Cameroon - Health, Fertility and Nutrition Project

Document of The World Bank FOR OFFICLAL USE ONLY Reprt No. P-6426-CM MEMORANDUM AND RECOMMENDATION OF THE PRESIDENT OF THE INTERNATIONAL DEVELOPMENT ASSOCIATION TO THE EXECUTIVE DIRECTORS ON A PROPOSED CREDIT IN THE AMOUNT EQUIVALENT TO SDR 29.5 MILLION TO THE REPUBLIC OF CAMEROON FOR A HEALTH, FERTILITY AND NUTRITION PROJECT FEBRUARY 7, 1995 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.  CURRENCY EOUIVALENTS The rate of CFA Francs 572 to the US Dollar was used for cost projections as of January 1994 The CFA Franc (CFAF) is tied to the French Franc (FF) in the ratio of FF I to CFAF 100 WEIGHTS AND MEASURES Metric System ABBREVIATIONS AND ACRONYMS CAS Country Assistance Strategy CFA Communaute Financiere Africaine CY Calendar Year ERC Economic Recovery Credit GOC Government of Cameroon IDA International Development Association [EC Information, Education and Communication IFC International Finance Corporation MEF Ministry of Economy and Finance MOPH Ministry of Public Health PHC Primary Health Care PHN Population, Health and Nutrition PPF Project Preparation Facility TCC Technical Committee for Coordination and Follow-up of Health Sector Projects FISCAL YEAR July 1- June 30  FOR OFFICIAL USE ONLY REPUBLIC OF CAMEROON HEALTH. FERTILITY AND NUTRITION PROJECT CREDIT AND PROJECT SUMMARY Borrower: Republic of Cameroon Beneficiaries: Ministry of Public Health (MOPH) Ministry of Economy and Finance (MEF) Poverty: Program of Targeted Interventions Amount: SDR 29.5 million (US$43 million equivalent) Terms: Standard IDA terms with 40 years maturity Commitment Fee: 0.50% on undisbursed credit balances, beginning 60 days after signing, less any waiver. Financing Plan: Government US$5.01million Communities US$0.07million IDA US$43.00 million Total US$48.08 million Economic Rate of Return: Not applicable Staff Appraisal Report: No. 12348-CM Maps: IBRD No. 26348, 26349 and 26350 dated October 1994. This document has a restricted distribution and may be used by recipients only in the performance of their X official duties. Its contents may not otherwise be disclosed without World Bank authorization.   MEMORANDUM AND RECOMMENDATION OF THE PRESIDENT OF THE INTERNATIONAL DEVELOPMENT ASSOCIATION TO THE EXECUTIVE DIRECTORS ON A PROPOSED CREDIT TO THE REPUBLIC OF CAMEROON FOR A HEALTH, FERTILITY AND NUTRITION PROJECT 1 . I submit for your approval the following memorandum and recommendation on a proposed credit to the Republic of Cameroon for SDR 29.5 million, the equivalent of US$43 million, on standard IDA terms with a maturity of 40 years to help finance a project for health, fertility and nutrition. 2. Sector Background. Cameroon's population of 12 million is growing at about 3% annually. Fertility remains high at 5.8 per woman, and the contraceptive prevalence rate for modem methods is less than 5%, despite good knowledge of methods and the desire to limit family size among couples. The health status of the population has improved considerably over the past three decades, but life expectancy at birth is only 55 years; the infant and child mortality rates are 65/1,000 and 126/1,000 respectively, and matemal mortality ranges from 250/100,000 live births in cities to 430/100,000 live births in rural areas. Infectious diseases, malaria, intestinal parasites, skin diseases, traumas and nutritional disorders are the dominant pathologies and sexually transmitted diseases, including AIDS, are a growing threat.. Results from the 1991 demographic and health survey indicate significant nutritional problems: 24% of children under five years suffer from moderate to severe chronic undernutrition (height- for-age measure); 3% suffer from moderate to severe acute undernutrition (weight-for-height measure); and 14% are underweight (weight-for-age measure). Iron deficiencies and anemia affect 40% of expecting or nursing mothers, and there is a high incidence of iodine deficiency and vitamin A-related disorders in some regions. 