Policy, Research, and External Affairs " WORKING PAPERS Population, Health, and Nutrition Africa Technical Department The World Bank August 1990 WPS 488 Prepaid Financing of Primary Health Care; in GuineamBissau An Assessment of 18 Village Health Posts h Per Eklund and K't Knut Stavem Flat-fee prepayment may be the only feasible cost recovery scheme for primary health care in rural villages of Guinea- Bissau. The level of satisfaction was high in this simple prepayment scheme for drugs and limited primary health care in 18 villages. In a larger health system or an urban area, it might be more difficult to administer such a scheme and to prevent abuse of the system. The Pohcy.Research. and Extemal Affairs Complcx diStnhnuiS PRI- WorkingPapcrs todLsseminatethefindings of work inprogress and to encourage the exchange of ideas among Hank staff and al others interested in dc%clopencnt issues 'These papers carry the names of the authors, rerlect rnly their vicws, and shoold he used and cited accordingly The findings, interpriauons, and conclusions are the authors own. They should not be attnbuied to the World Hank, its Hoard of Directors, its managetment. or any of its member counties. Policy, Research, and External Affairsj Population, Health, and Nutrition j WPS 488 This paper - a product of the Population, Health, and Nutrition Division, Africa Technical Department - was written as part of the Africa Regional Study on Health Financing, with financial support from NORAD and SIDA. Copies are available frce from the World Bank, 1818 H Street NW, Washington DC 20433. Please contact Karol Brown, room J9-112 extension 35073 (50 pages, including tables). With population growth increasing and budgets service, with drugs more readily available and declining, the need for cost recovery in health midwives better trained. care has grown. Eklund and Stavem report on a prepayment scheme for drugs and limited Still, the quality of service at village health primary health care at 18 village health posts posts can only be as good as the support they get (USBs) in Guinea-Bissau. from the rest of the health care system. Authori- ties must strengthen health center support At these health posts, adverse selection was services and improve the drug resupply system. reduced because enrollment in each village was Workers at each post could also use bicycles - almost universal. The villagers provided con- which might be offered through an incentive or struction materials and labor - and indicated credit scheme. their willingness to pay more if drugs were available on a timely basis. (Drugs are heavily Flat-fee prepayment may be the only feasible subsidized, and supplies rapidly depleted.) cost-recovery scheme at the village level. In a larger health system or in an urban area, it might Despite rapid depletion of drug stocks, the be more difficult to administer such a scheme levei of satisfaction was high. Villagers' will- and to prevent adverse selection and overuse of ingness to prepay was often linked to better services. The PRE Working Paper Series disseminates the findings of work under way in the Bank's Policy. Research, and Extemal | AffairsComplex. Anobjective oftheseries is to getthese findings outquickly, even if presentations are less than fully polished. I The findings, interpretations, and conclusions in these papers do not necessarily represent official Bank policy. Produced by the PRE Dissemination Center TABLE OF CONTENTS Acknowledgements ............... iii Abbreviations ............... iv I. Introduction .1 II. An Overview of the Country and the Health Care System. 4 The Country and the Economy. 4 The Health S>stem. 6 Health Finance. 9 Resource Mobilization through the USs .11 III. The Survey of Village Health Posts .14 Objectives and Methodology .14 Prepayment Schemes .17 Levels of Cost Recovery ................................... 20 Drug Availability and the Quality of Care .22 Determinants of Utilization of USB Services .23 Evolution of Prepayment Rates .25 IV. Conclusions and Recommendations .28 References ........ 32 This study was conducted as part of the Africa Regional Studies Program on Health Financing in Sub-Saharan Africa, managed by the Africa Technical Department, Population, Health and Nutrition Division, with financial support from NORAD and SIDA. - ii - TABLES 1. Vital Statistics, Guinea-Bissau, 1988 2. Health Facilities and Beds by Facility Category 3. Consultatioas at USBs by Type of Illness 1988 4. Distribution of USBs and Village Health Agents by Region 5. Coverage of USBs by Region 6. Public Health Expenditure, by Source and Budget Type 1988 7. Drug Prices 8. Ministry of Public Health Expenditure Allocation 9. Subsidies and Costs for Drugs per 100 Persons, Based on an Estimated Consumption for 6 months 10. Basic Data for Surveyed Regions 11. Sample of USBs by Regions 12. Population and Ethnicity of Survey Villages 13. Characteristics of USBs 14. Prepayment Systems 15. Drug Consumption 16. Level of Subsidization at the USBs, 1988 17. Supervision Visits and Drug Supply 18. Availability of Drugs in Surveyed USBs 19. Perceptions of Change in Quality 20. Visits to USBs and Distance to Nearest other Provider 21. Comparison of Prepayment Rates 1988-89 22. Major Problems Reported - iii - Acknowledgements the survey of 18 health posts was set up and executed in cooperation with officials of the Ministry of Public Health (MINSAP) over a period of three weeks in June-July 1989. In the execution of the Study, the assistance of MINSAP and its personnel is gratefully acknowledged. Our thanks are especially directed to Mr. Augosto Silva (Coordinator of USBs), Dr. Kaymah, and Mr. Estevao. We also acknowledge the assistance of Dr. Erling Larsson (WHO's Drug Action Program in Guinea- Bissau), Dr. Olle Liungman, Mr. Alberto Zamberletti, and the Swedish International Development Authority, which provided a vehicle for local transportation. At the World Bank, the support is acknowledged from Ishrat Husain, Martha Ainsworth, Carol Hoppy, Eugene Boostrom, A. Edward Elmendorf, and Emmerich Schebeck. - iv - Abbreviations MINSAP Ministry of Public Health PG Guinea-Bissau Peso USB Health Post (Unidades de Saude de Base) VHW Village health worker WHO World Health Organization Chapter I Introduction 1.01 The following are the findings from a study of a prepayment :.eme for drugs and limited primary health care at village health posts (USBs) in Guinea.-Biesau. The goals of the study were to assess how the scheme functions, its benefits and its contribution tc health finance in Guinea-Bissau. 1.02 One of the most important issues for African governments is how to finance the expansion of health care and improvement in the quality of services. The inadequacies of current public health care systems, combined with rapid population growth, have highlighted the need for additional resources to satisfy basic health needs. But in an era when economic growth rates are either low or negative, and when government budgets are no longer expanding and allocations to the health sector may be shrinking in real terms, merely maintaining the existing level of services out of existing revenue sources--let alone increasing them--is virtually impossible. Against this background, authorities must find ways to improve the use of available resources and mobilize additional resources. As a result, there is increasing interest in the concept of cost recovery. 1.03 One form of cost recovery is a prepayment scheme, in which healthy participants pay a premium ir advance, for which they receive free or reduced cost health care in the event they fall ill. By pooling risks, such schemes prevent the financial catastrophe that may result from illness or injury. Moreover, they are an equitable way to pay for care since the cost of treating illness is spread evenly over both the sick and healthy. Further, prepayment plans (as opposed to fee-for-service) permit funding of community health education on subjects such as family planning and nutrition, as well as of 2 curative care. Finasly, these plans are interesting in that, in principle, they could be designed to introduce a degree of progressivity, so those with higher incomes could bear a greater share of the cost. 1.04 These advantages must be weighed against several potential drawbacks. First, prepayment plans may raise the bill for medical care, because they are costly to administer. In the same vein, there is the related problem that actuarial principles need to be applied to set appropriate prepayment levels, so the scheme can be financially sound. However, because the information needed to do this is lacking in many African countries, rates would have to be set without adequate data, introducing substantial risk on the part of the insurer. 1.05 Second, the management of such schemes usually requires a minimum, and in some cases, sophisticated level of administrative skills which are often in short supply in low-income countries. should be noted that the handling of user fees--particularly exemntion programs designed to help the poor--requires a certain level of administrative skills, as well). 