Tanzania - Health and Nutrition Project

DOCUment of The World Bank FOR OFFICIAL USE ONLY Rept No. P-5201-TA MEMORANDUM AND RECOMMENDATION OF THE PRESIDENT OF THE INTERNATIONAL DEVELOPMENT ASSOCIATION TO THE EXECUTIVE DIRECTORS ON A PROPOSED CREDIT OF SDR 36.1 MILLION (US$ 47.6 MILLION EQUIVALENT) TO THE UNITED REPUBLIC OF TANZANIA FOR A HEALTH AND NUTRITION PROJECT FEBRUARY 5, 1990 Thi docuncfthas a rsbitecd distibution and may be used by retpientsonly in th perormance of tdimi offchd dudes. Its contents may not othews be dbiscoed witbout World Bank anthorizaton.  (January 1990) Currency Unit - Tanzania Shilling (TSh) US$ 1.00 - TSh 193 TSh 100 - US$0.52 FISCA. YaS IDA Fiscal Year - July 1-June 30 Central Government Fiscal Year - July I-June 30 District Government Fiscal Year - January 1-December 31 MEASURES 1 Meter (m) - 3.28 Feet 1 Square Meter (m sq) - 10.76 Square Feet ABBREVIATIONS AND ACRONVMS *MS - Central Medical Stores DANIDA - Danish International Development Agency DHP - District Health Plan ERP - Economic Recovery Program ESAP - Economic and Social Action Program IDA - International Development Association iEC - Information, Education and Communication MLG - Ministry of Local Government, Community Development, Cooperatives, and Marketing MOH - Ministry of Health NORAD - Norwegian Development Cooperation Agency ODA - Overseas Development Administration PHC - Primary Health Care PHN - Population, Health and Nutrition PSAP - Policy Social Action Programme PPP - Policy Framework Paper SDC - Swiss Development Cooperation SDR - Special Drawing Right SIDA - Swedish International Development Authority TFNC - Tanzania Food and Nutrition Centre UNICEF - United Nations Children's Fund UNPPA - United Nations Fund for Population Activities USAID - United States Agency for International Development WHO - World Health Organization  FOR OFFICAL USE ONLY Credit and Protect Sum8ra Borrowert The United Republic of Tanzania Baneficiariest Ministry of Health (tOH), Ministry of Local Government, Community Development, Cooperatives and Marketing (MLG) Amount: SDR 36.1 million (US$ 47.6 million equivalent) Termst Standard, with 40 years maturity Fimanclna Plan: at Government US$ 7.4 million IDA US$ 47.6 million Government of Belgium US$ 0.7 million DANIDA US$ 1.3 million -SDC US$ 12.2 million ODA US$ 0.1 million UNFPA US$ 0.7 million TOTAL USS 70.0 million Economic Rate of Return: Not applicable Staff Appraisal ReIorts Report No. 8217 - TA Malps IBRD No. 21769 Nlote: a/ Excludes taxes and duties of USS 2.8 million. This document has a restrked distribution and may be used by tecij$ents only in the Wefoamance of their official dutios. Its contents may not --herwie be disctosed without World Bank authodiztion.  MEMORANDUM AND RECOMMENDATION OP THE PRESIDENT OF TBE INTERNATIONAL DEVELOPtEKT ASSOCIATION TO THE EXECUTIVE DIRECTORS ON A PROPOSED CREDIT TO THE UTED REPBLIC OP TANZANIA FOR A HEALTH AND NUTRITION PROJECT 1. The following memorandum and recommendation on a proposed development credit to TFnzania for SDR 36.1 million (US$ 47.6 million equivalent) is submitted for approval. The Credit would be on standard IDA terms with 40 years maturity. The project would be co-financed by the Government of Belgium for USS 0.7 million equivalent, the Danish International Development Agency for US$ 1.3 million equivalent, the Swiss Development Cooperation for US$ 12.2 million equivalent, the British Overseas Development Administration for US$ 0.1 million, and the UNFPA for US$ 0.7 million. 2. Background. The capacity of the Government to deliver effective social services has seriously deteriorated during the 1980s largely due to the severe economic difficulties and mismanagement which Tanzania has experienced, as reflected in a decline in per capita GDP of about 2.3 percent per annum during the period 1980-85. In order to reverse this situation, the Government has committed itself to introducing and maintaining appropriate macro and sectoral policies. 3. At the macro-level, the Gemernment initiated a major program of economic reform in 1986 through the Economic Recovery Program (ERP). Encouraging progress has been made, checking the decline in economic growth and re-establishing the base for sustainable development. During 1989, the Goverament has prepared a follow-up macroecono,mic reform program, the Economic and Social Action Program (ESAP), which amongst its key objectives seeks to fully incorporate the social sectors in the process of economic adjustment, so as to reverse their decline through the implementation of a program of structural reforms. The Priority Social Action Program (PSAP) elaborates the Government's ESAP social sectors priorities, and provides a policy framework for the population, health and nutrition (PHN) sectors. 4. In population, the first National Population Policy is about to be approved by Government. This policy has a very ambitious target of reducing fertility by 30 percent by the year 2000, thereby contributing to a reduction in the population growth rate (currently about 2.9 percent per annum). UNFPA and the Bank have provided assistance to the Government in this exercise, but the real initiative has been from the Government, with the Party playing an important catalytic role. In March 1989, a donors conference was held, which was successful in mobilizing support for an expanded program of family planning. Major support for IEC and staff training will be coming from NORAD, SIDA, USAID and UNFPA; whilst an expanded supply of contraceptives will be coming from USAID and UNFPA. 