Niger - Health Sector Development Program Project

Document of The World Bank Report No. 15443-NIR STAFF APPRAISAL REPORT REPUBLIC OF NIGER HEALTH SECTOR DEVELOPMENT PROGRAM August 6, 1996 Human Development III Africa Region  CURRENCY EQUIVALENTS (as of April 1996) 1 US$ = 500 CFA franc I FF I100 CFA franc WEIGHTS AND MEASURES Metric System ABBREVIATIONS AND ACRONYMS AIDS Acquired Immune Deficiency Syndrome CFA Communautjfinanciere africaine (African Financial Community) CHD Centre hospitalier departemental (Departmental Hospital Center) CHU Centre hospitalier universitaire (University Hospital Center) CPPR Country Project Performance Review CPR Contraceptive Prevalence Rate CSI Centre de sante integre (Integrated Health Center) DDS Direction departementale de la sante (Departmental Health Directorate) DEP Direction des etudes et de la programmation (Directorate of Studies and Planning) DPhL Direction des pharmacies et laboratoires (Directorate of Pharmacy and Laboratories) DAF,'M Direction des affairesfinancieres et du matreiel (Directorate of Financial Affairs and Materials) EDF European Development Fund EU European Union FP Family Planning HD H6pital de district (District Hospital) HIV Human Immunodeficiency Virus ICB International Competitive Bidding IEC Information, Education, and Communication MCH Maternal and Child Health MFP Ministry of Finance and Plan MOPH Ministry of Public Health NCB National Competitive Bidding NGO Non-Governmental Organization ONPPC Office National des Produits Pharmaceutiques et Chimiques (National Chemical and Pharmaceutical Products Bureau) ORT Oral Rehydration Therapy PFP Policy Framework Paper PHC Primary Health Care PMA Paquet minimum d'activites (Minimum Package of Services) PPF Project Preparation Facility PTD Plan Triennal de Developpement (Three-year Development Plan) SA Special Account SNIS Systeme National d'Information Sanitaire (National Health Information System) SOE Statement of Expenditures STD Sexually Transmitted Disease UNFPA United Nations Fund for Population Activities USAID United States Agency for International Development WHO World Health Organization BORROWER'S FISCAL YEAR January I - December 31  REPUBLIC OF NIGER HEALTH SECTOR DEVELOPMENT PROGRAM Table of Contents P,age No. CREDIT AND PROJECT SUMMARY ...............................i 1. INTRODUCTION.I II. THE POPULATION. HEALTH AND NUTRITION SECTOR .2 A. Sector Overview .2 B. Past Sector Performance and Key Issues .5 C. National Policy and Medium-Term Sector Strategy .7 D. The Bank Group's Role and Sector Assistance Strategy . 1 Ill. THE PROGRAM AND THE PROJECT .13 A. Program Objectives .13 B. Summary of Program Description .13 C. Detailed Features of IDA Financing .15 D. Indicators for Program Monitoring and Evaluation .23 E. Program Costs and Financial Sustainability .24 F. Economic Analysis .26 G. Program Sustainability .27 IV. PROGRAM AND PROJECT IMPLEMENTATION .27 A. Status of Program and Project Preparation .27 B. Participatory Approach .27 C. Management and Coordination of Implementation .28 D. Monitoring, Evaluation and Supervision .29 E. Gender Impact .30 F. Environmental Impact .31 G. Procurement Arrangements .31 H. Disbursement .35 1. Accounting, Auditing and Reporting .37 V. BENEFITS AND RISKS .38 A . Benefits.38 B . Risks.38 This report is based on the findings of pre-appraisal and appraisal missions, which visited Niger in November 1995 and AprilMay 1996, respectively. Team members included: Mesdames/Messrs. Denise Vaillancourt (Mission Leader, AF4PH), Johanne Angers (Operations Analyst, AF4PH), Ernest Messiah (Public Health Specialist, AF4PH), Rougui Diallo (Program Officer, AF4NI), Regina Amadi (Consultant/Management Specialist), Marie-Paul Fargier (Consultant/Pharmaceutical Specialist), Raja Jandhyala (Consultant/Social Fund Specialist), Dr. Sanoussi Konate (Consultant/Public Health Specialist), Aboubacar Magassouba (Consultant/Project Management Specialist), Fernand Piotte (Consultant/Management Specialist), Dr. Gaston Sorgho (Consultant for the Government of the Netherlands/Public Heatlh Specialist), and Jacques Waechter (Consultant/Architect). Contribution to the mission's work was also received from WHO, UNICEF, and the EU. Mr. Lawrence Salmen (ENVSP) serves as Lead Adviser, and Ms. Marie-Odile Waty (AF3PH) and Mr. Willy De Geyndt (ASTPH) serve as Peer Reviewers.  ANNEXES 1. Basic Indicators 2. Major Causes of Morbidity 3. Organizational Structure of the Ministry of Public Health and Project Management and Coordination 4. Estimate of Additional Personnel by Level and by Category 5. Health Expenditures 6. Statement of Health Sector Policy 7. Economic Analysis 8. Health Sector Performance Indicators 9. IDA Supervision Plan 10. Technical Assistance 11. National, Regional and Overseas Training Plan 12. Disbursement Schedule DOCUMENTS IN PROJECT FILE  REPUBLIC OF NIGER HEALTH SECTOR DEVELOPMENT PROGRAM Credit and Project Summary Borrower: Republic of Niger Implementing Agency: Ministry of Public Health Beneficiaries: Population of Niger Poverty: Program of Targeted Interventions Amount: SDR 27.9 million (US$40.0 million equivalent) Terms: Standard IDA, with 40 years maturity Commitment Fee: Standard (a variable rate between 0-0.50 percent of the undisbursed credit balance, set annually by the Executive Directors of IDA) Onlending Terms: Not applicable Financing Plan: See paragraph 3.35 Net Present Value: Not applicable. Project design based on cost-effectiveness of sector strategies Staff Appraisal Report: No. 15443-NIR Map: IBRD No. 27872 Product ID No.: 1999 Vice President Jean-Louis Sarbib, AFR Country Director Theodore Ahlers, AFC13 Technical Manager Helena Ribe, AFTH3 Staff Denise Vaillancourt, AFTH3   REPUBLIC OF NIGER HEALTH SECTOR DEVELOPMENT PROGRAM I. INTRODUCTION 1.1 Niger, is a large landlocked country covering an area of 1.27 million km2, and is 600 km away from the closest seashore. The population estimated at 8.7 million in 1994--about half of which is less than 15 years old--is growing at about 3.3 percent a year which is above the average for Sub-Saharan Africa. The human resource base is weak with an adult literacy rate of only 14 percent (9 percent among women) and a primary school enrollment ratio of less than 30 percent. The slim natural resource base of degrading arable land is fragile due to low and irregular rainfall and low and declining soil fertility. As a result, Niger's fast growing population is becoming one of the poorest in the world. Per capita GDP has declined by more than 52 percent since 1980 reaching US$230 in 1994. The country's social indcators are among the lowest in the Sahelian countries. Life expectancy at birth of 47 years is one of the lowest on the continent and infant and child mortality rates are high. Niger has an open economy, with imports and exports of GNFS exceeding 30 perent of GDP; and strong trade links exist with Nigeria, which exerts considerable economic influence through long-standing trading and cultural bonds. 1.2 Besides the weak natural resource base, Niger faces additional constraints in the form of high factor costs, overdependence on uranium, past policies with significant anti-export bias, a relatively inefficient public sector and a small modern private sector, which is not competitive. The fall of urnamium prices starting in 1981 has revealed a chronic fiscal imbalance with inadequate revenue generation and uncontrolled wage bill that have saddled Niger with mounting budget and external deficits, and a rapidly rising debt service. To face these special challenges, Niger started in FY96 an adjustment program, supported by the Bank, to restore fiscal equilibria and provide for a minimum acceptable growth over the long-term. Implementation of the program has been uneven, although recently, the accompanying policies to the 1994 develuation have yielded some positive results. General economic activity has improved with 4 percent and 3 percent real GDP growth rates respectively for 1994 and 1995, compared to 1.4 percent in 1993. However, in reaction to a military takeover in late January 1996, several important donors have suspended budgetary aid causing uncertaincy for the budget situation and medium-term policy outlook. Now that the July 1996 Presidential election is concluded, it is expected that assistance to Niger will resume. Government's commitment and action on key reforms, the rapid resolution of the political transition, and the resumption of donor assistance will determine the feasibility of the reform program. 1.3 Putting the country back onto a development path will require: the pursuit of the reform agenda; the diversion of real resources toward private sector development; and actions to restructure public expenditures towards specific objectives to improve primary school enrollment and to increase basic primary health coverage. The pursuit of the reform agenda resides in Niger's ability to regain donors'confidence through an effective transition to democracy. Sustained success would depend on continued fiscal displine and aid flows, political stabilization, and the increase of investments to rekindle growth, especially in satisfying the large needs in social infrastructure.  2 II. THE POPULATION. HEALTH AND NUTRITION SECTOR A. Sector Overview 1. PHN Status: Causes and Consequences 2.1 Propelled by persistently high fertility (TFR = 7.1), Niger's population of 8.7 million is growing at an exceedingly rapid rate of 3.3 percent annually. Life expectancy is estimated at 47 years, infant mortality at 123 per thousand live births, child mortality at 223 per thousand, and maternal mortality at about 700 per 100,000 births. These indicators compare unfavorably with averages for low income countries (life expectancy of 62 years and infant mortality rate of 73 per thousand live births) and put Niger among the countries with the highest mortality in the world. Basic indicators for Niger are presented in Annex 1. 2.2 Niger's poor health status results from the high prevalence of tropical communicable and parasitic diseases, poor nutrition, high fertility (CPR = 2.3 percent), inadequate preventive and curative health services (covering less than one third of Niger's population), low access to safe drinking water and sanitation facilities, low levels of literacy and education -- especially among women -- and pervasive poverty. The leading causes of mortality for children under the age of 5 years are, in order of importance: measles, malaria, diarrhea, malnutrition and respiratory disease. The most frequent causes of morbidity for children in this same age group include respiratory infections, malaria, diarrhea and afflictions of the eye. Other diseases which severely affect the health of Niger's population include: skin affections, urinary tract infections, cerebral-spinal meningitis, yellow fever, cholera, schistosomiaisis, Guinea worm, leprosy and polio. Sexually transmitted diseases are estimated to have a prevalence of 300,000 cases annually, affecting 30 percent of pregnant women in urban areas, and of which 11 percent are found in people under the age of 15. Rising HIV infection rates and AIDS cases are of increasing public concern. A Bank-supported survey revealed seroprevalence rates in Niamey of 1.3 percent among pregnant women, 15.4 percent among prostitutes, 3 percent among truck drivers and 6 percent among those carrying STDs. With the growth in AIDS/HV, tuberculosis is resurging as a major public health concern. Annex 2 provides more details and data on the epidemiological profile of Niger and also presents principal causes of morbidity as reported by health facilities in 1990 and 1991. 2.3 Malnutrition is very prevalent, but often not diagnosed and generally under-reported. The most pressing of problems include protein energy malnutrition, anemia and vitamin A deficiency. Approximately 20 percent of newborns have birthweights of less than 2.5 kg. The survey on morbidity and mortality carried out in 1985 (period of the severe drought) revealed extremely high prevalence rates: 25 percent of children aged 6-59 months were severely malnourished. A national survey carried out in 1992 showed that 17 percent of children in this same age group were malnourished. Pockets of goiter also exist in several regions of the country, notably: Dosso, Tillaberi and Maradi. Among the factors adversely affecting nutritional status in Niger are: severe climatic conditions which cause seasonal and sometimes chronic shortages of food crops; inadequate allocation of household income; poor weaning practices; and pervasive poverty. 2.4 Poor PHN status threatens both the quality of life of Niger's population and prospects for achieving development goals. With a GDP per capita of US$230 (in 1994), Niger is caught in a vicious cycle of poverty and ill health, which has persisted despite national efforts to improve economic and social development. Constant ill health limits the country's ability to maximize returns on investments in education and training, and to increase its economic productivity. The current population growth rate implies the doubling of the population size in less than 25 years -- a rate of increase that will further  3 inhibit national efforts to improve the quality of life. Persistently high fertility and mortality have culminated in an increasingly youthful age structure: around half of the population is under 15 years old. Not only does this impose a severe burden on an under-employed labor force, it also poses greater demands on social services, which already are overextended. This will inhibit the country's prospects for generating adequate capital for economic growth. Furthermore, population growth that outpaces economic growth will contribute to poor nutrition and health status, which will, in turn, inhibit productivity and exacerbate poverty. 2. Structure and Organization of the Health System 2.5 Niger's public health system is structured around the administrative subdivisions of the country: central (or national); internediate (or departmental) and peripheral (composed of three subdivisions: arrondissement, communal and village levels). Annex 3 presents the current structure of MOPH administration, public health facilities and management committees that make up the health system, which are briefly described below. 2.6 Administration. At the central level, the Ministry of Public Health (MOPH) is composed of the cabinet of the Ministry, which includes: the chief of Cabinet, an adviser, an inspector general of health, an inspector general of pharmacies and laboratories and the secretary of the Minister. Attached to the cabinet are the general secretariat (managed by a secretary general and an assistant secretary general) and seven central directorates respectively responsible for: Financial Affairs and Materials; Studies and Planning; Family Health; Pharmacies and Laboratories; Preventive Health and Hygiene; Health Promotion; and Personnel Training and Management. Central MOPH is responsible for coordinating the formulation of sector policy and strategies, prepares investment plans and collaborates with the Ministry of Plan in mobilizing resources from external sources. It is responsible for setting and enforcing patient care norms and standards. It defines the functions and evaluates the performance of health facilities at all levels. Central MOH is also responsible for the deployment, supervision and evaluation of all categories of health personnel who work in the health sector. 2.7 At the regional level, the Departmental Directorate of MOPH (DDS) is responsible for managing health programs designed to implement the national health sector policy and strategy as adapted to the particular context of the department. The DDS is responsible for the allocation of resources within the region and for the provision of support to health facilities in the department and to central MOPH in planning, management and evaluation of health sector activities. It has primary responsibility for supervision and coordination of health services (curative, preventive and promotional) in the department. It monitors the operation of health facilities in order to assure that they function in line with MOPH directives and nationally set standards for patient care. The DDS coordinates the preparation of draft budget requests submitted to the MOPH for review and inclusion in the sector budget proposals. At the arrondissement or commune levels, the chief medical officer supervises primary health care facilities operating in the arrondissement or medical circumscription. 2.8 Public Services. The pyramid of health services offered in Niger is structured as follows. At the central level, third level referral services and specialized care are offered through three national hospitals (two in Niamey and one in Zinder), which also are responsible for research and training. Also offering third level referral services, tertiary care, research and training are a number of specialty centers including: the Anti-Leprosy Center; the National Anti-Tuberculosis Center; and the National Family Health Center. At the regional level, the Departmental Hospital Center (CHD), the second level referral facility, handles complicated cases, requiring medical specialists, which are referred from the arrondissement-level medical centers. Among the specialty services offered are surgery, pediatrics and internal medicine. The CHD is responsible, among other things, for the in-service training of regional  4 clinical staff. Three maternities located in Zinder and Tahoua also provide second level referral services. At the arrondissement level, primary health care and first referral serves are provided by the medical center, which generally consists of a dispensary, a small hospitalization unit, a maternity, a maternal and child health center and a laboratory. At the commune and, in some cases, at the village level, rural dispensaries, ward dispensaries and health posts provide primary health care services. Village health teams, generally composed of two traditional birth attendants and two first aid workers. provide very basic primary services at the village level. These teams cover about 50 percent of Niger's villages. 2.9 Private Services. The small private sector currently operating in Niger consists of the following: 10 doctors' offices; 3 practices offering deliveries, prenatal care and family planning; 2 psychologists' practices; 3 physiotherapists' practices; 48 health posts; 3 private hospitals (one in Tahoua and 2 in Agadez); 5 private clinics; 7 social/medical centers of the National Social Security Fund (CNSS); 13 private pharmacies (of which 12 in Niamey and I in Maradi); and 215 drug depots (of which 86 are cooperatives). As is noted in the policy section of this chapter, Niger is encouraging an expansion in private sector activity so as to improve coverage and reallocate public funds to underserved areas. 2.10 Other MOPH Structures. Over and above those responsible for administration and service provision, MOPH also includes structures responsible for training and for carrying out essential functions related to pharmaceuticals and laboratories. The Medical Circumscription for Training and Research (CIMEFOR), created in 1991, is situated in the medical circumscription of Doutchi (300 km from Niamey) and carries out training with a view to: strengthening primary health care delivery; building management capacity of district health teams; and improving supervision capacity of medical circumscriptions. Two national schools of public health (ENSP), located in Niamey and Zinder, provide basic and refresher training in public health and social action and also undertake related research. The aim of the National Center for Health Development (CNDS), established in 1991 with French assistance, and attached to ENSP/Niger, is to render health personnel better adapted to implement health policy reform, with a particular emphasis on community health, management and training. Due to lack of recurrent financing the CNDS is not functional. The Faculty of Health Sciences at the University of Niamey has been training medical students since 1974. 2.11 Also under the tutelage of MOPH is the National Office of Pharmaceutical and Chemical Products (ONPPC), whose functions include: the supply and distribution of drugs and other medical supplies to health facilities across Niger; the production of selected drugs and medical supplies; and, through its National Laboratory of Public Health, the quality control of drugs, products of traditional pharmacopoeia, food commodities, water and other products, such as pesticides and cosmetics. 2.12 Management Committees. At the central level, the National Health Committee is responsible for all intersectoral coordination and oversight of development questions related to health and health policy. It is responsible for adopting implementation plans; proposing changes to health policy; reorienting health programs, if needed; and mobilizing resources needed for implementation. The Minister of Health is President of this Committee, which meets once annually. The composition of this Committee is both multi-sectoral and high-level, encompassing the Ministers of all relevant Ministries (National Defense; Finance and Plan; Foreign Affairs; Agriculture and Livestock; Water and Enviromnent; National Education; Higher Education; Interior; Communication Youth, Sports and Culture; Social Development, Population and Women; Civil Service and Labor); a representative of the Economic and Social Affairs Committee of the National Assembly; and the Social Adviser of the Prime Minister. The membership of the Departmental Technical Committee (COTEDEP) includes all technical directorates at the departmental level and also is opened to representatives of traditional practitioners and locally elected officials. The mandate of this committee is intersectoral coordination and oversight of all development activities in the department. The Arrondissement Technical Committee (COTEAR)  5 and the Communal Technical Committee (COTECOM) are responsible for intersectoral coordination and oversight of all development activities, respectively, at the arrondissement and commune levels. As at the departmental level, their membership includes all heads of technical units and locally elected officials. Over and above these intersectoral committees, whose focus is on all sectors, there currently exists in Niger no decentralized intersectoral structures that focus on monitoring and evaluation of health sector policy and practice. B. Sector Performance and Key Issues 1. Quality and Access 2.13 Inadequate coverage and quality of health services constitute the main impediments to health sector performance, The dispersion and rate of growth of the population and the sheer size of the territory pose daunting challenges to improvements in service coverage and even to needed improvements in the quality of existing services. Low service quality is attributable to: the lack of resources available for primary health services; insufficient availability and affordability of essential drugs; inappropriate diagnosis and treatment of illnesses; low morale, lack of skills and insufficient numbers of service providers. A beneficiary assessment, undertaken as a part of the final evaluation of the first IDA investment in the health sector, provides added insight on the low utilization rates in Niger. Some personnel are perceived to lack respect and consideration for their clients and, occasionally to lack required qualifications. In addition, drug availability -- a top priority for clients of health centers -- is unreliable, at best. Weak referral capacities and inadequate support systems (particularly supervision, in- service training, logistical and maintenance support) constitute yet other factors, which severely compromise the quality of services. In addition, technical services are organized in an excessively vertical fashion: particular services are delivered only on particular days of the week. Not only does this make services extremely user-unfriendly, this practice also makes service delivery inefficient and in contradiction with the primary health care principle of services integration. Finally, there are some key primary services, which are neglected, or, at best, ineffectively delivered. Mostly of a preventive and promotional nature, these include: family planning services (CPR 2.3 percent); vaccinations (17 percent coverage of targeted immunizable diseases in children 12-23 months [14,4 percent if yellow fever is added]; and 23,4 percent tetanus coverage of pregnant women); nutrition; and information, education and communication activities. 