Document of The World Bank Report Ng: 17220 COM PROJECT APPRAISAL DOCUMENT ONA PROPOSED CREDIT IN THE AMOUNT OF SDR 6.2 MILLION EQUIVALENT TO THE ISLAMIC FEDERAL REPUBLIC OF THE COMOROS FOR A HEALTH PROJECT JANUARY 30, 1998 Human Development 2 Africa Region CURRENCY EQUIVALENTS (Exchange Rate Effective December 1997) Currency Unit = Comorian Francs KMF 1.00 = US$ 0.0025 US$ 1.00 = KMF 400.00 FISCAL YEAR January 1 - December 31 ABBREVIATIONS AND ACRONYMS CAS Country Assistance Strategy CPR Contraceptive Prevalence Rate CEP Cellule d'Ex&cution du Projet (Project Implementation Unit) CNFRSP Centre National de Formation et de 12echerche en Sante Publique DGTSM Direction Generale de la Tutelle, des Structures et des Moyens DHS Demographic and Health Survey IEC Information, Education and Communication KMF Franc de la Republique Federale Islamique des Comores MOH Ministry of Public Health and Population PNAC Pharmacie Nationale Autonome des Comores PTI Program for Targeted Interventions RHS Residual House Spraying SLMTV Service de Lutte contre les Maladies tb Transmission Vectorielle UNICEF United Nations Children Fund WHO World Health Organisation Vice President ...................... Callisto Madavo Country Director .......................Michael Sarris Sector Manager ....................... Nicholas Burnett Task Team Leader/Task Manager .............. Eileen Murray Islamic Federal Republic of the Comoros Health Project TABLE OF CONTENTS Project Financing Data Block A. Project Development Objective ............................................................2 1. Project Development Objective and key performance indicators ...........................................2 Block B. Strategic Context ............................................................2 1. Sector-related Country Assistance Strategy (CAS) goal supported by project .......................2 2. Main sector issues and Government strategy ............................................................2 3. Sector issues to be addressed by the project and strategic choices .........................................4 Block C. Project Description Summary ............................................................6 1. Project components ............................................................6 2. Key policy and institutional reforms supported by the project ...............................................6 3. Benefits and target population ............................................................7 4. Institutional and implementation arrangements .................................... , . , ., .7 Block D. Project Rationale ....................................9 1. Project Alternatives considered and reasons for rejection ......................................................9 2. Major related projects financed by the Bank and/or other development agencies ............... 10 3. Lessons learned and reflected in proposed project design .................................................... 10 4. Indications of borrower commitment and ownership ........................................................... I1 5. Value added of Bank support in this project ........................................................... 11 Block E. Summary Project Analyses ...........................................................1 I I. Economic ........................................................... I 1 2. Financial ........................................................... 14 3. Technical ........................................................... 15 4. Institutional ., 15 5. Social ....................... 16 6. Environmental Assessment ....................... 16 7. Participatory Approach ....................... 16 Block F. Sustainability and Risks ......................... 17 1. Sustainability ....................... 17 2. Critical Risks ....................... 18 3. Possible Controversial Aspects ....................... 18 Block G. Main Loan Conditions ......................... 19 1. Board conditions ....................... 19 2. Effectiveness Conditions ....................... 19 3. Other ....................... 19 Block H. Readiness for Implementation ......................... 20 Block I. Compliance with Bank Plicies ......................... 21 List of Annexes: Annex 1. Project Design Summary Annex 2. Detailed Project Description Annex 3. Estimated Project Costs Annex 4. Financial and Economic Analysis Annex 5. Financial Summary Annex 6. Procurement and Disbursement Arrangements Table A. Project Costs by Procurement Arrangements Table B. Thresholds for Procurement Methods and Prior Review Table C. Allocation of Loan Proceeds Annex 7. Project Processing Budget and Schedule Annex 8. Letter of Sector Policy Annex 9. Documents in Project File Annex 10. Statement of Loans and Credits Annex 11. Country at a Glance MAP Africa Regional Office Human Development 2 Project Appraisal Document Islamic Federal Republic of the Comoros Health Project Date: January 30, 1998 Task Team Leader: Eileen Murray Country Director: Michael Sarris Sector Manager: Nicholas Burnett Project ID: 52887 Sector: Pop. Health and Nutrition Program Objective Category: Poverty reduction Lending Instrument: Specific Investment Loan Program of Targeted Intervention: [xl Yes [ ] No Project Financing Data [] Loan [xl Credit [I Guarantee [ Other [Specifyl For Loans/Credits/Others: Amount (US$m/SDRm): US$ 8.4 million / SDR 6.2 million Proposed terms: [] Multicurrency [ Single currency, specify Grace period (years): 10 [] Standard Variable [ Fixed [] LIBOR-based Years to maturity: 40 Commitment fee: 0% Service charge: 0.75% Financing plan (US$m): Source Local Foreign Total Government 0.2 - 0.2 WHO 0.4 0.4 UNICEF - 0.1 0.1 IDA 0.7 7.7 8.4 Beneficiaries 0.9 - 0.9 Total 1.8 8.2 10.0 Borrower: Islamic Federal Republic of the Comoros Guarantor: N/A Responsible agency(ies): Ministry of Public Health and Population (MOH) Estimated disbursements (Bank FY/US$M): 1999 2000 2001 2002 2003 Annual 1.0 2.7 2.6 1.5 0.6 Cumulative 1.0 3.7 6.3 7.8 8.4 Project implementation period: 1998-2002. Expected effectiveness date: 7/01/98. Expected closing date: 12/31/02. Project Appraisal Document Page 2 Country: Islamic Federal Republic of the Comoros Project Title: Health Project A: Project Development Objective 1. Project development objective and key performance indlicators (see Annex 1): To reduce mortality from common diseases, particularly malaria, by ensuring a better utilization of health facilities for the delivery of quality health care to the vast majority of the population aad by organizing mosquito control activities to reduce the incidence of malaria. The principal outcome/impact of the project will be a reduction in the umder-five mortality rate from 100 per thousand in 1996 to 90 per thousand by the mid-term review and to 75 per thousand by the end of the project; also, the number of deaths due to malaria among under-five children is expected to decrease from an estimated 800 per year at present to 700 per year by the mid-term review and to 500 per year by the end of the project. B: Strategic Context 1. Sector-related Country Assistance Strategy (CAS) goal supported by the project (see Annex 1): CAS document number: N/A Date of latest CAS discussion: December 14, 1993 This project is consistent with the latest CAS, as discussed by the Board in December 1993. Comoros has now been classified as a "D Category" country and therefore a formal CAS for the country is no longer required for Board discussion. Three development priorities that have been identified jointly by the authorities, private sector and donors are as follows: (a) poverty reduction through sustained economic growth by creating a stable macro-economic environment, improvement of the business context, and providing better quality infrastructure; (b) human resource development and reduction in demographic growth--through improved literacy levels, better family planning and more accessible health services; and (c) protection of the environment. By ensuring a better utilization of health facilities for the delivery of quality health care, the project will respond directly to the second development objective. This operation will also address poverty alleviation by improving the health status and well-being of the population (particularly women and children). 2. Main sector issues and Government strategy: The overall macro-economic context continues to be troublesome. Public finances remain weak with an accumulation of external arrears up to US$43 million and civil servants salaries arrears up to 10 months by the end of 1996. A 1997 financial program was agreed with the IMF/Bank for a test period for February-July 1997 with specific financial benchmarks. Financial results of the first three months in 1997 were encouraging with major improvements in budgetary revenue and a declining trend of wage bill arrears. Civil servants were paid on a regular basis from January to November 1997, mainly due to a political commitment. There have been slippages again in payments to civil servants these past two months due to the political events. Subsequent Bank and IMF support to the Government's adjustment program would depend on a good track record. Health sector. The health sector consists of the central and regional units of the Ministry of Public Health and Population (MOH), and of three public hospitals, two medical and surgical centers, three urban medical centers, 12 health centers and a number of health posts, in addition Project Appraisal Document Page 3 Country: Islamic Federal Republic of the Comoros Project Title: Health Project to a nascent private sector. Health facilities are providing an integrated package of primary health care which, in addition to curative treatments, includes preventive activities, particularly for the maternal and child health activities (immunization programs, prenatal visits, maternal and child health, etc.) and family planning, and IEC. Despite some recent improvements, the Comoros health sector remains inefficient, as evidenced by the high prevalence of insect, food and water related diseases, and the low utilization of health care services. Malaria, for instance, remains the dominant disease in Comoros. MOH estimates that malaria is responsible for between 10 and 20 percent of deaths among children aged 0-5 years and between 20 and 25 percent of total hospital admissions. Despite the fact that more than 80 percent of the population lives within a five kilometer radius of a health facility which is a rather high percentage compared to the rest of Africa, utilization rates for curative services are estimated at well below one curative contact per capita per year, and less than 30 percent of deliveries are correctly assisted. Utilization of health services is limited by two main factors, namely poor quality of health facilities (due in part to insufficient funding) and poorly trained staff, including for management and finances. The almost complete lack of government funds over the past 10 years did not allow the country's health facilities to be fully operational in many cases, but the situation began to improve with the introduction of cost recovery. This lack of government funding could remain a problem for the larger health facilities, which may experience some difficulties to operate only with user fees. Total expenditure for health is believed to be below the minimum US$ 12.00 per capita per year required for just primary health care services. Another major issue pertains to the demographic situation characterized by high fertility and a population density rate in Anjouan of 221/km2. The Ministry of Health is aware of the situation and has included family planning activities into its basic health care package. Health center staff are also being trained in family planning issues under the on-going IDA financed PHR Project. IEC activities in the family planning area are on-going under the IDA financed PHR Project. These activities rely on both modern communication methods, such as radio, and on the traditional communication networks such as community groups, mosques, and market places. As a result of