Docum.et Of The World Rank FOR OMCIAL USE ONLY Repwrt No. P-4216-NIR REPORT AND RECOMMENDATION OF THE PRESIDENT OF THE INTERNATIONAL DEVELOPMENT ASSOCIATION TO THE EXECUTIVE DIRECTORS ON A PROPOSED CREDIT OF SDR 25.1 MILLION TO THE REPUBLIC OF NIGER FOR A HEALTH PROJECT February 26, 1986 Tis doc_aet s a rtrieted distribuion ad wy be used by recpits eoly in the perfornsee of their officl dldkl. Its contens mxy notherwise be disclosed witbout World Bank athorizaion. r CURRENCY EQUIVALENTS Currency Unit = CFA Franc (CFAF) US$1.00 = CFAv 385 CFAF 1 = US$.0026 CFAF 1 Million = US$2,597 WEIGHTS AND MEASURES Metric System FISCAL YEAR October 1 - September 30 GLOSSARY OF ACRONYMS EPI Expanded Program of Immunization FP Family Planning FED European Development Fund (Fonds Europ6en de Developpement) MCH Maternal and Child Health MOPHSA Ministry of Public Health and Social Affairs ONPPC National Pharnnaceutical Cor.panv (Office National des Produits Pharmaceutiques et Chimiques) PPIT Project Management Unit WHO World Health Organization UNFPA United Nations Fund for Population Activities UNICEF United Nations Children's Fund USAID United States Agency for International Development FOR OmCAL USE ONLY NIGER HEALTH PROJECT CREDIT AND PROJECT SUMKARY Borrower: Republic of Niger Beneficiary: Ministry of Public Health and Social Affairs Amount: SDR 25.1 million (US$27.8 million equivalent) Terms: Standard Project Objectives: The proposed project will assist the Government in introducing policy reform in the health sector. It will assist in the implementation of Niger's Structural Adjustment Program at the sectoral level through studies and reform programs aimed at improvements in investment planning, the allocation of recurrent expenditures, cost recovery, the availability of essential drugs, sector management and aid coordination. It will also assist the Government to define policies relating to population and family planning and nutrition. Moreover, in support of the sectoral reform program, the project will improve the efficiency of priority health programs: (i) maternal and child health care including family planning, control of malaria, diarrhea and other communicable diseases, (ii) health education and community initiatives in health and nutrition, and (iii) training of health personnel. Benefits: Through its support of the Government's reform program in the health sector, the project will help correct imbalances that have appeared in recent years in the allocation of resources in the health sector, ease financial constraints, increase the availability of essential drugs, reinforce planning and program execution in MOFHSA and improve donor coordination. Also, the project will strengthen priority health programs and services with particular emphasis on women and young children, the highest risk group in the population, and on rural services. It will improve the quality of health services available to 3.4 million people. Through the expanded immunization program, an estimated 1.2 million children nationwide, representing about 75X of children under five years of age, will be vaccinated against the major childhood diseases by the end of the project implemen- tation period. Risks: The project will be the first IDA-financed operation in the sector. There is, therefore, a risk of delays in implemen- tation. However, the Government is strongly committed to the reform program and anxious to move ahead with project imple- mentation. Local staff responsible for project implementation lThi dumenthas a icted dtribution and may be usd by ecipients only in the performace or their oMcialdutie Its contents may not otherwise be disclosed without World lank authonztaon. - ii - is vell qualified. Moreover, with financing from two PPF advances, a number of steps have been taken to ensure expeditious project start-up, and a project implementation workshop is planned prior to credit effectiveness. Estimated Project Costs: Local Foreign Total ------US$ Million- A. POLICY REFORM 1. Policy Development Studies - (.3 0.3 2. Funds for Implementing Sub-projects 1.5 1.8 3.3 Sub-Total A. 1.5 2.1 3.6 B. STRENGTHENING OF BASIC HEALTH AND FAMILY PLANNING SERVICES 1. Strengthening of Existing Services 5.3 7.9 13.1 2. Development of Health Education and Community Initiatives in Health and Nutrition 0.7 0.9 1.6 3. Health Manpower Development 1.0 2.3 3.3 Sub-Total B. 7.0 11.1 18.1 C. PROJECT MANAGEMENT AND ADMINISTRATION 0.4 1.0 1.4 D. REPAYMENT OF PPF ADVANCES 0.3 0.7 1.0 Total BASELINE COSTS 9.2 14.9 24.1 Physical Contingencies 0.5 0.9 1.4 Price Contingencies 1.5 2.4 3.8 TOTAL PROJECT COSTS 11.2 18.2 29.3 Note: Totals may not add up due to rounding. Estimated project costs are net of taxes and duties from which the project would be exempt. - iii - Financing Plan: Local Foreign Total -------US$ Million-- IDA 9.6 18.2 27.8 Government 1.5 - 1.5 TOTAL 11.1 18.2 29.3 Estimated Disbursements: FY87 FY88 FY89 FY90 FY91 FY92 FY93 --US$ Million-- - Annual 2.5 3.9 5.0 5.8 4.8 3.6 2.2 Cumulative 2.5 6.4 11.4 17.2 22.0 25.6 27.8 Rate of Return: Not applicable Project Completion Date: December 31, 1992 Staff Appraisal Report: 5937-NIR nD: IBRD 19460R INTERNATIONAL DEVELOPMENT ASSOCIATION REPORT AND RECOMMENDATION OF THE PRESIDENT TO THE EXECUTIVE DIRECTORS ON A PROPOSED DEVELOPMENT CREDIT TO THE REPUBLIC OF NIGER FOR A HEALTH PROJECT 1. I submit the following report and recommendation on a proposed development credit to the Republic of Niger in an amount of SDR 25.1 million (US$27.8 million equivalent) on standard IDA terms to help finance a Health Project. PART I - THE ECONOMY 2. This section is based on findings of the missions in 1984-85 that prepared the first Structural Adjustment Credit to Niger (Report No. P-4185- NIR). Annex I contains country data. Structural Characteristics of the Economy 3. With an area of 1.27 million km2, Niger is about 2.5 times the size of France. It is a landlocked country, and its closest access to the sea is 600 km from the southern border. The population is estimated at about six million and growing at 3% a year, which is above the average for Sub-Saharan Africa. Nearly 90% of the population is concentrated in a thin band along the southern border, in the 12% of the land that is considered arable. Rainfall is limited and often irregular, while soil fertility is low and declining, due to intensive use. Niger is one of the poorest countries of the world, with a per capita GNP of US$190 in 1984. The life expectancy at birth of 45 years is low, even by African standards. High infant and child mortality rates account for 60% of all deaths in the country. The adult literacy rate is only 8% (0.5% for women), and the primary school enrollment ratio not more than 23%. 4. The Nigerien economy has traditionally been dominated by subsistence agriculture, with millet and sorghum taking up 80% of the cultivated area. Livestock also provides an important source of income and export receipts. Except for the Sahelian drought periods, the country has always been self-sufficient in food production, despite its very limited agricultural resource base. The discovery of large uranium deposits in the late 1960s triggered the development of an important mining sector in Niger. Under highly favorable conditions in the world market for uranium during the late 1970s, the mining sector expanded rapidly; uranium became the country's principal foreign exchange earner and a major source of government revenues. As a result, Niger went through a period of rapid growth and modernization, and the public sector took a dominant position in the modern economy. The uranium boom ended in the early 1980s, when prices dropped and Niger's production decreased. Consequently, the share of the mining sector and the modern sector in the economy both declined significantly. 5. Niger has traditionally maintained an open economy, exporting and importing about 25% of its GDP. Strong trade relationships exist with Europe (mainly France) and neighboring African countries (particularly Nigeria). This openness has been facilitated by the West African Monetary Union, of which Niger is a member. The Union's central bank (BCEAO) issuea a comon currency for its member states, the CPA franc. Its full convertibility into French Francs, at a fixed rate of CFAP 100 - 2FF, is guaranteed by the French Government. In return, the monetary union imposes discipline over the monetary and balance of payments policies of its member countries. Past Economic Developments 6. During the first half of the seventies, Niger exhibited all the features of a resource-poor Sahelian country. Economic performance was dependent on a limited number of crops and livestock, which were severely constrained by poor soils and unfavorable climatic conditions. This was dramatically illustrated in 1972 when devastating droughts caused a sharp decrease in crop production and in the livestock herd. During the second half of the seventies, Niger's economic performance improved significantly, and real GDP grew at an average 7% per year. The growth of the rural sector accelerated, due to the favorable weather conditions and a successful herd rehabi'Litation program. The uranium sector went through a boom, boosting the share of the mining sector in GDP from 6% in 1975 to 13% in 1980. 7. This favorable economic performance ended abruptly in the early eighties as a result of two factors. First, real export prices of uranium fell sharply, by more than 502. between 1979 and 1982. Uranium export earnings stopped growing and uranium revenues dropped from 25% of government revenues in 1980 to 14% in 1983. Second, agricultural production was hampered by unfavorable climatic conditions, forcing Niger to increase food imports. As a result of these developments, real GDP stagnated in 1981-1982 and declined by almost 3% in 1983. This slowdown in economic activity vas accompanied by the emergence of sizeable fiscal and external deficits. Budgetary revenue, which had peaked at 13% of GD? in 1981, fell to 10% of GD? in 1983, reflecting the heavy dependence of revenues on the modern sector and on international trade. Public expenditures, on the other hand, continued to grow. Consequently, the budget deficit averaged 9% of GD? over the 1980/81-1982/83 period. At the same time, the external current account deficit (including official grants) averaged 9% of GDP. Export revenues of uranium as well as livestock products stagnated and, when expressed in US dollar terms, decreased substantially. The financing of this deficit forced the country to accumulate a heavy foreign debt, reaching 502 of GDP in 1983 (of vhich 77Z was public or publicly-guaranteed debt). As a result, the debt service ratio increased from 22% in 1980 to 34Z in 1983, while the public debt service/public revenues ratio increased from 11% to 45%. 