Document of The World Bank FOR OFFICIAL USE ONLY Report No. 11788-COM STAFF APPRAISAL REPORT FEDERAL ISLAMIC REPUBLIC OF COMOROS POPULATION AND HUMAN RESOURCES PROJECT NOVEMBER 19, 1993 Population and Human Resources Division Operations Department III Africa Region This document has a restricted distribution and may be used by recipients only in the perfornance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS Currency unit = Comorian Franc (CF) 1990 US$1 = CF 272 1991 US$1 = CF 282 1993 US$1 = CF 273 MEASUREMENTS 1 meter = 3.28 feet 1 kilometer = 0.62 mile 1 square kilometer = 0.39 square mile 1 hectare = 2.47 acres FISCAL YEAR January 1 - December 31 This report is based on the findings of an appraisal mission which visited Comoros in March 1993. The mission members were Daniel Viens (Mission Leader), Amolo Ng'weno, Michele Lioy, Pierre Mersier, Malonga Miatudila, Cung Tran-Luu (AF3PH), and Paul Geli (consultant). The report was prepared by Lynne Sherbume-Benz and Amolo Ng'weno. The report was processed by Val6rie Vincent, Roselyne Leroy and Hilda Emeruwa. Willy De Geyndt is lead advisor and Messrs. Steen Jorgensen and Alexandre Marc were the peer reviewers. Francisco Aguirre-Sacasa and David Berk are the Department Director and Managing Division Chief respectively for the operation. FOR OFFICIAL USE ONLY ABBREVIATIONS AND ACRONYMS AfDB African Development Bank AIDS Acquired Immuno Deficiency Syndrome ASI French NGO (Association Sante International) CARE International Development NGO CARITAS International NGO of the Catholic Church CCC Central Coordination Committee CDSF Community Development Support Fund CECI Canadian NGO (Centre Canadien d'Etudes et de Cooperation Internationale) CIR Country Implementation Review CPR Contraceptive prevalence rate CTARIAP Technical Commission on Adjustment and Strengthening of the Public Administration CYP Couple-years of protection DHE Directorate of Health Education DPI Directorate of Pharmaceutical Inspection ENS National Public Health School EPI Expanded Program of Immunization FAC Aid agency of the French Government (Fonds d'Aide a la Cooperation) FIRC Federal Islamic Republic of Comoros FP Family planning GDP Gross domestic product GNP Gross national product HIV Human Immunodeficiency Virus IDA International Development Association IEC Information, Education and Communication ILO International Labor Organization (of the UN) IMF International Monetary Fund MCH Maternal and Child Health MEN Ministry of Education MERCAP Macroeconomic Reform and Capacity Building Project MIS Management Information System MOH Ministry of Health NES National Executive Secretariat NGO Non-governmental organization PC Pilot Committees PHC Primary Health Care PEP Public Expenditure Program PNAC National Autonomous Pharmacy of Comoros RC Regional Committee RES Regional Executive Secretariat RHT Regional Health Team RMO Regional Medical Officer SSA Sub-Saharan Africa STD Sexually Transmitted Disease TB Tuberculosis UNDP United Nations Development Program UNFPA United Nations Fund for Population Activities UNICEF United Nations Children's Fund WHO World Health Organization This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. TABLE OF CONTENTS Basic Data .................................... i Credit and Project Summary .................................... ii I. BACKGROUND ...........................................1 A. Recent Economic Developments ............. ............................. 1 B. Conditions in the Social Sectors .......................................... 2 C. IDA's Assistance Strategy and Lessons Learned ......................................... 5 II. HUMAN RESOURCES SECTOR ISSUES .......................................... 6 A. Health Sector .......................................... 6 B. Education Sector .......................................... 9 C. Community Development .......................................... 10 III. THE PROJECT .......................................... 11 A. Project Objectives and Approach .......................................... 11 B. Project Description .......................................... 12 IV. PROJECT COSTS AND FINANCING ................... ....................... 23 V. PROJECT IMPLEMENTATION .......................................... 26 A. Project Preparation .......................................... 26 B. Project Management .......................................... 27 C. Implementation Schedule .......................................... 31 D. Project Monitoring and Reporting .......................................... 33 E. Implementation Issues in Comoros .......................................... 34 F. Procurement .......................................... 36 G. Disbursement .......................................... 38 VI. BENEFITS AND RISKS .......................................... 39 VII. CONDITIONS AND RECOMMENDATION ..................................... ..... 40 -2- (continued) Tables in Main Text Table 4.1 Summary Project Costs by Component Table 4.2 Summary Project Costs by Category of Expenditures Table 4.3 Allocation of IDA Credit by Disbursement Category Table 5.1 Implementation Schedule Table 5.2 : Procurement Arrangements Table 5.3 : Disbursement Categories Annexes Annex I : Community Development Support Fund (list of sub-projects) Annex II Information, Education and Communication Annex III Technical Assistance and Training Annex IV Summary Project Costs and Financing Annex V : Estimated Schedule of Disbursements Annex VI Performance Indicators Annex VII : Supervision Plan Annex VIII Selected Documents in the Project File Annex IX The Pilot Experience at Mitsoudjd Health Center Annex X : Health Component: Activity Implementation Schedule Annex XI : Comoros Demography and Health Resources, 1991 - i - BASIC DATA (1990 or most recent estimate) Comoros Sub-Saharan Africa Total Area (kmi): 1,862 23,066,000 Grande Comore 1,147 Anjouan 424 Moheli 290 Total Population (millions) 0.48 495 Population growth rate (annual %) 3.1 3.0 Population per km: Grande Comore 243 Anjouan 429 Moheli 109 Crude birth rate (per thous. pop.) 44.7 45.9 Crude death rate (per thous. pop.) 13.6 15.6 Life expectancy at birth (years): Overall 54.5 50.6 Female 55.9 52.4 Male 53.0 Infant mortality rate (per thous. live births) 114.5 107.3 Under 5 mortality rate (per thous. live births) 131.2 166.8 Total fertility rate (births per woman) 6.60 6.46 Primary school enrollment (% of school-age-group) 62.4 68.8 Population per physician 8,816 Population per nursing person 621 Population per hospital bed 363 Access to health care (% of pop.) 83%g Percentage of pregnant women receiving prenatal care: 1982 24 1989 70 Per capita GNP (US$) 510 340 Daily calorie supply (calorie per person) 1,960 2,120 Contraceptive Prevalence Rate (1991) 4% - 11 - CREDIT AND PROJECT SUMMARY Borrower: Federal Islamic Republic of the Comoros Executing Agencies: Ministry of Health and Community Development Support Fund (CDSF) Credit Amount: SDR 9.2 million (US$13.0 million equivalent) Terms: Standard IDA terms, with 40 years maturity Project Objectives: The overall objective of the project is to strengthen the development of human resources in the Comoros by: (i) increasing the efficiency and effectiveness of basic health services, through the establishment of efficient health regions and other supportive services, which will be capable of providing comprehensive good quality and cost effective health care, including family planning services and Acquired Immunodeficiency Syndrome (AIDS) prevention, and will involve community participation, self-management and cost recovery; and (ii) by promoting complementary community development initiatives to develop social infrastructure and grassroots participation in small-scale productive activities, through a Community Development Support Fund (CDSF). Project Components: The project has two components: population and health, and community development. The population and health component will build upon existing successful pilot programs for self-management and cost recovery to establish services capable of ensuring cost-effective and sustainable provision of comprehensive and good quality health care, including Family Planning (FP) and AIDS control services. To that end, the component will: (i) strengthen the capacities of the three health regions to plan, implement, administer, and supervise health care services, in part through improving and expanding the training of district health personnel; (ii) equip and rehabilitate two regional hospitals and a number of health centers; and (iii) promote family planning and AIDS control services. In the second component of the project, complementary community development activities as well as activities to encourage sustainable economic development would be supported through a Community Development Support Fund (CDSF). While demand driven, the CDSF would focus primarily on: training of communities and groups in micro-project development, management, and implementation; rehabilitation of social infrastructure (especially primary schools, water supply, and health posts); activities to promote the well-being and development of women; and income generating activities. - iii - Benefits and Risks: The project is expected to enhance the development of human resources by improving the health, education, and income status of the population. Through the health and population component, available primary health care is expected to improve with the strengthening of peripheral services and closer involvement of communities in their provision; Information, Education, and Communication (IEC) and better Family Planning (FP) services should increase the contraceptive prevalence rate, reducing fertility, as well as raising awareness of the need for AIDS prevention. The CDSF would complement activities in the health component by building upon strong community involvement and aiding communities and individuals to more effectively and efficiently channel community resources and implement local development efforts, including much needed rehabilitation of primary schools, water supply and health posts. It would provide an opportunity to strengthen the capacity of local associations and NGOs, as well as encourage the creation of new NGOs, in addition to enhancing the well-being and economic role of women in society. The main risks to the implementation of the project are weak Government capacity and potential delays due to political uncertainties. To address the first, the goal of the health and population component is to strengthen community involvement, both financially and managerially, in the provision of basic health services as well as to build Government capacity and improve the efficiency of these services. More specifically, personnel would be trained, a unit within the Ministry of Health would be created under the Directorate General of Health Services for procurement and administration of implementation, and technical assistance would be provided in key areas for capacity building. To insulate the CDSF from weak Government capacity and political interference, an autonomous agency staffed by selected, contractual employees would manage the fund. In addition, community training, strong CDSF supervision, a transparent management information system, and semi-annual auditing of accounts would enhance the overall efficiency of the community development component of the project. Project Cost Estimates: (in US$ thousands) Estimated Costs Local Foreign Total Support to the Health Sector 4,931 2,056 6,987 Community Development Support Fund 5,979 911 6,890 PPF 500 300 800 Total Base Costs 11,410 3,267 14,677 Price Contingencies 1,184 175 1,359 Total Project Costs 12,594 3,442 16,036 - iv - Financing Plan: (US$ millions) Local Foreign Total IDA 9,587 3,442 13,029 Government!' 3,007 - 3,007 Total 12,594 3,442 16,036 1/ Government contribution will include US$2 million in budgetary assurances to ensure adequate funding of health facilities to be rehabilitated; and US$1 million in community counterpart contribution to the CDSF. Estimated IDA Disbursements (US$ millions) IDA's Fiscal FY94 FY95 FY96 FY97 FY98 FY99 Annual 0.8 2.5 3.5 3.1 2.2 0.9 Cunulative 0.8 3.3 6.8 9.9 12.1 13.0 FEDERAL ISLAMIC REPUBLIC OF COMOROS POPULATION AND HUMAN RESOURCES PROJECT STAFF APPRAISAL REPORT I. BACKGROUND 1.1 The Federal Islamic Republic of Comoros became independent in 1975. It had a GNP per capita of about US$510 and a population of about 480,000 in 1992. Comoros, consisting of three islands off the east coast of Africa, is predominantly rural and highly dependent on external assistance. About 40% of GDP derives from agriculture, 50% from trade and other services and the rest from manufacturing and construction. Agricultural practices are undeveloped and marketing systems inadequate. Food production is insufficient to meet local requirements and the country imports large quantities of rice and meat. The manufacturing sector comprises primarily processing of export crops and a few small factories supplying the domestic market. Tourism is still at an incipient stage. Major exports are vanilla, cloves and perfume essences. 1.2 At independence in 1975, the country found itself with little infrastructure and low education and health standards. Political turmoil marked its first fourteen years of independence, culminating in the assassination of the President in 1989 and subsequent departure of the foreign mercenaries who had been controlling the country. The elected Governments which have followed have seen frequent cabinet reshuffles and an uncertain political landscape. Since independence, with support from the international community, economic and social infrastructure has improved. The country now has a fairly well-developed road network, an international airport, and a deep-water port in Anjouan. However, economic prospects remain constrained by the very small and segmented domestic market; the geographical remoteness from major markets; and the limited natural resources. A. Recent Economic Developments 1.3 Economic growth in the early 1980s was around 7% per year, but slowed to under 1 % in the late 1980s due to a decline in the construction and public works that had led the earlier spurt. Agricultural growth has continued at over 4% per year, but services have declined due in large measure to the adverse impact of the political unrest on tourism. Export earnings have been eroded due to declining terms-of-trade for vanilla and cloves, and exports presently cover less than half import costs. The major import is rice. 1.4 Inflation has been low and steady, averaging less than 4% during 1987-91, despite a large budget deficit. The Comorian franc is pegged to the French franc at FF1 = CF50. Due to the appreciation of the French franc vis a vis the US dollar, the Comorian franc has appreciated by about 60% in nominal terms (trade-weighted) and 25% in real terms in the late 1980s with serious consequences on growth. Central Government debt totalled US$170 million in 1990. Despite the concessional nature of most lending, the debt service ratio is about 19% and likely to remain at this level for several years. Due to a steady increase in the wage bill in the late 1980s and the weakness of the revenue base, the overall budget deficit 2 (excluding grants) averaged over 20% of GDP in the late 1980s. Despite measures in 1990 and 1991 aimed at reducing the deficit, domestic arrears remain substantial. 1.5 Reform Program. Major structural reforms are being undertaken which are oriented around better management of public finances, improvements in the climate for private investment and employment, export diversification, better social sector planning and management, and environmental protection. Reforms include improvements in the tax collection system, reductions in civil service staffing and benefits, restructuring of the management and financing of parastatal enterprises and the introduction of a new accounting system for public and private enterprises. IDA's Macro-Economic Reform and Capacity Building Credit (MERCAP), which became effective in December 1992, supports this reform process. In 1991 the Government of Comoros reached an agreement with the IMF and cleared arrears to the African Development Bank, opening the way for project lending to resume. A plan for civil service reform has also been undertaken. On trade, the Government has acted to reduce export taxes on vanilla, and to remove taxes and other levies on all other export crops. Improvements in domestic competition in these markets has also been encouraged. Export diversification is to be emphasized, especially into tourism, tropical fruits and agro-processing. The resumption of relations with South Africa has improved prospects for tourism. B. Conditions in the Social Sectors 1.6 Health, Population and Nutrition. The population of Comoros is relatively young (46% under age 15) and growing at 3. 1% per year. Internal and external migration rates are high. More than 40,000 Comorians live in France and a sizeable number in neighboring African countries. The relatively underpopulated island of Moheli constitutes a strong pole of attraction for migrants mainly from Anjouan. 1.7 Life expectancy is low at 56 years for women and 53.0 for men. Infant mortality is estimated at about 90 per 1,000 live births and maternal mortality at nearly 500 per 100,000 pregnancies. Available data indicate a high incidence of preventable diseases. In children, the leading causes of death are malaria, respiratory diseases, and diarrhea. Added to intestinal parasites, skin diseases, and trauma, these diseases account for most health facility visits by children under 5. Data from hospitals indicate high rates of obstetrical complications associated with pregnancies that are too early, too closely spaced, or too late. Only a quarter of births take place in health facilities. AIDS does not presently constitute a major public health problem. HIV seroprevalence rates are below 1 per 1000 (0.07% in 1992). However, given the extremely high prevalence of syphilis (19.2% among pregnant women in and around Moroni) and other conventional sexually transmitted diseases (STDs), this picture is likely to change with the anticipated improvement in international communications and expansion of tourism. As of December 1992, 16 HIV cases have been diagnosed, mainly among foreigners. 1.8 At the national level, current population problems are characterized by a very high density of population on arable land, high dependency burden, and a high level of unemployment. Comoros is one of the most densely populated countries in Africa, with an average population density of 205 persons per km2, or 398 persons per km2 of agricultural land. Anjouan is the most densely populated island, with 429 inhabitants per km2, compared with 243 in Grande Comore and 109 in Moheli. The proportion of children under 15 years of age and adults age 60 and over (3%) suggests an age dependency ratio of 1.03 and a heavy 3 burden for the economically active population. Government efforts to raise primary school enrollment are frustrated by the growing number of children aged 6 to 15. Unemployment is serious and growing and efforts to curb it are annihilated by persistent unfavorable demographic trends. Comoros' demography also has a strong negative impact on the environment. Forest degradation, especially in Anjouan, and severe soil erosion are just some of its many adverse environmental effects. 1.9 Family Planning (FP) services are available from most public sector facilities, including health posts. Despite a doubling of the use of modern contraceptive methods during the implementation of the Bank-financed Health and Population project (completed in 1991), the contraceptive prevalence rate (CPR) remains at a low 4%. Unmet demand for contraception is thought to be significant and there is now public consensus that the country is fast becoming overpopulated. A Population Unit exists in the Planning Ministry, but it has dealt primarily with the census. 1.10 The nutritional status of the population may be poor. One regional study showed protido-caloric malnutrition to affect over 40% of children under 5 with severe malnutrition as high as 10% in children under 5. Deficiencies of specific nutrients are also common. Many pregnant women suffer from moderate to severe anemia, and iodine deficiency disorders are highly prevalent in Anjouan. A diet low in protein, and traditions in which certain foods are taboo, may contribute to high malnutrition rates in children. 1.11 Overall, coverage of the health system is dense by African standards with 83% of the population living within one hour (walking distance) of a health facility. Health, population and nutrition services are administered through the Ministry of Health and Population. Service provision is currently organized through 20 health districts (14 operational with six to become functional in the future), each covering between 25,000 and 100,000 people. The districts are comprised of one health center and a constellation of health posts, dispensaries, and rural maternities. There are 15 health centers, and nearly 60 health posts and rural maternities. Tertiary care is provided in 2 hospitals with a total bed strength of about 700. Outpatient care at the tertiary hospitals is heavily utilized. Secondary care is provided in three surgical clinics with an average capacity of about 50 beds. A system of village pharmacies provide drugs at low cost and supplements private sector pharmacies. 85% of children are fully immunized. Public expenditures on health care are about 9% of public expenditures, and about 2% of GDP, for a total of about US$7.50 per capita. The wage bill comprises three fourths of the health budget. 1.12 Government policy since independence has stressed Primary Health Care (PHC) and has accorded priority to the delivery of basic services to the rural areas. Comoros has subscribed to the 1978 Alma-Alta Declaration, which prescribed a primary health care approach with the aim of ensuring health care for all by the year 2000. With external donor assistance, the actual orientation of the health services has generally mirrored the stated plans, with recorded achievements especially in increasing vaccination rates. 1.13 Education. Although education statistics are around the sub-Saharan African average, they were declining in the late 1980s and have only recently shown some improvement. Nonetheless, adult illiteracy is high (estimated at 50%) and the absolute number of illiterates may be growing as growth in literacy is estimated to be less than the population 4 growth rate. Gross primary school enrollment ratios were estimated at close to 90% in 1991, after falling over the five preceding years. Net enrollment ratios are about 62%. Rates of repetition are very high at about 35%. Pupil to teacher ratios in primary school are about 40:1. Double and triple shift classes are the norm, resulting in pupil-teacher contacts of 12-17 hours per week. Enrollment falls off in the secondary school years. The net participation rate in lower secondary overall was only 7% in 1991/92 according to Government statistics. In upper secondary it was less than 3%. As with most sub-Saharan African countries, salary costs consume most of the budget of the Ministry of Education, with supplies and teaching materials making up less than 3% of expenditures for primary education in 1991. 1.14 The Ministry of Education (MEN) employs about 1,800 teachers and 400 administrative staff. About 40% of public education expenditures goes to primary education, and 11% to external scholarships for university education for 750 students. Education consumes 22% of all public expenditures and about 4% of GDP. 1.15 Community Development. In Comoros, communities are traditionally very active in organizing local development initiatives, in part due to weaknesses in the central Government and in part due to cultural traditions. Lineage associations are very important in the social structure. The society is generally matrilineal (group membership and status is transmitted through the mother) and matrilocal (a newly married couple resides with the wife's lineage). The exception is the island of Anjouan which is not matrilineal. 1.16 Village society is very cohesive and village associations have a long tradition of investment in civic services, especially related to religion. Most villages have mosques, village squares, and markets which have been erected by the local communities. "Notables" play an important part in village society. Comorians abroad maintain their close affiliation with their villages, and constitute an important source of investment capital for village projects. Tlhis tightly-knit village structure is enhanced by the close physical proximity of houses -- villages are small urban units rather than dispersed farms; land is owned communally by the village as well as by individuals. 1.17 Women in Comoros are in a relatively privileged position compared to other countries. They are the owners of capital, especially real estate, and most are economically active. Women's groups are active at the village level all over the country. However, women bear the brunt of the country's poverty, as they spend long hours in collecting water and fuel, have very high fertility rates with negative health consequences, leave school earlier, and make up the majority of illiterates. 1.18 There also exist a number of other forms of association, including revolving credit societies ("tontines") and mutual aid groups for particular tasks, as well as other sporting, musical, and cultural associations. In general separate associations exist for men and women. Most associations have little organizational experience and, in some cases, meager financial resources. Government procedures require that associations register themselves with the Government ("declared" organizations). Some, in particular those for education (such as the parent-teacher associations), also receive Government support. There are a number of federations of associations, in particular the Federation of Women's Associations of Comoros, which has drawn support from UNDP; the National Coordination of Associations for Development, which coordinates the activities of NGOs with local associations; ULANGA, an 5 environmental federation; and professional associations. International NGOs active in Comoros include CARE, which implements a major environmental project for USAID on the island of Anjouan as well as interventions in the health sector; CARITAS, which runs a dispensary and school on Grande Comore and intends to expand activities to the other islands; and CECI, which supports community development and environmental initiatives. Other international NGOs active in Comoros include the International Committee of the Red Cross/Red Crescent, the Boy Scouts, the Lions and Kiwanis Clubs, Handicap International, Amici Raoul Follercao, Groupe de Service Volontaire and Amis du Pere Damien. C. IDA's Assistance Strategy and Lessons Learned 1.19 Health. The World Bank-financed Health and Population Project (appraised in 1982 and completed in 1991) was designed to help the Government develop a program to slow population growth and strengthen the management and delivery of basic health services. While many elements of the project had only minimal impact, the project did register some progress towards its objectives. Among its most important achievements were: (i) contribution to the creation of a network of family planning services accessible throughout the country in almost all health facilities, helping to change the initially very negative attitudes of political, religious, and traditional leaders toward family planning, and increasing the CPR to an estimated 4% today; and (ii) establishing the National Autonomous Pharmacy of Comoros (PNAC) which is now an autonomously managed operation which successfully operates on a cost-recovery basis and has greatly increased the population's access to essential drugs through its distribution systems which include cost-recovering village pharmacies. The reasons for the adverse results of other components of the project are diverse. At the time of project design, the Government was engaged in reorganizing its administration and economic system and the Ministry of Health, which was only created in 1980, was still in the process of organizing itself. Among the important problems were: (i) the MOH was not intimately involved in early stages of project preparation and there was a lack of ownership of the project; (ii) the project was a complex operation of six separate and unintegrated health sector components, each of which was run by a separate national coordinator; (iii) the project was designed for a vertical rather than an integrated approach to its activities, resulting in poor integration of these activities into the mainstream activities of the MOH; and (iv) project preparation did not provide the technical precision needed by a very new and weak MOH, (such as precision of which health posts were to be constructed) which resulted in considerable delays and poor implementation. Project design was generally too complex with excessive technical and coordination/management expectations of the MOH given the early stages of its organizational development. 1.20 The principal lessons to be drawn from the Health and Population project are the following: (i) project preparation needs to directly involve the principal implementation agency from the start and project design should be simple; (ii) activities should be integrated in a horizontal rather than vertical manner within the operations of the MOH; (iii) technical aspects of the project should be specified in detail and agreed by credit negotiations; (iv) future projects should ensure that the implementing agencies have the capacity to develop these technical aspects and technical assistance should be secured to ensure good performance; (v) because of the Government's fiscal situation, popular participation and cost-recovery should be explored to enhance sustainability prospects in future operations; and (vi) procurement procedures should be specified and agreed during negotiations. The proposed project has 6 benefited from the above lessons by working closely with the Ministry of Health from the outset, ensuring the specification of all technical details before negotiations, promoting cost recovery and community involvement in health facilities, and establishing the CDSF as an operational institution before negotiations. 