Tanzania - Health and Nutrition Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No. 8217-TA STAFF APPRAISAL REPORT THE UNITED REPUBLIC OF TANZANIA HEALTH AND NUTRITION PROJECT FEBRUARY 5, 1990 Population and Human Resources Division Southern Africa Department This dowment has a resicted dishibution and may be used by recpens only in the perfornance of their officid duies. Its coens my not oerwise be dbisod wihout Wodd Bank authoization.  CURRENCY EQUIVALENTS (January 1990) Currency Unit - Tanzania Shilling (TSh) US$ 1 = TSh 193 TSh 100 - US$0.52 Exchange Rates 1960 - 1974 US$ 1- TSh 7 1975 - 1981 US$ 1= TSh 8 December 1983 US$ 1 = TSh 12 December 1985 USS 1 - TSh 17 June 1986 US$ 1- TSh 40 December 1986 USS 1 - TSh 52 December 1987 US$ 1 - TSh 84 December 1988 US$ 1 - TSt 120 December 1989 US$ 1 - TSh 190 FISCAL YEARS IDA Fiscal Year - Julj 1-June 30 Central Government Fiscal year - July 1-June 30 District Government Fiscal Year = January 1-December 31 MEASURES 1 Meter (m) - 3.28 Feet 1 Square Meter (m sq) - 10.76 Square Feet  FOR OMCIL USE ONLY AIRuVIATXONS AND ACRONIMS AXO Assistant Chief Medical Officer iDnS Acouired Ismunodeficiency Syndrome CCH - Chama Cha Hapinduzi (the Party) CEDHA - Centre for Educational Development in Health. Arusha CHS - Central Medical Stores CKOH - City Medical Officer of Health DANIDA - Danish lnternational Development Agency DED District Executive Director DHT - District Health Team DMDT Department of Manpover Development S Training DMO - District Hedical Officer DSCC - Dar es Salaam City Council EDP - Essential Drugs Program EPI Expanded Program of lImunization DtR - Economic Recovery Program ESAP Economic and Social Action Program FAO - food and A4riculture Organization GOT - Government of t'nrania HIS - Health Information System IDD Iodine Deficiency Disorders IEC - Information. Education, Communication IUD - Intrauterine Device JNSP - Joint (WHO-UNICEF) Nutrition Support Programs MA - Medical Assistant MALD - Ministry of Agriculture and Livestock Development Me - Maternal and Child Health MLG - Ministry of Local Government, Community Development. Cooperatives, and Marketing MOE - Ministry of Education MOF Hinistry of Finance MOB - Hinistry uf Health NAPCO - National Pharmaceutical Company NCC CSD - National Coordinating Comittee - Child Survival and Development (programs) NGO Non-governmental Organization NVACG - National Vitamin A Consultative Group NPIC - National Population Information Centre ODA - Overseas Development Administration (Ul) PC - Planning Commission PD - Planning Department (HOH) PHC - Primary Health Care PHN - Population. Health and Nutrition PMO - Prime Minister's Office PSAP - Priority Social Action Program PSN - Program Supp4rt Network (MLG) PY Project Year RDD - Regional Development Director RHC - Rural Health Centre RMA Rural Medical Aide RMO Regional Medical Officer RHC - Rural Health Center SDC - Swiss Development Cooperation SIDA - Swedish laternational Development Authority TBA - Traditional Birth Attendant TCPD - Tanzanian Council for Population and Development TFNC - Tanzania Food and Nutrition Centre TFR - Total Fertility Rate UCI - Universal Child Immunization UMATI - Family Planning Association of Tanzania UNDP - United Nations Development Prbgram UNFPA - United Nations Fund for Population Activities UNICEF - Uz.ited Nations Children's Fund UNIPAC - UNICEF Packaging and Assembling Center VA Voluntary Agency VUW Village Health Worker WDC - Ward Development Committee WHO - World Health Organization 2MS - 2onal Medical Store 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.  TABLE OF CONTENTS Title Pae No. Basic Data ....... ,................................................ . i Credit and Project Summary .......... ........................ ii Estlmated Costs and Financing Plan ................................ iv-v I* INTRODUCTION AND ECONQMIC CONTN S 8 XT. . .e. ........ .*. 1 A. Introduction.... 1 B. The Economic and Policy Environ ment. .... 2 C. Government Strategy in the PHN Sectors............. 3 II. SECTORAL C)NTEXT AND ISSUES ........ ................. . 6 A. Basic Characteristics...................... .... 6 B. Health: Policies, Programs and Isssues 7 C. Population: Policies, Programs and Issues 15 D. Nutrition: Policies, Programs and Issues 18 E. Expenditures and Finacing.... . ........ . ... . 27 F. Donor Role in the PHN St sectors. 32 G. Role of IDA ... 0* .. 33 I1. TEE PROET.............. EC......T..... 34 A. Objectives and Summary Description. 34 B. Detailed Description. .... t ....... ...... . 35 C. Sectoral Policy Reform. ............. ...... 49 D. Relationship of Project to Programs of Special Emphasis 52 IV. PROJECT COSTS AND F.IANCING ................. .....**.. *. _. D. Cost E stimates ....... . ...... .*. ........ ... ...... 54 B. Financing ....................... 57 C. Procurement......*..... **.........# 58 D. Disbursements ..................... 62 E. Accutc....... o....... n....t s ..... 62 F. Accounting and Auditing. .................*......... 65 V. PROJECT MANAGEMENT AND ........... 66 A. Project Management................................. 66 B. Project Preparation and Implementation Schedule........ 67 C. Project Reporting. ..................................... 69 This report is based on the findings of an appraisal mission which visited Tanzania in October-November 1989. The mission was composed of Mr. J. Innes (Mission Leader), Dr. J. Lamboray (urban and rural PHC), Ms. J. Murphy (manpower development), Mr. H. Den Besten (consultant on pharmaceuticals), Mr. T. Greiner (consultant on nutrition), and Dr. M. Tanner (urban PHC, representing SDC). The report was prepared by Mr. J. Imes. Ms. M. Swan assisted in the preparation of cost tables and was also responsible for report processing.  Title Page No. VI. PROJICT BENEOITS AND RISKS .................................. 70 A. Benefits and Justification ............................. 70 B. Risks . ........................... ............. . ..... 71 VII. ASSURANCES AND UECOSMENDATION.. ... ........ ......... 72 ANNES 1. The Structure of the Ministry of Health ..................... 74 1.1 The Ministry of Health ................... . ... ....... . 74 1.2 The Planning Department (HOH) .......................... 75 Priority Social Action Program (PSAP) ..... 79 3. Terms of Reference for the Study on the Long-term Options for Financing the Health Sector ......................................... 93 4. Project Implementation Arrangements ..... 96 4.1. Project Coordinating Committee ......................... 96 4.2. Component I - Strengthening National PHN Systems ..... 97 4.3. Component II - Strengthening Rural PHC ................. 98 4.4. Component III - Strengthening Urban PHC. 99 5. Pharmaceuticals Procurement Program 1990191 ...100 6. The Pharmaceuticals Sub-Sector - Background ?ad Issues ...... 102 7. Recommendations of the Working Group on the National Drug Policy ....................................... 108 8. The Case for Reform in the Pharmaceuticals Sub-Sectr .......o 117 9. Micronutrient Deficiency Control Programs ..... ............. 124 10. Major Themes of the Revised PHC Strategy ............. *...... 132 11. District Selectton Criteria and Process ........c .......... 136 12. Strengthening Urban PHC - Dar es Salaam Health Project ...... 138 13. Project Costs ................... ........................... 151 14. Project Financing . ..................... . 159 15. Project Implementation Schedule ............................. 163 16. List of Documents on the Project File ....................... 165 LIST OF TABLES Table 2.1 Nutritional Status of Children Under 5.......... 19 Table 2.2 Estimated Prevalence of Malnutrition in Tanzania 1986187.9.9 . .22 Table 2.3 Total Health Expenditures (Mainland) (1986/87-1988I89) ..... 29 Table 2.4 Central MOH Recurrent Expenditures Budget, 1988189 ...30 Table 4.1 Project Cost Summary by Project Component .. 54 Table 4.2 Cost Summary by Summary Account. 55 Table 4.3 Financing Plan ....... .. .58 Table 4.4 Procurement Arrangements 60 Table 4.5 Allocation and Disbursement of the IDA Credit 63  LIST OF CHARTS Chart 2.1 Percent Low Birth Weight of Children Under 5.... 20 Chart 2.2 Nutritional Status of Children Under 5 .......... 21 Chart 2.3 Estimated Prevalence of Malnutrition in Tanani...................... 23 Chart 2.4 Estimated Prevalence of Malnutrition in Tanzania ............... .............. 24 Chart 4.1 Procurement Arrangements for the IDA Credit..... 61 Chart 4.2 Allocation and Disbursement of the IDA Credit... 64 MAPS 1. IBRD No. 21769 Tanzania - Strengthening National PHN Systems and Rural PHC 2. IBRD No. 21770 Strengthening Urban PHC: Greater Dar es Salaam PHC Facilities 3. IBRD No. 21771 Strengthening Urban PHCs Central Dar es Salaam PHC and Referral Network  HEALTR AND NUTRMOI PROJE Basic Data (All figures apply to 1987 unless otherwise indicated) Area ......... .......... ...... ,... 883,749 square km GNP per capita ...................... US$180 Population (1988) ........................... ... 23.2 million Rural population as proportion of total populationp...... a.................. 28.6 percent Crude birth rate. ............................... 49.8 per thousand Crude death rate .... ...... . ..... .......... . . 14.2 per thousand Population growtA rate .......................... 3.0 percent per annum Infant mortalityrate........................... 106 per thousand Child mortalityrate............................ 153 per thousand Life expectancy at birth (male)................. 51.4 years Life expectancy at birth (female)............... 55.0 years Daily Caloric supply per capita................ 2,192 calories D*i1y Protein Supply per Capita ............54 grams Population per physician........................ 24,400 persons Population per trained nurse ..................... 5,365 persons Public oxPenditure en Health (All figures apply to 1988189) Health share of total Government budget ............ 6.2 percent Health share of GDP ..................................... . . 1.8 percent Health share of Government development budget ....... 5.3 percent Health share of Government recurrent budget ......... 6.5 percent  - ii - TAZNZO HEALTH AND NUTRITION PROJECT Credit and Project Suumary Borrower: Government of the United Republic of Tanzania Beneficiaries: Ministry of Health (MOH); Ministry of Local Government, Community Development, Cooperative and Marketing (MLG); Planning Commission (PC); Tanzania Food and Nutrition Centre (TFNC). Amount: SDR 36.1 million (US$ 47.6 million equivalent) Tern: Standard, with 40 years maturity Pro1ect ObJectives: The proposed project will reinforce the Government's efforts (including the Economic and Social Action Program [ESAP] and Priority Social Action Program [PSAP]) to raise the quality, coverage and effectiveness of family planning, nutrition and basic health services in urban and rural areas, through providing support to critical and strategic elements of the PHN sectors, with particular emphasis on strengthening; () institutional capacity for planning, policy formulation and implementation; (ii) manpower development and training; (iii) sustainable provision and financing of pharmaceuticals and medical supplies; (iv) micro-nutrient deficiency programs; v) implementation of the national population policy; vi) rural PHC, through the implementation of the revised strategy in selected districts; and vii) urban PHC, through reform and rehabilitation. Proiect Description: In order to meet these objectives, the project will support improvements in: i) health planning, policy formulation and information system, through upgrading of staff skills, studies on health financing and the domest.Lc pharmaceuticals industry, and strengthening the project coordination capacity of the MOH; (ii) manpower development and trainina, through support to in-service training at the district level and the implementation of a realistic manpower plan; (iii) pharmaceutical and medical supplies, through reforms to the pricing, financing, management and procurement of pharmaceutical and medical supplies and the rehabilitation of the central warehouse facility; (iv) the implementation of national micro-nutrient deficiency control programs for vitamin A and iron, including training, stupplies and operations research; (v) the implementation of the national population policy, through building up the analytical, monitoring and implementation capacity of the Population Unit of the Planning Commission and establishing a National Population Information Centre; (vi) rural PUC, through the  - iii - implementation of the revised PHC strategy (incorporated in district health plans (DHP)) in 10 selected districts, including mobilization of communities, support to village PHC and nutrition initiatives, district management strengthening, rehabilitation and maintenance of health facilities; and (vii) urban PHC, through improved management, maintenance, supply systems and the rehabilitation of health facilities in Dar es Salaam. Related policy reforms will be supported in three major areas, namely: (i) the composition of and incentives for health sector manpower; (ii) the pricing, financing, budgeting and capacity building for procurement of pharmaceuticals and medical supplies; and (iii) the development of resource mobilization measures for the sector. Prolect Benefits and Risks: The project's main benefit is to assist the Government in undertaking much needed reforms in the PHN sectors, such as improving long-term sustainability and efficiency, and will provide an opportunity to improve services in neglected areas. It will also assist the Government in the implementation of the national population policy, thereby contributing towards reducing the pace of population growth, and in the implementation of a revised PHC Strategy as embodied in the new national nutrition and health policies, thereby contributing towards improved nutritional status for women and children in particular. The project represents a major response to the ESAP and will contribute significantly to the development of Tanzania's human resource base during the process of economic adjustment. The project has a strong institution-building focus in terms of planning, policy formulation and implementation in the MOH, the MLG and the Dar es Salaam City Council. Project risks are three-fold. Administrative capacity in the implementing agencies is weal:. In order to minimize this risk, the implementation capacity of these agencies is being strengthened under the project. The second risk is that of weak performance by staff (resulting from poor motivation due to low salaries) undermining effective implementation of project activities. The Government is most cocerned about this issue, and with IDA assistance, is already reviewing the remuneration policy for staff, as one key element of civil service reform to be supported in a Public Sector Managemsnt operation. The project will also contribute to reducing this risk through support to Government efforts to develop an improved incentives package for health sector staff, and the provision of non- salary inducements to staff (such as training, recognition, and improved supervision). The third risk is that the macroeconomic environment may deteriorate again if the Government fails to proceed with the reform program. The Bank and the international donor community are addressJng this risk through country dialogue, policy- based operations, the Consultative Group and liP procoss. Fundamentally the Government believes that the reform process, fully incorporating the social sectors, is its best strategy for economic advancement.  - iv - ESTIMATED COSTS AND FnRANcin PLAN at Prolect Cost Lty hb Project comment (US$ illion) Local Foreian Total sotimted Costs I. Strengthening Rational PUN Systems 4.0 34.5 38.5 a. Health Planning, Policy Formulation and Information System 1.0 1.6 2.6 b. Manpower Development and Training 1.2 1.6 2.8 c. Pharmaceutical and Medical Supplies 1.2 29.8 31.0 d. Micronutrient Deficiency Programs 0.4 1.0 1.4 e. National Population Policy 0.2 0.5 0.7 II. Strengthening Rural Primary Health Care 3.8 7.8 11.6 III. Strengthening Urban Primary Health Care 4.7 6.8 11.5 IV. Project Preparation Facllity 0.1 0.4 0.5 Total Baseline Costs 12.6 49.5 62.1 Physical Contingencies 0.5 1.3 1.8 Price Contingencies 3.3 2.8 6.1 Total Project Costs 16.4 53.6 70.0 a/ Excludes taxes and duties of US$2.8 million.  - v - Financing Plan al Local Foreian Total ------------- (USS million)-------__ IDA 5.3 42.3 47.6 Co-financings Government of Belgium 0.1 0.6 0.7 DANIDA 0.6 0.i 1.3 SDC 5.0 7.2 12.2 ODA 0.0 0.1 0.1 UNFPA 0.1 0.6 0.7 Sub-total 5.8 9.2 15.0 Governments of which - Central 2.4 0.7 3.1 - District 1.5 1.0 2.5 - Beneficiaries 1.4 0.4 1.8 Sub-total 5.3 2.1 7.4 TOTAL 16.4 53.6 70.0 Note: a/ Excludes taxes and duties of USG2.8 million. IDA Disbursements (1S1 million) IDA Fiscal Year 91 92 93 94 95 96 Amount Disbursed 5.0 6.4 12.6 12.2 9.0 2.4 Cumulative Amount 5.0 11.4 24.0 36.2 45.2 47.6 Percentage of Total 10.5 24.0 50.5 76.1 94.9 100.0  I. INTRODUCTION AND ECNOlIIC CONTEXT A. Introduction 1.01 Since 1986, the Government of Tanzania (GOT) has embarked upon an Economic Recovery Program (ERP). Increasingly, the GOT and the donor community have recognized that the issues of social sector development have not been adequately addressed in the reforms. To redress this imbalance, and reverse the decline in social sectors, the GOT prepared in 1989 the successor to the ERP, the Economic and Social Action Program (ESAP), which fully incorporates the social sectors into the process of structural reform. In addition, the GOT has prepared a Priority Social Action Program (PSAP) which highlights the government priorities in the social sectors under ESAP. The Bank and the donor community have responded favorably to the process of continued economic reform in Tanzania. In particular, this project and the Tanzania Education Planning and Rehabilitation Project, respond to both thes ESAP and PSAP in a fundamental way, in strengthening the analytical and implementation capacity for the reforms embodied in these programs, and in meeting key needs in the social sectors. 1.02 Through ext^nsive consultations, and analysis undertaken to orient its design and preparation, the project is predicated upon: - the current Tanzanian macro-economic framework, which seeks to establish a firm basis for sustainable economic growth (Chapter I); - the Government's sectoral policy, which is basically sound and is being updated in the light of the revised economic circumstances; in this regard a number of important policy documents have been prepared by Government including a new draft health policy, a revised PHC strategy, the first national population policy and a national drug policy (Chapter II); - the Government's efforts to strengthen its implementation capacity at the central and district level (Chapter II); - the Government's determination to mobilize additional resources for what has become a severely under-funded sector, through enlisting communities in the provision of their own services, introducing revenue-raising measures which will not deny access to health services by the poor, improving the efficiency of resource utilization (especially manpower and pharmaceuticals) and finally increased budgetary allocations (Chapter II); and - the key gaps in the overall program of investment in the PHN sectors and the need to provide an integrating framework for such investment, despite significant and growing donor support. Each project component is carefully designed to fill these gaps and provide such a framework, thereby complementing the efforts of other donors and  - 2 - reinforcing Government's efforts in the population, health and nutrition (PHN) sectors (Chapters III to VII). The remainder of this Introduction, focusing on the economic and policy environment, and on the Government's policy in the PHN sectors, sets the context for the detailed analysis and project activities as presented in subsequent chapters. B. The Economic and Policy Enviroment 1.03 In June 1986, the Tanzanian government launched the ERP in order to reverse the decline in the economy and lay the foundation for sustainable growth. Progress to date has been good, fiscal and external imbalances have been reduced, the basis for sustainable growth largely established, and the stage set for an extension of the ERP, through the ESAP. The directions of Government's policies under the program have been strongly endorsed by the international community, including the International Monetary Fund and the World Bank. These policies, together with increased external assistance, have had a positive effect on the economy. Gross Domestic Product (GDP), which stagnated and declined during the middle 1980s, has once more rebounded and is now estimated to be growing at between four and five percent per annum, thus allowing for sustained increases in per capita consumption. 1.04 The objectives of the ERP have been to increase the rate of growth of output (especially in agriculture and industry), to rehabilitate the physical infrastructure of the country, and to restore external balance. The main features of the program have been: (i) movement toward removing the overvaluation of the exchange rate; (ii) a supporting macroeconomic framework of prudent fiscal and monetary policies; (iii) measures to reduce price control, move away from administrative allocation of foreign exchange and reform the trade regime; and (iv) policies to improve the performance of the main productive sectors, beginning particularly by improving systems of agricultural marketing. 1.05 While the ERP has far surpassed previous structural adjustment efforts, much remains to be done in the coming years not only to consolidate and reinforce the reforms already undertaken, but also to tackle the next generation of reform issues on both the macro and sectoral fronts. 1.06 The first robust signs of recovery, after several years of stagnant output and falling per capita income, came in 1986 when GDP grew by 3.6 percent. GDP growth in 1987 reached 4.0 percent, rising to 4.8 percent in 1988, and is estimated to have moderated to about 4.4 percent for as well. Thus, over the last several years output growth has been sufficient to allow a modest growth in both per capita income and consumption. The most visible source of growth continues to be the agricultural sector, where overall production increased between four and five percent in both 1987 and 1988. The long contraction of the industrial sector's contribution to GDP has been reversed over the past two years. Manufacturing value added is estimated to have grown by 4.6 percent in 1987  and five percent in 1988. Growth has been particularly evident in output of farm implements and other agriculture-related items, consumer goods, automotive spares and building materials. Further real GDP growth per capita is forecast for 1990 and 1991. 1.07 The Government is now increasingly turning its attention to sectoral reforms, as evidenced by a focus on improving agricultural incentives and marketing, rehabilitating much deteriorated infrastructure (particularly the road network) and the social sectors (as a key base to future economic development and the sustainability of the results of the ERP). Thus the social sectors are fully integrated into the next phase of macroeconomic reform as embodied in the ESAP. The PSAP highlights Government priorities for the social sectors over the period 1990 - 1992, within the overall context of ESAP. Reform in the social sectors aims tot (i) contribute towards the alleviation of poverty in the short-term, (ii) lay the foundation for poverty reduction, through development of the human resource base over the medium and long-term, and (iii) buttress and sustain the political will to continue with the process of structural adjustment and macroeconomic reform. This project would make a major contribution to the Government's efforts to implement the ESAP and PSAP. C. Government Strategy in the PHE Sectors 1.08 At the time of independence, the health status of the population was very poor, reflected in an average life expectancy of only about 40 years. As was true throughout most of Africa at the time, health services had been largely concentraLed in urban areas, and the bulk of the population living in rural areas were without access to primary health care (PHC). 1.09 After independence, the Government committed itself to providing basic health services to the population, free of charge. While early development plans stressed the need to extend the health system to rural areas, the Government was not initially able to translate its stated intentions into reality, and the bulk of health expenditures continued to go toward urban, hospital-based curative care, primarily in Dar es Salaam. Following the Arusha Declaration in 1967, and a critical review of development expenditures in 1971, a health plan was adopted which set out explicit targets for reaching the rural population. It called for the opening of 25 new rural health centers (RHCs) and 100 new dispensaries each year, to be staffed by a new cadre of auxiliary health workers, with the intention of reaching population-per-facility ratios of 50,000 for RHCs and 6,500 for dispensaries by 1980. Throughout the 1970's, good progress was made in achieving these ambitious annual targets, and by the early 1980's over 200 RHCs and 2,200 dispensaries had been constructed and staffed. It is currently estimated that over 90 percent of the population lives within 10 km of a health facility. However, given population growth, the targeted population-per-facility ratios were not met, with urban areas now being particularly under-served. 1.10 This improved access to health care in rural areas, coupled with a number of special initiatives supported by the donor community (maternal  - 4 - and child health, expanaed program of immunization, d.iarrhea control, tuberculosis (TB)Ileprosy control, essential drugs) hias been translated into improved health rtatus for the population. Life expectancy has increased, infant and maternal mortality have declined, and a number of childhood diseases are claiming fewer lives. However, the gains have not been as great as one might have expected, given the country's commitment to, and progress in providing primary health care to the population. 1.11 Two factors are largely responsible for Tanzania't failure to translate its commitment to PHC into more dramatic improvements in the health status of its population. If the situation were allowed to continue, even the gains that have been made to date would be undermined. The first factor is the rapid rate of population growth since independence which has made it increasingly difficult for the Government to continue constructing and staffing new facilities fast enough to keep pace with increased demand. Despite its ambitious construction program, the Government is falling further and further behind in neeting its population per facility targets. Throughout the 1970's, the population grer at over 3 percent per annum, eventually outstripping GDP growth as the economy stagnated and income per capita declined. While preliminary results of the 1988 census suggest that the population growth rate may have declined to 2.8 percent per annum, it remains higher than what the economy can easily absorb, and jeopardizes the pace at which gains from the economic recovery can be translated into improved living standards. 1.12 The second factor is the past economic mismanagement which gradually squeezed out the recurrent resources (for pharmaceuticals, medical supplies, salaries) that are required if existing facilities are to function as designed. Between 1981 and 1986, budget allocations for health declined precipitously in real terms; a decline which is even more accentuated on a per capita basis (para 2.53). The lack of drugs and medical supplies has now reached crisis proportions, particularly in referral hospitals and urban PHC facilities which are not covered by the DANIDA-supported essential drugs program (EDP). 1.13 Fortunately, the Government has recognized the importance which both factors play in impeding attainment of its health and other social sector goals, and is actively pursuing strategies to address both issues as part of its reform program. First, after a carefully orchestrated consensus-building effort, supported by an SPPF, the Government will soon adopt a national population policy, with the specific objective of slowing population growth through a lowering of the fertility rate. While the major vehicle for realizing this objective will be the primary health care network - through an enhanced effort in family planning and child spacing activities offered as part of the maternal and child health care program - the national population policy recognizes the need for a wide range of other initiatives, including improved population research and policy-making capabilities, improvement in the status of women, their education and job opportunities, and encouragement of later marriages. The Government held a major donor conference in March 1989 to solicit grant support for its family planning/child spacing activities (primarily training and contraceptive supplies), and the response was very encouraging. The project will complement this support by strengthening the PHC delivery  - 5 - network (paras. 3.09 to 3.26) and the implementat,on of the National Population Policy itself (para. 3.08). 1.14 As stated in paras. 1.03 to 1.07, the secoud issue is being actively addressed under the Government's ERP and its successor, the ESAP, supported by the Bank, Fund and the international donor community as a whole. The initial years of the ERP had necessarily to give precedence in the allocation of limited resources to the productive sectors. It is only in the last two budget years that Government allocations for health have shown an increase in real terms. Within the context of the ESAP, Government has given an extremely high priority to the provision of vitally needed pharmaceutical and medical supplies. The proposed project will make a major contribution in this regard (para 3.06). Recognizing that even with many years of sustained reform effort, the Government will not be able to fund all desired social services from its own resources, it is exploring various alternatives for augmenting budgetary resources by tapping other financing mechanisms in the social sectors (education, health, and water supply). The project will support the Government's effort in the health sector to: Mi) mobilize resources through enhanced community participation (para. 3.14); (ii) review long-term options for financing the sector and implement appropriate resource mobilization mechanisms (para. 3.04 (b)) and (iii) introduce a program of reforms in the pharmaceuticals sub-sector (paras. 3.06 and 3.29). The Government is also revising its PHC strategy in the light of the economic difficulties confronted by the country. Implementation of this strategy is being supported under the project (paras. 3.09 to 3.16). 1.15 Chapter XI provides an in-depth analysis of prevailing sectoral conditions and issues in the areas of health, population and nutrition as they relate to the proposed project. The content of the project takes into account, and is to a large degree based upon, a Bank study of the population, health and nutrition sectors (Report No.7495-TAN), as well as on extensive discussions within Government and between Government officials, Bank staff, and other donors. Given existing and committed future donor support for population activities at the request of the Government, the project does not have a substantial explicit population component, rather as indicated in para. 1.13, it focusses on strengthening population policy implementation and the provision of services through the PHC network, with the Bank taking a supportive role. The Government will continue to utilize donor support, largely for commodity supply and information, education and communication (IEC) activities, with the assistance and coordination of the UNFPA.  I1. SECTORAL CONTEXT AND ISSUES A. Basic Characteristics 2.01 Accurate information on the health and nutritional status of Tanzania's population is limited. On the basis of trends extrapolated from the 1967 and 1978 census data, life expectancy at birth is estimated at about 48 years and the crude death rate at about 18 per thousand population. As in most developing countries, women and children are those most at risk. A 1983-84 survey of institutional deaths in rural health centers and hospitals in four regions (Dar es Salaam, Kilimanjaro, Mbeya and Mwanza) indicated an alarmingly high maternal mortality rate of 3.7 per thousand pregnant women admitted. Infant and child mortality rates are estimated at about 106 and 153 per thousand, respectively. 2.02 The major health problems in Tanzania today, as in many African countries, are infectious diseases (including most of the common tropical diseases), pregnancy-related conditions, and malnutrition. In 1984 (the most recent year for which both mortality and morbidity data are available), the most important diseases were malaria (responsible for 14 percent of child and 13 percent of adult deaths), acute respiratory and diarrheal infections, measles, sexually transmitted diseases (STDs), and tuberculosis; leprosy and schistosomiasis were also significant, and onchocerciasis was endemic in one relatively small area. According to morbidity data collected more recently under the Osentinel6 system established under the EDP, the picture has changed only slightly since then, except that the incidence of some of the important childhood diseases (measles, whooping cough, poliomyelitis, tetanus) have diminished significantly as a result of successful and intensive immunization campaigns. 2.03 While AIDS has not yet claimed a large number of victims in Tanzania compared to other diseases, the high positive HIV seroprevalence among certain population groups and the high rate of STD prevalence in the country (among the tea commonest causes of outpatient attendance) give grave cause for concern. STD prevalence is thought to be both an indication of high-risk behavior and a co-factor in heterosexual transmission of the lIV virus. As of August 1988, 3,718 cases of AIDS had been reported to WHO from Tanzania Mainland, but this total is thought to be a substantial underestimate of the true number. 2.04 Malnutrition and undernutrition, particularly among the highest at-risk groups (infants, young children and pregnant and lactating women), is a serious and widespread problem in Tanzania as in many other African countries. It is a complicating factor in other diseases, increasing the mortality rates for malaria, measles and complications from childbirth. A nutritional survey carried out in 1986-87 found 16 percent of births to be low birth weight, indicating poor maternal nutrition. This same survey indicated that 40 percent of children under 5 years of age were suffering from moderate malnutrition (above the median for countries with very high childhood mortality), while 6 percent were severely malnourished (marginally below the median). The national average calorie intake is estimated at 83 percent of requirements, suggesting that a significant  - 7 - proportion of households in Tanzania consume insufficient amounts of food for nutritional requirements. While the average diet lacks sufficient protein and, to a greater extent, fats and oils, it is also deficient in some important micro-nutrients, notably iodine, Vitamin A and iron. Iodine deficiency is widespread in much of the country, particularly in the mountainous interior regions; prevalence has been estimated at 41 percent nationally. Vitamin A deficiency is very common among children under 5; prevalence is estimated at 30 percent for this age group, and 6 percent for the population as a whole. Iron deficiencies are universal except among the highest socio-economic groups; 32 percent of the population are estimated to be anemic. The impact of iron-deficiency is most acute in pregnant and lactating women and children under age 5, especially following attacks of malaria. B. Realths Policies. Programs, and Issues The Health Services Infrastructure 2.05 Health care in Tanzania is provided by the Government, through an extensive network of facilities at the central, regional, district and village levels, and by a variety of private and semi-private individuals and organizations. The former includes services and facilities of the Ministry of Health (MOH), regional authorities, and district authorities. The latter includes services provided by voluntary agencies (VAs) such as churches and charities, industrial health services provided by certain industries and companies, private services offered by traditional healers and birth attendants, and by moonlighting physicians. In addition, other ministries such as that for local government and community development, agriculture, and public works have important programs which impinge upon the health and nutritional status of the population. 2.06 Government supported health facilities are designed for both primary contact between the user and provider, and for referral of patients to the appropriate next level of care should the initial contact not be equipped to deal with the ailment/problem. The Government's referral pyramid follows roughly the administrative structure of the country; namely, village, ward, division, district, region and zone. 1/ It comprises the followings (a) At the village level, village health workers (VHWs) are trained in basic first aid, sanitation and nutrition education. Tanzania embraced the concept of VHWs after the Alma Ata Conference as a means of delivering PHC at the village level, when it became apparent that budgetary constraints would not allow the construction of a dispensary in every village. To date, however, only about 1,800 VHWs have been trained, covering approximately 20 percent of the villages. 1/ Although "zone* is not an administrative designation, MOH has grouped the mainland's 20 regions into six zones to facilitate supervision.  - 8 - (b) Approximately 2,200 dispensaries have been built, each staffed by at least one rural medical aide (RMA). They are meant to provide both basic curative and preventive care, and to oversee any VUWs in their area. Each serves an average of four villages. (c) Rural health centers (RHCs), as conceived, were to be the nucleus of rural health services, with responsibility for supervising approximately six dispensaries. The 256 built to date are each staffed by a medical assistant (MA) assisted by a team of seven or eight trained health workers. They offer roughly the same curative and preventive services as dispensaries but with some in-patient capacity. Because RHCs do not provide services substantially different from those offered at village dispensaries, they are often bypassed by users in the referral chain, and as a result are largely under-utilized. (d) The 104 district hospitals are meant to offer both primary health care to those in the immediate vicinity as well as basic surgical, medical, maternity and pediatric services to those referred from lower level facilities in the district. Seventeen of these are VA hospitals which have been designated as district hospitals and are financially supported by Government. (e) The 17 regional hospitals offer the same services as district hospitals but have more sophisticated diagnostic and treatment procedures and more qualified personnel. (f) The four consultant hospitals (Dar es Salaam, Mbeya, Mwanza and Kilimanjaro), the first three of which also serve as regional hospitals, offer similar surgical, medical, maternity and pediatric services, but with more advanced equipment and specialized personnel. That in Dar es Salaam, the Muhimbili Medical Center, is the apex medical institution in the country, and includes a medical school. 2.07 As is evident, Tanzania has established a relatively wide and equitable coverage of health care, with public health facilities reasonably evenly spread throughout the country. Generally speaking, the utilization of health facilities is high although there is evidence of some decline due to a lack of drugs. Service standards have declined precipitously in recent years. Moreover, Tanzania should be able to obtain a significantly improved health and nutrition status for its population from the existing system, if it could be made to operate more effectively. Region-wide averages of population served per facility sometimes hide wide disparities among specific facilities. A sample of facilities undertaken by MOHIVHO as part of the PHC Review in 1984, indicated that some dispensaries served only about 1,500 people, while others were expected to serve populations many times larger than the target of 6,500. Major inequalities also exist in human and material resources allocated per facility. 2.08 While major advances have been made in delivering health care to the rural population, the emphasis on addressing this need has led to a major problem which now requires resolution. Tanzania's urban population  is experiencing a crisis in health care: there are far too few facil...ties at the primary level in urban areas. For example, the PHC Review mentioned above found that some dispensaries in urban Dar-es-Salaam were atterpting to cater for over 300,000 people. Urban residents therefore turn to hospital outpatient departments, which as a resilt see thousands of patients every day and cannot provide either adequate consultation time per patient or adequate care for referred patients with more seriuus complaints. Furthermore, as the donor-financed EDP does not supply tertiary facilities, nor primary or secondary facilities in urban areas, thus urban dwellers are not getting the drugs they need for their primary care. The situation in Dar es Salaam is especially serious; not only are there too few facilities at the primary level, but also the three district hospitals no longer function as hospitals because they lack the necessary equipment and supplies to do even simple surgical and medical procedures. As a result, the Huhimbili Medical Center is left as the only functioning hospital for the 1.36 million population. Naturally, its specialist services as the apex medical institution in the country suffer as a result. 2.09 Maintenance of health facilities is extremely poor. Budget allocations for both building and equipment maintenance are often small and/or used for other purposes. There is also a shortage of trained maintenance technicians. As a rule, maintenance personnel are provided by district or city public works units, and bureaucratic procedures, ever when funds exist, hamper effective response to repair requests, let alone appropriate preventive maintenance. Hence buildings and major equipment are generally in disrepair. The situation in Dar es Salaam is a case in point: all three district hospitals suffer from broken plumbing and clogged drains, unsafe wiring, doors and windows broken or missing, and a high proportion of broken/collapsed beds. Health Programs and Institutions 2.10 Following a 1983 decision to place responsibility for the delivery of health care at the local level in the hands of the district authorities, the health delivery system is administered at three levels: (i) at the central level, by the Ministry of Health (MOH); (ii) at the regional level, by the Regional Medical Officer (RMO), who reports to MOH on technical matters and to the Regional Development Director (under the Prime Minister's Office) on administrative matters; and (iii) at the district level, by the District Medical Officer (DMO), who reports to MOH through the RMO on technical matters and to the District Executive Director (under the MLG) 2/ on administrative matters. The MOH has overall responsibility for formulating health policies and strategies for implementing those policies; for planning; and for coordinating health services throughout the country. It currently has responsibility for operating the six central (consultant and special) hospitals and the Central Medical Store (CMS), for r'nning centralized support services and facilities (eg., health manpower development and training, drug procurement), and for operating national (vertical) programs (eg., EPI, AIDS Control). The RMO is in charge of the regional hospital and oversees 2/ Ministry of Local Governments, Community Development, Cooperatives and Marketing (MLG)  - 10 - the planning, management and supervision of all health activities in the region. The DM0 has primary responsibility for PHC at the district level, including administration of the district hospital, RHCs and dispensaries, as well as supervision, in-service training and support of all district health workers. In the latter capacity, he heads the district health team, which includes, inter alia, district coordinators for each of the special vertical programs managed from the center, however he frequently fails to have real control over these problems. 2.11 TLks organizational structure of the NOR is given in Annex 1.1. It is divided into five departmentss (i) health planning and (ii) administration, which report directly to the Permanent Secretary (PS); and (iii) hospital services, (iv) preventive services, and (v) manpower development and training - the technical nucleus of the Ministry - which report to the PS through the Chief Medical Officer, who is also responsible for overseeing regional health services. While the broad organizational structure of the MOH has remained largely unchanged since 1975, 3/ the role and responsibilities of each of the departments are currently being scrutinized to ensure that they are capable of fulfilling the changing role of the Ministry as an strategic policy and strategy formulating body. As part of this effort, the PHC Steering Committee and Secretariat was re- established in late 1988 as an in-house "think tank' to consider a number of basic issues regarding the future role and structure of the Ministry. The PHC Steering Comvittee is chaired by the Chief Medical Officer and cwposed of the Assistant Chief Medical Officers in charge of each of the technical departments and the head of the Planning Department. It is currently reviewing the PHC strategy to take into account curre.t budgetary constraints, the decision to decentralize delivery of health services, and the successful and unsuccessful experiences under past and ongoing programs. 