Mauritania - Health and Population Project

Documnt of The World Bank FOR OFFICIAL USE ONLY Report No. P-5603-MAU MEMORANDUM AND RECOMMENDATION OF THE PRESIDENT OF THE INTERNATIONAL DEVELOPMENT ASSOCIATION TO THE EXECUTIVE DIRECTORS ON A PROPOSED CREDIT OF SDR 11.8 MILLION TO THE ISLAMIC REPUBLIC OF MAURITANIA FOR A HEALTH AND POPULATION PROJECT OCTOBER 28, 1991 This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EOUIVALENTS Current Unit = Ouguiya (UM)/US$1.0 = UM 84 (August 1991) MEASURES Metric system ABBREVIATIONS AND ACRONYMS AfDB African Development Bank BMZ German Ministry for Economic Coordination ESPW Executive Secretariat for the Promotion of Women FP Family Planning LIC Low-income countries MOHSA Ministry of Health and Social Affairs MOP Ministry of Planning OED Operations Evaluation Department PPF Project Preparation Facility UNFPA United Nations Fund for Population Activities UNICEF United Nations Children's Fund WID Women in Development FISCAL YEAR January I - December 31 FOR OFFICIAL USE ONLY ISLAMIC REPUBLIC OF MAURITANIA HEALTH AND POUA I OEC CREDIT AND PROJECT SUMMARY Borrower: Islamic Republic of Mauritania Beneficiarles: Ministries of Health and Social Affairs, and Planning; and the Executive Secretariat for the Promotion of Women Credit Amount: SDR 11.8 million (US$ 15.7 million) Terns: Standard, with 40 years maturity Onlending Terms: Not applicable Financing Plan: IDA US$15.7 million Government US$ 0.7 million Local Communities US$ 0.3 million UNICEF US$ 2.4 million UNFPA US$ 3.0 million BMZ/Germany USS 2.3 million TOTAL US$24.4 million Economic Rate of Return: Not applicable Staff Appraisal Report: Report No. 9787-MAU Map: IBRD 23274 This document has a restricted distribution and may bi used by recipients only in the performance of their official duties. Its contents may not otherwise t, ::o. A without World Bank authorization. MEMORANDUM AND RECOMMENDATION OF THE PRESIDENT OF THE IDA TO THE EXECUTIVE DIRECTORS ON A PROPOSED CREDIT TO THE ISLAMIC REPUBLIC OF MAURITANIA FQR A HEALH AND POPULATION PROJECT 1. I submit for your approval the following report and recommendation on a proposed development credit to the Islamic Republic of Mauritania for SDR 11.8 million, the equivalent of US$15.7 million, on standard IDA terms with a maturity of 40 years to help finance a health and population project. The Government and local communities would contribute US$1.0 million. Cofinancing is expected from UNICEF (US$2.4 million), UNFPA (US$3.0 million), and the German Government (US$2.3 million). Part I of this memorandum describes the country's situation and Part II describes the proposed credit. I. Country Policies and Bank Group's Assistance Strategy Strucral Characteristics of the Economy 2. The most conspicuous characteristic of Mauritania is that virtually all of its vast 1.1 million square km is desert. Despite this fact, the country is endowed with natural resources (including iron ore in the north, rich fishing grounds off its coast, and the Senegal River Valley with its agricultural and livestock potential), which, with appropriate management could provide an adequate basis for sustained economic growth. 3. Although only 0.2% of the land area is suitable for agricultural production, the agriculture sector contributes about one third of GDP. Historically, rainfall has been erratic, but especially in the last twenty years, agricultural output has been constrained by recurrent drought. In the 1970s and early 1980s, this led to rapid desertification and structural dependence on food aid. Despite recent agricultural development in the Senegal River Valley, this dependence will persist for the foreseeable future. Moreover, the country faces serious environmental degradation deriving from deforestation, overgrazing and cultivation of marginal lands, all of which contribute to soil erosion. 4. Export earnings are generated by iron ore and fishing, although neither has yet established backward and forward linkages with other sectors that could increase value added. Following the buoyancy of the international iron ore market in the 1970s, mining's share of GDP and itU foreign exchange earnings fell sharply in the 1980's until world market prices recovered somewhat in 1989-90. In the late 1980s, the fishing sector became the predominant source of foreign exchange earnings (57% in 1989) and is a source for future economic growth, provided the policy framework is strengthened, including elimination of Government intervention in directly productive activities and export marketing, and adequate private capital is available for rehabilitation and new investments in the fishing fleet and related facilities. Improved resource management is required to avoid premature depletion of the fishing stocks. 5. Mauritania's multi-cultural population, made up mainly of Moors and Negro-Africans, was until recently largely nomadic. One ;'o fte country's most striking features in recent years has been the rapid acceleration of the process of sedentarization to which the country has yet to adjust fully. Whereas nomads constituted 54% of the total population in 1965, this fell to 35% in 1977, and further still to about 12% in 1988. In parallel with the sedentarization process, as recurrent droughts have constrained economic prospects in rural areas, there has been a process of concentrated migration to urban centers where about half of the population now lives. These two features have strained severely the budgetary resources available to deliver basic health and urban services, aggravating the already low -2- living standards for the majority of Mauritania's people. Selected social indicators illustrate this-life expectancy at birth is estimated at 46 years; infant mortality Is 125 per 1,000; and only 55% of school- age children attend primary school while less than 20% of the population is literate in either of Arabic or French. The population growth rate is currently 2.9% annually and rising. Per capita income in 1989 was estimated at US$490. Key Social Indicators are presented in Table 1 below. Table 1: Key Social Indicators MTA 1989 SSA 19 Population (million) 1.9 481.0 % urban 40.9 33.1 Growth Rate % 2.9 3.1 Fertility Crude Birth Rate (per 1000) 48.0 46.7 Total Fertility Rate (total births/female) 6.5 6.7 Mortality Crude Death Rate (per 1000) 19.0 15.5 Infant Mortality (per 1000) 125.0 106.0 Life Expectancy at Birth (yrs) 46.0 51.0 Medical Cr Population per physician (000) 11.0 4.8 Population per nurse (000) 5.3 2.5 % of children immunized: measles 69.0 52.6 DPT 32.0 45.7 % cf health expenditures in government budget 5.2 n.a. Education Primary Enrollment Ratio 52.0 66.8 Pupil/Teacher Ratio (primary) 50.0 41.0 Adult Illiteracy Rate 83.0 1/ 53.4 J1/ Estimate (average 85-88). Economic Performance and Adiustment Experience through 1989 6. In the early 1980s, droughts and declining international iron ore prices contributed to a decline in economic growth from 3.0 in the late 1970s to 0.2% by 1982-84. Exogenous difficulties were aggravated by weak economic management, characterized by large public investment and expenditure programs with dubious economic justification, unsustainable debt service burden and balance of payments deficits, regulated markets and inefficient public enterprises accumulating heavy financial losses. 