2. Sector Management 2.14 The quality and effectiveness of Niger's health system are seriously constrained by weak management capacity. Roles and responsibilities for management and decision-making are excessively centralized, particularly with regard to management of resources. Those best placed to make informed decisions on the optimal use of resources (i.e., those at the more decentralized levels of the system) have neither the authority, the means, nor the essential skills for carrying out key management functions. In fact, there is a lack of capacity at all levels of the system to carry out functions which are crucial to the efficiency and effectiveness of health sector operations, notably: planning, programming and budgeting; resource mobilization and aid coordination; management of human, physical and financial resources; training and supervision -- both of a technical and of an administrative nature; quality control; and monitoring and evaluation. Furthermore, roles and responsibilities at each level of the system for carrying out key management functions have not been clearly defined (although it must be noted that recent initiatives are addressing this issue). 2.15 Management tools, systems and processes are ambiguous and underutilized, if they exist at all, thus further inhibiting sector effectiveness. There are neither national norms nor rational criteria for the  6 effective and equitable allocation of sector resources. Budget allocation is based on past patterns without due consideration of real needs and equity concerns. Management of material and financial resources is inadequate due to the lack of a performing accounting system at all levels of the system. Systems for the evaluation of health personnel are inadequate. The setting up of a National Health Information System (SNIS) with the assistance of USAID has been a major contribution to improved sector management. Established at all levels of services its objective is the collection and analysis of information, its wide dissemination and its effective utilization in management and decision-making. It provides information on the extent of health problems of Niger's population and key information to facilite, at all levels of the system, the management, evaluation and improvements to program performance. Considerable effort, however, will be needed to exploit fully the utility of this tool, including: ensuring adequate human resources for its use; building capacity at DDS and district levels in its use; and encouraging its full analysis and use in decision-making by managers of health facilities. 2.16 Community Participation and Intersectoral Coordination are basic principles of the primary health care approach, embraced by Niger's health policy. Neither of these principles are as yet fully applied, however, although efforts are underway to improve performance in this regard. With the assistance of the first IDA-financed health project and that of USAID, pilot studies tested community participation in the financing of primary health services. These studies have demonstrated, as is the case in other countries, that community participation in the financing of health services and in the management of collected revenues provides communities with some leverage in their demand for quality services and incites the health system to be more client oriented and thus improve that quality. UNICEF (through the application of the Barnako Initiative) and projects financed by other partners have also applied various notions of community participation in the financing and management of primary health services. From this experience, the MOPH is now challenged to develop a framework for eliciting and applying nationwide the participation of communities in the financing and management of primary health services, in line with their comparative advantages, to render the system more accountable to its clients. Again, considerable efforts are being initiated by MOPH to this end. 2.17 The National Health Committee and its extensions at the departmental, arrondissement and commune levels (COTEDEP, COTEAR, COTECOM) (see para. 2.12) have not sufficiently focused on the review of health policy and its application. This is due primarily to two factors. First, its mandate is intersectoral and holistic in nature, which does not permit it to provide sufficient time to focus exclusively on the health sector. Second, even in the application of its intersectoral mandate, the lack of clear direction on how to focus on the key issues leaves it ill-equipped to carry out its functions concerning the health sector. While there is much scope for community participation, intersectoral coordination and collaboration with other partners (NGOs, private-for-profit sector, academia, etc.), particularly at the operational level, no organizational structure exists currently that would effectively elicit and coordinate such partnerships. 2.18 Human Resources. While crucial to achieving national objectives of improving the quality and coverage of services, many issues surrounding human resources for health severely dampen efforts in this regard. Human resources for health are inadequate in terms of numbers (ratios of technical staff to population are far below WHO standards) and distribution (80 percent of technical staff are in and around Niamey). Their skills are inadequate due to a number of factors. Basic training curricula are not well adapted to the real demands and responsibilities of service provision at the various levels of the system in Niger. Neither does in-service training respond to the urgent needs to strengthen service delivery quality. Health personnel are very demoralized: salaries are not received regularly; the system for management and evaluation of human resources is excessively centralized and is not designed to monitor performance and to reward or sanction such performance. The lack of a supervision system leaves technical staff isolated and does not give them the opportunity for fine-tuning of their skills and  7 positive feedback on their performance. Capacity for manpower planning is very low. Inadequate systems and skills for human resources management render MOPH hard-pressed to compile the most basic information on numbers of technical staff currently employed, their levels and allocation across the country. The human resources implications of the new reforms envisaged under the PDS had not been assessed, until the World Bank public expenditure review mission (April 1996) initiated this process. Annex 4 provides information on existing human resources for health and on projected needs for the next five years in light of planned reforms. 3. Health Financing and Financial Management 2.19 As with most Sub-Saharan African countries, there is an inverted expenditure pyramid in Niger. Three-quarters of all govemment expenditure on health is for expensive medical care that benefits a small minority of the population living in urban areas. A high percentage of the poor and those living in the rural areas are not reached by the health care system. In short, the budgetary allocations are both inefficient and inequitable. There is scope for improvement and cost savings in most hospitals. This would enable funds to be reallocated from hospitals to primary health care and from curative to preventive medicine, a shift that could improve access and health across the country. 2.20 Public expenditures on health have been relatively well protected during the fiscal crisis. Health's share of total expenditure increased from 4.2 percent in 1980 to 9.1 percent in 1990, dipped a bit in 1991 and then rose in the next two years. The total amount allocated to health was largely protected from overall cuts in 1992, and grew considerably through 1994. Per capita spending has increased from CFA franc 718 (about US$2.50) per inhabitant in 1980, to CFA franc 1,550 (about US$5.50) in 1990, fell for the next 3 years but was budgeted to rise to CFA franc 2,235 per capita (about US$7.70 before the devaluation and US$3.85 after) in 1994 (Annex 5, Table 1). 2.21 In the aggregate, households in Niger spend about 17 billion CFA franc in 1993 on health care- about 5.6 percent of total health spending, with urban households accounting for one quarter of out-of- pocket payments. There is little difference in the share of household spending devoted to health care by level of poverty, although this represents considerable variety in the amounts spent-the non-poor spend 4 or 5 times as much as the very poor. Rural households spend twice as large a share of income as urban households-7.5 percent compared to 4.0 percent-although the CFA franc amounts are very similar for the poor and very poor, but much higher for the urban non-poor than the rural non-poor (Annex 5,Table 2). C. National Policy and Medium-Term Sector Strategy 2.22 Fully aware of the constraints to improved sector performance, the MOPH has prepared a statement of health sector policy. Presented in Annex 6, the highlights of this policy statement are summarized in this section (annexes I to 3 of the policy statement can be found in the Documents in Project File). Three observations on the part of the MOPH provided the rationale for a reorientation in Niger's national health policy: (a) the dubious results achieved since independence through the elaboration and application of previous health policies; in essence health status has stagnated, if not deteriorated, with persistently high infant, child and maternal mortality rates and abysmally low service coverage; (b) the decrease in resources allocated to the health sector in light of a rapidly growing population and the national economic crisis; and (c) the inadequate organization of the health system, which is strongly centralized and which does not elicit participation of communities in sector management. 2.23 In support of a primary health care policy the Government will emphasize prevention through: infornation and sensitization of the population; an increase in vaccination coverage; and a reorientation  8 of sector investments in favor of better coverage. A particular emphasis will be placed on improving the health of mothers and children in the context of an appropriate policy of birth spacing. Drug policy will aim to provide to the population essential generic drugs of a sufficient quality and at an affordable price and to improve production capacity and supply/distribution policy. In the context of this policy the most vulnerable segments of the population will benefit from the organization of national solidarity, whose purpose will be partial recovery of health costs and equity. Personnel training programs will be strengthened and be more adapted to real needs. Investment programs for health infrastructure will be pursued and developed with a view to achieving enhanced decentralization and to bringing services closer to the population. 2.24 The major objective of this new health policy is to ensure continued improvement in health status of the population. The strategies through which this will be achieved are as follows: (a) the decentralization and reorganization of the health system, important components of which will be the establishment of health districts, the restructuring and reform of the pyramid of services and the organization of meaningful community participation in the financing and management of services; (b) the mobilization and improved management of sector resources: financial, human and physical; (c) the geographical extension of health coverage for improved access to services; a particular emphasis will be placed on the infrastructure of the health district, which, in principal should cover the majority of health needs of the population; (d) more effective training of health personnel, with a particular accent on adapting training curricula to real and evolving demands of their various posts in light of sector reforms; (e) improvements to service quality, encompassing curative, preventive and promotional services in the context of primary health care, with a particular emphasis on: developing first-referral capacity in the district hospital (reformed arrondissement-level medical center); preventive services for mothers and children; nutrition interventions; family planning services; and water and sanitation activities; (f) control of priority diseases, with a particular emphasis on STDs/AIDS, and other parasitic and infectious diseases; immunization-targeted diseases (measles, tetanus, polio, whooping cough, tuberculosis); treatment and prevention of malaria, diarrhea, and acute respiratory infections; and the eradication of onchocerciaisis, Guinea worm bilharziose, leprosy and polio; (g) improved availability and management of essential generic drugs; and (h) strengthening of information, education and communication capacity to elicit change in health behavior. 2.25 The Government's policy statement also encompasses its health financing policy, which aims to increase financial resources for health and to define clearly and elicit the fair and equitable financial participation of: the State (an increase in health's share of the recurrent budget from 5 percent to 10 percent is envisaged by the year 2000); local collectivities (a minimum of 5-8 percent of their recurrent budget would be allocated to health), the population (through application of the recently passed cost recovery law); the private sector (through extension of service coverage); and aid donors (particularly through investments and purchase of medicines). 2.26 In pursuit of policy objectives, the MOPH has prepared a Health Sector Development Plan (PDS) for the period 1994-2000. Based on a sound analysis of the health problems and issues, and of the inadequacies of health system organization and performance, and on lessons learned from implementation experience, it outlines specific objectives, strategies and actions that are key to the successful application of policy principles and the realization of policy objectives. The main components of the PDS are: (a) improve the quality and coverage of basic health services, with a particular focus on establishing and supporting the distict health system; (b) improve the availability and affordability of essential generic drugs to all of Niger's population through the restructuring and strengthening of the pharmaceutical sector; (c) improve sector effectiveness and efficiency through interventions to strengthen and decentralize strategic sector management and management of resources; and (d) expand and exploit sector capacity through efforts to appreciate more fully and to utilize more  9 effectively the capacity of various partners active in the health sector, in implementing national and district programs, including but not limited to: communities, NGOs, private-for-profit sector, civil society, and academia. This document provides the framework for the development of district plans. The planning process at the district level is ongoing and results so far have been impressive and encouraging. The process has been very participatory, including visits by the district teams to all facilities in the districts, consultations with the population, and involvement of various partners in the needs assessment and planning activities: district planning teams include health managers and service providers; a local representative of the Ministry of Plan; representatives of other sectors, representatives of the population, and, in some cases, representatives of NGOs. In addition, members of particularly successful district teams have provided technical assistance to other districts; and a number of workshops for district teams have provided them with the opportunity to seek advice from one another and to exchange experiences and best practices. District team members have noted that this process has been enlightening, particularly with regard to the solicitation of client perspectives, and has profoundly influenced plan content and ownership. 2.27 The quality and detail of the PDS and the ongoing district planning process have provided sufficient basis for IDA to opt for a SIP approach for its proposed second investment in the health sector. The PDS appropriately embraces a primary health care approach and its strategy is fully consistent with cost-effective sector interventions recommended in the 1993 World Development Report and in the Africa Region Policy Paper on Better Health for Africa. It constitutes a crucial component of Niger's overall development strategy to alleviate poverty and to develop its human resources base; and it is consistent with key national objectives, among which are: decentralization, community participation, and expansion of private sector involvement. Both MOPH and donors fully embrace the SIP principles, which have been reviewed and endorsed by stakeholders during past missions. It must be qualified, however, that SIP is not a starting point, but, rather, it is both a process and a medium-term goal to which MOPH, the Bank and other donors attach great importance. To date, four of the six criteria for a full SIP approach are satisfied. The PDS (a) is sector-wide in scope; (b) encompasses a coherent sector policy framework; (c) puts local stakeholders in charge; and (d) emphasizes full use of local capacity and minimal use of foreign technical assistance. One criterion is partially met: while all donors support the basic principals and strategy of the PDS, they have not yet channeled their ongoing and programmed assistance in support of its implementation, due in part to the fact that a multi-year Program, reflecting the full costs of its implementation, has not yet been produced. The last criterion, common implementation arrangements, is not yet in place and constitutes a formidable challenge. As a condition of project negotiation, and in support of the SIP approach, the Government submitted to IDA a revised draft statement of health sector policy, including three annexes (filed in the Documents in Project File), which would specify, respectively: (a) selection criteria for districts to be supported under the program/project; (b) Government's policy statement on the potential role of the private sector in health; and (c) a two-year recruitment and redeployment plan for health sector personnel, which would effectively address the human resources implications of the first two years of Program/project implementation. The Government has submitted to IDA the final, signed version of this statement, which was a condition of Board presentation. 2.28 In conjunction with the public expenditure review mission, the appraisal mission worked with MOPH to initiate the process of transforming the PDS into an initial five-year Program, which would provide the full costs of implementing the PDS, thus providing the framework for eliciting and managing more effectively donor aid to nationally-set objectives. The proposed project will include interventions aimed at institutionalizing this process through capacity building and operational support at the district, DDS and central levels. The project will support a process of ongoing review and refinement of the Program through which new and revised district plans and programs will be incorporated and other elements of the national Program will be revised and refined, as and when more concrete information is  10 secured. This process will also provide a mechanism for ongoing efforts to minimize costs and improve the effectiveness of the Program. Total Program costs have been provisionally estimated at US$275 million over a five-year period and will be refined routinely as a part of an annual review and revision of Program implementation and costs (para. 3.27). Results of an economic analysis of the PDS are summarized in paras. 3.38 and 3.39, and presented in detail in Annex 7. 2. Composition of Donor Assistance to National Policy and Strategy 2.29 Current Activity. Some 30 bilateral, multilateral and non-governmental partners have been providing assistance to the health sector in Niger. Their combined assistance to the Health Development Plan for the next five years is estimated at around US$140 million equivalent -- slightly over 50 percent of estimated Program costs for that period. Given that some donors are approaching the end of their respective program periods and their new programs of assistance have not yet been approved and incorporated into MOPH records, this figure is probably underestimated. Routine updating and exchange of information on external financing of the sector, to be supported under the proposed project will provide the basis for continuing dialogue with donors on how to further encourage and consolidate a SIP approach, to which essentially all -- Government and donors alike -- are committed. 2.30 Currently available data show that a considerable portion of aid to the health sector is allocated to construction/rehabilitation and equipment of health facilities to improve access and quality. Of the 24 partners on which data are readily available, 17 are financing construction/rehabilitation of health facilities at various levels of the system; 13 support maternal and child health and family planning activities; 12 support training of health personnel; 7 provide support to the provision of drugs and vaccines; 6 support management strengthening interventions; 4 support STDs/AIDS activities; and one or two support the following health programs: diarrhea, malaria, leprosy and IEC. Geographic subregions benefit from the focused interventions of one or a few donors, causing a balkanization of assistance, and consequently, added challenges for MOPH to implement its own health policy and harmonize approaches in this regard. Among the most important partners (and their areas of intervention) are: USAID (management strengthening; support to private sector expansion; priority health programs and services in selected subregions; IEC and family planning); European Union (pharmaceuticals; significant recurrent budget; health programs and services in selected subregions); African Development Bank (construction/rehabilitation of health facilities in selected subregions; services management); UNICEF (health services through the application of the Bamako Initiative in selected subregions; and nutrition activities); IDA's ongoing Population Project (strengthening of MCH/FP and reproductive health). 