2.12 The Department of Health Planning (the organizational structure of which is described in Annex 1.2) was, until recently, a small planning unit, responsible only for preparing the annual development budgets and for architectural design of new facilities. When it was upgraded to departmental status in 1985, it was given much broader responsibilities, more appropriate to the increasing complexity and size of the health system and to the changing role of the MOB. Its new responsibilities include, for example, establishment of a national health information system (HIS), coordination of external aid in the health sector, coordination of health systems research, and more thoughtful analysis of short-term and long-term development needs and priorities in light of budgetary constraints and changing epidemiological patterns. The establishment of a satisfactory HIS is of particular priority, if decentralization is to work. Up-to-date epidemiological information is needed both by local authorities for priority setting in the management of staff and other resources, and by central authorities for the compilation of national level data and the formulation of national health policies. Currently, data is collected at the facility level by the various special programs on separately designed 3/ Between 1985 and early 1989, MOB also had a Department of Social Welfare, which currently resides in the Ministry of Labor, Culture and Social Welfare.  - 11 - forms and forwarded by diverse channels to their program heads at headquarters. This is not only burdensome to health workers, but the information is not systematically pulled together and analyzed nor are the results fed back to local authorities. 2.13 Unfortunately, the department is not equipped to fulfill its enhanced role. Only 11 of the 32 approved positions are currently filled, and many of those on the job have not had training appropriate to their expected function. Particularly serious is the lack of a permanent director for the unit, a public health specialist, senior economist, senior statistician, and an epidemiologist. The existing economists, statisticians and architect:, while dedicated professionals, were, with few exceptions, trained in fields other than health planning. They are, however, slowly acquiring the appropriate skills through short-term and on- the-job training. The unit is further hampered, as indeed is the entire Ministry, by the lack of appropriate space, equipment and materials. 2.14 The Department of Hospital Services has responsibility for supervision of the four consultant hospitals and two special hospitals, and for providing technical advice to regional and district authorities for hospitals and rural health facilities within their jurisdiction and oversees relations with NGOs involved in providing health care. Thus the Department's overall function is to manage the health care system, the mrachinery which delivers health care. -.mportantly, it also operates the CMS, determines the supplies requirements for all hospitals in the country, and helps manage the supply requirements for rural health facilities, including the Essential Drugs Program (EDP). 2.15 The Central Medical Store (CMS) is responsible for supplying health facilities with drugs and other materials, but the system works imperfectly. In theory, CMS orders supplies on the basis of needs estimates prepared by the facilities themselves; supplies are delivered to the CMS warehouses in Dar and are distributed from there to five zonal stores, from which they are delivered to the regions, and from there to the districts, which in turn supply dispensaries and RHCs. As an exception to this general rule, drugs supplied by UNICEF under the EDP go directly to the zonal stores for further distribution, and vaccines supplied under EPI are delivered directly to the districts. In practice, except for drugs provided under the EDP, supplies have been very uneven, due both to budget constraints and poor planning. When needed supplies do not arrive on time, facilities purchase what they need locally if funds exist, improvise (for example, bits of torn waste paper may be used as registration forms), or do without. The MOH is aware that the system is no longer functioning adequately, and is seeking donor assistance to rectify the problem. 2.16 The most serious problems faced by this department stem from the gross shortage of funds available for drugs and medical supplies. These problems are exacerbated by deficiencies in the operation of the CMS and in the allocation and budgeting of funds for drugs through the Ministry of Local Government. Scarcity of pharmaceuticals and other basic medical supplies has become the most crucial constraint in the delivery of effective PHC services in the immediate term. In early 1989, the only significant supplies of pharmaceuticals in the country came from the donor- funded EDP, with virtually no supplies for the referral system. Moreover,  - 12 - with the exception of donor-financed medical supplies linked to vertical or area-based health programs, virtually no medical supplies have been procured utilizing GOT funds for the last three years. It is vital that the procurement and financing of these key inputs be established on a firmer and more sustainable basis. This requires some important policy reforms including: (i) financial reform of the Central Medical Stores (CMS); (ii) improved pricing and procurement policy for pharmaceuticals; (iii) increased budgetary allocations for pharmaceuticals and medical supplies; and (iv) improved management, efficiency and physical facilities for the CMS. The pharmaceuticals sub-sector is so central to the health sector, that it is covered in greater detail in Annexes 6 and 8. 2.17 Recognizing the importance of these issues, the MOH has made the establishment of an adequate pharmaceuticals and medical supplies system its number one priority. This is accordingly reflected in the ESAP, the shortly-to-be approved National Drug Policy and a study to develop an updated master plan for the CMS. In this context, the MOH, with support from the Ministry of Finance (HOF), is prepared to proceed with an integrated set of reforms and is requesting external assistance in their implementation. 2.18 The Department of Preventive Services is responsible for managing programs dealing with specific health problems and has broad responsibility for collecting and analyzing epidemiologic data, establishing guidelines for disease control, supervising environmental health, sanitation, school health and health education programs. Its most significant responsibility, however, is that for operation of most of the nationwide programs managed centrally, most importantly, (i) the maternal and child health (MCH) program, which includes the Expanded Program of Immunization/ Universal Child Immunization (EPI/UCI), family planning and child spacing programs, and nutrition surveillance; (ii) the village health worker (VHW) program; (iii) the TB/leprosy program; (iv) the National AIDS Control Program; (v) the diarrheal control program and a variety of lesser programs. 2.19 This department has been most effected by the addition of new programs and responsibilities in the MOH over the past decade as unmet needs were identified. While these vertical programs have individually been quite successful in dealing with the problems or issues they were created to resolve, the proliferation of vertical programs, with their own systems of supplies and support to health facilities, has gradually resulted in growing inefficiencies and duplications. The integration of these programs more fully into the delivery of primary health care at the local level becomes all the more pressing as the Government attempts to operationslize its decentralization strategy. The problem is perhaps epitomized by the MCH program. Though key to the delivery of primary health care at the local level, the program still functions relatively independently of the health services hierarchy, with MCH staff reporting more to their MCH supervisors than to the health worker in charge of the facility where they work. This issue is one of many being addressed by the PEC Steering Committee in its formulation of a revised PHC strategy (see also paras. 3.09 to 3.14 and Annex 10).  - 13 - 2.20 The Department of Mapower Dewlopeut and TrainiAg (DMDT) has responsibility for determining manpower requirements for the entire health uystem; piL-ning and implementing all health manpower training (except that of doctors which is done by the Faculty of Medicine under the supervision of the Ministry of Education); and formulating career development strategies for health staff, including in-service educational programs. The Department operates 98 schools throughout the country for basic and upgrading training of nurses and allied health manpower, with a total enrollment of approximately 7,500, and the Centre for Educational Development in Health, Arusha (CEDHA), responsible for teacher training, research and curriculum development, continuing education, and production of health learning materials. 2.21 Tanzania has been unusually successful in producing well-skilled health staff in large numbers since independence; some 21,000 health workers (doctors, nurses, medical assistants and aides) are currently employed. It has done this at a reasonable cost by encouraging the use of auxiliary health staff; for example, in 1987, the ratio of assistant madical officers and medical assistants to doctors was four to one. It has also relied to a large extent on the upgrading of staff 'in service' and on using iocal training institutions. This has provided a sound career development strategy and allowed a high rate of retention. 2.22 Given the size of the health labor force and the implications this has on the Government's budget in terms of training and salary support, it is essential that the assessment of health manpower needs be based on sound criteria and that their skills are appro":iately developed and maintained. However, despite this positive overall picture of the health manpower situation, there are several indications that the DMDT is not adequately addressing some of its very important responsibilities. First, manpower planning, as such, has been based on simplistic assumptions regarding appropriate staffing standards for each type of facility, without reference to either variations in workload or disease patterns, or to resources available to meet implied salary costs or complementary inputs. 'Staffing standards' approved by the Ministry in late 1987, which more than doubled those previously in effect, are clearly outside the resource capacity of the health sector for many years to come, and fail to acknowledge that existing health staff are unable to perform at full capacity now because they lack the necessary materials and supplies. Second, the curricula of the basic training institutions have never been appropriately revised to reflect the primary health care strategy, so that each of the vertical programs (EPI, MCH, family planning, etc.) finds it necessary to retrain even newly graduated health workers in the specifics of service delivery. This approach is not efficient, resulting an extensive absences of some staff from theit jobs, duplication of effort and/or inconsistency between training courses. Third, while considerable effort is being put into updating health learning materials to make them consistent with today's needs, the department is unable to ensure that they are delivered where they are needed in a timely manner. For example, hundreds of copies of the essential drugs handbook have remained stored in Dar since January 1989, rather than reaching the health workers who are expected to use them. And fourth, the quality of training being undertaken is, in some instances quite -oor, largely because the DMDT has not devoted sufficient effort to supervision.  - 14 - 2.23 Fortunately, the DMDT has already begun to address these deficiencies. With regard to manpower planning, the department has solicited the assistance of a WHO-financed specialist, who is assisting its manpower planning unit to undertake a new assessment of local staffing requirements based on the annual workload at each facility. The method being employed correctly involves the district health management team and, once elaborated, can be used as an ongoing management planning tool at the district level as well as an aid in projecting training reqsirements nationwide. Pro forma workload indicators developed in a preliminary workshop in October 1989 are being applied on a trial basis in two districts (Temeke district in Dar-es-Salaam region and Kilosa district in Morogoro region). These will be revised and retested in all districts of those regions before preliminary application nationwide. Evaluation of the entire exercise will be completed by about September 1991. 2.24 Once an assessment has been mie of manpower 'needs' based on sound criteria, a manpower development '-;.an should be formulated jointly by the DMDT and the Planning Department, t. Lng into account the resources likely to be available to the sector over time, and the need to allocate sufficient recurrent budget to non-salary expenditures if those health workers employed are to be effectively utilized. The output of the training institutions would be modified as necessary to reflect this long- term manpower development plan. 2.25 With regard to its other deficiencies, DMDT carried out an in- house review, which concluded that they result from both a shortage of staff with appropriate qualifications, and less than effective use of the staff who are available. Only one person in the department has had graduate level training in health manpower development, and he is stretched too thinly, having important responsibilities outside the division which he heads. The time of existing professional staff is too often taken up with administrative and clerical tasks rather than responsibilities more suited to their skills, due in >art to the low skill level of existing clerical staff, and in part to the lack of carefully defined job descriptions for professional staff linked to the department's priority functions. The in- house review recommended that an inspectorate be established to oversee teaching quality, and that technical, administrative and logistic functions be allocated to specific staff in each of the department's four divisions. Interestingly, if staff had suitable qualifications, it may even be that fewer staff would eventually be needed, with resultant savings in the salary bill. 2.26 The changing role of the MOH has presented another major challenge to the DMDTs to help prepare district health teams to take over the management responsibilities implied by the decentralization of health services. Not only is the DM0 to have responsibility for managing resources available to the health sector in the district, including their allocation among various programs, but also the DMO will be expected to take over responsibility for the in-service training of district health staff, the underlying assumption being that the day-to-day supervisors of district health workers are most cognizant of their needs for refreshing skills, and the changing demands on their time. The DMDT is therefore laying the groundwork for two ambitious training programs: the first,  - 1S - designed to give DMOs the management skills required to run large and complex health programs responsive to the PHC needs of the population; the second, designed to train district health teams (a) to recognize the training needs of their staff, (b) to formulate programs suited to those needs, and tc) to undertake the training. In order to carry out these programs, the DMDT has decided to create six zonal training centers, each responsible for the training of district health teams in three or four regions. Six existing training institutions would be used for this purposet CEDHA in the north, and training schools in Mtwara (south), Morogoro (east), Kigoma (west), Mwanza (lake), and Mbeya (southern highlands). Minor extensions to existing facilities will be required, except in the case of CEDHA where adequate facilities already exist. C. Populationt Policies, Programs and Issues Population Policies 2.27 The government has a long history of interest in and action on population issues. For example, concern over the difficulties of concentrating and serving a scattered rural population led to the evillagization, program of the 1970s which was, in effect, a national population redistribution policy. The government also early accepted the concept of child spacing as a desirable element of maternal and child health care and family welfare and supported the development of the Family Planning Association of Tanzania (UMATI) in the 1970s. 2.28 Tanzania's will soon adopt a comprehensive National Population Policy, reflecting the culmination of more than a decade of gradually growing concern over the socio-economic effects of rapid population growth, particularly the pressure on government educational, health and other welfare budgets. Recent economic shocks, recession and drought reinforced this concern. Against this background, two international conferences - the 1984 Second African Conference on Population, which gained impact from being held in Arusha, and the 1985 International Conference on Population in Mexico - caught public attention and awakened widespread interest in population growth among members of the Party (Chama Cha Mapinduzi - CCM), government and general public. These were followed up between 1984 and 1987 by a series of seminars and workshops on population and development, family life education and child spacing for government and Party officials and MPs, organized by UNFPA and UMATI with assistance from other bilateral and multi-lateral sources. 2.29 The recently-created Population Unit in the Human Resources Division of the Planning Commission (PC) has had the responsibility of drafting the policy. The Population Polic; Unit set up seven task forces covering different aspects of population issues, including (i) health, fertility and family planning; (ii) agriculture, food and nutrition; (iii) labor, employment and productivitys (iv) socio-cultural and legal aspects of population: women, youth and the elderly; (v) population, resources and environment; (vi) information, education, and communication; (vii) training, research, evaluation and statistics. These task forces were staffed by rembers of appropriate Ministries and government agencies, together with university professors and representatives of national organizations of women, youth, labor, UMATI etc. Upon completion of their  - 16 - reports, a number of seminars were held vith opinion leaderst and other interested parties financed by a SPPF provided by the World Bank to acquaint them with the findings of the task forces and to build a consensus for the emerging population policy. The Population Unit is now finalizing the arrangement for implementation which include the creation of the Tanzanian Council for Population and Development (TCPD), to determine future policy issues with respect to population, and will be composed of Ministers from 18 ministries, together with senior representatives from 7 party organizations and 4 religious organizations. Technical matters will be dealt with by the National Population Committee. The Population Policy Unit will serve as a Secretariat to both bodies. 2.30 .mongst its key objectives, the draft policy aims to: (i) integrate population variables into planning; (ii) improve the standard of living and quality of life of the population through protection of the environment and enhancing the provision of basic human needs; and (iii) achieve lower population growth rates through reduction of the birth rate by voluntary fertility regulation. The specific (and ambitious) targets are to: a) reduce the current estimated proportion of women who get married before age 20, by 50 per cent by the year 2000, in order to protect the health of the mother and child; b) achieve an average birth spacing of at least two years interval, by taking steps to attain a contraceptive prevalence rate of at least 30 percent by the year 2000; c) direct a significant proportion of the family planning program, in terms of family life education and appropriate family planning services, to all adult males by the year 2000; d) reduce the number of children a woman is likely to have during her lifetime (the Total Fertility Rate) now estimated at 7, to 5 by the year 2000; e) lower the infant mortality rate to at most 80 per 1,000 livebirths by the year 2000, through the improved provision of basic social services; and f) decrease maternal mortality from the present level of 200 per 100,000 by 25 percent by the year 2000, through improving access to and quality of services, and through fertility regulation. Population Programs and Institutions 2.31 Responsibility for population and family planning activities in Tanzania is shared by several institutions. In the field of family planning services, the MOH and UMATI take joint responsibility. For example, NOH is responsible for pre-service training of "alth workers in family planning through the introduction of appropriate courses into the basic pre-service training curricula, while UMATI offers in-service training for MNH health workers who received their basic training prior to this introduction or whose skills are felt to require upgrading or  - 17 - refreshing. UMATI is also responsible for commodity support, that is, it distributes contraceptive supplies received from donors (mainly IPPF and UNFPA) not only to its own regional offices, but also to MOH regional headquarters, from whence they are distributed to health facilities. MOH takes full responsibility for provision of family planning services in its facil.'ties, including routine supervision of health workers. 2.32 In the field of family planning demard creation and IEC (information, education and communication) activities, responsibilitiee are shared among a larger number of institutions, and the demarcation of tasks is less clear. Generally speaking, however, the division of roles is as follows: (a) UMATI has main responsibility for developing !EC activities directly related to family planning and its health benefits to mothers and young children; (b) MOH coordinates integration of this family planning education into its general health education program at health centers, dispensaries and hospital out-patient departments; (c) The Prime Minister's Office and the WAZAZI wing of the party network have concentrated on efforts to educate the public on the socio-economic consequences of large families; (d) The Ministry of Education (MOE) is responsible for the introduction of population education in the school curriculum, through a committee which includes representatives of MOE, MOH, UMATI and the Planning Commission. (e) A so far largely untapped IEC resource is the CCM, through its grass-roots organization. Once the National Population Policy has been adopted, the Party is expected to take a vigorous and leading role in this area. Coverage. Quality and Utilization of Family Plannins Services 2.33 An important achievement of recent years has been a dramatic increase in the accessibility of basic family planning services. About 85 percent of MCH clinics, and 79 percent of health facilities, now provide some kind of child spacing services (at least counselling), compared with around 40 percent some five to seven years ago. Over half of all MCH clinics provide a reasonably complete range of services. 2.34 The adoption by MOH in 1983 of the "National Child Spacing Program' stimulated most of this progress. Since then UMATI (jointly with HOH) has trained at least one or two members of each regional MCH Team (which consists of the Regional MCH coordinator, the RMO or his representative, the Regional Cold Chain Operator and the Regional Health Officer) as Trainers for their health staff in family planning communication and clinical skills, including IUD insertion; and this training has in turn been carried out, to varying degrees, in all regions. In addition, about 800 MCH aides and 100 public health nurses have received intensive four-week in-service family planning training courses directly  - 18 - from UMITI. Funding for most of these training activities by UMATI come from donors, notably UNFPA, SIDA and DANIDA. 2.35 Despite these improvements in coverage of family planning services, utilization is still very low. In the absence of good service statistics and contraceptive prevalence surveys, reliable estimates of contraceptive acceptance and use are impossible, but estimates by UMATI based on quantities of contraceptives distributed suggest that, at most, about five percent of women in the reproductive age groups are currently using modern contraceptive methods, and about eleven percent have ever used them. Another estimate by a UNFPA mission gives a figure of between five and six percent for 1986, of whom 85 percent are using oral contraceptives. Drop-out rates are high; UMATI estimates that 75-80 percent of rural acceptors discontinue use vithin a year, although continuation is usually much higher in urban areas. 2.36 At the same time, however, unmet demand for family planning is thought to be considerable. The discrepancy between apparently high demand and low utilization is to a large extent due an iacomplete integration of family planning into health services and a shortage of contraceptive supplies and equipment. Cognizant of these issues, the MOH convened a donors conference in March 1989 to solicit support for an expanded program of family planning. Substantial support has been pledged from NORAD, SIDA and USAID for IEC activities, and from UNFPA and USAID for training and contraceptive supplies. Together with the impetus of the National Population Policy, this support should be sufficient to enable the Government to close the gap between supply and demand of family planning services, generate increased demand and increase quality and effectiveness. D. tftritions Policies, Programs, and Issues Prevalente of Malnutrition 2.37 The nutritional surveillance system in Tanzania is underdeveloped, although UNICEF is assisting the Tanzania Food and Nutrition Centre (TFNC) in building up such a system. TFNC did undertake an important survey of child malnutrition during November 1986 - May 1987. This survey aimed to cover at least three health facilities in one district of each region, with an attempt to include one facility each in poor, rich and middle income areas. Broad results are shown in Table 2.1 and in Charts 2.1 and 2.2. 2.38 Based on the same survey, TFNC made national estimates of malnutrition for different population groups. These indicated that 80 percent of pregnant women suffered from anemia, 52 percent from iodine deficiency, and 13 percent from Protein-Energy-Malnutrition (PEH). School children and other adults showed hiigh prevalence of iodine deficiency (48 percent), and high levels of anemia (23 percent) and moderate malnutrition (22 percent). In this population group vitamin A deficiency was low (0.1 percent), being only a significant problem in children under 5 (30 percent). For the population as a whole, TFNC estimates prevalence of iodine deficiency at 41 percent, anemia 32 percent, PEM 27 percent and vitamin A deficiency 6 percent (see Table 2.2, Charts 2.3 and 2.4).  - 19 - 2.39 The 1986-87 survey found 16 percent of births to be low birth weight, an indication of poor maternal nutrition, while 40 percent of children under 5 years of age were suffering from moderate malnutrition and 6 percent from severe malnutrition. On the basis of these results, TYNC estimates that 1.8 to 2.6 million children in Tanzania (40-60 percent) are moderately malnourished (including the effects of both past and current undernourishment), and 180,000 - 260,000 (4-6 percent) severely malnourished. The prevalence of moderate malnutrition is above the median (31 percent) for countries with very high childhood mortality, but the prevalence of severe malnutrition is below the median of 7 percent; the incidence of low birth weight is around the median for Africa (see UNICEF, State of the World's Children, 1988). There are wide variations between regions in all indicators, which seem primarily related to general level of development. There appears to be no correlation between child malnutrition indices and adequacy of food production at the aggregate regional level; for example, the two regions of highest surplus food balance (Rukwa and Ruvuma) show the fifth and sixth highest levels of total malnutrition. TFNC found no evidence of any trend since 1960 from the various spot surveys conducted, except in areas where specific multi-sectoral nutrition intervention programs like the Iringa JNSP had been undertaken. Table 2.1 Nutritional Status of Children Under 5. 1987 Region Number Average Percent Percent Percent of Birth Low Birth Moderate Severe Clinics Weight Weight PEH PEM (kg.) Arusha 2 3.2 2.8 2.9 0.9 Dar es Salaam 4 3.0 18.0 33.0 4.5 Dodoma 3 3.1 0.7 39.3 4.0 Iringa 4 2.8 25.5 37.0 1.0 Kagera 3 3.0 8.7 68.0 8.7 Kigoma 3 3.1 4.8 23.1 11.3 Kilimanjaro 3 2.9 8.0 26.7 2.7 Mara 3 2.5 n.a. 24.5 7.2 Mbeya 3 n.a. n.a. 34.5 6.8 Morogoro 5 2.8 15.4 44.6 3.4 Mtwara 7 2.9 6.9 49.2 6.6 Mwanza 3 3.1 6.0 66.9 12.0 Pwani (Coast) 3 2.7 11.4 76.7 15.3 Rukwa 3 n.a. n.a. 47.1 14.3 Ruvuma 5 2.7 17.9 46.9 5.2 Singida 3 2.9 0.0 42.7 4.0 Shinyanga 4 2.9 13.7 41.8 6.4 Tabora 3 3.0 10.7 24.7 4.7 Tanga 3 2.8 9.9 21.4 2.1 Average for Tanzania 3.5 2.9 16.0 39.6 6.4 Sources TFNC Surveys, November 1986 to May 1987. Note: Survey data are not based on a truly random sample.  Percent Low Birth Weight of Children Under 5 1987 Region Arusha Dar es Salaam Dodoma Iringa - Kagera H Kigoma Kilimanjaro Mara - n.a. Mbeya -na Morogoro __ Mtwara Mwanza Pwani Rukwa n.a. Ruvuma _f_ . Singida _ Shinyanga _ III Tabora _ Tanga _ , __ ,_i___ij 0 10 20 30 40 50 * Percent Low Birth Weight  Nutritional Status of Children Under 5 1987 Region Arusha Dar es Salaam ... .. . ..... Dodoma . . Iringa ..... ..... . i . i KIgoma i Kilimanjaro ........ Mara .._.._.___i_ M beya ................ ------- Morogoro ................ ........ ara ..........~~~~~.... ........ Mwan a . .. ... ~~~.......... ... .....| . . . . . . . . ..... . ... Mtwara........ Mwanza ..... ........................ Pwani ............. Singida ~~~~~~~~~~....... . . ........... .......... ..... ......................l.l Rukwa ..... .......... :: _l Ruvuma..................... Singida ..... Tanga Tabora ... 0 20 40 60 80 100 * Percent Severe PEM [ Percent Moderate PEM  - 22 - Table 2.2 Estimated Prevalence of Malnutrition In Sanzania 1986-87 Population Group Pregnant Children School Total Vsno c 5 years Children & Other Adults Type of Malnutrition S No. I No. S No. Z No. Protein-Energy Malnutrition 13 91,000 52 2,280,000 22 3,700,000 27 6,070,000 Anemia 80 1,200,000 45 1,980,000 25 4,400,000 32 7,580,000 (Iron Deficiency) Iodine Deficiency 52 760,000 13 570,000 48 7,900,000 41 9,320,000 Vitamin A Def. 0.7 10,000 30 1,330,000 0.1 18,000 6.1 1,350,000 Sources TFNC estimates, 1987. Nutrition Programs and Policies 2.40 The health system plays an essential role in the dealing with malnutrition, particularly for the most vulnerable group, mothers and children. Among the activities included in the various special programs run by the Department of Preventive Services which promote good nutritional status ares (a) prenatal care of pregnant women, to protect both maternal and infant health; (b) promotion and support of breast-feeding and good weaning and child feeding practices; (c) surveillance of child growth through periodic weighings and recordings on the growth chart, to alert health workers and mothers to nutrition problems as they develop; (d) immunization of children against infectious diseases such as measles that can interrupt good feeding and growth; (e) oral rehydration therapy, to minimize nutritional losses from diarrheal diseases; (f) nutritional rehabilitation of severely malnourished children; and (g) family planning, to ensure adequate spacing of children and reduction of high-risk pregnancies which could result in the death or debility of a mother.  Estimated Prevalence of Malnutrition in Tanzania 1986-1987 Number 10,000,000 6,000,000 - --------- - . 6,000,000 . .-. _ --_ 4,000 00____. ._..... 2,000,000 . . .6 0 Protein Energy Iron Deficiency Iodine Deficiency Vitamin A Malnutrition (PEM) Anemia Deficiency Type of Malnutrition * Children Under 5 Pregnant Women M School Children & other Adults  Estimated Prevalence of Malnutrition in Tanzania 1986-1987 3,700,000 A 91,000 - 18,000 \ t ~~~~~~~10,000 | 1 760,0000 2,980,000 Pregnant Women 7,900,000 . | | 1 School Children * Protein Energy Maint & Other Adults Aei 1.980,000 I lodine Deficiency 1,330,000 ] Vitamin A Deficiency 570,000 Children Under 5  - 25 - 2.41 While the health system is thus designed to support the nutritional status of the population, nutritional issues go well beyond the health sector. Malnutrition is a problem with multi-sectoral determinants$ general income level, food production, disease and health status, water and sanitation, the workload of mothers, feeding customs, and nutritional knowledge. Approaches to preventing and treating malnutrition must therefore also be spread across many sectors. 2.42 In recognition of this reality, the Government established, in 1973, the Tanzania Food and NutrAtion Centre (TFEC), to provide a multi- sectoral overview for nutrition. TFNC is a parastatal with an inter- disciplinary Board attached to the Ministry of Health. Its mandate includess (a) planning and implementing a national food and nutrition program; (b) advising the government on nutritional matters; (c) providing nutrition training to health, agricultural and community development workers; (d) undertaking nutrition education of the public, (e) ensuring proper nutritional value of marketed food; and (f) carrying out nutritional research. 2.43 TFNC has accomplished a great deal since its foundation, with financial support from external donors, notably SIDA and UNICE3. Through its research and publications, knowledge of the nutritional situation in Tanzania has been greatly improved. A national nutrition education campaign UChakula ni Uhai (Food is Life) has been conducted. A national nutrition policy has been drafted, and is in process of being approved. To date a wide range of nutritional activities have been undertaken ranging from research on food storage, nutritional content, weaning practices, traditional food taboos and preparation methodologies. 2.44 TFNC has also devoted a lot of effort to micro-nutrient deficiency programs given their public health importance in Tanzania (see Table 2.2 and Chart 2.3). A program to combat iodine deficiency disorders (IDD) has been developed, and donor support obtained from the Netherlands (for salt iodination) and SIDA (iodized oil). The first five-year national program to combat Vitamin A deficiency is almost completed and is currently being evaluated. A second five-year program based on an interim evaluation of the first such program has been developed and requires finance so that it may commence in July 1990. A similar program for iron-deficiency anemia is under development, although further operational research is essential to determine an effective strategy. 2.45 In addition to the programs implemented or envisaged by TFNC, a number of nutrition-focused projects have been initiated in Tanzania. The largest of these is the Joint (VROIUNIC0F) Nutrition Support Prograi_e  - 26 - (JISP) i whose objective is the development of caumnity-based iwmrovements in nutrition and health, including amelioration of the situation of women. An important feature of the program, made possible by Tanzania's extensive local government system, is its reliance on existing regional and district development structure. A six-month preparation stage entails training of regional and district development staff, social mobilization to identify interested villages, election of village health committees with at least a minimum number of female members, selection of both a male and a female YEW, and preparation of a village register. Program activities at the village level are begun with an information film and a "campaign" day during which all children are weighed and, if necessary, immunized. Subsequently, each village has a 'health day, once a month or once a quarter for child weighings, immunizations, etc. Other activities added over time in selected villages in response to recognized problems have included informal day care for children of mothers working in the fields, vegetable gardens, small livestock raising, introduction of grain mills and other labor-saving devices such as more fuel- efficient stoves. 2.46 The Iringa Nutrition Programme (which commenced in 1983) is fully integrated into existing administrative structures. In the villages, the Village Health Committees, together with the Village Health Workers, are responsible for programme implementation and follow-up. Every three months they weigh all children under five years of age, compile the growth monitoring and child death information and discuss the reports with the Village Councils, which then take action within their power to address the problems which have been identified. The reports are then sent to the higher administrative levels, which include the Ward, the District and the Region, so that problem areas or villages can be identified and provided with special support. Critical activities aimed at increasing and sustaining people's capacity to tackle nutrition problems have included actions to increase accessibility to information about nutrition, the establishment of the village-based nutritional status and death monitoring system and integrated training. The programme also provides support to areas identified as crucial for the improvement of the nutritional status of children and women. 2.47 An evaluation of the program carried out in 1988 indicated significant improvements in the nutritional status of children. In the 168 villages included, the proportion of severely malnourished children dropped from 6 percent in 1984 to less than 2 percent in 1988, while the proportion of underweight children dropped from 56 percent to 38 percent over the same period. Although the start-up costs in the initial years we.e relatively high (US$25 per child per annum) as training, monitoring and supervision systems were being established, these have dropped substantially (now estimated at less than US$5 per child per annum) as experience has developed. After about 3-5 years, the villages are expected to be able to sustain the activities themselves with only limited supervision or technical support from outside. In view of the success to date, the program is currently being extended to Norogoro, Shinyanga, Rukwa, Kagera, Ruvuma, and Kilimanjaro regions, as well as Zanzibar with UNICEF support and financing from a variety of donors. Moreover, the Government is now trying to extend the approach to all other regions and has convened a National Coordinating Committee on Child Survival 41 Renamed the Iringa Nutrition Programme in 1988.  - 27 - and Development (NCC CSD) under the Planning Commission to oversee this process. 2.48 Tanzania has long recognized the essential role which clean water and sanitation play in maintaining the health and nutritional status of the population, and has given considerable priority to providing both potable water and sanitation systems. In urban centers, improved water supplies have been built to serve some 50-70 percent of the population, and in rural areas, about 45 percent: however, in both cases problems of inadequate maintenance and rehabilitation reduce the number actually served to about 25 percent. Host urban centers also have mains sewer based sanitation systems (serving perhaps 10-15 percent of the population), supplemented by septic tanks, cess pits or pit latrines. About 80 percent of the rural households have latrines, three-quarters of which are considered suitable by MOH. Generally speaking, however, expansion of both water and sanitation services is only just keeping pace with population growth, and greater efforts are needed in order to make substantial imprcvements. S. Expenditures and Financina Sources of Funds 2.49 The financing of the health sector in Tanzania is complex, with Government fundi.ng channeled through four sources: (i) the MOH - responsible for financing National Programs, e.g., AIDS cor.trol, referral hospitals and a variety of parastatals; (ii) the hLG budget - which provides the subvention to the districts to run dispensaries, RHCs and key programs; (iii) revenues of the District and Urban Councils from the development levy and other locally generated sources; and (iv) the Prime Minister's Office (PMO) budget - which essentially covers regional and district hospitals. Other sources of funding include the Voluntary Agencies (VA), which themselves receive subventions from the NOH, and multilateral and bilateral donors. All health care is officially free at Government health facilities, although some small charges have been levied for higher quality rooms in hospitals, and there is growing evidence of unofficial payments by clients in order to have access to scarce services, particularly in the urban areas. Users of VA facilities pay fees which are used to defray facility a substantial proportion of costs. The Government is now examining introducing a resource mobilization options for many types of health care, realizing that the government budget is inadequate to meet the demand for quality services. Much is also spent in the private traditional sector, but no precise estimates of such expenditure are available - in rural areas the payment is usually in the form of a gift in kind based upon successful treatment, although in urban areas there is a growing trend for traditional healers to require cash payments in advance. Another source of finance for the health sector is the contributions of communities. This has generally taken the form of construction of dispensaries by villages and the payment of village health workers (VHWs) either in cash or kind. While experience with such community mobilization has varied from location to location, such a means of mobilizing resources (specially for PHC) has much to commend it. Greater community participation and contribution is the most acceptable form of resource mobilization in Tanzania culturally. 2.50 Central (Mainland) Government development and recurrent expenditure for health for FY88189 was budgeted at TSh 6,567 million, of which  - 28 - 47 percent came through the MOH budget, 28 percent was through the MLG budget, and 25 percent was through the Office of the Prime Minister's Office/Regional budget. Of the MLG expenditure, 68 percent was budgeted to go to District (rural) Councils as subventions for recurrent health care and 24 percent similarly to Urban councils; the balance b6ing for development expenditure. The MLG subventions are expected to cover 70-80 percent of Government facility costs at District and Urban level, with the remaining 20-30 percent to be raised by District and Urban Councils from their own internal sources. Total Government health spending budgeted in 88189 would amounted to about TSh 7,300 million, depending on the extent to v'ich District and Urban Councils were able to fully complement the MLG subvention with funds, or about 6.5 percent of Government consolidated budget. 