1.21 Education. IDA has supported reforms in the education sector through two Education Projects. The objective of the ongoing second project is to assist institutional development in the Ministry of Education through: (i) improvements in education administration and planning, mostly through technical assistance, training, fellowships and study trips to other African countries; (ii) improvements in the quality of education at the primary and lower secondary level, which consist of training for underqualified teachers, training of advisers and principals and development of new teaching materials and guides; and (iii) upgrading of technical/vocational training through provision of training and equipment. This project has achieved some of its training goals, although progress has been slower than anticipated due in part to the lack of a clear Government policy on the direction and form to be taken by the education sector. This has been compounded by the reluctance of the Government to redefine its support of secondary education and foreign scholarships, delaying progress on financial aspects of the reform. The project has mainly encountered problems of management and financial discipline. Frequent changes in high level officials have led to lack of knowledge of the project and weak Government commitment. However, recent progress has been achieved in the reorganization of the education sector staffing and administration under the framework of the ongoing public service reform which is supported by MERCAP. Complementary community-based efforts to increase community involvement in primary schooling, including involvement in rehabilitation, maintenance, and equipping of primary schools, would be highly beneficial to increasing the sustainability of Government and donor efforts to improve the quality of primary schooling. The important lessons learned from these two education projects include: (i) the importance of the continuity of staff working on project implementation; (ii) the necessity of realistic expectations of the Government's ability to provide financial contributions; and (iii) the importance of and need to include communities in execution and planning of education sector activities. These lessons have been particularly instructive for the development of the CDSF, which directly supports community activities. II. HUMAN RESOURCES SECTOR ISSUES A. Health Sector 2.1 Many constraints hinder the improvement of health and demographic conditions in Comoros. Chief among these obstacles are weak delivery of health services at the periphery level and weakness of population activities. Weak delivery of health services 2.2 The delivery of health services, especially at the periphery level, remains weak due to: (i) MOH inefficient organization and management; (ii) inadequate infrastructure; and (iii) weaknesses of population and AIDS activities. 7 2.3 MOH IneMcient Organization and Management. The effectiveness of MOH health activities is hindered by poor organization, lack of resources, and overcentralization of the central administration. Medical regions and districts where most health care activities should take place have only nominal power and few resources, being ill equipped in terms of human, material, and financial resources and thus being unable to ensure the planning and implementation of good quality PHC services within their boundaries. The current level of centralization of the MOH and the heavy reliance on vertical programs preclude the involvement of the health regions in the preparation, implementation, and evaluation of health activities. For instance, medical doctors in charge of health centers are involved neither in the Expanded Program of Immunization (EPI) nor in the FP program, significantly lowering the potential impact of these programs. Additionally, efficiency is reduced by the lack of referral mechanisms and a lack of clarity as to the appropriate functions of each level of the health system. There is no organized system to prevent patients from anarchically moving from one level to another level of the health care system. The tendency for patients to bypass peripheral facilities results in underutilization of an overly dense network of health posts and overcrowding and inefficient use of hospitals. Secondary and tertiary health facilities are used as PHC centers. 2.4 The curricula used by the MOH for training health personnel does not conform to the skills needed for these workers to adequately perform their jobs. Both the level and mix of their current skills are inadequate. Existing health workers, including those trained at the National Public Health School (ENS), have not been adequately exposed to PHC and community health activities. About 70% of MOH workers have no formal medical education. A sizable proportion of nursing staff is made of untrained volunteers, particularly in peripheral facilities, who often operate without adequate supervision to assure satisfactory quality. In addition to problems in the quality of health workers, another manpower constraint results from inadequate distribution of health workers throughout the country. Because of the lack of proper management or an incentive system to attract workers and retain them in poorer rural areas, there are wide disparities in the distribution of health personnel among individual facilities, as well as a relative surplus of qualified nurses and midwives in hospitals and a shortage of nurses in PHC facilities particularly in remote areas. The main hospital in Moroni, El Maarouf, is disproportionately well staffed while rural health facilities are essentially staffed by often poorly trained volunteers. 2.5 Health Inrrastructure Inadequacies. Efforts to develop population and health activities in Comoros are also frustrated by the dilapidation and underequipment of health facilities. Health facilities are often decrepit and poorly maintained, medical equipment is generally minimal, and essential commodities are sometimes in desperately short supply. Lack of maintenance and other support from the central ministry and an inadequate flow of supplies and equipment impedes the operating efficiency of health facilities, especially at the peripheral levels. There is also a tendency to design and establish health structures without proper attention being paid to the size of the population to be served. The excessive number and size of facilities contributes to high unit costs of services provided by the MOH and lowers the efficiency of the Ministry, which in fact fails to provide adequate, if any services, at many of these health facilities. 2.6 Weakness of Population and AIDS Activities. Although significantly improved during the implementation of the Health and Population Project, FP services still 8 have obvious shortcomings and suffer from not being integrated into other MCH services. While the Health and Population Project's approach was to train four well-motivated and well-equipped mid-wives to promote and supervise FP activities and to improve conditions at the facilities which provided these services, activities at which it was successful, much remains to be done. Because this approach lacked the inclusion of physicians in the provision of family planning services, the impact was less than it could have been. In addition, there is almost no follow-up to motivate users to continue using contraceptives. The monitoring of clients, supervision of services, and management of contraceptives still remain weak and supplies of contraceptives, which to date are solely financed by UNFPA, are unpredictable and subject to inventory breakdowns. These and other factors make it difficult for clients to get appropriate support and treatment for their complaints and many get discouraged, failing to return to the center for further supplies. 2.7 IEC activities in the family planning area, which have been financed by the UNFPA and which relied in part on traditional communication networks such as mosques and markets, were somewhat successful in changing the cultural and religious climate in Comoros. At present, there is little religious opposition to the use of family planning for health and socio-economic reasons. However, there is no clear understanding of the demographic need to use family planning. In fact, current research indicates that many religious and traditional leaders are in favor of family planning for health and socio-economic reasons but do not understand the demographic need to limit population growth. In the last several years, IEC activities have been diminished for family planning due to a lack of human, physical, and financial resources. 2.8 Because the AIDS virus has not been a serious problem in Comoros to date, most Government officials and the population have not begun to address the potential impact this disease could have on Comoros. Comoros has had a National AIDS Control Program since 1990 and it has carried out some IEC activities aimed mostly to reach leaders and young people. However, although the program allocates about half of its resources to IEC, it does not have enough resources to carry out the studies necessary to the development of an effective IEC strategy. Trends experienced by other countries, (e.g. Djibouti and Cote d'Ivoire), which previously had low AIDS but high STD prevalence rates as Comoros currently does and which showed dramatic increases in AIDS over short periods of time, show that it will be crucial for Comoros to intensify its IEC campaign and to extend its condom distribution program in order to prevent a rapid contamination by HIV. Ongoing Activities to Address these Issues. 2.9 In order to create a more efficient health delivery system, Comoros has implemented a pilot program of autonomous administrative and financial management at one health center, which has been highly successful. At the Mitsoudje health center, the community participated in the construction of the center and is involved in its management, financing and maintenance. Support has also been provided by UNDP, with technical support from ASI, a French NGO. The center was authorized to charge fees, manage money received, and was given greater autonomy over personnel. 2.10 At present, receipts cover not only the operating costs of the center, but also a system of bonuses for the staff (tied to performance) as well as major and minor maintenance 9 and purchase of equipment. UNDP continues to defray the costs of the doctor, whose salary is higher than that of doctors in the public service. Utilization of the center continues to rise steadily in spite of the proximity of El Maarouf Hospital and the existence of fees for services. The utilization rate has reached a level of one curative visit per year per person living in the catchment area. A report issued in 1993 reviewing the pilot experience for the Government confirms that the system is efficient from the point of view of motivation of personnel as well as financial management and quality of services. A survey taken one year after the institution of the fee for service system at Mitsoudje showed that average household spending on health care in the catchment area had fallen after the institution of cost-recovery (and associated improvements in quality and reliability). However, it notes the importance of significant investments in training and modification according to local conditions. 2.11 The Government plans to generalize the principle of co-management with communities and of cost-recovery of health facilities. It has issued a decree permitting autonomous management of receipts in hospitals (December 1992) and, under the ongoing public service reform will, in 1994, elaborate a new management, financial and administrative system for health centers based on the model of the one in operation at Mitsoudje. 2.12 The Government of Comoros has recognized the need to expand the demand for, as well as the quality and the quantity of, fertility and AIDS control services. With substantial assistance from donors, the MOH continues to make commendable efforts to ensure a steady supply of condoms, pills, injectables and other FP commodities and to improve the country's capacity to prevent, diagnose, and treat STDs. However, the impact of these efforts is limited by the advanced state of dilapidation of most MOH health facilities. To motivate Comorians to change their behavior and to adopt practices which are conducive to better health, programs addressing major public health problems each have an IEC component. However, this approach has led to a fragmentation and unequal distribution of IEC resources, as well as a lack of coordination and ineffective use of existing resources. Presently, although family planning and AIDS prevention programs have more resources allocated to IEC than the other public health programs, they still do not have enough resources individually to carry out the necessary activities. The UNFPA IEC Population project focused on three types of activities: (a) training of health personnel and community workers in family planning interpersonal communication; (b) research on obstacles to the use of family planning; and (c) material production. However, because of limited resources there were shortcomings in the project, training was carried out only in project areas (ten villages), research sampling and methodology were inadequate, and materials were not pretested. This lack of adequate resources is likely to become worse as the budget of the next UNFPA IEC project, which started in April 1993, is lower than that of the on-going project. In the AIDS area, IEC activities have been limited and somewhat haphazard. They included one poster, some radio spots and shows and some sensitization seminars aimed at opinion leaders and young people. B. Education Sector 2.13 As in the health sector, performance in the education sector has been compromised by the weakness of policy leadership and frequent personnel changes at senior levels. Although some goals have been achieved in recent years, progress has been slower than expected due in part to significant political pressures against certain aspects of the education reform program. The Government's goals are: redistribution of expenditures in 10 favor of primary education; at the primary level, retraining of teachers, provision of teaching materials and rehabilitation of school facilities; and at the lower secondary level, retraining of teachers. The plans for the Public Expenditure Program for FYs 1992-95 indicate a gradual fall in allocations to secondary level education, a real decline of 3% between 1991 and 1994. An even sharper decline is predicted for foreign scholarships, falling by two thirds as the number of new scholarships is reduced to zero by 1994. External aid is expected to make up the difference with 100 new scholarships per year. However, pressures to increase admissions into upper secondary and foreign scholarships have delayed the full implementation of a system of financial controls. In addition, frequent strikes by primary teachers have undermined the progress of reform at that level. 2.14 Because significant resources remain in the Second Education Project and implementation has been extended to June 1994, the proposed Population and Human Resources Development Project would not directly address education sector issues. Additionally, there is a follow-up project planned in the education sector once the Second Education Project is completed. The proposed Population and Human Resources Development Project would affect education, however, by promoting complementary community involvement in the rehabilitation, maintenance, and equipping of primary schools, with technical and financial support from the proposed Community Development Support Fund. C. Community Development 2.15 Local NGOs and community groups are responsive to local felt needs, but they frequently lack an interface to the formal sector. However, the environment in which they work is improving. The intolerance of former Government leaders for "modern" associations, in particular the Scouts and other youth movements, has been replaced in recent years with a more welcoming climate. Associative life has flourished and the Government now welcomes the participation of community organizations in the elaboration and implementation of development plans. 2.16 The Government believes that the development and support of community organizations should play a vital role in socio-economic development. The contribution of community organizations in assessing local needs and capabilities can form an important part of social policy. Furthermore, community organizations may be best placed to implement certain activities. In particular, the contribution of community groups can be critical to the development of education and health institutions at a local level. After contributing their ideas and financial resources to the construction/rehabilitation of a school or clinic, community groups can play a crucial role in the sustainability of the institution by organizing and maintaining a system of financial management and maintenance. This could include cost sharing, contribution for key salaries (eg. teacher or nurse), maintenance responsibilities or insurance/mutual aid. 2.17 The main outstanding issue remains the managerial and organizational weakness of community organizations. There are significant needs for training in financial and other forms of management; for technology transfer for technology-intensive projects (eg. water supply or construction); and popularization of available funding sources and assistance with project preparation. Communities in Comoros are generally in a position to provide 11 financial and in-kind contributions to projects, with increased ownership, sustainability and impact resulting from this contribution. III. THE PROJECT A. Project Objectives and Approach 3.1 Project Objectives. The overall goal of the project is to strengthen regional and community involvement in population and human resource development through improving the delivery of basic health services and stimulating complementary community activities. To achieve this goal, the main objectives of the project are to: (i) support the establishment of efficient health regions and other supportive services capable of providing comprehensive and cost effective health care, including family planning services and AIDS prevention, through community participation, self-management and cost recovery, and (ii) support complementary community development initiatives to develop social infrastructure and grassroots participation in small-scale productive activities. 3.2 Project Approach. To achieve the first objective, this project will selectively continue past efforts initiated by the Government in the health sector with assistance from the donor community. The population and health component of the project constitutes an integral and essential part of a package which will be financed in parallel by the Comorian Government, French aid (FAC), UNDP, WHO, and UNICEF. The Bank's primary role is to rationalize and improve the efficiency of the MOH services, building upon successful experiments with administrative autonomy of health facilities and community participation. To achieve the second objective, a demand-driven social fund approach will be used to support existing active community involvement in local development through a Community Development Support Fund (CDSF). This approach will require the following: that the request for support from the Human Resources Project to the community's sub-project comes from the communities themselves; that the beneficiaries are directly involved in the planning, execution, and evaluation of the sub-project; that beneficiaries contribute either in-kind or financially to the sub-project's realization to assure sustainability; and that when necessary and/or desired the community benefits from training to increase its capacity to develop sub- project proposals as well as to implement and sustain sub-projects. 3.3 Because sub-projects which will be financed under the social fund are to be demand-driven, precise and well-defined rules and criteria for sub-project selection have been designed. To this end, a Manual of Procedures to regulate and facilitate CDSF operation has been prepared and was tested by means of sub-projects financed under the PPF. The Manual of Procedures is described in paragraphs 3.36-3.38, and is available in the project files. The adoption of a Manual of Procedures satisfactory to IDA by the Central Coordinating Committee (CCC) of CDSF is a condition of effectiveness of the proposed credit (para. 7.2(b)). The design of the CDSF is based upon lessons learned throughout the Bank and in the Africa region, in particular as spelled out in the regional study, "Social Action Programs and Social Funds: a Review of Experience in Design and Implementation," and "Socio-economic Development Funds: A guideline for Design and Implementation." The project is also based on experience gained from similar projects in Senegal, Mali, Zambia, Madagascar, and Burundi among others. Principal among these lessons are the importance of promotion 12 activities; the need for a good system of management of financial data; the need for clear objectives and project selection criteria; and the importance of training as a contribution to the effectiveness of the administration of the fund as well as the success of sub-projects. B. Project Description 3.4 The project will: (i) establish appropriate services capable of ensuring cost- effective and sustainable provision of comprehensive and good quality health care, including family planning services, AIDS prevention, and community participation in both management and cost recovery, and (ii) support a social fund to finance community activities (including education sector related activities and community level health activities). Support to Improve Health Services 3.5 To improve MOH efficiency and ensure cost-effective and sustainable provision of essential health services, this component of the project will have three sub- components: (i) improving MOH management at the regional level; (ii) equipping and rehabilitating regional hospitals and health centers; and (iii) promoting family planning and AIDS control activities. 3.6 Improving Planning, Implementation, and Monitoring Capacity of Regions. To strengthen and develop program planning, implementing and monitoring capabilities at the regional level, the project will build and expand upon the experiences gained from the above-mentioned Mitsoudje pilot program (para. 2.9). Overall management of the three health regions (one for each island) will be the responsibility of Regional Health Teams (RHT). Each RHT will be headed by a Regional Medical Officer (RMO) and will be charged with supervising the implementation of health programs throughout the region, organizing on- the-job training for regional health workers, and stimulating and streamlining comrnunity participation. RHTs will have the responsibility and authority for administrative and technical matters in their area, including the supervision of activities in hospitals and health centers against established norms and monitorable performance indicators which are to be developed during preparation and the first year of project implementation. To ensure good quality and socially acceptable health and population services, special efforts will be made to stimulate community participation in the planning, implementation, monitoring and evaluation of population activities. At the health center level, the population will be encouraged to participate by creating development committees at the village level, participating in the rehabilitation of facilities and placing representatives on the management committees. The health centers will be granted greater autonomy over the administration of personnel and the levying and management of fees. This will be complemented by reforms in the regulatory environment and in health personnel through the reform of the public service which is supported by MERCAP, as well as by improvements in the allocation and funding of the health sector budget which will be monitored both through the MERCAP credit and this project. 3.7 The project will also increase the productivity of regional personnel through a series of training activities for various health workers. A list and description of the basic training courses to be provided can be found in Annex 111. Special efforts will be made to endow regions and health facilities with qualified planners and administrators capable of properly carrying out the planning and the budgeting process required to efficiently utilize 13 human, material and financial resources. Service providers will receive appropriate training to raise their skills in the delivery of preventive and curative care. The training will emphasize the role of multi-purpose workers to dispense integrated basic health services (including FP and STD management). 1/ Under the Health Region scheme, RHTs are expected to play a pivotal and dual role in the development of health programs in their jurisdiction. As physicians, they will have to spend part of their time working in health facilities to handle difficult cases, particularly those identified by the auxiliary personnel at the health posts, dispensaries and rural maternities. As managers, they will be responsible for ensuring the provision of good quality services throughout their district. RMOs will receive adequate and specific training to help them carry out the dual function. As has been done in the Mitsoudje pilot, an appropriate incentive system will be established to both attract and retain health workers, particularly into underserved areas, as well as to improve staff performance. This will include regular and adequate supervision and may include incentives such as provision of transportation and housing facilities particularly for health cadres working in remote areas. 3.8 To ensure that FP services are integrated into the overall package of services provided by the health centers and are successful, the project will provide logistical support for the incremental supervision visits which will focus on: integration of FP into the MCH package, practical application of approved service norms, and the supply and procurement of contraceptives. Mechanisms will also be established to follow up on acceptors, motivate users to continue using contraceptives and accurately record the number of acceptors, users and couple-years of protection (CYPs). To prevent shortages of FP commodities, the project will finance a contingency fund to assume the regular supply of contraceptives. 3.9 Complementary and Prerequisite Actions Required at the Central Level. In order for health regions to effectively carry out the above program, several actions need to be undertaken at the central MOH level to enable them to provide adequate technical and operational support to the regional staff who implement the vast majority of activities. To ensure proper administration of the project, a Project Office will be established within the MOH Directorate General for health facilities. Additionally, MOH's central Directorates, particularly the Directorate of Health Education (DHI) and the Directorate of Pharmaceutical Inspection (DPI) will be strengthened. The Project Office will be headed by a Unit Chief who will report to the Director General. The Project Office will be responsible for the administrative task of overseeing the implementation of the component. This unit will provide assistance to help the relevant MOH units and RHTs develop and/or improve the following: (i) appropriate sector norms, rules, regulations and standards, including PHC therapeutic protocols, a Pharmaceutical Code, and MOH administrative and financial procedures; (ii) training modules for MOH staff based on agreed standards and functions to be performed by each category of personnel, as well as organizing training for RMOs in collaboration with the ENS; and (iii) a monitoring and evaluation system for the health regions which would assess the results of efforts invested in the sector. Terms of reference for the technical assistance (most of which will be local and regional) needed to aid the MOH in establishing systems and I/ With regard to FP, programs will be developed to train and explicitly and systematicaUy involve physicians (particularly Regional Medical Officers), nurses, auxiliary nurses, and pharmacists in the provision of FP services. Training modules will be developed and implemented in the management of FP services, communication, contraceptive technology, integration of FP and MCH services, and outreach programs. 14 procedures for improving MOH efficiency at central level are listed in Annex III. Funds will also be made available to finance technical assistance to aid the Government in improving its health information system (including public expenditure programming and resource management as well as disease trends) and improving the logistics system for the procurement and flow of supplies and equipment to districts. 3.10 Equipment and Rehabilitation of Health Facilities. Given the fact that the dilapidated physical state of the public health care facilities contributes to their low performances, selected priority MOH facilities will be partially rehabilitated and equipped so as to enable them to effectively carry out their normative functions. The project will finance partial rehabilitation, including waste disposal and sanitary water supply, equipment, technical assistance and training of health personnel, for a total amount estimated at US$3.4 million. For health centers to qualify for rehabilitation, full community involvement will be required. The CDSF will work with the MOH, mobilizing communities to participate and undertake part of the rehabilitation, as well as assure community commitment to maintenance and management of these facilities. As a condition of negotiations, preliminary architectural plans, as well as time tables for rehabilitation of the designated health facilities, and a preliminary list of medical equipment, grouped by lot for bids were finalized and submitted to IDA (para.7. 1(b)). 3.11 Expanding and Improving Family Planning and AIDS Control Activities. The project will support activities to improve the availability and quality of fertility and AIDS control services, as well as the demand for these services. During preparation and the first year of the project three studies will be conducted. One study using qualitative techniques will assess the factors which influence decisions on family size and the underlying causes behind the low demand for FP services and low rate of continuity among FP users. A second study will collect data on knowledge, attitudes and practices with regard to sexuality and AIDS in Comoros. A third study will investigate what are the credible sources of health and family planning information for Comorians and what are the best channels to use for each target group. The three studies will help to provide first hand information to assist in the improvement and design of multi-media, well-targeted IEC strategies and the formulation of other population and AIDS activities. Based on the findings of these studies and on the results of the beneficiary assessment study to be undertaken during the first year of the project, appropriate IEC messages will be produced and disseminated according to the selected strategies and any corrective operational and managerial measures will be adopted. 3.12 In the field of family planning, four priority groups will be targeted by information, education and communication activities, namely, religious and political leaders; women aged 15 to 49; men who are married to women of reproductive age; and young people. Support will be given to both modern and traditional media. In stimulating the demand for FP, person-to-person education will be combined with an enlarged mass communication effort (seminars, radio programs, theater, mobile video, etc.). A similar approach will be used for AIDS IEC activities which will be targeted mostly to young people and to opinion leaders. Over the life of the project, group meetings will be held to guarantee social acceptance and support. As mobilizing religious leaders is critical in addressing these issues in Comoros, conferences for religious and other social leaders would be held annually on each island. Representatives of women's and youth groups would be invited. Leaders of community organizations will be trained in interpersonal communication and community mobilization with particular reference to FP and AIDS and will be used as "relays" to disseminate FP and AIDS 15 messages. Other "relays" who will be trained will be journalists for whom four seminars will be held. The project would also finance two study tours so that Comorians can learn from other countries' experience. Two months of technical assistance will be provided for specific tasks as required (Terms of Reference are in Annex III). Access to good quality family planning and AIDS control services will be expanded through the rehabilitation of health facilities and the adequate training and supervision of health workers. Special attention will be given to ensure regular supplies of commodities required to perform fertility and AIDS control activities, including contraceptives, antibiotics and lab reagents in all health facilities. To improve the availability and quality of fertility and AIDS control services, the project will support the following: (a) equipping 20 laboratories to improve their diagnostic capacities; (b) training and supervising service providers and lab technicians; (c) ensuring regular supply of commodities required to carry out fertility and AIDS control activities; and (d) monitoring the impact of these control activities. 