Document of The World Bank FOR OFFICIAL USE ONLY JiZ, ZZ ..5- R, Report No. 9180-SE STAFF APPRAISAL REPORT REPUBLIC OF SENEGAL HUMAN RESOURCES DEVELOPMENT PROJECT MARCH 12, 1991 Population and Human Resources Operations Division Sahelian Department Africa Region This document has a restricted distribution and may be used by redpients only in the peformance of their official duties. Its contents may not otherwise be disclosed without World Bank authorzation. CURRENCY EOUIVALENTS Currency Unit = CFA Franc (CFAF) / US$1.0 = CFAF 260 (October 1990) MEASURES I m= 1.09yd. I m2 = 10.16 sq. ft. I kilometer (km) = 0.62 mile ABBREVIATIONS AND ACRONYMS AFVP Association francaise des Volontaires du Progres AGETIP Agence d'execution des Travaux d'Intdr8t Public contre le sous-emploi AIDS Acquired Immune Deficiency Syndrome ASBEF Association Senegalaise pour le Bien-Etre Familial APH Association pour la Promotion de l'HOpital CDEPS Centre departemental d'Education populaire et sportive CHO Community Health Organization CHU Centre Hospitalier Universitaire CONAPOP National Population Commission CPR Contraceptive Prevalence Rate CS Comite de Sante CSU Component Support Unit DAEB Direction de l'Alphabetisation et de l'Education de Base DGAE Directorate of General Administration and Equipment DHDP District Health Development Plan DHR Division of Human Resources DHS Demographic and Health Survey DMO District Medical Officer DMO2 Second District Medical Officer DSA Directorate of Social Affairs ED Essential Drugs FLE Family Life Education FP Family Planning HEU Health Education Unit HP Health Post HPN Health Post Nurse HRD Human Resources Division IEC Information, Education and Communication IPM Institut de Prevoyance des Maladies IPPF International Planned Parenthood Federation MCH Maternal and Child Health MCWC Ministry in charge of the Condition of Women and Children MEFP M;nistry of Economy, Finance and Planning MOHSA Ministry of Health and Social Affairs MOI Ministry of the Interior MYS Ministry of Youth and Sports NGO Non-Governmental Organization PAIP Priority Action and Investment Program PBEF Projet Bien-Etre Familial PCU Project Coordination Unit PEF Projet Economique des Femmes PHC Primary Health Care PNA Pharmacie Nationale d'Approvisionnement PRA Pharmacie Regionale d'Approvisionnement PSFP Projet Sante Familiale et Population (USAID) RHDP Regional Health Development Plan RMO Regional Medical Officer RNI Rate of Natural Increase SANFAM Sante de la Famille SRO Small Rural Operations STD Sexually Transmitted Disease UNDP United Nations Development Programme UNFPA United Nations Fund for Population Activities USAID U.S. Agency for International Development VSPP Volet Secteur Prive et Parapublic WID Women in Development WHO World Health Organization FISCAL YEAR for FY91-92: July 1, 1991 - December 31, 1992 starting FY93: January I - December 31 FOR OMCIAL USE ONLY REPUBLIC QF SENEGAL HUMAN RESOURCES DEVELOPMENT PROJECT Population and Health Table of Contents CRED1T AND PROJECT SUMMARY i PART I: INTRODUCTION 1 PART II: THE POPULATION AND HEALTH SECTORS 1 A. Population: A New Policy and Action Program Taking Shape 1 1. Sectoral Background 1 2. Issues in Family Planning Delivery 3 3. Government's Population and Family Planning Strategy 4 B. Health: A Sector in Need of Reform 6 1. Sectoral Background 6 2. Issues in Hlealth Service Delivery 9 3. Government's Health Strategy 11 4. Financing the District Health System 14 C. The Bank Group's Role 16 PART III: THE PROJECT 18 A. Project Objectives and Description 18 B. Part I: Implementing the National Population Policy 19 1. Strengthening the National Family Planning Program 19 2. Promoting the Status of Women 22 3. Reaching Young Men and Women 24 4. Institutional Strengthening for Promoting the National Population Program 25 C. Part II: Implementing the National Health Policy 26 1. Developing the District Health System 26 2. Promoting Essential Drugs 30 3. Institutional Strengthening in the Health Sector 32 D. Project Costs and Financing Plan 33 This report is based on the findings of an appraisal mission which visited Senegal in June 1990, comprising Messrs./Mmes T.J. Ho (Economist/Mission Leader); R. Vaurs (Sr. Economist); P. Geli (Implementation Specialist/Consultant); J.P. Unger "Public Health Specialist/Consultant); J. Lecomte (Family Planning Specialist/Consultant); L. Camire; (WVID Specialist/Consultant); B. Dumont (Functional Literacy Expert/Consultant); D. Dupety (Arcn'';ct/Consultant); and A. Diawara (Operations Officer/IBRD Dakar). Mr. Aubrey Williams (EXTIE) and R. Castadot (EMTPN) were the peer reviewers/lead advisors for the operation. Mr. Plorent Agitch and Ms. Katherine Marshall are the managing Division Chief and Department Director, respectively, on this matter. 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. (Table of Contents, continued) PART IV: PROJECT IMIPLEMENTATION 34 A. Status of Project Preparation and Readiness 34 B. Project Coordination and Management 35 C. Project Monitoring and Evaluation 37 D. Specialist Services 37 E. Procurement 37 F. Disbursements 39 G. Accounting, Auditing and Reporting 41 PART V: PROJECT BENEFITS AND RISKS 41 PART VI: AGREEMENTS TO BE REACHED AND RECOMMENDATIONS 42 i Basic Data Sheet and Comparative Indicators 45 2-1 Organization Chart of MOHSA 47 3-1 The National Family Planning Program 48 3-2 Promoting Women in Development 63 3-3 Reaching Young Men and Women 71 3-4 Proposed District Health Care System 77 3-5 Training Programs for District Health Personnel 85 3-6 Health District Development Plans 100 3-7 Personnel Redeployment and Recruitment for the District Health System 103 3-8 Financing Plan for the District Health System 114 3-9 Proposed Reform of the National Pharmacy 127 3-10 Proposed Revised Structure of Community Health Organizations 146 3-11 Monitoring Indicators for the National Population Policy 152 3-12 Program and Project Costs 160 3-13 Key Documents in the Project File 171 4-1 Specialist Services 173 4-2 Disbursement Profile 175 4-3 Supervision Plan 176 MAP: IBRD 22835 REPUBUC OQ SENEGAL HUMAN RESOURCEiVLOMN PROJECIT PopulatiQn and Health CREDI1 AND PROJECT SUMMARY Borrower: Republic of Senegal Benefiela=: Ministries of Health and Social Affairs; Economy, Finance and Planning; Interior; Youth and Sports Services; Women Credit AmL nt: SDR 25.4 million (US$35.0 illlion equivalent) Ten: Standard, with 40 years maturity Deseriftion: The objectives of the proposed project are to support Government's efforts to: (i) control fertility and reduce the rate of population growth, through the implementation of a National Population Program; and (ii) restructure the health sector to enable it to provide basic health services of improved quality and wider accessibility, through the implementation of its National Health Policy. To achieve these objectives, the project would finance investments for (a) population to: (i) strengthen the National Family Planning Program; (ii) promote the status of women; (iii) sensitize youth on family welfare issues; and (iv) strengthen institutional capacity to promote the national population program; and (b) health to: (i) develop the district health system, including the promotion of community health organizations; (ii) promote the use and availability of essential drugs; and (iii) strengthen institutional capacity in the health sector, with emphasis on manpower development, and budgeting and financial planning. While the project is a specific investment operation, it will involve the adoption and implementation of key policy measures in both the population and health sectors including: (i) liberalization of regulations on contraceptive distribution and use; (ii) adoption of organizational norms for the district health system, ensuring sufficient budgetary allocations, personnel redeployment, and adoption of organizational and procedural guidelines for community health associations; and (iii) promotion of essential drugs. Beniefits and Risks: The population component would have broad benefits in terms of increased awareness of population issues and increased receptivity to family planning, especially among women in rural areas and youth in semi-urban areas. Family planning services would be extended to over 350 health posts in the country (from an insignificant number at present), and over 150 practitioners and pharmacists in the private sector would be able to offer services and information. Government's ability to coordinate, implement and evaluate population-related action programs would be strengthened. As a result of the above package of services, the contraceptive prevalence rate should rise from the present level of 3.4% to around 14% by 1995, providing the momentum required for an increase to around 22% by the year 2000 - assuming the necessary level of effort is maintained. Restructuring measures in the health sector would help reduce unit costs of basic health care, making possible a significant improvement in quality and coverage with relatively minor increases in resource allocations. The exact value of these cost savings is difficult to quantify. They would include savings on the cost of drugs (around 50-75% decrease in cost per episode), scale economies derived from integrating vertical programs into the standard service package for health posts and health centers, and savings on hospital costs of primary cases pre-screened at the post and center levels. Increased mobilization of private resources to cover the cost of health services would improve the long-term sustainability of gains in quality and coverage and increase accountability within the health service system. The health compQnent would benefit most of the population through improved availability of drugs and quality of services which would increase utilization rates in about half of existing facilities by as much as three times current levels. In addition, over three million peopie in three regions in the project's zone of concentration would gain improved access to basic services through a 30% increase in the number of health posts in these regions. Although the project makes no direct investment at the hospital level, hospitals will be relieved of present excessive demand for basic care as a result of improved primary- and secondary-level services and hence be better able to provide specialized services. Tlhe main risks are: (a) the complex nature of the project and consequent expected implementation difficulties; (b) the many different changes required in policy orientation of the Government at the macro level, and in the behavior of service providers at the field level, and the possibility that these changes may not occur at the desired pace; and (c) heavy dependence on local health committees for resource mobilization at the health post level, and the difficulty of ensuring their efficient operation. To minimize implementation risks, close attention has been given during preparation to definmng implementation arrangements and inter-ministerial working relatonships; the project will, however, require more than average supervision. k;xtensive policy discussions during preparation within the Government and between the Government and IDA (and including other donors) improve the chances of continued Government commitment to its newly adopted policies. To minimize risks stemming from the "human element" in service providers, close attention has been given to supervision and training aspects of all components. Special efforts to improve management of community health organizations (including revision of internal regulations, and training for health personnel on supporting their development) and information campaigns aiming to clarify the role of these organizations to the general public would improve their chances of success. - iii - REPUBLIC OF SENEGAL HUMAN RESOURCES DEVELOPMENT PROJECT Population and Health SUMMARY AND PROJECT COST ESTIMATES (US$ million) a/ Estimarte Costs h lfowa Fore, TCn 1. Strengthening the National Family Planning Program 0.6 2.6 3.2 2. Promoting the Status of Women 2.2 2.5 4.6 3. Reaching Young Men and Women 0.3 1.3 1.7 4. Institutional Strengthening for Promoting the National Population Program 0.1 0.2 0.3 5. Developing the District Health System 5.4 8.1 13.5 6. Promoting Essential Drugs 0.2 3.6 3.7 7. Institutional Strengthening in the Health Sector 0.1 0.3 0.4 8. Pm;ect Coordination and Management 0.5 2.6 3.1 9. Refinancing of PPF and SPPF 0.3 0.5 0.8 TOTAL BASE COSTS 9.7 21.6 31.3 Physical Contingencies 0.7 1.8 2.5 Price Contingencies 1.1 3.0 4.1 TOTAL PROJECT COSTS 0 2 37 Financing Plan: USS million IDA 35.0 Government -2a TOTAL 37.9 p/ Totals may not add up due to rounding. h/ Net of taxes and duties. - iv - Estimated Disbursements: ----USS million- FY 2X 93 24 95 Annual 8.5 12.6 11.6 2.3 Cumulative 8.5 21.1 32.7 35.0 REPUBLIC OF SENEGAL HUMAN RESOURCES DEVELOPMENT PROJECT Population and Health I. INTRODUCTION 1 .1 The Government of Senegal has requested IDA's assistance in financing a project to help achieve its goals for human resources development. Total project costs are estimated at US$37.9 million. The Government would contribute about US$2.9 million. The remaining US$35.0 million would be financed by IDA. The Basic Data Sheet and comparative indicators are found in Anmex 1. 1.2 The proposed project is the first of a series of operations to be developed under the umbrella of a comprehensive human resources development program which constitutes a key element of Senegal's medium-term social and economic development plan. The proposed project focuses on the population and health sectors; a second project, scheduled for FY92, will focus on the education and training sectors. Both projects aim to maximize quality of and access to basic social services through a clearer definition of sectoral priorities, strict adherence to these priorities in the allocation of rescerces, improved relevance in the content of services delivered, greater operational efficiency, and the mobilization of additional resources, public and private. These objectives would be attained through a combination of policy reform measures and investments to support the adopted reforms. 1.3 The proposed project would be IDA's second intervention in the development of health services in Senegal. The first project did not include any significant investment in the population sector, thus the present project is IDA's first intervention in that sector. Policy measures and investments included in the project have been developed through extensive dialogue with Senegalese authorities based on a Population Sector Memorandum (June 1987), and through discussions leading to the preparation of the National Population Policy (April 1988) under the third SAL and of the National Health Policy (June 1989) under the ongoing Rural Health Project (Cr. 1310-SEN). Donors involved in both the health and population sectors have participated actively in policy and program formulation. Experience in implementing policy and program activities under the ongoing project has also been applied. II. THE POPULATION AND HEALTH SECTORS A. Population: A New Policy and Action Program Taking Shape 1. Sectoral Background 2.1 The National Population Program. Senegal's population totalled 6.9 million according to the 1988 census, and is estimated to be growing at 3.2% p.a. (up from 2.4% prior to 1975). Prospects are bleak for a significant decrease in this rate by the year 2000, given continued reductions in the death rate (1.2% projected for 2000, compared with 1.9% at present), unless a reduction in fertility takes place. Increasingly concerned by these prospects and their impact on the country's future social and economic performance, Government adopted a comprehensive Population Policy Staternant in April 1988, calling explicitly for reduced fertility and setting out a multi-sector strategy to attain this objective. While not setting specific demographic targets, the policy statement presents two scenarios for Senegal's -2- demographic transition: a low-growth scenario which calls for a contraceptive prevalence rate (CPR) of 29% to reach a rate of natural increase (RNI) of 2.87% in 2001, and a medium-growth scenario calling for a CPR of 15% for a RNI of 3.21% in the same year. The conclusion drawn is that a 'significant" decline in fertility is necessary if development efforts are to remain unshackled by excessive population growth. 2.2 Since adoption of the national policy. Government has defined a US$85 million Priority Action and Investment Program (PAIP) designed to give a major impetus to ongoing population and family planning activities. Among the key elements of the PAIP is the definition of a National Family Planning Program that sets quantitative objectives for tl- short and medium terms - CPRs of 14% by 1995 and 22% by 2000 1 -- and defines a coherent framework for all family planning (FP) activities in the country. The magnitude of the effort required can be seen in perspective by noting that CPR was estimated at only 2.6% in 1986, compared with a rate of I % in 1978. Not limited to family planning activities, however, the PAIP includes a cross-sectoral range of actions that would help transform the social and economic environment to favor more rapid fertility decline (including improved maternal and child health, promotion of women's status, increasing involvement of youth, improved employment opportunities, and population-related legislation). The multi-sectoral nature of the PAEP signifies an important evolution in official attitudes towards population-related actions, from a narrow concern for the effects of high fertility on the health of mothers and children, to wider concerns for family welfare and national development objectives. Adoption of the program and actions takea so far by the Government to initiate implementation of the policy (public information campaigns have been stepped up, family planning effcrts intensified) make Senegal one of the more advanced Sahelian countries in terms of its outlook on population issues. 