Tunisia - Population and Family Health Project

Document of The World Bank FOR OFFICIAL USE OiNLY Report No. 9128-TUN STAFF APPRAISAL REPORT REPUBLIC OF TUNISIA ]LATION AND FAMILY HEALTH PROJECT FEBRUAR% 19, i991 ian Resources Division II t and North Africa Region listribution and may be used by recipients only in the performance of s ma! not otherAise be disclosed %ithout WAorld Bank authorization.  REPUBLIC OF TUNISIA POPULATION AND FAMILY HEALTH PROJECT STAFF APPRAISAL REPORT CURRENCY EOUIVALENTS (As of September 1990) Currency Unit = Tunisian Dinar (TD) US$1.00 = TD 0.85 TD 1.00 = US$1 18 FISCAL YEAR January 1 - December 31 GLOSSARY OF ABBREVIATIONS Basic Health Care Crude Birth Rate Crude Death Rate Contraceptive Prevalence Rate Centre Regional d'Education et Planning Familial Demographic and Health Survey Family Planning International Bank For Reconstruction and Development Infant Mortality Rate Maternal a..d Child Health Management Information Systems Ministry of Finance and Economic Development Maternal Mortality Rate Ministry of Health Ministry of Planning and Regional Development Married Women of Reproductive Age Non-Governmental Organization Net Reproduction Rate National Office of Population and Family Planning (Office National de la Famlille et de a Population) President Directeur General Project Implementation Unit Project S.eering Committee Republic of Yemen Syrian Arab Republic Total Fertility Rate United Nations Fund for Population Activities United States Agency for International Development RESPONSIBILITIES: ger : Maria Mac Donald, Sr. Population Specialist, EMTPH Ner : Steven Sinding, Population Adviser, PHRDR ief Andrew Rogerson, EM2PH Kemal Dervis, EM2DR  FOR OFFICIAL USE ONLY REPUBLUC OF TUNISIA POPULATION AND FAMILY HEALTH PRO4IEC STAFF APPRAISAL REPORT TABLE OF CONTENTS PAGE NO. DEFINITIONS .......................................................... i LOAN SUMMAY . .................................................... ii-iii BASIC DATA SHEET .................................................. iv 1: BACKGROUND AND ISSUES ............................................ 1 A. Country Background ......................... 1 B. Populton ............................................ 2 1. Population Growth ............................................. 2 2. Contraceptive Prevalence ....................................... 4 3. Family Planning Policies ........................................ 5 4. Family Planning Service Delivery .................................. 7 C. Health and Nutrition ............................................... 9 D. Challenges and Directions .......................................... 11 E. EXTERNAL ASSISTANCE TO THE POPULATION, HEALTH, AND NUTRITION (PHN) SECTOR . ...................................................... 14 F. RATIONALE FOR FURTHER BANK INVOLVEME.NT .......................... 16 II: THE PROJECT ..................................................... 17 A. PROJECT OBJECTIVES ............................................ 17 B. PROJECT DESCRIPTION .......................................... 17 1. Integrating FP/MCH in Fixed BHC Facilities .......................... 18 2. Expanding Outreach Services to Increase Access to FP and MCH .... ...... 19 3. Improving the First Referral Level of Care ............................ 21 4. Quality Enhancement ........ ............... I .................. 21 C. ENVIRONMENTAL CONSIDERATIONS .................................. 24 IlI: PROJECT COSTS AND FINANCING ...... ......... ....................... 25 A. Costs ........................................................ 25 B. Financing ........ ............................................. 28 C. Procurement ................................................... 29 D. Disbursements .. . ...................................... ....... 31 This report is based on the findings of an appraisal mission that visited Tunisia October 1-22, 1990. Mission members were Maria Mac Donald 'Mission Leader/Sr. Population Specialist); Hjalte Seder'of (Sr Dperations Officer); Claire Voltaire (Operations Analyst); and Bernard Heneman (Public Healrh Consultart; This document has a restricted distribution and may he used by recipients only in the performance ot their OftiCial duties Its contents ma% not otherwise he disclosed without World Bank authorization  REPUBLIC OF TUNISIA POPULATION AND FAMILY HEALTH PROJECT STAFF APPRAISAL PEPORT TABLE OF CONTENTS (cont'd.) PAGE NO. IV: NANAGEMENTAND IMPLEMENTATION ................................. 33 A. Management ................................. 33 B. Implementation ............................... 34 V: BENEFfS AND R .. 35 A. Benefits .................. 35 B. Risks ................. 36 Vl:ASSURANCES ............. 37 ANNEX 1 Table 1: Contraceptive Prevalence Rates by Region (1978-1988) Table 2: Distribution of Married Womrn hy Methods of Contraception (1988) Table 3: New Acceptors by Method, ONFP Program (1964-1988) Table 4: Tunisia: New Acceptors by Method, ONFP Program (1964-1988) Table 5: Evolution of ONFP Activities (1964-1988) Table 6: The ONFP Budget (1981-1990) Table 7: Mean Parity by Region (1989) Table 8: Contraceptive Prevalence by Mother's Age and Residence (1988) Table 9: Percentage of Infants (0-4 months) Breastfed Exclusively Table 10: Public Health Facilities (1990) Table 11: Needs Index ANNEX 2 Table 1: Maternal Services by Governorate (Public Sector) Table 2: Percentage of BHC Centers Offering Family Planning Services by Governorate Table 3: Percentage of the Population Covered by Family Planning Services Table 4: Distribution of Mid-Wives by Governorate Table 5: Projected Number of Contraceptive Users - Tunisia (1990-2005) Table 6: Training of Hospital Personnel Table 7: Population and Family Health Project Training Program Summary ANNEX 3 Table 1: Organization ov the Population and Farlily Health Project MAPS  I I - RE&GIJ C OF TUNISIA POPULATION AWD FAMILY HEALTH PROJECT STAFF APPRAISAL REPORT DEFINITIONS OF POPULATION. HEALTH AND NUTRITION TERMS Contraceptive Prevalence Rate The percentag of married women of reproductive age who are using (or whose husbands are using) any form of contraception. Crude Birth Rate Number of live births per year per 4,000 people. Crude Deafth Rate Number of dGuh per year per 1,ooo people. Infant Mortality Rate Annual deat of infarts younger than 1 year old per 1,000 live births during the same year. Life Expectancy at Birth The number of years a newborn child would live if subject to the age- specific mortality rates prevailing at time of birth. Maternal Mortality Rate Number of maternal deaths per 100,000 live births in a given year attributable to pregnancy, childbirth, or post-partum. Net Reproduction Rate The average number of daughters that would be born to a woman if during her lifetime she were to conform to the age-specific fertility and mortality rates of a given year. A net reproduction rate of 1.00 means that each generation of mothers is having exactly enough daughters to repace itsef in the population. Rate of Natural Increase The rate at which a population is increasing (or decreasing) in a given year due to surplus (or deficit) of births over deaths expressed as a percentage of the base population. Rate of Population Growth The rate at which a population is increasing (or decreasing) in a given year due to natural increase and net migration, expressed as a percentage of the base population. Total Fertility Rate The average number of children a woman will have if she experiences a given set of age specific fertility rates throughout her lifetime. Serves as an estimate of the number of children per family.  - ii REPUBLIC OF TUNISIA POPULATION AND FAMILY HEALTH PROJECT STAFF APPRAISAL REPORT Loan Summary Borrower: Republic of Tunisia Amoun: US$26.0 million equivalent Terms: Seventeen years, including five years grace, at the standard variable interest rate. Descriptlion: The Popuilation and Family Health project aims to assist the Government of Tunisia (WI)8 to law bow huIUt nd nto by tuuetn bes healh ewe srvices to undeprileged groups with a rong focus on mother and children. The quantitative targets of the project are to recruit about 30,000 new family planning acceptors per year in the public sector while continuing to serve over half a million women with such services throughout the project period. Further reductions in mortality and morbidity would be addressed through: (i) reducing regional disparities in access to basic health care (including the first referral level of care) and in the availability of resources; and (ii) improving the quality of Basic Health Care (BHC) of which Family Planning/Maternal and Child Health services (FP/MCH) is a critical component. The project would provide: (a) works and equipment to BHC facilities to accommodate the strengthening of FP/MCH services and upgrade the technical quality of the services; (b) mobile clinics and vehicles to deliver family planning and other basic health services with a strong focus on underserved areas; (c) ambulances and equipment for the district hospitals; (d) works and equipment for 5 peri-urban diagnostic centers; (e) educational materials and expert services for a comprehensive pre- and in-service training program for staff who are to deliver the services; (f) expert services to improve strategic planning and monitoring capacities; and (g) spare parts and expert services for the development of a maintenance program for vehicles, equipment and buildings. Benefits: The project would ensure the inciusion of the poor in the demographic transition, improve access to effective basic health care services and reduce regional disparities in family planning and heatch indicators. The project would also contribute to the efficiency of the health sector by strengthening the focus on BHC and by treating morbidity at an earlier stage. The project would create the basic conditions for further fertility decline and thus permit Tunisia to achieve the goals of its population policy which is an integr3l part of its human resources strategy and labor market planning. Risks: Possible risks include the fungibility of budgetary resourrds which could draw resources away from the lowest level of care towar&d nospital-based curative services. As the GOT is fully aware of the importdnce of including the rural poor in the demographic transition to reach the demographic goals, this risk is minimized. Furthermnre, the National Office of Population and Family Planning (ONFP), will continue lo monitor the achievement of family planning targets and assist the responsible staff to meet the planned level. Difficulties in attracting the necessary staff to underserved areas is another risk. To counteract this, recruitment of staff and trainees originating from such areas will receive priority and mobile teams will be targeted to such areas.  