Oman - Health Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No. 6544-ONI STAFF APPRAISAL REPORT SULTANATE OF OMAN HEALTH PROJECT April 15, 1987 Population, Health and Nutrition Department Division III This document has a restricted disiribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authoriztlon.  CURRENCY EQUIVALENTS Currency Unit: Omani Rial (R.O.) US$ 1 = 0.384 R.O. 1 R.O. - US$ 2.604 (Exchange Rate from January, 1986) FISCAL YEAR January 1 to December 31 PRINCIPAL ACRONYMS USED BHC Basic Health Care BHCDS Basic Health Care Delivery System BRHO Batinah Regional Health Office DC Development Council DOF Directorate of Finance, Ministry of Health DSPF Directorate of Statistics, Planning & Follow-up FPMS Financial Planning and Management Section GNP Gross National Product HIS Health Information Section -SMP Health Services and Manpower Planning IHS Institute of Health Sciences MCH Maternal and Child Health Care MOF Ministry of Finance MOH Ministry of Health MOSAL Ministry of Social Affairs and Labor ODA United Kingdom Overseas Development Agency RHO Regional Health Officer UNDP United Nations Development Plan UNICEF United Nations Children's Fund USAID United States Agency for International Development WHO World Health Organizarion WEIGHTS AND MEASURES The Sultanate of Oman uses the Metric system of weights and measures.  FOR OFFXIAL USE ONLY SULTANATE OF OMAN HEALTH PROJECT STAFF APPRAISAL REPORT Table of Contents Pate No. BASIC DATA SHEET ... . * . . . * * . . * * . a * * * * i * * * * DEFINITION OF POPUIATION, HEALTH AND NUTRITION TEMS . . . . . . . . . ii LOAN AND PROJECT SUMHARY . . . . . . . . . . . . . . . . . . . . . . . iv I* BACKGROUyND ............................................................. I II. SECTOR STATUS AND ISSUES . . . . . . . . . . . . . . 1 A. Population, Health and Nutrition Status . . . . . . . . . . . 1 B. The Health Care Policy and System . . . . . . . . . . . . . . 2 C. Population and Nutrition: Policy and Services . . . . . . . . 4 D. Health Sector Issues and the Role of the Bank . . . . . . . . 5 E. Role of Other Donors . . . . . . . . . . * . . . . . . . . . . 6 III. THE PROJECT . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 A. Project Objectives and Design .. . .. . ... .. . . . . .. .. 7 B. Summary of Project Composition . . . . . . . . . . . . . . . 8 C. Project Description . . . . . . . . . . . . . . . . . . . . . 9 IV. PROJECT COSTS ANDFINANCING .................... 15 A. Cost of the Project .... . . . . . . . . . . . . . . . . . 15 B. Project Financing ...l.a. . . . . . . . . . . . . . . . . . 18 C. Project Recurrent Costs ... . . . . . . . . . . . . . . . . 18 D. Procurement .. . . . . . . . . . . . . . . . . . . . . . . 19 E. Disbursement . . . . . . . . . . . . . . . . . . . . . . . . 21 F. Special Account ......... ... ... ... .. .. . 22 G. Accounts and Audits .. . . . . . .. . ...... .. .. 22 V. PROJECT IMPLEMENTATION . . . . . . . . . . .......... 22 A. Status of Project Preparation . . . . . . . . . . . . . . . . 22 B. Organization and Management .. . . . . . . . . . . . .... 23 C. Monitoring, Reporting and Evaluation . . . . . . . . . . . . . 25 This report is based on the findings of an appraisal mission in October 1986 to the Sultanate of Oman composed of Messrs./Mdmes. Santiago Friedmann (mission leader), Harry Go, Taraneh Tavana and Margaret Valdivia, PHND3; Edward 0. Pratt and Robert Wickham (consultants). This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.  SULTANATE OF OMAN HEALTH PROJECT STAFF APPRAISAL REPORT Table of Contents (Cont'd) Paite Nos Al *kJC BeneftsT * M * It . . . . . . 26 V . P ROiJts . . . . . . .. . . . . . . . . . . . . . . . . . . . 26 VII. AGREEMENTS AND NDCECATIONS . . . . . . . . . . . . . . . . . 27 M&D IBRD No. 19897 AnnexeC: Annex 1: Demographic and Health Information, and Ministry of Health Infrastructure and Expenditures Annex 2: Implementation & Procurement Schedules, Staffing Program, Fellowbhips, Technical Assistance Programs, and Local Training Programs Annex 3: Project Cost Tables Annex 4: The Basic Health Care Delivery System (BECDS) Annex 5: Selected Documents and Data Available in the Project File Charts: Chart 1: Organizational Chart of the Ministry of Healtb Chart 2: MOB Health Facilities by Type Chart 3: Ministry of Health, Directorate of Statistics, Planning & Follow-up  SULTANATA OF OKAX HEALTH PROJECT STAFF APPRAISAL REPORT Basic Data Sheet A. General Country Data Ye Sourcg Population Estimate (millions) 1.1 1984 (2) Population Projections (millions) Population for Year 2000 1.8 (1) Stationary