3. Over the past 15 years, Government of Cameroon (GOC) policy has emphasized curative care and hospital construction at the expense of preventive services. There are marked disequilibria in the deployment of staff and financial resources relative to the distribution of the population and their health needs. Poor management of the health care system has resulted in a chronic shortage of drugs, materials and medical equipment, lack of facility maintenance, limited non-wage operating funds, and lack of retraining and supervision of health staff. The referral system has broken down, especially in cities, creating overcrowding and a high demand for primary care services at tertiary care facilities. Sector coordination mechanisms are weak, particularly in view of the multiplicity of donors, and the fragmentation of donor-sponsored projects. 4. GOC's new health sector policy, formulated with active Bank assistance during project preparation, stresses low-cost preventive services delivered in decentralized health districts with active community participation and support. Government has also issued a national population policy aimed at fertility reduction and child spacing. 5. Project Objectives. The project has three objectives: (a) to provide institutional support for continued development of the national population policy and rapid implementation of a national family planning and information, education and communication (IEC) strategy; (b) to promote complementary organizational and administrative reforms needed to strengthen the management of health sector resources, and to advance the decentralization of health services; and (c) to expand the coverage of primary health care (PHC) to currently underserved low-income populations, and improve the quality of services delivered.  - 2 - 6. Project Description. The project would assist the Government through the year 2000 with a combination of national-level support for efforts to reorient and reorganize primary health care delivery, and intensive regional-level assistance for decentralization of basic health care services in 18 health districts currently not receiving extemal financial aid. Nationally, the project would provide assistance to implement the national population policy adopted in 1993; develop public PHN services; train MOPH managers and service providers; supply essential generic drugs, vaccines and contraceptives; and expand communication activities. Regionally, the project would support the expansion of quality primary health care coverage to approximately three million people through the establishment of 18 fully functional health care districts. Coverage would be divided between rural and urban areas, with IDA assistance to nine rural districts in the Center, East, West and Far-North provinces and nine urban districts in Yaounde and Douala. The specific components of the project are as follows: (i) Assistance in the Development and Implementation of the National Population Policy and Family Planning/IEC Strategy (US$1.8 million or 5% of total base cost): by supporting the activities of the National Population Commission; and improving demographic data collection and dissemination for population policy-making and operations, (ii) Organizational and Administrative Reforms of the Ministry of Public Health (MOPH) to Strengthen the Management of Health Sector Resources and Promote Decentralization of Health Services (US$1.5 million or 4% of total base cost): by supporting the strengthening of MOPH's health scrvices and management structures; and developing health management information systems; and (iii) Expansion of Primary Health Care Coverage and Improvement in the Quality of Health Service Delivery (US$34.7 million or 90% of total base cost): by supporting PHC services through decentralized health districts; improving family planning, maternal and child health services; and strengthening nutrition interventions. The quality of service delivery would be assured by strengthening training and retraining of health personnel at all levels of the system, including community health workers for outreach activities; supplying essential generic drugs, vaccines and contraceptives to public health facilities; and strengthening the Health Education Unit of MOPH and expanding communication programs through IEC. 7. Project Implementation. The project would be implemented by the existing departments and technical services of MOPH and MEF. The Technical Committee for Coordination and Follow-up of Health Sector Projects (TCC) established with PPF funds, would coordinate the overall implementation process and would be responsible for liaison with the operating departments and the donors. Annual program-budgets would be submitted to IDA for approval. The implementing structures would be strengthened by the project to carry out the planned activities. 