2.3 Family Planning (FP? Activities. First introduced in 1970 in a private clinic, modern contraceptive services have become increasingly available over the past two decades. In 1974, the Senegalese Family Planning Association (Association senegalaise pour le bien-8tre familial - ASBEF), an affiliate of the International Planned Parenthood Federation (IPPF), was created, opening a PP clinic in Dakar. The first puMlicly-run FP center opened in Dakar in 1975. With the establishment in 1981 of the USAID-funded Family Health and Population Project (Projet Sante Familiale et Population - PSFP) covering six regions, FP services became available on a larger scale. That project is now in its second phase (through July 1992). Mole recently, the UNFPA-funded Family Welfare Project (Projet Bien-Etre Familial - PBEF) has undertaken expansion of services in the four remaining regions (1988-1992). The first officially-sponsored attempt to offer services outside the public sector was initiated in 1985 through the Private and Parapublic Sector Component (Volet Secteur Prive et Parapublic - VSPP) of the PSFP. This component, which aims to introduce FP services in clinics serving large private and parapublic enterprises, has covered 45 clinics to date, serving 4,158 contraceptors as of June 1990. A growing number of NGOs, including ASBEF and Pathfinder Fund, have become involved in various aspects of family planning service delivery and IEC. In July 1990, an NGO called Sant6 de la Famille (SANFAM) was organized to continue private sector activities initiated under the VSPP. 2.4 Because of the still widely respected pronatalist tradition and the general lack of knowledge about FP methods in Senegal, even among health professionals, activities to promote FP and to provide correct information regarding benefits and risks, as well as service availability, are essential to the FP program. Information, education and communication (EC) activities to promote FP have to 1 The figurs reprst CPRs for modern contrecepdve menihods, conrsponding to thc officialy ated objectives of 22% in 1995 and 28% in 2000, which include modem methods as well as th natural" method. - 3 - date focused on: (i) training of health personnel, social development agents, and volunteer auxi'iaries, who together constitute the principal channels for face-to-face communication on FP; (ii) production of pedagogical materials for field personnel and promotional materials such as posters and tee-shirts; (iii) production and diffusion of radio and television spots and other written and audio-visual material for the mass media; and (iv) seminars o-i FP for local journalists. A highly visible and apparently successful mass media campaign was carried out from July 1988 to June 1989. Most of these activities have been carried out with support from the USAID-funded PSFP. 2. Issues in Family Planning Delivery 2.5 Knowledge. attitudes and practice. Important changes in attitudes towards family planning have v en attained over the past years. The Demographic and Health Survey (DHS) of 1986 showed that 70% of women of childbearing age knew of at least one modern contraceptive method, compared with only 23% in 1978. Two other surveys, conducted in 1986 and 1987, showed a favorable attitude of men towards FP as a means to space births; however, there was almost unanimous opposition from men to FP as a means to limit the number of births. The second survey also showed interest in FP among both urban and rural populations. Without necessarily attributing causality, it is encouraging to note that these changes have occurred during a period marked by efforts to promote FP through Cz-e-to-face communication as well as through the mass media. However, contraceptive prevalence rates remain low (in 1986, 10.0% for all methods combined: 2.6% for modem methods) compared to the level of knowledge and the reported positive attitudes. Evidently, more intensive IEC efforts as well as more extensive provision of FP services must be undertaken if the ambitious targets of the national FP program are to be attained. In addition, the multi-sectoral approach of the PAIP, which goes beyond specific FP activities to create the social and economic environment that would favor wider acceptance, is becoming increasingly important. 2.6 FP Service Delivery. The number of centers/clinics offering FP services increased from 24 in 1984 to 90 in 1988; the number of FP acceptors served in these centers increased from 397 to 45,811 during the same period. These figures represent an impressive achievement and provide grounds for optimism with regard to the feasibility of FP program targets, provided expansion of service delivery continues and service quality is maintained. To date, service delivery in the public sector has focused on health and MCH centers, located mostly in urban areas. Training of health personnel has been largely limited to doctors and midwives in these centers, with only a small percentage of nuiqes trained. While urban-based services must be maintained, even strengtlhened, to meet growing demand, expansion must now turn towards serving rural communities, primarily through the network of rural health posts (typically served by one nurse), village-level "cases de sant6" (served by a community health agent and a "matrone") and, eventually, through other existing networks of social service or development agents. At the same time, service delivery in urban areas could be strengthened through the establishment of new FP clinics in key urban centers through the continued expansion of services in private and semi-public enterprises (VSPP), and through the network of private health practitioners. 2.7 Institutional Issues. The recent government restructuring has combined responsibility (within MOHSA) for both FP delivery and FP-IEC, thus simplifying the institutional zetup for program management. Inter-ministerial coordination remains important, however, because implementation of FP- IEC activities depends on a variety of communication channels: social development agents of the Ministries of Interior (for women's groups), of Youth (for youth groups), and of Agriculture (for farmers), and the Directorate of Social Affairs of MOHSA; the Ministry of Education (schools and -4 - functional literacy programs); and mass media channels of the Ministry of Coxmmunication and Culture. It is essential that MOHSA, and in particular the Health Education Vnit responsible for FP-IEC, take strong initiatives to develop and maintain working relationships with these ministries to maximize access to its different target populations. 3. Government's Population and Family Planning Strategy 2.8 Government's population and FP strategies are embodied in the PAIP and the National FP Program document. The key elements of these strategies include expanding FP-IEC and service delivery, promoting the status of women, involving youth in population and FP efforts, reducing legal and regulatory constraints to fertility decline, and strengthening sectoral leadership in population. These strategies are described briefly below. The proposed project would assist Government in carrying out key elements of this strategy. Official adoption of the FP Program document, as discussed and finalized at negotiations, is a condition of credit effectiveness. 2.9 Developing FP-IEC. The Government's FP-IEC strategy aims to continue past and ongoing efforts, with a particular focus on: (i) broadening and deepening research on fertility-related behavior; (ii) linking FP-IEC to activities of interest to target groups such as maternal and child health, functional literacy, and promotion of women, to facilitate its acceptability; (iii) standardizing operational methods and messages, and improving coordination among different projects; (iv) optimizing resource use; and (v) using a multimedia approach with mass media and face-to-fpe communication channels operating in tandem. The objective is to have 80% of the population informed correctly about the benefits of FP and about the existence and correct utilization of modem contraceptive methods by the year 2000. [In contrast to the 70% of women reported to "know of" a modem contraceptive method in 1986, this objective stresses the importance of coffect information about contraceptives and their use.] 2.10 To implement this strategy, at least three important changes must occur. First, because the proposed program will require a significant infusion of resources, it is necessary to instill greater cost consciousness than is presently evident, thus the need for careful monitoring and evaluation of all aspects of the program including assessment of the cost-effectiveness of various aprroaches. Second, there is need to "professionalize" promotional efforts, perhaps learning from commercial marketing methods which, like FP-IEC, also aim to change "consumer" behavior. This translates operationally into more scientific "market" research, coordinated orchestration of messages sent through different communication channels, and other similar methods used in commercial marketing. Above all, a strong locus for leadership and professional expertise must be established. While the Health Education Unit in MOHSA has some of the necessary technical competence in communication and production, it needs further reinforcement in research and management skills if it is to take on this lead role for FP-IEC, in addition to growing demands for its other services. 2.11 The interpersonal communication program involving social development agents and their network of volunteer auxiliar'es demands particular attention. Considerable effort is being invested in training these agents and auxiliaries in FP-IEC, and an ambitious expansion program is proposed. While the training program is well developed, there is litde follow-up on implementatioa in the field and little knowledge as to the impact of their activities. Anecdotal evidence indicates, for example, that logistical constraints significantly curtail agents' mobility, hence their effectiveness. These operational aspects of the IEC "delivery system" must be reviewed with a view to improviag efficiency and effectiveness. 2.12 Expanding Family Planning Services. Government proposes to speed up expansion of FP services within the public health system. The immediate priority is to expand FP to the health post level, of which there are over 600 at present. The objective of this strategy is to capitalize on the interactions between FP and maternal and child health (MCH) by completely integrating these services, in particular taking the opportunity to provide FP-IEC or offer FP services during other MCH contacts (prenatal visi.s, vaccination, nutritional surveillance and education, etc.). Hence, increased credibility of all MCH services at this level would be a necessary prerequisite for successful FP expansion. In the long run, the objective is to "de-medicalize" FP service delivery, making contraceptive advice and distribution available through as many channels as possible. 2.13 MOHSA is preparing to issue, by early 1991, a series of instructions clarifying regulations on the prescription and distribution of contraceptives. A new version of the decree defining MCH services wouIh .aiclude FP as part of the basic MCH package and authorize health post nurses (HPNs) to distribute all types of contraceptives, except IUDs. Village health workers and "matrones" would distribute condoms and spermicides; in addition, "matrones" would be allowed, upon completion of appropriate training, to resupply pills after prior prescription. The proposed project will provide assistance for training programs to accompany this liberalization of contraceptive distribution. 2.14 Finally, MOHSA recognizes its lack of sufficient resources to reach its ambitious FP targets and the need to t-ke a stronger position on encouraging FP service delivery through channels outside of public health facilities. Among key potential participants would be private medical and paramedical practitioners, pharmacists and staff of pharmaceutical "depots" (to whom people often go for advice on FP), non-health workers involved in the "social marketing" of contraceptives, and private FP organizations such as ASBEF and SANFAM. Thus its role will have to expand from strict service delivery to promotion and development of alternative FP channels. The proposed projet will provide assistance for FP activities in the private sector. 2.15 Promoting the Status of Women. Recognizing that significant change in fertility rates would require radical change in women's behavior, particularly in taking decisions regarding their reproductive lives, the national population program calls for actions to improve women's status in society, specifically calling for: improving schooling and literacy rates for women and girls; promoting technical and professional training for women; organizing information campaigns for men and women on these and related issues; diffusing technologies to alleviate women's domestic and agricultural chores; and supporting women's groups, of which there exist over 3,600 at present. Some of these actions have been included in the Action Plan for Women adopted during the Decade for Women (1975-1985) and implemented with assistance from various donors and NGOs. These actions will receive additional support under the proposed PAIP. 2.16 Reaching Young Men and Women. The Population Policy Statement correctly identifies young men and women as key participants in the effort to change fertility behavior in the immediate and long run. It thus calls for efforts to help mobilize their energies to contribute to their self-improvement while participating more effectively in their country's development goals. The PAIP calls for strengthening programs identified in the Ten-Year Action Pean fc YGU - c "nurses, vocational training, social and cultural facilities, vyn"th asociations - and combining these programs with informa.cX and education programs fobrsdi on family welfare, safe sexual practices, and responsible parenthood. - 6 - 2.17 Reducing Legal and Regulatory Constraints. The Population Policy Statement calls for revising or fine-tuning legal and regulatory measures which could have an impact on couples' desired number of children and their access to family planning information and services. A study conducted by Government found that, in addition to inexplicit regulations directly governing FP and contraceptive use, existing fiscal laws and social security measures also worked in favor of larger families. Beyond these measures, the legal environment was found to be fairly liberal compared to other countries. However, implementation of existing legal statutes was found lacking, due to the public's ignorance about their rights and, for aspects concerning women, the "social-religious" interpretation made by officials responsible for applying them. Government proposes to: (i) take immediate action to clarify regulations on FP access (para. 2.13); (ii) further explore the socio-economic implications of revising specific fiscal and related measures; and (iii) initiate information campaigns targeted at those responsible for making and applying the laws audges, politicians, etc.) as well as those most affected by them (women, youth, health personnel, etc.). 2.18 Strengthening Sectoral Leadership. "Population" is only beginning to take shape as a high priority "sector" within the Senegalese administration and has yet to develop a strong locus of leadership for policy promotion as well as for coordination of its multi-sectoral operational elements. The institutional structure responsible for population-related activities is well-defined: the National Population Commission (CONAPOP), serving as advisory body to the Interministerial Council on all population matters; and the Division of Human Resources (DHR) in the Ministry of Economy, Finance and Plan (MEFP), serving as Secretariat to the CONAPOP. This structure, which has successfully led the effort to develop and adopt a national population policy and to define the PAIP, must now shift efforts towards coordinating the implementation of a large, cross-sectoral action program involving around ten ministries and numerous NGOs and dornor agencies. It must also lead the effort to gain legitimacy for population- related issues by increasing their visibility and raising consciousness at the highest levels of political leadership. B. Health: A Sector in Need of Reform 1. Sectoral Background 2.19 Health Status. While significant improvements in mortality were experienced particularly in the '50s and '60s, mortality rates remain high in Senegal. The death rate is 16 per thousand, and life expectancy at birth is 48 years. These rates, while better than in the rest of the Sahel, are worse than in most other African countries or in other countries at a similar income level. Infant and child mortality predominate (86 and 113 per thousand, respectively, in 1986), with diarrhea, respiratory disease and malaria as the leading causes of death and illness. Among adults, maternal mortality is a leading cause of death for women of reproductive age. The high fertility rate is recognized as a major factor affecting maternal and child health. Ironically, high fertility rates are, in turn, a consequence of high infant and child mortality. Malnutrition is also a contributor to poor health. Senegal's serious nutritional problems are not problems of overall food supply but rather of seasonality, infectious disease, and maternal overwo.k. Cardiovascular disease, trauma and sexually transmitted diseases (STD) are also important health problems. The Government is conscious of the potential threat of the spread of the HIV infection and is taking active preventive measures to stem this threat through the implemantation of a medium-term action plan on AIDS, with strong assistance from the international donor community. - 7 - 2.20 The Health Service Sector. The public healti' system consists of administrative units and health facilities under the direction of the Ministr3 Health and Social Affairs (MOHSA). Administrative units are defined according to po.itico-administrative government units at the central, regional and departmental levels (the latter are called "circonscriptions m6dicales"). Public health facilities are organized in pyramidal fashion: (i) at the bottom of the pyramid, the hgaith post, which is the first level of contact with the formal health system, but which may supervise a number of community health units ("cases de sante" and "maternites rurales") staffed by community health agents (village health workers and "matrones"); (ii) the second level, the health center, which is the referral level for the health post and which may be linked with a maternal and child health (MCH) center; (iii) the regional hospital; and (iv) the National Hospital System (Centre Hospitalier Universitaire - CHU) consisting of three hospitals in Dakar. The "circonscription medicale', which consists of one to three health centers and all health posts in a given department, is considered to be the basic operational unit at the periphery. In 1988, there were 1,400 "cases de sante" (1 per 5,200 inhabitants), 659 health posts (I per 11,500 inhabitants) and 47 health centers (1 per 142,300 inhabitants). Seven of the ten regions (excluding Dakar, Fatick and Kolda) have a regional hospital. 