Malawi - Population, Health and Nutrition Sector Credit Project

Document of The World Bank FOR OFFICIAL USE ONLY C./i Z--- 71 _- A - M/ Report No. 9036-MAI STAFF APPRAISAL REPORT REPUBLIC OF MALAWI POPULATION, HEALTH AND NUTRITION SECTOR CREDIT Population and Human Resources Division Southern Africa Department kis document has a restricted distribution and may be used by recipients only In the performance of -ir officsal duties. Its contents may not otherwise be disclosed without World Bank authorization.  CURRENCY AND EQUIVALENTS February, 1991 Currency Unit = Malawi Kwacha (MK) MK 1.00 = US$ 0.89 US$ 1.00 = MK 2.68 SDR '.00 USS 1.48 Republic of Malawi Fiscal Year: April 1 - March 81 ABBREVIATIONS AND ACRONYMS AIDS Acquired Irmune Deficiency Syndrome AfDB African Development Bank CCAM Chitukuko Cha Amayi of Malawi CDA Community Development Assistant CHN Community Health Nurse CDW Community Development Workers CHS Chief of Health Servicos CHV Community Health Volunteer CIDA Canadian International Development Agency CUS Centrol Medical Stores CS Child Spacing DEPD Department of Economic Planning A Development Devpol Statement of Development Policies DHO District Health Officer DPMT Department of Personnel Management and Training EC European Community ENM Enrolled Nurses Midwife EPI Expanded Program on Immunization HCW Home Craft Worker HEU Health Education Unit HIV Human Immuno-D-ficiency Virus HRID Human Resource Institutional Development HSA Health Surveillance Assistant ICB International Competitive Bidding IDA International Development Association IDD Iodine Deficiency Disorders IEC Information, Education and Communication IUD Intra Uterine Device JICA Japanese International Cooperative Agency KCH Kamuzu Central Hospital KfW Kreditanstalt fur Wiederaufbau LCD Local Competitive Bidding MCH Maternal and Child Health MIM Malowl Institute of Management MOA Ministry of Agriculture MOCS Ministry of Community Services MOH Ministry of Health MOLG Ministry of Local Government NGO Non-Governmental Organization ODA Overseas Development %.;ministration OPC Office of the President and Cabinet PHAM Private Hospital Association of Malawi PHC Primary Health Care PHICS Promoting Health Interventions for Child Survival PIU Project Implementation Unit PSIP Public Sector Investment Program RHT Regional Health Team RMCH Regional Maternal A Child Health Coordinator RNO Regional Nurse Officer RPHI Regional Public Health Inspector SRN State Registered Nurse QECH Queen Elizabeth Central Hospital TBA Traditional Birth Attendant UNDP United Nations Development Program UNFPA United Netions Fund for Population Activities USAID United States Agency for International Development VHC Village Health Committee WFP World Food Program WHO World Health Organization WID Women in Development  FOR OMCIAL USE ONLY REPUBLIC OF MALAWI Population, Health and Nutrition Sector Credit Table of Contents Page No. Basic Data 1 Credit and Project Summary ii Estimated Costs and Financing Plan iv I. INTRODUCTION .......................... ...................... 1 Av Economic and Policy Environment........................... 1 B. Government's Commitment to the Social Sectors ............ . 2 II. THE POPULATION, HEALTH AND NUTRITION SECTORS ................ 4 A. Basic Characteristics of the Sector . . 4 B. Issues and Constraints ......... . . 15 C. Bank Group Experiernce and Lessons Learned ................arn 23 D. Role of Other Agencies and Organizations . ................. 23 III. GOVERNMENT'S STRATEGY ............................... ............... #25 A. The Reform Program ................... ..................... 25 B. The Revised Public Expenditure Plan ..................... 26 C. Priorities for Programs and Services..................... 29 IV. THE PROPOSED PROJECT ............. . 36 A. Objectives, Rationale, and Summary Description ...*....... ..36 B. Detailed Description ...................................... 38 C. Project Cost .............................................. 43 D. Financing Plan ............................................ 47 E. Procurement ............................................... 48 F. Disbursement ................................... *................ 50 G. Implmettin........ nt.................. 51 H. Reporting and Monitoring .................................. 51 V. BENEFITS AND RISKS ............................. ............. 53 A. Benefits ................................ ... 53 B. Risks .............................. . . .. . ........ .# 54 VI. AGREEMENTS AND RECOMMENDATIOVS ................................ 55 This report is based on findings of an appraisal mission that visited Malawi in June 1990 and comprised Ms. Nwanganga G. Shields (Mission Leader, IDA), Messrs. Michael Mills (Health Economist, IDA), David Sebina (Public Health Specialist, IDA), Ms. Hope Phillips (Research Assistant, IDA) and Messrs./Mesdames. R. Chhabra (WID Specialist, Consultant), J. Huddart (Health Manpower Specialist, Consultant), L. Hansen (Architect, Consultant), J. van Haperen (Pharmaceutical Specialist, Consultant), J. Levinson (Nutrition Specialist, Consultant) and W. Lynn (IEC Specialist, Consultant). Dr. Anthony Measham (Division Chief and Public Health Specialist) was the lead advisor for this operation. Ms. Patricia Samuel provided secretarial support in the preparation of the report. Messrs. David de Ferranti and Stephen Denning are the managing Division Chief and the Department Director, respectively, for this operation. 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.  Title Page No. Arunex A - Letter of Health Development Policy.......... 58 Annex AA - Policy Action Program........................ 65 Annex B - Annual Review Actions................ 77 Annex C - Hospital Efficiency Improvement Component.... 84 Annex D - Primary Health CareFund..................... 89 Annex E - Studies and Evaluation, Technical Assistance, Fellowships.......... 91 Annex F - Supervision Plan.... 98 Annex G - Studies & Evaluation, Technical Assistance and Fellowships.... 101 Annex Ti - Ten Leading Causes of Death 0-4 years and 5-14 years....... 102 Annex T2 - Ten Leading Causes of Admission Among Children Under Five.... 103 Annex T3 - Number of Health Institutions Under Ministry of Health ........ ........ 104 Annex T4 - Health Centres, Hospitals, Dispensaries, PECs per Populationp....................... 105 Annex T5 - Health Facilities, Number of Beds by Controlling Agen cy... 106 Annex T6 - Out-patient Returns by District and Controlling Agency.y ... 107 Annex T7 - Number of Health Institutions Under Local Government, 1989..... 8 108 Annex T8 - Number of Traditional Birth Attendants by 109 Annex T9 - Summary of 1995 Staff Requirements at Minimum Standards & C&G Recommended Standards (MOH, PHAM & LG ) 110 Annex T10 - Projected Staffing 1995, 2000 Based on Current & Proposed Training Intakes ......... 111 Annex Tll - Manpower Projections 1989-2000 Based on Proposed Training Intakes & Reduced Student Dropout Ra t e s 112 Annex T12A- Investment Program (In Detail) 113 Annex T12B- Recurrent Costs of Investment Program.............* 116 Annex T12C- Recurrent Budget Projection................... 120 Annex T12D- Investment Program by Source of Fundinges ng... 124 Annex T13 - Summary Account by Project Componenton.e.**.. t.. 125 Annex T14 - Financing Plan by Disbursement Category........... 133 Annex T1S- Disbursement Schedule...h... 135 Annex T16 - Implementation Schedule..he t ul................... 136 Annex T17 - List of Documents in the Project File............. 137 Chart 1 - Organization Chart of Ministry of Health Hedqatr.... 138 Chart 2 - Organization Chart for Ministry of Health Regional and District Organization.... n.. 139 Chart 3 - Functional Organization Chart - Malawi Ministry of Heal th......... ......... . .... 140  Table 3.1 Development Expenditures for 1991/92-1995-96...... 27 3.2 Ministry of Health - Estimated Recurrent Expenditures for 1990/91 and 1995196 ......... 29 Table 4.1 Health Investment Financing Plan.................. 37 4.2 Summary of Project Cost by Component............... 44 4.3 Summary of Project Costs by Category............. 45 4.4 Assumed InflationRates........................... 46 4.5 Financing Plan by Component....................... 47 4.6 Project Cost by Procurement Method and Disbursementb............. 48 MAP IBRD No. 22688  - i - BASIC DATA Country Data Per Capita GNP (1989) US$179 Total Population 8.0 million Population Growth Rate 3.5 percent Health, Population and Nutrition Indicators Infant mortality rate (1990) 148 per 1,000 Survival to age 5 (1990) 245 per 1,000 Survival to age 5 for female (1990) 248 per 1,000 Maternal mortality (1988) 250 per 10,000 Crude death rate (1990) 20 per 1,000 Crude bitth rate (1990) 54 per 1,000 Total fertility rate (1990) 7.8 Life expectancy at birth (1988) 48 (female) 47 (male) Population per physician (1988) 60,000 Population per nursing staff (1988) 3,110 Birth attended by health staff (1985) 59 percent Babies with low birth weight (1985) 10 percent Daily caloric supply per capita 2,310 Public Expenditure on Population, Health and Nutrition Percent MOH share of total Government budget 7.7 MOH share of GDP 2.7 MOH share of development budget 11.6 MOH share of recurrent budget 6.3  - ii - MALAWI POPULATION HEALTH AND NUTRITION SECTOR CREDIT Credit and Proiect Summary Borrower Republic of Malawi Beneficiaries: Ministries of Health and Community Services Credit Amounts SDR 38.6 million (US$ 55.5 million equivalent) Terms: Standard IDA Terms Project Oblectives: The project's objectives are to improve quality, access, efficiency, and effectiveness in the sector through: (a) strengthening of basic programs, focussing on primary health care, maternal and child health care, child spacing (family planning), malaria control, AIDS program, nutrition interventions, and women in development activities; (b) strenathening of support services, focussing on staffing issues, pharmaceuticals, and IEC; (c) efficiency improvements, focussing on management strengthening, hospital decongestion, cost shaiing, and budget reform; and (d) support to the Goveranent's social dimeraions of adjustment initiative. Proiect Description. In line witb these objectives, the project's component on strenathening of basic programs will include: (a) for primary health care and maternal and child health care, development and expansion of the Health Surveillance Assistants into outreach-oriented and village-based PHN promotera and service providers; rehabilitation and/or construction of rural health centers; provision of rural housing where needed to attract essential personnel; and provision of some vehicles to improve the effectiveness of district level services; (b) for malaria, improvements in logistical support, in the supply of anti-malarial drugs, and in support for drug resistance monitoring; (c) for AIDS, acceleration of efforts in education and prevention campaigns and in acquisition of blood screening equipment; (d) for child spacing, launching of a Family Welfare Council to promote family planning and expansion of the MOH's program; (e) for women in development, institutional strengthening, upgrading of training activities, and testing of small scale demonstration projects on appropriate technology dissemination and credit provision; and (f) for nutrition, extension of a community-level food security approach developed and tested by UNICEF, and a micronutrient deficiency program. The component on strenathenina of support servieas will include: (a) for staffing issues, upgrading of training programs and facilities for health cadres currently in critically short supply, and evhancement of personnel management information and planning capabilities; (b) for the IEC program, expanded activities for training health workers, and provision of resources for conveying population, health, and nutrition messages to communities; and (c) for pharmaceuticals, technical assistance and training on drug procurement, distribution and production, and improvement of facilities and equipment. The component on efficiency improvements will include (a) rehabilitation of three urban health centers and