8. Project Sustainability. Long-term benefits would include reduction of fertility, morbidity and mortality for targeted groups. Medium-term benefits would be clear PHN policies and strategies focused on prcventive services, improved strategic planning and management of MOPH, increased public resources for health and a more efficient use of available resources, and more effectively trained and competent PHN personnel. Cost recovery and active beneficiary participation in the financing and management of services would promote self-reliance for increased levels of recurrent budgets. The fertility reduction activities will, in the long-run, case the growing pressure on natural resources and the demand for social serviccs and cmployment.  - 3 - 9. Lessons from Previous IDA Involvement. This would be the Bank Group's first freestanding operation in the PHN sector in Cameroon. Experience with other Bank projects suggests that project execution activities should be integrated into MOPH's existing departments and technical services and that the timely availability of counterpart funds and the budget approval/expenditure process should be closely monitored to minimize delays.. Based on the findings of a recent government review, IDA would assist the Government in reforming and improving its procurement procedures and processes. 10. Rationale for IDA Involvement. The most recent country assistance strategy (CAS) discussions took place on June 16. 1994 during the Board presentation of the Economic Recoverv Credit (ERC). This project is consistent with the CAS. The Cameroon CAS emphasizes the development of the human resources sector and stronaly focused interventions to alleviate povertv. including improvements in the deliverv of social services to low-income groups. In the health sector. Government policy emphasizes the strengthening of family planning activities, the improvement of primarv health care services and the establishment of programs to combat nutritional deficiencies. The CAS provides that IDA will support the implementation of this policy through the proposed health, fertility and nutrition project. Through a Japanese Grant for Population and Health administered by IBRD and the PPF-financed preinvestment studies, IDA has played an active and key role in the successful PHN sector policy dialogue with GOC, which has produced major shifts in health and population policies in Cameroon. With coordinated donor support of the PHN policy, GOC now wants to move to an implementation phase of the new policies and needs the financial support of IDA to translate policies into operational programs. IDA assistance complements the activities of other donors, and is focused on geographical areas where no other donor support is envisaged. 11. Agreed Actions. Although a consensus now exists within Cameroon to decentralize the health system by creating the health districts, to liberalize the drug market, and to redeploy health personnel into underserved areas, GOC has been slow in passing the enabling legislation to permit MOPH to initiate action. Prior to Board presentation of the project, GOC implemented the following measures: (i) adoption of an administrative text decentralizing health districts and instituting the new organization of MOPH health services that stresses low-cost preventive primary health care, family planning and nutritional services and their efficient management; (ii) expansion of the membership in the MOPH's TCC to include other key ministnres concerned with PHN issues, and to strengthen external aid coordination within an organized framework; and (iii) nomination of the Financial Officers for the five provinces covered by the project and a Financial Officer for the Central level, on terms and conditions satisfactory to IDA. On drug policy, GOC has established an interim Central Drug Supply Store (CIAME) and its regional distribution centers jointly owned and operated with the non-profit private providers to broaden the competition for pharmaceutical procurement and distribution. During negotiations, GOC agreed to: * As conditions of IDA credit effectiveness: (i) prepare and finalize the standard bid documents in form, substance and format acceptable to IDA, including the bid documents for the first year of the project; (ii) enter into a multi-year contract with an auditing firm under terms and conditions satisfactory to IDA to establish an accounting