8. When the uranium boom came to an end, a number of serious imbalances in the structure of the economy became evident. First, during the uranium boom, the Government began to use the public expenditure program as the primary instrument for allocating financial resources in the economy and for generating economic growth. Public investment became focused on infrastructure and building projects, while agricultural -3- investments encountered serious problems. Recurrent expenditures favored personnel and transfer payments over operation and maintenance, to the detriment of existing infrastructure and basic public services. These imbalances were exacerbated in the early eighties by rapidly increasing interest payments on public debt, a decline in tax revenues, and inadequate cost recovery for public services. Second, although uranium revenues started to decline in 1981, the Government continued to implement its ambitious development plan by relying increasingly on external borrowings. To finance growing budget and external deficits, the country accumulated a heavy foreign debt, which rose to US$ 915 million at the end of 1984. or 65% of GDP. A substantial share of this amount was committed on co-mercial terms. Without debt relief, the debt service ratio would have risen to 47Z in 1984. Third, during the late seventies, public enterprises proliferated into uneconomic activities and acquired privileges that discouraged private sector development. Many of them incurred substantial operating losses and became a drain on the government budget and the financial sector. This negative performance was caused by government regulatory policies in the areas of pricing, marketing and employment, by excessive government interference in day-to-day management, and by lack of qualified personnel and inadequate accounting practices. Finally, the rural development strategy which the Government pursued over the last ten years to achieve food self-sufficiency was implemented through large-scale projects, using unproven technology and heavy institutional infrastructure. The Government intervened actively in input, product and financial markets, to overcome perceived weaknesses in private sector activities. This distorted market incentives for agricultural production and caused substantial budgetary outlays. 9. The Government began addressing some of these difficulties in the 1982/83 budget year, by taking austerity measures such as a freeze in wages and salaries, cutbacks in material, supplies and investments, and tighter control over foreign borrowings. A stabilization program was initiated and subsequently supported by three ID Standby arrangements, the last of which was approved in November 1985. Debt rescheduling agreements were reached with the Paris Club in November 1983. 1984 and 1985, and with the London CluD in early 1984. The objectives of the stabilization program are to: (i) improve the tax effort; (ii) limit the growth of current expenditures; (iii) reduce and restructure investment expenditures; (iv) reduce the Government's domestic arrears; (v) improve the financial performance and limit the size of the parastatal sector; (vi) liberalize marketing and trading policies; and (vii) restrain foreign borrowing. Implementation of this program has been satisfactory, although the impact of the recent drought on public expenditures and on the balance of payments required some modification of the initial targets. By 1985, the deficits in the budget and the current account had both been reduced significantly, to about 52 of GDP. The reduction in the budget deficit reflected mainly a substantial cutback in investments; efforts to limit and restructure current expenditures or to increase revenues have been less successful. The reduction in the current account deficit was to a great extent a result of a sharp decrease in imports, brought about by demand management policies. 10. Real GDP is estimated to have fallen in 1984 for the third consecutive year. The sharp decline of 16% in 1984 is due primarily to a - 4 - very serious drought, which resulted in a 30-40% decline in food crop production and in a 40% loss in the livestock herd. Other factors with a negative impact on GD? were the closure of the Nigerian border since 1984 and the reduced level of public expenditures. GDP growth in 1985, which has been estimated at 7.1%. is due mainly to a strong recovery of the rural sector following abundant rainfall. The outlook for 1986 assumes that the recovery of the economy from the drought will continue. Niger's Development Prospects 11. In the present circumstances, Niger faces a double challenge. First, the country has to overcome the financial imbalances and structural weaknesses that are the legacy of the uranium boom. Second, it has to develop its national economy on a very narrow resource base, as regards both physical and human resources. The recent decline in real GDP clearly indicates the need to complement continued austerity with policy measures that allow the country to restore a minimum acceptable level of growth. In the short term, the focus should be on improving the efficiency with which existing resources are utilized. In the longer term, continued efforts will need to be made to expand the productive base of the economy. This will necessitate further development of the agricultural sector pard of Niger's human resources, in combination with an acttve prograr. to slow down population growth. 12. Structural Adjustment Program. In 1985, the Government decided to complement its stabilization program with a structural adjustment program. This program mainly addresses the efficiency issues. The first phase focuses on policy improvements in three areas where the problems are most acute and where policy change would have the greatest beneficial impact on the budgetary and balance of payments position: (i) public resource management, (ii) parastatal reform, and (iii) agricultural policy. IDA is supporting the program through a structural adjustment credit, approved in February, 1986. 13. Under the adjustment program, a more efficient use of budgetary resources will be pursued to better utilize existing investments, expand essential services and strengthen the basis for future economic development. A three-year budget program has been adopted for the period 1985/86-1987/Z8 reflecting: (i) restructured recurrent expenditures with increased allocations for operation and maintenance, a freeze in personnel expenditures in real terms and reduced transfers to consumers; (ii) restr-ictured investment expenditures, with more emphasis on directly productive investments, human resource development, and rehabilitation of existing infrastructure; (iii) expanded domestic resource mobilization through cost recovery efforts; and (iv) improved external debt management. This program will be reviewed and rolled over annually. 14. The Government's parastatal reform program, which is designed to increase the efficiency of public enterprises as well as to encourage private investment, covers three areas: (i) revisions in incentive policies; (ii) improvements in the legal and institutional framework for the parastatal sector; and (iii) rehabilitation, privatization and liquidation programs for individual enterprises. In this context, price -5- and trade controls have been considerably relaxed, legislation clarifying the relationship between the state and individual enterprises has been adopted, and rehabilitation of the most important enterprises has been initiated. Privatization or liquidation efforts are underway for other public enterprises. 15. The Government has reformulated its rural development strategy and supporting policies to improve the efficiency of its interventions in this sector and to limit their budgetary impact. First, the sectoral investment program is being reoriented, emphasizing quick-yielding, small-scale productivity projects, farmers' participation, and rehabilitation of existing infrastructure. Second, the operations of the cereals marketing and storage agency (OPVN) have been limited to the management of a reduced security stock; its price stabilization role has been eliminated. Third, subsidies on agricultural inputs is being curtailed in order to expand their availability and limit the budgetary impact. Fourth, a reform program of the agricultural credit system, which had practically collapsed under severe financial strains, has been initiated. Finally, the agricultural research program is being reoriented towards more applied research at the farm level and more farm systems research, In order to strengthen the basis for longer-term agricultural growth. 16. Expansion of Resource Base. In the medium term, the structural improvements referred to above should make it possible to gradually increase economic growth without causing undue strains on the government budget and the country's balance of payments. The reform measures will reduce the policy impediments to higher and more productive utilization of the country's existing resource base. However, this resource base is small and the extent of supply responses to the improved policy framework is uncertain because of Niger's present low level of development. A necessary corollary to the oolicy reforms, therefore, is a concerted effort to reduce the country's severe resource constraints and expand the productive base of the economy. This relates primarily to a further development of the agricultural, industrial and energy sectors, and to an accelerated development of Niger's human resources. 17. The scope for further development of agriculture in the longer run is uncertain, given the low and diminishing fertility of the soil and the unstable climatic conditions in the Sahel region. Food self-sufficiency in the eighties and beyond can only be achieved through a gradual improvement in yields on land that is already under cultivation and through an effective population policy. In addition, support for better use of modern agricultural inputs, the development of small scale irrigation schemes, and applied research on rainfed agriculture will be important for the future development of Niger's rural sector. In industry, development is handicapped by the limited size of the domestic market, the landlocked position of the country, and the lack of local raw material resources. Nevertheless, private initiative should be encouraged by improved promotion and incentive policies. Finally, the development potential in energy and mining should be better assessed by geological surveys and exploration activities. An important coal deposit was identified in 1983, but high transportation costs cast serious doubts on the economic viability of its -6- development. Similarly, small oil reserves have recently been discovered, but their exploitation apnears to be uneconomiLal at this stage. 