1.06 Third, prepayment schemes may elicit two additional problems, adverse selection and *moral hazard., Adverse selection occurs when more patients with greater health problems (or those at greater risk) selectively enroll. Moral hazard occurs when patieats who have prepaid use more services than they need because there are few ways to penalize what could be considered "overuse., However, one way to avoid the latter problems is for health providers to require deductibles or minimal co-payments from insured patients for the use of services. 3 1.07 Finally, although prepayment plans can effectively pool the risk of high medical costs across healthy and sick individuals, they do not necessarily improve the availability of health care to the very poorest people. The most destitute in society can not afford user fees; neither are they likely to be able to afford prepayments or insurance premia. 1.08 Recently, community-level insurance schemes controlled by local. authorities and financed/administered either by villages or rural health care providers have begun to attract attention. First, these programs have the potential to reduce adverse selection, since it is possible to obtain universal enrollment (in each village). Second, their revenues might be more easily shielded from ministries of finance and centrally placed authorities who have been known to use these funds for other governmental programs. Until now, few data were available on the operation and performance of such community-based prepayment schemes in Sub-Saharan Africa. It is hoped that the experience of prepaid financing of primary health care and the dispensing of drugs in Guinea- Bissau described here will provide some lessons and guidelines that can be applied elsewhere. 4 Chapter II An Overview of the Country and the Health Care System The Country and the Economy 2.01 Guinea-Bissau is a small country on the west coast of Africa with an area of 36,125 square kilometers and a population estimated at 950,000. Eighty percent of the population is rural, located in villages of between 100- 1,000 inhabitants, with an average size of 300. Roughly one-third of the land area is swamp or waterway, making many villages difficult to reach. The 1979 census recorded 33 ethnic groups (the largest being the Balantas, Fulas, Mandingas and Mandjacos). 2.02 The country is divided into eight regions (Biombio, Cacheu, Oio, Bafata, Gabu, Tombali, Quinara and Bolama), districts and villages. The most decentralized political and administrative structure is the village committee, which consists of five members--generally three men and two women--el;cted by the villagers. It functicr;s as an intermediary between the central government and the villagers. Important issues are discussed in village-wide meetings, called "general assemblies." 2.03 Economic activities in Guinea-Bissau are largely subsistence based. Favorable natural resources include rich coastal waters, uncultivated arable land, dense forests and mineral deposits. Yet, with an estimated 1988 per capita income of about US$160, the country is among the poorest in the world. The large rural sector produces primarily for self-consumption. Agriculture, fisheries 5 and forestry account for sbout 90 percent of employment and an estimated 50 percent of GDP. Marketed output is largely confined to export crops, primarily cashews, groundnuts and palm kernels. Rice is the main food crop. In the 1950s, Guinea-Bissau was a net exporter of rice (around 40,000 tons a year), but since 1962, the country has relied on imports to supplement domestic production. 2.04 Guinea-Bissau is entering the second phase of a structural adjustment program. Economic growth ha; improved in recent years, with an annual growth rate of over 4 percent since 1984 (except for 1986). The government expects that growth will continue at 4-5 percenit a year in real terms and that inflation rates will drop. Production, especially in agriculture, is expected to increase as a result of improved incentives, but performance is constrained by very limited transport infrastructure, credit and extension services. Between May 1987 and the end of 1988, the Guinea-Bissau peso (P.G.) was devalued by over 400 percent. A reliable price index for inflation is unavailable, but food prices are estimated to have risen by 120 percent in 1986, 110 percent in 1987 and 80 percent in 1988. 2.05 Demographic and social indicators place the country among the werld's poorest: Life expectancy at birth is only 39 years,compared to 42 and 48 in neighboring Guinea and Senegal, respectively. Infant mortality is estimated at between 180-200 per 1,000 live births and almost one third of all children die before the age of five (see Table 1). Studies conducted between 1982-1984 found that 16-35 percent of the children surveyed were malnourished. The most common health problems are malaria, diarrhea, upper respiratory infections, measles, tuberculosis, neonatal tetanus and malnutrition. 6 The Health System 2.06 Health care services are offered at national, regional and district hospitals, at health centers (clinics) and at community-managed village health posts (USBs) (see Table 2). Private hospital care is not available. The country receives substantial aid from foreign governments as well as from non- governmental organizations (NGOs), which support the government-managed health care institutions, 2.07 Tertiary health care is provided in two national and four regional hospitals. Basic health services are provided in district hospitals and health centers. The 12 district hospitals have catchment populations of 20,000-50,000. The 121 health centers treat outpatients only and have catchment populations of 5,000-12,000. Oio, Bafata and Biombo Ere the most disadvantaged regions. 2.08 TIere are 450 village health posts (USBs), wiiich form the base of the health care structure. Their creation reflects the goals of the 1976 National Health Plan, which emphasized the decentralization of services, preventive care (without neglecting curative services), the use of simple techniques and practices and education for health personnel, including village health workers (VHWs) and village midwives who form a volunteer staff. Although they receive assistance from the Ministry of Health in the form of construction materials, an initial stock of drugs, supervision and training, the USBs are entirely locally-managed and staffed. 2.09 USBs administer simple treatments and basic drugs. They are located 7 in standard tvo-room structures constructed of local materials (generally dried zw..d on a frame of branches or mud bricks), with one room for 'general receiving' and a second 'or prenatal care. The inventory of drugs at the USB is restricted to 12 essential items and bandage materials. The six most common conditions/diseases treated at USBs are malaria, diarrhea, conjunctivitis, cough, pain and wounds (see Table 3). Table 3: Consultations at USBs by type of illness (1988) Tombali Pitche Sum Percent region sector* -------------------------------------------- Malaria 10843 12072 22915 27 Conjunctiv. 6076 4995 11071 13 Diarrhea 5323 2429 7752 9 Cough 5429 3609 9038 11 Wounds 7429 3002 10431 12 Pain 10246 9731 19977 23 Other 2164 1707 3871 5 Total 85055 100 *In Gabu region Source: Service statistics 2.10 The USB is normally staffed by at least one VHW and one midwife, if not more, selected by the village political committee. Midwives, who are drawn from among the traditional birth attendants, provide prenatal care and perform deliveries. Most midwives and VHWs have little or no education (as is the case vith the vast majority of the rural population) and they are trained for 15 days by nurses at the health centers and district hospitals. These individuals are not paid in cash or in kind for their time but they enjoy prestige and,in some villages, may be helped by other villagers with their agricultural activities, 8 such as land clearing and/or harvesting. By the end of 1988, 1,560 VHWs and 1,200 midwives had been trained (see Table 4). The 15-day introductory course is supplemented by an annual 5-day refresher course. 2.11 The USB is open two hours each morning, but closed in the afternoon to allow the staff time to work in the fields or perform some other occupation to earn a living. If more than one villager is trained for each category of staff (VHW or midwife), these individuals rotate shifts. However, when the USB is closed, the VHWs and midwives are regularly on call. Complicated cases are referred to health centers and district hospitals. However, USBs often may be quite far from these referral centers and some of the most severe cases may require ambulance services, which are scarce. Nurses from the health centers and district hospitals sometimes provide intermittent support to the villages to assist with immunization programs and some provide maternal and child care services. 2.12 Approximately 220,000 people or roughly 20-25 percent of the population live in villages with USBs (see Table 5). However, the proportion of population covered varies among regions: For example, no USB has been established in the Biombo region, while at least 56 percent of the population in the Gabu region are serviced by village health posts. 