Senegal - Integrated Health Sector Development Program Project

Document of The World Bank Report No. 16756-SE STAFF APPRAISAL REPORT REPUBLIC OF SENEGAL INTEGRATED HEALTH SECTOR DEVELOPMENT PROGRAM August 8, 1997 Human Development 2 Africa Region  CURRENCY EQUIVALENTS (as of 02/15/97) Currency Unit CFAF CFAF = US$0.001675 US$1.00 = 560 CFAF WEIGHTS AND MEASURES 1 m= 1.09yd 1 m2 = 10.16 sq. Ft 1 kilometer (Cm) = 0.62 mile ABBREVIATIONS AND ACRONYMS AIDS - Acquired Immunodeficiency Syndrome CC - Consultation Curatives CHU - Centre Hospitalier Universitaire CONGAD - Conseil des Organizations Non Gouvernementales d'Appui au Developpement CPN - Consultations Prenatales CPR - Contraceptive Prevalence Rate DAGE Direction de L Administration Generale et de I 'Equipement DHS Demographic and Health Survey EDCP - Endemic Disease Control Project EVP - Programme Elargie de Vaccination FP - Family Planning GDP - Gross Domestic Product .IV - Human Immunodeficiency Virus IDA - International Development Association IHSDP - Integrated Health Sector Development Program IPM - Health Maintenance Funds MHIA - Mutual Health Insurance Associations MPHSA - Ministere de la SanA# Publique et de I Action Sociale NGO - Non-Governmental Organization NHDP - National Health Development Plan NHSAP - National Health and Social Action Plan NTP - National Training Plan ORT - Oral Rehydration Technique PDRH - Human Resources Development Project PHC - Primary Health Care PNA - Pharmacie Nationale d Approvisionnement PNDS - Plan National de D6veloppement Sanitaire PNPF - Programnme National de Planification Familiale PPF - Project Preparation Facility PTIP - Plan Trienniel d'Investissement Public SIP - Sectoral Invesment Program SNGE - Service National des Grandes Endemies SSU - Sector Support Unit STID - Sexually Transmitted Disease UNFPA - United Nations Fund for Population Activities USAID - US Agency for International Development WHO - World Health Organization FISCAL YEAR January 1 - December 31 VicePresident J.-L. Sarbib Country Director M. A. Ayub Technical Manager 0. Pannenborg Task Team Leader A. Bach-Baouab Task Team Assistant A.-S. Ville  REPUBLIC OF SENEGAL INTEGRATED HEALTH SECTOR DEVELOPMENT PROGRAM TABLE OF CONTENTS Page No. PROGRAMAND CREDIT SUMMARY .......................................................................................ii I. INTRODUCTION .1 A. Background and Strategy .1 B. The Sectoral Context .2 The Economic Situation .2 Demographic trends .3 Social Indicators .3 Sector Organization.4 C. Issues and Actions .5 Health Finance.5 (a) Government Expenditures .5 (b) Private Resource Mobilization .8 (c) External Aid to the Health Sector .10 Health Care Provision.10 (a) Primary Health Care .11 (b) The Hospital Subsector .11 Reproductive Health.12 Human Resources Development .13 D. Government Policies and Strategic Framework .13 The National Health and Social Action Development Plan .15 The Sectoral Investment Program Approach .15 Lessons Learned from IDA experience .16 Rationale for IDA Involvement .17 The Country Assistance Strategy .18 II. PROGRAMIMPLEMENTATION .19 A. Program Objectives and Strategy .19 Development Objectives.1. 9 Program Strategy . ................................................................................................................................................... 19 (a) The Reform Program ....................................................... 21 (b) Improved access to and quality of public health services .22 (c) Improvements in the management and delivery of RCH programs .24 (d) Strengthening the MPHSA institutional capacity .25 (e) Reorganization and reinforcement of epidemiological surveillance .27 (f) Improvement of the quality of life of deprived families and vulnerable social groups .28 III. COSTS, FINANCING AND SUSTAINABILITY 29 A. Summary of Program Costs .29 Sources of Funding ...31 B. IDA Credit Financing .31  IV. IMPLEMENTA TIONAND MONITORING ................................................................... 33 A. Implementation and Monitoring ................................................................................ 33 Multidonor Coordination and Aid Management ................................................................................. 33 Participation and Partnerships ................................................................................ 34 The Planning, Approval, Implementation and Monitoring Cycle ........................................................................... 34 Monitoring and Evaluation ................................................................................. 34 Program Management ................................................................................ 