2.51 VAs receive a large part of their funding from government, which subsidizes 100 percent of the operating costs of the 17 VA hospitals designated as District hospitals and provides both staff grants (full salary at Government scale for 'certified, staff) and bed grants (TSh 1,000 for each 'approved' bed) to other VA hospitals. For FY88189, TSh 298 million was allocated in the budget for 'designated District hospitals" and TSh 69 million for other VA hospitals, amounting, on average, to about one-third of VA hospital operating funds. Another one-third of VA funding comes from users fees. The remaining third comes from external sources. Because Government subsidies are calculated on a per-bed basis, they have been criticized for creating incentives to favor inpatient over outpatient care. 2.52 Tie most important donor contribution to the Tanzania health care system, at least for operating costs, has been from DANIDA (through UNICEF), which between 1983 and 1987 provided nearly US$ 30 million in drugs and medical supplies. The total annual inflow, from all donors, is now around US$ 11 to 12 million of donor provided pharmaceutical supplies. Districts are expected to pay the CMS for drug kits delivered to RHCs and rural dispensaries within their jurisdiction, since their development levy, in theory, has been calculated to cover the costs of such kits. In practice, however, the Districts frequently do pay the CMS for drugs received, first, because the budget allocation for drugs is often insufficient to cover the full costs of the kits; second, and more importantly, because the Districts run short of funds, with their own revenues insufficient. The facilities themseLves have no user fee revenues. VA RHCs and dispensaries are able to pay CMS more regularly for drugs received, as they charge fees for services provided. In aggregate, CMS recovers about 50 percent of the cost of these drug kits. Expenditure Levels 2.53 Over the period 1980/81 - 1986/87, aggregate central government expenditures on health rose nominally but declined by 9 percent in real terms. In an attempt to improve the resource position of the sector, total central budgetary resources for the health sector were increased in nominal terms by 43 percent between 1986/87 and 1987/88 and by a further 41 percent between 1987/88 and 1988189, was an increase of 11 percent in each year. The situation is not so encouraging if viewed on a per capita basis. Between 1980/81 and 1985/86, central government resources (including the MLG budget) for health, on a per capita basis, declined by 37 percent in real terms, although there has been some recovery since this time. While focusing exclusively on central government health expenditures slightly underestimates  - 29 - total expenditures on health, the revenues which district and urban councils have thus far been able to mobilize for primary health appear in general to be insignificant. Per capita health expenditures have declined despite recent efforts to bring the aggregate spending on health back to the real levels that pertained at the beginning of the decade. Table 2.3 Total Realth Expenditures (Mainland) 1986187 - 1988189 (TSh aillian) 1986/87 1987/88 1988/89 Planning and Development Ministry of Health 69.4 76.0 285.9 Regional Authorities 62.5 57.3 124.5 District Councils 64.4 61.1 78.9 Urban Councils 42.5 28.2 68.3 238.7 222.6 557.6 Recurrent Expenditures Ministry of Health 1,316.6 1,950.9 2,774.0 Regional Authorities 929.4 1,130.1 1,488.7 District Councils 560.6 1,042.0 1,290.8 Urban Councils 210.9 315.0 457.4 3,017.5 4,438.0 6,009.9 Total 3.256.2 i.660.E 6,567.5 Source: Ministry of Health, February 1989 2.54 Table 2.4 below shows a functional breakdown of the central MOH recurrent budget. While this breakdowns suggests a pattern of recurrent spending in Tanzania weighted toward curative care (as might be expected at the central level), it is in fact impossible to estimate on the basis of available information what are the relative shares between preventive and curative services, or what the optimal share would be. Hospital services account for 68 percent of the MOH budget, of which 77 percent is allocated to grants and subventions. This includes support to the 17 VA designated district hospitals (TSh 298 million), other VA hospitals (TSh 69 million), the Muhimbili Medical Center (TSh 783 million) and the Bugando and Kilimanjaro consultant hospitals (TSh 285 million). 'Preventive services", as such, are allocated only 6 percent of the central MOH budget, but this underestimates the actual expenditures on preventive care since all hospitals offer preventive services (eg., immunizations), and most training expenditure (10 percent of the MOB budget) is for primary health care workers. Moreover, the real responsibility for preventive health care is at the district level and is therefore reflected in the MLG recurrent budgets, rather than that for KOH  - 30 - (the PMO budget is largely curative as it covers the regional and district hospitals. Table 2.4 Central MR Recurrent EXpenditures Budget, 1988189 (TSh '000) Percent of Function Amount Total 200 Administrative and General 51,923.6 1.9 448 Hospital Services 1,875,643.3 67.6 449 Preventive Services 162,980.6 5.9 450 Manpower Planning and Training 290,440.6 10.5 451 Medical Supply 33,347.6 1.2 452 Health Planning 3,268.5 0.1 453 Government Chemical Laboratory 41,162.2 1.5 454 Social Welfare 309,258.2 11.1 455 National Food Control Commission 6,049.8 0.2 Total 2,774,074.4 100.0 Source: Ministry of Health and Social Welfare, Republic of Tanzania Recurrent Expenditures Budget, 1988189 Structure of the Investment Budget 2.55 In 1988189 the three central government (MOH, MLG and PHO) investment budgets together total TSh 558 million, of which or 52 percent, came from the MOB, 26 percent from the MLG and 22 percent from the PMO. 'When donor support is fully accounted for, as much of it is off the budget, 75 percent of investment expenditure is contributed by foreign funding. However, much of this - eg. drugs, vaccines should more appropriately be reflected in the recurrent budget. The broad structure of the MOB investment budget (including foreign funding) appears to be appropriate and consistent with the policy emphasis on preventive care. Of this amount, 67 percent is allocated for preventive care, 30 percent for curative care, and 3 percent for training. Allocations within the preventive care category also appear appropriate: about 30 percent each for the immunization and diarrheal control programs, and 10 percent for research. The AIDS control program is well funded. Health Sector vith the Overall Fiscal Framework 2.56 The health sector has been seriously affected by the overall developments in public sector finance in Tanzania over the last decade. As the Public Expenditure Review (PER) Al clearly demonstrates, that in addition 5/ See Tanzania Public Expenditure Review, World Bank, Report No. 7559- TA, May 22, 1989 (3 Volumes), which provides a fuller discussion of all these issues.  - 31 - to running a substantial public sector deficit (financed by grants from donors, foreign and domestic borrowing) for most of the last decade, there have been significant changes in the composition of public expenditure. The share of public expenditure going to investment (development expenditure) has been squeezed from 40 percent of the total to below 30 percent, as the requirements for debt service have increased. No--debt service recurrent expenditure (Central and Regional Supply Votes) has fallen slightly as a share of public expenditure. More striking however, is the change in the composition of such expenditure. The share of Personal Emoluments has fallen from about 30 percent to under 20 percent, as grants (mainly subsidies to parastatals) and other contractual and contingent liabilities have grown. Whilst in aggregate, the share of recurrent expenditure allocated to Other Charges has not been compressed significantly, in sectors such as health, its failure to grow has led to a chronic underfinancing of key inputs to the sector such as pharmaceuticals and medical supplies. This issue, and the fact that real wages in the public sector are only 20 percent of their level in the late 1970s, have undermined the effectiveness of the health system. 2.57 The Government recognizes that it has some major issues to resolve in the area of public sector finance and public rector management. The Government therefore intends to introduce reforms in these areas, drawing upon the analysis of the PER, and utilizing the support of IDA and other donors in a proposed Public Sector Management operation (FY92). One of the first sectors to be addressed by the Government is health, due to the seriousness of its problems, the sensitivity of its services and the fact that it is a sector identified as a core area for public expenditure. This emphasis is reflected in the strong focus on this sector in the ESAP and PSAP, see para. 1.07 and Annex 2. Specifically, the Government intends to tackle the following: a) introduce an improved incentive and remuneration package for health sector staff; and b) finance adequately the supply of pharmaceuticals and medical suppliest and to do this the Government will: c) increase the efficiency of all health sector expenditure, especially for expenditures on manpower and pharmaceuticals, through a rational and streamlined allocation of staff, and reducing losses and polypharmacy, in the case of pharmaceuticals; d) enlist communities more effectively in taking more responsibility for their own health and nutrition status; r e) raise the share of the recurrent budget going to health (from the current level of about 11 percent to 14 percent of the Central and Regional Supply Votes, and at least maintain such a level thereafter); and f) examine and then implement other options for mobilizing resources for the health sector (see para 2.58).  - 32 - Resource Mobilization in the Health Sector 2.58 Given the difficulties in providing an adequate level and quality of PHN services to the population funded purely from tight budgetary repources, the Government has been grappling with cost-effective mechanisms to generate more resources for the sector, which would not restrict access by the poor to services. A number of actions aimed at strengthening the financial base of the health sector have already been identified (as noted above) includings (i) increasing the efficiency of resource utilization within the sector, (ii) improving the financing arrangements for critical inputs such as pharmaceuticals and medical supplies, (iii) raising the share of the budget allocated to the health sector over the medium-term, and (iv) catalyzing PHC initiatives at the community level, thereby shifting the responsibility for provision of basic PHN services to communities themselves. In addition to these measures, the Government proposes to introduce measures to generate addltional resources within the health sector. In order to lay a strong foundation for these measures, it proposes to undertake a study on the long- term options for financing the health sector, analyzing the efficiency and equity issues involved in various cost-sharing and resource mobilization mechanisms. The Terms of Reference for this study are attached as Annex 3. F. Donor Role in the PEN Sectors 2.59 The donor community has made a significant contribution to the development of the health sector in Tanzania since independence. Donor involvement in the health sector was at its height during the mid to late 19709 following the Arusha Declaration, which placed an emphasis on meeting the basic needs of the population. During this period, the Nordic countries, and SIDA in particular, made a considerable contribution to expanding the health system. During the 1980s, the emphasis shifted towards providing the necessary drug_ and other irputs, to enable the existing system to continue functioning. DANIDA has been preeminent in this regard, funding the EDP and EPI through UNICEF. Other donor support for pharmaceuticals imports has come and in some cases continues to come from the Governments of Netherlands, UK, Italy, Switzerland. UNFPA is the major supplier of contraceptives at present, with USAID offering substantial support for a major increase in supply. Donors such as UNFPA, NORAD and SIDA provide assistance in training staff in FP techniques and supporting IEC efforts. 2.60 Donors have also supported a large number of PHC ir-itiatives both as free-standing projects and related to other sectors. During the 1980s, for example, a number of donors have appended health components to water supply projects, eg. SIDA in the HESAWA (Health, Sanitation, and Water) Project. Other donors financing area-based PHC programs include UNICEF, DANIDA, the Swiss Development Cooperation in Kilombero District, the Federal Republic of Germany in Bagamoyo District Region, NORAD in Rukwa Regions, and the British ODA's assistance in Mbeya. 2.61 In the field of nutrition, an important approach has been developed with the assistance of WHO/UNICEF, funded by the Italian Government, in Iringa Region, with a focus on health and nutrition at the village level. This is currently being replicated in other seven regions with donor support through UNICEF (see para. 2.47). Additional support in nutrition comes from SIDA and UNICEF for institution building for the TFNC. SIDA and the Government of the Netherlands are also financing the Iodine Deficiency Program.  - 33 - 2.62 While some donors have re-evaluated their contribution to the health sector, others are newly convinced that assistance in this sector is vital to the maintenance of human capital in the country, and must not be neglected. Donors do have an important role to play not only in strengthening national programs and supporting area-focused PHC initiatives, but also in helping the Government confront the major policy trade-offs in the sector. 2.63 Although a unit exists within the MOH ostensibly for coordination of external aid, such coordination has been very weak due to staffing constraints. This has made it difficult, among other things, to ensure that lessons learned under one program are applied elsewhere. It will therefore be important that, as the PHC Steering Committee develops a strengthened health strategy for the nation, it ensures that lessons learned from these many initiatives (both positive and negative) be incorporated. G. Role of IDA 2.64 In addition to key support to the ERP and the process of macroeconomic reform, IDA has a substantial portfoMio of investment operations in Tanzania. Increasingly, IDA support is being channelled through operations which focus on sectoral adjustment, e.g., Tanzania Agriculture Adjustment (TANAA) Program, or have a substantial policy content, e.g., Integrated Roads Program (PY91) and Education Planning and Rehabilitation (FY91). This project also has a strong policy content (see paras. 3.28 and 3.29) and complements the policy-based operations of the Bank which support the process of macroeconomic reform. The policy reform elements supported by this project (in manpower, staff remuneration, financing in the pharmaceuticals sub-sector, resource mobilization for the health sector, and increasing the health sector share of the budget - as outlined in para 3.29) have a strong forward linkage to the proposed Public Sector Management operation (FY92). 2.65 The propesed project is the first in the health sector and comes from the culmination of two years of dialogue with the Government, which included the preparation and agreement with Government of the Tanzania Population, Health and Nutrition Review (7495-TA). The project responds both to the priorities outlined in that report and the perceived priority needs of the Tanzanians, embodied in the ESAP and PSAP (see paras. 1.01 to 1.07 and Annex 2). It is anticipated that this project will form a strong basis for a long and fruitful relationship between IDA and the Government in the population, health and nutrition sectors. 2.66 A number of future initiatives have some bearing upon the project, including the proposed rood security and women in development (WID) reviews. The experience gained from and dialogue with Government on these issues in the context of project preparation will serve as inputs to these reviews. The recommendations of the reviews will be incorporated into project implementation wherever this is feasible - particularly as the project includes important elements relating to food security and WID (see para. 3.14). It is proposed that the experience gained from Component II (Strengthening Rural PHC) will be developed and expanded as a major component of future IDA-assisted operations in the sector such as the Human Resources I project (FY93S).  - 34 - III. THE PROJECT A. Obiectives ad Sumsarv Description 3.01 Proiect Ob1ectives. The proposed project will reinforce the Government's efforts (including the ESAP and PSAP) to raise the quality, coverage and effectiveness of family planning, nutrition and basic health services in urban and rural areas, through providing support to critical and strategic elements of the PHN sectors, with particular emphasis on strengthening: (i) institutional capacity for health planning and policy formulation; (ii) PHN manpower development and training; (iii) sustainable provision and financing of pharmaceuticals and medical supplies; (iv) micro-nutrient deficiency programs; (v) implementation of the national population policy; (vi) rural PHC, through the trial implementation of the revised strategy; and (vii) urban PHC, through reform and rehabilitation of the system. 3.02 Summary Description. In order to achieve these objectives, the project, which complements ongoing and planned PHN activities in Tanzania financed by other donors and will be implemented over a five year period commencing July 1990, is composed of three components as follows: Component I - Strengthening National PHR Systems a) Health Planning, Policy Formulation and Information System - strengthening of the planning and policy formulation functions 1/ of the MOH; policy-oriented studies on the long- term financing for the health sector and domestic pharmaceuticals industry; establishment of an integrated Health Information System (HIS) at the central, regional, and district levels; project coordination; b) Manpower Development and Training - formulation of a manpower plan for the health sector, which takes account of resource constraints; strengthening of the Department of Manpower Development and Training; support to in-service training at the district level based in Zonal Continuing Education Centres; (c) Pharmaceuticals and Medical Supplies Financing and Procurements reform of the pricing, financing, budgeting and procurement for the pharmaceuticals sub-sector; procurement of pharmaceuticals and medical supplies (disbursed in three portions according to the Government's implementation of agreed policy reforms); training of staff; rehabilitation of the CMS; (d) Micronutrient Deficiency Control Programss support to the five year programs for vitamin A and iron deficiencies; l/ Similar activities in nutrition are taking place with support of UNICEF.  - 35 - (e) National Population Policys support to the Population Policy Unit of the Planning Commission in managing the implementation of the National Population Policy; establishment of a National Population Information Centre. Camponent I! - Strentthening Rural Primary Health Care (f) Implementation of the recently revised PHC Strategy in ten selected districts, including: community mobilization for PHC activities at the village level; support to village PHC initiatives, including nutrition programs, rehabilitation and strengthening of health facilities, improved water supplies; strengthening of district health management; improvements to supply and maintenance systems; rehabilitation of the district hospitals; monitoring and evaluation for feedback to PHC policy formulation. Component III - Strengthenin. Urban Primary Health Care (g) Within Dar es Salaam: improvement of management and supply systems; operations research on and support to urban community participation; rehabilitation of the basic health network, including the district hospitals; establishment of an effective maintenance system; construction of a limited number of basic health facilities in under-served urban areas; monitoring and evaluation as a feedback to PHC policy formulation. Furthermore, related policy reforms will be supported in three major areas, namely: (i) establishing a firmer and more sustainable financial base for the sector, through a variety of resource mobilization mechanisms which do not restrict access to services by the poor; (ii) increasing the efficiency of resource use by improving the composition, quality and motivation of health sector manpower; and (iii) establishing a sustainable and adequate supply of pharmaceuticals through reforms in the pricing, financing, budgeting, and procurement of pharmaceuticals and medical supplies. B. Detailed Proiect Description 3.03 In addition to substantial support to the health sector, the project makes major contributions to the Government's programs and policies in population and nutrition. With respect to population, the project will (i) strengthen the Government's capacity to implement the national population policy (Component Ie.) and (ii) develop the capacity to deliver effective family planning services at the district level through PHC strengthening in urban and rural areas (Components II and III). In the field of nutrition, the project will (i) provide for the integration of nutrition data within the overall health information system (Component Ia.), (ii) finance imports of pharmaceuticals and medical supplies for the treatment of malnutrition disorders (under Component Ic.), (iii) support the implementation of the vitamin A and iron-deficiency control programs (Component Id.) and (iv) most importantly, catalyze and support community nutrition activities as an integral aspect of PHC in rural and urban areas (Components II and III), thereby contributing substantially to the replication of the highly successful elements of the Iringa JNSP to four  - 36 - regions (see paras. 2.45 to 2.47). Component I is described in detail in paras. 3.04 to 3.08, Component II in paras. 3.09 to 3.16 and Component III in paras. 3.17 to 3.26. Related sectoral policy reforms are described in paras. 3.27 to 3.29. The relationship of the project to World Bank programs of special emphasis is given in para. 3.30. I - Strengthening National PHN Systems (US$ 38.5 million) 3.04 Health Planning, Policy Formulation and Information System (US$ 2.6 million). This sub-component will strengthen planning, management, and the requisite health information system, finance key policy-oriented studies to be undertaken and provide for the coordination of the Component I of the project. (a) Health Planning: As noted in para. 2.13, the Planning Department (PD) is weak and is in urgent need of strengthening through the upgrading of existing staff and the placement of staff in key unfilled positions. The skills of key existing staff in the Planning Department (PD) will be upgraded through appropriate training (up to a total of 66 person-months) in health planning, health economics, financial management and related disciplines. Tanzanian or African training courses will be used whenever adequate courses exist, and any resultant cost- savings could be used to increase the amount of training provided. All staff chosen for such training will be required to return to work in the MOH according to normal GOT procedures. Training will be focused on economists, statisticians and planners already working in the PD and those to be recruited. During negotiations the Goverament confirmed that it would Increase depleted staff levels of the Planning Department (PD), thr-,ugh the allocation of six additional staff by July 1, 1993, to fill the following six vacant positionss i) Public Health Specialist, ii) Senior Economist, iii) Senior Statistician, iv) Epidemiologist, ,) Health Economist, and vi) Economist (see para. 7.01 (a)). The project will also support the work program of the Building Section, responsible for designing health facilities, with drawing office supplies, thereby strengthening the implementation capacity for components II and III. (b) Health Policy Formulation: Funds will be provided for two policy-oriented studies on key issues confronting the health sector. Firstly, a comprehensive study on the options for the long-term financing of the health sector in Tanzania will be undertaken with the support of 9 person-months of foreign consultants' services and a working group in the MOR. The study will make recommendations on the appropriate mix of financing mechanisms for the health sector, taking account of Tanzania's socio-economic status and the need to maintain access by the poor to health care. Terms of reference for the study were reviewed during negotiations and are attached as Annex 3. During negotiations, the Government gave assurances that Government and IDA ill jointly review the study's recommendations and agree upon a plan of action by April 30,  - 37 - 1992, (see para. 7.01 (b)). Secondly, due to its impact on the pharmaceuticals sub-sector, a study would be undertaken, with the support of 20 person-months of consultants' services, to analyze the economic and financial viability of the domestic pharmaceuticals industry. During negotiations, the Government gave assurances that Government and IMk will jointly review the study's recommendations and agree upon a plan of action by July 1, 1992 (see para. 7.01Cc)). The project will also support the initial implementation of the jointly agreed plans of action emanating from both these studies; through the provision of supplies, training and equipment for the long-term financing options, and the provision of raw materials to the domestic pharmaceuticals industry through the OGL under Component Ic., if justified by the domestic pharmaceuticals study. (c) Health Information System (HIS): As noted in para. 2.12, Tanzania lacks an adequate and integrated HIS capable of providing timely, adequate and selected data to enable health managers to manage health services more effectively. This lack is noticeable at all levels of the system. At the central MHH regional and district levels, data is fragmented, outdated and unavailable to policy-makers. At the facility level, a plethora of forms, and inadequate understnnding of the meaning and managerial use of the informaticiL, result in poor quality data which furthermore, is not even ised by the facility staff as a basis for planned improvementc and monitoring of rervice delivery and coverage. Build.ag upon support already provided by DANIDA, the development of the HIS will follow two paths. First, starting at the central MOH level, the HIS will draw data (including nutrition status and growth monitoring data) from a limited number of health programs such as MCH/FP, EDP and EPI. As experience is gained over time, the HIS will be expanded to draw data from the remaining programs, eventually covering all sources and types of ihformation as the system is improved. In parallel, the information requirements for the management of the health system at the facility, district and regional levels will be carefully determined in the context of Components II and III. An information kit has already been developed for the district level, comprised of an initial starter kit (furniture and non- expendable items) and a recurrent kit (forms, stationery etc.). This kit system will be implemented on a trial basis in about 15 districts (with DANIDA and IDA support). It will then be evaluated by the GOT, DANIDA and IDA, modified as necessary based upon this evaluation and in order to integrate the information requirements of all tiers of the health system, and replicated to the remaining 104 districts. Contracts for the supplies and equipment in these HIS kits, other than for the trials, will not be awarded until the joint review is undertaken and the viability of the approach established. Careful analysis of data requirements for all levels (district, regional and national) will be undertaken so that the number of forms for the HIS will be kept to the minimum. Once experience has been gained in operating the revised manual system, computerization of the HIS will be expanded from the central level to the  - 38 - regional level and finally to selected districts. The project will provide for 36 person-months of consultants' services to complete the design work on the HIS, and undertake trials at the district level in Dar es Salaam (under Component III - see para. 3.20), and in rural areas (including some of those included in Component II - see para. 3.14 (b)). The project will provide for the necessary computers (central and regional levels), software, training of staff, costs of supervision and supplies to run the system. (d) Proiect Coordination: The costs of coordination of project activities for which the MOH is responsible will be covered, including the salary of the Project Coordinator, Accountant and Procurement Officer, and the related operational expenses for which the MOH is responsible (see Annex 4.2 for an organogram of the project coordination arrangements within the MOH). Financial provision of US$ 0.2 million is made within the project to assist the MOE in preparing future projects for possible IDA and donor support. 3.05 ( M r Development and Trainia CUS$ 2.8 million). This sub- component will strengthen the DMDT's ability to carry out its increasing responsibilities both with regard to ensuring the quality of basic training given to the country's primary health staff and to support the Government's long-term effort to strengthen district health teams in the management of human and other resources allocated to them. The project will also support the development and implementation of a manpower plan, and concomitant training plan, which takes adequate account of resource constraints (see para. 3.29 (a)). (a) DMDT Strengtheningt The organization of the Department will be strengthened through the addition of an Inspectorate responsible for ensuring the quality of training of health manpower, and by the establishment of technical, administrative and logistic units in each of the department's divisions. Graduate level training in health manpower education would be provided to the three persons selected to head the Inspectorate, and the two divisions responsible for basic education of nursing and allied health staff. Provision would also be made for office equipment and supplies, and for six person-months of consultant services to help design improved logistic and administrative systems. The GOT and IDA have agreed upon the outlines of the new organizational structure of the DMDT and the MOH is currently preparing a detailed plan of action for implementing the reorganization, adoption of which will be a condition of disbursement of the overseas training for DMDT staff (para. 7.02 (a)). (b) Zonal Training Centers and In-service Trainings Support would also be provided to the Continuing Education Division of DMDT for the upgrading of five of the six existing training schools so that they can function as zonal training centers for district health teams. The project includes the provision of textbooks and other learning materials; a classroom, small dormitory for  - 39 - vorkshop participants and storage facilities for learning materials at each site; and vehicles for distribution of materials to districts and for supervision. The principals at two of the six schools are experienced health educators, but the remaining four have had no specialized training in either public health or education. Graduate level training in health manpower education will be provided to the persons selected to head these four schools. During negotiations, agreement was reached with Government on the criteria to be used in selecting candidates for training under this component. The criteria seek to ensure that the persons selected have appropriate experience and aptitude for the enhanced roles they will be playing. 3.06 Pharmaceuticals and Medical Supplies (US$ 31.0 million). The project will assist the GOT in implementing its revised national drug policy which will be approved by Government shortly (the recommendations of a working group on the content of the policy is attached as Annex 7), and responds to four strategic issues in the pharmaceuticals sub-sector, supplementing the support of key lonors such as DANIDA, UNICEF and WHO, namely: (i) addressing the immediate shortfall in funding for pharmaceuticals and medical supplies; (ii) improving the necessary mechanisms for the long-term financing, budgeting and procurement of pharmaceuticals and key medical supplies; (iii)facilitating the storage of pharmaceuticals; and (iv) strengthening the management of the pharmaceuticals sub- sector. (a) Procurement of Pharmaceuticals and Medical Supplies. In order to address the immediate shortfall in supply, US$ 10 million will be provided for the procurement of priority drugs and medical supplies in accordance with the agreed procurement program and financing plan for 1990;91 (see Annex 5). Total procurement requirement for vital and essential pharmaceuticals and medical supplies for 1990191 is estimated at US$ 32.1 million; of which US$ 6.7 million is accounted for by the EDP funded by DANIDA, a further US$ 1.6 million is to be made available by ODA for hospital Outpatient Department drugs, US$ 4.6 million from other donors and US$ 9.1 million from Government sources. The IDA project funds will thus provide 31 percent of the finance for the 1990/91 pharmaceuticals and medical supplies procurement program, as a major contribution to the PSAP and to address priority needs. The MOB will utilize this support to supply essential drugs to urban MCH clinics, dispensaries and health centres (not yet covered by the EDP financed by DANIDA) as well as procuring d-ugs for the referral network and vital medical supplies for the whole health system As the IDA support diminishes, the GOT will progressively take over the financing of these kits (see para. 3.06 (b)).  - 40 - (b) Refom in the Sub-Sector. The Government, desiring to secure the long-term financing of the pharmaceuticals sub-sector, has committed itself to a series of reforms in the pricing, financing, budgeting and procurement of pharmaceuticals, including establishing a more effective institutional framework for the CMS. These reforms are outlined in para. 3.29 (b), with additional background in Annex 8). Subsequent finance from the Credit amounting to USs 18 million (in two equal portions of US$ 9 million each) will be released in support of these reforms and measures to mobilize additional resources for the health sector. This second portion of USS 9 million, will be made available in support of the pharmaceutical sub-sector reforms to finance procurement of vital and essential pharmaceuticals and medical supplies (as outlined in para. 3.29). Satisfactory progress In implementing the agreed reforms in the pharmaceuticals sub- sector (see para. 3.29 (b)) will be a condition of disbursement for the second portion of funds (para. 7.02 (b) ti)). The third portion, amounting to US$ 9 million, will be made available for similar procurement, in support of the Government's introduction of measures to mobilize resources for the health sector based upon the study outlined in para. 3.04 (a) and Annex 3 (the third portion). Satisfactory progress in implementing the agreed plan of action for resource mobilization for the health sector (see para. 3.04 (b)) will be a condition of disbursement for the third portion of funds (para. 7.02 (b) (ii)). (c) Rehabilitation of the CMS: Given the deplorable state of the C4S central warehouse facility, and given that finance for the rehabilitation and construction of the ZMS has already been secured, the central CMS warehouse facilities in Dar es Salaam will be rehabilitated and handling equipment upgraded. A major report was prepared on strengthening the operations of the CMS in 1983 (the Bannister Report). This is being updated and revised through a study which is being funded by DANIDA, and will include recommendations on improvements in its management and institutional organization as well as the physical rehabilitation of the CHS . However, neither DANIDA nor any other donor currently has the resources to finance the actual rehabilitation. Given the complex status of the CMS, with the buildings and the warehouse staff pertaining to the Ministry of Works, and various other cadres pertaining to the MOH (pharmacists), MOF (accountants) and the CMS itself (day- laborers) there is an urgent need to simplify the management structure, ownership and improve efficiency. There is also a need to streamline the manpower of the CMS, reducing underemployed labor and increasing the remuneration of a more professional staff. A candition of disbursement for the rehabilitation of the CMS warehouse complex is IDA approval of the revised institutional status of the CMS, and the plan of action for its physical rehabilitation (see para. 7.02 (c)). In order to protect the investment in the rehabilitated CMS, the maintenance system in the CMS will be strengthened through the provision of supplies and the training of maintenance staff,  - 41 - complementing the assistance from other donors such as UNICEF and DANIDA. The rehabilitation will result in a reduction of losses of pharmaceuticals and medical supplies by about 10 percent, as well as facilitating improved management through a better physical structure for the complex. (d) Management and Procurement Trainint. The managerial and procurement capabilities of the CMS will be further strengthened through 42 person-months of training of key managerial, pharmacist, procurement and warehousing personnel in Tanzania and abroad, in the fields of procurement, financial control and warehouse management. Such training under the project will complement that already provided by DANIDA, UNICEF and WH0, and will in part be provided through institutional support from an international procurement agency. 3.07 Micro-Nutrient Deficiency Control Programs (USS 1.4 million). The project will support the Government's five-year programs to combat Vitamin A and iron-deficiencies in Tanzania (further details on this sub- component may be found in Annex 9). A program to combat the third of the major micro-nutrient deficiencies, namely iodine, has been supported by SIDA (iodized oil capsule distribution) and the Government of Netherlands (capacity to iodize salt). During negotiations, Government gave assurances that it will undertake and review with IDA a mid-term evaluation of both programs, according to protocols acceptable to IDA, not later than December 31, 1992 (see para 7.01 (d)). (a) Vitamin A Deficiency Control Program: The first five-year National Vitamin A Deficiency Control Program will finish in June 1990. An evaluation of this program undertaken by TFNC Indicated that a continuation of the program, with some modifications, would be vital to consolidate its achievements, and reduce the incidence of xerophthalmia (vitamin A deficiency induced blindness) and enhance the immune systems of small children, thereby reducing child morbidity and mortality. The new five-year program has been approved by the National Vitamin A Consultative Group (NVACG) and appraised by IDA. The program has six lines of action: (i) training of Medical Assistants (MAs) and Rural Medical Aides (RMfAs) in the recognition of clinical requirements for Vitamin A therapy and more effective Vitamin A tablets administration (due to a lack of understanding, the vitamin A capsules are frequently not prescribed to those at risk and unused stocks currently build up month by month through the EDP); (ii) the promotion of the production and consumption of Vitamin A-rich foods such as palm oil in suitabie regions (including a pilot in Kyela district) and fresh fruits (the extension service of the Ministry of Agriculture and Livestock Development (MALD) will be responsible for this activity); (iii) nutrition education and public information on Vitamin A deficiency (appropriate IEC materials, focussing on a message that each child should be given fruits like guava, mango etc. with each meal, will be developed using such media as films, dances and songs; staff will also be trained in utilizing these IEC naterials); (iv) the TFNC  - 42 - laboratory vill be strengthened in order to carry out analytical and research work on Vitamin A and iron deficiency through the provision of equipment and chemical reagents; (v) research will be undertaken on morbidity/mortality risk related to Vitamin A and the socio-cultural factors contributing to the inadequate intake of Vitamin A rich foods, and the effects of traditional food preparation methods on the availability of Vitamin A; and (vi) technical support will be provided to the NVACG and Vitamin A program through 10 man-months of consultant services. (b) Iron Deficiency Control Program: Likewise, the project will support the five-year National Iron Deficiency Control program which has four lines of actions (i) training of MAs and RMAs in the recognition of clinical iron deficiency and in the effective admir.istration of iron supplements to vulnerable groups; (ii) promotion of the production and consumption of iron-rich foods (such as green leafy vegetables) and particularly vitamin C rich fruits which assist the body in the uptake of iron from the food (the extension service of the MALD will be responsible for this activity); (iii) development and utilization of appropriate IEC materials, targeted particularly to pregnant women; and (iv) a program of research of morbidity, mortality risk related to iron-deficiency, the socio-cultural factors contributing to the inadequate intake of iron-rich foods and a strong program of operational research on compliance with iron supplementation tablets and the trials of alternative pharmaceutical compounds. 3.08 Implementation of the National Population Policy (US$ 0.7 million). In order to oversee the impnementation of the shortly-to-be- approved hational Population Policy (see paras. 2.28 to 2.30), the GOT has established the Tanzanian Council for Population and Development (TCPD) (see para 2.29) . The secretariat to the TCPD will be the Population Policy Unit of the Planning Commission (PC) which will be supported through the provision of 24 man-months of local and foreign short-term consultants services; supplies, equipment and the renovation of office space; training of key support staff in demography and related population fields; and support to a program of research on population and development. Support to the TCPD will be an important aspect in strengtheniAg the policy environment for all the population activities integrated within PHC strengthening under Components II and III of the project. In addition, a National Population Information Centre (NPIC) will be established under the PC in order to provide a research and resource base for population issues in the country. It will be supported through the provision of books, periodicals, supplies, equipment, training of staff and 20 man-months of local and foreign short-term consultants services. II. Strengthening Rural Primary Health Care (USS 11.6 million) 3.09 The PHC Secretariat of the MOH is in the process of formulating the revised PHC Strategy, which will comprise operational guidelines for the recently drafted National Health Policy. During negotiations, the Government gave assurances that it will agree with IDA on the revised PEC strategy by December 31, 1990. The project will support the implementation  - 43 - of the revised PHC Strategy, developed by the PHC Secretariat of the MOH, in ten selected districts (see paras. 1.14 and 2.63s Annex 10 provides an outline of the major issues being addressed in the revised Strategy). The experience of the implementation will be carefully evaluated and will be used to revise and further refine the PHC strategy. The successful aspects will be later replicated on a larger scale as part of a national program of revitalizing PHC in Tanzania for which Tanzania will require external support including that of IDA. Population (including family planning services) and nutrition conotitute core components of the PHC strategy. 3.10 District Selections The selection criteria and procedures followed for the selection of the ten districts are given in Annex 11. The following districts qualified: Resion District Population a/ a) Kigoma Kasulu 320,518 Kibondo 176,262 b) Lindi Kilwa 150,212 Lindi Rural 284,523 Liwale 52,211 Nachingwea 118,071 c) Singida Iramba 290,260 Singida Rural 285,092 d) Tabora Igunga 203,097 Nzega 295,613 Total 2,175.859 a/ From 1988 Census. (A map - IBRD No.21769 - showing the location of these districts is attached.) 3.11 District Health Plan (DHP): For each of these districts, a District Health Plan tDHP) will be developed based upon the revised PHC strategy. Disbursements of IDA funds will be for elements of the agreed DHP. During negotiations, Government gave assurances that by November 30 each year, for each district included in the trial implementation of the PUC strategy, the GOT will submit the district health plans for the forthcoming year, developed in accordance with the approved guidelines (paras 3.14 and 7.01 (f)), for IhA approval for the forthcoming district financial year (para 7.01 (e)). During the first two years of operations, as the ten districts will be in different stages of starting up, this date requirement will be waived. However, IDA approval will still be sought for each district plan prior to the disbursement of funds. The staff of the Program Support Network (PSN) - see para. 5.03 - together with requisite staff from the MOH and MLG will assist the districts in fulfilling this requirement. Finances will be channelled directly from the MLG to the district concerned through the recently approved Account No. 6 which  - 44 - provides the DMO with control over the funds as a first signatory (see para. 3.13). Maintenance of this financial arrangement will be a condition of continuing support to the district concerned (para. 7.02 (d)). 3.12 Role of the DM0: As the DMO will have a key role in overseeing the implementation of the DHP, it is vital that the DMO's time is not concentrated on managing the district hospital. Cognizant of this the MOH has already authorized each district to appoint an Officer in Charge to run the district hospital on a day-to-day basis, reporting to the DM0. 3.13 Initial ImDlementation: In order to start up project activities during the first project year, a *basic package" of PHC support will be provided to 5 out of the 10 districts, chosen according to their proven commitment to PHC as measured by the percentage of their own revenues allocated to the health sector over the preceding three year period. The five districts thus selected were Kibondo, Kilva, Nachingwea, Singida Rural and Igunga. The basic package will consist of (i) a vehicle for the DMO, (ii) equipment and building materials to rehabilitate two dispensaries (assuming an input of community labor), (iii) management training, supplies and equipment for the District Health Team (DHT), (iv) US$ 20,000 for high priority rehabilitation or equipment for the district hospital, and (v) US$ 10,000 for support to community PHC initiatives in the locality of the two rehabilitated dispensaries. In order to facilitate control over these funds, the GOT has opened an account (Account No. 6) in the ten selected districts through which funds for this component of the project will pass, with the DMO acting as the first signatory (para. 7.02 (d)). 