these efforts, the latest Demographic and Health Survey (DHS) in 1996 has shown that the Contraceptive Prevalence Rate (CPR) has increased from 3 percent to 8 percent in only a few years. There is, however, no clear understanding of the demographic necessity for family planning. In fact, it appears that many religious and traditional leaders are in favor of family planning for health reasons but do not understand the demographic need to limit population growth. Even though MOH has fulfilled its obligation on the clinical front, population control, in order to have the intended impact, needs to be endorsed by the cabinet and addressed by many line ministries simultaneously. Due to the current country context, the Government is reluctant to adopt a multisectoral approach to tackle the population problem. Government strategy. In the last few years, Comoros has adopted a series of comprehensive and far-reaching reforms aimed at improving the management and efficiency of its health system at all levels in order to ensure a better delivery of good quality health care. Based on the sector policy letter that was sent to the Bank in November 1993 in connection with the ongoing PHR project, law No. 94-016, which outlines a new general framework for the health system and defines the mandate and responsibilities of the public sector, was passed on June 17 1994; Project Appraisal Document Page 4 Country: Islamic Federal Republic of the Comoros Project Title: Health Project several decrees were issued in 1994 and 1995 to follow up on implementation. The reforms included: (i) a reorganization of MOH with more emphasis on the Regional Directorates and a redefinition of the role of the central units; (ii) the conversion of public hospitals and health centers into public establishments with administrative and financial autonomy or into not-for- profit private organizations, with boards of directors and management committees; (iii) the implementation of an important personnel redeployment plan; (iv) a complete overhaul of the financing arrangements with the introduction of cost recovery (fees for service and income from the sale of drugs); and (v) health facilities managing their bank accounts. The most important accomplishment of these reforms is the participation of the communities/beneficiaries in the management of health facilities through setting up tarification levels and funding allocations. A more detailed description of the health sector reforns together with the legal texts that have been enacted can be found in the "Note d'Information sur la Reforme du systeme de Santf aux Comores" which is included in the project file (see Amlex 9). The scope and depth of those reforms which are being implemented in parallel with the initial development of private health care, are in a way unique in the sub-Saharan African context. A new letter of sector policy was submitted in December 1997 summarizing the accomplislhments of the sector and outlining what remains to be done. Although the major part of the reforms has been implemented, there have been some delays and setbacks. Boards of directors are not in place for all health facilities and directors have not always been appointed in accordance with normal procedures outlined in the legal texts enacted as part of the reforms. Also, many managers of health facilities do not know the procedures for accounting for funds and need training in finance and management. In addition, central and regional units of MOH lack the capacity to plan, monitor and audit activities performed by the health sector. Health facilities have already begun exploring creative financing mechanisms such as twinning arrangements with health facilities at the same level in France and other countries. For example, the health facilities of Mb6ni and Fombouni have been receiving support from abroad in the form of technical assistance and equipment. 3. Sector issues to be addressed by the project and strategic choices: Sector issues addressed by the project are the low utilization of health facilities, the high environmnental risks affecting health, the insufficient funding and the poor institutional capacity of the health sector. To increase the utilization of health services, the project will support, along with other donors, the rehabilitation of health facilities together with the provision of equipment, and the training of health facilities managers and health workers. As the condition of health facilities improves in parallel with quality health care, utilization rates should increase considerably at first and then level off. A condition of disbursement for the civil works category of the "rehabilitation and equipment of selected health facilities" component will be that, for all health facilities which will be rehabilitated by the Project, all boards of directors are in place and all directors have been appointed in accordance with legislative texts Sections 3 to 13 of Presidential Decree 95-053 regarding hospitals and Sections 9 to 20 of Presidential Decree 95- 054 regarding health centers. In an effort to improve thte efficiency of the health sector, the project will rehabilitate and equip selected health facilities, finance training for MOH and health care personnel and support a wide range of mosquito control activities, including source Project Appraisal Document Page 5 Country: Islamic Federal Republic of the Comoros Project Title: Health Project reduction, use of impregnated bednets, biological control, and residual spraying, aimed at reducing the burden of malaria and preventing mortality and incapacity. The issue of the underfinancing of the sector will be addressed during public expenditure reviews and an attempt will be made to account for community financing and the full range of MOH's contribution, including the payment of health personnel salaries and contributions in kind. Community spending patterns for health care will be assessed. Generally, the project will support the expansion of cost recovery in order to allow for a significant increase in expenditure levels. Regarding the poor institutional capacity of the health sector, the project will support the training of the managers and employees of health facilities to enable them to make rational allocative and spending decisions and to provide better quality care; training will also be provided to the civil servants working in the central and regional units of MOH to enable MOH directors to plan, coordinate and monitor sector activities. Twinning arrangements with hospitals in foreign countries will be explored as a means of obtaining additional support for health facilities. The project will also provide MOH with specialized technical assistance in fields such as health insurance and finance, malaria, etc. In addition, the project will provide vehicles, office equipment and supplies. Project Appraisal Document Page 6 Country: Islamic Federal Republic of the Comoros Project Title: Health Project C: Project Description Summary 1. Project components (see Annex 2for a detailed description and Annex 3 for a detailed cost breakdown): Component Category Cost ]ncl. % of Bank- % of Contingencies Total financing Bank- _____ (US$M) financing (a) The rehabilitation and equipment of Physical, 3.1] 31% 3.1 38% selected health facilities (including the Project Hombo hospital and the Domoni Management medical and surgical center in Anjouan, the Mitsamiouli medical and surgical center in Grande Comore, and selected health facilities in Moheli) to facilitate the delivery of good quality health care to the population, which will also have a direct favorable impact on cost recovery by those health facilities. (b) The control of malaria by Physical, 3.9 39% 2.3 27% improving case management at all Policy, levels of the health service, educating Institution the population for a better utilization of Building, the services and improved case Training, management at home, and preventive Project activities including mosquito control to Management reduce the incidence of the disease. (c) Institutional strengthening to Policy, 2.4 24% 2.4 28% facilitate and support the increased Institution utilization of quality care by the Building, population and the further Training, implementation of the health sector Project reforms, including (i) training in Management Comoros of MOH as well as health facilities staff in the delivery of quality health care, management and accounting; (ii) studies fDr the development of altemative mechanisms for health financing; and (iii) technical assistance, logistical support, and equipment for MOH's Central and Regional Directorates and the Pharmacie Nationale Autonome des Comores--PNAC (the agency in charge of the marketing of drugs). (d) Project Implementation Unit 0.6 6% 0.6 7% Total 10.0 100% 8.4 100% 2. Key policy and institutional reforms supported by the project: The project is designed to support the ongoing health sector reforms which are described in B2 above. See also B3 for a discussion of the sector issues to be addressed by the project. Project Appraisal Document Page 7 Country: Islamic Federal Republic of the Comoros Project Title: Health Project 3. Benefits and target population: The main benefit from the project will be improved family welfare and lower mortality and morbidity rates, particularly among women and children, through reduced exposure to malaria and increased utilization of good quality health services. Additional benefits will be enhanced efficiency of the health care system due to: (i) significant improvements of the quality of health infrastructure; (ii) improvement of the technical and managerial efficiency of health professionals; (iii) an increase in financial resources for the health sector (the component will create a more favorable climate for cost recovery schemes since health facilities will be in better physical shape and provide better services); (iv) improved distribution of powers and responsibilities between the national and local authorities; (v) promotion of a sense of ownership and accountability at the local level; and (vi) allocation of sector resources according to local priorities. Three (out of four) of the health facilities to be rehabilitated are on the islands of Anjouan and Moh6li, and the malaria control program will be particularly important for the islands of Anjouan and Moheli, which are the most affected by poverty. Therefore, the percentage of project beneficiaries will have a significantly larger proportion of poor people than the country's population as a whole, so that the inclusion of the project in the Program for Targeted Interventions (PTI) is justified. 