Population 4.5 (1) Assumed Year for Reaching Net Reproduction 2035-40 Rate of one (NM-I1) GNP Per Capita (US$) 6,490 1984 (2) Urban Population (X of total) 27 * (1) Primary Enrollment L te (Z) 89 19851 (1) Area (Square Kilometers) 300,000 (1) Population Density (per ha under cultivation) 36 1985 (4) B. Ponulation Crude Birth Rate (per 1,000) 45 1984 (2) Crude Death Rate (per 1,000) 14 1984 (2) Annual Rate of Population Growth (Z) 4.5 1973-84 (2) Total Fertility Rate 6.8 1984 (2) Infant Mortality Rate (per 1,000) 110 1984 (2) Life Expectancy at Birth (Years) 53 1984 (2) Population Age Structure (X): 0 - 14 years 44.9 (1) 15 - 64 Years 52.5 * (1) 65+ years 2.6 * (1) C. Health Sector Resources Population per Physician 1,580 1984 (3) Population per Nursing Person 700 1984 (3) Population per Hospital Bed 524 1984 (3) Total Expenditure on Health as Z of GNP 3.4 1983 (4) 10 Budget as I of Total Governmental Budget 3.9 1985 (4) D. Hospital Utilization Total Admissions per 1,000 Population 137.6 1984 (3) Total Patient Days per 1,000 Population 663.5 1984 (3) Occupancy Rate (X) 98.9 1984 (3) Average Length of Stay (days) 4.8 1984 (3) * Most recent estimate - between 1982 and 1985 1 Gross enrollment includes over-age and repeating students. SOURCES: (1) Economic and Social Indicators Data Sheet, World Beak, June 1986; (2) World Development Report 1986; (3) Annual Statistical Report, Sultanate of Oman, MON, 1984; (4) Mission estimates.  - ii - SULTANATE OF OMAN HEALTH PROJECT STAFF APPRAISAL REPORT Definition of Population, Health and Nutrition Terms Child Mortality Rate: Annual deaths of children 1-4 years of age per 1,000 children in the same age group. Contraceptive Prevalence Rate: The percentage of married women of reproductive age who are using a modern method of contraception at any time. Crude Birth Rate: Number of births per 1,000 population in a given year. Crude Death Rate: Number of deaths per year per 1,000 people. Degree of Malnutrition: The Gomez classification scale distinguishes three degrees in malnutritionu: First (mild): 75-902 of median weight for age; Second (moderate): 61-75X of median veight; Third (severe): 601 or less of median weight and all children suffering from edema. Dependency Ratio: Population 14 years or under and 65 years of age or over as percentage of active population (aged 15 to 64 years). Indicates proportion of population that needs economic support. Infant Mortality Rate: Annual deaths of infants under 1 year of age per 1,000 live births during the same year. Life Erpectancy at Birth: The number of years a new-born child would live if subject to age-specific mortality rates prevailing at time of birth.  - iii - SULTANATE OF OMAN IRALTE PROJECT STAFF APPRAISAL REPORT Definition of Population, Realth and Nutrition Terms (Cont'd) Low Birth Weight (LBW): Infants weight at birtb less than 2,500 gr. LBW may be associated with either pre-term (less than 37 weeks gestation or full-term but small for dates (38 weeks or more) of gestation. Maternal Mortality Rate: Number of maternal deaths per 100,000 births in a given year attributable to pregnancy, childbirth or post-partum. Morbidity: The frequency of disease and illness in a population. Prevalence Rate: The number of persons having a particular disease at a given point in time per population at risk; usually expressed per 1,000 persons per year. Rate of Natural Increase: The rate at which a population is increasing (or decreasing) in a given year due to a surplus (or deficit) of births over deaths, expressed as a percentage oZ the total population. Replacement Level Fertility: Level of fertility at which a cohort of women on the average are having only enough daughters to replace themselves in the population. Total Fertility Rate: The average number of children that would be born to a woman if she experiences a given set of age-specific fertility rates throughout her lifetime. Serves as an estimate of average number of children per family.  - iw - SULTANATE LiP OMox HEALTH PROJECT STAll APPRAISM* REPORT Loan and Pro lect Sugmri Borrower: Sultanate of Oman Executing AUency,: Ministry of Health Am2unt## US$13.3 Million Equivaleut Terms: Repayment in 15 yeais, including 3 years of grace, at the Bank's staudard variable interest rate. Project Obiectives: The proposed project would: (a) reduce mortality and morbidity, particularly of 300,000 inhabitants of the predominantly rural Batinah region; (b) strengthen Govertment's institutional capacity to plan and manage the health sector; and (c) prepa:e the way for the country-wide implementation of a more efficient service delivery model. Proiect Description: Part A: Realth Services Develooment. The proposed project would assist the MOE to implement a basic health care delivery system (BUCDS) which integrates curative and preventive care and health promotion. It wvould help MOE to: (a) establish BHCDS in Batinah as the first phase of its nationwide implementation through: establishing a new Regional Health Office; completing the network of BRC facilities; and supporting outreach activities; (b) strengthen regional training by supporting the establishment of pre-service and in-service training programs in Batinash and other regions; and (c) strengthen health promotion by supporting nationwide health educstion activities tbrough the Health Education Section of MOR. Plt B: Strznatheaiu MO4 s He,alth Sector Plannina and Manaaement Cauabilitv. The proposed project would assist the MOR in improving sector efficiency, effectiveness, and financing, by strengthening the NOR a analytical, planning and management capability. The project would support an institution-building process focused on improving management information systems in health and finance; improving financial planning and management; and developing health services and manpower planuing. The project would help MOB to establish: (a) a new Realth Information Section and a new Health Services and Manpover Planning Section within the Directorate of Statistics, Planning and Fol ow-up; and (b) a new Financial Planning and Management Section within the Directorate of Finance.  - v The project will be carried out over five years and would p,ovide funds for civil works, equipment, furniture, vehicles, materials, drugs and supplies; technical assistance, fellowship and training, and incremental operating costs. Benefits 6 Risks: The project would yield three benefits: (a) reduce mortality and morbidity, particularly among poor people in rural areaq, and infants, chiidren and women of childbearing age as a result of expanded health services coverage and intensified healtb promotion activities; (b) ease the demands of the health sector for public resources as a result of greate. efficiency and effectiveness of service delivery, improved investment planning and use of resources for operation, and the introduction of cost containment and cost recovery measures; and (c) reduce dependence on expatriate labor through the establishment of training programs. In addition, the project would develop MOH's institutional capacity to expand the cost-effective BHCDS throughout Oman. The Government has made a fiim commitment to provide adequate budgetary resources and all project components are included in the MOH budget under the Tbird Five Year Plan (1986-90). The principal risk relates to the fact that the reorganization and expansion of health services would, at least in the initial phase, make for considerable demands on the management skills and adaptability of NOR staff, and call for a sustained commitment on their part. However, participation in the project preparation and app-aisal has given MOE staff an understanding of the project's potential for achieving the country's health objectives in the most cost-effective way. Moreover, the high piiority of the projects health objectives and the understanding of the project's potential fo3 improving efficiency and effectiveness in the sector together with the impact of the project's institution-building and training components should deepen this understandi.ng and increase MOH capability to implement it. The project provides for the establishment of a strong regional management for the new basic health care delivery system and for its monitoring.  - vi - Es&ia4atd Costs: imni Rials %iill) l)S$ (Mill) _ Foreig X Total Iacal Foreim Total Local ForeMi Total ciwe Bse Costs Al ELI SEfVlCJ DWLA3I 1. Eetablisbivg M6 in Batinah 4.2 2.9 7.1 10.8 7.5 18.3 41 68 2. EStablishilg Regicnal .Trainizi 0.3 0.2 0.5 0.8 0.6 1.4 44 5 3. S tir Health Provtia 0.2 04 _0.6 0.5 1.0 1.5 i66 6 Subtotal HEALT SEIRVCES 4.7 3.5 8.2 12.1 9.1 21.2 43 79 B. _I KS PLNR AMAND = CAPAMM 1.0 1.0 2.0 2.6 2.5 5.1 49 19 C. IlE(bU K4!llZI 0.0 0.2 0.2 0.5 Q 81 2 Total Base Costs 5.7 4.7 10.4 14.8 12.1 26.9 45 100 Physical Contingencies 0.1 0.2 0.3 0.4 0.7 1.1 72 4 Price Cotimencies 0.8 0.2 1.0 2.1 0.5 2.6 19 10 TOM ALDJE1 COaTS 6.6 5.1 11.7 17.3 13.3 30.6 44 114 _m== - Financing Plan: Local Foreign Total ----------- US$ Million-- Gove-nment 17.3 - 17.3 Baik - 13.3 13.3 TOTAL 17.3 13.3 30.6 =t5z_t *m: sinm m-t: m Estimated Disbursements: Bank FY: 1988 1989 1990 1991 1992 1993 1994