18. Developing human resources is crucial for future economic growth in Niger, although investments in this area have a very long gestation period. Primary education will have to be expanded as a first priority, and profession--l and vocational training -- designed to meet the specific requirements of the Nigerien economy - is needed to reduce the skilled manpower constraints. Health programs should focus on improving basic health services in the rural areas and on preventive rather than curative health care. Finally, the current rate of population growth of 3Z a year puts unbearable pressure on the country's scarce resources, and on budgetary allocations for public services. Therefore, Niger's development program has to be accompanied, as a matter of great urgency, by an active policy of reducing population growth. 19. To further these development objectives, a major effort will be required, both on the part of Niger and its aid donors. The Nigerien Government needs to continue the review of investment strategies and to make adequate counterpart financing available for project implementation. External financial assistance would have to increase in volume and be provided on highly concessionary terms, preferably in the form of grants, in light of the country's external debt situation. Aid coordination needs to be strengthened to ensure that assistance projects are in line with the Government's adjustment and development strategies. In addition, Niger requires increased non-project assistance to support policy reform, and donors should consider recurrent cost financing. In view of the government budget constraints, which are expected to persist, donors should continue to finance local costs. Finally, in order to keep Niger's debt service burden manageable in the future, donors should be prepared to consider supplementary measures of debt alleviation. PART II - BANK GROUP OPERATIONS IN NIGER 20. Twenty-seven IDA credits have been approved for Niger as of February 28, 1986, for a total amount of US$303.7 million equivalent. There has been one IFC investment, in the amount of US$2.2 million. Ten IDA credits, amounting to US$100.9 million, were for the rural sector (drought relief, rural development, forestry, irrigation and livestock). Eight credits have been for roads, aiming primarily at upgrading the main and feeder road networks. Eight other credits covered telecommunications, education, power and industrial development, and economic and financial management assistance to the Government. A Structural Adjustment Credit in the amount of US$60 million equivalent was approved by the Executive Directors in February 1986. Annex II contains a summary statement of Bank Group Operations in Niger as of September 30, 1985. 21. While the Government's macroeconomic performance in recent years has been quite satisfactory, experience with project preparation and implementation has been mixed. The Second Maradi and Dosso Rural Development Projects (Credit Nos. 1026-NIR and 967-NIR) have encountered major difficulties due to inadequate institutional arrangements, managerial -7- problems, a lack of proven technical packages for rainfed farming, high investment and operating costs of irrigation, and poor credit recovery. These projects, as well as the First Livestock Project (Credit No. 885- NIR), have also been affected by slow administrative procedures, and the recent severe drought. To assist the Government in alleviating the effects of the drought, the Association amended several ongoing agricultural projects to finance seeds and destocking of herds. Highway and feeder road construction projects have been and are being implemented on schedule. Social infrastructure projects, on the other hand, have suffered some delays, largely because of the inexperience of implementing institutions. In the early 1980s, project implementation was also adversely affected by the shortage of counterpart funds due to the Government's financial difficulties. Under the Special Action Program, the financing plan of several projects was revised to reduce required government contributions, which had originally been set during the uranium boom period, in line with the more limited resources available in the mid-1980s. Also, revolving funds were introduced to help accelerate disbursements. Reflecting the difficulties faced in the early 1980s, the disbursement ratio dropped from 59Z in FY80 to 16% in FY83. The ratio increased to 26% in FY84 following the introduction of the Special Action Program. The disbursement ratio of 23% in FY85 is slightly below the ratio for Senegal (26%) and Mali (28Z), but significantly higher than that for Burkina (13%), Sahelian countries at a similar level of development. 22. IDA's lending program in recent fiscal years has consisted of an average of two projects per year amounting to about US$20 million. The program has been small largely because of difficulties in project preparation. The strong policy dialogue that has developed over the last two years between IDA and the Government and Niger's eligibility under the Special African Facility have led to a substantial increase in lending to Niger. In addition to the proposed credit and a Structural Adjustment Credit approved in February, we also plan to submit a Transport Sector Credit for consideration by the Executive Directors later this fiscal year. We hope to maintain an increased IDA lending level in the coming years. provided that the Government remains successful in formulating and implementing a program of comprehensive policy reform. 23. An important focus of future IDA operations will be on continued macroeconomic reforms and on their translation into policy measures at the sectoral level. Lending instruments have been diversified to include structural adjustment credits and other forms of policy-based lending, as well as project lending operations that aim to assist the Government in both increasing the efficiency of resource use and, in the long run, expanding the country's productive base. Depending on the success of the Government's efforts to implement the first phase of the structural adjustment program, we would propose additional structural adjustment credits in the future to extend the reforms to other areas. In addition, sector-based lending operations would assist the Government in implementing its sectoral strategies, in particular through: (i) revised investment programs which emphasize maintenance and cost-effectiveness; (ii) restruc- tured recurrent expenditure budge;s; and (iii) additional cost recovery measures. - 8 - 24. Recent and future IDA operations reflect this approach. The Irrigation Rehabilitation Project, approved in PY65, focuses on the rehabilitation of existing infrastructure and on increased cost recovery in irrigated areas. A similar sectoral approach is being taken in the proposed Health Project and will also be proposed in upcoming transport and education projects. A planned Public Enterprise Rehabilitation Project will provide technical assistance and training for the implementation of parastatal reforms and will finance the rehabilitation of key public enter- prises. Priority will continue to be given to agriculture, the key sector for future growth of the country. Due to the absence of appropriate technologies for rainfed cultivation, it is difficult to determine at the present time how agricultural production could be strengthened in the long term. The Government is, therefore, formulating a new agricultural research strategy in connection with its structural adjustment program. As a first step, IDA will assist in the implementation of this strategy through an agricultural research project. Second, a number of new production approaches will be tried through a small rural operations project that will test various agricultural input packages under different climatic and soil conditions. PART III - THE POPULATION, HEALTH AND NUTRITION SECTOR General 25. The health status of the population in Niger is among the poorest in West Africa. Life expectancy at birth is a low 45 years. Infant and child mortality rates are both high at 139 and 28 deaths per 1,000 live births, respectively, and account for 60% of all deaths in the country. Maternal mortality is also high -- nearly 1,000 out of 100,000 pregnancies result in the death of the mother. Preventable and treatable diseases such as malaria, diarrheal disease, measles, meningitis, tuberculosis, pneumo- nia, hepatitis. poliomyelitis and tetanus, combined with inaccessibility to potable water, poor sanitation and malnutrition, are responsible for high mortality, especially of infants and children, as well as for high morbidity. Malaria, diarrheal disease and measles alone account for 60% of recorded deaths, and are particularly severe among children under five, where they are responsible for 80% of deaths. Malnutrition, especially of children and nursing mothers, is a serious problem in spite of theoretical availability of sufficient food in normal rainfall years, and has become worse as a result of the recent drought. Population growth is estimated at 3% per year, with the average Nigerien woman bearing seven children. In the absence of effective population programs, Niger's population will increase from its present level of 6.1 million to 11 million by the year 2000. 