iii - REPUBUC OF TUNISIA POPULATION AND FAMILY HEALTH PROJECT STAFF APPRAISAL REPORT Loan Summary (cont'd) Estimted Prolect Costs: Local Foreign Total * - - tUSS millior.; --.-- A. FIRST-TIER BHC SERVICES 1. FIXED SERVICES 4.5 5.8 10.3 2. OUTREACH SERVICES _. -.2 18.6 Sub-Total 13.8 15.1 28.9 B. REFERRAL SERVICES 1. INFRASTRUCTURE IMPROVEMENTS 2.4 2.1 4.5 2. MEDICAL EQUIPMENT 1.4 4.1 Sub-Total 3.8 4.7 8.5 C. QUALITY IMPROVEMENTS 1. TRAINING 1.0 0.0 1.1 2. DRUGS, CONTRACEPTIVES AND CONSIU4ABLES 3.9 11.1 15.0 3. MAINTENANCE PROGRAM o.n 0.0 0.0 Sub-Total 5.0 11.1 16.0 D. PROJECT MANAGEMENT 03 0.1 0.4 TOTAL BASELINE COSTS 22.9 30.9 53.9 Physical Contingencies 1.0 1.3 2.3 Price Contingencies 3.1 3.9 7.0 TOTAL PROJECT COSTS aQ 3.2 63.2 1/ Includes USS16.4 million in taxes and duties Tot s may not add up due to rounding. Financirn Plan: IBRD 26.0 26.0 Goverrvnent 27.0 10.2 37.2 Total 27.0 36.2 63.2 Estimted Disbursmmnts: Bank Fiscal Year 92 93 94 95 96 97 .C-..........USS million).------------------- Annual 0.2 4.2 7.8 8.0 4.4 1.4 Cumulative 0.2 4.4 12.2 20.2 24.6 26.0 Rate of Retrn: Not applicable Maps: IBRD 22666, 22667, 22668, 22669  - iv. REPUBUC OF TUNISIA POPULATION AND FAMILY HEALTH PROJECT STAFF APPRAISAL REPORT BASIC DATA SHEET" Year A. Generl Countr Deta 1. Population 19Wi (millions)2' 7.9 1989 2. Area (km2 in thousands)2' 164 1990 3. Popuabn Densiy (per kmi) 91 1989 4. GNP Per Capita (USS)41 1,210 1988 5. Total External Debt (In Millions Of Dollars)51 6,672 1988 6. Estimated Unemployment Rate (%)" 15.3 1989 7. Male Literacy Rate (% of Males 12+ years of age)7" 68 1985 8. Female Literacy Rate (% of Ferma I+ year of age)71 41 1985 Moo Pra Slch E wbo / t0 t9W 10. Female Primary School EnroUment Rat 89 1989 11. Percenage of Population Wih Access To Eectricity71 Urban (%) 95 1989 Rural (%) 40 1989 B. PouRlution3' 1. Annual Rate Of Population Growth (%)2/ 2.3 1989 2. Population Projections (millions)3/ 9.9 2000 11.5 2010 13.6 2025 3. Urban Population (% of Total)5' 54 1988 4. Population Age Structure3/ 0-14 Years (%) 38.1 1989 15-64 Years (%) 57.9 1989 65(4+) Years (%) 4.0 1989 5. Crude Birth Rate (per 1,000 popu!stion)'0' 25.2 1989 6. Crude Death Rate (per 1,000 population)'"/ 6 1989 7. Life Expectancy At Birth5/ Female 67 1988 Male 65 1988 8. Infant Mortality Rate Per 1,000 Live Births61 National Average 51.6 1989 Average For Urban Populations 32.2 1989 Average For Rural Populations 68.5 1989 9. Risk of Dying By Age 5 (per 1,000 population)5' Female 50 1988 Male 63 1988 10. Total Fertility Rate1"/ 3.5 1989 11. Women of Childbearing Age8/(As percentage of Total Population) 22 1988 12. Maternal Mortality Rate Per 100,000 Live Births (Community Data From Rural Areas)5/ 11000 1980 13. Percentage of Women Receiving Prenatal Care19 Urban 71.9 1988 Rural 43.2 1988 14. Percentage of Married Women Using Contraception81 Any Method 50 1988 Modern Method 40 1988 15. DOependency Ratios9 71.8 1989 IT' Liwwin o IndicAled, figure are Wold Bank esimateg 2/ Annulre natiol t des atiltiqual WAsae_ (1990; MWlU4 de anto publique; R8publiqu. Tunisienne 3/ Worlda en ** - R.I by2010 5/ ounty Econw Memiturn The Routl of TuntsIa Vol.1, *8044-TUN. Mah, 1990 5/ Woltd Debploq~ Flepod 1990; PFaty, The WWortd Obt Goup S =3poputlon etrl AFalnffials; Mnl de Is stpmIAu,Juin logo 7/ UNCF The SW* ofdthe WerWChdn, 1990, Odord U nwra Pro less 8/ Enqu&A D6maWupl" st de SsntA en Tunib 19t8; Minl - do Is Ssr*6 Publq; Tunis. Tunbi. October 1989 9/ Bubto R.A.; Euroe. Mbiddle E end North AfUlca (EMENA; Worldg Papr *328; The Word Bank Group; 1969 IO/ Analys ritrospectlv de f 4voIution do ia popuation totale at ectK, Minislre du plan et du d6veioppernnt regir, Septembre 1990  . v - REPUBLIC OF TUNISIA POPULATION AND FAMILY HEALTH PROJECT STAFF APPRAISAL REPORT BASIC DATA SHEET (cont'd) Year C. Nutition 1. Babies Born With Low Bifth Weight (*)k2/ 1.9 1989 2. Daily Calorie Su9ply Per Capita as percentage of Requirements 123 1985 3. Daily C3lorie Supply Per Capita5' 2,994 1986 4. Percentage of Population With Access To Publicy Provided Water`/ on (% 100 1986 Rural (%) 31 1986 0. Health Sector Resources 1 Governmental Expenditures on Health as % of GDP Total Expenditures On Health As % of GDP 4.5 1987 Total Expenditures On Health Per Capita (US$) 62 1987 2. Percentage Share of Total Household Consumption on Medical Care5/ 6 1989 3. Population Per Doctor Ratio2/ 1,750 1989 In Tunis (The Capital City) 800 1989 In Rural Governorates 2,000 1989 4, Pc-ulation Per Nurse Ratio2'/ 5. P. ;lation Per Hospital Bed2' 500 1989 6. Percentage of Births Attended By Health Staff7' 68 1988 7. Number Of Beds By Type Of Hospital2/ Univerity Hopitals 7,723 1989 Regional Hospitals 4,912 1989 District Hospitals 2,860 1989 E. HosDiail UtIlIzAtIon 1. Average Occupancy Rate (%)2/ 63 4 1989 2. Average Length Of Stay (Days)2' 6.8 1989 Percentage of Hosprtal Days By Type of Hospital University Hospitals 57.8 1989 Regional Hospitals 29.4 1989 District Hospitals 12.8 1989 3. Average Number of Contacts With Health Services Per Person/Per Yeare 2.30 1989 _ _...__ _._ ............................. _._......... ..................................................................... .................................... .............. .................. . ............. . T/ Unls othenwoee Indicated, figur are World anaik simatmOS 2' Annuaire nationl des seiatstiques e,itaires (IN:t minimilrre do Ia tantI publique; 86publicius Tunisienne / Woid Barnk Pro$ectli, 190 whefe NPR - 1 by 2010 4/ Country Economic Memoraum, The Fepublic of Tunitia. Volt. #8044.TUN. March, '990 5/ World Pio~ P;porl 10; Fy The W-j Bank Group 6/ Poitl populaIon et saint4 Familale; Minist6re do la tnt publique, Juin 19O0 7/ UNICEF: The Stde 0f the Wores Cthildren 1900, Odord Unirslty PFes, 1989 / Enqute D"rnaphique et do Snt6 en Tunis 1M; Milnisttoe de la Sajnt4 Publique; Tunis, Turisie, October 1989 /Subl*a R A; Europ, MIddle Eas and North AS= (EMENA4; Wertlng paper 0328; The Word Benk Group; 19B / Analy r6trospecthe do rvolution de la population totale s ectKe, Minist8re du plan et du d6vloppement rigional, S*ptembre 1990  REPUBLIC OF TUNISIA POPULATION AND FAMILY HEALTH PROJECT STAFF APPRAISAL REPORT I ACKGRAC ND AM N IS 1UES A . COUN1TRY BA 1.1 After a decade of strong grow*h, the Tunisian economy started to experience difficulties in the early 1980'8. Oil production declined and world prices fell, but economic measures necessary to adjust for those changes were not initiated promptly. By 1985, a balance of payment crisis was imminent. After a period of demand constraint, the Government introduced policy revisions that broadened into a ride-ranging program of structural adjustment. Specifically, the Government's strategy is to transform the economy from a state controlled into a dynamic market-driven, export-oriented economy able to provide jobs at home and compete effectively abroad. This strong adjustment program has been supported by the Bank through five adjustment operations: two Agricultural Adjustment Loanis (ASAL) in FY87 and FY89 (Lns No.2754 and 3078), the FY87 Industry and Trade Policy Adjustment Loan (ITPAL, Ln No.2781), the FY88 Structural Adjustment Loan (SAL, Ln. No.2962) and the FY90 Public Enterprise Restructuring Loan (PERL, Ln. No. 3109). 1.2 While the economic adjustment process proceeds, a major concern of the Government is the continuing high level of unemployment which affects 15.3% of the working age population. Stagnating migration opportunities, the relatively young age structure and the increasing participation of a better educated female labor force will make it difficult to reabsorb the currently unemployed (316,000) and to create about 45,000 new jobs each year. The Tunisian Government is fully aware of these challenges and has received Bank support for an Education and Training Sector project in FY89 (Ln No.3054) and a recently approved FY91 Employment and Training Fund (Ln No.3255) aimed at adapting the existing labor force to changing job patterns. The Bank is assisting the Government in strengthening the education sector throvih an operation, planned for FY92, which will improve the capacity and quai.ty of t,ie higher education system. While a concerted attack on unemployment is being waged through salient labor market reforms and the promotion of economic growth, the Government's long term strategy is to achieve a balance between the number of labor force entrants ani the absorptive capacity of the economy. Thus, reducing the rate of population growth is an essential aspect of the Governmer.t's human resources strategy. ].3 Although Tunisia has given high priority to human resources development, the education sector has not been able to keep pace with the increasingly large cohorts passing through the system. As a result, the quality of education remains sub-standard and retention in the system is weak; of those children who enroll in school, only one in three go beyond grade 6, one in five go beyond grade 9, and only one in twenty children progress to higher education. Smaller birth cohorts would lead to greater per capita investment in education and facilitate the development of a qualifi&d labor force while, in the medium term, better education, especially of females, would contribute to slower population growth.  S. POPION 1.4 The Govornment policy of moderating population growth has received broad political, religious and legislative support mince Independence. Legislative changes such as the 1956 "Code du statut personnel" (Personal Status Law), and other policy initiatives were introduced to raise the atatus of women and provide them with choices beyond motherhood. Female education has consistently been encouraged: while in 1965 only 52 girls per 100 males were enrolled in primary school, the gap had narrowed to 81 by 1987. Female employment rates have increased from 5.5% in 1966 to 20.3% in 1989. The Government remains committed to raising the status of women and promoting their full involvement in society, including the workplace, despite the preosuree to make jobs available for the currently (largely sale) unemployed. The goal of the population policy to achieve an average family size of 3 children per family by the year 1996 is close to being achieved in urban areas. H!owever in rural areas, where the average family has about 5 children, attainment of that goal remains a challenge. 