2.31 Prospects. The extent of external support to the health sector is both an asset and a liability. It has furnished sorely needed assistance to improve and expand Niger's health services, but it has also coerced MOPH into accepting a project approach, which has at times fragmented efforts, ignored national priorities and strategies, and created inequities. In reaction to the coup d'etat of January 1996, virtually all bilateral assistance was suspended. However, now that the July 1996 Presidential election is concluded, it is expected that development of new projects will resume. Because it is a sound and well articulated document, the preparation of the PDS has already stimulated enhanced donor coordination. Virtually all donors endorse the district approach proposed in the PDS and have expressed their willingness to support its implementation -- some through direct support to districts. Two important opportunities must be seized by MOPH to mobilize resources in support of the PDS: (1) negotiations of new or renewed programs of several major donors; and (2) the holding of a Health Sector Round Table, planned for 1997. The strengthening and decentralization of MOPH capacity for strategic management and aid coordination is key to enabling MOPH to take advantage and effectively manage these opportunities. In addition, annual reviews and revisions of Program content, costs and financing, in  I1 which all donors will participate (para. 3.27), should serve as an important vehicle: for reviewing the availability and relevance of donor financing, for effectively channeling such assistance into a single Program, and for possibly mobilizing additional aid to the sector. D. The Bank Group's Role and Sector Assistance Strategy 1. The First IDA-Funded Health Project (Cr. 1 668-NIR) 2.32 On March 20, 1986 a first Health Project in Niger was approved by the Board in the amount of SDR 25.1 million (US$27.8 million equivalent). The project was closed in June 1995 and an ICR, discussed and approved by Bank and Government, will be submitted to the Board in early FY97. Part A of the project supported health sector adjustment through: (a) the financing of studies aimed at strengthening financial and operational management, improving basic health services, increasing cost recovery, improving essential drugs availability and developing population and nutrition policies; and (b) the funding of proposals for implementing policies emanating from the above-mentioned studies or operational experience. Part B supported improvements in basic health and family planning services through activities to: (a) improve facilities and strengthen priority programs; (b) develop health education and community initiatives in health and nutrition; and (c) develop health manpower. 2.33 The objective of assisting the Government in introducing policy reform in the health sector within the overall framework of its structural adjustment program was substantially achieved under the project. Studies aimed at improving sector policy were carried out and were instrumental in the development and initiation of key reform measures. Most program objectives were also substantially met. Project investments to upgrade technical skills of service providers and to strengthen infrastructure of selected health facilities contributed to improvements in the quality and coverage of basic health services. In addition, a number of priority health programs and services were strengthened through improved strategic management strengthening and through direct support to implementation activities. Program objectives for vaccination coverage and training were not fully achieved, however. While this project is considered to be successful overall, it must be qualified that its success is defined through process indicators. Persistently high levels of morbidity and mortality and high birth rates demonstrate that indeed much remains to be done to improve health status in Niger. 2.34 Three categories of factors constrained the Government's capacity to implement the project: political events; financial constraints; and organizational/managerial constraints. The political events, which occurred during the life of the project, caused activities in all sectors to slow down and even to come to a standstill. The high tumover of Health Ministers during the life of the project (8 Ministers in 9 years) caused numerous delays, as each new Minister revisited and questioned project objectives and imnplementation progress. Financial constraints included lack of counterpart funds and cash flow problems, and inflation propelled by the 1994 devaluation. Management/organizational capacity to implement a project of this magnitude and complexity was inadequate. The highly centralized structure of the MOPH, heavy bureaucratic and administrative procedures and the vertical structure of health programs left decentralized administration and services with, at best, a very passive role in project implementation. 2. Population Project (Cr. 2360-NIR) 2.35 Approved by the Board of Executive Directors on April 30, 1992, this project aims at assisting the Government in implementing an effective national population program, with the primary objective of accelerating the onset of fertility decline by increasing the contraceptive prevalence rate as rapidly as possible, reducing maternal mortality, promoting attitudes favoring a reduction in family size norms, and  12 enhancing the capacity of women to effectively participate in socio-economic development. An important component of this project (about 70 percent of total project cost) is the strengthening of maternal and child health services through health infrastructure rehabilitation and technical training. The mid-term review of this project, carried out in April 1996, has recommended that this component be revised to accommodate fully the reforms and service norms and standards outlined in the PDS. This decision is supportive of a SIP approach and will ensure coherence in IDA's support program to Niger's health sector development. 3. Key Lessons Learned 2.36 It was also learned that program/project objectives should be sufficiently modest and based on a sound knowledge of the existing situation. Objectives should be commensurate with the resources put at the disposal of program/project staff. Clear targets and indicators should be set at the outset. Key stakeholders should be identified at the outset and involved in all stages of design and development. A least cost approach should drive the project design and costing exercise. A rolling planning process would have introduced both rigor and more flexibility during project implementation. A more holistic and rigorous assessment of institutional capacity would have modified project design and introduced more deliberate interventions to strengthen that capacity. 2.37 Inadequate management/institutional capacity is found to be more constraining of good sector performance than resource availability. More effort must be devoted to develop capacity in management of resources and in decentralized strategic sector management in order to improve sector effectiveness. Financial participation of the communities has caused them to be more involved in, and more demanding of, health service delivery, prompting the public service to strive to be more client oriented. This process should be nurtured and supported in future operations. 2.38 Concerning project management, the most significant lessons were: the need to provide project staff with sufficient training in Bank procedures and requirements; the need for improved mechanisms for coordination and communication; and the need to minimize turnover of program management and service delivery staff. Implementation experience also revealed the importance of integrating and "mainstreaming" project activities more fully into MOPH operations, at all levels. 2.39 Implementation experience has demonstrated the importance of health personnel supervision. Investments in service quality improvements were not fully exploited or consolidated due to a lack of technical support and follow-up that should have been provided through the implementation of a well designed supervision program. Likewise, a lack of follow-up and evaluation of training investments left MOPH incapable of ensuring optimal utilization of newly acquired skills and of assessing the utility of training to guide future investments in human resources development. The lack of a clear policy on preventive activities and on health education caused them to receive low attention and priority under the project, despite the importance attributed to them in project design and documentation. Greater emphasis on all of these--supervision, training evaluation, policy on prevention and promotion--would have contributed to enhanced service quality. 2.40 It is encouraging to note that the many of these lessons are reflected already by the Government in its Health Sector Development Plan, and by the Bank in its Sector Investment Program (SIP) approach. These lessons have featured prominently in sector dialogue and provided an important basis for the appraisal of the Government's Program, and of IDA's proposed support to its implementation.  13 4. Rationale for IDA Involvement in the Sector 2.41 IDA's Country Assistance Strategy (CAS) emphasizes human resources development as a priority objective. IDA's continued involvement will help the Government focus on weaknesses in health sector strategic management and management of resources, including aid coordination for enhanced sector effectiveness and efficiency. IDA has a comparative advantage in having established a successful policy dialogue with the Government on sectoral issues -- a dialogue enhanced most recently through a participatory and extensive ICR process, which was deliberately focused on application of lessons for improved sector performance. In the spirit of a sector investment approach, IDA support to PDS implementation will focus on areas of comparative advantage where IDA can best exploit it leverage, experience and expertise (essential drugs, policy reform, macroeconomic linkages, capacity building). Also in support of a sector investment approach, IDA financing will be flexible so as to be constantly responsive to evolving opportunities and constraints throughout the project's life. 5. Future IDA Assistance Strategy 2.42 Key features of the new sector approach, which are guiding the design and implementation of the proposed IDA intervention include: a coherent sectoral framework that would provide the basis for eliciting and coordinating the various contributions of donors; Government initiation and ownership of sector activity and increased partnership activity; a deliberate and systemic approach to capacity building, management strengthening and institutional development,, which would encompass the (often untapped) potential roles of all partners in sector development; a better appreciation of client perspectives and more efforts to respond to the needs and demands of clients; choice of indicators that would emphasize performance of the system and impact of interventions; the adoption of a learning approach, which would be pragmatic, rather than theoretical, and which would be subject to ongoing evaluation and refinement in light of experience; economic and financial viability, encompassing the importance of establishing priorities, cost-effectiveness of interventions; a full appreciation of recurrent cost implications and cost containment; and the importance of forging better links and partnerships with central and other ministries at all levels of the system to understand opportunities and constraints of decentralization, public finance, civil service reform, etc. (i.e. macroeconomic linkages) and to improve intersectoral coordination and collaboration to achieve better health. This approach has been thoroughly discussed and well received by the Government and donors alike. III. THE PROGRAM AND THE PROJECT A. Program Objectives 3.1 With the overall objective of improving the health and wellbeing of Niger's population, the PDS seeks to: (a) improve the quality and coverage of basic health services, with a particular focus on establishing and supporting the district health system; (b) improve the availability and affordability of essential generic drugs through the restructuring and strengthening of the pharmaceutical sector; and (c) improve sector effectiveness and efficiency through: (i) interventions to strengthen and decentralize strategic sector management and management of resources; and (ii) efforts to appreciate more fully and to utilize more effectively the capacity of various partners active in the health sector in implementing national and district programs. B. Summary of Program Description 3.2 The implementation of national sector policy and strategy will be carried out through the following components:  14 1. Improving the Quality and Coverage of Basic Health Services through the Establishment and Support of a District Health System (US$242 million equivalent): 3.3 This component will support the restructuring and reform of the pyramid of health services in support of a district health approach. In line with newly established norms and standards for infrastructure, equipment and staffing of reformed health facilities, and with the definition of the minimum package of services to be offered at each level, this component will (a) upgrade and extend district services through the rehabilitation and construction/equipment of health infrastructure (b) improve district-level service quality through: activities aimed at better organization of work at the health facility level; rational prescription practices; improved integration of services; and improved supervision and in- service training of health personnel. This component will also support activities to strengthen patient referral capacity and management of district, departmental and national hospitals. This component also envisages support to the implementation of cost recovery, including the establishment and application of tools for the management of drug stocks and collected revenues; training; and the purchase of drug stocks and other essential medical and laboratory supplies for health facilities. In addition, this component will strengthen priority programs and services, with a particular emphasis on maternal and child health, STD/AIDS, tuberculosis and on prevention and promotional activities. 2. Improving the Supply and Distribution of Essential Generic Drugs (US$7 million equivalent): 3.4 This component will contribute to the implementation of strategies deftned in the National Pharmaceutical Master Plan, which aims at improving the availability, quality and affordability of essential generic drugs to all citizens of Niger. Assistance to the Pharmacy and Laboratory Directorate (DPhL) and to the Inspectorate General of Pharmacies and Laboratories would include equipment, supplies, material, technical assistance, training and recurrent financing for: the revision of the legal framework for pharmaceuticals; establishment of a registration system for drugs; the strengthening of a pharmaceutical inspection service; and the development of a national pharmaceutical documentation service. The Program also envisages the implementation of Government's decision to demonopolize and restructure the ONPPC to permit a dynamic competition in the drug sector and to develop capacity for procurement of essential generic drugs. 3. Building Capacity and Forging Partnerships in Support of Health Sector Reform' (US$27 million equivalent): 3.5 This component will develop national capacity for strategic management and for management of resources to enable MOPH to realize the objectives of the national and district PDS effectively and efficiently. Activities will include: establishing the health district; strengthening of management capacity of the DDS; and realigning central level functions in light of decentralization and its newly evolved role. The component will also develop and strengthen effective partnerships with various stakeholders (communities, NGOs, academia, private sector) according to their comparative advantages in support of PDS goals. To this end it will support and nurture community participation in the management, financing and implementation of sector activities, and it will encourage and support district-based innovative activities through contracting arrangements. The component will also support project management activities.  15 C. Detailed Features of IDA Financing I. Improving the Quality and Coverage of Basic Health Services (US$31.5 million equivalent) 3.6 The PDS envisages a restructuring of the health pyramid through the creation of health districts with a view to better accommodate primary health care objectives. Within the health district, rural dispensaries and some health posts, at the commune and village levels, will be transformed into integrated health centers (CSI), which will provide primary health care activities through professional paramedical staff; and arrondissement-level medical centers will be transformed into district hospitals, comprised of a maternity, surgical facility, general medical facility, a laboratory and a simple radiological facility. Departmental hospital centers (CHD) will be strengthened to provide second referral services to district hospitals, and national hospitals will be strengthened to provide third-level referral services to CHD. 3.7 This component will support implementation of PDS objectives to improve the quality of basic health services and to extend coverage in selected districts (departments). Diffa, Maine-Soroa (Diffa), Goure, Mirriah, Tanout (Zinder) will be supported with IDA financing; and Filingue and Say (Tillaberi) will be supported through a proposed parallel financing arrangement with the Netherlands. The following criteria established jointly with MOPH during the preappraisal mission and reviewed during the appraisal mission guided the choice and prioritization of districts to be supported under this project: (a) lower than average coverage -- less than 20-25 percent; (b) readiness of district health plans and participatory nature of the planning process; (c) relatively little or no support from other donors and/or multiple aid donors supporting district activities, but neither coordinated nor necessarily focused on core activities contained in district plans; (d) poverty and isolation of the population; and (e) ongoing, but limited Bank support to districts (under the Population Project, Credit 2360-NIR). 1.1 Strengthening Services at the District Level 3.8 The primary focus of this component will be to support the implementation of district health plans. While coverage is extremely low and in need of expansion, highest priority is being accorded to improving the quality of existing services, for which there is much scope. The project will thus upgrade and maintain the technical skills of service delivery staff through the refinement and application of diagnostic and treatment protocols for addressing the priority health problems in Niger. It will also support the development and delivery of refresher and in-service medical/technical training and the development and implementation of an integrated supervision system, which will monitor, nurture and support skills development. Specialized training will also be provided to selected medical and paramedical staff to enable them to deliver first-referral services at the district hospital effectively. 3.9 The project will also support adherence of districts to the norms and standards recently established for infrastructure, equipment and staffing of health facilities to enable them to deliver the minimum package of services defined in the PDS. The project will thus finance the upgrading of existing basic and first-referral services through the transformation of rural dispensaries and health posts into integrated health centers (CSI) and of medical centers (CM) into district hospitals. The upgrading will involve the rehabilitation and/or expansion of existing health infrastructure, the provision of replacement and incremental medical and technical equipment, furniture, vehicles and other essential material and supplies, and the provision of safe water supplies. The project will also support extension of very low coverage in these districts through the construction and full equipment of new integrated health centers (CSI). The project will also finance the incremental operating costs to keep rehabilitated and new infrastructure maintained and functioning. Adherence to staffing norms and standards for  16 reformed and new facilities will require the redeployment, and recruitment of additional personnel. Government counterpart financing will cover these costs under the project. As a condition of disbursement for construction and equipment of new health facilities, the Government will provide a plan, referred to in annex 3 of the statement of health sector policy, satisfactory to IDA, for redeployment, retraining and recruitement of health sector staff to ensure that upgraded and new health facilities will be sufficiently staffed and operational in line with MOPH staffing norms. This plan will be reviewed and agreed with IDA during the annual programming exercise (para. 3.27) and will be in full respect of the Policy Framework Paper (PFP) document, which limits future recruitments (across sectors) to replacements of voluntary departures, but which accords highest priority to social sectors. The construction and rehabilitation will be reviewed in light of agreed quotas, and revised downward in the event that quotas fall short of staffing requirements. Priority will be accorded to staffing of existing, upgraded services. 