4. Institutional and implementation arrangements: Implementation period: 4 years Executing agency: Ministry of Public Health and Population (MOH) Proiect management: The General Secretary of the Ministry of Public Health and Population (MOH) will be responsible for overseeing the implementation by MOH directorates and line agencies of all operational aspects of the project (including close follow-up of the on-going health sector reforms). See Annex 2 for the implementation arrangements for each component. The Cellule d'Ex&cution du Projet - CEP (Project Implementation Unit) will continue to be located in MOH and will report directly to the General Secretary of MOH. This support unit will be responsible for: (a) preparing annual work programs and corresponding budgets; (b) ensuring the coordination of the different components; (c) maintaining a proper accounting system for each component and keeping the project accounts; (d) managing the special account for the IDA credit; (e) preparing bidding documents and monitoring the overall procurement process; (f) administering contracts for the civil works financed under the project in collaboration with the General Directorate for Supervision, Structures and Means (DGTSM); (g) preparing quarterly and annual progress reports; (h) recruiting independent auditors and ensuring that audits are performed annually in a timely fashion; (i) managing all technical assistance contracts; (j) organizing the mid-term review in 2000; (k) preparing the implementation completion report for the project; and (1) collecting data on the financing of the health sector. The unit's high level staff will include an executive director, an accountant and a procurement specialist, each having at all times qualifications and experience acceptable to IDA. Although the high level staff have performed satisfactorily under the on-going project, the Government has indicated its wish to re- advertise these positions (as is the case for the new Education and Social Fund Projects) so that either the present staff are confirmed in their positions or that better candidates are recruited. Project Appraisal Document Page 8 Country: Islamic Federal Republic of the Comoros Project Title: Health Project Proiect coordination: The General Secretary of MOH will be responsible for the coordination of activities under the project. Project oversight: Policy guidance will be provided by the Minister of MOH. In addition, a management committee chaired by the Minister and consisting of the General Secretary, the two General Directors and the three Regional Directors (and other higher level staff of MOH that may be invited to attend depending on the matters to be d:iscussed at any particular meeting) will participate in project planning and monitoring. The Executive Director of the Project Implementation Unit, CEP, will attend all meetings and record minutes for each of these meetings. The management committee will approve the annual work prograams and budgets, review progress in all project activities, monitor performance indicators (tableau de bord), and trigger any corrective action that may be necessary. Accounting, financial reporting and auditing arrangements: A computerized accounting system by the name of TOMPRO was put in place in the project implementation unit (CEP) and is functioning adequately. Project staff are familiar with the software and intend to use it during this project also. All audit reports under the on-going project were unqualified. A special account for the IDA credit will be opened and maintained with a commercial bank acceptable to IDA. An independent auditor acceptable to IDA will audit the use of all IDA funds, including the special account for the IDA credit and statements oif expenditures. Audit reports will be submitted not later than six months after the end of the fi-nancial year. The auditor's terms of reference were agreed with IDA during negotiations, an(d the signing of a contract (one year, renewable for a maximum of three years) with the auditor is a condition of effectiveness of the IDA credit. Monitoring and evaluation (M/E) arranzements: Monitoring procedures and project progress reports will focus on progress in, and impacts of, the implementation of the project, measured against specific targets and actions set in the detailed implementation programs or work programs, all of which will be reviewed and revised each year throughout the project life. General progress of the project will be measured against a list of key indicators, which are included in the Project Design Summary (Annex 1), the Detailed Project Description (Annex 2) and the Implementation Plan in the Project Implementation Manual. The M/E of some of those indicators will be conducted through specific surveys and beneficiary assessments. In addition, each year, MOH will prepare its work programs and budgets for the next year, to be discussed with IDA and other donors at the annual project implementation review that will take place no later than November 30 of each year. By December 31, 2000, a mid-term review of the Project will be carried out in accordance with terms of reference and monitoring indicators acceptable to IDA; a beneficiary assessment will be scheduled at that time to obtain population perspectives on health issues. MOH will submit to IDA agreed upon quarterly progress reports summarizing the status of the project and the degree of compliance with covenants in the credit agreement. Within six months of the closing of the IDA credit, an Implementation Completion Report (ICR) will be prepared by IDA, with MOH contributing its own evaluation of the Project to the ICR. Under the overall guidance of the Management Comnmittee and the General Secretary of MOH, M/E of the project will be the shared responsibility of the MOH directorates and divisions, but particularly of the Division for Epidemiology, Planning and Statistics (Division Epidemiologie, Project Appraisal Document Page 9 Country: Islamic Federal Republic of the Comoros Project Title: Health Project Planification et Statistiques), with the assistance of the Project Implementation Unit (CEP). The Project Implementation Unit, in collaboration with the General Directorate for Supervision, Structures and Means (DGTSM), will be mainly responsible for monitoring the rehabilitation and equipment of health facilities. D: Project Rationale 1. Project alternatives considered and reasons for rejection: Reforms in the health sector have given the responsibility of the management of health centers in part to community groups so the role of the Ministry has changed. To some extent, the project is protected from the political and fiscal pressures which could have an adverse impact if one were to judge from the Government's track record in the execution of other key programs, coupled with the fact that civil servants are unmotivated due to salary arrears of about a year. Therefore, the only logical choice is to continue providing support for the reform by financing items such as rehabilitation and equipment of health facilities, training of health personnel and technical assistance to enable health facilities to deliver good quality care while being self-sustaining. Preference was given to training in Comoros because it is the most cost-effective method since it can benefit the largest number of staff. The alternative of using one method of malaria control has been rejected because experiences from many programs have shown the superiority of integrated programs coordinating the activities of the general health services, other sectors and community action, and developing complementary mosquito control as required. Project Appraisal Document Page 10 Country: Islamic Federal Republic of the Comoros Project Title: Health Project 2. Major related projects financed by the Bank and/or other development agencies (completed, ongoing and planned): Sector issue Project Latest Supervision (Form 590) Ratings (Bank-financed projects only) Implementation Development Progress (IP) Objective (DO) Bank-financed low utilization of health facilities; Population and Human HS HS insufficient funding; and poor Resources, expected to close on institutional capacity of the health 6/30/99. sector. low utilization of health facilities. Social Fund (Board presentation in December 1997) Other development agencies low utilization of health facilities; WHO Health Project (on- high environmental risks affecting going) health; insufficient funding; and poor UNICEF Health Project (on-. institutional capacity of the health going) sector. UNDP Health Project (on- going and new one planned in 1998) FAC Health Project (on-going) UNFPA Health Project (on- going) Community Development (EU) (on-going) IP/DO Ratings: HS (Highly Satisfactory), S (Satisfactory), U (Unsatisfactory), HU (Highly Unsatisfactory) 3. Lessons learned and reflected in the project design: This project builds on the successful results in terms of attainment of development objectives as well as implementation progress of the on-going IDA-financed PHR Project. IDA has been involved in the health sector for over 10 years; the key lesson learned is that, with only one exception, the Government has not provided the health sector with any financing except for wages (and even the payment of wages has been a problem). This trend is likely to continue since there is about a year of arrears in civil servant salaries which is a much more pressing issue politically for the Government than providing non-wage allocations to the health sector. Thus, the project has been designed in order for the health facilities to be able to function to the maximum extent through cost recovery mechanisms and external financing. Generally, the Government does not have a good track record in terms of providing agreed upon counterpart funds. This issue will be tackled as part of any discussions on an eventual structural adjustment program. In any event, the beneficiary participation (i.e. the payments made by patients under the cost recovery arrangements in the health sector) as well as the payment of salaries will be counted as counterpart funds. In addition, health facilities have already began to explore creative Project Appraisal Document Page 11 Country: Islamic Federal Republic of the Comoros Project Title: Health Project financing mechanisms such as twinning arrangements. 4. Indications of borrower commitment and ownership: Experience has clearly shown that when communities are given the proper support, they become key actors in the development process. In the health sector, significant reforms were undertaken rendering health facilities autonomous, and the Government as well as the population remain committed to the further "operationalization" of the reforms since substantial improvements in health care are noticeable (e.g. in most cases health facilities are properly staffed and drugs are readily available). The last five years have witnessed the development of an excellent participatory process which resulted in a broad base consensus regarding sector reforms to the extent that the communities successfully resisted the decision by the newly elected officials to reverse reforms. As community groups become more involved in the management of these health facilities through boards of directors or local associations of users, the quality of health care should improve, since the services provided will be properly accounted for and payments made by users will be reinvested into the purchase of drugs, medical supplies, etc. In addition, malaria control activities should build upon the strong community development characteristics of Comoros. 5. Value added of Bank support in this project: The Bank has worked in complete partnership with MOH providing them with the necessary technical inputs for the implementation of the on-going project and the preparation of the proposed project. In view of the problems with counterpart funds and the payment by the Government of civil servants salaries and operating subsidies to health facilities, the Bank has been instrumental in helping MOH prepare a project for the rehabilitation and equipment of health facilities that could become self-financing. In addition, the Bank made sure that the highest quality experts were involved in the preparation of specific components, such as malaria control, in order to ensure good results on the ground. E: Summary Project Analysis (Detailed assessments are in the project file, see Annex 9) 1. Economic (supported by Annex 4): [ ] Cost-Benefit Analysis: NPV=US$ million; ERR= % [x] Cost Effectiveness Analysis: [ Other (Specify) Annex 4 examines the economic and sectoral context and the financial situation of the health sector, and shows that the investments included in the project are the most cost effective manner to facilitate the delivery of good quality health care. The Islamic Federal Republic of the Comoros is one of the poorest countries in the world, with real per capita income of about US$ 460 (1996) and an estimated human development index of 0.33 1. The country suffers from a weak administrative apparatus and a shortage of qualified personnel, growing foreign trade imbalances, inadequate basic infrastructure, lopsided national income distribution, an inappropriate framework of institutions, laws, and regulations, and the adverse effects of population growth. The country embarked into an adjustment process with some positive results, but improvements have been obtained through sacrifices, extremely high social costs, and stagnation in investments. The country's health sector has been hit hardest. Its budgetary