Mali - Health Development Project

Document of The World Bank FOR OFFICIAL USE ONLY Report No. 4465-MLI STAFF APPRAISAL REPORT REPUBLIC OF MALI HEALTH DEVELOPMENT PROJECT November 15, 1983 Population, Health and Nutrition Department 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 EQUIVALENTS Currency Unit = Malian Franc (MF)l/ US$1.00 = MF 746 MF 1 = US$0.0014 MF 1,000 = US$1.35 FISCAL YEAR January 1 - December 31 1/ The Malian Franc is tied to the French Fran.c in the ratio of 1 French Franc to MF 100. The French Franc is currently floating.  FOR OFFICIAL USE ONLY REPUBLIC OF MALI HEALTH DEVELOPMENT PROJECT Staff Appraisal Report Table of Contents Page No. Basic Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Acronyms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . viii I. THE HEALTH SECTOR. . . . . . . . . . . . . . . . . . . . . . . 1 A. Health Status. . . . . . . . . . . . . . . . . . . . . . . 1 B. Organization of the Ministry of Public Health and Social Affairs.. ............ 2 C. Sectoral Resources.3. . ......... 3 - Coverage of the Public Health System . . . . . . . . . . 3 - Health Manpower. . . . . . . . . . . . . . . . . . . . . 6 - Pharmaceutical Supplies. . . . . . . . . . . . . . . . . 7 - Intersectoral Support. . . . . . . . . . . . . . . . . . 8 - Health Sector Financing. . . . . . . . . . . . . . . . . 9 E. Issues . . . . . . . . . . . . . . . . . . . . . . . . . . 10 F. Bank Group Involvement in Health . . . . . . . . . . . . . 12 II. THE PROJECT. . . . . . . . . . . . . . . . . . . . . . . . . . 12 A. Project Concept and Objectives . . . . . . . . . . . . . . 12 B. Project Composition. . . . . . . . . . . . . . . . . . . . 13 This report is based on the findings of an IDA mission which visited Mali in October 1982 comprising A. Williams (Administration and Management), S. Foster (Economist), M. Furst (Rural Development Specialist); M. Jancloes (Public Health Specialist), C. Sinclair (Architect), D. Vaillancourt (Operations Assistant), and M. El Fekih (Consultant, Pharmaceutical Specialist). 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.  Page No. C. Detailed Project Description . . . . . . . . . . . . . . 15 - Manpower Development . . . . . . . . . . . . . . . . . . 15 - Drug Supply and Utilization. . . . . . . . . . . . . . . 16 - Strengthening MOPHSA's Capability in Planning, Coordination and Health Education. . . . . . . . . . . 18 - Development of Primary Health Care at the Regional Level ............ 19 - Primary Health Care O)bjectives and Strate!gy. . . . . . . 21 - Retraining of Field Staff. . . . . . . . . . . . . . . . 22 - Construction and Equipment of Healt'h Facilities. . . . . 22 - Project Zone Drug Supplies . . . . . . . . . . . . . . 23 - Village Level Health Education ..23 - Monitoring, Research and Evaluation. .24 III. PROJECT COST AND FINANCIAL PLAN. . . . . . . . . . . . . . . . 25 IV. PROJECT IMPLEMENTATION, PROCUREMENT, DISB3URSEMENT AND AUDITING . . . . . . . . . . . . . . . . . . . . . . . 28 V. PROJECT BENEFITS AND RISKS . . . . . . . . . . . . . . . . . . 36 VI. AGREEMENTS REACHED AND RECO'MMENDATIONS . . . . . . . . . . . . 38 TABLES IN MAIN TEXT 3.1 Project Cost Summary . . . . . . . . . . . . . . . . . . . . . 25 3.2 Estimated Price Escalation Rates . . . . . . . . . . . . . . 26 3.3 Financing Plan . . . . . . . . . . .. . . . . . . . 27 4.1 Disbursement Schedule. . . . . . . . . . . . . . . . . . . . . 34  - liii- Page No_. ANNEXES 1. Supporting Tables, Charts and Maps . . . . . . . . . . . . . 40 Tables T-1 Comparative Health Status Indicators . . . . . . . . . 40 T-2 Staffing Norms for District and Subdistrict Health Centers ... . . . . ..... . . . . . . . 41 T-3 Health Manpower Training Institutional Capacity. . . . 42 T-4 Estimated Total Health Expenditures. . . . . . . . . . 43 T-5 Public Expenditure on Health, 1972-82. . . . . . . . . 44 T-6 Delivery of Primary and Secondary Health Care in the Kita - Bafoulabe - Kenieba Project Area: Comparative Indicators . . . . . . . . . . . . . . . 45 T-7 Proposed Evaluation Criteria and Major Indicators. . . 46 T-8 Project Cost by Functional Categories and Years. . . . 48 T-9 Summary Cost by Project Expenditure and Functional Categories. . . . . . . . . . . . . . . . 49 T-lO Civil Works Implementation Schedule. . . . . . . . . . 51 T-11 Incremental Operating Costs, Year 6. . . . . . . . . . 52 T-12 Estimated Schedule of Disbursements. . . . . . . . . . 55 T-13 Summary of Technical Assistance. . . . . . . . . . . . 56 T-14 List of Vehicles ... . . . . ..... . . . . . . . 57 Charts C-1 Ministry of Public Health and Social Affairs Organization Chart ... . . . . . . . . . . . . . . 58 C-2 Proposed Organization of Malian Pharmaceutical Subsector . . . . . . . . . . . . . . . . . . . . . . 59 C-3 Organizational Structure of DNAFLA and Structural Relationship with ODIPAC . . . . . . . . . . . . . . 60 C-4 National and District Project Coordination Chart . . 61 Map M-1 IBRD 16998 ... . . . . . . . . . . . . . . . . . . . 62 2. Construction Technology. . . . . . . . . . . . . . . . . . . 63 3. Primary Health Care Delivery Scheme. . . . . . . . . . . . . 65 4. Methodology for Initiating Village PHC Activities. . . . . . 67 5. Selected Documents and Data Available in the Project File. . 71  - iv - MALI HEALTH DEVELOPMENT PROJECT Basic Data Total Area. . . . . . . . . . . . . . . . . . . . . . . . . 1.24 million km7 Total Population (mid-1982) . . . . . . . . . . . . . . . . 7.1 million Density per km2 (mid-1982). . . . . . . . . . . . . . . . . 5.8 Rate of Natural Increase of the Population (1980) . . . . . 2.8% Crude Birth Rate (1981) . . . . . . . . . . . . . . . . . . 49 Crude Death Rate (1981) . . . . . . . . . . . . . . . . . . 21 Life Expectancy at Birth (1980) . . . . . . . . . . . . . . 45 Infant Mortality Rate (1980). . . . . . . . . . . . . . . . 154 Urban Population as % of Tota:L Population (1980). . . . . . 20 Adult Literacy Rate (1977). . . . . . . . . . . . . . . . . 9% Primary School Enrollment (1979). . . . . . . . . . . . . . 28% Age Structure 0 - 4 . . . . . . . . . . . . . . . . . . . . . . . . . 18.3% 5 - 14 . . . . . . . . . . . . . . . . . . . . . . . . . 28.1% 15 - 49 . . . . . . . . . . . . . . . . . . . . . . . . . 42.6% 50+ . . . . . . . . . . . . . . . . . . . . . . . . . . 11.0% Population per Physician (1977) . . . . . . . . . . . . . . 25,560 Population per Nurse (1977) . . . . . . . . . . . . . . . . 2,380 Daily per Capita Calorie Supply (as percentage of requirement, 1977). . . . . . . . . . . . . . . . . . . . 83% Percentage of Married Women of Reproductive Age Using a Modern Contraceptive Method (1980). . . . . . .0 ..2% Per Capita Gross National Product (1980). . . . . . . . . . US$190  - v - DEFINITIONS Adult Literacy Rate The percentage of persons aged 15 and over who can read and write. Case Fatality Rate : Percentage of deaths due to a disease among the total number of people who have contracted the disease. Child Death Rate : The number of deaths among children one to four years of age per 1,000 children in that age group in a given year. Crude Birth Rate : The number of births per 1,000 population in a given year. Crude Death Rate : The number of deaths per 1,000 population in a given year. Incidence Rate The number of new cases of a disease which occur in a population during a specified period of time. Usually expressed as the number of cases per 1,000 persons. Infant Mortality Rate : The number of deaths of infants under one year of age in a given year per 1,000 live births in that year. Life Expectancy at Birth : The number of years an infant will live if the current age/sex specific mortality trends prevailing at time of birth were to continue. Maternal Mortality Rate : The number of deaths to women who die due to pregnancy and childbearing complications in a given year per 100,000 live births in that year. Morbidity : The frequency of disease and illness in a population.  - vi - DEFINITIONS (cont.) Prevalence Rate : The total number of people affected by a disease estimated either at a specific time (point prevalence'l or over a stated period (period prevalence) expressed per 1,000 popu:lation (in case of low figures, prevalence is expressed per 100,000 population). Rate of Natural Increase The rate al: which a population is increasing (or decreasing) in a given year due to a surplus (or deficit) of births over deaths, expressed as a percentage of the total- population. Total Fertility Rate : The average number of children that would be born alive to a woman during her lifetime if she were to pass through her childbearing years conforming to tlhe age-specific fertility rates of a given year.  - VIIL -- ACRONYMS ADAUA Association pour le Developpement Naturel d'une Architecture et d'un Urbanisme Africains (Association for the Development of Traditional African Urbanism and Architecture). AMPPF : Association Malienne pour la Promotion et la Protection de la Famillie (Malian Association for the Promotion and Protection of the Family. DHE : Direction de l'Hydraulique et de l'Energie (Directorate of Hydraulics and Energy). DNAFLA : Direction Nationale de l'Alphabetisation Fonctionelle et de la Linguistique Appliquge (National Directorate of Functional Literacy and Applied Linguistics). DNHPA : Direction Nationale de l'Hygiene Publique et de l'Assainissement (National Directorate of Public Hygiene and Sanitation). DNPFSS : Direction Nationale de la Planification et de la Formation Sanitaire et Sociale (National Directorate of Planning and Health and Social Training). MOPHSA : Ministry of Public Health and Social Affairs MCH : Maternal and Child Health MCH/FP : Maternal and Child Health and Family Planning MTTP : Ministare du Transport et des Travaux Publics OACV : Operation Arachide et Cultures Vivrieres (Grourndnut and Food Operation). ODIPAC : Office de Developpement Integre pour la Production Arachidiare et Cerealere (Office of Integrated Development for Groundnut and Cereal Production). OMP Office Malien de Pharmacie (Malian Office of Pharmacy). PCU : Project Coordinating Unit LPCU : Local Project Coordinating Unit PPM : Pharmacie Populaire du Mali (People's Pharmacy of Mali) TBA : Traditional Birth Attendant   - viii - MALI HEALTH DEVELOPMENT PROJECT INTRODUCTION i. Mali's 7.1 million people are among the world's least privileged, surviving on an annual per capita income of US$190. Eighty percent of the population live in rural areas and derive an even lower annual per capita income of US$100 from subsistence agriculture and nomadic livestock enter- prises. Less than 10% of the adult population are literate; many rural villages do not even have one literate person notwithstanding the Government's attempts to promote functional literacy. Only 18% of the rural population have a year-round source of safe water and women spend a significant proportion of their time collecting water. With almost half of the population under age 15, the dependency ratio is high and consequently the productivity of the population as a whole and their potential for generating savings above consumption requirements are low. Out migration has been substantial. ii. The country's impoverishment is more