1. POulation Growth 1.5 Despite concerted efforts to moderate population growth, the population of Tunisia has doubled since Independence, up from 3.8 million in 1956 to 7.9 million in 1989. The prevailing rate of natural increase (2.3%) implies a population doubling time of 35 years. If fertility remains at present levels, the population will reach 10 million by the year 2000 and 16 million by 2026. However, if fertility continues to decline according to the Government of Tunisia's (GOT) medium-range projections, the population will not exceed 9.8 million in the year 2000 and could stabilize at about 13 million by 2026. To maintain a balance betweer. the natural resources of the country and its human inhabitants, the Government is committed to achieving this lower growth path. Since it is unlikely that emigration will be a major factor in relieving population and labor market pressures in the future, slower population growth has to be achieved through further fertility reduction. PooDU lation Trends 1952-1971 1972-1981 1982-1990 a/ Natural Increase 2.8% 2.7% 2.3% Net Increase 2.2% 2.6% 2.2% 1966 1975 1989 C-,de Birth Rate 45.1 36.0 25.2 ,per 1,000 pop.) Crude Death Rate 15.0 9.0 6.0 (per 1,000 pop.) Note: a/ 1990-91 data are estimated. Source: Analyse retrospective de 1'6volution de la population, Ministere du Plan et du Developpement  1. 6 The high, though declining, natural increase of the po.uiation is due to dramatic declLnes in mortality not matched by similarly large decreases in fertility. Most mortality reduct_on occurred between 1966 and 1976 whenr the Crude Death Rate (CDR) declined from 15 to 9 per thousand primarily due to a reduction in both the Infant Mortallty Rate (114R) and .ie incidence ft contagious diseases. The CDR, currently estimated at 8 per thousand, compares favorably with induscrialized countries which tend to have an older age structure. The high IMR of 140 per thousand in 1966 declined to its present level of 51 per thousand live births, which is the lowest rate in the Maghreb and about average for countries on a similar level of development. When mortality declines start earlier and at a faster rate than fertility, the ine'itable outcome is a young age structure with a high built-in momentum for future population qrowth. (Bee Nabr.b (Morocco, Algeria, Tunisial "The Demographic Challenge to Sustainable Economic Development, No. 8903-EMN, August 21, 1990.1 1.7 Figure 1 traces the decline in fertility from Independence in 1956 to 1989. The Crude Birth Rate (CBR) declined fror. 45 to 25 per thousand population and the Total Fertility Rate (TFR) from 7.1 to 3.5 children per woman. Though some countries (in other Regions) have experienced more rapid declines in tertility, Tunisia has been the most successful among Arab countries (see Figure 2). The impact on the age structure is already apparent: the proportion of the population under the age of 15 years has dropped to 38%, as compared to 42% in the Arab region, and is projected to decline to 30% by the year 2001. Figure 1 Fertility Rates In Tunisia CBR 3nd TFR for 1956, 1976, and 1989 55 ...................................................... Legend so . . . ...................................... ....... 45 ............. .............. - - Crude Birth late (t ) 40 -.5.......................................... a T,tal Ferttiity Rate 35 . . . 30 .. . . . ... . . . . . .. . . . . . 25.> .. . .. 20 .. . . 15 .. .. . . . . . 10 X. .. . . 5. 1956 1976 1989 Source Analyse Retrospective, Septeubre 1990  -4- Figure 2 illustrates the total fertility rate (TFR) in Tunisia comparei tn other lower-middle income countries in the Arab Region. Figure 2 TFR For Lower-hiddle Income Arab Countries TFR d GNP US$481-US$20f0 in 1987 7- 4 5- 4 3 2.5 ROY SAR JORDAN MOROCCO EGYPT TUNISIA Somre: Bulatao, Iorking Papef No. 328, 1989 2. Contraceptive Prevalence 1.8 The decline in fertility levels I.S associated with a substartial increase in the age at marriage (from 19 to 24 years for females during the 1980's) which, in turn, is linked to female education and employment befcre marriage. It is unlikely that the age of marriage will increase much further. In addition, an active Family Planning (FP) program initiated in the r>i- 1960s has resulted in significant declines in marital fertility. 1.9 The 1988 Tunisian Demographic and Health Survey found that virtua7.y 100% of Married Women of Fertile Age (MWFA) knew of one or more nrodern contraceptive methods and 40% were using one of such methods. An additinralI 10% of MWFA practiced traditional methods, i.e. periodic abstinence and coitus interruptus. The use of contraception is, however, unevenly distributed, whereas 64% of MWFA in Tunis use contraception, the percentage drops to 32% in the Central-West Region and 41% in the South (see Annex 1, table 1). Schooling is also a major differentiating factor. While only 42% of illiterate MWFA practiced FP, 57% of those with primary education and 66% with secondary education practiced. MWFA with secondary education have on average 2.7 fewer children than illiterate ones, and 1.5 fewer than MWFA with primary edu^ation.  1.10 Clinical methods, i.e. those that require the involvement of health personnel in a clinic context such as contraceptive sterilization and the Intra Uterine Device (IUD), are clearly the most prevalent FP methods. While these methods are highly effective, the dependence on medical staff and physical infrastructure presents a constraint for servicing rural populations. To overcome this constraint, the "Office National de la Famille et de la Population' (ONFP) has re-ently introdlced injectable contraceptives and implants, equally reliable methods, which can be delivered outside a clinical context, e.g. in pharmacies and "meeting points". In addition, a "social marketing of contraceptives" project, managed by ONFP, distributes contraceptive pills and condoms at subsidized pricee through commercial wholesalers and pharmacists. (For detailed service delivery data see Annex 1, Tables 2, and 3.) Abortion in legal in Tunisia and available on request. As it is not considered a family planning method, abortion is not included in the Contraceptive Prevalence Rate (CPR). 1.11 The number of abortions, fluctuating between 20,000 and 23,000 per year (a ratio of one abortion per 10 live births), has remained virtually constant over the last 15 years, demonstrating that the decline in fertility is due to preventive programs, i.e. family planning. The low ratio of abortions to live births in a country where abortion is legal also indicates that abortion tends to be used as a fall-back mechanism for contraceptive failure and not as a FP method. A patient who receives an abortion is routinely counseled about FP methods and given priority for receiving reliable FP methods. 1.12 In spite of the increases in the CPR, the needs for contraceptive protection are not yet satisfied. The 1988 Demographic and Health Survey found that about 57% of Tunisian women desired to halt childbearing completely and 21.3% to delay the next birth for at least two years. In rural areas, 25% did not want any more children while 25% wanted to postpone the next birth. This data suggests a strong nationwide market for FP. In addition, there are indications that poor quality of FP services discourages continued practice of FP. Fully 60% of married women of reproductive age (MWRA) have used a modern method in the past. but now only 40% are using them. This is a high drop-out rate. The primary reason given for discontinuation is fear of side effects, which indicates that counseling and the quality of services should be improved to retain clients in the program. 3. Family Planning Policies 1.13 The significant advances made in moderating population growth are due to the strong and consistent commitment by the Government to its multi- sectoral population policy and its determination to achieve the quantitative goals. However, consensus about the most appropriate policies and strategies for the delivery of FP services has been more difficult to achieve. The debate has centered around "vertical" programs and "integrated" approaches. "Vertical" FP programs deliver only contraceptive methods, i.e. birth control, while "integrated" FP programs address, in addition, the health concerns of mothers and children to bolster reproductive health and child survival. In practice, the Government has made choices based on expediency and has  - 6 - supported both approaches although the emphasis has been on vertical progra.m The experience gained has laid a blueprint for future directions for the program. It is therefore relevant to describe here the evolution of service delivery policies and the lessons learned since the initiation of the program. 1.14 When the family planning program was initiated in 1964, the Ministry of Health (MOH) was charged with the provision of FP services as an integral part of its health activities. However, due to the Ministry's focus on curative hospital care and the shortages in personnel and other resources, service delivery expanded only slowly, to 38 service points by 1973. This low level of activity did not meet the demographic objectives of the GOT. 1.15 To accelerate the FP effort, the Government created, in 1973, a specialized institution, the "Office National de la Famille et de la Population" (ONFP), charged with the responsibility to carry out a mission of research, orientation, coordination and delivery of population and FP activities. This policy was supported by the Bank and other major population sector donors and reflected the belief, prevalent in the 1970s, that vertical programs were the most effective approach to motivate the public tc accept FP. Adequate grant and loan financing of the population program, strong political commitment to its success, and substantial technical assistance, contributed to the rapid expansion of the program and rapid increases in contraceptive prevalence (see Annex 1, Tables 4 and 5). 