construction of two others to  - iii - shift more outpatient care away from the more costly and overcrowded hospitale, (b) rehabilitation of one district hospital, construction of another, and replacement of worn-out equipment in selected other hospitals; (c) introduction of reforms in patient fees; and (d) budget reforms involving increases in the MOH budget and the share of it devoted to outreach and peripheral health serices. The component on the social dimensions of ad1ustment initiative will l.;_lude support for a "social support program fund" to assist small scale pilot interventions derived from felt needs of communities and expressed through Government or NOO channels. Justification and Riskas The proposed credit is designed to support the Government's population, health and nutrition programs and the key adjustment measures stressed in the Policy Framework Paper, including especially improved internal efficiency and increased cost recovery. The credit would fund a major strengthening of district health services, provide support for priority programs, reduce the incidence of malaria and malnutrition, finan^e an accelerated program of manpower development and continue the institution building activities initiated under the Second Family Health Project. There are three main risks. First, the fiscal difGiculties and constrained Government expenditures pose the risk that the health budget may not increase fast enough to permit timely completion of the investment plan and adequate funding of the system. This risk is being minimized by the Government's commitment as stated in the Statement of Development Policies (Devpol) to allocate more resources to MOH and by the requirement that MOH submit its forward budget estimates after approval by the Ministry of Finance for IDA review. A second risk concerns the introduction of cost sharing mesures and their effect on demand for health services in the rural areas. This risk is being minimized by the gradual pace proposed. A final risk concerns the consolidation of peripheral services, since there may not be enough doctors to have one in each district as the District Health Officer (DHO) responsible for district health management team. This risk is being minimized by the provision in the credit for the training of district health administrators. Furthermore, the credit provides for the system to be evaluated two years after its inception and adjusted if necessary.  - iv - REPUBL:S OF MALAWI POPULATION. HEALTH AND NUTRITION PROJECT Estimated Costs and Financina Plan a/ Local Foreign Total ---------(TuS$ Million)------ Estimated Cost Proiect Component Strengthening of Basic Program 9.3 12.9 27.2 Strengthening of Support Services 6.4 12.8 19.2 Efficiency Improvement 4.7 11.5 16.2 Social Programs Support 0.25 0.25 0.5 Total Basic Cost 20.7 42.5 63.2 Contingencies . 3.6 7.5 11.1 Total Prolect Cost 24.3 50.0 74.3 Financing Plan IDA 16.7 38.8 55.5 EC 3.9 7.2 11.1 Netherlands/WHO 1.4 1.4 Government 6.3 6.3 TOTAL 26.9 47.4 74.3 Estimated IDA Disbursement 1991 1992 1993 1994 1995 1996 Annual 2.5 11.4 13.3 12.6 9.0 6.7 Cumulative 2.5 13.9 27.2 39.8 48.8 55.5 a/ Excludes taxes and duties of US$2.3 million.  MALAWI POPULATION, HEALTH AND NUTRITION SECTOR CREDIT I. INTRODUCTION A. Economic and Policy Environment 1/ 1.01 Over the last ten years, Malawi has been confrornted with a series of external shocks: falling world prices for exports; rapid escalation in import prices, paLticularly for fuel, intermediate and capital goods; an escalation in regional political tensions, which disrupted external transport routes and led to rapid increases in transport costs and a large, continuing flow of Mozambican refugees to Malawi; and poor weather and an infestation of the cassava crop which undermined food production and security. In the early 1980's severe foreign exchange shortages caused a build-up of arrears on import payments, stringent rationing of foreign exchange, and import bottlenecks. The ba ance of payments came under severe strain, the Government budget deficit rose to unsustainable levels, and inflation increased. 1.02 The Government has responded to these major economic problems through a program of adjustment measures aimed at restoring macroeconomic stability and growth. This has included price adjustments and decontrol, improved public sector resource management and strict control of Government expenditures, exchange rate adjustmen.s, export promotion and diversification programs, strengthening of public sector policy and planning capacity, and parastatal reform. Since 1981 these efforts have been supported by three structural adjustment loans, successive IMF stand- by operations, an IMF extended facility, and, in 1988, a large Industrial and Trade Policy Adjustment Credit and an IMF Enhanced Structural Adjustment Facility. Despite periodic setbacks, Malawi has made good progress in implementing its adjustment program. Real GDP fell by 6 percent in 1980-1981, but then recovered to grow at an annual average rate of 3.1 percent through 1986. It declined by about 1.5 percent in 1987, but growth in 1988 at 3.6 percent exceeded expectations and is projected to accelerate to between 4 and 5 percent in the siort-term, making possible a gradual recovery in real per capita incomes. 1.03 The country's macroeconomic difficulties and the consequent need for adjustment have resulted in severe constraints on the Government's budgetary allocations for sectoral expenditures. The large and increasing external debt burden crowded out public expenditure and restrained the scope for new investments and increased recurrent expenditures. Interest payments claimed an average of more than 17 percent of total Government expenditures each year from 1982 to 1988. However, interest payments are projected to remain at their 1988/89 level in kwacha terms through 1991/92, implying that they will claim a decreasing share of total expenditure and leave room for some recovery in discretionary public spending. A higher rate of economic growth is also being projected, which will be ^f additional help in easing resource constraints. 11 See also: Malawi Public Expenditure Review, Report No. 7281-MAI, 1990, and Malawi Growth Through Poverty Reduction, Report No. 8140-MAI, 1990.  - 2 - B. Government's Commitment to the Social Sectors 1.04 The Government is strongly committed to supporting progress in the social sectors, including population, health and nutrition measures in particular. The country's development strategy, as summarinied in the Statement of Development Policies (Devpol), recognizes the vital role of the social sectors in overall development. For example, on health, Devpol stresses the need "to raise the level of health of all Malawians through reduction in the incidence of illness and occurrence of death in the population by de!eloping a sour.d service delivery system capable of promoting health, preventing, reducing and curing disease, protecting life, and fostering the general well being, and increased productivity'. Government support for the social sectors has become more pronounced in recent years, after earlier periods of emphasis on other sectors engaged in production of goods and services. Recent budget allocation decisions have effectively increased the social sectors' share of public resou-ces relative to other sectors. 1.05 A first "Health Plan" (1965-1969), launched shortly after independence, concentrated primarily on the development of curative services and nursing manpower. An evaluation of this plan indicated that these interventions by themselves were unlikely to improve the health status of the people. A new 15-year Health Plan (1973-1988) was subsequently prepared, and the major priorities identified were the development of basic health services, control of communicable diseases, expansion of curative services, manpower development and improvement in the organization of the Ministry of Health (MOH). This plan was amended in 1975 and again in 1978, with a slight shift of emphasis to expansion of maternal and child health (MCH) services and introduction of a pilot primary health care (PHC) program. Implementation of the 15-year plan was hampered by inadequate financial resources and scarcity of trained manpower and experienced administrators. 1.06 In the mid-1980's a comprehensive National Health Plan was prepared for the period 1986-1995. Among its goals are the achievement of a 33 percent drop in early childhood mortality and a major improvement in maternal health. Specifically, the plan aims at a reduction of the infant mortality rate from 151 to 100 per 1,000 live births and of the under-five mortality rate from 330 to 200 per 1,000 live births during the five-year period. Its main objectives are to extend peripheral and especially community-based services, along with modest strengthening of hospital services; to accelerate manpower development and improve personnel management; to strengthen the management of service delivery; to improve child survival; to improve the implementation and effectiveness of key programs; and to improve the nutritional status especially of mothers and children. Child spacing (CS) activities are also included. Some significant achievements were made during the first three years of the Plan, but progress was again constrained by lack of financial and human resources. In addition, a number of important policy issues, particularly concerning the management of the sector, became more clearly identified. The currently proposed project was designed within the broad parameters of  - 3 - the National Health Plan, but incorporating an updated Investment program and also addressing the newly identified pol:cy issues (Chapter III). 1.07 The Government recognizes the importance of: improved population, health, and nutrition services for enhanced labor productivity; the links between better social Indicators and reduced fertility levels; and the need to reduce morbidity and mortality rates as a social goal in itself. In view of the Government's sustained efforts to deal with its macroeconomic problems, its clear policy statements emphasizing the need to maintain fiscal restraint but also givo increased priority to the social sectors, its recognition of the inter-relationships between economic growth and achievements in the social sectors, and the continuing poverty and extremely low socio-economic status of most of the people, it is appropriate that additional efforts now be made to strengthen, accelerate and support the country0s ongoing programs and activities in the population, health and nutrition sectors.  - 4 - II. THE POPULATION. HEALTH AND NUTRITION SECTORS 2.01 The principal features and issues facing the population, health and nutrition sector are described in this chapter under the following headingst A. Basic Characteristics of the Sector Population, Health and Nutrition Status Organization of Health Services and Facilities Programs and Policies Manpower and Training Support Systems Management of Health Services Financing and Resource Allocation B. Issues and Constraints Coverage of Basic Services Program Effectiveness Health Manpower Support Systems Management and Decentralization Resource Mobilization and Efficiency C. Bank Group Experience and Lessons Learned D. Role of Other mencies and Organizations A. Basic Characteristics of the Sector Population, Health and Nutrition Status 2.02 The primary indicators of PHN status underscore the extensive poverty and difficult circumstances that the country faces. 2/ Under- five mortality is about 25 percent and life expectancy is approximately 48 years. Maternal mortality is now about 250 per 100,000 live births. Total fertility is 7.8 births per woman and the crude birth rate is 54 per 1000 population. Over half of Malawian children are about two standard deviations below expected height for age. The leading diseases in Malawi are malaria, respiratory infections, symptoms related to the abdomen and gasttointestinal tract, skin conditions and accidents. Schistosomiasis and a variety of helminths are endemic. Acute infections (such as pneumonia and measles), cholera and diarrhoea, and chronic infections (especially 2/ For a more extended discussion of the material in this section, see Malawi: Human Resource Development Study, Report No.7854-MAI, 1989. Also seet Malawi: Population Sector Study, Report No. 8513-MAI, 1990 and Malawi: Food Security Report, Report No. 8151-MAI, 1990.  