allocations represent between 5.5% and 6% of the country's consolidated budget, a far cry from the 10% recommended by WHO. Those allocations have been theoretical, to a great extent, since Project Appraisal Document Page 12 Country: Islamic Federal Republic of the Comoros Project Title: Health Project operating subsidies are not paid to health facilities (exceptionally, 1995 allocations were paid in 1996) and the payment of salaries to civil servants is very irregular. On the other hand the contribution of the population to the operating costs of the health sector has been increasing substantially in recent years. Overall, annual spending on health in Comoros represents about US$ 14 per capita, or about 3% of GDP. The contents of the project have been carefully selected on the basis of the following criteria: (i) the Government's priorities; (ii) the socio-economic and political context, particularly the Government's concern for national reconciliation; (iii) the performance of the health system and of MOH; (iv) the results and impact (or lack thereof) of past experiences; (v) the implications of the different components regarding the needs for operation and maintenance and the means (available or to be provided) to cover those needs; (vi) the components' impact on development as well as the health status of the population; and (vii) the financing that could be provided by other donors in the context of other projects or programs. Regarding the financing of the sector, the shift away from government towards user financing seems irreversible; it should be encouraged and facilitated, together with the promotion of measures to develop savings, solidarity and social protection. In designing the project, priority has been given to investments capable of generating additional financial resources (rehabilitation of health facilities, improvement of the quality of health care through training, etc.) or reducing expenditures (control of malaria). The Government's contribution to the financing of the health sector is likely to remain at about US$ 1.7 million per year, and will cover essentially the salaries and other personnel costs of civil servants, including the salaries of those civil servants working in health facilities. As for cost recovery from the community, one can be reasonably optimistic about the ability of health facilities to raise revenues since even the most optimistic forecasts have been exceeded (in 1997, revenues are estimated to increase by about 50% compared to 1996). Overall, user fees and the proceeds of the sale of drugs will represent about US$ 2.0 million a year. It is realistic to assume that health facilities will be able to function even without operating subsidies from the Government provided, however, that: (i) health facility personnel who are civil servants are paid regularly by the Government; (ii) the cost of training health personnel is financed by Government or donors; (ii) major physical rehabilitation of structures and equipment replacement is financed by the Government or donors; (iii) health facilities are managed and operated correctly and efficiently; (iv) health facilities can manage and operate their own pharmacies; and (v) certain parameters (such as the percentage of health services provided at no cost to those who cannot pay, and the invoicing based on lump sum amounts) remain within acceptable limits. The financial forecasts for the next five years (1998-2002) show that a substantially higher level of expenditures for health (close to US$ 18 per capita, compared to about US$ 14 on average for the last five years) could be achieved and financed through a reasonable mix of budgetary allocations, grants and loans, and community contributions. It is worth noting that the community contributions would represent about 23 percent of the total financing for the health sector as a whole, but about 38 percent of the operating expenses of health facilities. The component for the rehabilitation and equipment of health facilities has been designed taking into account the condition of existing structures and equipment and the necessity to adopt the most cost-effective solution, through least-cost rehabilitation and limiting new constructions and through the purchase of appropriate equipment (i.e., the least expensive equipment, but also the Project Appraisal Document Page 13 Country: Islamic Federal Republic of the Comoros Project Title: Health Project one that is the easiest to operate and maintain). The design of the component has taken into account its direct impact not only on the health of the population but also on the revenues of the health facilities. This will ensure that the health facilities will be able to generate enough revenue to subsidize their less profitable units and to operate even if they do not receive operating subsidies from the Government. On the economic front, the Government views malaria as one of the main causes of absenteeism from work and school. People are hit hardest by the effects of the disease during the period when farm work is heaviest and the result is a significant reduction in productivity and economic growth. The reliance on an integrated program, coordinating the activities of health services and communities and developing complementary vector control as required, is the most efficient and cost-effective. The selection of the specific activities is based on the characteristics of each island which allow for different approaches with great variances in costs (it is worth noting that the cost of treatment of breeding areas of anopheles with larvivorous fish or larvicides -- a very effective form of vector control for Grande Comore -- is negligible). Malaria has tremendous direct and indirect costs for governments (ministries of health) as well as family economies, placing a strain on tight family budgets. Both the direct and indirect costs of malaria are always difficult to measure or estimate in most countries, and Comoros is no exception. The best that can be done is to provide an order of magnitude of the costs involved, and it would not make sense to attempt to compute a rate of return. However, in assessing whether it is appropriate for Comoros to spend US$ 3.9 million for malaria control, one should consider the potential savings in direct health costs of US$ 2.0 million and the indirect losses of US$ 3.6 million that could be mitigated or avoided. There is no doubt that a reduction in the incidence of malaria will improve the quality of life of Comorians and benefit the Comorian economy as a whole, through lower absenteeism and higher productivity. It will also have an impact on the tourism market, since tourists will be less apprehensive of contracting the disease. The major element of the institutional strengthening component is training. The definition of the training program is based on an analysis of the training needs of MOH staff and of health facility personnel. A conscious choice has been made to continue to develop a local capacity for training in the Centre National de Formation et de Recherche en Sante Publique (CNFRSP) in Moroni. All training, whether long-term or short-term, will be in country, with the participation of foreign training institutions. One advantage of this approach is that most of the moneys spent will remain in Comoros. It is also the most cost-effective way of upgrading the skills of MOH staff and health professionals. For example, it is estimated that the long-term training of a person in Comoros will cost from US$ 3,000 to US$ 6,000 per year, as compared to about US$ 20,000 per year for training abroad. For short-term training, the cost differential is even greater. In addition to the cost aspect, training in Comoros will also have a number of important advantages compared to overseas training: (i) it will allow the staff to continue to exercise their professional activity, without prolonged interruptions; (ii) it will permit the adoption of a curriculum focusing on local practices and the solution of the health problems of Comoros or of the problems of health facilities; (iii) it will limit the risks which are inherent in overseas training (difficulty to adapt the acquired knowledge to deal with local problems; possibility that the trainees will not return home or, if they do return home, will not be assigned to posts with the functions and responsibilities which the training was supposed to help them carry out). Project Appraisal Document Page 14 Country: Islamic Federal Republic of the Comoros Project Title: Health Project 2. Financial (see Annex 5): The proposed credit of US$ 8.4 million would cover aboult 85 percent of total project costs. In addition, to certain items financed by other donors (UNICEF and WHO, for a total of US$ 0.5 million), the cost of the project includes the salaries of civil servants working on the project components (a Government contribution of US$ 0.2 million), and beneficiary contributions for impregnated bednets i(US$ 0.9 million), which are in addition to the fees paid for services rendered in health facilities. In view of the significant contribution made by beneficiaries which will also be accounted for as the counterpart contribution, the IDA credit will finance 100 percent (net of taxes) of expenditures for all disbursement categories in the credil: agreement. MOH has obtained a waiver for taxes and duties for all items financed by the IDA credit. The fiscal impact of the project needs to be assessed in terms of the Government contribution during the implementation period and of the recurrent cost implications after the project closes. As mentioned above, the most that the Government could provide is the payment of the salaries of civil servants working in health facilities and in the central and regional units of the MOH. During the implementation period, it would be unrealistic to expect that the Government could make any contribution to the investment costs, which would have to be financed 100% by IDA or other donors. Regarding the recurrent cost implications, the support provided by the project to cost recovery within the framework of the sector reforms wilil enable the health system to become progressively financially viable with users meeting the operating costs of health facilities, whereas the Government will continue to pay the salaries of personnel and mobilize the external financing necessary to cover the cost of expansion, major rehabilitation and equipment of physical facilities. Experience from cost recovery in health facilities in Comoros has proven to be a success. It is clear that users do not mind paying for quality health care, drugs, and other related services. Cost recovery is now well accepted by the Comorian population. All services except for priority health services, such as immunization, are rendered for a fee. Each health facility fixes its own tariffs based on the population's willingness to pay. The Board of Directors of the health facility in question negotiates this tariff structure directly with MOH. An interesting feature of the Comorian Society is the fact that community groups are very dynamic and have strong safety nets built-in. Poor members of the community are not denied health care since either the community will contribute or the health facil ity will absorb the cost. The selection of activities/departments to be included in the rehabilitation and equipment of health facilities is based on the positive impact that those investments would have on the revenues of those facilities, in addition to their impact on the health status of the population. When operated properly, departments, such as radiology, pharmacy, maternity and clinics with private or semi-private rooms, have a good potential for revenue generation. An analysis of the finances of some major health facilities shows that even hospitals and medical centers could function without operating subsidies from the Government, provided that the Government pay the salaries of civil servants and provide for the trainin,g of health personnel, that major rehabilitation and equipment replacement are financed by donors, that the facilities are properly managed with sound financial practices for collection of fees for services, that the facilities manage and operate their own pharmacies, and that certain parameters such as the percentage of services provided free to the poor and the percentage of billings on a lump sum basis remain Project Appraisal Document Page 15 Country: Islamic Federal Republic of the Comoros Project Title: Health Project within acceptable limits. Therefore, the fiscal impact is likely to remain limited to a Government contribution to pay the salaries of civil servants and to service the external debt. Malaria control will require a major investment in the development of mosquito-control activities which are expected to achieve significant results during the duration of the project and become sustainable thereafter, being based on community action under the guidance and support of an effective health system. 