concretely reflected in the ill health of its people. At any given time, many Malian children suffer from gastrointestinal illness which, in turn, reduces the absorption rates from food consumed and thereby contribute signficantly to undernutrition. Consequently, other infectious diseases such as malaria and measles become extremely dangerous and often fatal. The crude death rate is high at 21 per 1,000, largely attributable to mortality in the 0-1 age group. Average life expectancy at birth is 45 years; in western Mali it is 33 years--about the lowest in the world. Poor health status also affects the pace of development. High morbidity, particularly due to malaria and dysentery, is a major cause of time lost from work among adults. iii. Social pressures to replace lost children contribute to high fertility. Women have an average of 6.7 children. A high crude birth rate of 49 per 1,000 with given mortality results in a rate of natural increase of 2.8% per year implying potentially serious economic and social consequences. Assuming little or no decline in fertility and mortality, Mali's population is projected to increase to 12 million by the year 2000. As elsewhere in the world, high fertility in Mali is associated with poor maternal and child health and high mortality rates. Although 60% of the -otal land area consists of desert or semi-desert, the land mass and small Dor,ulation lead most Malians to conclude that the rate of population growth roses no immediate problem. The Government as yet has no official population pc licv; family planning is permitted for health, not demographic purposes. Ir 1972, the Government repealed a colonial law that forbade the importation and distribution of contraceptives. At the same time, family planning services were made available in certain areas as part of maternal and child health, the first such measure in francophone West Africa. However, development of a population policy to allow systematic promotion of a family planning program is still needed.  - ix - iv. The rapid population growth coupled w:Lth poor harvests caused by unfavorable weather conditions and low producer incentives have transformed Mali into a net cereal importer. It is estimated that over 10% of the 1-5 age group, and 7% of those aged 6-10 suffer frorn severe protein/calorie malnutrition. Estimates of the percentage of children moderately malnourished are as high as 25%. While according priority over the past decade to food self-sufficiency and a rise in nu)tritional levels, the Government was able only in 1981-82 to pull together a body of international experts to begin to formulate a national food and nutrition policy. v. Recognizing that population, health and nutrition status are interwoven, the Government believes that the best immediate means by which to promote change in these areas is through integrated maternal and child health/family planning services (MCH/FP). This consists of antenatal care, improved birth attendance, vaccinations, nutritional education, and birth spacing education and services. vi. In response to poor health conditions, the Government of Mali has sought to develop a health policy with strong emphasis on disease prevention and maternal and child health maintenance at the village level. This policy was adopted as early as 1964 (over a decade before the World Health Organization (WHO) drew up its international strategy of primary health care) and has since been supported by various international and bilateral aid agencies. Mali's adoption in 1978 of the WHO/UNICEF primary health care strategy reinforced this policy. Accordingly, the 1981--85 National Development Plan set out to promcte community health by taking account of the felt needs of the population and encouraging their active participation in health development, through traditional and other forms of association and a multisectoral support system based principally on integrated rural develop- ment operations. vii. Until now, Mali's pursuit of these policies (largely through donor financed pilot projects) has been based on short-cut so:Lutions which often circumvent the existing health service delivery system in order to reach a dispersed, unsupported village population. Invariably, these efforts are tenuous and falter after the withdrawal of donor support--mainly because of poor planning, the substitution of technical assistance for local management, inadequately trained and supported health manpower, and weak supervision and support due to inadequate drug supplies and the neglect of the basic network of district level health centers and subcenters. Inescapab:Ly, Mali's public health system must acquire the technical capability to manage community level health programs while providing credible services to the accessible popula- tion. Only to the extent that these difficult preconditions are nurtured can low-cost village level first-aid, disease prevention, and health education be sustained. Through the proposed project, the Government seeks IDA assistarnce for priority activities of strengthening existing health services by develop- ing its national capability in health manpower training, drug supplies, and! health planning and management, while providing improved viLlage-level services to three of the unhealthiest, hitherto inaccessible and therefore neglected districts in the western region of Mali.  I. THE HEALTH SECTOR A. Health Status 1.01 Mali's health statistics are incomplete and its health information system unreliable. Quality epidemiological data are provided only through surveys. The most recent survey was undertaken in three districts of western Mali by the national university1/ to obtain baseline indicators for t:he design and future evaluation of the proposed project (para. 2.30). Data show that health status is poor; the population's perception of health as a priority is very high, surpassed in many areas mainly by the need for adequate water supply.2/ 1.02 Mortality. The crude death rate of 21 per 1,000 compares unfavorably with other West African countries (19 per 1,000) and low-income countries in general (12 per 1,000). Comparative health status indicators are shown in Annex 1, T-1. Infant mortality, a key health status indicator, is as high as 255 per 1,000 live births in some rural areas. Infant mortality is chiefly due to diarrhea, malaria, tetanus, respiratory diseases and malnutrition. Measles is the most common cause of death of children aged one to four, and malnutrition linked with measles and diarrheal disease is also a major cause of infant death. Survey data show that in some areas 12% of women die during pregnancy or upon delivery. This reflects not only the poor quality of prenatal and delivery care, but also the impact of poor maternal nutritional status, heavy workload even during pregnancy, and frequent childbearing. Clearly child spacing and improved MCH services are key requirements for improving the health of the population. 1.03 Morbidity. Most of the ill-health of Malians is caused by diseases which can either be prevented or treated, using existing technologies. The first cause of morbidity is malaria; its incidence is highest during the rainy season from June to October, and rural people are the most seriously afflicted. The high incidence of acute diarrhea and gastro-intestina]L illness is caused principally by poor sanitation and hygiene and by consumption of unsafe water. Other preventable or treatable diseases such as measles, whooping cough, and acute respiratory infections account for much of the high morbidity. Guinea worm spreads around water points and is a major source of disability; each case results in about 50 days of temporary incapacity. 1.04 Several blinding disorders exist including trachoma, with a female predominance, xerophtalmia (a blinding condition in children of preschool age), cataract, and onchocerciasis which is responsible for approximately 1/ Ecole Nationale de Medecine et de Pharmacie du Mali, Evaluation Sanitaire des Cercles de K!&ni!&ba, Bafoulabe, Kita: Rapport Pr6liminaire, Bamako, Mai, 1981. 2/ S.N.E.D. (Mali), Projet d'alimentation en eau et developpement sanitaire: Rapport socioenonomique, Bamako, Fevrier 1982.  - 2 - half of the blindness in west:ern Mali. The blindness rate varies considerably, but is generally high, reaching more than 10% in certain villages. Clinical treatment: of trachoma and cataract is feasible in Mali at present. Unfortunately, clinical treatment of onchocerciasis is not recommended in hyperendemic areas at present; such treatment is often ineffective, of long duration, has serious side effects and requires active follow-up and supervision. However, the regional onchocerciasis control program financed by a consortium of donors, including the Bank, and executed by WHO, will be extended to western Mali. B. Organization of the Ministry of Public Health and Soci'al Affairs (MOPHSA) 1.05 Most of the medical services in Mali are run by the MOPHSA.3/ An organization chart is presented in Annex 1, C-1. Health services are organized to conform to the structure of the public administration whereby regional and district medical ofl'icers have discretionary authority over health programs and budgets. The central government is responsible for planning, statistics, the coordirnation of health services, training, technical operating procedures, administration of external aid, the operation of hospitals, and enforcement. of public health laws. 1.06 Until 1980, the central MOPHSA administration was concentrated into two technical directorates, namely the National Directorates of Public Health (DNSP) and Social Affairs. I'he adoption of primary health care required the development of a technical capability at the national level with more emphasis on community health education and sanitation, and better planning and coordination. To these ends, a new Directorate of Planning and Health and Social Training (DNPFSS) was set up, responsible for planning investments, evaluating their effectiveness, monitoring health status, and overseeing basic initial training of paraprofessionals and inservice training programs. A Directorate of Public Health and Sanitation (DNHPA) was created out of the DNSP to reflect a stronger emphasis on community health education and environmental health. 1.07 The MOPHSA has benefited from IDA-financed project preparation advances (para. 3.08) which in early 1981 permit:ted the DNPFSS to set up 3/ The main exceptions are the Armed Forces (which run their own health system), the parapublic sector (National Social Security Institute, PPM and state enterprise dispensaries), missionary services, and the traditional medical sector. Two important regional services outside MOPHSA are the Western African Institute of Tropical Ophthalmology and the Marchoux Institute (leprosy) which are under the supervision of the Organization of Coordination and Cooperation for Endemic Disease Control (OCCGE).  - 3 - offices and hire health planning consultants to assist in preparing the proposed project. The use of these resources was significant insofar aLs they permitted MOPHSA to draw central and district level staff into the planning process (hitherto undertaken mainly by donor agencies themselves). The DNPFSS was also able to take the lead in drawing on non-MOPHSA resources, such as the School of Medicine and Pharmacy and a local Malian consultant firm, to undertake epidemiological and socio-economic surveys in the proposed project zone (paras. 2.18 - 2.19), the first such health sector pre-project data gathering exercises in Mali. Persuaded by examples of the use of traditional building techniques for the provision of health facilities in Upper Volta and Mauritania, the DNPFSS successfully collaborated with Mali's Ministry of Transportation and Public Works (Annex 2) in applying these techniques to health infrastructure planning under the proposed project. Parallel preparation of the proposed IDA-financed rural water supplies project was conducted out of DNPFSS office facilities in close collaboration with MOPHSA, thus reflecting new emphasis on the need for intersectoral coordination in disease prevention, environmental health and community health education. Similarly, in the course of preparing the proposed project, the DNPFSS joined with the Pharmacie Populaire du Mali (PPM), under the Ministry of State Enterprises, to plan improvements in pharmaceutical policy and the management and utilization of drug supplies (para. 1.22). These impressive institution-building initiatives were time consuming but have significantly improved the MOPHSA's planning capacity and have generated strong support for smooth implementation of the proposed project. C. Sectoral Resources Coverage of the Public Health System 1.08 To implement national health policy, the MOPHSA is attempting to develop a pyramidal health system down to the subdistrict level. The system comprises 12 national, regional and secondary hospitals (up from 3 in 1960) with a total of 2,500 beds; 46 district health centers (19 in 1960); 52 MCH facilities (none in 1960); and 382 subdistrict centers (138 in 1960). Despite poor conditions, hospital utilization is high; patients bypass the lower level facilities and go directly to hospitals for even minor ailments because the lower level facilities are often unable to provide even a basic level of care. 1.09 Many district health centers are merely old dispensaries that were upgraded in name after the 1977 administrative decentralization which created a greater number of districts and subdistricts. Each of Mali's districts now has a health center staffed by one or two doctors. Each subdistrict health center is staffed by a qualified or auxiliary nurse. Maternity and MCH facilities are staffed by a midwife; numerous rural maternities built by local residents are staffed by young women who received on-the-job training at a Government maternity. The standard staffing pattern of district and subdistrict facilities is given in Annex 1, T-2.  - 4 - 1.10 Each regional system serves a population averaging one million, but due to difficult road conditions and long distances, in most of Mali the district health center must function as a self-contained health system an,:! be capable of carrying out emergency surgery and most types c,f basic care. 'Fhe district center staff are also responsible for providing technical suppor: to the subcenters and village health workers, allhough the lack of vehicles and operating budget makes this more theoretical t:han real. I'he lack of medical equipment and drugs and generally poor support leaves many young doctors discouraged after a year's service. Most of the former dispensaries that were upgraded to health centers are at least 30 years old; equipment and laboratory facilities are virtually non-existent, making piroper diagnosis and treatment difficult. Although the Government's promotion of village-level primary health care require a credible health center and subcenter support system, in less developed regions, such as western Mali, the support system is functionally ill-equipped to meet the challenge. 1i11 Throughout Mali, effective medical coverage of the population is estimated at 15% - 20% maximum, with coverage as low as 5% in the western and northern regions. To improve medical coverage and strengthen maternal and child care and family planning services, the Government experimented with several village health programs (described be'low) whose results are being taken into account in expanding services. 1.12 In 1964, training of traditional birth attendants (TBAs) in hygienic delivery practices was begun in the Sikasso region. This resulted in a significant reduction in tetanus among mothers and the newborn, increased detection of risk cases and evacuation to the district maternity prior to delivery, and a reduction in maternal mortality. By 1970, the Governor of Sikasso and MOPHSA agreed on a program to organize village health teams in the region comprised of rural midwives (matrons), TBAs and female village health volunteers. Midwives were selected and pa''d by villagers for each delivery they performed. 1.13 Between 1970-75, 120 rural maternities were constructed by villagers and 342 rural midwives trained by MODPHSA. There was a tripling of reported deliveries. These eff'orts were further expanded through the IDA-financed First Mali Sud-Agricultural Project and Swiss bilateral aid. However, the Sikasso program has had mixed results due to a high attrition rate of midwives (many having been unmarried when recruited, and who then moved on after marriage), insufficient remuneration, unsuitable location of many rural maternities (leading to low utilization) and frequent rupture of drug supplies managed by ruiral cooperatives and supplied bly the PPM. 1.14 The extension of the Government's program to Koualikoro in 1974 followed a more rigid approach that required mandatory construction of village maternities, village support of a midwife and aide (both receivirng monthly salaries), and the selection of volunteer male village health workers. This approach failed principally because the construction and salary requirements were resented.  - 5 - 1.15 In 1978, the United States (USAID) and the Government of Mali agreed to undertake a demonstration rural health project in two pilot zones in the Kayes and Mopti regions. The project aimed at extending health services to the village level at an investment cost of $2 equivalent per capita and operating costs of $0.40, integrating health care with other com- munity development activities, and serving as a model for a national rural health system. Emphasis was placed on the selection and training of volun- teer village health workers and TBAs, basic MCH services, the improvement of wells, and the creation of village pharmacies. The project was executed by MOPHSA with technical and management assistance provided by Harvard University. 1.16 Although a final project evaluation is still unavailable, various project implementation reviews have pointed out that the system is too passive, too curative in its orientation, and lacking in real village parti- cipation and support. As in Koulikoro, village financing was assured only if villagers and their health associations agreed voluntarily to support prede- termined activities. Drug supplies posed numerous problems. In several villages where there was inadequate control of village health workers managing supplies there was a financial leakage in excess of 20% of supposed assets. Drugs were imported from the USA expressly for the project, and supplied through MOPHSA without improving national or regional distribution capability. Supervision from health centers to villages was too expensive, representing 63% of all operating costs, and had to be scaled back. Because the project expanded horizontal coverage without strengthening the ref-erral system, subdistrict and district health centers were unable to support the project's aims. Because initial and revised cost assumptions were based only on village level services, without taking the referral system into account, it was not possible to assess the financial replicability of the demonstra- tion scheme. 1.17 The growth of family planning services has also been modest: only 0.2% of women between the ages of 15 and 44 are estimated to use a modern method of contraception presently. No data are available on the shar,e of commercial pharmaceutical outlets, private consultations, non-government dispensaries or traditional practices (although research on traditional methods has been conducted with Canadian support). The majority of family planning program acceptors (70%) are young, educated women who use the urban-based services of the Malian Association for the Promotion and Protection of the Family (AMPPF). The AMPPF has benefited from the assis- tance of the Canadian International Development Research Center and the International Planned Parenthood Federation. Government services are provided in 21 out of 56 maternity MCH centers operating in Mali. The Ministry of Public Health and Social Affairs runs these services, trains staff, and evaluates family planning activities with support from the United Nations Fund for Population Activities (UNFPA) and the United States Agency for International Development (USAID). Like the AMPPF, the quality and use of Government services are heaviest in urban centers. Not surprisingly,  - 6 - inadequate and poor quality prenatal and maternity care in rural areas and the consequent low utilization of MCH services, are responsible for low family planning acceptance rates outside the cities. A recent survey showed that the majority of acceptors from rural areas were referred to urban centers by physicians or learned of these services through word of mouth; few were referred from MCH centers directly. The quicker rural MCH services are improved and health education provided at village level, the greater the likelihood that family planning will be accepted by the rural residents. Significant increases in acceptor rates, however, are likely to remain modest pending a clear reduction in extremely high rates of infant mortality in most regions of the country. Health Manpower 1.18 The main categories of health manpower are physicians, nurses and midwives. In addition, community based health field workers, functional literacy workers and traditional birth attendants are used for health relaiied activities. MOPHSA employs over 4,300 health professionals and paraprofes-- sionals, of whom 234 are doctors and surgeons, 1,996 are nurses, and 268 a:re midwives. Using World Health Organization norms, the Government has established specific targets for ratios of heal]th personnel to population. Current health manpower production falls short of these requirements. Hea:lth personnel (physicians, nurses and allied health personnel) are currently trained at four different health professional training schools. The type of manpower trained and student enrollment at each school is given in Annex 1, T-3). But, in view of severe budgetary constraints and actual absorptive capacity, it is advisable not to increase production rates for the foresee-- able future. The Government is more immediately concerned with improving l!:he quality of basic and inservice training, and redressing the distribution currently skewed in favor of cities and large towns. New physicians are assigned to two years' mandatory service in rural areas, and other health personnel are assigned as a matter of priority to health development projects in rural areas. 