26. The reasons for the poor health of the population are numerous: (a) the environment is difficult, providing only meager subsistence to a majority of the population; (b) coverage of health services remains low despite major efforts to expand health infrastructure and a village health worker program; (c) there is little access to health education and information; literacy is low, and the population is often unaware of what causes disease and what simple measures can be taken to prevent it; and (d) nutrition and family planning concerns have been inadequately addressed in government policy and through the health services. Moreover, financial constraints and inadequately trained manpower limit the scope for rapid improvements. -9- The Health System 27. Since independence in 1960, government policy in the health sector has emphasized primary health care and preventive medicine, and precedence has been given to the delivery of basic health services to rural areas, where the majority of the population lives. Consequently, a network of rural dispensaries and village health worker teams has been established and constitutes the base of the system. The key health providers are the nurses that staff the rural dispensaries; they are responsible for a variety of curative and preventive services, supervision and in-service training of village health teams, health and nutrition education, and recordkeeping. Where maternal and child health services are not available, the dispensary nurse also is responsible for pre- and post-natal care. Health problems that cannot be resolved at the village or dispensary level are referred to medical centers, usually located in provincial capitals. These centers are directed by higher-level nurses. There is also a separate network of maternities and maternal and child health care centers, located primarily in urban areas. Two national hospitals and five depart- mental hospitals complete the national referral system. Drug procurement and distribution is handled by the Office National des Produits Pharmaceutiques et Chimiques (ONPPC), a state-owned company which is under the jurisdiction of the Ministry of Public Health and Social Affairs (MOPHSA) and runs its own network of pharmacies and produces some drugs. An informal network of ambulatory private drug merchants complements the ONPPC network. A small private sector operates six clinics, four maternities and two pharmacies in Niamey. 28. KOPHSA is responsible for the formulation and implementation of uational health policy and for management of the country's health system. Operations are decentralized at the departmental level, where medical officers head the seven departmental directorates of health, and at the provincial level, where medical centers are located. Health System Performance 29. The health system has not responded adequately to the needs of the population. While hospitals tend to be reasonably well provided for in terms of staff and supplies, this has not been the case with local facili- ties, which have suffered from relative neglect in recent years, when they have borne the brunt of budget cuts. As a result, buildings and equipment have deteriorated, drugs are scarce, and facilities are inadequately staffed. Rural dispensary nurses are able to fulfill only some of their responsibilities; lack of supplies and drugs seriously compromises their effectiveness and consequently the population's confidence in their services. Provincial medical centers are hardly more than oversized dispensaries for lack of equipment and supplies. Furthermore, access to either of these facilities is limited in practice to persons living within a 10 km radius (about one-half of the total population). The population beyond this area relies mostly on occasional servicea, mainly immunization, provided by a small team of mobile units, and on traditional practitioners. Until recently, there has been an almost total lack of in-service training and technical super"-sion of middle and lower-level personnel. - 10 - 30. Drugs are expensive and scarce. ONPPC imports over 4,000 drugs, mostly in brand name form and in small quantities, and consequently, in many instances, at unnecessarily high prices. Drugs are sold through the ONPPC network to private middlemen and consumers, and to the MOPHSA, which provides them free of charge in its facilities. However, the drug budget of the Ministry has barely increased over the past five years, and the Ministry is no longer able to supply its facilities adequately. As a result, private expenditures on drugs at ONPPC outlets have risen sharply as patients often have to buy their own medicine in order to be treated in public facilities. 31. The impact on health status of the village health worker system is unclear. Village health teams were introduced in Niger as early as 1964, but it is only recently that coverage has attained some significance, reaching 46Z of villages in 1984. The system has suffered from a lack of supervision, and recently, the displacement of whole villages due to the drought may have led to the dissolution of many health teams. The United States Agency for International Development (USAID), which has been providing the bulk of the financing for the system, is at present reviewing it. 32. Major health problems, particularly those affecting women and children, are addressed through special health programs which have not met needs. Before its recent revision, the malaria control strategy of chemoprophylaxis of women and children was neither sustainable nor cost- effective given the Government's resource constraints. Despite the financial support of various aid donors, the diarrheal disease control program suffers from a lack of proper coordination and management. Immunization coverage is low (20% at best), and a national program of immunization did not exist until recently. The delivery of maternal and child health services is impeded by lack of equipment and logistical support. Family planning services are not currently provided by the MCH network. 33. The inefficiencies in the health system highlight weaknesses in MOPHSA. While higher and middle-level staff in MOPHSA are technically competent, it lacks administrative and management skills. Moreover, MOPESA suffers from weak planning, programming and project analysis, poor information, and av ineffective system of monitoring and evaluation. Consequently, investment decisions have borne little ielationship to sectoral development objectives. In addition, manpower needs and recurrent costs have not been considered when planning investments. Health Expenditures 34. Recurrent public expenditures for health totalled CFAF 6 billion, or 7.5% of total recurrent outlays in 1984. The MOPHSA recurrent budget accounted for CFAF 4.5 billion. Personnel costs have been steadily increasing over the past few years as a result of ambitious training programs of paramedical staff and of the policy which guarantees employ- ment in Government to all graduates in health-related disciplines. To accommodate the growth in personnel expenditures, spending on supplies has been curtailed. Personnel costs represented 45Z of MWPHSA recurrent - 11 - expenditures in 1979 as compared to 522 of the 1985 budget, and would have accounted for 64Z of the projected 1990 budget if government policy had remained unchanged. At the same time, private expenditures for health services have been increasing, as public facilities have not been able to provide the necessary services. Private expenditures now total about half of public recurrent expenditures; they are mostly for drugs and services purchased from ONPPC and the private facilities. 35. Despite stated government policy, the balance of recurrent health expenditures has gradually shifted in recent years towards urban hospitals and medical evacuations, resulting in an undesirably strong emphasis on curative, rather than preventive, health care catering to a small urban minority. Some 50% of the budget allocation for personnel and supplies are for hospitals, 40X for provincial-level medical facilities, and only 10% for rural dispensaries. This is despite the fact that over ten million consultations are held every year in dispensaries and provincial level facilities, compared with 350,000 hospital admissions. The investment budget has also emphasized the urban and hospital sector, while the major category in the investment budget in the rural sector represented operating costs of village health worker teams. Health Policy 36. The Government remains committed to a policy of primary health care and preventive medicine, primarily aimed at rural areas. Emphasis is given to expanding coverage and quality of health care services in general, and to serving the most vulnerable segments of the population in particular. The Government is aware of the imbalances that have appeared in the sector over the past few years, and the need to correct them. Moreover, as budget resources can be expected to remain constrained in the foreseeable future, successful adjustment in the sector will depend on the Government's ability to control growth in expenditures and to better match objectives with programs. Under the structural adjustment program that the Government is implementing with the assistance of IDA, a health sector strategy has been included as part of the Government's Letter of Development Policy agreed to in connection with the Structural Adjustment Credit (Annex IV). The strategy reflects the emphasis on preventive rural health services in both the recurrent and investment budgets. In addition, the strategy calls for broadening the revenue base through new and improved cost recovery measures, and building up an adequate institutional capability to plan and implement policies and programs and effectively monitor investments and operations. Through the proposed project, the Association would assist the Government in formulating and implementing specific policy measures supporting this strategy. Nutrition Policy 37. While the Government acknowledges that malnutrition is a major health problem in Niger, data on the extent and distribution of nutritional deficiencies 'n the country have not been collected systematically, and the problem of malnutrition and its determinants is not well understood. This contributes to the absence of any policy or national program to improve the nutritional status. Some attention is being given to nutrition education - 12 - and recuperation of malnourished children, and a modest, but successful nutrition pilot project is being run in about 60 villages in three provinces by the Government with the help of the United Nations Children's Fund (UNICEF) and the World Health Organization (WHO). Population Policy 38. In the past, the Government has for the most part regarded the country's population growth rate as acceptable, although it is high. Provision of family planning services for maternal and child health reasons has been allowed, but these services have never been widely available or actively promoted. Recently, however, the Government, in providing for the basic needs of the population, has started