3. Technical: Overall, the project is technically sound. The preparation of the components is based on international as well as regional norms and practices, and the project will be carried out in accordance with acceptable standards. Innovations, such as community financing and the health sector reforms, are based on sound technical, financial and economic considerations. Investment costs for the project are based on prevailing market unit costs, with appropriate allowance for inflation and, whenever applicable, a reasonable level of physical contingencies. All health activities included in this project will have a direct impact on the health status of the population. The issue of access to health facilities is addressed in a systematic manner on the basis of needs, equity, opportunities and comparative advantages within the context of the geographical constraints in Comoros. In addition, the strategy adopted for the control of malaria is quite comprehensive and based on current regional and global strategies adapted to the ecology and social realities of Comoros, taking into account the experiences of past efforts to control malaria in the country and in the region. 4. Institutional: a. Executing agencies: MOH demonstrated that, with the assistance of donors and consultants, it can formulate and implement very comprehensive health sector reforms (see B.2). The reforms represent a significant accomplishment given the country's political context. Nevertheless, the weak absorptive and implementation capacity of the MOH is a widely recognized issue. MOH staff are currently being trained in public health issues, management, accounting, etc., but the lack of adequate funding for operating expenses and maintenance expenses is likely to remain a problem. The impact of such deficiencies on the delivery of health care services to the population is being minimized by the improvement of the operations of the health facilities. Health Facilities As part of the health sector reforms, all health facilities in the country became autonomous in 1996. This implies that each health facility (hospitals as well as health centers) has a Board of Directors which, among other things, participate in the nomination of competent hospital and health center directors and staff, approve the budget and monitor its implementation, and review and approve health facility accounts. These Board of Directors' functions have become extremely important in the context of the reforms, to ensure in particular that in the implementation of the cost recovery schemes that have been put in place in each health facility all funds are accounted for. Since, unfortunately, not all board of directors are in place and not all directors have been appointed, the establishment of board of directors and the appointment of directors in accordance with normal procedures in all health facilities which will be rehabilitated under the project will be a condition of disbursement of the IDA credit for the civil works category for the "rehabilitation and equipment of selected health facilities" component. A training program for health workers is underway for skills enhancement in order to ensure the provision of quality health care, as well as sound management and accounting. Project Appraisal Document Page 16 Country: Islamic Federal Republic of the Comoros Project Title: Health Project b. Project management: Since the management capacity of the MOH is generally weak, the project implementation unit (under the guidance of the General Secretary of MOH) will play an important role in the monitoring and coordination of project activities. In addition, key MOH staff will receive further training and high quality specialized technical assistance will be recruited for assignments in particular in the areas of health economics and health sector management. 5. Social: There are no major social issues faced by this project. Since the ultimate objective of the project is the improvement of the health status and well-being of the population in general, and of women and children in particular, the project will have a very positive social impact. Experience in Comoros has shown that the introduction of cost recovery has not prevented the poorest people from receiving health care, since they have been cross-subsidized by those who can afford to pay. In the future, the health insurance scheme component will enable poor people to have access to quality health care in a more structured manner. The project will promote the provision of good quality health care to an increasing number of people through an improvement in the effective coverage of care at the health center level coupled with good quality referral care. The control of malaria will not only alleviate the main health problem of the population but remove some major obstacles for economic and social development (such as ill health at the time of greatest need of manpower for agriculture). The development of communal antimalaria activities will contribute to strengthen social concerns and solidarity. The project will also focus on the islands of Anjouan and Moh6li which have a greater proportion of poor people than the island of Grande Comore. 6. Environmental assessment: Environmental Category [JA [ B [xl C The promotion of a better health and hygiene will have a positive environmental impact, but there could be some environmental risks linked to the disposal of hospital wastes. The construction of incinerators for the disposal of health facility waste will be a condition of disbursement for the health facilities to be rehabilitated under this project. The implementation manual provides guidelines for waste disposal of all health facilities. Any construction/ rehabilitation of buildings will be done in accordance with acceptable standards, and no environmental damage is foreseen in the implementation. Malaria control will be based on improved case management and the extensive use of biological control methods, particularly larvivorous fish, complemented by the promotion and support of the use of bednets. The use of insecticides will be limited to the impregnation of bednets as well as indoor residual house spraying in selected regions with non-toxic insecticides. The project will also have a positive impact on the environment by rehabilitating latrines in selected health facilities and promoting personal and group hygiene. 7. Participatory approach: a. Primary beneficiaries and other affected groups: The key stakeholder groups are women and children (the main users of the health system) for the project as a whole, the population at large for the malaria control component and the staff of MOH and health facilities for the institutional strengthening component. The design of the project is essentially based on the perception and assessment of stakeholder needs by medical personnel and MOH staff.. The strategy is for information sharing at the beginning of project implementation, and consultation through a Project Appraisal Document Page 17 Country: Islamic Federal Republic of the Comoros Project Title: Health Project beneficiary assessment at the time of the mid-term review. b. Other key stakeholders: Other key stakeholder are the cofinanciers, WHO and UNICEF, for which the form of participation is collaboration. F: Sustainability and Risks 1. Sustainability: Project sustainability will be ensured by: (a) improving MOH's overall capacity to manage the sector; (b) participation through cost recovery mechanisms that are being put in place in order for health facilities to benefit from well operating revenue-generating departments (pharmacy, radiology, private clinic, etc.) and provide better health services; (c) health facilities operating their own pharmacies as a means of ensuring instant revenues as well as access to generic drugs; (d) MOH paying in a timely manner the salaries of civil servants working in health facilities, in addition to stipends from the proceeds of user fees; (e) close adherence to the health sector reforms to ensure that competent staff in the health facilities are in place at all times; and (f) improving the capacity of health workers to attract and properly treat patients. The introduction of some form of health insurance mechanism, to be studied under the project, may help to ensure that the sustainability of health facilities is not achieved at the expense of equity. The sustainability of malaria control will be based on the full integration of case management and epidemiological information into the general health service and in the build up of community based activities of mosquito control, guided and supported by the responsible unit of the MOH. Nevertheless, as illustrated below, the project presents a number of risks including the non- payment of civil servants (particularly those working in health facilities), irregular Government commitment and the political instability. The project has been designed in such a way that it could be implemented despite these issues. In any event, it is appropriate for IDA to take some risks at a time when Comoros has requested support from the donor community as a means for reconciliation. Project Appraisal Document Page 18 Country: Islamic Federal Republic of the Comoros Project Title: Health Project 2. Critical Risks (reflecting assumptions in the fourth column of Annex 1): Risk Risk Ratinnz Risk Minimization Measure Annex 1. cell "from Outputs to Obiective" - Health sector reforms are not implemented and M - Bank to ensure implementation of maintained, and health personnel are not paid and reforns and payment of personnel drugs are not available. through overall macro-economic and sector dialogue. - Communities are not involved in malaria control M - IEC campaigns to increase community activities to ensure that impregnated bednets are participation in the malaria control actually used and that cisterns keep containing larva program. eating fish. Annex 1. cell "from Components to Outputs" - Lack of political stability. H - Project has been designed to work with a community focus. - Project is not properly managed by MOH and M - Bank supervision will focus on Project Implementation Unit (CEP). implementation and management issues. - Components are not implemented in a timely M - Bank supervision will focus on manner and within budgets. implementation and management issues. Overall Risk Rating M Risk Rating - H (High Risk), S (Substantial Risk), M (Modest Risk), N lNegligible or Low Risk) 3. Possible Controversial Aspects: The Government's record for the payment of civil servants salaries and of the operating subsidies of MOH and of the health facilities is not good. In the future, the non payment of the salaries of the personnel of MOH central and regional units and of the operating subsidies of those same units, although undesirable, would not be catastrophic for the population. On the other hand, the failure of Government to pay the salaries of civil servants working in health facilities would certainly affect the delivery and quality of health care services, particularly if those same health facilities do not receive any operating subsidies, as is the case at present. If salaries are not paid, user :fees collected in hospitals and health centers are likely to be diverted to provide some form of compensation to personnel to enable them to survive, instead of being used for the purchase of drugs and the operation and maintenance of the facilities. Project Appraisal Document Page 19 Country: Islamic Federal Republic of the Comoros Project Title: Health Project G. Main Loan Conditions 1. Board Conditions: (a) Transmission of signed letter of sector policy. 