1.19 Efforts to retain skilled personnel iLn rural areas are frustrated by poor working conditions and professional isolation. In 1981, the DNPFSS (with support from the U.S. Government) conducl:ed a manpower training needs survey in the three districts of the proposed project zone (western Mali). The majority of respondents complained about a lack of materials, drugs and transport. Forty-six percent did not know who was their immediate super- visor: they could only name the physician/med:ical officer as their head. Ninety-seven percent had no educational/informational journals or materials. Eighty-five percent of the nursing and paramedical staff haLd never received inservice training. Training was requested in all key areas: supervision, pedagogical techniques required for communicat-ing with patients and traininLg village health workers, environmental sanitation and the protection of water sources, diagnostic, laboratory and other specialist skills, and family planning. Ninety-eight percent had no informaltion or training in family planning, although 50% of the respondents said that they had been approached  by patients on the subject. The Government recognizes the need to launch a national inservice program of continuing education and make reforms in basic education by increasing the public health content of medical and nurses' training. Pharmaceutical Supplies 1.20 Soon after Independence, drugs were imported mainly through MOPHSA and distributed through its health facilities free of charge. Due to deteriorating public finances and weak management, MOPHSA could not meet the fast growing demand for drugs. It became heavily indebted to foreign suppliers, and had to rely on French Government grants to supply the drugs while debts were paid off. Meanwhile, the Government authorized the Ministry of State Enterprises to create a parastatal Pharmacie Populaire du Mali (PPM) to import drugs for the commercial sector. 1.21 The PPM is one of the few profit-making parastatals in Mali. A diagnostic study of the PPM was financed by the Bank as part of the preparation of the parastatal rehabilitation project being developed by West Africa Projects Department. The study, which is available in the project file, was done by a French consulting firm--PA Conseiller de Direction. It reviewed the financial situation of the PPM and noted that although the PPM is profitable and its sales volume is growing at 11% annually, improvements are needed in its management and procurement practices. It is undercapi- talized and has very low liquidity, largely because of excessive fiscal pressure applied by the Government. Almost half of PPM's drug sales are made in the capital, where about 10% of the population lives. 1.22 Aware that the system was failing to support national primary health care objectives, the Government undertook a study of the pharmaceutical sector in the process of preparing the proposed project. The study was cofinanced by the Mali Government, the European Development Fund, the French Fonds d'Aide et de Cooperation, the United States Agency for International Development, and IDA. The study proposed (and the Government subsequently adopted) key policy changes and a restructuring of the pharmaceutical system to improve procurement and distribution and reduce the cost of essential drugs by at least 30% of their present cost. 1.23 The main policy changes provided for payment for outpatient drugs (with the exception of treatment of chronic diseases, such as leprosy and tuberculosis), adoption of a limited list of about 200 essential drugs for MOPHSA facilities, procurement of these drugs in bulk international competitive bidding, and the setting up of a revolving fund to procure drugs. 1.24 The structural reforms adopted involve distributing the different functions of the system among three organizations (see Annex 1, C-2). First, responsibility for drug purchase and distribution would be taken away from MOPHSA and entrusted to the PPM which would supply its network of 92 retail  - 8 - stores, 300 commercial outlets, and all public health facilities. Second, MOPHSA would strengthen its capability to coordinate and oversee drug policy, monitor drug utilization and needs, and inform prescribers and the public. Third, local production and research (particularly in the commercialization of traditional medicine) would be grouped under the Office Malien de Pharmacie (OMP). As a MOPHSA affiliate, OMP would take charge of the existing intravenous solut:ion manufacturing plant, the Institute of Traditional Medicine, and the new essential drug factory, currently under construction with assistance from the People's Republic of China. A joint MOPHSA/PPM/OMP purchasing commissJion would be formed to determine the annual.. bid program, quantities to be manufactured and imported, and official sales prices. These proposals repre!sent an important, positive step forward. Intersectoral Support 1.25 The Government has attempted to draw on intersectoral resources, notably in the area of rural deve]Lopment, water supplies, and education in order to complement the activities of MOPHSA. Agriculture dievelopment projects have operated in Mali. on the assumption that farmers respond better to extension efforts and participate more actively in market:Lng, credit and input supply activities if at least a nucleus of villagers has attained a minimal level of functional literacy and numeracy in their own languages. Functional literacy components have therefore been included in rural development projects in southe.rn and western Mali. Tco date, 3,500 out of about 10,000 villages in Mali have benefited from functional literacy campaigns. Health education has been successfully introduced into post-literacy teaching materials. The Government plarns (witha support from the proposed IDA education prc,ject) to extend literacy actions to 2,000 new villages over the next five ye.ars, principally through existing Rural Development Operations (ODRs). 1.26 The National Directorate of Functional Literacy and Applied Linguisitics (DNAFLA), for which aLn organization chart is shown in Annex 1, C-3, is under the Ministry of Education and is in charge of :Literacy programs. However, where a literacy program is included as a component of a rural development project, responsibility for execution of the component is given to a coordinator seconded by DNAFLA to the ODR. 1.27 The literacy network. and. agricultural extension agents are, therefore, the only Government supported personnel who are legitimately present, active and influential at the village level. Continuing efforts are needed to draw on their ability and willingness to assist in organizing village level health care, health education and hygiene, particularly as regards the provision and use of water. 1.28 The health and nutritional status of tlhe rural population is directly related to the availability and accessibility of uncontaminated water. The principal source of rural water supp:Ly is groundwater which is generally found in small and discontinuous acquifers, and is usually of good  - 9 - quality and available in sufficient quantity to satisfy future requirements. Annual rainfall ranges from 250 mm to 1,300 mm, and is unevenly distributed. In the Sahelian zone, the dry season may last up to nine months, during which period the traditional dug wells tend to dry up, forcing villagers to rely on the few remaining contaminated surface sources (ponds and small rivers) several kilometers away. About 25% of the villages or only 18% of the entire rural population have access to safe water from modern water points, while more than 7,000 villages still rely on unsafe water from traditional sources. Health Sector Financing 1.29 Health Expenditure. Total expenditures in Mali for 1981 were estimated to be about 16.7 billion MF (US$22.4 million) of which approximately 54% was private expenditure, mainly on drugs. MOPHSA's public expenditure accounted for about 30% of the total, and foreign assistance for the remaining 16%. This corresponds to a total per capita expenditure of about 2,300 MF (or US$3.08). No estimate could be made of expenditures on private practice of medicine, nor for health expenditures by the Armed Forces, nor for traditional medicine. (See Annex 1, T-4). 1.30 Recurrent Expenditure. Due to a steady deterioration in Mali's public finances, the recurrent budget for health has decreased from about a 9% share of the national budget in 1972 to about 6% at present. This is equivalent to about 0.75% of GDP. At the same time, MOPHSA has continued to absorb new graduates of the medical and nursing schools, which has mea,nt that the ratio of personnel to material has been rising with a concomitant reduction in the productivity of each individual worker. Personnel account for between 60-75% of expenditure since 1976. The 1982 recurrent budget totals 5,026 million MF (US$6.7 million) (Annex 1, T-5). Public recurrent expenditure in real terms has declined from about 981 MF per capita in 1972 to 793 in 1981. 1.31 The bulk of recurrent expenditure benefits the urban areas since a disproportionate percentage of health personnel as well as drug distribution outlets are concentrated in Bamako and the regional capitals. An analysis of expenditure in three districts in the First Region (western Mali), which reflects the situation of other rural areas, demonstrates this unequal distribution. Some 7% of Mali's population lives there, yet only 2.4% of higher level health professionals are assigned there, and only 1.3% of the Pharmacie Populaire's sales are made in the zone. The recurrent costs in this area, primarily for personnel, are about 150 MF per capita; it is likely that total recurrent expenditures there do not exceed 200 MF, which is roughly one-fourth of the national per capita public health expenditure of about 800 MF. 1.32 Investment Expenditure. MOPHSA's 1982 investment budget was 459 million MF (US$6.2 million), mainly in the form of foreign donor support. As in the past, actual investment depends on the availability of prepared  - 10 - projects and donor commitments. Of the Pharmacie Populaire's 1981 investment program of 110 million MF, which was approved by the Ministry for State Enterprises and the Ministry of Plan, only 3 million were realized due to withholdings by the Ministry of Finance. This compares with the PPM's import duty and tax bill of 1,016 million MF (see para. 1.35). V. Issues 1.33 Planning and Coordination. MOPHSA's pursuit of community based primary health care based on small-scale demonstration projects made necessary the development of a health planning/program coordinating capability. The establishment of the Directorate of P'lanning and Health and Social Training (DNPFSS) marked an important step forward. But the DNPFSS's presumed coordinating function was subsumed under planning. Furthermore, because DNPFSS was placed at the same level as other technical directorates, it has not developed a viable coordinating capability within and outside MOPHSA. Implementation of the Kayes/Mopti demonstration project and preparation of the proposed Health Development project revealed that a high-level coordination capability is urgently needed. Following appraisal of the proposed project, the Council of Government Mintisters adopted MOPHSA"s plan to create a small Project Coordination Unit (PCU) attached directly to the Minister of Health and Social Affairs. The PCU (para. 4.03) would coordinate project activities through existing technical directorates. Planning and evaluation would, for the time being, remain within the DNPFSS as a technical activity. The performance of the PCU, its relationships with the DNPFSS, and the feasibility of separating planning and coordination wou'ld be reviewed during mid-term and final evaluations of the proposed project to determine the most effective location of plannirLg and coordination functions (para. 4.17). 