3.14 Full Implementation: For the subsequent support to the particular district concerned in the implementation of the PHC strategy (as embodied in the DHP), conditions for the continuing disbursement of funds for a particular district will be: (i) fulfillment of the MON directive to release the DMO from the day-to-day management of the district hospital, through the appointment of an Offi^er in Charge of the district hospital (para. 3.12), (ii) continuation of the channelling of funds through Account No. 6 and (iii) IDA approval of the DIP for the district concerned (para. 7.02 (d)). Responsibility for monitoring the compliance by the districts with these conditions will reside with the PSN (para. 5.03). The project support will have three lines of action as follows: (a) Support to Village PHC Initiatives (USS 3.2 million). As discussed in para. 2.52, the Government is unable to provide adequate resources for the PHC needs of the population. Moreover the effectiveness of such services has been weakened due to a lack of responsiveness to community needs. As may be seen in paras. 2.45 to 2.46, Tanzania has much experience in mobilizing resources and commitment at the community level, with communities assuming a greater responsibility for their PHC needs. Building upon past experience, the project will support community mobilization activities at the village level in the ten districts selected. District level staff will be trained in community mobilization through preparatory workshops. Following such training, these staff (in cooperation with relevant party officials) will hold behavioral change campaigns in selected villages of the district according to the annual plan. The I  - 45 - objective of these campaigns will be to: (i) catalyze the latent ability of communities to assess, analyze and then act upon their PHUN situation (the triple A approach)t (ii) explain to communities the type of support the district can offer (e.g., matching grants, support to the health system); and (iii) establish follow-up procedures and plan future actions. Communities will prepare plans for PHC initiatives, identifying the inputs required (including community labor inputs). Matching funds for these initiatives will be provided by the district government, up to a maximum of forty percent of the total costs. In general, it is expected that communities will cover the costs of skilled and unskilled labor, raise contributions in cash or in kind, with the district assisting in the procurement of manufactured inputs (such as roofing sheets, hand-mills, etc.). The full range of eligible activities will be indicated in the DHP guidelines (see para. 3.14 (c)) but includes activities related to nutrition, family food security, child care, rehabilitation of health dispensaries, grain hand-mills, protection of traditional water sources and simple improved water schemes in arid areas. Altogether, it is estimated that about 70 percent of such disbursements will be for nutrition-related activities. In each case, the community will be responsible for the operation and maintenance costs of the activity conceived. Such an undertaking from the community will be a pre-condition for district support. The activity selection criteria, financing arrangements, terms and conditions of district support will be fully developed in the DHP guidelines (see para. 3.14 (c)). (b) Strengthening the District PHC System (US$ 3.8 million). The project willt (i) strengthen the district health management team (DHT) through training in community mobilization, management, planning, financial control and other key areas; (ii) furnish vehicles for the DHOs, and appropriate forms of transport for other key staff; (iii) provide supplies and furniture equipment for the DHT; (vi) strengthen the maintenance system through the provision of supplies, equipment and means of transport; (v) rehabilitate dispensaries and rural health centres including supplies of equipment; and (vi) support the program of awareness campaigns at the village level and ongoing supervision of the health system. The health information system (Component Ia.) and support to continuing education of staff (Component lb.) are important complementary inputs to the district level under the project. (c) Strengthening the District Health Referral System (USS 3.2 million). The district hospital plays an important role in the health system as it is the first point of referral. The project will support the high priority rehabilitation or upgrading of the district hospitals in up to five of the selected districts. In order that the focus of the DMO does not become concentrated on the district hospital to the neglect of other aspects of PHC, approval for rehabilitation will only be given after adequate progress has been made in the implementation of aspects (a) and (b) of para. 3.14 above (i.e. normally after at least one year of  - 46 - satisfactory implementation). IDA will review jointly with the GOT the performance of each district in the implementation of its DHP, on an annual basis based upon agreed criteria, to determine which districts will be eligible for such support. Each district will then be eligible for financial support for priority rehabilitation according to guidelines prepared by the MOH, which will include inter alia, rehabilitation of existing buildings, repair and replacement of key equipment, and when justified, limited new construction. The DHT will prepare proposals in accordance with guidelines prepared by the MOH. According to these guidelines, each district will have a ceiling established on the finance available for rehabilitation according to the following basis; (i) US$ 50,000 equivalent per district (in the case of a district hospital) and US$ 150,000 equivalent per district in the case of a regional hospital ie. Singida Rural and Kilwa), plus (ii) USS 1 dollar equivalent per capita. During negotiations, Government provided assurances that by December 31, 1990 the GOT will agree with IDA ont (i) guidelines for the rehabilitation of the district referral system in the 10 selected districts; and (ii) list of criteria for evaluating the performance of the districts in implementing their DIPs; and (iii) guidelines for the preparation of district health plans (DIP) para. 7.01 (f)). 3.15 Monitoring and Evaluation (USS 0.4 million). As many of these activities are innovative, and as a key objective is to evaluate and monitor the trial implementation of the revised PHC Strategy, Monitoring and Evaluation of this component is critical. Initially, baseline data will be collected for each district according to a survey instrument to be developed. Monitoring and evaluation will have three aspects: (a) day-to-day management monitoring - the Project Support Network (PSN) (see para. 5.03) will undertake day-to-day monitoring related to implementation, based on regular reports from the districts concerned (submitted monthly) and field supervision (not less than four times a year to each district). The results of such monitoring will be used to resolve problems as they arise; (b) regular program evaluation - a fuller annual evaluation (including repetition of a sample survey linked to the baseline survey) and a program of knowledge, attitude and practice (KAP) surveys will be undertaken, to evaluate the results of project interventions and to act as a feedback to policy-maker in the revision of the PHC Strategy. The PSN will commission various institutions to undertake these tasks; and (c) external evaluation - a major evaluation of the component will be undertaken by an agency not involved in implementation, in order to assess the overall impact of the component, outline major improvements which may be necessary, and indicate which areas should be expanded and replicated under a future national program of PHC strengthening which will be supported by donor and IDA assistance. The scope of work, relevant protocol, short-list and  - 47 - qualification of firms/agencies proposed to undertake this evaluation will be submitted to IDA for approval. The results of the evaluation will be submltted for IDA review by December 31, 1992 based upon a protocol agreed with IDA by June 30, 1991 (see para 7.01 (d)). 3.16 Project Management (US$ 1.0 million). Provision is made under the project to cover the costs of project management by the Program Support Network (PSN) in the MLG for this component of the project. Details of these arrangements are given in paras. 5.03 and 5.04. The project will provide for 42 person-months of short-term consultants services in the field of public health, nutrition and other related areas, as well as two 4 wheel drive vehicles, supplies and equipment for the PSN. In addition, the project will finance the limited incremental operating costs, salary and travel per diem of the coordinator for this component, and the other key staff (program manager, public health specialist, community development specialist, rural economist, architect/civil engineer, accountant and procurement specialist). As noted in para. 5.03, these staff will be seconded from existing positions. III. Strentthening Urban Primary Health Care (US$ 11.5 million). 3.16 As noted in paras. 2.07 to 2.09, since independence Tanzania has concentrated the implementation of PHC in rural areas to the relative neglect of urban areas. PHC in urban areas presents a number of difriculties not experienced to the same degree in rural areas. Firstly, unless adequate steps are taken for its prevention, it is easier for the urban population to by-pass lower-tier health facilities and proceed directly to a hospital for treatment, thereby overloading the hospital and creating higher costs and inefficiency in the system. Secondly, effective community participation may be more difficult in urban areas (especially in those which have developed rapidly and contain heterogenous populations). Thirdly, in view of large population concentrations, and the rapid growth of urban areas (with the provision of key infrastructure lagging behind), increased problems of disease related to environmental sanitation occur. In order to address these issues, and develop a more effective strategy for urban PHC, trial implementation of a strengthened urban PHC system will be undertaken firstly in Dar es Salaam 2/ and subsequently replicated in other urban areas during future projects. 3.17 This component of the project will support the implementation of the Government's approved policy to devolve administrative and financial control of the health system in Dar es Salaam to the three districts which constitute the region. This component will be fully cofinanced by the Swiss Development Cooperation (SDC) and DANIDA (see para. 4.09). 2/ Dar es Salaam has been chosen both because the needs are particularly great as it is by far the largest urban area of Tanzania, with a population of 1.36 millior. (1988 Census), compared to only 0.22 million for Mwanza, the second largest urban agglomeration, and because it provides the best opportunity for close monitoring and evaluation of the results so that they may be fed back into strategy development.  - 48 - 3.18 The final details regarding the scope and implementation arrangements of this component are subject to an intergovernmental agreement between Tanzania and Switzerland which will be finalized shortly; an outline is provided in Annex 12, however. Within this context, the key objectives of this component of the project are outlined below: 3.19 Management and Planning of PlC. Management strengthening of PBC in Dar es Salaam, including training of the City Medical Officer of Health (CKOH) and three DM09 in management, planning and financial control. In addition to the training, the project will provide for office space, furniture, equipment and vehicles for the CMOH and three DMOs in order to supervise PHC services. The services of a project adviser will be made available in order to help launch the varied project activities. 3.20 Health Information System (HIS) Develo2ment. The project will provide for short-term consultants'services to assist in the development of an adequate HIS, together with a computer, supplies, equipment and a vehicle for supervision. The experience gained in formulating an effective management and HIS in Dar es Salaam will be an important input into the detailed arrangements for the extension of the improved HIS nationwide (see para. 3.04 lc)). 3.21 Community Particivation and the District PHC Comnittee. The project will strengthen the involvement of the community representatives and organizations in PHC management at the village (rural periphery), ward and the district level, especially in the areas of: (i) needs identification; (ii) community resources mobilization and funding of the recurrent costs; and (iii) enhanced community control of resources utilization. The project will provide funds to support urban community PHC initiatives. The process for the disbursement of these funds will be similar to those for Component II (see para. 3.14 (c)). 3.22 Realth Facility Rehabilitation. As part of the program of strengthening PHC, existing health facilities (compricing 4 health centres, 15 dispensaries in Ilala District, 15 dispensaries in Kinondoni District and 18 in Temeke District) will be rehabilitated to enable effective delivery of health services. This rehabilitation program will include the referral network of the three district hospitals which are unable to render surgical services at present and are in a deplorable state of repair, hindering the provision of effective services of all types. Rehabilitation will be undertaken in two phases, with the highest priority facilities (16 dispensaries, 3 health centres and the three district hospitals) commencing under the first phase. During the second phase, the remaining facilities which are essential to the PHC system will be rehabilitated. 3.23 Health Facility Maintenance. A key need within Dar es Salaam is the establishment of maintenance teams which will provide effective and efficient maintenance of district health facilities, in order to ensure that the rehabilitated facilities are not allowed to decay again. Small brigades of skilled staff will based at each of the three district hospitals, consisting of at least one electrician, plumber, carpenter, stone-mason and support staff, thereby forming a maintenance brigade (MB). All staff will be recruited from the existing pool of staff under the City  - 49 - Engineer, thereby obviating the need to expand the staffing of the district. Each MB will be headed by a brigade chief, who will plan the work program to cover maintenance needs both within the hospital and for outlying facilities, in accordance with directives from the DMO. The project will provide for vehicles (one 4 wheel drive and 3 motorbikes) for each MB togetner with training in maintenance management for the MB chief, tools equipment and supplies. 3.24 Imaroved Access to PHC. In order to extend PlC services to underserved communities, particularly on the urban periphery, a limited number of new PHC facilities will be constructed in such areas. These facilities will both complement the activities supported under para. 3.21 and act as a base for the trained staff in catalyzing covmunity activities. A preliminary assessment of underserved areas has already been made. This will be complemented by a thorough needs assessment, financed under the project, which will determine the: - criteria for the priority ranking of underserved areas; - staff requirements, type and size of facility needed (based upon a sound functional analysis)s - government and community contributions for the construction and equipment of the facility; and - means of covering the recurrent expenditures, including keeping costs low by re-assigning under-utilized staff from other facilities. 3.25 REy Supplies. Vital medical supplies, basic diagnostic and other essential equipment will be provided to the health network, as virtually all PHC units and the three hospitals are lacking even the most basic items and equipment. Accountability for the supplies and equipment will be vested with the responsible officers in-charge of the facilities. The DMO will monitor the performance of such staff in protecting equipment from loss or avoidable damage. 3.26 Nutrition and other Operational Research. Provision will be made for operations research on PHC, the determinants of ill-health, with a particular focus on at risk groups and che vulnerable. Operations research on urban nutrition will be a major area of attention. Due to the lack of adequate data on nutritional status and the limited experience of nutritional programs in Dar es Salaam, the project will support, on a trial basis, nutrition monitoring and operations research on nutritional interventions targeted to women and children in Dar es Salaam. The data gathering and operations research will be undertaken jointly by TFNC and the DSCC in one district of Dar es Salasm. The results will be carefully monitored. A full evaluation will establish whether an urban nutrition program will need to be developed. C. Sectoral Policy Reforms 3.27 Recognizing the decline in the performance of the sector, and the scope for significant gains in terms of health service quality, leading to improved health status, the Government has committed itself to a number of key reforms which will be supported under the project. these includes  - so - Financing the leath Sector 3.28 In addition to measures to improve efficiency of resource use within the sector (see par.. 3.29 below) and mobilize resources from communities by enabling them to play a greater role in the provision of their own health and nutrition services (Component II of the project), the project will support the Government in the implementation of some of these key reforms. During negotiations the Government provided assurances that bys a) April 30. 1992, the GOT and IDA will reach agreement on a plan of action for the long-term finacing of the health sector (para 7.01 (b)); and (b) July 1, 1991, the GOT will reach agreement with IDA on the share of the recurrent budget allocated to the health sector and an improved incentives package for health sector staff (para 7.01 (g)). As outlined in the Policy Framework Paper for 1990, a rise in the health sector's share of the recurrent budget (Regional and Central Supply Votes) from its current level of 11 percent to 14 percent by 1990191, would represent a satisfactory share. The Government is already formulating an improved incentives package for health sector staff. Efficient Use of Resources 3.29 In order to increase the output of quality services from the health system, Government intends to rationalize and improve the utilization of key resources to the health sector - manpower and pharmaceuticalsimedical supplies. During negotiations, the Government provided assurances, that bys (a) December 31, 1991, the GOT will submit the draft health sector manpower plan for IDA approval, and by July 1, 1992, the M0D will commence implementation of the health manpower plan taking into account IDA's comments (para 7.01 (h)). The focus of this plan is to rationalize the output of trained manpower in accordance with the priority needs of the health system and the financial capacity of the different tiers of Government to remunerate staff adequately so as to provide an incentive to deliver quality services. Over time, this will result in slower growth and rationalization of staffing levels, re-allocation of staff within the sector, increasing focus on in-service as opposed to pre- service training and a better trained, more motivated and dedicated cadre of staff committed to providing the best service to clients; (b) It will undertake the integrated set of reforms in the pricing, financing, budgeting, and procurement of pharmaceuticals and medical supplies, in accordance with paras. 3.06 (b) and 7.02 (b). The major elements of these reforms are highlighted below: Pricing Policy  - 51 - (i) The pricing policy of the C0S will be refonmed so that all phanmaceuticals and medical supplies will be sold at replacement cost (based on the prevailing exchange rate and import prices). In order to do this efficiently, without constantly revising prices, prices will be set once for the following year based on the projected average exchange rate and international prices for the item. (ii) The 1S8 will increase its margins on sales to the Governmnt. and voluntary agency hospitals fron 5 percent to a level sufficient to cover all operations costs (including exchange rate risks which may not be fully covered by Ci) above; preliminary analysis indicates that a level of 10 percent might be appropriate). The existing margins for other categories of consumers such as parastatals, NGOs and the private sector will be reviewed and adjusted as necessary. CMS financial position will be kept under constant review and changes in prices and or margins will be implemented if warranted tj maintain the viability of the revolving fund. Ciii) Recently all sales have been strictly on a *cash-and- carry basis-. The CMS will maintain this policy and discontinue the pxovision of credit to customers. Financing and Budgeting of Pharmaceuticals (iv) The annual budget for pharmaceuticals will be calculated so as to provide for adequate budgetary coverage for stems Mi) to (iii) above. (v) As IDA funds diminish, the Government will increase its own budgetary allocation in TSh sufficient to offset this reduction, to allow for inflation, exchange rate movements and increased demands due to population growth. This will be confirmed in a financing plan with a Government undertaking to provide adequate budgetary allocations for pharmaceuticals purchase over the period 1991/92 to 1994/95. (vi) The Government will prepare an action plan to clear past arrears and debts from the public sector (predominantly district governments and central ministries) to the CMS thereby replenishing the CMS revolving fund (the current level of indebtedness is given in Table 1 of Annex 7). (vii) The ceiling on the CM1 revolving fund will be raised fron its current level of TSh 200 million to TSh 2 billion. Thereafter, the ceiling will be adjusted upwards regularly to reflect movements in the exchange rate, the inflation rate for pharmaceuticals and  - 52 - increased pharmaceuticals demand due to population growth. This will be achieved through the provision of a waiver for the CMS to pay the TSh counterpart to the Bank of Tanzania for the pharmaceuticals and medical supplies financed by the proceeds of the IDA credit. (viii) In order to avoid the non-payment by districts for their EDP kits, funds provided by the central government for this purpose will be deposited quarterly in advance with the CMS, with the districts entitled to draw EDP kits up to the value of the amount deposited. Any further withdrawals of pharmaceuticals and supplies will have to be paid for by the districts themselves. Capacity Building for Procurement (ix) The Government will build up the procurement capacity of the CMS through a program of on-the-job and formal training with an International pharmaceutical procurement agency. The Government will ensure that the staff trained continue to render service to the CMS. In the interim, as this capacity is being developed, the CMS will utilize international procurement agencies as required. Institutional *x) The managerial and institutional structure of the CMS will be revised by the MOR in order to improve its efficiency and effectiveness. Terms and conditions of staff serving in the CMS will be improved in order to enhance staff performance. D. Relationship of Prolect to Programs of Special Emphasis. 3.30 The project responds to a number of World Bank programs of special emphasis. a) Human Resources Development. The project, together with the Education Management and Rehabilitation Project, will help the Government tackle strategic issues in the human resources sector, improve policy formulation and planning, strengthen implementation capacity and secure a more financially self- sustainable basis for the provision of services. b) Population. The project supports the Government in the implementation of the recently approved population policy, including the strategic planning aspects (t.rough the Planning Commission) and service delivery (through Co.mponent II, Strengthening Rural PHC and Component III, Strengthening Urban PBC). c) Women in Development (WID). Women are key beneficiaries from any well-designed and implemented PHC program. It is anticipated  - 53 - that women will be significant beneficiaries under th s project in terms of improved health care (especially reduced mortality at child birth), and increased child spacing. The benefits from the introduction of labor saving technologies, child day care centres and improved nutrition accrue largely to women under the types of village-level health and nutrition initiatives which are to be supported under the project. d) Povert? Alleviation. As stated iu the project objectives, the project seeks to reduce poverty both directly and indirectly through support to PSAP. The successful implementation of the project should improve health and nutrition status, thereby contributing to the relief of human suffering and the provision of basic human needs. Moreover, a successful demonstration by the Government that it is improving the social sectors, and the population's access to basic services, will help foster an environment within which macroeconomic reform can continue. e) Environment. The project makes a contribution towards the preservation of the environment through a reduction in the rate of population growth. The planting of fruit trees supported Component Id, Micro-nutrient Deficiency Control Programs, and the protection of traditional water sources under the Component II, Strengthening Rural PHC, will also make a contribution towards reducing soil erosion.  - 54 - IV. PROJECT COSTS AND FINANCING A. Cost Estimates 4.01 The total cost of the proposed five-year project is estimated at TSh 17.8 billion or US$ 70.0 million equivalent, net of customs duties and taxes on civil works and locally-procured goods and services (approximately USS 2.8 million equivalent). Items imported directly for the project would be exempt from import duties and taxes. The foreign exchange component of the project is estimated at USS 53.6 million or 76.5 percent of total project costs. Detailed costs are presented in Annex 13 and are summarized by component in Table 4.1 and by summary account in Table 4.2. Table 4.1 Proiect Cost Summary by Proiect Comkonent (USS million) Local Foreign Total T. Strengthening National PIN Systems 4.0 34.5 38.5 a. Health Planning, Policy Formulation and Information System 1.0 1.6 2.6 b. Manpower Development and Training 1.2 1.6 2.8 c. Pharmaceutical and Medical Supplies 1.2 29.8 31.0 d. Hicronutrient Deficiency Control Programs 0.4 1.0 1.4 e. Implementation of National Population Policy 0.2 0.5 0.7 II. Strengthening Rural Primary Realth Care 3.8 7.8 11.6 III. Strengthening Urban Primary Health Care 4.7 6.8 11.5 IV. Project Preparation Facility 0.1 0.4 0.5 Total Baseline Costs 12.6 49.5 62.1 Physical Contingencies 0.5 1.3 1.8 Price Contingencies 3.3 2.8 6.1 Total Project Costs 16.4 53.6 70.0  - 55 - Table 4.2 Cost Summary by Summary Account (US$ million) Local Foreign Total I. Investment Costs A. Civil Works 5.7 6.1 11.8 B. Supplies 0.1 3.2 3.3 C. Pharmaceuticals - 28.0 28.0 D. Equipment 0.2 4.8 5.0 E. Furniture 0.1 0.4 0.5 F. Vehicles - 0.9 0.9 G. Consultants Services 0.3 3.3 3.6 H. Training and Workshops 1.4 0.8 2.2 I. Project Preparation Facility 0.1 0.4 0.5 Total Investment Costs 7.9 47.9 55.8 Physical Contingencies 0.5 1.3 1.8 Price Contingencies 2.6 2.6 5.2 Total Including Contingencies 11.0 51.8 62.8 II. Recurrent Costs A. Travel and Per Diem 1.3 - 1.3 B. Salaries 1.3 - 1.3 C. Building Operation & Haintenance 0.8 0.2 1.0 D. Equipment & Vehicle Oper.& Maint. 1.2 1.3 2.5 E. Utilities & Services 0.1 0.1 0.2 Total Recurrent Costs 4.7 1.6 6.3 Price Contingencies 0.7 0.2 0.9 Total Including Contingencies 5.4 1.8 7.2 Total Baseline Costs 12.6 49.5 62.1 Physical Contingencies 0.5 1.3 1.8 Price Contingencies 3.3 2.8 6.1 TOTAL PROJECT COSTS 16.4 53.6 70.0 4.02 Investment Costs. Base costs for the project are in July 1989 prices. Construction costs (for both building and engineering works) are based on estimates prepared by the MOH together with assistance from a PPF- financed consultancy firm. The estimates were reviewed and found  - 56 - satisfactory during appraisal. As most civil works included in the project involve rehabilitation of existing facilities (many with substantial community participation), unit costs vary widely, but generally range from US$50 per square meter (m2) to US$200 per m2. The unit cost for new construction activity is between US$300 and US$400 per m2. This is comparable to construction prices for similar facilities elsewhere in Tanzania and in other Southern and Eastern African countries. Unit costs for vehicles, pharmaceuticals and medical supplies were based on international c.i.f. prices. Costs of furniture, equipment, and supplies include 10 percent in count-y handling costs and are based on lists prepared by the MOH and MLG. During appraisal the cost estimates included in the lists were checked against price quotations given in international catalogs (including the UNIPAC catalog produced by UNICEF's procurement wing and found to be satisfactory). Cost estimates for foreign consultants' serviceE include salaries, allowances and airfares. The costs of training were based on prevailing course rates and allowances for study within Tanzania and abroad. 4.03 The project's foreign exchange component of US$ 53.6 million was calculated on the following basis: (a) civil works and furniture - 45 percent of total cost estimate; (b) equipment - 95 percent; (c) supplies - 95 percent; (d) training workshops - 20 percent; (e) vehicles and pharmaceuticals - 100 percent; (f) consultants' services - variable between 0 percent and 100 percent; (g) local salaries, travel and per diems - 0 percent; (h) building operation and maintenance - 30 percent; (i) vehicle and equipment operation and maintenance - 50 percent; and (j) utilities and services - 30 percent. 4.04 Physical contingencies of 10 percent have been added to civil works, equipment, furniture, vehicles and supplies. Price contingencies were calculated based on Bank estimates of international and domestic inflation and assume the following expected annual percentage rates of increase by project year (PY): 1990191 1991192 1992193 1993194 1994195 PYl PY2 PY3 PY4 PY5 Local 21.0 15.0 12.0 10.0 10.0 Foreign 4.9 4.9 4.9 4.9 4.9 Exchange rates used anticipate the maintenance of a constant real exchange rate, based on the December 1989 exchange of US$ 1 equals TSh 190. 4.05 iecurrent Costs. Salaries, travel and per diem allowances have been based upon the prevailing rates within the -overnment, with adjustments made to reflect the order of magnitude of future incentives packages to be introduced by the government (see para 7.01 (g)). Operations and maintenance costs for buildings, equipment and vehicles, and the costs of services and utilities, have been based on prevailing rates, adjusted so as to provide adequate coverage for these 4tems. 4.06 Mindful of the serious budgetary difficulties facing the GOT, every effort has been made to minimize the incremental recurrent costs implied by the project. This annual increment will amount to about US$0.3  - 57 - million in the first year, and will rise gradually to about US$1.8 million by the last year of the project. About 30 percent of the incremental recurrent costs will be borne by benefi-iary communities, about 33 percent by district governments and 37 percent by the central government. These incremental outlays, which will cover salaries and allowances for a limited number of essential senior technical and managerial personnel, plus operation and maintenance (O&M) of vehicles, equipment, and buildings, are equivalent to only about 1.5 percent of total projected MOH recurrent expenditures for FY89/90 and less than 1 percent of district governments expenditures. The financial burden on Dar es Salaam is however more significant, if adequate provision is to be made for the maintenance of buildings. The SDC will agree on covenants with the Dar es Salaam City Council (DSCC) regarding this matter. In addition, the proposed IDA- financed Urban Sector Technical Assistance Project will assist the DSCC to raise substantial revenues from property tax, thereby providing the resources to absorb these additional costs. The MOH and district Governments should thus have no difficulty in absorbing these recurrent costs. 4.07 Most importantly, a number of project activities will contribute directly to reducing recurrent expenditures. For example, in the pharmaceuticals sub-sector, rationalisation in prescription, and the reduction of polypharmacy, will result in smaller prescribed dosages, leading to savings of up to 20 percent in pharmaceuticals usage. Improvements in procurement and storage of pharmaceuticals and medical supplies is estimated to reduce costs by up to 20 percent and reduce losses of supplies by up to 10 percent. respectively. Financial policy reforms supported by the project - including enhanced community participation, the introduction of resource mobilization measures, improved decentralised budgeting, and enhanced efficiency in the sector as a whole - will assist in establishing the long-term sustainability of the health sector. B. Financing 4.08 The total project cost of US$ 70.0 million equivalent (excluding taxes and duties) would be financed by (i) the GOT, including beneficiaries central and district governments, (ii) IDA, and (iii) a number of multilateral and bilateral sources (the financing plan is shown in Table 4.3 below). The IDA Credit of US$ 47.6 million (SDR 36.1 million) will cover about 68 percent of total project cost and 79 percent of the foreign exchange cost. The GOT contribution of US$ 7.4 million equivalent, or about 11 percent of the total, will finance salaries, allowances, and the O&M costs of vehicles, equipment, and buildings. It is composed of central government contributions of USS 3.1 million for component I and the management of Component II, district government contributions of US$ 2.5 million for components II and III, and commu.ity beneficiary contributions amounting to US$ 1.8 million to cc er imputed costs of self-help labor and the other inputs in cash and kind to commence and maintain the village level PHC initiatives of Components II and III. 4.09 Co-financing from other external sources includest (a) US$ 12.2 million equivalent from the Swiss Development. Cooperation, for civil works, supplies, equipment and technical assistance for Component III -  - 58 - Strengthening Urban PHC; (b) US$ 1.3 million equivalent from DANIDA for the elements of Component Ia (Health Information System) and part of the costs of the rehabilitation of the district hospitals in Dar es Salaam (Component II); (c) US$ 0.7 million equivalent from the Governmeat of Belgium for technical assistance for the health information system and Component II - Strengthening Rural PHC; (d) USS 0.7 million from UNMPA for the implementation of the National Population Policy; and (e) US$ 0.1 million equivalent from the British ODA to finance the study on thr long-term financing options for the health sector. No cross-effectiveness conditions are specified as the components, whilst related, are free standing, and may proceed independently of one another. Table 4.3 Financins Plan al Local Foreign Total -----------(US$ million)---------- IDA 5.3 42.3 47.6 Co-financings Government of Belgium 0.1 0.6 0.7 DANIDA 0.6 0.7 1.3 SDC 5.0 7.2 12.2 ODA 0.0 0.1 0.1 UNFPA 0.1 0.6 0.7 sub-total 5.8 9.2 15.0 Government: of which - Central 2.4 0.7 3.1 - District 1.5 1.0 2.5 - Beneficiaries 1.4 0.4 1.8 Sub-total 5.3 2.1 7.4 TOTAL 16.4 53.6 70.0 Note: a/ Excludes taxes and duties of US$2.8 million. C. Procurement 4.10 Project-related procurement arrangements are summarized in Table 4.4 below. Items financed by IDA will be procured according to IDA guidelines as elaborated in paras 4.11 to 4.14 below. Where procurement of  - 59 - similar items is involved, the MOH and MLG will ensure reasonable standardization of such items, irrespective of the source of finance. 4.11 The major civil works contract for the rehabilitation of the CMS warehouse complex in Dar es Salaam and all other civil works packages valued at more than USS 250,000, will be awarded on the basis of international competitive bidding according to IDA guidelines. For civil works tenders, local contractors will be eligible for a margin of preference of 7.5 percent as compared to the quote of competing foreign contractors. Civil works contracts for the lower tier health facilities in rural areas, with an average value of about US$ 40,000 per contract, will be awarded on the basis of local competitive bidding (LCB) (aggregating to US$ 2.0 million), given that international firms are not expected to show an interest in these relatively small and scattered works whose completion is spread over time. However, if international firms are interested, they will not be precluded from participation. Since some sites for rural dispensary and clinic rehabilitation are scattered in remote areas in the 10 districts chosen for Component II, where private contractors are unlikely to venture, civil works related to this subcomponent may be undertaken by force account (up to a to+rl value of US$ 0.4 million equivalent) by the appropriate district government. Disbursement will be on the basis of completed units based upon agreed production standards, strict productivity control and accounting. 4.12 Contracts for equipment, pharmaceuticals, supplies and vehicles worth more than US$ 100.000 will be awarded on the basis of international competitive bidding (ICB) procedures according to IDA guidelines. In addition, procurement of pharmaceuticals may be through UNICEF or a similar international procurement agency, selected in accordance with IIA guidelines for the procurement of consultants services. For goods tenders, local suppliers will be eligible for a margin of preference of 15 percent as compared to the c.i.f. price of competing imports, or the prevailing customs duty, whichever is lower. Procurement of equipment, furniture, supplies and vehicles which cannot be grouped into bid packages of US$ 100,000 or more (mainly for such items procured for the ten scattered districts under Component II - Strengthening Rural PHC) may be procured through: (a) LCB procedures aggregating to US$ 0.8 million equivalent, or (b) oprudent international and local shoppings by comparing prices obtained from three independent suppliers, aggregating to US$ 3.1 million equivalent. LCB procedures in Tanzania have been reviewed and are acceptable to IDA, except that the Government has been advised that any local preference for parastatals will not apply to the Bank-financed portions of the project. 4.13 Consultants' services will be procured in accordance with IDA guidelines. Other items including travel, per diem, salaries and operating costs will be approved through regular Government procedures. .  - 60 - Table 4.4 Procurement Arrangements a/ b/ (US$ million) Procurement Method ICB LCB Int./ Other Total Local Shopg. I. Investment Costs A. Civil Works 7.2 6.7 c/ - 1.2 c/ 15.1 (3.4) (2.0) - (0.4) (5.8) B. Pharmaceuticals 28.0 - - - 28.0 (28.0) - - - (28.0) C. Equipment 3.5 - 1.5 d/ 1.2 el 6.2 (3.5) - (1.5) - (5.0) D. Furniture - - 0.7 d/ - 0.7 - - (0.3) - (0.3) E. Supplies 1.8 0.8 d/ 1.0 d/ 0.5 el 4.1 (1.8) (0.8) (1.0) - (3.6) F. Vehicles 0.5 - 0.5 d1 - 1.0 (0.4) - (0.3) - (0.7) G. Conaultants Services - - - 4.1 f/ 4.1 _ _ _ (1.6) (1.6) H. Training & Workshops - - - 2.6 / 2.6 _ _ _ (1.7) (1.7) II. Recurrent Costs A. Travel & Per Diem - - - 1.5 g/ 1.5 (0.5) (0.5) B. Salaries - - - 1.6 &l 1.6 C. Building O&M - - - 1.3 ^l 1.3 D. Equipment/Vehicle O&M - - - 3.1 ^/ 3.1 E. Utilities & Services - - - 0.2 ^/ 0.2 III. Proiect Prep.Facility - - - 0.5 0.5 - - - (0.5) (0.5) Totals 41.0 7.5 3.7 17.8 70.0 (37.1) (2.8) (3.1) (4-6) (47.6) a/ Costs include physical and price contingencies. b/ IDA amounts are shown in brackets. c/ Small scattered civil works contracts financed by IDA and SDC under LCD end force account including imputed value of community self-help labour. d/ Small packages of items funded by IDA, SDC, UNFPA and DANIDA. e/ Equipment and supplies procured by beneficiary communities and/or according to procedures of cofinancing agencies. f/ Consultants services procured in accordance with IDA and cofinanciers guidelines. zi Items procured in accordance with Government regulations. These are acceptable to IDA and the cofinanciers.  Procurement Arrangements for the IDA Credit (US$ 47.6 million) ICB 37.1 ^ t O t h e~~~~~~~Ohr 4.6 Int./Local Shopping 3.1 Procurement Method 8I Procurement Method  - 62 - 4.14 Contract Review. Bidding packages for civil works valued at more than US$ 100,000 equivalent (mainly the rehabilitation of the CHS warehouse complex and some district hospitals) and for goods valued at more than US$ 100,000 will be subject to IDA's prior review of procurement documentation, including tender documents, evaluation reports, and draft contracts. Thereby 85 percent of disbursements from the credit will be subject to prior contract review. Smaller packages will be subject to random post-award review by IDA. The MOH and MLG will therefore be required to keep full procurement documentation on file for easy access. For technical assistance, invitations for proposals, firms' submissions, evaluation reports, and draft contracts for large consultancy assignments will be reviewed by IDA prior to award. Similarly, for individual consultancies, IDA will review terms of reference, curriculum vitae, and draft letters of appointment before such appointments are made. D. Disbursements 4.15 The IDA credit will be disbursed over a period of five-and-half years, from 1990-1996, with disbursements completed by December 31, 1996 six months after project completion. The proposed allocation of the credit and the percentage of expenditures covered is given in Table 4.5 (further details are provided in Annexes 13 and 14.) All applications to withdraw proceeds form the IDA credit will be fully documented, except for training and workshops, and civil works and goods valued at less that US$50,000, for which disbursements will be made against certified statements of expenditure (SOE). Disbursements for civil works undertaken through force account will be on the basis of evidence satisfactory to IDA of completion of the relevant units. Supporting documentation will be retained by project executing agencies and will be available for review as requested by IDA supervision missions and project auditors. . Accounts 4.16 Special Accounts. In order to expedite disbursements, the Government will establish two Special Accounts for the project, one each for the MOH and the MLG subcomponents, in a commercial bank acceptable to IDA. An initial amount of US$ 1.25 million and US$ 0.75 million equivalent will be deposited by IDA to the MOH and NLG accounts, respectively, after receipt and approval of a appropriate withdrawal applications. These amounts are estimated to cover about four months of eligible payments by each project executing agency. Replenishment applications will be submitted monthly and will be accompanied by full documentation except for items eligible for disbursement on the basis of certified statements of expenditure (SOE). 4.17 Budgetary Provision. Adequate provision will be made in the annual budgetary estimates of each implementing agency so that project activities will be ivplemented in a timely and effective manner. By May 31 of each year, GOT will reach agreement with IDA on adequate budgetary provision to support the project during the subsequent financial year (see para. 7.01 (i)). The amounts budgeted will include the GOT counterparts, IDA and co-financier portions in both the recurrent and development budgets, as appropriate for project interventions in the MOH, MLG, TFNC,  - 63 - Planning Commission and the 10 districts selected for Component II. In order to facilitate prompt commencement of the project, the MOH and MLG have already made adequate budgetary provision for fiscal year 1989/90. Table 4.5 Allocation and Disbursement of IDA Credit IDA Allocation Percentage of Expenditure Disbursement Category to be Financed SDRm a S$ m 1. Ministry of Health a) Civil Works 100 2 of foreign and i) Civil works for 85 2 of local expenditures. Component I b. 0.8 1.0 ii) CMS rehabilitation 1.5 2.0 b) Vehicles, Furniture, 2.3 3.0 100 Z of foreign and Equipment and Supplies 85 2 of local expenditures. c) Consultants Services 1.3 1.7 100 2 of total expenditures. and Training d) Travel and Per Diem 0.1 0.2 100 2 of eligible expenditures. e) Pharmaceuticals & Medical Supplies 100 X of total expenditures. i) First portion 7.6 10.0 ii) Second portion 6.8 9.0 iii) Third portion 6.7 9.0 f) Overseas Training 0.3 0.3 1002 of total expenditures. 2. Ministry of Local Government a) Civil Works 1.8 2.4 100 2 of foreign and 85 2 of local expenditures. b) Vehicles, Furniture, 4.4 5.8 100 2 of foreign and Equipment and Supplies 85 2 of local expenditures. c) Consultants Services & 0.5 0.7 100 2 of total expenditures. Training e) Travel and Per Diem 0.2 0.3 100 2 of eligible expenditures. 