7. In 1985, the Government launched an adjustment program aimed at restoring external viability and laying the foundation for sustainable growth. The program's key objectives were: (i) annual growth of 3.5%, sufficient to generate a modest growth in per capita income; (ii) containment of fiscal and external imbalances; and (iii) protecting the welfare of the most vulnerable factions of the society. Emphasis was placed on policy reforms in six key areas: public administration, banking and public enterprise, energy, food policy, and private sector promotion. Concurrently, measures were introduced to monitor the social impact of the reform program. -3- 8. The Government's economic reform program received strong endorsement and significant financial support from the donor community, and soon after its introduction economic performance improved considerably. Real GDP growth rose from an average of 0.2% per year during 1982-84 to 3.4% per year during 1985-89. Despite the social and economic disruption caused by the border dispute with Senegal in 1989, progress in implementing adjustment measures continued, accompanied by modest economic growth. A strengthened incentives framework and favorable weather conditions combined to produce significant increases in agricultural production which contributed to a lower level of food imports, and in turn, an improvement in the balance of payments. With strict budgetary discipline, internal and external deficits were reversed or brought within manageable proportions. 9. The economy underwent a significant reorientation towards market-based mechanisms. Price controls were liberalized, import licenses and quotas were abolished and the processing and marketing of rice was privatized. Important steps were taken to consolidate public resource management, especially in containing the wage bill, as well as streamlining and improving the efficiency of public investments, which declined from 22.6% of GDP in 1985 to 13.0% in 1989. Public enterprise reforms included rehabilitating two key enterprises (SNIM, the mining firm, and SONELEC the water/energy utility) and divestiture of a number of other public enterprises. The combination of these measures helped to more than double the private share in total investment, from 7.4 to 16.7% between 1985 and 1989. Banking restructuring was also undertaken although further reforms are still required. 10. To provide protection for the most vulnerable groups against the short-term adverse effects of adjustment, food aid and food-for-work programs were adopted. Education and health services have been sheltered from budgetary cuts, although there is a need now to increase these sectors' share in public expenditures. To compensate the employment effects of civil service and public enterprises reforms, programs aimed at employment generation, training and promotion of micro enterprises were undertaken, albeit on a limited basis. These efforts were later incorporated in a Reinsertion Program aimed at facilitating the resettlement of returnees from Senegal. Economic Performance in 1990 11. Concern among many donors over alleged human rights issues led to a decline in external support in 1989. In 1990, a number of factors contributed to a dramatic decline in economic growth (- 1.9%, compared with a forecast of 3.0%) and altered markedly the country's economic perspectives. In addition to reduced aid flows which led to a significant scaling back of public investment projects, the principal factors contributing to the poor performance in 1990 were a drop of 23% in crop production and a 30% decline in fisheries output. Iron ore production also declined by some 6%, but overall earnings improved as a result of higher world market prices. The 1990 balance of payments position deteriorated sharply, reflecting poor fish export performance, reduced workers' remittances, a higher oil import bill, and lower disbursements from external assistance. The current account deficit increased from 13.9 to 19.6% of GDP, while the overall deficit nearly doubled to some $89.4 million. Reserves were drawn down by $35.9 million, to less than one month's imports. -4- Table 2: Sw&ed Economic Indicators .ti J8A .1M2 .1990.12 (prol.) REAL GROWTH RATES (%) GDP 5.6 2.7 4.1 -1.9 3.3 GDP/Capita 2.7 0.0 1.5 -3.2 0.3 DEBT SERVICE 11 Debt Service ($) 195.0 254.0 370.0 185.4 185.7 olw interest 71.3 78.0 66.6 72.0 73.8 Debt Service Ratio 42.00 51.00 73.00 37.00 33.70 Debt ServicelGDP 30.5 28.5 39.3 26.8 14.8 RATIOS TO GDP Gross Investment 26.1 16.3 13.5 14.3 16.6 Domestic Savings 14.0 5.0 6.3 6.1 6.4 Public Investment 15.4 10.4 8.1 8.5 8.2 Private Investment 3.1 2.7 2.1 2.7 3.3 Government Revenue 22.3 22.7 21.4 21.4 21.4 Government Expenditure 22.1 20.5 19.7 18.2 18.1 Overall Deficit (-) 1.5 -1.1 -5.2 -0.8 1.7 GDP Deflator 7.3 6.4 9.2 6.5 4.1 Exports Vol. Growth 0.0 -0.1 -0.5 -13.7 1.1 Exports (fob)/GDP 52.1 45.1 44.6 41.6 40.8 Imports Volume Growth 0.3 -7.0 -3.5 7.9 2.5 Imports (fob)/GDP 49.8 36.9 35.4 38.3 36.7 Current Account/GDP -35.0 -21.8 -15.8 -19.9 -18.9 I Before rescheduling. 12. In the aftermath of the Gulf crisis and amid continuing concern in the donor community over Mauritania's internal situation, the country faced a severe financial crisis, as anticipated external funding, from a variety of donors, has failed to materialize. As a result, a Fourth Year Policy Framework Paper, intended for review by the IMF and the Bank in late 1990, has not yet been finalized, pending agreement on a revised macroeconomic framework. Without an agreed medium term program and its associated financing, implementation of key reforms has slackened, particularly in the area of public resource management. Government has not yet streamlined the Public Investment Program (PIP) and reduced expenditures to levels commensurate with available resources. The Bank launched a public expenditure review in May 1991, to bolster Government capacity to program and implement expenditures in line with development priorities. Discussion of this report's main conclusions and renewed agreement on key policy measures would clear the way for agreement on the 4th Year PPP. -5- Growth Prospects and Economic Outlook 13. Despite past progress, economic performance in 1990 amply demonstrated that the Mauritanian economy remains fragile and vulnerable to exogenous factors. Its revenue base is inelastic and its debt service burden, very heavy. Without macroeconomic stability and maximum efficiency in the use of all public resources, sustainable growth will remain out of reach. Near-term economic prospects, ulready constrained by a narrow resource base, have been rendered even more precarious by recent uncertainties on the Government's commitment to pursue its reform agenda. This commitment must be reestablished for the economy to once again generate even modest growth in per capita income. The most promising sources of growth are in agriculture, livestock, and fishing, with some potential also in small scale industries, services and construction. Important steps have already been taken to ensure an appropriate incentive framework enabling the private sector to become the primary generator of future growth. Further measures are necessary to strengthen the financial sector and improve the performance of fishing. 14. For the immediate future, through 1992 a modest level of economic growth is forecast, some 2.9%, equivalent to the population growth, and thus not sufficient to generate any growth in per capita income. For the medium term, economic growth is projected at 3.0-3.5%, from 1993 onwards. This however is predicated on a series of favorable assumptions concerning weather conditions, stable world market conditions for fish and iron, full implementation of the adjustment progrm, especially with respect to public resource management and private sector incentives, and adequate support from the donor community. 