tuberculosis) are also serious problems. Sexually transmitted diseases are common, Acquired Immuno-Deficiency Syndrome (AIDS) is spreading rapidly. The major causes of mortality as reported to the MOH during 1989 are presented in Annex Ti, while Annex T2 contains the leading causes of hospital admissions. This disease pattern stems particularly from malnutrition and infections related to environmental and social factors. Crude death rate is about 20 per thousand. Mortality levels are higher than in neighboring coun:ries, principally because of the high prevalence of under-nutrition and the high incidence of malaria. Reducing under-five mortality would dramatically improve overall the life expectancy of the people. 2.03 Malaria infection rates in Malawian children are generally considered to be greater than 50 percent. This is a hyperendemic situation. Most symptomatic infections are in children younger than five years of age and are due to Plasmodium falciparum, the most malignant of the human malarial species. Malaria is the major cause of admission to facilities by children below the age of 5, and accounts for 29 percent of all hospital admissions and 12 percent of the reported deaths. Malawi also has a considerable amount of anemia, which is generally considered to be related to malaria (see Annex T2). Of particular concern is the fact that there has been a significant increase over the past several years in childhood morbidity and mortality caused by malaria. A comparison of 1985 MOH data with the most recent (1988) data shows a 43 percent increase in hospital admissions, an 85 percent increase in hospital deaths, and a 30 percent increase in the case fatality rate for the disease. 2.04 AIDS, though so far reaching a much smaller fraction of the population than many other diseases, is growing by epidemic proportions. Although there are as yet no reliable estimates for the extent of the Human Immuno-deficiency Virus (HIV) prevalence, the range cited by experts is from 15 percent to 23 percenc of all adults. Testing of blood donors, antenatal mothers, and bar girls indicate that the HIV infection is spreading at an alarming rate, and the high risk group are men and women between the ages of 25-45. The actual number of AIDS cases (i.e., where HIV infection has led to illness) has been reported as 8,083, as of March, 1990. In other countries in the region, it is estimated that the known cases represent about 40 percent of the total number of cases; if this is the case in Malawi, there would now be approximately 20,000 cases of AIDS in the country. 2.05 Maternal mortality in Malawi is high (170 per 100,000 live births), even though Malawian women on average each have more than three ante-natal visits during the period of pregnancy. Probeble reasons for the high mortality rate are poor maternal nutrition, lack of referral (due to transport constraints) for high risk cases, and an inadequate ualarm" and follow-up system for obstetrical emergencies. For a large number of Malawian women, an additional pregnancy carries a high risk of serious complications or death. 2.06 Malnutrition plays an important part in infant and child mortality in Malawi. A large proportion of deaths among children is attributed to diseases that usually are not fatal in adequately nourished  - 6 - persons. The 1981/82 National Sample Survey of Agriculture revealed a high prevalence of chronic malnutrition distributed fairly evenly throughout the country. The overall rate was 56.5 percent. This compares with 37 percent and 28 percent for Kenya and Zimbabwe respectively. A survey carried out in Lower Shire in 1983 also revealed an overall prevalence of severe Vitamin A deficiency of about 4 percent. In combination with measles, Vitamin A deficiency accounts for 15 percent of blindness in the country. In addition iodine deficiency disorders (IDDs) in Malawi are both more severe and more widespread than in most other parts of Africa. Unlike many other countries where IDDs are limited to small mountain regions, the problem in Malawi affects the entire country. Roughly one-third of the population lives in areas of severe endemicity (in which up to 65 percent suffer from goiter and up to 1.5 percent from cretinism), while the remainder of the country is characterized by intermediate or moderate iodine deficiency. Organization of Health Services and Facilities 2.07 The MOH has the primary responsibility for the development of policies, strategies and programs for health care in Malawi. MOH services are provided at five lrvels: community, rural health facilities, district hospitals, central hospitals, and special hospitals. Services at the community level consist of a reasonably extensive network of outreach activities through mobile clinics and the PHC program. Community level services stress activities and interventions associated with under-five care (health education, environmental sanitation, diarrheal disease control, immunization and growth monitoring). Much of the work carried out at the community level is the responsibility of health surveillance assistants (HSAs), who are supervised by health assistants at the nearest fixed facility. Most of the 550 HSAs presently deployed are men. For the future, it is intended that the role of HSAs should be widened from one of communicable disease control and environmental health work to one of multi- purpose community health work. 2.08 The MOH also runs 20 rural hospitals, 113 dispensary/maternity centers, 9 maternity units, 93 dispensaries and 15 health posts (Annex T3) which offer similar services: curative care; pre-natal, natal and post- natal care for mothers; infant and child care; and community health services. Several health centers also run nutrition clinics focussing on nutrition education, food preparation demonstration, and free food supplements. The peripheral health facilities are well used, with the daily patient loads usually ranging between 100 and 200. There are, however, many areas of the country still not served by health facilities, and also some considerable regional variations with regard to the distribution and coverage of health facilities (Annex T4). 2.09 The MOH has 21 district hospitals which serve as referral hospitals for their respective districts and which offer all the health services available at health centers. The two central hospitals function as referral facilities for the district hospitals, and they are also used for various training activities. There is only one general hospital. Special hospitals offer specialized services, including mental health services and in-patient care for leprosy and tuberculosis cases. There is  - 7 - a total of 13,192 beds in the country of which 6,815 are in MOH facilities (Annex T5). Utilization of hospital services, both inpatient and outpatient, is very high. The three central hospitals, Kamuzu Central Hospital (KCH) at Lilongwe, Queen Elizabeth Central Hospital (QECH) at Blantyre and the Zomba General Hospital, are all overcrowded. QECH has an in-patient capacity of 892 beds, but in-patient numbers vary between 1,200 and 1,500 daily. Out-patients average about 1,000 daily and about 700 children are also immunized daily. At KCH, the situation is slightly worse. A recently commissioned study by Bennett 3/ showed that most of the users of these hospitals originate from the cities where the hospitals are situated, only a small percentage come from the surrouniing districts, and only a very small minority are referred from other districts. 2.10 The Private Hospital Association of Malawi (PHAM), made up of religious and other private volunteer agencies, operates hospitals, rural hospitals and health centers in the country. PHAM hospitals account for just over one third of all admissions and for nearly half of the other health services in the country. PHAM facilities see about 1.3 million total out-patients annually (Annex T6). The services offered by PHAM are similar to those of the MOH, but at PHAM facilities fees are charged for curative services (although preventive services are available free of charge). Despite efforts by the MOH and the PHAM secretariat, the quality of services provided at individual PHAM facilities varies enormously. PHAM training institutions also produce nearly 70 percent of the country's enrolled nurses. PHAM receives an annual subsidy from the MOH, but financial constraints have caused a number of PHAM units to ask the Government to take over their operations. However, the Government has been unwilling to do this. 2.11 Local government authorities under the Ministry of Local Government (MOLG) also play a major role in the delivery of health care. The district councils operate 102 units--19 dispensaries, 76 maternity units and 9 health centers in 22 of the 24 districts of the country (Annex T7). Forty five of these health units are adjacent to MOH facilities. The cities of Blantyre, Lilongwe, Mzuzu and the municipality of Zomba also operate health services. Local authorities charge fees for their services. Other agencies, such as the army, police, estates and industries, provide curative and preventive services for their employees, and there is a small number of private doctors, paramedicals and nurses in the country. The work of the Government is complemented by a variety of Non-Governmental Organizations (NGOs). About 1,000 traditional birth attendants (TBAs) are scattered mainly throughout the rural areas (Annex T8), but they are not formally linked with MOH. There are about 18,000 traditional practitioners with no link to the Ministry of Health. 3/ F. J. Bennett: Report on Urban Primary Health Care for the Ministry of Health, Malawi, June 1989.  -8- Proarams and Policies 2.12 Primary Health Care. Malawi formally adopted a PHC approach in 1978. The program now consists of training district and health center staff in PHC concepts and in community sensitization, and in the establishment of Village Health Committees (VHCs) which are responsible for initiating PHC activities at the community level. The VHCs work closely with the HSAs. The program was first introduced in three districts and was then expanded to a further six. The program was evaluated in October 1985 by the MOH, and it was co,icluded that the quality of supervision by the health workers was good, that the participation of communities was very encouraging, and that the general understanding and acceptance of the concept of self reliance was developing well. The evaluation also concluded that the intensive education approach adopted by Malawi provided a solid base for nationwide expansion of the program. The PHC concept has now been introduced in all the 24 districts. 2.13 Maternal and Child Health. The objectives of the Maternal and Child Health (MCH) program which was initiated in 1973 are to strengthen and expand MCH services throughout the country, to strengthen the training of health workers, to increase immunization coverage of all children, to improve the nutritional status of children, and to decrease the incidence of underweight children through growth monitoring, nutrition education and food supplementation where necessary. In addition to the services provided at the health facilities, use is also made of Traditional Birth Attendants (TBAs) in service delivery. Despite an impressive beginning, however, shortages of equipment and supplies, weaknesses in the cold chain, and poorly trained staff resulted in only about 40 percent of children being immunized by 1988. Since then an expansion of the immunization program has been launched with major grant funding from the Italian Government through UNICEF, and it is hoped that by the end of the program period about 90 percent of children will be covered. 