3. Proiect Preparation 0.4 0.5 Amount due. U Facilit I 4. Unallocated 1.4 1.7 TOTAL 36.1 47.6 j _ .~~~~~~ ! !  I~~~~~~~~ AW... .."..........N ...., . ..... _ t ~~~aD H..~~~~~~~~~~. .......... -s 40 2~~~~~~~~~~~~~~~~~~2C X 73 1 ~I !U8 Z C) " V90  - 65 - P. Accountinh and Auditing 4.18 The MOH and MLG will each maintain separate detailed accounts for their respective subcomponents. At the end of each financial year, project accounts and financial statements suitable for auditing will be made available for audit by independent auditors acceptable to IDA. Audited financial statements acceptable to IDA vill be submitted to IDA within nine mouths of the end of the central government's fintncial year, i.e. by March 31 each year, (see para 7.01 (j)). SOEs will be included in the audit and specifically addressed in the audit report.  - 66 - V. PROJECT M&N&GEMENT AND IMPLEMENTATION A. Proiect Management 5.01 The main responsibility for project management will rest with two ministriest ti) the MOH, for components Ia, b, c and d and (ii) the MLG, for the administration of Components I1 and III. The Planning Commission will be responsible for the implementation of Component le. In order to coordinate project activities, a Project Coordination Committee (PCC) has been formed, comprising representatives of these two main ministries (MOK and MLG), the MOF, Planning Commission, TFNC and the Dar es Salaam City Council (DSCC). The PCC is chaired by the Permanent Secretary from the MOH (an organogram of the PCC is attached as Annex 4.1). The PCC will meet at least every quarter in order >o review progress and resolve outstanding issues. It will review the bi-annual progress reports before submission to IDA (see para. 5.11). 5.02 Within the MOH, a project coordinator from the Planning Department has been appointed to coordinate proje-t implementation. An organogram outlining these arrangements is attached as Annex 4.2. The Project Coordinator will be assisted by an Accountant and a Procurement Officer, who have already been appointed. The Project Coordinator will liaise closely with the relevant staff in the following departments and agencies of the MOH, who are responsible for the implementation of activities as fol.lowss - Planning Department - for Component Ia (Health Planning, Policy Formulation and Information System). - Department of Manpower Development and Training (DMDT), in particular the continuing education section, for Component Ib,. Manpower Development and Training. Responsibility for the implementation of district level continuing education will be with the DMO of the district concerned, under the guidance and supervision of the DMWT. - Department of Hospital Services (DHS) for Component Ic, Pharmaceuticals and Medical Supplies. Procurement and distribution of the pharmaceuticals and medical supplies will be the responsibility of the CMS (which currently reports to the ACMO of the DHS) see paras. 2.14 to 2.17. - Tanzania Food and Nutrition Centre (TFNC) for Component Id. TFNC will coordinate other agencies (such as the MALD and MOE, see para. 3.07) involved in the execution of the micro-nutrient deficiency control programs. - PHC Secretariat, which reports to the Chief Medical Officer, and is responsible for preparing and refining the PHC strategy, the implementation of which will be supported through Component II (see para. 5.03).  - 67 - 5.03 Likewise, within the HLG, a Project Coordinator from the Department of Local Government has been appointed. The coordinator will be assisted by a Program Manager who will head a small unit (the Program Support Network - PSN) located in the Department of Local Government, which will be responsible for management, monitoring and evaluation of Component II, Strenthening Rural PHC. The PSN will be based in Dodoma, with a sub- office in Dar es Salaam, and will draw upon existing staff on a full-time basis ftom the MLG (a Community Development Specialist, an Accountant and a Procureuent Officer; the last two have already been appointed). A Public Health Specialist will be made available on a full-time basis from the MOH, and an Architect/Civil Engineer from the Ministry of Works on a similar basis. Staff, whose qualifications are acceptable to IDA, will be appointed to the position of Community Development Specialist and assigned to the positions of Public Health Specialist and Civil Engineer by December 31, 1990 (see para. 7.01 (k)). Field supervision will be undertaken jointly with staff from the MOH, drawn from either the central or zonal level. The PSN will ensure that the selected districts adhere to the conditions of continuing disbursement to the district concerned (see paras. 3.14 and 7.02 (d)). The MOH will maintain responsibility for sectoral policy guidance for the PHC strategy implementation. The PHC Secretariat of the MOH will maintain regular contact with the PSN in the MLG. Both the MOH and MLG are represented on the PHC steering committee. An organogram outlining these arrangements is attached as Annex 4.3. 5.04 Execution of the PHC Strategy will be the responsibility of the ten district governments selected (see Annex 11). The DMO will take overall responsibility for supervising implementation at the district level, will be the first signatory on funds released to support the district PHC program, and will hold the function of the program coordinator at the district level. He will report to the DED on all administrative matters, the RMO on technical matters, and receive guidance on implementation priorities from the District PHC Committee. The DMO will act as first signatory for project expenditures (through Account No.6) with the District Executive Director being the second signatory (see para. 3.13). 5.05 Subject to the details to be established in the inter- governmental agreement between Tanzania and Switzerland relating to component III, the Dar es Salaam City Council (DSCC) will be responsible for implementing Component III, Strengthening Urban PHC. The City Medi'l Officer of Health (CMOH) will supervise the three DMOs in the Dar es Salaam region, who will be responsible for project implementation in their own districts. The CMOH will chair a Coordinating Committee for the project component and will be assisted in this task by a project adviser, whose main function will be to catalyze and advise on project start-up activities. An organogram outlining these arrangements is attached as Annex 4.4. 5.06 The Chief of the Population Policy Unit of the Human Resources Division of the Planning Commission will be responsible for implementing the subcomponent to assist the implementation of the National Population Policy.  - 68 - B. Project Preparation and ImPlementation Schedule 5.07 Status of Proiect Prenaration. The project has been prepared by designated teams within the MOH and NLG. A PPF was approved by IDA to assist project development and to cover some project start-up costs prior to credit effectiveness, includings a) consultant services for a PHC documentation centre, analysis of patient load at the Muhimbili Medical Centre, and an assessment of rehabilitation needs for the Dar es Salaam health system: b) supplies, equipment and vehicles for the sections of the MOH and MLG responsible for project development; c) travel, per diem and other costs for planning workshops and staff training related to project components (especially Component II - Strengthening Rural PHC); and d) the provision of the basic package of inputs for PHC strengthening to five rural districts through Component II (see para. 3.13). 5.08 The GOT has also benefitted from support from other donor agencies in the preparation of this project. DANIDA has financed consultants services and other support for: (i) strengthening the health information system; (ii) the reformulation of the PHC strategy by the PHC Secretariat; (iii) an assessment of the rehabilitation and equipment needs of the three district hospitals in Dar es Salaam; and will finance the (iv) cHS master plan study (see para. 3.06). The SDC has provided substantial inputs for the preparation of the Urban PHC Component, including financing the planning workshop to develop the component framework. The WHO has financed consultant services to assist in a re-evaluation of manpower needs. UNICEF, through dissemination of the results and experience of the Iringa JNSP, has inspired many of the developments in the social mobilization and nutrition aspects of the PHC strategy. FAO and SIDA have assisted TFNC in developing the vitamin A deficiency control program. UNFPA has assisted in financing the preparation of the sub-component to assist in the implementation of the national population policy. 5.09 The project is in a state of preparation which will permit timely implementation because: (i) terms of reference for 80 percent of consultants services and for the key policy studies have been discussed and agreed with Govermnent; (ii) final procurement lists for pharmaceuticals and medical supplies for the first portion of the Credit (up to the agreed amount of US$10 million) have been prepared and approved by IDA; and (iii) the MOB and MLG nave already appointed key staff (paras 5.02 and 5.03) and made adequate budgetary provision for the project in FY 1989/90 (para 4.17). 5.10 Project Implementation Schedule. The project will be implemented according to the schedule outlined in Annex 15.  - 69 - G. Prolect Reporting 5.11 To facilitate close monitoring of the project, the project executing agencies will also submit to IDAs (a) bi-annual progress reports providing details of implementation progress, constraints and project expenditures during six-month period under review; and (b) within six months of the project's closing date, a final project completion report (PCR) on the implementation experience and project outcomes, prepared in accordance with IDA guidelines on PCRs. IDA will supervise the project regularly (about twice a year). An annual review of project implementation will be undertaken jointly with IDA and any cofinanciers wishing to participate. 5.12 IDA and the GOT will undertake a comprehensive review of Component le. Micro-Nutrient Deficiency Control Programs and Component II (Strengthening Rural PHC) no later than December 1992 (see para. 7.01 (d)) according to agreed evaluation protocols. The results of the review of rural PHC will help to determine future IDA assistance to Tanzania in this area.  - 70 - VI. PROJECT RENMPITS AND RISKS A. Benefits and Justification 6.01 The proposed project is a major contribution to the ESAP and the Governments reforms to the health sector, and therefore buttresses the process of economic reform by contributing both to poverty alleviation in the immediate term, and to poverty reduction in the medium term through building up Tanzania's human resource base. 6.02 Benefits to the Government. The project will assist the Government in undertaking much needed reforms in the health sector, such as improving long-term sustainability and efficiency, and improving access to services in neglected areas of the country and the quality of services nation-wide. The project will strengthen Government's capacity to implement other key policies in the PHN sectors, such as the national population, drug and nutrition policies. The project has a strong institution-building focus in terms of planning, policy formulation and implementation in the MOH, the MLG and the Dar es Salaam City Council. The project represents a major response to the Government's ESAP, and will contribute significantly to the development of Tanzania's human resource base during the process of economic adjustment. 6.02 Benefits to Communities and Households. Communities and households will benefit from improved access to and quality of preventive and curative services. The entire popila-tion utilising health services should benefit from the improved availability of pharmaceuticals and medical supplies under Component Ic. Given the specific items to be procured through the IDA credit, this will benefit about 10 million people per annum in terms of better diagnosis of disease (through increased supplies for laboratory tests), about 2 million people in urban areas in terms of improved availability of essential drugs and 0.5 million people in terms of improved drugs for in-patient treatment. The benefits of the micro-nutrient deficiency control programs are more narrowly focussed. In terms of Vitamin A deficiency, on a conservative basis, the control program should reduce the incidence in children under 5, by 20 percent in the first year (260,000 cases - see Table 2.2) and by up to 50 percent by the fifth year (650,000 cases). The iron-deficiency control program, as it is newer and more experimental, is estimated to make an impact from the second year onwards. A conservative estimate would be that the incidence of iron deficiency anemia would be reduced by 3 percent in PY2 (benefiting about 40,000 pregnant women, 60,000 children under 5, and 240,000 others) with a reduction of 20 percent in PY5 (benefiting approximately 240,000 pregnant women, 400,000 children under 5 and 1.6 million others). Direct benefits of PHC strengthening will be focussed on the populations of those areas of the country receiving concentrated support under the project namely, the ten selected districts (about 2.2 million persons) under Component II, and in Dar es Salaam (at least 1.4 million persons) under Component III. In rural areas benefits will include improved nutrition, access to family planning services, sanitation, and water supply as aspects of the district PHC program. The benefits to households from other elements of Component I are more diffuse, but the impact of a more effective and sustainable health system for the whole population will be significant. 6.03 Benefits Nationally. For the country as a .nole, project benefits include a healthie: population and labor force, contributing to increased output. A reduction in the incidence of micro-nutrient  - 71 - deficiencies within the population, improved child nutrition, and a strengthened health system able to provide more effective preventive and curative services are all important in this regard. Strengthening the implementation of national population policy, thereby contributing towards reducing the pace of population growth, will reduce the rate of increase of pressure on Tanzania's physical resource base (thereby contributing to the protection of the environment), and on the recurrent budget for the provision of social services to a rapidly expanding population. Due to the demographic issues involved, with the exception of the demand for MCH services and to a lesser extent primary education, such benefits will only accrue to any significant extent from the year 2000 onwards. B. Risks 6.04 Whilst there has not been a previous IDA-assisted project in the health sector, the preparation of the project has benefited from an analysis of the implementation experience of IDA-assisted projects in other sectors and donor funded projects in the health sector. The lessons learnt have been incorporated into the design of the project so as to minimize any risks and effectively manage them during implementation. The main risks are three-fold: (a) The first risk is that efficient implementation will be hampered by weak administrative capacity in the implementing agencies. In order to minimize this risk, the implementation capacity of these agencies (MOH, MILG and the offices of the DMOs and CMOH in Dar es Salaam) is being strengthened under the project, through the provision of training, additional staff, and technical assistance. (b) The second risk is that the inferior performance by staff (resulting from poor motivation due to low salaries) may undermine effective implementation of project activities. The Government is aware of this issue and is already reviewing the remuneration policy for staff, with a view to moving towards a program of reform of the civil service to be supported in the Public Sector Management operation (FY92). The project will also contribute to reducing this risk through the provision of non-salary inducements to staff (such as training, recognition, and improved supervision) and a dated covenant on the introduction of an improved incentives package for staff (see para. 7.01 (g)). (c) The third risk is that the macroeconomic environment may deteriorate again if the Government fails to continue the program of economic reform with due diligence. This risk is being addressed by the Bank and the donor community through country dialogue, policy-basel operations and the PFP. Fundamentally, the Government recognizes that integrating the social sectors into a continuing program of coherent economic reform provides the best route for the resolution of Tanzania's economic malaise.  - 72 - VII. ASSURANCES AND RECONOEUD&TIONS 7.01 During negotiations agreements were reached with Government on the following: (a) by July 1, 1993, the MOH will have strengthened the Planning Department by a net increase of six staff, filling the existing vacancies for a Public Health Specialist, Senior Economist, Senior Statistician, Epidemiologist, Healtih Economist and an Economist (para. 3.04 (a)); (b) by April 30, 1992, the GOT and IDA will reach agreement on the plan of action for the long-term financing for the health sector (paras. 3.04 (b) and 3.28 (a)); (c) by July 1, 1992, the GOT and IDA will review the study on the domestic pharmaceuticals industry and agree on a plan of action (para. 3.04 (b)); (d) by June 30, 1991, the GOT will submit an evaluation protocol, satisfactory to IDA, for the mid-term evaluatio.. of the implementation of the PHC strategy in rural areas, and by December 31, 1992, undertake this evaluation (in accordance with the agreed protocols) and a similar one for the Micro-nutrient Deficienty Control Programs, and review them with IDA (paras. 3.07, 3.15 (c) and 5.11); Ce) by November 30 each year, for each district included in the program of PHC strengthening, GOT will submit the district health plans for the forthcoming year, developed in accordance with the approved guidelines (para. 7.01 Cf)), for IDA approval for the forthcoming district financial year (para. 3.11). tf) by December 31, 1990, the GOT will agree with IDA on: (i) the revised PHC strategy; (ii) guidelines for the rehabilitation of the district referral system in the 10 selected districts under Component It; (iii) the list of criteria for evaluating the performance of districts under Component II; and (iv) guidelines for the preparation of district health plans (DHP) (paras. 3.09 and 3.14 (c)); (g) by July 1, 1991, the GOT will increase the share of the recurrent budget allocated to the health sector to a level satisfactory to IDA and adopt an improved incentives package for health sector staff (para. 3.28 (b)); (h) by December 31, 1991, the GOT will submit the draft health manpower plan for IDA review and comments, and by July 1, 1992, the MOH would commence implementation of the health manpower plan, taking IDA's comments into account (para. 3.29 (a)); Ci) by May 31 each year, the GOT will reach agreement with IDA on adequate budgetary provision to support the project and ensure  - 73 - that these funds are allocated i' a timely manner to the project entities (para. 4.17); (j) no later than 9 months after the closing of the central government's fiscal year (ie. by March 31 each year), the GOT will submit accounts for the project, audited by independent auditors, to IDA for approval (para. 4.18); and (k) by December 31, 1990, the GOT will appoint a community development specialist and assign a civil engineer (from the Ministry of Works) and public health specialist (from the MOH) to the PSN, whose qualifications are acceptable to IDA (para.5.03). 7.02 The following would be conditions of disbursement: (a) for the overseas training of Y)MDT staff, the GOT will adopt a plan of action for strengthervcg the DMDT satisfactory to IDA (para. 3.05 (a)); (b) (i) for the second portion of funds for the importation of pharmaceuticals and medical supplies, the GOT will furnish evidence to IDA that satisfactory progress has been made in the implementation of the agreed set of reforms in the pricing, financing, budgeting and capacity building in the procurement of pharmaceuticals (paras. 3.06 (b) and 3.29 sb)); (ii) for the third portion of funds for the importation of pha-maceuticals and medical supplies, the GOT will make sat..sfactory progress in commencing the resource mobilization measures for the health sector, as contained in the agreed plan of action for the long-term financing of the health sector (paras. 3.04 (b), 3.06 (b) and 7.01 (b)); (c) for the rehabilitation of the CHS warehouse complex, that IDA is satisfied with (i) the revised institutional structure for and (ii) the plan of action for the rehabilitation of the CMS (para. 3.06 (c)); and (d) for the release of funds for the particular district concerned in Component II (apart from the "basic package" of PHC inputs), the GOT will ensure that (i) the district has appointed an Officer in Charge of the district hospital thereby releasing the DMO from the day-to-day management of the district hospital (para. 3.12), (ii) funds will continue to flow through Account No. 6, and (iii) the DHP for the district concerned is submitted to IDA for approval (paras. 3.13, 3 14 and 7.01 (f)). 7.03 The institutional arrangements for implementing the project have been reviewed by IDA and foi-d to be satisfactory (Annex 4 and Chapter V). 7.04 With the above assurances, the proposed project forms a suitable basis for granting of an IDA Credit of SDR 36.1 million (US$ 47.6 million equivalent) to tne United Republic of Tanzania, at standard IDA terms, with a 40-year maturity.  - 74 - TANZANIA ANNEX 1.1 Page 1 of I HEALTH AND NUTRITION PROJECT ORGANIZATION STRUCTURE - MINISTRY OF HEALTH 44 _____~~~_ _.., . dii i I i W~~~~~~~~~~~~~~d I I  - 75 - AMUU 1.2 Page 1 of 4 TANZANIA HEALTH AND NUTRITIOW PROJECT THE STRUCTURE OF THE 'LAAINGN DEPAMRENT I. Introduction 1. In 1985 the Planning Unit of the MOH was upgraded into a full department whose director was answerable directly to the Principal Secretary. Initially the new department consisted of four sections, namely those for: planning; evaluation, information, and statistic; building5 and projects agreements and contracts. The planning section was later split into a planning section (long-term planning) and a budget section (annual development plans). In 1988, the planning section was further disaggregated in a planning section and a health systems research section. In the meantime the evaluation, information and statistical section contracted to a more modest statistical section, which is currently being expanded again into a national health information section. The projects agreements and contracts section has evolved into the donor coordination section. 2. The actual staffing situation is as follows: Staff Higher Level i) Statistical Section (Health Information Section) (4) ii) Health Systems Research section (1) iii) Planning Section (1) iv) Budget Section (2) v) Contracts Section (3) + (Donor Coordination Section) vi) Building Section (2) Plus the Acting Director of Planning (1) Total (14) The functions of the different sections of the Planning Department have not always been clearly redefined in accordance to its evolving structures. Furthermore, due ts, a chronic shortage of experienced manpower and logistic support, the PlannIng Department has always performed far below expectations. This had led to dissatisfaction, both within the Department (ending up in a lack of motivation and frustration) and outside  - 76 - Aunex 1.2 Page 2 of 4 the Department (resulting into the relative neglect of its coordinating role). 3. The roles of the different sections are as follows: I. The Statistical Section 4. The Statistical Section is supposed to: - collect, compile and order statistical data on the health status of the country; - write and make available statistical reports for the use by other directorates, regions or any other institution dealing with health; and - survey population trends 1/. 5. Good informational services from this section have been in high demand throughout the Ministry sinee its inception. However, the section has been confronted with various difficulties: - several vertical programmes devoloped their own reporting systems independently of each other, and of the Statistical section, resulting in overlapping efforts, inefficient scattering of data collection and compilation, and fragmented information, which is not really useful for systematic health management purposes; and - the statistical section has never been designated as the overall focal point for all reporting systems. A lot of information (hospital reports, district or regional annual reports, etc.) does not find its way to the section, but rather remains scattered within the Hinistry or is not collected on a systematic basis although available in the periphery or other ministries. TI. The Realth System Research (HSR) Section 6. This section has taken over most of the applied, problem solving research activities of the Planning Section (see below). Its purpose is not to execute its own research (although it can occasionally initiate such research if no alternatives emerge), but rather to coordinate and orient research efforts going on elsewhere in the country, and to support the implementation of policy recommendations. 11 The Statistical Section was initially expected to evaluate health plans and project implementation as well and to advise the ministry accordingly, but it was soon realized that in this role the section was duplicating efforts from the Planning and Budget sections. I  - 77 - Anmex 1.2 Page 3 of 4 III. The Planmins Sectian 7. Since the transfer of the responsibilities for the annual development plans to the Budget Section, and of the HSR activities to the HSR section, the role of the Planning Section has mainly been in the development of long-term sector plans and of guidelines for regionalldistrict health planning. The section is also responsible for the monitoring of the activities of the parastatals under the MOH (MHhimbili Medical Centre, National Institute for Medical Research and Tanzania Food and Nutrition Centre). IV. The Budget Section 8. The Budget Section has taken over the short-term planning activities of the Planning Section, i.e., - the preparation of the annual development budget of the MHf; - the 6-monthly monitoring of the development projects; and - the quarterly financial reporting on the progress of these development projects. 9. The Budget Section advises on the acceptability of development projects proposed by the regional or district authorities since some of the costs of those decentralized initiatives will have to be supported by the central government (e.g., training of personnel, hospital equipment). Due to a lack of adequate manpower and logistics, the preparation of the development budget has frequently been limited to the compilation of annual development plans on the basis of departmental sub-plans, adjusted to fit into the ceilings and guidelines set by the Ministry of Finance, without rigorous analysi; of each project. V. The Contracts Section 10. The Contracts Section must continuously update the information on all donor support to the health sector, including loans, grants, technical assistance, and fellowships. The Section is also supposed to monitor the actual use of donor support on a 6-monthly basis, and evaluate and negotiate the donor contributions to the health sector on the basis of prioritized needs as defined by the National PHC Steering Committee and the overall health strategies of the country. Although recognized as very important given the crucial role the donor community plays in the health sector, the Contracts Section has been chronically under-stalfed and has never been really operational. The strengthening of this Section and developing it into a full donor coordination office is an extremely high priority. VI. The Building Secticn The Building Section is mainly a technical section, preparing plans for rehabilitation of health facilities, preparing terms of reference for tender procedures (including building standards, etc.), monitoring the implementation of building projects on a quarterly basis (for use by the Budget section).  - 78 - ANU 1.2 Page 4 of 4 PERSONNEL IN THE PLANNING DEPARTMENT ACTUAL APPROVED STRENGTH DESIGNATION ESTABLISHMENT AS PRESENT 2/ 1987/88 1988/89 Director 1 1 Senior Economist I 1 1 1 Senior Economist II 1 1 1 Economist I - 1 - Economist II 2 2 - Economist III 4 2 4 Health Secretary I 2 1 - Health Secretary II - 1 2 Health Planner - 1 - Medical Demographer - 1 Epedemiologist - 1 Computer Analyst - 1 Architect I 1 1 1 Architect II 1 1 1 Assistant Executive Engineer 1 1 1 Building Inspector 1 1 1 Principal Statistician 1 - Senior Statistician 1 - - Statistician I 1 1 - Statistician II 1 1 - Statistician III 2 2 2 Statistical Assistant I 2 2 2 Statistical Assistant II 2 2 1 Statistical Assistant III 2 2 - Personal Secretary III 1 1 - Typist III 1 1 - Accounts Clerk 1 1 1 Office Attendant III 1 1 - TOTAL 31 32 18 Source: Ministry of Health, Planning Department 21 As of June 1989.  - 79 - ANNEX 2 TANZANIA Page 1 of 14 HEALTH AND NUTRITION PROJECT PRIORITY SOCIAL ACTION PROGRAMME A SUMMARY 1. The commitment to provision of basic social services for the population as a whole has been a consistent feature of Tanzanian Government policy since the 19608. Targets for universal primary education, rural health care and universal access to clean water have been at the forefront of the planning process from the start. However, the economic difficulties which have confronted all sectors and regions of Tanzania for more than a decade, have been undermining earlier achievements in the social sectors. The urgent need to reverse this decline, as well as the need to address possible dislocations arising from the economic reforms, is the broad justification for the Priority Social Action Programme (PSAP). This programme is an integral part of the Economic Recovery Program, Phase II, i.e. the Economic and Social Action Programme. 2. The Government's response to the economic crisis has been to embark on a process of structural adjustment since the early 19808. This process has been accelerated during the Economic Recovery Programme 1986/7 to 1989. During the ERP, substantial progress has been made in terms of macro-economic objectives, with output increasing at an average annual rate of 3.9 percent per year during 1986 to 1988, faster than the rate of growth of population. The implications of this economic success for the standards of living of the mass of the population are not straightforward, however. partly because of unevenness in sectoral performance, partly because the economic recovery has required a focus on productive sectors in resource allocation, and partly because of the potentially unfavorable short term impacts of ERP. Central to the economic recovery is a decline in employment in some sectors, in order to shift resources into more productive and profitable sectors. Therefore the ERP has had widely varying effects, depending on the sources of peoples incomes and the speed with which they can respond to the new economic. environment. 3. Although the aims of ERP in the social sectors have been to maintain the commitment to provide for the basic needs of the population, to rehabilitate social and physical infrastructure and reactivate existing capacity, resources have not been adequate to achieve these objectives. Therefore, the social services have continued to perform poorly and to deteriorate. Because of the essential contribution of social services to productivity growth in the medium and long term, it is clear that economic recovery will not succeed without a strategy for revitalizing these services. This is the rationale for the PSAP, which aims to rehabilitate and enhance basic welfare services, both because of their importance in themselves and because of their essential contribution to productivity growth in the medium and long term. PSAP is not a replacement of government activities in the social sectors, but is intended to consolidate and extend them. However, PSAP is not simply a programme ... increase resources for the social sectors; it is alio a programme for restructuring the systems of delivery, finance and managem8 t of social services to ensure greater efficiency in the use of resources, a wider coverage and their sustainability in the longer term. Thus the PSAP is designed to be an integral part of the continuing process of economic recovery, indeed, the nezt phase of economic adjustment will  ANNEX 2 - 80 - Page 2 of 14 explicitly integrate the economic and social sectors in the form of an Economic and Social Action Programme. 4. The context of the PSAP is, therefore, the need to address with urgency the problems of content and coverage of social services, and to ensure tb*t economlc growth results in beneflts for low income groups. To address t.Aese concerns, immedlate actions are proposed in the areas of health, education, water supply, food security, incomes and employment. The measures are designed to provLde for improvements and for the organizatLonal reforms which will ensure that these improvements are consolidated and extended. TSE STRATEGY FOR PRIORITY ACTION IN THE SOCIAL SECTORS 5. It is recognized that constraints on the central government budget will continue to limit allocatlons to the social sectors, and that any comaitment to soclal devalopment must be based on a realistic assessment of likely resource availability. Furthermore, the problem facing the social sectors are only partly a result of the economic crisis which has confronted Tanzania since the 19708. Central to the PSAP is an acknowledgment that lessons must be learned from past experience in order to secure sustainable financing arrangements, an incentive structure and management systems which enable the full utillzation of existing capacity, and maintenance procedures hilch conserve the capital stock, as wall as a renewed focus On targeting vulnerable groups. 6. Because the PSAP aims to achieve both an lmmediate improvement in resource availability and to undertake necessary Lnetitutional restructuring, the time horizon for the programme is three years. The reorganization of delLvery systems, management and financing arrangements is a complex matter, which in many cases must be done through sequential stages. It will require time to develop the commnaity participation stressed by the PSAP, thus the programme requires a three-year period before effective results can realistically be achleved. 7. The strategy involves an analysis of the economlc requirements of each of the social sectors, in term of capital investments and recurrent requlrements, the latter comprLsing labor, traniLng, materlal inputs and maintenance. The emphasis of the strategy is on rehabilitation and management of existing facilitles, training, retraining and incentives, mechanisms of dLstrLbutLon of recurrent inputs, and maLntenance procedures. Methods of financing these requLiements are also examined, in the light of severe government budget limitations, and the strategy proposes that the financing of social sectors in the medlum and longer term wlll requlre a combination of budgetary shLfts, user charges and coammunity contrlbutlons. StrategLes to Increase local tax revenues are also under conslderatlon, together with the feaslblilty of insurance schemes. The preclse combination of methAds of financing social se-vLces will need to be reviewed and adjusted on a continuing basis. The PSAP itself hLghlights the issues whieh need to be taken Into account in constructing a sustaiLable financlal system.  ANNEX 2 Page 3 of 14 - 81 - 8. In the short term, additional donor financing of both local and foreign exchange costs of reviving the social sectors will be necessAry. The Government is aware of the issue of sustainability. which has Implications for the design of programmes. In particular, programe design must involve greater awareness of the recurrent costs associated with projects to which donors provide capital support, and further consideration of the role of donors on the recurrent side. This is of vital importance in the context of the PSAP, since constraints are appearing increasingly in the form of the TShilling budget, In addition to shortages of imports. 9. Donor support to PSAP should take into account Tanzania's continuing foreign exchange constraints. This means that PSAP should, as far as possible, be financed by donors on a grant basis. 10. The PSAP addresses issues of management, accountability and implemntation capacity as part of its concern with the longer run sustainability of the social programmes. The government is embarking on a restructuring of public expenditure. In addition, decentralizlztion is proposed to facilitate community monitoring and control, and the programme addresses the training needs which these community level structures will require. It is recognized that these developments will take time, and that it is unlikely that they will be fully operational throughout the country within the period of the PSAP. One of the PSK? objectives is to undertake pilot testing and the initial phases of implementation. Further issues of management and organization concern the central provision of certain services, such as drugs, textbooks and national food stocks. The PSAP Includes recommendations for improvement in these areas along with its proposals for decentralization. The issue of implementation capacity is also addressed, in terms of the need for a review of implementation bottlenecks, action to redress them, and the training implications of improved implementation. 11. In the contezt of limited resources, it is clear that targeting, i.e. the design of policies to ensure that benefits are focused upon the most vulnerable groups in the population and the poorest regions of the country, is an urgent necessity. The identification of such vulnerable groups is a major priority in the formulation of a policy-oriented research programme. The outcome of this research will form the basis of improved targeted interventions in the future. A SUMOMRY OF THE PRIORITY SOCIAL ACTION PROGR&MOE 12. The Priority Social Action Programm contains practical optlons to fulflll the following objectivess to mobilize resources to prevent further deterioration of the vocial sectors, and restore performance in the short run; to move towards a more sustainable social service delivery system in the medium term; and to ensure an improved system of food security, by enhancinb food availability and by Increasing levels of employment. More specifically the objectives ares (i) to make institutional and management reforms which can - ~~~~~~A  ANNEX 2 - 82 - Page 4 of 14 enabling environment for improved efficiency, accountability and mobilization of community support, and hence sustainabilityg (ii) to restore an adequate supply of and effective demand for basic instructional materials in schools and to improve the learning environment; (iii) to restore an adequate supply of essential drugs and health care equipment in order to safeguard standards of provision of universal basic health services; (iv) to rehabilitate and improve maintenance of existing water facilities in order to provide improved access to safe watert (v) to improve the distribution of food from surplus to deficit areas so as to reduce the wide market4ng margins between producer and consumer prices for staple foodstuffs; (vi) to accelerate the creation of employment and income generating activities in small-scale manufacturing and services; (vii) to support coiamiuty-based public work schemes to create employment opportunities for low Income people and improve their access to food and other essential goods and services, with preference being given to women; (viii) to provide a nutritional "safety-net' if necessary for families who are unable to earn enough to buy adequate food. 13. The selection of projects making up the PSAP portfolio follows from these objectives. The overall criterion guiding the choice was the commitment to safeguard Tanzania's long standing basic needs objectives. 14* The financLug requirements for PSAP are summarized in Table 1. The total cost of the entire three-year program is $314.65 million. Of this total, $179.69 mlllion is expected to be provided through projects and programs already in the pipeline, for which donors have previously indicated their anticipated level of finAncial support. That leaves an unfunded gap of $134.96 million, which is the 9i now being requested from donors. In addition, donors are requested to reconfirm commitments already made and speed up disbursements. 15. gstimtes for the outer years are necessarily less firm than for the first year. These figures vill be updated on a yearly basis. 16. Further details are discussed in the following secions, sector by seci . For *' seci , 4 o 01 reports ve also been prepared whicb  ANNEX 2 - 83 - Page 5 of 14 carry detailed analysis of the policy issues involved. These are available on request. TABLE 1 PRIORITY SOCIAL ACTION PROARAM (1989190-1991/92) SuDmARY OP FINANCING REQUIREMENTS (US$ MILLIONS) TOTAL RIfElENTs 1969/1900 1900/1991 1991/1992 TOTAL EducatIon 22.04 21.95 1.556 60.84 Hbalth 45.60 60.00 67.60 160.00 Water Supply 24.00 24.60 29.60 70.20 Food S.curity 6.64 5.54 5.7t 16.01 Employment 2.08 2.18 2.14 6.80 P romM t:U"? 99.91 104.22 110.62 814.65 EUEML SUPO ALRDY IDENTFE Educetion 10.69 10.59 10.59 81.79 Health 26.00 83.70 86.60 96.80 Water Supply 17.20 17.20 17.20 51.60 Food S eurIty 0.00 0.00 0.00 0.00 Employment 0.00 0.00 0.00 0.00 Programe Total 8.709 61.49 64.89 170.69 -UMM GAP - PSAP RE4UEST Education 12.24 11.85 4.96 28.55 Helth 19.60 16.80 20.90 68.70 Water Supply 0.70 7.36 12.06 26.60 Food Scurity 5.64 5.64 5.78 16.81 Employment 2.08 2.18 2.14 6.80 Prorm Touta 40.09 42.60 46.09 104.08 PROJECTS IN EDUCATION 17. The objective of priority interventions in the educational sector is to ensure a smooth transition from a centrally funded school system to one that will be mainly funded by the local community. In this transitional period, within the framework of the proposed PSAP interventions, the institutional details of the new system will be developed and refined. Efficiency and cost-effectiveness will be fundamental principles of the new system. Institutions such as Tanzania Elimu Supplies (TES) will be exDected to run commercially. Given the magnitude of work involved in school material production and distribution, this activity will be opened up for other bodies and institutions to permit broader participation. PRIMARY EDUCATION 18. For Primary Education the main objectives that require immediate action ares (M) production and distribution of textbooks;  ANNEX 2 - 84 - Page 6 of 14 (ii) the absence of effective demand for books and other school materials which would requLre an increase in the Government's subvention to Districts from the present TShs.200/pupil to TShs.450/pupill (iii) improvement of the distribution of school materials at district level first by removing the TES monopoly over textbook distribution and secondly by providing support for district level transport; (iv) improvement of the learning environment by supporting the rehabilitation of badly rundown schools; (v) increaring parent and community involvement in schools by reviving Parents Committees and establishing the Community Managed Primary School System in pilot areas; (vi) transport for school inspectors. 4 SECONDARY EDUCATION 19. Secondary education is seriously under-funded and is in great need of immediate support in the form of textbooks, teaching materials and laboratory equipment and supplies. Since Tanzania is nearly at the bottom of the African league in secondary education enrolment rates (only 6 per cent in 1987), and in view of the demonstrated ability of parents to build and run private secondary schools, it is proposed to support this effort on a priority basis by establishing a Fund in Support of Community Financed Secondary Schools. OTHER 20. School Transport. The reforms currently being made have significantly reduced the Government's capacity to provide adequate transport services to the student population. While the number of students has been increasing yearly, the urban public transport system, which itself has been facing serious capacLty problems, has been unable to transport students to and from school at the required times. Coupled with the rapidly increasing transport costs, including fares, the level of hardship for many students has increased and the absenteeism rate has soared. This applies to students at all levels, from primary to university. An important activity in PSAP will be to provide adequate and reliable transport to students. To accomplish this, special buses will be obtained and set aside for the sole purpose of transporting students. 21. Books. Although the requirements for teztbooks and other teaching materials have been shown for primary and secondary schools, serious shortages have occurred at the university and other institutioos of higher learning. The current book supply program cannot cope with the \igh dweand of these institutions and the piblic at large. In order to imprav* this situation, a special allocation for books, which will be placed at the  ANNEX 2 -85- Page of 14 bookstores of these Institutions as well as in general libraries, is requested under the PSAP. 22. Table 2 below provides a sumc,ey of PSAP projects in the education sector, the amounto of donor supports already secured and the gap for which futher donor support will be required. The Government is requesting an additional US$28.55 million. The bulk (69 percent) will go to meeting urgent requirements in primary schools, even though considerable support has already been secured for textbooks and the rehabilitation of primary schools.  