempt to translate sector objectives into efficient and balanced programs that would be appropriately reflected in recurrent and investment expenditures, broaden the revenue base through new and improved cost recovery measures, and build up an adequate institutional capability to plan and enforce proper policies and programs and effectively monitor investments and oper-tions in the sector. Through the proposed project the Association will assist the Government in formulating and implementing specific policies. F. Nutrition Policy 2.15 While the Government acknowledges that malnutrition is a major health problem in Niger, data on the extent and distribution of nutritional deficiencies in the country have not been collected systematically, and the problem of malnutrition and its determinants is not well understood. This contributes to the absence oi any policy or national program to improve nutritional status. Some attention is being accorded, however, to nutrition education and recuperation of malnourished children; and a modest, but successful nutrition pilot project is being run in about 60 villages in 3 provinces by the Government with the help of UNICEF and WHO (para. 3.25). G. Population Policy 2.16 Although extremely high, the Niger Government has for the most part regarded its population growth rate as acceptable. Moreover, the idea of limiting family size or reducing the growth rate has been opposed by most Nigerien officials, as well as by religious authorities. Provision of family planning services for maternal and child health reasons has been allowed, but these services have never been widely available or actively promoted. However, family planning services are gradually becoming more available in Niamey, where a National Family Health Center opened in November 1984. The center, operating with assistance from UNFPA, provides limited family planning services for the population in and around Niamey,  - 7 - and conducts research and training in maternal and child health care and family planning, infertility and sterility problems, and demography. 2.17 Recently, the Government has become more concerned about population growth, as national economic and financial difficulties have deepened and self-sufficiency in food production, a top-order national priority, appears increasingly difficult to achieve in the future. Early in 1985 the Government reversed its position on the population issue and now appears to be seriously considering a policy to check population growth and reduce maternal and infant mortality. The Government is also in favor of establishing a national family planning commission; improving the collection and analysis of socio-demographic data; introducing legislation on family planning including related medical practices and family relations; and training health staff in maternal and infant health care, including family planning. USAID and UNFPA are assisting the Government in elaborating all of these aspects with a view to developing a national population policy. Under USAID financing, a number of studies are underway that will help define the parameters of such a policy. 2.18 Despite an official change of position described above, it is still uncertain if a more general appreciation of the issue has emerged. Religious opposition may remain strong. Moreover, formidable barriers remain to the rapid expansion of family planning services: access to contraceptives is limited to married women who obtain their husbands consent; and knowledge of contraceptives and particularly of their health benefits is limited. There clearly seems to be a demand, however, for these services. Traditional birth control is reputed to be widely practiced, and the response to the opening of the above-mentioned center has been lively with over 2,000 new acceptors for contraceptives between November 1984 and June 1985. The center plans to expand provision of family planning services to maternities and maternal and child health centers around Niamey over the next 12 months, and training of midwives in family planning methods is underway. H. External Assistance 2.19 In 1984, external assistance to the health sector amounted to US$4.5 million (US$0.72 per capita). Among multilateral donors, WHO provides technical support and training to MOPHSA; UNICEF programs focus on drug procurement, immunizations, nutrition and rural health; and UNFPA supports family planning activities. The main bilateral donors are: FED with a program to expand the health network; France, which provides physicians, and USAID, which finances the village health worker program and planning and management assistance (para. 3.07). A number of other donors are active, providing training, scholarships, technical assistance and equipment. Non-governmental organizations support basic health services in the countryside. External assistance is relatively uncoordinated, and more effective aid coordination will become necessary to channel external funds to priority programs and projects consistent with the sectoral adjustment effort.  I. Bank's Role in the Health Sector 2.20 The proposed project will be the first IDA-financed project in the health sector in Niger. IDA intervention in the sector is justified on several grounds. First, human resource development is key to long-term development in Niger and should be an important element of any strategy that aims at improving the country's very limited potential. A healthier population is a part of such a strategy. Second, through its structural adjustment dialogue, the Association has assisted the Government in beginning to formulate a coherent health sector strategy. The project will be the principal vehicle to assist the Government in implementing structural reform within the health sector and in developing population and nutrition policies. Third, while external funding has been relatively abundant in the sector, it is uncoordinated and leaves some priority areas and policy issues uncovered. Through the project, the Association will encourage aid coordination and investment planning, in support of an overall sector strategy, and will complement donor financing through its support of efficiency improvements in priority programs. III. THE PROJECT A. Project Objectives 3.01 The proposed project will support measures to improve overall efficiency and effectiveness in the health sector. It will help the Government implement its reform program in the sector through studies and programs aimed at improving investment planning, the allocation of recurrent expenditures, cost recovery, the availability of essential drugs, management and aid coordination. It will also assist the Government to develop policies related to population and family planning, and nutrition. In support of the reform program, the project will strengthen priority health programs and services: (i) maternal and child health care including control of malaria, communicable diseases and diarrhea, family planning and nutrition, (ii) health, hygiene and nutrition education and community initi- atives in health and nutrition, and (iii) training of health personnel. B. Project Composition 3.02 The proposed project will support: A. Policy Reform in the Health Sector through: 1. The provision of 20 months of technical assistance to undertake studies to develop health sector policy reform aimed at strengthening financial and operational management, improving basic health services, increasing cost recovery and improving availability of essential drugs and the development of population and nutrition policy, based on operational experience gained from Parts B.1 and B.2 of the project;  - 9 - 2. The funding of proposals for implementing policies emanating from the above-mentioned studies or operational experience; B. Basic Health and Family Planning Services 1. Strengthening of ExistinD Services through: Rehabilitation and re-equipment of local level facilities and technical assistance to strengthen the syste, of maintenance of facilities; and the provision of drugs, equipment, materials, technical assistance, training and funding for incremental operating costs to strengthen priority health programs, including control of malaria, diarrhea and comunicable diseases, and maternal and child health care, including family planning; 2. Development of Health Education and Community Initiative in Health and Nutrition through: The provision of equipment, materials, technical assistance, training and funding for incremental operating costs, to develop a health education program and to extend ongoing pilot community nutrition activities to an additional 3 provinces; 3. Health Manpower Development through: The provision of equipment, materials, technical assistance, fellowships, and funding for incremental operating costs to improve basic training, to support a program of regular in-service training and field supervision of paramedical staff, and to train specialists needed for certain health programs. C. Detailed Features A. Policy Reform 3.03 Under the proposed project, the Bank will assist the Government in refining and implementing its health sector strategy (para. 2.14). The project will finance studies and support reform measures related to: (i) investment and recurrent expenditures; (ii) cost recovery; (iii) avail- ability of essential drugs; and (iv) sector management, including aid coordination. The project will also support development of population and nutrition policies. 