2.14 Malaria. To support and extend the work carried out at its health facilities, the MOH has a major program to combat malaria. At present, the Government strategy for malaria control has been based solely on the use of anti-parasitic drugs, mostly because of the availability of an inexpensive and effective drug, chloroquine. This strategy was modified in 1984 with the discovery of the presence of a chloroquine-resistant strain. In order to reduce the resistance, selective pressure on the parasite, routine chloroquine prophylaxis in young children was discontinued. Because pregnant women were considered particularly susceptible to malaria infection, prophylaxis coverage of this group, and other high-risk groups was continued. In addition, alternative drugs were introduced to treat those cases not responsive to chloroquine. The current methods available to control malaria, although imperfect, would be effective provided that they were properly selected and applied on a persistent, or even continuous, basis. However, the program at present is severely constrained by a lack of sufficient equipment and vehicles. 2.15 AIDS. The Government recognizes that the AIDS epidemic poses a major health and socio-economic threat. In 1986 it established a technical committee to study the situation and provide advice. As a result, a multi-  - 9 - sectoral Information, Education and Communications (IEC) committee has been established to assist in the preparation and dissemination of AIDS and other related information. In 1987, the Malawi AIDS Control Program was established within an initial framework of the Short-Term Plan financed through the World Health Organization (WHO). Preparation then started on a Medium-Term Program, and in June 1989 a resource mobilization meeting was held to solicit funds for the program. A national AIDS secretariat has been formed within the MOH to plan, coordinate and monitor all AIDS control activities in the country. An AIDS Committee composed of politicians, church and community leaders as well as public servants was appointed in 1989. The MOH is being assisted in this program by other agencies and the PHAM in particular has also introduced a program to try to prevent the spread of HIV infection and cases of AIDS. 2.16 Child Spacina. Child Spacing (CS) activities in Malawi are an integral part of the MCH program. The overall management of the program is the responsibility of the Controller of Preventive Health Services, but the Chief Public Health Nurse is responsible for its day-to-day implementation. 2.17 CS activities began in 1983, when they were provided at the three big hospitals. Initially, they were only provided by doctors, but the number of providers increased due to the training of more Enrolled Nurse Midwives (ENMs) and Community Health Nurses (CHNs) in CS. Services (including information, education, consultations, supplies and referral where necessary) are now available at hospitals, at clinics and at the community level. At the central and district hospitals, services are available on all workdays, whereas at the health centers they are available twice a week. There are now 168 CS units in health centers and district hospitals, and 15 in PHAM facilities. By the end of 1988, about 27,630 new clients were being served, compared to only 3,205 in a84. The range of services offered include temporary, long-term and permanent methods, with the pill being the most popular method. Forty percent of all new clients use the pill, while the remaining 60 percent are distributed among Depo Provera (15 percent), Intra Uterine Device (IUD) (10 percent), surgical contraception (3 percent), and other barrier methods (32 percent). 2.18 No accurate estimate of the current contraceptive prevalence rate is available, but rough indications from available data suggest that the prevalence level for the country as a whole may be about 3 percent. There is a growing demand for condoms, which is partly attributable , he AIDS program. Knowledge among women of modern methods of contracept; -% estimated in 1984 from the Family Formation Survey then to be about f. percent, but it is probably slightly higher now. Furthermore, it is clear that there is unmet demand for more CS services, as the 1988 Family Formation Survey found that 70 percent of urban women and 60 percent of rural women desired either to space or to stop child bearing. 2.19 In order to expand the CS program, commodities are to be distributed at the community level by HSAs assisted by community leaders. The Government is piloting the program in three villages in three districts, and it is also mobilizing agriculture extension workers and Community Development Assistants (CDAs) as motivators. Consideration is now being given to using TBAs as service providers as well. The Government  - 10 - has also decided to introduce population education into the schooling system; and there has already been a trial run of social marketing of contraceptives, with condoms and foam tablets being made available to retail shops at a subsidized price. 2.20 To supplement the efforts of the MOH, as well as to coordinate all CS activities in the country, the Government has recently established a parastatal, the Family Welfare Council. The Council will be a major channel for IEC activities. In addition, the Government intends to encourage the formation of an NGO to promote the expansion of service delivery. 2.21 Although the Government does not have an explicit population policy, there are a nuriber of related measures that the Government has recently taken. For example, there has been a concerted effort to us-e various informational and educational programs to popularize CS, including mobilization of civic, community and political leaders to disseminate the benefits of smaller family size and safe motherhood. To date, about 1,000 opinion leaders in 17 districts have been sensitized, and articles on the importance of CS appear regularly in the newspaper. A large number of extension workers have also been trained to motivate and educate the public, while over 400 niurses, abvut 250 support staff and 20 trainers have been trained as service providers. Other important steps have been taken and these provide indirect evidence of the Government's commitment to addressing the population issue. These include: (a) the creation of a Population Planning Unit at the Office of the President and Cabinet (OPC) with responsibility for assessing the need for a population policy; (b) coordination of population issues and integration of population in the development process; (c) the establishment of a Demographic Unit at Chancellor College; and (d) measures to improve the coordination of Women In Development (WID) activities which can play a central role in motivating women to space their children. 2.22 Women in Development. 4/ Reaching, organizing and improving the lot of women have become integral to Malawi's development goals. The Government has created a National Commission on Women and also a special department, Chitukuko Cha Amayi M'Malawi (CCAM), within the Office of the President and Cabinet to coordinate women's affairs. In addition, the Ministries of Community Services (MOCS) and Agriculture (MOA) have active women's programs. Recently, the MOA has shifted its emphasis from a home economics bias (designed for farmers' wives) to recognizing women as farmers and organizing women's groups to increrse their access to technical information and credit. This shift in emphasis is needed in the MOCS, particularly in the type of service provided by Community Development Workers (CDWs) and Community Development Assistants (CDAs) who are trained in Magomero. The MOLG also employs Home Craft Workers (HCWs), who conduct weekly courses for rural women and who carry out educational activities at MCH clinics. 4/ For further discussion of the WID activities see Malawi: Women in Development Sector Report, Report No. 8612-MAI.  - 11 - 2.23 Nutrition. Until recently, nutrition services in the rural areas were provided only at health centers and hospitals. The services provided at these facilities included growth monitoring, nutrition education and some food provision under the World Food Program (WFP) assisted vulnerable group feeding program for children experiencing growth faltering. Nutrition rehabilitation centers have been established at 25 health centers, but attendance at these centers is spotty and follow- up by their staff is impossible. In 1987 MOH began the training of Community Health Volunteers (CHVs) as providers of nutrition services at the community level. About 1,500 CHVs have been trained at Government and PHAM facilities. The CHVs work with other community-level personnel, and are responsible for growth monitoring, identification of children at risk, provision of nutrition education, follow-up home visits, and in a few areas the provision of WFP food to at-risk mothers and children. During their training (a one-week session repeated at periodic intervals) these volunteers are also taught about the simple treatment of diarrheal and respiratory infections, and about the distribution of chloroquine. 2.24 It has increasingly become recognized by the Government that malnutrition in Malawi should be seen as a problem of household food insecurity: small and dwindling land holdings, food stocks depleted as much as seven months before the next harvest, often negligible cash reserves, and overworked mothers with neither the time nor the resources to provide adequate child care and feeding. To augment the work of the MOH, therefore, the Government and PHAM also established nutrition-related programs in the MOA, the MOCS and the Department of Economic Planning and Development (DEPD) of OPC. For example, pilot area-based integrated programs geared to enhancing the food security of the lowest income households have been introduced in Ntchisi, Mzimba, Nkhata Bay, and Mangochi Districts. The central element of this approach is the provision of a package of hybrid maize and soyabean seed, fertilizer and food to dangerously food-insecure households (characterized by malnourished children, small holdings and early depletion of food stocks) to permit these families to (a) cultivate their own land; (b) increase agricultural yields; and (c) become exposed to extension and credit systems. The nutrition-related work of the different ministries is now being coordinated by an Interministerial Food Security and Nutrition Advisory Committee. 2.25 At present the possibility of salt iodination is inhibited primarily by the high cost of salt at the consumer level in rural areas. The consumption of salt by low-income rural families is at present too low to make salt a viable carrier of iodine. Salt in Malawi is imported mostly from South Africa, repackaged and then distributed through numerous intermediaries. At present, retail salt prices in rural areas are between two and three times the import price. Manpower and Training 2.26 There is a severe lack of health manpower in Malawi: the ratio of 1 doctor for more than 60,000 population is the lowest anywhere in Africa. In many respects, medical assistants and clinical officers function as physician substitutes, but the ratio of 1 per 11,330 population still makes them more th.nly distributed than doctors in most countries.  - 12 - There is a ratio of 1 registered nurse per 129000 population, 1 enrolled nurse per 4,000, 1 health inspector per 75,000, and 1 HSA per 25,000. Due to these sow numbers and also low salary levels, spending on personnel currently accounts for only approximately 30 percent of the annual recurrent expenditures of the MOH in Malawi, as compared to figures of between 50-80 percent in other countries in the region. In order to review the manpower needs of the sector, in 1988 the Department of Personnel Management and Training (DPMT) set up an interministerial co=nittee to examine all the staff positions in MOH and to prepare a report on total manpower requirements for the sector. The resulting Complement and Grading Review Report, which recommends the creation of 2,925 new professional posts to cover the immediate needs, has now been accepted by the Government. 