3.13 Policy Measures. In addition to technical support for project implementation, the Government has provided IDA with a health policy letter which includes the policy measures described below: 3.14 The letter outlines the programs and intentions of the Government in the health sector. It recapitulates the National Health Development Plan of 1991, which identifies the priority programs, which are (a) the promotion, through information, education and communications, of healthy lifestyles and behaviors; (b) the promotion of maternal and child health, including pre- and peri-natal care, vaccinations and family planning; (c) efforts against endemic diseases, including malaria, diarrheal diseases and AIDS; and (d) the supply of essential medicines, notably through the development of village pharmacies. The letter stresses the importance of population policy and family planning goals both in the health sector and in the national economic agenda. 3.15 The letter continues by describing the reforms of the system of administration and financing of health facilities, in line with the overall reform of the public service taking place under the mantle of the Structural Adjustment Program. Specifically, the reforms envisage that the public system of health care will be simplified to focus on health centers and hospitals and these public health facilities will be endowed with new powers of financial and administrative management, including a universal principle of cost recovery. Improved central services of IEC, supervision/inspection and training will support the public health activities of these more independent facilities. The use of mobile teams for specific campaigns will be reduced and replaced with facility-level health teams with an integrated and diversified mandate and composition. The central functions of monitoring, training and program management will be decentralized to the regional level (one region per island). The staffing will be reoriented in favor of more qualified workers with a better geographical distribution. 3.16 This new arrangement will be codified in a set of new regulations and administrative procedures under development in 1993. These regulations define the involvement of communities in the management of health centers and their representation in the governing boards of hospitals. They define the parameters under which cost-recovery can take place, and the mechanisms by which the funds so generated are managed (all funds are retained at the facility level). They also define the relationships of facility management to civil servants and to the public service, including guidelines for performance-related incentives at the facility 16 level (incentives at the regional and central levels will be addressed as the system develops). Finally, they define the roles and responsibilities of the various levels (Central, Regional and facility) for maintaining public health objectives, including training, supervision and IEC. 3.17 At the same time, with the Ministry of Finance, the MOH is putting together a budgeting process which will lead to more rational funding of the health sector. By December 31, 1994, the Ministry of Health will, with the Ministry of Finance, produce a public expenditure program to cover 1995-97 and review it annually with IDA; this will be a rationalized budget responsive to program needs. The involvement of the Ministry of Finance will ensure that the program is feasible from a budgetary perspective. During negotiations assurances were given by the Government that the budget for the MOH will be credited at a level which maintains the 1992 level of real expenditure, including at least 20% of the total in non-salary funding, that the budget will be reviewed annually with IDA, and that the budget for the current and subsequent fiscal years will be reviewed annually with IDA (para. 7.1(c)), starting with the 1995 budget. 3.18 Under the project, IDA will finance the rehabilitation and equipping of three regional offices, and two hospitals (Hombo and Fomboni). The project will also provide funds for the rehabilitation and equipping of health centers, the selection and scale of which to be decided on the basis of community mobilization and participation. The project will finance the production of training modules and in-service training for health planners and administrators, regional medical officers, medical doctors, nurses and midwives, and technicians. The project will also provide for a limited number of study tours and analytical studies. Technical assistance to the Project Office in the MOH will also be provided for by the project. 3.19 Sustainability of Regional Health Program. The proposed project will lay the groundwork for the sustainability of the health system of the Governmnent of Comoros, which is weak due to the current large Government deficit and weak institutional capacity. The project aims to enhance sustainability of health activities through improvement of health sector management, human resource development, health financing, improved STD/FP services, and health facility rehabilitation. This will build upon successful pilot programs which increase beneficiary participation in both management and financing of health services. The operational sustainability of the project will be achieved by relying on the involvement of experienced private firms/NGOs and local communities to implement the various project components. 3.20 Recurrent cost implications of the health component. The reforms to be undertaken under the project are budget neutral. There will be no new facilities constructed and staffing will conform to the public sector rationalization under way for the Government overall. For the Ministry of Health, this reform implies no net change in the number of people employed, but there will be a shift towards more qualified employees. The slight rise in the wage bill will be offset by a mild reduction in public spending on non-salary items, which will be increasingly covered by cost-recovery. In order to fully reflect the Government's commitments and obligations, the project cost tables indicate the Government's contribution of staff and supplies, without which the rehabilitated facilities cannot function. The only incremental recurrent cost implication of the health component is the operating cost of the Project Office. As the Project Office's purpose is to supervise administration of project 17 activities (procurement, disbursement, etc..), it is not expected to continue after the end of the project. 3.21 A new institutional structure for the health sector has been was signed and is expected to be implemented in early 1994. This will have only a slight and progressive effect on the health sector wage bill, which is covered by reallocations from other sectors, under the overall adjustment program, and is not a consequence of this project. Non-salary costs at the health center level, while woefully inadequate, will be shifted in large measure to the communities through cost-recovery (fee for service) and community responsibilization. Some of these savings will be redeployed to the hospital level, and the hospitals will also mobilize resources through cost recovery. Cost recovery already fully pays for medications, and the operating costs of laboratories, radiology services and dentistry. It is conceivable that these adjustments would result in a decrease in the recurrent budget of the Ministry of Health. However, this does not imply a decrease in expenditures, which have historically been well below the budget. 3.22 In 1994, the Ministry of Health will issue a Public Expenditure Program (PEP) to cover the years 1995-97, the execution of which will be reviewed jointly by the Government and IDA annually and at the mid-term review as agreed during negotiations (para. 7.1(i)). The PEP will cover investment and recurrent expenditure at the facility level, and will conform to the Government's structural adjustment plan as well as serving the aims of the reform of the health sector. It will take into account recurrent cost implications of investment projects. 3.23 The goal of the PEP is to provide a realistic budget that will be followed, and in which facilities, suppliers and contractors can have faith. In the past, budget allocations have been reasonable, but actual payments have lagged far behind, with commitments being around two-thirds of allocations for non-salaries expenditures in 1989-92 and actual payments lower still. The process has begun with the development of the Public Investment Program in 1992. The PEP would analyze actual payments, reducing highly fungible categories (fuels, food) and aiming for full funding of all allocations. 3.24 The criteria for budget allocation in the health sector have been simplified by the proposed reforms of the public health system. On the investment side, no new facilities are to be built in the immediate future (before at least the year 2000). Investments are in rehabilitation, equipment and human capital, and these are limited largely by the availability of donor funds. On the recurrent side, the proposed reforms would significantly reduce non- salary expenditures at the lower levels (health centers and health posts) as these will become the responsibility of the community and the beneficiaries. At present the distribution of non- salary expenses is about 30% to central functions and 70% to hospitals, both of which are very underfunded. The new structure of the health system will require increased and improved performance by the center. At the same time, the need for increases in funding of recurrent costs for hospitals remains commanding. This distribution of allocations between administration and hospitals is therefore likely to remain much the same. The following agreements have been reached with the Government: (i) the budget executed in each year of the project will be no less than the commitments for 1992 in real terms (CF800 million); (ii) the budget executed in each year of the project will contain no less than 20% will be allocated to non-salary expenditures; (iii) medical evacuation costs, which are currently disproportionately 18 high (CF36 million in 1992), will be reduced as agreed under the MERCAP program (CF20 million in 1993); and (iv) the budgets for health facilities will be allocated on the basis of contracts between the MOH and the facilities starting in 1995. These agreements are reflected in the letter of health policy. The Community Development Support Fund 3.25 The CDSF is designed to encourage community participation in sustainable economic development, support and develop the capacity of communities and non-Government organizations, and complement sectoral development strategies, especially in the education and health sectors. It will bring additional financing and technical support to the realization of community projects. Together the activities funded by the project will have a synergistic effect on improving human resources, promoting overall economic development, and alleviating poverty. While the social fund will be demand-driven, i.e. sub-project ideas will come from the communities themselves, and the criteria which have been developed to screen and evaluate the projects will determine which sub-projects are to be funded by the CDSF (see para. 3.31), the primary focus is expected to be on the following types of activities: rehabilitation of basic infrastructure, especially primary schools and water supply; income generating activities; activities which promote the well-being and development of women; and training of communities and groups in appropriate technologies and in resource and project development and management. As mentioned above, the selection of sub-projects will be subject to a set of precise criteria in the Manual of Procedures which was drafted and discussed during project preparation, reviewed during appraisal, and was finalized during negotiations (para. 7.1(a)). 3.26 Rehabilitation of basic infrastructure. The vast majority of sub-projects to bp financed under this category are expected to be the rehabilitation of essential services (rimary schools, water supply, health posts), but could also include the rehabilitation of feeder roads, bridges, markets, and food storage facilities. In the case of rehabilitation of essential infrastructure, project support will be possible if communities express these as their priority needs, contribute to the costs of project implementation, and develop a viable maintenance scheme. Already there have been over 20 requests for sub-projects in the rehabilitation of primary schools, which are being refined, and about a dozen in water supply. (A list of sub-project requests which have been received to date and are expected to be completed during the first year of project implementation is listed in Annex I). The NGO CARITAS is also working with communities in the area of primary health care and is responding to several communities interested in submitting proposals for the rehabilitation of health posts. Although sub-projects proposals have not been submitted to date for the rehabilitation of feeder roads and bridges, the project is open to financing these infrastructures when they constitute missing links for income generating activities. Labor intensive work will be preferred whenever proven as technically and economically efficient and insofar as it generates employment opportunities. In coordination with the Ministry of Health, the CDSF will help to mobilize and train communities for their participation in the rehabilitation and management of health facilities, funds for which are provided under the health component of the project. 3.27 Income generating activities. The project will encourage the poor to launch small-scale, viable, productive activities in sectors where a demand can be identified or expected and which have durable real income gains. The project will assist implementing 19 agencies to organize groups, particularly women's groups, to undertake sub-projects. The project will finance specific vocational training and basic management, accounting, and marketing support. Because the creation and expansion of small businesses is critical to the growth of the Comorian economy, this is an important element of the project. However, the CDSF will enter this field very cautiously for the first two years of its operation because experience with cooperative enterprises is small. For this reason, for the first two years of CDSF operation, the project will work closely with a UNDP/ILO project which already has some experience in lending working capital to micro-enterprises. During the first phase of two years, the CDSF will complement the UNDP/ILO's activities by providing, where necessary, training and technical assistance in work planning, supervision, and production. Support will also be given where needed to the expected hundred small contractors who will have contracts making furniture for the CDSF-funded rehabilitation projects. The CDSF will not extend credit. After two years, an evaluation will be carried out by the CDSF to draw on the experience and make proposals to launch the second phase of the program. 3.28 Training. As the CDSF is aimed at promoting self-reliant, sustainable socio- economic development of rural communities, by increasing the local institutional capacity for development planning and implementation, training would play a crucial role in helping communities attain the proposed targets. Training is expected to be both supply and demand driven. It is foreseen that communities will need training in organizing, developing sub- projects, and managing the implementation and maintenance of them. The estimated training plan (Annex III) is expected to involve approximately 1800 members of the Community Pilot Committees which will be involved in micro-project execution (see para. 5.15), 180 book- keepers, 600 masons, 180 carpenters, 360 school furniture makers, 100 fitters and plumbers, 270 painters, and 2000 rural women in the three islands. Training activities will be coordinated by the Information and Training Unit. Staff and technical assistants would actively participate in training. Seminars in communication and training methods for technical skills in production will be organized with a view to strengthening the training corps. Training for managers at both central and local level will provided by consultants from the NGO CECI, which supports management development for the component. Training for the development of women will be carried out by CARITAS' professional staff. Basic skills training for workers will be provided on-the-job by mobile teams composed of job site supervisors, foremen, and part-time teachers hired under the project. Training will also be provided by the private sector or other implementing agencies, especially for sub-projects which request specific training. 3.29 Promotion of women. The women of Comoros are in general economically active and interested participants in the development process. This project seeks to support and further develop this participation of women. The CDSF approaches women's issues through two different means: special programs for women, and inclusion of women in all the regular activities of the CDSF. In the first instance, it offers a program of training for rural women in the areas of literacy, family planning, nutrition, mother and child health, and income generating activities. Through this program, women who are already active in their communities will also be given special coaching to assist them in project formulation and community organization, helping them to make proposals to the CDSF and other donors. The other means is through the general program of projects, where the CDSF will target activities that are mostly carried out by women (child care), provide disproportionate benefits to women (education, nutrition, water supply etc.), or include women as equal partners (all village 20 residents must be members of the community committee). Projects will be monitored and care will be taken to maintain a high percentage of projects with significant benefits to women. 3.30 Institutional Structure. The overall structure of the CDSF is a Central Coordination Committee (CCC), a National Executive Secretariat (NES), Regional Committees (RC), Regional Executive Secretariats (RES), and Pilot Committees (PC). The CCC acts as the Board of Directors for the CDSF, setting overall policies at the central level, while the Regional Committees are the oversight and policy organizations at the local level. The Executive Secretariats are the administrative/executing organizations which deal with the day- to-day operations of the CDSF. The PCs are the community groups which in most cases will be responsible for implementation of projects at the community level. Detailed division of labor between the groups is presented in Chapter V under Project Management (para. 5.9). 3.31 Sub-Project Selection Criteria. Selection of sub-projects will take into account a series of criteria, including: (i) formation of a community pilot committeel/ responsible for the overall management of the CDSF financed sub-project; (ii) assurances were obtained during negotiations that the community's contribution would be not less than 20% of the total cost of each sub-project (although in the case of communities annually identified as the poorest this could fall to 15%); (iii) an assessment of cost effectiveness as reflected in the cost per beneficiary; (iv) for sub-projects involving construction, strict observation of rules applied in environment protection (i.e. ban on the use of corals and beach sand); (v) adherence to norms established by technical ministries, and consistency with the sector strategies and programs; (vi) cost of sub-projects which are not beyond the capacity of community contribution or user charges; and (vii) provision for maintenance of infrastructure and/or sustainability of sub-project operation beyond the project period, including recovery of operating costs where appropriate; to this end, for many types of sub-projects, the CDSF would require that communities provide evidence of their ability and willingness to ensure appropriate maintenance of the sub-project beyond the period of CDSF assistance as one of the criteria of sub-project selection. In determining the costs of sub-projects, the CDSF would take into account the imputed value of the contribution (in kind and in cash) to be made by the beneficiary community, as well as all financial costs. Sub-Project Cycle 3.32 Promotion and Identification. An intensive IEC campaign has taken place on all three islands during preparation of the project and more than 70 community committees have been established with the support of the RESs. These intensive campaigns will continue periodically, although the RES on each island will continuously fulfill this promotion function, making frequent field visits to disseminate information about the opportunities offered by the project, as well as to explain to potential beneficiaries the approach, objectives, and procedures of the project. For the periodic intensive IEC campaigns innovative techniques such as media coverage and competitions will take place to encourage individuals and organized groups to formulate projects. To fulfill their function, the RESs will: (i) liaise with local constituencies and keep in contact with representatives of various organizations working at the local level in order to be ready to identify new projects and to help their designers to put them into an 1/ Or availability of an implementing agency. 21 articulated manner, and (ii) collect sub-project requests. Promotion efforts will be intensified in areas where poverty is known to be widespread and especially severe. Specialists in social marketing and information, education and communication will be called upon to help design and launch the more intensive campaigns. 3.33 Appraisal Procedures. Each initial sub-project request is to be logged in by the RES and classified according to the type of activities it belongs to. Then the following steps are taken: (i) the project is pre-sorted and declared eligible on the basis of the category of activity, the project amount, the target population, and the sponsor agency; (ii) a field visit is organized; (iii) all criteria are reviewed and the budget analyzed. If the sub-project is judged appraisable, it is then transmitted to the relevant Regional Technical Department which has up to two weeks to object to or comment upon the proposal;I/ and (iv) depending on sub-project amount, final approval of grants is decided either by the Regional sub-project committee or the NES. At each step there is a possibility to re-enter the cycle, with better, updated, or more complete information. The methodology to be used in the appraisal of each type of sub-project is described in detail in a Manual of Procedures containing detailed selection criteria for each type of sub-project. 3.34 Sub-project Execution. Once sub-projects are approved, their implementation is the responsibility of either a pilot committee or an implementing agency. Pilot committees will implement most infrastructure sub-projects and will plan and organize the work, procure goods and contracts for works, and make sure that the beneficiaries participate and contribute as planned. Procurement procedures must follow IDA guidelines and are detailed in the Manual of Procedures of the CDSF. All payments to suppliers, small contractors and artisans, however, will be made directly by the CDSF within the amounts of the grants for the sub- projects. Where needed, RES staff will assist pilot comrnittees managing the implementation of sub-projects through strong supervision. 3.35 Income-generating activities and training activities, as well as some basic infrastructure sub-projects concerning several villages (for which there is no pilot committee) will be carried out by implementing agencies (NGOs, professional associations, or other non- profit organizations and technical assistance projects), will also follow the CDSF Manual of Procedures for procurement in particular. The proceeds of the grants will be made available by the CDSF to the implementing agencies in accordance with a disbursement schedule included in the financing agreement between the CDSF and the Implementing Agency, which will be responsible for paying their own suppliers and contractors and be subject to audit by the CDSF's auditors. No credit will be given under the project. The project will work with the on-going UNDP/ILO credit project on a complementary basis. 3.36 Manual of Procedures. A detailed Manual of Procedures has been developed for the CDSF. The Manual of Procedures is for daily use by the CDSF Administration. It guides all decisions regarding the administrative and financial management of the CDSF itself as well as the selection, appraisal, supervision and evaluation of sub-projects. It defines the 1/ This is to assure that sub-projects fit within the overall sectoral strategies. If it does not, the sub-project will either be redesigned or abandoned. 22 institution and its mandates, and spells out the responsibilities and administrative arrangements for the CDSF, its three regional secretariats and its community-level interactions. 3.37 The Manual describes the general types of subprojects eligible for financing, and the criteria for selection, as explained in para 3.31. It details the administrative steps by which the CDSF would receive, evaluate, approve, supervise and post-evaluate a project, including guidelines for procurement consistent with the World Bank's guidelines. It details the financial and auditing requirements for the CDSF Administration as well as for sub- projects. It describes the recruitment and management of CDSF personnel in an appendix. 3.38 A dozen annexes are attached to the Manual of Procedures. These annexes also form an integral part of the daily routine of the CDSF, as they give the legal structure for the organization and a number of sample documents encountered frequently by CDSF staff. The first two annexes give a copy of the laws creating the CDSF and defining its organization and operation. Sample documents include an application for membership in the CDSF for a Pilot Committee; a model statute of association for a Community Development Association; model meeting minutes; a model request for official recognition of a Pilot Committee; a sub- project application form; a model convention between the CDSF and the Pilot Committee; a model protocol of agreement between the CDSF and an executing agency (such as an NGO); and a sub-project supervision form. In addition annexes include procedures for procurement of works and equipment; and standard bidding documents. 3.39 Economic Rationale of CDSF. The economic rationale for the investment (non-income-generating) activities that it funds are principally: (i) it serves identified needs which are perceived by the community rather than being centrally-planned; (ii) it raises additional local resources for self-defined and targeted grass-roots development efforts; (iii) it assures the recurrent costs of the operations, which, relative to traditional investments, presents a saving both in the Government's recurrent budget and in the cost of later rehabilitation of the dilapidated investment; (iv) in some cases, it provides investments that would be impossible otherwise (due to the remoteness of the village, for instance); (v) usually there is a cost saving over centrally planned investments, especially for labor; and (vi) community supervision and management reduces leakages, and in many cases will increase quality. Intangible benefits include the empowerment and ownership of communities; their contact with the outside world and the Government; the empowerment of youth and especially young women; and tremendous capacity building and training at the community level which could then better harness local resources in the future. 3.40 Sustainability of CDSF. There are two levels of sustainability relevant to the CDSF: sustainability of the sub-projects financed, and sustainability of the institution itself. Concerning the former, the Manual of Procedures stipulates that before any sub-project can be financed by the CDSF, its sustainability after CDSF intervention must be assured. To achieve this, each sub-project must include a plan for community participation in financing, implementing, and maintaining the activity after sub-project support is completed. The assessment of this plan is an integral part of the appraisal of the sub-project. Without acceptable plans for the sub-project's sustainability, it will not be supported by the CDSF. The question of whether the CDSF institution itself should be sustainable is one to be answered during the mid-term review of the project. If the CDSF is successful at efficiently helping communities to implement sub-projects which have a proven track record at improving the 23 living standards of the population and generating bottom-up development, then, as experience has shown, these types of funds have no problem in raising the money from external donors, organizations, and the Government to continue their work. If it is determined at mid-term review that needs still exist at the community level and operations look successful enough to merit continuation of the CDSF after the life of the project, a financing advisor will be recruited to be in charge of fund-raising for the CDSF to assure its sustainability after the end of project. If at the end of project execution it is decided to dismantle the CDSF, the benefits of the sub-projects and training undertaken during project execution will continue. 