to become concerned about population growth, as it has faced greater financial difficulties and self-sufficiency in food production appears increasingly difficult to achieve. The Government is now actively considering a policy to check population growth and reduce maternal and infant mortality. In this connection, the Government intends to establish a national family planning commission, introduce legislation on family planning and related medical practices and family relations, and train health staff in maternal and infant health care. USAID and the United Nations Fund for Population Activities (UNFPA) are assisting the Government in these efforts, which are expected to result in the formulation of a national population policy. Moreover, family planning services are gradually becoming available in Niamey, where a National Family Health Center opened in November 1984. The center, operating with assistance from UNFPA, provides limited family planning services for the population in and around Niamey, and conducts research and training in maternal and child care and family planning, infertility and sterility problems, and demography. The response to the center has been good and has led to over 2,000 new acceptors for contraceptives between November 1984 and June 1985. The center is training midwives in family planning methods and will expand provision of family planning services to maternities and maternal and child health centers around Niamey over the next 12 months. External Assistance 39. In 1984, external assistance to the health sector amounted to US$4.5 million (US$0.72 per capita). Among multilateral donors, WHO provides technical support and training to MOPHSA; UNICEF programs focus on drug procurement, immunizations, nutrition and rural health; UNFPA supports family planning activities and the European Development Fund (FED) assists in a program to expand the health network. The most important bilateral donors are France, which provides physicians, and USAID, which finances the village health worker program and planning and management assistance for MOPHSA. A number of other donors provide training, scholarships, technical assistance, and equipment. Non-governmental organizations support basic health services in the countryside. External assistance is relatively uncoordinated, and more effective aid coordination will be necessary to channel external funds to priority programs and projects consistent with the structural adjustment effort. This issue will be addressed in connection with the proposed project (para. 47). - 13 - Bank's Role in the Health Sector 40. The proposed project will be the first IDA-financed project in the health sector in Niger. The Association's intervention in the sector is justified on several grounds. First, human resource development is central to long-term development in Niger and should be an important element of any strategy that aims at improving the country's very limited development potential. Second, through its structural adjustment dialogue, the Association has assisted the Government in the formulation of a health sector strategy. The project will be the principal vehicle to assist the Government in implementing structural reform within the health sector and in developing population and nutrition policies. Third, while external funding has been relatively abundant for the sector, it is uncoordinated and leaves some priority areas and policy issues uncovered. Through the project, the Association will encourage aid coordination and investment planning in support of the sector strategy; IDA will complement donor financing through its support of efficiency improvements in priority programs. PART IV - THE PROJECT 41. The Government requested IDA financial assistance in the health sector in February 1982. Project preparation began in mid-1983. Two advances under the Project Preparation Facility have been approved (in August 1983 and in February 1986) totalling US$1 million equivalent. The proposed project was appraised in June 1985. Negotiations were held in Washington in mid-February 1986. The Nigerien Delegation was headed by H.E.M. Abdou Moudi, Minister of Public Health and Social Affairs. The Staff Appraisal Report (No. 5937-NIR) is being distributed separately to the Executive Directors. A Supplementary Project Data Sheet is given in Annex III. Project Objectives 42. Through the proposed project, IDA will assist the Government in introducing policy reform in the health sector. It will assist in the implementation of Niger's structural adjustment program at the sectoral level through studies and programs aimed at improving investment planning, the allocation of recurrent expenditures, cost recovery, essential drugs availability, sector management and aid coordination. It will also assist the Government to define policies relating to population and family planning, and nutrition. Moreo-ver, in support of the sectoral reform program, the project will assist in improving the efficiency of priority health programs relating to (i) maternal and child health care including the control of malaria, diarrhea and other communicable diseases and family planning, (ii) health education and community initiatives, and (iii) training of health personnel. - 14 - Detailed Features A. Policy Reform 43. Investment Planning. Under the Government's structural adjustment program, the share of the health sector in the investment program is projected to rise substantially, from 1.7X in 1984/85 to 4Z in 1987/88, reflecting the increased importance that the Government attaches to human resource development. The composition of the investment program for the health sector has been adjusted to improve coverage and quality of health care services in rural areas and to emphasize rehabilitation, while limiting new investments in physical facilities, including hospitals. In connection with the proposed project, the Government will review annually with the Association all investment expenditures made in the health sector in the previous year and those proposed for the following three years. 44. Recurrent Expenditures. Given the shortage of financial resources, the reform program includes measures to restructure the recurrent budget and to improve efficiency in the health sector. The growth in the health sector wage bill has been curtailed to release funds for materials and supplies. Priority is being given to staffing, equipment and maintenance of facilities in the rural areas. To reduce transfer payments, the Government is overhauling the system of medical evacuations and has already introduced beneficiary participation in its financing. To ensure an adequate balance between staffing and the availability of materials and supplies, new entries into nursing schools have been sharply reduced in 1985/86 from an initially programmed 140 to 20 students. This curtailed enrollment will meet the higher level staffing requirements in line with the projected expansion in the health system. As a result of the reduction, the MOPHSA wage bill is now expected to stabilize at 552 of MOPESA recurrent expenditures. This will permit increased expenditures for materials and supplies. To alleviate pressure on the recurrent budget, maintenance of small infrastructure will be gradually transferred to the beneficiaries, and the feasibility of transferring some central budget expenditures to local authorities will be examined. In connection with the proposed project, the Government will review annually with the Association the composition of its recurrent budget for the health sector as well as the recurrent cost implications of its investment program. 45. Cost Recovery. Under the reform program, the Government aims to increase cost recovery for public health services. Improved cost recovery measures will take into account the ability of beneficiaries to pay, the collection costs, and the type of user charge most appropriate for the service provided. The Government has already enforced a stricter applica- tion of the hospital fee system and is seeking ways to initiate cost recovery at the local level. The proposed project will support these Government initiatives, initially, by financing studies to (i) improve the fee collection system in national and departmental hospitals, and (ii) develop appropriate cost recovery measures for basic health services. Subsequently, the project will support the implementation of cost recovery - 15 - measures. The Government confirmed that a plan of action for improved fee collection in hospitals will be completed by August 31, 1986, and an action plan for cost recovery from basic health services will be completed by December 31, 1988 (see also para. 49). 46. Essential Drugs Policy. In an effort to lower costs and increase availability of essential drugs (para. 30). the Government has drawn up an essential drugs list based on a determination of needs by level of facility. Furthermore, it has formulated an essential drugs policy, which is in the early stages of implementation. The project would provide assistance to implement this policy, in particular to improve the procurement process, and educate drug prescribers and the population at large about essential drugs. Under the project, alternative ways to extend the drug distribution system will also be studied. 47. Sector Management and Aid Coordination. The analytical and managerial capabilities of the MOPUSA will be strengthened through a program of institutional development. Under the proposed project, studies will be financed which will examine ways to achieve improvements in (i) financial management; (ii) hospital management; (iii) cost effectiveness of basic health services and operations; and (iiv) cost effectiveness of proposals for the use of the university hospital facilities. Efforts to improve management in MOPHSA are underway. The Ministry has defined functions, staffing and financial requirements for each level of service, and has drawn up job descriptions for each level of staff. In addition, with USAID assistance, MOPHSA has undertaken a staff inventory, and has begun to develop a planning, monitoring and evaluation capability in the Ministry, including development of management systems for information, financial control and human resource management. IDA is collaborating closely with USAID, and the monitoring and evaluation systems which will be introduced under the project will be integrated into the management information system. Also, funding will be available under the IDA credit to support the manage-aent program being financed by USAID. if necessary. Furthermore, to enstre that the Government, the Association and all other donors coordinate their efforts around the sectoral strategy. the Government will organize annual meetings of all aid agencies participating in the financing of health sector activities in Niger. 