3.10 The project will support the implementation of the "minimum package of services" (PMA) to be delivered through the CSI and district hospital facilities, employing a quality assurance approach. Encompassing preventive, promotional and curative activities and the effective management and integration of priority health programs, the PMA focuses primarily on the most cost-effective interventions aimed at Niger's most vulnerable groups: mothers and children. Among these interventions, those of a preventive/promotional nature include: vaccinations; antimalaria prophylaxis and micronutrients for pregnant women; family planning; malnutrition prevention through growth surveillance, breastfeeding promotion, weaning practices and nutrition education; prenatal, delivery and postnatal care and identification and referral of high-risk pregnancies; water, hygiene and sanitation promotion; health education and information; and school health. Curative interventions include management, treatment and proper referral of priority illnesses, such as diarrhoea, acute respiratory infections, malaria, measles and severe malnutrition and chronic disease (tuberculosis, leprosy, eye disease). Basic management activities include: strategic management (information, operational research, monitoring, evaluation, coordination, planning, programming), and management of resources (personnel, drugs, material, financial resources). Project support to the implementation of the PMA at the CSI and HID levels includes: purchase of material, equipment, drugs and other essential supplies, and the financing of various activities, including training, service delivery, information campaigns, epidemiological surveillance and other relevant studies, supervision, monitoring and evaluation. 3.11 Support of Cost Recovery Activities. Pilot studies and projects carried out over the past several years in the context of IDA's first intervention in the sector have provided the opportunity for much acquisition of experience and reflection. Following the adoption in July 1995 of the cost recovery law for basic health services, a number of activities have already been undertaken in support of its successful application, including: the development of a training program for management of drug stocks and revenues from cost recovery; training in good prescription practices and effective use of generics; and studies to assess operating costs of districts, encompassing district hospital and CSIs. An overview of experience and accomplishments to date can be found in the Documents in Project File. The project will support the implementation of cost recovery activities in the project area through the provision of initial drug stocks in all CSI and HD in the project area and in the Diffa CHD and Zinder National Hospital, and through the establishment and support of management activities. Specifically the project will provide technical assistance in streamlining management tools for cost recovery, which are, at present, overly complicated and cumbersome. The project will also provide training of HD and CSI personnel and of community managers in the utilization of simplified tools for management of drug stocks and for the collection and management of financial resources generated through cost recovery activities. In addition it will cover the recurrent costs of management.  17 3.12 Despite the experience accumulated through various pilots, cost recovery is still in an experimental phase: to date, collected revenues have not been utilized to cover drugs and other operating costs; and cost recovery activity is virtually non-existant at the HD level. Project support to cost recovery is thus designed around a learning approach. Financing of studies and monitoring, evaluation and supervision activities will permit MOPH to apply lessons and continually review and refine cost recovery approaches. Among the elements of this programn that will be reviewed and refined during the life of the project are: (a) pricing of drugs and services (during negotiations, the Government gave assurances that it will adopt a pricing mechanism for essential generic drugs in both the public and the private sectors by March 31, 1998; (b) the clear definition of the costs to be covered by the financial participation of communities; (c) the clear definition of costs that will continue to be borne by the public budget (e.g., chronic disease for which treatment is expensive [diabetes, tuberculosis, leprosy, hypertension]; and financing of essential generic drugs in departmental and national hospitals); (d) streamlining of management tools for cost recovery; and (e) more effective and quicker reinvestment of revenues to replenish drug stocks and possibly to cover other costs. MOPH has developed criteria for determining ability to pay of indigenous clients, which would be applied at the level of the facility with input from the communities. Those deemed unable to pay would be exempt from service fees. Monitoring of financial access and consequent utilization rates of vulnerable groups and of the success rates of direct and indirect cost recovery mechanisms will be carried out under the project. While the law on cost recovery for basic health services (Law No. 95-014 of July 3, 1995) was passed almost a year ago, the Government decree outlining how this law will be applied nationwide has not yet been signed. As a condition of disbursement for drugs, the Government will adopt a decret d'application acceptable to IDA, for Law No. 95-014 of July 3, 1995, on cost recovery. 1.2 Strengthening Patient Referral Capacity of Hospitals 3.13 The project seeks to strengthen hospital management and patient referral capacity of hospitals through the execution of studies, which would clearly define the roles of first-, second- and third-level referral facilities (HD, CHD, and national hospital, respectively), and which would outline procedures for patient referral between the various levels of services. An additional study would evaluate hospital management and recommend ways to improve management systems and practices and thus efficiency of hospitals. In line with the recommendations of these studies, the project would rehabilitate and re-equip Diffa CHD to enable it to fulfill its role as second-level referral facility. In addition, tools, systems and training to strengthen hospital management and patient referral capacity would be developed in line with recommendations of these studies. These would be applied in district hospitals covered under this project, in Diffa CHD and in the National Hospital of Zinder. 1.3 National Program for STD/AIDS 3.14 The project would support Niger's national program for sexually-transmitted diseases and Acquired Immune Deficiency Syndrome (STD/AIDS). With a view to strengthening both management and implementation of program activities, project assistance would include: purchase of equipment, materials, drugs and other essential supplies, technical assistance in program design and management, and the financing of program activities, including training, service delivery, patient counseling, information, education and communication (IEC) activities, epidemiological surveillance and other relevant studies, supervision, monitoring and evaluation.  18 2. Improving the Supply and Distribution of Essential Generic Drugs (US$ 3.7 million equivalent) 3.15 The overall objective of this component is to support MOPH in the implementation of strategies defined in its National Pharmaceuticals Master Plan. This assistance will contribute to the development of an essential drugs policy, which will ensure that essential drugs and medical supplies included in MOPH national list will be: (a) available nationwide; (b) sold at an affordable price in light of the purchasing power of the population; (c) sufficiently responsive to quality norms; (d) used rationally; and (e) serve as the basis for the application of the recently adopted cost recovery law for basic services. Assistance will be delivered through the following two components. 2.1 Strengthening of DPhL and of the Inspectorate General for Pharmacies and Laboratories 3.16 In order to enable DPhL to guide and oversee the implementation of pharmaceutical policy and strategy, the Program will support the following capacity building activities: (a) the revision of the legal framework for pharmaceuticals, which will permit the regulation of all drug-related activities and which will be included in the Pharmaceutical Chapter of the Public Health Sector Code (during negotiations, the Government gave assurances that it will introduce into Parliament at the very latest three months after credit effectiveness a draft pharmaceutical law satisfactory to IDA); (b) the establishment of an effective registration system for drugs which would, among other things, permit the definition of selection criteria for brand-name drugs authorized for commercial activity; (c) the strengthening of a pharmaceutical inspection service, and its gradual decentralization to DDS level; and (d) the development of a national service of pharmaceutical documentation. Institutional development will be achieved through (a) short-term specialized technical assistance; (b) provision of equipment, furniture, office equipment; (c) the provision of an initial stock of essential pharmaceutical documents and information; (d) financing of fellowships; and (e) financing of essential recurrent costs. 2.2 Restructuring of ONPPC 3.17 In the context of the Policy Framework Paper (PFP) discussed with Government in April 1996 and in line with technical discussions carried out through sector dialogue, the Government has committed itself to the demonopolization and restructuring of ONPPC. A plan of action for the demonopolisation and restructuring was discussed and agreed and is reflected in the sector policy framework paper agreed between the Bank and Government. An important principal behind the restructuring of ONPPC is the revision of its legal status in line with its mission. ONPPC should be a national enterprise with a social and public health vocation and a non-profit status. While under the technical responsibility of MOPH, it would have total financial and managerial autonomy. During negotiations, Government gave assurances that it would, at the very latest three months after credit effectiveness, introduce into Parliament a law that would demonopolize ONPPC. The restructuring of ONPPC must rest on the principal of separate accounting and financial statements for each of the discrete functions: quality control and laboratory work; production; and acquisition, distribution and retailing. Only when this principal is satisfied, can decisions to privatize and to separate one or more of these functions from others be made. During negotiations, Government gave assurances that a new legal status for ONPPC's essential drugs procurement unit, satisfactory to IDA, will be adopted no later than December 31, 1997. The new legal status will ensure that this unit will fulfill a social mission (the provision of essential generic drugs to all of Niger's population at the lowest possible cost) and that it will be accorded sufficient managerial and financial autonomy tu run effectively and in accordance with standard business practices. During negotiations, Government gave assurances that a new draft legal status for the remaining functions of ONPPC (quality control and laboratory, production, and acquisition,  19 distribution and retailing ) will be presented and reviewed at the time of the mid-term review (before end-1999) and final versions, satisfactory to IDA, will be adopted no later than June 30, 2000. 3.18 Within the overall framework of the restructuring on ONPPC and with support from the EU, the following Program activities are envisaged: (a) strengthening of ONPPCs general accounting and establishing of an analytical accounting system of the different functional units of ONPPC to provide a clear picture of the financial situation of each; (b) negotiations and activities for resolving the problem of debts and credits, in light of financial situations of various functions; (c) extending the services of the essential drugs procurement unit of ONPPC to all interested clients, including private sector; (d) establishment of a simple computerized management system for stock management, billing, monitoring of consumption, procurement management and forecasting; (e) strengthening procurement capacity for essential generic drugs; (f) restructuring of the unit responsible for purchase of specialty drugs; (g) strengthening of stock management procedures; (h) strengthening of financial management; (i) improvements to quality assurance activities; (j) study of channels of distribution, logistics and retailing of state pharmacies and their eventual transformation into autonomous regional or district depots. Activities envisaged to demonopolize ONPPC will be included in the Project Operational Manual. 3.19 Given its importance as a Government strategy, and given the political and financial sensitivities associated with the pharmaceutical sector in Africa, a close, participatory and well coordinated approach to the monitoring and evaluation of this Program component is strongly recommended. The following activities will be closely monitored: (a) for DPhL: elaboration of legal framework for pharmaceuticals; dissemination and application of a revised list of essential generic drugs; functioning drug registration system; official and operational commission on drugs; and (b) for ONPPC: semiannual audit of accounts and management procedures; production costs of essential generic drugs in line with international averages; operating costs and margins applied to production costs; good management procedures; good logistics; good quality of essential generic drugs; constant availability of essential generic drugs; selling prices of essential generic drugs at health facilities. 3. Building Capacity and Forging Partnerships in Support of Health Sector Reform (US$4.8 million equivalent) 3.20 The fulfillment of goals and objectives laid out in the PDS is surely a challenge and will require considerable effort to mobilize and use most effectively national capacity in this regard. Indeed, the most far-reaching and radical reforms included in the PDS are those aimed at strengthening the capacity and the efficiency of the public sector through the streamlining and decentralization of key management functions and those aimed at expanding sector capacity through the recognition and utilization of the potential capacity of other, non-public national partners, including communities, NGOs, academia, and the private-for-profit sector, to name only a few. This is a radical departure from current practice and could have far-reaching effects. Decentralization and participation, together, could reorient accountabilities in a fundamental way. Districts (the operational/services level), rather than central MOPH, will be the focal point of health activity, and their needs should drive the setting of priorities, the work programs and mandates of the DDS and central levels, and the mobilization, coordination and allocation of resources to the sector. Community involvement in the financing and management of health sector activity will render the health system much more accountable to the clients it is meant to serve. Effective recognition and use of the potential of other national partners in health service delivery, support services and management could expand sector capacity significantly without exerting additional pressure on an already overextended public sector. The project will support the following activities to these ends.  20 3.1 Strengthening and Decentralization of Key Management Functions 3.21 The general objective of this component is to develop national capacity for strategic sector management and for management of resources at all levels of MOPH administration to enable it to realize the objectives of the national and district PDS in an effective and efficient manner. Given the decentralization strategy embraced by the PDS -- most particularly the establishment of health districts -- a primary focus will be placed on the establishment and strengthening of the district health office (and the district health team). Program interventions at the DDS and central levels will be oriented around the objective of supporting and providing technical backstopping to district health teams. The real challenge of the decentralization reform will be to reorient incentives and accountabilities so that higher levels of MOPH administration will be serving and supporting the more peripheral levels rather the reverse. Another important emphasis of this component is the nurturing and support of the SIP approach, which should be institutionalized within MOPH at all levels. 3.22 Establishment of Health Districts. The Government gave assurances that no later than 12 months after credit effectiveness, the project will establish district health offices and district health teams in the project area. It will provide technical assistance and training to establish district health teams and to develop their skills in technical and managerial training, supervision and quality control, administration, team building, strategic sector management (planning, programming, operational research, monitoring and evaluation), and management of human and financial resources. In addition, the project will support the development and delivery of training modules for health personnel working in district facilities to develop their skills in the organization and management of services, and in the management of resources (physical, human and financial). The project will also provide office and technical equipment, vehicles, supplies and materials for the district offices, and it will finance operating costs of health district management, including, inter alia: communications, supervision, monitoring and evaluation activities and periodic planning and programming activities. In support of the SIP approach, during negotiations, Government provided assurances that, as soon as district health teams have been established, districts will undertake, on a quarterly basis, participatory evaluations of performance in implementing district plans, with a view to reviewing and refining programs, financing plans and budget allocations in light of experience and accomplishments. An important objective of these evaluation mettings will be the identification and resolution of constraints to program performance. These evaluations will be submitted to the DDS, which will consolidate them at the departmental level. 3.23 Strengthening of DDS Capacity. The project will finance technical assistance, workshops and training to enable the DDS of Diffa, Tillaberi and Zinder to redefine and effectively fulfill their evolving roles in light of sector reforms laid out in the PDS. A particular emphasis will be given to the development of DDS skills in technical backstopping of districts through the design and implementation of training and supervision protocols, team building, administration, strategic sector management and management of resources. The project will also provide DDS with necessary incremental equipment, vehicles, supplies and materials to enable them to carry out their functions. In addition, incremental operating costs of the DDS will be supported under the project, including: communications, supervision, monitoring and evaluation and periodic planning and programming activities. In line with the SIP approach, during negotiations Government provided assurances that participatory evaluations of departmental performance in implementing the PDS (including the collection, consolidation and analysis of district plans within a department) will be carried out on a semi-annual basis. On the basis of program performance and lessons learned, programs, financing plans and budget allocations will be reviewed and revised, and submitted to MOPH central level for review and consolidation. 3.24 Strengthening of Central MOPH Capacity. The project will finance technical assistance, workshops and other activities which would culminate in the restructuring of central MOPH to enable it  21 to fulfill more effectively and efficiently its evolving role in light of sector reforms. A particular emphasis will be placed on the integration of health programs and services in support of the district health system and in line with the "minimum package of activities" (PMA). A first and crucial activity will be the development of an institutional/organizational framework that would clearly define roles and responsibilities at all levels of the system for strategic sector management. This would also include the preparation/revision of post descriptions, ensuring the coherence and complementarity among the functions and responsibilities carried out by the various actors in the system at each level, and clarifying the interrelationships of these roles. The project would also support the definition and establishment of systems, processes, procedures and management tools that would guide and facilitate the smooth and accurate implementation of these functions. The preparation of operational manuals would be undertaken in this regard. 3.25 An important contribution to building MOPH capacity in strategic sector management will be project activities to strengthen and consolidate the various information systems currently available in MOPH. With project assistance various information systems will be linked so that they can be used in an interactive manner to facilitate evaluation and decision-making. Among the information systems to be linked are: MIS, health information system, personnel management system, and infrastructure management system. In addition, the project will support the strengthening of the electronic communications system within central MOPH and between the various levels of decentralization. Through technical assistance and training, the project will also strengthen MOPH capacity for management of human and financial resources. In order to support central MOPH in carrying out its new functions, the project will provide necessary equipment, vehicles, supplies and materials and it will finance incremental operating costs, including communications, supervision, monitoring and evaluation, and periodic planning and programming activities. 3.26 The project would also develop human resources for carrying out the strategic management functions, in terms of numbers, skills mix and allocation of staff. Under the Program, additional personnel would be assigned and/or existing staff would be reallocated. Long-term and short-term training in various elements of strategic management (public health, planning/programming, monitoring and evaluation) would also be provided. In addition, in-service training curricula will be developed and implemented: training of trainers would be under taken to develop and ultimately implement cascade training. Given the importance of strategic management at the district and DDS levels, the design and implementation of a viable supervision system for guiding and facilitating strategic sector management will also constitute an important project activity. In addition, the project would finance the provision of furniture, equipment, vehicles, as well as the recurrent costs to support the implementation of these functions. 