3.04 Investment and Recurrent Expenditures. Under the Government's structural adjustment program, the share of the health sector in the investment program is projected to increase substantially, from 1.7X in 1984/85 to 4% in 1987/88, reflecting the increased importance attached to  - 10 - human resource development. The composition of the investment program for the health sector has already been adjusted to better reflect sector objectives; the emphasis will be on improving coverage and quality of health care services in rural areas, and on rehabilitation, while limiting investments in physical facilities, including hospitals. Likewise, the Government has already taken decisions on and pinpointed priority areas for action with regard to the recurrent budget that will improve health sector efficiency and effectiveness. Priority will be given to staffing, equipping and maintenance of facilities in rural areas. The growth in the wage bill -ill be curtailed to ensure the availability of funds for materials and supplies. In line with the new policy of matching the training of new paramedical staff with the growth in the service network, new entries into nursing schools have been reduced in 1985/86 from an initially programmed 140 to only 20 students. This reduction in student intake will still more than cover demand for nurses through 1990 (Annex 3-1). Now, instead of a 10% annual increase in MOPHSA sector wage bill over the next five years, this reduction of student intake will cause the MOPHSA wage bill to grow at a slightly lower rate than that of MOPHSA recurrent expenditures and the share of personnel costs in the recurrent budget to stabilize at 55% thus arresting a further deterioration of the materials/supplies share of the health budget. To alleviate pressures on the recurrent budget, the project will support improvements in the current maintenance system for health facilities (para. 3.12); simple maintenance functions will be gradually transferred to beneficiaries, and the feasibility of transferring other central budget expenditures to local authorities will be examined. The system of medical evacuations abroad will be overhauled; beneficiary partic- ipation in the costs of these evacuations has already been introduced, which is expected to result in a reduction in health subsidies of about CFAF 200 million. A study will be financed under the project to examine the cost effectiveness of different alternatives for the use of the university hospital facilities. To ensure that all of these orientations do in fact materialize, the Government confirmed during negotiations that it will review annually with the Association (i) all investment expenditures made in the health sector in the previous year and those proposed for the coming three years, as part of the rolling public investment program, with particular attention being given to recurrent cost implications; and (ii) the allocation of recurrent budget and manpower resources with regard to its support of health sector strategy. Sector management studies to be financed under the project (para. 3.07) will review cost effectiveness of services and propose means to improve financial management, both of which will facilitate appropriate resource allocation. 3.05 Cost Recovery. Under the reform program, cost recovery for Government services will be gradually improved, taking into account the ability of beneficiaries to pay, the collection costs and the type of user charge most appropriate for the service provided. This will allow a continuation and expansion of R number of basic services for the majority of the population, despite increasing budgetary constraints. In recognition of the need for mobilization of additional resources for the health sector, the Government has already enforced a stricter application of the hospital fee system and is seeking ways to initiate cost recovery at the local level. The proposed project will support these Government initiatives, initially,  - 11 - by financing studies to (i) improve fee collection in national and departmental hospitals and (ii) develop appropriate cost recovery measures for basic health services. Subsequently, the project will provide the necessary funds to begin to implement cost recovery measures (para. 3.09). 3.06 Essential Drugs. In an effort to lower costs and increase availability of essential drugs (para. 2.07), the Government has drawn up an essential drugs list based on a determination of needs by level of facility. Furthermore, it h.s elaborated an essential drugs policy, which is at the early stages of implementation. The project is ready to finance any assistance needed to implement this policy, in particular to help improve the procurement process and educate drug prescribers and the population at large about essential drugs. The project will also finance a feasibility study on alternative ways to extend the drug distribution system. 3.07 Sector Management. As part of the adjustment strategy for the health sector, the analytical and managerial capabilities of the MOPHSA will be strengthened through a program of institutional development. Under the proposed project, studies will be financed which would examine ways to achieve improvements in (i) hospital management; (ii) financial management; and (iii) cost effectiveness of basic health services and operations. The staff training program to be supported under the project (para. 3.28) will place particular emphasis on developing skills in management, econamicS and statistical techniques in line with a policy which emphasizes training and upgrading of personnel in service. Efforts to improve management in MOPHSA are underway. MOPHSA has defined functions, staffing and financial require- ments for each level of facility, and has drawn up job descriptions for each level of staff. In addition, with USAID assistance, MOPHSA has undertaken a staff inventory, and it has begun a program to develop a planning, monitor- ing and evaluation capability within MOPHSA, including development of management information, financial control and human resource management systems. The Bank is collaborating closely with USAID in this endeavor: the monitoring and evaluation systems that are being introduced in the project will be integrated into the general monitoring and evaluation framework, and funding will be available under the IDA credit to support the MOPHSA/USAID management program, if necessary. Furthiermore, to ensure that the Govern- ment, the Association and all other donors coordinate their efforts around a commonly understood sectoral adjustment policy, the Government confirmed during negotiations that it will organize annual meetings of all aid agen- cies participating in the financing of health sector activities in Niger. 3.08 Development of Population and Nutrition Policies. Bank efforts to assist in the development of a population policy will be advanced through a project component, which, as a complement to USAID/UNFPA assistance (para. 2.17), is designed to satisfy unmet demand for family planning services outside of Niamey and to support family planning program development and implementation (para. 3.20). The Bank will collaborate closely with UNFPA and USAID in their efforts to assist the Government in developing a national population policy. To this effect, and in view: of the fact that the program is at its earliest development stages, funds have been set aside under the project to test and support implementation of any new ideas or initiatives in family planning service delivery which might emerge as a result of  - 12 - operational experience gained during the course of project implementation and which might lead to program refinement and policy development. A similar approach will be taken to develop a nutrition policy; pilot nutrition activities at the community level and the development of a nutrition surveillance system, both of which will be supported under the project (paras. 