48. Development of Population and Nutrition Policies. In addition to project assistance to extend family planning services outside Niamey described in para. 54 below, the Association will support the Government's efforts to develop a policy to check population growth and reduce maternal and infant mortality. To this end, IDA intends to collaborate closely with UNFPA and USAID. Funds have been set aside under the project to test and support the implementation of new ideas or initiatives for delivery of services resulting from operational experienci and eventually lead to program refinement and policy development. A similar approach will be taken for the development of a nutrition policy: the project will support pilot activities at the community level and the development of a nutrition surveillance system; these elements are expected to contribute to the formulation of a national nutrition policy. - 16 - 49. The Government will formulate action plans based on the results of the studies discussed in paras. 45-48 in consultation with IDA according to a specified timetable (Annex III, Section II1.3). US$3.5 million have been allocated under the project to begin Jmplementation of action plans based on the findings of these studies and on operational experience derived from the project. Disbursement of these funds will be conditioned on the Association's approval of proposals from the Government. The Association will approve each plan of action taking into account its relationship to the Government's health policy, its potential impact, its financial viability, and the availability of resources to support incremental operating costs. B. Basic Health and Family Planning Services 50. In support of the Government's policy of developing rural services and preventive medicine, the project will assist in strengthening, particularly in the rural areas, priority programs which address the most urgent health problems affecting women and young children, the highest risk groups in the population. These programs include control of malaria, diarrhea and other communicable diseases as well as maternal and child health care, including family planning. Program activities will be reinforced through the project's health education, community initiative and training components. Furthermore, the project will encourage integration of these programs into a coordinated primary health care effort which is the most cost effective approach of delivering these services. Project support to these programs will include the rehabilitation of local level health facilities, and the provision of equipment and materials, drugs and vaccines, vehicles, technical assistance, training, logistical support for supervision and monitoring, and incremental operating costs. Project assistance to each of the programs is described below. (1) Strengthening of Existing Services 51. To reduce the incidence of malaria in Niger, the Government has designed a national malaria control program with assistance from WHO. The program is effective given the Government's financial and manpower constraints, and will be supported under the project. It uses chemotherapy with particular focus on children, limiting chemoprophylaxis to pregnant women: it will permit children to develop natural immunities and will retard evolution of chloroquineresistant strains of malaria. The drug requirements will be reduced. dosages will be standarized and sufficient quantities of chloroquine will be made available. The program also includes surveillance of malaria incidence, drug resistance monitoring, enhanced diagnostic capacity, staff training and community education. Activities will be carried out bv existing institutions. An initial stock of chloroquine that will cover estimated needs for one year (about CFAF 26 million) will be provided under the project; the chloroquine stock will be replenished through revenues from its sales. she Government will recover all costs related to the sale of chloroquine. As a condition of credit effectiveness, the Government will establish an account in a commercial bank to operate the revolving fund for the replenishment of chloroquine. All proceeds from the sale of chloroquine will be deposited into this fund. The account will be opened by ONPPC. - 17 - 52. The Government also has formulated, with WHO assistance. a national policy to reduce mortality from diarrheal disease. While program activities are financed b7 Belgium. Holland, USAID, WHO and UNICEF, there is a lack of funding fo. program management and administration which will jeopardize the efficient operation of a well-conceived and essential program. Therefore, the project will provide technical assistance to develop a program monitoring and evaluation capability and to assist in periodic program evaluation and logistical support to the management unit. 53. With USAID and WHO assistance, the Government has prepared an expanded program of immunization, which will be an integral part of Niger's preventive health care system. The program aims at protecting children under five against measles, pertussis, poliomyelitis, diphtheria, tetanus and tuberculosis; it is complemented by immunization of children up to age 15 against yellow fever. Pregnant women will be vaccinated against tetanus. Project assistance to the program will allow MOPHSA to implement the program, whose progress will be closely monitored, on a nationwide basis. The Government will prepare and submit to the Association by September 1 of each year an evaluation of the previous year's campaign, including coverage achieved, and proposed target coverage for the following year based on that evaluation. IDA agreement to the annual proposal will be a condition of disbursement for funds to purchase vaccines that year. 54. Niger's innovative approach to maternal and child health services (MCH) goes beyond typical MCH services to include literacy programs and income-generation opportunities for women, home economics instruction and other health and nutrition education-related activities. This approach, particularly the expansion of outreach services, will be supported under the project. In addition. the project will complement assistance by UNFPA and USAID to family planning (FP) through the extension of FP activities outside Niamey; FP activities would be introduced in maternities and MCH centers in all seven departments. The project will provide gynecological equipment and contraceptives and specialized training in PP-related disciplines for physicians, who will be responsible for program development, training other staff and providing a referral capability for FP and other MCH complications. In addition, under the project, FP acceptance will be studied in three departments. The results of this study will assist in refining the FP program including FP education. The project will also promote population policy dialogue and development, described in para. 48. and FP education, described in para. 56. 55. To ensure adequate implementation of improved programs at the local level, the project will alsc finance necessary rzpairs and re-equip- ping of local level health facilities, which constitute the most cost- effective means of providing primary health care services to the greatest number of beneficiaries. As the MOPHSA budget has become increasingly constrained, maintenance of local health facilities has suffered, and most of them are in urgent need of repair. Also, facility design has proven to be inappropriate to efficient use and maintenance of facilities. A rehabilitation program for local level facilities has already been drawn up by the Government. To improve maintenance performance in the future, the project will provide technical assistance to design health facilities which - 18 - require little maintenance and to strengthen the maintenance system. The Government will present to the Association for its approval a plan of action for strengthening the maintenance system and new designs by January 31, 1987. (2) Development of Health Education and Community Initiatives in Health and Nutrition 56. Health Education. The project will assist MOPHSA in developing a health education program to support the Government's primary health care strategy. The program will emphasize malaria control, diarrheal disease control, immunization, maternal and child health care, family planning, nutrition, and personal hygiene. Use will be made of the extensive radio and television network in Niger, which reaches even remote villages, of existing health facilities, and of community and youth groups. Audiovisual materials will be prepared and used in curricula of functional literacy programs of primary, secondary and paramedical schools, where health education skills will be emphasized. Messages will be delivered through the departmental directorates of health, in health facilities, by mobile units, and by local organizations. Field research will be carried out before preparation of teaching materials to ensure their adequacy. Also. systematic feedback from the field will help improve the focus of the health education messages on specific target groups. 