2.27 Responsibility for manpower planning, training and deployment is divided among: (a) the MOH Planning Division, which ia responsible for projecting manpower requirements; (b) the Clinical, Nursing and Preventive Health Services Divisions, which liaise with the relevant professional councils and training institutions with respect to basic (pre-service) training for their respective cadres of staff, and with hospital superintendents and DHOs to identify in-service training needs; (c) the Training Division, which is responsible for administrative arrangements for training; and (d) the Personnel Division, which is responsible for administering the placement, conditions of service and deployment of staff. In addition, responsibility for coordinating the intakes of higher level staff lies with the DPMT and the Public Service Commission, while the Appointments and Disciplinary Committee of the MOH has responsibility for the lower cadres. 2.28 The basic health training courses offered in Malawi, together with the official student capacities, are listed in Annex Tll. Malawi does not have a medical school, but implementation has started on a project for final year clinical training of medical students to be done within the country. Recent MOH projections of health manpower requirements (Annex T9) indicate that an additional 8,500 staff would be required by 1995 to staff existing developments and improve staffing standards to those recommended by the Complement and Grading Review. However, at current rates of training intake and student drop-out, only 54 percent of total staff requirements could be achieved by 1995, with the achievement dropping to 43 percent by the year 2000 (Annex T10 and Tll). Support Systems 2.29 Pharmaceuticals for the health sector are supplied by the Central Medical Stores (CMS), which in 1984 was made a self-financing and self-accounting body. In 1989-90, its annual turnover was around MK18.0 million. Pricing of drugs is currently fixed at their CIF value plus 12.5 percent to cover all operating costs. The CMS is responsible for the procurement, inventory control, store keeping, repackaging and distribution of pharmaceuticals, and for the manufacture of simple products. The MOH has been attempting to address the problems of pharmaceutical ordering, supply and distribution for several years, but the implementation of the improvements has run into major difficulties due to (a) structural  - 13 - difficulties in the design of the new CMS; (b) lack of trained manpower; and.(c) lack of proper procedures for stock control, storage of goods, processing of requests, assembling and distribution of goods. Also, although the CMS is expected to be self-financing, it is chronically short of cash because its major client, the Government, has not been able to reimburse it for the drugs provided to the MOH. 2.30 Contraceptive commodities for use in the CS program are obtained from donor agencies, mainly the United States Agency for International Development (USAID) and the United Nations Fund for Population Activities (UNFPA). Quantities needed are determined and ordered by MOH in Lilongwe only on the basis of past shipments, with the quantities shipped over the past nine months being doubled to give the total for the following nine months. The commodity distribution system is operated from the CMS, which also handles customs clearance and storage of the ordered commodities. District hospitals make requisitions to the CMS, which distributes the commodities to them, and the district hospitals then redistribute supplies to lower-level health facilities. 2.31 Information. Education and Communication (IEC). The key unit in the MOH responsible for IEC and materials production is the Health Education Unit (HEU). It is severely under-staffed and under-equipped, and is unable to coordinate a cohesive health education and promotion program. However, the unit is presently being strengthened through the Promoting Health Interventions for Child Survival (PHICS) project, which was recently signed with USAID. Under this project there will be support for 31 additional professional staff over a period of 8 years and improvements in physical facilities and equipment. At the district level, IEC work will be coordinated by the district health education officers. 2.32 In Malawi, mass media channels are limited: although the radio's coverage is about 80 percent of the land mass, it reaches only 20 percent of the population. Health programs are broadcast two hours a week, but the programs are not timed to reach the maximum audience. Although there is no television in Malawi, the Departments of Agricultural Extension Services, Forestry and Information have film projectors in each district. The major constraint to production of audio visual and for visual materials appears to be the high cost. Management of PHN Services 2.33 The Principal Secretary, as the senior manager In the MOH, is responsible for both its technical and administrative 'branches (see Chart 1). The Chief of Health Services (CHS) has overall responsibility for the technical services. On the administrative side, the Deputy Secretary is responsible for the administrative units such as finance, personnel, administration and internal audit. Below the MOH headquarters, the health care delivery system has three levels: regional, district and peripheral. Each of the three regions has a Regional Health Team (RHT) comprised of a Regional Health Officer (RHO), Regional Public Health Inspector (RPHI) and a Regional Maternal and Child Health (RMCH) Coordinator and a Regional Nursing Officer (RNO), each reporting directly to the RHO. The District Health Officer (DHO) is responsible for all the health services in the  - 14 - district. Peripheral health services are the responsibility of medical assistants in charge of health centers, and together with health assistants and in some districts, Community Health Nurses (CHN), they are responsible for village level health activities. 2.34 A comprehensive study of the MOH organizational and management structure was undertaken in 1984. Following this, a major review of the MOH was also undertaken as part of the Civil Service Review, and its report highlighted some of the major managerial problems facing the Ministry: unclear reporting rel&tionships and authority lines; undefined individual roles and lack of job descriptions; too many layers of authority; over- centralized decision making process; inadequate management support system; and lack of control over expenditures. As a result, the new structure was put in place in 1987. Chart 2 shows the managerial relationships outside the headquarters, and Chart 3 gives the structure at the district level. Financing and Resource Allocation 2.35 Malawi is a poor country and, historically, the Government has only been able to allocate a very small budget in absolute terms to the MOH. However, the proportion of the budget allocated to the MOH was also relatively low for many years, even by the standards of the African Region. From 1970/71-1974/75 the proportion of the total budget going to the health sector averaged 5.0 percent, and from 1975/76-1979/80 it remained at a similar average 51. More recently the situation has begun to improve. In the first half of the 1980s, the proportion rose slightly to 5.6 percent, and in the period 1985/86-1988/89 it rose further to an average of 6.9 percent. 2.36 The estimates for 1990/91 show a recurrent provision for the MOH of MK66.8 million. This is equivalent to 6.3 percent of the total of MK1,056 million including all statutory expenditures, or 7.1 percent of the total of MK945 million if debt service provision is excluded. This amount is inadequate even to cover the full operating costs of existing services, let alone to pay for the recurrent costs of new projects. In 1989/90, for example, actual recurrent expenditures of the MOH were MK72.9 million, compared to an original vote of only MK57.3 million. Covering the incremental recurrent costs of investment activities already underway would require an addition of about MK13 million. 2.37 On the development side, the budget has historically been dominated by external support; and with funding thus heavily influenced by the timing of project approvals and the details of project design, the historical trend has been erratic. Under the development program for 5/ The precise figures depend on whether estimates or actual expenditures are used; on whether the recurrent and development budgets are combined or analyzed individually; on the particular sub- periods chosen; and particularly on whether the total expenditure figure is defined to include debt service charges, etc. In this case, it is assumed that all statutory expenditures are included.  - 15 - 1990/91, it will receive MK42.4 million, which is 11.6 percent of the total Public Sector Investment Program (PSIP) of MK365 million. 2.38 Malawi has consistently devoted a large proportion of its health expenditures to the provision of curative care. In recent years, a major effort has been made to construct more lower-level health facilities, but resources have been inadequate to enable all the needs to be met. Recurrent expenditures also reflect the emphasis on curative care, with an average of 82 percent of MOH recurrent expenditures between 1983/84 and 1986/87 devoted to curative care, 12 percent to administration and training, and only 6 percent to preventive care. In particular, a large proportion of the MOH budget has been spent on the central and general hospitals. In 1989, 75 percent of all service delivery staff (in established posts) were hospital-based; 50 percent were deployed at the referral and special hospitals, and 25 percent at the district hospitals. 2.39 The MOH has a history of cost overruns of budget estimates. While this problem has been considerably reduced at the aggregate level, there is still a serious lack of financial control in many facilities. Detailed work has been carried out by the MOH to identify ways in which expenditures could be reduced without reducing the quality of services provided, and each of the studies done has concluded that substantial savings could be made. It is believed that these could amount to approximately MK4-5 million annually. 2.40 All public health services, except in the paying wards of the central hospitals, are provided free. The revenue from private patient fees amounts to about MRO.75 million, or roughly 1 percent of the MOH budget. Private patients in MOH facilities do pay fees, but they are subsidized to the extent that their fees do not fully cover the cost of services provided to them. B. Issues and Constraints Coverage of Basic Services 2.41 Malawi cannot lessen its high disease burden without expanding the coverage of its basic health services. Community health workers are the key to effective implementation of PHC and much greater attention, therefore, needs to be paid to the development and extension of programs emphasizing the use of village-based workers, and especially the HSAs. It is the intention of the Government to greatly expand the numbers of HSAs over the next few years (paras 3.12, 4.06). For this program to be effective, the new role of the HSA as a multi-purpose health worker (para 3.12) needs to be clearly defined and endorsed, and monthly and annual work programs prepared. It will also be critical for the role of the HSAs to be clarified vis-a-vis other community-level workers such as CHVs, CDAs and CDWs, and HCWs. CHVs are presently involved primarily in nutrition-related activities, and their work clearly complements that of the HSAs (para 3.19). Under the responsibility of the MOCS, the role of the CDAs and CDWs is to be reoriented more towards the needs of rural women. Similarly, the HCWs employed by the MOLG could play a larger role in health and CS  - 16 - activities. Consideration is also being given to ways in which more use could be made of TBAs. 2.42 For these outreach workers to be effective, it will be necessary for them to be supported through a wider network of fixed health facilities in presently underserved areas, and through better logistical and supervisory support, Additional housing will also be needed in some areas. The quality of services now provided by local authorities will need to be improved (para 4.06). At present, these services are of variable quality, but they are mainly substandard due to lack of trained staff, poor maintenance, medical supplies and equipment, and the absence of systematic and regular technical supervision. The MOH and MCLG have already been discussing ways of improving the situation, and a joint MOH/MOLG committee has made major recommendations on improvements through management changes (see par". 