3.25-3.26), are expected to lead to policy dialogue and the elaboration of a national policy on nutrition. 3.09 The studies to be financed under this component will be executed over a three-year period and their recommendations will be translated into plans of action (Annex 3-2 and Annex 3-3). The project will finance 20 months of technical assistance to undertake these studies. During negotiations the Government provided assurances that it will elaborate plans of action based on study results in consultation with the Association according to a specified timetable. A sum of US$3.5 million has been earmarked under the project to begin to implement the plans of action based on the findings of these studies or on operational experience derived from the project; this assistance will focus particularly on improved cost effectiveness of basic health services, financial management, hospital management, cost recovery at the hospital and peripheral levels, essential drugs policy, drug distribution, development of population and family planning policies and activities, nutrition policy development and malaria vector control (para. 3.16). Disbursement of these funds will be conditional upon the Association's approval of the plans of action. The Association will appraise each plan of action in accordance with the following criteria: (a) its relationship to the Government's health policy and investment programs; (b) its potential impact; and (c) its financial viability and the availability of resources to support incremental operating costs. The agreement to undertake proposed activities will be in the form of a simple exchange of letters between the Association and MOPHSA. B. Basic Health and Family Planning Services 3.10 In support of the Government's health sector reform program and its policy orientation towards the development af rural services and preventive medicine, the project will improve tte efficiency, effectiveness and coverage of priority programs and services, particularly those aimed at improving maternal and child health, including family planning, and will make a particular effort to strengthen outreach of these services. It will also develop a far reaching health education program and support health- and nutrition-related community initiatives, both of which should lead to more effective utilization of health services by the population. The project will place particular emphasis on management and administration of services and programs; monitoring and evaluation systems will be introduced into all the programs financed under the project and will be integrated into the overall health management information system that is being developed with USAID assistance (para. 3.07). 1. Strengthening of Existing Services 3.11 The focus of project intervention under this component is on local level health facilities, which should provide basic primary health  - 13 - care services (control of malaria, diarrhea, and communicable diseases and maternal and child health care) and related outreach services. These represent the most cost-effective way of extending essential services to the greatest number of beneficiaries in urban and rural areas. 3.12 As the MOPHSA budget has become increasingly constrained, maintenance of health facilities has suffered, and large parts of the existing health network, especially older facilities, are in urgent need of repair and refurbishment. Facility design has, moreover, proven to be inappropriate to efficient use and maintenance of facilities. The project will finance necessary repairs and re-equipping of existing medical centers and dispensaries. A rehabilitation program has already been drawn up by the Government. Procedures for implementation of works and technical and financial controls exist that are acceptable to the Bank. To improve maintenance performance in the future, the project will provide four months of technical assistance to design efficient, low-cost maintenance, health facilities, and two months of technical assistance to strengthen the existing maintenance system. During negotiations the Government provided assurances that it will present to the Association a plan of action for the strengtheaing of the maintenance system and new designs by January 31, 1987. 3.13 The project will assist in strengthening of priority programs which address the most urgent health problems affecting women and young children, the highest risk group in the population. These programs include control of malaria, diarrhea and communicable diseases and maternal and child health care, including family planning. Furthermore, the project will foster integration of these programs into a coordinated primary health care approach to ensure the most cost effective delivery of services. Project interventions to this effect will complement USAID efforts to streamline and integrate services as a part of its management assistance to MOPHSA (para. 3.07). Project assistance to each of the programs is described below. 3.14 Malaria Control. To enhance its efforts to reduce the incidence of malaria in Niger, the Government has designed a national malaria control program with assistance from WHO which essentially is a rationalization of already ongoing activities. The program supports a policy of chemotherapy with particular focus on children, limiting chemoprophylaxis to pregnant women. Such a policy is efficient given operational, logistical and financial constraints; it will permit children to develop natural immunities and will retard evolution of chloroquine-resirtant strains of malaria. The drug requirements will be reduced, dosages will be standarized and chloroquine will be made available in sufficient quantity to all levels of health care. The program also includes treatment, surveillance of malaria incidence and patterns, drug resistance monitoring, enhanced diagnostic capacity, staff training and community education. Activities will be fully integrated into existing health structures. A program coordinator, trained in malaria control under a WHO grant, has been appointed to manage the program.  - 14 - 3.15 In support of the program, the project will provide the following: (i) an initial stock of chloroquine that will cover the estimsted needs of the population for one year; replenishment of the chloroquine stock (about CFAF 26 million annually) will be secured through revenues from its sale; (ii) laboratory equipment to improve diagnostic capacity in three selected medical centers; (iii) fellowships to train one entomologist and one sanitary engineer for program implementation; (iv) support for comunity education and staff training in malaria under the respective components (paras. 3.22 and 3.28); and (v) logistical support for supervision and monitoring of activities. As a condition of effectiveness the Government will, through the intermediary of ONPPC, establish an account in a commercial bank to operate the revolving fund for the replenishment of chloroquine as described in (i) above. During negotiations the Government provided assurances that all proceeds from the sale of chloroquine will be deposited in this fund. 3.16 The project will finance two months of technical assistance to determine the feasibility of a malaria vector control program which is being considered by the Government. While the project would be prepared to support its implementation if justified, it is expected that such a program will not be deemed feasible in the Sahelian context of Niger. 