3.27 Annual Reviews. To encourage and guide sound strategic management, agreement has been reached during negotiations that MOPH would convene annual meetings with all aid donors and NGOs active or interested in Niger's health sector to coordinate assistance, exchange experiences and harmonize their various approaches to health sector development in different regions of the country and at different levels of the health system. These meetings would draw on the participation and input of the DDS and health districts on the basis of their respective plans and experiences. Agreement has also been reached that the MOPH would undertake annual reviews of Program and project performance in the implementation of the PDS, and revision of the following year's plan in light of experience gained, lessons learned and emerging opportunities and constraints. An important objective of these reviews, to which would be attended by MFP, donors, health service providers, representatives of the population and other key stakeholders, is the identification and resolution of constraints to program performance. Specifically, the Government would submit to IDA for its review, and to other donors, at least four weeks prior to the Annual Review of Program Performance (to occur no later than April 30 of each year),  22 an annual sector performance report, to be prepared by district health teams and consolidated at DDS and central levels, on the progress made in the implementation of the Program. This report would focus on key performance indicators (summarized in para. 3.33 and shown in detail in Annex 8) and would highlight successes and constraints in achieving Program objectives. It would also assess compliance with financial, audit and other covenants relating to the project. Drawing on lessons of the previous year's experience, this report would also include the following forward-looking elements: (a) the updated three-year rolling development plan for the health sector; (b) Government's salary and non-salary recurrent budget allocations to the health sector for the following fiscal year; (c) an action plan for the implementation of the Program and the project for the forthcoming FY, including a proposed budget and financing plan and a detailed staffing plan for facilities to be built, rehabilitated or upgraded and proposing solutions to implementation problems and constraints; and (d) an assessment of the continued relevance of the five districts in the project area for IDA intervention. This report would be discussed and reviewed on the occasion of the Annual Review and its forward-looking elements finalized in light of discussions and conclusions and in consideration of IDA's opinion. Following the Annual Reviews the Government would implement these elements and would take any corrective action deemed necessary to remedy constraints identified during the Review or any other measures to facilitate achievement of Program objectives. 3.2 Development and Strengthening of Partnerships in Health 3.28 In light of the intersectoral and multidisciplinary nature of the health sector and in support of the decentralization and integration strategies embraced by the PDS, the objective of this component is to mobilize and more fully utilize the capacity of the various stakeholders and beneficiaries in the elaboration, implementation, management and evaluation of national health policy and practice. Such capacity is currently underappreciated, underutilized and ill coordinated, despite the need to supplement the capacity and resources of MOPH to implement the PDS. This component will thus seek to exploit more fully the capacities and potential contributions of the various partners in health (NGOs, communities, civil society, academia, etc.) to permit them (a) to contribute to PDS implementation in line with their comparative advantages, and (b) to combine and coordinate more effectively their efforts and resources (human, financial, physical) in support of the implementation of national and district plans. 3.29 Community Participation. Various approaches are being tried in Niger to increase community participation. Within the framework of myriad ongoing projects and initiatives, communities have contributed to health sector activity through labor and in-kind inputs and through financial inputs in the context of cost recovery pilots. Most recently, communities have participated in a meaningful way in the elaboration of district health plans, including the analysis of sector issues and constraints, and the planning and programming of priority interventions. This participation has prompted the population to be more demanding of service quality and to insist on more decision-making power, and has culminated in a deep-rooted ownership of district health plans. Currently all actors involved in sector reform are searching for mechanisms for community participation. The PDS tries to address the issue through creation of structures and committees at the district level and below. However, it is not clear whether these structures and committees will truly represent the populations they are meant to serve. 3.30 Strengthening of community participation in health will thus be undertaken through a learning approach. The project will support a number of activities to permit MOPH and other national partners to appreciate and benefit from relevant experience in the subregion and, as well, to deepen and enhance its own national experience in this regard. It will finance study tours to Mali and Benin, and possibly additional African countries, which have considerable experience in health sector community participation. The project will also support the implementation, review and finetuning of community participation mechanisms, as laid out in the PDS. Specifically, it will finance: training of health  23 personnel and committee members in management and participatory techniques; studies and operational research; and exchanges of experience among the various districts covered under the project. In addition, the beneficiary assessments, to be carried out at the project's outset and at the time of the mid- term review (para. 4.5), will gather information and insight on what role the population feels it should play in the strategic management and implementation of health sector activity. During negotiations, assurances was received from Government that, by the time of the mid-term review, it will have carried out an evaluation of the community participation experience and prepared a draft legal framework for community participation in health satisfactory to IDA. This evaluation and draft legal framework would be discussed and reviewed at the mid-term review and the legal framework submitted to Parliament for its adoption after the mid-term review workshop. 3.31 Community Initiatives through Contracting. With a view to expanding capacity of district health personnel and to achieving a fuller appreciation and utilization of non-public sector capacity, the project will finance small contracts between the districts and various partners in the communities. These contracts would be the vehicle for implementation of crucial, cost-effective elements of the district PDS, which tend to be neglected (in Niger and elsewhere in the subregion), and for which public sector health personnel do not necessarily have a comparative advantage. Contracts would be small-scale and oriented around preventive and health promotional activities, with a particular focus on health problems and issues of Niger's two most vulnerable groups: mothers and children. They also may have a public health orientation (water, hygiene, santiation, school health...) or they may target essential support activities to health operations (maintenance, operational research). Partners eligible for entering into small contracts with the health district would include: community- or district-based groups, organizations, associations and NGOs, local/national training, consulting and research institutions, and qualified individuals (such as students of public health, traditional practitioners, trained service providers not employed by the public sector, and village health workers). Procedures for the review and award of contracts by the districts, for disbursement against contracts by the DDS, and for supervision and verification of contract implementation by both the districts and the DDS will be spelled out in the Project Operational Manual. As this is a new initiative, the effectiveness and outcome of small-scale district contracting will be evaluated at the time of the mid-term review and possibly extended to other districts beyond those five initially covered under the project, if proven to be successful. Indicators to evaluate the pilot phase of this initiative were discussed and reviewed during negotiations and were included in a supplemental letter. 3.3 Project Management and Coordination 3.32 To support and assist MOPH in carrying out the various functions inherent to project management and coordination and responsive to a sector investment approach, the MOPH at all levels (central, departmental and district) would be strengthened through the provision of technical assistance, training, equipment and materials, and logistical inputs to facilitate monitoring and evalutation and supervision functions. Further details on the project management and coordination structure are found in Chapter IV. D. Indicators for Program Monitoring and Evaluation 3.33 In line with Bank guidelines, indicators were reviewed and discussed with MOPH. Six indicators for implementation (input and output) and six for outcome/impact have been selected jointly with Government. The implementation indicators are: number of facilities rehabilitated/constructed and equipped; number of service delivery staff trained; availability in health facilities of drugs included in Government's official essential generic drugs list, frequency of orders for stock replenishment, and number and duration of ruptures in essential drugs stocks; number of district health teams trained and  24 functioning; number of planning/programming meetings taking place at the district, DDS and central levels; and number of small-scale service contracts awarded by the districts to various local partners. The outcome/impact indicators are: health coverage, utilization rates, annual recurrent expenditures of district health facilities vs. real annual costs, planned vs. actual financial contributions of key financiers (communities through cost recovery, local collectivities, and central budget), transformation of the PDS into a multi-year Program, which should serve as an instrument for strategic sector management and aid coordination (number of annual action plans prepared), and permanent and meaningful participation by the population in strategic sector management (number of functioning community management committees). These indicators, presented in Annex 8, were deemed appropriate, given the reform nature of the Program. In addition to these, however, the health status of the population in the five districts to be covered under the project and their own evaluation of health service quality will be tracked, respectively, through three epidemiological surveys and three beneficiary assessments to be carried out at the project's outset, mid-term, and completion. Monitoring and evaluation arrangements are discussed in para. 4.5. E. Program Costs and Financing and Financial Sustainability 3.34 Program Costs. The total cost of PDS implementation over the next five years is estimated at about US$275 million equivalent, of which US$135million equivalent is for investment and US$140 million equivalent is for recurrent costs. Over 75 percent of total costs will support district (basic and first-referral) health services. Table 3.1 summarizes the Program costs by component and sources of financing, and Table 3.2 summarizes it by expenditure category and sources of financing. Annex 7 provides financing and costing details and basic assumptions for calculating the costs. Table 3.1: Estimated Program Costs by Components and by Sources of Financing (US$ Million, including contingencies) OTHER LOCAL COMMU- Govt. IDA DONORS ADMIN. NITY TOTAL % OF COMPONENT Amount Amount Amount Amount Amount Amount TOTAL A. IMPROVING QUALITY AND COVERAGE OF BASIC HEALTH SERVICES l.Strengthening Swviceasat DistrictLevel 88.9 25.5 82.8 5.7 10.4 213.3 77.4 2. Strengthening PatientReferral Capacity of Hospitals 7.4 4.3 10.2 - 21.9 7.9 3. National Progran fer STD/AIDS 1.7 1.7 - - - 3.4 1.2 4. National Program for Tuberculows Control 1.2 - 2.0 - 3.2 1.1 Subtotal IMPROVING QUALITY AND COVERAGE OF 99.2 31.5 95.0 5.7 10.4 241.7 87.7 BASIC HEALTH SERVICES B. IMPROVING SUPPLY AND DISTRIBUTION OF ESSENTIAL DRUGS 1. Strengthening ofDPhL 1.1 0.2 1- - .3 0.5 2. Restructuring ofONPPC 2.1 35 - - _ 56 2.0 Subtotal IMPROVING SUPPLY AND DISTRIB. OF ESSENTIAL DRUGS 3.2 3.7 - 6.9 2.5 C. BUILDING CAPACITY & FORGING PARTNERSHIPS IN SUPPORT OF HEALTH SECTOR REFORM I. Strengthening and Decentralization of Key Management Functions 10.0 1.4 8.0 - - 19.4 7.0 2. Developnent and Strengthening of Partnerships in Health 2.0 1.8 - - - 3.8 1.4 3. Project Management and Coordination 2.0 1.6 - - 3.7 1.3 Subtotal BUILDING CAPACITY AND FORGING PARTNERSHIPS 14.0 4.8 8.0 - 26.9 9.8 TOTAL 116.4 40.0 103.0 5.7 10.4 275.5 100.0  25 Table 3.2: Estimated Program Costs by Expenditure Category and by Sources of Financing (US$ Million, including contingencies) OTHER LOCAL COMMU- Govt. IDA DONORS ADMIN. NITY Total For. Amount Amount Amount Amount Amount Amount % Exch. Local 1. Investment Costs Civil Works 7.8 15.0 53.1 3.1 - 79.0 28.7 45.3 33.3 Goods - 5.7 19.8 - - 25.5 9.2 22.7 2.3 Training - 2.8 8.5 - - 11.3 4.1 1.1 10.2 Studies,Research and Surveys - 1.3 3.3 - - 4.5 1.6 - 4.5 Consulting Services - 3.5 11.4 - 14.9 5.4 3.5 11.4 Total Investment Costs 7.8 28.3 96.0 3.1 135.2 49.1 72.6 62.5 11. Recurrent Cosb StaffSalaries (incl. contractual) 61.3 0.1 - 0.5 61.9 22.5 - 61.9 Essential Drugs and Labs. Supplies 3.0 8.5 5.0 - 10.4 26.2 9.5 26.2 Supervision Cost 12.2 0.5 0.5 - - 13.2 4.8 - 13.2 Maintenance and Operating Costs 32.0 2.6 1.5 2.1 - 39.0 14.1 - 39.0 TotalRecurrentCosts 108.6 11.7 7.0 2.6 10.4 140.4 50.9 26.2 114.1 TOTAL 116.4 40.0 103.0 5.7 10.4 275.5 100.0 93.9 176.6 Note: Totals may not add up due to rounding. 3.35 Program Financing Government is expected to contribute US$116.4 million equivalent over the program period, of which US$7.8 million for investments and US$108.6 million for recurrent costs. Local administrative budgets (collectivites locales) will contribute some US$5.7 million for investment (US$3.1 million equivalent) and recurrent (US$2.6 million equivalent) costs. In addition, revenues generated from cost recovery are estimated to finance some US$10.4 million equivalent of recurrent drug costs. These estimates are based on MOPH's health financing policy, as proposed in the PDS (and supported in the PFP), which specifies that: health's share of the State recurrent budget should increase from its current (1996) level of 6.6 percent to 10 percent by the year 2000; that a minimum of 5-8 percent of local administrative budgets should be allocated to health; and that revenues generated from cost recovery should eventually cover 100 percent of drug costs at the primary level, and a progressively smaller percentage for the higher levels of care. IDA will contribute US$40.0 million equivalent, and the balance of PDS costs (US$103.0 million equivalent) will be covered by the various external partners active in the sector (multilateral and bilateral agencies and NGOs), as laid out in their program commitments. MOPH's challenge will be to manage effectively external aid coming into the sector and to channel it directly to cover activities included in the PDS. Given the quality and appropriateness of the PDS document, donors have expressed willingness to contribute to its objectives and are keen to achieve better coordination in the sector. Annual review meetings of Program costs and financing (para. 3.27), and a possible Donors' Round Table in 1997 will be important vehicles for this work. 3.36 Financial Sustainability. By the end of the initial five-year period, recurrent costs of health system functioning (encompassing already existing and incremental recurrent costs) will amount to about US$33 million equivalent annually. National contributions to annual recurrent costs by the end of the project are projected to exceed this amount, encompassing the financial participation of Government (US$24.8 million equivalent), local administrative budgets (US$0.8 million equivalent) and revenues generated from cost recovery (US$5.4 million equivalent). These estimates, detailed in Annex 7, Appendix 1, are based on the assumption that the projected financial contributions of the various national partners, as laid out in the PDS will, in fact, be realized. This objective is feasible but at the same time, a challenge, and will be monitored very closely over the Program period. It must be noted that, given Niger's very precarious economic and financial situation, implementation of an eventual second phase of the PDS will require the support of external partners over the medium-term. The health  26 financing policy laid out in the PDS is cognizant of this very real constraint and takes into account the programmed contributions of external partners, including NGOs, who have contributed, and will continue to contribute both to investment and recurrent costs. 3.37 These estimates are tentative, at best, and provide only a basis for continued monitoring and refinement in light of experience. The public expenditure review and health missions provided an opportunity to collect information and establish a data base on costs and financing of the PDS. This work represents an important, albeit initial, step. A crucial next step will be the ongoing review and refinement of program costs, objectives and financing plans in light of experience. The PDS, with assistance from the proposed project, will strengthen MOPH capacity in programming, budgeting and financial planning, monitoring and evaluation to this end. An important instrument in monitoring and evaluating program sustainability will be the annual reviews of program performance, which will review Program costs and financing (actual and projections) and pace of implementation. Depending on Program experience and perspectives for the future any one or several of these variables may well be revised to ensure the feasibility and financial sustainability of Program content. F. Economic Analysis 3.38 The 1993 World Development Report (WDR) evaluated the cost effectiveness of various health interventions and found two clusters of selected interventions to be highly cost effective: (a) public health interventions (immunizations, family planning, improvements to household environment, AIDS prevention, and school-based services); and (b) clinical services (pregnancy related care, family planning, STD prevention and control, control of tuberculosis, and prevention and treatment of diseases, which most severely affect adult, infant and child mortality: acute respiratory infections, measles, malaria and acute malnutrition). Africa region-specific economic analysis carried out in the context of Better Health for Africa (BHA) has revealed that these cost-effective interventions provided in the form of a minimum package of services, through a well-functioning district system with proper referral capacity, should enable African countries to manage more than 90 percent of health care demands; and reduce the burden of disease by 30 percent. 3.39 An economic analysis of the PDS, with input from the public expenditure review mission, evaluated the appropriateness, affordability, feasibility and cost-effectiveness of reforms, approaches and activities envisaged in the government's Program document. Results of this analysis show that Niger's PDS is perfectly in line with recommendations of WDR '93 and with BHA for achieving cost effectiveness, both through its choice of interventions and through its proposed mode of delivery. Both the Bank and MOPH acknowledged, however, that national and district PDS goals and objectives are very ambitious, given a number of constraints, including: timeframe, management and absorptive capacity, human resources implications, recurrent financing implications and political instability. An important lesson learned from the implementation of the first IDA-financed health project was the need to set goals and objectives that are cognizant of and commensurate with implementation constraints. This economic analysis thus aimed to provide concrete guidance on where and how the risks and constraints would be mitigated, the costs of implementing the PDS might be minimized, and how the effectiveness of proposed interventions could be maximized, and to provide guidance on how to set priorities and phase interventions, in light of these constraints. The results of this analysis have served to refine Program design and interventions (including IDA's planned support to Program implementation), and also should serve to guide the transformation of the national and district PDS into a detailed working Program. The findings and recommendations of the economic analysis are fully subscribed to by MOPH and are presented in Annex 7.  