system for the project and to monitor its operations; (iii) enter into a contract with a consulting firm under terms and conditions satisfactory to IDA to prepare the training programs and to monitor and evaluate their execution; and  - 4 - (iv) nominate key project staff including six procurement specialists and six financial officers on terms and conditions satisfactory to IDA. * As conditions of disbursement against the category related to drugs: (i) adopt regulations instituting the Central Drug Supply Store and organizing its management and operations; (ii) finalize and publish appropriate legislation conceming pharmaccutical policy and regulation, and (iii) propose satisfactory measures for ensuring the quality of imported generic drugs. * During project implementation: (i) take all necessary measures to increase progressively the share of the health budget from 5.0 percent of the total Govermment budget in FY 93/94 to 7.0 percent by FY 96/97; 8.0 percent by FY 98/99; and 10.0 percent beginning in FY 99/00 and allocate the increases to non-salary expenditures until the end of the project; (ii) carry out a fertility survey every two years and a contraceptive prevalence survey annually starting in CY 1996, both in accordance with terms of reference acceptable to IDA, and fumish the results to IDA for comments; (iii) submit to IDA before June 30, 1996 a plan of action to develop sectoral strategies for the implementation of the National Population Policy and implement it; (iv) take the necessary measures to ensure equitable geographical distribution of staff and improved intemal management of civil service personnel assigned to MOPH; (v) review with IDA in June of each year a) all health sector investment expenditures made in the previous year and those planned for the next three years, with particular attention to their recurrent cost implications; and b) the expenditure of the non-salary recurrent budget across existing programs and services; (vi) submit to IDA not later than April 30 of each year evidence that the previous year's budget was spent as originally intended, and prepare and discuss the proposed operating budgets for the subsequent year; (vii) maintain a system acceptable to IDA for cost recovery accounting and financial management of the health centers and district clinical facilities; (viii) submit to IDA by December 31, 1995 a national program for expanding family planning services over the 1996-1999 period and implement it; (ix) evaluate annually the technical and management training activities undertaken during the previous year and fumish to IDA for its review and approval by March of each year detailed plans based on that evaluation;  - 5 - (x) keep the TCC's Secretariat fully staffed throughout project implementation; (xi) for all scholarships funded by the project, (a) submit for IDA approval the proposed candidate (including his/her functions and qualifications), training institution, and course of study; and (b) take all necessary measures to ensure that successful candidates bind themselves to serve for at least three years in posts for which they were trained; (xii) carry out annual beneficiary assessments based on the agreed service indicators; and, jointly with IDA, hold a mid-term review of the entire project not later than June 30, 1997. 12. Poverty Category. The project is included in the Program of Targeted Interventions since it focuses on depressed urban areas and 'bidonvilles" with high concentrations of the urban poor and on underserved low-income rural areas. 13. Environmental aspects. The environmental category assigned to this project is C. It would have no direct adverse impact on the environment, rather positive effects via reduced fertility and rehabilitated health facilities. 14. Program Objective Categories. The project supports Cameroon's antipoverty strategy by expanding primary health care and family planning services to approximately 3 million low-income people in underserved health districts, mostly women, children under five years and adolescents. The institutional measures would strengthen MOPH's ability to provide services nationwide, thereby improving coverage of basic health services and access to care. 15. Participatory Approach. The project will expand the health facilities with beneficiary communities involvement and support. Day-to-day management of the decentralized PHN structures would be carried out jointly with local health committees. 