3.17 Diarrheal Disease Control. The Government has, with WHO assistance, designed a national policy to reduce mortality from diarrheal disease. The policy includes the introduction of oral rehydration techniques, training of health personnel in diarrheal disease control and systematic community education. A national committee to combat diarrheal disease has been formed - a de facto program management unit headed by the Director of Health Services - and activities have begun on a pilot basis in one department. Financing of program activities is covered by various aid donors (Belgium, Holland, USAID, WHO and UNICEF) with the important exception of program management and administration which none of the donors is willing to finance. Such a financing gap will jeopardize the efficient operations of a well conceived and essential program. The project will, therefore, support technical assistance to develop program monitoring and evaluation capability (2 months) and to assist in periodic program evaluation (5 months) and logistical support to the management unit. Program activities will be reinforced through this project's health education and training components (paras. 3.22 and 3.28). 3.18 Expanded Program of Immunmization (EPI). The Government has, with USAID and WHO assistance, designed an expanded program of immunization, which will be an integral part of the preventive emphasis of Niger's health care strategy. The program is aimed at protecting children under five against measles. pertussis, poliomyelitis, diphtheria, tetanus and tuberculosis; it is complemented by immunization of children up to 15 against yellow fever. Pregnant women will be vaccinated against tetanus. M0PHSA will adopt a three-pronged approach, endorsed by WHO, to implement the program: (a) vaccinations would be administered at fixed health facil- ities; (b) fixed facilities would provide outreach services to the population within a 15-km radiums of the facility; and (c) the population outside the 15-km radius would be served by means of mobile units. The  - 15 - mobile units will provide other outreach services, including the promotion of village-level health and nutrition activities. Project assistance to the program will provide MOPHSA with its first opportunity to implement the program on a nationwide basis. It was agreed during negotiations that program progress will be closely monitored. The Government will prepare and submit to the Association, by September 1 of each year, an evaluation of the previous year's campaign, including coverage achieved, and a proposed target coverage for the following year based on that evaluation. IDA agreement to the annual target coverage proposal would be a condition of disbursement of funds to purchase vaccines that year. The project will provide vaccines, cold chain and other technical equipment, storage facilities, vehicles, materials, staff training, and will also finance incremental operating costs. Furthermore, the project will finance 6 months of technical assistance for program monitoring and evaluation and a morbidity and mortality study of EPI target diseases to provide initial base data. 3.19 Maternal and Child Health (NCR) Services. The approach to maternal and child health services in Niger incorporates the social as well as physical well-being of women, transcending typical health services to include literacy programs and income generation opportunities (sewing classes and facilities) for women, home economics instruction and other health and nutrition education activities. This approach is both innovative and potentially very effective and it will be actively supported and developed under the project. Specifically, the project will provide small vehicles and motorbicycles and finance operating expenses for village consultations and home visits. Baby scales will be provided to all MCH facilities and sewing machines and accessories will be purchased for all MCH centers. MCH activities will be reinforced through the project's health education (which will target women's groups, literacy programs and MCH centers), community initiative and training components, all of which place particular emphasis on this target group. 3.20 Family Planning (FP). The project will support the introduction and integration of family planning activities into the broader context of NCH services, as described above. It will expand the provision of family planning services beyond Niamey to maternities and MCH centers nationwide. All 7 departments will be provided with gynecological equipment and contraceptives; specialized training will be provided for 3 gynecologists, 3 pediatricism and 5 family health/FP specialists who will be responsible for program development, training other staff and providing a referral capability for FP and other MCH complications. FP education will be provided for under the project's health education component (para. 3.22). Nine months of technical assistance will be financed for a study on current acceptance of family planning in 3 departments to refine program development. These efforts will complement UNFPA/USAID interventions which are focused primarily on research, training, the provision of services in and around Niamey and palicy development (para. 2.17). It is expected that operational experience gained from program implementation will lead to further program development and refinement, and will enhance policy dialogue. In this respect, close collaboration will be maintained with UNFPA and USAID in their efforts to assist the Government in defining a  - 16 - national population policy. Furthermore, the project is ready to finance, through its special fund (para. 3.09), any initiative in support of program and policy development. 3.21 Primary responsibility for execution of the MCH/FP component will be shared between the MOPHSA Directorate of Maternal and Child Health and Social Affairs and the National Center for Family Health. Adequate mechanisms for coordination already exist and their history of cooperation has been excellent to date. 2. Development of Health Education and Community Initiative in Health and Nutrition 3.22 Health Education. Currently very little is being done in the field of health education in Niger even though this is considered to be a priority area by MOPHSA. To improve the situation, the project will assist MOPHSA in developing a well structured health education program in support of the Government's primary health care strategy. The program will emphasize central themes - malaria control, diarrheal disease and immunnization programs, maternal and child health care and family planning, nutrition and personal hygiene. It is designed to make full use of the very extensive radio and television network in Niger, which reaches even remote villages, of existing health facilities, and of community and youth groups. Films, radio and television programs and slide shows on basic health, nutrition and family planning themes will be produced, and posters and literature on health will be prepared. The materials will be introduced in functional literacy programs, primary and secondary schools and the paramedical schools, where health education skills will be incorporated into the curricula; the departmental directorates of health will receive materials for use in health facilities, by mobile units, and by local and village-level organizations for integration into their regular activities. Schools and directorates will be provided with technical equipment, and staff will be trained in their use. To ensure the effectiveness and appropriateness of the various productions, field research and tests will be undertaken prior to preparation and dissemination of materials- and systematic feedback from the field will help improve focus of the health education messages on specific target groups. 3.23 The Health Education Division in the Directorate of Training, Health Education and Nutrition will be in charge of the component. Previously a unit, it has recently been upgraded to divisional status, and its staffing is being strengthened. A qualified division chief will be appointed, and four new staff will be brought in, three with training in public health, and one technician, to be trained in audio-visual equipment maintenance and repair under the project. Health education officers, trained in communications, will be appointed to each of the seven depart- mental directorates of health to promote the use of health education materials. 3.24 The Health Education Division will receive technical support in the preparation of education materials from other government agencies, notably the Ministry of Information, which is well qualified to prepare audio-visual material. The total cost of production of health education materials, including equipment investment, estimated at $0.5 million, will  - 17 - be borne by the project, as will be incremental operating costs. The project will, moreover, provide one month of technical assistance to help finalize a work program for the division and develop working methods; six months for a social scientist for field studies; and four months per year of the services of a media specialist over the life of the project. The project will also finance overseas training and study tours for division staff and for the health education officers. 