2.13 Qualified health personnel in the rest of the system are scarce. Current staff ratios are below the norms except for medical doctors in the tertiary care system (national and regional hospitals) and auxiliary nurses at the health centers: In the district hospitals, there are 1.3 physicians on 9 average per facility, against a norm of 2.7, and only 1.3 registered nurses on average, opposed to a norm of 5.3. In the health c,nters, there are just 0.5 registered nurses cn average, compared to a norm of 1.1. This means that one out of every two health centers is without a qualified nurse. 2.14 Regional imbalances exacerbate the ratios further: In 1987, there was one physician per 7,440 inhabitants nationally, a doctor/population ratio that exceeds WHO recommendations. In Bissau, the capital, the ratio was one per 2,450 while in the rest of the country the ration was one per 13430. The most disadvantaged regions were Biombo (one physician per 66,900), Oio (one per 53,430) and Tombali (one per 33,450). Health finance 2.15 Domestic funding for health care is very limited and is declining in both absolute and relative terms. The Ministry of Public Health (MINSAP) has become increasingly dependent on foreign assistance, a situation that does not promote stability and sustainability of drug supplies and essential programs: available data suggest that in 1982, one third of the total public expenditure for health (US$7 million) was from outside sources (2). By 1988, however, foreign assistance (amounting to US$13.4 million) was covering 97 percent of the capital budget and at least 76 percent of the recurrent budget (see Table 6) External support for primary health care, including the USBs, is provided by UNICEF,bilateral donors and several NGOs. 2.16 A recent report estimated actual cost recovery of total health 10 expenditures in 1988 at US$9,448, or 0.5 percent of MINSAP recurrent expenditure (3). The largest sha;e of these receipts (38 percent, or $3,623) were generated through prepayment collections at the USBs. The remainder was generated through user fees at health centers (32 percent) and hospitals (30 percent). Revenue from user fees is not retained at the collection point, but is forwarded up through the system into an account at the Ministry of Public Health, to finance the recurrent costs of the USB program. 1 2.17 When viewed against total expenditures, cost recovery seems insignificant. There are several reasons. First, fees in the health care system have become almost negligible in real terms. For example, the current fee for a consultation is P.G.100 at national and regional hospitals. P.G. 50 at district hospitals and P.G. 30-50 at health centers. These fee levels were set in 1978 and have not been adjusted, despite annual inflation of about 100 percent from 1986-88 alone.2 To put these figures in perspective, in July 1989, the price of a chicken in the rural locations visited by the survey team ranged from P.G. 4,000-6,000 and one kilo of rice cost about P.G. 1,000. Second, few patients pay fees, because at least 50-60 percent of all visits are exempt for paying: for example, government employees, children under 15 and pregnant women are exempt. Further, referral visits to higher level facilities are free. 2.18 A proposal to increase fees by 600-1,000 percent was made in 1988, 1 This has been the case for the past two years; prior to that time, user fee revenue was sent to an account in the Treasury (Dr. Erling Larsson, personal coamunication). 2 At 1989 exchange rates, these fees are the equivalent of US$0.05, $0.025 and $0.015-0.025. 11 but was never approved by the General Assembly. In addition, the exemptions listed above would have continued. These exemptions should be limited to the most destitute; groups able to pay (such as government workers) should not be exempt. 2.19 In principle, drugs are free for patients admitted to hospitals, to hospital-based ambulatory care and to health centers. However, because drugs and dressings are reported to be scarce in the health care centers, patients must often buy their medications and supplies at local pharmacies where prices range from 2 to 15 times those of competitive international rates (see Table 7). Since MINSAP spend only 7.1 percent of its total budget on drugs, scarcities are not surprising (see Table 8). 2.20 MINSAP obtains most of its drugs as donations from donor organizations. Drug purchases by MINSAP occur mainly through the parastatal organization, Farmedi, which is also respc.Asible for dispensing drugs to the Hinistries of Rural Development and Fisheries. Farmedi operates a chain of about 10 pharmacies, three of which are located in Bissau (4). Farmedi drug prices are high; they include import duties, taxes, interest payments and a 20 percent profit margin. The few private pharmacies that exist are scattered. Resource Mobilization through the USBs 2.21 The USB system is based on community participation and involves considerable local resource mobilization. A contract between the village leaders and the Ministry of Public Health defines responsibilities as the following: 12 1. The village provides the labor and most construction materials for building the health post. MINSAP provides materials for windows, doors, and hinges. 2. The government supplies simple equipment, including a metal cupboard for storing drugs, a bed, stretcher, four chairs, one obstetrical stethoscope, one lantern, a kit of posters and other teaching aids, and an initial stock of drugs estimated to last for six months (for the population of each village). 3. The village must collect funds under the prepayment system to ensure that the initial drug supply is continually replenished. 4. The village decides on the fee levels for the prepayment scheme, whether payment is based per capita, per adult or per household, and the timing of payments. 5. The village selects one or more of its residents to be trained as VHWs and midwives. 6. Some villages create special health subcommittees to oversee USB operations, but in the smaller villages, the responsibilities are performed by the political comuittee. 2.22 Funds are collected at USBs by the village committee treasurer or 13 one of the health staff and a record of the contributions is kept in each village. The funds are then transferred through the regional health directorate to Bissau, where they are deposited into a special account earmarked for recurrent costs for the USB p;ngram. 2.23 Drugs are sold to USBs with substantial subsidies, set at the central level and equal across regions. Drugs are bought by the government with foreign exchange; the rate of subsidy has increased sharply because drug prices to USBs have remained constant, despite rapid depreciation of the local currency (by over 400 percent between May 1987 and the end of 1988, and then continued in 1989). For example, at 1987 exchange rates, the subsidy on US drugs was 60 percent; but by 1989, essential drugs at the USBs were subsidized by at least 90 percent because of the depreciation of the peso against the dollar.3 In 1989, the USBs were charged a cost for the different drugs that ranged from 1-33 percent of current competitive international prices (see Table 9). 3 The average exchange rate in 1988 was P.G. 1,120/$l; in July 1989 it has risen to P.G. 1,970/$l. 14 Chapter III The Survey of Village Health Posts Obiectives and Methodology 3.01 The objective of the 3-week field survey in June-July, 1989, was to gather information on the prepayment schemes and their potential for mobilizing more resources for the health sector. The survey attempted to explore the folloving: 1. Physical conditions of USBs, staffing patterns and availability of drugs; 2. Community perceptions about health status; 3. Frequency of visits to USBs, trends in utilization and in quality of services; 4. Extent of participation in each village studied, use of co- payments, and trends in prepayment rates; 5. Actuarial soundness of the system; and 6. Level of subsidization and cost recovery. 3.02 Two questionnaires were designed in Guinea-Bissau, approved by MINSAP's USB coordinator and field tested during the first round of interviewing in the Oio province. One questionnaire was used to interview groups of village inhabitants. It solicited data on village characteristics, preferences for health care, decision-making mechanisms, the structure and frequency of prepayment of fees and community willingness to pay. A second questionnaire vas 15 administeced to VHWs and midwives to gather information about these health workers, as well as on the physical structure of the USB and on the stock of drugs. In addition, a number of individual interviews were conducted with village residents to obtain demographic data, and information about the drugs used and preventive health measures taken.4 3.03 In order to survey as diverse a population as possible, the administrative regions of Oio, Tombali and Gabu--located in different parts of the country--were selected, as they represent various ethnic groups, religions and cultivation practices. These three regions contain 295 USBs, or 66 percent of the total (see Table 10). 