16. Benefits. Through the establishment of nine rural districts in Center, East, West and Far- North provinces and nine urban districts in Yaounde and Douala, the project would support expansion of quality primary health care coverage to approximately 3 million people. Within these 18 districts, project objectives are to: reduce matemal mortality by 30 to 50%; increase vaccination coverage for the main target groups (children under five years and childbearing-age women) from under 40% to between 60 and 80%; increase the modem contraceptive prevalence rate from less than 5% to between 10 and 20% by the year 2000; and enhance the nutritional status of the most vulnerable population groups. The project is expected to improve the overall efficiency and effectiveness of PHN sector operations by: strengthening sector resource management and coordination; and by enhancing the productivity and improving the quality of services provided by MOPH personnel. Increased availability of low-cost essential drugs, contraceptives and vaccines would raise the credibility of PHN services, increase utilization of services, and reduce illness and premature deaths from preventable and curable diseases. 17. Risks. Because of the relatively recent adoption of the population and health policies, some difficulties and potential delays should be anticipated in translating policy orientations into clearly defined institutional relationships and an overall strategy into implementable programs. Specifically, the existence of entrenched distortions and rigidities in the health care system and MOPH's generally weak coordination of activities may prove difficult to overcome in a first project. The possibility of a lack of continued Government commitment to new PHN policies poses another risk that will be closely monitored to ensure  adherence. Government has already established the legal basis for participatory community structures and their relationships to MOPH, during project implementation, internal coordination would be strengthened by restructuring MOPH's management and formalizing coordination links within the TCC. Consultant services would assist GOC agencies in implementing the project. Finally, previous experiences of other projects indicate that while the proposed reforms are generally supported by providers and consumers, they are complex and would require extensive and continuous effort to educate the public. The project would support the Health Education Unit of MOPH which is responsible for these infornation activities. PART III - RECOMMENDATION 18. 1 am satisfied that the proposed credit would comply with the Articles of Agreement of the Association and I recommend that the Executive Directors approve it. Ernest Stem Acting President Washington, D.C. February 7, 1995 Attachments  Schedule A REPUBLIC OF CAMEROON HEALTH, FERTILITY AND NUTRITION PROJECT Summary of Project Cost Estimates and Financing Plan (net of taxes and duties, in US $million) PROJECT COST ESTIMATES: Local Forei2n Total A. ASSISTANCE IN DEVELOPMENT AND IMPLEMENTATION OF NATIONAL POPULATION POLICY AND FP/IEC STRATEGY I. Supporting the Activities of the National Population Commission 0.49 0.33 0.82 2. Improving Demographic Data Collection and Dissemination 0.72 0.29 1.01 B. ORGANIZATIONAL AND ADMINISTRATIVE REFORMS OF MOPH 1. Strengthening MOPHs Services and Structures 0.24 1.00 1.24 2. Developing Health Management Information Systems 0.13 0.18 0.31 C. EXPANSION OF PHC COVERAGE AND SERVICE QUALITY B4PROVEMENT I. Supporting PHC Services through Decentralized Health Districts 4.03 18.83 22.86 2 Improving Family Planning and Maternal and Child Health 1.22 1.10 2.32 3. Strengthening Nutrition Interventions 1.12 3.65 4.77 4. Strengthening Training and Retraining of Health Sector Staff 0.94 0.50 1.44 5. Supplying Essential Generic Drugs, Vaccines and Contraceptives 0.15 2.38 2.53 6. Expanding Communications Program through EEC 0.31 0.57 0.88 D. PROJECT PREPARATION ADVANCE - 0.60 0.60 TOTAL BASE COSTS 9.35 29.43 38.78 Physical Contingencies 0.83 2.43 3.26 Price Contingencies 2.86 3.18 6.04 TOTAL PROJECT COSTS: 13.04 35.04 48.08 FINANCING PLAN: IDA 8.03 34.97 43.00 Government 5.01 0.00 5.01 Communities 0.00 0.07 0.07 TOTAL 13.04 35.04 48.08  Schedule B Page 1 of 2 REPUBLIC OF CAMEROON HEALTH, FERTILITY AND NUTRITION PROJECT Procurement Methods and Disbursements Procurement Arrangements (US$ '000) Procurement Method International Local Competitive Competitive Consulting Project Element Bidding Bidding Services. Otherb Total Cost Civil Works 16,665.4 2,941.0 - - 19,606.4 (16,665.4) (627) (16,665.4) Vehicles 3,307.3 3,307.3 (2,819.6) - - (2,819.6) Medical & other imported equipment 4,162.7 - - - 4,496.7 (4,162.7) - - - (4,162.7) Materials - 18.3 - - 18.3 (15.7) - (15.7) Furniture - 502.4 - - 502.4 (452.6) - - (452.6) Drugs Yrs 1-3, Vaccines & Contracep. 