3.25 Community Initiative and Nutrition Policy Development. In its effort to assist the Government to develop a national nutrition policy and to develop comunity responsibility for its own health, the project will support (i) the extension, to an additional 3 geographically dispersed provinces (about 60 villages), of an ongoing Niger/WHO/UNICEF pilot project for village-level nutrition improvement; and (ii) the development of a nutrition surveillance system. The Niger/WHO/UNICEF project, which has been in operation for about one year, has proven to be a successful means of eliciting villagers' (particularly women's) interest and participation in their own wellbeing. Under the project's scheme interested villagers receive financial and technical support to undertake self help activities such as small-scale food production, storage and marketing, water supply and sanitation, and health and nutrition education. Interested villages are encouraged to choose one or two activities initially, but have the option to undertake additional ones later. This component will have close links with the health education component as it will allow villagers the opportunity to put health and nutrition messages and heightened awareness into practice. It is expected that the combined effects of these two components could lead to more effective utilization of health services. 3.26 The project will finance the salaries of 6 trained staff to be based at the provincial level (2 per province), who will function as resource people and initiate contact with villages. It will also provide supplemental equipment and logistical support to provincial level technical services which will provide villages with the technical support they need to execute activities. The project will finance equipment and materials for village projects, but the villages will be financially responsible for maintenance and other operating costs once initiatives are in operation. The project will also finance 3 months of technical assistance to help MOPESA integrate the development of a nutrition surveillance system into the health information system being developed with USAID assistance (para. 3.07). During negotiations the Government provided assurances that it will present to the Association for its approval a nutrition surveillance system by March 31, 1987, and begin its implementation according to an agreed timetable. 3.27 Day-to-day management and supervision of this component at the central level will be the responsibility of the program coordinator, already in place for the ongoing program. An interministerial coordination committee ensures cooperation of technical services. Annex 3-4 provides details of the administrative arrangements. 3. Health Manpower Development 3.28 Although adequately trained health personnel is essential to the effective delivery of basic health care services, training programs in Niger  - 18 - have not kept pace with evolving priorities in the health sector, and in-service training and supervision of MOPHSA staff have been practically non-existent. Recently, however, the Government has begun to address these deficiencies. Curricula in paramedical schools have been revised to address current priorities and needs. The In-Service Training Division has been strengthened and in-service training programs have been drawn up. These training programs will take place at departmental levels and be carried out by departmental training teams. The project will permit the Government to begin implementation of its in-service training programs. It will provide 4 months of technical assistance to support implementation and program evaluation. It will support the training of trainers in order to set up the departmental training teams, and will provide training materials, logistical support and operating costs to enable the teams to carry out the programs. In-service training sessions would for the most part be bi-annual and would include all levels of staff. Training programs emphasize public health management, administration of basic care and maternal and child health care, including nutrition, family planning and health education, malaria control, immunization and oral rehydration therapy. By the end of the five-year project life, all MOPHSA paramedical staff will have had at least two in-service training cycles. The In-Service Training Division will prepare a detailed in-service training program annually. 3.29 An essential complement to a good in-service training program is a program of regular supervision that provides technical support and guidance to field staff. The Government is well aware of the deficiencies in past field supervision, and considers the departmental training teams well placed to provide such technical support. During negotiations the Government agreed to submit a program for supervising field staff by the end of December 1986. Such a program could be eligible for financing under the project's special fund for implementing sub-projects (para. 3.09). 3.30 The project will finance a number of fellowships for advanced specialized training in skills directly related to implementation of the various programs under the project. They are detailed in AnDex 3-5. During negotiations, the Government agreed to submit annual training plans and study tour and fellowship proposals for review and approval by the Association no later than July 31 of each year. IV. PROJECT COST AND FINANCING PLAN 4.01 The total cost of the project is estimated at US$29.3 million equivalent, net of taxes and duties, with a foreign exchange component of US$18.5 million, or 62% of total project cost. The project will be financed by IDA (US$27.8 million, or 95' of total project cost) and the Government (US$1.5 million, representing about 40X of incremental salaries and operatings costs including those associated with project management). The cost estimates and the financing plan are summarized in the Credit and Project Summary. The detailed project costs are given in Annexes 4-1 through 4-4. the financing plan in Annex 4-5, and the bases for estimating project costs in Annex 4-6.  - 19 - 4.02 When fully developed, the project will require annual incremental budgetary outlays on the order of CFAF 484 million (US$ 1.3 million) in constant 1985 prices. A detailed breakdown of these incremental recurrent costs are presented in Annexes 4-7 and 4-8 and their financing in Annex 4-9. This amount represents an increment of 10.1% over the 1985 recurrent health budget. To date many vaccines have been financed by the donor community on a grant basis and it is assumed that this will continue to be the case, which will reduce domestic funding requireunts by CFAF 129 million. The gross balance of project incremental recurrent costs to be borne by the Government will therefore amount to to CFAF 355 million (US$923,000), or 7.4X of the 1985 health recurrent budget. Improvements in cost recovery from hospitals and local facilities are estimated to generate approximately CFAF 200 million and CFAF 100 million, respectively. This combined with cost recovery of chloroquine estimated at CFAF 26 million annually (para. 3.15) and savings of CFAF 200 million to be achieved through overhaul of medical evacuations (para. 3.04), will amount to CFAF 526 million in additional budgetary resources per year, far exceeding project incremental recurrent costs and resulting in a net savings in Government recurrent expenditures. The health project may therefore result in substantial net savings in recurrent expenditures for the Government. V. PROJECT IMPLEMENTATION 5.01 Preparation. Two advances under the Project Preparation Facility, totalling US$1.0 million, have been approved by IDA in August 1983 and February 1986, respectively, to finance the salaries and operating costs of a project preparation team; renovation and equipment of an office to house the preparation team, and eventually, a project management unit; technical assistance to complete preparation of the various project components; study tours, training, fellowships and seminars for national staff directly related to project implementation; and the financing of start-up activities. 