1.34 Recurrent Costs. Tle Government recognizes its financial constraints and impossibility of increasing the recurrent health budget. Tte growing disequilibrium between MOPHSA salary requirements and funds available for materials and logistics together contribute to a deterioration in services, programs and ongoing projects. MOPHSA intends, therefore, to: (i) strengthen its recurrent budget analysis, forecasting and planning capability (para. 2.14); (ii) hand over its drug distribution functions to the PPM (para. 1.24); (iii) elncourage the purchaLse of drugs prescribed on an outpatient basis; and (iv) develop and test a scheme (currently underway at the Gabriel Toure Hospital in Bamako) to promote cost recovery by charging for hospitalization, deliveries, X-rays and labcratory examinations. Receipts under this experiment would be retained by the hospitals and health centers to purchase drugs through the PPM for in-patient needs. A portion of these funds at the health center level would, if available, be used to assist with infrastructure and equipment maintenance. MOPHSA has proposed to extentd and evaluate this scheme in ortgoing pilot projects as well as the proposed project zone (para. 2.26).  - 11 - 1.35 Drug Supply. The PPM needs more effective management and increased working capital to: (a) provide drugs commercially at least cost in support of the new policy requiring payment for drugs; (b) open new outlets in underserved areas; and (c) take over from MOPHSA responsibility for supplying the public health system. The PPM is seeking technical assistance to improve its planning and management. In order to pay suppliers promptly at reduced prices, the PPM proposes to set up a revolving fund of about $2 million. Although the revolving fund is an appropriate means of improving the PPM's liquidity, the long-term viability of expanded operations can be assured only if its working capital increases in the medium-term. Undercapitalization reflects a siphoning of PPM's profits in support of other sectors of the economy. The issue is critical and is being addressed in the framework of the Bank's attempt to improve the financial situation of parapublic enterprises in Mali. 1.36 Extension of Primary Health Care. The Government has had successes and disappointments (paras. 1.02 - 1.06) in reorienting the health system toward a village-based preventive system. The experience of pilot programs indicates that without abandoning these approaches, there is a need to: (a) ascertain specific village interests and solicit support and agreement for feasible activities; (b) increase reliance on available local resources--such as literacy and agricultural extension workers--as legitimate carriers of information directly to interested villagers; (c) re-emphasize the preventive aspects of primary health care with respect to health education, nutrition, birth spacing, child care, the safeguarding of water sources and the hygienic use of water; and (d) most importantly, as stated in the current Development Plan (1981-85), address basic preconditions of primary health care--namely the improvement of existing public health services--prior to attempting to expand coverage to the village level. 1.37 Population Program. Without a successful population program, the Government's goal of improving maternal and child health as well as providing enough food and raising educational levels will be all the more difficult. The strengthening of maternal and child care and integration of family planning with it is an important step forward. This needs to be put in the framework of a national population policy which should allow for face-to-face motivation, expanded role of voluntary organization and inclusion of demograhpic factors in development planning. With UNFPA assistance, a population unit has recently been established in the Ministry of Plan to help develop a population policy. The Unit will undertake studies related to the impact of population growth on development. This analysis will help provide information necessary for population policy development. 1.38 Manpower Development. The focus of health training at all the professional schools is on curative health care services; students are ill-prepared to address the problems of rural population. Public health accounts for only 10% of the nursing school curricula. Nursing schools'  - 12 - curricula have not been revised in over ten years. Students also need to receive practical training under field conditions. F. Bank Group Involvement in Health 1.39 The Bank Group's involvement in health in Mali dates back to 1976 when the first Mali Sud Agricultural Project included a health component. A second follow-up project and health component has been appraised. These components were designed to support village level primary health care in th, Sikasso region. Additional Bank involvement has been indirectly through support for the introduction of health themes into the functional literacy programs conducted in western Mali through the First Education Project and the OACV (now ODIPAC) Rural Development Project.. The Bank's support for the Onchocerciasis Control Program includes Mali (para. 1.04). 1.40 While encouraging these health components, the Government nonetheless has long sought a wider Bank involvement in the health sector. In late 1977, the President of Mali requested the Bank to undertake a free-standing health project. A sector mission visited Mali in 1978; its main recommendations, which included a priori the creation cf a MOPHSA health planning unit followed by the development of health and water supply projects, was accepted by the Government. The Government's advocacy of combining water supply and health interventions is based on the recognition that a water supply program is one of the basic actions which might reinforze the effects of health programs. Adequate quantities of safe water are a widespread, priority need. Tne Government assunies reasonably that organizing villagers around water resource management would provide a practical basis for preventive community health education (hygienic water use being important in the reduction of Guinea worm, 'hepatitis, diarrhea, conjunctivitis, and various skin diseases). Conversely, the promotion of primary health care activities would permit knowledgeable villagers to take a more direct role in maintaining water sources. These assumptions have shaped the design of the proposed Rural Water Supplies Project (Appraisal Report #4402-MLI), to be implemented in conjunction with t'he village-level primnary health care component of this Health Development Project (paras. 2.28 and 2.29). II. THE PROJECT A. Pro-ject Concept and Objectives 2.01 The foregoing health sector review illustrated the severity of health conditions, low medical coverage, inadequacies of human and financial resources, and the inefficiency or inertia of the public health system, particularly in the rural periphery.  - 13 - 2.02 The project is designed to reduce these deficiencies and is based on the 1981-85 National Development Plan insofar as it addresses major bottlenecks affecting the entire health sector--health manpower, drug supply, and health planning and administration--while at the same time, helps improve health conditions in three of the poorest, least healthy districts of Mali. The project, therefore, has two discrete but mutually reinforcing parts. At the national level, the project would: (a) improve the training of health manpower; (b) improve the availability and utilization of essential drugs; and (c) strengthen MOPHSA's capabilities in planning and coordination. At the regional level, the project would, in three districts: (a) strengthen the existing public health network in accordance with primary health care objectives; and (b) develop health education, water hygiene and related primary health care activities at the village level. B. Project Composition Part A 2.03 At the national level, the proposed project would provide: (a) Health Manpower Development: (i) basic and inservice training of medical and paramedical personnel through the provision of 34 manmonths of technical assistance, materials and operating costs for curriculum development, and field training, together with about 18 fellowships for inservice specialist trainees. (b) Drug Supply and Utilization: (i) two manyears of technical assistance for improving the financial management of the PPM, and an initial stock of drugs to improve its financial status by establishing a special drug purchasing account; and (ii) office facilities, materials, two vehicles, vehicle operating costs, and 14 manmonths of technical assistance to assist MOPHSA to strengthen its pharmaceutical planning and control services, test and develop a policy of payment for drugs, organize information for the public and health manpower on drug prescription and consumption, and publish an essential drug list and treatment manual. (c) Planning, Coordination and Health Education: (i) office equipment and two vehicles, eight manmonths of technical assistance, 13 fellowships and short-term training in health planning, together with consultant services for pre-investment studies;  - 14 - (ii) a MOPHSA national and local Pro-ject Coordinating Unit, supported by about 9 manmonths of management: technical assistance, 14 manmonths of specialist services in procurement and external auditing, about 3 vehicles, office materials and operating costs; and (iii) three manmonths of technical assistance, equipment and materials to improve MOPHSA's Health Education Services; andi a small center comprising office facilities and a library serving Planning, Documentation and Health Education Services. Part B 2.04 At the regional level, the project would provide: (d) Development of Primary and Secondary Health Care: (i) equipment, drugs, operating costs and 48 manmonths of technical assistance for the implementation of a program of health services at the district, subdistrict and village levels; (ii) travel allowances, per diems and. materials for retraining of field staff; and (iii) construction of 3 replacement district health centers, 18 subcenters, and renovation of 3 additional subcenters, including equipment and furniture, 6 four-wheel drive vehicles, 12 motorcycles, 15 motor bicycles, 18 bicycles, operating costs and maintenance. (e) Village Level Health Education: (i) training of village level health workers, and promotion of innovative aclivities by community groups contributing to the improvement o:E the health status of the population. (ii) 8 manmonths oi advisory services to assist in the preparation and evaluation of health-related literacy materials, together with teachin.g materials for literacy program field staff; and (iii) inservice training, incremental salaries and allowances for literacy program iEield staff; one four-wheel drive vehicle and 6 motorcycles and 6 radios, including operating costs and travel al:Lowances for community health education;  - 15 - (f) Monitoring, Research and Evaluation: (i) a microcomputer, 25 manmonths of technical assistance and operating costs to monitor and evaluate project activities, measure changes in health status in the project area, and strengthen MOPHSA's primary health care research and evaluation capability. C. Detailed Project Description Part A Manpower Development 2.05 As shown earlier (paras. 