3.41 Environmental Effects of the Project. Although this is illegal, sea-sand or ground coral is often used in construction in Comoros. During project preparation, a specialist in tropical construction worked with the Comorians to develop several different prototype construction techniques which use local materials other than sand and coral (crushed volcanic rock for instance) which have been successfully shown to minimize negative environmental impact. These methods are being tested on sub-projects during preparation, for instance in the rehabilitation of school classrooms, to determine their quality, durability, cost-effectiveness, ease of use, and acceptability by local communities. If communities are found to be using any environmentally damaging materials, CDSF financing will stop immediately for that sub- project. Close supervision is facilitated by the regional offices of the CDSF. To minimize environmental risks in the health component, the project will also finance the development of appropriate waste disposal and sanitary facilities. IV. PROJECT COSTS AND FINANCING 4.1 The total cost of the project is US$16.0 million net of taxes and duties in August 1993 prices. The Health component accounts for US$7.8 million, the Community Development Support Fund for US$7.9 million and the PPF for US$0.4 million. Price contingencies have been calculated at 1.9, 2.7, 3.5, 3.5, 3.5% for foreign expenditures and at 4% for local expenditures, for the five years of project implementation starting in 1994. There are no physical contingencies, because the scale and number of health centers to be rehabilitated as well as the scale and number of sub-projects of the CDSF will be a function of the amounts allocated in the respective categories of expenditure. The project cost summary by component and by category of expenditure are in Tables 4.1 and 4.2 below. These costs are based on estimates provided by MOH and CDSF with assistance from a consulting firm. The appraisal mission reviewed these costs in collaboration with the entities which will be in charge of executing the various components. The detailed costs of the project are shown in Annex IV. 4.2 The IDA contribution is US$13.0 million, of which US$6.0 million will be allocated to the health component and $7.0 million to the CSDF. The project will be financed by IDA, the Government, and local communities. During negotiations, it was agreed that the contribution of the communities to the CDSF has been set at a minimum of 20%, except for the poorest communities in which case the contribution would fall to 15% (para. 7.1 (k)). To allow for the CDSF to put priority on the poorest communities, the cost tables reflect an average contribution by communities of 16%. The costs shown for the health component do not reflect the Government's contribution to the salaries of staff working part time on the 24 project, materials, office space and other incidental contributions. However, they do reflect the Government's commitment to provide adequate staffing and supplies to rehabilitated facilities. Table 4.1: Summary Project Costs by Component (US$ thousand) USS thousand % Foreign Total Exchange Base Costs Local | Foreign | Total A. Support to Health Sector 1. Support to Central Level 272 384 656 59 5 2. Support to Regional Level 165 275 440 63 3 3. Health Facilities Rehabilitation 3,829 996 4,825 21 33 4. Family Planning Program 106 151 257 59 2 5. STD/AIDS Program 107 182 289 63 2 6. Project Office 452 68 520 13 3 Sub-Total 4,931 2,056 6,987 29 48 B. Community Development Support Fund 1. Administration 1,075 0 1,075 0 7 2. Sub-Projects 4,904 911 5,815 16 40 Sub-Total 5,979 911 6,890 13 47 C. PPF 500 300 800 38 S TOTAL BASELINE COSTS 11,410 3,267 14,677 22 100 Price Contingencies 1,184 175 1,359 13 9 TOTAL PROJECT COSTS 12,594 3,442 16,036 21 109 4.3 The cost for rehabilitation of selected sites was estimated from 40 to 60% of the cost of new construction; depending the status of the facility this results in costs of US$220 to US$330 per m2. Training abroad was estimated at US$5,000 per person/year and for local training US$600 per person/month. Local salaries and operating expenses were estimated using UNDP standards. 4.4 Customs duties and taxes. All items imported for the purpose of executing this project as well as the major imported items purchased locally will be exempt from direct customs duties and taxes, in line with the standard practice of the Government. 25 Table 4.2: Summary Project Costs by Cateeory of Expenditures (US$ thousand) US$ US$ % Total Foreign Base Exchange Costs Local Foreign r Total - 1. INVESTMENT COSTS A. Equipment, Vchicles, Mat. 493 1,237 1,730 72 12 B. Training 449 620 1,069 58 7 C. Civil Works 1,590 0 1,590 0 11 D. Technical Assistance 199 199 398 50 3 E. PPF 500 300 800 38 5 F. CDSF Sub-Projects 4,904 911 5,815 16 40 TOTAL INVESTMENT COSTS 8,135 3,267 11,402 28 78 It. RECURRENT COSTS A. Operating Costs 2,200 0 2,200 0 15 B. CDSF Administration 1,075 0 1,075 0 7 TOTAL RECURRENT COSTS 3,175 0 3,175 0 22 TOTAL BASELINE COSTS 11,410 3,267 14,677 22 100 Price Contingencies 1,184 175 1 359 13 9 TOTAL PROJECT COSTS 12,594 3 16,036 21 109 4.5 IDA is the sole source of foreign funding for the project. The Government will cover the salaries of the civil servants involved in the project, including those on the Project Office staff, and the operating costs of the facilities which are already in the budget of the MOH for a total estimated at about US$2 million. The contribution of communities in CDSF sub-projects would be a minimum of 20% except for the poorest communities, and is calculated at 16% of the sub-projects financing for a total estimated at about US$1 million. Recurrent costs for the health component indicate the Government's commitment to provide a full complement of staff and supplies to the rehabilitated facilities; however, the reforms proposed for the health sector and supported by this project are budget neutral. The only incremental recurrent cost associated with the health component is the cost of the project office, which is a temporary cost. Maintenance of facilities rehabilitated under either component will be assured by the local communities and does not therefore have budget implications either. Table 4.3 below shows the proposed allocation of the IDA credit by disbursement category. 26 Table 4.3: Allocation of IDA Credit by Disbursement Category (in US$ thousand) Foreign Local Total Exp. Exp. Amount % A. Goods Equipment, vehicles, 1,440 446 1,886 15 furniture, supplies B. Civil Works 1,733 1,733 14 C. Consultancies 220 215 435 3 D. Training 614 551 1,165 9 E. Project Ofrice Operating Costs 590 590 4 F. CDSF Operating Costs 1,172 1,172 9 G. CDSF Sub-Projects 975 4,273 4,273 40 H. PPF 300 500 800 6 Total Disbursement 3,549 9Z480 13,029 100 V. PROJECT IMPLEMENTATION A. Project Preparation 5.1 Health Program. A team of international consultants worked out the health component with the MOH Directorate General. Very close contact has also been maintained with all donors involved--UNDP, WHO, UNICEF, UNFPA, the French Cooperation, etc.-- and most preparation missions have been joint with these donors. Under the MERCAP, the MOH is engaged in major reforms of its personnel and administration, complementary to the project's goals. Regulations redefining the roles and powers of health facilities and communities with regard to financial and administrative management are under preparation and their application to the facilities to be rehabilitated under the project is a condition of disbursement for civil works (para. 7.3(b)), as is implementation of the new organisational chart in the facilities to be rehabilitated. 5.2 Community Development Support Fund. Considerable work has been undertaken on the preparation of the CDSF. Extensive IEC campaigns have been undertaken by the National Preparation Committee on each of the three islands to sensitize communities about the CDSF. Regional preparation committees were chosen on each island to form the Regional Executive Secretariats during the preparation period. Preparation work has progressed quite well, due in large part to the Government's determination to strengthen its 27 policy of support to grassroots activities, and equally to the enthusiastic adherence of communities to the project's objectives. The Presidential Act setting up CDSF was signed on January 6, 1993, and the Presidential Decree defining its functions signed on April 13, 1993. The National Executive Director, who was selected through broad consultation, was appointed by the Chairman of the Preparation Committee. The Regional Executive Directors have also been appointed. 5.3 More than 45 sub-projects estimated at US$1,200,000 equivalent have been identified by communities and regional committees; ten totalling about US$200,000 are being implemented and nine sub-projects related to the sectors of school rehabilitation and water supply have been completed successfully with the community's contribution exceeding in some cases 20% of the total cost of the sub-project (see Annex I for a list of sub-projects to be implemented in the first year of the project). B. Project Management 5.4 To facilitate execution of the two components of the project, separate implementation structures will be used for each component. For the health component strong support will be given to the Ministry of Health to improve its capacity to implement the health program. Because of the cross-sectoral nature of the social fund, it will not be directly tied to a particular ministry but will be independent and autonomously run. Health Program 5.5 Within the Ministry of Health a small Project Office will be established under the Directorate General to aid the MOH in the administration of the IDA credit. The Project Office will be responsible for overseeing the implementation of the component. In particular, this unit will perform the following administrative tasks: (i) prepare annual work programs and corresponding budgets; (ii) coordinate the activities of the various components; (iii) maintain an accounting system for each project sub-component satisfactory to IDA and prepare quarterly and annual financial reports; (iv) prepare all bidding documents in a manner acceptable to IDA; (v) prepare quarterly and annual progress reports; (vi) ensure that audits are performed annually in a timely fashion; (vii) manage all technical assistance contracts for the project; and (viii) perform a mid-term review of the health component during the third year of project implementation. The Project Office high level staff will include a project director, an accountant, and a procurement specialist, with necessary support staff. Terms of reference for the Project Office and its staff members are included in Annex III. Assurances were given during negotiations that Project Office higher level staff at all times have qualifications and experience acceptable to IDA (para. 7. l(d)). In addition, the person responsible for procurement within the Project Office will attend a training course on Bank procurement during the first year of project implementation. 5.6 Architectural design, preparation of bidding documents, bids, and supervision of civil works financed through the project will be executed by a private firm or NGO recruited with procedures acceptable to IDA. The Project Office will be responsible for coordinating these activities as well as visiting the sites regularly. In the same way the procurement of goods, technical assistance and training will be executed by private firms or NGOs recruited with procedures acceptable to IDA. The Project Office's Director will be 28 responsible for coordination of all these activities according to the Work Plan. The recruitment of private firms and/or NGOs for the first year, the procurement of goods, the preparation of architectural design and bidding documents will be a condition of effectiveness (para. 7.2(e)). 5.7 At the regional level, project implementation will be executed by the Regional Health Teams with the assistance of the Project Office. The RHTs which are headed by the RMO will be charged with supervising the implementation of health programs throughout the region, organizing, with the assistance of the contracted private firm or NGO, on-the-job training for district health workers, and stimulating and streamlining community participation. RHTs will have the responsibility and authority for administrative and technical matters in their region, including the supervision of activities in hospitals, health centers, rural maternities, pharmacies, and health posts against established norms and monitorable performance indicators. 5.8 For IEC activities, the project will strengthen management capacities of the unit which will have the responsibility to plan, coordinate and supervise IEC activities. A consultant will assist MOH in reorganizing its IEC activities, in defining the mandate of the unit which will have the responsibility to coordinate and plan IEC health and population activities, and in establishing the coordinating mechanisms between the IEC coordinating unit and the various projects/programs, in preparing the job descriptions for the IEC central and regional staff, and establishing procedures to ensure that resources are shared between programs. This strengthening will take place before the credit becomes effective and will be done in collaboration with other concerned donors, in particular with UNDP which is preparing a development communication project. Social Fund 5.9 Because of the nature of the social fund, its management has been given to an organization, the Community Development Support Fund, which has administrative and financial autonomy from the Government. The CDSF will enter into an agreement with the Government regulating the channeling of the proceeds of the IDA credit. The signing of that agreement will be a condition of effectiveness of the proposed credit (para. 7.2(a)). During negotiations, the Government and CDSF gave assurances that this agreement and any amendment thereto will be acceptable to IDA (para. 7. 1(e)). While the headquarters of the CDSF is on the island of Grande Comore, because of geographical location, difficulty of communications, and specific characteristics of each island, each of the three islands will have a regional bureau. A bank account will be opened for each regional bureau and the deposit of US$5,000 equivalent in each account will be a condition of effectiveness (para. 7.2(f)). During negotiations, the Government and the CDSF gave assurances that the positions of National Executive Director, Regional Executive Deputy Directors, and other higher level personnel will be filled at all times with personnel whose qualifications and experience are satisfactory to IDA (para. 7.1(f)). 5.10 Central Coordination Committee. The primary task of the CCC, which meets twice a year, is to act as a Board of Directors setting the overall policies of the CDSF. As such, its responsibilities are: 29 Define and orient the general policies of the CDSF; Approve the annual budget and financial management procedures which are submitted by the National Executive Director of the CDSF; Analyze the audit reports on the management of the CDSF; Examine and adopt appropriate procedures which will enable the CDSF to support projects in the poorest areas; Approve the global objectives of each Regional Committee's annual plan; Adopt the Internal Rules and the Personnel Statute of the CDSF which are submitted by the National Executive Secretariat; - Adopt the Manual of Procedures (para. 3.36); and - Appoint the National Executive Director and the Regional Executive Deputy Directors through open competition. 5.11 The CCC will be composed of 15 members who are to be named by decree - 7 representatives of the public administration (from the Ministries of Finance, Plan, Equipment, Education, Health, and Production, and a representative from the Prime Minister's office), 8 representatives from the provinces (2 from each island) and 2 from national associations. The president of the CCC will be nominated by his peers. 5.12 National Executive Secretariat. The NES is a permanent body composed of the National Executive Director, an accountant, an administrative assistant, a procurement specialist and a secretary. Their main tasks are the following: - Assure the financial and administrative management of the CDSF, including preparing the budget of the CDSF; - Establish the financial accounts and prepare all other financial management statements; - Assure the management of the IDA special account for the CDSF under the responsibility of the National Executive Director; - Assure that all procurement follows the procurement rules stipulated in the Manual of Procedures; - Study and propose to the CCC the elements of a national policy and a financing strategy for community development; - Write and submit to CCC semi-annual evaluation reports on the activities of the CDSF and propose necessary adjustments; 30 - Define and create a data base of unit costs which are to be applicable during sub-project evaluation; and - Approve sub-project requests which are FC5 million (about US$17,000) and above, forwarding those above equivalent of FF350,000 (FC17.5 million or about US$60,000) for non-objection from IDA; 5.13 Regional Committees. For each of the three islands, there will be a RC which is composed of 8 members. The presidents are elected by their peers. The members include: a representative of the Regional Finance Directorate, a representative of the Regional Directorate of Plan (Community Development), and 6 other non-Government members chosen on the basis of their qualifications and their knowledge of communities and their problems. The primary responsibilities of the Regional Committees are the following: - Develop and propose to the NES a regional community development policy and strategy; - Review and endorse or modify the annual programs developed by the Deputy Regional Director; - Evaluate the impact of the CDSF on the development and welfare of the island and propose modifications and adjustments; - Appoint a Regional sub-projects committee which will be responsible for selecting sub-projects, approving grants of less than CF5 million (about US$17,000) and submitting to the NES for decision all sub-projects above FC5 million; and - Collaborate with the RES to assure close liaison between local communities and the CDSF to help define projects which respond to the needs of the poorest groups. 5.14 Regional Executive Secretariats. The RES is headed by the Deputy Regional Director who is the regional representative of the CDSF and has an accountantl/, a specialist in communication, and a secretary as support. The RES is responsible for: - Animating the IEC campaign of promotion of the CDSF in the communities of the island; - Preparing the annual action program for community development on the island; - Furnishing technical and financial support to communities in the preparation and execution of projects; - Appraising sub-project requests according to the criteria and procedures in the Manual of Procedures; - Assuring timely disbursements according to advancement of work; and - Submitting quarterly reports to the RC on the state of advancement of sub- project implementation. I/ This individual will also receive training in contracts and procurement to assure they fulfill this function at the regional level. 31 5.15 Pilot Committees. The PCs are community groups which work with the RESs of the CDSF to: - Identify sub-projects according to needs of the community; - Prepare with the RESs a proposed budget for the sub-project, including the contributions of the community towards the sub-project realization; - Obtain firm commitment from the community or communities on their participation in the execution and monitoring of work during project implementation; - Sign the financial contract with the CDSF; - Mobilize local human, material, and financial resources necessary for execution of the sub-project; and - Report periodically to the RES on the state of advancement of sub-project implementation. 5.16 IDA review of sub-projects. The CDSF would have the authority to approve sub-projects costing the equivalent of FF350,000 (about US$60,000) or less. Sub-projects that have a total cost of more than FF350,000 equivalent would be submitted to IDA for prior review. All sub-projects would, however, be subject to random ex-post review by IDA during project supervision. C. Implementation Schedule 5.17 Implementation Schedule. The project Implementation Schedule by category is shown in Table 5.1 below. The project is expected to be completed by December 31, 1998, and the Credit closed by June 30, 1999. 32 Table 5.1: Implementation Schedule (US$ million) Project Elkment Project Year Total 1 2 3 4 5 Payments Remarks Credit Inning Sign/Effectiveness/Close xx x Civi Works A.3 Facilities Rehabilitation 0.04 0.20 0.80 0.60 0.10 1.74 LCB A.6 Project Office 0.02 0.02 LCB xxx xx xxxx xxxx xx Goods A.l Central Level 0.05 0.10 0.15 0.10 ICB xx xxxx xxxx 0.05 Lah A.2 Regional Level 0.02 0 03 0.05 0.03 ICB xx xxxx 0.02 Lah A.3 Facilities Rehabilitation 0.90 0.43 1.33 0.92 ICB xxx xx 0.41 Lah A.4 Famnily Planning 0.03 0.03 0.06 ICB xxx xx A.5 STD/AIDS 0.07 0.05 0.04 0.16 ICB xx xxxx xxx A.6 Project Office 0.08 0.08 Lah xxx Consultancie A.1 Central Level 0.03 0.08 0.10 0.21 xx x xx A.3 Facilities Rehabilitation 0.08 0.08 (UNV) xxxx A.4 Family Planning 0.03 0.03 0.06 xxx xx A.5 STD/AIDS 0.01 0.02 0.02 0.01 0.01 0.07 x xx xx x x Tr g A.l Central Level 0.05 0.10 0.11 0.09 0.35 x x x x A.2 Regional Level 0.06 0.10 0.10 0.09 0.05 0.40 xx xx xxx x x A.3 Facilities Rehabilitation 0.04 0.04 0.04 0.02 0.14 xx xx xx x A.4 Family Planning 0.02 0.05 0.08 0.03 0.18 x xxx xxx xx A.5 STD/AIDS 0.01 0.02 0.05 0.08 x x xxx CDSF Administration B.l Administration 0.23 0.24 0.24 0.24 0 24 1.17 xxxx xxxx xxxx xxxx xxxx CDSF Sub-Projects 0.53 1.20 1.30 1.20 1.20 5.43 0.50 Lah B.2 Sub-projects xxxx xxxx xxxx xxxx xxxx 4.93 LCB Miscellaneous A.6 MOH Project Ofrice 0.09 0.09 0.09 0.09 0.09 0.45 PPF Refinancing 0.80 0.80 TOTAL (Bank Financed) 2.10 3.29 3.50 2.43 1.71 13,03 xx refer to quarters 33 D. Project Monitoring and Reporting 5.18 Health Component Monitoring. The Project Office will monitor and evaluate project implementation according to the agreed performance indicators (Annex VI). The Project Office will have an overall view of problems and issues in project implementation and be in position to recommend any corrective actions that maybe required. It was agreed that a project performance review, including management, will be carried out annually under terms of reference acceptable to IDA and that the review findings and recommendations will be discussed with IDA no later than October 31 of each year of project implementation. Because community involvement is so important to the success of this component, this annual review will also include an beneficiary assessment which looks into how beneficiaries feel health services to be improving as well as further changes and modifications which could continue to improve services. During negotiations, the Government gave assurances that, no later than July 31 of each year of project implementation, the Project Office will make available to IDA the necessary documents and evidence for a review of (i) project implementation; and (ii) the status of maintenance and operations of buildings rehabilitated with IDA credits (para. 7. 1(b)). 5.19 CDSF Sub-Project Monitoring. Strong monitoring of sub-project implementation and impact will be conducted by the RES and reviewed by the NES. The monitoring will be physical and financial, and will take into account the impact of the sub- project on beneficiaries. The physical and financial monitoring will be included in the Management and Information System (MIS). The signature of a contract with a consulting firm to put in place the MIS will be a condition of effectiveness (para. 7.2(d)). During RES supervision missions a detailed supervision report will be prepared indicating the physical advancement of the project and flagging any implementation issues. The views of the beneficiaries and the implementing agencies will also be recorded during these missions. Every disbursement by the RES will be monitored through the MIS. A summary of the findings of the supervision missions will be presented in the quarterly reports with recommendations to improve the implementation and design of sub-projects. 5.20 During project implementation improvements would be made to strengthen the MIS's capacity for the establishment and maintenance of "community profiles" - a set of social indicators on communities where CDSF financed projects have been, or will be carried out. Performances indicators would also be used to reflect the number and type of beneficiaries of each type of project, such as the number of classrooms rehabilitated, beneficiaries of water supply sub-projects, health care visits, vaccinations, trainees, in order to monitor real benefits provided under CDSF sub-projects. Based on the results for the period of project preparation, outcomes expected for the lifetime of the project could be quantified as final targets. The number of beneficiaries are expected to be approximately: (i) 50,000 for the water supply sector, involving 40 villages; (ii) 35,000 for the sewerage sector; (iii) 2,000 rural women; (iv) 15,000 students in primary schools; (v) 1,500 trainees in basic skills at the community level; and (vi) 40,000 health care visits per year (additional to 75,000 existing at present). The implementation of sub-projects will be monitored against a set of quantified performance indicators which will be adjusted every year. The indicators are summarized in Annex VI. 34 5.21 To help monitor the quality and effectiveness of project implementation, each RES will carry-out annual Beneficiary Assessments (BA) for a selected number of sub-projects representative of the portfolio under implementation. Local consultants will be used for this purpose. The information collected will focus in particular on the level of participation of the beneficiaries in the sub-project, their view of the usefulness of the sub-project, the immediate benefit of the sub-projects for the community, the relation with implementing agencies, the sustainability of the activities undertaken, and any other issue relevant to the local population. The findings of the BA will be presented in the annual report and will be discussed with the CCC. Agreement was reached during negotiations on performance indicators for both components of the project (para. 7. 1(g)). 5.22 Accounts. Separate accounts will be maintained for each component. Such accounts will be maintained in accordance with internationally recognized accounting principles and practices which are satisfactory to IDA. 5.23 Audits. The accounts, statements of expenditures and documentation relative to procurement will be audited annually by an external auditor for each component acceptable to IDA. Audits will be undertaken on a semi-annual basis for the CDSF. Audits will be undertaken annually for the health component. Audit reports will be submitted to IDA three months after the end of the period. The audits will include managerial, technical and financial aspects of the project, will follow the International Standard for audits and accounting, and will include a statement on the adequacy of the accounting system and internal controls, the reliability of the statements of expenditures as a basis for loan disbursements, compliance with financial covenants and for the CDSF compliance with the Manual of Procedures. The audit reports will include a management letter. Agreement was reached during negotiations on the content and timing of the audits (para. 7. l(h)). As a condition of effectiveness, the Government will sign a contract or contracts with independent auditors, for each component, satisfactory to IDA (para. 7.2(c)). 5.24 Mid-term Review. It was agreed during negotiations that a mid-term review will take place not later than October 31st 1996 (para. 7.1(f)). In addition to the topics covered in the annual and quarterly reviews, the mid-term review will examine in particular the sustainability of the CDSF as an institution. If the institution is deemed sustainable, alternative sources of funding will be sought to ensure its existence beyond the end of the project. E. Implementation Issues in Comoros 5.25 Comoros has a poor implementation record mainly due to high turnover of personnel working on the projects, slow disbursements, and lack of Government counterpart funds. During the FY92 ARIS review process, three out of four projects were considered problem projects. However, since then there has been considerable progress. A Country Implementation Review (CIR) was undertaken in early 1993 which has focused the country's attention on project implementation, and significant improvements have been seen in disbursements for all ongoing projects, which were US$4.5 million in FY93 as opposed to US$2.1 million in FY92. 5.26 The administrative reform coordinated by the CTARIAP will rationalize the personnel budget for all the ministries; significant progress has been made and the process is 35 expected to be completed in early 1994. A reduction of at least 100 unqualified technical staff of the MOH is a condition of disbursements for civil works for the rehabilitation of health facilities (para. 7.3(a)). 5.27 Lessons drawn from the implementation experience in Comoros include: (i) institutional and political commitment is key to project success, including continuity of project staff; (ii) recurrent funding and Government financial planning have presented a problem; (iii) projects should be as simple as possible and avoid excessive need for multi-agency coordination; and (iv) maintenance of physical investments is poor and linked to poor motivation of public servants. 5.28 This project will address these shortcomings in several ways: (i) the relevant institutions have been thoroughly involved in the project preparation (Ministry of Health and staff of the CDSF); (ii) essential legal texts for both components have been enacted before Board presentation; (iii) project design and administrative arrangements have been kept as simple as possible, with two components; and (iv) maintenance of physical investment is more likely due to community participation in financing of investments and management of their operation. 5.29 In addition, for the health sector: (i) technical details for the civil works for the health component have been completed before negotiations; (ii) the project works within the framework of the structural adjustment program, and in particular is based on a reform of the entire public health system; and (iii) the project leverages additional resources through cost- recovery and community responsibilization. The Government is reforming the budget process and has assured that financing of the health sector will be at a level commensurate with its efficient functioning (see para 3.17). For the CDSF: (i) successful pilot operations have been undertaken during project preparation under the PPF; and (ii) the CDSF has been created with staff independent from the public administration. 5.30 In order to ensure that the project objectives and the World Bank's procedures are well understood within the implementing institutions, there will be a project launch workshop at which administrative arrangements will be reviewed. A mid-term review will take place after somewhat more than 2 years (presently scheduled for October 1996), which will allow the Government of Comoros and IDA to review progress and make changes as necessary. Particular focus of this review will be on the budget executed in the health sector, the maintenance of investments made under the CDSF, the future of the CDSF and the level of community contribution in CDSF activities (para. 5.25). 36 F. Procurement 5.31 Procurement arrangements are summarized in Table 5.2 below: Table 5,2: Procurement Arrangements (US$ million) Project Element ICB LCB Other Total Costs 1. Goods 1.27 0.56 1.83 (1.27) (0.56) (1.83) 2. Civil works 1.76 1.76 (1.76) (1.76) 3. Consultancies 0.42 0.42 (0.42) (0.42) 4. Training 1.15 1.15 (1.15) (1.15) 5. MOH Oper. Costs 2.44 2.44 (0.45) (0.45) 6. CDSF Inc. Op. Cost 1.19 1.19 (I. 19) (I. 19) 7. CDSF Sub-Projects 4.93 1.52 6.45 (4.93) (0.50) (5.43) 8. Refinancing PPF 0.80 0.80 (0.80) (0.80) Total 1.27 6.69 8.08 16.04 _ (1.27) (6.69) (5.07) (13.03) Figures in parenthesis represent IDA financing. 