1.16 By 1980, it became increasingly evident that the vertical approach to FP service delivery was effective in serving women who had a pre-existing demand for fertility regulation, i.e. the urban and better educated, yet it was less effective in generating demand among groups in adverse social settings, i.e. the poor and rural populations. Regional differentials in fertility levels and disparities in the practice of FP among social groups increased, thereby demonstrating the limits of success with the vertical approach. Furthermore, the institutional separation between the FP progran anc the Basic Health Care (BHC) services led to the neglect of maternal care and contributed to exacerbating the disparities in health indicators between social classes and regions. The ONFP, conscious of its mandate and responsibility to implement the population policy, lacked confidence in the capacity of the BHC system to deliver FP services, in the required quantity and quality, given the lack of re3ources available. 1.17 Encouraged and supported by donors (see paras 1.48 and 1.51), the MOH expanded its involvement in FP/Maternal and Child Health (MCH) by experimenting with pilot integrated projects which introduced and strengthened FP and MCH within the context of BHC services in a number of geographical areas. These projects demonstrated that the provision of FP services, as an integral part of the BHC package, is more sensitive to the clients as counseling and services can be provided in the course of other visits for other services, and are therefore more effective in attracting those women who are less pre-disposed to practice FP. In addition, the availability of staff trained in FP strengthens maternal care, a neglected service thus far. The projects also demonstrated that the shortages which had prompted the  initiation of the vertical FP program i.e. in female staff and material resources, could be overcome at a reasonable cost. 1.18 As a result, the Government started, in the mid-1980, to re-examine its FP service delivery approaches and the debate on the relative merits of vertical versus integrated approaches sharpened strategic thinking on future directions of the population program. A short overview of the experience of the program and the prevailing strengths and weaknesses of the three significant sources of FP services: (i) the ONFP, (ii) the Basic Health Care (BHC) network, and (iii) the private sector, is useful here to document the current situation. 4. Family Plannna service Deliver, 1.19 The ONFP, the institution charged with the implementation of the population policy, is financially autonomous and depends on the following authorities: (i) a Supreme Council which defines its general directions; the Prime Minister is President and the Minister of Health is Vice-President; (ii) the Ministry of Health under which authority the ONFP is placed and to which its personnel formally belong; (iii) and an Administrative Council composed of a "President Directeur General" (PDG) and eight other members designated by the MOH, which is responsible for day-to-day management of the ONFP. The ONFP's service delivery strategies are summarized below. 1.20 A key responsibility of the ONFP is establishing FP service delivery targets for the 23 governorates in accordance with the goals of tne GOT's population policy. This responsibility is managed through regional delegates which have direct knowledge of implementation capacities and field conditions. Achievement of the targets is monitored through the supervision system, service statistics, evaluations and operations research. At the national level, ONFP implements a strong program of public education and coordinates population related activities with other Ministries and the Regional Administrative Structure to assure a multi-sectoral approach to population activities. 1.21 The ONFP service delivery system includes one training center and one regional family planning center (Centre Regional d'Education et Planning Familiale (CREPF)] in each of the governorates which provide a full range of family planning services (including contraceptive sterilizations and therapeutic abortions). In addition, ONFP provides FP services in BHC facilities through scheduled visits by 67 ONFP mobile teams to over half of the BHC facilities (800 out of 1505) whose own staff cannot or do not provide such services. ONFP also operates 10 mobile clinics which serve hamlets where no fixed health facilities exist and manages a "social marketing of contraceptive program" to distribute contraceptives (orals and IUD's) through commercial wholesalers and pharmacies at subsidized prices. Countrywide, the ONFP has about 1200 staff and a non-salary budget of TD4 million (1990). 1.22 The ONFP currently provides about 2/3 of all FP services in the public sector and can be credited for most of the progress made in FP prevalence (see Annex 1, Tables 4 and 5). A clear sense of purpose, adequate  - 8 - financing (primarily through grant aid) and high quality technical assistance throughout most of its existence explain its excellent performance. Grant aid has however sharply declined over the last five years and now amounts to only about 10% of ONFP's budget. The bi-lateral aid program with the United States Agency for International Development (USAID) has come to an end in December lSQO and, in the future, funding is expected to be forthcoming, at a much lower level, from special programs on a competitive basis with other eligible countries. As a result, at least one (financing) and possibly another one (technical assistance) of the three factors for success are at risk (see Annex 1, Table 6). This has led the Government to re-evaluate future strategies and priorities (see 1.37). 1.23 The BHC System. In parallel with ONF4P's swift expansion, the MOH ha3 also increased its FP service delivery capacity (see para 1.51) but at a slower pace. It now provides integrated FP and MCH services in 16% of its clinics (as compared to 55% of clinics ::eceiving FP services from ONFP through visits.) However, only a fraction of the potential of the BHC network to deliver FP services has so far been realized. A 1987 survey of BHC staff demonstrates this point: only 52% of midwives, less than 20% of physicians, and only 5% of nurses had any involvement in FP service delivery or counseling. This lack of involvement by BHC staff in FP service delivery can be explained by the fact that physicians and nurses, until recently, did not receive pre- or in-service training in FP and were not motivated to provide such services because ONFP's staff used to receive performance incentives not available to BHC staff and ONFP disposed of more operating resources. 1.24 The Private Sector. The private sector has not played a major role in FP service delivery because users who could afford private services have adequate access to free high quality specialized services offered by ONFP and the Social Security clinics. As a result, only 10% of IUD insertions and contraceptive sterilizations were carried out in the private sector. Private sector involvement is more evident in the provision of supplies, i.e. contraceptive pills, condoms and injectables (which are subsidized through the social marketing program.) The Government intends to stimulate private sector participation in FP by training private physicians and health staff in workplace based services. This strategy is likely to be supported by USAID through technical assistance and project grants. Non-governmental organization (NGO) participation in FP is very limited in scope. It is likely that the early commitment to population activities by the Government has pre- empted the emergence of NGOs strong in FP advocacy and service delivery. 1.25 ComDlementarv roles in service delivery. Several factors have contributed to a recent re-evaluation of the relative roles of ONFP, the BHC system and the private sector in FP service delivery. The key factors are: (i) the reduction in grant aid for ONFP which eliminated its salary advantages and reduced operating funds; (ii) the introduction of FP as a module in physician and nurse training colleges; and (iii) successful pilot "integrated" projects (see para 1.18 and 1.51). The conclusions reached on future policy directions and program strategies are discussed below (paras 1.35 to 1.45).  C. ELT3 AND WUTRITION 1.26 Health and Nutrition Status. In the last three decades, the health status of Tunisians hab improved significantly due to better living conditions, greater access to education, improvements in nutrition, the development of both preventive and curative health care services, and lower birth rates. Life expectancy has increased from 48 years in 1960 to 66 years in 1988. The IMR of 51 deaths per 1000 live births is the lowest in the Maghreb and about average for lower middle income countries. However, this progress has not been equally distributed. A recently completed study on Infant Mortality entitled "Un enfant et deux Tunisies", found that the IMR in rural areas (68 per 1,000) is more than double that of urban areas (32 per 1,000.) In those areas where infant mortality is high, fertility levels are also high, indicating that access to FP and to child health services are deficient in the same geographical areas (see Annex 1, Tables 7 and 8.) 1.27 Though severe malnutrition is rare in Tunisia, i.e. 3% of children between 3 months and 3 years, 15% of those children suffer from mild malnutrition. Stunted growth is especially elevated in the south and central regions of the country. Tunisia is located in the zinc deficiency belt, thus some of the stunting may be due to zinc deficiency as well as the usual undernutrition and infection complex. Nutrition is linked to infant and child morbidity and school performance which in turn have an indirect effect on future fertility aspirations. 