Haiti - First Health Project

Document of The World Bank FOR OFFICIAL USE ONLY c - d? f ?35 5t .4 Repon No. 8008-HA STAFF APPRAISAL REPORT HAITI FIRST HEALTH PRO-JECT NOVEMBER 28, 118S Human Resources Division Country Deparcment III Latin America and the Caribbean Regional Office TMis docoent ha a *estcd distiuto ad may be used by nensooby Ihe perfomuance of thei offiifl dudes. Its contnts may not othebwse be dBsosed o Wold Bak todza  CURRENCY BQUVALENTS Currency Unit - courde (G) US$1.00 - G 5.00 G 1.00 - US$.20 GOVERNM}NT OF HAITI FISCAL YEAR October 1 to September 30 I I I  FOR OMCIAL USE ONLY MITI FIRST HEALTS PROJECT Table of Contents Page No. [ GLOSSARY OF ACROIKS. .................. . . .... ... IV DEFINITION OF PCPULATION. HRALTS AND NUTRITION TERS .....................v B ASIC DATA .RO.ECT W..I .... ........ *............. vii CREDIT A Stts. . Y .. ............ I. INTBODUCTION. ............................. 1 II. THE BRALSE SECTOR.. .04*e.6e*000000 .00 .0 .0*.O.* . . 01 A. Status .......................* .............................. .u Population ...........1..........0.... Health ........ ..o......*..........3 Nutrition .........................5 The Health Care System ... ...... ............. 6 Health Financing ......................................... 9 Health Manpower ......................10 B. tey Sector Issues ............... ....... 11 C. IDA' K ole ..........................12 III. THE PROJECT S.......................... A. Px-oject Objectives ........................1 | B. Project Detcription......... ......... 14 C. Project Components ............. . ........................ 15 Institutional Developme t.......................... l ... 15 Service Delivery .... ......... .17 Epidemic Prevention and Control ....21 I This report is based on findings of an appraisal mission consisting of Xavier Coll (mission leader), Bruce Carlson (family planning specialist), Maria Victoria Lister (operations assistant), Carlos Trabucco (procurement specialist), and Jean Pierre Schwarta and Carlos Mena (consultants) which visited Haiti it. June 1989. 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.  ii Page go. IV. PROJECT COSTS AND FINhNCING .... .............................. .. 24 A. Cost of the Prosect ........................... 24 B. Project FiRecing uetCos..................... ... . .. .26 C. IAcremuntan Acudt ........Co ... 26 D. Procuremeat ................ ;2 V . Disbursement ................................................. 28 P. Accounts and Audits ......... .... .. ... **..29 V. PROJECT *... ... ... ... 00* ... 29 VI. PROJECT BENEFITS. JUSTIFICATION AND RISKS .... .......... ....... . . .31 A. Benefits and Justification ................. .,. ...... .31 B. Risks ...................... ............. ................... 31 VII *IAURDEENTS REACHED AND R MBMTION .....o 32 ANNEXESX ............ S5.. .............. . ....... .........35 ANNEX l s ...... ..... S T .. 003 Table 1 Prevalence of Modern Contraceptive Methods Table 2 Total Fertility Rate Table 3 Principal Causes of D ath, All Ages Table 4 AIDS Cases Relative to Other Countries In the Americas Table 5 Prevalence of Malnutrition by Region ANNEX 2: ......... O... ,..40 Table 1 Existing Structure of the Ministry of Public Health and Population Table 2 Proposed Structure of the Ministry of Public Health and Population Table 3 Structure of the Vestern 8ealth Regional Bureau Table 4 Health Facilities In the Western Health Region Table 5 NGO Presence by Region in the Health Sector Table 6 Aggregate Health Expenditures Table 7 Patient Fees for Services - Haiti Public Health System  iii Pago No. ANNEX 3% 4 Table I Reorganization of the Western Realth Region Table 2 Planned Departinnt and Distrlct Administration Structure Table 3 Programatic Areas In the Westem Health Region Table 4 Personnel of the Programmtic Areas of the 13SDK Table 5 Service Activities of the Health Agent Table 6 NGOs to Receive Project Financing Table 7 List of Health Centers and Dispensaries to be Constructed/Rehabilitated Table 8 Health Centers vhere Photovoltaic Energy Would be Installed Table 9 Monitoring & Evaluation of Project Outputs Table 10 Tuberculosis Control Table 11 AIDS Prevention and Control Activities ANNEX 4: Areas of Technical Assistance .................................... 61 t ~ANNEX Ss5...t6 Table 1 Project Components by Year Table 2 Suhmmary Accounts Cost Summeary Table 3 Summary Accounts by Year Table 4 Sumary Accounts by Project, Component ANNBX G6s. ** ...... &.