5.32 Civil works. For the health component civil works contracts will be awarded following competitive bidding procedures acceptable to IDA in accordance with IDA guidelines for procurement. Refurbishment of existing buildings will be awarded following Local Competitive Bidding (LCB), up to an aggregate amount of US$1.9 million. Tenders will be advertised locally, bidders will be given minimum 45 days for submission of bids. Evaluation criteria will be specified. All bids will be opened in the presence of bidder's representatives. Eligible foreign contractors will be allowed to participate in the bidding, and standard bidding documents will be reviewed and approved by IDA prior to advertising. For the implementation of this sub-component, a selected private firm/NGO will be contracted to help the Project Office prepare bidding documents, launch bids, select contractors, prepare contracts and supervise works. 5.33 Goods. Goods financed under the project will include vehicles, furniture, medical equipment, and other equipment and materials. Except as provided below, goods will be procured through International Competitive Bidding (ICB) in accordance with IDA's Guidelines for Procurement under IBRD Loans and IDA Credits (May 1992). Contracts for 37 goods procured through ICB would amount to about US$1.4 million. Other goods, which cannot be grouped into bids packages of at least US$25,000 equivalent, up to an aggregate amount of US$1.4 million, would be procured through prudent shopping on the basis of price quotations from at least three suppliers. This consists of supplies and operating costs of the project office of the MOH and for the CDSF (US$0.2 million and US$0.6 million) as well as other goods to be procured under the health component, mainly supplies (US$0.15 million), vehicles (US$0.10 million) and communication and computer equipment (US$0.35 million). 5.34 Technical Assistance. For the technical assistance (US$420,000) and training (US$1.15 million), consultants will be selected in accordance with the "Guidelines for the Use of Consultants by World Bank Borrowers and by the World Bank as Executive Agency." The work program and financing have been described in such a manner as to encourage the use of consultants from Comoros, and, where expertise does not exist in the country, consultants from the region. Details on consultancies are given in Annex III. 5.35 CDSF. For the CDSF, civil works will be carried out by local communities according to the Manual of Procedures agreed by IDA. For sub-projects financed under the CDSF (US$5.4 million), the executing agency responsible for sub-project implementation will be responsible for procurement and will follow IDA's guidelines for procurement (paras 3.34 and 3.35). Because most of the executing agencies and local communities lack experience in procurement, the CDSF will assist them for the preparation of bidding documents, bid evaluation, contract award, and contract management. Prior to signing the sub-project contract, the CDSF will assure that procurement procedures to be followed are in compliance with agreed guidelines detailed in the Manual of Procedures. Contracts for goods and civil works for sub-projects will be awarded as follows: (a) contracts ranging in size from US$20,000 to US$100,000, up to an aggregate amount of US$4.0 million, will be awarded on the basis of LCB; (b) for contracts valued at less than US$20,000 equivalent, up to an aggregate amount of US$1.5 million, local bidding would take place through notices posted in the villages and in the offices of the CDSF as well as by radio. Results of such bidding would be published officially; and (c) for contracts valued at less than US$20,000 equivalent, up to an aggregate amount of US$0.5 million, the beneficiary agencies will carry out local shopping and would provide CDSF with all relevant documentation for review, indicating its choice among the offers presented. Aggregate amounts for procurement methods for sub-projects add up to more than the total amount of the IDA credit allocated to sub-project execution ($5.4 million), in order to allow the CDSF the flexibility to make greater use of LCB wherever possible. Supplies provided under CDSF's financing will be delivered to the executing agencies as the need for them arises according to the sub-project implementation schedule and under the supervision of the NGO CECI (refer to CECI's terms of reference in Annex III chapter II). 5.36 Bank Review Requirements. Prior review by IDA would be required for all consultancy contracts for individuals or for contracts of over US$10,000 equivalent. Working drawings, draft tender documents, master lists of furniture, equipment, supplies and vehicles will be reviewed by IDA. For the health component, IDA review of tender documents prior to award will be required for contracts above US$50,000 equivalent for civil works, and US$25,000 for goods. For the CDSF, any sub-project of a total investment of FF350,000 equivalent (about US$60,000) or more will be subject to prior review by IDA. All other contracts will be subject to selective post award review by IDA. The use of IDA's standard bidding documents for goods and works and IDA's letter of invitation for consultants will be 38 made mandatory by the Project Office and contracted private firms/NGOs. Assurances were obtained during negotiations that the Manual of Procedures of the CDSF, including its annexes on procurement and standard bidding documents, will be at all times acceptable to IDA. IDA will organize a project launch workshop when the Credit is effective and will prepare an implementation manual including IDA's standard bidding documents for goods and works and IDA's standard letter of invitation for consultants, for the use of the Project Office and contracted private firms/NGOs. Agreement on the use of IDA's standard bidding documents was obtained during negotiations (para. 7.1(j)). G. Disbursement 5.37 The proposed IDA Credit of SDR 9.2 (US$13.0 million) will be disbursed in accordance with table 5.3 below: Table 5.3: Disbursement Categories US$ _______________________________ thousand % Goods Equipment, vehicles, 1,700 100 furniture, supplies Civil Works 1,600 100 Consultancies 400 100 Training 1,100 100 MOH Oper. Costs 400 100 CDSF Inc. Operating Costs 1,100 100 CDSF Sub-Projects 4,900 100 PPF 800 100 Non-Allocated Tj 13,00 TOTAL - 300 Note: Health component: Government contribution of staff and supplies for which IDA does not disburse are not shown. CDSF component: contribution of the beneficiaries in kind and in manpower are not shown. 5.38 All disbursements will be fully documented except for: (i) payments under contracts and subprojects of less than US$10,000; (ii) training; and (iii) incremental operating costs which will be submitted under statements of expenditure (SOE). The Project Office within the MOH and the CDSF will be responsible for monitoring disbursements. The SOEs and all records such as contracts, orders, invoices, and payroll vouchers will be retained by these units for inspection by supervision missions and reviewed by the annual audit. The Project Office director and the CDSF Executive Director will be the primary liaison persons between IDA and the borrower for all disbursement issues pertaining to the project. The closing date of the credit will be June 30, 1999. 39 5.39 Special Account. To ensure that funds for this project are readily available and to facilitate disbursement MOH and CDSF will each open a Special Account in French Francs in a commercial bank on terms and conditions satisfactory to IDA. Initial deposits each of US$200,000 will be advanced to those accounts from the IDA credit. The funds in these special accounts will be managed by the Project Office and the CDSF and all documentation pertinent to these accounts will be maintained in a manner acceptable to IDA for inspection during regular supervision missions. The Project Office director and the CDSF Executive Director will be responsible for their respective disbursements during project implementation, will provide monthly statements to IDA and will be responsible for submitting applications for the replenishment of these accounts. All payments of less than US$10,000 will be made through the Special Accounts. Payment requests above this threshold may be submitted under the direct payment, reimbursement or Special Commitment procedure. The Special Accounts will be replenished monthly, or when one-third of the Special Account has been disbursed, whichever is sooner. 5.40 The standard disbursement profile for health projects in sub-Saharan Africa is nine and a half years. However, there is a pipeline of sub-projects that have been developed which will be appraised by credit effectiveness. In addition, standard bidding documents and procedures will be developed by effectiveness for the health component. Therefore, disbursements will pick up rapidly after the first year of project implementation. The estimated schedule of disbursements is at Annex V. VI. BENEFITS AND RISKS 6.1 Benefits. The project is expected to enhance the development of human resources by improving the health, education, and income status of the population. Through the health and population component, available primary health care is expected to improve with the strengthening of peripheral services and closer involvement of communities in their provision; information, education, and communication and better family planning services should increase the contraceptive prevalence rate, reducing fertility, as well as raising awareness of the need for AIDS prevention. The CDSF would complement activities in the health component by building upon strong community involvement and aiding communities and individuals to more effectively and efficiently channel community resources and implement local development efforts, including much needed rehabilitation of primary schools, water supply and health posts. It would provide an opportunity to strengthen the capacity of local associations and NGOs, as well as encourage the creation of new NGOs, in addition to enhancing the well-being and economic role of women in society. 6.2 Risks. The main risks to the implementation of the project are weak Government capacity and potential delays due to political uncertainties. To address the first, the goal of the health and population component is to strengthen community involvement, both financially and managerially, in the provision of basic health services as well as to build Government capacity and improve the efficiency of these services. More specifically, personnel would be trained, a unit within the Ministry of Health would be created under the Directorate General of Health Services for procurement and administration of implementation, 40 and technical assistance would be provided in key areas for capacity building. To insulate the CDSF from weak Government capacity and political interference, an autonomous agency staffed by selected, contractual employees would manage the fund. In addition, community training, strong CDSF supervision, a transparent management information system, and semi- annual auditing of accounts would enhance the overall efficiency of the community development component of the project. VII. CONDITIONS AND RECOMMENDATIONS 7.1 During negotiations, agreement was reached with the Government as follows: (a) agreement on the Manual of Procedures of the CDSF, which is to rule selection and execution of all sub-projects; and that any change will be submitted to IDA for approval (para. 3.25); (b) in collaboration with the Government, IDA will, not later than October 3 1st, 1994 and, thereafter, not later than October 31 of each subsequent year, undertake a joint annual review of the project during which they will exchange views generally on all matters relating to the progress of the project, and in particular financial and procurement performance of the CDSF and MOH (containing the findings of the independent audit), CDSF sub-project performance, and progress made by the MOH in light of the agreed performance indicators. Three months prior to the annual review, a report will be submitted to IDA reviewing the situation and describing problems encountered and solutions to be applied. These reports will contain a draft budget and work program, and will review maintenance and operation of physical investments. Quarterly reports will also be submitted. (para. 5.18); (c) the budget for MOH will maintain the 1992 real level of expenditure with at least 20% in non-salary expenditures, and the budget for the current and subsequent fiscal years will be reviewed annually with IDA (para. 3.17); (d) the CDSF and the Project Office are to be staffed at all times with competent higher-level personnel with terms of reference, experience, and qualifications acceptable to IDA (para. 5.5 and 5.9); (e) the agreement between the Government and the CDSF for the channeling of the proceeds of the IDA credit and any amendment thereto will be acceptable to IDA (para. 5.9); (f) not later than October 31, 1996, a joint mid-term review will take place. In addition to the topics covered in the annual and quarterly reviews, the mid- term review will examine in particular the sustainability of the CDSF as an institution. (para. 5.24); 41 (g) agreement on performance indicators for each component which can be found at Annex VI. (para. 5.21); (h) for the CDSF component, audits twice a year. The health component will have annual audits. Independent audit reports will be submitted to IDA (para. 5.23); (i) that MOH will issue a public expenditure program for the health sector for 1995-97 by December 31, 1994, which will be reviewed annually with IDA. (para. 3.22); (j) agreement on standard bidding documents for civil works, purchase of goods, and the recruitment of consultants (para. 5.36); (k) the contribution of communities in CDSF sub-projects and involvement in local health initiatives is a minimum of 20% except for the poorest communities (para. 4.2); and (l) that no sub-project would exceed the equivalent of FF450,000 (about US$80,000), and that prior review by IDA will be required for all sub-projects exceeding FF350,000 equivalent (about US$60,000) (para. 5.16). 7.2 Credit Effectiveness will be conditional on the following measures: (a) the Financing Agreement between the Government and CDSF has been duly executed; (para. 5.9); (b) the Manual of Procedures has been adopted by CDSF (para. 3.3); (c) the Government will sign a contract or contracts with independent auditors, for each component, satisfactory to IDA (para. 5.23); (d) a contract, acceptable to IDA, for the installation of a management information system for CDSF has been signed (para. 5.19); (e) the Government has recruited the private firms or non-governmental organizations for the procurement of goods, for the preparation of architectural designs and bidding documents, for the supervision of civil works, and for the preparation and supervision of training programs, during the 12 months period immediately following effectiveness (para. 5.6); and (f) the Government has opened, on behalf of the CDSF, a bank account in local currency, to be operated and maintained by CDSF, in each of the three sub- regions, and has made an initial deposit of US$5,000 equivalent into each such account (para. 5.9). 42 7.3 As a condition of disbursement of the civil works for rehabilitation of MOH facilities: (a) the unqualified technical health personnel of the MOH, as determined as of June 1, 1993, has been reduced in number by not less than 100 agents; (para. 5.26); and (b) the facilities to be rehabilitated have been (i) vested with financial and managerial autonomy in accordance with the administrative reform program detailed in the letter of health policy; and (ii) reorganized and the staff redeployed, as needed, to meet the requirements of the revised organizational structure prepared in 1993 (para. 5.1). Recommendation 7.4 Subject to the above assurances and conditions, this project constitutes a suitable basis for an IDA credit of SDR 9.2 million (US$13.0 million equivalent) to the Federal Islamic Republic of Comoros on standard IDA terms with 40 years maturity. 43 ANNEXES 44 ANNEX I Page 1 of 3 COMMUNITY DEVELOPMENT SUPPORT FUND LIST OF SUB-PROJECTS (FIRST YEAR) VILLAGE TYPEfWORK (COS BENEFICIARIES (FC 1,000) NGAZIDZA School Reh/Cons Students Oussivo ................................. 3,000 160 Simamboini ................................. 3,660 160 Ouroveni ................................. 2,750 120 Didjoni ................................. 2,400 120 Kopveni ................................. 7,000 160 Moemboidjou ................................. 1,200 120 Sidjou ................................. 7,000 160 Djongue ................................. 7,000 160 Diboini ................................. 2,400 120 Nyambeni ................................. 1,500 120 Mal ................................. 7,700 240 Kandzile ................................. 3,640 160 Ntsinimoichong ................................. 2,300 120 Dimadjou ................................. 9,500 240 Itsandzeni ................................. 7,000 160 Chouani ................................. 2,400 120 Iconi II ................................. 10,000 320 Water Supplv Inhabitants Kandzile ................................. 1,020 1,100 M iali ................................. 800 780 M vouni ................................. 1,200 3,800 Sada ................................. 1,500 210 Health Post Simboussa ................................. 2,400 600 Sidjou ................................ 1,600 500 Koimbani ................................. 4,100 800 Bahani ................................. 1,600 1,100 M bibodjou ................................. 1,100 1,740 Diboini ................................. 1,600 600 Nyambeni ................................. 1,000 ........................... Bambani ................................. 4,500 ........................... Chindini ................................. 2,000 ........................... Rural Road Djongue ................................. 10,000 ........................... N 'Droue ................................. 13,000 ........................... 45 ANNEX I Page 2 of 3 NGAZIDZA School Reh/Cons Students Oussivo ................................. 3,000 160 Simamboini ................................. 3,660 160 Ouroveni ................................. 2,750 120 Didjoni ................................. 2,400 120 Kopveni ................................. 7,000 160 Moemboidjou ................................. 1,200 120 Sidjou ................................. 7,000 160 Djongue ................................. 7,000 160 Diboini ................................. 2,400 120 Nyambeni ................................. 1,500 120 Male ................................. 7,700 240 Kandzile ................................. 3,640 160 Ntsinimoichong . ................................ 2,300 120 Dimadjou ................................. 9,500 240 Itsandzeni ................................. 7,000 160 Chouani ................................. 2,400 120 Iconi II ................................. 10,000 320 Water Suyvlv Inhabitants Kandzil6 ................................. 1,020 1,100 Miali ................................. 800 780 Mvouni ................................. 1,200 3,800 Sada ................................. 1,500 210 Health Post Simboussa ................................. 2,400 600 Sidjou ................................. 1,600 500 Koimbani ................................. 4,100 800 Bahani ................................. 1,600 1,100 Mbibodjou ................................. 1,100 1,740 Diboini ................................. 1,600 600 Nyambeni ................................. 1,000 ........................... Bambani ................................. 4,500 ........................... Chindini ................................. 2,000 ........................... Rural Road Djongue ................................. 10,000 ........................... N'Droue ................................. 13,000 ........................... TOTAL COST: 127.870.000 FC 46 ANNEX I Page 3 of 3 COMMUNITY DEVELOPMENT SUPPORT FUND LIST OF SUB-PROJECTS (FIRST YEAR) VILLAGE TYPE/WORK Co BENEFICIARIES (FC1 ,000) MWALI School Reh/Con Students Oualla .............................. 3,100 160 Ndrondroni .............................. 7,800 240 Nioumachoi .............................. 7,600 320 Mbatse .............................. 3,930 160 Miringoni .............................. 4,200 160 Bangoma .............................. 13,800 400 Barakani .............................. 5,800 80 Kanalene .............................. 9,900 160 Njimbia .............................. 9,900 160 Siry Ziroudany .............................. 9,900 160 Hoani .............................. 4,200 160 Bandaresalam .............................. 4,500 120 Health Post Kangani .............................. 10,220 ........................... Ndrondro .............................. 10,220 ........................... Infrastructure Oualla2 Rural road 3,600 ........................... Hoani Rural road 2,300 ........................... Fomboni Sewerage 18,000 ........................... Domoni Sewerage 6,900 ........................... Water Supplv Nioumachoi .............................. 2,000 ......................... Hamba .............................. 5,000 ......................... TOTAL COST: 142.870.OQOFC 47 ANNEX II Page 1 of 5 INFORMATION. EDUCATION AND COMMUNICATION Background 1. The Government of the Comoros has recognized the need to use Information, Education and Communication (IEC) to motivate its population to adopt health practices which are more conducive to good health. For this reason, it has included in all its major public health program an IEC component. However, this program approach has, as in many countries, lead to a fragmentation of IEC activities. Because each project or program has an IEC component, the resources allocated to IEC activities are not allocated on the basis of national health priorities but on a program basis, and in some cases, on a project basis, which lead to coordination problems within programs. The resources allocated to IEC are often limited and linked to the importance the project designer had given to IEC rather than to real needs. Consequently, some programs have more IEC resources than others and some do not have any. Presently, the IEC Population Program and the National AIDS Control Program (NACP), discussed below, have more human and financial resources than the other public health programs. 2. Population IEC activities have been carried out in the Comoros by the First IEC Population Project since the launching of the national family planning program in 1986. This project as well as that which is presently on-going was financed by UNFPA and executed by FAO. The objectives of the Second Population IEC project are to increase awareness of family planning and to eliminate the obstacles to the use of contraceptives. This project, which spent an average of US$185,000 a year on family planning IEC, concentrated its activities in three main areas: a. Training of health personnel and of community workers in family planning interpersonal communication and counselling. However, these training activities have been limited to project areas (about ten villages) and only 160 health personnel and about 60 community workers were trained; b. Research studies the objectives of which were to identify psycho-socio-cultural obstacles to family planning and minimize the risk that formal and informal opinion leaders speak out against the use of contraception. These research activities were to provide a data base on social organization, cultural models and ideal family size which could be used to develop an IEC strategy and appropriate messages for different target groups. However, the studies although useful must be interpreted with caution because the samples were very small and the methodology was not always as rigorous as it should have been; and c. IEC material production which was carried out in the audio-visual center of the project. Here too, because of limited resources, some short cuts were taken and materials were not always pre-tested before they were produced, but only evaluated after they had been produced and distributed. This practice has led to the production of materials which were not understood by the target groups. 3. The purpose of these activities was to inform opinion leaders and target population about family planning. To this end, the IEC Population project organized seminars, conferences and study tours for officials. For example, in December 1987, a colloquium brought together in 48 ANNEX II Page 2 of 5 Moroni many religious leaders including the Grand Mufti to discuss the acceptability of family planning in an Islamic context. The Grand Mufti then went to Morocco in March 1988 to observe how a muslim country dealt with family planning. In addition, several seminars were organized for village religious leaders. These activities succeeded in making family planning more acceptable in the Comoros. The Grand Mufti and some other religious leaders endorsed openly the use of contraception for health and socio-economic reasons in 1988. However, neither leaders or the public seem to understand that population growth is a problem and that slowing the rate of this growth is necessary for the country. 4. The second Population IEC project will end in April 1993 and is to be renewed at the request of the Government, however, according to the UNFPA, the level of financial support is to be reduced (only US$110,000 is budgeted for 1993). Consequently, the existing need for additional support will become even greater. 5. The Government of the comoros launched its National AIDS Control Program (NACP) in June 1990 with a resource mobilization conference. Its first Medium-Term Plan was prepared at that time. Since then, the NACP has been supported by several donors. In 1992, the program received about US$246,300 from four donors: WHO/GPA provided about US$160,000, the European Economic Community (EEC) US$36,000, the Republic of South Africa US$12,500 and the UNDP US$37,500. About half of these funds were used for IEC activities while the other half was used for laboratory activities and epidemiological surveillance. For 1993, WHO committed US$160,000 which will be added to the US$40,000 left over from 1992-93 EEC contribution and US$37,000 provided by the UNDP. WHO has indicated that they intend to maintain the present level of support until 1995, but no other financial aid is assured. Therefore, if the NACP is to continue its IEC activities as well as to detect STDs and to develop the capacity to do blood screening to prevent the spread of HIV, it will need additional resources. AIDS IEC activities have included the production of one poster, several awareness and information seminars for opinion leaders and youth, radio shows, radio spots and songs. Although the program spend about half of its resources on IEC activities, it does not have enough resources to do the research necessary to develop messages and produce IEC materials appropriate for the various target groups. In addition, the program personnel need to be trained in these areas. 6. The other public health programs have even fewer resources than the family planning and the NACP. The Extended Program of Inoculation (EPI), financed by UNICEF and WHO, has limited financial and human resources (it does not have an IEC specialist on staft) but it disseminate messages during soccer matches and in theater plays. It cannot however, use the radio for lack of resources. The National Malaria Control Program, also financed by UNICEF and WHO, has very few resources for IEC. The other public health programs--nutrition, water and sanitation and mother and child health--have no or very few IEC activities. 7. IEC activities at the level of the ministry are to be coordinated by the National Health Education Service (NHES) that was created in May 1991. For the period 1992-93, WHO has programmed US$34,000 to support this service, some local training and the production of IEC materials. However, this service is very weak: It is in fact constituted by only one person who is involved in EPI and malaria IEC activities but who spend most of its time on AIDS IEC activities and who has moved to the NACP office. The Population IEC project carry out its activities independently not only of the NHES but also of the MCH/FP program. 49 ANNEX II Page 3 of 5 8. In conclusion, some IEC activities are carried out in the Comoros, but they are concentrated in two programs. In addition, because each program/project has its own IEC component and there is no coordination between programs/projects, IEC resources are fragmented, no program has the capacity to produce quality IEC and some program cannot have any IEC activities. Projects generally do not have resources to conduct studies that are necessary to better understand target groups, to know what are the best communication channels for each group and thereby develop more appropriate and better targeted messages. To remedy this situation, the Health component of the IDA project proposes, on the one hand, to reinforce the planning and coordination capacities of the NHES, and, on the other, to provide resources to support IEC activities for priority public health programs. Proposed Project Activities 9. The objectives of the Health component of the project are to: (i) increase the efficiency of the Ministry of Public Health and Population (MOH) at the central and regional levels (institutional reinforcement) so that it can provide better quality services to the Comorian population; and (ii) to support priority programs such as the family planning and the NACP. Because IEC has an important role to play to increase contraceptive prevalence rates and prevent the spread of HIV contamination, the project proposes to: (i) assist the MOH to reinforce its IEC capacities both at the national and the regional levels; and (ii) support the IEC components of the family planning program and the NACP. These IEC activities, although program specific, will need to be carried out in the context of the national IEC strategy for health and population which will be developed by the Directorate for Health Education which will be created to replace the NHES in collaboration with the various public health and population programs. A. Institutional Strengtheing 10. Rationale. Program/project managers who need to use IEC to reach their objectives and international donors who support these programs/projects recognize that, in order to improve quality and cost-efficiency of IEC activities, it is necessary to reinforce the NHES and to replace it by a National Health Education Directorate (NHED), as was suggested in the preparation document written by the Government and the Association Sante-Internationale. This institutional strengthening will assist the MOH to carry out its IEC activities for all its programs, but in particular for its priority programs. The mandate of this directorate should be to: (i) plan and coordinate IEC activities of the different health and population programs; (ii) control the quality of the IEC materials produced by the programs/projects; (iii) provide technical assistance to IEC staff at the central and the regional levels; (iv) identify studies which need to be carried out to develop appropriate messages, prepare terms of reference for these studies and supervise them; and (v) produce or supervise the production of IEC audio-visual and printed materials. In the case of the last two activities, the NHED would be encouraged to sub-contract to outside experts from both the public and the private sectors. 