1.28 Data from the 1988 Tunisian Demographic and Health Survey (DHS) record a national average of 13% women (8% in urban areas and 16% in rural areas) who exclusively breastfeed their infants in the first four months after birth. This is a low breastfeeding prevalence and is likely to be a significant contributory factor to infant mortality and morbidity and low nutrition status. It also indicates that women do not fully benefit from the contraceptive protection provided by frequent breastfeeding. The average number of months that a mother continues to breastfeed varies by the educational status of the mother and by the level of socio-economic development of the region. Uneducated women breastfeed for an average of 18.2 months, women who have completed primary education for 13 months and women with more education 9.8 months. In urban areas, women breastfeed for a shorter period of time (Tunis 10.3 months, Central-East 14.7 months, and North East 14.9 months) than in rural areas of the North West (19.1 months) and Central-West (18.0 months). The South is in an intermediate position at 15.5 months (see Annex 1, Table 9). 1.29 The Health System. In the post-colonial era, the emphasis has been on the increase of access to health care services. The ratio of population per physician has decreased from one physician per 8,000 population in 1965 to one per 1,750 population in 1989. However, urban areas have benefitted disproportionally from this expansion of services, as illustrated by the 1989 physician per population ratios which are 1 per 800 in Tunis and 1 per 2,000 population in rural governorates. Almost 50% of physicians are specialized, of whom 72% have teaching responsibilities. This specificity reinforces the urban hospital based orientation of the Tunisian health care system since  - 10 - specialist services are primarily available in the University Hospitals and Specialist Institutes. 1.30 Public Health Facilities. The Tunisian health care system has also developed significantly in terms of physical infrastructure. Designed as a coherent network, public health facilities are strategically located and classified according to the level of care provided. In 1989, University, Regional and District Hospitals provided 58%, 30% and 13% respectively of the number of days in hospitals, reversing the normal pyramid-type constellation. 1.31 At the first lev-l the 95 District Hospitals and 6 free-standing maternities, 1505 BHC centers and 2140 "meeting points", are intended to provic.e basic ambulatory care and first level hospital services. The size and staffing of the BHC facilities vary with the size of the population being served and the population density. About half of the BHC facilities are of the smallest type (type I and type II) and are staffed by paramedics only, usually males (see Annex 1, table 10 for a complete listing of BHC facilities by type). To maximize the use of scarce human resources and provide access to higher levels of expertise, those small centers are periodically visited by itinerant physicians, midwives and nurses. However, due to the age of the vehicle pool and their lack of maintenance, the arrival of medical teams is often unpredictable and irregular. 1.32 In addition, service quality and diagnostic capabilities are severely deficient. The physical structures are in disrepair, equipment is scarce or absent and essential drugs are unavailable for substantial periods of time. This results in low technical attractiveness of the peripheral units for service providers and patients alike. Low quality of EHC is the root cause of the dramatic differentials in health status between urban and rural areas and social classes. Pr-ients who have the opportunity to do so turn towarda better equipped regional and teaching hospitals which, as a result, are overburdened by patients that could have been treated at a lower level of care, at an earlier stage and at lower cost. Midwives, who are vital for the delivery of maternal care (as well as FP), are sparsely spread over the BHC network because of the more attractive job opportunities in the hospital sector. 1.33 At the higher level of care. the 22 Regional Hospitals are the second referral level, located in the major urban city of the Governorate, and are designed to provide the population with some specialist care and hospital services. The third level of care, the 19 Teaching and General Hospitals and 4 Specialized Institutions, are located in the four largest urban poles (Tunisia, Monastir, Sousse and Sfax) and offer the highest level of care. 1.34 Health Expenditures. Health expenditures were estimated at 4.5% of GDP in 1989 (or USS62 per person per year). This compares to health expenditures of 5% to 8% of GDP in other middle income countries. Public sector expenditures represented 44.3% of total health expenditures (recurrent and investment budgets) and finance 50% of the ambulatory care visits and about 90% of the hospitalizations. Both the hospital sector, which consumes  - 11 - 70% of MOH resources, and BHC have suffered from insufficient budgetary allocations as MOH resources declined, in real terms, from 2.5% in 1985 to 2.3% in 1989. Since 1989, the Government has started to redress this situation by committing to a progressive increase in the allocations to the MOH. This is likely to be reflected in the Public Expenditures Program of the VIIth Development Plan now in preparation. At the same time, the efficiency of the hospital sector is to be enhanced through the Hospital Restructuring Support project developed in parallel with this project. As burden-sharing arrangements between the Government and the social insurance program are improved and efficiency in hospital management achieved, the resources of the public health sector would increase and permit a better repartition of resources within the sector. This would assist the Government in its efforts to maintain the BHC system at an adequate level. D. e NAIL AND DIR3CTUl3 1.35 DemograDhic Challenees. The GOT intends to address the challenges of the next phase of the demographic transition to achieve zero population growth by the year 2026. If fertility continues to decline at a moderate rate to attain replacement level (i.e. one daughter per woman) by the year 2010 (an achievable goal while maintaining the voluntary and non-coercive nature of the population program), the momentum derived from the gqe structure will maintain low rates of population growth up to the year 2026. To achieve replacement level fertility by 2010, the current TFR of 3.45 children per woman should reach a level of 2.98 by 1996. This implies that the CPR of 40% for modern contraceptive methods has to increase to 45% of married women of fertile age (MWFA), all other factors remaining equal, e.g. age at marriage, duration of breastfeeding, proportions married, etc. Due to the large influx of young women into the reproductive age groups (the result of past high levels of fertility), about 30,000 additional couples should adopt FP each year in tie public sector and about 20,000 additional couples in the private sector (physicians and pharmacists) while continuing to serve the half million (528,000) currently practicing couples. 1.36 According to the study entitled "Un enfant et deux Tunisies", fertility in rural areas (TFR: 5.7) is significantly higher than in urban areas (TFR: 3.4) and about half of the Tunisian population is rural. The target group of women to be recruited as new FP acceptors will therefore increasingly be the rural poor. The population groups with the highest fertility also suffer disproportionally from high infant mortality, child morbidity and low education levels. Consequently, their motivation to practice FP is weak. They also have the least access to FP and maternal services. Combining FP with MCH and other BHC services, as practiced in a minority of centers, maximizes the impact on health and FP status, increases staff productivity, and reduces the patient flow to hospitals. However, the low share of the health budget spent on BHC has prevented a generalization of the integrated service model. Low staff morale and operating resources in the BHC system also discouraged the ONFP from entrusting the delivery of FP services to the routine BHC services.  - 12 - 1.37 Future Directions. The Government, in full agreement with the MOH and ONFP, has decided to accelerate the integration of FP and MCH into the routine BHC services because integrated services have proven to be more cost- efficient to address disparities in fertility and mortality levels and more effective in attracting the specific target groups to FP. The Bank and other donors to the Tunisian population program (notably USAID and United Nations Fund For Population Activities (UNFPA) fully agree with thib approach, while pointing out that improving the quality of BHC must be pursued simultaneously to obtain the desired results. This will require a recurrent budget which is sufficient to sustain a minimum acceptable level of service quality. The experience of ONFP in FP service delivery would be mobilized by the MOH for training, supervision, operations research and the monitoring of FP services. Reducing ONFP's service delivery burden through integration of FP services with the routine BHC activities would have the additional benefit that ONFP can concentrate its efforts on the development of innovative strategies such as promotion of the private sector, social marketing, and public education. USAID will continue to assist the ONFP to pursue these low-cost strategies. 1.38 The GOT proposes to phase the integration effort over a 10-year period. This is a realistic goal which takes into account the need to transfer skills and experience from one institution to another. To ensure that FP will not loose its priority in the multitude of problems facing BHC services, the process of "integration" would be subject to a system of checks and balances with the full involvement of ONFP which has the most experience in the subject matter. 