35 B. Procurement ................................................................................. 35 C. Disbursement ................................................................................ 40 D. Accounts, Audits and Reporting ................................................................................. 41 E. Environmental Impact ................................................................................. 42 V. BENEFITS AND RISKS .................................................................. 43 A. Benefits .................................................................................. 43 B. Risks ................................................................................. 43 VI PROGRAMDEVELOPMENT OBJECTIVESAND PERFORMANCE INDICATORS ..45 VII. A GREEMENTS REACHED AND RECOMMENDATION .............................................. 47 ANNEXES Summary of Economic Analysis Social Indicators Lettre de Politique Sectorielle IDA Supervision Plan Repartition of Health Infrastructure Guide des Operations de Partenariat avec les ONG Planning de Passation des marches Procurement Arrangements Monitoring Indicators Detailed Costs of the Program Organizational Chart of the Ministry of Health and Social Action Bibliography This report is based on the findings of an appraisal mission that visited Senegal in May 1997, comprised of Mnes/Messrs. A. Bach Baouab, Mission Leader; Linda English, Sociologist/Economist; Malonga Miatudila, Public Health Specialist; Serge Theunyck, Operation Specialist; Alassane Diawara, Operation Specialist; Bernard Abeille, Procurement Specialist; Abdou Salam Drabo, Participation Specialist; Yan der Horst, Public Health Specialist (Netherlands Cooperation); Jean Perrot, Economist (WHO); A. Pohto Ananpolo, Public Health Consultant, Matts Borgenvall, Public Health Consultant (Nordic Development Fund) and K. Kobler, Economist (KFW). The mission was also joined by Mmes/Messrs G. Borghese, Sall, Public Health Specialists (UNICEF); B. Floury, Public Health Specialist; Pascal Brouille, Economist, J.P Bettiga, Hospital Management Specialist (French Cooperation); G. Merrit HNP Officer (USAID); G. Desesquelles, Economist; P. Eerens, Public Health Specialist (E.U.); N. Lanbion (AfDB). Legal and disbursement support were respectively provided by Kishor Uprety and Wolfgang Chadab; support for Nutrition was by Tonia Marek, Public health and Nutrition Specialist ; report preparation was provided by Alex Norsworthy, consultant and Anne-Sophie Ville, Task Team Assistant; Willy De Geyndt, Xavier Coll and AnnTinker were the peer reviewers. Mahmood A. Ayub and Ok Pannenborg are the Country Director and Technical Manager, respectively.  SENEGAL INTEGRATED HEALTH SECTOR DEVELOPMENT PROGRAM CREDIT AND PROGRAM SUMMARY Borrower: Republic of Senegal Beneficiary: Ministry of Health and Social Action Poverty: Not applicable Credit Amount: SDR 35.9 million (US$50 million equivalent) Terms: Standard IDA terms with 40 years maturity Commitment Fee: Standard Financing Plan: See Schedule A Program Objective: The purpose of the Credit is to provide support for the implementation of the Government's Integrated Health Sector Development Program (IHSDP). The program objective is to: (a) improve the management and financial viability of the public health system; (b) improve access to quality health care for the vast majority of the underserved and vulnerable groups in urban and rural settings; and (c) contribute to fertility decline and reduce the high population growth rate by improving the management and delivery of reproductive health services. Program Description: The Credit will support a broad sector expenditure program to cover an initial five-year period (1998 to 2002) of Senegal's ten-year National Health Development Plan (NHDP) which has been adopted by the Government as the main conduit for its efforts to expand the population's access to public health care and to improve the health system's financing and management. The Government has approached IDA and other donors to jointly support the IHSDP. The proposed Credit would thus complement other donors' contributions to the sector and help finance the gap in IHSDP funding requirements. The SIP initiative: The Sectoral Investment Programm initiative adopted for the IHSDP emphasizes a continuing policy dialogue and phased funding, based on yearly operational plans financed with other bilateral and multilateral organizations, eligibility criteria for program resources and sectorwide performance indicators. It is based on a three-year rolling expenditure plan. IDA credit disbursements can be made against any of the IHSDP components after the Bank is