15. For the longer term, development of human resources is an obvious priority as this will have a significant impact on overall growth prospects. In addition, further devalopment of both agriculture and livestock is possible. In urban areas, small scale industries could be established, assuming adequate banking and infrastructure services. In the past, worker remittances from abroad have been significant and these could again contriute to economic growth to the extent that they are reinvested, e.g. in small scale industries or construction. In the mining sector, presently known dcposits of iron ore will be depleted within twenty years and while there is some mineral exploration underway in some of the more remote parts of the country, as yet, these have not revealed any significant deposits. Overhanging all prospects for real growth in per capita income will be the Government's ability to deal effectively with rapid population growth, presently 2.9% and likely to reach 3.1% by 2000 without effective action. Thus, the Governments recognition under the proposed project of population as a fundamental development issue and its intention to formulate and implement a national population policy are encouraging. . Central Development Issues 16. Mauritania's economic challenge is not only to restore economic growth, but also to ensure an equitable distribution of its benefits among all groups of the population. Most important on the immediate agenda are: further improvements in public resource management and more effective public expenditure policies; further enhancement of the enabling environment for private sector investment and growth, including fisheries and banking/credit reforms; and human resource issues, including a national population policy. 17. In the area of public resource management, the recent PER exercise confirmed serious weaknesses in Mauritania's capacity to program, budget and monitor public expenditures. In addition to staffing and institutional inadequacies, this reflects the absence of a medium term macroeconomic outlook which seriously dilutes expenditure planning as an instrument of multi-year programming. The link between development objectives and public expenditure planning needs to be strengthened to ensure -6- that expenditure patterns reflect expressed development or social priorities. The PER exercise now underway will propose measures to restructure expenditures, ensuring protection for priority sectors such as health and primary education, as well as measures to improve planning and budgeting procedures, taking adequate account of the absorptive and implementation capacities of technical ministries. The distributive implications of public expenditure planning and implementation will have a critical impact on overall equity concerns. Since remedial actions in these all of these areas will take some time to be fully internalized, we anticipate pursuing this dialogue under subsequent PERs. 18. Mobilizing private sector energies as the primary engine of economic growth will depend on further strengthening of the private sector incentive framework. In particular, efforts should focus on completing liberalization cf pricing policies, deregulation of distribution of basic commodities, and restructuring of the public enterprise sector, including the complete abolition of state monopolies and further divestiture of non-essential public enterprises. Moreover, Mauritania maintains discretionary controls over the allocation of foreign exchange. Liberalization of this regime would allow the private sector to operate without undue constraints in a more open environment. 19. The fishing sector clearly tepresents the country's most valuable resource. Already contributing some 60% of foreign exchange earnings and 20% of Government revenue, and despite recent poor performance, this sector offers the greatest potential for expansion of private sector activity, economic growth, government revenue generation and export earnings. However, an inappropriate policy framework, inadequate resource management and excessive Government intervention have seriously eroded the sector's efficiency and performance. Remedial measures aimed at clearly delineating the respective public and private roles in sectoral activities, privatization of marketing activities, improving the efficiency of local enterprises' operations (both administrative and technical) are all necessary. 20. While substantial banking restructuring was carried out under SAL I, the banking system continues to suffer from a precarious liquidity position with high levels of non-performing assets and low loan recovery rates. The most important sectoral issue concerns UBD, the sole completely Government- owned bank. UBD has been unable to improve its poor performance in debt recovery and it continues to accumulate of non-performing assets, mostly in agriculture, small scale enterprises and the fishing sector. Although UBD represents a persistent drain on public resources Government has thus far resisted its liquidation. One obstacle is that UBD is presently the sole source for agricultural credit, although this department, like others in UBD, has had little success in improving loan recovery. A pilot program, under the on-going Agricultural SECAL, is testing a package of reforms aimed at improving the efficiency and increasing the autonomy of UBD's agricultural credit operations. If successful, this could lead to the separation of agricultural credit from UBD's other operations, eventually leading to its privatization either as a broadly based cooperative or by opening it to commercial banks. More generally, much remains to be done to transform credit policies and the financial system from one closely controlled by the Central Bank to a market based system with financial intermediation capacities under proper prudential rules. Proposed actions include creation of an inter-bank money market, further liberalization of interest rates, elimination of quantitative credit controls and setting reserve requirement ratios. 21. Finally, limited resources and pressing equity concerns make the human agenda a top priority. Meeting increased demand for basic social and urban services, resulting from the high population growth rate (which appears to have been increasing in recent years), the transformation from a primarily nomadic to a primarily sedentary population, and rapid urbanization over the past ten years has been difficult with constrained financial resources. To improve access to these services in the future, selection criteria based on efficiency and economic justification should be strictly applied in designing and delivering services. For the longer term, the question of demographic growth is being addressed through -7- the formulation of a population policy under the proposed project. Realistically, however, this cannot be expected to show results for some years to come. 22. The Government"s priority in education is to increase primary enrollment. Policies in this area should promote equitable access to enrollment by all factions of the population. Efforts to minimize costs while ensuring quality standards are %warted by low population density in many regions and the need to provide curricula in two languages (French and Arabic), once again underscoring the need for careful project selection. The Government has already moved decisively on some fronts, namely encouraging school construction by community groups and introducing a distribution system for text * books. Links between vocational training and the naeds of the economy should be strengthened with the private sector encouraged to participate in the planning, management and financing process. In secondary and tertiary education, steps have already been taken to limit access and fellowships to levels which the * economy can sustain. Country Astan Strategy Past Bank Group Assistance 23. The Bank Group's commitments to Mauritania, as of September 30, 1991, amounted