3,616.5 - - - 3,616.5 (3,570.4) (3,570.4) Drugs Yrs. 4-6 689.3 - - - 689.3 Short-Term Consultancy - - 1,399.3 - 1,399.3 (1,399.3) (1,399.3) Fellow ship,Training Abroad - - 620.1 - 620.1 * - (566.1) (620.1) Local Tmg./Semnmars/Studies - - 3,893.4 250 4,143.4 (3,893.4) (250) (4,143.4) OperationlMaint.lGen. Oper. Costs 'Superv. - - - 8,469.2 8,469.2 - - - (7,833.4) (7,833.4) Incremental salarieslRedeplovmt. costs - - - 518.9 518.9 PPF Refinancing - - 600.0 - 600.0 - - (600.0) - (600.0) TOTAL 28,441.2 3,461.7 6,603.3 9,238.1 48,080 (27,218.0) (1,095.3) (6,603.3) (8,083.4) (43,000) Employment of consultants vould be in accordance with IDA guidelines. Includes minor items (repair contracts, office supplies, etc.) costing US$20,000 or less which would be procured internationally or locally on the basis of price quotations from at least three reputable suppliers. Non ICB/LCB Aggregated as Other Note: Figures in parenthesis are the respective amounts financed by the IDA credit.  Schedule B Page 2 of 2 IDA Disbursements Amount SSOOO) Percentage of Categories MOPH MEF Expenditures Total to be Financed 1) Civil Works 16,600 100 16,700 100% foreign; 85% local 2) Equipment, Furniture, Materials and Vehicles 7,100 400 7,500 100% foreign; 85% local 3) (a) Generic Drugs, Contracep. and 2,600 Vaccines (b) Drugs for the health centers and 1,000 3,600 100% district clinical facilities 4) Consultant Services 1,400 1,400 100% 5) Training, Workshops and Studies 3,700 1,000 4,700 100% 6) Operating Costs 2,900 600 3,500 100% foreign; 95% Local 7) Operations and Maintenance of 1,800 200 2,000 95% Build, Veh. and Equip. 600 600 Amount due as specified in 8) Refunding of PPF Section 2.02(c) of the Credit Agreement 9) Unallocated 3,000 Total 43,000 ESTIMATED IDA DISBURSEMENTS: IDA FISCAL YEAR FY95 FY96 FY97 FY98 FY99 FY2000 FY2001 Annual 0.7 8.6 6.7 8.0 7.6 7.8 3.4 Cumulative 0.7 9.3 16.0 24.0 31.6 39.6 43.0  Schedule C REPUBLIC OF CAMEROON HEALTH, FERTILITY AND NUTRITION PROJECT Timetable of Key Project Processing Events (a) Time taken to prepare: One and half years (b) Prepared by: Government and IDA c) Appraisal Date: June/July 1994 (d) Negotiations: December 1994 (e) Planned Date of Effectiveness: June 1995 (f) List of relevant PCRs and PPARs: None  Schedule D Page 1 of 2 REPUBLIC OF CAMEROON HEALTH, FERTILITY AND NUITION PROJECT Status of Bank Group Operations in Cameroon (as of 12131/94) Anount in US# miLLion (tless cancellations) Loan or FiscaL Undis- Closing Credit No. Year Borrower Purpose Bank IDA buried Date ---------- ------ -------- ....... .... ... . Credits 29 Credits(s) closed 354 20 C26271-34(S) 19 CAMEROON ERC 32.80 33.62 12/20/95 C26270-CM(S) 1994 CAMEROON ERC 75.00 1.28 06/30/95 TOTAL number Credits 2 107.80 34.89 Loans 43 Loans(s) closed 959.40 L29120-CM 1988 CAMEROON COCOA REKAB 61.70 20.82 12/31/95(R) L30140-C 1989 CAMEROON LIVESTOCK SECTOR DEV 21.00 7.67 06/30/95 L31850-C4 1990 CAMEROON AGRIC.EXT.TRAINING 21.00 13.55 03/31/97 L33880-04 1992 CAIEROON FOOD SECURITY 23.00 18.50 06/30/99 TOTAL number Loans a 4 126.70 60.55 TOTAL*** 1,086.10 462.00 of which repaid 397.12 32.47 TOTAL held by Bank & IDA 688.98 429.52 Amount sold 8.45 of which repaid 8.45 TOTAL undisbursed 149.98 =3=0 Notes: * Not yet effective t' Not yet signed *" TotaL Approved, Repayments, and Outstanding balance represent both active and inactive Lons and Credits. tR) indicates formally revised Closing Date. (5) indicates SAL/SECAL Lons and Credits. The Met Approved and Bank Repyn nts are historical value, all others are warket value. The Signing, Effective, and Closing dates are based upon the Loan Departsmnt officaL data wad are not taken frco the Task Budget file. Asaont in USt *(llion (Los caeltatinw) Low or FiscaL . C............ Credit No. Year lorrower Pupoe a Ii usa Datasn C25760-C 1994 CANERoo SAC 50.00 DO. 0/30;;O994 C25761-oi 1994 CAMEROON SAC 51.00 .00 03/24/1995 L309M-CM 1989 CAMEROON SAL I 100.00 .00 06/30/1994ut Total CAIEROON 100.00