ANNEX 2 -86 - Page 8 of 14 TABLE 2 PRIORITY SOCIAL ACTION PROGRAM: EDUCATION US$ MILLIONS) 1g9/19"0 1900/1001 1M91/1M TOTAL TOTAL REJIR!MENTS 22.88 21.95 16.66 60.82 PRIM"RY EDUCATION 14.05 13.18 11.67 89.08 Tontboois 3.49 8.40 8.46 10.68 Exercise books and mterials 4.76 8.8 2.80 10.89 Distributioh Support to Districts 0.42 0.98 0.72 2.12 Rebhb. of peimay schools, 3.68 8.68 8.68 11.49 sethom comunity participation 0.65 0.56 0.64 1.70 Transport of *chool Inspectors 1.00 1.00 1.00 8.00 SECOISARY EDUCATION 6.78 2.00 2.00 10.74 Textbooks 2.67 2.57 0.47 5.61 Laboratory Equipant/suppl)ie 2.21 2.21 0.71 5.18 Support to community schools 2.00 2.00 2.00 6.00 OTHER 2.00 2.00 0.60 4.50 School transport 1.00 1.00 0.00 2.00 Books 1.00 1.00 M.CI 2.60 EXTiRNAL SUPPORT ALREADY IDENTIFIDC 10.60 10.60 10.60 21.60 PRIMARY EDUCATION 7.41 7.41 7.41 22.28 Toxtbooke (1IDA) 8.45 8.46 8.50 10.48 Exercise books and materials 0.00 0.00 0.00 0.00 Distribution Support to iestrict 0.12 0.12 0.12 0.86 Rehab. of primary choonl 8.68 8.68 8.88 11.45 Strengthn community participation 0.00 0.00 0.00 0.00 Transport of school Inspector 0.00 0.00 0.00 0.00 SECONDARY EDUCATION 3.16 8.16 8.16 9.54 Txtbooks 0.47 0.47 0.47 1.41 Laboratory Equipmsnt/supplies 0.71 0.71 0.71 2.18 Support to counlty schools 2.00 2.00 2.00 6.00 OTHER School transport 0.00 0.00 0.00 0.00 Books 0.00 0.00 0.00 0.00 WUDB GAP PSAP 1 JEST 12.24 11.85 4.90 28.55 PRIMARY EDTION 6.64 6.75 4.46 16.85 Textbook* 0.00 0.00 0.00 0.00 Morclse books and atrials 4.76 8.38 2.80 10.89 Distribotlon Support to Districts 0.80 0.66 0.60 1.76 Rehab. of primry schools 0.00 0.00 0.00 0.00 ftrengthn comunity 9rptlelpstion 0.68 0.56 0.64 1.70 Transport of school lnspector 1.00 1.00 1.00 8.00 SECONDARY DUCATION 8.00 8.60 0.00 7.20 Textbooks 2.10 2.10 0.00 4.20 Laboratory Equip snt/suppli 1.50 1.50 0.00 8.00 Support to community schools 0.00 0.00 0.00 0.00 OTHER 2.00 2.00 0.50 4.60 School tranort 1.00 1.00 0.00 2.00 Rooks 1.00 1.00 0.60 2.50  ANNEX 2 - 87 - Page 9 of 14 23. Other urgent issues are also being addressed by the Government such as the need for better salaries for teachers and the rehabilitation of public secondary schools. 24. The Tertiary Education Sector has not been fully covered by the PSAP. In addition, there are a number of ongoing and planned activities in Education which will be addressed outside the PSAP. PROJECTS IN HEALT- 25. Like the other social services health is constrained riumarily by inadequate financing, poor management and inadequate staff compensation which has eroded worker morale, performance aud productivity. Various programmes are underway to alleviate these problems in the medium term. Specifically a comprehensive master plan for an improved medical supply is being worked out. Also, the Government is actively examining the introduction of alternative sources of finance, such as user-fees, comminity contributions and participation in support of health services. 26. However, in the short term, immediate support is needed to improve the situation because the time lag involved in developlng appropriate community based structures to manage and account for the funding of the health sector is bound to be long. 27. Priority action is needed to: Mi) improve the supply of pharmaceuticals, particularly essential drugs and other basic equipment and supplies by filling the gap left by the donor supported Essential Drug Programe (EDP) which presently covers only RECe and dlspensaries in rural areas; (ii) provide referral transport to a small number of Rural Health Centers and district hospitals on a pilot basis in order to enable the referral system to function satisfactorily; (iii) establish a credit scheme to enable Primary Cooperatlve Societies to purchase referral transport for dispensaries In their respective areas and to establlsh a Health Transport Maintenance Fund at each level, financed by the Secretaries members; (iv) strengthen current efforts in AIDS control by establishing a reserve fund from which emerging problems can be studied and remedial action taken lmmediately to speed up the implementation of the AIDS Control Programme; (v) introduce a pilot Health Insurance Scheme In Dar es Salaam In order to test and develop appropriate arrangement to protect those who have been adversely  ANNEX 2 -88 - Page 10 of 14 affected by the withdrawal of parastatal health services to the general public; (vi) whert feasible extend/develop a two-tier (grided) medical service system in order to raise additional revenue by charging the relatively well.off for higher grade services in order to support a basic health service that remains free for all; (vii) in addition, in order to reverse the deterioration of health facilities, it is proposed to embark on a rehabilitation programme, involving community participation to the maximum extent possible. The prograime would also involve the establishment of a decentralized maintenance system within the health sector; (viii) in order to improve resource management within the health sector, it is proposed to embark on a training programe for health managers, in management skills and information systems 28. The project portfolio for the energency action programe in health is summarized in Table 3 below. Over the 3 years it will require approximately US$30 m$Ilion p.a., totalling US$91.20 million for the whole period. The bulk (81Z) is for the supply of drugs. PROJECTS IN WATER SUPPLY 29. The Government has long given priority to supplying both urban and rural populations with Improved water services and a number of projects funded by donors are underway to meet this objective. Most donor support is directed at the development of new systems or the expansion of existing systems. Some donors also assist with rehabilitation and maintenance work on existing systems. Overall, however, rehabilitation and maiutenance efforts for existing systems has lagged behind investments in new systems resulting In the deterioration of water services for much of the urban and rural population. Resources are required to rehabilitate existing pumping facillties and deliver systems, and improve maintenance capabilities. The priority program for water will focus on these rehabilitation and maintenance requirements and as such will complement existing water supply development programmes thereby ensuring better management and increased efficiency in the deliver of water services. The PSAP will provide support in three areass rehabilitation of existing urban and rural systems, strengthening of maintenance capabilitiesg and training and institution building. So. Much of the rehabllitation efforts will aim at halting the deterloration of the bar ss Salaam system which serves the largest urban population In the country. Priority will also be given to the rehabilitatoan of pumps and ancillary equipment in existing rural systems. Maintenance  ANNEX 2 -89- Page I Iof 14 PfrI V SOCIAL ACTION PROORAMMEt HEALTH 050 1IL1IONS) 1IM1AM0 1M/1001 1001/1002 TOTAL TOTAL RElyDREUENTs 45.60 50.00 57.50 181.00 20.00 27.50 29.00 02.60 quypp nt/Spplleo *.00 7.00 5.00 n1.00 En. Ref. Tramp. 2.40 2.40 2.40 7.20 AIDS Control 1.00 1.00 1.00 8.00 Health Finne. Scheme 0.40 0.40 0.40 1.20 H"elth Fe. babsS. 2.00 4.00 7.00 18.00 Healtb Met. Tr"o. 0.70 0.70 0.70 2.10 VIlIa"e mu Init. 8.00 7.00 11.00 28.00 EXTERNAL SUPPORT ALREADY IlENTXFI 20.00 88.20 86.60 96.80 Snags 10.80 22.00 22.50 62.60 Equlpee*t/Supl _Ie 6.00 2.10 2.40 6.50 Em. Ref. Tranap. 0.00 0.00 0.00 0.00 AIDS Control 1.00 1.00 1.00 8.00 Hnelth Fimn. S _b.. 0.80 0.20 0.10 0.60 Health fac. Rehab. 1.20 2.40 8.20 0,J0 Heblth Mpt. Tang. 0.50 0.70 0.60 1.60 VI Ilag mm Init. 8.70 5.80 6.60 15.60 UINUIU P CA P5W RSIUEST 19.50 16.80 20.90 56.70 Drugs 7.70 5.50 6.50 19.70 f uipnentSuppl l_e 7.00 4.90 8.60 15.50 Em. Ref. Trranp. 2.40 2.40 2.40 7.20 AD Control 0.00 0.00 0.00 OX, HeaIth Flan. Scheme 0.10 0.20 0.80 0.60 HeaIth PF. Rehab. 0.t0 1.80 8.60 6.20 Healtb Nbs. TeRg. 0.20 0.00 0.10 0.80 Villag BE lnit. 1.80 1.70 4.20 7.20 capacity will be strengthened for both urban and rural systems through the provision of repair and maintenance kits, leak detection and control equipment, and water purification and testing chemicals. In addition, vehicles, mobile workshops and commiuncation equipment will be provided on a limited basis to Improve response time in emrgency situations. Training and Institutional str egthening will be emphasized to ensure that proper maintenance procedures are developed and implemented. Training will be supported by the Water Training Institute and will focus on the operation and mainteLance of water schmes, particularly at the village level The PSAP will also provide upport for improved operation of the National Urban Water Authority (UHA). A *tw{ning arrangement between NUVA and an ezperienced water suply and sanitation agency abroad will be developed to Improve NUVA's technical and managerial capacities, with emphasis on Improved maintenance, repair and revenue ge'aeration. In addition to the requirments above, completion of on-going development projects expected to generate ls the last year of the PSAP additional requirements for maintenance of the new syst_e. 31. Table 4 provides a breakdown of priority item required by the water sector. The unfuded gap over three years totals US$26.5 million. ROJECTS IN FOOD S8CURITY ! I  ANNEX 2 Page 12 of 14 - 90 - 32. As a result of the reforms in food grain pricing and marketing, there are now greatly improved incentives to farmers to produce food for sale. However, marketing infrastructure, including transport, storage information services and credit have not yet been developed sufficiently to ensure that consumers are not adversely affected by unduly large interseason and interregional variations in food grain prices. At present, high urban TABLE 4 PRIORM SOCIAL ACTION PROORUAME: WATER SUPPLY (IUS MILLIONS) 109/11990 1"0/111 12M1/1M TOTAL TOTAL RhIllREYEFTS 24.00 24.60 29.60 75.20 R.hsblltltblon 4.60 5.20 6.20 13.00 Maintenanc 4.00 4.00 4.00 12.00 Training & I..tltution Bld. 0.40 0.40 0.40 1.20 Water $upply Deelopemot 15.00 15.00 20.00 50.00 EXTERNAL SUPPORT IDENTIFIER 17.20 17.20 17.20 51.60 Rdh.bi ltation 2.20 2.20 2.20 .6.60 U.lntaeon .- - - Training A latitution Bldg. - - - - Water Supply Ohelopmmnt 1.OO 15.00 15.00 45.00 TOTAL UIUIWD OP-PA Ro= 6.80 7.40 12.40 26.60 REHABILITATIO11 2.40 J.00 8.00 *.40 Pump. & Spenr 0.40 0.40 0.40 1.20 Waer t.OAr. 0.20 0.20 0.20 0.60 Pipe Fitbi.. & ACC. 0.40 0.40 0.40 1.20 Lor Ravm Pumping Station 1.40 2.00 2.00 5.40 MAINTUNANCE 4.00 4.00 4.00 12.00 Chemicals 1.70 1.70 1.70 5.10 W & Mobi l. Wrk.hop 0.40 0.40 0.40 1.20 Coma. Equipment 0.40 0.40 0.40 1.20 Leak Doteotion A Control Dteih 1.60 1.50 1.60 ' 4.60 INSXTII1TIONAL WLRDONS a TRAINIO 0.40 0.40 0.40 1.20 T.imning Arrang. tor NA 0.20 0.20 0.20 0.60 Operation a moist. Training 0.20 0.20 0.20 0.60 YAITENANCE REIIUWM FOR RCENTLY 0VELOPE SWIWE - - 5.00 6.00 food prices coexist with large rural food stocks which cannot be moved to locations close to urban markets. In addition to high transport costs, most traders do not have storage capacity, and during heavy rains have difficulty in moving food from rural areas. The lack of storage facilities for the growing private grain trade sector means that a reasonable level of stocks camnot be held in urban areas. This increases the sharp fluctuations in prices. The situation is worst in Dar es Salaam which is the largest food deficit area. 33. To rectify this situation on a priority basis the following actions are proposeds tl) public support for Improved market informationg  ANNEX 2 - 91 - Page 13 of 14 tll) the mobilisation of both road and rail transport to bring grain from the surplus areas to Dar es Salaamt (Wii) the construction of Grain Centrs which will be leased out to grain dealers and cooperatives; (iv) the expansion of private gaddy milling in the Mwanza areas (v) credit for grain traders; (vi) special interventions in livestock and fish markets. 34. A total of US$16.45 million is needed to cover the priority interventions in the food sector as summArized in Table 5. 35. Even with adequate food supplies on the market, some iow income households may still find it difficult to buy enough food until the Government'ia policies have had a chance to generate more jobs aw-d raise incomes. Priority actions to create a 'safety-netg for these households are discussed in the next section. TABLE 5 PRIORITY SOCIAL ACTION PROGRAMs FMOD SECURITY (US$ MILLIONS) 1909/1990 190/191 1991/19w 2 TOAL LORiWED GAP4W 5.54 5.U4 5.78 16.61 Mob. of Tra"J.tor Ora 2.00 2.00 2.00 6.00 wagonor TAZARA A m I.60 1.? 1.67 5.00 Lveck Wago 0.t0 0.30 0.40 1.00 Orais stor. Cet. (DIM) 0.60 0.50 0.50 1.50 Pady MIIIng Lk.1Rg. 0.8 0.30 0.40 1.00 An.F.d Ind. (OM) 0.67 0.67 0.66 2.00 Livestock KpreJ As.e. 0.10 0.10 0.10 0.80 PROJECTS FOR INCOMES AND DEPLOYMENT 36. A three-pronged approach vill provide the basis for priority actions to ensure that everyone has access to an adequate amount of food. The first set of interventions aims to accelerate the growth of employment and income generation In small-scale manufacturing and services. This provides the main way of stimulating self-sustaining growth processes and ensuring that the benefits of the ERP are distributed as widely as possible. However, the rate at which new jobs can be created may not be sufficient to provide adequate Incomes quickly enough to remove the threat of nutritional decline. The second and third elements of the strategy, temporary public works schemes and income transfers, are designed to provide a 'safety-net' for those who cannot find new jobs.  ANNEX 2 -92- Page 14 of 14 37. This approach requires a more precise definition of sources of vulnerability to food insecurity than is possible at present and better ways of identifying families hose nutritional welfare may have been affected by economic stagnation and the short run consequences of the MP. 38. The intention is to finance training support and credit for small scale industries and services largely from counterpart funds. However, sos ezternal fin..nce will be required to provide tools and other artisan-type inputs. 39- Table 6 provides a sumnary of the sosts of the PSAP for incomes and t .oyment projects, which totals US$4.3 million. TAULE 6 RIORTm SOCIAL ACTION MGM: EhPLOYMENT (M MILLIONS) 1580/100 1050/108 101/1082 TOTAL UDNRED GAPP T 2.08 2.18 2.14 6e.0 Sb4to Ieir.I S.. 1.18 1.88 1.84 4.00 L Int.Rd.Vabl (OMb o0.80 0.o0 0.40 1.00 Tr"e Plnt.Shen" 0.40 0.o0 0.40 1.80 40. The requirements for employment generation and the provision of a *safety-net,' are likely to be much longer than the PSAP Request in Table 6. However, in view of the limited ezperience in Tanzania with these type of interventlons, it is necessary to begin with a pilot exercise to develop cost-effective approaches that can be repeated on a wider scale.  - 93 - ANNEX 3 Page 1 of 3 HEATHI AND NUUTRION PROJECT STUDY ON THE LONG TRIM OPT1ONS POR PINANCING HEALTH CARE IN TANZMNIA TRM OF REFuREE (TOR) Pre-ambles Since Independence, Tanzania has focussed on provision of basic needs to its population and self-reliant development. These principles were enunciated forcefully in the Arusha Declaration (1972), which amongst other objectives aimed for free health care for all. From the mid-1970s onwmrds, economic difficulties have severely weakened Government's capacity to adequately fund social services such as health and education. Various forms of cost-sharing and cost-recovery have already been introduced in the education sector, and now the Government wishes tc strengthen self-reliance in health sector, to ensure long-term financing of health care for its population without adversely affecting low income groups in society. In order to finance the health sector, it is unlikely that one measure alone would be sufficient, rather a series of measures may need to be adopted. Some measures such as charges for medical investigations. vaccinations for travel abroad, for medical services rendered to foreigners in Tanzania, can be introduced fairly easily. Other measures, such as health insurance, cost- sharing for drugs etc. are far more complex and require further study; whilst the Government has already decided to shelve indefinitely proposals for a registration fee. Objectives of the Studys The objective of the study is to help the Government identify and prioritise possible measures to assist in the long-term financing of the health sector. Scope of Works The study will examine a range of possible measures/options to finance the health sector, and for each such measure wills i) determine the likely amounts of revenue to be raised; ii) determine the organizational arrangements (including control of funds collected, acountability etc.), and estimate the costs of such arrangements; iii) assess the impact of such measures on various population groups (especially the vulnerable and low income); iv) based on (iii) recommend categories of services rendered or population groups attended who should be exempted from payment; v) how much decentralisation (discretion in setting fee levels should be given to districts and or facilities);  - 94 - ANNEX 3 Page 2 of 3 vi) make recommendations oan (a) mechanisms required to maximise the health benefit from the expenditure of such revenue (e.g. whether revenue should be retained at facility, district or central Ministry of HealthlTreasury level); and vii) indicate the practical steps required to implement each measure (including the need for trial implementation including the cost of such trials). The options to be examined include the following (specific issues additional to those listed above and included in brackets). A) Cost-Sharing for Pharmaceuticals - (Patients would share the cost of pharmaceuticals prescribed - not necessarily 100 percent). Should such a scheme atart in an area currently not receiving adequate public sector pharmaceuticals supply e.g. an urban area llke Dar es Salaam? If patients were to pay even full cost for drugs at public health facilities, how much cheaper would this be for patients than buying from private pharmacies? In rural areas could payment be made in kind (e.g. maize, rice, chickens), if so, how could this be managed? Should there be cross-subsidisation of drugs? What exemptions should there be?). 5) Cost-Sharita for Hospital Food - (Patients would share the cost of food provided In hospitallhealth centres). How would this be collected? What impact would it make on the volwaes of meals provided by the hospitallhealth centre i.e. if relatlvesifriends were to provide meals to patients there could be a co6t-saving as well as a revenue-raising potential. The logistical impacts on public horpitals of relat3'res providing meals and the experieace of voluntary agency hospitals in this regard should be reviewed. C) Two-tier Hospital System - (Expansion of the existing limited Grade 1 bed facilities providing better amenities to those who can pay. Would the additional revenue collected more than offset higher costs? What level of charges should be established? What level of demand might there be at these fee levels?). D) Health Insurance - (Beneficiaries would pay a premium which would then cover the costs of medical services provided - premia could come from: I) employers, or deductions from employees pay, for the formal sector. ii) premium payments from the self-employed (who could be given a card proving they had paid, when requesting medical services). iII) levies on primary cooperatives (to cover rural inhabit'.nts) - who could also be given a card); and iv) foreign tourists (who could make a payment on arrival to give short-ternm medical cover). (Several issues need special attentions Should such insurance be applicable to all citizens on a mandatory basis or on an 'optional' free  - 95 - ANNEX 3 Page 3 of 3 to choose basis, what would be the ramifications of these? If optional, would those covered be entitled to higher quality service such as under a two-tier system? Should there be some system of co-payment or deductible - what would be the ramifications of this? Should the premia collected go to a central health fund? If so how would this be allocated to facilities? Would setting up a billing system (with facilities sending payment requests to the central fund be feasible? How would this be controlled? How could payments from the different categories of persons (i) to (iv) be ensured). The consultants should provide information on the advantages, pitfalls, problems and consequences of health insurance as it has been operated in other (particularly) African countries. E) Capitation Fee - Parastatals (and perhaps private firms) would pay a capitation fee to enaole their employees to have access to the Government health referral facilities (regional and referral hospitals, Muhimbili Medical Centre). F) Strengthened Link between Develoume,t Levy and Health System - (A specified portion of the Development Levy (DL) could go to health, thereby strengthening the link between the Development Levy and health care ptzwided. Efficient delivery of service could result in a reduction in the overall DL; alternatively the DL could be raised to increase the health portion in order to improve or develop services. (As the DM0 would be responsible for rendering services and would be accountable to the District Council through the DED, communities would be able to make a strong link between their payment of DL, health services rendered and the responsibility of the DM0). G) CoimmitX Health Maintenance Funds and Oranizations - Could funds be established at the village level to cover the costs of referring patients etc.). Is the experience of health maintenance organisations (BMOs) applicable to Tanzania - especially in rural areas). H) Special Fund Raisins Events - Celebrations, festivals, lotteries etc. to raise funds for the health system. I) Reduced Overseas Treatment - This is really a cost-saving measure. (Could more use be made of regional referrals to countries such as Zimbabwe, Kenya? What would be the investment costs required to reduce overseas referrals - would the:e be economically viable?). The consultants should highlight the consequences for the health system in not adopting any of the measures above i.e. either reduced service quality or the need for the Government to increase budgetary allocations to the health sector.  - 96 - Page 1 of 1 HEALTH AND NUTRITION PROJECT OVERAIL LROJA T COORDINTION The organogram for the Project Coordination Committee is as follows: Project Coordination Committee (PCC) Chairman - Permanent Secretary MOH L m~~~~o Lim LLZ L+rA  - 97 - AMNK 4.1 Peg. 1 of 1 UKALIW A-" NU3XION mmOUC cffPONI It NATIOIAL Pn SYSTDSs |Ministryr of Health (MOB) Chief Medical Officer (CMO) Planning Dept. (PD) ACMO ACMO Hospital A Pre Manpower Services vent Planning TNC Proect Comission Coordinator(PC) - - - - - - - - _____-_Reporting Links - - - -Coordination Links  - 98 - AMK 4.3 Pago 1 of 1 ULTE AD M ON PCT CONPONEUT 1 - STRENGTUUNING RURAL PRC Organogram of the Implementation Arranga-.ntas PHC Steering Committee. PC -- | Project Secretariat Support Coordination, Technical Network Discus&'on (PSN) F E I V N A A L N U C A E T I RHO~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ N IR}lO I (DED)I District RHC|_ Committee Advice on Policy r-_nFinance  - 99 - TANZANIA HEALTH AND NUTRITION PROJECT ANNEX 4.4 Page I of I COMPONENT III STRENGTHENING URBAN PHC ORGANOGAM OF THE IMPLEWENTATION ARRANGEMENTS Central Government [ MLG City council [ Cit Director City Health Department City Medical Of ficer of Health AssstaceUnit District DM0 DMO District Medical Assistant Officer _ City Director Fineace District District Etc. Etc. Officer Public Health Health Officer Nurse  - 100 - ANNEX 5 Page 1 of 2 TANZANlA MEALTS AND NUTRITION PROJECT PROCCRNUT PROGRAM FOR PARUANCEUTICALS 1990/91 Background 1. Provision of an adequate supply of pharmaceuticals and medical supplies to the health system is the number one priority in the sector. Without these supplies, effective services cannot be delivered. In addition to the supply of pharrzaceuticals, the situation with respect to medical supplies and equipment is particularly acute. Virtually no supplies have been imported over the last few years outside of special donor supported health programs, especially that for AIDS. This had led to a situation in which certain items, programs, and areas of the country, are relatively well supplied, whilst others have only minimal supplies. This is not conducive to an efficient use of scarce resources, nor is it equitable. 2. Pharmaceuticals Requirements (1990191). Making a conservative estimate for of the requirements vital (life-saving) and essential drugs for all the tiers of the health system, the total requirement for 1990191 would be US$27.5 million. Sources of Finance: The current committed sources of finance includes Amount Source US$ m equivalent Items a) Governrent i) CMS through the OGL 3.00 -Overall Program ii) CMS through the Preferential 1.50 -Overall Program iii) Procurement of Locally Manufactured Drugs 2.50 -Essential Drugs b) Donor Support i) DANIDA 6.73 -EDP Kits ii) ODA 1.60 -OPD Kits iii) FRG Commodity Aid 2.13 -Overall Program iv) Other Donors 2.00 TOTAL 19.46 Leaving an unfunded balance to be covered by the IDA Credit of US$ 8.04 million.  - 101 - ANNEX 5 Page 2 of 2 3. Medical Suwplies (1990191). Given the extremely low stock of medical supplies in the country, there is a great urgency to replenish stocks. About US$ 15 million is required for this purpose, however the annual consumption of the highest priority supplies is estimated at around USS 3 million. Sources of Finance: The current committed sources of finance include: Amount Source USS m eouLvalent a) Government i) Procurement of locally produced items 2.11 b) Donors i) Various 0.50 TOTAL 2.61 Leaving an unfunded balance to be covered by the IDA Credit of US$0.39 million. 4. The balance of the first portion of the IDA Credit funds (US$1.57 million, i.e., US$10 million minus $8.04 minus $0.59) will thus be utilized to replenish vital stocks of supplies commencing with laboratory reagents and equipment.  - 102 - ANNEX 6 Page 1 of 6 TANZANIA HEALTH AND NUTRITION PROJECT THE PEARM&CEUTICALS SUB-SECTOR - BACKGROUw AND ISSUES I. Procurement and Distribution 1. Tanzania has developed a national list of essential drugs, consisting of 192 items, whir.h must be followed by the government pharmaceutical system. The establishment of this list has been successful in reducing drug purchases, improving patterns of drug utilization, management, information and monitoring, and facilitating bulk purchase of drugs with a consequent reduction in drug costs. 2. Selection, procurement and distribution of drugs and medical supplies in Tanzania is handled by three main agencies Central Medical Store (CMS), National Pharmaceutical Company (NAPCO) and Non-governmental hospitalsIagencies 3. The Central Medical Store (CMS), which is a part of the MOH, is responsible for the procurement, distribution and supply of all drugs and medical supplies for the MOH; it also handles the distribution of all drugs supplied under the UNICEF/DANIDA-supported EDP. Procurement of drugs, which must be from the national list of essential drugs, is by importation, barter protocol, purchase from local manufacturers, or donor grants. About 66 percent of all drugs and medical supplies in Tanzania are procured by CUS, and it charges a 5 percent service fee on all items for the public health system and NGO facilities, and a 50 percent fee for parastatals. 4. Foreign exchange for the importation of pharmaceuticals is allocated by the Central Bank to CMS, which then invites tenders. Selection aAong tenders received is made by the Pharmaceutical and Supplies Committee. 4'The next several steps of obtaining import licenses, opening letters of credit and shipment of the stock itself usually take between 6 and 10 months. CMS is then responsible for warehousing and distributing goods to MOH facilities. From CMS warehouses, supplies are moved to five zonal medical stores located (ZMS) in Iringa, Moshi, Mtwara, Mwanza and Tabora, and from there they are distributed to their assigned regions. 5. There are a number of areas that need improvement in the present CMS system, as followst - the CMS procurement section is severely understaffed and lacks the skills and training needed for trading on the international market, hence it must rely heavily on suppliers with representation in Tanzania; - to guard against items going out of stock, CMS buys and stores larger than needed quantities of goods, thus tying up scarce capital and storage space; - there is no effective quality control of incoming supplies, no chemical, microbiological or physical testing of products is  ANNEX 6 -103 - -Page2`of 6 one, other than occasional visual inspection, although CMS is constructing a central laboratory capable of running most of the required tests; - CMS's physical facilities are in poor condition and receive inadequate maintenance - only a few buildings have suitable shelving and equipment for pharmaceutical storage, and temperature control and air conditioning are major problems; - the organization of shelving, storage and distribution from stores is poor, with much time wasted searching for items and no established system for removal of out-dated, useless items. Some drugs are even left in the open air for long periods, resulting in deterioration of quality; - the inventory management system is ineffective, with the CMS microcomputer usually out of order, and there is no precise information available on stocks - hence the rate of pilferage is high (estimated at about 30 percent for non-EDP drugs). - the CMS practice of subdividing bulk deliveries of drugs into appropriate quantities for health facilities, (to promote the rational use of drugs) is carried out manually - thus there is room for error and increased drug losses in re-packaging; and - the ZMS also lack adequate equipment, inventory control, accounting capability and maintenance. 6. The CMS supply and distribution system also suffers from chronic shortages of supply in areas not covered by the EDP program. Since in general only a quarter to a half of orders are fulfilled, regional and district administrations have come to disregard the normal quarterly ordering cycle and place orders frequently. CMS then sends them whatever is in stock. Thus expensive and inappropriate drugs may be used - for example ampicillin for common colds, quinine injections instead of chloroquine etc. The only items supplied in adequate quantity are locally produced infusion solutions. 7. The Essential Drugs Program supplies pharmaceuticals in the form of essential drug kits to MOH rural health facilities through a DANIDA- financed, UNICEF-implemented program in place since 1983. UNICEF handles all procurement. Quantities are determined on the basis of one smaller yellow kit (36 items) per 1,000 consultations for dispensaries, and one larger blue kit (52 items) per 2,000 consultations for RHCs. The UNICEF Packaging and Assembling Center in Copenhagen procures pharmaceuticals through international tender and packages them in the two types of kit. Substantial cost savings are thus realized, amounting to 30-40 percent of drug costs. UNICEF is further responsible for delivering kits directly to Zonal Medical Stores, at which point they enter the normal CMS system. The ZMS then delivers them to District Stores and facilities pick them up there either directly themselves or through the EPI transport system. DANIDA gives technical support to CMS to assist it in its part of this distribution system. The EDP distributes about 35,000 kits a year to dispensaries and about 4,000 kits a year to RHCs, on a monthly delivery schedule. It has been extremely successful in assuring a regular and  ANNEX 6 - 104 Page 3of 6 adequate flow of pharmaceutical supplies to those parts of health system covered by it, namely MOH lower-level rural facilities. 8. The National Pharmaceutical Comany (NAPCO) is a parastatal company under the Ministry of Industry and Trade which sells pharmaceuticals to the general public, private pharmacies, parastatal medical facilities, regional trading companies, and VA health facilities. It accounts for about 30 percent of Tanzania's total pharmaceutical imports. NAPCO is a profit-making company with large investment holdings in the local pharmaceutical industry (TPI and Keko, see paras. --). It generally buys brand-name products, specialty pharmaceuticals and medical supplies, and sells them with at least a 30-40 percent mark-up in price, depending on what the market will bear. Its prices are in fact extremely high, because of its captive market. For example, imported brand-name chloroquine syrup is sold for six times the price of a generic product from a local manufacturer, and more than double the price from a private importer. Actual profit figures were not available, but NAPCO's sales have risen recently, from TSh 141 million in 1984185 to TSh 291 million in 1986187. Foreign exchange allocations to NAPCO over the past three years have fluctuated widely. 9. NAPCO's procurement is handled mainly through a purchasing committee, consisting of the General Manager, Branch Managers, Marketing and Operations Manager and a professional pharmacist; however there is at present no technically qualified member. This committee draws up the list of items to be purchased, taking into account quality, demand, price comparison, financial factors and delivery schedules. The quality of products is monitored, certificates of analysis are requested for each item and all are checked for quality, quantity and price by the Societe General de Surveillance (SGS) based in Geneva. 10. NAPCO handles the distribution and supply of pharmaceuticals to some non-governmental health facilities and private pharmacies. It has a warehouse and five retail stores in Dar es Salaam, Dodoma, Moshi, Mwanza and Mbeya. These are generally clean, well maintained, stocked and organized, with air-conditioned rooms for storage of temperature-sensitive items. Inventory control is computerized. No re-packaging or transportation is done. Warehouses and stores are secure and pilferage is not an important problem. 11. Non-Governmental Agencies are known to import substantial quantities of drugs and medical supplies, but little precise information on quantity, variety or value is available. There is sometimes a problem with some of the NGOs who receive bulk drug donations without adequate discussion with donors of drug selection, quantities, quality control procedures, or even language used on the package and labels (which sometimes is unknown to most Tanzanians). Major creligious organizations, such as the Catholic and Episcopalian churches and the Muslim Council (Aga Rhan Foundation), procure supplies through their overseas procurement departments and hence obtain cost savings through high volume purchases. They do their own monitoring of the quality of their procurement. 12. The Private Sector. Under the Economic Recovery Program, the Government allows free importation of pharmaceuticals on the national essential drugs list, through the own use of foreign exchange and the Open General Licence (OGL). These private importers sell to non-governmental  - 105 - ANNEX 6 Pag-e4 ~of 6 health facilities and private pharmacies. There are no government procedures for monitoring these products for selection, quality or safety or their storage systems, although in theory the Pharmacy Board must approve all drug impe-ts. II. Local Production 13. Tanzania has four major established pharmaceutical manufacturers, whose combined installed capacity amounts to about 10 percent of the country's drug requirements. They ares - Reko Pharmaceutical Company (Keko), government-owned - Tanzania Pharmaceutical Industries (TPI), government-owned - Mansoor Daya, privately-owned - Shelly's Chemical Company Ltd., privately-owned. 14. The Keko Pharmaceutical Company is a parastatal company under the Ministry of Industry and Trade and is located in Dar-es-Salaam. It was established in collaboration with the People's Republic of China, which supplied machinery and expertise, and in 1982 also received a DANIDA grant of Danish Kroner 14 million Kroner for physical plant rehabilitation and additional equipment to produce infusion solutions. Keko's current work force is 130 employees, and it occupies four buildings for, respectively, offices, production facilities including laboratories for quality monitoring, and two warehouses. None of the production or storage areas are air-conditioned. The plant is not poorly maintained and is in dire need of rehabilitation; however the laboratories are adequately equipped and staffed. 15. Keko's current production capacity, using relatively simple technology, is 1.2 billion tablets and one million liters of infusion solution. Currently, only tablets of aspirin, paracetamol, chloroquine and tetracycline are produced, although there is capability for 10 other products. In recent years only a fraction of production capacity has been used (about one half in 1987), due to shortages of raw materials, packaging materials and spare parts. Production over the last three years has been rising steadily for tablets (from 44 million in 1985 to 373 million in 1987), but fluctuating for solutions (from 202,000 liters in 1985, 496,000 in 1986, and 399,000 in 1987). Only very basic quality testing of products is carried out, and as a result quality control is poor. This is also due to the lack of stringent quality requirements by CMS, the major buyer. 16. All Keko's production is purchased by CMS or NAPCO. Generally speaking, Keko is a profitable enterprise, though it has suffered lo ses in the past. In recent years however, these profits may only be paper profits reflecting inventory valuation gains due to devaluation (1986 profits were TSh 17.5 million). 17. Tanzania Pharmaceutical Industries (TPI) is also a parastatal under the Ministry of Industry and Trade, and is located in Arusha. It was established in 1976 by the Ministry with a development Joan from the Tanzania Investment Bank and technical support and management from a Finnish company Orion, partially financed by FINNIDA. Since 1984, however  - 106- ANNEX6 Page 5 of 6 it has been under local management, though it still uses technical assistance from Orion, including validation of quality assurance tests. TPI's current work force amounts to over 130 employees. The physical plant is well designed and maintained, with adequate air-conditioned areas. Quality control is good, and there is an excellent laboratory for all necessary tests. 18. TPI has large state-of-the art production facilities and can produce 36 products in solid, liquid, semi-solid or injectable forms. At present it produces 24 items and has capacity for 1.5 billion tablets, 50 million capsules, 10.5 million injection vials, and 0.5 million liters of liquid semi-solids. This capacity could be doubled easily by doubling the current single 8-hour shifts. However since 1984 only a small fraction of production capacity has been used, due to low foreign exchange allocations for procuring raw materials. Currently most raw materials are being donated by Finland or Norway. 19. TPI sells almost all its products to CMS and NAPCO and has frequently encountered difficulties in receiving payment. It is a viable and profitable enterprise, capable of producing quality products at competitive prices, and has shown consistent profits since 1985; 1986 profits were TSh 21.9 million. 20. Mansoor Daya is a privately-owned pharmaceutical manufacturer in operation since 1965. It is 56 percent owned by Tanzanian nationals and 44 percent owned by the Twyford Laboratories of the UK. The current work force is 50 employees. The factory is located in Dar es Saiaam and occupies one large building. The physical plant and production facilities are inadequate in some. respects, for example, there are no air-conditioned areas. In addition, insecticides are manufactured in the same building as drugs for human consumption, a dangerous practice which the Government intends to rectify. There are only two staff in the quality department, and testing is minimal due to lack of facilities. 21. Mansoor Daya can produce tablets, capsules, liquids, lotions, aerosols and pastes in over 50 formulations. There is installed annual production capacity for 300 million tablets, 6 million capsules, 180 thousand liters of liquid and 0.5 million aerosol units. However only a fraction of production capacity is being used due to lack of foreign exchange and spare parts. 22. All Mansoor Daya products are sold to NAPCO or to private pharmacies; CMS has discontinued buying from Mansoor Daya for the last 3 years. Prices are competitive. The only data that could be obtained on production, pricing and profits, were that the company had sales of TSh 27 million in 1986 and TSh 14 million in 1987, and makes a pre-tax profit of about 20 percent on turnover. 23. Shelly's Chemical Company, Ltd. is a privately-owned pharmaceutical company located in Dar es Salaam. Its current work force is 39 employees. It occupies one large building, with another under construction. Physical plant and production facilities are good, but still need improvement. Quality control of the manufactured product is adequate, but none of the currently marketed formulations have been properly tested.  ANNEX 6 - 107- Page6`of 6 24. At present, Shelly's has the capacity for annual production is 35 million tablets, 13: million capsules, 250 thousand liters of liquids. 20 thousand kg. powders and 20 thousand kg. creams. It plans to increase this capacity subetantially over the next year or tvo, following expansion and improvement of current physical plant and production facilities. However since 1984 only a fraction of capacity has been used due to a limited supply of raw materials and lack of adequate space. Nonethelfss, production has generally r.Aen over the past three years. 25. Shelly's products are sold to NAPCO, to local private hospitals. and to private pharmacies, but not to CMS. Prices are competitive with P both imported drugs and other local manufacturers. Shelly's is a viable and profitable company, and made profits of TSh 4.5 million in 1986187. 26. Generally speaking, the four Tanzanian pharmaceutical companies described above have many similar problems. All have suffered from low utilization of production capacity due to shortages of foreign exchange, and all but TPI are in need of rehabilitation expansion and improvement of physical plant and quality control systems. There are also additional structural problems for the entire Tanzania local pharmaceutical industry, including uncoordinated working regulations of the Treasury, MOH, Bank of Tanzania and Ministry of Industry and Trade and disruptions in the regular suply of glass and plastic bottles, paper cartons, etc. from domestic manufacturers. 27. On the other hand, all the companies benefit from the large national demand for pharmaceuticals coupled with shortages of foreign exchange for imported drugs. Thus all have low inventory and real interest costs, and can charge high prices. The highly controlled supply and distribution system, with CHS and NAPCO the only two important buyers, means that companies have no marketing or promotion costs. Indeed this situation of essentially captive markets is probably largely responsible for the generally low investment in quality assurance and control shown by the companies. There are no research and development costs, since most formulations are supplied free. The Government has abolished the 100 percent import duty on active drugs and raw materials, thus substantially reducing the cost of raw materials. Depreciation costs shown in the accounts are small because of the low exchange rate rates used (historic accounting practices have resulted in valuing capital at exchange rates for the 1960s and 1970s, when the plants were built. However, this implies that the firms are not in reality providing sufficient depreciation for assets which need to be substantially revalued in the light of the currency devaluation - a more adequate reflection of depreciation costs would wipe out many of these firms paper profits. Moreover, pharmaceutical products are simple and cheap to manufacture, since only a few processing steps are required to turn the raw material into a final product. It is therefore not surprising that all the companies now make profits despite severe underutilization of capacity and t..e other constraints mentioned above.  - 108 - ANNE 7 Page 1 of 9 TANZANIA HEELTR AND NUTRITION PROJECT UDCCIUENDATIONS OF TSE WOMGI GROUP ON THE NATIONAL DRUG POLICY The following represents the recomendations of a working group, comprised of Government officials together with the technical expertise from WHO and DANIDA, to the MO on the content of a national drug policy. The KOH is still reviewing these recommendations. It is anticipated that the Government will adopt the National Drug Policy later in 1990. introduction a. The overall objective of the national drug policy is to make available to all Tanzanians at all times the essential pharmaceutical products which are of quality, proven effectiveness and acceptable safety at a price that the individual and the community can afford, when these are needed to prevent, cure or reduce illness and suffering. b. In addition to making pharmaceutical products available, the national drug policy aims at rationalizing the use of drugs through better information, prescription and compliance. Rational use of drugs include the availability of alternative methods of treatment when the use of pharmaceutical products is unnecessary. c. The national drug policy aims at developing and supporting the national pharmaceutical industries with a view to increase local production, thus encouraging self reliance. d. The national drug policy aims at using the potential of traditional medicines of acceptable safety side by side with allopathic medicines when such treatment is acceptable to the individual. DRUG AVAILABILITY To ensure that essential drugs are available to all Tanzanians the policy will be achieved through a careful selection, procurement, distribution and quality assurance. 