3.04 On average, 35 percent of the population in these regions live in villages with USBs, although inter-regional variations are substantial: For example, in Tombali and Gabu, at least 42 and 56 percent, respectively, have access to USBs. In Oio only 14Z of the population is covered. In all three regions, villages with USBs are larger on average than the typical Guinea-Bissau village, this is particularly noteworthy in the region of Gabu, where the average village had 185 inhabitants but the average village with a USB was three times as large (555). 3.05 It was decided that the sample would include villages that were reasonably accessible and which contained USBs established before. Most 4 A detailed questionnaire for household interviews had originally been prepared to obtain information on households' ability and willingness to pay, frequency and number of visits to the USB. Given the limited time, however, this questionnaire was not used. 16 important, the villages were chosen out of the population of USBs wfere the prepayment scheme had been operating for at least six months. Based on these criteria, 18 villages were sampled: six were selected at random from each of the three regions. Two of those initially chosen were replaced because they were too remote to visit in a reasonable amount of time. Only villages with USBs were visited; the characteristics of villages without health posts are not known. The villages sampled in Oio represented 14.6 percent of the region's population; in Tombali, the figure was 5.9 percent and in Gabu, 4.9 percent (see Table 11). The 18 USBs sampled represent 6.8 percent of all USBs established in the three regions before 1988. In two of the three, the villages visited were larger than the average village with a USB: in Oio, three large villages had 1,200-1,600 inhabitants. 3.06 There were an average of 540 permanent residents in the 18 villages surveyed (see Table 12), although during the wet season some experience a temporary influx of agricultural workers to harvest crops. The survey captured a wide ethnic diversity, reasonably representative of rural villages across regions. The two large muslim ethnic groups, the Fula and Mandinga, accounted for 44 percent of the population in the villages sampled, but only 35 percent of Guinea-Bissau's total population, based on the most recent census (1979). The remaining groups are predominantly animist. Ten of the villages were ethnically homogeneous. 3.07 Once the study team arrived in the villages, they explained the purpose of the visit and the method by which villages were selected. They stressed that the village had not been chosen because of any particular 17 characteristic. A group of five villagers were selected which included at least two women (with the exception of two villages). At least one representative of the village political committee, and usually the president or treasurer was present during the group interview, although this individual was generally not questioned. Each respondent was asked to answer the questions, without assistance or coaching, and responses were recorded; later, an average was calculated for each group or village. 3.08 The group of 2-4 VHWs and midwives was interviewed by the medical doctor on the study team. After this, the physical condition of the USB structures was evaluated and the stock of drugs was recorded. Prepayment Schemes 3.09 Organization and management. USB structures in the sample were an average of four years old, with a range in age of from two to ten years (see Table 13). Only 4 of the 18 buildings visited were in less than satisfactory condition. In general the buildings were clean and very well maintained. On average, each USB has a volunteer staff of three midwives and three VHWs, wh!.le the minimum found were two midwives and one VHW. Both categories average 1.1 per 100 inhabitants, although the range is wide--0.3-5.0 midwives per 100 inhabitants and 0.1-6.7 VHWs. 3.10 Prepayment terms. Rates and methods of prepayment vary substantially among ivillages, suggesting a high degree of autonomy at the village level in determining the payment structure (see Table 14). For example, in 1988, annual 18 fees per adult male varied from P.G. 20- 500, with a mean of P.G. 203.4. S The average annual collection per capita, in 1988. based on total population in each village, was P.G. 181, with a range of P.G.28-981. The collection effort in 1 of the 18 villages was extraordinarily high, P.G. 981 per capita P.G. 1,400, per capita when collections of agricultural produce are included. This village apparently served as a model and visitors were oftei taken there. 6 Adults usually contribute to the prepayment plan twice a year and are given receipts that serve as proof of membership and entitle them to free drugs and services at the time of each visit. The VHWs normally keep a record of visits and payments, but midwives also assist in this function. In 10 of the 18 villages, the prepayment rates are the same for men and women. In four, the rate is lower for women than men. In two, only men pay. In another two, the rate is fixed per household. In one, the rate is fixed per married adult, and single adults pay a lower rate. Prepayments are assessed on children in only two villages. Only one village charged a copayment for each visit to the USB, which was P.G. 50 (or 25 percent of the annual rate for adult males and females). 3.12 Some villages made in-kind contributions of agricultural produce. In 1988, four contributed the value of a crop, produced through joint labor on a common field. In addition to supplementing the funds collected to buy drugs, these contributions have been used to finance other community needs, such as the construction of a tin roof for the USB building, or to provide assistance to the 5 In mid-1988, P.G. 350 was equal to US$0.31, but had depreciated by July, 1989 to US$0.18). 6 Because this village was so atypical, some of the analyses for the survey were confined to the remaining 17 villages, where the collection effort is more the *norm." 19 poor and sick in the village. 3.13 Participation in the prepayment schemes is high above 9go on average. In half tho villages surveyed, all households were participating. In tho rest. the portion not participating was about 10 percent of the population, although in one village. 30 percent did not participate. Explanations for non- participation were not obtained. Those residents not participating are allowed to obtain drugs once or possibly twice, but are then required to join the scheme, unless they are destitute or sick. Residents from nearby villages that do not have US8a are normally permitted to obtain drugs in emergencies. 3.14 Community control of USBs is strong and prevents abuse of the system (i.e., hoarding drugs for future use or sale on the black market). The village political committee, through its president or treasurer, normally supervises USB operations, and village inhabitants are known to each other. Also, VHWs closely moitor the dispensing of drugs based on the illness diagnosed. This kind of control possibly explains why there is apparently no excessive demand for drugs. Hoarding of drugs was not mentioned during the interviews as a problem. 3.15 Prepayment levels in the USBs surveyed exceed the price of seeking care directly at health centers. The mean number of visits to health centers Is 2.4 time a year. The consultation fee in health centers presently ranges betw en P.G. 35-50 per visit (an amount that considerably understates the complete treatment costs). Thus, someone visiting a health center would pay (in theory) a total of P.G. 120 a year. But since about half of those presenting themselves are exempt from payment, per capita charges fall to about P.G. 60 per 20 year. Nevertheless, the fees at the health centers have remained fixed since 1978, and have declined dramatically in real terms. Raising the fees and tigntening exemptions would improve cost recovery at health centers and raise the incentives to use USBs. 3.16 The spread between prepayment levels and fees for service at referral centers (when they are nearby) reduces the incentive to join the prepayment schemes. It must be noted, however, that although those paying the consultation fee at the health centers are entitled to free drugs, these are rarely available and patients often pay high prices to obtain drugs at distant pharmacies. Levels of Cost Recovery 3.17 The level of cost recovery per capita for 1988 in our sample of 18 villages was P.G. 181, or US$0.16; when the village with exceptionally high fees is excluded, the average was P.G. 134, or US$0.12. MINSAP has made independent estimates of drug consumption at the level of USBs by region (see Table 15). This estimate is based on recorded deliveries and is assessed at lowest international price: actual purchase data were not available. This comparison shows that the cost of drug consumption at the level of USBs in 1988 was US$0.14 in Oio and US$0.22 in both Gabu and Tombali. Our sample estimate for cost recovery of US$0.12 to 0.16 is at the lower end of the range found. 