2.21 The private health care sector is active but mostly concentrated in the Dakar Region. There are 25 private clinics, 47 health posts, and 272 doctors/dentists and 32 nurses with private practices. The private, non-profit sector runs one hospital and 85 health posts. Finally, several government ministries offer health services to their particular constituencies; outstanding among these is the HBpital Principal run by the Armed Forces Ministry and considered to be the best hospital in the country. Large private and public enterprises also offer on-site health services, which are funded through a social security-type system known as the Instituts de Prevoyance Maladies (IPM). 2.22 Drug Supplies. The pharmaceutical market is divided into a dynamic and growing private sector, and a stagnant and inefficient public sector. The private sector consists of two local manufacturers (SIPOA, which produces about one hundred products under generic form and in which government owns a minority interest; and PARKE DAVIS); three importers-wholesalers; and around 120 pharmacies (mostly in the Dakar area) and 140 commercial distribution points - Wd6pOts" - where drugs are sold along with other commercial products (in Dakar and larger towns). The public sector consists of the National Pharmacy (Pharmacie Nationale d'Approvisionnement - PNA), managed by MOHSA, which supplies public health facilities and community health organizations. SIPOA has been the main supplier vis-4-vis the public sector for all drugs it produces. Otherwise, the PNA supplies itself through the international market (primarily French sources) and receives donations from international aid agencies. Donated drugs also reach health facilities directly at all levels of the health pyramid. Finally, there is an active black market in drugs. 2.23 Prices in the private drug market are controlled, based on a fixed margin on purchase price. Smaller margins are allowed for a number of drugs on a "social list" in order to lower prices. However, these smaller margins reduce the private distributor's incentive to carry "social" drugs and have had the contrary effect of limiting availability. In addition, because the private market carries drugs mostly in non-generic form, drug prices can be several times higher than they would otherwise be for the least expensive generic equivalent. 2.24 Traditionally, all pharmaceutical needs of clients of public health facilities were met through the public distribution system. Because of budgetary limitations and the growing needs of a larger popula.ion, the public sector has failed to meet that need, and clients are turning to the private -8 - commercial sector. As a consequence, the private pharmaceutical market has grown, with annual sales of about 15 billion CFAF; in contrast, the public sector budget for drugs is around 1 billion CFAF. To the public, this has meant significant increases in the cost of health care, growing inaccessibility of drugs, particularly in rural areas where there are few private commercial outlets, and declining confidence in public health services. Furthermore, prescription practices characterized by frequent overprescription and use of specialty rather than generic names contribute to increasing, unnecessarily, the cost of drugs to health sector clients. Finally, although the Goverment has a stated policy on promoting essential drugs and has had an official essential drugs list for several years, it has taken little concrete action to date to implement this policy. 2.25 Helth Personnel. In 1988, there were 459 doctors in Senegal (1 per 17,000 population), 2,487 nurses (1 per 3,000 population), and 482 midwives (1 per 14,000). These numbers indicate a shortage of doctors - relative to standard norms of 1 per 10,000, and of midwives (norm: 1 per 5,000); however, nurses are present in satisfactory numbers (norm: 1 per 5,000). The majority of health personnel are employed in the public sector, particularly in MOHSA. A census of public health personnel counted, as of December 31, 1989, a total of 5,027 agents of whom 5% were in central and regional administration, 31 % in hospitals (19% in national hospitals in Dakar), 42% in health centers and health posts, and 22% in other specialized services. These figures do not include community health agents and traditional midwives working in "cases de sante" who, in 1986, numbered 2,424. At the health post and health center levels, there is a deficit of doctors and administrative personnel, but a large excess of support personnel, both technical (nurse's aides, medical technicians, etc.) and non-technical (janitors, etc.). Paramedicals (nurses, midwives and "agents sanitaires") are also largely in excess at present, but this excess should be absorbed over the coming years if the number of health posts increases, as needed to keep up with population growth. (See Annex 3-7 for a discussion of personnel allocation issues.) 2.26 Forty-five percent of public health personnel are concentrated in Dakar, which has 22% of total population. A large number of those personnel, however, are found in the different national services and in the National Hospital. In fact, only 28% of health center and health post level personnel are located in Dakar, indicating that Dakar, while generously endowed, is in fact less privileged than may appear as far as basic care services are concerned. 2.27 Health Financing. The latest comprehensive analysis of health expenditures was done in 1981, when the Senegalese population spent about US$18 equivalent per capita on health. This figure was in line with the average for lower middle-income countries like Senegal. Forty percent of health expenditures originated in the ,rivate sector; public sector sources included the central budget (33%), local budgets (9%) and foreign aid (18%). At the time, health expenditures constituted about 1.2% of GDP, and private spending, about 1.4% of total private consumption expenditure, of which about half went to drug purchases. Trends in funding sources for health have not been well documented since 1981, except for central budget allocations. After dropping to an all-time low of 3.8% in 1986-88 from a high of 9% in the early 1970s, MOHSA's share in the national budget has recovered in recent years, reflecting Government's concern to protect social expenditures during this period of economic adjustment. A total of 11.5 billion CFAF (4.7% of national budget) is commnitted in the revised FY90-91 budget. In spite of this recent increase and because of overall budgetary constraints and an increasing population, allocation per capita has decreased in real terms. In addition, data on actual expenditures show a growing gap between budget commitment and actual spending, this gap reaching 15% in 1986-87. The shortfall - 9 - has mostly affected non-wage expenditures which, as a result, would have received only half of the original commitment. 2.28 Not surprisingly, private spending on health increased rapidly during the 1980s. Drug imports net of public sector consumption doubled, and the two private hospitals in Dakar remained filled to capacity, their combined budgets reaching a level as great as the combined budgets of the national hospital complex and the seven regional hospitals. Health insurance exists but on a limited scale - a Social Security System for employees in the modem sector (IPM), and private insurance, mostly used by expatriates - and little is known of the amount actually spent in these programs. Civil servants, military personnel and students also have their own health facilities and subsidized access to hospitals. 2.29 Since the early eighties, Senegal has experimented with users' fees in basic health facilities. Attempting to duplicate a highly successful experiment in Pikine, a suburb of Dakar, a network of community health organizations - consisting of "Comites de sante" (CS) at the health post level, "Associations pour la promotion de la sante" (APS) at the health center level, and "Associations pour la promotion de l'hOpital' (APH) at the hospital level - was developed and codified under a ministerial order dated February 25, 1983. Amounts collected have been low, representing less than 5% of total private spending (over the past five years, fees collected averaged US$1 million equivalent per year or about US$0. 15 per capita). There is every indication, however, that these contributions constitute the bulk of funding for drugs reaching health posts since only a small amount of publicly provided drugs seems to trickle down to these facilities at present. A disturbing factor is the apparent loss of momentum of these associations, as evidenced by the decrease in amounts of funds mobilized since 1985. 2. Issues in Health Service Delivery 2.30 Performance of the Public Health Sector. Between 1978 and 1986, the number of consultations registered in public health facilities decreased by 58.5%, the number of consultants by 35.8%, the number of hospital days by 67.3%, and the number of persons hospitalized by 22.5%. These figures are even more striking given that, during the same period, Senegal's population grew by almost 25%, and the number of health facilities actually increased. The decline in utilization resulted from a critical degradation in the quality of services at all levels of the health service system as a result of: (i) insufficient recurrent resource allocation to the sector; (ii) inefficient use of available resources; and (iii) a dysfunctional health service system. 2.31 Insufficient Allocation for Recurrent Expenditures. The limitations in budgetary allocations to the health sector (para. 2.27) have mainly affected availability of material inputs. Drug shortages are severe at all levels, but especially at the lowest levels of the pyramid. Other important inputs to health operations have been constrained: resources for the purchase of fuel and the maintenance of vehicles, essential inputs for supervision of field personnel, are practically non-existent except where project-related donor funds are available. Lack of supervisioa is a major cause of deteriorating service quality. Finally, maintenance of physical infrastructure is similarly neglected, fuelling the constant preoccu n to reconstruct facilities. 2.32 Inefficient Use of Sector Resources. There are striking inefficiencies in the use of the sector's principal resources: manpower, drugs, and financial resources. Certain types of health personnei are in short supply (doctors and administrative staff) while others are present in excess (paramedicals, technical specialists and support personnel). Deployment to rural health posts is particularly difficult; - 10- in 1989, around 5% of the 618 health posts were "non-functional" for lack of personnel. The lack of clear norms on staffing needs and task definition for different levels of the health pyramid has resulted in unsystematic allocation of personnel, unequal distribution of work load, and a lack of accountability. Whiie norms for distmZI level personnel have recently been defined, there is urgent need to define norms for hospitals and other specialized structures. Insufficient equipment and drugs, as well as poor personnel management practices have led to low productivity and widespread demoralization. There are also fundamental problems in the basic training for medical and paramedical personnel which continues to be modem-sector hospital-oriented, not adjusting to changing priorities in the sector nor to the realities of conditions in the health service sector in the country. 2.33 Inefficiencies in the use of dr stem from two basic problems: (i) non-cost-effective prescription practices, including incorrect prescription, over-prescription, and excessive reliance on expensive brand-name products where generics are available; and (ii) inefficient procurement, distribution and storage practices at the National Pharmacy and in most health facilities. The National Pharmacy is plagued with problems: chronic shortages of the most essential drugs, lack of qualified personnel (most pharmacists prefer to work in the profitable private sector), inflexible financial and procurement practices tied to the rigid public accounting and procurement systems, and overall weak management (see Annex _-2). Personnel in health facilities are not trained in drug management, resulting in excessive losses due to wastage and theft. While the private pharmaceu:ical sector is highly profitable, profits are made largely on expensive brand-name and highly specialized drugs to the detriment of low-cost essential drugs which would better serve public health objectives. 2.34 Financial management of the extensive network of health facilities is constrained by the rigidities of the public budgeting and accounting system and by weaknesses in budget management and planning. While budgetary allocations are defined for the basic operating units in the system - hospitals and health departments ("circonscriptions m6dicales") - these units have little effective control over their resources. Control rests with administrative units at the central level and, to some extent, at the regions, which are largely unable to cope with the vast planning effort required. The annual budget exercise is a mechanical process by which current allocation is rarely submitted to re-assessment. Any cuts caused by shortages of funds are applied across-the-board with wages being protected. Budget sub-categories are added on a case-to-case basis, to meet specific emergency or ad hoc needs. The budget has thus become an heterogeneous list of items making the document ineffective to use as a tool for planning, execution and control. 2.35 The large potential for community participation in health financing is also constrained by poor management of CHO funds. In many cases, receipts from service fees collected by these associations are either used to hire support personnel in excessive numbers, channeled to uses not directly related to health service delivery, or hoarded for use as political war chests by local leaders; health personnel are often not associated in decisions on the use of funds. Even where funds are made available to purchase drugs, these associations are frequently obliged to buy high-cost (non-generic) drugs from private sources because of chronic shortages in the National Pharmacy system. 2.36 Finally, poor financial management is manifest in the lack of oversight of resources pouring into the sector from international donors and NGOs. There is no systematic effort to monitor external resources: information on the nature, size or geographic distribution of resource flows from individual projects/donors are not centrally maintained, much less information on the aggregate of all contributions. Priorities are defined by individual donors rather than government and, because system- - 11 - wide norms on resource use do not exist, government is in no position to propose alternatives. There is clearly much potential to channel extemal resources more productively. 2.37 Dysfunctional Health Pyramid. The health pyramid described in para. 2.20 above is not functioning as it should. While some problems can be attributed to inefficient resource allocation, they are also due to organizational flaws, the most prominent being: (i) absence of realistic and/or clearly defined norms governing the functions assigned to each level of the pyramid, staffing patterns, individual staff assignments, minimum resource needs, geographic coverage, etc.; (ii) undefined norms for administrative, managerial and supervisory roles linking successive levels of the system; (iii) insufficient distinction, de facto, between first line and referral levels, with most health centers unable to offer basic surgery, laboratory and radiology services needed for effective referral; (iv) unequal distribution of health posts, with a shortage in urban areas, resulting in excessive recourse to hospitals for even minor problems; and (v) excessive reliance on vertical programs. In responding to the call for emphasis on primary health care (PHC) services in the early 1980s, various special programs were established to promote different elements of the PHC package (vaccination, MCH care, diarrhea management, family planning, etc), lrgely with assistance from donors. These programs were mostly established with separate, highly centralized management, supervision, and logistical systems, resulting in gross inefficiencies in the use resources. There is need to integrate these services into the existing system, which itself should develop into an efficient health pyramid able to deliver the minimum PHC package through multi-purpose health posts in the first instance, and through efficient referral, supervision and support at the higher levels of the system. 3. Government's Health Strategy 2.38 The National Health Policy. Over the past two years, MOHSA has made an exceptional effort to reassess performance in the health sector and to plan reform in the health service system. After extensive discussions within MOHSA and consultation with donors active in the sector, Government issued in June 1989 a Declaration of National Health Policy defining principal strategic orientations for the sector. The new policy presents a 13-point strategy for reform of which the key elements are: (a) increased participation by the population through CHOs and through the private and NGO sectors; (b) rationalizing the use of drugs, as well as drug production, procurement and distribution; (c) promoting decentralization by strengthening the health district system, integrating vertical programs, and improving support capacity at the central and regional levels; and (d) improving management of human, material and financial resources. The policy statement also calls for institutional reform including the reorganization of MOHSA, restructuring of the National Pharmacy, defining the legal status of community health organizations, revising texts governing use of municipal funds earmarked for health, obtaining financial autonomy for hospitals, greater budgetary autonomy for other health facilities, and restructuring of the system of schools and training facilities in public health. 