to US$417 million for 32 operations comprising 3 Bank loans, 28 IDA credits and one IFC investment. The 3 loans, totalling US$146 million, were for iron ore mining operations (US$66 million to MIFERMA in 1960, US$60 million to SNIM in 1979 for the Guelbs Iron Ore project, and US$20 million f, SNIM's rehabilitation in 1985). The 28 IDA credits totalled US$271 million and included three adjustment operations (SAL I, AGSECAL and PESECAL), eight agricultural projects, five transportation, three education, two industry, and seven technical assistance operations. IFC has financed two investments in Mauritania, an edible-oil refinery in 1985 and a gold mining j ' - venture with Australia in 1991. The Bank Group's exposure has averaged some 8% (on a disbursement basis) of total external capital assistance to Mauritania. Past lending is summarized in Table 3 below. Table 3: Composition of IDA Lending. FY 85-96 FYa5-91 FY92-96 ** US$ mill, Perent U Mill. Per Agriculture 15.1 9.7 20.0 25.1 Industry and energy 21.7 14.0 - Infrastructure - - 20.0 25.1 Human resources 18.2 11.8 25.7 32.2 Adjustment lending (SALs/SECALs) 80.0 51.6 14.0 17.6 Technical assistance 10, .92.2 - - TOTAL COMMITMENTS 155.0 100.0 79.7 100.0 ** Excluding Reserve Program -8- Country Assistance Strategy and Priorities. 24. The overriding objective for IDA's country assistance strategy in Mauritania is to lay the basis for long term sustainable growth and to ensure an equitable distribution of the benefits of such growth among all segments of the population. From the mid to late 1980s, IDA's program focussed on support for the Government's adjustment efforts. During this time a series of significant economic reforms were adopted (para. 8). For the future, IDA's strategy will be to broaden and deepen the reform process, while complementing these efforts with selected investment operations designed to generate a supply response and restore growth in per capita incomes and living standards. To meet these objectives, IDA's strategy would focus on the following critical areas: (i) Promoting private sector-based economic growth, as the optimum vehicle for generating sustainable future growth in employment and incomes. Major efforts in this area would include promoting development in fishing and agriculture, completing financial and credit policy reforms to revitalize the banking sector, continued strengthening of the incentive framework and further rationalization of the public enterprise sector. These would be addressed through a combination of policy-based and investment operations aimed at strengthening sectoral policy frameworks, correcting current market distortions, and providing investment resources for directly productive activities; (ii) Improving the roductivity of public sector resource use. Interventions here would focus mainly on strengthened public expenditure procedures, including programming and monitoring of public investment programs and recurrent expenditures, and continued public enterprise reform. These would be implemented through lending operations, Policy Framework Papers prepared in conjunction with the IMF and economic and sector work; and (iii) Addressing critical socia -issues. These efforts would aim at developing a national population policy, improving delivery of basic health services, development of human resources and poverty alleviation. Interventions would comprise a combination of policy- based and investment operations together with economic and sector work and on-going Sneial Dimensions of Adjustment efforts. TriAers and Performance Indicators 25. For the period FY92-95 the most likely lending scenario would be a program consisting of 4-5 operations with an approximately equal split between adjustment and investment. The probability of reaching agreement with the Government in the near future on a menu of policy issues is very high. What is uncertain is the pace of implementation which the Government will be able to sustain, especially given present social sensitivities and political uncertainties. This suggests that the adjustment agenda should be kept within easily monitorable bounds and a realistic timeframe to allow the consolidation of consensus both within the Government and with key interest groups. Implementation of the base lending scenario would be conditioned on clear evidence of strong commitment to be signalled initially by the successful completion of the 4th Year Policy Framework Paper, tOereby reinstating Mauritania's compliance with the requirements of the IMF/ESAF program and permitting it to seek debt relief from the Paris Club donors. The main issues to be agreed in the context of the PFP relate to scaling back public expenditures to conform with the reality of decreased revenues and external assistance, restructuring public expenditures to protect priority social sectors, abolishing the public monopoly on fish marketing and opening this activity to the private sector, and liberalizing the foreign exchange allocation regime. Progress on these issues would clear the way for subsequent policy based operations in banking, -9- fishing, and agriculture. A particular issue which would affect the decision on moving to a higher lending scenario would be implementation of land tenure reforms under the on-going AGSECAL, ensuring land rights for returnees from Senegal, since this would critically affect preparation of subsequent agricultural operations. 26. A low case scenario would result from failure to agree on a program of economic reforms. In this case, IDA assistance would revert to a core program of two investment operations, likely reduced in scope, in human resource and agricultural services. While we ascribe a low probability to this scenario, the current environment could seriously retard the pace of economic reform as well as the ability to implement investment operations. 27. With macro adjustment issues to be address in the framework of subsequent PFPs, the operational cornerstone of future adjustment efforts would be a proposed Private Setor Development w . This operation would address interrelated concerns in fishing and banking. To promote the most efficient exploitation of fishing resources, the operation would articulate a sectoral strategy, delineating respective roles for public and private actors, and privatize remaining joint venture fishing firms. The needs of banking sector, whose precarious liquidity position reflects mainly the poor record of loan repayment by the fishing sector, would be addressed in the same project through further credit policy reforms and completion of the restructuring of the banking system initiated under previous operations. This would include divestiture or privatization of UBD, the one remaining State bank, and completion of privatization of the joint venture bank, BNM. Also, the project would undettake a feasibility study on developing financial intermediation capable of attracting small savings and generating private investment funds. 28. In the agriculture ser, IDA's strategy involves (i) policy and institutional reforms aimed at diversifying production and increasing productivity; (ii) project support for expansion of irrigation schemes and extension, research and training; (iii) encouragement of private sector parti,ipation; and (iv) attention to environmental protection issues and improved resource management. An AGSECAL, approved in February 1990, is supporting continued efforts in the key areas of liberalization of cereals marketing and pricing policy, land tenure and institutional strengthening. These activities complement efforts under four other ongoing agriculture projects. Private sector irrigation and agricultural services projects are under preparation. 