2. Effectiveness Conditions: (a) Finalization of bidding documents for the civil works for the health facilities (Hombo Hospital and Domoni Medical and Surgical Center in Anjouan and Mitsamiouli Medical and Surgical Center in Grande Comore). (b) The Project Implementation Plan/Manual prepared by MOH is satisfactory to IDA. (c) Independent auditor satisfactory to IDA has been recruited for a three-year period. (d) The Executive Director, the accountant and the procurement specialist have been recruited. 3. Other [classify according to covenant types used in the Legal Agreements.]: Condition of disbursement for the civil works disbursement categorv: For each health facility to be rehabilitated by the project: (a) The establishment of Boards of Directors and the appointment of General Directors or Chief Medical Officers in accordance with procedures outlined in decrees 95-053 and 95-054-PR. (b) An adequate financial system has been established and is operational and financial statements are produced and validated by MOH and are satisfactory to IDA. (c) Adequate incinerating facilities for waste disposal have been built on the premises and are operational. (d) Draft bidding documents, acceptable to IDA, have been prepared and submitted to IDA for review. Execution of the Project (see also Section 4): The Government/Executing Agencies will: (a) Ensure that the positions of Executive Director, accountant and procurement specialist of the Project Implementation Unit (CEP) in MOH are filled at all times with personnel whose qualifications and experience are satisfactory to IDA. (b) Conduct with IDA and other donors comprehensive annual project implementation reviews no later than November 30 of each year. (c) Carry-out with IDA and other donors, no later than December 31, 2000, a midterm review of the project in accordance with terms of reference and monitoring indicators acceptable to IDA. Financial Covenants(see C-4 and Annex 6 on procurement and disbursement arrangements). Disbursements and Special Accounts (see Annex 6 on procurement and disbursement Project Appraisal Document Page 20 Country: Islamic Federal Republic of the Comoros Project Title: Health Project arrangements). Procurement and Consultant's Services (see Annex 6 on procurement and disbursement arrangements) H. Readiness for Implementation [ ] The engineering design documents for the first year's activities are complete and ready for the start of project implementation. CEP staff and consultants currently working on the preparation of engineering design documents. [ ] The procurement documents for the first year's activities are complete and ready for the start of project implementation. CEP staff and consultants currently working on the preparation of bidding documents for the civil works for health facilities, the finalization of which is a condition of effectiveness of the proposed credit. [x] The Project Implementation Plan has been appraised and found to be realistic and of satisfactory quality. Project Appraisal Document Page 21 Country: Islamic Federal Republic of the Comoros Project Title: Health Project I. Compliance with Bank Policies [xl This project complies with all applicable Bank policies. Eileen Murray Nicholas Burnett Michael Sarris Task Team Leader Sector Manager Country Director Project Appraisal Document Annex 1: Page I of 3 Country: Islamic Federal Republic of the Comoros Project Title: Health Project Annex 1 Project Design Summary Comoros: Health Project Narrative Summary Key Performance Monitoring and Critical Assumptions Indicators* Evaluation Sector-related CAS Goal: (Goal to Bank Mission) (1) Poverty reduction (1) Poverty monitoring. Poverty assessments, Economic and socio- through sustained and/or quantitative and political stability, and economic growth by inter qualitative surveys to economic growth. alia providing better monitor (i) the quality infrastructure, and percentage of the population below the (2) Human resource (2) Monitoring of human poverty line, and (ii) development through inter resource development. human resource alia more accessible health development. services. Project Development (Objective to Goal) Objective: To reduce mortality from - Under-five mortality rates - Health statistics and - Food security is common diseases, decreased from 100 per reports from MOH ensured. particularly malaria, by thousand in 1996 to 90 per regional directorates. ensuring a better utilization thousand by the mid-term - There is a reduction in of health facilities for the review and to 75 per thousand - Mini demographic the rate of population delivery of quality health by the end of the project. surveys undertaken by growth. care to the vast majority of independent consultants. the population and by - Number of deaths due to - Other basic social organizing mosquito malaria among under-five - Beneficiary assessments services (such as control activities to reduce children decreased from an by independent education) needed for the incidence of malaria. estimated 800 per year at consultants. human resource present to 700 per year by the development are also mid-term review and to 500 provided. per year by the end of the project. - Number of curative visits per capita per year increased from an estimated 0.4 at present to 0.8 at mid-term and to 1.0 by the end of the project. - Beneficiary satisfaction with services provided. * These are targets, not forecasts, discussed with the MOH. Project Appraisal Document Annex 1: Page 2 of 3 Country: Islamic Federal Republic of the Comoros Project Title: Health Project Narrative Summary Key Performance Indicators M4onitoring and Critical Assumptions Evaluation Outputs: (Outputs to Objective) (I) Increased number of (1) Number of health facilities - Quarterly and annual well functioning health rehabilitated by the project: 2 progress reports prepared - Health sector reforms facilities. by mid-termn and 4 by the end by MOH. continue to be of the project. implemented and - Reports on sales of maintained, and health - Number of health facilities bednets prepared by personnel are paid and equipped to national standards PNAC. drugs are available by the project: 5 by the end of through PNAC or other the project. - Special surveys. channels. - Number of health workers - Midterm and - MOH staff and health trained by the project in completion evaluation personnel trained various medical techniques: reports prepared by MOH continue to work in the 200 by mid-term and 300 by and Bank staff. health sector in Comoros. the end of the project. - Supervision missions by - Involvement of Bank staff. communities in malaria (2) Efficient and - Sales of bednets: 50,000 in control activities to performing malaria control 1998, and 20,000 per year in ensure that impregnated program. 1999 and thereafter. bednets are actually used and that cisterns keep - Number of bednets containing larva eating impregnated: 60,000 in 1998; fish. 80,000 in 1999; 100,000 in 2000; 120,000 in 2001; and 140,000 in 2002. - Starting in 1999 and every year thereafter, number of houses in intensely infected areas receiving three residual sprayings per year: 13,000. - Starting in 1999 and every year thereafter, number of villages where all cisterns have larva eating fish: 241 (211 in Grande Comore and 30 in Anjouan). (3) Improved supportive - Number of MOH personnel and management capacity (at central and regional levels) of MOH. trained: 80 by mid-term and 110 by the end of the project. Project Appraisal Document Annex 1: Page 3 of 3 Country: Islamic Federal Republic of the Comoros Project Title: Health Project Narrative Summary Key Performance Indicators Monitoring and Critical Assumptions Evaluation Project Components/Sub- Inputs: (budget for each (Components to Outputs) components (see Annex 2 component) for project description): (a) Rehabilitation and (a) Total cost of US$ 3.1 - Quarterly and annual - Minimum of political equipment of hospital and million, incl. contingencies. progress reports by stability medical centers. MOH. - Availability of a (b) Malaria control. (b) Total cost of US$ 3.9 - Disbursement reports by sufficient number of local million, incl. contingencies. MOH and Bank. contractors, and training facilities/trainers. (c) Institutional (c) Total cost of US$ 2.4 - Financial audit reports strengthening. million, incl.. contingencies. submitted by independent - Involvement of financial auditors. communities, particularly (d) Project Implementation (d) Total cost of US$ 0.6 for malaria control Unit (PIU). million, incl. contingencies. - Bank supervision activities. mission reports. - PNAC is functioning normally. - Project is properly managed by MOH and Project Implementation Unit (PIU). - Components are implemented in a timely manner and within budgets. Project Appraisal Document Annex 2: Page I of 13 Country: Islamic Federal Republic of the Comoros Project Title: Health Project Annex 2 Health Project Project Description Context In terms of utilization, Comoros' health services continue to rank among the lowest in the world. Despite the fact that more than 80 percent of the population live within a five kilometer radius from a health center, the number of contacts with health services for curative care remains well below 1 per capita per year, and less than 30 percent of deliveries are correctly assisted. Low utilization of services is partly attributable to the population's perception of the inadequate level of health care. Health services are offered in dilapidated buildings which have not been properly maintained and the equipment is mostly non-operational or outdated. In addition, health care staff are unmotivated (due to salary arrears) and in most cases lack basic health care skills. Comoros' health care system is characterized by lack of accountability in hospital management; insufficient resources for health facilities to balance their budget and maintain their equipment; and low efficiency in the use of resources by the public sector. Public hospitals and health centers are staffed with managers who do not know the procedures for accounting for funds. In addition, regional and central units of MOH lack the capacity to plan, monitor, and audit activities performed by the health sector. The administration is also constrained by a reporting system which does not permit administrators to determine the coverage or the unit or total costs of services, to search for more cost-effective ways of providing services or to plan on the basis of results or available resources. Recent years have witnessed the development of a consensus on the need to improve the efficiency of the health care system. A courageous and far-reaching reform program has been adopted which led among other things to the establishment of PNAC, an autonomous institution responsible for the supply of essential generic drugs; and the introduction of cost-recovery mechanisms. In 1994, the Government enacted legislative texts (loi cadre 94-016/AF) rendering the country's public health facilities autonomous and defining their roles (e.g. health care level provided by each type of health facility) and management structure (e.g. hospital to have a Board of Directors, etc.). As a result of these successful and far-reaching reforms, hospitals were transformed into autonomous public health institutions. Cost recovery mechanisms were put in place and are yielding positive results. Preliminary findings from a beneficiary assessment confirm that the population is willing to pay for health care provided that it is of good quality. Expected impact of the project The various components of the project are aimed at reducing the mortality from common diseases, particularly malaria, by ensuring