satisfied that resources are available for all critical activities. This would be achieved through joint Government/Donors annual implementation reviews. The annual operational plans and budgets would cover both the investment and the recurrent costs. The operational plans cover policies, priority actions and measurable targets for that year. The IDA Credit would finance investment spending, and reimburse a specific share of recurrent expenditures for that year. The MHSA's capacity for joint annual programming and budgeting has been demonstrated throughout the NHDP and IHSDP design process and more particularly during the donors' round table meeting held on May 2, 1997 and subsequent program  ii appraisal conducted from May 26 to June 11, 1997. The IHSDP covers the following general areas: (a) strengthening and expanding health care coverage through the renovation of some of the existing Primary Health Care facilities and construction and equipping of new ones in underserved periurban and rural areas and basic improvements in infrastructure, equipment replacement and bio- medical supplies for district, regional and national hospitals in order to reinforce the quality of referral care and enhance the credibility of the PHC network; (b) enhancing effectiveness and efficiency in the management and provision of ambulatory and in-patient care through the development of treatment guidelines, training of medical, paramedical and management personnel and the provision of shortterm expert services and teaching aids; and (c) developing the institutional capacity of the Ministry of Health in the management and monitoring of health interventions at all levels of the system. The program would also provide support to help promote community involvement in health care management and the participation of the private sector and NGOs in the promotion and delivery of health and family planning information and services under contractual arrangements with MHSA. In addition, it intends to support Government's efforts to mobilize alternative resources for health sector financing through better regulation and monitoring of the health insurance system, and the promotion of community cooperative health insurance schemes. Benefits & Risks: Major benefits include a better managed and more efficient public health system; improvement of the health status of the population; better maternal and child health and a reduction in preventable infant and maternal deaths and lower fertility and population growth rates. The main risks are: (i) continuation of a weak implementation capacity at the MHSA and difficulties in attracting and maintaining critical staff in the regions, reduced by recruitment and training measures adopted by the MHSA; (ii) devolution of health administration to local government without adequate preparation which could slow down program implementation. This risk will be alleviated through better articulation of the roles of regional and local institutions promoted by the general decentralization reform and existing decentralized entities of the MHSA; (iii) uncontrolled increase in health expenditure and unforeseen economic difficulties which could jeopardize the financing and sustainability of health services; and (iv) a slower than expected change in sexual and fertility behavior among the population. The likelihood of occurrence of these risks is minimized by limiting program interventions to core investments and rationalizing health expenditures and incremental recurrent costs; providing training and technical assistance; and by better targeted information, education and communication campaigns and consistent monitoring. Environmental: The handling and management of medical waste and hazardous materials were assessed during program preparation and specific recommendations for incinerators, fire protection and waste disposal will be drawn up for health facilities construction. All program-financed construction would include drainage, solid waste disposal and sanitary facilities. The program will have no negative effects on the environment but will contribute to reducing environmental risks. Economic Rate Not applicable. of Return Map IBRD 28941 Project ID SE-PE-2369  Estimated Costs of the Sector Investment Program US$ millions (equivalent) 1998 1999 2000 2001 2002 Total % of _______ ~~Total Investment 17.71 25.74 23.00 20.36 20.36 107.16 31.2 Recurrent expenditures 30.79 32.60 34.40 37.23 40.32 175.35 42.7 Personnel 23.56 24.55 25.5 5 26.57 27.59 127.82 26.1 Total 72.07 82.88 82.95 84.16 88.27 410.33 100.0 Estimated Financing Plan (US$ million equivalent) Government Population Local Communities Donors Total % nvestment 19,066 8.6% 0 0.