1. DruM selection a. The policy aims at selecting pharmaceutical products in accordance with the concept of essential drugs. Essential drugs are those of the utmost importance and are basic, indispensable and necessary for the health needs of the population.  - 109 - AMn 7 Page 2 of 9 b. The selection of drugs will be done by a committee of experts and will be based On specific criteria such ass disease pattern safety, efficacy, quality cost and price therapeutic advantage c. Drugs will be selected and distributed as generic drugs. All registered drugs will bear their generic name (INN) even when available under brand names only. d. The policy aims at keeping the number of drugs in the market reasonably small. It will allow for a maximum of two brand name products for each drug on the national drug list. e. The pharmaceutical legislation and regulations will reflect the national drug policy. f. The registration of drugs will be manufacturer specific. 2. Drut Procurement a. The procurement policy aims at securing both the necessary quantity and quality of pharmaceutical products, according to the national drug list, which will meet the medical needs of the majority of the population. Donations will only consist of drugs included int he national drug list. Procurement will be directed towards manufacturers in preference to brokers and trading houses. b. Criteria for procurement planning will be that essential drugs are given priority. Priority will also be given to local manufacturing companies and when feasible to regional manufacturers before considering overseas suppliers. c. The procurement policy aims at securing the lowest possible price without affecting quality. This policy aims at coordinating and consolidating national procure_ent for both the public and the private sector. The policy also aims at keeping the prices for imports of both raw materials and finished goods at the low end of international price levels. d. The long-term objective is to achieve optimal self-reliance through a snift from importation to increased local production. In addition to drug formulation the policy will later aim at producing intermediate and raw materials when there is a national comparative advantage or to enter into production partnerships within the region.  - 110 - ANNEX 7 Page 3 of 9 3. Distribution a. The aim of the drug distribution policy is to ensure that essential drugs are always available to those who need them and are distributed in the most cost effective manner. b. Only registered drugs will be distributed in the country. c. Drugs will continue to be distributed through the public, parastatal and private sectors. - The CMS will distribute drugs to the health sector according to the National Essential Drugs List (EDL). - Parastatals, other private organizations and the private pharmacies will distribute essential drugs as a priority. d. In the pharmacies the sale of essential drugs under generic name at low cost will be promoted. e. A better coordination among the three sectors will be sought mainly In the field of transportation and storage. f. Storage, inventory control, quality surveillance, facilities will be modernized to meet the requirements of an effective distribution system. 4. Quality Assurance a. The aim of the policy is to ensure that drugs reaching the patient are safe, effective and of high quality. The quality assurance system will include managerial, technical and legal elements. b. The drug inspection system will assure that the policy is achieved in all aspects and at all levels of the drug supply system. The relevant aspects of testing samples will be carried out in national drug control laboratories under the authority of the Government Chemist. c. All specifications on pharmaceutical products will be stated in laws and regulations. RATIONAL DRUG USE 1. Education and Trsina a. The aim of the national drug policy is to ensure that drugs are prescribed, dispensed and used rationally. Education and training of health workers will be a major element to achieve rational drug use.  - 111 - ANNEX 7 Page 4 of 9 b. Education of doctors, dentists, pharmacists, nurses, medical assistants, rural medical sides and others will include all the pillars of PHC so that the place of a national drug policy is viewed in its proper perspective. c. Curricula for health workers will contain the necessary elements of the essential drugs concept to allow conceptualization of rational drug use from the start of training. d. Continuing education will emphasize the importance of rational drug use. e. Standard treatment schedules for comnoz 4iseases will be prepared for use by all health workers. f. Education and training of scientific and technical manpower for drug research, evaluation, control and distribuion will be emphasized, and allowance will be made for training of personnel in management of the national drug policy. g. All prescriptions will be made using the generic (INN) name of the drug. h. Education and training will incorporate instructions in the use of alternative treatments where drugs are not indicated. 2. DruP Infomation a. The aim of the drug policy is to ensure that unbiased information about the correct handling and use of drugs is available to health workers at all levels and to the end user. b. Independent and reliable, scientifically-based literature aiming at rational prescribing and dispensing will be disseminated to health workers and health units at all levels, including hospital pharmaceuticals and supplies committees. C. A national formulary will be developed to provide information about the essential drugs and standard treatment schedules to heLj,th workers at all levels. d. Information about drugs, appropriate drug use, and alternatives to drug use will be disseminated tu the public and to the individual end user in a language understandable to all. 3. Control of Misuse a. The policy will aim at controlling the import, distribution and use of illicit, adulterated and/or illegal imported drugs. In addition  - 112 - ANNEX 7 Page 5 of 9 It is the aim to reduce dispensing and sale without medical judgement as well as overprescription and polypharmacy. 4. Hospital Pharmaceuticals and Supplies Cammittees a. Hospital Pharmaceuticals and Supplies Coamittees will be made operational in all hospitals in Tanzania. b. The comuittees vill be made responsible for the hospitals estimation of drug requirements, the drug budget, monitoring of standard treatment schedules and overall drug use, the provision of up-to-date information to prescribers and dispensers, and other matters pertaining to the rational use of yharmaceutical products. c. The Ministry of Health in collabore'I.on with Muhimbili Medical Centre will establish a coordination centre for all hospital Pharmaceuticals and Supplies Committees. This centre will monitor the functioning of all committees. 5. Advertlilna and Promotion a. Ethical criteria for drug promotion and advertisement will be established in order to support the improvement of health care through rational drug use. They will constitute legal obligations. b. Labelling and advertisements for drugs must be based on scientifically established evidence and be in good taste. Advertising must be objective and in accordance with the pharmaceutical legislation. c. Advertising to the public must be educational in purpose and restricted to over-the-counter (OTC) drugs. Drug advertising directed at children will not be permitted. d. Promotion will be in keeping with the national health policy and in compliance with the national regulations. e. Scientific studies and surveillance must not be misused as a disguised form of promotion. f. Medical representatives must possess a relevant technical background. The total number of representatives in Tanzania will be strictly limited.  - 113 - ANNEX 7 Page C of 9 N ONAL PCTICL PROWCON 1. Promotion a. The national drug policy aims at promoting the national pharmaceutical industries (parastatal and private) with a view first to become self-reliant in formulation of drugs from Imported raw materials. b. The policy also aims at increasing the national capability in packaging, bottling, labelling and production of chemical quality excipients (glucose, salts, starch, dyestuff, etc.). c. The long-term policy is to support the gradual development of self- sufficiency in the production of intermediary and raw materials on such chemical entities, where Tanzania has a comparative advantage in production. Where feasible, regional joint production of both finished products and raw materials will be promoted. d. An integral part of the national policy is to promote and support production in hospitals of a specified range of pharmaceuticals. e. The promotion and development of the national pharmaceutical industries will become a multi-sectoral activity both encouraging national and international investment and transfer of technology. It will provide the necessary protection until the industries have matured to full competitiveness. f. It is the policy to encourage research and development of drugs based on natural products. 2. Product Ranae and Coordination a. The aim of national production will be to produce essential drugs in sufficient quantities to meet the national demand. Priority will be given to those used to treat the main diseases of Tanzania. b. Public and private pharmaceutical manufacturers will work in consonance to produce the quantities of essential drugs without unnecessary competition using the most economic methods. c. Prior to achieving self-sufficiency for all the essential drugs needed, local pharmaceutical industries will use their capacity to produce a limited number of vital drugs to satisfy demand. d. An effective co-ordination of national production will involve intersectoral inputs from MON, MOP, Minietry of Industries and Trade, BOT and private pharmaceutical companies. The MOB will coordinate these activities.  - 114 - ANNEX 7 Page 7 of 9 3. Pricing Kechanism a. The policy of pricing for locally produced drugs aims at keeping prices us low as possible at levels which individuals or institutions can afford. b. Price discriminAtion will be allowed in favor of vital and essential drugs from the national drug industries. c. Patents policy within the national drug policy will be in line with existiwg Tanzanian laws governing patents for both processes and products. TRADITIONAL MEDICINES 1. Promotion a. The aim of the national drug policy will be to promote the use of safe traditional medicines in organised health care along the lines of Primary Health Care. 2. Research and Production a. The research and production of traditional medicines will be directed towards prevailing health conditions and the needs of the country. b. Medically and economically justified medicines will be given priority in research and production. c. The short-term aim of research will primarily focus on the identification of traditional remedies, screening of traditional materia medica, and assessing the safety of the products. d. The long-term objective of the research is to assess efficacy of the drugs and to develop appropriate methodology and technology for industrial production. 3. Safety and Use a. The policy aims at using traditional medicines of acceptable safety and effectiveness. b. Research into the safety of the medicines which appear to have wide acceptability by users will be undertaken so that traditional medicines take their rightful role in health care delivery system.  - 115 - ANNEX 7 Page 8 of 9 LaRO L COOPERATION a. The national drug policy aims at maximising intersectoral cooperation anJ collaboration in order to reach the overall goal of an efficient, cost-effective and modern pharmaceutical sector ihich contributes both to the personal health and the economic health of the nation. b. The Ministry of Health vill become the focal point for this cooperation. It will establish a high level committee to oversee that the policy is being duly coordinated between tb2i various sectors and that collaboration contributes to the objectives of the national drug policy. The sectors involved are: Ministry of Health Ministry of Industries and Trade Ministry of Communication and Works Customs Treasury Bank of Tanzania National Chemical Industries Private Drug Manufacturers Pharmaceutical Society of Tanzania Christian Medical Board of Tanzania Others. TECNICAL COOPERATION WITH OTHER COUNTRIES a. The aim of the technical cooperation with other countries - developing and developed - is to maximize utilization of the limited resources. b. Technical cooperation within the region (SADCC and PTA) will be fostered in the following areas: production of drugs, research and development, transfer of technology, evaluation of drugs, joint procurement of raw materials and finished products, training and manpower, development and exchange of information and emergency situations. ANNEX c. Increased use will be made of regional facilities mainly in the field of quality assurance. FINANCIL RESOURCES a. The aim of the national drug policy is to provide essential drugs to those who need them at the lowest price consistent with good quality.  - 116 - ANNEX 7 Page 9 of 9 b. Requirements for financial resouirces will be based on careful estimation of the total quantities of drugs needed in the country through all sourcess Ministry of Health, parastatals, NGO's, private wholesalers and pharmacies, including the cost of local production. c. The policy will be directed towards involvement of different governmental, parastatal, private organisations and individuals where justifiable, towards partial financing of drug supplies. d. The Ministry of Health will work in close collaboration with all interested parties, including the Planning Commission, Ministry of Finance, Ministry of Industries and Trade, the Bank of Tanzania, so that due priority is given to financing of essential drugs for the nation. LIGISLATION a. Legislations and regulations as well as the organisation and functions of the regulatory authorities will be developed to support the objective of the National Drug policy. b. Other legislation which affect the implementation of the policy but under the armpit of other ministries will be worked out in collaboration between these ministries and the Ministry of Health.  - 117 - ANNEX 8 Page 1 of 7 URALTI AND NUTRITION PROGRAM THE CASE FOR REFORM IN THE PHAUMACIUTICALS SUB-SECTOR INTRODUCTION 1. There are five main problem areas in the pharmaceuticals sub- sector as follows: (a) Arrears in payment; (b) Procurement procedures; (c) Budgetary control; (d) Central Medical Stores; and (e) Domestic Pharmaceutical Production. A) ARRSARS IN PAI)1 2. There is considerable pressure on the CMS to provide pharmaceuticals and medical supplies even when Government agencies do not have sufficient budgetary allocations to pay for them. This has resulted in the accumulation of enormous arrears to the Central Medical Stores (CMS), as may be seen from table A7.2.1 below: TAWLS A8.1 - CNS DEBT SMOURY AT 30TE JUNE 1989 Aency TSh Mlllions Regions 117 Ministries 30 Dar es Salaam City Council 115 Town Councils 22 District Councils 115 Mission Hospitals 13 Muhimbili Medical Centre 136 Parastatals 20 Ministry of Defence 25 Zonal Stores-(estimates) Mwanza 143 Tabora 85 Iringa 64 Mtwara 74 TOTAL 847 3. The impact on the CMS, and in turn on the domestic pharmaceuticals industry, has been severe. Non-payment of debts has led to an erosion of the value of the revolving fund to the extent that it now operates on a TSh 400 million overdraft facility at the Bank of Tanzania and its current overdraft exceeds this level at approximately TSh 700 million. As CMS is not paid, in turn it is not able to pay all its debts and limits its  - 118 - ANNEX 8 Page 2 of 7 payments to the main domestic manufacturers, KERO and TPI. This jeopardizes the financial performance of the enterprises and disrupts production, thereby raising their unit costs. B) PROCURUMENT PROCEDURES OGL Requirements 4. Strict procedures exist to ensure that the country's scarce foreign exchange resources are used in accordance with predetermined policies of the Government. Foreign exchange for the importation of pharmaceuticals until recently has been allocated by the Bank of Tanzania (BOT) to CMS, which then invited tenders. However, the Government has recently introduced the Open General Licence (OGL) facility which is available for use by the importers of pharmaceuticals. 5. The BOT has imposed strict prccedures on importers to ensure that they have the funds available to meet their requirements 2 (a) Government Departments have to demonstrate that the funds available within their budget to pay for imported goods; and (b) Parastatal and private sector companies have to provide 100 percent of the TSh equivalent price at the time that the Letter of Credit is opened. 6. These requirements have a significant effect on the availability of drugs because: (a) Government Budgets do not make sufficient provision for the procurement of drugs, as explained in the introduction to this report and considered further in the following section; (b) Parastatal pharmaceutical companies do not have the funds available to provide the 100 percent deposit required by the Bank of Tanzania and therefore have to borrow the necessary funds at commercial interest rates (currently 31 percent). As the lead in time for the procurement of drugs or the necessary raw materials is anything from six months to a year, the financial burden placed upon the Parastatals is heavy; and (c) Mission Hospitals may have the funds to deposit 100 percent of their procurement but it means that the opportunity cost of using the interest foregone to buy further drugs is lost.  - 119 - ANNEX 8 Page 3 of 7 Import Procedures 7. The following procedures must be followed for the importation of essential drugs: a. Proforma invoice required from supplier; b. Pharmacy Board ensure that the drugs requested are on the Essential Drug List and issue a Permit; c. An import licence is obtained from the BOT; d. A letter of credit is opened with the BOT and a deposit of 100 percent lodged with the bank; e. Pre-shipment documentation is obtained through the BOT; f. Frequently, procurement of drugs takes more than four months, so it is necessary to obtain a new import licence; g. Pharmaceuticals are cleared through the port with the import documents. 8. The process is time consuming and further delays the import of essential drugs. The procedures involved usually take a minimum of twelve weeks which together with a lead in time for manufacture and shipment of sixteen to eighteen weeks, means that procurement will often take six to nine months. Consideration should be given to extending the duration of the import permit at least in the case of essential drug imports. Price Variations on Procurement 9. In the table below the variety of recent prices paid for certain common pharmaceuticals is highlighted : TABLE 8.2 - MNIT PRICES OF PEARNACEUTICALS (TSh) Domestic Products FOB UNIPAC Product Units price price price Aspirin 1000 390 435 207 Chloroquine 1000 2100 1595 1095 Tetracycline 1000 3250 1776 1365 Paracetamol 1000 1200 479 719 Salin Solution lltr 250 194 196 Anti acid tablets 1000 2120 457 625 10. The table clearly demonstrates that the major drugs manufactured locally are considerably more expensive than those imported, at least for current levels of output. There was also some evidence to suggest that drugs procured under tied national aid programmes were more expensive than drugs procured on the general market or through UNIPAC.  - 120 - ANNEX 8 Page 4 of 7 C) BUDGETARY CONTROL Inadequate Budgeting 11. Underfunding of pharmaceutical purchases through the budget has had a number of undesirable effectos (a) Unfair pressure is placed upon those with responsibility for controlling stocks to issue them when no funds are available; (b) Inadequate supplies of stocks are available to meet needs; (c) CMS is not paid for its issues, and its revolving fund is severely depleted; (d) Pharmaceutical manufacturers receive payment only after waiting for additional funds to be made available to CMS which can lead to inefficient procurement and expensive loss of production. Control of the Budget 12. Given the nature of essential drug expenditure, it is important that control of the budget is in the hands of those who have the power and authority to procure the drugs and issue the drugs. There is a strong argument for suggesting that the only organization that can adequately do that is CMS because it is the only body which can influence the purchasing cost of the drugs by the quality of their procurement procedures, and it is best placed to know the overall procurement needs of the health system. D) CENTRAL MEDICAL STORES 13. Financially, the CM8 operates through a revolving fund whereby it procures drugs from suppliers both in Tanzania and overseas and sells them with a mark up to cover its costs to other parts of the Health Service. However, this revolving fund has, over recent years, been severely de- capitalized by the inability of many of its customers to pay for the drugs they have received. The table below shows how the fund has reduced in value over recent years. 14. The table shows the rapidly worsening state of CMS and the acceleration in this situation since 1987, when the rate of devaluation of the TSh accelerated. It further shows how the lack of adequate budget provision in the Central Government Estimates has seriously weakened their debtor position and led to the need for the TSh 400 million overdraft facility with the BOT, which it is likely to exceed. The position would be even worse if CMS were required to pay the interest on the overdraft, but as a Government department, the interest is met by the BOT. This position has been caused by the inability of CMS to recover its debts from government departments. It would now seem very unlikely that the departments will ever be in a position to pay off these debts. The most appropriate course of action would seem to be to write off the historic  - 121 - ANNEX 8 Page 5 of 7 debts of the departments at some agreed date, say the debt outstanding prior to 1989. This should only be contemplated as part of a overall package of measures designed to put the revolving fund back on a vi.'ble footing, so as to avoid a recurrence of the problem. TABLE 8.3 - CS PFUNDS POSITION BALANCE AT DEBTORS YEAR EDG Bu AT JUN 30 AT YEAR END YEAR END 1979 (6.0) 49.3 1980 25.8 65.5 1981 33.5 74.3 1982 67.4 118.0 1983 29.1 132.3 1984 18.8 156.9 1985 (32.8) 276.9 1986 26.7 335.8 1987 (113.7) 442.0 1988 (141.6) 937.0 1989 (Estimated) (700.0) 961.0 Mark-uo 15. CM0 covers its costs by charging a 5 percent mark-up on its sales to government departments and higher mark-up rates to other customers. In the table below a comparison has been made between the departmental charges (mark-up) and the expenses charged through the Price Adjustment Account. TABLE 8.4 - UNDR RECVERY BY CM DEPARMBNTAL mNDR CHARGES EXPENSES RECOVERY TSh'OOO TSh'00O TSh'OOO 1986 22945 69631 46686 1987 36552 62242 25690 1988 45402 66121 20719 16. The table highlights the under recovery that CMS make on its departmental charges. Whilst this is not significant in the overall scale of CMS's financial problems, it is a demonstration that there is a need to increase the mark-up to about 10 percent to cover the direct costs and future exchange rate risks. Such mark-ups should be kept under constant review to ensure that they remain adequate. Pricing Policy 17. CMS has a policy of selling its drugs and medical equipment at the weighted average price of its procurement plus the mark-up. In a period of  - 122 - ANNEX 8 Page 6 of 7 rapidly increasing prices, this leads to an erosion of the value of the revolving fund in real terms. (The only exception to this rule is made where the goods can be manufactured locally, where the CMS bases its price from the latest price of the lot..ily produced goods). Only by selling its stock at latest invoice price will CMS be able to maintain the real level of the revolving fund. In addition the latest invoice price should be adjusted to reflect the current exchange rates so that the price reflects the current invoice price. Capitalization of the Revolving Fund 18. As has already been demonstrated, the revolving fund has been severely depleted by the effects of exchange rate pressures on procurement prices and the inability of government departments to pay for goods received. In order to resolve these problems, an integrated package of refonms will have to be introduced simultaneously at the beginning of the accounting period (ie. fiscal year). The actions to be taken would include the following: (a) the recapitalization of the revolving fund by a once-off cash injection sufficient to meet its current needs for procuring vital and essential drugs and equipment; (b) the inclusion in the budget of sufficient funds to ensure the procurement of one years supply of vital and essential drugs and equipment; *c) the adoption of a higher level of mark u' on goods; (d) the adoption of improved accounting and stock control systems to enable the suggested amendments to stock pricing to be implemented; and (e) the write off of the old government department debt together with the Introduction of a requirement to provide funds in advance of procurement or through the surrender of the drugs element of the budget to CHS. m) D4STIC RC PODCTION 19. Items that are procured locally are considerably more expensive than those imported from overseas. A recent (April 1988) WHOIDANIDA report on the pharmaceutical industry in Tanzania concluded that the products were generally of a good quality and were fairly efficiently produced. An analysis of their costs and production levels revealed that their production figures were low and, particularly in the case of TPI, were inadequate to meet their high level of fixed costs. In the table below the production levels of TPI have analyzed;  - 123 - ANNEX 8 Page 7 of 7 TABLE 8.S - TPI CAPACITY UTILZATION (percentage of Installed capacity) YEAR TABLETS CAPSULES SYRUPS GRANULES INJECTABLES 1984 19 20 9 7 16 1985 10 35 11 7 53 1986 21 16 9 1 26 1987 17 8 12 11 40 1988 14 - 12 1 11 20. Such a low level of capacity utilization, when coupled with high fixed costs lead inevitably to high prices. For a 10 percent increase in production there is a fall in unit costs from 495 to 371. At 50 percent capacity utilization, there is a further fall in units cost to 256. When it is appreciated that 100 percent production is only based on one 8 hour shift for 5 days a week, it is clear that there is a considerable opportunity to reduce unit costs, reduce prices to CMS and save foreign exchange on the added value element of the drugs produced.m A similar picture emerges from a review of KEKO cost structure, although the effect is not so marked, because TPI has relatively new plaat with high financing costs whilst RER0's premises are older, with lower financing costs. 21. Production figures are low not because of poor demand, but rather scarcity of raw materials which is itself caused by a lack or 'ash to procure the raw materials. The lack of cash is in part due to CHS being unable to meet its obligations to the local drug producers which once again leads to the failure to make adequate provision in the budget for medical products. This failure to make adequate provision for medical goods in the budget leads to: (a) departments not paying their debts; (b) CMS revolving fund being forced to rely for its survival on an overdraft from the BOT; (c) RERO and TP1 being short of funds; (d) KEKO and TPI having to reduce production; and (e) the unit cost of items supplied to CMS and the health sector is higher than it would need to be.  - 124 - ANNEX 9 Page 1 of 8 TAN IlL DK&LTB AND NUTRITION PROJECT Miczonutrient Deficieacy Control Program A. The Second National 5 Year Program for the Prevention and Control of Vitamin A DeflcA2aca and Xerophthalmia in Tanzania I, Program Obiectives Broad Obiective To reduce Vitamin A deficiency, xerophthalmia and nutritional blindness to a level where they are no longer of public health significance by the year 2000. Specific Objectives: Short term: To make vitamin A capsules available in all health facilities in Tanzania, for children at high risk of developing xerophthalmia and train health workers on its proper administration. Long term: To ensure regular and adequate dietary intake of vitamin A and Vitamin A conservation in young children by: a) Initiating public awareness and action about nutritional childhood blindness and poor nutrition through all available forms of media. b) Promoting breastfeeding. c) Reinforcing nutrition education programs in order to motivate the consumption of both Vitamin A and provitamin A rich foods consumed by high risk populations, especially preschool children. d) Motivating households to have home gardens and asssociated horticultural practices. e) Motivating the consumption of edible oils especially Red Palm Oil. f) Reinforcing efforts on programs aimed at reducing the prevalence and severity of vitamin A deficiency contributory factors as measles, protein energy undernutrition, diarrhea and upper respiratory tract infections. II. Program Design The program is composed of a closely-related specific projects/ activities:  - 125 - AMNEX 9 Page 2 of 8 PROJECT NO. I. VITANIN A CAPSULS DISTRIBUTION ObJectives 1. To improve availability of Vitamin A capsule (VAC) in hospitals and use of VAC provided at lower levels via Essential Drug Program (EDP). 2. To revitalize the regional Vitamin A Deficiency (VAD) surveillance system. PROJECT NO. 2: TRIAL PRODUCTION AND CONSffPTION OF VITAMIN A RICE FOODS ObJectives To promote the production and consumption of dark green Leafy vegetables (DGLV), fruits, red palm oil and animal foods rich in vitamin A, at household, school and community levels for the control of vitamin A deficiency. Trial 1: DGLV Production and Use. Trial 2: Red Palm Oil Production and Use. PROJECT NO. 3s NUTRTION EDUCATION AND COhhHDICATION Objectives To create awareness on the importance of the consumption of Vitamin A rich foods espeuially for children and lactating mothers and on the importance of preventing diseases related to Vitamin A deficiency. PROJECT SUPPORT ACTIVITIES 1. LABORATORY DEVRMNT OBJECTIVES: a. To strengthen TPNC Laboratory as a reference Laboratory for the purpose of research monitoring and evaluation of the Vitamin A Control Program. b. To support Tanzania Bureau of Standards (TBS) Muhimbili Medical Centre (MMC) and Sokoine University of Agriculture (SUA) Laboratories to establish the capacity for Vitamin A analysis. 2. OPERAflORAL RESEARCH OBJECTIVE: To answer basic questions about the causes of Vitamin A deficiency, effective methods of prevention and control under Tanzania conditions. 3. MONITOING AND EVALUATION OBJECTIVEs To monitor and evaluate the progress and success of the national Vitamin A Control Program.  - 126 - Page 3 of 8 III. Proarsa Orpanization 3.1 The program is part of the Tanzania Prevention of Blindness Program (TPBP) which is under the National Prevention of Blindness Committee (NPBC) chaired by the assistant Chief Medical Officer Prevention in the KOH. Experience of successfu' national control programs indicate that an intersectoral committee representing relevant institutions seems to be an effective mechanism for managing Vitamin A deficiency control program. Thus. the National Vitamin A Consultative Group (NVACG) was formed in 1987 as a National Unit of the International Vitamin A Consultative Group (IVACG), which is responsible for: a) Coordination at the national level of institutional strategies to combat Vitamin A deficiency and xerophthalmia; and b) Formulation of strategies and policies with regard to control measures. Coaposition of the WACG The composition of the NVACG (which is chaired by the MALD, the secretariat being in the TFNC) is as follows: Ministry of Health Tanzania Food and Nutrition Centre (TPNC). Muhimbili Medical Centre (MMC) Ministry of Education Ministry of Agriculture and Livestock Development Ministry of Agriculture Training Institute Chama Cha Mapinduzi (CCM) Tanzania Bureau of Standards Sokoine University of Agriculture (SUA) - Department of Food Science and technology The NVACG has four task forces, namely on Vitamin A in PIC, Nutrition Education. Coamunication, and Laboratory development.  - 127 - ANNEX 9 Page 4 of 8 B * PRELDEIEMRY OUTLINE OP A PLAN OF ACTION FOR ANMIIA CONTROL IN ThANUI 1. Introduction a. Situation analysis b. Justification for control program 2. Policy basis a. Relevant government policy statements b. Government institutional basis c. Collaborating institutions 3. Objectives a. General b. Specific 4. strategies a. Research b. Laboratory strengthening c. Training d. Planning Workshop e. Interventionlpilot studies f. Strengtheningladjustment of ongoing programs g. Monitoring/evaluation h. Resource mobilization Description of activities l.a. Situation analtsis - National Anemia Consultative Group (.V--CG) will conduct a literature search, including published as well as locally available unpublished sources. - A local consultant will be contracted to write a comprehensive and synthetic review of the available material,l including conclusions as to (a) severity of anemia in different sex/age groups, pregnancy and lactation in different areas of the country, and (b) the extent to which inferences can be made regarding how much of this anemia is due to iron deficiency, folic acid deficiency, hookworm, malaria, and schistosomiasis, (c) the prevalence and geographical/age/sex distribution of each of these diseases. This will form the basis for an Anemia Situation Analysis. 4.a. Research The project will include two research projects. One of these will be chosen by N&CG as having the highest priority in facilitating the  - 128 - ANNEX9 Page 5 of 8 development of a national plan for the control of anemia. The other will be a study of compliance by pregnant women with health workers' prescriptions regarding iron tablets and malaria prophylaxis and reasons for any non-compliance. This will be mainly a gualitative study and thus will be conducted mainly by the TFNC sociologist. The study will take place in one village in each of the four regions of the country receiving PHC. support from IDA (Lindi, Singida, Tabora, and Kigoma). Various categories of health professionals in the same areas should be interviewed on their perceptions regarding these drugs and how they believe the local women perceive them. 4.b. Laboratory development (see below under 4.f.) 4.c. Pilot etudies Pilot studies will, if possible, take place in the 10 districts included under Component II of the Project. Study Is Search for methods to increase campliancke with iron suwplementation in premancy There will be three groups: one control, a second to test whether compliance with prescriptions of ferrous sulphate and prophylactic chloroquine can be improved by health worker and patient education, and a third to test whether compliance is greatly improved by providing slow-release iron tablets (which are free from side effects, but more expensive). Group ls Control area. Group 2: In this area, efforts will be made to improve compliance. How this will be done will depend partly on the findings and recommendations from the compliance research project described above. Relevant health workers will receive extra training and supervision. They will be asked to inform pregnant women better why iron, folic acid and malaria prophylaxis are being provided to them, and to listen carefully and respond sympathetically to any complaints about side effects. The dose of ferrous sulphate provided will be only two tablets containing 60 mg elementul iron each per day during pregnanzy. Where less than four months of treatment has taken place, it will be continued after delivery. The pregnant women will be questioned about side effects from iron tablets and the with complaints will be asked to try taking a half tabl. with each meal and to return in to weeks to discuss whtt. r this helped. The women will also be advised not to consume coffee or tea at or soon after taking the iron tablets. Group 3: In this area, slow-release iron tablets will replace the usual ferrous sulphate tablets in the essential drug kits. If the first workshop recommends it, Paludrine will replace  - 129 - ANNEX 9 Page 6 of 8 chloroquine for use in malaria prophylaxis or pregnant women. Health workers should not be told what the slow- release tablets are, but simply iraormed that they are another form of the iron medication they have been giving to mothers. They should not be given any special training, nor should they be told that the effectiveness of these iron tablets is being tested. When the test is over, they should be asked whether they believe the new tablets have less side effects and whether they thought compliance was better. If Paludrine is given, its effectiveness and compliance with it will be compared with chloroquine. The extent to which it is saved by others and uned in family treatment of malaria symptoms will also be determined, including the use of qualitative research methods. Study 2a Effects of increased fruit coneumution on anemia urevalence This pilot study will be conducted in cooperation with the National Vitamin A Deficiency/Xerophthalmia Control Program. One district will be chosen as control district and one as experimental. In each district, a probability sample from appropriate vulnerable groups will be examined for Vitamin A and iron status, pre- and post- treatment. (Sample sizes will be determined by a statistician.) Anyone found to be severely deficient in Vitamin A will be treated immediately with retinol capsules and anyone found to be severely anemic will be provided with iron tablets and referred for treatment. Control: This will be Kasulu District. Everyone between 1-45 years of age will be provided with iodized oil capsules. For most, this should be their second dose. The first was distributed in 1987.) In addition to the studies needed for this to serve as a control district, an IDD evaluation study will be conducted at the same time. (Estimates will be made regarding whether acceptance of the capsules is higher or lower than the first time. A sample of the population and health workers who were there in 1987 will be asked about side effects that time and this will be compared to the extent possible with levels of side effects experienced during the second round. An impact evaluation of the second round of capsule distribution will be conducted based on the planned pre- and post-examinations.) Experi- In Singida Rural District, an attempt will be made to mental: increase production, household availability and use in the diet of preschool children of five foods: papaya, mango, guava, pumpkin, and yellow meet potato. This will be done through a social marketing approach combined with distribution of seeds or seedlings for home cultivation through primary schools. This district is one in which a school feeding program has already began. It is close enough to the Tengeru Horticultural Center to be able to receive technical assistance and supervision from them.  - 130 - ANNEX 9 Page 7 of S Workshops will be held to train the trainers (for example, ward coordinators, who already were involved in the school feeding program as trainers) and eventually one teacher in each primary school should learn how to plant and care for these crops. The will also learn about Vitamin A and iron and its increased absorption with Vitamin C at the same meal. Relevant teaching materials will be provided to them. Agricultural extension in this district should be sensitized and prepared to assist the project. For example, teachers should be able to call for help with any problems experienced with plant diseases, etc. A supervisory horticultural extension worker should be provided with a motorcycle by the project. The social marketing component will aim to encourage the growing of these foods and their consumption. In particular, mothers will be encouraged to provide one of these foods to their young children with or after every meal. They should also be encouraged to consume these fruits themselves. The population-based pretest should be done just before the seedlings are distributed to the schools. Thus, no education or communication component should be included before this time. The post-test should be done about one year after seedlings have begun to be distributed t the students for planting at home. (In addition, extra studies on IDD may need to be done in the Control area.) 4.d. National Anemia Planning Workshops i. First workshops situation analysis and researchipilot project planning - The First National Anemia Workshop will be for one week, including two days on the topic of situation analysis. A select group of experts and a small group of key decision- makers will be invited. - The anemia situation analysis will be presented and reviewed, suggesting any necessary additions/revisions. - For the next two days, working groups will examine research plans and pilot study plans, recommending any necessary changes and advising on local and regional manpower and other resource needs. - On the final day, recommendations will also be made to the National Anemia Consultative Group (NACG) regarding any extra research or pilot studies deemed necessary to assist in developing a national anemia action plan.  - 131 - ANNEX 9 Page 8 of 8 ii. Second Workshops two years later for reviewing progress and results from the research and pilot studies s0 far conducted; whether any complementary research/pilot studies are needed; and to determine the extent to which any components of a national anemia action plan can begin to be implemented. 4.e. Monitoring and evaluation i. An anemia monitoring network will gradually be formed during the five-year period. This will consist of an appropriate staff member from (a) every regional hospital, (b) sentinel hospitals. A sentinel hospital is defined as one where hemoglobin (and/or other indicators of anemia) is measured on all pregnant women attending for routine prenatal care. Hospitals which take blood only on patients suspected of having anemia will not be included, (c) national experts in anemia. ii. Capability of measuring hemoglobin and perhaps other indicators of anemia will be strengthened in all regional hospitals. The method used will be standardized, using the most appropriate cyanmethemoglobin method. Equipment will be purchased where necessary and training will be provided, and the existing system for purchase and distribution of necessary reagents will be strengthened if necessary. iii. A standard form for reporting will be prepared and distributed to all regional and sentinel hospitals (preliminary draft attached). These forms will be submitted quarterly to NACG. iv. A National Anemia Newsletter will be initiated, edited, printed and distributed by NACG to all participating hospitals and other interested parties.  - 132 - ANNEX 10 Page 1 of 4 TANZANIA MEALTE AND NUTRITION PROJECT MAJOR TiDEMS OF THE REVISED PRIMRY DUT CARE STRATEGY I. Introduction 1. Since the early 1970's, Tanzania has been in the forefront of the implementation of primary health care (PHC) as the fundamental health strategy of its health sector. Early progress in the social sectors, including the implementation of the PHC strategy, has been undermined by the general deterioration of the economy. Tanzania has come to rely progressively on donor support it the health sector, without integrating this support within an overall strategy or framework. Conscious of this, in mid-1989, the MOH developed a revised national health policy emphasizing the centrality of PHC. Within the context of this policy, the objective of revising the PHC strategy is to pride such an integrating framework taking account of the following issues: i) the changed economic circumstances, particularly the changing role of the state, with its need to reduce commitments and mobilize resources for key social sectors; -i) the various donor financed PHC initiatives in the country, the need to carefully evaluate them, learn any lessons, and replicate the positive aspects; and iii) the centrality of the Ministry of Health (HOH) in establishing and maintaining health policy, but with the district being responsible for service delivery, with technical support from the regional level under the guidance of the MOH. 2. The remainder of this Annex outlines the major themes which the revised PHC strategy will encompass. II. General Observations 3. Good health is a major resource for social, economic and personal development and an important dimeasion of quality of life. Health promotion goes beyond health care and aims at advocacy for health. The overall health policy in Tanzania is to improve the health of all Tanzanians. The specific objectives of the health policy are to: (a) improve the health of the population by decreasing infant mortality and increasing life expectancy through provision of adequate and equitable maternal and child health services, control of communicable diseases and treatment of common conditions;  - 133 - Annex 10 Page 2 of 4 (b) ensure that health services are available and accessible to all people wherever they are resident in the country, whether in urban or rural areas; (c) move towards self sufficiency in manpower by training all cadres required at all levels from village to national referral level; (d) sensitize the community on common preventable health problems so that the community itself can identify their problems and woik out priorities in finding appropriate solutions; (e) promote awareness in Government and the community at large that health problems can only be adequately solved through multi- sectoral cooperation, involving such sectors as education, agriculture, water and sanitation, community development, women organizations, Party and non-governmental organizations; and (f) create awareness through family health work that the responsibility for ones health rests squarely with the individual himself as an integral part of the family. 