* ..... .. 66 Table 1 Procurement Limits by Type Table 2 Allocation of Credit Proceeds Table 3 Estimated Schedule of Disbursements Table 4 Implementation Schedule ANNEX 7: Selected Documents and Data Available in the Project File ....... 70 MAP IBID No. 21848  iv GLOSSARY OF ACRONY)S ADG Assistant Director General AIDS Acquired Immunodeficiency Syndrome AGAPCO Agenc- d'Approvisionnement des Pharmacies Communautaires (Haitian Agency for the Creation of Commune Pharmacies) AOPS Association des Oeuvres Privees de Sante (Association of Private Health Organizations) BCG Bacillus Calmette-Guerin. Vacclne Against Tuberculosis' BCPLT Bureau de Coordination du Programme de Lutte Contre la Tuberculose (Bureau of Tuberculosis Control) BHSDM Basic Health Services Delivery Model CAT Croisade Antituberculose (Antituberculosis Crusade) CIDA Canadian International Development Agency CONAPO Conseil National de la Population (National Council of Population) CWTO Civil Works Technical Office DESE Direction d'Education Sanitaire et r'Entralnement (Directorate of Health Education and Training) FP Family Planning GOH Government of Haiti HIV Human Immunodeficiency Virus HUEH H8pital Universitaire de 1'Etat Haitien (Haiti University Hospital) IDA International Development Association IEC Information, Education, Communication ICC Internationa' Child Care IMR Infant Mortality Rate iS International Shopping. MSPP Ministere de la Sante Publique et de la Population (Ministry of Health and Population) MEF Minist6re de l'Economie et des Finances (Ministry of Economy and Finance) MOP Ministere du Planning et de la Coordination Externe (Ministry of Planning and External Coordination) NGO Non-governmental Organization NRL National Reference Laboratory PA Programmatic Area PAHO Pan American Health Organization PHC Primary Health Care PMU Project Management Unit PPF Project Preparation Facility SNEM Service National des Endemies Majeures (National Endemic Disease Service) TB Tuberculosis TFR Total Fertility Rate UNFPA United Nations Fund for Population Activities UNICEF United Nations Children's Fund USAID United States Agency for International Development WHO World Health Organization WHR Western Health Region  v DRFIN!TION OP POPULATION. K TLT AND NUTRITION TERMS Adult Literacy Rate The percentage of persons aged 15 and over who can read and write. Child Mortality Rate Annual deaths of children 1-4 years old per 1,000 children in the same age group. Contraceptive P:evalence Rate The percentage of married women of reproductive age who are using a modern method of contraception at any time. Crude Birth Rate Number of live births per year per 1,000 people. Crude Death Rate Number of deaths per year per 1,000 people. Degree of Malnutrition The Gomp' classification scale distingulshes three degrees in malnutrition, namely: first (mild): 76-902 of expected (or standard) weight fo; age; second (moderate): 61-752 of expected weight; third (severe): under 60X of expected weight. Dependency Ratio Population 14 years and under and 65 years and over as percentage of population aged 15 tc 64 years. Incidence Rate The number of persons contracting a disease as a proportion of the population at risk, per unit of time; usually expressed per 1,000 persons per year. Infant Mortality Rate Annual deaths of infants under 1 year per 1,000 live births during the same year. Life Expectancy at Birth The number of years a newborn child would live if subject to the age specific mortality rates prevailing at time of birth.  vi Maternal Mortality Rate Number of maternal deaths per 1,000 births in a given year attributable to pregnancy, childbirth or post-partum complications. Morbidity The frequency of disease and illness in a population. Mortality The frequency of deaths in a population. Neonatal Mortality Rate The number of deaths of infants under 28 days of age in a given year per 1,000 live births in that year. Perinatal Mortality Rate The number of fetal deaths after 28 weeks of pregnancy and of infant deaths under 7 days of age in a given year per 1,000 live births. Prevalence Rate The number of persons having a particular disease at a given point in time per population at risk; usually expressed per 1,000 persons per year. Rate of Natural Tncrease Difference between crude birth and crude death ratess usually expressed as a percentage. Total Fertility Rate The average number of children a woman will have if she experiences a given set of age-specific fertility rates throughout her lifetime. Serves as an estimate of average number of children per family.  