3.18 The total recurrent cost to the government of servicing a USB village of 400 inhabitants in 1988 (in 1988 prices) is estimated at P.G. 795 per capita. This amount reflects the full cost of drugs (P.G. 580 per capita) procured at 21 lowest international prices and the cost of supervision (see Table 16). The range of cost recovery was extreme, however: from 3 percent to 123 percent of estimated recurrent costs. Of course, not all villages consumed the quantity of drugs per capita that is assumed in this average (P.G. 580). Without knowledge of the value of drugs actually consumed by each USB, the actual cost recovery rates cannot be computed. 3.19 MINSAP pays no salaries to the village health agents who are selected by the village and donate their time. Thus, the prepayment levels in Table 14 understate the true level of contributions at USBs, since they exclude the value of health workers' time and the village contribution to constructing and maintaining the USB structure. In a few instances, villagers help the health workers plough or harvest their fields. 3.20 The survey of health posts did not attempt to gather data on the total resources mobilized through the prepayment scheme: The sample was too limited to permit a reliable estimate for the entire population enrolled in some 450 USBs operating a-:ross Guinea-Biscau. However, in 1988, mean collection per capita for our reduced sample of 17 USBs was P.G. 134. Given that 450 USBs have an average of 400 participants (the average population per village), total prepayment in 1988 would have reached the equivalent of US$12,240, an amount that is 3 times the reported cost recovery from USBs in 1988 of $3,623 (Chapter 2), and that would raise cost recovery from USBs alone to 0.7 percent of MINSAP recurrent health expenditure. 22 Drug availability and the quality of care 3.21 Health posts had an average of seven o"t of the 12 essential drugs in stock, with a minimum of three and a maximum of 11 (see Table 17). The resupply of drugs is driven by the level and frequency of contributions from the village and constrained by fluctuations in the availability of drugs at the central storage in the capital. On average, the most recent shipment was received two months before the survey occurred, but drug supplies were replenished every 8 months; in half of the villages, drugs were restocked only once per year. More than half had chloroquine, aspirin, tetracycline, eye ointment and oral rehydration salts (see Table 18), with the latter drug available in at least 80 percent of the USBs sample. The fact that two months after the last shipment the USBs had depleted stocks of almost half of the 12 essential drugs suggests that USBs suffer from drug shortages much of the time. A particular concern is that half of the health posts had already run out of chloroquine, the key drug for treatment of malaria. 3.22 During the three months prior to the survey, supervisors from the health centers made an average 4.1 visits per USB, although the number varies widely in the deferent regions (see Table 17). For example, while the USBs in Oio were more distant from a referral center (an average of 18 km., as opposed to 13 km. in the other two regions), they had more frequent supervision visits, more recent and frequent resupply of drugs, and more drugs in stock than USBs in the other two regions. Several of the USBs in Gabu had received no supervision visits and most USBs in Gabu and Tombali were resupplied only once a year. The data suggest that the more distant USBs receive proportionately more 23 supervision compared to those that are 'ocated closer to the referral centers. 3.23 Staff from the health centers help the VHWs give preventive health education, which was offered in 14 villages, or 78 percent of the sample. Topics included the importance of clean water, adequate latrines, balanced nutrition, vaccinations and protection against mosquitos. Training in early weaning was provided in ten of the villages. 3.24 The USBs were highly regarded. In all villages, respondents rated the overall performance of USBs as positive (see Table 19). Further, when asked if the overall quality of service had improved, remained constant or decreased over the last three years, all respondents stated the quality of service had improved. In two-thirds of the villages, respondents noted that more drugs had become available. In two villages, they reported the drugs were less available but that the proficiency or skills of the VHWs had improved. Other reasons included "more polite personnel," "more qualified personnel," "improvements to the physical structure of the USB," "good treatment," and "less waiting time." In general, waiting time at the USBs was less than a half hour per visit, usually 5-10 minutes. Determinants of Utilization 3.25 Precise data for visits to USBs were difficult tc obtain, but rough estimates can be calculated in the following manner. VHWs and midwives reported the number of patient visits for the seven days prior to the interviews. These numbers were transformed to visits per 100 inhabitants in each village (CONSA). 24 The five community respondents also reported the number of visits for each of their households during the month prior to the interview. From this data, a second estimate of the average number of visits per household in each village was obtained (CONSB). The means of the two variables for visits per month for 100 persons become 13 and 20 for CONSA and CONSB, respectively (see Table 20). The corresponding mean number of annual visits per capita becomes 1.6 and 2.417. This is within the range of visits to USBs obtained through secondary data sources, which show a range of 0.73 to 4.61 annual visits to USBs per capita. 3.26 With regard to the trend in the number of visits to USBS and to alternate providers over the last three years, the respondents revealed that visits were increasing in five villages, decreasing in 11 and constant to declining in two. In 10 out of 18 villages, a traditional healer could be found in the immediate community or nearby. There was no obvious competition in service delivery between the USBs and traditional healers. Only in two villages did respondents state that the frequency of visits to the traditional healer had remained constant over the last three years. 3.28 The number of visits per capita is not significantly related to the level of prepayment rates or collection per capita. A priori, there are reasons to expect that villages with high rates would use the USB more: i.e., the higher the rate paid, the more drugs become available (since the USB can afford to purchase more) and one could anticipate a higher number of visits. But, there 7 Note that this annual average could only be estimated by assuming that the week and month prior to the survey were typical for the 12-month period. If consultations the month of the survey were higher or lower than the average month due to seasonality, then the estimate of annual visits would be biased upward or downward, respectively. 25 was no statistically significant diffe.rence between the villages. 3.29 Statistical analysis suggests that the frequency of visits to USBs is driven by the availability of drugs and the distance referral centers. 8 The number of visits to the USEs increases when drugs are available and decreases with the distance to the nearest referral center; that is the more distant is the referral center, the fewer are the visits to the USBs. This finding suggests that the USBs are important sources of referral for health centers and that the USBs and health centers do not compete for patients. Obtaining free care at referral centers normally requires a referral slip from the USB. However, the further the distance to the referral center, the higher is the private opportunity cost of seeking such care--due to the associated cost of travel or walking--and patients are less likely to report to a USB for referral slips. As the distance to the health center decreases, so too does the cost of passing through the USB to obtain free care at the health center. USBs distribute a limited number of simple drugs and have little capacity for diagnosis and treatment. The quality of service they provide is linked to the medical support, vaccination campaigns and advice they receive from personnel at the centers. Evolution of Prepayment rates 3.31 Prepayment rates were raised between 1988 and 1989 in eight villages and lowered in only one. On the average, the annual rate for married men was 8 The relationship between the actual number of drugs in stock and the number of visits was not statistically significant, but the relation between the number of visits trend in drug availability. However, the mean number of visits per household to USBs was so low as to suggest that drugs were not available a good deal of the time. 26 raised by 29 percent, and for married women by 66 percent. 