1.18 - 1.19), there is a need to improve the quality of basic training at the national level, and to develop inservice training at the regional level in line with primary health care program requirements. In addition to being handicapped by very poor field conditions, students are inadequately prepared after graduation because of major gaps in their public health training and a lack of prior exposure to practical team work during their basic training. There is insufficient up-to-date professional literature in school libraries and at health facilities. 2.06 Objectives. At the national level, the project would improve the quality of health manpower in medicine, pharmacy, dentistry, nursing, midwifery, allied technical fields and community development by stregthening the basic and inservice training. 2.07 To strengthen the basic training, the project would improve the curriculum of the National School of Medicine, the Secondary School of Nursing, the Nursing School at Point "G, and the National Center for Community Development. Teaching content would be strengthened in the following areas: public health management, administration and economics; maternal and child health, and family planning; health education; epidemiology and biostatistics; drug prescription; and adult education. During an initial five-month period, a needs assessment survey would be conducted, followed by four months' drafting of new course proposals. An additional four-month workshop period would evaluate these proposals, leading to further revision and the adoption of a definitive program (five months). Teacher orientation, experimentation and evaluation would occur during an additional six months. The libraries of each school would be provided with updated reading material in each field to be strengthened. To develop teamwork under practical field conditions, the project would provide field training three times annually to students from each of the four schools. With respect to inservice training, the project would provide up to six annual training sessions for various categories of MOPHSA personnel working in rural areas to bring them up to date with professional developments in public health and to share regional experiences in primary health care. To  - 16 - increase the availability of master trainers (thereby providing a larger pcol of trainers for national inservice training), the project would provide 12 short-term (three months) fe:Llowships in training techniques to existing and potential trainers in MOPHSA, the Medical and Nursing Schoo'Ls and the National Center for Community Development. Because of the need for doctors skilled in eye surgery (see paral. 2.21), the project would in addition provide 6 fellowships to MOPHISA medical personnel for specialization in this area. Based on project experience, DNPFSS would develop a Long-term inservice training program (para.. 2.24). 2.08 Categories and Targets. The improvement in basic training would benefit annually about 50 students in medicine, pharmacy and dentistry, about 180 student nurses, midwives, sanitary technicians and laboratory techni- cians, and about 25 students in community development. FieLd training of 45 days' duration would be provided to all final year students in three groups three times per year. Annual inservice training (six days) would be provided to about 100 MOPHSA personnel. 2.09 Implementation. The proposed curriculum reform would be organized by an ad hoc committee of five persons from each of the schools concerned and MOPHSA's Directorate of Planning and Training (DNPFSS), withi a lead coordira- tor provided by the DNPFSS. They would be supported by 26 manmonths of technical assistance in curriculum development, nursing, MC]1/FP, health economics and management, adult education methods, and community develop- ment. Per diems and materials would be provided for workshop participants. An additional eight manmonths of technical assistanceL would be provided to assist in orienting teachers to the new curriculum. Field training would be provided at three district hetalth centers in Kita, Bafoulabe/Mahina and Kenieba (western Mali). The pro-ject would finance minor upgrading of existing facilities to provide appropriate dormitory and conference facilities in each of these districts. The DNPFSS would coordinate field training; and trainers would be provided by each of the schools concerned. Likewise, the DNPFSS would organize annual inservice seminars, as has been done in the past, at appropriate meeting halls at the regional level. Drug Supply and Utilization 2.10 Drugs are essential to improving the health status of Malians, and, as noted in paras. 1.20 - 1.24, the price of drugs is generally high, supplies are inadequate, particularly in rural areas, parallel distribution by MOPHSA and the PPM has been inefficient (free MOPHSA distribution along- side a commercial PPM network), and both prescription and consumption habits are poor. The project would: (El) assist the PPM in supplying both the commercial sector and MOPHSA facilities more efficiently; (b) assist MOPHSA in planning and coordinating the needs of the national pharmaceutical sector, as well as developing and testing a drug cost r,ecovery scheme in its health facilities; and (c) support MOPHSA's attempts to improve prescription and drug consumption practices.  - 17 - 2.11 Strengthening the PPM. The project would strengtnen the PPM's management and improve its procurement and distribution so that drug a,aila- bility is more widespread at lower cost to the consumer. The PPM is adequately staffed at the central management level. But, because the PPM has imported drugs principally from a few major suppliers in France, its manage- ment has had relatively limited experience in purchasing in bulk through competitive bidding, analytical accounting and pricing. For these purposes, the project would provide two manyears of technical ass stance. To permit the PPM to pay suppliers promptly, thereby reducing pui 1S.iSng costs and sales prices, the project would provide $1.9 millior i-o,rchase an initial stock of drugs, the sale of which would be used to ccr,i e a PPM purchasing account. Completion of an initial audit of the PPM's accounts and the selection of management technical assistance under terms and conditions acceptable to the Association would be a condition of disbursement of the IDA Credit allocated for the purchase of drugs for the PPM. During negotiations, the Government provided assurances, first, that it would (a) not later than June 30, 1984, open and thereafter maintain a Pharmaceutical AccGunt in Malian francs in a commercial bank on terms and conditions satisfactory to the Association; (b) ensure that any receipts from the sale of drugs financed from the proceeds of the Credit be promptly deposited into the Pharmaceutical Account; and (c) not later than at the end of each calendar quarter, starting the calendar quarter ending September 30, i984, maintain in the Pharmaceutical Account a balance of not less than 100,0003CUC00 Malian francs. Secondly, (a) not later than December 31, 1984, the Government would furnish to the Association a plan of action for strengthening management of the PPM satisfactory to the Association; (b) not later than March 31, 1985 implement such measures as shall be agreed upon between the Borrower and the Association; and (c) not later than March 31 of each year, thereafter, review the effects of such measures in consultation with the Association. Thirdly, (a) not later than December 31, 1984, the Borrower would prepare and furnish to the Association for its review and comment a five-year investment plan for the PPM, and (b) not later than December 31, 1985, implement such measures from the plan as shall be agreed upon between the Borrower and the Association. 2.12 Strengthening MOPHSA's Pharmaceutical Planning and Cost Recovery Capability. Under the proposed reform of the national pharmaceutical system, MOPHSA would play a central role in coordinating drug policy and planning. To these ends, the project would strengthen MOPHSA's Inspectorate of Public Health and Social Affairs which would: (a) review existing legislation regarding the pharmaceutical sector and, through its inspection service, enforce appropriate legislation; and (b) serve as a secretariat for standing committees in charge of licensing and authorizing drug imports, determining drug nomenclature and formulating official lists of drugs for public health facilities, and planning, executing and evaluating reforms of the national pharmaceutical system. To these ends, the Inspectorate would be provided with a special Division in charge of inspection and policy, planning and licensing. The project would provide renovated office space for the Division, together with office equipment, two vehicles and vehicle operating  - 18 - costs. In addition, twelve manmonths of technical assistance would be provided to assist in setting up the Division and in testing implemention cf the Government's proposed policy of payment for drugs (para. 2.26). During negotiations, the Government provided assurances thal MOPHSA would, not later than June 30, 1984, establish and thereafter maintain a Division of Pharmacy and Drugs within MOPHSA's Inspectorate of Public Health and Social Affairs, under terms and conditions satisfactory to the Association. 