2.39 Efforts to further develop elements of the above strategy are ongoing, and advances have been made in several key areas. These strategies are described briefly below and, where appropriate, presented in detail in annexes to this report. The proposed project would assist Government in carrying - 12 - out key elements of this strategy, with focus on the district health system, drug availability, community participation, and management and planning. 2.40 Developing the District Health System. Reform in the organization of basic health services through the development of health districts Is the centerpiece of the sector reform program. The "district", which would consist of a health center (serving a population of 150,000 to 300,000) and all health posts within its zone of responsibility (around 15-30 health posts per district), would replace the "circonscription medicale" as the basic operational unit in the system. While the latter is defined strictly along politico-administrative lines, the district will also take demographic and geographic criteria into consideration. Services at the district level will be reorganized on the basis of the following principles: complete and equitable coverage of the entire population through the definition of "zones of responsibility" for each health post and health center; clear delineation of tasks of the health post and the health center and of staffing norms and resource needs; integration of vertical services into the appropriate level of health facility; organization of a district management team and definition of its functions; and organization of community participation through community health organizations. Forty-five districts have been identified to cover the entire country. The proposed district health service system is described in detail in Annex 3-4. 2.41 Comparison of new coverage norms with the existing network indicates a sufficient number of health centers but a lack of health posts to cover the present population. In addition, health posts are inequitably distributed, with an excess in some rural areas but with marked shortages in urban areas. Health center and health post personnel would need to be redeployed to conform with staffing norms (para. 2.44) and retrained on new technical and managerial skills required for the system. To implement the proposed reforms, each district will prepare a District Health Development Plan (DHDP) delineating zones of responsibility per health post, outlining an action plan for personnel reallocation and retraining and for establishing improved management and service delivery systems, and describing resource needs and funding sources. (3he DHDP is described in detail in Annex 3-6.) To ensure the ultimate success of the district system, more efficient mechanisms to facilitate budget execution at the district level, and hence to strengthen the district's budgetary autonomy, will be sought. 2.42 Promoting Essential Drugs. To meet its objective of improving the cost and availability of drugs, MOHSA intends to operationalize its essential drugs (ED) program on a countrywide scale. To this end, it has revised the official ED list, giving closer attention to cost-effectiveness in drug selection and the use of generic names, and defined regulations for its application. These regulations include the strict application of the ED list by the PNA, by all regional hospitals and district-level facilities, and by community health organizations. A medium-term reform program for the sector will focus on: (a) ensuring sufficient and timely financial flows from two principal sources - user fee revenues and budgetary allocations - to support purchases of essential drugs for health system clients; (b) improving procurement, distribution and management of EDs in the public health system through (i) a reform of PNA, and (ii) improved drug management in public health facilities; (c) improving prescription practices; and (d) informing the general population on the existence of lower-cost options for drugs'. Although the medium-term focus of the reform would be the public distribution system, the strategy for the longer run is to create a strong, open market for low-cost essential drugs involving both public and private sectors. The demand- and supply-generation objectives of the medium-term program are pre- conditions for eventually creating this market. In the long term, growing demand combined with other incentives should encourage private pharmacies to carry essential drugs under their least expensive forms. A long-term strategy for promoting essential drugs, including deflning PNA's role in the pharmaceutic-a- - 13 - market and identifying appropriate incentives for the private sector, will be the subject of a study to be undertaken under the proposed project. 2.43 Promoting Community Health Organizations (CHO). Recognizing that Government alone can no longer support the growing cost of health services, MOHSA intends to strengthen its partnership with CHOs and improve their ability to mobilize and manage community resources. The immediate priorities are to: (a) clarify the terms of the "contract" between Government and CHOs, stressing the type of participation expected from the community and the nature of assistance to be provided by Government (para. 2.49); (b) assist CHOs in setting a structure of user fees or seeking other funding sources (including local governments) to meet their financial commitments; (c) define rules on organization and internal procedures of CHOs to be applied nationwide to reduce misallocation and improve management of funds; and (d) train District Medical Officers and Health Post Nurses to support CHO development. A review of experience with CHOs over the past decade and of their current problems shows the need for the following organizational and procedural changes: (i) granting legal status to health committees which operate at the health post level; (ii) ensuring better representation in the designation of representatives to the CHO general assemblies and the selection of CHO board members, and periodic re-election of board members; (iii) giving first priority to operational expenditures of the health facility in the use of user fee receipts; and (iv) establishing a system of co-management of CHO funds raised through user fees, making the DMO or HPN a co-signer, together with a designated CHO representative, on CHO fund withdrawals. The proposed revised structure of health organizations and their organizing principles are detailed in Annex 3-10. 2.44 Manpower Planning. MOHSA recognizes that there is an urgent need to strengthen its personnel management policies and is taking corrective measures to this end. Immediate priority has been given to identifying reallocation and recruitment needs for basic health care. Upon completion of a census of all health personnel and comparison of current deployment patterns to current needs and projections for 1995 (to adjust for population growth), MOHSA has defined a redeployment and recruitment plan in two phases: an emergency plan for FY90-91, and a medium-term plan for FY91-92 to FY95-96 (see Annex 3-7 for details). The FY90-91 plan calls for reallocation of personnel to: (a) fill 60 of the 85 positions for doctors at the district level through redeployment, and make provision for recruitment of the remaining doctors in the FY91-92 budget; (b) satisfy naramedical requirements in 565 existing health posts to be retained under new coverage norms and 44 health centers; (c) endow all regional hospitals with at least one surgeon and one gynecologist; and (d) appoint or identify one administrative agent (could be a paramedic, in the absence of a trained administrator) for each district. This plan would involve the redeployment of 17 doctors and the recruitment of 25 new ones. Health personnel recruitment is protected, within certain limits, under the SAL IV civil service restructuring program, and the proposed recruitment would not exceed those limits. 2.45 The medium-term plan (1991-96) gives priority to the following actions: (a) assignment of a nurse, midwife or "agent sanitaire' to each new health post as expansion proceeds; (b) redeployment of support personnel at the health post level, possibly to be re-hired by local health committees through' user fee revenues; (c) redeployment of personnel at existing centers and posts considered to be in excess under new coverage norms and of all excess personnel in centers to be retained; (d) recruitment of a third doctor in districts where the population exceeds 250,000 (about 13 districts by 1995) and of district administrative personnel; and (e) definition of staffing norms for hospitals and other specialized structures and subsequent reallocation, recruitment or dismissal of personnel following these norms. Personnel - 14 - allocation within and among districts will be a key element of district and regional development plaw (para. 2.41). 4. Financing the District Health System 2.46 Cost of the District System. The proposed district health system, once in place, would cost around 6.1 billion CFAF annually to operate: 3.4 billion for salaries, 1.8 billion for drugs, and 0.9 billion for other costs. These estimates are based on a population size of 8.7 million, the projected population for 1995. They are also based on assumptions of improved levels of utilization and operational efficiency as well as reductions in drug prices to international market levels, conditions which are expected to be in place after implementation of district-level and drug sector reforms during the period 1991-95. (These assumptions and others on which the following discussions are based are detailed in Annex 3-8.) It is estimated1 that a total of 4.3 billion CFAF is currently available to fund the district system, from two principal sources: 4.0 billion from the national budget (or 35% of total MOHSA budget allocation for FY90-91), and 0.3 billion from user fees raised through community health organizations. Of this total, 3.3 billion CFAF would go to salaries, 0.6 billion to drugs, and 0.5 billion to other costs. Comparing current funding levels with projected needs for FY95-96 would thus indicate a need to increase the overall level of resources for the district system during the years 1991 to 1995 by 1.7 billion CFAF, almost all of it needed for non-salary payments. The funding gap could be as much as twice that amount, however, if no improvement in current drug prices and prescription practices are realized. 2.47 The proposed financing plan for the district system for 1995 is summarized in Table 1 below. It takes into consideration the limited prospects for budget expansion in the medium term, as well as the large potential for increasing user fees if the right conditions prevail. Hence, it relies heavily on an increase in revenues from user fees, from 0.3 to 1.6 billion CFAF over the five-year period. Government contribution to non-salary costs would increase from 0.9 billion to 1.4 billion CFAF. The sections that follow describe how the proposed resource mobilization and reallocation will be accomplished, for both user fees and budgetary contributions. - 15 - Table 1: Resource Mobilization Requirements FY95-96 (in billion CFAF) FY90-91 FY95-96 Annual Rate of Increase (%) Total Cost 4.33 6.06 7.0 Salaries 3.29 3.36 0.4 Drugs 0.57 1.85 26.6 Other costs 0.47 0.85 12.6 Gov't budget 4.03 4.43 1.9 Salaries 3.14 3.00 -0.9 Drugs 0.42 0.67 9.8 Other costs 0.47 0.76 10.1 User fees 0.30 1.63 40.3 Salaries 0.15 0.36 19.1 Drugs 0.15 1.18 51.1 Other costs (-) 0.09 (e) 2.48 User Fees. At the health post (HP) level, user fees are expected to cover 100% of the cost of drugs and of salaries for support personnel (45% of total cost, 76% of costs excluding the nurse's salary), with Government budget allocations covering the nurse's salary and other operating costs. This would amount to 1-3 million CFAF per year per HP, for utilization rates of 2,500-7,500 episodes per year, and would correspond to an average client contribution of around 400 CFAF per episode. This rate is higher than current rates of 250-350 CFAF but lies within what s considered to be affordable in Senegal. Given the higher unit cost of services at the health center (HC) level, the share of client contributions would be significantly less at this level, covering only 5% of total cost (12% of costs excluding salaries). These contributions would be derived from fees to be charged for hospitalization (1000 CFAF per stay) and from laboratory fees (250 CFAF per exam). 2.49 Under the proposed financing plan, client (or community) contributions are essential to the functioning of the HP, and the organization of a local health committee to mobilize and manage the required resources is a sine qua non for HP survival. In addition, sufficient resources must be mobilized, whether from direct user fees or from other sources (ocal governments, etc.). If current practice of relying on user fees continues, rates would need to increase to around 400 CFAF per episode. Finally, revenues earned from user fees must be used appropriately, that is: (a) channelled back into HP operations (and not hoarded or used for other "projects"), and (b) allocated appropriately between drugs (at least 70% of revenues), salaries (around 25%), and other recurrent items (around 5%). These elements will have to be included in the rules on CHO procedures to be adopted by the Government. 2.50 Although the share of client contributions would be smaller at the HC level, active participation of the district-level association (Association pour la Sant6) is also required. In addition to allowing participation by the client community in routine HC management, the association's involvement would make it legally possible to retain receipts at the HC level without turning them over to the Treasury, as would otherwise be required if fees were collected directly by the health facility. - 16- 2.51 Budget allocations. The proposed total increase of 0.5 billion CFAF in budget allocations for non-salary costs over the five-year period would represent an annual increase of around 1% per year of total MOHSA budget allocations. If MOHSA's share of national budget allocation were allowed to increase from its current level of 4.7% to around 7% by 1995 (the WHO-recommended level is 10%), and assuming that the national budget remains at least constant (in real terms), the 0.5 billion would represent no more than 10% of the total increase in MOHSA's budget and is hence clearly affordable. The projected increase in MOHSA's budget would be in line with Govermment's stated policy of protecting social sector expenditures during the current period of budget restructuring, and is being proposed under the ongoing Public Expenditure Review. 2.52 The resource mobilization effort required of Government during the period under discussion involves not only increased budgetary allocations for the district, however, but also measures to ensure that the full amounts allocated are actually made available at the district level. This would involve an effort to facilitate actual transfers from Treasury through MOHSA, to the district level, thus strengthening the spending autonomy which presently exists at the DMO level. One priority measure would be to present MOHSA's budget on a functional basis, distinguishing allocation for non-salary items (separating essential drugs) for each of the 45 new health districts. C. The Bank Group's Role 2.53 The Bank Group's involvement in the population and health sectors in Senegal includes the Rural Health Project (Cr. 1310-SEN), signed on February 2, 1983, and assistance for the development of the National Population Policy and the elaboration of the PAIP through SPPF funding. The adoption of the population policy and the subsequent definition of an action program have gone a long way in legitimizing the "population issue" in Senegal. The present project proposes to capitalize on that momentum to accelerate the desired decline in fertility levels and hence, in population growth. 2.54 The ongoing Rural Health Project (scheduled completion is December 31, 1991) is the Bank's first intervention in the health sector. Its objective is to provide technical, logistical and management support for primary health care in rural areas in Senegal. It consists of five components: (a) strengthening basic health services through the construction/rehabilitation of 9 health centers; (b) upgrading training of health personnel; (c) improving the supply and utilization of basic drugs; (d) developing health education services; and (e) strengthening planning and management capacity in the MOH. 2.55 The project has had mixed success in attaining its objectives. Activities under the first component contributed to completing coverage nationwide with respect to health centers. As a result, infrastructure needs at that level are well met. However, the accompanying improvements in service quality that were expected through the training and 'drugs" components have been less satisfactory, due principally to two problems: first, implementation of these activities was long-delayed and sporadic, causing significant differences between the project's targeted outputs and what has actually been accomplished; second, specific training activities were selected in an ad hoc manner, rather than being part of an integrated program with a well-defined strategy. Progress has nevertheless been made in the development of a pharmaceutical sector strategy, including improvementr in the official list of essential drugs, preparation of practical recommendations for the reform of the National Pharmacy and recommendations for improvements in the cost recovery system. These reforms will be implemented under the present project. -17 - 2.56 Support to the Health Education Unit (HEU) in the MOH has helped to create a stronger, more professional unit. This unit has, for example, been at the forefront of the highly-visible AIDS prevention program. With its new responsibilities for FP-IEC, the HEU has assumed still another difficult task. It is also expected to take the lead in developing and implementing public information campaigns on essential drugs and on community health organizations. To help it better structure its wide- ranging activities, the HEU is receiving technical assistance from USAID to prepare a general strategy on health education. It will also receive material and technical assistance under the present project. 