5.02 The recruitment of local staff needed to strengthen MOPHSA services is underway. A rehabilitation program for health facilities has been prepared by the Government. Terms of reference for the policy reform studies to be financed under the project were agreed upon at negotiations. 5.03 Management. The Ministry of Plan will be responsible for implementation of the policy reform component in collaboration with MOPHSA. MOPHSA will implement the basic health and family planning services component with assistance from the Ministries of Education and Public Works and others, as appropriate (Annex 5-1). Adequate procedures for collaboration between these ministries exist. 5.04 The basic health and family planning services component will be integrated into existing services of the MOPHSA. These services will be appropriately strengthened with local staff and technical assistance as described in Chapter III. Particular attention will be paid to minimizing the need for incremental staff. The capabilities of health facilities to execute the programs financed under the project will be strengthened through: (i) streamlining and functional integration of programs into a cost effective basic health care approach; (ii) appropriate training; and  - 20 - (iii) the study and subsequent implementation of policies to improve mnagement and cost effectiveness of services. Furthermore, the combined effects of USArD planning and management assistance and project support of monitoring and evaluation of programs should reinforce implementation capability. 5.05 A Project Management Unit (PMU) will be attached to the Office of the Minister of Public Health and Social Affairs. It will be responsible for overall coordination of project activities, assistance in the preparation of annual work programs and budgets, procurement of goods, processing of credit withdrawal applications and consolidation of project progress reports. The PMU will consist of a director, an administrator and an accountant, as well as support staff. It will be assisted by a full-time, internationally recruited specialist in project management and implementation, and 8 months of short-term technical assistance to set up a project accounting system, audit project accounts and assist in procurement. The project organization scheme is set out in Annex 5-1. The establishment and adequate staffing of the PMU and the setting up of a project accounting system is a condition of effectiveness. 5.06 The project will provide a total of 146 months of technical assistance, which would be recruited in accordance with IDA guidelines. Arrangements to ensure proper recruitment and management of technical assistance, through the employment of the services of a consulting firm, were agreed on during negotiations. The technical assistance is summarized in Annex 5-2. 5.07 The project is expected to be implemented over a period of five and one half years (Annex 5-3). Project copletion is estimated for December 31, 1992, however, in accordance with a seven-year disbursement profile (para. 5.10). 5.08 Procurement. Because of their relatively small size and wide dispersion in remote areas, civil works contracts, all of which would be for renovation of local health facilities, would be awarded following local competitive bidding (LCB) according to procedures acceptable to the Association. However, for individual civil works contracts valued under CFAF 5 million (about US$13,000 equivalent), prudent local shopping procedures acceptable to the Association would be applied. The aggregate amount of the above exceptions is not expected to exceed US$0.6 million equivalent. Contracts for furniture, equipment, vehicles, materials, drugs and vaccines would be awarded after international competitive bidding (ICB) according to procedures acceptable to the Association. Exceptions to ICB would be for (i) contracts with a value of less than US$75,000 equivalent, each of which would be awarded after LCB according to procedures acceptable to the Association; and (ii) small value items costing less than US$10,000 equivalent per contract that would follow prudent local shopping procedures acceptable to the Association. The aggregate amounts of these two exceptions is not expected to exceed the equivalent of US$700,000 and US$200,000, respectively. Purchases of medical equipment, vaccines and drugs would be made following UNICEF's international procurement procedures, in the event that they expedite procurement and limit costs. They are acceptable to the Association. The items would, otherwise, be procured through ICB, except where there is only one existing supplier. A list of  - 21 - items to be procured through UNICEF would be determined and agreed upon during project implementation. Procurement arrangements are sumnarized in Annex 5-4. 5.09 Items would be grouped to the extent practicable to encourage competitive bidding and to per-it bulk procurement. Review of tender documents by the Association prior to award would not be required for contracts for civil works as tne cost of individual contracts is not expected to exceed US$150,000 equivalent. However, such review would be required for contracts for furniture, equipment, vehicles, materials, drugs and vaccines costing more than US$50,000 equivalent each. This is expected to result in coverage of about 70S of goods contracts. Where ICB procedures are used, domestic manufacturers would be allowed a margin of preference of 15X or the existing applicable rates of duties, whichever is lower, over the c.i.f. prices of competing foreign suppliers. 5.10 Disbursements. The credit of US$ 27.8 million equivalent will be disbursed over seven years against the following items net of taxes: (a) civil works (US$2,400,000): 100l of total cost; (b) furniture, equipment, vehicles, materials, and drugs (US$6,000,000): l00X of total cost; (c) vaccines (US$4,400,000): l00X of total cost; (d) technical assistance, studies, fellowships, training (US$6,900,000): l00X of total cost; (e) funds for implementing results of studies and innovative activities (US$3,500,000): l00X of total cost; (f) operating costs (US$2,000,000): 90% initially, declining to 30% toward the end of the project; (g) refunding of the project preparation advance (US$1,000,000); and (h) unallocated (US$1,600,000). A disbursement plan and an estimated schedule of disbursements, the latter based on the West Africa regional profile for 35 education projects of February 1984, are at Annexes 5-5 and 5-6, respectively. 5.11 Reimbursement applications to IDA will be grouped into packages of at least US$20,000 equivalent and will be fully documented, except for expenses related to project administration and miscellaneous operating costs, training and contracts of less tuan US$10,000 equivalent. These expenses would be reimbursed against certified statements of expenditures, for which documentation would be retained for review by IDA supervision missions and the project auditors. 5.12 Special Accounts. To facilitate the pre-financing of expenditures by the Government, an amount of US$1.0 million will be advanced from the IDA credit and deposited in a Special Account held in a local bank under the  - 22 - control of the Project Director. The Special Account would cover about three months of estimated project expenditures. In order to ensure that the Government's counterpart financing is promptly available, the Government will establish a separate replenishable Local Advance Account, and will deposit, in local currency, an initial amount of CFAF 30 million (US$78,000 equivalent) representing the approximate amount of Government counterp,art financing for 3 months *f project activities. Opening of this account and depositing the initial amount of CFAF 30 million is a condition of credit effectiveness. 