a better utilization of health facilities for the delivery of quality health care to the vast majority of the population (which would be more satisfied with the services provided) and by organizing mosquito control activities to reduce the incidence of malaria. Under the project, the under-five mortality rate is expected to decrease from an Project Appraisal Document Annex 2: Page 2 of 13 Country: Islamic Federal Republic of the Comoros Project Title: Health Project estimated 150 per thousand in 1995 to 100 per thousand by the mid-term review and to 80 per thousand by the end of the project. Also, the number of deaths due to malaria among under-five children is expected to decrease from an estimated 800 per year at present to 700 per year by the mid-term review and to 500 per year by the end of the project. Project Component 1: Rehabilitation and equipment oi Selected Health Facilities - US$ 3.1 million (total cost of component), to be financed by the IDA credit. Context In order for health centers and hospitals to attract patients and provide proper health care, the Government continues to place a high priority on rehabilitarting health facilities. In- 1995, a major rehabilitation program for health facilities began under the IDA financed ongoing PHR Project. In parallel, the PHR Project has been financing on the job training for all health workers in management and health care delivery techniques. These training activities are expected to enable health personnel to deliver good quality health care. Expected impact This component, together with the training of health personnel included in component 3 on institutional strengthening, is expected to increase the beneficiary satisfaction with the services provided and, therefore, to increase the utilization of health facilities, as measured by the number of curative visits per capita per year, which would increase from an estimated 0.4 at present to 0.8 at mid-term and to 1.0 by the end of the project. Hombo Hospital--Anjouan The Hombo Hospital in Anjouan is the reference hospital for approximately 200,000 inhabitants. Significant parts of the hospital including the surgery and maternity wings were rehabilitated under the on-going PHR Project. The main objective of the proposed rehabilitation will be to ensure that the hospital is capable of charging fees for quality services rendered. Experience shows that hospital receipts are mainly derived from the dispensary, the clinic which has individual more luxurious rooms, the radiology department, and the pharmacy. As a result of this analysis, the project will finance the rehabilitation of the above mentioned parts of the hospital. This will enable the hospital to generate enough revenue to subsidize its less profitable units and operate even if it does not receive operating subsidies from the MOH which will probably be the case judging from the previous track record. All rehabilitations will be undertaken using the most cost-effective solution. The base cost for the rehabilitation and equipment of the Hombo Hospital is estimated at $1,010,000. Project Appraisal Document Annex 2: Page 3 of 13 Country: Islamic Federal Republic of the Comoros Project Title: Health Project The following units will be rehabilitated: Dispensary $130,000 Clinic $200,000 Radiology $ 37,500 Miscellaneous $ 62,500 Total $500,000 The following wings will be equipped: Radiology $300,000 Clinic $ 20,000 External consultations $ 135,000 Generator $ 25,000 Vehicle $ 30,000 Total $510,000 Domoni Medical and Surgical Center--Anjouan The Domoni Medical and Surgical Center, located less than 50 kilometers from the Hombo Hospital, could provide primary health care to about one half of Anjouan's population, or about 100,000 people. The center has not been properly maintained due to MOH's lack of funds. The same underlying principle of rehabilitation used for the Hombo Hospital in Anjouan will apply to this health facility. This is to say that Domoni's high revenue generating services will be fully rehabilitated and equipped thereby ensuring that the center will have sufficient receipts to subsidize other less profitable units and operate even if the Ministry of Health does not provide any operating subsidies. Given the proximity of the Hombo Hospital, the Domoni Medical and Surgical Center will operate as a primary health care center, therefore its rehabilitation will not include surgical units. The base cost for the equipment and rehabilitation of the Domoni Medical and Surgical Center is estimated at US$ 478,000. The following units will be rehabilitated: Dispensary $190,000 Hospitalization $ 42,500 Laboratory $ 35,000 Maternity $ 27,500 Total $295,000 Project Appraisal Document Annex 2: Page 4 of 13 Country: Islamic Federal Republic of the Comoros Project Title: Health Project In addition, the following wings will be equipped: Maternity $ 35,000 Laboratory $ 28,500 Clinic $ 20,000 Hospitalization $ 57,000 External consultations s 10,000 Generator $ 7,500 Vehicle S 30,000 Total $188,000 Mitsamiouli Medical and Surgical Center-Grande Comore The Mitsamiouli Medical and Surgical Center is situated in the northern part of Grande Comore. The center comparatively speaking is in fairly good shape due to the fact that American missionaries were heavily involved. The situation has changed since these missionaries have left. However, the center still manages to charge for services including hospitalizations since the inhabitants of the region receive financial support from relatives abroad and therefore are wealthier, willing and able to pay for quality health care. Civil works will consist once again in the rehabilitation of revenue generating entities of the health facility in order for it to generate as much revenue as possible by charging for quality services and be able to subsidize less profitable parts of the health facility and operate even if operating subsidies are not received from the MOH. T-he base cost for the equipment and rehabilitation of the Mitsamiouli Medical and Surgical Center is estimated at US$ 927,900. T-he following units will be rehabilitated: Clinic $135,000 Hospitalization $144,000 Emergency $56,400 Surgery $120,000 Maternity $1 18,000 Total $573,400 Project Appraisal Document Annex 2: Page 5 of 13 Country: Islamic Federal Republic of the Comoros Project Title: Health Project The following wings will be equipped: Maternity $34,500 Laboratory $28,500 Clinic $20,000 Dentistry $45,000 Generator $25,000 Vehicle $15,000 Radiology $90,000 Intensive care $36,000 Surgery, sterilization $61,000 Total $354,500 Health Facilities in Moheli A provision of US$ 100,000 has been made for further rehabilitation activities for the Fombouni Hospital as well as the Wanani Health Center. For the Fombouni Hospital, it is envisaged that a private clinic would be added to this facility as a means for it to generate further revenue for the Wanani Health Center, it is envisaged that the site would be extended to include 2 to 3 more rooms for hospitalization. A detailed proposal including architectural designs, detailed cost estimates and bidding documents would have to be reviewed by the Bank prior to final approval of the works. Implementation In order for these rehabilitation efforts to have a maximum impact in the context of the health sector reforms, the General Directorate of Supervision, Structures and Means (Direction Generale de la Tutelle, des Structures et des Moyens - DGTSM) will have to collaborate closely with MOH's Regional Directorates, the project implementation unit (Cellule d'execution du Projet - CEP), the Boards of Directors and the Management Committees of the health facilities. MOH lacks the expertise to supervise major civil works. Therefore, an engineering/architectural consulting firm acceptable to IDA will be recruited to finalize the architectural designs, prepare bidding documents and participate in bid evaluation. In addition, it will supervise the selected contractors to ensure that works are undertaken based on the agreed upon architectural drawings and specifications. Finally, this firm will issue the substantial and final completion certificates for the works. The General Directorate of Supervision, Structures and Means (DGTSM) will: (a) participate in the selection of the engineering/architectural consulting firm; (b) work with the Project Implementation Unit (CEP) to finalize architectural drawings and equipment lists; (c) approve the detailed cost estimates; (d) participate in the evaluation of bids and the recommendations for awards; (e) and participate in the supervision of the works and in the substantial and final Project Appraisal Document Annex 2: Page 6 of 13 Country: Islamic Federal Republic of the Comoros Project Title: Health Project completion of works processes. The Project Implementation Unit (Cellule d'Execution du Projet - CEP) will: (a) establish the timetable and budget for the component; (b) prepare the documentation to recruit the engineering/architectural consulting firm, call for proposals, evaluate the proposals received and make recommendations for the selection of a firm; (c) prepare the bidding documents for works and goods, call for bids, evaluate the bids and make recommendations for awards; (d) supervise the works and participate in the substantial and final com[pletion of works processes; (e) ensure receipt and appropriate delivery of equipment; and (f) prepare the borrower's part of the Implementation Completion Report (ICR). The Boards of Directors and Management Committees of the health facilities will: (a) define clearly their needs in terms of rehabilitation and equipment; (b) be consulted prior to the finalization of the architectural drawings, equipment lists and implementation timetables; and (c) participate in the review process for the substantial and final completion of works and in the delivery of equipment. The Regional Health Directorates will participate in the supervision of works and in the review process for the substantial and final completion of works. The General Directorate of Public Works (Direction Gdnerale des Travaux Publiques) will ensure adequacy of proposed rehabilitations and will be part of the committee which will prepare bidding documents, evaluate bids and make recommendations for awards. Project Component 2: Control of malaria - US$ 3.9 million (total cost of component), to be financed by IDA credit: $2.3 million; WHO: $0.41 million; UNICEF: $0.13 million; beneficiaries: $0.9 million; and Government: $0.12 million. Context In Comoros, as in most Sub-Saharan Africa, vector-borne diseases, in particular malaria and diarrhea diseases, remain among the most important causes of morbidity and deaths. Malaria, alone, is responsible for 10 to 20 percent of all deaths of children between 0 and 5 years of age, 20 to 25 percent of hospital admissions and close to half of the ambulatory consultations. In the case of malaria, the Government in collaboration with WHO and UNICEF has taken a number of proactive steps to put in place a control program in all three islands. Health facilities have been provided with guidelines for diagnosing and treating malaria. Commendable efforts have been made to ensure regular availability of drugs required for the treatment and chemoprophylaxis of malaria. In addition, district hospitals have been equipped with equipment for laboratory diagnosis, such as microscopes. Recently,, concerns about the development of drug-resistance have led the Government to revise its strategy regarding vector-borne diseases. The new strategy combines two complementary approaches, namely (a) the strengthening of general health services to ensure chemoprophylaxis, adequate diagnosis, and appropriate treatment, and (b) improving the capability for control of disease transmission, through mosquito Project Appraisal Document Annex 2: Page 7 of 13 Country: Islamic Federal Republic of the Comoros Project Title: Health Project control. The strategy is supported by donors, particularly WHO and UNICEF. WHO is committed and will continue to finance the malaria related activities in the health centers (training of health