2.57 Finally, support for planning and management activities at the central level have also had mixed results. An overly ambitious program to develop health planning (including the preparation of a computerized macro-model for health sector planning which has had no practical application to date, and the development of an elaborate methodology for the preparation of regional health plans) has been a learning experience at best, the result of inappropriate technical assistance. Computerization of health personnel data has been attempted with unclear results to date. 2.58 Rationale for IDA Involvement. IDA's involvement in the human resources sectors has grown over the last few years, particularly with the increasing focus on human resources as a key asset in development in the Sahel and on improved basic services (education and health) as essential to the anti- poverty effort. In population, IDA's position as Government's lead partner in the macroeconomic dialogue has provided the opportunity to maintain needed focus on the population question and its relevance to the country's total development effort. This dialogue reached a watershed point with the declaration of the national population policy under the third SAL. Satisfactory implementation of this policy will require continued support, in collaboration with concerned donors, to help Government define and mobilize the means to implement the Population Action Program. In health, preparation activities of the present project have provided a vehicle to advance reflection within MOHSA and dialogue between MOHSA and the donor community on much needed reform. Both the donor community and concerned government agencies are looking to the Bank to maintain this position of leadership and ensure that the momentum of reform continues and that sufficient resources are mobilized within and outside the country. 2.59 D)onor Assistance and Coordination. Many donors are involved in the population and health sectors. UNFPA and USAID have been particularly active in the population sector. Recent advances in that sector would not have been possible without these two agencies' continued presence over the last decade in both areas of policy development and family planning operations. IPPF's affiliate in Senegal, ASBEF, has been active particularly in Dakar, although it has kept a relatively low profile. Besides their activities in support of publicly-provided family planning services, USAID has contributed to private sector initiatives, UNFPA to youth-oriented activities, and both donors to Women in Development (WID) efforts. UNDP and UNIFEM are also traditionally involved in the WID sector. In health, donor participation has until recently been scattered and, for the most part, geographically- or program-focused. A large number of donors are involved, including bilaterals (Belgium, France, Germany, Italy and USAID), multilaterals (UNICEF, UNFPA, WHO, the European Community, the Islamic Bank, the Arab Fund, and IDA), and NGOs (AFVP and World Vision). Much needed coordination in both population and health sectors has developed gradually over the last two years with UNFPA and Belgium serving, respectively, as lead agencies. Preparation of the present project has in large part served as the stimulus for such coordination, with donor groups participating extensively in discussions on policy and program elements of the project. This coordination has also facilitated dialogue between Government and the donor community. - 18- 111. THE PROJECT A. Project Objectives and Description 3.1 The project will support Government efforts to: (i) control fertility and reduce the rate of population growth, through implementation of its National Population Program, following strategies described in paras. 2.8-2.18; and (ii) restructure the health sector to enable it to provide basic health services of improved quality and wider accessibility, through implementation of its National Health Policy, following strategies described in paras. 2.38-2.45. While the project would be an investment operation, it will involve the adoption and implementationi of key policy measures in population and health including: (i) liberalization of regulations on contraceptive distribution and use; (ii) measures In support of the district health system, including adoption of organizational norms for the district, ensu c1ng sufficient budgetary allocations, personnel redeployment, and adoption of organizational and procedural guidelines for community health organizations; and (iii) measures to restructure the health sector towards the promotion of essential drugs. 3.2 As appraised, the Government's five-year Human Resources Development Program would include investments organized in two parts: population and health. 3.3 For population, the program would: (i) strengthen the National Family Planning Program through (a) expansion of FP services in the public health system, (b) extension of FP services through private sector channels; and (c) promotion of FP through information, education and communication (Base cost: US$4.8 million); (ii) promote the status of women through (a) functional literacy training; (b) extension of the network of "cases-foyer" (centers for local women's group activities); (c) provision of labor-saving equipment for household work; and (d) institutional strengthening of the Women's Ministry (Baseco : US$7.1 million); (iii) sensitize youth on family welfare issues through Family Life Education programs (Mms M: US$2.0 million); and (iv) strengthen institutional capacity to promote the national population program through (a) population research and information dissemination; and (b) strengthening capacity for monitoring and evaluation (Base cot: US$0.6 million). 3.4 For health, the program would: (i) develop the district health system through (a) development of training programs for health district personnel; (b) development of financial management systems for districts; (c) promotion of community health organizations and (d) assistance for implementation of district development plans in the regions of Dakar, Thies and Diourbel (Base cost: US$17.6 million); - 19 - (ii) promote the use and availability of essential drugs through (a) reform of the National Pharmacy; (b) supply of an initial stock of drugs for health districts; (c) information campaigns for prescribers and the public; and (d) development of a long-term strategy for the pharmaceutical sector (Base cost: US$4.8 miiiienI); and (iii) strengthen institutional capacity in the health sector, with focus on managing manpower development, and budgeting and fi. ancial planning (Baseost: US$0.5 million). B. Part I: Implementing the National Population Policy 1. Strengthening the National Family Planning (FP) Program 3.5 This component will support implementation of the National Family Planning Program. In complement to activities under other ongoing projects, particularly two major ones funded by USAID and UNFPA, it aims to increase contraceptive prevalence rate in Senegal to 14% by 1995 and expand the delivery infrastructure to allow continued increase in FP acceptance beyond 1995 (to 22% by 2000). It has three sub-components: (a) Expanding FP services through the public health system (b) Extending FP services through private sector channels (c) Promoting FP through information, education and communication (IEC) Activities of this component are described in dettail in Annex 3-1. 3.6 Expnd!ug FP Services through the Public Health System. The USAID- and UNFPA- funded projects have so far given priority to establishing FP services at the health center (MCH center) level and building capacity at the national level to plan and manage a national program. This program would extend the accesmibllity of services to the health post (HP) level, thus representing a major effort to expand FP coverage by taking them one level further down in the health service pyramid. In keeping with Government's stiategy for FP delivery, a fully-integrated MCH-FP package will be offered at the HP level. Around 720 FA-s in both urban and rural areas will offer the MCH-FP package by the end of the program period. To aacomplish this objective, program activities will include: a) Training in. UP for 720 health post nurses (HPN) b) Provision (if contraceptives to meet 25% of national needs c) Support foi Iv CH and nutrition activities at the HP level d) Improving M,C;I/FP instrction in Schools of Public Health 3.7 Training of HPNs 'In FP will focus on: (i) contraceptive techniques for all methods except IUDs, for which clients would be referred to the health center; (ii) FP counselling; (iii) promotion of FP during other MCH service con acts (pre-natal visits, vaccination, nutritional surveillance and education, curative services, etc.); and (iv) follow-up of FP acceptors. In keeping with Government's strategy to develop a unified approach to FP activities, the program would assist in the development of a standard set of training modules to be used throughout the country, pulling together materials currently being used in ongoing projects. The standardized modules would be discussed and finalized at a national seminar (to be held in PY1) at which representatives of different projects and donor agencies, as well as MOHSA staff, would participate. Training of HPNs would begin in PY2 (see An= 3-5 . - 20 - 3.8 Contraceptives will be provided to supplement supplies expected through ongoing UNFPA- and USAID-funded projects, which would meet around 75% of national needs. A standard list of contraceptives (types of pills, injectibles, etc.) has been drawn up by MOHSA and agreed on by UNFPA and USAID. This list has been integrated into the official list of essential drugs. Project- supplied contraceptives will be selected from this list. 3.9 An important pre-condition for the rapid expansion of FP is the liberalization of regulations on the distribution and use of contraceptives. To this end, MOHSA has recently issued instructions to (i) lift laboratory exam requirements for prescription of hormonal contraceptives, and (ii) authorize distribution of contraceptives in pharmaceutical "depots". In addition, as gnditins of effectiveness it will adopt a new version of the decree defining MCH services that would include FP as part of the basic MCH package, and authorize HPNs to distribute all types of contraceptives except IUDs. 3.10 Successful promotion of FP activities at the HP would depend on the credibility of MCH services being offered in these facilities and their ability to attract potential clients for FP. For this reason, the program would also strengthen MCH services at the HP level, with particular emphasis on pre-natal consultation, well-baby care (including growth monitoring and vaccination), and nutritional rehabilitation. Program activities would include: (a) training for HPNs on MCH service delivery, maintaining family records for proper monitoring of clients, and time-management skills to better organize their tasks; (b) provision of material and equipment for MCH-FP services; (c) development of operational approaches for nutritional surveillance and education, including the following experimental activities: social marketing of growth charts, introduction of nutritional activities into women's groups' programs and in activities of social structures (social centers, etc.), and strengthening nutritional activities of village health workers; and (d) preparation of a national nutrition strategy and program taking into account results of these experiments. 3.11 Finally, the need for high-cost on-the-job training programs will be eliminated in the long run by improving MCH-FP instruction in Schools of Public Health. To accomplish this objective, the program will provide assistance for the development of revised curricula, production of teaching materials and training of instructors in the National Schools of Public Health. 3.12 For this sub-component, program assistance would include: (i) specialist services for the preparation of revised curricula (1 month international); (ii) 2 seminars (on the MCH-FP training module and on the basic training curriculum); (iii) re-equipment for MCH-FP services of HPs in 26 districts outside the zone of concentration of the district services component; (iv) contraceptives to meet 25% of national needs in the public sector; (v) the cost of nutrition experiments; and (vi) training of instructors in the Schools of Public Health. Costs of development of training modules and direct costs of HPN training would be financed under the district services component (para. 3.37). 3.13 Extending FP Services Through Private Sector Channels. This sub-component will extend FP services through private sector channels including: a) Strengthening and extending FP services in private and parapublic enterprises, in private clinics and through commercial pharmaceutical outlets; and b) Institutional and operational support for the IPPF-affiliated Association Senegalaise pour le Bien-etre Familial (ASBEF). - 21 - 3.14 Activities in part (a) build on achievements of the "Private and parapublic sector" component (VSPP) of the USAID-funded project (PSFP). They will be implemented by the newly- formed NGO SANFAM (para. 2.3) or by other NGOs with similar objectives. Thirty-four new clinics in public and private enterprises will be added to the program, and 65 others already in the program will benefit from follow-up supp'rt. One hundred twenty pharmacists, each accompanied by two assistants and 200 pharmaceutical "depot" agents, will be trained in FP-IEC. 3.15 Assistance to ASBEF will include: (a) the creation of a FP clinic in Kolda (this would be its fifth clinic outside Dakar); (b) support for IEC activities; and (c) direct institutional support. For its IEC activities targeted specifically at youth groups, ASBEF will also have access to funds under the "youth" component of this project. 3.16 For this sub-component, program assistance would include: (i) training in FP of private sector doctors, nurses, pharmacists and their assistants, ASBEF staff and volunteers; (ii) contraceptives (except for contraceptives for the commercial pharmaceutical sector which will be supplied by USAID); (iii) equipment for MCH/FP services (private enterprises) and FP-IEC (ASBEF); (iv) partial support for operating costs of SANFAM, ASBEF or other participating NGOs. Participation of NGOs not heretofore identified will be subject to prior IDA approval. 3.17 Promoting FP through Information. Education and Communication aEC). This sub- component will: a) Develop and implement improved operational approaches for face-to-face communication through: i) an initial evaluation of ongoing field operations in PY1; ii) development of improved operational approaches on the basis of evaluation results iii) extension of coverage of face-to-face communication activities through social development agents of MOI and MCJHSA and volunteer auxiliaries b) Develop and implement FP-IEC programs through the mass media c) Strengthen institutional capacity at the national level through: i) institutional support for the Health Education Unit (HEU) of MOHSA ii) a program of "market research" on contraceptive acceptance and use. 3.18 The evaluation of ongoing field operations will focus on agents of the MOI ("mattresses" and "monitrices") and of the Directorate of Social Affairs (DSA) of MOHSA ("agents sociaux", "assistants sociaux", etc) who have benefitted from training in FP-IEC under ongoing USAID- and UNFPA-funded projects. The objective is to assess both impact and efficiency of these activities, with a view to recommending possible changes in approach. In particular, focus will be given to the integration of FP-IEC activities with other responsibilities of these agents. A key feature of the evaluation will be to assess the extent to which the "training and visit" approach used for agricultural extension agents could be applied to improve the operational efficiency of the "social extension" system. To this end, the evaluation team will include a T&V specialist (see terms-of-reference in Annex 3-1). Results of the initial evaluation will be used to reassess ongoing activities, revise training programs and message contents and, if appropriate, reorganize field services. Training and equipment of social development agents under this sub-component will thus start in PY2, after completion of the initial evaluation. - 22 - 3.19 At the national level, special attention will be given to finding ways to apply commercial marketing techniques to FP promotion and to building capacity within the HEU in this respect. To this end, the HEU would receive assistance to set up a twinning arrangement with a firm or institution with the relevant experience in marketing (e.g., a commercial marketing team) that would help plan strategies and transfer know-how. The program would also include support to carry out market research studies. 3.20 Program assistance would include: (i) specialist services on evaluation of face-to-face communication, "training and visit" systems, marketing and design (30 months local, 16 months international); (ii) training for HEU staff and MOI and DSA field personnel; (iii) a fellowship on social psychology; (iv) operating costs of the initial evaluation; (v) incremental recurrent costs for HEU; (vi) production costs of radio and TV programs, press releases and promotional materials; (vii) equipment for HEU and MOI and DSA field personnel; and (viii) market-research studies. Fifty "monitrices" and "maftresses" participating in the WID component as well as 750 volunteer auxiliaries belonging to beneficiary women's groups will have priority in receiving training, equipment and logistical support. 