5.13 Accounting. Auditing and Reporting. The PMU will maintain all project accounts, which will be audited annually by auditors acceptable to the Association. Certified copies of the accounts and the auditors report will be forwarded to the Association for review within six months after the end of each fiscal year. Quarterly reports on the progress of implementa- tion will be submitted to IDA by the Project Management Unit. A project completion report will be submitted to IDA within six months of the closing date. VI. PROJECT BENEFITS AND RISKS 6.01 Benefits. Through its support for the Government's health sector reform program, the project will help correct imbalances that have appeared in the allocation of resources in the health sector in recent years. Investment and budgetary resources will be directed increasingly towards the rural population and for basic health care; financial constraints will be eased as public funds devoted to medical evacuations abroad are reduced and as efficient administrative mechanisms for recovering part of the cost of curative services are developed; a national essential drugs policy will improve the availability of drugs and reduce their costs to the state and the individual consumer. Project support for the institution building effort in MOPHSA will provide a permanent capability for better planning, policy implementation and donor coordination. 6.02 In support of the reform program, the project will strengthnu key maternal and child health programs, complemented by health education, the development of community initiatives and the upgrading of personnel skills, all of which will contribute to improving the health status of the most vulnerable segments of the population. Support for family planning activities will expand services in urban areas and extend them to rural areas and facilitate policy development. Project support of pilot nutrition activities and nutrition surveillance development should lead to elaboration of a national nutrition policy. 6.03 The project will improve the quality of health services available to about 3.4 million people (over half the total population of Niger). Of these, about 1.5 million will benefit directly from services provided by rural dispensaries within walking distance (up to 5 km) of their neighborhoods. The remainder will benefit from basic health care, including immunization, targeted beyond the immediate catchment area of dispensaries by means of outreach services. Under the immunization program, an estimated 1.2 million children under the age of 5 will be vaccinated against major  - 23 - childhood diseases, representing 75X of all children within this age group. This coverage will be maintained with an annual vaccination of about 300,000 children representing 75S of the new 0-1 year-old cohorts. 6.04 Risks. The project will be the first IDA-financed operation in the sector in Niger. There is therefore a prima facie risk of delays in implementation. However, the Government is strongly committed to the project and anxious to move ahead with implementation. Local staff responsible for project implementation is of high quality. Moreover, much has already been done under two PPF advances to ensure expenditious project start-up. To lend further support, a project implementationi workshop is planned prior to effectiveness, and during the first year of implementation an intensive supervision effort is anticipated. VII. AGREEMENTS REACHED AND RECOMMENDATION 7.01 During negotiations, the Government provided assurances that: (a) by the dates indicated, it will present to the Association detailed plans of action based on the following studies to be financed under the project (para. 3.09, Annexes 3-2 and 3-3) (i) hospital fee system (August 31, 1986) (para. 3.05); (ii) cost effectiveness of proposals to use the aniversity hospital facilities (September 30, 1986) (para. 3.04); (iii) cost effectiveness of basic health services and operations (May 31, 1987) (para. 3.07); (iv) financial management and hospital management (March 31, 1988) (para. 3.07); (v) cost recovery of basic health services (December 31, 1988) (para. 3.05); and (vi) extension of the drug distribution system (March 31, 1989) (para. 3.06); (b) it will review annually with the Association (i) all investment expenditures made in the health sector in the previous year and those proposed for the coming three years, as part of the rolling public investment program, with particular emphasis being given to recurrent cost implications; and (ii) the allocation of budget and manpower resources with regard to its support of health sector strategy (para. 3.04); (c) it will organize annual meetings of all aid agencies participating in the financing of health sector activities in Niger (para. 3.07);  - 24 - (d) all proceeds from the sale of chloroquine will be deposited in the revolving fund for the replenishment of chloroquine; (para. 3.15); (e) it will submit to the Association for its approval by September I of each year an evaluation of the previous year's vaccination campaign, including coverage achieved, and the proposed target coverage for the following year based on that evaluation (para. 3.18); (f) it will submit to the Association for its approval a plan of action for strengthening the maintenance system, including efficient, low cost designs for rural health facilities by January 31, 1987 (para. 3.12); (g) it will submit a program for supervising field staff for review and approval by the Association no later than December 31, 1986 (para. 3.29); (h) it will present to the Association for its approval a nutrition surveillance system and a timetable for its implementation by March 31, 1987 (para. 3.26); (i) it will submit annual training plans and study tour and fellowship proposals for review and approval by the Association by July 31 of each year (para. 3.28); and (j) it will have the Special Account, the Local Advance Account, the chloroquine account and all other project accounts for each fiscal year audited by independent auditors, and it will furnish to the Association audit reports within six months after the end of each fiscal year (para 5.13). Conditions of Effectiveness 7.02 As conditions of effectiveness, the Government will: (a) through the intermediary of ONPPC, establish an account in a commercial bank to operate a revolving fund for the '-eplenishment of chloroquine for the anti-malaria program (para. 3.15); (b) establish and adequately staff a PMU and set up an appropriate project accounting system (para. 5.05); and (c) establish a local advance account and deposit an initial amount of CFAF 30 million in it (para. 5.12). Conditions of Disbursement 7.03 Conditions of disbursement are as follows: (a) disbursement against implementation of proposed activities, based on study results or operational experience derived from the project, will be conditioned upon the Association's approval of  - 25 - plans of action prepared by the Government in collaboration with the Association and supported by a feasibility study (para. 3.09); and (b) disbursement against purchases of vaccines will be conditioned on the Association's approval of the proposed target coverage for the following year's immunization campaign (para. 3.18). 7.04 On these conditions, a credit of US$27.8 million equivalent for this project is recommended.  - 26 - ANNEX 1 NIGER HEALTH PROJECT BASIC DATA A. General Country Data 1. Total Area (sq. ki) .................................... 1,267,000 2. Total Population - (mid-1983 Estimate) (millions) ............. 6.1 3. GNP per capita, US Dollars (1984) ....... .................... 190 4. Enrollment in Primary School (X) (1982) ....................... 23 5. Enrollment in Secondary School (X) (1982) ....................... 5 B. Population Data 1. Population Density (per sq. km) (1983) .4.8 2. Urban Population (%) (1983). . . ........... ................... 14 3. Average ADDual Population Growth Rate (%) - 1965-73 .2.6 - 1973-83 .3.0 - 1980-2000 .3.2 4. Annual Population Natural Increase (1985) . .3.0 5. Total Fertility Rate (1985) . . . 7.0 6. Crude Birth Rate per 1,000, (1985) . . . 51 7. Crude Death Rate per 1,000 (1985) ............................. 21 C. Health and Nutrition Data 1. Life Expectancy at Birth (1983) (years) . . 45 2. Infant Mortality Rate per 1,000, (1983) . ............... 139 3. Child Death Rate per 1,000, (1983) .. 28 4. Population per Physician (1980) ............................ 38,790 5. Population per Nursing Person (1980) ......................... 4,650 6. Daily Calorie Supply per capita (1982) . ............. 2,456 7. Daily Calorie Supply as % of Requireent (1982) . ......... 105 Source: The World Bank, World Development ReDort, 1985, and World Bank Estimates.  - 27 - ANNEX 2-1 NIGER HEALTH PROJECT Comparative Health-Related Indicators Low-Income Economies 1/ Sub-Saharan (excl. China Niger Africa and India) 1965 1983 1965 1983 1965 1983 Crude birth rate 48 52 48 47 46 43 Crude death rate 25 20 22 18 21 16 Infant mortality rate 181 139 156 119 147 115 Child death rate 46 28 35 23 27 18 Life expectancy at birth 41 45 43 47 45 51 i/ Countries with a GNP per capita of less than $400. Source: The World Bank, World Development Report. 