2.13 Improved Prescript-ion and Drug Consumption Practices. The proposed reform of the pharmaceutical secl:or would be based in part on more widespre,ad use of lower cost generic drugs, a reduction in the list of drugs to be provided at public health facililties, and reorientation of prescribers and the public with regard to changes in national pharmaceutical policy. To these ends, the project woulcd provide revised editions of tlhe essential druig list, drug formulary, and standardized prescribers' treatment manual. The reorientation of prescribers wou]Ld be undertaken through regional seminars for physicians, pharmacists and managers of PPM supplied sales outlets. The press, radio and regional government officials would also participate. Sessions would be organized by a team made up of MOPHSA officials and including a Professor of Therapeutics at the School cf Medicine and Pharmacy. A film on drug prescri'ption and consumption practices would be produced. Two manmonths of specialist assistance in mass media information would be provided to assist t.he press and radio to simplify and diffuse the information campaign to the public at large. During negotiations, the Government provided assurances that by December 31, 1984, (a) it would adopt an essential drug list, drug formulary and standlardized treatment manual; and (b) present to the Association for its review arad comments a study on the effectiveness of its reforms of the pharmaceutical sector, to be followed by similar studies and reviews no later than December 31 of each year thereafter. Strengthening MOPHSA's Capability in Planning, Coordination and Health Education 2.14 As indicated in para. 1.07, MOPHSA needs continuing support in its attempt to develop a stronger capability in hea:Lth planning, project implementation and coordination, and community health education. With respect to planning, steps need to be taken to improve budge!t forecasting a!nd analysis with a view toward making better provisions for the continuation of viable primary health care projects during and especially af'er the termination of foreign assistance. The project would provide eight manmontris of technical assistance in health planning to help MOPHSA's Directorate of Planning and Training (DNPFSS) in this regard. To permit the DNPFSS to develop further the evaluation and project formulation process begun during the preparation of this project (para. 1.07), the project would provide consultant services to the DNPFSS for preinvestmtent studies with a view toward inter alia: (a) preparing proposals for further improvements in health planning, including formulation of budgetary mechanisms enabling reasonable cost recovery; (b) preparing of a cost and feasibility analysis of a nationwide primary health care program; (c) designing outreach programs and  - 19 - projects for strengthening primary health care activities, including maternal and child health/family planning and nutrition at the community level; and (d) developing a long-term national MOPHSA inservice training program (para. 1.19). To improve the availability of qualified personnel, the project would provide 13 fellowships in planning, evaluation, statistics, and computer programming, together with training in health economics for about 10 existing MOPHSA administrative personnel. During negotiations, the Government provided assurances that, by December 31, 1984, it would establish and thereafter maintain within DNPFSS the following full-time positions and hire the following personnel to fill such positions whose qualifications and experience shall be satisfactory to the Association: (i) a statistician; (ii) a health planner; (iii) a training specialist; and (iv) an evaluation specialist. By December 31, 1987, the Government would submit to the Association for its review and comments preinvestment studies mentioned above, and, not later than December 31, 1988, furnish to the Association a plan of action for the implementation of the recommendations emanating from these studies. 2.15 In support of the need for a stronger MOPHSA capability in project implementation, (para. 1.33), the project would set up a Project Coordinating Unit (PCU) attached to the Office of the Minister of Health and Social Affairs which, by working through existing Directorates and line agencies, would be responsible for coordinating implementation of this project and for authorizing all project related expenditures. Organizational details are given in para. 4.03 and an organization chart is provided in Annex 1, C-4. About fifty-seven manmonths of technical assistance would be provided through the project to support the PCU at the national and regional levels, together with 10 manmonths of accounting services and four manmonths of procurement services for the preparation of equipment lists and bidding documents. 2.16 In support of MOPHSA's need to develop community health education services (para. 1.36), the project would provide three manmonths of technical assistance to MOPHSA's Health Education Division to assist in developing a health education program, including the design of appropriate community education materials for the village level, local language press and national radio (see paras. 2.28 - 2.29). A small facility, (about 360 m2), equipment and reading materials would be provided comprosing: (a) DNPFSS offices for health planning; and (b) a center with a library serving the existing Documentation and Health Education Services. Part B Development of Primary Health Care at the Regional Level 2.17 Three districts (Kita, Bafoulabe and Kenieba) in the western (Kayes) region, have been selected for the development of a primary health care system under the project (see Map IBRD 16998). The districts are  - 20 - located immediately to the west of Bamako, the capital, and on the northern and eastern borders of Guinea and Senegal, respectively. 2.18 Health Status. These districts were selected because the health status of the population and the availability of health services are extremely poor. Infant mortality is 255 per 1,000 in these districts, compared with 150 nationally (a comparison of health indicators is presented in Annex 1, T-6). The epidemiological survey conducted in These districts during project preparation (para. 1.01) indicate that: life expectancy at birth is 33 years, twelve years 'Less than the national average. Maternal mortality is estimated at 1,000 per 100,000 pregnancies. Malaria accounts for 27% of all deaths in children, 0-9 years. Intestinal diseases, linked to the unavailability of safe water, was one of the most frequent complaints cf villagers surveyed. The prevalenice of goiter is as high as 29%; 18% of the adult population have a history of hepatitis. Blindness prevalence is 3%, mainly due to cataracts, trachoma and onchocerciasis. The prevalence of clinical protein-calorie malnutrition is 10.8% for the 3-1 age group, 14.82 between ages 1-4, and 1.1% in the 5-9 age group. These data underscore the need for developing a health program aimed at improving basic health care with emphasis on maternal and ch-ild health. 2.19 Economic and Socia:L Characteristics. About 455,000 people live in the proposed project zone, which is generally rugged and remote. Annual rainfall from 700 to 1,200mm occurs only during the four-mocnth rainy season.- --June to September. Transport is rudimentary and a major impediment to economic development and the provision of health services. Although the railway runs through Kita and Bafoulabe, it serves only those villages in close proximity. The road network is little more than unimproved track, and is better in Kita than BafouLabe and Kenieba, where many villages are isola- ted during the rainy season. The majority of the populationn is engaged in rain-fed cultivation of subsistence crops, prim!arily millet and sorghum. Groundnuts have been cultivat:ed as a major casb crop through a large-scale IDA assisted rural development agency (Operation Arachides et Cultures Vivrieres, or OACV, and its successor Office de Developpement Integre pour la Production Arachidiere et Cerealiere, or ODIPAC). A year-round supply of publicly available water supply is extremely limited (3.4 public wells per 1,000 population). Less than one-fifth of school-age children are estimatetd to attend schools. However, through the OACV and ODIPAC projects, about 7_'0 functional literacy centers have been establish,ed in the project zone--a key framework through which to promote community level primary health care. 2.20 Health Services. For the majority of the population, the nearest source of "modern" medical care is a public subdistrict health center, most of which are poorly equipped and in disrepair. Drugs are practically availa- ble only at sales outlets run by the PPM and ru.ral cooperatives. Traditional birth attendants are the most widely available and utilized source of maternity care (averaging five TBAs per village). A credible referral syst:em from villages to health subcenters and centers is non-existent. Evacuation to a maternity is likely to occur only in situations where the woman is  - 21 - already experiencing life-threatening difficulties while in labor. Primary Health Care Objectives and Strategy 2.21 In response to these conditions, the project would assist the Government in improving the quality of primary health care services to the population of Kita, Bafoulabe and Kenieba. To achieve this objective, the project would upgrade the network of district health centers and subcenters, retrain existing paramedical personnel attached to these facilities, and initiate the process of promoting primary health care, community health education and the hygienic use of water at the village level. The project would help improve the population's health status by reducing the incidence of major diseases as identified during the epidemiological survey. Specifically, the project would provide an integrated program of health services through the following interventions: malaria (Chemoprophylaxis of children under five, and adult self-treatment); diarrhea (through health education of mothers in the correct use of homemade oral rehydration solutions); respiratory infections (through antibiotic therapy at health centers); childhood diseases (through vaccinations at health centers); complicated deliveries, pre- and postnatal problems and family planning (through a referral system from the village to the district health center level); tuberculosis and leprosy (through screening of suspected cases and treatment of positive cases); malnutrition (through preventive education of mothers); blindness (through surgical interventions against trichiasis and cataracts); conjunctivitis (through self-treatment at the village level), and guinea worm (through protection of wells). A summary of proposed interventions, tasks and levels of responsibility is presented in Annex 3. 2.22 In contrast to previous primary health care demonstration projects (1.12 - 1.16, 1.36), the proposed project is designed to provide these services progressively first at the district health center, followed by the subdistrict level, thereby assuring a credible capability prior to developing primary health care at the village level. This strategy implies a gradual, cumulative coverage of the population, averaging 12% annually, and reaching a maximum effective coverage of 45% at the end of the project (about 5% are effectively covered to date). First to be served would be the population immediately covered by three health centers in the three districts, followed by those covered by 21 subcenters. Thereafter, primary health care and health education services would be extended to 112 villages within reasonable access of health centers and subcenters (see Annex 4). Supervision of district level services would be provided by the regional medical director; the PCU, through its project manager based in Kita (para. 4.05), would provide technical support. Subdistrict health centers would be supervised by the district level medical officer; subdistrict nurses would supervise village level activities. Subdistrict nurses would group together at the health center for workshops pertaining to the organization and implementation of the proposed health program activities.  - 22 - Retraining of Field Staff 2.23 About 186 MOPHSA pe!rsonnel (6 physicians, 60 nurses, 3 certified midwives, 21 rural midwives, 64 nursing assistants, and 32 auxiliary and technical personnel) who currently provide services in the project zone would be retrained in order to carry out the health programs as designed. 2.24 A project preparation advance has been provided to commence inservice training of project: zone personnel prior to credit effectiveness. The three district level physicians would improve their ski:Lls in surgery and obstetrics during a six-month period in Bamako. All nurses would be retrained in obstetrics and F[CH/FP at the Kita 'health, center over a two-month period. Training sessions wcould be organized by the DNPFSS. At the start of the project, the PCU and DNPFSS would organize an initial ten-day orientation workshop for key administrative staff (3 medical officers, 3 certified nurses, 3 first-cycle nurses, 3 midwives, 3 community development and sanitary technicians, 3 accountarnts and 3 statisticians' of the district health centers to review the health programs and training requirements of the project. Basic literacy in the vernacular of the project zone would also be introduced. Four training sessions, each of ten days' duration, would then be provided to all district level personnel, with the objective of improving their skills in accordance with the technical and managerial requirements of the program desribed in para. 2.21. Subsequently, simi:Lar t-raining would be provided to subcenter staff in eaLch district at the start of the project. For the duration of the projeZct, refresher training and continuing education would be provided to health center and subcenter personnel for a period of 12 days per year. All such inservice training sessions would be conducted at the district health center. A te!am of trainers would be organized comprised of a trainer from the DNPFSS, the Director of t'he PCU and the proposed project zone coordinator, a representative of the national Directorate of Public Heath, and specialists provided by the S,zhool of Med-icine and Pharmacy, the Nurses' Training Schools and the 'National Cent-er for Community Development. The project would provide training materials, transportation costs and per diems. Forty-eight manmonths of technical assistance would be provided to assist in implementing and evaluating the proposed health service and training programs. Construction and Equipment of HeaLlth Facilities 2.25 Because existing health facilities in the project zone are ill-equipped, run-down and inappropriately designed, the project would construct three replacement district health centers with 60 beds at Kita, and 48 beds each at Bafoulabe and Kernieba. Each center would provide hospitalization, outpatient clinics, a maternity unit, opthamological and dental units, pharmacy and refrigeration, radio communication, and community health education and inservice training rooms. One center would be provided with x-ray equipment serving the entire zone. In addition, 18 replacement and 3 renovated subeenter health facilities wouLd be provided (see Map IBRD 16998) and would include: examinLation and treatment rooms for both curative and preventive health services; a delivery room; a basic laboratory with microscope; pharmacy with refrige!ration; and radlio communication (solar  - 23 - powered refrigeration and radio communication would be provided for about 10 isolated subcenters). To assist in supervision, the project would provide the district health centers and subcenters with a total of 6 four-wheel drive vehicles, 12 motorcycles, 15 motor bicycles and 18 bicycles, and finance operating and maintenance costs. During negotiations, the Government provided assurances that it would maintain adequate staffing of all project health centers, operate all facilities appropriately, and ensure adequate maintenance of all buildings, furniture and equipment provided by the project. Project Zone Drug Supplies 2.26 In order to assure an adequate supply of drugs at the 21 proposed health centers and subcenters (pending the setting up of a new national drug supply system), the project would provide an initial stock of drugs to each of these facilities. Purchases would be made through UNICEF with the objective of testing and developing a cost recovery system at these facilities. The PPM would resupply these facilities in accordance with the proposed pharmaceutical reform. MOPHSA will establish an initial payment scheme for each day of hospitalization, deliveries and laboratory examinations. The proposed Division of Pharmacy and Drugs would assist in testing and evaluating the proposed scheme. Village Level Health Education 2.27 As noted in paras. 1.12 - 1.16, village level primary health care demonstration projects have been implemented in Mali with varying degrees of success. The project would attempt to build on these experiences by providing training of TBAs in monitoring pregnancies, referral of risk cases, normal deliveries, family planning information, nutrition demonstrations and malaria chemoprophylaxis. The project would also support the selection and training of village health workers as has been attempted elsewhere in Mali. However, MOPHSA has agreed that, unlike, for example, the Koulikoro experience (para. 1.14), neither the village health worker model nor rural matrons would be imposed upon the population. The selection and support of village health workers and TBAs would be a community responsibility--training would be provided at health centers and subcenters. A fund of US$200,000 would be provided for such training, and for innovative primary health care activities. The fund would be managed by the PCU and audited annually. 2.28 The project would, in addition, support the local rural development agency (ODIPAC) and the functional literacy agency (DNAFLA) in an attempt to inculcate simple notions of primary health care, health education and the protection and maintenance of water points provided by the proposed Rural Water Supplies project. The proposed methodology for undertaking these activities is presented in Annex 4. A functional literacy program has been in operation for several years in the project area; DNAFLA has already produced and tested prototype community health education and training materials which would be developed further under the project. The  - 24 - organizational structure of DNAFLA and its structural relationship with ODIPAC are presented in Annex 1, C-3. 2.29 The project would finance incremental salaries and allowances for 20 existing DNAFLA field workers (sub-zonal chiefs) for a three-year period. Basic training, salaries, allowances, materia]s and transportation would be provided for six additional field workers needed to cover the project areai effectively. Annual inservice training seminars would be provided for all 26 field workers by national DNAFLA staff and health and wate!r subject matter specialists. Inservice training would also be provided for about 140 ODI]'AC agricultural extension agents, district and subdistrict health center staLf, sanitation and community development technicians in the project area. They would be trained in group dynamics, adult teaching techniques, and the use of functional literacy for health education. Travel allowances would be provided for DNAFLA specialist health and water subject matter specialist staff to prepare teaching materials. Similar allowances, one four-wheel drive vehicle and operating costs would be provided for supervision, monitoring and evaluation by DNAFLA. Eight manmonths of advisory services would be made available for the development of teaching materials and their evaluation. Monitoring, Research and Evaluation 2.30 As mentioned in para. 1.34, the DNPFSS would strengthen its role in planning and evaluating health services. In addition to strengthening planning (para. 2.14), the project would improve the DNPFSS's evaluation capability first in the project zone by developing a reporting system based on operational data on locations and numbers of population served, service!s delivered, drug consumption and disease incide!nce. The DNPFSS would draw up simplified data collection forms to be filled monthly by each health facility, aggregated at the district level, and transmitted to MOPHSA at tlhe regional and central levels. Five manmonths of technical assistance would be provided to assist in designing and implementing the system. Evaluation indicators are provided in Annex 1, T-7. A microcomputer would be provide!d to the DNPFSS for data storage and analysis on the assumption that the system would gradually be expanded to other regions cf the country. Four manmonths of specialist assistance would 'be provided to set ul? the computer system. Four manmonths of technical assistance would also be provided to assist the DNPFSS to conduct midterm and final evaluations of the project. At the enld of the project, MOPHSA and i:he School of Medicine and Pharmacy would undertake a follow-up epidemiological survey in the project area to measure changes in health status. Evaluation design will take into account the differences in health status, if any, in regions without adequate water supply and the regions with water supply. Twelve manmonths of technical assistance and operating costs would be provided to assist the MOPHSA to undertake program evaluations, applied research in the effectiveness of primary health care, and to assess the experimental payment for services scheme. A summary of techni.cal assistance and consulting services, provicled under the project is described in para. 4.02 and listed in Annex 1, T-13. A similar list of vehicles is shown in Annex 1, T-14.  - 25 - III. PROJECT COST AND FINANCIAL PLAN Project Cost 3.01 The total project cost inclusive of contingencies is estimated at US$17.6 million equivalent net of taxes. The estimated costs and foreign exchange components, given in Annexes 1, T-8 and T-9 are summarized as follows: Table 3.1 MALI HEALTH DEVELOPMENT PROJECT PROJECT COST SUMMARY (MF Million) (US$ Million) X of -------------------------------------------Foroim I of Total Local Foreigrn Total Local Foreigr Total Exchange Base Custs A, NATIONAL LEVEL TRAINING 173.8 323.3 49,1 0. 2 0.4 0.7 65.0 4.8 PHARMACEUTITCAL 154,3 1YS1,?7 1;973,9 0.2 2.4 2.6 92.2 19.1 STRENGTHENING OF MOPSHA 594,9 1403,.2 li?98.1 0.8 1.,9 2_7 70.2 19.3 Sub-Total NATIONAL LEVEL 923.1 36546.1 41469.2 1.2 4.8 6.0 79.3 43.2 B. PROJECT ZONE ( NB; HEALTH SERVICES 3.474 t.9 1, 329.9 4Y804.9 4,7 1.8 6,4 27.7 46.4 VILLAGE HEALTH PROMOTION 232.6 98.9 331,C5 03 0.1 0.4 290.8 3,2 Sub-Total PROJECT ZONE ( NBKt ) 3.7.7..6 1428,8 5t136.4 5.0 1,9 6.9 277.6 49.6 C. REPAiYMENT OF PPF 209.6 536.4 746.0 0.3 0?7 1.0 71.