2. Promoting the Status of Women 3.21 This component will support the network of women's groups and their associations (i.e., unions of women's groups), key vehicles for improving women's status. It has four sub-components: a) Functional literacy training for 6,300 women - members of management committees of women's groups and women's associations b) Extension of the network of "cases-foyer" (centers for local women's group activit As) in 45 "arrondissements" c) Provision of labor-saving equipment for household work d) Institutional strengthening of the Ministry of Women The first three sub-components will be managed and implemented by the Ministry of Interior (MOI), working through its network of monitors ("monitrices") in the local Centers for Rural Development. Program activities will cover five regions chosen for the large number of active women's groups: Fatik, Kaolack, Louga, St. Louis et Ziguinchor. Ten monitors per region will be assigned to participate on a full-time basis in program activities. Seventy-five groups and nine associations per region will receive program assistance. Activities of this compotrnt are described in detail in Annex 3-2. 3.22 Functional Literacy for Women. This sub-component will organize functional literacy courses for over 6,000 members of management committees of women's groups that would benefit from the "cases-foyer" and the labor-saving equipment installed through the program. Reading materials will be oriented towards subjects of interest to women: management of labor-saving equipment or of income- generating activities, health (including nutrition) and family planning. Women will also learn to prepare simple project proposals for income-generating activities to help them seek financial assistance from ongoing projects such as the UNDP-funded "Projet economique des femmes" (PEF) and the IDA-funded Small Rural Operations (SRO) Project. Pedagogical materials developed under the PEF and other similar projects will serve as basic training documents, with a minimum of revision or development. Literacy classes will be led by village literacy agents who will be trained and supervised by the program monitors. These monitors will in turn be trained by literacy experts of the Directorate of Literacy and Basic Education of the Ministry of Education or of the PEF. Program assistance would include: (i) training - 23 - of monitors and of village literacy agents; (ii) development and production of literacy materials; and (iii) operating costs for functional literacy classes. 3.23 Extension of the network nf "cases-foyer". This sub-component will extend the network of "cases-foyer" in 45 "arrondissements" to serve as a locale for women's group activities (including FP- IEC) and to be managed by the local women's association. It builds on a successful pilot experience with seven cases-foyer organized under the USAID-funded project (PSFP) and the PEF project. One problem identified under the pilot experience was the poor maintenance of the physical infrastructure. To address this problem, beneficiary women's associations will be encouraged to organize income-generating activities from which a part of revenues could be used to cover maintenance costs of the case-foyer; if necessary, they would apply for funds available through the SRO Project (of which up to US$1.4 million equivalent has been reserved for women's groups) for the start-up of such projects. Literacy training for members of management committees for the cases-foyer (para. 3.22) will provide the necessary assistance in project preparation. Program assistance would include construction and equipment of 45 cases-foyer. 3.24 Labor-saving Equipment for Household Work. This sub-component will provide food processing equipment and manual water pumps to 375 women's groups. Provision of food processing equipment would be combined with a group-savings scheme that would familiarize women with the practice of savings and of making monthly payments, and thus prepare them for eventual contact with the formal credit system. It builds on successful experience in the PEF and other NGO-supported projects having similar objectives, as well as similar experiences in neighboring countries. 3.25 Upon receipt of the food processing equipment, each women's group would sign a contract agreeing to "repay" 50% of the cost of the equipment. Monthly payments would be deposited into a bank account held in the group's name which would be monitored (but not controlled) by the Component Support Unit (CSU) in the MOI (para. 4.8), in collaboration with a banking institution. Upon completion of repayment, the group would be allowed to withdraw the total amount paid for use in other income earning or social welfare projects. Beneficiary groups would have to meet certain qualifying criteria to demonstrate their readiness to operate and maintain the equipment, including organizing a management committee to oversee equipment use, and setting up maintenance and cost recovery arrangements. Groups receiving manual water pumps would not be required to "repay" any part of investment cost; they would, however, be subject to the same qualifying criteria, including presenting a plan for maintenance of the equipment. Support structures to facilitate installation and maintenance of equipment (including training programs for maintenance personnel, identification of sources of spare parts, etc) have been put in place under the PEF and similar NGO-funded projects. Project monitors will guide beneficiary groups in seeking assistance from technical experts of these projects to fulfill qualifying criteria. Functional literacy training to be provided for members of the management committee (para. 3.22 above) will include subjects on equipment management and maintenance. Details on the management and terms of the savings scheme and on qualifying criteria are given in Annex 3-2. 3.26 For this sub-component, program assistance would include: (i) the cost of equipment for up to 375 women's groups; (ii) training for community millers and repair mechanics; and (iii) an initial stock of spare parts. To avoid problems experienced in withdrawal of funds from the collaborating banking institution under the PEF, Government gave assurances during negotiations that, by December 31, 1991, an agreement will be signed between the CSU of the MOI and a banking institutionunder terms acceptable to IDA. -24- 3.27 Institutional Strengthening of the Women's Ministry. The Ministry in Charge of Women and Children (MCWC) Is presently preparing a long-term WID strategy with assistance from IDA (under proposed SPPF financing and Bank sector work) and other donors. To contribute to that exercise as well as to assist in the continued development of practical operational approaches to promote WID, MCWC will monitor and evaluate the effectiveness and impact of activities carried out under this project as well as the overall success of all programs aimed at improving women's status and their access to improved economic opportunities. In addition, it will review curriculum content of basic training programs for monitors in order to adapt them to the new roles played by these agents under the proposed WID strategy. Finally, it will participate actively in the mid-term review of the proposed project, focusing on the sustainability of the approaches used to promote and support women and their associations. To generate greater awareness about women's roles and problems, the MCWC will also carry out informational and promotional activities through the mass media and through a series of seminars. Assistance to MCWC for strategic planning, monitoring and evaluation activities as well as for its informational activities would be provided under the program. It would include: (i) specialist services for monitoring and evaluation and for information-awareness campaigns (11.5 months international); (ii) training for MCWC staff; (iii) seminars at the national and regional levels; (iv) production and dissemination of mass media materials; (v) incremental recurrent cost support; and (vi) office equipment and furniture for MCWC. 3. Reaching Young Men and Women 3.28 This component will support FP-IEC activities for youth through: a) IEC programs on Family Life Education (FLE) and related topics of interest to youth including family planning, population issues, family welfare, STD, AIDS, etc.; and b) rehabilitation of youth centers (centers for youth association activities). It complements assistance of the proposed UNFPA-funded FLE Project which covers both IEC and community-oriented activities of youth associations. For IEC activities, the Ministry of Youth and Sports (MYS) will call on the services of the Health Education Unit of MOHSA which will develop youth- oriented programs and will provide the services of trainers, training material, and IEC materials targeted to youth. MYS will be responsible for seeking ways to best integrate FP-IEC activities with other youth association activities. Rehabilitation of youth centers will take place in the context of a broader program to train youth in artisanal skills (carpentry, masonry, etc.) organized under the UNFPA-funded project. Under that project, these skills would be applied as well to other community-oriented activities such as sanitation, reforestation, etc. Program activities will cover the peri-urban areas in the regions of Dakar, Thies, Kaolack, and St. Louis. 3.29 Program assistance would include: (i) rehabilitation and equipment of 12 departmental youth centers (Centres departementaux d'Education populaire et sportive - CDEPS) and 26 training centers ("Foyers de jeunes"); (ii) specialist services on FLE and related topics; (iii) training of MYS agents on FLE; (iv) vehicles for 4 regional offices; and (v) production of mass media materials. Activities of this component are described in detail in Annex 3-3. -25 - 4. Institutional Strengthening for Promoting the National Population Program 3.30 This component will strengthen institutional capacity to create and maintain a policy environment conducive to the attainment of the objectives of the national population program. It has two sub-components: a) Population-related research and dissemination of information on population-related issues to natioial and local leaders; b) Monitoring and evaluation of implementation of the Population Action and Investment Program (PAIP). These activities will be led by the Division of Human Resources in the Ministry of Economy, Finance and Planning in its capacity as lead agency for the population program and secretariat to the National Population Council (CONAPOP). Program assistance complements ongoing assistance from UNFPA to the Population Unit in this Division and the Communication Unit (UNICOM) in the Ministry of Communication and Culture. 3.31 Population Research and Information Dissemination. This sub-component will provide assistance for continued research on key determinants of population growth in Senegal (women's economic and social roles, girls' education, infant mortality, urbanization, and legal and regulatory constraints), channel information on research results to appropriate sector planners and policy-makers, and assist these leaders in adjusting sectoral or regional plans to be more responsive to population objectives. Research on legal and regulatory constraints will focus on priority topics identified through an earlier study including- the legal age at marriage, laws on matrimonial status (choice between polygamy and monogamy), family allowances and other family-support measures, and the application of laws affecting women's status in society. Dissemination seminars on legal constraints would address those responsible for making or applying laws audges, politicians, religious leaders, law enforcement authorities) as well as groups most affected by these issues (women, youth, social workers, health personnel). An Advisory Committee on Population Research consisting of academics and operational personnel will be created to review research proposals from individual researchers or research institutions, preferably Senegalese or from the Sahel region. Proposals should identify policy-makers or sector planners who will use research results and include a program for their dissemination (seminars, workshops, etc.) and application. To ensure coherence and avoid duplication, it is recommended that the Advisory Committee on Research screen all population research activities managed by the Human Resources Division (HRD), regardless of source of funding. The HRD will seek agreement from other major donors in this respect and will invite them to participate in the selection of committee members. Annual research and dissemination programs will be discussed with IDA during the annual project implementation reviews (para. 4.11). 3.32 Program assistance would include: (i) specialist services to carry out research studies (50 months local); (ii) 10 dissemination seminars; and (iii) translation and printing of research results. 3.33 Monitoring and evaluation of the National Population Program. The Human Resources Division (HRD) will develop and maintain a system to monitor progress in the implementation of the national population program. In collaboration with lead agencies for each of the eleven components of the PAIP, it has prepared a list of key measurable indicators, principal sources of data and the agencies responsible for collecting them (see Annex 3-1 l. By project start-up, HRD will have developed and - 26 - installed (under PPF financing) a central monitoring system including the supporting data- collection/updating systems organized in collaboration with concerned agencies. This matrix of key indicators will be presented to IDA for review each year during the annual project implementation review. To evaluate the overall impact of the population program over time, a second Demographic and Health Survey will be conducted in late 1991 and a third one in 1996. (The first DHS was conducted in 1986.) This survey would provide information on fertility, contraceptive prevaicnce; knowledge and attitudes on family planning, and infant and child mortality. Special evaluation studies on specific elements of the population program will also be carried out during the period between the two household surveys. 3.34 To support these activities, program assistance would include: (i) specialist services for developing the monitoring system (2 months local, 2 months international); (ii) equipment and recurrent costs for computerization; and (iii) costs of special evaluation studies and partial costs for two DHS surveys (the DHS Project and USAID would fund the remaining costs, at least for 1991). C. Part II: Implementing the National Health Policy 1. Developing the District Health System 3.35 This component would assist Government to put in place the new district health system that will serve as the basic operational unit for health care delivery (para. 2.40-2.41 above and Annex - 4). This would involve the application of new norms of coverage, staffing, and resource allocation and the establishment of new managerial systems in the 45 health districts in the country. To achieve this objective, this component would include four sub-components: a) development of training programs for health district personnel b) development of a financial management system for districts c) promotion of community health organizations d) assistance for implementation of District Health Development Plans (DHDP) in 19 districts in the regions of Dakar, Thies and Diourbel The first three sub-components would cover all 45 districts in the country. The last one, which largely involves construction and equipment activities, would cover all districts in the three selected regions. 3.36 To set the stage for implementation of the above project activities, Government has issued instructions (a) defining the structure and norms of coverage, function, staffing, management and supervision of the district system, and (b) delineating the 45 health districts in the country. In addition, to ensure appropriate allocation of personnel resources to the district system, the completion of implementation of the redeployment and recruitment measures defined in the emergency plan for FY90-91 (para. 2.44) is a condition of credit effectiveness; and Government gave assurances during negotiations that it vould, through 1996, implement the redeployment and recruitment measures defined in the medium-term plan for FY91-96 (para. 2.45). 3.37 Development of Trainine Programs for District Health Personnel. This sub-component will support the development of a package of training programs for District Medical Officers (DMO) and Health Post Nurses (HPN) to prepare them for their new responsibilities, both managerial and technical, and assist them in preparing a districL plan to guide the implementation of reforms in their district. The second district doctor (DM02), who will share supervision and training responsibilities with the DMO, - 27 - will participate in the relevant training program. He will also receive training in emergency surgery. Regional Medical Officers (RMO), who are responsible for overseeing health district development within their regions, will participate in all programs addressed to DMOs. Programs to be developed include: For DMOs: a) Preparation of a District Health Development Plan (DHDP) and set-up of district operations b) Management of drugs, community health organizations, and financial management of health districts and health posts For DMOs and DMO2s: c) Management of district operations, and supervision and training of HPNs For DMO2s: d) Emergency surgery; each DMO2 will be accompanied by one health center nurse who will be trained in anesthesia techniques For HPNs: e) Management of a health post, including the minimum package of survices and administrative activities Approaches, objectives, organization and implementation calendars for each of the above programs are detailed in Annex 3-5. Given the large number of HPNs in the country (over 600 at present, over 900 in principle by 1995) and the importance of practical aspects of their training, nurses' training will be carried out in two phases: an initial two-week seminar followed by a series of supervision-training visits by the doctor over a six-month period. The supervision visit is thus an essential element of the proposed training program. Around 720 HPNs will be trained during the five-year program implementation period. 