29. In the area of human resource development, the Education Sector Restructuring Project, approved in July 1988, is helping to expand access to and improve the quality of primary and secondary education. It is promoting cost-effective use of sector resources and encouraging puIdic policies to balance outputs from the secondary and higher educational cycles with labor market demand. A second Education Restructuring Project is planned. In health and population, the project proposed in the current document aims at assisting the Government to improve delivery of basic health and family planning services, and to articulate an action-oriented population policy. * 30. Public Enrrise reforms have been addressed under a series of projects, the most recent of which was approved in 1990. Building on earlier operations, this recent operation seeks to improve the efficiency of resources invested in the sector, with particular actions including (i) modification of the legal and institutional framework, aimed at eliminating state monopolies and facilitating increased private sector participation, up to and including full private ownership of the majority of PEs; (ii) a program of divestiture to reduce the size and scope of the sector; and (iii) financial restructuring programs for key enterprises remaining in the sector. A particular focus of the PESECAL is SNIM, the iron ore mining enterprise, by far the largest PE in Mauritania, which has received three IBRD loans in the past. -10- Following some delays in anticipated cofinancing for SNIM's financial restructuring, overall implementation of the reforms under this program is now proceeding satisfactorily. 31. The Bank's recent interventions in the infrastructure sector have consisted mainly of highlighting the priority of maintenance expenditures over new investments in the course public investment reviews, SAL I and successive PFPs. For some years resource constraints have prevented IDA's direct participation in infrastructure investments. During this time, despite continuing urban migration, especially since 1989, Nouakchott's water supply facilities have been grossly under financed and today only a small fraction of the capital's population has access to clean water. A project is now under preparation aimed at rehabilitating and extending Nouakchott's water supply network to serve low income residential areas with piped water for the first time. The project would also provide further institutional strengthening measures for SONELEC, the water and power utility, to enhance its financial sustainability and operating efficiency. In order to accommodate this operation within Mauritania's current IDA allocation, we will be seeking considerable cofinancing for this project. Programs of Special Emphasis 32. Private sector promotion is a feature of a number of on-going and proposed operatics. Both sector adjustment operations (AGSECAL and PESECAL) directly address private sector issues. For the future, besides the Private Sector Development Project, the Small Scale Irrigation project would have as a primary objective to mobilize private resources for irrigation facilities. In addition, complementary economic and sector work would examine sources of growth and constraints to private sector expansion. Moreover, in the context of the recent IFC gold mining project, streamlined procedures were adopted in approving the investment with the Australian partner which could provide a useful model for facilitating foreign private investment in the future. Efforts aimed at poverty alleviation are incorporated into both our operational and economic work programs. A primary objective of the recent public expenditure review is to reorient public expenditure patterns to safeguard poverty related programs. A poverty profile is under now preparation whose results will be used to better focus future poverty related activities. The SDA work program in Mauritania, with German bilateral support, is one of the more successful in the Africa Region. It includes measures to mitigate the employment effects of public enterprise restructuring, to continue monitoring and analyzing living standards and improve social policy formulation. Two rounds of an integrated SDA survey have already taken place, with the results of the second to be available by late 1991. One result of the first survey was to highlight the importance of women-headed households (32% nationwide). This generated a WID assessment, planned for FY93, which will examine a broad range of economic, cultural and institutional issues constraining the full participation of women in productive activities. In addition, the Health/Population project proposed in the current document includes a WID component which addresses functional literacy, strengthens women's income earning capacity through promotion of cooperatives, and develops a national WID strategy and action plan. 33. A food security study is planned for FY93 which would identify critical areas of food insecurity in terms of demographic, geographic and ethnic factors, identify the effects of externally assisted adjustment and investment programs and propose ameliorative strategies. The food security impact of administrative and political changes affecting the Negro-African population in the Senegal River Valley would be specifically addressed. Finally, in recognition of the impact of envinmental factors on development, a range of environmental issues, including management of renewable and nonrenewable resources, population growth, desertifi-tion, and deforestation will be examined in an environmental assessment scheduled for FY93. - 11 - 34. While ample aid flows for both adjustment and investment requirements were available through the late 1980s, the current environment is much more constrained. Recent poor economic performance has been compounded by retarded implementation of economic reforms, which together with continuing social and political difficulties have caused some donors to reexamine historical aid flows. While the Bank stands ready to support Mauritania, IDA resources alone are insufficient to meet both adjustment and investment needs. Thus, Mauritania will need to reassure dono- that internal social issues are being adequately addressed in order to mobilize necessary levels of supi it This should clear the way for IDA to once again resume its traditional catalytic role in mobilizing donor support for Mauritania, including within the context of the second round of the Special Program for Africa. 35. Priorities for aid coordination will be to ensure: maximum efficiency in the use of this assistance consistent with economic development priorities and a sound public expenditure program (reflecting an appropriate balance between new investments and rehabilitation and between investment and current expenditures), broad based donor consensus on the policy reform agenda, and the availability of resources for both investment and adjustment. The public expenditure review presents an ideal forum for discussion of these issues and we have stressed to the Government the importance of involving the donor community in these discussions. A number of donors have already been involved in the preparation of the report and it is tentatively planned to convene a donors' meeting early in 1992 to discuss the findings of this report, following Bank/Government review. Risk 36. The past year has seen considerable social and political tension in Mauritania. A new Constitution was adopted in July 1991 and, with presidential and legislative elections imminent, opposition political parties are now being formed. This atmosphere of rapid change, together with recent poor economic performance, have contributed to greater uncertainties as to the high degree of official commitment to the adjustment program which has typified our dialogue with Mauritania in the past. We are attempting to reestablish this dialogue on its previouw footing. In the meantime, we are concerned that immediate economic prospects are uncertain and demand decisive action in a number of areas as already discussed. While, in the past, Mauritania has demonstrated its ability to act swiftly and resolutely, given present circumstances, there is some risk that the Government's capacity to sustain its agenda of economic reforms could prove inadequate. For this reason, it will be necessary to clearly define priorities, with careful phasing of key actions, to minimize implementation delays and maximize Mauritanian ownership of the program. 