9 These rate hikes confirm the importance villages attach to drug availability (see Table 21). These increases are worth noting because the official price of drugs has not changed since early 1988. This means the increase in payments is due to increased consumption of drugs. Rates were ttso raised in early 1989 to improve the quality of care at the USBs. In Gabu, women 3.n three villages contributed half-kilogram of rice, valued at about P.G. 500 to enable them to attend annual refresher courses. 3.32 Respondents favored increasing prepaymenit contributions even further if this would assure the availability of drugs. They were asked, ware you willing to pay an additional P.G. 500 a year to obtain a more secure supply of drugs?" and in all the villages sampled, the answer was affirmative. In two villages, two women cqualified the response, based on an assured food supply, since they had experienced hunger in 1987. Respondents were also asked if they would make an additional annual contribution to pay the midwives, but 10 of the 18 villages were opposed. A frequent explanation was that since members of the political committee were not paid, it would be unfair to reimburse the midwives or VHWs. 3.33 In the final analysis, respondents' ability and willingness to pay depended on the growth of their income; they emphasized the need for inputs and extension advice so as to increase agricultural production. Agricultural prices were improving, but supply response was constrained. In 10 of the 18 villages, 9 Increases are computed for the sample of 17 villages (excluding village t1). 27 the two major overall problems were related to agriculture (see Table 22): A recurrent theme across regions was the need for agricultural inputs (particularly insecticides). The labor constraint in preparing the land and plowing was a dominant theme in the villages viqited in the Oio region, and it was felt that animal traction would help to overcome this problem. Farmers in the Tombali region referred to the salinization of their rice fields, which curtails yields. 3.34 The long distance to potable water is another constraint on available household labor resources that could be used in alternative pursuits. Respondents in at least 13 villages stated that distance to water was one of the three major problems faced: In one village, the distance to a water source was at least 8 kilometers in the dry season. 3.35 Bicycles at the USBs can facilitate communications with the health centers and are highly valued. Health workers in five villages visited in the course of this study said the lack of a bicycle was one of their three major concerns. In fact one village in Gabu (called Saucunda) had started a collection to buy one for this reason. 28 Chapter IV Conclusions and Recommendations 4.01 In the introduction it was stated that prepayment schemes are often complicated to manage and reply on actuarial information that is not always available in developing countries. The prepayment scheme in the village health posts (USBs) in Guinea-Bissau is an example of a simple scheme that pools risks for basic primary health care services (particularly drugs), while simplifying management demands. Once prepayment levels have been determined by the village, the prepayments are collected all at once and forwarded up through the health system. This system is easier for illiterate villagers to manage than one of user fees for consultations and drugs. The latter would require an accounting of fee revenues for each use of various services by different categories of clients and finding a way of safeguarding the funds. The USB prepayment scheme is also much easier to manage than most insurance schemes, since there is no billing necessary, providers are not being reimbursed for services used and it is not necessary to assess prepayment rates based on risk. The services provided by USBs are highly subsidized, however, and limited to prenatal care and treatment of a few basic ailments with essential drugs. 4.02 Two additional pitfalls of prepayment schemes noted in the introduction were adverse selection (when only those with a high risk of illness join a prepayment scheme) and moral hazard (when those who join the scheme use more services than they would have in its absence). Both problems lead to rising treatment costs and premia, which in the extreme can reduce enrollments and drive the scheme out of business. In the village health posts in Guinea-Bissau, 29 adverse selection is prevented by almost universal membership within each village participating. Moral hazard is avoided through the vigilance of village health workers and midwives, who dispense drugs only as needed based on diagnosis, and by the pressure of the local community. 4.03 Although the level of cost recovery from the village health post prepayment scheme is low, this understates the total amount of resource mobilization. Villagers provide construction materials for the USB and the labor of village health workers and midwives for implementation and management of the scheme -- none of which is reflected in cost recovery figures. Further, respondents indicated their willingness to prepay greater amounts, provided that drugs could be made available on a timely basis. Drugs are heavily subsidized to the USBs, however, and their price has not been regularly increased to reflect inflation and devaluation. The degree of subsidization of USB drug supplies is thus increasing over time. 4.04 The survey found that the level of satisfaction with the village health posts was high, despite evidence that drug stocks are rapidly depleted. Respondents' willingness to prepay was often linked to improvements in the quality of service, including greater availability of drugs and better training for village midwives. Yet, the quality of service that can be provided at village health posts depends critically on the extent of support from the rest of the health care system. Even when villagers prepay, drugs are not available immediately because of more general problems of finance and procurement in the health system. The health posts also rely on supervision, training and referral services from health centers. If authorities wish to strengthen the USBs, they 30 must strengthen the health center support services and improve the drug resupply system. In addition, making bicycles available at each health post would improve the ability of workers to reach the more distant households, to communicate with the health center and to evacuate patients in an emergency. Bicycles might be offered through some sort of incentive or credit scheme. 4.05 In the context of village-managed health services in Guinea-Bissau, a flat-fee prepayment may be the only type of cost recovery feasible; a system of user fees for services or drugs might exceed the administrative and management capacities of the typical village. Would such a simple prepayment scheme work in the rest of the health system, in health centers and hospitals and in urban areas? It would probably be more difficult to administer such a scheme in urban areas or over large administrative tracts in rural areas, since the practice of almost universal participation (as occurs at the village level) that prevents adverse selection would be difficult to achieve. Overuse would also be difficult to prevent when the patient is not known by the health worker and there is no community pressure to conserve resources. 4.06 The capacity to administer user fee schemes already exists in health centers and hospitals in Guinea-Bissau, and this seems to have the greatest potential for resource mobilization at those levels in the short run. However, the very low level of user fees and the large number of exemptions at higher levels of the health system are limiting cost recovery and are discouraging use of USBs. Further, since user fee revenues are not retained at health centers, but sent upward to the Treasury, there is little incentive to enforce collections. To raise cost recovery for health centers and hospitals, 31 consultatLon fees should be raised and the number of exemptions tlghtened. 32 References (1) Mwabo, Germano. "Complementary Approaches to Financing Health Servlces in Africa". World Bank, July 1989. (2) Lewis, Maureen A. f"The Private Sector and health Care Delivery in Developing Countries: Definition, Experience and Potential'. Washington, D.C.: The Urban Institute, April 1988. (3) MINSAP/WHO. 'Plan pour le developpement des Soins de Sante Primaire, 1989- 95w. Bissau, March 1989. (4) Tibouti, Abdelmajid. "The Financing of the Health Sector in Guinea- Bissau". MINSAtP/WHO, April 1989. (5) World Bank Staff Appraisal Report, Guinea-Bissau. Report No. 6644-GUB. Washington, D.C., March 1987. 33 TABLE 1 VITAL STATISTICS, GUINEA-BISSAU, 1988. Total population 950,000 I of Population under 16 years 47 Z of Population urbanized 28 Crude birth rate (per thousand) 46 Population growth rate (per year) (1970-80) 3.5Z Mortality rate (per thousand) Tnfants 180-200 1 - 4 years 270 Life expectancy at birth (years) 39 Illiteracy Rate 84Z Population per medical doctor (1987) I'-au (capital) 2,450 Rest of country 13,430 Source: IKCSE, August 1988. 