3.38 Training in emergency surgery will be joindy organized with the Belgian and French TA programs, which are providing surgeons at three facilities to be used as training centers: the health center at Guediaweye, regional hospitals in St. Louis and Ziguinchor. A total of 24 DMO2s and 24 nurse- anesthetists will be trained during the program period. Priority will be given to DMO2s and nurses in the program's zone of concentration and in the nine health centers that were constructed or rehabilitated under the IDA-funded Rural Health Project. 3.39 In addition to the above training activities, two districts will be set up as Training Zones where "best practice" in district management and service delivery will be established in a "real-world" environment. Except for an initial intensive investment in technical assistance and training, and regular supervision visits from technical assistance teams, the two districts will function on budgets and allocations of human and other resources no different from other districts. The Training Zones would serve as a place for practical training of DMOs where they would return for refresher training after an initial period of managing operations in their own districts. Thirty PMOs will be trained here during the program period, with priority given to DMOs in the three regions of concentration (para. 3.45). The practical training course will also serve in the long run as an orientation course for new doctors taking up posts as DMOs for the first time. Two districts have been selected (one urban - Nabil Choucair (Dakar) - and one rural - Tambacounda) as training zones. 3.40 Program assistance would include: (i) specialist services (65 months local, 7 months international) to set up and supervise the Training Zone; (ii) development of training materials and operational guidelines; (iii) participation by DMOs, DM02s, and HPNs in training seminars; (iv) 20 -28 - vehicles for supervision and on-the-job training; (v) minor rehabilitation and equipment of health centers in the Training Zones; (vi) recurrent costs of training and research activities in Training Zones; and (vii) annual meetings of all DMOs at the national level. Operating costs directly related to service delivery in the Training Zones will be financed through the districts' normal operating budgets. 3.41 Developing a Financial Management System for Districts. This sub-component aims to develop budgeting and financial management procedures for health districts in preparation for establishing financial autonomy by 1992. Activities will include: (a) development of mechanisms to facilitate actual expenditures by districts of their budget allocations, including a review of procedures for preparation and execution of district budgets; (b) a review of criteria applied in allocating budgets to different health facilities; and (c) establishment of a standardized, simplified accounting system at the district level. During negotiations, Govermment gave assuranges that it would present MOHSA's budget in a format that would clearly delineate drug and material allocations for the 45 districts in the country throughout the project period. Finally, to ensure sufficient budget allocations to health in general and to the health district system in particular, Government gave assurances that: (a) the percentage share of the government's recurrent budget allocations to MOHSA for the health sector would increase to 5.25% during FY 91-92, to 5.75% during FY93, to 6.25% during FY94, to 6.75% during FY95, and to 7.25% during FY96; (b) total drug and material allocations to the 42 districts would be at least 1.5 billion CFAF in FY91-92, 1.1 billion CFAF in FY93 and, subsequently through FY96, this amount would increase by at least 10% every year in real terms2; and (c) it will furnish to IDA, by October 30 of each year, (i) the draft recurrent budget for health for the upcoming fiscal year, and (ii) the draft investment budget for the health sector for the coming three years. 3.42 Program assistance would include: (i) specialist services on budgetary and accounting procedures for the public sector (I month local, 4 months international); and (ii) training of 45 district administrators on the accounting system. 3.43 Promoting Community Health Organizations. CHOs will play an essential role in mobilizing local resources for district operations, particularly at the health post level. Public health personnel, local officials, and the general public need to be made fully aware of this fact and to understand the terms of the partnership between Government and the community. Training for DMOs and HPNs on district operations (para. 3.37) will include orientation on the role of CHOs and skills on how to support CHO development. To further promote CHO development, this sub-component will provide support for: a) public information campaigns on CHOs and how they should function b) dissemination of guidelines for members and officers of health committees and associations c) a study on the effectiven; ss of the cost recovery system in PY3. To strengthen the regulatory framework within which CHOs would function, in particular to reduce misallocation and improve management of funds, Government will issue regulations governing the 2 Smegal's Fisd Year will change from July I-June 30, to January l-Dcember 30, tarting in 1992. Its 1991-92 budget thus rpiaen an 18wmonth budget. - 29 - organization and management of CHOs, defining procedures for the transformation of existing CHOs to conform with new regulations, and requiring that only CHOs in conformity with new regulations will be permitted to operate in public health facilities. These regulations were discussed and finalized during negotiations; their adoption is a condition of credit effectiveness. 3.44 Under this sub-component, program assistance would include: (i) specialist services for development of information campaigns and guidelines, and evaluation of cost recovery efforts (4 months local, 4.5 months international); (ii) seminars for local leaders (mayors, "prdfets'); (iii) production of radio and television spots and posters in 6 local languages; and (iv) printing of guidelines. This component is discussed in detail in Annex 3-10. 3.45 Assistance for Implementing District Development Plans in Three Regions. This sub- component will provide assistance to 19 health districts in the regions of Dakar, Thies, and Diourbel to implement the.ir district health development plans (DHDP). Assistance will include: a) Establishment of the network of district health facilities through (i) construction, equipment of 90 new HPs; (ii) transformation of 12 MCH centers into HPs; (iii) re- equipment of around 190 existing and transformed HPs; (iv) rehabilitation, re-equipment of 5 existing HCs and 7 district pharmacies b) Logistical support for supervision and management systems at the district level c) Strengthening management and support capacity at the regional level Districts will also receive an initial stock of essential drugs under the essential drugs component (para. 3.54). Each participating district must have adopted a district development plan, with IDA approval, to qualify for assistance. All facilities receiving assistance (including new construction) must be included in the approved district coverage plan. In addition, no civil works on HPs will be started unless a local health committee has been organized in accordance with new regulations (para. 3.43). For the supervision of construction of new HPs, MOHSA will employ consultants, although MOHSA may want to use AGETIP (Agence d'execution des travaux d'inter8t public contre le sous-emploi) as executing agency since all the new HPs will be in urban areas. 3.46 Each district will receive equipment and furniture worth up to 5 million CFAF to partially re-equip and refurnish existing and transformed HPs. The DMO will determine priority needs for HPs in the district selected from a standard equipment and furniture list for HPs and will present a request to the Component Support Unit (CSU) in MOHSA, which will procure the equipment for all districts. 3.47 At the regional level, the Regional Medical Officer (RMO) will oversee the district level reform program and provide the needed technical and administrative support for its implementation. He will be particularly involved in the preparation and monitoring of DHDPs and in planning and implementing personnel redeployment between districts. RMOs in the three regions of concentration will receive the necessary training and logistical support to carry out their leadership responsibilities. 3.48 Program assistance would include: (i) construction/rehabilitation and equipment of HPs, HCs and district pharmacies; (ii) information system registers and instruction manuals for HPs, HCs and district management teams; (iii) fellowships for master's degrees in public health with an emphasis on the management of health district operations for two of the three RMOs, and study tours for all 3 RMOs - 30 - to observe successful projects in other countries; (iv) minor rehabilitation of 3 regional health offices, and provision of material and equipment; and (v) establishment of regiontal document centers. 2. Promoting Essential Drugs 3.49 This component will support MOHSA's strategy to promote wider use and availability of essential drugs and to significantly reduce their cost, focusing on strengthening demand and supply elements in the public distribution system, as called for in its medium-term plan for the pharmaceutical sector (para. 2.42). It includes four sub-components: a) reform of the National Pharmacy b) supply of an initial stock of drugs for health districts c) information campaign. for prescribers and the public d) development of a long-term strategy for the pharmaceutical sector Certain activities to be undertaken under the district services component, including training of health personnel on the use and management of drugs (para. 3.37), measures to ensure sufficient budgetary allocations for drugs at the district level (para. 3.41), and support for CHO resource mobilization efforts (para. 3.43), also constitute key elements of the essential drugs program. 3.50 Reform of the National Pharmacy. This sub-component will support actions necessary to enable the National Pharmacy (PNA) to perform its function as the principal supplier of low-cost essential drugs to the public health system. It will include: a) adoption of restructuring measures to grant PNA the financial flexibility to fulfill its commercial functions while retaining its status as a government entity b) support for the establishment of improved managerial, financial, procurement and distribution systems. 3.51 As part of its restructuring program, PNA iLas been granted a three-year exemption from standard Government procurement procedures which are slow and unsuited to the nature of the pharmaceutical market. In addition, to ensure prompt release of budget allocations for drug expenditures, funds from budget drug allocations will be channelled on a regular basis into a commercial bank account to be held at the level of PNA. To access these funds, each district would submit to PNA every four months a list of drug purchases worth up to one-third of its annual budgetary allocation. PNA will cede the equivalent amount in drugs, in addition to any other drugs to be purchased on a cash basis using district revenues from CHO contributions or other sources. PNA will monitor drug transfers and budget allocation expenditures separately for each district, as it will for each of its other clients. An initial deposit of 350 million CFAF will be made into the commercialibank account to be held by PNA as a condition of credit effectiveness. During negotiations, Government gave assurances that it will replenish this account every three months. 3.52 PNA will undertake major organizational reforms to improve its internal efficiency including: staff reinforcement and clearer task definition, restriction of its product range to items in the official list of essential drugs; improved managerial, financial and procurement systems (including maximum use of ICB procedures and placing multi-year drug orders); and adjustment of its pricing policy tc cover internal operating costs (to be set initially at a margin of 5% over acquisition cost). The - 31 - proposed internal reorganization of PNA is described in detail in Annex 3-9. During negotiations, Government gave assurances that PNA stocks will be maintained in conformity with the official list of essential drugs throughout the project period (starting in PY2) and revise the list of essential drugs only after prior agreement with IDA. 3.53 Program assistance would include: (i) specialist services on PNA organization and management (11 months international); (ii) training on drug management and distribution for PNA personnel (210 days local, 10 months external); (iii) minor civil works, equipment and furniture; (iv) salaries of 2 pharmacists and a "contrBleur de gestion" on a declining basis (100% in PYI-3, 50% in PY4-6); and (v) other recurrent costs for PY1-3. 3.54 Provision of an Initial Stock of Drugs for Health Districts. To stimulate district operations and to revive cost recovery efforts, this sub-component would "prime the pump" of the drug supply system by providing an initial stock of drugs at the PNA, the HC and the HP levels. Program assistance would include: (i) 200 million CFAF worth of drugs for PNA to complement its existing stock (400 million CFAF value) and thus complete an initial revolving stock of 4 months' drug needs for district level facilities; (ii) 4 months' supply of drugs for all district HCs; and (iii) 4 months' supply of drugs for 16 HPs in every district in the country (a total of 720 HPs). Supplies to PNA and to all HCs will be provided in PYl. Supplies for each HP will be provided upon completion of the HPN's training under the district services component and would thus be phased in over PY2-6. Because the level of referrals to the HC is expected to be at less than full capacity at the start of the program, drug needs are estimated for this purpose at 70% of capacity. 3.55 To ensure that the initial stock will be renewed through efficient management and cost recovery, each district must fulfill the following criteria to qualify for assistance under this sub- component: (a) adoption of district health plans consistent with nationally adopted norms; (b) completion of training in drug management for the DMO; (c) organization of the district pharmacy according to guidelines, and (d) setting of fees for the health center and agreement to apply them immediately upon receipt of project-supplied drugs. Each HP receiving assistance must fulfill the following criteria: (a) completion by the HPN of the initial two-week seminar on HP management; (b) (re)organization of the local health committee according to new regulations; and (c) setting of fees for the health post and agreement to apply them immediately upon receipt of project supplied drugs. All facilities receiving assistance must be included in the approved district coverage plan of the DHDP. The DMO will certify to the fulfillment of the above criteria for the district as a whole and for each HP receiving assistance. The CSU will verify ex post, through random checks, the validity of these certifications. During negotiations, Government gave assurancA that it will allocate the initial stocks of drugs provided under the project only to those Health Centers and Health Posts that meet the above-mentioned eligibility criteria. 3.56 Informnation Campaigns on Essential Drugs. This sub-component will support the promotion of essential drugs through a public information campaign aimed at the general public, members and officers of community health organizations, and public and private health practitioners and pharmacists. Two types of activities are planned, in addition to the training programs for district health personnel to be carried out under the district services component: (a) information campaigns for the general public; and (b) dissemination of essential drugs lists (including price information) and prescription guidelines to health personnel in the public and private sectors. The project would finance: (i) services of a specialist in social marketing (1.5 months international); (ii) production of television and radio spots - 32 - and of posters in six local languages; (iii) reprinting of the essential drugs list and prescription guidelines ior distribution to private health practitioners and pharmacists, NGOs and medical insurance plans of large enterprises (1PM). 3.57 Development of a Long-term Strategy for the Pharmaceutical Sector. This sub-component would provide assistance for the development of a long-term pharmaceutical sector strategy whose objective would be the development of a strong, open market for low-cost essential drugs involving both public and private sectors (para. 2.42). Two special studies will be carried out under management of the CSU in PY3 as inputs to the preparation of the strategy: (a) analysis of the long-term flnancial viability of PNA; and (b) alternative market structures for the supply of essential drugs, with focus on the role of PNA and of the private sector. These studies will take into consideration experience during the first two years of project implementation, particularly as concerns operational efficiency of PNA and any improvements in the cost and availability of essential drugs. Among other things, the option of transforming PNA into an autonomous public entity will be considered in the light of study findings. Representatives of the commercial drug sector as well as concerned NGOs will participate to the extent possible in preparation of the strategy. Program assistance would include: (i) 8.5 months of specialist services (internationally recruited) to carry out the two studies and prepare the strategy; and (ii) a national seminar to discuss the proposed strategy. 