11. Activities. This will be done by strengthening: (i) IEC and management capacities of the existing IEC staff of the various programs/projects, both at the central and the regional level; and (ii) production capacities for audio-visual and print materials of the IEC Population project so that this production unit can produce higher quality materials, not only for the IEC Population project but for all the ministry programs (the project does not intend to give the center the capacities to produce more materials nor to provide the center with capacities to produce other than audio and video tapes and to do simple printing as it does at present. It is 50 ANNEX II Page 4 of 5 expected that much of the material production will be sub-contracted). International technical assistance will be necessary to assist the MOH to: (i) organize its new directorate and to define its mandate and that of the provincial team; (ii) identify the coordination mechanisms between the various programs/projects and the NEHD and to specify how the resources will be shared; and (iii) establish supervision mechanisms for the various levels. This technical assistance will also assist the MOH to prepare job descriptions for all the personnel who will be carrying out IEC activities at the central, regional and community levels. 12. In order to strengthen the capacities of the central level IEC personnel, the project will finance one long-term training for the NHED Director and a two-month IEC training in Africa for three IEC staff. For the regional personnel, the project will finance one-month foreign training for three regional IEC officers. In addition, a session for the training of trainers in interpersonal communication and community mobilization will be organized in Moroni. This training will be carried out with the assistance of an international consultant who will assist the NHED personnel in adapting a curriculum developed and pre-tested in Zaire and in carrying out the workshop. 13. The equipment to be provided by the project will increase the capacities of the central material production unit to produce higher quality materials, it will not increase it ability to produce more materials nor will it provide new capacities such as the capacity to do photography or serigraphy. In addition, the four mobile videos will make it possible for the IEC personnel at the central level and in the three regions to make audio-visual presentations at seminars or in villages. B. Support to IEC Activities for Priority Programs 14. Rationale. Resources available for IEC activities are too limited even for priority programs. The strengthening of the NHED and of the regional teams will contribute to a higher quality and a better cost efficiency, but additional support will be necessary to ensure that these programs can reach their objectives. 15. Activities. The objectives of the IEC activities for the family planning and the AIDS control programs are the following: (i) motivate target populations to use contraceptives or, in the case of the AIDS program, to adopt low risk behaviors; (ii) develop messages based on an in-depth knowledge of the target audience; and (iii) disseminate messages using a multimedia strategyl/ tailored to the media habits of the target audience. In order to reach these objectives, the project propose to finance the following activities: a. Two study tours: One for family planning and the other for AIDS. The family planning tour could be to one of the Muslim countries that has been successful in setting up training, monitoring, supervision and evaluation mechanisms in an integrated context (FP and MCH) such as Tunisia. It is also a country where a mobile strategy has been tested and from which the Comorian could learn. The AIDS study tour should be to a country which has one of the most successful AIDS prevention IEC Program in Africa; 1/ The media that can be uaed are radio (national and local), theater, video, traditional media and interpersonal communication. 51 ANNEX II Page 5 of 5 b. Several studies: (i) a knowledge, attitude and practice (KAP) study on AIDS and sexuality; (ii) a target audience survey to determined what are the privileged means of communication for the various target audiences, their media habits, etc.; (iii) a study on obstacles to family planning and causes of discontinued contraceptive use; and (iv) some qualitative studies as needed (for example, focus group discussions, in depth interview, points of service intercept studies); c. Training: (i) ten workshops to train "relays", i.e. persons who will assist in disseminating messages, such as leaders of community associations. These "relays" will be trained in interpersonal communication and community mobilization, with particular reference to FP and AIDS; and (ii) four seminars for radio and print journalists; d. IEC Materials: Design, pre-test and production (by NHED or by a sub-contractor under the supervision of NHED and of the concerned program) of IEC materials which could include audio-visual materials (video or audio tapes), theater plays, songs, sketches, flip charts, in agreement with identified needs; and e. Technical assistance: Two months of technical assistance to assist with specific tasks which will be identified as the project progresses. It could be to assist with the design and the execution of studies or to design printed material such as a flip chart. 52 ANNEX III Page 1 of 18 TECHNICAL ASSISTANCE AND TRAINING I. HEALTH COMPONENT A. Description of Project Office 1. A small Project Office will be put in place and attached to the General Director of Health within the Ministry of Health. The office will be located in a building belonging to the Ministry of Health, and its rehabilitation will be financed through the PPF. 2. The Project Office will be responsible for ensuring that project components are being executed in a timely fashion. More specifically, the Project Office will: (a) prepare annual work programs and corresponding budgets; (b) coordinate the activities of the various components; (c) maintain an accounting system for each project sub-component satisfactory to IDA and prepare quarterly and annual financial reports; (d) prepare all bidding documents in a manner acceptable to IDA; (e) prepare quarterly and annual progress reports; (f) ensure that audits are performed annually in a timely fashion; (g) manage all technical assistance contracts for the project; and (h) perform a mid-term review of the project during the third year of project implementation. 3. The Project Office will be comprised of nationals, including a project director, a financial director, an engineer/procurement specialist and the necessary support staff. 4. Studies and supervision of civil works financed through the project will be executed by a private firm or NGO recruited with procedures acceptable to IDA. The Project Office engineer will be responsible for coordinating these activities as well as visiting the sites regularly. In the same way procurement of goods, technical assistance and training will be executed by private firms or NGOs recruited with procedures acceptable to IDA. The Project Office's Director will be responsible for coordination of all these activities accordingly to the Work Plan. 5. Regarding procurement, standard bidding documents for civil works and equipments (as well as equipment lists) were prepared during the appraisal mission. However, short-term international technical assistance has been budgeted to assist in the finalization of these lists and the preparation of technical specifications for civil works. In addition, the person within the Project Office that will be responsible for procurement will attend a training course on Bank procurement during the first year of project implementation. 53 ANNEX III Page 2 of 18 B. Terms of Reference for Staff of the Project Office Coordinator 6. The Project Office Coordinator will be responsible for the overall management of the activities and resources of the health component. More specifically, the Coordinator's responsibilities will include: - plan yearly work plan for the Project's health component; - implement the Project's rules and regulations; - review and submit annual budgets for the Project's health component; - ensure application of rules and standards regarding administrative and financial operations of the Project; - negotiate, collect and distribute financial and material resources for the benefit of the health component of the Project; - manage the Project Office staff and consultants for the benefit of the Project; - review, comment on and promptly distribute the quarterly and annual reports of the Project's health component; - comment on the Project's audit reports - review and comment on conventions, contracts or agreements for the implementation of project activities to be signed by the Minister of Health and Population; - ensure relationships with partners of the Project on behalf of the Minister or the MOH Director General; - follow and supervise a strategy of hiring NGOs and private firms to execute civil works and purchase equipment; and - assist the Minister in the selection of implementing agencies and consultants; 7. Duration will be for five years (renewable every year). 8. Profile. The Project Office Coordinator must have a university degree in Social Sciences. Previous experience with donor-financed project would be a strong advantage. Must be fluent in spoken and written French. 54 ANNEX 11I Page 3 of 18 Accountant 9. Under the supervision of the Project Coordinator, the Accountant's responsibilities will be as follows: assist in establishing the Project's yearly budget based on work program to be submitted to IDA; monitor and insist on the application of rules and standards regarding administrative and financial operations of the Project; prepare quarterly, annual and other reports on the various aspects of the administrative and financial management of the Project in accordance with the rules of IDA as contained in the document "Financial Reporting and Auditing of Projects Financed by the World Bank" (March 1982); - maintain all accounting records; - monitor closely expenditures pertinent to the Project; - monitor carefully the implementation of financial operations on a cash basis; - establish logistics for the benefit of the Project; - provide input on IDA requirements for the automation of the accounting system; 10. Duration would be for five years (renewable every year). Procurement Specialist 11. Profile. The Procurment specialist must have at least 3 years of work experience as an accountant, preferably having worked on a donor-financed project. A university degree, with a major in accounting, would be preferred. Familiarity with computers will be required. The Accountant will have to become familiar with IDA disbursement and other procedures. Fluency in French necessary. Proficiency in English would be desirable. 12. Under the supervision of the Project Coordinator, the Procurement Specialist's responsibilities will be as follows: prepare and finalize documents for the selection of implementing agencies; prepare conventions, contracts or agreements for the implementation of project activities to be signed by the Minister of Health and Population; supervise the work of private firms and NGOs responsible for the elaboration of bidding documents for civil works, equipment, vehicles and the selection of companies to perform civil works required under the project, following the standard bidding documents provided by IDA, and in accordance with IDA's rules 55 ANNEX III Page 4 of 18 as contained in the document "Guidelines for Procurement under IBRD Loans and IDA Credits" (May 1992) - prepare documents for hiring consultants, in accordance with IDA's rules as contained in the document "Use of Consultants by World Bank Borrowers and by The World Bank as Executing Agency" (August 1981); draft terms of reference, and participate in consultations for the selection of consultants; and - coordinate the work of contractors performing civil works undertaken under the project, including regular visits to the building sites. 13. Duration would be for five years (renewable every year). 14. Profile. The procurement specialist would have training and/or extensive experience in procurement for civil works and equipment, preferably for a large institution. Experience with a World Bank project would be highly desirable. Training as an engineer or architect will be a plus. The procurement specialist would have to become quickly familiar with IDA procurement guidelines. Fluency in French is necessary. Proficiency in English will be desirable. C. Terms of Reference for Technical Assistance Supervision of Pharmaceutical Sector 15. The Consultant in the National Directorate of Pharmaceutical Inspection (Direction Nationale d'Inspection Pharmaceutique) will assist MOH in strengthening of the capacities of the Directorate to monitor and enforce the application of regulations and standards regarding Comoros' pharmaceutical sector. The Consultant will assist in the preparation of a comprehensive National Pharmaceutical Code and in the design of therapeutic protocols for Primary Health Care Workers. He/she will also develop task and performance standards for MOH Pharmaceutical Inspectors. He/she will conduct inspection of the PNAC, private and community pharmacies, and other units involved in the distribution of pharmaceutical products. 16. Duration would be for three years (renewable every year). 17. Profile. The Consultant must have a university degree in Pharmacy and at least 5 years of experience in drug management, preferably having worked in a successful health project as a team leader. Familiarity with Sub-Saharan Africa will be a strong advantage. Proficiency in French will be required. Health Administration 18. The Consultants in Health Administration will assist MOH in preparing rules, procedures and administrative standards required for improving the performances of health facilities. Based on these documents, the consultants will design working tools and curricula to be used for the training of cadres in charge with the management and supervision of health facilities. They will also conduct training for MOH administrative staff, including managers of health facilities, secretaries and accountants. 56 ANNEX III Page 5 of 18 19. Duration would be: 5 persons-months in the first year; 2 persons-months in the second year. 20. Profile. The Consultants must have at least 5 years of experience as Health Administrators. They will have a university degree with major in Health Administration. Training in Health 21. The Consultants in Training in Health will assist MOH in preparing health service policy and standards documents. Based on these documents, they will help design therapeutic protocols for Primary Health Care Workers and curricula for FP and STDs-AIDS. They will also develop task and performance standards for supervisors. In addition, they will conduct clinical skills workshops for physicians and refresher training courses in comprehensive primary health care for nurses and midwives. 22. Duration would be: 4 persons-months in the first year 3 persons-months in the second year 3 persons-months in the third year 23. Profile. The Consultants must have a good experience in training in health, preferably working for an institution specialized in human resources development in Sub-Saharan Africa. Familiarity with FP and AIDS will be a strong advantage. Proficiency in French will be required. Social Studies 24. Consultants in Social Studies will assist the MOH in the administration and organization of survey activities particularly in the field of AIDS and Family Planning and in formatting the protocols of result analysis. The Consultants will also be responsible for the training of the staff who will participate in survey activities. 25. Duration would be: 4 persons-months in the first year; 3 persons-months in the second year; 3 persons-months in the third year 57 ANNEX III Page 6 of 18 26. Profile. The Consultants will have good experience in designing and leading surveys in social sector, particularly regarding the data processing, statistical and social areas. Information. Education and Communications 27. The objective of this consultation would be to: (a) operationalize the National Health Education Directorate (NHED) of the Ministry of Public Health and Population (MOH); and (b) define the coordination mechanisms between the various programs and the NHED. 28. In order to achieve these objectives the consultant will work in close collaboration with the NHED personnel and with the personnel of the various health and population programs and with the concerned donors. In particular, the consultant will coordinate with the United Nations Development Program (UNDP) which is presently developing a Development Communication project. 29. The consultant will assist the NHED personnel to organize a three-day seminar that will have the following objectives: * Identify issues facing the MOH in the areas of IEC; * Review the mandate of the NHED; * Identify mechanisms for coordinating health and population IEC activities and develop an organization chart specifying how the various programs will relate to the NHED; * Make an inventory of human (number of persons and skills), financial and material resources which should be put at the disposal of the NHED; * Identify the personnel who would have the responsibility to carry out IEC activities at the periphery; * Specify how IEC activities will be manage both at the central and peripheral levels. Participants in this seminar would include the management personnel of the various health and population programs, representative of the concerned donors and the regional medical officers. 30. The consultant will assist the NHED personnel to: * Prepare a one year activity plan corresponding to the health and population priorities of the Ministry; * Prepare job description for the personnel of the NHED and for the regional IEC personnel; * Review, in close collaboration with program personnel, the job description of the person(s) responsible for IEC activities in each of the various health and 58 ANNEX III Page 7 of 18 population programs and specify the procedure by which this/these person(s) will collaborate with NHED personnel; * Assess the training needs of the IEC personnel (in the NHED, in the programs and in the regional team) and prepare a training plan; and * Identify the task for which short term technical assistance will be needed and prepare terms of reference for each of the needed consultations. 31. Duration would be eight weeks. 32. Profile. The consultant should have experience in developing social communication programs in the field of health and population in less developed countries and a minimum of five years of professional experience in Sub-Saharan Africa. The consultant who will be fluent in spoken and written French should at least have a Master's degree in social sciences or in social communication. D. Trainin2 Activities in the Health Sector Training in Management for 15 higher-level staff of the MOH 33. Objectives. To provide a team of 15 higher level MOH staff with the capability to set up and operate an efficient system for personnel management; health center supervision; budget management; and staff training. These training programs will be provided by WHO's Public Health Training Centers. 34. Location: Africa 35. Schedule: First year (5 people) Second year (5 people) Fourth year (5 people) 36. Duration would be 3 months. Management training for 3 Regional Medical Officers 37. Objectives. To provide each of the country's health regions with a senior physician able to efficiently ensure the smooth development of priority health programs throughout an island. This training will be provided by institutes with experience in training District Medical Officers. 38. Location: Africa 39. Schedule: First year (for the 3 physicians) ANNEX III Page 8 of 18 40. Duration would be 3 months. Training in public health for 3 nurses from the Regional Health Teams 41. Objectives. To provide each of the 3 regional health teams in the country with one nurse specialized in Public Health and having the capacity to assist the Regional Medical Officer in organizing Public Health activities. This training would be provided by a French- speaking Public Health School. 42. Location: Africa, Europe or Canada 43. Schedule: Fourth year (for the 3 nurses) 44. Duration would be 18 months. Training in public health for 6 nurses from the Regional Health Teams 45. Obiective. Provide each of the three regional health teams with 2 nurses qualified in public health and capable of planning, administration, and evaluation public health activities at the island level. This training will be provided by the WHO's Public Health Institutes or other national institutes which train district health staff. 46. Location: Africa, Europe or Canada 47. Schedule: First year (for 3 nurses) Second year (for 3 nurses) 48. Duration would be for 3 months. Training in management for 5 hospital directors 49. Objectives: To provide each of the country's 5 hospitals with the capacity to set up and operate an efficient system of management of human, physical and financial resources. This training will be provided by specialists in hospital administration. 50. Location: This training will take place partly in Moroni and partly in well- managed hospitals in France. 51. Schedule: First year (for Hombo and Fomboni hospitals directors) Third year (for directors of the three other hospitals) 52. Duration would be 6 months, of which 3 months in Moroni and the remaining in France. 60 ANNEX III Page 9 of 18 Training in management for 15 managers from health centers 53. Objective: To provide each of the 15 country's health centers with a high level staff able to set up and operate efficiently a system of management for human, physical and financial resources. The candidates for this training will be recruited from among BEPC graduates from Comoros' school of management science. This training will be provided by specialists in hospital administration. 54. Location: Moroni. 55. Schedule: First year (for 5 managers) Second year (for 10 managers) 56. Duration would be for 3 months. Training in administration for 5 MOH secretaries 57. Objectives. To provide 2 central Directorates and 3 regional Health Teams with an agent able to take responsibilities usually delegated to a director's assistant, regarding mainly the efficient use of office equipment, mail preparation, filing and office organization. Candidates to this training will be recruited from among the Government's administrative staff. This training will be provided by specialists in Administration. 58. Location: Moroni. 59. Schedule: First year (for the 5 secretaries) 60. Duration would be for 3 months. Training in management for 27 high level staff of the MOH 61. Objectives. To integrate the techniques of good management of resources into the functioning of the programs of the ministry. Consultants specialized in health administration will provide the training. 62. Location: Moroni. 63. Schedule: Second year (for the 27 staff) 64. Duration would be for 3 days. 61 ANNEX 111 Page 10 of 18 Training in FP for 9 high level staff of the MOH 65. Objectives. Increase the number of MOH staff able to adequately provide a wide range of FP services, including IUD and NORPLANT. Training will be provided by institutions specialized in FP training. 66. Location: African or Asian Islamic countries. 67. Schedule: First year (for 1 physician and 2 nurses) Second year (for 2 physicians and 2 nurses) Third year (for 2 nurses). 68. Duration: 8 weeks. Training in FP for 150 MOH staff 69. Objectives: To increase the number of MOH agents able to adequately provide essential FP services (counseling, contraceptive methods, pill, injectable contraceptives). The upgrading of FP agents will be provided jointly by consultants and by high level MOH staff trained in FP. 70. Location: main administrative towns of Comoros. 71. Schedule: First year (for 25 agents in one session) Second year (for 50 agents in 3 sessions) Third year (for 75 agents in 3 sessions). 72. Duration would be for 2 weeks. Training for Director of National Health Education Directorate 73. Objectives: To have one IEC professional who can provide leadership and technical expertise in communication planning, strategy development, and material design and production. 74. Location: University offering advanced communication training in French. 75. Schedule: Starting academic year of the first year of the project 76. Duration: 18 months 62 ANNEX III Page 11 of 18 Training for 3 regional TEC Coordinators 77. Objectives: To have, in each region, one agent trained in IEC and who will be able to provide technical leadership, coordinate regional IEC activities, supervise community level IEC activities and liaise with the central level. 78. Location: To be determined. 79. Schedule: First year of project implementation. 80. Duration: 3 - 4 weeks. Training for 3 IEC agents at the central level 81. Objectives: To increase the number of agents who have expertise in IEC and provide assistance to the various health and population programs and to the regions. 82. Location: Africa 83. Schedule: To be determined 84. Duration: 5 - 8 weeks Training of trainers in interpersonal communications and social mobilization 85. Objectives: To have IEC trainers who will be able to trained community workers and health personnel in interpersonal communication and social mobilization to motivate the public to adopt new health practices. 86. Location: Moroni 87. Schedule: During the first year of the project. 88. Duration: Three weeks. Technical training of 3 laboratory assistants 89. Objectives. To provide each health unit in the country with a lab assistant able to adequately carry out examinations to identify STD (sexually-transmitted diseases) agents, including AIDS, having the capability to keep laboratory records up-to-date, ensure adequate supplies of reagents, ensure the maintenance of lab equipment, train other lab assistants, and provide supervision and quality control of the lab activities conducted throughout the island. The training of these lab assistants will be provided in a laboratory with experience in MST and AIDS training. 90. Location: Yaounde. 63 ANNEX III Page 12 of 18 91. Schedule: First year (for 1 lab assistant) Second year (for 2 lab assistants) 92. Duration would be for 3 months. TRAINING PLAN: HEALTH COMPONENT Person-months of training provided: Subject Year I Year 2 Year 3 Year 4 Year 5 Management: Local 36 43 Foreign 30 24 15 Public health: Foreign 9 9 36 18 Family planning: Local 15 25 40 Foreign 6 8 4 IEC: Foreign 9 18 3 Laboratory techniques Foreign 3 6 64 ANNEX III Page 13 of 18 II. COMMUNITY DEVELOPMENT SOCIAL FUND COMPONENT A. Terms of Reference: Assistance of NGO 93. General context. Presidential Decree No 92-054/PR of March 14 1992 provides for an NGO to assist the Preparation Committee in the preparation of community development activities. The Canadian NGO CECI was identified and its support has proved efficient. To ensure the continuity of this intervention, CECI has been called upon to continue to help the CDSF with the following tasks: (a) organization and animation of the public awareness and information campaign; (b) identification and preparation of micro-projects solicited by village communities; (c) management of work sites and/or installation of sub-projects; and (d) administrative and financial management of the CDSF. 94. Composition of CECI team. The CECI team consists of a coordinator (36 months), an accounting expert (3 months) and 4 volunteers (1 accountants and 3 specialists in project management for community development: 36 months for each). This composition as well as the duration of the intervention could be revised in the light of new needs and of the evolution of the CDSF, particularly for interventions promoting the status of women (nutrition, child care, health, literacy, home economics etc). Coordinator 95. Working under the authority of the Executive Director of the CDSF, the coordinator has, among others, the following tasks: Administrative and financial management: assure the management of the funds of the CDSF, which come in large part from the IDA credit; in that regard, observe the specific procedures in the Credit Agreement and in the manual of procedures of the CDSF; plan and control quarterly and annual reports submitted by the regional offices; prepare the financial statements in conjunction with the accounting specialists; assure the financial control and supervision of the projects financed by the CDSF, and analyze any irregularities; participate in the editing of periodic reports on activities; help to put in place the accounting unit; and train the responsible national personnel in financial management. Technical assistance: help to coordinate the activities of the cooperants; put in place a supply system for work sites, and provide efficient support for the realization of micro-projects; establish to this end a system of information management which will allow the periodic supervision of the situation at the work sites and of works completed in the different regions; help, as much as possible, with the preparation of sub-projects; and organize and participate in seminars for the central and regional staff of the CDSF on the following subjects: (a) identification, preparation and appraisal of micro-projects, and (b) organization and management of work sites and/or sub-projects financed by the CDSF. 65 ANNEX III Page 14 of 18 96. Profile. Preferably engineer in rural civil works; proven experience in the organization and management of projects and work sites; previous experience in rural development projects; knowledge of computers required; team spirit and communications aptitude; perfect spoken and written French. Volunteers 97. Working under the authority of the Regional Sub-Directors, the volunteers would have, amongst others, the following tasks: - Public awareness and information: participate in the training of the members of the Pilot Committees; in that regard, initiate simple techniques adapted to the Comorian situation; participate, with the cooperation of the nationals responsible, in the organization and animation of the public awareness and information campaign promoting the CDSF; in this campaign, pay particular attention to the principal themes relating to the introduction of a new culture of community organization and management, keeping in mind: the objectives of the CDSF, the assemblage and/or the coordination of different village associations, the classification of development activities based on the resources available, the identification and preparation of sub-projects, the preparation of an annual budget, the programming of activities according to the financial capacity of the villages, and the introduction of a budget for upkeep and maintenance. - UTechnical Assistance: participate in the identification of community development sub-projects; help with the preparation of sub-projects solicited by the village communities; animate the public awareness campaign aimed at mobilizing human, financial and material resources toward the realization of the sub-projects; participate in the organization, programming and supervision of activities at the work sites; supervise, in close cooperation with national specialists and the CECI coordinator, the supply system for the work sites; establish periodic reports on progress at the work sites for the central and regional authorities, signalling any anomalies observed. 