27 G. Program Sustainability 3.40 More efficient management of human, material and financial resources will enable the sector to achieve a greater measure of sustained growth. Profits generated from the sale of drugs would be used by communities to reconstitute stocks. Cost recovery for drugs would also enable the GON to divert funding from drug purchase to essential operation and maintenance expenditures. The project will facilitate integration of specific prevention programs for the control of endemic diseases into the mainstream of primary health care contributing to a more efficient use of limited resources. Clearer demarcation of primary health care and referral services and the shifting of expenditures from the more costly clinical care toward basic health care and preventive medicine should reduce use of higher tier facilities for services that could be provided at a lesser cost at lower levels. In this instance as well, cost effectiveness gains should be made. Improved quality of health service through training and redeployment of personnel to primary health care facilities, and availability of drugs at affordable prices should stimulate increased and more effective utilization of health services. Revision of MOPH policy and strategy for human resources and revision of MOPH health financing policy in light of cost recovery should also contribute to the increased sustainability of implementing the national and district-level PDS. Decentralized and participatory strategic management to be supported and nurtured under this project should result in increased ownership of the PDS by the various stakeholders -- perhaps the most important contributing factor of all to long-term sustainability of interventions. MOPH commitment to achieving a greater client orientation is reflected in its intention to carry out periodic beneficiary assessments. The beneficiary assessment, itself, is a key tool for enhancing project sustainability in that it provides periodic feedback on the degree of client identification and, ultimately, ownership of sector reform initiatives. The institutionalization of the beneficiary assessment approach is a major aspect of management reform envisaged in the Program and underscores an effort on the part of MOPH to improve on an ongoing basis the quality of its operations. IV. PROGRAM AND PROJECT IMPLEMENTATION A. Status of Program and Project Preparation 4.1 The proposed project was prepared in response to a request from the MOPH to IDA to assist in supporting the implementation of the main reforms contained in the PDS and in strengthening MOPH capacity for strategic sector management and aid coordination. The PDS and district plans (about 17 to date) have been prepared by the MOPH in collaboration with a wide range of stakeholders, including other ministries, private sector health care providers and non-governmental organization (NGOs), community representatives, and multilateral agencies, including USAID, EU, WHO, AfDB, UNICEF, UNFPA and IDA. A Japanese Grant has financed most of the preparation activities, particularly consultancies, studies and support to the district planning process. Additional funding assistance is provided through a project preparation facility (PPF) to cover for the costs of preparation and start-up activities to be carried out prior to credit effectiveness. These activities consist primarily of studies to collect baseline data (epidemiological survey and beneficiary assessment) in the project area, technical assistance, workshops and training to establish district health teams, to strengthen DDS capacity to prepare the ground for decentralization of key management functions and also to establish project management and coordination in the MOPH. B. Participatory Approach 4.2 MOPH's commitment to decentralized, participatory planning is evident in the ongoing district planning exercise through which key stakeholders at the district level, including representatives of the population, are initiating a strategic management process within the framework of the PDS. Government  28 preparation of the PDS and Bank missions have been carried out through extensive field visits, and workshops and discussions with a spectrum of stakeholders both in and outside of Niamey. In addition to efforts to institutionalize involvement of beneficiaries and other stakeholders, a baseline beneficiary assessment will be carried out in the project zone at the outset and will be repeated periodically during the project life -- and eventually extended to all districts. In addition, the design of this project draws heavily on the outcome of the ICR for the IDA's first health intervention, which sought and reflected a spectrum of (often varied) perspectives, including those of: communities, service providers, MOH technical and managerial staff at the central and departmental levels, the unions and an independent evaluator. C. Management and Coordination of Implementation 4.3 In support of the decentralization strategy embraced by the PDS and in light of lessons learned under IDA's first investment in the sector, Program and project management will be fully integrated into the MOPH structure so that the technical directorates at the center, as well as the decentralized levels of MOPH (DDS and districts) will be given full and direct responsibility for implementing the various components of the project. Annex 3 shows the organizational structure of the MOPH and the project management structure, and gives details on the functions of key directorates in the MOPH. 4.4 The Secretary General of the MOPH will be responsible for overseeing program and project management and coordination and for ensuring its smooth and efficient implementation. The Directorate of Studies and Planning (DEP) will oversee all sector investments and will be strengthened during the program period to take on the management and coordination of program implementation. The Directorate of Financial Affairs and Materials (DAF/M) will have overall responsibility for procurement and disbursement activities required by the program. These functions will be handled by the two relevant divisions of the DAF/M. The Division of Materials will be responsible for procurement activities as described in para. 4.18, while the Division of Financial Affairs will be responsible for disbursement and accounting/financial activities, as described in para. 4.27. A Project Coordinator (full- time civil servant) attached to the MOPH's General Secretariat, who has been nominated prior to negotiations, is responsible for: (a) facilitating implementation of project activities by the different central level directorates and the concerned DDS; (b) working closely with the DAF/M to ensure that accounting, auditing, and procurement procedures agreed to with IDA are respected and carried out according to agreed implementation and procurement plans; and (c) maintaining regular contact with the Bank on the technical aspects of project implementation. To assist MOPH and to supplement capacity, a locally recruited long-term consultant with experience in the management of externally-funded health projects, aid coordination and participation will advise MOPH staff on program coordination and management and on reform implementation. The recruitment of this adviser with qualifications and experience satisfactory to IDA was a condition of Board Presentation. During negotiations, Government gave assurances that it would maintain until project completion the adviser to the MOPH and that overall responsibility for project coordination in each of the three DDS to benefit from direct IDA assistance would rest with the DDS director, who would delegate day-to-day coordination functions to his deputy. These deputies (or departmental coordinators), whose appointment would be a condition of effectiveness, would be responsible for project management and supervision at the DDS level. During negotiations, Government gave assurances that DDS staff designated to act as departmental Project Coordinators shall, at all times until completion of the Project, have qualifications and experience satisfactory to IDA and that the staff of each of the three DDS would include at all times a financial specialist with qualifications and experience acceptable to IDA. Specific responsibilities of these coordinators would include: facilitating implementation of project activities at the DDS level; working closely with all relevant services of the DDS; maintaining regular contact with donors and with the two central directorates (DEP and DAF/M) on the technical aspects of project implementation; providing  29 advice and assistance to the DDS and its various services in program management and aid coordination in light of experience and responsibilities inherent in this position; and attending quarterly meetings held at the district level (para. 4.6). Training of key staff at the central and DDS levels as well as technical assistance will be provided for under the Japanese Grant and the PPF. A project operational manual, satisfactory to IDA, which will lay out roles, responsibilities, procedures and processes for the coordination, management, implementation, monitoring and evaluation of project activities (including the refinement and agreement on appropriate performance indicators), will be adopted and submitted to IDA as condition of effectiveness. The manual will also provide guidance on procurement and disbursement, accounting, auditing and reporting. The project operational manual (including the policy and procedures manual for contracting arrangements for small-scale services at the district level -- para. 3.31) will be discussed during the project launch workshop, scheduled to take place at the latest shortly after effectiveness. This manual will include a detailed first year work program (implementation plan). D. Monitoring, Evaluation and Supervision 1. Monitoring and Evaluation. 4.5 Careful and regular monitoring and evaluation of the program is needed to assist in taking timely measures to address and resolve implementation difficulties. The district health teams will take a lead role in program monitoring and evaluation and, as such, will provide the mechanism for eliciting the inputs from Government, beneficiaries and donors in this regard. In order to strengthen the capacity of the district health teams and the staff at the DDS and the central levels in playing this role, the project will provide training in key areas of management at the onset of project implementation. Key indicators selected for tracking implementation and output/impact are described in para. 3.33 and presented in Annex 8. Beneficiary assessments and epidemiological surveys will be carried out in selected districts to provide baseline data both of a qualitative and quantitative nature and will be undertaken at the project mid- term and at its end to monitor and measure project performance. The epidemiological surveys will permit tracking of changes in health status, while the beneficiary assessments will provide clients with a means for voicing their needs, preferences and assessment of service delivery quality and will shed light on the effectiveness of mechanisms for community participation in sector management. Monitoring and evaluation arrangements will provide: (a) a systematic measure of performing and non performing health facilities; (b) a means for carefully assessing the critical factors associated with the quality of health service delivery; and (c) an assessment in the development of health care coverage. Beneficiaries and other stakeholders will be deliberately involved in the monitoring and evaluation process. MOPH MIS capacity is sufficiently strong thanks to USAID assistance, and will be an important instrument for project monitoring and evaluation. Details on monitoring and evaluation activities will be described in the Operational Manual. 2. Supervision 4.6 Government. District, departmental and central level personnel will supervise project activities during their regularly scheduled supervision trips. Their tasks will be, among other things, to address any issues hindering smooth implementation of the Program. In certain cases they will be expected to alert relevant authorities on problems needing immediate actions (i.e., staff sanctions, training, etc.). The district health teams will each meet quarterly to review progress and discuss and resolve field-level project implementation problems; the DDS will meet semiannually to review progress on program/project implementation and to discuss and resolve departmental level issues. Semiannual reports will be prepared by the DEP based on the results of the departmental meetings indicating the program's physical/financial status as well as its progress on the institutional issues. The project coordinator would also prepare semi- annual reports (para. 4.29).  30 4.7 IDA Because of the sectoral nature of IDA's support and the decentralization of the proposed activities, IDA supervision will draw on Resident Mission assistance, particularly to: (a) foster the SIP approach; (b) maintain close coordination with other donors; (c) carry out periodic field visits to the project zone; and (d) facilitate communications with Headquarters and ensure smooth project implementation. To the extent feasible, IDA's supervision from Headquarters will draw on the various expertise necessary to monitor sector reforms. These missions will draw, inter alia, on the semiannual progress reports to provide the basis for the issues to be discussed in the field. 4.8 The details of the Bank's supervision plan are provided in Annex 9. Two supervision missions per year will be required: (a) early in the calendar year to inter alia evaluate implementation of the program, conduct the annual review of project progress during the previous year, and examine the annual audit of the project's accounts; and (b) late in the calendar year to review the proposed annual programs and budgets for the following year. At least one of these missions will coincide with a meeting at the DDS and, on occasion, at the district level. All partners in the sector (donors, NGOs, beneficiaries, etc.) will be involved in these reviews. 4.9 Mid-term Review. Assurances were obtained from Government at negotiations that a mid-term review (MTR) would be carried out to monitor progress of project implementation. As in the case for the Annual Reviews (para. 3.27), four weeks prior to the mid-term review workshop, the Government will submit to IDA for its review and comments a report that would evaluate past performance according to agreed indicators and that would also include key forward-looking elements. In addition, this report would also include assessments of: (a) the effectiveness of small-scale district contracting, judged against specific performance indicators; (b) progress in the application of the health financing policy, as outlined in the PDS and prospects for its finetuning; (c) relevance of health sector human resource strategy in light of reforms, progress in its implementation, and prospects for its finetuning; (d) project's impact on health status in the project area through an epidemiological survey; (e) project's performance and impact from the perspectives of various key stakeholders, including beneficiaries, DDS staff, local authorities, and service providers working in the project area; and (f) the sustainability of both Program and project, considering their financial, operational, technical and administrative requirements. The MTR would be the responsibility of the MOPH, which would coordinate and ensure its preparation, execution and follow up activities. It would be participatory in its design. The results would be reviewed jointly by the Government and the Bank, in full consultation with key stakeholders, and recommendations emanating from the MTR process would be implemented promptly based on an agreed schedule. E. Gender Impact 4.10 Improvements in access to and the quality of family planning, health and nutrition services will have an immediate positive impact on the life of women in a number of ways. Raising the Contraceptive Prevalence Rate (CPR) will permit women to space births and thus alleviate the burden of maternal depletion and continuous childbirth and the temptation to resort to unsafe abortions. Improved access and outreach will also offer them the opportunity to deal with other obstetric problems and problems of infertility or sub-fecundity which currently disrupt family life. The integration of family planning, maternal and child health, and nutrition services will offer protection to mother and child and lay a solid foundation for healthy growth of newborns and the welfare of their mothers. Effective management and referral of high-risk pregnancies and complications at delivery would save women's lives and offer them a better chance of bringing up healthy children. Systematic monitoring of the nutrition of women will reduce the current high rate of anemia among pregnant women and reduce the incidence of low birth weight. Such improvements will free women's resources and enable them to pursue economic and social activities that fully integrate them into development activities and, as such, complement the recently  31 approved IDA investment in primary education, which supports national strategy to increase school enrollment for girls. Finally, efforts to encourage and formalize the participation of women in the management and implementation of health programs should expand their opportunities to improve their own health status and that of their children. F. Environmental Impact 4.11 The project will have a positive environmental impact through activities promoting human and household waste disposal and sanitation. The health promotion activities by the health district teams, local partners, and community management comittees will create greater community awareness of the measures needed to protect the environment and keep public places (health facilities, schools, and markets) clean and provided with basic sanitation facilities. In-service programs under the project will include training of clinical staff in proper procedures for handling and disposing of blood products, needles and other hazardous materials and in mobilizing communities to improve the environment for better health. The project will also provide safe water supplies in all health facilities that it covers. G. Procurement Arrangements 4.12 Table 4.1 below summarizes the estimated program cost by expenditures and the proposed methods of procurement. A Country Procurement Assessment Report was completed in October 1985. At that time, the laws and regulations which had been enacted over the last four decades, remained somewhat outdated and sometimes contradictory. With IDA's assistance (under the Public Enterprise Insitutional Development Project, Cr. 1838-NIR), the Government prepared new comprehensive procurement regulations and, in April 1989, promulgated a new public procurement code. Article 5 of the procurement code, allow IDA's procedures to take precedence. In order for National Competitive Bidding (NCB) procedures to be acceptable to IDA, the credit document should include a waiver of the regulation that grants preference to local contractors and suppliers. NCB procedures will provide for the following elements: (a) permit participation of foreign bidders if they wish to participate; (b) explicit statement to bidders of the evaluation and award criteria; (c) local advertising with public bid opening; (d) award to lowest evaluated bidder. All works, goods and services financed under the IDA credit would be procured in accordance with Bank guidelines and standard bidding documents for Intemational Competitive Bidding (ICB) and for Consultant Services (Procurement under IBRD Loans and IDA Credits, January 1995, and Guidelines for the Use of Consultants by World Bank Borrowers and by the World Bank as Executing Agency, August 1981).  32 - Table 4.1: Summary of Proposed Procurement Arrangements */ (US$ million, including contingencies) Procurement Method Expenditure Category ICB NCB Other N.l.F. Total Cost 1. WORKS (a) Consuctbon and Rehabilitation of CSIs 11.6 63.3 74.9 (11.6) (11.6) (c) Extension and Rehab. of HDs and CHD 3.2 3.2 (3.2) (3.2) 2. GOODS (a) Medical Equipment and Materials 3.9 13.0 16.9 (3.9) (3.9) (b) Office Equipment and Fumiture 1.0 0.05 3.7 4.8 (1.0) (0.05) (1.0) (c) Essential Drugs and Supplies for Labs. 8.5 0.1 18.4 27.0 (8.5) (0.1) (8.6) (d) Vehicles 0.7 0.1 2.7 3.5 (0.7) (0.1) (0.8) (e) Small Materials 0.1 0.3 0.4 (0.1) (0.1) 3. CONSULTING SERVICES, RESEARCH AND STUDIES 2.0 2.6 4.6 (a) Project Supervision, ImplementWon and (2.0) (2.0) Monitoring Support 1.5 8.8 10.3 (b) Institutional Development (1.5) (1.5) 1.3 3.3 4.5 (c) Research, Studies, and Surveys (1.3) (1.3) 4. TRAINING 2.8 8.6 11.3 (2.8) (2.8) 5. INCREMENTAL RECURRENT COSTS (a) Incremental Contractual Salaries 0.1 61.8 61.9 (b) Operating Costs j/ 4.1) 48.152. 4.1 48.1 52.2 (3.2) (3.2) TOTAL: 16.3 12.6 12.1 234.5 275.5 IDA FINANCING: (16.3) (12.6) (11.2) (0.0) (40.0) */ Figures in parentheses are the amounts financed by IDA, PPF included. All values in parentheses are net of taxes and duties. Totals may not add up due to rounding. / Operating costs include office consummables, field supervision and associated subsistence allowances, buildings, vehicles and equipment maintenance and operating costs. N.I.F.= Not IDA-financed: Other donors under parallel financing; Government and Communities. 4.13 Works. Civil works financed under IDA include: construction and rehabilitation of Integrated Health Centers (CSI I and 2), extension of medical centers into district hospitals (HD) and rehabilitation of the departrnental hospital (CHD) of Diffa, rehabilitation of offices at the central and departmental  33 levels (Departmnents of Diffa and Zinder), staff housing, and boreholes. Contracts for extension and rehabilitation (district hospitals and CHD) estimated at more than US$200,000 per contract would be awarded on the basis of international competitive bidding (ICB) in accordance with the Bank's guidelines. The extension of HD and rehabilitation of CHD would be grouped into one package of several lots and bidder will be allowed to bid for one, two ...., or all lots. Contracts for construction and rehabilitation estimated at less than US$200,000 equivalent per contract up to an aggregate of US$11.6 million equivalent would be awarded on the basis of national competitive bidding (NCB). Communities will provide for the fencing of all CSIs constructed and/or rehabilitated under the project. 4.14 Goods. Goods financed by IDA under the project would include: essential drugs, office furniture and equipment, communication and small medical apparatus, medical equipment and supplies, vehicles, documentation, and training materials. (a) Goods. Goods that can be grouped into packages of at least US$100,000 each would be procured through ICB using Bank's Standard Bidding Documents for the Procurement of Goods, January 1995 (Details on ICB for essential drugs and disposable medical supplies are shown in para. 4.14[b].). Goods which can be competitively procured nationally and which cannot be grouped into packages of at least US$100,000 equivalent each would be procured through NCR under procedures acceptable to IDA, up to an aggregate amount of US$1.0 million equivalent. Small items and goods which cannot be grouped into bid packages of at least US$50,000 equivalent will be procured on the basis of price quotations obtained from at least three reliable suppliers, provided that the aggregate amount of such procurements does not exceed a total of US$0.3 million equivalent. For specialized software and standardization of equipment, procurement would be needed under direct contracting up to an aggregate of US$0.05 million equivalent. (b) Essential Drugs and Disposable Medical Supplies. Essential generic drugs and disposable medical supplies would be procured through ICB by the management unit (Cellule de Medicaments Essentiels et Generiques) of the ONPPC established by the EDF. The procurement of drugs would be on the basis of the Bank's Standard Bidding Documents for the Procurement of Pharmaceuticals and Vaccines, (September 1993), and the procurement of disposable medical supplies would be based on the Bank's standard bidding documents for goods. The performance of the ONPPC on procurement matters would be subject to periodic review by IDA. Essential drugs and disposable medical supplies would correspond to the approved MOH's formulary for drugs and to pharmacopea norms, for departmental and district hospitals and CSIs. A preferential margin of 15 percent or the applicable customs duty, whichever is less, over the c.i.f. prices of competing goods would be given for locally produced drugs in accordance with the Bank's guidelines for all ICB procurement. All bids would be submitted on a c.i.f. basis for imported goods and on an ex-factory basis for locally manufactured goods. 