1.39 The MOH is well aware that the overall credibility of BHC services is low due to insufficient recurrent budgets and low staff morale. However, the low share of the MOH in the GDP (see para 1.34), escalating cost of hospital care and the inefficiencies in the management and financing of hospitals, have so far obstructed a redistribution of resources within the sector. Two key reforms are needed to assist the Government in achieving an efficient and affordable health system: (i) reform of the financing and management of hospitals. This reform will be supported by the Bark through a Hospital Restructuring Reform project (to be presented to the Board simultaneously); and (ii) reform of FP/MCH service delivery strategies within a stronger BHC system. This second reform will ensure that health services will be provided at the lowest and least costly level of care. 1.40 To improve the credibility of the BHC system and to attract better staff to those facilities, the Government intends to increase the share of BHC (including district hospitals) in the recurrent budget of the MOH from the current 30% to 40% by the end of the project period. During Negotiations the Government provided assurances that the annual growth rate of the BHS non- salary operatiag budget would be positive and at least equal to the annual growth rate of the overall MOR non-salary operating budget. During yearly prospective reviews and the final evaluation, achievement of this goal will be monitored and assessed. 1.41 Geographical Distribution of Resources. To assist the Government to achieve an equitable distribution of BHC resources, the MOH has developed,  - 13 - with Bank assistance, an inventory of existing BHC resources (infrastructure, personnel and vehicles) by governorate. These resources have been pro-rated by population size and adjustment factors introduced for dispersion, strength of the private sector and difficulties of access/road infrastructure. On that basis, an index of relative degrees of access to BHC services has been developed, i.e. adjusted ratios of clinics and different categories of health care staff per 1000 population in accordance with the standards adopted by the Government for the development of the BHC structure. A "needs index" has been developed based on those adjusted ratios to indicate what an ideal distribution of resources (In accordance with the Tunisian standards) would look like. The "needs index" indicates priority areas for the allocation of project investments and serves as a tool to measure progress on improving equitable access to BHC services (mm Ann-x 1, table 11) during the project period. 1.42 It must be realized however that satisfaction of unmet needs cannot be the only rationale for determining resource allocation during the VIIIth Development Plan. Limits to redistribution are set by the necessity to maintain the existing network of BHC services (see Annex 2, table 8) and the affordability of further expansion. The improvement of BHC in underserved areas and adherence to the "needs index" as a guide for resource allocation will therefore be, to the extent feasible, by preferential resource allocation to underserved areas. It is not suggested to reduce BHC resources in the areas which already have access and resources above the Tunisian standards; firstly, because the standards indicate minimum acceptable levels; secondly, because once the physical infrastructure exists, human resources are needed to complement _t; and, thirdly, closure of well frequented clinics is socially undesirable. 1.43 The allocation of resources, in particular of vehicles and equipment, would be closely coordinated with the timing of recruitment of appropriate staff, in particular midwives, for specific areas. Detailed planning for the recruitment and assignment of staff is only possible on a yearly basis. The MOH will therefore prepare Yearly Resource Allocation -nd Implementation Plans which specify its resource allocation plans by governorate and define the location of centers to receive additional staff and material resources. 1.44 In those areas which already have a fair share of resources, government policy is to improve quality of services through training, technical support and refurbishing of the physical infrastru_..ture without expanding staff numbers and infrastructure. This would ens-.'e that deprived areas obtain a (gradual) redress in resource availabilit; while more favored areas maintain the existing level of resources (for ;. growing population). 1.45 The Government provided assurances, during Negotiations, that the yearly Resource Allocation and Implementation Plans, will be submitted to the Bank by December 30 of each year for review and comments. Resources for expansion would be distributed in accordance with the "needs index". As a condition of loan effectiveness, the Resource Allocation and Implementation Plan for the first year of project operation will be submitted to the Bank for review and comments.  - 14 - B. ITERIIAL ASSISTANCF TO -UB POPMLAIO. MALSH AND NUTRITION SFCTOR 1.46 Experience with Past Lending and the Bank's Role. Tunisia was one of the first recipients of Bank group lending for population activities with a US$4.8 million IDA credit approved in 1971. The project was designed to strengthen the Tunisian FP program by improving access to FP and MCH. It provided for: (i) the construction and equipment of four maternity hospitals, 29 MCH centers and an extension of the Avicenne Paramedical Training School in Tunis; and (ii) the provision of management consultants and technical assistance for paramedical training and the evaluation of the MCH/FP program. The project, first administered by the MOH ane later, from 1974, by the ONFP, was scheduled for completion by the end of 1975, but was not completed until 1981. As a result of the delays in implementation and price escalation, the total estimated cost increased to about US$35 million, up from the initial Appraisal estimate of US$7 million. Additional financing was provided by NORAD (the Norwegian Development Agency) and the Government. The project's impact on FP acceptance and MCH status was substantial although difficult to quantify due to a shortage of benchmark data. The training activities financed under the project contributed to an important expansion in the number of paramedics. 1.47 A second Health atid Population project was identified in 1977. Preparation took more than three years. The IBRD loan of US$12.5 million became effective in 1982. The loan closing date was extended twice from the original of December 31, 1986 to September 30, 1989. US$4 million of the Loan was cancelled in March 1987 due to dramatic appreciation of the US dollar. The overall purpose of the project was to integrate FP services with preventive and curativa care, nutrition, health education and sanitation services in 8 governorates. The project comprised the following components: (i) construction and/or remodelling of 140 health posts, 325 dispensaries, 90 staff houses, 2 regional health education centers, 6 paramedical schools and 8 maintenance workshops; (ii) strengthening of the MOH managenent capacity through the provision of a Management Information System (MIS); (iii) a national health education program; and (iv) a training system and its infrastructure, and training and redeployment of health personnel in the project areas. 1.48 The Project Completion Report (October 11, 1990) lists as achievements of the project: (i) strengthening of the BHC capabilities and the commitment of the MOH to BHC; (ii) establishment, staffing and providing equipment for major BHC infrastructure in 8 governorates; and (iii) an improved health training system. However, significant factors impeded full achievement of the project objectives: a. institutional overlap between the MOH and the ONFP prevented the planned integration of FP/MCH in the BHC services; b. a combination of project complexity, scale and inadequate preparation affected achievement of the MIS, health education and applied research components;  - is - c. the Borrower's reluctance to use technical assistance funds affected the quality of training programs, civil works supervision and use of consultants; and d. cumbersome bidding and evaluation procedures delayed procurement. 1.49 Other Lessons Learned. The Bank has consistently emphasized preventive and simple curative care and the integration of FP into the routine BHC services. Though significant progress was made, the project fell short of the desired result for a number of reasons: (i) the inefficiency ot the hospital sector which consumes most of the sector resources. This issue will be addressed by the proposed Bank financed Hospital Restructuring Support Project; (ii) the preference of health staff to work in urban areas and hospital surroundings. This factor has diminished in importance due to a better supply of staff competing for fewer job opportunities in the cities and the recent introduction of compulsory service in assigned areas for public health physicians, for a period of 2 years; and (iii) the squeeze in budgetary resources for recurrent costs which will be addressed through an increase in overall health sector resources and a larger share for BHC within the overall budget (para 1.40). 1.50 Other External Assistance to the Population and Health Sectors. Vaccination and oral rehydration programs were initiated and are on-going with UNICEF support. USAID has provided overall program support to ONFP for over 25 years. Due to competition for graz.t funds from countries with even more urgent needs, Tunisia has now "graduated" to project funding only i.e. for discreet types of activities. Integrated projects, introduced and supported by bi-lateral donors, such as Belgium, Canada, the Netherlands and Norway, have been completed and were successful in demonstrating the effectiveness of such approaches. After completion, these activities continue with MOH support and, in spite of some decline in quality due to insufficient operating budgets, remain successful. The UNFPA is currently financing a project integrating FP/MCH in the BHC system. This project is very promising and, together with the completed bi-lateral integrated approaches, has served the GOT as the model for both future FP service delivery strategies and the proposed Bank operation. The UNFFA will continue its support for integrated FP/MCH services during the VIlIth Development Plan in particular through research, training, strengthening of the Management Information system, basic equipment and contraceptives. 1.51 The bi-laterally funded integrated projects benefitted from intensive technical assistance support and adequate resources which were key factors for their success. For various reasons (see para 1.50), the Bank's project (TUN-2005) achieved some key objectives but did not succeed in furthering the integration effort. Currently, all donors support and recommend integrated FP/MCH services within the BHC network as the most viable strategy to motivate and expand FP practice among those women who have not yet adopted the practice.  - 16 - 1.52 Links with Other Human Resources OperationS in Tunisia. A; mentioned, population activities are closely related to other human resourceo issues such as health, education and employment with a mutually benef &.a' effect. The Bank's Human Resources sector program for Tun.esia also includes other planned operations: (a) Hospital Restructuring, FY91, (b) Employi..ert. and Training, FY90, and (c) Higher Education, FY92, which will, directly arl indirectly, contribute to the objectives of the Population and Family Health Operation through improving social indicators of the Tunisian population and reducing regional disparities in education and employment prospects. Ihe achievement of population objectives with che assistance of this project, in turn, will facilitate human resources development through moderating the rate of populatinn growth. P. RATIONALE FOR FUER BANK IVOLVUIT 1.53 This population and family planning project is an opportunity to consolidate the sporadic Bank involvement in population and health activities in Tunisia over the last two decades and to assist the government of a country which has maintained strong political commitment to achieving zero population growth through a voluntary non-coercive FP program. At a time when the h rd- to reach geographical areas and the poorest social strata need attention and other donor support is curtailed, moving the contraceptive prevalence rate to a much higher p4iteau i- .~ difficult challenge. The Government is committed to address those demographic challenges through an integratel approach to FP service delivery which will also reduce disparities in heaith status. The project has the full commitment of the Government, including the MOH and ONFP, and deserves strong Bank support. 1.54 In addition, the strong commitment of the Government to bring about a fundamental reform in both population and health atrategies provides a unique opportunity to simultaneously improve the efficiency of the health sector and the quality of FP services through strengthening of BHC. The proposed Hospital Restructuring Support Project will facilitate a comprehensive restructuring of major teaching and specialized hospitals ani improve the burden-sharing arrangements between the State, insurers anJ patients. The two health sector operations address the fundamental reforms necessary for increasing health sector resources, improving efficiency ar:_ achieving the goals of the population policy. 1.55 Finally, Tunisia is expected to host the 1994 World Populaticr Conference. This is a proper venue as Tunisia has achieved significant progress on the demographic transition and is a trailblazer in the provision of FP services within the African continent and the Arab World. Renewed Bank support for population operations in the country would receive high visibility and might encourage other countries to adopt similar strategies.  - 17 - I: TIM PROJ A. PROJICT OwJUCTIVUS 2.1 The objectives of the Population and Family Health project are to increase the Contraceptive Prevalence Rate (CPR) for modern methods from 40% to 45% and to improve the health status of the population, especially of women and children in rural areas. These objectives would be puirsued through two strategies: a. strengthening of family planning and maternal and child health services (FP/MCH) within an improved Basic Health Care (BHC) package; b. targeting BHC for population groups with the highest fertility and mortality levels and inadequate access to BHC services. 3 PROJtCT DRSCRIPTIu 2.2 The proposed project is designed to cover the first S-year phase of a 10-year assistance program. In this first phase, the focus would be on strengthening and expanding FP and MCH service., as a routine component of BHC services, with particular emphasis on underserved areas. In addition, FP/MCH outreach and the first referral level of care would be strengthened. In the second phase, the focus would be on consolidating the gains of the first phase and on linking the improved BHC system to higher lIfvels of care through an effective referral system. 2.3 The project consists of 4 components: - integrating FP/MCH services in fixed BHC facilities; - expanding outreach services to increase access to basic health and FP services; - improving the first referral level of health care; and - quality enhancement of the BHC system. 2.4 The project would provide for: (i) the refurbishing of the infrastructure and equipment of the BHC centers to both permit the provision of FP/MCH and improve the quality of BHC; (ii) the replacement and expansion of vehicles for outreach activities in underserved areas; (iii) the acquisition and replacement of ambulances and equipment for the first referral level; (iv) the provision of expert services and teaching aids for a continuous training program for BHC staff; (v) spare parts and technical assistance for a maintenance system for vehicles, equipment and buildings; and (vi) the financing of operations research, impact evaluations and technical assistance.  - 18 - 1. Inteqratin FPC In Fixed BBC Facilities (US510.3 millioan 2.5 Family Planning. FP services would be provided by female Ministry of Health Btaff who have received pre- or in-service training in FP and MCH, and/or physLcians (see para. 2.15). The target number of women to be served will be set by the Office National de la Famille et de la Population (ONFP), in accordance with current practices, to meet the national target to increase the CPR (for modern methods) from 40 to 45% by 1996. The specific targets per governorate will be agreed upon by the Regional Health Directors and approved by the Project Steering Committee in the context of the Yearly Resource Allocation and Implementation Plans. Supervision would be ensured through the regional project team and, when necessary, remodial training provided through the regional ONFP supervising midwife, on the job or in ONFP's specialized centers. Additional performance monitoring, i.e. for meeting service delivery targets, will be by analysis of service statistics, sentinel centers and periodic surveys (see para 2.16). 2.6 Specialized Family Planning Centers (CREPF8. The regional CREPFs (specialized family planning center managed by ONFP) will continue to provide FP referral care and surgical services. Tunis is the only governorate with no CREPF to serve as a FP referral facility. The project would provide for the upgrading of an existing small FP center, located in a populous area of Tunis, to be fully equipped as a CREPF. The upgraded facility would also accommodate an existing depot for contraceptives managed by ONFP. 2.7 Maternal Care. In additioin to FP, safe motherhocd would be one of the key project objectives. All physicians and female staff ..n clinical settings and outreach service delivery, i.e. midwives, obstetrical nurses and other nurses, would receive initial training or refresher tra- ;.ng in gynecological screening and pre- and postnatal care (see para. 2.15',. .'"is would assist the qovernment's efforts to increase the nationail average of t,t !.east one visit for pre-natal care from 67% of women to 85%, and for 4 visits (focused on high risk pregnancies) from 21% to 40k. The pe-centage of women rece,' ng post-natal care would increase from 39% to 50% by tht. end of the project p;:.iod and include FP counseling (see Annex 2, tables 1 to 5) to ensure spa7 t.ag of births and protection of breast feeding. 2.8 In rural areas, the proportion of women delivering withi the assistance of a trained health care worker is 59%. No reliable statiso.cs are available to assess differentials in maternal morte.lity yet clinic records indicate that a large proportion of maternal mortality (and complications of childbirth affecting infants) could have been prevented by timely referral to appropriate levels of care. The project would strengthen the infrastructLre for normal childbirth in district hospitals and peripheral maternities and increase the rate of assisted deliveries from 59% to 70%. Ambulances would be provided to facilitate transport to higher levels of care as needed. A survey has been initiated to establish baseline data for the *evaluation of project achievement. 2.9 Child Health Services. Well-baby-care and under-five-clinics would be introduced in the 75% of BHC clinics that currently provide immunization  - 19 - services. The expansion of child services is easier to realize than services directed at women because it is culturally acceptable for male nurses, the only type of staff in most of the smallest type of clinics, to Berve children. Screening of infants, growth monitoring and health education for mothers, especially for the promotion of birth spacing and breastfeeding, would be a strong feature of the services available at the BHC clinics. Detected cases of malnutrition would be reported to the social services for an analysiB of the family's social and economic situation and long term assistance provided through those channels. 2.10 To identify the specific needs for extension/rehabilitation of the physical facilities of the BHC system and for equipment, the Regional Health Directors have updated the listing of c-nters (including district hospitals) with consideration of the number of spaces, equipment, state of repair, etc. and have compared this information with the standards developed for and agreed with the Bank for the previous project (Health and Population Loan 2005-TUN). The project would finance the priority needs identified which involves civil works and equipment for about 35% of the centers. Specifically: (i) the extension and rehabilitation of about 160 existing centers to adapt the infrastructure to the need for privacy in the provision of FP/MCH, and (ii) the provision of essential small equipment for about 400 centers. 