57. Community Initiative and Nutrition Policy Development. The project will support (i) the extension to an additional three provinces (about 60 villages) of an ongoing pilot project for village-level nutrition improvement, and (ii) the deavelopment of a nutrition surveillance system. The village-level nutrition program being financed by WHO and UNICEF has been in operation for about one year and has proven to be a successful means of eliciting villagers' (particularly women's) interest in their well-being. Under the project, interested villagers will receive financial and technical support to undertake self-help activities such as small-scale food production, storage and marketing, water supply and sanitation, and health and nutrition education. The project will finance the salaries of six trained staff to be based at the provincial level (two per province) who have been trained and will act as resource people and initiate contact with villages. It will also provide equipment and logistical support to provincial level technical services which will provide villages with technical support. The project will also finance equipment and materials for village projects, but the villages will be financially responsible for maintenance and other operating costs once the programs are in operation. In addition, the project will help MOPHSA develop a nutrition surveillance system which will be integrated into the health information system. The Govermment will present to the Association for its approval a proposal for a nutrition surveillance system and a timetable for its implementation by March 31, 1987. (3) Health Manpower Development 58. The project will assist the Government to begin implementation of its program for in-service training and field supervision of MOPHSA's paramedical staff. Training programs will emphasize public health management, administration of primary health care and maternal and child - 19 - health care, including nutrition, family planning and health education, malaria control, immunization and oral rehydration therapy. In-service training sessions, which will be carried out by departmental training teams to be set up under the project, vill emphasize the same subjects. By the end of the project implementation period, all MOPHSA paramedical staff will have had at least two in-service training cycles. Training will be reinforced through a program of regular supervision to ensure technical support and guidance to field staff. Finally, funding will be provided for specialized training in skills directly related to implementation of the various programs financed under the project. The Government will submit a program for supervising field staff by the end of December 31, 1986, and will submit annual training plans, including study tour and fellowship proposals, for review and approval by the Association no later than July 31 of each year. Project Cost and Financing 59. Total project cost is estimated at US$29.3 million equivalent net of taxes and duties, with a foreign exchange component of US$18.5 million, or 62Z of total project cost. Base costs are in February 1986 prices. Price contingencies for both local and foreign costs are as follows: 7% for 1986 and 1987, 7.5Z in 1988, 7.7% in 1989, 7.6% in 1990, and 4.5% in 1991 and 1992. Physical contingencies of 10% have been applied for all expenditure items except national staff salaries and recurrent costs. Cost estimates for rehabilitation works are based on recent quotations by local suppliers. 60. The proposed IDA credit of SDR 25.1 million (US$27.8 million) will finance about 95% of total project costs net of taxes. The Government will meet the remaining (local) costs of US$1.5 million equivalent. While there is no formal cofinancing for the project. IDA will collaborate closely with other donors. As discussed above, the Government will organize annual meetings of donors, and IDA will coordinate its activities on population policy and health management vith USAID and UNFPA (paras. 45 and 48). A detailld breakdown of costs is given in the Credit and Project Summary. Cbst Recovery Under the Project 61. When fully developed, the project will require annual incremental budgetary outlays on the order of CFAF 484 million (US$1.3 million) in constant 1985 prices. This represents an increment of 10.1% over the 1985 recurrent health budget. Most of the costs (81%) relate to the vaccination campaign and the training activities (CFAF 325 million and CFAF 66 million, respectively). To date, many vaccines have been financed by the donor community on a grant basis and it is assumed that donor assistance in this respect will continue. This would reduce domestic funding requirements by CFAF 129 million. Gross incremental recurrent costs to be borne by the Government will, therefore, amount to CFAF 355 million (US$923,000), or 7.4% of the 1985 health recurrent budget. However, savings totalling CFAF 526 million are expected from Improvements in cost recovery from hospitals and local facilities estimated to generate approximately CFAF 200 million and CFAF 100 million, respectively; revenues from the sale of chloroquine - 20 - estimated at CFAF 26 million annually, and savings of CFAF 200 million to be achieved through the overhaul of the system of medical evacuations (para. 44). Therefore, the project will result in overall savings to the Government. Project Implementation 62. The project will be implemented over a period of five and one-half years. The Ministry of Planning will be responsible for imple- mentation of the policy reform component in collaboration with MOPHSA. MOPHSA will implement the basic health and family planning component which will be integrated into existing services. These services will be streng- thened with local staff and technical assistance. Attention will be paid to minimizing the need for incremental staff. The implementing agencies' capability to execute the programs financed under the project will be strengthened through the integration of programs into a primary health care system, training, and the study and subsequent implementation of policies to improve management and cost effectiveness of services, as described in paras. 45-47 above. Moreover, the planning and management assistance being financed by USAID and project support of monitoring and evaluation should reinforce the Ministry's implementation capability. 63. A Project Management Unit (PMU) will be attached to the Office of the Minister of Public Health and Social Affairs. It will be responsible for overall coordination of project activities. The PMU will consist of a director, an administrator and an accountant, as well as support staff. It will be assisted by a full-time, internationally-recruited specialist in project management and implementation, and short-term technical assistance to set up a project accounting system, audit project accounts and assist in procurement. The establishment and staffing of the PMU and the setting up of a project accounting system are conditions of credit effectiveness. 64. Technical Assistance. The project will provide a total of 146 months of technical assistance for the following project activities: project management, 68 months; policy reform studies, 20 months; health education, 27 months; training, four months; vaccination program, six months; health facilities maintenance, six months; family planning, nine months; diarrhea control program management, two months; nutrition surveillance, three months; malaria vector control study, one month. Procurement and Disbursement 65. Procurement. Because of their relatively small size and wide dispersion in remote areas, civil works contracts, all of which will be for renovation of local health facilities, will be awarded folloving local competitive bidding (LCB) according to procedures acceptable to the Association. However, for individual contracts valued under CFAF 5 million (US$13,000 equivalent), prudent local shopping procedures acceptable to the Association will be applied. The aggregate amount of the above exceptions is not expected to exceed US$0.6 million equivalent. Contracts for furniture, equipment, vehicles, materials, drugs and vaccines will be awarded after international competitive bidding (ICB) according to - 21 - procedures acceptable to the Association. Exceptions to ICB will be for (i) contracts with a value of less than US$75,000 equivalent, each of which will be awarded after LCB according to procedures acceptable to the Associatior; and (ii) small value items costing less than US$10,000 equivalent per contract that will follow prudent local shopping procedures acceptable to the Association. The aggregate amounts of these two exceptions is not expected to exceed the equivalent of US$700,000 and US$200,000, respectively. Purchases of medical equipment, vaccines and drugs will be made folloving UNICEF's international procurement procedures, also acceptable to the Association, in the event that they expedite procurement and limit costs. A list of items to be procured through UNICEF will be determined and agreed upon during project implementation. Othervise, the items will be procured through ICB, except where there is only one existing supplier. Procurement arrangements are summarized in Annex V. 66. Items will be grouped to the extent practicable to encourage competitive bidding and to permit bulk procurement. Review of tender documents by the Association prior to award will not be required for civil works contracts as their cost is not expected to exceed US$150,000 equivalent in any single case. However, such review will be required for contracts for furniture, equipment, vehicles, materials, drugs and vaccines costing more than US$50,000 equivalent each. This is expected to result in prior review by IDA of about 70% of goods contracts. Where ICB procedures are used, domestic manufacturers will be allowed a margin of preference of 15Z or the existing applicable rates of duties, whichever is lower, over the c.i.f. prices of competing foreign suppliers. 67. Disbursements. The credit of US$27.8 million equivalent will be disbursed over seven years against the following items net of taxes: (a) civil works (US$2,400,000): 100% of total cost: (b) furniture, equipment, vehicles, materials, drugs (US$6,000,000): 100% of total cost; (c) vaccines (US$4,400,000): 100% of total cost; (d) technical assistance studies, fellowships, training (US$6,900,000): 100% of total cost; (e) funds for Implementing results of studies and innovative activities (US$3,500,000): 100Z of total cost; (f) operating costs (US$2,000,000): 90% initially, declining to 30% toward the end of the project; (g) refunding of the project preparation advance (US$1,000,000); and (h) US$1,600,000 will be unallocated. 68. Special Accounts. To facilitate disbursements, an amount of US$1 million will be advanced from the IDA credit and deposited in a Special - 22 - Account held in a local bank under the control of the Project Director. The Special Account will cover about three months of estimated project expenditures. In order to ensure that the Government's counterpart financing is promptly available, the Government will establish a separate replenishable Local Advance Account in local currency of about CFAF 30 million (US$78,000 equivalent) representing the approximate amount of Government counterpart financing for three months of project activities. Opening of this account and depositing the initial amount of CFAF 30 million is a condition of credit effectiveness. 