37. An additional risk is that available financing from other donors could be insufficient to support both adjustment and investments priorities. Mobilizing adequate donor support has been a periodic constraint in the past, and, more recently, a reality. While lately there has been some tentative evidence of renewed donor interest in Mauritania, the public investment program, most particularly the * infrastructure sector, remains underfinanced. Donor coordination will thus be a focus of overall country assistance strategy. II. The Health and Population Project 38. Sector Background. While Mauritania lies at the upper end of the scale for low-income countries (LIC), its health pattern is comparatively poor: life expectancy at birth is 46 years and infant mortality is 125 per thousand, compared with averages of 60 years and 72 per thousand for LICs. This - 12 - anomalaus health situation is largely due to insufficient and unstable food supplies, poor sanitary and health practices, and a weak health delivery system. As part of its economic reform program for 1989-91 ("Programme de Consolidation et de Relance") which hinges strongly on human resources development as a source of long-term economic growth, the Government included measures to improve accessibility and quality of health services in the country. The Ministry of Health and Social Affairs (MOHSA) has taken steps to improve sectoral planning and management. Its strategy is spelled out in a Medium-Term Health Plan for 1991-94 which centers around efforts to: (i) decentralize organization and management of health services; (ii) mobilize resources in favor of a regional health system; (iii) redefine the central level's role in planning and technical and logistical support; and (iv) improve the accessibility of low-cost essential drugs. The Ministry's resource mobilization efforts are based on a partnership between the Government and clients in the financing of basic services, including an increase in budgetary allocations for recurrent expenditures for health and the introduction of cost recovery. With respect to population, strong pronatalist traditions have shown signs of gradual erosion in recent years. In 1986, the Government adopted a policy aimed at promoting family planning (FP) in the context of improving maternal and child health. During negotiations with the Bank and the IMF on the Fourth Policy Frp.aiework Paper in June 1990, the Government agreed to take steps towards the preparation of a population policy. A Directorate of Human Resources was created in the Ministry of Plan (MOP) in April 1991 to prepare this policy and a related plan of action. In the meantime, the Government is taking action in several key population areas: promoting maternal and child health, developing family planning services, promoting the status of women, and strengthening demographic research and data collection. 39. Proiect Objectives. The project will: (i) improve the quality and accessibility of basic health and family planning services following a strategy of decentralization of service delivery; (ii) assist the Government to articulate a national population policy and define a corresponding program of actions; and (iii) enhance women's ability to participate in and contribute to the country's social and economic development. A heavy emphasis is placed on policy reforms related to the proposed investments which are secured by specific project conditions. 40. Proiect Description. The project comprises the following components: (a) develooent of the regional health service system (52% of total base costs) including assistance for personnel training and equipment maintenance, for introduction of cost recovery, and for strengthening services in the regions of Brakna, Hodh el Gharbi and Nouakchott; (b) strenathening of capacity at the central level to support regional health services (13%) including support for programs of special interest (family planning, health education and nutrition), and improvement of management systems; (c) development of a population policy and action plan and assisting in its implementation (8%); and (d) xansiono opportunities for women's participation in urban and rural economies (15%), including functional literacy training, support for women's cooperatives, and institutional support for the Executive Secretariat for tne Promotion of Women (ESPW). The credit will also finance Project Coordination and Management and the refinancing of the PPF (12%). Schedules A to D annexed to this memorandum provide summaries of project costs and financing plans, procurement methods and disbursements, key project processing events, and status of Bank Group operations. 41. ProIect Implementation. Each health-related component will be implemented by the relevant unit in the MOHSA. The population policy will be prepared by the Directorate of Human Resources in the MOP, and the WID component will be implemented by the ESPW. Family planning activities in the private sector will be organized in cooperation with the Order of Doctors, Pharmacists and Dentists, and the Association of Pharmacists. Technical assistance on micro-projects for women's cooperatives will be provided through the Food-for-Work Unit in the Food Security Commission; this unit has experience in assisting cooperatives, and will expand its services for women's groups through - 13 - the present project. The project supports the improvement of management, planning and technical capacities in the key implementing agencies. 42. Proiect Sustainability. Institutional strengthening of Regional Health Directorates, redeployment and retraining of regional health personnel, and strengthening of sectoral planning and support capacities of central-level units in MOHSA will be undertaken under the project to ensure project sustainability of decentralization efforts. These actions will be backed up financially by the introduction of cost recovery, increased allocation of budgetary resources to the regions, and improvements in drug financing and procurement procedures to reduce the cost of drugs. Institutional support for the ESPW will allow it to better conceptualize, undertake, and monitor programs for women which will, to the extent possible, be integrated into the regular work programs of different technical and service ministries. 43, Lessons Legned. Although this is the first IDA credit in the health and population sectors in Mauritania, it benefits from the experience in other Sahelian countries which has demonstrated the importance of careful preparation of software elements in health sector activities: appropriate and well-designed training programs, attention to recurrent cost needs, effective decentralization, and efficient allocation of personnel resources. In population, the project follows the recommendations of the Bank Task Force on Population in Africa and of an ongoing OED evaluation of eight case studies (including the case of Senegal) regarding the need to pursue separately but in parallel, the population and family planning programs. These and other studies have also drawn attention to the necessity of improving opportunities for women to participate in the economy, thus enabling them to take a more active role in fertility reduction programs. 