34 TAILZ 2 EALTS FACILITIES AND BUDS BY FACILITY CATEGORY. No. of No. of units beds National hospitals 2 633 Regional hospitals 4 299 Sector hospitals 12 279 Health centers 122 - Village health posts 4U0 Sources MINSAP TALS 4 mm ues(M A5 M AM TOeIl I 1la 406 846 86 8.1 Cssh go me to 4.4 1.6 e.9 in m m i.0 e .0 ole 6 m" 14 4.6 1.6 *.IJ is s o i.e as. LaMesa 54 us Us 8.0 8.8 biases U in n 4.6 8.? TAL 446 nu 11a -WI 4 m in . *. 35 TABLE 5 COVERAGE OF USBS BY REGION Population al Total Region Participating Population Coverage 2 Tombali 29,334 70.000 42 Cacheu 37,2000 145,000 26 Cabu 69,400 125,000 56 Oio 20,615 145,000 14 Bolama 12,528 30,000 42 lafata 42,288 145,000 29 Quinara 7,793 40,000 19 Biombo 0 65,000 0 Lissau 0 165,000 0 Total 219,158 930,000 24 Source: MINSAPIWHO l1 Assuming 100 percent participation of the population in village with USBs; this survey of 18 USBs in 3 regions found that 90 percent or more of the village population actually participate in the USB prepayment scheme. PWLIC I6A4PTh =mm~3 ST M Me uagLnr iw ON "Um @wT M-U) UUW.Y 3 "WN 3 TOTAL S FUSION OF PWUCL AM AID Messrese% 5ueqls r 178 8.4 MS 41.7 ? 8 76.8 CaPiWi ISiPiud1t 12 26 72 U4 M 5.$ ts79.6 67.2 7.21 82M too 1841 1oo 170.4 _tCs Tl 1ths (186 36 143U 7 L&ir Mica, OIWA *t - ALY 1* Asset C.; ded Cods Orus swi. 01t_ ews Piase Cast totte c 4 eweaath- 320 Ji.. %* as tweel .-se 45 C, 1. *) Z - .e"d) . i.amo..) Loft 1e.rs.e--) .) CO.sIe .) 1 r' A;eill iR If _ t00 4C0 117 138 35 1 0.pa"i6ialiW Ci - I01 Io t U O 198 2 t tr Ass mg0 0 as *0 0.8 - 8 2 2 r Pepseam MO _ _ . , , 3 T.Hes,,, .dasale 2I0 " US S- - it to 3 ?.Ckl4foiR 2J0 o 40 s0 2.4 1s 15 I Oleis ya ie "t - I-, - 4l 2n71 4 T.Ckle l*eashe.ic 0 as SC *0 - - 27 S 7.Cklaropmaiie 100 = -S - - - 34 T.1ticsv.tamin. - no O. - 16 2 1 ?*s,u Ie eye aji t_. L S - sO -" 225 1 hsteteis/Pba_s sdasre so - - to - - 4. 5 T.feppja aIlhafsl is.gidj - - 0.2 - 4 2 1 T?.9.7throein 2S0 1 _77 u T - I *SU lr; * Stabiatt1. I *i Injectable - daest .ft_# ;_iont. al the seesais. Code for tfArg of dnig: I * Antibiotic tand othel e isiar.ei.l dew 2 * ent*pyrtes;i * algsis 3 Aeitrsretwsasl de 4 * Newaelesi. ga em%igsftesic dne30 5 * Nb"t *) Tablet in d;ffaras atltegtke e eiAd o this tablet atan1s@V *e3 Seld by on ait. i .e. I tablet. *ee) ,ivaa sh1 raI . olad in paks" of t10 unite. i.*. 10 tblet. BROW) e s *datel s.ease 8.8.8?, July &on sleaem" eats ) Leat iAteetatimmot or WIZPAC prices. 130. % 0 I * 1975 r_1o_e ,mlaest mtal. Tjpig;,llp i; pechteo So 4a to tablets. po) 1*to setusl peie. but searvded a; iofefseatias to heath wSet. as as the invoice. ;s order to isfs.abmel Me rest amt of the *eW. 37 TABLE 6 MINISTRY OF PUBLIC IEALTH tEXNDITURC ALLOCATION INCLUDING FORCIGN AID IN 1998 (BY ZXPENDITURE TYPE) (USS CURUENT PRICES) MINISTRY x FOREIGN S TOTAL OF PUBLIC AID HEALTH BVDGET ersonnel 639236 42.6 638077 6.2 1677313 :^ 3 Medicine 131345 6.7 960000 7.2 1091345 7 t Food Supplios 283263 14.5 3325767 24.8 3609030 23.5 hipping 266514 14.6 0 0 286514 1.9 Fuel/Power 194851 9.9 0 0 194851 1.3 Workshops, Supplies. 134061 6.J 83644 0.6 217905 1.4 Outreach Activities Maintenance Equipment 4309 0.2 94095 0.7 98404 0.6 ther Expenses 16ll 0.6 266490 2.2 300301 2 Construction 0 0 3619431 26.5 3819431 24.9 Building Repairs 36560 2.1 590377 4.3 628937 4 Equipment 14039 0.7 1715459 12.6 1729498 11.3 Seminars & Scholarships 0 0 1245190 9.3 1245190 8.1 Studies 21222 1.1 450440 3.4 471662 3 Total 1959211 100 13411170 100 15370381 120 SOURCE: MINSAP (Tibouti) 1969 38 TABUI 9 SUBSSDlES AND COSTS FOR DNUS PEP 100 PEtRSNS, MASO ON AN ESTMATED CONSJWTZ0 FOPR 6 MONTHS (equal to what each USS rPecsl ws for the f rPt 6 months) ---cost to US-- ----p I co ----- Cost to US cost l9o0 *) /replacesmet Unit Total cost * Units price cost Unit Totel (3)/(S) cost cost (1) (2) (3) (4) (5) (6) Drug P.O. P.O. U.S.D. P.O. S Cloroquine syrup 60 ml (CO q/6 l) C 45 226 2.23 21964 1X Cloroquino 100mg, 1000 T 1 1600 1600 6.20 10244 16l Aspirine adults, 1000 T 1 800 300 1.50 290W 10l Sulphonmide C00mg 1000 T 0.5 1200 600 - Wultivitamin-, 1000 T 1 5oo 5oo 1.50 3132 16s Ferric sulphate, 1000 T 1 200 200 2.10 41S? tC R*hydrating *alto s0 15 750 - Antibiotic skin ointment 3 5 15 - Eye ointment 10 so Soo 0.30 5910 tT lodino solution 13 1 I 0.1 360 36 0.U 109 a8x Potassium permnganate, 20 T 1 20 20 - Merchurochroee 2X solution, 100 1 1 1 no - Sanzyl benzo*te pure, 1 I 1 260 250 - Cotton 45W0-50 gr. 1 280 230 2.17 4275 a3 Ligature 5 e9cm 4 25 100 0.12 044 l13 Ligaturo 7.5609 5 30 150 0.15 1479 102 Absorbent gauto bandage 20c aSc 2 60 100 - Sterile compress 7.604cm 20 4 to 0.01 8270 28 Surgical tape 7cm-4.5c 1 200 200 1.25 244 *3 SUm 57P1 609o *Ql Notes - a informtion not available. *a procurement data from the Social Infrastructure & Reol f Proj ect Source: MINSA 109 39 TABLE 10 BASIC DATA FOR SURVEYED RECIONS -_____-_____-__________________ PROPORTION AVERAGE POPtLATION OF TOTAL VILLAGE PMTICI- AVERAGE COVED BY SIZE HEALTH PATIWO VILLAGE us WIIN PULATI VILLAGES 130 HOSPITALS CENTR US IN USOS SIZE ( @l 146.000 625 281 2 14 02 20,6015 88 14.2 70,000 227 S 24 IOS ",84 272 41.9 115,000 070 1i 2 14 15 01,400 555 5.5 SVL 840,000 1,012 211 7 5 255 11U,I4I 406 85.1 85.15 NNW - MISSION TABLE II TA3LE I2 SAWLE OF USO. BY RECION ------------------------ POPULARATIOH AM ENIGtCITY OF UVVEY VILLAS USO* SAMPLED ----SAW.E------ NO OF CREATED Us9e COVERACE AVERAGE PflKI ETHDC REGION PRIOR TO VILLACE REGION VILLAOE NO. PPtULATION H WI. U GROUPS SIZE I) --------…---------------------…--______________________ 010 TCUALANA I 28 84 3 010 GA4-NhUDA 2 14 20 S (3) 010 CUTNHIA 1600 87 ----------------------------------------------------- ---------- 010 MANDIND OA 4 1250 0 2 010 UEAM S ON U 2 010 41 6 14.6 65 010 SAREJ"UlA 6 to6 100 1 TOUSALI CAICOCA 7 426 12 5 TOWALI ""0CUMA * *0 0 1 TOAHLI 101 6 6.9 911 TOMALI TCHOIINTI 9 200 0 1 TOMBALI CLATOCE 10 60 0 2 TOMBALI QUISIL 1 no6 0 1 O,W 122 6 4.9 TOISALI CtCUW 12 4" 0 1 QAOU SAMA TAC 13 an 100 1 OAU MEDDM N 14 goo 100 1 ----------------------------------------------------______----- _ _ C OASU 8ILONCA is 8 100 I TOTAL 264 13 e.g sO OAUl COINA 16 100 160 1 CAS LENSE3 TE 17 l 6 S ----------------------------------------------------------______- OABU SAUCUtDA 1i 67 100 1 sC£: 1369 SUMVEY MEAN C40 SO 2 1) SUMER OF PERSONS. SOURCEt 1069 sUtTEY TAKLE 13 CHARACTERISTICS OF USSS TOTAL TOTAL YEARS HEALTH HEALTH SINCE PHYSICAL VIULAGE AGENTS MIDWIVESJ V ./ AGENTS/ CONSTRUC- CONDITION HEALTH (MIDWIVES 100 INMS- 100 VIMB- 100 111MB EQ:ON VILLAGE NO. POPULAUTION TION .0) MIMDWVES WORKERS AND VIS) ITANTS ITANTS TANTS 010 ICHALAIA 1 203 2 2 1 * 4 0.5 1.s 2 010 GA-NAUDA 2 1466 6 1 6 8 9 0.4 0.2 0.6 010 CUTHIA a 1s0o a 1 4 5 9 0.8 0.3 0.6 010 AINGAvim 4 1250 6 1 4 1 C 0.3 0.1 0.4 010 VAM 6 SW00 2 2 a I 6 0.4 0.4 0.9 010 SAREDUm 6 IS6O a 2 4 a 7 2.5 1.9 4.4 TONDALI CAICOCA 7 429 8 1 6 4 9 1.2 0.9 2.1 TOWALI IICUBA I 350 a 1 2 3 C 0.6 a.D 1.4 TOHALI TOIINTI 9 200 6 1 2 2 C 1.6 1 2.6 TOOAUI CLATCHE 10 6o s 0 2 4 7 5 6.7 11.7 TOWBALI QUIBIL 11 60o 9 1 a 4 7 0.0 1.1 1.9 TOWALI CUtUOA 12 469 10 1 2 2 4 0.4 0.4 0.9 amJ SAWA TAC 13 see 2 0.5 C 4 9 1.8 1 2.8 QAWU mm A 14 590 2 1 5 a S 0.8 0.5 1.4 am BILONCA 16 099 2 1 2 2 4 0.5 0.5 1 OAWu COINA le 100 3 2 2 1 a 2 1 8 OamU UNUE I 331 5 0.6 2 & 5 0.0 0.9 1.5 @a U SAUCISA 1s 676 7 0.6 * 5 10 0.1 0.9 1.7 640 4 1 a I 6 1.1 1.1 2.2 SOUbCE: USDB I96 SURVEY OTES so * DIME FIN STANDARD OF BUILDINO: THE VALUES OF t0o, *1s AND 2 SIGNIFY UNSATISFACTORY, SATISFACTORY AND NOOD COIITION, RESPECTIVELY TABLE 14 FE -PAlIFII SSIf lEini -------LEVEL OF ASsESSMENT ------cv,cl Agp g,li CoPay- INEUM- -l i --- Nsil. lWUllS m tI*UIUCiI wntI Awl nai or PAWHENT FuM of Ka o ?AMNI ,wirA =w- No0 10111111 I 26I iso in19111 "I gml Ii' I sit WNWUM 2 144. I3 IS 145 5059 36 S oil ChIllA 3 1OS 55 2 Uf 4 6 ii, inDIuiw A 17 20 so so u os 331 31$ 511 443 9 off amE s ' IN 3 I ll USE10 Su3 5 off SIUKII 5 1S0 so Km55 5 Il 2% S 15111 ICICEI 7 429 I n S2HS 220 21 3St low I ucuuimi I isis m n5S 2524 3 say UREi 1 is so so is NIl 2S 0 6 GmN on 14. In so 3 I' 1 2150 oS townsU I? HJI 13II 3 SN 6S 2 go WINI Is WS I0 2 1 V 3 SM: 1059 simYn 43 TARU 15 as canrO By a-i n US ) Health Total Uses Per ToOtl per centers per capita participant region capita Saftst 5061 0.12 Sela.a/SIJagoe 2518 0.20 Cacheu 4512 0.12 Cabu 13706 0.11 9742 0.14 41601 0.33 Ol 4599 0.22 Tomball 19449 0.28 6406 0.22 Quinera 654 0.06 Gelrnee-4loou 151154 0.1 3U492 0.15 681706 0.57 (- tota ) ---- ----- ----- ------ e) eoe oan *etual volume 19 and UVIPAC prieo * 306 to cover distribution costs Souree: IIINSP/ TAKLE M6 LEMVELO S*IDIZATION AT TME INS P.0. IN im PRICU COLLECT/ CAPITAI C*LLECT/ CO" O CAPITA/ MM ADM./ REGION VILLAG NO. POPULATION YEA CAPITA M I/ 010 TCHALANA 1 20J ge1 128 0t0 OA-NAMUDA 2 14ff 6 7 010 CoTA I 1o0 G0 I 010 MWADINSA 4 1260 $1s 40 010 UWAN I 900 Is 10 010 SA11 0 6 10o0 166 21 TOMAU CACOCA 7 420 290 26 TOALIu NAOUA S 8 0 12 9 TOAULI To4NTuI o 200 246 $I TOM AL CLATCOE 10 0 110 14 TOALA Q=3DL 11 9W 251 St T9WALL CW0MA 12 466 186 17 am MAATAC 18 so0 56 7 USI DM N 14 560 40 5 1 BILONC 1$ 801 26 a amU COINh 1i 100 275 as 4AU LUUIl*IS 17 881 l 4 amJ SAUVMA 18 576 lot 1? MOAN 640 181 28 EAN XCL VIULAUU O I 134 17 S0iDME: 1I6 SLMYK NOTU 1. AVEtAGE REClQI COST P CAPITA OF P.O. 795 DNCU11 P.O. rA&U 1 744 SPERMVISION VISITS Am Mu SIPLY -------OU UPLY…--------- DISTANCE LAST TO 5POtVISION SHIPWNT FREQUENCY STOOC REFERIAL VISITS WmnT 0 MO OF DUGS 1/ CENTER REGION VILLAGE NO. POrLATION LST $MTN$ (KM) _______________e _ _ _ _e - _ ___ _ _____________________________________________________________ 010 TChALANA I 208 9 1 6 9 20 010 CA-NMU.A 2 1465 9 I 6 7 32 010 CUTHIA a lo6 6 2 1 7 16 010 MINAN 4 1260 6 1 a 11 22 010 MASh 5 GM0 9 1 8 9 11 010 SARON6A a iso J 2 a 11 a TOMBALI CAICOCA 7 429 6 2 6 5 7 TOMBALI NHACUA a nO * 4 6 3 6 TOMBALI TO4INTUI 9 200 S 4 12 1 26 TOMBALI CLATCNE 10 so 6 * 12 6 30 TOMBALI QUIUIL 11 60 0 S 12 7 3 TOMBALX CUCUMBA 12 4" a 2 12 7 6 AU SAMBA TAC 1is g 2 2 12 11 13 GAU MIEDINAM 14 $50 2 2 6 7 1i 5ABU DILONCA is 399 0 2 12 7 14 5AWU COINA 16 100 * 2 12 t 10 5ASU LENQJE 17 "1 * 12 16 CAWU SAUCUNA 1S 575 0 3 12 7 ____________ -_____ _ ------- ------- -_ ------- ---_____ WEAN 640 4 2 * 7 15 e_____________b e - - - __________ _ _ ________ SOURCE: 1919 SURVEY NOTES 1) NUMBER OF DU STOCKED AT TIE OF VISIT. 