vii MAITI PIRsr HATH PROJECT Basic Data General Total Area 28.000 square km Total Population 6.2 million Population Density 204 4.habitantslsquare km Rural Population as Proportion of Total Population 74X Adult Literacy Rate 35Z Primary School Enrollment (1986) 782 Secondary School Enrollment (1985) 182 GNP per capita US$360 Population, Health and Nutrition Total Fertility Rate (1986) 6.8 Crude Birth Rate (1986) 35/1,000 Crude Death Rate (1986) 13/1,000 Life Expectancy at Birth (1986) 54 years Infaat Moitality Rate (1986) 11911,000 Child Death Rate (1987) 22/1,000 Maternal Mortality Rate (1980) 3671100,000 Population growth 2.12 Population per Physician (1981) 8,200 Population per Trained Nurse 6,333 Population per Hospital Bed 1,150 Population within Reach of Health Services 702 Proportion of Birthe Attended in a Health Institution 252 Froportion of Pregnant Women Receiving Antenatal Care 242 Proportion of Children Between I and 2 Years of Age Fully Iminized (1989) 542 Contraceptive Prevalence Rate (Modern Methods) 4.9? Daily per capita Calorie Supply (as percentage of requirements) 962 Sources World Development Report (1988) and staff estimates. All figures apply to 1988 estimates unless otherwise indicated.  ix HAITI FIRST HEALTH PROJECT CREDIT AND PROJECT SUMMARY Borrower: Republic of Haiti Beneficiary: Ministry of Health and Population (MSPP) Amount: SDR 22.2 million (US$28.2 million equivalent) Terms: Standard IDA terms. Project Description: The project aims at assisting the Government of Haiti (GOH) in improving the country's health status through selected investments linked to increased efficiency and effectiveness of expenditures in health. It would specifically: (a) rationalize the allocation of re;ources for primary health care (PHC) within a more coherent institutional framework; (b) implement, in the Western health region, a Basic Health Services Delivery Model (BHSDM), based on the GOH stated PHC policy, and conceived as a framework for all public and private health activities; and (c) support the Acquired Immunodeficiency Syndrome (AIDS) medium- term prevention and control program, ani the national tuberculosis (TB) control program. These objectives would be supported by three key measures: (a) the restructuring of the MSPP budget over the project implementation period; (b) increased coordination, dialogue and inte'ration between the private and public sectors; and (c) the implementation of personnel recruitment and retirement policies as provided by current legal regulations. Benefil The project's main benefit would be to extend health service coverage and improve the health status of up to 2.1 million people in the Western health region, particularly of mothers and childrers, and control the spread of two major epidemics (AIDS and TB) nationwide. A second major benefit would be the improvement of the effectiveness and efficiency of the health system: first, by addressing financial and institutional issues; and second, by rebuilding beneficiary trust in public services. A third benefit would be the establishment of a framework that would facilitate future external financing of PHC programs, and integrate more effectively services provided by the public and private health sectors. Risks: The project faces four main risks: (a) the weak organizational and implementation capacity of the MSPP compounded by the political aud social instability of the country; (b) the lack of financial discipline and budgetary control in the sector; (c)  x the possibility of delays in implementing the sector's dec6ntralization strategy, particularly with regard to personnel; and (d) the sector inexperience with IDA-financed and policy-based health projects. These risks would be reduced by attention to institutional development, technical assistance, improved donor coordination, and the creation of a small and high-caliber PHU. The gradual phasing of policy measures, supported by annual progress reviews, would also minimize project risks. In addition, technical discussions on procurement and disbursements took place at IDA headquarters prior to negotiations, and intense supervision efforts by IDA (four missions per year) have been planned, particularly for the first two years of implementation. estkiated Costes al Local Foreign Total