2. Bwandina Outreach Services To Increase Access To FP And CH (USs 18.6 *illion) 2.11 The project would support two outreach strategies: (a) by outreach teams, utilized by the BHC system as well as the ONFP, to provide access to physicians and nurses in hamlets which have the smallest type of health structures (type I and type II); and (b) by mobile clinics. (a) Outreach FP teams. As 320 BHC centers gradually assume responsibility for FP/MCH service delivery during the project period, visits by ONFP outreach FP teams would become redundant in those places. Twenty six ONFP teams would thus become available for expansion of visiting services to those BHC clinics which do not provide any kind of FP services and to increase the visiting frequency to those clinics that are currently being (sporadically) served. The new itineraries for the "mobile teams" will be determined in yearly plans by the regional delegate of ONFP and agreed upon by the Regional Health Director. The itineraries would be reviewed by the project implementation team and endorsed by the project steering committee. As 16% of BHC centers currently provide FP and MCH as a regular part of their services and ONFP visiting teams provide FP sessions in 55% of BHC centers, a quarter of all BHC centers do not provide any such services. By the end of the project period, FP services would be integrated in a total of 40% of BHC centers, thus improving quality of services and regular access. ONFP would then provide services in nearly all other BHC clinics through visiting teams.  - 20 - (b) Outreach with FP/MCH mobile clinics. The 10 ONFP mobile clinics, staffed with a midwife and a nurse/educator, serve about t00 assembly points (out of 2140 points) with monthly Visits. The number of mobile clinics would be increased to 15 during the project period and serve an additional 250 points. A study carried out by the Population Council estimates the cost per woman served in mobile clinics as only slightly higher than care delive-ed in a fixed clinical setting. As the population served by the mobile clinics has no access whatsoever to other social services (except for immunization provided by male itinerant paramedics), this is a cost-effective service to reach the rural underserved with FP. To maximize the benefits of those visits, the ONFP will also offer screening of children and expand gynecological services. Pre-natal care is already available in the mobile clinics but post-natal check-ups will receive greater emphasis. 2.12 To facilitate outreach by various categories of health staff, the project would finance the provision of about 455 vehicles and an initial stock of spare parts. About three-quarters of those vehicles are replacements for aged cars which should have been replaced years ago yet, due to financial constraints, were not. Currently, about half the vehicles are not fully operational because of frequent breakdowns, lack of spare parts and high repair costs. The cars used by outreach teams serve over 1,000 BHC clinics in hamlets which have to be reached over poorly maintained routes. Cars used for supervision, school health services and evacuations to the first referral level of care will be replaced and some additional vehicles provided. In addition, the project would finance 15 mobile clinics, of which 10 are replacements, to ensure FP/MCH services in areas without fixed facilities and expansion into new areas. 2.13 The Ministry of Health (MOH) will reinforce its control over the allocation of vehicles through the introduction of a system which will record, in addition to the current tracking systems, the purpose for which the car is to be used, the zones in which the vehicle will operate and the type of staff it will transport. The regional project implementation teams, under the direction of the Regional Health Directors, will be responsible for defining priorities for the allocation of project vehicles and submit their priority needs to the Project Implementation Unit (PIU) for approval. These vehicle allocations will be a component of the Yearly Resources Allocation and Implementation Plans to be submitted to the Bank for review and comments (See 1.45). The Regional Health Directors will supervise the vehicle-control system on behalf of the Project Implementation Unit.  - 2 1 - 3. Ilvroving The First Referral Level Of Care (USS8.5 million) 2.14 District Hospitals. The project would reinforce the quality of referral care to enhance the credibility of the BHC network and to reduce the pressure on higher level hospitals. Under this project, the coverage and quality of the services to be provided in district hospitals would be improved through refurbishing of buildings, provision of additional X-ray and laboratory equipment for 50 district hospitals and the provision of 158 ambulances. (a) Diagnostic Centers. Five diagnostic centers will be established in the three largest cities of the country, introducing a new service delivery channel for ambulatory specialist care in Tunisia. The centers will make a strong contribution to the quality of care in the BHC network through streamlining referrals for the usual clientele of BHC centers i.e. the rural and the poor. This will contribute to raising the credibility of the system and to the health/equity objectives of the project. It will also have a beneficial effect on the efficiency of the health sector as a whole by relieving the flow of patients to higher level hospitals. Three of those centers will be accomodated in, to be expanded and refurbished, BHC centers of the larger (type IV) and two will be new constructions. (h) Maternities. The project would provide for the refurbishment of the 6 rural maternities to ensure increased capacity to assist normal deliveries and the care of premature and low birth weight babies. In addition, the maternities will introduce systematic post-partum counseling on infant feeding and strengthen FP and gynecological services. 4. Quality Enhancesent Of The BBC System (US$16 *illion) 2.1S The following components would ensure that the quality of the services to be provided and expanded would be attractive to the clients and enhance the credibility of the system: (a) Technical Trainina. A comprehensive training program, for BHC in general and MCH/FP in particular, will be delivered by the MOH for a majority of BHC staff. (See Annex 2, table 6.) The training will be at the central level for management staff and for trainers, at the regional level for paramedics and at the local level for auxiliary nurses. A training coordination unit for the project has already been assigned at the central level, consisting of a physician and a senior paramedic instructor, and training of trainers has started. The MOH Training and Research Institute will be fully involved. At the regional level, the in-service training courses will be the responsibility of the regional training teams under the direction of the Regional Health Director. The teams consist of the director of the paramedic schools and a professional manpower trainer. The facilities of the regional paramedical schools will be used for the training. UNFPA will finance some of the training activities.  - 22 - (b) Management Training. Senior level staff at the governorate level will be required to participate in a three year, part time Public Health Master course aimed at improving planning, supervision, evaluation and training skills. Nine out of eleven training modules have been prepared and appraised. The other two modules, for management and evaluation, will be developed with the assistance of external experts during the project period. In addition, training materials and technical information sheets will be developed and regularly updated with technical assistance provided by Tunisian Medical Schools, the ONFP and external consultants. The project would provide for a vehicle, technical assistance, printing and audio-visual equipment for the training function. The KOH expects that about half the costs of the planned training programs will be financed by UNFPA and UNICEF. (See Annex 2, table 7 for a complete listing of training) (c) Maintenance. Maintenance of MOH facilities, vehicles and equipment has been the responsibility of the Regional Health Directorates in each governorate. Lack of resources and the fact that responsibility for maintenance does not lie with the primary user have often led to inadequate maintenance. Available resources are first used at the hospital level to the detriment of the smaller centers. To address this issue, the MOH will prepare a comprehensive maintenance program for implementation by December 1993, for which 8 staff-weeks of expert services will be financed (US$20,000.) In addition, one maintenance workshop is being equipped on a pilot basis (US$24,000). A study will be realized by the MOH to assess the cost-effectiveness of in-house maintenance compared to sub-contracting to the private sect-r and the feasibility of private sector contracts in the more ist Ated areas. During Negotiations, the Government provided assurances that terms of refeLence for a study/evaluation of the BHS maintenance system for vehicles, equipments and buildings would be reviewed with the Bank by December 31, 1991; that this study would be carried out by December 31, 1992; and that all necessary actions would be taken to implement, by December 31, 1993, a maintenance system based on the recommendations of this study. (d) Pharmaceuticals. Government policy is to provide essential drugs (a 150 item list) free of charge to consumers. At present, there is a discrepancy between the value of prescriptions issued by BHC staff each year (TD$12 million) and the value of drugs supplied to BHC centers (TDS8 million. ) It would be desirable but not essential for the project's performance to ensure the supply of the full range of free drugs as a large proportion of those drugs is for chronic diseases not directly related to the project objectives. The project does, however, fund a sub-list of essential drugs to include contraceptives, vaccines and other preventive pharmaceuticals for which free or highly subsidized provision is justified (US$9.8 million). A regular supply of these essential drugs will improve quality of services and the credibility of the BHC system.  (e) To assist the G r.i:n . :' ::. , ::a: . t. c, . free drug policy, the pc es. ...-i i.rt a ;-I Cf rIcrc?. t. L'n practices in a repfeser a'. f b1iiJ ..t.:i , , h i ch drugs are prescrit)ed ar;t t,; ' i tI l. O1 ' n ChIines w-_bid be proposed in accordance oith tno f.:.d.3 of t'.e stui,. A formai h