98. Profile. Volunteers manifesting a strong interest in the problems of community development at the village level; training in communications required; sense of public relations; knowledge of work site management; capability to endure the conditions of living and transport as well as frequent visits to remote villages; fluent in spoken and written French. Accounting Specialist 99. Working under the Executive Director, under the technical supervision of the CECI Coordinator, the specialist would have, among others, the following tasks: help to establish the accounting and financial system of the CDSF; putting in place, in that regard, a computerized system of financial information; propose the procedures of budget preparation and cash flow plan; 66 ANNEX III Page 15 of 18 define the procedures for engaging expenditures, and the instructions for use of bank accounts, conforming to the Manual of Procedures for the CDSF; supervise the institution of financial and accounting arrangements; plan and control the quarterly and annual reports; prepare the financial statements; assure the control and financial supervision of projects financed by the CDSF, as well as analyze any irregularities noted; assure the training of national responsible for accounting and financial management at the central and regional levels; and - participate in the editing of periodic activity reports. 100. Profile. Proven experience in computerized financial management. Experience desirable in international projects especially those financed by the World Bank; sense of public relations; knowledge of communications desired; ability to maintain activities according to the hours of work in the main office or on visits to regional offices and work sites. Results ExDected 101. Financial and administrative management. A structured and organized Executive Secretariat would be functional, endowed with appropriate means and procedures of work, and staffed with qualified professionals. More precisely, a reliable and proven system of supply and financial management would have been established within six months of the intervention by CECI (target date: December 1993). The financial management cell would be endowed with capable local personnel. Organizationally, the Manual of Procedures would be put in place; the functional relations between the different posts and levels of decision would have been established; the information system would be in position and working: financial and technical documents would be produced according to the calendar forecast and would be of sufficient quality according to an external audit (monthly accounts, financial reports, logbooks, annual reports). 102. Technical Assistance. At least 50% of the villages of Comoros would have benefitted from the technical and financial support of the CDSF for the realization of their program of community development; the same number of pilot committees would be installed and trained by the CDSF; the rate of activity would be 20 sub-projects per year in Grande Comore and Anjouan, and 10 in Moheli; at least 50% of villages which have completed a project with financing from the CDSF will be maintaining their investments using a budget for upkeep and maintenance. 67 ANNEX In Page 16 of 18 B. Training Activities 1991-95 103. Introduction. As the CDSF component is aimed at promoting self-reliant, sustainable, socio-economic development of rural communities, by increasing the local institutional capacity for development planning and implementation, training would play a crucial role to help communities attain the proposed targets. 104. Objective. The general objective of the training plan is: (a) to help implement a new concept of community development based on an effective use of available resources through a better organization and management, and a larger concern for maintenance of existing public property; (b) train managers for communities in basic techniques of management, project and budget preparation, and communication. The training plan has also its own specific objectives, which are: (i) at the intermediate and lower level to train manpower that is needed to implement sub-projects in various sectors (school rehabilitation, water supply system, post health construction, etc.); (ii) to provide support to small contractors who have contracts with communities through the CDSF's financing; (iii) to help promote women's development by providing training in primary health care, nutrition, child care and by improving literacy rates. 105. Training Plan. The training plan would involve: (a) 1800 members of the Community Pilot Committees from about 180 villages (Grande Comore: 800 agents, Anjouan: 800 agents, Moheli: 200 agents); (b) 100 book-keepers -one for each community-; (c) 100 warehouse-keepers; (d) 600 masons, 180 carpenters, 360 school furniture makers, 100 fitters and plumbers, and 270 painters; (c) 90 job site supervisors; (d) 2500 rural women in the three islands. 106. Organization of Training. Training activities will be coordinated by the Information and Training Unit (ITU). In view of the special nature of the CDSF, both activities must be coordinated very closely if they are to be successful: a. Information. In the area of information, ITU's main responsibilities are: (i) to coordinate main activities of the information campaign on the the CDSF; (ii) to identify main issues in implementing the CDSF's program, in particular introducing a new concept of organization and management at the community level, and the community adopting a maintenance budget as a conditionality for the financing of any micro-project by the CDSF; (iii) to organize seminars and colloquys on community development, by special attention to the social behavior of communities; and (iv) to propose a strategy of information for the CDSF, and an appropriate action plan. b. Training. ITU's responsibilities are: (i) to propose a training strategy, in accordance with the needs of each community and in response to the main issues identified, (ii) to draw up the training programs with the participation of professional staff and consultants both national and expatriate, (iii) to propose suitable measures to associate supervisory staff closely with training activities; (iv) to provide for monitoring and control of training; and (v) to evaluate training actions and propose adequate actions to improve the quality of training provided. 107. Strategy of Training. The function of training should be understood by all as crucial to the CDSF's success. Staff and technical assistance would actively participate in training. To this end, terms of reference for their assignment would include specific clauses on training, 68 ANNEX III Page 17 of 18 and their participation will be clearly defined in close coordination with ITU to ensure a coherence in methodology and evaluation of training; the performance of consultants will be finally evaluated to a large extent on their ability and efforts in providing training to local staff; in addition, seminars in communication and training methods for technicians skilled in production will be organized with a view to strengthening the training corps and ensuring effective monitoring of trainees in their place of work. 108. Several modes of training will be used to help implement the training plan: a. training in management for managers at both central and local level will provided by CECI's consultants, whose experience and skills have proved to be satisfactory during the project preparation. Trainees would be selected through the formation of the Pilot Village Committees among the best educated habitants and/or those recognized for their strong leadership. Training would consist of 2 to 3 one-week seminars organized yearly for groups of about 12 trainees. The majority of training would, however, be delivered on-the-job during the period of project identification, preparation and implementation. Topics of discussion would include: (a) the CDSF's objectives, organization, and financing procedures; (b) project preparation, proposals, and implementation, (c) community development and organization, (d) budget preparation and monitoring, (e) work planning and organization, (f) communication and reporting, and (g) specific issues either political and social or economic relevant to the new concept of community development and organization; b. training for women's development would be carried out by CARITAS's professional staff whose performance is well-known in this area; training would be conducted for one half-day a week for 10 months, including reading, arithmetic, home economics, family book-keeping, child care, basic health care, nutrition and tailoring; each trainee would have to pay an annual tuition fee of 1,200 FC. The impact of this program is likely to be important but not sufficient in relation to national needs. During the project implementation support would be provided by the CDSF to build up the training capacity of local NGOs, particularly Women Associations, in improving the literacy rate and delivering training at the most remote and poorest villages. c. training for workers in basic skills will be provided on-the-job by mobile teams composed of job site supervisors, foremen and part-time trainers hired under the project. Trainees for each job site would be selected and divided into professional and qualification groups. Training programs would start with a two-day orientation session including presentation of the main features of work, organization of the job site, preparation of materials, testing of equipment and inventory of individual tools, discussion of individual assignment. Most training would be delivered on the job. Each group of trainees would be placed under the responsibility of a foreman whose professional qualification and communication ability are confirmed after test. Foremen are responsible for ensuring the quality control, providing technical advice, and organizing theoretical training as necessary. 69 ANNEX III Page 18 of 18 TRAINING PLAN: CDSF (1991-95) SPECIALTY GDE COMORE ANJOUAN MOHELI TOTAL (trainees! (trainees) (trainees) (trainees) Management 800 800 230 1.830 Job site 80 80 23 183 Supervision Accounting 80 80 23 183 Basic Skills Masons 280 280 70 630 Carpenters 80 80 20 180 Fitters 40 40 15 95 Painters 120 120 30 270 Furniture makers 160 160 40 360 Women 1.000 500 500 2.000 development TOTAL 2.640 2.140 951 5.731 COMOROS POPULATION AND HUMAN RESOURCES DEVELOPMENT Project Cost Estimates Projects Components by Year Totals Including Contingencies Totals Including Contingencies FC SUS 01 02 03 04 0S Totat 01 02 03 04 05 Totat A. Support to Heatth Sector 1. Support to Centrat Levet 36125 77507 54065 19373 0 187070 134 287 200 72 0 693 2. Support to Regionat Levet 15057 33222 36644 29059 14127 128108 56 123 136 108 52 474 3. Heatth Facitities Rehabit 130695 381596 497306 273914 140024 1423535 484 1413 1842 1014 519 5272 4. FamiLy Ptanning Program 4106 33251 27455 9081 0 73893 15 123 102 34 0 274 5. STD/AIDS Program 6300 30675 29146 14179 3151 83450 23 114 108 53 12 309 6. Project Ilptementation Un 52149 25734 23830 24783 25774 152270 193 95 88 92 95 564 Sub-Total 244432 581983 668446 370389 183077 2048327 905 2155 2476 1372 678 7586 B. Commiunity Dev. Soc. Fund 1. Adninistration 59211 61579 64043 66604 69268 320706 219 228 237 247 257 1188 2. Sub-Projects 169107 370792 385113 400223 415928 1741163 626 1373 1426 1482 1540 6449 Sub-Total 228318 432371 449155 466828 485196 2061869 846 1601 1664 1729 1797 7637 C. PPF 219469 0 0 0 0 219469 813 0 0 0 0 813 Total PROJECTS COSTS 692219 1014355 1117601 837216 668273 4329665 2564 3757 4139 3101 2475 16036 0 Vatues Scated by 1000.0 11/3/1993 11:52 (D 0 < Fh COMOROS POPULATION AND HUMAN RESOURCES DEVELOPHENT Project Cost Estimates FC Project Components by Year Base Costs Totat 01 02 03 04 05 FC SUS A. Support to Health Sector 1. Support to Central Level 35640 74250 49950 17280 0 177120 656 2. Support to Regional Level 14850 31860 34020 25920 12150 118800 440 3. Health Facilities Rehabit 128250 363150 454950 238950 117450 1302750 4825 4. Family Planning Program 4050 31860 25380 8100 0 69390 257 5. STD/AIDS Program 6210 29430 27000 12690 2700 78030 289 6. Project Implementation Un 51300 24300 21600 21600 21600 140400 520 Sub-total 240300 554850 612900 324540 153900 1886490 6987 B. Community Dev. Soc. Fund 1. Administration 58050 58050 58050 58050 58050 290250 1075 2. Sub-Projects 166050 351000 351000 351000 351000 1570050 5815 Sub-total 224100 409050 409050 409050 409050 1860300 6890 C. PPF 216000 0 0 0 0 216000 800 Total BASELINE COSTS 680400 963900 1021950 733590 562950 3962790 14677 Physical Contingencies 0 0 0 0 0 0 0 Price Contingencies 11819 50455 95651 103626 105323 366875 1359 Total PROJECT COSTS 692219 1014355 1117601 837216 668273 4329665 16036 Taxes 0 0 0 0 0 0 0 Foreign Exchange 171957 300162 273013 108986 75270 929389 3442 Values ScaLed by 1000.0 11/3/1993 11:52 tD O COMOROS POPULATION AND HULAN RESOURCES DEVELOPMENT Project Cost Estimates Sufary Accounts by Year Totals Including Contingencies Totats Including Contingencies FC SUS 01 02 03 04 05 Total 01 02 03 04 05 Total 1. INVESTMENT COSTS A. Equipment, Vehicles, Mat. 36088 250387 194572 11142 0 492189 134 927 721 41 0 1823 S. Training 36136 86864 100399 68107 18837 310342 134 322 372 252 70 1149 C. Civil Works 13770 85925 205532 151796 19331 476354 51 318 761 562 72 1764 D. Technical Assistance 37262 32785 36879 3037 3151 113113 138 121 137 11 12 419 E. ppf 219469 0 0 0 0 219469 813 0 0 0 0 813 F. CDSF sub-projects 169107 370792 385113 400223 415928 1741163 626 1373 1426 1482 1540 6449 Total INVESTMENT COSTS 511832 826752 922495 634306 457246 3352631 1896 3062 3417 2349 1694 12417 II. RECURRENT COSTS A. Operating Costs 121176 126023 131064 136307 141759 656328 449 467 485 505 525 2431 B. CDSF Acdninistration 59211 61579 64043 66604 69268 320706 219 228 237 247 257 1188 Total RECURRENT COSTS 180387 187602 195107 202911 211027 977034 668 695 723 752 782 3619 Total PROJECT COSTS 692219 1014355 1117601 837216 668273 4329665 2564 3757 4139 3101 2475 16036 Values Scaled by 1000.0 11/3/1993 11:52 C- Fhs COMOROS POPULATION AND HUMAN RESOUJRCES DEVELOPMENT Project Cost Estimates Table 10. Support to Central Level Detailed Cost TabLe FC Totals lncluding Contingencies Quantity Unit Cost Base Costs In SUS SUS 01-05 Total 1-05 01 02 03 04 05 Total 01 02 03 04 05 Total 1. INVESTMENT COSTS A. Equipment repinfolec - - - 52000 100000 0 0 0 152000 52654 104097 0 0 0 156751 B. Technicat Assistance Foreign - - - 30000 52000 62000 0 0 144000 30442 54432 67210 0 0 152085 IEC foreign - - - 0 12000 12000 0 0 24000 0 12561 13008 0 0 25570 IEC local - - - 6000 12000 12000 0 0 30000 6088 12561 13008 0 0 31658 Sub-Total 36000 76000 86000 0 0 198000 36531 79555 93227 0 0 209313 C. Training Foreign - - 20000 70000 70000 50000 0 210000 20278 73117 75667 56055 0 225118 Local - - - 6000 14000 14000 14000 0 48000 6083 14623 15133 15696 0 51536 IEC foreign - - - 18000 15000 15000 0 0 48000 18250 15668 16214 0 0 50133 Sub-Total 44000 99000 99000 64000 0 306000 44612 103409 107015 71751 0 326787 Total INVESTMENT COSTS 132000 275000 185000 64000 0 656000 133797 287061 200241 71751 0 692851 Total 132000 275000 185000 64000 0 656000 133797 287061 200241 71751 0 692851 11/3/1993 11:51 -10 0_ 0) COMOROS POPULATION AND HUMAN RESOURCES DEVELOPMENT Project Cost Estimates Table 20. Support to Regional Level Detailed Cost Table FC Quantity Unit Cost Base Costs in SUS 01-05 Total 1-05 01 02 03 04 05 Total 1. INVESTMENT COSTS A. Equipment, Vehicles, Hat repinfo - - - 0 18000 30000 0 0 48000 S. Training Foreign - - - 45000 90000 90000 90000 45000 360000 Local - - 4000 0 0 0 0 4000 IEC foreign - - - 6000 6000 6000 6000 0 24000 IEC local - - 0 4000 0 0 0 4000 Sub-Total 55000 100000 96000 96000 45000 392000 Total INVESTMENT COSTS 55000 118000 126000 96000 45000 440000 Total 55000 118000 126000 96000 45000 440000 11/3/1993 11:51 c-I 0< COMOROS POPULATION AND HUMAN RESOURCES DEVELOPMENT Project Cost Estimates Table 20. Support to Regional Level Detailed Cost Table FC Totals Including Contingencies sus 01 02 03 04 05 Total 1. INVESTMENT COSTS A. Equipment, Vehicles, Hat repinfo 0 18590 31945 0 0 50534 B. Training Foreign 45626 94008 97286 100900 52324 390144 Local 4056 0 0 0 0 4056 IEC foreign 6083 6267 6486 6727 0 25563 IEC local 0 4178 0 0 0 4178 Sub-Total 55765 104453 103772 107626 52324 423941 TotaL INVESTMENT COSTS 55765 123043 135717 107626 52324 474475 Total 55765 123043 135717 107626 52324 474475 11/3/1993 11:51 OC. ii COMOROS POPULATION AND HUMAN RESOURCES DEVELOPMENT Project Cost Estimates Table 30. Health Facilities Rehabilitation Detailed Cost Table FC Quantity Unit Cost Base Costs in SUS 01-05 Total 1-05 01 02 03 04 05 Total 1. INVESTMENT COSTS A. Civil Works Hombo Hospital - - - 10000 200000 340000 0 0 550000 Fomboni Hospitat - - - 10000 0 150000 190000 0 350000 CS/Cm - - 10000 100000 200000 300000 60000 670000 Sub-Total 30000 300000 690000 490000 60000 1570000 B. Equipment Hombo Hospital - - - 0 650000 0 0 0 650000 Famboni Hospital - - - 0 0 200000 0 0 200000 CS/Cm 0 0 400000 0 0 400000 Sub-Total 0 650000 600000 0 0 1250000 C. Training Foreign - - - 0 20000 20000 20000 15000 75000 Local - - - 0 15000 15000 15000 0 45000 Sub-Total 0 35000 35000 35000 15000 120000 D. Technical Assistance VNU - - - 85000 0 0 0 0 85000 Total INVESTMENT COSTS 115000 985000 1325000 525000 75000 3025000 11. RECURRENT COSTS ..... ....... . A. Goverrnent contribution - - - 360000 360000 360000 360000 360000 1800000 Total RECURRENT COSTS 360000 360000 360000 360000 360000 1800000 Total 475000 1345000 1685000 885000 435000 4825000 11/3/1993 11:51 01 0<1 COMOROS POPULATION AND HUMAN RESOURCES DEVELOPMENT Project Cost Estimates TabLe 30. Health Facilities Rehabilitation Detailed Cost Table FC Totals Including Contingencies Sus 01 02 03 04 05 TotaL I. INVESTMENT COSTS A. CiviL Uorks Hombo Hospital 10200 212160 375099 0 0 597459 Fomboni Hospital 10200 0 165485 217999 0 393683 CS/Cm 10200 106080 220646 344208 71595 752730 Sub-Total 30600 318240 761230 562207 71595 1743872 S. Equipment Hombo Hospital 0 676633 0 0 0 676633 Fomboni Hospital 0 0 215216 0 0 215216 CS/CM 0 0 430432 0 0 430432 Sub-Total 0 676633 645648 0 0 1322280 C. Training Foreign 0 20891 21619 22422 17441 82373 Local 0 15668 16214 16817 0 48699 Sub-Total 0 36559 37833 39239 17441 131072 D. Technical Assistance VNU 86254 0 0 0 0 86254 Total INVESTMENT COSTS 116854 1031431 1444711 601446 89037 3283479 II. RECURRENT COSTS A. Goverranent contribution 367200 381888 397164 413050 429572 1988874 Total RECURRENT COSTS 367200 381888 397164 413050 429572 1988874 Total 484054 1413319 1841875 1014496 518609 5272353 11/3/1993 11:51 El 0) COIiOROS POPUULATION AND HUl4AN RESOURCES DEVELOPMENT Project Cost Estimates Table 40. Family Plaming Program Detailed Cost Table FC Totals Including Contingencies Quantity Unit Cost Base Costs in SUS SOS 01-05 Total 1-05 01 02 03 04 05 Total 01 02 03 04 05 Total 1. INVESTMENT COSTS A. Equipment IEC - - - 0 15000 0 0 0 15000 0 15615 0 0 0 15615 Contraceptives - - - 0 30000 0 0 0 30000 0 31229 0 0 0 31229 Sub-Total 0 45000 0 0 0 45000 0 46844 0 0 0 46844 B. Training IEC foreign - - - 0 0 18000 0 0 18000 0 0 19457 0 0 19457 IEC local - - 0 3000 6000 0 0 9000 0 3134 6486 0 0 9619 Foreign - - - 0 30000 30000 30000 0 90000 0 31336 32429 33633 0 97398 Local - - - 15000 15000 15000 0 0 45000 15209 15668 16214 0 0 47091 Sub-Total 15000 48000 69000 30000 0 162000 15209 50138 74586 33633 0 173566 C. Technical Assistance IEC study - - - 0 10000 0 0 0 10000 0 10468 0 0 0 10468 IEC surveys - - - 0 15000 10000 0 0 25000 0 15702 10840 0 0 26542 IEC other - 0 0 15000 0 0 15000 0 0 16260 0 0 16260 Sub-Total 0 25000 25000 0 0 50000 0 26169 27101 0 0 53270 Total INVESTMENT COSTS 15000 118000 94000 30000 0 257000 15209 123151 101687 33633 0 273680 Total 15000 118000 94000 30000 0 257000 15209 123151 101687 33633 0 273680 11/3/1993 11:52 00 0< COMOROS POPULATION AND HUMAN RESOWRCES DEVELOPMENT Project Cost Estimates Table 50. STD/AIDS Programs Detailed Cost Table FC Totals Including Contingencies Ouantity Unit Cost Base Costs in SUS Sus 01-05 Total 1-05 01 02 03 04 05 Total 01 02 03 04 05 Total I. INVESTMENT COSTS A. Equipment IEC - - - 0 15000 0 0 0 15000 0 15615 0 0 0 15615 Diagnostic - - - 0 23000 0 0 0 23000 0 23942 0 0 0 23942 Suppties & reagents - - - 0 40000 40000 37000 0 117000 0 41639 43043 41268 0 125950 Sub-Total 0 78000 40000 37000 0 155000 0 81196 43043 41268 0 165507 B. Technical Assistance IEC surveys - - 0 10000 10000 10000 10000 40000 0 10468 10840 11247 11670 44225 IEC research - 0 5000 5000 0 0 10000 0 5234 5420 0 0 10654 IEC other - - 15000 0 0 0 0 15000 15221 0 0 0 0 15221 Sub-Total 15000 15000 15000 10000 10000 65000 15221 15702 16260 11247 11670 70100 C. Training IEC foreign - - - 8000 0 0 0 0 8000 8111 0 0 0 0 5111 IEC local - - - 0 6000 0 0 0 6000 0 6267 0 0 0 6267 Foreign - - - 0 10000 45000 0 0 55000 0 10445 48643 0 0 59088 Sub-Total 8000 16000 45000 0 0 69000 8111 16713 48643 0 0 73467 Total INVESTMENT COSTS 23000 109000 100000 47000 10000 289000 23333 113610 107947 52516 11670 309075 Total 23000 109000 100000 47000 10000 289000 23333 113610 107947 52516 11670 309075 11/3/1993 11:52 (D 0 0) COMOROS POPULATION AND HUMAN RESOURCES DEVELOPMENT Project Cost Estimates Table 60. Project Implementation Unit Detailed Cost Table FC Totals Incltuding Contingencies Quantity Unit Cost Base Costs in SUS SUS 01-05 Total 1-05 01 02 03 04 05 Total 01 02 03 04 05 Total 1. INVESTMENT COSTS A. Civil Works - - 20000 0 0 0 0 20000 20400 0 0 0 0 20400 B. Training Foreign - - - 10000 10000 0 0 0 20000 10139 10445 0 0 0 20584 C. Equipment Repinfovehfurn - - - 80000 0 0 0 0 80000 81006 0 0 0 0 81006 Total INVESTMENT COSTS 110000 10000 0 0 0 120000 111545 10445 0 0 0 121991 II. RECURRENT COSTS A. Operatin costs - - - 80000 80000 80000 80000 80000 400000 81600 84864 88259 91789 95460 441972 Total RECURRENT COSTS 80000 80000 80000 80000 80000 400000 81600 84864 88259 91789 95460 441972 Total 190000 90000 80000 80000 80000 520000 193145 95309 88259 91789 95460 563962 11/3/1993 11:52 0C 0 COMOROS POPULATION AND HUMAN RESOURCES DEVELOPMENT Project Cost Estimates TabLe 70. CDSF Adninistration Detailed Cost Table FC Quantity Unit Cost Base Costs in SUS 01-05 Total 1-05 01 02 03 04 05 Total 11. RECURRENT COSTS A. Adninistration CDSF administration - - - 215000 215000 215000 215000 215000 1075000 TaRUE.S 5 215000 215000 215000 215000 10--000 Total RECURRENT COSTS 215000 215000 215000 215000 215000 1075000 Total 215000 215000 215000 215000 215000 1075000 11/3/1993 11:52 00 0< S h c: COMOROS POPULATION AND HUKAN RESOURCES DEVELOPMENT Project Cost Estimates Table 70. CDSF Achninistration Detailed Cost Table FC Totals Including Contingencies SUS 01 02 03 04 05 Totat 11. RECURRENT COSTS A. Acdninistratlon CDSF administration 219300 228072 237195 246683 256550 1187800 Totl ECURET CST 2130 228072--- 237195--- 246683-- 256- 1 Total RECURRENT COSTS 219300 228072 237195 246683 256550 1187800 Totat 219300 228072 237195 246683 256550 1187800 11/3/1993 11:52 a) O C COMOROS POPULATION AND HUMAN RESOURCES DEVELOPMENT Project Cost Estimates Table 80. CDSF Sub-Projects Detailed Cost TabLe FC Quantity Unit Cost Base Costs in SUS 01-05 Total 1-05 01 02 03 04 05 Total 1. INVESTMENT COSTS A. Sub-projects CDSF sub-projects - - - 500000 1100000 1100000 1100000 1100000 4900000 Govt & Cmmnty Participatn - - - 115000 200000 200000 200000 200000 915000 Sub-Total 615000 1300000 1300000 1300000 1300000 5815000 Total INVESTHENT COSTS 615000 1300000 1300000 1300000 1300000 5815000 Total 615000 1300000 1300000 1300000 1300000 5815000 11/3/1993 11:52 00 CO, 0< FH COYOROS POPULATION AND HUMAN RESOURCES DEVELOPMENT Project Cost Estimates Tabte 80. CDSF Sub-Projects Detailed Cost Table FC Totals Including Contingencies SUs 01 02 03 04 05 Total 1. INVESTMENT COSTS A. Sub-projects CDSF sub-projects 509023 1161142 1205698 1252836 1301822 5430522 Govt & Cmmnty Participatn 117300 212160 220646 229472 238651 1018230 Sub-Total 626323 1373302 1426344 1482308 1540473 6448751 Total INVESTMENT COSTS 626323 1373302 1426344 1482308 1540473 6448751 Total 626323 1373302 1426344 1482308 1540473 6448751 11/3/1993 11:52 03 OCl 0 COMOROS POPULATION AND HUMAN RESOURCES DEVELOPMENT Project Cost Estimates Table 90. Project Preparation Facility Detailed Cost Table FC Totals Including Contingencies Quantity Unit Cost Base Costs in SWS SUs 01-05 Total 1-05 01 02 03 04 05 Total 01 02 03 04 05 Total -- - - , - - .. ... .... -- - - - - -- - - - - - -- - - - - -- - - - - - -- - - - - -- - - - - - -- - - - - -- - - - - - -- - - - - - 1. INVESTMENT COSTS A. PPF PPF - - - 800000 0 0 0 0 800000 812850 0 0 0 0 812850 TotaL INVESTMENT COSTS 800000 0 0 0 0 800000 812850 0 0 0 0 812850 =======Z ======== Z======= ======== ======== ======== ======== ======== ======== ======== ======wt w=====rs Total 800000 0 0 0 0 800000 812850 0 0 0 0 812850 11/3/1993 11:52 OD 00 cn '-1 H O q 86 ANNEX V Page 1 of 1 ESTIMATED SCHEDULE OF DISBURSEMENTS QUARTER DISBURSEMENTS | ACCUMULATED DISBURSED l_________________ ______________I_ DISBURSEMENTS |_ % FY94 March 31, 1994 0.4 0.4 3 June 30, 1994 0.4 0.8 3 FY95 September 30, 1994 0.5 1.3 4 December 31, 1994 0.6 1.9 5 March 31, 1995 0.7 2.6 5 June 30, 1995 0.7 3.3 5 FY96 September 30, 1995 0.7 4.0 5 December 31, 1995 0.8 4.8 6 March 31, 1996 1.0 5.8 8 June 30, 1996 1.0 6.8 8 FY97 September 30, 1996 1.0 7.8 7 December 31, 1996 0.8 8.6 6 March 31, 1997 0.7 9.3 5 June 30, 1997 0.6 9.9 5 FY98 September 30, 1997 0.6 10.5 5 December 31, 1997 0.6 11.1 5 March 31, 1998 0.5 11.6 4 June 30, 1998 0.5 12.1 4 FY99 September 30, 1998 0.5 12.6 4 December 31, 1998 0.4 13.0 3 87 ANNEX VI Page 1 of 4 PERFORMANCE INDICATORS: HEALTH COMPONENT I. Indicators of Activity Value at start Value at Value at (1991) mid-point end (1999) l___________ (1996) 1. Total number of outpatient visits per year 850000 2. Medication distributed annually by public 70,20 145,75 establishments (value in FC millions) 3. Contraceptives other than condoms 7131 17490 distributed annually by the FP program (couple- years of protection) 4. Condoms distributed per year (thousands of 287,897 600 1200 units) 5. Doses of vaccine administered annually by 126 the EPI program (thousands of doses) 6. Pre-natal consultations per year 20442 68000 7. Births correctly assisted per year 5780 20000 8. Consultations/visits for family planning per 18253 30000 50000 year 10. Number of HIV tests performed per year 25000 11. Number of human treponema palladium 25000 type A tests performed per year 12. Cumulative number of health facilities made 0 3 5 functional under the project (minimum) 13. Cumulative number of higher level staff of the 0 50 80 MSPP trained under the project l 14. Cumulative number of health workers of the 0 75 150 MSPP trained locally under the project 15. Cumulative number of participant-days 0 500 750 provided in seminars financed by the project l 16. Cumulative number of health facilities 0 3 5 rehabilitated by the project (minimum) 17. Cumulative number of functioning regional 0 3 3 health teams 88 ANNEX VI Page 2 of 4 I. Indicators of Achievement Value at Value at Value at start mid-point end 1. Percentage of required reports actually received 90 95 and correctly drawn up . - 2. Percentage of supervision visits performed 75 90 relative to norms and provisions of MSPP 3. Number of new consultations per resident 0,5 1 2 per year 4. Percentage of pregnancies correctly 46,6 60 90 monitored 5. Percentage of births correctly attended 27.2 40 60 6. Percentage of children correctly vaccinated 84,96 95 7. Percentage of people over age 14 who have 90 heard of AIDS 8. Percentage of people over age 14 who have 90 heard of family planning 9. Percentage of adults (over 15 years) who know 90 the 3 means of transmission of AIDS 10. Percentage of adults (over 14 years) who know 90 how to effectively protect themselves against AIDS 11. Number of active users 3384 20000 12. Annual consumption of contraceptives (number 7,42 12 18 of couple-years of protection per 100 women aged 15 to 49 years). 89 ANNEX VI Page 3 of 4 III. Indicators of Impact Value at Value at Value at start mid-point end 1. Gross mortality rate (per 1000 population) 13,6 10 2. Maternal mortality (per 10000 pregnancies) 460 100 3. Infant mortality rate (per 1000 live births) 91.9 60 4. Under-five mortality rate (per 1000) 131.2 75 5. Mean birth interval (months) 36 6. Global fertility rate 216,2 110 7. Number of high risk pregnancies per 1000 25 women age 15 to 45 (per year) l 8. Number of cases of neo-natal tetanus 10 9. Number of deaths from malaria among children 2200 700 aged less than 5 years l 10. Number of deaths from diarrheal diseases 1800 600 among children aged less than 5 years l 11. Annual growth rate of HIV seropositivity among 0 pregnant women 12. Seropositivity rate for human treponema 22,1 2 palladium type A among pregnant women If 13. Contraceptive prevalence rate (according to 3,2 7 10 survey) 90 ANNEX VI Page 4 of 4 Indicators of Performance of the FADC The performance of the FADC will be evaluated every three months, in particular at the end of each fiscal year, based on the indicators of performance established in the light of the results obtained during the preparation of the project. These indicators translate, depending on the sector of intervention, into numbers of classrooms rehabilitated or constructed (education); the number of beneficiaries of water supply and rural roads projects (social infrastructure); the number of medical visits at the level of remote villages (primary health care); the number of women benefitting from literacy programs and other training for the promotion of women (women in development). Furthermore, indicators were also agreed for the evaluation of the FADC in other ways, such as (i) the effect of capacity building efforts at the village level, in particular in terms of the number of village steering committees trained in administrative and financial project management; (ii) the improvement of the techniques of local labor, through the introduction of improved techniques in the sub-projects of the FADC. Results expected at the end of each year are the following: (a) education: 3,000 students benefiting from 35 to 40 rehabilitated classrooms; (b) water supply: 10,000 beneficiaries; (c) health care: 40,000 health care visits; (d) women in development: 4,000 women trained in literacy, childcare, nutrition, and artisanry; (e) roads and bridges: 2,000 people; (f) management strengthening: 40 steering committees trained in project management; (g) human resources: 800 people trained in different professions. The management capacity of the FADC will also be evaluated, based on the following annual indicators: (a) ability to assist the preparation and implementation of sub-projects: 50 sub- projects approved and 40 sub-projects completed; (b) popularisation campaigns: training of 30 steering comrnittees; (c) sustainability of the interventions of the FADC: 20 steering committees still in operation after the completion of sub-projects, as measured by the creation of a maintainance fund, and by the constitution of units responsible for the maintainance of the works completed; (d) participation of other donors in sub-projects; (e) training of local NGOs working in the fields of literacy and women in development (3 NGOs per year). 91 ANNEX VII Page 1 of 1 SUPERVISION PLAN Approximate Date Activity Staff 05/94 Project Launch and Project Supervision E, IS, SFS, PHS, CDS, FA, JECS 09/94 Supervision mission E, IS, CDS, PHS 03/95 Supervision rmission E, CDS, HFS 07/95 Supervision rmission (annual review) E, IS, CDS, PHS, SFS 01/96 Supervision mission E, CDS, PHS 06/96 Joint Bank/Governnent Mid-Term review E, IS, CDS, PHS, HFS, SFS, FA, JECS 10/96 Supervision mission E, CDS, PHS 02/97 Supervision mission E 06/97 Supervision mission (annual review) E, IS, CDS, PHS 10/97 Supervision mission E, CDS, PHS 02/98 Supervision rnission E 09/98 Final supervision mission E, IS, CDS, PHS E = Economist (task manager), IS = implementation specialist, PHS = public health specialist, FA = financial analyst, SFS = social fund specialist, IECS = specialist in information, education and communications, CDS = community development specialist, HFS = health financing specialist. Expected staff inputs represent 75 sw broken down as follows: 20 in 1994, 15 in 1995, 20 in 1996 and 10 in 1997 and 1998. This does not include the TM's desk work. Due to the implementation record in Comoros and the fact that there is no resident mission in Comoros which can maintain contact with the project, supervision missions are correspondingly heavy. 