45 TABLE 18 AVAILABILITY OF DRUGS IN SURVEYED USBS Percent of health posts vith nine drugs surveyed at the time of visit. Chloroquine tablets and syrup .56 Aspirins 300 mg .83 Sulphonamide .67 Multivitamins .39 Ferric sulphate/folic acid .61 Tetracycline eye ointment .61 Antibiotic dormic ointment .30 Benzyl benzoate (disinfectant) .28 Oral rehydration salt .83 Average .56 Source: 1989 Survey TABLE 19 PERCL-TIONS OF CHANCE IN QUALITY IVROVEMENT IN QUALITY DUE TO GOOD EVALUATION WAITING INCREASE/ TREATMENT/ OF USD TIME DECREASE MORE MORE MORE OTHER /MORE LESS REFERRALS LES THAN DRUGS POLITE QUALIFIED IOPRVO CONFI- WAITING IMPROVED 1/2 NMOS PERSON- PERSON- CONSTRUCT DENCE NEL EL V4LANE NO. a) 2) 8) 4) 4) 4) 4) 4) 4) 4) TCULAA 1 1.0 1.0 1.0 1.0 0.6 0.2 A-NAMiDA 2 1.0 1.0 1.0 0.6 0.5 0.5 0.6 CUTHIA a 1.0 1.0 1.0 1.0 0.2 oIwIn" 4 1.0 1.0 1.0 1.0 1.0 1.0 USE 5 1.0 1.0 1.0 1.0 1.0 1.0 1.0 SMuIm * 1.0 1.0 1.0 1.0 1.0 CAICOCA 7 1.0 1.0 1.0 1.0 0.2 1HUM 0 1.0 1.0 1.0 1.0 TGIINTI 9 1.0 0.0 1.0 0.2 O.S CLATOE 10 1.0 1.0 1.0 1.0 5flIL 11 1.0 1.0 1.0 1.0 0.2 CLWA 12 1.0 1.0 1.0 0.6 0.2 0.2 SAM TAC 1i 1.0 1.0 1.0 1.0 MIA U 14 1.0 1.0 1.0 1.0 0.8 BDLONt is 1.0 1.0 1.0 -1.0 0.6 0.4 cODS 10 1.0 1.0 1.0 1.0 1.0 1.0 WISSen 17 1.0 1.0 1.0 -0.6 1.0 SAgIlSA 1i 1.0 1.0 1.0 0.2 0.6 0.2 KM: 1.0 1.0 1.0 0.7 0.1 0.7 0.0 0.0 0.5 0.2 oF 01RVATINS 1s is is 1s 7 0 2 2 4 1 1) uDEX 036611$ WIN SI* SATISFACTION AMD WIH *0 NOS SATISFACi-i;; WnH Us. 2) * D OaiES 1in *N1 OCCaU"mmnc Of 1H Eer, Ius *nnn *0 .00 OCCUPMENCE. *a DM X MSUMES *ITH *10 DNliSA AM WIH *-1' A KCESASE. 4) Da ES OSISEs WITN 00*0 NO IN FI IN QOALITY AMN WITH *10 M IMPOENT; MDSX CA ES UEM EVAUATION OF USUALLY FIVE XI6VISUALS INEUVI. 47 TABLE 20 VISITS TO USBS AND DISTANCE TO NEAREST OTHER PROVIDER Visits/ Visits/ Distance Month Month Main Age to Nearest 100 100 Bracket Provider Persons Persons of Region Village No. Population (K)L (CONSA)1I (CONSB)2/ Patients 010 Tchalana 1 203 20 6.3 5.6 1-5 010 Ca-Namuda 2 1465 32 11.7 8.9 0-1 010 Cuthia 3 1600 15 6.7 7.1 0-1 0OT Mandingan 4 2250 22 1.7 7 16-45 010 Maque 5 800 11 8.6 25.3 1-5 010 Saradonha 6 160 6 34.0 42.1 1-5 Tombali Caicoca 7 428 7 18 20.1 1-5 Tombali Nhacua 8 350 6 11 25.3 1-5 Tombali Tchintebi 9 200 25 0 9.9 1-5 Tombali Clatche 10 60 30 0 23.5 1-5 Tombali Quibil 11 360 3 6 19 1-5 Tombali Cucumba 12 468 6 27.5 33.5 1-5 Gabu Samba Tac 13 386 13 11.1 19.1 1-5 Gabu Medina H 14 590 18 26.9 22.7 5-15 Gabu Bilonca 15 399 14 7.5 9.9 N.A. Gabu Coina 16 100 10 25.7 27.7 5-15 Gabu Lenquente 17 331 16 N.A. 4.9 1-5 Gabu Saucunda 18 575 7 N.A. 44... 1-5 Mean 540 15 13 20 Sourcet 1989 Survey Notes: 1. Derived from number of visits during the seven days prior to the survey; Data from the VHWs. 2. Derived from number of visits per household during the month prior to the survey; data from coamunity representatives. 48 COWARISON PR-*AYMWT RATIES 19049 ----Im --- 1909- NOMAUZED NORMALIZED ANNUAL PAY POm MWNU PAY PU INCRASE AULT ADLT MARIED MARIED ---1966 --- MARIED MARIED AOA.T AMA ADUT ADULT REGION VILLAGE NO. POPULATION MALE FEMAL MALE FEMA MALE FEMALE ----------- ----------------------------- - -a- - ------ 010 TCNALAVA 1 208 2000 2000 4000 4000 2000 2000 010 OA-NAMDA 2 145 I50 100 200 200 s0 100 0o0 CUTHIA * 1600 600 S0 1000 iOOO so Soo 010 MANDINA 4 1250 00 *00 S00 500 0 a 010 MAQJ S 000 100 SO 200 100 too so O0O SAREDOM4A 6 160 200 100 200 200 0 100 TOMBALI CAICOCA 7 420 200 200 200 200 0 0 TOMALI WHACUIA S U50 1S0 1C0 1S0 10 0 0 TOMBALI TCHITDI 9 200 500 400 22C 223 -275 -175 TO4ALI CLATO4E 10 60 200 200 400 400 n0 200 TOMIALI IQUIIL 11 00 250 250 260 250 0 0 TONOALI CUCUNOA 12 4" 250 250 800 nO so so GASU SAMA TAC Is se Soo 0oo Soo 6oo 200 200 GABU MEDIN M 14 5o0 s0 SO sO sO 0 0 GASU 8ILONCA 1C 890 100 0 600 S00 400 500 GABU COINA 16 100 500 500 SOO 1000 0 SOO GASU LENQUENTE 17 "1 s0 0 so 600 0 SOO GASU SAUCUNDA 1t $76 240 240 240 240 0 0 MEAN (19) sO 847 822 526 578 179 251 MEAN (17) 249 2s $21 S71 72 140 SOURCE: 199 SUJRVEY NOTES INCLUDES NEW FE OF PG S0 OR .5KG O RtICE PER M TO PAY FOR TRAINING COURSES PM MID-WIVE Di VILLAGS NO:S 15,1C A 17 TABLE 22 MAJOR PROBLEMS REPORTED ------USS------ No ROOF ZINC VIUAOE NO. 0 SCHOOL ZINC ATER ROD USITOS HEALTH BICYCLE OF WOS TOUWAW I 2 a I AWIC.WLTAL DM". LUA CSTT IN PLWN OA-401A 2 1 a I AmIOumI& 11T, LMU CWPt4 Im 1W1N CVRUIA a 1 2 AWITiw. L WVM. LW CNPADIN IN m PING MMVDGWII4A 2 AGRICORi1MM. NMW ID CTICISE l. CIT WAE S 1 2 a SMUSSIA 6 2 a CAICOCA I 1 2 NTft IP TO I AWAY IN MY #AM N M F INSECTICUC3 NUiNA 6 2 1 AICIITWEt SALUDNITIU. _ INKCTICUE TOgRWI 9 2 a I AIaLTUI 9uINATIM, _ RICE ?nUM CaUTOf 10 1 2 AOtIOULiWE: &ALIMIATIN, SILTUS 1IIL 11 1 ASIICULlM: an OF RICfE ""mm. h = MOJT OaJt 12 1 SAWA TAC i a 1 2 mImS 14 1 2 SIWEC 1 1 2 a R4CI rLmS a mm, 11-11 RiW. DIUICiT CtlI 16 2 1 a M_JlUS ICULIUl3t WMll 1W3. DICT PAE WISWIE 17 1 2 8 mm At DA Iflm rm a Ejw . _4t u SAUA to I a AE w mm M: NO OF S ATIOS 11 4 2 is a 1 a * 2 R I 6 0 0 10 0 1 0 1 1 A 2 4 1 1 2 a 1 a O RAW a I & I 1 0 0 a I I SaNE: "sw? 69 PRE Working Paper Series Contact TJI AlbuhDM for pape WPS469 Modeling Economic Behavior in J. Barry Smith August 1990 M. Abundo Peru's Informal Urban Retail Sector Morton Stelcner 36820 WPS470 What Do Alternative Measures of Alexander J. Yeats August 1990 J. Epps Comparative Advantage Reveal 33710 About the Composition of DevGloping Countries' Exports? WPS471 The Determinants of Farm Gershon Feder August 1990 C. Spooner Investment and Residentia: Lawrence J. Lau 30464 Construction in Fost-Reform China Justin Lin Xiaopeng Luo WPS472 Gains in the Education of Peruvian Elizabeth M. King August 1990 C. Cristobal Women, 1940 to 1980 Rosemary Bellew 33640 WPS473 Adjustment, lnvestmenm, and the Riccardo Faini August 1990 R. Sugui Real Exchange Rate in Developing Jaime de Melo 37951 Countries WPS474 Methods for Measuring the Effect Anne Maasland August 1990 P. Dixon of Adjustment Policies on Income 39175 Distribution WPS475 Does Divestiture Matter? A Ahmed Galal August 1990 G. Orraca-Tetteh Framework for Learning from Experience 37646 WPS476 Health Insurance in Sub-Saharan Ronald J. Vogel August 1990 K. Brown Africa: A Survey and Analysis 35073 WPS477 Private Participation in the Delivery Thelma A. Triche August 1990 M. Dhokai of Guineas Water Supply Services 33970 WPS478 Interrelations Among Child Mortality, John Marcotte August 1990 S. Cochrane Breastfk gding, and Fertility in John B. Casterline 33222 Egypt, 1975-80 WPS479 Conversion Factors: A Discussion Michael Hee August 1990 E. Zamora of Alternate Rates and Corresponding 33706 Weights WPS480 An Evaluation of Neutral Trade Policy Jaime de Melo August 1990 R. Sugui Incentives Under Increasing Returns David Roland-Holst 37951 to Scale WPS481 The Effects of Trade Reforms on James Tybout August 1990 R. Sugui Scale and Technical Efficiency: Jaime de Melo 37951 New Evidence from Chile Vittorio Co'bo WPS482 Membership in the CFA Zone: Shantayanan Devarajan August 1990 R. Sugui Odyssean Journey or Trojan Horse? Jaime de Melo 37951 PRE Working Paper Series Contact T16 AuthorDAu for paper WPS483 An Evaluation of the Main Elements Refik Erzan August 1990 G. llogon in the Leading Proposals to Phase Paula Holmes 33732 Out the Multi-Fibre Arrangement WPS484 Stock Markets, Growth, and Policy Ross Levine August 1990 R. Levine 39175 WPS485 Do Labor Market Distortions Cause Ram6n Lopez August 1990 R. Luz Overvaluation and Rigidity of the Luis Riveros 34303 Real Exchange Rate? WPS486 A RMSM-X Model for Turkey Luc Everaert August 1990 S. Aggarwal Fernando Garcia-Pinto 39176 Jaume Ventura WPS487 Industrial Organization Implications Timothy Condon August 1990 R. Sugui of QR Trade Regimes: Evidence Jaime de Melo 37951 and Welfare Costs WPS488 Prepaid Financing of Primary Health Per Eklund August 1990 K. Brown Care in Guinea-Bissau: An Knut Stavem 35073 Assessment of 18 Village Health Posts WPS489 Health Insurance in Zaire Donald S. Shepard August 1990 K. Brown Taryn Vian 35073 Eckhard F. Kleinau