5. In health, a new national health policy has been prepared, which seeks to update the primary health care (PHC) strategy in the light of the  -2 changed economic circumstances and to secure the financial sustainability of the sector. In this regard, the Government is evaluating alternative options for the long-term financing for the sector which do not restrict the access of poor households to adequate services. Tanzania is benefiting from significant support from the donor community in the health sector in meeting its-objectives of "Health for All by 20000, with both DANIDA and UNICEF featuring prominently, and growing support from such donors as the British ODA, Italian Government, NORAD, SIDA, SDC and WHO; the national AIDS program in particular has been well-funded. However, both the problems and the needs of the sector are still Imuense. 6. In nutrition, the Government is determined to reduce the high incidence of malnutrition; some 40 percent of children under 5 suffer from moderate and 6 percent suffer from severe malnutrition. In addition, micro-nutrient deficiencies are significant public health problems 41 peruent of the population experience some degree of iodine deficiency; iron-deficiency anemia is hyper-endemic amongst pregnant w) :.n: and vitamin A deficiency is a severe problem for children. The Tanzani Food and Nutrition Centre (TFNC), which has benefited from the support of donors such as SIDA and UNICEF, has developed national micro-nutrient deficiency control programs. The iodine deficiency cont_ol program is already receiving support from the Netherlands and SIDA. Efforts to improve child nutrition more generally have made encouraging progress in are;r such as the Iringa region, through a community-based approach. supported by UNICEF, the Italian Government, WHO and other donors. The Government is seeking resources to replicate these approaches nationally. 7. Given Government's clear comaitment to appropriate policies, the major challenge it faces now is to deal effectively wit. several specific problems impeding implementation. First, the planning, information sYstem and policy formulation capacity of the MOR is weak and needs to be strengthened to complete the design of and carry out a program of rational reforms. Second, serious deficiencies exist in two critical PHU sub- systems, namely manpower and pharmaceutical and medical supplies. A more appropriate mix of trained manpower has to be established and a greater emphasis must be given to improving the quality of existing manpower through effective in-service training. Equally, radical reform is required in the critical areas of financing, pricing, procurement and distribution of pharmaceuticals and medical supplies to ensure the sustainability of these vital inputs. The Government has begun to address these issues through a DANIDA-financed master plan for the Central Medical Stores (CMS) and in the context of the draft National Drug Policy, prepared vith assistance from WHO. Third, the quality and effectiveness of PHI services need to be improved, through a renewed emphasis on an appropriate and cost- effective primary health care (PHC) strategy, which emphasizes community participation. PHC services in urban areas in particular, which have suffered from two decades of relative neglect, need to be improved. 8. Project Objectives. The proposed project will reinforce the Government's efforts (including the ESAP and PSAP) to raise the quality, coverage and effectiveness of family planning, nutrition and basic health services in urban and rural areas, through providing support to critical and strategic elements of the PHN sectors, with particular emphasis on strengthening: (i) institutional capacity for planning and policy  -3- formulation and implementation; (ii) manpower development and training; (iii) sustainable provision and financing of pharmaceuticals and medical supplies; (iv) micro-nutrient deficiency programs; r) implementation of the national population policy; vi) rural PHC, through the implementation of the revised strategy in selected districts; and vii) urban PHC, through reform and rehabilitation. 9. Proiecc Description. To meet these objectives, the project will support improvements int i) health planning, policy formulation and information syste , through upgrading of staff skills, studies on health financing and the domestic pharmaceuticals 'ndustry, and strengthening the project coordination capacity of the MON; (ii) manpower development and training, through support to in-service training at the district level and the implementation of a realistic manpower plan; (iii) pharmaceutical and medical supplies, through reforms to the pricing, financing, management and procurement of pharmaceutical and medical supplies and the rehabilitation of the central warehouse facility; (iv) the implementation of national micro-nutrient deficiency control programs for vitamin A and iron, including training, supplies and operations research; (v) the implementation of the national population policy, through building up the analytical, monitoring and implementation capacity of the Population Unit of the Planning Commission and establishing a 'National Population Information Centre'; (vi) rural PHC, through the implementation of the revised PHC strategy (incorporated in district health plans (DHP)) in 10 selected districts, including mobilization of communities, support to v