44. Rationale for IDA involvement. IDA's involvement in the human resources sectors has grown over the last few years with the increased awareness of the key contribution of human resources to development in the Sahel and, when education and health services are improved, to the poverty alleviation effort. While Mauritania's health sector benefits from assistance from numerous donors, this assistance has most often focussed on specific projects or programs, i.e., a vertical approach. System- wide reforms such as those involving fundamental changes in health services organization, manpower development, pharmaceutical sector reform, and development of institutional capacities for planning and management, often extend beyond other donors' mandates because of the extensive policy dialogue required to develop a national consensus on such reforms, as well as the scale of resources required to implement them. The Government has used the occasion of the preparation of the present project to undertake reviews and design reforms of the above key aspects of health delivery, and is looking to IDA to take the lead role in helping implement the proposed reforms. In DocLJation, IDA's position as the Government's lead partner in the macroeconomic dialogue has provided the opportunity to inject needed focus on the population question and its relevance to the country's development effort. With positions within official circles now gradually changing, IDA's main role is to encourage and actively support the development of an official population policy and of programs to support this policy. In parallel, IDA will work to ensure availability of resources for FP activities, and will support efforts to focus attention on the role of women in the promotion of family welfare. 45. AgMe Actions. The following are conditions of credit effectiveness: (a) adoption of a ministerial instruction defining the structure and norms for the regional health system, and of a decree regarding the implementation of primary health care and cost recovery; (b) creation of a separate budgetary chapter for operational and drug budgets for health regions in MOHSA's 1992 budget; (c) opening a "Drugs Account" for the purchase of essential drugs and medical supplies under conditions satisfactory to IDA; (d) adoption of the new organizational structure of MOHSA; and (e) completion and transmission to IDA for comment of the document "Principal Elements of a National Population Policy". During negotiations, the Government gave assurances that it will: (a) implement MOHSA's personnel - 14 - redeployment and recruitment plan for 1992-96; (b) increase MOHSA's share of Government's recurrent budget to 5.5% in 1992, and by additional increments of 0.5% per year to reach 7.5% in 1996; (c) maintain separate budget categories for regional allocations and a minimum allocation of UM60 million for drugs and UM90 million for other material inputs in real terms, at 1991, prices through 1996; (d) by February 28, 1995, submit the findings of the study to evaluate the cost recovery experience and discuss it with IDA within two months; (e) transfer budgetary allocations to the "Drugs Account" three times a year, audit the account semiannually, and apply procurement procedures for drugs involving shopping in the international market and under generic form; (f) by December 31, 1994, adopt a national population policy and its action plan; and (g) carry out joint annual evaluations with IDA and a mid-term evaluation of the project. 46. Environmental Aspects. Actions to reduce population growth will have a direct positive effect on the environment in the long run. 47. Program Objective Categories. The project contributes directly to the Governments human resources development and poverty alleviation objectives. Developing a population policy, extending FP services, and promoting women's interests are key steps toward attaining improved maternal health and the long-term objective of reducing the rate of population growth. 48. Project Benefits. The health component will directly benefit over 750,000 people, mostly women and children in three regions, who would gain improved access to basic services. In addition, the quality of health services throughout the country will improve as a result of intensive retraining of regional-level personnel. Sector-wide restructuring measures will stabilize financing and help reduce unit costs of basic health care, improving the prospects for a large and sustainable improvement in service quality and accessibility. The exact value of cost savings is difficult to quantify. They will include savings on the cost of drugs (around 50-75% decrease in cost per episode) resulting from the essential drugs program, more efficient use of personnel through redeployment, scale economies derived from integrating vertical programs into the standard service package for regional health facilities, and savings on hospital costs of primary cases pre-screened at the post and center levels. Institutional reform at the central and regional levels of MOHSA will ensure more responsive and efficient administration and management. By the end of the third year of project implementation, cost recovery systems would be established in all regional hospitals, health centers and health posts in three regions (40% of the total population). Mobilization of private resources to cover the cost of health services will improve the sustainability of gains in quality and coverage, and increase accountability within the health service system. The population component will facilitate the integration of family planning into the standard package of services offered in public health facilities, in particular in health centers and health posts. By the end of the project, family planning services of good quality will be extended to all 53 health centers in the country with a major positive impact on the welfare of mothers and children. Although only a small increase in the contraceptive prevalence rate can be expected during the project period (from insignificant levels at present to around six to eight percent), the basic infrastructure for service delivery will have been put in place, and initial consensus-building established to prepare the country for large- scale increases in the subsequent five to ten years. By helping the Government to establish a clear policy on population issues, the project will also help to establish the legitimacy of family planning activities and reinforce effectiveness. In addition to the direct economic and educational benefits to members of women's cooperatives, the WID component will improve awareness of population issues and will increase receptivity to family planning, especially among women in rural areas. 