4. Primary Health Care is defined as 'essential health care based on practical, scientifically sound and socially acceptable methods and technology made universal accessible to individuals and families in the community,through the full involvement,and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community". 5. Primary health care starts with the community and in the community providing care as close as possible to where people live and work. Both the social goals and the means to achieve it are in agreement with the Party policy of Socialism and Self-reliance. Therefore, the PHC approach has been adopted by the Government as the rational and equitable way of improving the health of the population of Tanzania.Primary health care is delivered at the first level of contact of individuals, the family and community with the national health system being it village health worker, dispensary, health centre or hospital. 6. The primary health care strategy recognizes that health is determined by a variety of factors, not all of which are commanded by the health care system. Hence, it is essential to involve other sectors such as education, agriculture, water, community development as well as the Party and leaders at all levels. Only a concerted effort by all parties involved can bring about good health. 7. The primary health care strategy aims at coordinating all basic health services and programmes to maximize utilization of available resources, and thereby deriving full benefit from the efforts invested.  - 134 - Annex 10 Page 3 of 4 8. Primary health care addresses the main health problems in the community, providing promotive, preventive, curative and rehabilitative services. II. Basic Requirements for Primary Health Care 9. Community Involvement. Genuine community involvement is the most essential prerequisite for a successfully implemented primary health care strategy. To be genuine it must be based on truly voluntary involvement, and very importantly, there must be a real devolution of authority and power as well as responsibility. It is considered imperative that the commmnity should be involved right from the planning base, through implementation to monitoring and evaluation. Involvement must be generated and maintained from village to national level. In order to ensure genuine community involvement mechanisms will be created to channel community views to institutional and community organizations in health. 10. Multi-sectoral Collaboration. Good health does not only require a strong health service, but is involves several other sectors as stated above. To foster true multl-sectoral collaboration coordination of planning, implementation and evaluation of all health-related activities must be achieved. Thus sectors and organizations such as CCM, NGOs, Education, Agriculture, Water and Community Development must work together in preparing and implementing joint action plans for health, which seek to improve the social and economic well-being of the comunuity. Service systems should strive to support initiatives which come from the communities. 11. Dibtrict Health Services - Centrality of the District. National plans of action must institute a fair distribution of resources and programmes throughout the country with preferential allocation to under- served Districts. The most suitable and practical unit for identifying and improving its health services is the district where health professionals, auxiliaries, workers from other sectors and community members have the opportunity to coordinate their activities This decentralized administrative system to the district is emphasized to also facilitate the development of district health systems. 12. The district health plans must be developed by the District PHC committees chaired by the District Commissioner. The other members of the PHC committee aret - District Executive Director - District Agricultural Development Officer - District Livestock Development Officer - District Water Engineer - District Community Development Officer - Secretary-Social Services Community of CCM - District Health Officer - District PHC Coordinator - District MCH Coordinator and - DMO - Secretary  - 135 - Annex 10 Page 4 of 4 13. The district action-programme should be a joint action observings - individual and family action - community action - bottom up planning, - inter-sectoral action and - integration of vertical programs. 14. Community-based Health Care (CBHC). CBHC is health care by the people. This care begins at home and in the community. It frequently exists in the communities as a traditional health system provided by Traditional birth attendants (TBAs), Traditional healers (THs) and mothers. TBAs and Tis provide mainly curative care. In order to give impetus to CBEC the Goverment has introduced a cadre of village Health workers (VHCU) who in particular concentrate on the preventive aspect of bealth care. The main objective is to promote individual and family well-being. In a number of villages the Government and NGOs have supported small CBHC projects in order to achieve this objective. IV. Key Issues In the PlC Strategy 15. The key issues addressed in the reised strategy includes I) Mobilization of resoratces for PHC; ii) Health planning and udgeting; iii) Community participazion: iv) Women and health; v) Leadership for PHC vi) Basic and continuing education, including staff development; vii) Supervision; viii) Research in health; ix) Effective IEZ x) Promotion of household food security and adequate nutrition; xi) Adequate supply of water and basic sanitation; xii) Maternal and child health including family planning; xiii) Immunization against major preventable diseases; xiv) Prevention and control of epidemics and local endemic diseases; xv) Appropriate treatment of common disorders and injuries; xvi) Provision of essential drugs and equipment.  - 136 - ANNEX 11 Page I of 2 TANZAU DEALT! AND NUTRITION PROJECT DISTRICT SELECTION CRITERIA AND PROCESS I. Criteria The selection of the 10 districts to be included in the trial implementation of the revised PEC strategy will be based on two sets of criteriat A) Health need; B) Commitment to PBC. These criteria will be applied in a two step manner as follows: Stop :s All regions to be ranked according to Infant Mortality Rate (IMR). Malnutrition data for under-five children will be used as a cross- check. Decisions Poorest 10 regions go forward to step 2. Filters All districts with significant donor support (actual or committed) will be removed from the list. Step 2: All of the remaining districts to be ranked by allocation of their own funds for health as a percentage of own funds (i.e. Central Government subvention funds excluded) as a measure of commitment to health. Supplzmentary infonmation will be included based upon the known competence and commitment of the DMO and DED. The top 10 ranking districts from step 2 will be chosen. II. Selection Pro.ess Selection of the PHC trial implementation districts was done by the PEC Secretariat with representatives from both the MOH and the MLG. The criterion used in the selection of 10 trial implementation districts was mainly based on the level of infant mortality rate and external donor support.  - 137 - ANNEX 11 Page 2 of 2 First Step Regions with infant mortality rate In descending order were listed as follows$ Reaion INK Rukwa 170* Ruvuma 170* Kigoma 163 Mtwara 161 Mbeya 161* Iringa 152* Lindi 151 Shinyanga 150* Morogoro 140* Tabora 140 Mara 140* Mwanza 139* Singida 137 Kagera 133* Dodoma 133* Coast 121 Tanga 112 Arusha 108 Dar es Salaam 108* Second Step Those regions which receive external donor support in relation to Primary Health Care were excluded. These have been marked with an asterisk in the table above. These exercise left seven regions for consideration and these were arranged in descending order: Re&ion INn Kigoma 163 Lindi 151 Tabora 140 Singida 137 Coast 121 Tanga 1Y2 Arusha 108 Third Step The remaining four regions with high IMR were then selected. These are Kigama, Lindi, Tabora and Singida. All Districts in the regions among those with very high IMR were picked except for Kigoma urban and rural districts which are expected to have donors in the near future. All four districts of Lindi region were earmarked, namely Lindi, Nachingwea, Liwale and Kilwa. The committee decided then to choose two districts from each of the remaining two regions. Igunga and NzeRa from Tabora, and Iramba and Singida for Singida region. The criteria used here were the performance of respective DfO'a In PlC activities.  - 138- ANNEX 12 Page 1 of 13 DAR Z8 SALWMI Ufla HLT! VROJE!CT 1. Proieat Sumaarz The Dar es Salaam (DSM) Urban Health Project covers component III of the IDA Tanzania Realth & Nutrition Project (THNP). It was initiated two years ago and developed by a fully participatory approach involving beneficiaries, and donors during pre-appraisal missions (Nay, July/August 1989), and the appraisal mission (October/November 1989) including the 6 days project preparation workshop. The DSM urban health project covers the administrative area of _he DSM City Council (DCC), i.e. the three districts Temeke, Ilala and Kinondoni with a population of approx. 1.4 million (growth rate 5% per annum). The goal of the project is to strengthen the DCC to rehabilitate functionally and structurally the DSM urban and rural primary health care (PHC) delivery system which has progressively deteriorated over the years. Being based on and following the national health sector policies, the project will contribute to the government's effort to provide effective health services to the population of DSM through (i) strengthening of health management capacity of the DSM health system, (ii) the rehabilitation of existing health facilities, i.e. 3 district hospitals, 4 health centres and 49 dispensaries, (iii) the provision of medical equipment and supplies, ana (iv) the improvement of health services coverage by the construction of additional health facilities where proven necessary. Furthermore, the experience gained during planning and implementation of the project will be used to generate national urban PKC strateqies and guidelines. The benefioiaries of the DSU urban health project are (i) the population of the three districts of Dar es Salaam, (ii) the Ministry of Local Governments, Community Development, Cooperative and Marketing (NIGCDCK) including the DSM City Council (DCC) with the City Health Department and (iii) the Ministry of Health (NOR). Donors of the project involve (i) Swiss Development Cooperation (SDC), (ii) Danish International Development Association (DANIDA) and (iii) IDA. The present proposal for a project document is fully based on the outcome of the project preparation workshop that was held in Dar es Salaam from 24.10. - 28.10.1989. A comprehensive workshop report (appendix 1) has been compiled and distributed to all participants, beneficiaries and donors concerned in December 1989. The present document - attempts to compile the elements of the DSM Urban Health Project with the aim to achieve a project document that will form the basis for the clearance and subsequent implementation of the project, - focusses on the project components that will be subject to the bilateral funding arrangement between the Swiss and the Tanzanian governments thus, the contributions of the other  - 139 - ANNRX 12 Page 2 'f 13 donors such as DANIDA and IDA are not detailed, outlines the first five years of this project with a particular emphasis on the first two years. Section 3 reviews briefly the Tanzanian health sector and presents specific health delivery constraints in DSM as well as the strategies to overcome the prevailing problems. Sections 4 and 5 summarize the goal and the relevant developmental objectives of the OSM urban health project to reach the goal within a five year period. Section 6 presents the proposed components and subcomponents of the project with regard to activities and inputs required. 2. IntraduatioA The thrust and main project content of the DSM urban health project were identified during the Kay 1989 IDA mission in which SDC was represented. Extensive discussionu were hesld with Tanzanian governkent officials who also led a field visit to selected health facilities in DSN which provided insights to the mission participants. An initial set of components was agreed with the government. During the subsequent July/Atugust IDA preappraisal mission the possible project components were reviewed and a tentative proposal wae prepared. This was done in both formal and informal vays. The preappraisal mission was followed by two important srep4 which have taken place in Dar es Salaam. First, an invaluable health facility survey was conducted by the o-H in collaboration with the Estates Department of the Universi- ty of DSM (appendix 2). The results of the survey have been submitted to the MOH and a number of interested parties. The health facility survey contains clear indications of what needs to be rehabilitated according the level of health facility, the type of work to be undertaken, workmanship required, scheduling of activities and costing. In addition, the report proposes the establishment of three health facility maintenance teams, one for each district under the leadership of the DM0. Furthermore the facility survey shows that DCC must ensure effective preventive maintenance of old and new health facilities. Secondly, a five-day project preparation workshop, attended by a cross-section of future possible implementors in the DCC, MNGCDCI, NOR and two non-governmental agencies, was held the last week of October 1989 (appendix 1). The basic background document was the draft project proposal prepared during the July/August IDA preappraisal mission. In addition, the health facility survey report was one of the background documents reviewed at the workshop by the participants. The tasks of the workshop during the five days of deliberation included extensive discussion of the issues and problem listed in the draft project proposal. It was necessary for all the participants to understand the issues at hand and to also bear  - 140 - ANNEX 12 Page 3 of 13 comon perception of the best way to solve the problems. Above all, it was crucial that the participants were fully aware of the alternative solutions and their implications to Tanzania and the amount of the resources available. Extremely wide consensus was achieved at the workshop regarding: - The Main health and health service problems of DSM; - the most desirable project components; - possible effective strategies of the project; - necessary implementation arrangements in which the three existing districts (Teseke, Ilala, Kinondoni) will become the effective focal points for decision making regarding district health development plans and programme implementation (administrative decentralization within Dcc into the three districts is already a reality); - a rational administrative structure for the implementation of the project: - scheduling of activitles within the overall framework of the project based on equity/coverage priorities; - priority areas which need further assessment and the necessary studies. There are these achievements of the workshop which finally led to the drafting of the present proposal for a project document to be submitted to the Tanzanian and Swiss Governments for further negotiations and agreements. 3. The Ntalth Sector in YanMana - Achieveamets and Problems General Tanzania has a reputation as a country having created and developed the health sector based on primary health care principles emphasizing community health workers (CHW). The Tanzanian health sector development aiming at equity often served as a model in Africa and many other parts of the developing world. After independence the Tanzanian government attempted to extend health services to rural arcas and to achieve high accessibility of health services in all parts of the country. It also committed itself to providing basic health services free of charge. These goals and commitments lead to a substantial increase of lower level health facilities (dispensaries, rural health centers) and to efforts of training grass-root and midlevel health cadres such as rural medical aids, health officers, medical assistants, public health and NCR (mother child health) nurses. Particular progress was made in the seventies and this development resulted in the fact that 90% of the population lives within the range of 10 km of a health facility. In addition, the PHC strategy - as declared at Alma Ata in 1978 - was adopted by Tanzania and efforts were made to train more CHW with particular emphasis on preventive activities as well. This development and the implementation of major more vertical health prograMMes through bilateral and multilateral donor support (such as the immunization programme, child survival programmes, TB and leprosy control, essential drug programme) has definitely increased the quality of health care and also resulted in an improved health status as reflects^d in morbidity and mortality data.  - 141 - ANNEX 12 Page 4 of 13 Despite these developments the situation in the health sector is deteriorating: Underserved areas increase and there ic an acute shortage of medical equipment and drugs as well as a substantial lack of motivation among the various health cadres as a reflection of inadequate salary schemes not covering essential needs. The deterioration of the health sector is mainly due to the population growth at a level of approx. 3% per annum as well as the economic constraints. The former factor lead to a gradual decrease in health service coverage due to the population growth that was not matched by the development efforts in the health sector. The economic constraints on the other hand have led to a gradual deerease of the funds allocated to the health sector, i.e. although central government health expenditure rose nominally between 1980 and 1987, it declined by approx. 10% in real terms. Dar es Salaam Health Serviess The development of the Tanzanian health sector as outlined above had a particular impact on urban settings. The PHC strategy and the relevant national guidelines (endorsed by the MOH in 1983) focussed primarily on rural areas. This applied not only on the staff development (chiefly the strengthening of the CHW level), but also on the construction of new health facilities based on the national standards (1 health center per 501000 inhabitants, 1 dispensary per 10'000). Consequently, urban areas with high population increase rates (Dar es Salaam approx. 5% per annum) became substantially underserved leading to congestions and shortages at the existing health facilities and a shift of basic health care to higher level facilities that ought to perform referral roles, as reflected in the Muhimbili Medical Center performing actually activities of a district hospital. The lack of sufficient funds being allocated to the health sector led to a gradual structural deterioration of the health facilities, to a major crisis in the provision of medical supplies, equipment and drugs as well as to social pressure, low motivation and commitment of the health staff. Thus, one is confrontod with a situation whereby (i) 500'000 out of the 1,4 million inhabitants of Dar es Salaam region are underserved, (ii) the quality of care is low at all levels, and (iii) consequently the acceptability of the government health services is low. More specifically, the following reasons led to the present situation: - Health services infrastructure is not distributed equitably within the city. The access to health facilities is poor for many parts of DSM, notably also the more rural areas where the population is dispersed and where communication is difficult. In the city center, health facilities are concentrated in certain areas which are not necessarily accessible to the growing locations. There are no health facilities in some areas of DSM. On the other hand available evidence shows a selected number of over-burdened health facilities; - Excessive immigration to 0SK has created unplanned pockets of large populations in areas which are already underserved in most of the basic public health services. According to th& 1988 national census, OM has an annual growth rate of 4.8* compared to the national rate of 2.8%. Currently, DSM  - 142 - ANNEX 12 Page 5 of 13 accounts for nearly 6.0% of the national population. The fast growth rate has exacerbated health services delivery and demand and has skewed provision, health promotion and needs; - There has been progressive deterioration of services in DSM over a long time. Buildings have not received preventive maintenance, they continue to deteriorate to extremely poor conditions, in some, and contributed to interruption of service delivery. Water, power supplX, drainage and sewage disposal and basic furniture are in poor condition. Rehabilitation of the buildings is estimated to cost a considerable amount of money. Further, it is estimated that preventive maintenance would require an annual allocation of about USS 300,000 (at October 1989 rate of exchange, 1US$ = TSH 145 -> 43'500'000 TSH) compared to a present government allocation for maintenance of TSH 100'000. - Deteriorating economic conditions have had their impact in the performance of the health sector, as in other sectors. Shortage of basic equipment, supplies and drugs are common and do not in anyway satisfy the demand for services. Health staff face mounting professional and social pressures to provide services they cannot without the necessary inputs. DMO lack adequate facilities to work in, offices are as congested as the 'atient areas. Adequate health management is neglected due to the existing conditions and inadequate health information system; - Health management is concentrated at the DCC, the City Hall, where all decisions are made. Centralization of decision-making away from the location of problems, often makes timely decision-making difficult. In consequence the DMO is responsible for the district, but has no authority to solve the problems he finds or develop the district from one level of care to another. - The Tanzanian health delivery standards policies partly reflected do not seem to apply in DSM. strategies to Overcome the Problems Despite the great problems of the DSM health sector implying seemingly insurmountable financial requirements which would be needed to reverse the trends, available information clearly indicates that a well planned urban health programme can reverse that downward spiral. Presently prevailing government commitments, policies and strategies will form the basis of such a programme. This basis consists of: - Awareness of the near-crisis situation of the DSM health services and recognition of the basic determinants of the problem are seen at all levels, i.e. the DCC, the central goverment and the population. - MOH recognizes the previous emphasis on rural PHC and urges to establish an urban PHC strategy based on the experience to be made while improving the DSM health services. - The central government and DOC wish to implement the decentralization policies for decision-making and resource allocation at district level.  ANNEX 12 - 143 - Page 6 of 13 There are plans to extend the essential drug programme (EDP) to urban areas as well. The government coumitment to alleviate the situation is further reflected in the current evaluation of novel approaches to the financing of the health sector involving the communities. 4, Goal of tho Dar es Sal_am _rban-gealth projeot considering the evolution of and the present status of the DSM health services (as outlined in section 3), the goal of the DSM health project will be: Strengthen the DCC to resuscitate and rehabilitate the DSM urban and rural primary health care delivery system which has progressively deteriorated over the years. Being based on and following the national health sector policies, the project will contribute to the government's effort to provide effective health services to the population of DSM through (i) strengthening of health management capacity of the DSM health system, (ii) the rehabilitation of existing health facilities, (iii) the provision of medical equipment and supplies, and (iv) the improvement of health services coverage by the construction of additional health facilities where proven necessary. Furthermore, the experience gained during planning and implementation of the project will be used to generate national urban PHC strategies and guidelines. 5. Obteotives of the Dar es Salas. Urban Health prolct Within the goal of the project (section 4), the following developmental objectives of the project were identified: 5.1. Strengthen the Offices of the CMOH and the DMOs in district-based (decentralized) health management and health planning with the aim to improve the effectiveness of health services, to optimize the use of resources and to provide operational and health indicators by districts for further health development. 5.2. Evaluate and monitor by basic operational studies the needs for health services in DSM, the type of service required, the size the catchment population and the optimum location of the new facility among the many needy areas of DSM, with the aim to sequence project implementation based on priorities and to establish a system that helps to monitor project performance with regard to coverage, quality of care and acceptability of care. 5.3. Rehabilitate the structure of the existing health facilities and construct new health facilities in underserved areas with the aim to achieve and improve health service coverage and to ensure structurally sound and medically/hygienic acceptable working conditions.  - 144 - ANNEX 12 Page 7 of 12 5.4. Establish a district-based health facility maintenance scheme with the aim to provide preventive maintenance for all health facilities. S.5. Provide medical equipment and supplies to all rehabilitated or newly constructed health facilities with the aim to ensure that health facility workers have the necessary medical tools and instruments to deliver effective health services. 5.6. Generate through the implementation and continuous evaluation of the project information about the crucial determinants in urban health care delivery with the aim to contribute to the development of the national urban PHC strategy and guidelines for implementation, emphasizing community involvement and participation. Figure 1 shows the framework for the improvement of the DSN health care delivery system based on the objectives 5.1.-5.6. 6. Summary of Project content by Component/Sub-componeit with regard to activities and inputs: The following project components were identified based on the objectives 5.1.-5.6: 1. Support to the CNOH and DMOs in district-based health management and health planning, 2. Evaluate and monitor the DCC health service coverage and the underlying health service user and provider patterns, 3. Rehabilitate and expand DCC health facility infrastructure within the context of developing an urban PHC strategy, 4. Establish district-based health facility maintenance schemes, 5. Provide medical equipment, supplies and drugs for DCC health facilities. 6. Conceptualize the experience gained in components 1-5 for the benefit of developing a national urban PHC strategy. The following section will outline the activities and inputs for each component with its respective subcomponents. It must be emphasised that the details of the proposed activities are found in the relevant chapters of the Report of the Project Preparation Workshop (appendix 1) and the Report on the Health Facility Survey (final version 10.1989, appendix 2); these details are therefore not repeated here. *.1. alazeEauci xuaviu ANDaemmmN an inauun 6.1.1. X lith manage3eat supportj  - 145 - ANNEX 12 Page 8 of 12 Mliv.tit w - Develop and provide adequate task-oriented management approaches for CNR01 and DROs, - Strengthen district-based decision-making and resource allocation, - Introduce a district health management system, - Create and promote district health management teams, - Identify staff needs and demands to understand determinants of staff motivation and methods to maintain it at CMOH- and at district-level. Iniouts:, - Ensure implementation of decentralization policy through project agreements and project set-up (organizational and decision-making structure), - Construct and equip new offices for CMOR and DMOs, - Provide transport to COH and DMOs, - Enable initial seminars in each district with CMOH, DMOs and their teams to familiarize with and continuously strengthen their new role(s), - Commission a study on a comprehensive staff motivation and incentive scheme that is feasible for DCC management staff. 6.1.2. Health planning support AgtivitieS - Establish annual operational plans for each district as a collaboration between CMOH, DM08 and their teams, - Breakdown of the annual plans into monthly activity charts for each DMO and his team, - Follow the implementation of the operational plans based on the monitoring of the relevant indicators set in the plans, - Determine staff standards and staff performance standards based on existing health facility structures, Inputs - Provide on-the-job joint planning/training (district-based and health facility-based) through experienced health planner (approx. 2 man-months per year and district), 6.1.3. Xealth servio. saagecet support Activities - Evaluate existing health service management with regard to user and provider factors, - Establish diagnostic criteria for the major causes of morbidity for each health facility level (1 st priority: dispensaries), - Establish case management criteria/guidelines for major causes of morbidity and for each facility level, - Establish drug utilization standards and drug supply orders based on the criteria in accordance with the EDP principles,  - 146 - ANNEX 12 Page 9 of 13 Establish/re-establish case referral criteria, Ensure record keeping at each health facility level based on sub-component 6.1.4., Identify methods and means of creating and maintaining the motivation of the health facility staff (see also 6.1.1), Identify approaches to build and maintain community involvement and participation in urban health care activities, Ensure continuing education and special training of health facility staff, Monitor staff performance in relation to project objectives and against the background of the motivation and incentive scheme (see also 6.1.1.) Undertake coverage and user/provider study according to 6.2.1. and 6.2.2. based on the detailed separate protocol (submitted to CHOH on 15.1.90), Commission and undertake in-depth study on a possible staff motivation and incentives structure (as for 6 1 1.), Implement findings of the motivation/incentive study at district level, Provide staff transport in each district, CMOH, DMO and public health experts to evaluate the results of the user/provider study, on-the-job training/introduction and follow-up of the diagnostic criteria and case management quidelines, Establish operational links with EDP. 6.1.4. Health information system Activities - Establish a MOH endorsed health information system for the DCC, with particular regard to the minimum required data for each level of health facility, - Train staff of health facilities in the use of the health information system, - Enable and ensure rapid retrieval of health information for each level of facility. Lnnats - CNOH and expert collaboration with MOH, particularly the health information unit and the EDP, - Launch initial training and follow-up courses (partly linked with inputs 6.1.1.-6.1.3.), - On-the-job training linked with inputs 6.1.2. and 6.1.3. 6.1. S. Traiaing of staff from the office of CMao and of ODU-  - 147 - AMEX 12 Page 10 of 13 - Determine training needs for the staff of CMOH and DMO teams and establish criteria for eligibility for training, - Regularly train or facilitate training and upgrading of the staff of CMOH and OMOs, i.e. the district health team, in (i) special subjects/fields and (ii) in the handling of their day-to-day activities, mainly activities 6.1.2. - 6.1.5. InDut - Allocate man-months and -years as well as funds for training within &nd outside Tanzania, based on activities of 6.1.2. 6.2.* EVALUATION AND MONTORING ^ 1 aenLTE SWEvIC COVERAGE 6.2.1. Initial coverage study in relation to user/providor patterns Note A detailed study protocol for subcomponents 6.2.1 and 6.2.2. has been compiled and submitted to the authorities for clearance on 15.1.1990. The final study protocol is found in appendix 3 (not annexed to this draft document). Activities - Undertake a series of descriptive studies to assess the coverage of health services in the three districts, incl. the pattern of health service use and provision, - Launch a household-based analytical study to understand determinants of health service utilization and determinants of community involvement and participation, - Establish criteria for the rational planning of health service extension based on thri operational studies mentioned above. Inputs - Provision of consultants and local (district-based) health service staff for the studies, - Analytical/evaluation capacity at CMOH and DMO level by training and activities of the project assistance unit. 6.2.2. Continuous monitoring of coverage development and user/provider patterns Actvties - Establish monitoring criteria based on the evaluation of 6.2.1. with regard to choice of indicators and timing; emphasis is put on a set of both service- and community- based indicators.  - 148 - ANNEX 12 Page 11 of 13 ZnIu - Allocate one man-month per year of district health management team and one man-month per year of consultant/expert support throughout project implementation. 6. 3. -m RBXLrtAY!OM hZD an TNNSZOX OF MIALT SERVXC 6.3.1. Rehabilitation of existing health facilities Activities - Establish rehabilitation standards based on the September 89 health facility survey on district hospitals, health centers and dispensaries (a detailed report of the health facility survey including costing was compiled by the MOH and the Estates Dept. of the University in October 1989, appendix 2), - Compile bill of quantities for the structural rehabilitation works, - Establish rehabilitation schedule (with regard to priorities (see 6.2.1. and 6.2.2.1 and timing) and launch rehabilitation programe, - Coordinate hospital rehabilitation with the specific DANIDA inputs with regard to standards and timing, - Associate maintenance teams (6.4.) to hospital rehabilitation as on the job training. Tnp-uts - Commission detailed enginsering study assessing the first two years of project implementation, - Appoint building expert to CNOH/project team, - Select and contract building companies, - Establish indicators to monitor structural rehabilitation 6.3.2. Eztension of health facilities to underserved areas Activities - Plan expansion of health services based on the results of sub-components 6.2.1., 6.2.2. and the engineering study of 6.3.1. with regard to priority and standards (structure, function and staffing), - Establish construction schedule and launch it, - Monitor implementation. InDlts - Assign man-months of building expert (6.3.1.) to expansion planning and implementation, - Select and contract builders.  - 149 - ANNEX 12 Pane 12 of 13 6.4 a umMnTnMaNO OF' RB3ILTYKED AND NEW HLYXNi IAOILITYES Aetivities - Form and train district-based health facility maintenance teams for structural maintenance works, - Introduce concepts of preventive maintenance of buildings and major equipment Inputs - Endorse position (decentralization, DMO responsibility) of district-hospital based maintenance unit within DCC health department through project agreement - Training programme/courses for maintenance teams, - Provide work environment for maintenance teams; workshop, transport, equipment. 6.5. PROVISION oF XMDICAL EOUXPMMNn. SUPPES AND DRUGS 6.s.l. provision of medical equipmsent and supplies Activities - Review list of equipment and supplies present, for repair and needed for each health facility, - Establish procurement list and procurement schedule, - Repair defect equipment as established in the review mentioned, - Establish control/surveillance system to maintain rehabilitated/resupplied levels at each health facility. flPmts - Assign man-mc.aths of health planning expert for review, procurement and monitoring, - Equipment and supplies according to needs, - Assign man-months of district-based maintenance teams for the repair of equipment. 6.S.2. Provision of drugs for health facilities - Ensure coordination of rehabilitation schedule with the EDP schemes for urban hospitals, health centers and dispensaries, - Relate effect of the activities of sub-components 6.1.3. and 6.1.4. to the qualitative and quantitative composition of the EDP sets for the DS0 health facilities, - Provide management and logistic support to EDP to ensure continuous drug supply from central units to districts and the health facilities, - Monitor and ensure the rational use of drugs based on the activities of sub-components 6.1.3. and 6.1.4. Inputs - Functional sub-components 6.1.3. and 6.1.4. - Assign man-months of CMOH and/or project assistance unit t 's i  - 150 - TANZANIA ANNEX 12 *ANZAI Page 13 of 13 HEALTH AND NUTRITION PROJECT Nu . sad mlt- Health Manage t~~~sedait.asz by I a elth AesIwlItee I " XItbo d oetvtetesaow H 4 *_ _ w . 11 ~~~~avalaled Da.eattallUttSwal arni Healthcg"n t gt: ,st ;e4gtm I Otte1U OpAm _____ ~~~~the aeeienitt Lppeottat I hae 3q I_ baeS sawima at bett _ ls_eeUtaac Moaetiiate - I P I_ uti_isi *~~~~~d seaf I I ___ Ate. AI u reta .d StztgwAiel @bJaettva (Link objeastiv-aftion (Vagtal) Lin UAhMI~- Ouspet (patg) latar-satise" (Ponst")  TANZANIA HEALTH AND NUTRITION PROJECT Summary Accounts by Year Base Costs (TANZANIAN SHILLINGS Million) Foreign Exchange 1990/1991 1991/1992 1992/1993 1993/1994 1994/1995 Total % Amount 1. INVESTMENT COSTS ________________ A. CIVIL WORKS 366.2 716.9 695.0 332.5 139.8 2.250.4 51.7 1,164.3 B. SUPPLIES 86.5 134.3 199.7 120.5 83.0 624.0 96.1 599.9 C. PHARMACEUTICALS 1,900.2 1,710.2 1.710., 0.2 0.2 5.321.0 100.0 5.321.0 0. EQUIPMENT 146.1 257.0 290.6 152.1 113.2 959.1 96.1 922.0 E. FURNITURE 20.1 27.7 25.6 17.1 7.9 98.5 75.4 74.2 F. VEHICLES 84.3 27.6 30.4 15.2 7.6 165.0 100.0 165.0 G. CONSULTANTS SERVICES 149.8 173.1 137.9 112.6 118.2 691.5 90.9 628.3 H. TRAINING AND WORKSHOPS 100.7 113.9 88.6 61.2 51.8 416.2 35.0 145.8 I. PROJECT PREPARATION FACILITY 88.3 - - - - 88.3 75.4 66.5 Total INVESTMENT COSTS 2.942.1 3,160.6 3.178.0 811.4 521.7 10,613.8 85.6 9.087.0 II. RECURRENT COSTS _______________ A. TRAVEL & PER DIEN 66.0 59.5 38.3 37.8 39.6 241.1 0.0 0.0 B. SALARIES 28.8 46.0 77.3 48.5 36.0 236.6 0.0 0.0 . C. BUILDING OPERATION& MAINTENANCE 10.7 28.2 45.5 53.9 58.1 196.4 30.2 59.2 V' 0. EQUIPMENT & VEHICLE OPERATION & MAINTENANCE 31.2 66.3 106.3 128.3 142.1 474.2 50.7 240.4 E. UTILITIES & SERVICES 4.6 6.2 7.8 7.8 * 7.8 34.1 36.0 12.3 Total RECURRENT COSTS 141.3 206.2 275.2 276.3 z83.5 1.182.4 26.4 311.9 Total BASELINE COSTS 3.083.4 3.366.8 3.453.2 1.087.7 805.2 11.796.2 79.7 9.398.9 Physical Contingencies 55.3 102.7 110.4 52.0 19.1 339.5 70.5 239.2 Price Contingencies 683.5 1,361.7 1.884.9 940.2 821.3 5.691.6 68.6 3.906.8 Total PROJECT COSTS 3,822.2 4.831.2 5.448.4 2.079.9 1.645.6 17,827.3 76.0 13.544.9 Foreign Exchange 3,266.6 3,821.7 4,264.5 1,227.3 964.8 13,544.9 0.0 0.0 February 5, 1990 17:26 Io o  TANZANIA HEALTH AND NUTRITION PROJECT BREAKDOWN OF SUKARY ACCOUNTS (US$ '000) Bease Costs Total lncl. Cant. Local (Excl. Duties & Local (Excl. Duties & For. Exch. Taxes) Taxes Total For. Exch. Taxes) Taxes Total I. INVESTMENT COSTS A. CIVIL WORKS 6.128.1 5.716.0 - 11,844.1 7.467.8 7,675.2 - 15.143.0 B. SUPPLIES 3,157.3 126.8 - 3,284.1 3,954.6 174.8 - 4,129.4 C. PHARMACEUTICALS 28.005.0 - - 28,005.0 28,005.0 - - 28,005.0 D. EQUIPMENT 4,852.8 194.9 - 5.047.? 5.938.3 262.5 - 6.200.8 E. FURNITURE 390.6 127.8 - 618.4 482.2 173.2 - 655.5 F. VEHICLES 868.5 - - 868.5 946.2 - - 946.2 G. CONSULTANTS SERVICES 3,306.7 332.9 - 3.639.6 3,684.9 372.8 - 4.057.8 H. TRAINING AND WORKSHOPS 767.2 1.423.1 - 2.190.3 828.9 1,773.8 - 2.602.7 I. PROJECT PREPARATION FACILITY 350.0 114.5 - 464.5 363.2 127.6 - 490.8 Total INVESTMENT COSTS 47,826.2 8,036.0 - 55,862.2 51.671.3 10.559.9 - 62,231.2 II. RECURRENT COSTS A. TRAVEL 8 PER DIEN - 1,269.1 - 1,269.1 - 1.534.2 - 1.534.2 n 8. SALARIES - 1,245.0 - 1.245.0 - 1.575.5 - 1.575.S t C. BUILDING OPERATION & MAINTENANCE 311.8 721.8 - 1,033.7 367.3 944.6 - 1,311.9 0. EQUIPMENT S VEHICLE OPERATION & MAINTENANCE 1.265.2 1,230.8 2.495.9 1,488.9 1,609.4 - 3,098.3 E. UTILITIES 8 SERVICES 64.5 114.9 - 179.4 74.6 147.1 - 221.7 Total RECURRENT COSTS 1,641.5 4,581.6 - 6,223.1 1,930.8 5,810.8 - Z.741.6 Total 49,467.7 12,617.6 - 62.085.3 53.602.1 16.370.7 - 69,972.8 February 5, 1990 17:26 3 w  TANTANIJA HEALTH AM6 MITUITION PR ,OACT 8BlAttt OF StU_M ACCOUINiTS 4TANZANIAN SHILLINtIS U gllon) eas Costs Physlcal Conti kgOeat" Prie Contignc fIo Total SAcl. Cont. Local Local Local Local t(xel. kato. a for, (ltd. outle 6 (Esnl. Duties (encl, k.1,4a6 For. Etch. Taus) taxes total Extt. Tfaz) Tfe Total For. Etch. Tazes) Texas Total For. Etam. Tae.) faze Total 1. ttVESTEtNT COSTS A. CIVIL MORS t.t64.3 1.086.0 - 2.250.4 99.2 92.6 - 191.9 663.2 803.6 - 1,66.8 1,0262. 1.902.2 - 3.900.I B. SUPPLIES 699.9 24.1 624.0 51.6 2.4 - 61.2 233.6 to.7 - 403.3 1,042.3 48.1 1.081.5 C. P AICEUTICALS s.32t.0 - - 0.321.0 - - - - 1,066.4 - - t.065.4 6,987.3 0.0 - 8.887 3 0. EQUIPMENT 022.0 37.0 - 959.1 73.6 3.0 -76.6 855.1 28.6 - 13.7 1.680.9 60.6 - 1619.6 E. .FUMirTRE 74.2 24.3 G-.$ 7.3 2.4 a- .7 43.1 18.1 - 61.2 124 6 44 9 - 169.4 . VENICLES 168.0 - - 165.0 - 67.9 - - 67.9 232.9 - - 232.9 .. 4. cOtrNUTANTS SERVICES 626.3 63.3 - 691.8 - - - 332.4 33.1 - 365.6 840.7 06.4 - 1,057.1 vj N. TRAINING A4ND IDRKSaOPS 145.6 270.4 416.2 * _ 64.3 192.2 - 256.5 210 t 462.6 - 672.7 0 A. PRtoC7 PREPARATINP FAClEITr 66.8 21.6 08.3 - - - - 15.6 7.1 - 22.7 82 1 28.8 - 110.9 Total ItNESTMENT COSTS 9.067.0 .526.8 - I0.613.6 239.2 100.3 - 339.8 3.6e1.7 1,102.4 - 4.794.l 13.017.9 2.720.6 - ts.747.4 is. RECIRENT COSTS A. TRAVEL 6 PER DIEN 241.1 241.1 - - - - 108.8 - 1s5.s 386.6 - 396.6 8. SALARIES - 236.6 - 236.64 - - - - t1ot7 - .187 - 418.3 - 418.3 C. sUILDING OPERATION 6 MAINTt EtNCE 59.2 137.1 - 196.4 - 41.2 121.3 162.5 100.4 258.8 - 358.9 D. EQUIPMEWT S VEHICLE OPERATION o MAINTENANCE 240.4 233.8 - 474.2 - - 66.2 206.3 - 372.5 406.6 '40. I _ 560.7 E. UTILITIES 5 SERVICES t2.3 21.6 - 34.1 - - 7.7 17.6 - 25.3 20.0 39.4 - 89.4 Total RECURREHT COSTS 311 .9 870.8 - 1.182.4 - - - - 215.1 662.4 - 897.8 827.0 t,82 .9 - 2.079.9 Total 9,398.9 2.397.3 - 11,796.2 239.2 100.3 - 339.8 3,906.6 1.704.8 - 5,691.6 13,544.9 4.282.4 - 17.827.3 ftrugwy S. 1*90 17:26 0t  TANZANIA HEAtTH MO NUTRITIONt PROJECT Sumary Accounta by Year Totals Including CantlngencIO Totala Including Contingnc5es (TANZAAtAN SHILLINGS Msillion) (US$ 00) 1990/4t99l 1991/4992 1992/1993 1993/1994 1994/ 1995 Total t290/1991 1991/t992 1992/1993 1993/1994 1994/1995 Total 1. INVESTMENT COSTS A. CIVIL WORKS 510.6 1.166.2 1,272.1 666.0 294.2 3.909.1 2.259.2 4.683.7 4.6C0.2 2295.t8 1.004.2 15. 43.0 B I SLWPLIES 117.0 210.5 349.8 233.5 177.7 1.089,5 547.8 645.3 1,320.0 839.9 606.4 4.129.4 C. PI4ARMACEUTICALS 2.200.2 2.24S.2 2.385.3 0.3 0.3 6.897 .3 I0.004.0 9,004.0 9.001.0 1.0 1.0 28.005.0 C. EOUIP4IENT 195.2 399.9 S05. 288.3 232.0 3 .6 9, 35 863.8 9.602.0 1.906.2 1.037.1 791.8 6.200.8 E. FURNITURE 27.4 44.5 46.t 34.0 17.4 169.4 424.2 178.7 173.8 122.3 59.4 665.5 F. VEHICLES 403.9 39.3 48.4 26.6 14.7 232.9 459.5 157.9 1482.7 95.8 50.3 946.2 G. CONSU1TANTS SERVICES 184.7 246.6 218.8 192.9 244.1 1.057.1 847.1 990.2 825.8 693.8 730.9 4.057.8 H. TRAINING AND WDRKSltOPS 128.0 169.0 149.8 417.0 409.4 672.7 566.2 678.7 564.4 420.9 372.3 2.602.7 1. PROJECT PREPARATION FACILITY - 10.9 - - _ 440.9 490.8 _- - 490.8 Total INVESTMENT COSTS 38637.8 4.516.2 4,975.2 1,5S8.6 1,059,6 15,747.4 t6,006.7 18.4375 18.774.2 5,606.5 3.616.3 62.231.2 It. RECURREWN COSTS A. TRavEc 5 PER DIEN 86.7 92.4 67.1 70.8 79.6 396.6 383.5 37t.0 253.2 254.8 271.7 4,534.2 S. SALARIES 37.9 71.4 136.2 95.1 77.7 4t8.3 167.7 286.6 513.9 342.3 265.1 1.575.5 C. IEUILOING OPERATION a MAINTENANCE 13.9 42.9 78.1 102.4 121.7 358.9 61.4 172.1 294.6 368.4 415.4 1.3'1.9 0. EQUIPMENT 4 VEHICLE OPERATJiONt MAINTENANCE 39.9 99.0 178.6 238.2 290.9 846.7 476.7 397.7 674.1 857.0 992.9 3.098.3 E. UTILITIES B SERVICES 5.9 9.4 13.3 14.7 46.2 59.4 26.3 27.6 50.0 52.7 55.t 224.7 Total RECURRENtT COSTS 184.3 345.0 473.2 521.3 586.1 2.079.9 815.5 t,266.0 1.785.7 1.875.2 2.000.2 7,741.6 ~~~~~~~~~........ .... ........ - -.--.--.......--- .-.-.......- .... ..... ----- .......... .... --- ..... ........- Total PROJECT COSTS 3,822.2 4,83t.2 5;448.4 2,079.9 t.6,45.6 17821.3 46,942.2 49,402.5 20,559.9 7,481.7 5,6t6.5 69,972.8 February S. 199 17:26 I,- 09 iOD  TANZANIA HEALTH AND IUTRITItON t .