3.24 et seq). Proaram Strenathenina 2.43 Primary Health Care. The country's disease pattern has to be addressed through a multi-sectoral approach rather than the health sector working in isolation. Malawi has therefore chosen PHC as the strategy to enable it to achieve an improved health status for its people. Although the PHC program is proceeding well, there are several problems that have been identified: scarce transport, lack of adequate supervision of peripheral and community-based staff due to the pressure of work facing the existing higher-level health personnel, and need for continued PHC education efforts. Because of lack of transport, VHCs and area teams are not adequately supervised from the district level (paras 3.12, 4.06). In addition to improving the mobility of the dis*rict teams, there is also need to increase the mobility of area and village workers and to intensify education programs to facilitate further implementation of PHC activities. 2.44 Maternal and Child Health. Despite the ongoing expansion of the MCH program with Italian Government ard4 UNICEF support, MCH services are still constrained by lack of transport, drugs and IEC materials. Mothers with young babies under two use the services less than mothers with older children, partly because many people still live a long way from clinics. Also, despite a high rate of antenatal attendance, use of the facilities for postnatal care is extremely low. In viaw of the weaknesses of the program, the poor nutritional status of much of the population, and continuing high fertility levels and largely unregulated pregnancies (which often result in short birth intervals and the early weaning of children), it is understandable that infant and child mortality rates have remained inordinately high (paras 2.47 et seq and 3.14, 4.08). 2.45 Malaria. In view of the massive health problems caused by malaria and the constraints presently facing the existing control program, the MOH wants to give high priority to strengthening the program. In the short term, this will require additional vehicles and equipment. For the longer term, however, there is need for more planning of ways to bring the disease under control within the available financial and human resources of the country. Given the continued evolution by the paras%te to develop higher degrees of chloroquine resistance, the MOH has to consider the use  - 17 - of additional methods, including anti-vector measures, as supplements to the current antiparasitic strategy (paras 3.15, 4.07). However, anti- vector methods at present cannot be used cost effectively, because baseline data on mosquito ecology, bionomics and behavior are not available. 2.46 AIDS. After a slow start, the AIDS program has become increasingly successful in promoting health education about AIDS. However, funding for the program has been inconsistent and inadequate. This has partly been due to an earlier lack of agreement between the Government and the donors about proposed supplementation of national staff salaries and standardization of rates of allowances. There is also need for the medium- term plan to be extended into specific action programs to be carried out by the district and regional health teams, which should be involved in the planning process. Also, the AIDS program needs to be integrated with the activities of the other relevant MOH departments, particularly including the CMS and the various sections of the Department of Preventive Services. In addition, linkages should be established between the program and other relevant Government departments and NGOs (paras 3.16, 4.07). 2.47 Child SDacinf. In view of the evidence that a high proportion of women want to space their children, the challenge for the CS program is to extend the provision of services and to broaden the knowledge of people about them. There are still facilities where CS services are not provided, and in many others services are not fully integrated with the other PHC services. If services were fully integrated and offered daily, and if they were made available at all existing health centers, whether operated by the MOH, PHAM or MOLG, then substantially more clients could be served. 2.43 For the expansion of CS services within health facilities to take place, however, it will be necessary for several constraints to be overcome. Concerning training, constraints include the following: (a) in the past there was a reluctance on the part of the School of Nursing to integrate CS training fully into the pre-service training of registered nurses (RNs), but the situation is changing; (b) the very low intake levels of enrolled nurse midwives for both pre-service and in-service CS training; (c) the general reluctance of Catholic missions to offer modttrn CS methods in their health facilities or to provide comprehensive CS training in their training centers; (d) the inadequate number of training personnel, due to lack of an established overall MOH strategy for training or an attractive career structure for trainers; (e) the inadequacies in the design of training courses, which are generally too lengthy and seldom differentiated according to cadre of staff being trained; and (f) the lack of a built-in mechanism for supervision, guidance and follow-up of trainees after completion of their training courses. 2.49 Improvements are also needed to the CS logistics system, which has functioned poorly for several reasons. MIich of the record keeping in the CS program is inadequate, making it difficult to monitor and forecast demand for commodities. The MOH and the CMS have not coordinated well, and adaptations have not been made sufficiently to changes in patterns of demand or program priorities. As a result, although also partly because demand in the early years of the CS program grew far faster than envisioned, donor supplies of contraceptives have been erratic. Periodic  - 18 - shortages of commodities at all levels have plagued the program throughout its history and severely affected its effectiveness and impact. The MOH is aware of these logistical weaknesses and is trying to get a contraceptive logistics monitoring system in place. 2.50 Women in Development. The MOCS already has an extensive institutional extension network available for the promotion of WID activities and is capable of having a substantial impact on rural women's lives. However, the focus of the present MOCS program is still largely on home economics, since most of the staff are primarily trained in this subject. Initiating new activities to emphasize income-generating skills will require a different skill mix among the staff of the 7'nistry. The MOCS is aware of the need for staff who are able to organize women's groups for activities other than home economics and advise on credit facilities, and has already requested assistance from the Overseas Development Administration (ODA) of The United Kingdom (UK) for senior staff training in new skills (paras 3.18 and 4.09). 2.51 However, there is a complementary need to reorient the role of Magomero Community Development College, which is the principal institution for the local training and retraining of CDAs and HCWs. Magomero lacks proper orientation of its curriculum and professional staff, and it has highly inadequate facilities. Many of the existing extension staff were not trained appropriately to address the current needs of women in Malawi, and they cannot be expected to change the attitudes and ideas of women without retraining. Unless major changes are made at Magomero, the planned changes in the orientation of the extension staff will not come about. For the MOCS to implement its new policies, steps will also need to be taken to obtain additional administrative support, expertise and resources to carry out its plans. In particular, resources will be needed to promote new WID activities on a pilot basis at the local level (para 3.18 and 4.09). 2.52 Nutrition. The early results of the ongoing CHV program have been encouraging, and the Government is planning to expand it. This will require further development of the CHV identification and training program, and specific guidelines need to be developed for educational and home visits, for follow-up of children experiencing growth faltering, for responses to associated diseases (malaria, diarrhoea and respiratory infection), and on the relationship of the volunteers and the HSAs. More extensively trained HSAs are necessary to support CHVs and provide linkage to the health system. This chain of responsibility and support is sound, but it must be articulated more explicitly. 2.53 While child feeding and related practices often can be improved, little progress can be expected in reducing malnutrition and associated diseases through educational efforts unless food insecurity at the household level is also reduced. The Government has therefore recognized that its efforts to promote nutrition and growth monitoring through the use of CHVs need to be supplemented with other measures to address household food insecurity (paras 3.19 and 4.10). These include activities to increase the incomes of poor rural women and the introduction of appropriate labor-saving technology.  - 19 - 2.54 While iodized oil capsules presently are being distributed in the highest risk areas, the only viable long-term solution to iodine deficiency disorders is salt iodination. The Government needs to undertake a systematic study of the salt distribution system to examine the extent of competition, the ease of entry and the cost breakdown at each stage, in order to identify ways of lowering costs to rural families and enabling salt iodization to be a practical strategy (para 3.20). Health Manpower 2.55 Increases in training capacity are urgently required to improve the supply of health manpower, particularly at the community and first line referral levels. There is clearly an urgent need to increase training outputs, particularly for the medical assistant and ENM cadres who form the backbone of the peripheral health services (para 3.21). These increases in outputs will require not only additions to existing training structures, but also improvements in the utilization of their capacity. 2.56 Unfortunately, the existing structures and procedures do not include adequate mechanisms for ensuring the coordination of manpower planning with overall service plans, or with decision-making on training and staff deployment/utilization. Targets for health manpower supply are not clearly linked to health needs or based on forecasts of available financial resources, and insufficient preparation is made for the deploy- ment of graduates following training. Requests for increases in the number of authorized posts for the MOH are not coordinated between the different divisions nor sufficiently related to planning priorities. Coordination of basic and in-service training is weak, and there is a lack of information on the numbers, skills and distribution of existing staff to guide manpower decision-making. In addition to expanding its output of manpower, therefore, the MOH needs to improve its capacity for the development, periodic review, and updating of long-term projections of manpower requirements (paras 3.24, 4.12). 