1985  - 28.- ANNEX 2-2 NIGER HEALTH PROJECT Ranking of Reported Diseases Type of Disease As percentage of all diagnoses re- ported from general consultations Malaria 18% Respiratory Diseases 12% Wounds and Lacerations 10% Diarrheal Diseases 10% Trachoma and Conjunctivitis 8% Skin Diseases 5% Source: Ministry of Health Project Preparation Document, "Projet Sante, Banque Mondiale, Niger", June 1985.  -29- /HEX 2-3 PziLMu1 Halth FaclitLes bY DeP.t=M 198 Agodez Dlfff Domn Nwalt NLSWY Tabom 1 r Ttt B.ipitg 1 1 1 1 - 2 1 1 8 Medical aters 3 3 5 7 6 1 7 6 38 MA cers 2 1 1 3 2 10 2 6 27 Materrfties 4 3 6 10 7 3 9 8 50 Dif 8pez 16 11 32 37 53 12 34 34 229 Mb:ile uts 1 1 1 1 1 - 1 1 7 Pbarwes 2 2 2 2 3 2 3 2 18 P dation 150M3 230.95 834.650 1.137.88 1.411.919 1.198.336 1209.534 6.143.S9 S aum HPS  - 30- ANNEX 2-4 Page 1 of 2 NIGER HEALTH PROJECT FUNCTIONS AND TRMINI OF HEALTH PERSONNEL Medical Personnel 1. Health personnel at the highest rank of the civil service, requiring university or graduate-level education, consist mainly of physicias and a smll number of dentists and pharmacists. They are trained in Niamey, Dakar, Abidjan and Lo.e; a small number is sent to France, mainly for medical specialization. Niger began its own medical training program at Faculte des Sciences et Sante of the University of Niamey in 1974. It has so far produced s80e 140 graduates. Para-oedical Personnel 2. Infirmiers Dipla ffs d'Etat (state nurses) receive three year training at the Ecole Nationale de Sant6 Publique (ENSP) in Niamey. The uini-um educational qualification for entry into the program is the Certificat d'Etudes de Premier Cycle (BWP), obtained after ten years of school. Besides performing the full range of nursing duties, the state nurses are placed in charge of health centers, where an important responsibility is the supervision of dispensary-level nurses. 3. Infirmiers Certifids (certified nurses) receive one year of training at the Ecole Nationale des Infirmiers Certifi6s et des Aides Sociales (ENICAS). Upon graduation, the certified nurses are usually assigned to work at least one year in a health center under close supervision of a state nurse, after which they will be in charge of a rural dispensary. Usually, the certified nurse is the only person with some medical training in a cluster of villages, and he or she may be responsible for providing health care to as iany as 10,000 people. He or she provides curative and preventive services, supervision and retraining of village health teams, health and nutrition education, and recordkeeping. Where MCR services are not available, the certified nurse is also responsible for the pre-and post-natal care and infant nutrition advice. 4. Sates Femnes (midwives) are responsible for all care and treatment during pregnancy and delivery except in critical cases. Training is provided at ENSP and is similar in length and entry requireuents to that of state nurses. Midwives are posted at medical facilities above the dispensary level, thus in practice work in the main towns. 5. Aides Assistants de 1'Action Social (social workers) staff health and MCH centers and Atents d'Hygiene et de l'Assainissement (sanitation  - 31 ANNEX 2-4 Page 2 of 2 maiistants) are found at departmental health directorates where they oversee sanitation activities. They are trained at ENICAS. 6. Villate Health Worker Teams (VET) are composed of one or two sale health workers and one or two traditional midwives. The VHT is responsible for distribution of simple medicines according to specific symptoms; treatment of wounds and fractures; monitoring of normal deliveries and referrals of abnormal cases; instilling sound concepts of personal and environmental hygiene; and health education, in particular with respect to nutrition and sanitation practices. The members of the VET are chosen by the villagers and receive some two weeks of training in health centers. At the conclusion of training, the VET receives small midwifery and pharmacy kits. Supervision is handled by dispensary nurses.  - 32 - ANNEX 2-5 NIGER HEALTH PROJECT Health Staff Allocated by Major Category and Type of Facility, 1984 Doctors Nidwives State Nurses Certified Nurses Hospitals 14 22 134 166 Medical centers 1/ 11 155 127 298 Dispensaries - - 38 249 Mobile ur4 3 - 19 26 Administration 19 2 10 30 Other 5 4 19 20 Total 52 18' 347 789 Total Available 2/ 64 266 554 1,006 Staff in Rural Facilities 3/ 6 62 125 360 -Z Share 12 34 36 46 1/ Including maternities and MCH centers. 2/ The difference between total available nigerien staff and active staff mainly reflects staff in trainimg. 3/ Medical centers, including maternities and MCH centers, in rural areas, rural dispensaries and mobile units.  ,~~~~~~II IiA 1,1H 1, eE M It li'' ii pI; 1111 1 , 1~I, I! l';] {i XW~~~1} S I't1  -34- ANNEX 2-7 NIGER HEALTH PROJECT Realth Coverage Coverage (Z of population) Village health teams 45 Fixed health facilities: - excludiDg dispensaries 15 - plus dispe-aaries 40 - plus outreach to 15 km from facility 55  ANNEX 2-8 NIGER NEALTH PROJECT Village Health Worker System 1972 1978 1980 1984 Villages with teams 275 1,496 2,223 3,898 Health assistants 500 2,185 3,335 6,611 Birth assistants 594 1,836 3,225 7,056 Villages with teams (x) 3.2 17.3 25.8 45.2 Source: Ministry of Planning.  - 36 - ANNEX 2-9 NIGER HEALTH PROJECT Health Expenditures, 1984 (CFAF millions) I. Public Expenditures Ministry of Public Health 4,455 Ministry of Higher Education 350 Ministry of Finance 1,090 (of which medical evacuations) (800) Others 105 Total Public Expenditure 6,000 (52S) II. Private Expenditures Drugs (ONPPC) 2,800 Other 200 Total Private Expenditure 3,000 (26%) III. External Assistance Technical Assistance (replacement cost) 500 Drugs and supplies (estimate) 1,000 Village Health Worker program 1,000 Total External Assistance 2.500 (22S) Grand Total 11.500 (100X)  - 37 - AWNE[ 2-10 NIGER HEALTH PROJECT Recurrent Budget for Health. 1984 (CFAF million) 1. Ministry of Public Health and Social Affairs Amount Percent of Total Personnelj] 2,150 36 Drugs and Vaccines 1,150 19 Training (nurses, midwives)J/ 310 5 materials and Supplies 845 14 Subtotal MOPHSA 4,455 74 2. Ministry of Finance Medical evacuations2/ 800 13 3. Ministry of Higher Education Training (medical doctors)V/ 350 6 4. Others 395 7 TOTAL 6,000 100 O/ Salaries of professors and other staff of the para-medical schocls are included under training, not under personnel. If they are included in the personnel category, the share of personnel in the MOPHSA budget rises to about 53S (from 48% otherwise). 2) Medical evacuations of about 180 persons, mostly to hospitals in France. j/ Includes doctors trained both in Niamey and abroad.  - 38 - ANNE= 2-11 NIGER HEALTH PROECT Two Scenarios for Personnel/Materials Conposition of NDPHSA Recurre8t Budget for the Period 1986-1990 (CFAF '000) 1986 1987 1988 1989 1990 Scenario 1: No change in health Manpower policy Total recurrent budget 5,100 5,390 5,690 6.000 6,340 of which: Personnel 2,753 3,069 3,419 3,766 4,105 Residual for materials and other operating costs 2,347 2,321 2,271 2,234 2,235 Personnl as percent of total recurrent budget 54% 57% 60% 63% 65% Scenario 2: Reduction of intake of student nurses from 140 to 20 beginnig in school- year 1985/86; lower entry levels Total recurrent budget 5,100 5,390 5.690 6,000 6.340 of which: Perwonel 2,724 2,998 3,142 3,295 3,459 Residual for materials and other operating costs 2,376 2,392 2,548 2,705 2,881 Personmel as percent of total recurrent budget 53Z 56% 55Z 55X 55% Note: A 5.62 axnual increase in the MOPESA budget is assumed in line with the azxual increase assumed for the total government budget over the 1986-90 period. The perwnel excpe ditures assume the recruitment of all new graduates and replacement of aiziliary staff. An estimated attrition rate has also been incorporated into calculations. Sources: MOPHSA data and World Bank estinates.  AIINM 2-12 NEMR Health Sector Irueataent Prram, 1979-68 Total 1979-83 ) 198- (2) 1979-5 (2) 198-88 (Z) A. DLopenocies 4,280 (28) 1,413 (16) 5,693 (23) 4,376 (20) B. Ibternities and NfH (ireers 795 (5) 400 (4) 1,195 (5) 3,500 (16) C. )mlacic Oeater (oiemert level) Nk - 260 (3) 260 (1) 195 (1) D. Hmgtat l. 9 1,097 (7) 3,529 (39) 4,626 (19) 1,100 (5) E. SdDols (mig a aidcaJl) .