4.15 Consultant Services, Research and Studies. The total costs for consultant services, research and studies is estimated at US$4.8 million equivalent. The majority of consultancy services required under the project would be in large part for project implementation, supervision, management assistance, training activities, surveys, research and studies, and architectural and engineering services. A concerted effort will be made to identify and recruit national consultants, wherever possible, and it is expected that a large share of contracts will in fact be awarded nationally. In the spirit of partnership (para. 3.31) and based on proven experience in the field, sole source contracts (about 5 percent of the total amount) with national training institutions such as Ecoles Nationales de Sante Publique (Zinder and Niamey) or University of Niger would be drawn for carrying out key activities of the project such as national training programs and operational research (the selection of the institution would be based on a capacity assessment carried out by the MOPH). Contract arrangements would also be made with various partners  34 at the district level-to carry out services (small-scale) needed in the context of implementing the district health development plans. Technical assistance will also be used in the development of a follow-on operation. Details on consultancies will be included in the operational manual. Technical assistance is itemized in Annex 10. 4.16 Training includes training abroad (US$0.2 million equivalent), and regional and national training (US$2.6 million equivalent). Whenever appropriate, external training will take place in the Africa region. Details on external and national training are provided in Annex 11. Plans for external and local training needs will be discussed at each level of the health system during the periodic reviews. Training to be financed by the IDA credit will be subject to its review on an annual basis. IDA and MOPH have agreed to pursue in the context of these annual reviews, opportunities for strengthening specialization training of Niger's Faculty of Health Sciences and thus minimize need for external training. 4.17 Recurrent Costs, including consumables, communications and other administrative costs, incremental contractual salaries (excluding civil servant salaries), field supervision and subsistence allowances, building and vehicle/equipment operation and maintenance, will be procured and paid for following regular Government procedures, acceptable to IDA. IDA's financing would be reduced from 90 percent to 80 percent after June 30, 1999. 4.18 Procurement Management and Coordination. An assessment of the country's capacity in carrying out civil works management during project implementation was carried out during appraisal. Based on its result, it has been agreed that for civil works associated with the construction and rehabilitation of CSIs (I and 2), a contract would be drawn with an engineering management firm such as Nigetip to prepare bidding documents, launch of tenders, and supervise construction/rehabilitation sites. For civil works associated with the extension and rehabilitation of HD and CHD to be procured under ICB, it was agreed that a qualified architectural and engineering firm would be recruited to carry out architectural and engineering studies under the direct control of the MOPH. Details on the civil work program will be included in the Project Operational Manual. Except for the construction and rehabilitation of CSIs, the Division of Materials of the DAF/M will have the responsibility for managing and monitoring all procurement activities of the program financed by IDA. The procurement will be carried out by staff of the Division of Materials assisted before and during project implementation by a locally recruited procurement specialist with relevant experience in externally funded projects. In addition to this assistance, relevant MOPH staff will receive adequate training as part of pre-project activity in procurement for IDA-financed projects. Although the DAF/M Director will be responsible for the overall administrative and contractual arrangements of the program, he will liaise closely with the Division of Materials head on all matters related to the preparation, implementation and monitoring of work plans for the smooth execution of procurement of all works, goods, and services, including the preparation of bidding documents and launching of tenders. In some cases, the DAF/M will also carry out evaluation (based on contract amount), and report the results to the Government and to IDA for review. In addition, adequate records on procurement progress, (including staff reports on site visits, the timing of works and goods procurement; and compliance with agreed methods of procurement) will be maintained by the DAF/M. These data will be used in MOPH's program monitoring system. A schedule for key procurement steps, which was discussed and agreed upon during negotiations will be included in the Project Operational Manual. 4.19 Review by IDA. IDA-financed contracts for works and goods above thresholds of US$200,000 and US$100,000 equivalent, respectively, would be subject to IDA's prior review procedures. Prior IDA review would also apply to consultant services and training contracts estimated to cost more than US$100,000 equivalent for firms and US$50,000 for individuals. Prior review would apply below these  35 thresholds for terms of reference, single-source hiring of firms, amendments of contracts raising the contract value to US$100,000 or more for firms and US$50,000 or more for individuals. Post-review of awarded contracts below the prior review thresholds would apply to over 50 percent (about US$20.0 million equivalent) of these contracts. A timetable for the preparation of bidding documents for works, goods, and services as part of project preparation activity has been agreed upon and will be included in the Project Operational Manual. 4.20 Assurance was obtained during negotiations that procurement of goods, works and consultants' services required for the program and to be financed out of the proceeds of the credit will take place in accordance with procedures satisfactory to IDA. Procurement information will be collected and recorded as follows: (a) prompt reporting of contract award information by the Borrower; (b) comprehensive semi-annual reports to IDA by the Borrower, indicating: (i) revised cost estimates for individual contracts and the total project, including best estimates of allowances for physical and price contingencies; (ii) revised timing of procurement actions, including advertising, bidding, contract award, and completion time for individual contracts; (iii) compliance with aggregate limits on specified methods of procurement; and (iv) a project final report prepared within the three months of the credit's closing date. H. Disbursement 4.21 The project, which supports the PDS, is expected to be completed within a five-year period by December 31, 2001 with a credit closing date of June 30, 2002. The disbursement schedule takes into account: (a) the considerable amount of time and resources invested by the MOPH in preparing and planning the PDS; (b) the level of support received from all parts of the government to the PDS and as subscribed in the Policy Framework Paper (PFP); (c) the selection of the health sector as a first step towards implementing Government's policy of decentralization; (d) the high degree of ownership and commitment towards the program at all levels of government (central, departmental and district levels); and (e) the strengthening of MOPH capacity by adding an adequate number of qualified and trained staff in the Directorates of Studies and Planning (DEP) and Financial Affairs and Materials (DAF/M) as well as the strengthening of the capacity at the departmental and district levels in management, monitoring, supervision, evaluation and control of activities. The estimated disbursement schedule is given in Annex 12. 4.22 Table 4.2 gives the categories and amounts to be financed out of the IDA credit, and the percentage to be financed in each category.  36 Table 4.2: Withdrawals of the Proceeds of the IDA Credit Amount of the Credit Allocated Category (US$ Million) % of Expenditures to be Financed 1. Civil Works: 100% foreign, 90% local (a) Construction of new facilities 6.3 (b) Other works 7.0 2. Goods, including Vehicles: 100% foreign, 100% local (ex factory (a) For new facilities 1.5 costs), and 90% local expenditures for (b) Other 2.5 other items procured locally 3. Drugs 8.5 100% foreign, 100% local (ex factory costs), and 90% local expenditures for other items procured locally 4. Consultant Services, Research, 100% and Studies (a) Pilot initiatives 0.4 (b) Others 4.4 5. Training (including training materials) 3.0 100% 6. Operating Costs a/ 3.4 90% up to June 30, 1999; thereafter 80% 7. Refuinding of PPF 0.7 8. Unallocated Total IDA Financing 40.0 a/ As defined in para. 4.17 above. 4.23 Conditions of Disbursements. The conditions of disbursements are as follows: (a) categories l(a) and 2(a) (construction and equipment of new facilities): the Government will provide a plan, referred to in Annex 3 of the statement of sector development policy, satisfactory to IDA, for redeployment, retraining and recruitment of health sector staff in order to ensure that upgraded and new health facilities will be sufficiently staffed and operational in line with MOPH staffing norms and in full respect of the PFP; (b) category 3 (drugs): the Government will adopt a decret d'application acceptable to IDA, for Law No. 95-014 of July 3, 1995, on cost recovery. 4.24 Disbursement and withdrawal procedures are detailed in The World Bank Disbursement Handbook (1992). All disbursements are subject to the conditions of the Development Credit Agreement and the procedures defined in the Disbursement Letter. The Operational Manual will further outline the role and responsibilities of the staff of the Division of Financial Affairs of the DAF/M with regard to disbursement/payment and financial accounting.  37 4.25 Special Account. To facilitate project implementation and reduce the volume of withdrawal applications, a Special Account will be opened in FCFA in a commercial bank in terms and conditions acceptable to IDA. The authorized allocation amounts to FCFA 750 million and covers about four months of eligible expenditures. Upon effectiveness, an amount of FCFA 375 million representing 50 percent of the authorized allocation will be deposited in the Special Account. The remaining balance will be made available when the total amount withdrawn from the credit account and/or special commitments issued amounts to the equivalent of US$20 million. The Special Account will be used for all payments below US$300,000 equivalent. Replenishments will be submitted monthly. All replenishments should be fully documented except for: (a) contracts of less than US$200,000 equivalent for civil works and US$100,000 for goods; (b) contracts of less than US$100,000 equivalent for consulting services - firms, and US$50,000 equivalent for consultants services - individuals; and (c) training and operating costs, which will be claimed on the basis of Statements of Expenditures (SOEs). All supporting documentation for SOEs will be retained for review by periodic Bank supervision missions and external auditors. 4.26 Government Financing. Government financial contribution to the health sector would be monitored through the accounting and monitoring system to be established with the assistance of an auditor and the MFP. The MFP will be required to make quarterly allocations to the MOPH on the basis of an agreed budget for the program, proposed by Government, and accepted by IDA one month before the beginning of each fiscal year. As a condition of credit effectiveness, the Government will open a Project Account and deposit an initial amount of 50 million CFAF (equivalent to the first year of counterpart expenditures). Assurance was received at negotiations that this project account will be maintained during project implementation. Improvements to MOPH's accounting system would also be undertaken in the context of the project's management strengthening efforts. I. Accounting, Auditing, and Reporting 4.27 Overall responsibility for the program's financial management would rest with the Division of Financial Affairs at the DAF/M. Vouchers and checks for payment will be signed by the financial controller and transmitted to the Project Coordinator (DEP) for processing through the DAF/M Director. Project accounts, as well as the project special account and disbursements under SOEs, will be audited annually by independent auditors acceptable to IDA whose selection will be a condition of effectiveness. Also, as a condition of effectiveness, the Government will furnish evidence satisfactory to IDA that a computerized accounting and financial management system for the implementation of the project has been established in the DAF/M and in the DDS within the project area, and that qualified and experienced accountants have been appointed. Establishment of such an accounting system will include the preparation of an accounting procedures manual, and training of accountants. 4.28 Audited accounts and reports will be submitted to the MOPH, MFP and IDA not later than six months after the end of each fiscal year. The auditor would establish a "Long Form Report" as described in the Bank's Guidelines for Financial Reporting and Auditing of Project Financed by the World Bank, March 1982. Audit on project expenditures would include an examination of the substantiating documentation and a verification that: (a) project accounts permnit identification of all receipt and payments; (b) goods have been received or work performed; (c) payments have been made; (d) all expenditures have been legitimate; and (e) the special account has been used appropriately; along with an opinion on the reliability of the SOE procedures and on whether the goods, works, and services acquired under the project were being utilized in accordance with its objectives. The auditors would also include the management report revealing possible shortcomings in staffing and systems, and evaluate the accounting system and efficiency of the internal control procedures. There is no outstanding audit for the First Health Project (Cr. 1668-NIR, closed June 30, 1995).  38 4.29 Reporting. During negotiations, the Government gave assurances that it will: (a) submit to IDA for its review and comments, semi-annual progress reports on the status of the project; and (b) prepare and submit to IDA, on the basis of guidelines satisfactory to IDA a completion report that would cover, inter alia, the execution of the operation, its costs and benefits, the performance of the Government and the Bank, and a plan to ensure Program sustainability. V. BENEFT&S AND RISKS A. Benefits 5.1 IDA's intervention will provide some one million people with improved access to preventive and curative care. Increased vaccination coverage of children and availability of quality pre- and post-natal care and family planing services would contribute to efforts to reduce infant and maternal mortality and to efforts to increase contraceptive prevalence. The project's support of STD/AIDS activities would also reinforce the GON's efforts to prevent the spread of AIDS and reduce STD transmission. In addition, community participation in the management and financing of health services would enhance people's awareness of health issues, render the health system more accountable to the clients it is meant to serve, and facilitate the adoption of more advanced policy reforms. The project would also improve the effectiveness and efficiency of the national health system through: improved planning of health interventions, more efficient management of resources, fuller utilization of non-governmental capacity. In addition, more efficient utilization of the various referral levels of the health system and the generalization of the use of generic drugs would together help contain costs of health services. A more detailed assessment of Program and project benefits is presented in the economic analysis in Annex 7. B. Risks 5.2 The most prominent among the country risks is the tenuous macroeconomic situation, which puts into question Niger's ability to provide its counterpart financing of the Program. Implementation of the Program in the North risks being delayed if the peace agreement with the Tuaregs is not implemented. Tlhe most significant institutional risk is Government commitmnent and capacity to decentralize. Decentralization is one of Niger's stated priorities, albeit with uncertain implementation schedule. Commitment within and outside MOPH, capacity, mechanisms, and the pace of decentralization are not, however, fully evident. The various dimensions of decentralization (political, administrative and operational) will most likely take place slowly, and at various paces. While establishment of health districts will be initiated at the Program's outset, its success will be subject to risks associated with building sufficient administrative and financial capacity at the decentralized levels -- tasks associated with the public sector management reforms, not yet in place. Given that PDS strategy is anchored in economic analyses and lessons of experience contained in WDR '93 and BHA technical risks are likely to be small, and related to adaptation of experience and lessons to the Nigerien context. There is a risk that cost recovery will limit or prohibit utilization of services by the poorest and most vulnerable groups. Efforts to strengthen partnerships in health is risky in that it is a new approach, but is one well worth pursuing. VI.A FfARE M 6.1 During negotiations, the Government gave assurances that it would: (a) prepare and adopt a pricing mechanism for essential generic drugs in the private and public sectors by March 31, 1998 (para. 3.12);  39 (b) not later than three months following Effective Date it will introduce into Parliament: (i) a draft pharmaceutical law, satisfactory to IDA (para. 3.16); and (ii) a law that would demonopolize ONPPC (paras. 3.17); (c) adopt no later than December 31, 1997 a new legal status for ONPPC's essential drugs procurement unit, satisfactory to IDA, that would accord it sufficient managerial and financial autonomy (para. 3.17); (d) present a new draft legal status for following functions of ONPPC--quality control and laborator, production, and acquisition, distribution and retailing--at the time of the mid-term review, and adopt no later than June 30, 2000 the final versions of the legal status, satisfactory to IDA (para. 3.17); (e) establish district health teams in the project area no later than 12 months after credit effectiveness, and that districts will undertake, on a quarterly basis, as soon as district health teams have been established, participatory evaluations of performance in implementing district plans, with a view to reviewing and refining programs, financing plans and budget allocations in light of experience and accomplishments. These evaluations will be submitted to the DDS, which will consolidate them at the departmental level (para. 3.22); (f) carry out on a semi-annual basis participatory evaluations of departmental performance in implementing the PDS. On the basis of program performance and lessons learned, programs, financing plans and budget allocations will be reviewed and revised, and submitted to MOPH central level for review and consolidation (para. 3.23); (g) undertake no later than April 30 of each year annual reviews of Program and project performnance in the implementation of the PDS and revision of the following year's plan in light of experience gained, lessons learned and emerging opportunities and constraints (para. 3.27); (h) at least four weeks prior to the Annual Review of Program Performance MOPH, submit to IDA for its review and to other donors an annual sector performance report, drawing on reviews and reports carrried out at the district and departmental levels, and encompassing both a retrospective of the past year's performance and forward-looking elements. This report would provide the basis for discussions at the Annual Review (para. 3.27); (i) implement plans and decisions agreed to during the Annual Reviews and take any corrective action deemed necessary to remedy constraints identified during the Review or any other measures to facilitate achievement of Program objectives (para. 3.27); (j) undertake by the time of the mid-term review of the project an evaluation of community participation experience culminating in the elaboration of a draft legal framework for community participation in health. This evaluation and draft legal framework would be discussed and reviewed at the mid-term review and the legal framework introduced into Parliament for its adoption after the mid- term review workshop (para. 3.30); (k) maintain until project completion the long-term national adviser to the MOPH on sector reform and PDS implementation with qualifications and experience satisfactory to IDA (para. 4.4); (1) designate DDS staff to act as departmental Project Coordinators at all times until completion of the project with qualifications and experience satisfactory to IDA and that the staff of the  40 three DDS would include at all times a financial specialist with qualifications and experience acceptable to IDA (para. 4.4); (m) carry out in consultation with IDA a mid-term review of the progress made in carrying out the project, which would include an epidemiological survey and a beneficiary assessment (para. 4.9); (n) maintain a Project Account in a commercial bank satisfactory to IDA (para. 4.26); and (o) submit to IDA for its review and comments semi-annual progress reports on the status of the project, and prepare and submit to IDA, on the basis of guidelines satisfactory to IDA, a completion report, including a plan to ensure Program sustainability (4.29). 6.2 As conditions of Board Presentation, the Government: (a) submitted to IDA the final, signed statement of health sector policy, including the three annexes (para. 2.27); and (b) recruited a long-term national adviser to MOPH on sector reform and PDS implementation with qualifications and experience satisfactory to IDA (para. 4.4). 6.3 As conditions of effectiveness, the Government would have: (a) adopted a Project Operational Manual, including, inter alia, a work program for the first twelve months period after the Effective Date, all satisfactory to IDA (para.4.4); (b) appointed in each of the three DDS (Diffa, Tillaberi, and Zinder), a departmental project coordinator with skills and experience satisfactory to IDA (para. 4.4); and (c) opened a Project Account and deposited a sum equivalent to the first year of counterpart expenditures (50 million CFAF) (para. 4.26). (d) furnished evidence, satisfactory to IDA, that a computerized accounting and financial management system for the implementation of the Project has been established in the DAF/M, and in the DDS of Diffa, Tillaberi, and Zinder, and that qualified and experienced accountants have been appointed (paras. 4.27); and (e) selected project auditors under terms and conditions satisfactory to IDA (para. 4.27). 6.4 The following will be conditions of disbursement: (a) construction and equipment of new health facilities: the Government will provide a plan, referred to in Annex 3 of the statement of sector development policy, satisfactory to IDA, for redeployment, retraining and recruitment of health sector staff in order to ensure that upgraded and new health facilities will be sufficiently staffed and operational in line with MOPH staffing norms, and in full respect of the PFP (para. 3.9 and 4.23); and (b) drugs: the Govermment will adopt a decret d'application acceptable to IDA, for Law No. 95-014 of July 3, 1995, on cost recovery (paras. 