69. Accounting, Auditinig and Reporting. The PMU will maintain all project accounts, which will be audited annually by auditors acceptable to the Association. Certified cop-es of the accounts and the auditors' report will be forwarded to the Associat4on for review within six months of the end of each fiscal year. Quarterly reports on the progress of imple- mentation will be submitted to IDA by the Project Management Unit. Project Benefits and Risks 70. Benefits. Through its support of the Government's health sector reform program, the project will help correct imbalances that have appeared in the allocation of resources in the health sector in recent years. Investment and recurrent expenditures will be directed increasingly towards the rural population and for primary health care; financial constraints will be eased as public funds devoted to medical evacuations abroad are reduced and as efficient administrative mechanisms for recovering part of the cost of curative services are developed; a national essential drugs policy will improve the availability of drugs and reduce their costs to the state and the individual consumer. Project support for the institution- building effort in MOPHSA will provide a permanent capability for better planning, policy implementation and donor coordination. 71. In support of the reform program, the project will strengthen key maternal and child health programs, complemented by the development of community initiatives and by the upgrading of personnel skills, which will contribute to improving the health status of the most vulnerable segments of the population. Support for family planning activities will expand services in urban areas and extend them to rural areas and facilitate policy development. Project support of pilot nutrition activities and nutrition surveillance development will lead to the elaboration of a national nutrition policy. 72. Through the strengthening of existing services, the project will improve the quality of health services available to 3.4 million people (over half the total population of Niger). Under the expanded immunizatiou program, an estimated 1.2 million children nationwide, representing about 75% of children under five years of age, will have been vaccinated against major childhood diseases by the end of the project implementation period. 73. Risks. The project will be the first Bank-financed operation in the sector in Niger. There is, therefore, a risk of delays in implemen- tation. However, the Government is strongly committed to the sectoral - 23 - reform program and anxious to move ahead with project implementation. Local staff responsible for project implementation is well-qualified. Moreover, with financing from two PPF advances, a number of steps have been taken to ensure expeditious project start-up. In addition, an initial project implementation workshop is planned prior to credit effectiveness, and during the first year of implementation, an intensive supervision effort is anticipated. PART V - RECOMMENDATION 73. 1 am satisfied that the proposed Credit will comply with the Articles of Agreement of the Association, and I recommend that the Executive Directors approve the proposed Credit. A.W. Clausen President Attachments Washington, D.C. February 26, 1986 - 24 - ANN I T AB9 LE9 36 Page I of 6 IECKN - SOCIAL INOICATOIS DATA SHUT HOST (NOS( AECET ESTIATE) IlCERT LOW INoCU ArICA NESS #02HZ 19601k 1970ab ESI^TNAL SOUtH oF 3*165 ArRIcA s. oF sAMA AA ITWESA SQ. rJ) nrtAI. 1267.0 1267.0 1217.0 AItIOILTURAL 125.0 130.0 133.2 Sw CU NP (U53) .. .. 240.0 23S.8 1063.8 inw owumnu a cairn (KILOGNAS OF OIL EQUIVALIUY) 3.0 16.0 32.0 62.3 561.5 POA m an ML Sala POPUIlATION.aiO-TEa (THousANDs) 3234.0 4146.0 6062.0 DREAO POPULATION1 C OF TOTAL) 5.0 6.4 13.M 20.1 32.0 POPUlATION PNOJECTIOUS POPULATION IN fEAR 20O0 (HILL) 10.5 STlTIOIT PoPULoN (KILL) 40.0 POPULATION flEVIWIN 2.0 PoPMATtoll Oem R SQ. M. 2.6 3.3 4.6 33.2 65.1 P SQ. 1X. AGRI. LAND 25.3 31.9 ".1 112.8 124.8 POPULATION ACE STUCTUES (Z) 0-14 YU 44.7 46.2 45.9 46.0 45.6 15-64 YUS 52.6 51.1 51.4 50.8 51.5 65 AND ANOM 2.5 2.5 2.5 2.9 2.7 POPLATUIN GROM rN (Z) TOTAL 1.2 2.5 2.9 2.8 2.9 CREA 3.0 6.2 6.9 6.4 5.1 CiRD BIRTH uRATn (ER TRWUS) 47.3 49.6 52.0 47.2 47.0 CRUDE RAE NATE (PER TlWOlS) 26.0 24.2 19.7 17.8 15.0 COS *PEODUCfIO RATE 3.3 3.3 3.4 3.3 3.2 FAMILY PULNN ACCEPTONS. ANNUAL (THOUS) .. GUNS (C Or HARRIEM WSSR) .. .. 1.0 i/ 3.3 6.4 I000 - mmmcmn ISDX OP FOOD MOD. CAPXTA (1969-71-100) 112.0 96.0 U6.0 83.3 82.9 PE CAPITA SOMY Of CLOrES CZ Op NQUIUTS) 100.0 86.0 100.0 67.7 96.5 PEOTINIS (CUANS rPE DAT) 65.0 56.0 71.0 51.9 55.4 OF CII ANUIL AID PULSE 18.0 16.0 26.0 c 13.7 16.5 CHE (ACS 1-4) DEATh aT 51.0 61.0 28.0 23.1 16.6 LIFE SEPCT. AT NIC (TEARS) 40.6 41.4 A4*9 47.8 52.0 INVAE HOST. RATE (ME ?M) 191.0 171.0 19.0 119.5 108.6 ACCSS TO SWI WATER (STOP) TOTAL .. 20.0 3.03 27.1 42.4 URBAN .. 3.0 41.0# 63.5 67.5 RURAL .. 9.0 32.0 id 1w.3 35.8 ACCES T ET UTA DISPOSAL (X Or PULATION) TOTAL .. 1.0 7.0 Id 26.5 Z1.9 UtW .. 10.0 36.0 71 65.4 57.7 RSNAL .. .. 3.0 A 20.8 20.7 POPULATIO PE PHYSIICIAU 92400.0 60090.0 3879.0 f 27901.7 11791.7 POP. PE WUES PERSO 9240.0 If 7260.0 4650.0 0A 330.4 2459.6 P. Pr HOSPITAL U5D TOTAL 2480.0 2300.0 1640.0 L. 1273.6 9l.1 READ .. 370.0 *20.0 7 426.2 368.6 IUAL .. 430.0 2020.0 A 3292.5 4371.9 ADH5SIONS PE HOSPITAL D 10.4 lb 3'.7 .. .. 27.2 AWNACK SIZE oFr HOUSEHOLD TOTAL .. .. UUU .. .. . .. BANAL .. .. . .. AWAC NO. OF PSNSONS/RO TOTAL .. .. . .. URNA .. .. . .. BAAL .. .. . .. scesz or WULNGS ni EI.ET m. .. .. .. WUL .. .. . .. -25- ANz I TAI LK 2Ai ji2Page 2 of 6 NICER - flOt INDICATORSDATA SWUM? mica u rtma CtL (SZCn1Wn AVERAGES) La evIl (C? RECEC T MTINITIUT) /b ac3%1 Uls tames1 AMICA MIDDLE taNOMw 196di iviolk gaiiiTal, soon I7 AAR VA A1FICA S. Ur bANAMA ADJUMSD U0170T RATIOS ERInARYs TOTAL 1.0 14.0 3 7.3 91.7 ALit 7:0 14.0 29.0 A 17.b 100.U FWWA.LE 3.0 9.0 17.0 f 54.9 53.2 SECONDARY: TAl 0.3 1.0 4.0 1 13.5 17.3 MAIA 1.0 2.0 51.0 17. Z5.0 pleat: a.i ho 2.0 9: .1 14.3 VOCATIOtAL Cl Or scAwRY) 4.3 2.7 1.J 13.2 5.9 PUPIL-TIAO(U RATIO PRIMR 43 0 M.0 413.0 ". 4L1, SRCNDR 11.07 20.0 28.U /c 2?.4 Z5.5 ASaCa CAz5slneoUsaaD FoM 0.3 1.4 2.. . 3.6 20.3 34IG REcZIVESt/ThOUSAID MP 1.0 35.0 45.9 ISA 1U7.L TV URCEMVEUSIThIJUSAJD 10F .- .. 1.2 2.e 2Q.O SUSFAPER ("DAILY CSIUIUL INTErZST") ctmCULAueU PER rHOUSAND POPULATION 0.3 0.5 0.9 5.0 13.4 C lNM AssAL ATtMADNC/CAPITA .. 0.2 .. O. 0.4 Jams -a SOTAL LJ0 FOICE CTr30) 1014.0 1320.0 1900.0 F31 (PIRCLET) 9.0 9.7 10.2 34.2 36.2 WRIQULTURE tCRucNT) 91.0 93:0 91.0 77.5 54.5 INWST (PECc) 1.0 2.0 3.0 af 9.7 18.3 PAITICEPATtON LtT CMCS) TOTAL 32.9 31.3 31.3 39.3 3b8A PALS 60.2 5.1 57.3 50.9 47.1 FEMLE 5.9 0.1 0.3 23.1 27.2 ECOMIC CPEIECT RtATO 1.4 1.5 1.5 1.3 1.3 :2Rec or PRIVATE INCM REEVSD n 1N01 OV INldS .- OF ..-. aSz 20X a, nlousuous# .. .. ..... LOU=S2PorIUS3OLDS .. .. LOUIS 402Or MCUSUIOLOS . - umw a ETKATS ss 5Ul DoEv IWIE LEL (USE PRI CAPITA) UR .. .. 111.0 t 105.5 59U.7 RURAL .. .- .. p5.0 275.3 snAmD -ruLTI lOVT? IxWE LEVEL CUSS FR CAITA) UR .. .. .. 113.1 545.0 RURAX' '' ...S. 07.0 201.1 ESTIMATED POP. ouLOW AnSOUr 1011?! INCODM LEVE (Z) URII .A. . 34-. RURAL .. .. .. 01.6 Ot AVAILASLX Nr APPLICAJLE NOTES /t The poop eer_ag fer aft lu11tetC Wre ,eisuer welt$ i er1g_tc ean_. CanreP ot emetries song the indicators dupen - uvutls tq of dues nd se an iet. lb ISnae. atber oe stud. Det. for lo late r tmses 1959 ass 1181; "Dat ter 1970" be"mtwe 199 and 1971; s_d data for 'Nut RecentiRnte between 1041 ant 1I43. Ic 1977; Id 1930; a 1973; aL 1925 JA 1,'0: & 1104: LA 190. Jus. 1955 ANNEX I - 26- Page 3 of 6 DEFINfliONS OF SOCIAL INDICATORS Noun: Altbough the data ae drawn from sounx geerally judpd the mot authoritative and reliable, it should also be noted that they may not br interatiuonally comprable because of the luck or tandardired definition and cocepta used by di*ffrent countnrs in colleting the dea. Tuhe datb arc, nonethelss, usful to deaibe orda of magnitude, indicate trendrs and diartnn cerCftain major digec betwen coumtri. The refence groups are (1) the ame counoty group or the subject country and (21 a country group with somewhat higher averag income than the ountry group otbe ubjectountry (excpt or-High Incone Oil Exporter group where -Middle Income North Africa and MiddleEast- ichon beauseor.uonger socio-cultural affinities). In the refernce group dat the s*ngs ae population uwighted a*ithmetic mnas for ech indicator and shown only when majority of thec coumiries in a group ha dau for that indicator. Sie the coverag ofcountne among the indicson delends on the availability ofddta and is no uniform, caudon must be excrsed in relating avermes orone indictor to anothr. These avgs are only useful in comparing the value orone indicator at a time amons the coutmry and reference groups. AREA (thousand sq.km.) Crude irth Rare (per thosaN)-Number of live births in the year Total-Total surface area comprising land area and inland wates;k. per thousand of mid-year population; 1960. 1970. and 1983 data. 1960. 1970 and 1983 data. Crude Deth Rate (per thtumand)-Number of deaths in the year AricEtral-Estimatc of agricultural area used temporarily or per thousand or mid-year population; 1960. 1970, and 1983 data. permanently for crops, pastures. market and kitchen gardens or to Gross Reptdwdia Ruse-Average number of daughters a woman lie fallow. 1960, 1970 and 1982 data. will bear in her normal reproductive period ir she experiences present age-specific fertility rates; usually five-year aveages ending GNP PER CAPITA (USS)-GNP per capita estimates at current in 1960, 1970, and 1983. market prices, calculated by same conversion method as World .Oy Panniug-Acceptor. Anal (sheunds)-Annual num- Bank Atlas (1981-83 basis); 1983 data. berof acceptors ofbirth-control devices under auspices ornational ENERGY CONSUMPTION PER CAPITA-Annual apparent family planning program. consumption of commercial primary energy (coal and lignite. Fandly Pfana-Usrs (peret ofjr id wea)--The percen- petroleum, natural gs and hydro-, nuclear and geothermal dec- tage of married women or child-bearing age who are practicing or tricity) in kilograms of oil equivalent per capita; 1960. 1970. and whose husbands are practicing any form of contraception. Women 1982 data. ofchild-bearing age are generally women aged 1549, although for some countries contraceptive usage is measured for other age POPULATION AND VITAL STATSlnCS groups. Total Popultion, Mid-YHear (thousand)-As of July 1; 1960. 1970, FOOD AND NUTRMON and 1983 data. Urban Pepttio
Группа Всемирного банка · Memorandum & Recommendation of the President
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