2.57 Given the prevailing financial constraints, the recurrent cost implications of incremental training outputs will require careful prioritization in the deployment of the additional staff. Based on current projections of the recurrent health budget, improvements to the staffing standards of primary health services will only be achieved to the extent that expansions to hospital services are carefully controlled. Weaknesses in Support Systems 2.58 Pharmaceuticals. Although the program to upgrade its operating procedures has been underway in recent years and the CMS has been able to realize some considerable savings by bulk purchasing, additional savings could be achieved by improved efficiency through efforts to address the structural problems of the CMS, the lack of adequate manpower, still inappropriate procedures, and the need for standard treatment guidelines. There is also an urgent need for the Government to address the financial problems facing the CMS, including the cash flow constraints caused by late payments by the Government itself. To deal with these issues, the Government has recently prepared a national pharmaceutical program for the  - 20 - period up to 1995 (paras 3.22 and 4.14). Some steps are already being taken to implement it. For example, to ensure an adequate supply of essential drugs, the Government is undertaking a drug utilization study which will be completed in 1991. In order to improve drug utilizat4on, the Government is preparing draft treatment guidelines and a training program to ensure that the guidelines are used. The CMS is also developing a computerized standard stock, inventory cmntrol and procurement system in order to improve efficiency and is recruiting and training additional staff. 2.59 Information, Education and Communications. The Government has recognized and emphasized the important role which IEC should play in bringing about a transformation of Malawi's health profile. The PHC approach pursued in Malawi, with emphasis on building local support and initiatives through VHCs, has created a supportive environment and base for IEC. At present, however, health education efforts are severely constrained by lack of health manpower at the periphery, by the weak structure and staffing of the HEU, and by limited mass media channels. 2.60 The lack of manpower at the peripheral units and an insufficient number of community health workers clearly undermine the health workers' ability to establish personal rapport, which is essential for influencing behavioral change or adoption of desired practices. Also, the lack of female HSAs particularly limits interaction with women in the community. At the central level, the HEU presently lacks a clear conceptual vision and overall framework for a health education effort which reflects planned priorities, strategies, themes, target groups, selected media mix, channels and projected material needs. In the absence of the ability to plan in advance and provide strong coordination, IEC initiatives are being undertaken by compartmentalized programs that treat the HEU only as a materials production supplier. Finally, while mass media have an important role to play in building an enabling environment and in creative awareness, there is lack of exposure of messages to the people. The major constraint to production of audio-visual and other materials appears to be the high cost, and the HEU needs additional resources in order to extend its mass media work (paras 3.23, 4.13). Mana2ement and Decentralization 2.61 The Civil Service Review Report and the Complement and Grading Review Report argued for some fundamental changes in management in the MOH, and in particular for improved communication and coordination within the ministry, clarification of functional responsibilities between administrative and technical departments, and between the different technical areas, and strengthening of management functions such as planning, personnel and training, and accounting. In particular, personnel management in the MOH is currently overly centralized and poorly staffed. Because of the persisting managerial problems in the MOH, and especially in view of the overlap of responsibilities between the administrative and technical wings, the Malawi Institute of Management (MIM) has been commissioned to organize training programs in management intended to improve communication and team spirit at all levels of MOH.  - 21 - 2.62 The management problems of the NOH are particularly felt at the district level, where there is a lack of coordination between the various health activities and programs: PHC, preventive health, curative services and IEC . Although these programs are all directed to the same set of people and even though the underlying principles of the PHC approach imply an integration of all such programs, peripheral workers are given separate training on health, child-spacing, diarrhoea and malaria control, etc. The Civil Service Review Report and the Complements and Grading Report recommended some fundamental changes, including decentralization of administrative and financial authority for health services to the regions and districts, and strengthening of the district health teams (Annex A Attachment A and Annex B). 2.63 Besides the managerial problems of the MOH, severe difficulties are also caused by the fragmentation of health services at the district level and the associated problem of insufficient coordination between the facilities operated by the MOH and the local authorities. Their respective health services are not well coordinated or integrated, with many instances of duplication of service. The difficulties are compounded by the different financing arrangements. In contrast to the MOH, local government facilities depend on fees to meet their recurrent expenses, as the general purpose grant received from the MOLG is inadequate. However, the fees collected are insufficient to meet the cost of providing an acceptable, high level of service, and anyway the revenue from fees goes into the general p.ol and is not directly used for health services. The differing fee systems between the MOH and the local authorities also create a distortion in health service utilization patterns. Furthermore, the local authorities do not have the technical and professional expertise and capacity to operate health services independently, and the supervisory capacity of the MOH is not formally available to them as the MOH regional and district health te-ms view the local authority units as parallel systems for which they are not responsible (Annex A Attachment A and Annex B for specific policies to deal with this). 2.64 Management difficulties have also arisen due to poor coordination between the MOH and the PHAM. Plans have, however, been formulated to enable MOH to: (a) establish peripheral health staff positions in PHAM facilities; (b) utilize the training capacity of PHAM for its training needs; (c) integrate district level supervision and in-service training for PHAM and MOH programs; (d) adopt standardized preventive and curative interventions at PHAM and MOH health facilities; and (e) standardize job descriptions and training for health staff (para 2.63 and Annex A and B for specific actions). Resource Mobilization and Efficiency 2.65 There is now clearly an urgent need to redress the past rather low priority given to the development of population, health and nutrition activities (and particularly inadequate health manpower development). The Government has indicated its strong commitment to the sector, and the existing allocation to the health budget will be increased slightly. This will be particularly important for the MOH recurren; budget. At the same time, however, with economic growth projected to be not more than  - 22 - marginally above population growth, and with the Government committed to containing the overall size of public expenditures, the budget of the MOH will continue to be highly constrained. 2.66 There is evidence of significant inefficiency in the use of resources in the health sector in Malawi, and it will be critically important for the Government to ensure that best possible use is made of all existing resources. First, there is an inappropriate allocation of resources towards hospitals. The bulk of the ministry's budget is still inappropriately taken up in curative care, and especially on the three major hospitals in Lilongwe, Blantyre and Zomba. The health system now faces a vicious circle of inappropriate resource allocation leading to inappropriate demand patterns (with huge numbers of patients seeking care at unnecessarily high levels of the system) and to operational inefficiency due to the resulting congestion of high-level facilities and overwork of high-level staff. But efforts to reduce the proportion of the budget going to the hospitals need to be accompanied by policy changes and investments to improve the community and peripheral health services, and to encourage patients to seek care at appropriate levels. Government need to consider introduction of user charges, particularly for drugs as well as fees for services (para 3.27). 2.67 In contrast, at present it is calculated that approximately 33.6 percent of the total MOH recurrent budget is spent on district health services. From analyses of spending in selected districts, it has been calculated that about 20.2 percent of the total budget is being used by the district hospitals and about 13.5 percent by the outreach and peripheral services. In order to improve the quality and coverage of health services in the rural areas, the proportion of the overa'll budget allocated to outreach and peripheral services in particular will need to increase. 2.68 Operational inefficiency, however, also arises from other factors. The relatively low level of spending on personnel due to insufficient numbers of trained staff has clearly led to significant inefficiency, and this needs to be corrected urgently through the manpower development program. There is the issue of waste and unauthorized expenditures. The MOH has already begun to implement some measures to reduce costs (for example, at the CMS), but much more remains to be done part'Lrlarly in the major hospitals. This will require some developmental expenditure and an upgrading of the accounting skills of financial staff. Finally, due to the differing fees charged by PHAM hospitals and local authorities, patients seeking health care often do not go to the nearest facility. Referral patterns are also distorted since an MOH facility may be reluctant to send a patient to another facility where he/she would face a charge. 2.69 The MOH needs to be very selective in deciding upon new items of expenditure, as there are already many competing pressures for additional resources. About MK14 million would be needed to bring staffing levels up to the levels recommended in the Complement and Grading Review Report, even without allowing for the additional workload caused by population growth at existing health facilities. In addition, the incremental recurrent costs arising from investments now being implemented are estimated to amount to  - 23 - about MK13 million, of which the planned new medical school would account for half. In terms of new items of expenditure, priority should be given to programs aimed at the country's largest disease problems. C. Bank Group Experience and Lessons Learned 2.70 The International Development Association (IDA) has been involved in the health sector in Malawi since 1971, when a health component was included in the Karonga Rural Development Project. All the agricultural projects since then have included health components with a total investment of about US$4.5 million. Inputs have ranged from enlarging and modernizing the Karonga Hospitals, to bilharzia control programs and the development of sub-centers and health posts. A Health Sector Review was undertaken by IDA in 1980, and Population Sector Reviews in 1984 and in July 1989. In 1988 the Bank also undertook a Human Resource Study, which takes a longer-term perspective of sectoral issues. 