3.12 and 4.23). 6.6 Recommendation. Subject to agreement to the above, the proposed program will constitute a suitable basis for an IDA credit of US$40.0 million equivalent to the Republic of Niger on standard IDA terms with a maturity of 40 years.  ANNEX I Page 1 of 1 REPUBLIC OF NIGER HEALTH SECTOR DEVELOPMENT PROGRAM BASIC INDICATORS Population Niger SSA Total Population a/ 8.7 559.0 million Population Growth Rate a/ 3.3 2.9 per annum Total Fertility Rate a/ 7.3 6.2 children per woman GNP per capita a/ 270 n.a. (US$) Maternal Mortality Rate a! 700 n.a. per thousand births Education Primary School Enrollment - Total a/ 29 67 of relevant age group Secondary School Enrollment - Girls b/ 4 18 of relevant age group Health Crude Birth Rate (CBR) b/ 52 45 live births per thousand pop. Crude Death Rate (CDR) b/ 19 15 deaths per thousand pop. Infant Mortality Rate (IMR) 123 93.1 per thousand births Life Expectancy at Birth a/ 47 52 years Coverage of deliveries a/ 3,989 n.a. Population per National Physician a/ 35,141 n.a. persons Population per Nurse b/ 659 n.a. persons Population per Hospital Bed b/ 1,922 n.a. persons per bed Child malnutrition Height-for-age (stunted) c/ 32.3 n.a. % of under-5 child Weight-for-age (wasted) c/ 15.8 n.a. % of under-5 child Weight-for-age (undernourished) c/ 36.2 n.a. % of under-5 child Water supply Access to Safe Water 59 n.a. of the population Sources: a\ The World Bank. Social Indicators of Development. 1995. April 1995 b\ Ministere de la Sante Publique. projet de Plan de Developpement Sanitaire 1994-2000. May 1994 c\ Demogmphic and Health Survey, 1992 Note: SSA = Sub-Saharan Africa.  ANNEX 2 Page I of 3 REPUBLIC OF NIGER HEALTH SECTOR DEVELOPMENT PROGRAM MAJOR CAUSES OF MORBIDITY La situation epidemiologique actuelle du Niger, se caracterise par une forte predominance des maladies infectieuses et parasitaires. Les principales morbidites rapportees par les formations sanitaires sont presentees dans le tableau 14. Elles se resument comme suit: * Le paludisme : demeure la premiere affection avec une incidence annuelle de 1170 cas pour 10.000 habitants. En effet, le paludisme sevit de facon end6mique, avec des variations saisonnieres. Des phenomenes de chloroquino-resistance ont commence A apparaitre dans certaines regions (Gaya, Tillaberi). 3 Les Infections Respiratoires Aigues : constituent la deuxieme morbidite chez les enfants de moins de cinq ans. * Les maladies diarrh6iques constituent la premiere morbidite chez les enfants de moins de 5 ans. * Les affections ophtalmologiques: une enquete nationale effectuee en 1989 (par le Programme National de Lutte contre la Cecite) a determine le taux de Cecite au Niger A 2,2%. Elie depasse le seuil etabli par l'OMS (0,5%). Les causes principales demeurent: * les maladies conjonctivo-corn6ennes et carentielles pour 0,75% * les cataractes degeneratives et secondaires pour 0,6% * les glaucomes degeneratifs et secondaires pour 0,6% * les autres causes qu'elles soient traumatiques, h6reditaires ou indeterminees pour 0,3% des cas. 80% des affections oculaires cecitantes sont curables et/ou evitables. * Les affections dermatologiques: dominees par les infections bacteriennes et parasitaires (Impetigo, Furoncle, Pyodermite, Gale..) constituent la cinquieme cause de morbidite dans la population. * Les affections gynico-obstitricales: 1'etat de sante du couple mere/enfant, constituant 70% de la population, demeure preoccupant: La mortalite maternelle est de 7 pour mille. Elle est l'une des plus elevees au monde. Sur une periode de 15 ans (1973-1988), 4 grandes etiologies ont ete degagees representant au total 75% de deces maternels en milieu urbain: * hemorragie de la delivrance 21 % * ruptures uterines 20% * infections 18% * eclampsies 15 %  ANNEX2 Page 2 of 3 * En zone rurale, les donnees sont incompletes. 11 a ete constate neanmoins que l'insuffisance de consultations prenatales et les accouchements non assistes sont parmi les principaux facteurs qui font courir sur la mere nigerienne de serieux risques de deces par hemorragie, ruptures uterines, infections et eclampsies. * Les affections urinaires * La rougeole est la premiere cause de deces des enfants de moins de 5 ans. Elle se remarque par des epidemies saisonnieres, dont les plus importantes depuis 1981 etaient celles de 1984-85 et de 1990- 1991. La couverture vaccinale chez les enfants de moins de 24 mois n'est que de 27,8%. * La meningite cerebro-spinale est frequente surtout pendant la saison seche lorsque souffle I'harmattan, avec un taux de morbidite de I a 2%. L'6pidemie la plus importante depuis 1981 etait celle de 1985-86. * La fievre jaune sevit de maniere endemique dans certains pays voisins, ce qui represente un risque serieux d'eclosion des foyers epidemiques au Niger. * Le cholera a une tendance endemo-epiddmique depuis 1984, et particulierement dans le sud du departement de Maradi et le long du Goulbi de Maradi (frontiere avec le Nigeria). * La schistosomiase apparait avec un fort taux de prevalence de 40% a 70% dans certaines regions du pays, notamment, le long du fleuve et autour des mares permanentes. * La lepre reste un fleau social et un probleme non negligeable de sante publique avec un taux de prevalence de 1,0%o. * La dracunculose (ver de Guinee) s6vit de maniere endemique dans certaines regions, particuli6rement le long du fleuve et au sud du pays, elle represente un important probleme de sant6 publique a cause de son aspect handicapant. Dans les 5 departements identifies comme zones endemiques lors de 1'enquete nationale sur le ver de Guin6e realisee en 1991, 32.829 cas ont 6t6 recenses. La plupart des cas (64%) se trouvent dans le departement de Zinder. L'arrondissement de Mirriah, departement de Zinder, est le plus touche du pays avec 457 villages endemiques totalisant 17.763 cas. * Les maladies sexuellement transmissibles (MST) sont en progression. Elles occupent le premier rang de la morbidite dans la population adulte (15 ans et plus), et dans le d6partement de Diffa, le 8eme au niveau national. Elles affectent 30% des femmes enceintes en milieu urbain, et on estime la pr6valence globale a 300.000 cas par an dans le pays. Parmi les cas notifi6s, 11 % se trouvent chez les personnes de moins de 15 ans. * L'importance de la poliomy6lite est tres probablement sous estimee dans les formations sanitaires, vu la difficulte de diagnostic au debut de la maladie. Peu de cas ont ete enregistres en 1990 et 1991 (39 et 57 respectivement). Pourtant la couverture vaccinale pour la poliomyelite est tres basse, de 20,1 % chez les enfants de 12 a 23 mois en 1992.  ANNEX 2 Page 3 of 3 * Le syndrome d'immuno-deficience acquise (SIDA): Les premiers cas de SIDA au Niger ont ete depistes en 1987. De 1987 a 1992, 809 cas de SIDA ont et notifies pour 1'ensemble des formations sanitaires. Ce norme est passe a 921 cas le 30 juin 1993. Une recente enquete epidemiologique (MSP/BANQUE MONDIALE, Mai-Juin 1993) a Niamey a reve1l les taux de seroprevalence suivants: 1,3% chez les femmes enceintes; 15,4% cliez les prostituees; 3,0% chez les routiers; 6,0% chez les porteurs de MST. II existe au Niger les deux virus VIH 1 (93%) et VIH 2. Ces donn&es nous permettent d'estimer a environ 52.000 le nombre de s6ropositifs dans le pays. Si la transmission n'est pas reduite nous auront 90.000 seropositifs en 1998 et pres de 6.000 orphelins de mere pour cause du SIDA. L'importance de la migration vers les pays c6tiers a haute prevalence et le multipartenariat sexuel favorisent la transmission du virus. * La tuberculose reste un problrme majeur au Niger. Meme si le nombre de cas rapporte est relativement bas, le Centre National Antituberculeux estime une incidence annuelle (nombre de nouveaux cas par an) de 1,5 pour mille. Avec la croissance du SIDA/VIH la tuberculose pourrait connaitre une recrudescence. * La malnutrition protemo-energetique, I'anemie nutritionnelle et la carence en vitamine A, sont des problemes preoccupants de sante publique. Pres de 20% de nouveau-nes ont un poids a la naissance inferieur a 2,5 kg. L'enquete sur la morbidite et la mortalite realis6e en 1985 (periode de grande secheresse) faisait etat de taux de prevalence de malnutrition tres eleves, 24,9% des enfants de 6 a 59 mois subissait une malnutrition aigue t < -2 E.T. poids/taille). Une enquete nationale menee en 1992 a demontre un taux de malnutrition aigue de 16,9% chez ce meme groupe. Les tranches d'age les plus touchees sont les enfants de 6 a 23 mois (periode d'introduction des aliments solides et de sevrage). II existe de poches d'endemie de goitre, notamment dans les departements de Dosso, Tillaberi et Maradi. 3 La mortalite infanto-juvelule (< 5 ans) est tine des plus elevee de l'Afrique. L'enquete demographique et de sante au Niger en 1992 (EDSNIDHS) I'a estimee a 318 pour mille pour les quatre annees avant 1'enquete, soit presqu'un enfant sur trois meurt avant l'age de cinq ans (taux de mortalite infantile 123 pour mille, mortalite juvenile - I a 4 ans - 223 pour mille). Les principales causes de mortalite pour les enfants de moins de 5 ans sont, par ordre d ' importance, la rougeole, le paludisme , les diarrhees , la malnutrition et les pneumopathies. Pour la meme tranche d'age, les causes de morbidite les plus frequentes concernent les affections respiratoires, le paludisme, les diarrhees, et les affections ophtalmologiques. * La couverture vaccinale contre le tetanos pour les femmes enceintes est tres basse, en 1992, 23,4% des femmes avaient requs au moins une injection antitetanique lors de la derniere grossesse. La meme annee, la couverture pour toutes les maladies cibles du PEV est tres faible: 17,4% des enfants de 12 a 23 mois (si l'on y ajoute le vaccin contre la fievre jaune. Ia couverture n'est que de 14,4%). * L'EDSN 1992 a fait ressortir egalement une prevalence contraceptive modeme tres basse, a peine 2,3%. * Au Niger, 32,1 % de la population vit dans un rayon de 5 km d'une formation sanitaire fixe, chiffre retenu pour representer la couverture sanitaire (cf. Tableaux en annexe). m:4exph\johanne\nigcr\heatlh2\Annex2.doc  ANNEX 3 Page I of 5 REPUBLIC OF NIGER HEALTH SECTOR DEVELOPMENT PROGRAM ORGANIZATIONAL STRUCTURE OF THE MOPH AND PROJECT MANAGEMENT AND COORDINATION La mise en oeuvre du Plan de Ddveloppement Sanitaire se fera par le Ministere de la Sante Publique (MSP) a travers ses structures administratives et fimancieres. La gestion du programme sera decentralis6e et concernera aussi bien le pouvoir de decision que celui de la gestion des ressources. Toutes les directions du MSP auront la responsabilite en ce qui les concerne d'exdcuter les activites qui sont de leur ressort. I. Ministbre de la Sante Publique Niveau Central Les directions du niveau central du MSP impliquees dans la mise en oeuvre du programme sont les suivantes: La Direction des Etudes et Programmation (DEP): a la responsabilite, en tant que charge de la planification et la programmation et coordination de toutes les activites du MSP et de leur suivi, d'assurer la coordination technique de l'execution du programme. Elle assurera la budgetisation des activites programmees dans le cadre du programme/projet. Au sein de la Division Planification et Relations Internationales, une personne est chargee d'entretenir des relations avec les partenaires exerSant dans le domaine de la sante. La Direction des Affaires Financieres et du Matdriel (DAF/M): qui a en charge la gestion du budget alloue au MSP, a la coordination financiere du programme et projet A travers le suivi systematique et la verification de toutes les operations financieres. Elle est composee de deux divisions. La premiere, la Division des Affaires Financieres assurera le suivi budgetaire et la comptabilisation de toutes les operations financieres du programme, I'acquisition des biens et la gestion du materiel et des equipements et des immobilisations. Quant A la seconde, la Division du Materiel, elle aura la responsabilite de la construction, de la rehabilitation et de l'equipement des infrastructures sanitaires pour lesquelles elle assure la maintenance et l'entretien. Dans le cadre du programme, elle aura la responsabilite d'elaborer et de passer les marches des hopitaux de districts et CHD et utilisera les services d'une agence telle que le NIGETIP pour realiser tous les travaux de construction et de foumiture en mobilier des Centres de Sante Integres (CSI). La Direction de la Formation et de la Gestion du Personnel (DF/GP): a la responsabilite de la formation du personnel A forner ainsi que la gestion et le recrutement du personnel additionnel necessaire pour la realisation du programme. La Direction de la Pharnacie et Laboratoire: a pour tache de mettre en oeuvre le Plan Directeur Pharmaceutique du pays et faire appliquer la poplitique pharmaceutique. L'approvisionnement en MEG des formations sanitaires sera assurer par cellule des medicaments essentiels de l'ONPPC. L'Inspection General des Pharmacies et Laboratoires: elle est charge du respect et de I'application et de la reglementation pharmaceutique. Coordination Nationale du Proiet: un Coordinateur National, relevant du Secretariat General, sera responsable de la realisation des activites quotidiennes du programme et de la coordinations de l'execution des composantes. De plus il assurera la liaison entre le Gouvernement et la Banque Mondiale. Le coordinateur national sera aide dans son travail par un conseiller, recrute sur les fonds du projet. Ce dernier aura pour tache de conseiller aussi bien le Coordinateur National du projet que  ANNEX 3 Page 2 of 5 1'ensemble du personnel technique du MSP sur tous les problemes de partenariat et de gestion du projet. Niveau Dtfpartemental Dans le cadre de la decentralisation des service, la Direction Departementale de la Sante (DDS) assurera l'execution et la gestion financiere du programme au niveau du departement. Ainsi la DDS sera renforce en ressources humaine, financiere et materielle. Un DDS-Adjoint sera charge en tant que coordinateur regional du projet, de l'execution et du suivi de tous les aspects techniques. La gestion financiere au niveau departemental du programme sera sous la responsabilite du chef service administratif et financier. 11 sera aide dans ces taches par un comptable recrute dans le cadre du projet. Ce dernier sera charge de la formation des gestionnaires des districts du ressort de son departement. Niveau District Le district sera le dernier niveau de la structure de gestion du programme, sous la responsabilite d'une equipe cadre de district, coordonn6e par un medecin-chef. Au sein de cette equipe le gestionnaire sera charge de la tenue des comptes, le suivi budgetaire du district et de la supervision des gestionnaires des CSI rattaches au district. Ce gestionnaire fera partie de l'Equipe cadre de district (ECD). II. Structures de Consultation Proposees Niveau Central Comite National de Sante: Ce comite est charge de toutes les questions de sante et de politique sanitaire du pays, il adopte les bilans d'execution, reoriente les programme et mobilise les ressources necessaires a leur realisation. Comite Technique National de Sante: Comite dirige par le Secretaire General du MSP, il a pour fonction d'examiner les rapports de suivi et evaluation et de preparer les sessions du Comite National de Sante. Niveau Departemental Comite Technique Departemental: Ce comite veillera a la mise en oeuvre du programme, determine les priorites et mobilise les ressources necessaires. Comite technique Departemental de Sante: Ce cornite developpe une approche integree de realisation des activites de sante, propose des reorientations et veille a l'execution du programme. Niveau District Comite Technique d'Arrondissement : Ce comite aura pour r6le de veiller a la mise en oeuvre du plan regional, de determiner les priorites, de participer et faciliter le suivi et I'evaluation du plan regional et mobiliser les ressources necessaires a la mise en oeuvre du plan. Comite de Sante de District :11 a pour fonction d'elaborer et de suivre l'execution du plan de developpement du district. II identifie les themes etet fait promouvoir la recherche operationnelle, participe a l'evaluation du plan et propose des reorientations. m:4exph/johanne/niger/health2/gestion.doc  Organigramme du Ministere de la Sante Publique DAF/M:Dir.des Affaires Financieres et du Materiel | s DEP: Dir.Etudes et Programmation Sante Pubiq DF/GP: Dir. Formation et Gestion Personnel PDHL: Dir. Pharmacie et Laboratoire DPS: Dir. Promotion Sante ONPPC InpenGenerale DSF: Dir. Sante Familiale de b Sanle ONPPC: Office National Produits Pharmaceutiques et Chimiques SNIS: Systeme National d'Information Sanitaire Sed bire | Secrebire | I G6 n6raIn It MSTaSIDA SNIS | Pro,e E.V. | DAF l l DEP l l DPS DFIGP DPHl DSF DPSA 0 Dv. Agaires Finandi res Dv Rech. Etud et Do Div.Fomnnain Sanitaire Dv. Formaton Dv. Approvisionnement Div SMI Dv. Assanssernent Di. Ma riel Dv. P anri 0 F io Div.Protedion Sanibaire Dv. Gesbon Personnelle. Di. Gesbon Conbacptis Dv. Sui Enant Div. EPS @ Dv. SWins hhmnier Dv. PharnL Tradinnele Dv. Nutlon Dv. Hygi ne Dv. Lutte Contre Maladies Div PF  Structure de gestion du Projet Secrn taire Ge ne ral! MSP Coordonnateur du projet CIonseiler Techvnique du projet DAF DEP DPS Division du Division Affaires DDS. Mate riel Financie res Spedaliste Passation Comptable des Marche s gestionnaire Equipement Ge nie DDS-Adjoint DDS-Adjoint DDS-Adjoint et mate riel Civil Diffa Tillabe ri Zinder Coordinateur Coordinateur Coordinateur DApa,tental . D$parterWtaf DNpw1enttaf Service Service Service financier financier finanrer Gsvi~%able lCcwabbrr Convtabie OQZ 0 '-'  ANNEX 3 Page 5 of 5 CURRENT STRUCTURE OF THE MINISTRY OF PUBLIC HEALTH Administrative Ministry of Health (MOH) LEVEL Division/ Subdivision Health Facilities Intersectoral Cornmunity Administration (pyramid of Coordination Participation services) Central Ministry Three national National Health of Health hospitals CENTRAL National (Lamorde, Niamey, Zinder) and other specialized centers Departmental Departmental Departmental |NTERMEDIATE Departmnent Bureau of MOH Hospital Center Technical (DDS) (CHD) and two Committee Matemities (COOTEDEP) Arrondissement Medical Medical Centers Arrondissement Various types of circonscription Technical committees Committee established by (COTEAR) differentprojects PERIPHERAL Commune Rural dispensarie Various types of city wrd committees dispensaries and established by Health Posts different projects Village or Village Health City Ward Committes  ANNEX 4 Page 1 of 1 REPUBLIC OF NIGER HEALTH SECTOR DEVELOPMENT PROGRAM Estimate of Additional Personnel by Level and by Category PROGRAMME | PROJET Theor Reel dWf. Depart Theor. Reel def. retraite >2000 M6dicaux & param6dicaux MEDECIN 265 198 67 4 6 14 0 MD CHIRUR. URG. 68 0 68 0 12 0 12 PHARMACIEN 18 15 3 1 3 0 3 INF.DIPLOME 1069 1154 0 16 171 126 45 AIDE-ANESTH. 96 17 79 1 12 3 9 AIDE-CHIR. 98 8 90 0 12 0 12 INF. SP 16 0 16 0 6 0 6 INF. STAT. 55 4 51 0 9 0 9 MANIP. RX 51 2 49 0 6 0 6 LABORANTIN 303 165 138 0 39 9 30 INF. CERTIFIE 1133 916 217 72 198 108 90 SAGE-FEMME 310 269 41 2 95 23 72 MATRONE 281 159 122 48 96 21 75 ss-total 3763 2907 941 144 665 304 369 Autres qualifications AGENT 162 153 9 2 31 18 13 D'HYG.ASSAINIS CHAUFFEUR' 494 244 250 83 122 33 89 CONTROL.TRESOR 47 8 39 0 6 0 6 CUISINIER 16 29 0 18 0 0 0 ECONOMISTE 10 0 10 0 2 0 2 GARDIEN 13 24 0 12 0 0 0 GESTION. 74 222 0 6 12 21 0 INGEN. (SANIT & 17 9 8 0 3 0 3 TECH.BIO.) MANOEUVRE 1005 983 22 386 160 85 75 PILEUSE 0 9 0 3 0 0 0 PLANTON 9 21 0 6 0 1 0 SECRET. 134 137 0 19 12 8 4 TECH.TP 109 50 59 6 27 3 24 TRAV.SOC. 263 418 0 2 31 68 0 ss-total 2353 2307 388 543 406 237 216 'Les besoins en chauffeurs sont artificiellement elev6s dans la mesure oiu il est prevu un chauffeur par CSI.  ANNEX 5 Page I of 1 REPUBLIC OF NIGER HEALTH SECTOR DEVELOPMENT PROGRAM Health Expenditures Table 1: Health and Public Expenditure 1991-94 (millions of CFAF) Puhlic Health 1991 1992 1993 1994 Actual % total 1-4 Actual % total 1-4 Actual % total 1-4 Actual % total 1-4 Recurrent expenditures 1. Wages 3,392 58.58 4,090 58.92 4,102 64.91 3,864 43.94 Number of Staff (5,371) (5,534) (5,727) (6,022) 2. Equipment 2,229 33.21 2,279 32.83 1,611 25.49 3,997 45.45 of which drugs /vaccines 1,006 14.99 1,348 19.42 943 14.92 2,961 33.67 3. Transportation 151 2.25 173 2.49 207 3.28 532 6.05 4. Student transfers 400 5.96 400 5.76 400 6.33 400 4.56 Total 1-4 6,712 100 6,942 100 6,320 100 8,794 100 Capital expenditures 5. Capital expenditures 3,097 2,749 4,632 9,678 --- Total 1-5 9,809 9,691 10,952 18,472 --- Total expenditures 110,700 104,100 101,600 160,000 --- Percent of health sector 8.86 9.31 10.78 11.54 --- Source: World Bank 1994. Table 2: Household expenditure on health and budget share. per annum. per capita Total Non-poor Poor Very Poor Urban Budget share in percent 4.0 4.2 3.9 3.3. Health exp. in CFAF 3,100 5,000 1,500 900 Population 1,377,400 658,400 719,000 363,600 Total Exp 4,371 3,292 1,079 327 . in CFAF million Rural Budget share in percent 7.5 7.2 8.2 8.1 Health exp. in CFAF 1,900 3,300 1,100 900 Total Exp. in CFAF 12,833 7,827 5,005 2,215 million Niger Budget share in percent 6.2 5.9 6.7 6.8 Health exp. in CFAF 2,100 3,700 1,200 900 Population 8,299,600 3,030,300 5,269,300 2,824,800 Total exp. in CFAF 17,203 11,119 6,084 2,542 million Source: ENBC 1993. m :4exph\johanne\niger\health2\annex l .doc  ANNEX 6 Page 1 of 13 REPUBLIOUE DU NIGER Washington le 13 juin 1996 NflNTSTERE DE LA SANTE PUBLIOUE SECRETARIAT GENERAL N: 0001/MSP/SG/Wash LE MINISTRE DE LA SAiNTE PUBLIQUE A Mr CHARLES P. HUMPHREYS Directeur pi Afrique Centre Ouest Banque Mondiale. Washington DC. 3bjet: Documents de politique sectorielle. Monsieur le Directeur, Dans le cadre de la mise en oeuvre du Programme de developpement pour le secteur sanitaire au Niger, jai I'honneur de vous transmettre les documents suivants: - Declaration de politique sectorielle de sante adopte par le conseil de Cabinet en juillet 1995 - les annexes relatifs: aux choix d'intervention dans les districts sanitaires a la strategie de developpement du secteur prive sanitaire a la gestion rationnneUle des ressources humaines du secteur sante. Tout en vous souhaitant une bonne reception de ces documents, je vou o sicur le Directeur, I'assurance de ma haute consideration U: 4 documents. AMPLIATIONS -MF/P - Mission Residente  ANNEX 6 Page 2 of 13 REPUBLIOUE DU NIGER Washington le 21 juin 1996 MINISTERE DE LA SANTE PUBLIOUE SECRETARIAT GENERAL N: 0002/MSP/SG/Wash LE MINISTRE DE LA SANTE PUBLIQUE A Mr CHARLES P. HUTPHREYS Directeur pi Afrique Centre Ouest Banque Mondiale. Washington DC. Objet : Documents de politique sectorielle. Monsieur le Directeur, Suite aux observations formule'es par I'Equipe sante lors des discussions techniques qui se sont tenues du 17 au 19 juin 1996, j'ai l'honneur de vous transmettre les documents ainsi amendes. II s'agit des annexes relatifs: - aux choix d'intervention dans les districts sanitaires * a la strategie de developpement du secteur prive' sanitaire