92 ANNEX VIII Page 1 of 1 SELECTED DOCUMENTS IN THE PROJECT FILE 1. Preparation report of the Government for the health component, prepared by the consultants Association Sante-International (ASI). Five volumes: - General presentation and executive summary - The health system - Financial and administrative management - Equipment needs - Civil works needs 2. Interministerial Order of December 21 1992 concerning an autonomous regime of management of receipts and expenses in hospitals. 3. Tripartite review of Mitsoudje Pilot Project between the Government of Comoros, UNDP and ASI, January 1993. 4. National plan for development in health: perspectives for the year 2000, MOH, March 1991, Moroni. 5. Operational Manual of the CDSF (AF3PH division files) 6. Said Islam Moinaecha Mroudjae and Sophie Blanchy: The status and situation of women in the Comoros, UNDP, March 1988, Moroni. 7. Women in Comoros, CECI 8. Notes on poverty in Comoros (AF3PH division files) 9. Decree of January 6, 1993 concerning the creation of the CDSF and its administrative structures; and that of April 23, 1993 concerning its organization and operations. 93 ANNEX IX Page 1 of 4 THE PILOT EXPERIENCE AT MITSOUDJE HEALTH CENTER 1. The project consists of the construction and equipment of a health center, the installation of a system of management to ensure the operating costs of the center, and the elaboration of a model of health services that could be reproduced in other areas. Money was raised in the community for the construction of the facility, and UNDP has provided major assistance. The French NGO ASI has been engaged for technical assistance. The project is to run three years of which 2 are completed. A review was conducted in January 1993, the report of which is in the project files. 2. The center, located on the island of Grand Comore in the relatively wealthy village of Mitsoudje, includes services of external consultation, MCH/FP, EPI, laboratory, dentistry as well as hospitalization for observation. As the center is about 40 minutes away from Moroni by car, serious cases are evacuated to the hospital there, as are radiology requests. 3. All services are paying, except for vaccinations. Surveys were conducted in the local area to determine what the rates should be. For instance, the rate of FC200 to see a nurse (triage) was fixed to equal the cost of the taxi fare to Moroni where treatment would be free at a regular clinic. The tariff is shown below: Consultation triage 200 physician (direct) 1,000 emergency 500 Care emergency 1,000 injections 100 dressing 1,000 incision 1,500 circumcision 3,000 Laboratory (depending on 500 exam) 1,000 1,500 Dental care 1st cons. 1,000 2nd cons. 500 Hospitalization 1,000 Childbirth 1,500 Prenatal cons. 500 Evacuations 1,500 94 ANNEX IX Page 2 of 4 There is no formal system of fees for the indigent. This will depend on the discretion of the staff, and rebates are rare. All receipts are retained at the facility level. 4. Drugs are supplied through a village pharmacy installed within the center. Patients must pay for their drugs, as with all other pharmacies in Comoros. Review of the system shows that patients spend on average FC 900 per prescription and that virtually no patients were unable to fulfill this prescription (either through lack of money or due to lack of stock in the pharmacy). However, a problem noted in the report is that the margin allowed by the PNAC (20%) does not cover all the center's costs in running the pharmacy, and discussions are under way regarding the possibility of increasing this margin. 5. When setting up the center, the project also conducted surveys in the area on what the population expected from their health center. One important complaint about public health services is that the patients are treated impolitely. Therefore at Mitsoudje, care was taken to train all the staff in patient relations. Reception staff in particular are evaluated on their courtesy. When the center was first in operation, a "greeter" was posted at the reception to explain to newcomers the philosophy of service and cost recovery. 6. Management of the center is shared by a committee of local residents, and by the doctor. Other than requiring conformity with standards for a health center, the Ministry of Health has very little involvement in the operation of the facility. 7. Staff in the center consist of 18 civil servants and 3 unskilled staff hired contractually by the center. The doctor is on detachment from the government service, and is paid by the project at a rate about twice that of doctors in the Ministry of Health. In addition to their regular salaries, staff receive a "prime" based on their individual performance and on the receipts on the center. This prime averaged about 25% of their salaries in January 1993. The center also has the right to return to the public service any employees who do not meet the standards of their work. This has already occurred twice. 8. The results: The center became operational in April 1992. Consequently, definite conclusions are premature. However, important initial reactions were reflected in the evaluation report and confirmed by the officials of the Ministry of Health. 9. Financially, the center is doing very well. Receipts have been rising about 10% per month and have reached over FC1 million for the month of January 1993. About 30% of receipts come from direct consultations with the doctor (bypassing the triage stage). This amount will enable the center not only to cover all recurrent costs but also to establish a reserve for minor and major maintenance and equipment purchase. The budget of the health center (proposed 1993) is attached. Although the salary of the doctor is at present paid by UNDP, the center expects to be able to fully make up the difference from the receipts once the doctor reverts to the public service at the end of the project in 1994. 10. Satisfaction with the services provided is indicated by the steady and continuing rise in utilization and by the fact that at present (early 1993) about half of all patients come from outside the catchment area of the center. This demonstrates the willingness and ability of the population of Grande Comore to pay for services that are perceived to be of high quality and reliable. Note: if all health centers were similarly improved, Mitsoudje would lose some of these clients, reducing the efficiency of its services and receipts, especially in dentistry. 95 ANNEX IX Page 3 of 4 11. Although the center now sees significantly more patients than most health centers in Comoros, and this number continues to increase, the total utilization has not yet achieved more than a relatively low level of utilization relative to population (about one visit per year per person in the catchment area), and only about a quarter of childbirths take place in the center. There is no system of house calls by center staff. The bed occupancy rate is very low (about 10%). The center appears, like many in Comoros, to be oversized and possibly overstaffed. 12. The report comments that Mitsoudje remains, like most health centers, isolated from the levels above and below it. It does not have technical supervision from above, nor does it supervise the 2 health posts in its area. Feedback on referrals is poor between the health center and the hospital. 13. Some lessons: (1) Local surveys and extensive training were important in providing the center with policies and skills that are suited to their local environment. (2) Real results are achievable, but the time taken may be longer than expected. 14. Some caveats: (1) Not all communities are as financially able as that of Mitsoudje, and tariffs must be set at the facility level to adjust for this. Consequently, the government must keep an eye on where subsidies are needed, especially for major maintenance and investment. (2) Not all communities are as cohesive as those of the Grande Comore. More time and effort may be required on the other islands to bring the community into the management of the centers. (3) The presence of a doctor has been very important for the credibility of the services. Not all health centers at present have a doctor. (4) The centers must have real responsibility over personnel, as is the case at Mitsoudje. (5) A good quality facility manager is very important, and most in place would need significant retraining to fulfill this task. At Mitsoudje the manager is a qualified accountant, but this is not considered necessary. 96 ANNEX IX Page 4 of 4 BUDGET PROVISIONS FOR 1993 MITSOUDJE HEALTH CENTER (FC) Budget items State Total including Fees Pharmacy WFP project Staff expenses -Staff of the Ministry of Health 9,820,000 9,820,000 (doctor included) -Transportation 4 680,000 4.680,000 -Local salaries 420,000 420,000 -ASCSM staff 960,000 960,000 -Receptions 420,000 420,000 Supplies -Medical supplies 1,500,000 1,500,000 -Other supplies 480,000 166,000 312,000 (fuel, maintenance) -Support to management 600,000 150,000 450,000 -Outside services 60,000 60,000 -Electricity 1,300,000 1,300,000 -Food supply 200,000 200,000 Maintenance/working equipment -Automobiles 300,000 300,000 -Fixed assets 300,000 300,000 -Rehabilitation 250,000 250,000 -Technical material 200,000 100,000 100,000 Sub-total Administrative expenses 21,490,000 11,786,000 8,542,000 960,000 200,000 Capital expenditures New fixed assets 720,000 144,000 576,000 Provision for major repairs 4,875,000 3,875,000 1,000,000 Automobile 2,400,000 2,400,000 Sub-total Capital expenditures 7,995,000 4,019,000 3,976,000 Grand total Administrative expenses + capital expenditures 29,485,000 15,805,000 12,518,000 960,000 200,000 97 ANNEX X Page 1 of 3 HEALTH COMPONENT: ACTIVITY IMPLEMENTATION SCHEDULE ACTIVITY YR -1 YR 1 YR 2 YR 3 YR 4 STRENGTHENING OF MOH EFFICIENCY Appointment of Project Office Staff X members by MOH Minister in agreement with IDA Appointment of DHE Staff members by X MOH Minister Definition of DHE coordinating X mechanisms by MOH with support from Technical Assistance Appointment of Regional Health Team X Staff members by MOH for a 5 year contract Training of a DHE Staff member as IEC trainer Training of 3 MOH Staff in IEC X Training of 15 MOH cadres in the X X X management of Public Health programs Training of 5 MOH cadres as X Executives Secretariats, 2 for MOH central directions and 3 for Regional Health Teams Training of 27 MOH cadres in the X management of health programs. Elaboration of documents on MOH X norms and procedures and on Pharmaceutical Legislation with support from Technical Assistance Elaboration of MOH therapeutical X protocols, with support from Technical Assistance Organization of 5 workshops on MOH X objectives and strategies for a total of 210 participants-days 98 ANNEX X Page 2 of 3 ACTIVITY YR -1 YR I YR 2 YR 3 YR 4 Training of 3 Regional Medical X Officers in Health District Management Training of 2 nurses per each of the 3 X X Health regions in the management of Health District Training of 3 accountants for the 3 X Regional Health Teams (RHT) Provision of equipments to 3 RHTs and X MOH Central Directions Promulgation of texts on autonomy of X health facilities by the Head of State. Physical rehabilitation of Hombo X hospital Physical rehabilitation of Fomboni X Hospital Physical rehabilitation Sima Health X Center Physical rehabilitation of Moroni X Health Center Physical rehabilitation of Foumboni X Health Center Provision of equipments and seed X money to the 5 health facilities rehabilitated under the Project Training of 5 cadres in Hospital X X Administration Training in Comoros of 15 managers of X X Health Centers Supervision of RHTs by the Staff from X--- ---- ---- ----X MOH central directions Supervision of health facilities by RHT X- ---- ---- ----X Staff 99 ANNEX X Page 3 of 3 ACTIVITY YR -1 YR 1 YR 2 YR 3 YR 4 PROMOTING FP ACTIVITIES Organization of workshops on FP for X X X X leader and the general public to a total of 1800 participants-days Realization of 3 studies/surveys in the X X field of FP Training of 3 physicians and 6 nurses X X X in FP technic Training in Comoros of 150 health X X X workers in FP technic Delivery of equipments to MOH X Direction of Maternal and Child Health Provision to DMCH of an amount of X X X X money equivalent to US$3,000 as a contribution to the direction's recurrent costs SUPPORT TO THE NATIONAL AIDS CONTROL PROGRAM Organization of workshops on AIDS X X X X for the general public to a total of 2000 participants-days Realization of 5 transversal surveys in X X X X the field of AIDS Training of a Staff member of the X National AIDS Control Committee Elaboration of STD therapeutical X protocols Delivery of standard equipment X required for laboratory work to 20 MOH laboratories Provision of reagents and other X X X X commodities required for laboratory work on STDs to 20 laboratories Training of 3 lab technicians in STDs X X and AIDS 100 ANNEX XI Page 1 of I COMOROS DEMOGRAPHY AND HEALTH RESOURCES. 1991 FIRC Grande Anjouan Moheli Comore POPULATION Total population 476.059 259.425 193.157 23.477 Under 5 population 84.262 45.918 34.189 4.155 Women aged 15 - 49 106.637 58.111 43.267 5.259 HEALTH FACILITIES Health Posts 55 29 18 8 Health and Medical Centers 15 4 7 2 Rural Maternities 4 2 1 1 Hospitals/Surgical clinics 5 2 2 1 PERSONNEL Comorian Physicians 22 14 7 1 Expatriate Physicians 31 16 11 4 Midwives (total) 75 52 16 7 Midwives (who have undergone a 46 23 16 7 specific training in Family Planning either in or outside Comoros) Nurses 131 86 57 4 Technicians 48 20 22 6 Health Auxiliaries 560 262 220 78 Sources: MSSP, Memento des Statistiques Sanitaires et Demographiques, 1991. ANNEX XWI 101 Page 1 of 6 REPUBLIQUE FEDERALE ISLAMIQUE . - DES COMORES ----------- Moroni, le . MINISTERE DE LA SANTE PUBLIQUE A l'attention de Monsieur Fransisco Aguirre-Sacasa Directeur du Departement IlIl R6gion Afrique, Banque Mondiale Washington D.C. Objet: Politique de d6veloppement Sanitaire aux Comores Monsieur le Directeur, 1. J'ai l'honneur de porter a votre connaissance par la pr6sente, les politiques et les strat6gies que le Gouvernement de la Republique F6d6rale Islamique des Comores entend poursuivre afin d'accro?tre l'efficacit6 des actions men6es dans les domaines de la Sante et de la population. 2. Depuis son accession a la souverainete internationale en 1975, le pays s'est fixe comme objectif d'assurer un niveau acceptable de soins de sante pour tous ses habitants. La politique sanitaire des dix dernieres ann6es a et6 ax6e sur les soins de sante primaires, mettant I'accent sur la disponibilit6 A 1'6chelon le plus periph6rique, d'un ensemble de services de sant6 prioritaires. Ainsi, conform6ment A 1'esprit de la declaration d'Alma-Ata, nos efforts ont-ils privilegie (a) I'immunisation de tous les enfants contre les six maladies cibles du Programme Elargi de Vaccinations, (b) La disponibilit6 et I'accessibilite universelle aux medicaments essentiels sur tout le territoire, (c) la surveillanc6 correcte des grossesses et des accouchements, (d) I'accbs aux m6thodes modernes d'espacement et de controle des naissances et (e) La prevention, la surveillance et le controle des principales endemies, et epid6mies, notamment le paludisme a Plasmodium Falciparum, la filariose et les maladies sexuellement transmissibles y compris le SIDA. 3. Malgre des succes signicatifs et I'appui important d'organismes d'assistance et de bailleurs de fonds de la communaut6 internationale (PNUD, OMS, UNICEF, FNUAP, CEE, COOPERATION FRANCAISE, APEFE, CARE, LIGUE ISLAMIQUE, BANQUE MONDIALE, BANQUE AFRICAINE DE DEVELOPPEMENT, etc.. .la Republique Fed6rale Islamique des Comores doit deployer des efforts additionnels afin d'atteindre l'objectif de la sante pour tous, mentionne plus haut. Les taux de mortalite se trouvent encore a des niveaux inacceptables. La situation qui prevaut a l'heure actuelle est caracteris6e par la precarit6 de 1'etat de sante des populations, notamment des femmes en age de procreer et des enfants. La pathologie demeure dominee par le paludisme, les infections respiratoires aigues, les maladies diarrheiques, les maladies sexuellement transmissibles, ainsi que par d'autres maladies infectieuses et parasitaires. Les difficult6s socio-6conomiques du pays aussi bien que l'organisation et le fonctionnement du systeme de sante limitent l'acces des groupes A risque aux soins primaires de bonne qualit6. 102 ANNEX XII Page 2 of 6 - Plan National de Developpement Sanitaire. 4. Depuis mai 1991, le pays s'est dote d'un Plan Sanitaire qui definit les grandes orientations et les axes prioritaires de la politique Sanitaire dans la perspective de l'an 2000. Les activites et les programmes prioritaires poursuivront les memes objectifs que par le pass6, a savoir: la promotion par l'information,l1'ducation et la communication, des comportements favorables a la sante, la prestation des services de sant6 maternelle et infantile, y compris les vaccinations, la surveillance pr6- et peri-natale et la planification familiale, la lutte contre les eridemies et les 6pidemies, en particulier le paludisme, les infections respiratoires aigues, les maladies diarrh6iques, les maladies sexuellement transmissibles et le SIDA; et enfin l'approvisionnement et la fabrication locale de medicaments essentiels, notamment par le d6veloppement du reseau des pharmacies mises en place selon la strategie de l'lnitiative de BAMAKO. 5. Toutefois, la forte croissance demographique des Comores et la structure de la population (le rapport d'age est tr6s d6plac6 au ben6fice des classes d'fge les plus jeunes) requierent une attention toute particuliere car ils soulevent des problemes sp6cifiques dans l'organisation des services et en matiere d'education pour la sant6: on pensera en particulier aux complications sanitaires dont souffrent beaucoup de femmes en age de procreer ( trop d'enfants, trop rapproches, meres trop jeunes ou au contraire trop agees.) Nous d6velopperons donc des efforts particuliers dans le secteur de la planification familiale et de la population, appuyes dans notre action. Notre strategie en la matiere s'organisera selon deux axes: I'IEC, cibi6e sur des groupes sensibles ( femmes de 15 a 49 ans et leurs maris, jeunes, leaders d'opinions) sera renforcee et 61argie; I'accbs aux m6thodes modernes d'espacement de controle des naissances et aux fournitures correspondantes sera g6neralise. Notre objectif est d'ameliorer le taux actuel d'utilisation des moyens modernes de regulation et de parvenir a un taux de 20% d'utilisatrices/ utilisateurs en I'an 2000. - R&organisation du systeme de sant6 6. Au terme d'une periode de plus de quinze ann6es, les responsables politiques du pays ont duj prendre acte d'une evolution irreversible de la demande de soins , de pr6vention des maladies et de protection de la sante. L'augmentation continue des depenses de sante, la volont6 et la capacite de participation de la population a la resolution des problemes de sante impose une profonde et rapide reorganisation du systeme comorien.Pour des raisons qui tiennent a la fois des choix de societ6 effectues en R6publique Federale Islamique des Comores et des capacit6s 6conomiques et sociales du pays, il est devenu evident qu'au cours des prochaines annees, la politique nationale de la sante devra s'appuyer sur le developpement concerte du secteur public, du secteur prive, et communautaire meme si le secteur public a pour mission de constituer toute l'armature du systeme. 7. Afin de faciliter la mise en oeuvre de ce developpement, le Gouvernement a decid6 d'initier un ensemble de reformes institutionnelles qui concernent tous les niveaux de notre systeme sanitaire. Son objectif est d'offrir a 1'ensemble de la population l'acces a des soins de qualite et a une protection toujours efficace, associant les possibilit6s combin6es d'une accessibilite g6neralis6e independamment des ressources et du statut social d'une part, et d'un libre choix 6ventuel a l'initiative de l'utilisateur, d'autre part. 103 ANNEX XII Page 3 of 6 Une ioi-cadre permettra de d6finir les conditions dans lesquelles les secteurs publics, priv6 et communautaire pourront s'organiser et se d6velopper en foncion des besoins et des moyens du pays. 8. Pour assurer un developpement coh6rent du secteur priv6, et communautaire I'ETAT mettra en place les organismes professionnels charg6s d'organiser et de contr6ler la pratique priv6e des professions m6dicales ( medecins, sages- femmes, infirmieres, pharmaciens, para-medicaux) et 6tablira les regles regissants les autorisations des installations, des constructions et des equipements. 9. Pour ce qui concerne le secteur public, la strat6gie d6veloppee mettra un accent particulier sur l'amelioration de la qualit6 des services fournis a la population. Elle impliquera: (a) la rehabilitation des structures sanitaires, (b) la fourniture d'equipements et de materiels essentiels pour garantir la coherence et la continuit6 des services prioritaires, (c) ia formation pertinente et la r6partition adequate des personnels de sant6 et (d) la mise en place de proc6dures de suivi et d'6valuation des activit6s sur le terrain. La mise en oeuvre de cette strat6gie n6cessitera un recours plus important au financement exterieur mais elle permettra d'assurer une meilleure protection de la population et de maintenir, voire de restaurer sa confiance dans un systeme qui joue un r6le essentiel dans le d6veloppement du bien-etre economique et social du pays. (e) -Le maintien de la carte sanitaire actuelle et l'interdiction de toute construction de nouvelle formation Sanitaire avant l'an 2000. - Reforme institutionnelle et statutaire du secteur oublic 10. Pour parer aux graves difficuites de fonctionnement qui se sont manifest6es ces dernieres annees dans le secteur public,et pour lui donner toute la souplesse de fonctionnement et d'adaptation n6cessaire a une evolution rapide de la demande et des techniques, le Gouvernement a entrepris une profonde r6forme institutionnelle et statutaire de ce secteur.D'une maniere gen6rale, un accent particulier est mis sur la rationalisation du systeme sant6 et sur l'adaptation du secteur public aux realit6s demographiques et socio-economiques regionales. A cet effet, les services et les structures de soins et de prevention relevant du Ministere de la Sant6 Publique seront replaces dans un dispositif pyramidal hi6rarchise ou les services de sant6 periph6riques seront etablis a partir du Centre de Sant6 de district, veritable f6derateur des activit6s sanitaires effectuees par lui et par les postes de Sante qui lui seront r6f6r6s, y compris la distribution des m6dicaments reconnus essentiels. Chacun des centres de sant6 de district sera lui-meme r6f6re pour ses activit6s m6dicales et soignantes au centre hospitalier Regional (CHR) situe dans le chef-lieu de sa region, et son action sanitaire sera coordonnee avec celles des autres centres de sant6 de la region par l'interm6diaire des structures relevant de la direction Regionale de la Sant6 et des Affaires Sociales. ANNEX XII Page 4 of 6 11. Dans le souci d'accro^tre la rentabilite des moyens mis en oeuvre et conformement a l'esprit de la Declaration d'Alma-Ata, le Gouvernement organisera l'offre des services sur le principe de l'integration des activites des programmes verticaux nationaux, en remplacant progressivement les equipes mobiles par des elements polyvalents et integres au sein des 6quipes chargees du fonctionnement des services de sante peripheriques. 12. La distribution des soins de sante par le secteur public s'appuiera sur une responsabilisation accrue des cadres de la sante et des communaut6s et sur une participation directe a la gestion des structures, ainsi que sur un dispositif de financement combinant des ressources locales, nationales et eventuellement exterieures a des financements assures sur le budget de l'Etat. Les 6l6ments critiques essentiels de cette participation communautaire seront la decentralisation, I'intensification des activites d'information, d'education et de communication a tous les niveaux, la generalisation du principe du recouvrement des couts, la dotation de toutes les formations sanitaires d'une autonomie de gestion financiere et administrative avec integration des representants des communautes dans les instances de d6liberation et de d6cision. 13. Les formations sanitaires seront dotees d'un statut et d'un ensemble d'instruments juridiques conformes a leurs missions et a l'exercice de cette autonomie. La volonte d'etablir et de garantir l'efficacite de la gestion des centres hospitaliers regionaux se materialisera notamment par leur transformation en Etablissements Publics Hospitaliers dotes de la personnalite morale, conformes aux dispositions des textes legislatifs en vigueur. Ces etablissements seront dotes d'un Conseil d'Administration qui assurera le contr6le direct du fonctionnement et de l'usage des ressources allouees et de recettes apportees par la tarification officielle des actes effectues. Ces conseils seront composes de trois categories de membres, a savoir: des representants des collectivites territoriales, des representants des personnels de I'etablissement et des personnalites exterieures reconnues pour leur competence et leur interet dans l'un des domaines touchant au fonctionnement et aux activit6s du centre hospitalier Regional. Les representants regionaux du ministere criarge de la sant6 assisteront aux r6unions du Conseil d'Administration et y feront entendre la voix et les observations du ministere, en particulier en ce qui concernera le budget de fonctionnement, les equipements et la politique de developpement. L'Etat pourra allouer des subventions en particulier pour I'acquisition d'equipements lourds et pour la realisation de travaux d'am6nagement ou d'extension. II participera directement au financement des activites de chaque etablissement hospitalier en mettant a sa disposition, un effectif de personnels agents de l'Etat, de toutes disciplines, places sous I'autorite hierarchique des responsables de la direction du centre hospitalier Regional. Des conventions pourront soutenir la realisation d'activites specifiques a l'etablissement au regard des besoins regionaux ou nationaux. 105 ANNEX XII Page 5 of 6 14. Les Centres de Sante, (CS) les centres medico-urbains (CMU)et les centres medico-chirurgicaux (CMC) se verront dotes dans le meme temps du statut d'Etablissements prives sans but lucratif avec des missions de service public. Confies a des associations sans but lucratif cr6es a cet effet et agr6es par le ministere charg6 de la sante, ces centres disposeront des moyens n6cessaires a leur fonctionnement par le biais de dotation en personnels et en credits provenant du budget de l'Etat et affectes par convention et par le droit a percevoir le montant d'actes tarifes. La gestion des Postes de Sante sera confiee a des associations villageoises de soutien, qui se verront par convention, autoris6es a percevoir le montant d'actes tarif6s pour en couvrir les frais de fonctionnement. La participation de I'Etat, outre la prise en charge eventuelle de travaux de construction ou de rehabilitation, s'exprimera par des moyens affectes au poste au sein du budget du centre de sante de reference. 1 5. Les depenses engag6es par le Gouvernement pour participer au financement de ce dispositif devront se maintenir au niveau r6el des engagements reconnus pour 1992, soit au moins 800 millions de francs Comoriens. 20% au moins de ces engagements devront etre consacres aux depenses non salariales. a partir de 1995 les budgets des formations Sanitaires seront alloues sur la base des contrats existants entre le Ministere de la Sante Publique et les formations sanitaires, et ce en relation avec le programme des d6penses Publiques que le Ministere de la Sant6 Publique 6tablira. 1 6. La mise en place de toutes les reformes mentionn6es ci-dessus n6cessitera la formation en gestion des responsables des etablissements sanitaires et de ceux des niveaux central et regional du Ministere de la Sante Publique. Des m6canismes seront mis en place pour assurer une repartition adequate des cadres form6s et garantir leur motivation et leur stabilit6. 17. Pour r6aliser un tel programme, I'echelon national du Ministere sera restructur6 de facon a lui permettre de: i) renforcer ses capacit6s d'appui aux r6gions sanitaires, ii) developper un systeme d'information sanitaire susceptible d'am6liorer la gestion de programme de sante, ii) mobiliser et coordonner I'aide exterieure pour une meilleure utilisation de ressources sectorielles. 106 ANNEX XII Page 6 of 6 18. A l'echelon regional, la reforme consistera A la mise en place d'une equipe de sante dans chacune des 7ies. Chaque 6quipe sera dirigee par un medecin, directeur regional de la sante, et aura pour taches specifiques de: a) programmer et mettre en oeuvre 1'ensemble des actions de sante au niveau de la region, y compris les activites d'information, d'education et de communication a destination de la population, b) programmer et coordonner les activites A realiser dans les structures de sante peripheriques pour satisfaire aux programmes verticaux nationaux, c) promouvoir et suivre la mise en place des nouvelles dispositions concernant la gestion et le fonctionnement des structures publiques de soins et de prevention, d) veiller au bon fonctionnement de ces structures et y faire connaltre les points de vue, les recommandations et les decisions du Ministere, e) favoriser la concertation locale, regionale et des partenaires sur le fonctionnement et les orientations A donner au developpement du systeme de sant6, en particulier par le biais de Comites locaux et regionaux de Developpement sanitaire. 4{*4*444 19. Nous sommes tout a fait conscients de l'ampleur de la tache entreprise, mais nous y avons ete vivement encourages par les appuis que nous avons recus tant de la part des organismes internationaux qu'auprAs de la population desireuse de voir s'am6liorer et se consolider un systeme de sante pour lequel elle temoigne un attachement constant. Nous ne doutons pas que notre action conduira A une sensible am6lioration de la sante de tous et aux developpements des comportements responsables en matiAre de demographie, de protection de la sante, d'hygiAne de vie et de solidarite nationale. 20. Nous vous prions de bien vouloir agreer, Monsieur le Directeur 1'expression de notre tres haute consideration; Pour le Gouvernement, LE PREMIER MINI STJ - LE MINISTRE,DE;A.SANTE PUBLIQUE CHEF DU GOUVE V . i' T6NTANZANIA 4 heoINS> Grs- s r nand The a s b2°) pev , I 2 wa ,oj S-12* 120 ondisfor ei,*rnoIuseowf The Mawb Wor&dBon Group. Th. I bo.,newns 5^OuW and Ownto the iCOMOROS McyofI bondones shown an Ifus n`q ' FR. o'o not i , on the poad e . H56'6 *d M'Ben; on thy bspl s otvs of.on 16 * s du* \ M O MOZAMBIQUE or ony nonement or acconce p/ ofuc boundaies. 6 MAD GASCRE16 / oc r s 10 0 300 I 0 ~~~Oichili -16' 8.rO lO 2D AS C AR 16° NGAZ IDJA .11 MiLES0 48 5,2 1 / ~~~~~~~(GRANDE 3-4' ~ COMORE) MORON koni 77," 0 CCOMOROS Bsondomodji PUBLIC SECTOR HEALTH FACILITIES Misoudje ROADS 0 TOWNS Ouizioini * HOSPITALS --------------- PATHS CONTOURS (elevations in feet) 0 HEALTH CENTERS AIRPORTS * SPOT ELEVATIONS (in feet) PORTS REEFS 12' 12'1 I;; . NZWANI Ouni (ANJOUAN) mutsamuclu Bamboo MWALI*23 (MOHEU) Ie Minngorgl C ---abn Domoni Ouol6ho,h0 u NiumacLo' 5 0 25 640 I I I I I I MILES 5 0 25 _ lI, I I I I I '0 KILOMETERS 4 10 4 O