3. Institutional Strengthening in the Health Sector 3.58 This component continues support initiated under the Rural Health Project (Cr. 13i0-SE) for institutional development at the national level. It focuses on: (a) manpower planning and development; (b) budgeting and financial planning; (c) physical asset management; and (d) institutional support for the Directorate of General Administration and Equipment (DGAE) in MOHSA. 3.59 For manpower development, MOHSA would: (a) carry out studies to define staffing norms for regional hospitals and specialized structures of the ministry (Public Hygiene, specialized health centers, etc); (b) continue development and maintenance of a computerized personnel information system to monitor progress in redeployment and recruitment; and (c) prepare a program for the restructuring of the education and training system in the health sector. The restructuring program could be financed under the proposed second Human Resources Development Project on education and training (FY92S). During negotiations, Government gave assurances that it will complete the studies on staffing norms for regional hospitals and specialized studies of MOHSA, and discuss the findings of the studies and recommendations with IDA by June 1993. 3.60 For management and planning, MOHSA would: (a) in complement to work to be carried out for the district level (para. 3.41), review existing procedures for budget preparation and execution for the ministry as a whole, and recommend measures for improvement; (b) develop and introduce mechanisms to monitor the flow of financial resources from the budget, community health organizations, local governments and donors and their use; (c) complete the inventory of existing assets (infrastructure and equipment), assess their condition, and introduce an asset management system (including methods for programming new purchases and maintenance and for maintaining up to date records of facilities); and (d) review the functions and activities of the four divisions of DGAE, recommend an appropriate organization and suitable management syst-ms, and assist in the implementation of recommendations. - 33 - 3.61 Program assistance would include: (a) specialist services to carry out six studies (31 months local, 13 months international); (b) seminars and workshops on various management systems; (c) local training of staff on computer utilization (10 months); and (d) 1 vehicle, office equipment, and their operating and maintenance costs for DGAE. D. Project Costs and Financing Plan 3.62 The total program costs over the five-years of implementation is estimated at US$52.8 million equivalent (net of taxes and duties). No decision has been made on the financing plan for the complete program but a number of bilateral and multilateral donors have expressed interest in cofinancing. They include France, Belgium, Canada, UNICEF, UNFPA. Program costs net of taxes are shown in Annex 3-12, pages 1 to 5. 3.63 Given the urgent need to renew efforts in the population and health sectors and to capitalize on the current momentum of reform, and because anticipated cofinancing may not be completely available for several more months, the available funds (IDA, US$35.0 million; Government, US$2.9 million) would be used to support a project consisting of all activities planned for the first three years of the five-year program. In the event that cofinancing is obtained for certain components or activities in the project, it would be possible to reallocate IDA funds thus freed to other activities in the program, which has already been appraised in its entirety by IDA. 3.64 The reduced project would cover the same range of activities described in the preceding section, with the following changes in physical targets: Physical Targ Component/Activity Program Project Strengthening the FP Program - HPNs tiained in FP service delivery 720 360 - new FP clinics in the private sector 34 21 - private clinics receiving follow-up 65 30 - social agents trained in FP/IEC 766 384 Promoting the status of women - women trained in functional literacy 6,300 2,000 - "case-foyers" constructed 45 30 - women's groups receiving equipment 375 225 Institutional strengthening for population activities - Demographic and Health Surveys 2 1 Developing the district health system - HPNs trained in HP services management 720 360 - DMO2s trained in emergency surgery 24 12 - DMOs trained in practical training zones 30 10 - new HPs constructed 90 60 - MCH centers transformed into HPs 12 4 Promoting essential drugs - HPs receiving an initial stock of drugs 720 360 - 34 - 3.65 7ne total cost of the project, net of taxes, is estimated at US$37.9 million equivalent with a foreign exchange component of US$26.4 million (70%). Base cost estimates are US$31.3 million at February 1991 prices. Costs exclude direct taxes and import duties which, although not waived, would be paid by government. Physical and price contingencies are estimated at US$6.6 million (17.4% of total cost) with physical contingencies representing 8% of base cost. Price contingencies assume: (a) a domestic inflation rate of 5% during the life of the project; and (b) foreign inflation rates of 9.0% for PYl, 1.1 % for PY2, .4% for PY3 and 1.6% for PY4. The project would be financed by IDA (US$35 million or 93% of total cost), and budgetary allocations from the government (US$2.9 million or 7% of total cost). More detailed project cost estimates and terms of financing are given in Annex 3-12, pages 6to 11. 3.66 Recurrent cost implications. Program invesmn would generate net incremental operating costs estimated at about US$8.0 million over the five-year implementation period, of which US$4.2 million would be absorbed by Government, with the balance to be absorbed by health system users. Expressed as a percentage of the FY90-91 health budget, incremental Government cost would be 0.7% in PYI and 2.3% in each subsequent project year. Salaries of 25 district doctors account for 25% of these costs, drugs 57% and other costs 18%. A large part of contraceptive costs are included under the "drugs" category above, except for those to be distributed through the private sector which would be financed through donors' contributions or direct purchase by users. Non-health components of the program are not expected to generate significant recurrent costs. Restructuring measures taken under the ptrogram would generate significant cost savings which are, however, difficult to quantify. These would include savings on the cost of drugs (average cost per episode would decrease by 50-75%), scale economies derived from integrating vertical programs into the standard service package for health posts and health centers, and savings on hospital costs of primary cases pre-screened at the post and center levels. IV. PROJECT IMPLEMENTATION A. Status of Project Preparation and Readiness 4.1 Following adoption of the National Population Policy in April 1988, project preparation started under coordination of the former Directorate of Human Resources in the Ministry of Planning (currently the Division of Human Resources in the Ministry of Economy, Finance and Planning). The population component was prepared by staff from the former Ministries of Planning and of Social Development and from the Ministries of Youth and of Health, and the health component by staff of the Ministry of Health. Preparation was complicated by one major and two minor Government reorganizations that occurred over the last eighteen months, all of which affected key ministries involved in project preparation and/or implementation. Notwithstanding the resulting transitional problems, preparation has continued on track owing primarily to Government's strong commitment to promoting human resources development. 4.2 During preparation, much attention was given to building consensus on newly-adopted policy orientations, both within Government and within the donor community, and on developing common approaches to operationalizing these new policies. Measures touching on specific elements of the larger policy package (contraceptive use and distribution, essential drugs, decentralization, norms for the district health system, etc.), are in advanced stages of preparation. Implementation plans have also - 35 - been clearly defined. Draft terms of reference for the preparation of the training activities scheduled for PY1 as well as for the initial evaluation of ongoing FP-IEC activities also scheduled for PY1, have been prepared by Government. Furniture and equipment lists have been finalized. Preparation of training programs and of construction standards for "cases-foyer" and for health posts have been initiated under PPF funding and under the ongoing Rural Health Project. Under the PPF (No. P572-0-SE), an amount of US$600,000 was approved by IDA on June 12, 1989. Senegal benefitted also of an SPPF of US$180,000, approved on November 25, 1987, for the preparation of the national population policy. B. Project Coordination and Management 4.3 Because of the complexity of the project, comprising seven components involving six different ministries, high-level coordination will be provided by an Interministerial Committee. The Interministerial Committee is chaired by the Minister of Economy, Finance and Planning, and includes the Ministers of Interior, Health, Education, Women's condition, and Youth and Sports. The Committee will provide overall guidance and supervision for project implementation. It will be responsible for policy decisions, especially of an interministerial nature, and for the resolution of any major implementation problems that may arise. The Committee will approve annual work programs and budgets for each component, review progress reports and evaluate results, and initiate any corrective actions that may be necessary, including modifications to policies, programs and budgets already approved. 4.4 While implementation responsibility for project components rests with the respective ministries, a Project Coordinating Unit (PCU) in the MEFP will be responsible for overall project coordination and administrative and financial matters, as well as monitoring and evaluation. Specifically, the PCU will: serve as a secretariat to the Interministerial Committee; * consolidate annual work programs and budgets prepared by the ministries responsible for project components; - procure goods and services (preparing bidding documents based on executing ministries' requests, calling for bids, organizing bid evaluation, etc.) for its own needs and for the women, youth and population sector institutional strengthening components; - handle disbursements (preparing the documentation necessary for withdrawal applications) and manage the Special Account established for the requirements of the PCU and the women, youth and population sector institutional strengdtening components; - maintain the project accounts and make arrangements for Audit; - consolidate progress reports for all project components for submission to the Interministerial Committee and to donors; - supervise and coordinate monitoring and evaluation activities for all project components; and - liaise with donors on all project matters. 4.5 The PCU will be headed by a Project Manager with a good knowledge of administrative procedures and experience in management and will also include a deputy project manager, preferably an economist/planner, responsible inter alia for monitoring and evaluation, an accountant, an administrative and financial assistant, and support staff. The PCU will employ short-term experts, particularly to assist in project monitoring and evaluation. - 36 - 4.6 Since the bulk of the project will be implemented by various divisions in the Ministry of Health (MOHSA), the Ministry will maintain a Component Support Unit (CSU) for Health that will be autonomous and will provide logistical support to the executing divisions and handle procurement and disbursement (including a separate Special Account) for all the requirements of the Ministry. The CSU for Health will consist of: - a Director, with experience in management and in public health; - a Deputy Director, preferably a health planner/economist; - a civil e.-gineer; and - three accountants, and support staff. 4.7 For the various MOHSA components and sub-components, management and implementation responsibilities will be as follows: - the National Family Planning Program component will be implemented by the MCH-FP division of MOHSA and NGOs for the sub-component aimed at expanding FP and MCH services and by the Health Education Unit of MOHSA in collaboration with the MCH-FP division and the Social Affairs Directorate of MOHSA, the MOI and the Ministry of Culture and Communication (MOCC) for the IEC sub-component; - the District Health Services component will be implemented by the Directorate of Public Health in collaboration with the Directorate of General Administration and Equipment and the HEU of MOHSA, Dakar University or other sources of training expertise, and the Ministry of Interior; - the essential drugs component will be implemented by the Ministry of Economy, Finance and Plan (MEFP), the National Pharmacy, and the CSU, the Directorate of Public Health and the Health Education Unit of MOHSA; - the Component for institutional strengthening in the health sector will be implemented by the Directorate of General Administration and Equipment and the Training and Research Bureau of MOHSA in collaboration with the Directorate of Public Health. 4.8 The component for promoting the Status of Women will be managed and implemented by the Ministry of Interior (MOI) in collaboration with the Ministry in charge of the condition of women and children (MCWC). At the central level, a CSU for Women in the Executive Secretariat of the Centers for Rural Development of the MOI will be responsible for overall component coordination. The CSU for Women will consist of a Director, a Deputy Director, three specialists in functional literacy, FP- IEC and community development, an administrative assistant, an accountant and support staff. The component will be implemented in the field by staff of the Centers for Rural Development in collaboration with the Health Education Unit of MOHSA and the Directorate of Literacy and Basic Education of MOE. The MCWC, which will also have a Component Support Unit (CSU) responsible for monitoring and evaluation, will be closely associated with the component implementation. 4.9 The component for reaching young men and women will be managed and implemented by the Ministry for Youth and Sports (MYS)/Directorate of Youth and Socio-educational activities, in collaboration with the MOHSA/Health Education Unit. The CSU for Youth, to be established in MYS for the UNFPA-funded project, with the participation of the International Labor Organization (ILO), will also be responsible for overall coordination of this component. - 37 - 4.10 The staffing of the Project Coordination Unit (PCU) and of the Component Support Units (CSUs) in MOHSA, MOI, MCWC and MYS with personnel whose qualifications and experience are satisfactory to IDA would be a condition of effectiveness. During negotiations, Government gave assurances that the PCU positions and those of the CSUs in MOHSA, MOI, MCWC, and MYS will be filled at all times with personnel whose qualifications and experience are satisfactory to IDA. C. Project Monitoring and Evaluation 4.11 Monitoring and Evaluation will be carried out during the life of the project by the implementing ministries and agencies as well as by the CSUs and the PCU. Each implementing unit would monitor its own activities and submit semi-annual progress reports to the component's CSU, who would in turn report to the PCU. The PCU would therefore have an overall view of problems and issues in project implementation and would be in a position to recommend to the Interministerial Committee any corrective actions that may be required. Joint IDA/Government reviews of project implementation would be carried out on an annual basis. Such reviews are designed to examine the progress of implementation to date, discuss the results of the previous year's work program and agree on the following year's work program and budget. Donors supporting the project would be invited to participate in the annual reviews. During negotiations, Government gave assurances that, by October 31 of each year, it would organize a review meeting to be attended by staff of the PCU and CSUs and representatives of IDA in order to review (i) the draft annual work program and budget for project activities to be undertaken during the next fiscal year, (ii) the draft recurrent budget for health for the next fiscal year (para. 3.41), and (iii) a draft investment budget for the health sector for the coming three years (para. 3.41). The final versions of the project annual work program and budget, and investment budget for health would reflect the comments made by IDA. 4.12 After three full years of implementation, the Government, IDA and cofinanciers would undertake a more comprehensive and detailed evaluation of the progress of project implementation, including assessments of whether the strategies being followed are producing expected results and whether those strategies need to be modified in light of changing circumstances. During negotiations, Government gave assuranc that it will undertake, by June 30, 1994 at the very latest, a comprehensive evaluation of the project. D. Specialist Services 4.13 The program includes a total of 389 person-months of specialist services (of which 67% to be locally recruited). Program costs also include about CFAF 480 million (about US$1.84 million equivalent) for technical fees comprising architectural services and engineering services for studies and supervision of construction. Details on specialist services are given in Annex 4-1. E. Procurement 4.14 The following table shows the procurement arrangements for the project by category of expenditure: - 38 - Procurement Method by Cateeorv of Expendituro (US$ million) Amounts and Methods of Procurem
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Senegal - Human Resources Development Project : Population and Health
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