49. Rilh. The main risks are: (a) possible delays in procurement and distribution of essential drugs (due to the radical nature of proposed changes, bureaucratic inertia, and possible vested interest); (b) difficulty in ensuring efficient cost recovery due to the novelty of the cost recovery approach - 15 - in the Mauritanian context, and its dependence on organization of local health committees for resource mobilization; and (c) logistical difficulties related to the desert environment and their effects on maintenance and supervision as well as on motivation of personnel at the periphery. The Government has shown its determination to improve drug distribution and cost recovery by initiating substantive policy reforms and carrying out cost recovery experiments in anticipation of large-scale implementation. The expected reinforcement of the Directorate of Pharmacy and Drugs (with AfDB financing) will further strengthen drug procurement and distribution. MOHSA's policy of combining strict enforcement with improved incentives for personnel being redeployed to remote areas also reflects its sensitivity to this potential problem. To reduce risks resulting from logistical difficulties, close attention has been given to supervision and equipment maintenance in project design. In addition, an annual review of work program and1 budget will be done. 50. Recommendations. I am satisfied that the proposed credit will comply with the Articles of Agreement of the Association and recommend that the Executive Directors approve the proposed credit. Lewis T. Preston President Washington, D.C. October 28, 1991 Attachments b:mtamop/EJamwan ShdA Page 1 of I ISIAMIC REPUBIC OF MAURITANIA HEALTH AND POPULATION PROJECT SUMMARY AND PROJECT COST ESTIMATES (US$Million) g/ sintdCosts h/ Loal Famis leta 1. Development of the Regional Health Service System 1.7 8.5 10.3 2. Strengthening Capacity at the Central Level to Support Regional Health Services 0.6 2.0 2.6 3. Defining a National Population Policy and Action Program 0.5 1.0 1.5 4. Promoting the Status of Women 1.1 1.9 2.9 S. Project Coordination and Management 0.6 1.1 1.7 6. Refinancing of PPF 0.8 0.0 0.8 TOTAL BASE COSTS 5.3 14.5 19.7 Physical Contingencies 0.3 1.2 1.5 Price Contingencies 1.2 2.0 3.2 TOTAL PROJECT COS 6.7 17.7 24.4 IDA 15.7 Government 0.7 Local Communities 0.3 UNICBF 2.4 UNFPA 3.0 BMZ/Gormany .3 TOTAL 24.4 Totals may not add up due to rounding. hl Net of taxes and duties. a:omWr-e.oaplanems Schedule B Page 1 of 2 ISLAMIC REPUBLIC OF MAURITANIA HEALTH AND POPULATION PROJECT Procurement Method and Disbursements Procurement Method by Catomory of Expanditue (US$ million) Amounts and Methods of Procurement (USS million including contingencies) ap, Category of expenditures ICA & 91155 MA 191 1. Civil works 3.10 0.80 0.20 2.30 al 6.40 (3.10) (0.80) (0.20) - (4.20) 2. Vehicles, equipment, materials, 3.70 1.10 0.10 2.40 6/ 7.30 furniture, drugs and contraceptives (3.70) (1.10) (0.10) (4.90) 3. Spocialist services, studies and - - 4.20 3.00 c/ 7.10 training - - (4.20) - (4.20) 4. Incremental Operating Costs - - - 2.80 d/ 2.80 - - - (1.60) (1.60) 5. Refinancing of PPF - - - 0.80 0.80 - - - (0.80) (0.80) TOTAL COSTS 6.80 1.90 4.50 11.30 24.40 Total Financed by IDA (6.80) (1.90) (4.50) (2.40) (15.70) Totals may not add up due to rounding. NOTE: Figures in parentheses are the respective amounts financed by the IDA credit. Footnotes indicate amounts financed by other donors and procured under their procedures. a/ US$2.30 million: US$0.3 local Communities c/ US$3.10 million: US$1.9 UNFPA US$0.6 UNICEF US$0.7 UNICEF US$1.4 BMZ US$0.4 BMZ 61 US$2.1 million: US$1.0 UNFPA d/ US$1.2 million: US$0.2 UNFPA US$0.9 UNICEF US$0.1 UNICEF US$0.5 BMZ US$0.2 BMZ US$0.7 Government 30~ 8 Pag 2 of 2 ISAMC REPULI OF MAURMTNM HEALTH AND POPULATIO PROEC Category of Expenditures Proposed IDA Allocations % of Expenditures (US$ Million) Financed by IDA Civil works 3.8 100% Vehicles, equipment, materials, furniture, drugs and contraceptives 4.3 100% Specialist services, studies and training 3.9 100% Incremental operating costs 1.4 70% Refinancing of PPF 0.8 Unallocated 1.5 TOTAL 15.7 Estimae IDA pdbrseent: USs million FY 22 2a % 21 26 2 2A Annual 0.9 3.1 2.7 3.6 3.2 1.8 0.4 cu~native 0.9 4.0 6.7 10.3 13.5 15.3 15.7 a:sebed-.mapnaannexe SChuleC Page 1 of 1 ISLAMIC REPUBLIC OF MAURITANIA HEALTH AND P LATI Timetable of Key Project Processing Events (a) Time taken to prepare 34 months (b) Prepared by Government with IDA assistance* (c) First IDA mission May 1988 (d) Appraisal mission departure April 1991 (e) Negotiations September 1991 (f) Planned date of effectiveness February 1992 (g) List of relevant PCRs and PPARs n.a. * This eport is based on the findings of an appraisal mission which visited Mauritania fhom April-May 1991, comprising Meare./Mmes. TJ. Ho (Boonomist/Mission Leader); A. Sales (Public Health SpecialistlConsultant); J. Herault-Delanoe (IEC Specialist/Consultant); J. Leconte (Family Planning Specialist/Consultant); and E. Huyboas (Health Financing and WID Specialet). Mr. R. Hecht and Mr. R. Castedot were the poor maviewes for the operation. After negotiations, Ms. Eva Jarawan was eeponsible for preparing tho documents for board prentation. Mr. Birer Fredsikeen and Ma. Katharine Mashall are the managing Division Chief and Department Director, respectively. Schedule D Page 1 of 2 ISLAMIC REPBLIC OP MAURITANIA HEALTH AND POPULATION PROJECT Status of Bank Gro,u Operations (as of September 16, 1991) Amounts in US$ million (less cancellations) W!L9 oUndis- Closing 9MeILUL. _Year Pug2 A MA k!rsed Date Credits 19 Credits closed 129.52 1292-MTA 1983 Technical Assistance II 4.60 .20 06130/91R 1567-MTA 1985 Public Enterprise TA & Rehab. 16.40 2.22 12/31/91R 1571-MTA 1985 Small-scale Irrigation 7.50 4.59 06/30/93 1572-MTA 1985 IDF II 5.25 3.82 12/31/91 1658-MTA 1986 Livestock H 7.60 6.48 06/30/95R 1865-MTA 1988 Develop. Management 10.00 5.15 12/31/94 1943-MTA 1989 Education Sector Restructuring 18.20 11.82 06/30/94 2093-MTA (S)* 1990 Agric. SECALIrriTion improv. 25.00 15.78 1231/95 2166-MTA (S)* 1990 P.E. Sector Adjustment 40.00 22.51 12131/92 2167-MTA - 1990 P.B. Sector Institutional Dev. 10.00 8.05 06/30/98 TOTAL number credits 10 144.55 80.63 lanna 3 Loans closed. 146.00 All closed for Mauritania TOTAL number loans = 0 TOTAL 146.00 274.07 of which repaid 11 5.98 TOTAL held by Bank & IDA 33.82 268.09 Amount sold 63.35 of which repaid 63.35 TOTAL undisbursed Kq9 NOTES: * Adjustment credits * Total approved, repayments, and outstanding balance represent both active and inactive loans and credits. (R) indicates formally revised Closing Date. (S) indicates SAL/SECAL loans and credits. a:cind-4.mia (da-anexcenshm) Schedule D Page 2 of 2 S n C Inest In Mautn (As of June 30. 199) Elingtuss mnion) Xk=o imm et1~MU 1968 SONIMA Mining 9.24 1.2 10.44 1991 MORAK Mining 34. 9,j Total gross commithta 12.61 2.02 14.63 L a=~ i, terminaton, repayments, sales and eange adjutnts 2ä LZ Total nmmt held by IFC 3.37 0.82 4.19 of which undibursed 3.37 - 3.37 * ad b~t pnu td IBRD 2327 ROAGS MAURITANIA ROuTEs NATIONAL CAAI HEALTH AND POPULATION PROJECT &I'LON^' REGIONCAPTALS PROJET SANTÉ POPULATION CHEFA1EUDE REGION DFPARTMFNT CAPNTALS CH EFVIU DE IEPART EMENT REGIONS OF PROJECT CONCENTRATION'REGIONS DE CONCENTRATION DU PROJET REION BOUNDARES STRENGTENING Of REGIONAL HEALTH SERVICES COMPONEST -IM!TES REGONALES COMPOSANTE RENFO~EMENT DES SERVICES DE SANT9 RtGIONUX CTNA OUNDAREs fRONTIEPES NEATIONMJES REGIONS OF CONCENTRATIONIRÉGIONS DE CONCENTRATION INDCATCS THE ERRIORY OF THE WOMEN IN DEVELOFMFNT COMPONENT/COMPOSANTE FEMMES ET DéVELOPPMENT FORMER MPAOROm CACOARA MOROCCO NVEERN ~AHRA, IDA \NDIQUE (E TEER F IRE G ANCEN SÅHÅRA ESPAGNOL SAARAOCCIENTAL. UNICCF 0 50 100 150 200 250 KILOMETERS HEALTH CENTERS/CENTRES DE SANTÉ TYP mAKngnTl ALGERIA STYPE 8 TYPE 8 @Bir Mogreln E REGIONAL HOSPITALS/HPITAUX RtGIONAUX Elo Zouérart ~ RIK M A L I NOUADHIBOU .N Ouadane ATAR Ciget IJAKHLFI •NNChtnguett A T A R NOLUDHI80OU01 AKJOUJT • @Oueft TAGAN I TIDJIKJA HODHm ECH IRAR/A @C HA RGUI NOUAKCHOTT Ouåd Naga MoudjériA Tichit utilimit afor ederdra ALG A om l @ aBki ABrKN - Tintene . . N A Keur Mossåne o Mbagn BeTjino lm gh BOgué @KFFA li ROSSO Bbab o 1 Manguel HQDH EL Bsikounou KAED ..Mbout .d.A A GRAR81 jig; Amourid -, N, : :- Yen'l nkss Maghanma _bu Ths inop 1h b~ pamd by M A L ssp' onhe M A L I pi f I Groo SEdP, 1991 SEPTEMBER 1991