2.71 Bank lending in the population, health arnd nutrition sector has focused on support for PHC and on improving the management and delivery of health services. The First Family Health Project (Credit 1351 MAI, signed May 20, 1983) provided SDR 6.3 million for a comprehensive national health plan; an improved planning, monitoring and evaluation capacity; improved system of financial accounting and health service statistics; an epidemiological survey capacity; an efficient, cost-effective system of pharmaceutical procurement and distribution; the first phase of the national PHC program; and introduction of CS activities. The project closed on 9 December 31, 1988. The ongoing Second Family Health Project (Credit 1767 MAI signed May 7, 1987) provides SDR 8.7 million equivalent in support of the Ten Year National Health Plan (1985-1996). The objectives of the project are to: (a) improve the health status of families through expansion and strengthening of PHC programs; (b) increase the availability and accessibility of CS services within the MCH program; (c) strengthen the MOH capacity to plan, manage and evaluate health services in the framework of a decentralized system; and (d) design and implement a multi-sectoral family health program through other Government agencies. Implementation of the project is proceeding very well and the project is expected to close by its original closing date. 2.72 Evaluation of the completed project indicates that, with minor exceptions, the project objectives were met. It also identified major weaknesses in the Government's accounting procedures. Lessons learned from this project included the need for a competent project coordinator to be appointed as soon as the project became effective; the need for Bank supervision missions to visit all the project facilities and/or activities once a year; and the need for the supervision team to include all the relevant specialties. The project completion report also made a strong case for a more realistic implementation period. The present project has addressed the issues raised in the completion report. D. Role of Other Agencies and Organizations 2.73 A number of multilateral and bilateral donors have been involved In the health sector in Halawi. The African Development Bank (AfDB)  - 24 - through its First Rural Health Project has provided funds for extension/replacement of health centers and a district hospital, and for ambulances and staff housing. USAID has been involved in funding improvements to rural water supply systems for the control of communicable diseases, for epidemiological studies and for manpower development, and through its PHICS project is now funding the training of HSAs and their deployment in seven districts. In addition, the PHICS project focuses support on building up HEU capacity at the headquarters by strengthening management skills, staffing levels, training, production resources, delivery systems and evaluation capability. The ODA has funded fellowships for medical students and has provided supplementary salaries for British doctors working in Malawi. The Dutch, Egyptian and other governments are supporting the MOH through technical assistance. The Dutch Government has also supported the development of the Central Medical Stores. The European Community (EC) has funded the replacement of Karonga District Hospital, the building of Mulanje Hospital and construction of health centers in the Mulanje district. In addition, the EC has provided funds for IEC activities in relation to AIDS. The West Germany aid agency, Kreditanstalt fur Wiederaufbau (KfW), has funded the construction of Machinga Hospital and is also funding the rehabilitation of 14 health centers. It is also providing commodity aid to cover the cost of drugs, and it may support the rehabilitation of Zomba Hospital. The United Nations Development Program (UNDP) is supporting the strengthening of the Community Health Department of the medical school. WHO is at present supporting the PHC program through provision of clean water, drugs, in-service training and technical assistance. UNICEF is assisting in the training of TBAs, in the diarrhoeal disease control, in related IEC activities, and in the training of community-level health personnel. It is also supporting the MCH program, with funding from the Italian Government. The Japanese International Cooperation Agency's (JICA) assistance is in the form of experts, vehicles, equipment and drugs. The Canadian International Development Agency (CIDA) has supported rural health by providing funds for bore holes for health centers. UNFPA has funded a long-term technical advisor at the HEU, a variety of materials production and training activities related to CS, and training of TBAs. UNFPA is planning to develop a follow-up project which will focus primarily on providing support to HEU staff. UNFPA has also supported family life education for the Malawi Young Pioneers and is working with the Department of Information to introduce family life education into its activities. UNFPA also supports CS activities and health education in schools. A number of external voluntary agencies are also involved in health care delivery and training through assistance to PHAM hospitals and training centers. This project complements and reinforces the activities of other donors in the sector. The Bank's resident representative in Malawi is the co-chairman of the donors' subcommittee on health.  - 25 - III. GOVERNMENT'S STRATEGY 3.01 To work towards its objectives for PHN as outlined in Chapter I and to address the issues outlined in Chapter II, the Government has adopted a strategy for the 1990's that involves two crucial initiatives: a reform program to improve policies, programs and services in PHN; and a revised public expenditure plan to guide the allocation and use of resources in the PHN sectors. These two initiatives are introduced briefly in sections A and B below; further details, by program area, are then discussed in section C. A. The Reform Program The main priorities of the reform program are: - strengthening of basic services, especially in PHC, MCH, malaria, AIDS, child spacing, WID and nutrition; - upgrading of support services, especially in manpower development, IEC and pharmaceuticals supply; - improvement of efficiency in PHN facilities and programs, with particular attention to reducing costs at hospitals, shifting more patient care from hospitals to less costly "filter clinics", and strengthening capacity building of PHN institution and staff. - improvement of policies determining how PHN services are financed, with particular attention to patient fees (and cost- sharing, more generally) and the PHN sectors' share of total Government expenditure. - strengthening, as part of all the above, the decentralization of responsibilities in PHN service delivery, and role of local groups and communities, non-governmental authorities below the central level. 3.02 The reform program was developed through an iterative consultation process, taking into account (a) the objectives set out in the National Health Plan; (b) the Government's stated intention to increase the priority to be given to the sector within the anticipated continuing overall resource limitations; (c) i:plementation constraints; (d) ongoing activities including projects already funded by other donors; and (e) the feasibility of policy change and the need to ensure full consensus over sensitive issues. The specific actions to be undertaken are summarized in the Government's Letter of Health Development Policy, which has attached to it a Policy Action Program in the form of a matrix of specific objectives and measures (Annex A and para 6.01). The reform program constitutes a comprehensive attempt by the Government to address the main issues facing the PHN sector, and has been thoroughly discussed within MOH and with other parts of the Government in order to ensure that there is strong commitment  - 26 - to all elements of the program. The Government is setting up a monitoring and evaluation committee to ensure that the reforms are implemented and adhered to. As shown in Annex A, the Government has already begun to implement some of the most significant measures, such as the establishment of the Manpower Development Unit and the increases in private patient fees. 3.03 The program when fully implemented would improve the quality and coverage of peripheral and community services through the deployment of more trained staff, and through improvements in logistical and supervisory support; improve equity through wider access to health facilities and through the expansion of community-based population, health and nutrition services; increase the effectiveness and efficiency of resource use by ensuring that peripheral services receive a larger proportion of budgetary funds and by efficiency improvements in the major hospitals; improve the administration and management of the health care services by rationalizing and decentralizing their management and administration at the periphery, and by improving personnel and training management; improve the workings of the CMS; and strengthen education and motivation efforts through the adoption of an integrated and coordinated plan for IEC programs. B. The Revised Public Expenditure Plan 3.05 The revised public expenditure plan covers both the development (i.e., investment) and the recurrent ("revenue') budgets of the MOH for the period up to 1995/96. These budgets are interdependent, with the recurrent budget having to allow for the incremental costs of ongoing development projects, and with the components and phasing of the new development program being determined by the likely availability of recurrent funds. The incremental recurrent costs of the additional community-based staff to be trained are included in the development plan. The revised expenditure plan and the associated policy reform plan are intertwined, with each depending for its success on the other. 3.06 The design of the expenditure plan has been based on the need to reorient substantially the MOH budget, and especially the proportion of it allocated to the central hospitals. The revised plan will give priority to increased spending on the periphery and to steps to induce greater efficiency. This will be done through measures to: (a) build up peripheral and outreach services and programs, especially through the accelerated program of manpower development; (b) build more filter facilities to enable patients to seek care at lower-cost delivery points; (c) increase budgetary provision for priority services, and strengthen management and accounting systems to ensure that such budgets are actually used for these purposes; (d) begin to use the pricing system to affect patient demand patterns; and (e) improve the efficiency of the central hospitals. Specifically, priority in the allocation of new resources will be given to the salary and operating costs of additional outreach and peripheral workers. In the health development program, particular emphasis will be placed on such activities as PHC and the MCH programs, malaria control, AIDS prevention and control, the CS program, nutrition, WID activities, health education and information, training activities, the provision of transport at the community level, and improved communications between the district level and  - 27 - the periphery. Regarding new construct4.on, prioraty will be given to the expansion, rehabilitation and consolidation of selected low-level rural and urban facilities. 3.07 Development Expenditures for 1991192-1995196. The investment portion of the revised expenditure plan Is summar:zed in Table 3.1, and the details are shown in Annex T12A. While the investment plan reflects the Government's stated policy to give increased priority to the sector, there still had to be considerable selectivity in the choice of new projects and programs to be included and careful phasing particularly of large projects with significant recurrent cost implications. The first few years of the revised investment plan are dominated by continuation of activities already underway, since development projects usually take several years Zo implement. Although the program is based on the period 1991/92-1995/96, allowance has also been made for some initial expenditures to take place in the present fiscal year, 1990191. TABLE 8.1: Investment ProDrm 5Su ry) (MK mlIlon)In constant prIcoo -----------------------------------------------------------------------__----__----------- 1991/92 1992/93 1993/94 1994/95 1995/96 Total 1. Onnolna ProJ-ct S/ Donor Fundod 40.1 87.3 22