staff, supply of anti-malarial drugs, etc.). UNICEF has agreed to contribute to community mobilization activities and provide selected equipment to MOH's Directorate of Endemic and Epidemiological Diseases. The proposed activities are based on several pilot interventions for mosquito control during the last 50 years. Expected impact This component is expected to decrease the number of deaths due to malaria among under-five children from an estimated 800 per year at present to 700 per year by the mid-term review and to 500 per year by the end of the project. Description In addition to case management, the component will support preventive activities directly related to mosquito control, thus breaking the cycle for the transmission of the parasite. Specific activities include: (a) Case management at all levels of the health services (base cost: US$ 0.5 million, to be financed by WI-HO). This activity aims at improving the diagnosis and treatment of malaria. Within the context of integrated health services, it will include the training of personnel and support for the functioning of a formative supervision system at district, regional and national levels, and it will ensure that the central and the district laboratories are adequately equipped, staffed with competent personnel and operating satisfactorily, and that drugs are available and properly used. It will also include the monitoring of drug sensitivity with support to the operation of sentinel posts for monitoring drug resistance. The chief medical officers of the health districts will be responsible for the implementation of this sub-component, with the assistance of the central and regional directorates for training, supervision and evaluation. The supply of drugs will be the responsibility of PNAC. (b) Indoor residual house spraving (RHS) (base cost: US$ 0.9 million, to be financed by IDA and Government). This activity will be limited to areas where malaria and filariosis is highly transmittable and where the reproduction of the vector takes place in a multitude of gites larvaires which are scattered and difficult to access. These areas include Moheli (all the three health districts) and the southwest part of the island of Anjouan (the two health districts of Pomoni and Sima). The insecticide to be chosen will have a limited toxicity and will not cause environmental damage. Pyrethrinoide-based insecticides are prime candidates and the insecticide to be used will be considered after it has been approved by WHO and vector susceptibility tests completed. The chief medical officers of the health districts will be responsible for the implementation of this sub-component, with the assistance of the SLMTV for the selection of insecticides (technical specifications), the storage and delivery of insecticides to districts, the training of spraying Project Appraisal Document Annex 2: Page 8 of 13 Country: Islamic Federal Republic of the Comoros Project Title: Health Project personnel and the supervision of the spraying, and with the participation of the CEP for the procurement of insecticides. Starting in 1999, and every year thereafter, about 13,000 houses (corresponding to a population of about 65,000) will receive three residual sprayings per year. (c) Treatment of breeding areas of Anophelines with larvivorous fish or larvicides (base cost: insignificant - less than $10,000 - to be financed by IDA). This activity will take place mainly in Grande Comore and in parts of Anjouan where water basins (bassins d'ablution) in dwellings as well as mosques constitute the only places where the vector is reproduced. This activity will entail the construction and/or rehabilitation of 9 breedinlg basins, the maintenance of those breeding basins, and the supply of larva eating fish to the breeding basins and, from them, to the village cisterns. The CEP will be responsible for the rehabilitation/construction of the breeding basins. The SLMTV will be responsible for the supply of fish to the breeding basins, and the health districts will be responsible for the supply of fish to village cisterns with the active participation of communities. Regional health teams will carry out intense site supervision to ensure that cisterns have at all time larva eating fish. Starting in 1999, and every year thereafter, all the cisterns in 241 villages (211 in Grande Comore and 30 in Anjouan) will have larva eating fish. The population to be protected by this activity is estimated at about 345,000 living in about 69,000 houses. (d) Sunplv. distribution and impregnation of bednets with pyrethroid insecticides (base cost: US$1.3 million, to be financed by IDA and beneficiaries). This activity's main objective is to promote the utilization of impregnated bednets at a price which is accessible to the population. The project will finance the purchase in 1998 of 50,000 bednets which will be distributed to the health facilities to be sold to households. The proceeds from these sales will be used for the purchase of additional bednets (20,000 per year in 1999 and thereafter). These bednets will be impregnated with pyrethrinoide insecticide every 4 to 6 months by the health technician of the district under the supervision of the health district medical officer. The procurement of the first 50,000 bednets will be done by the CEP on the basis of technical specifications prepared by the SLMTV. These bednets will be distributed to health facilities, using as a basis, the population served. The number of bednets sold is estimated at 50,000 bednets in 1998, and at 20,000 per year in 1999 and thereafter. The number of bednets to be impregnated is estimated at 60,000 in 1998; 80,000 in 1999; 100,000 in 2000; 120,000 in 2001; and 140,000 in 2002. (e) IEC campaigns to increase community participation in the control of vector-borne diseases (base cost: US$ 0.1 million, to be financed by UNICEF). E-very year, three malaria awareness days will be organized. In addition, information sheets on malaria will be integrated in school curriculum, and pamphlets will be distributed in all the public areas of each village. The Project Appraisal Document Annex 2: Page 9 of 13 Country: Islamic Federal Republic of the Comoros Project Title: Health Project SLMTV, in collaboration with the IEC division of MOH and with the CEP, will be responsible for the implementation of this sub-component. (f) Strengthening MOH's Division for Vector-Borne Diseases - Service de Lutte contre les Maladies ai Transmission Vectorielle - SLMTV (base cost: US$ 0.6 million, to be financed by IDA). This will include the rehabilitation of offices and laboratories, the provision of equipment and technical assistance, as well as logistical support for this MOH division. The CEP, in collaboration with the SLMTV, will be responsible for the implementation of this sub- component. Implementation Arrangements Generally, the MOH's Division for Vector Borne Diseases (Service de Lutte contre les Maladies a Transmission Vectorielle-SLMTV) will oversee the implementation of the malaria control component. The SLMTV will work in close collaboration with the three regional directorates, the health districts, the project implementation unit (Cellule d'Execution du Projet--CEP), the PNAC, and the IEC division of MOH. It will also enlist the participation and support of community groups and village elders (notables) through IEC campaigns at the village level. More specifically, the SLMTV will: (a) prepare annual work programs explicitly defining the activities that need to take place during the following year and the corresponding detailed budgets; (b) prepare the technical specifications for the bednets and insecticides, and for the breeding basins; (c) deliver larva eating fish to health districts breeding basins; (d) store the insecticides for house spraying purchased by CEP, and deliver them to the health districts; (e) train the personnel that will do the indoor residual house spraying, and supervise such spraying; (f) in collaboration with the IEC division and CEP, implement the sub-component to increase community participation; (g) in collaboration with CEP, implement the sub-component for the strengthening of SLMTV; (h) closely liaise with UNICEF and WV-HO; and (i) prepare quarterly progress reports including the monitoring of mortality and morbidity indicators. The health districts will be responsible for the case management sub-component, the sale of bednets to households, the impregnation of bednets, the delivery of larva eating fish to village cisterns, and the indoor residual house spraying. The CEP will be responsible for the initial purchase of 50,000 bednets and for the procurement, through WHO, of insecticides, the construction/rehabilitation of breeding basins, the logistical aspects of the IEC campaigns to increase community participation, and the strengthening of the SLMTV. The PNAC will be responsible for the supply of drugs for case management and chemoprophylaxis. Community groups will be responsible for creating malaria awareness among the population in order to ensure in particular that impregnated bednets are actually used and that cisterns keep containing larva eating fish. Project Appraisal Document Annex 2: Page 10 of 13 Country: Islamic Federal Republic of the Comoros Project Title: Health Project Project Component 3: Institutional Strengthening to Facilitate and Support the Increased Utilization of Quality care by the Population and the Further Implementation of the Health Sector Reforms - US$ 2.4 million (total cost of component), to be financed by the IDA credit. Context Health sector reforms have already yielded positive results on the ground. However much remains to be accomplished in order for these reforms to have a long-term positive impact on the Comorian health system. The MOH needs guidance oni how best to fulfill its new mandate. MOH does not have the capacity to supervise properly the various on-going health projects, including the planning and monitoring of national as well as regional health policies and strategies. In addition, MOH has not been able to coordinate the external aid flowing into the health sector, therefore it is not making optimum use of its resources. Even though financial as well as managerial audits are undertaken on a piecemea,l basis, MOH lacks the expertise and leverage to provide constructive recommendations as to how best improve the situation in the various health facilities. Despite donor financing, for a variety of reasons, MOH has not been able to put in place a viable health statistics system and therefore health statistics are virtually non-existent. On the management side, MOH lacks the capacity to properly manage its personnel, and make the necessary personnel assignments; therefore several key positions such as midwives and accountants are currently vacant. Also, MOH is not in a position to judge, or even less to quantify the resources necessary to put in place various programs at the level of each health facility. Finally, without some form of health insurance or other social protection mechanism, there is a risk that the sustainability of the cost recovery system may be achieved at the expense of equity. Particularly noteworthy among the health sector reforms was the implementation of an important personnel redeployment plan. Five hundred non-qualified workers were laid off in 1994 and the Ministry's skill mix was reassessed to ensure that health facilities had the most suitable candidates in each position. Seventy five health workers were transferred among the various health facilities and 127 licensed health practitioners were recruited to fill in key positions. In addition, ten Comorian doctors who were studying abroad were offered a competitive package to return home after studying abroad. Finally, there are still doctors studying abroad who will return by December 1998. The ongoing PHR Project includes an important training program consisting of both short-term and long-term training in Comoros by the Centre National de Formation et de Recherche en SantJ Publique (CNFRSP) with the support of an expatriate consultant and the participation of a foreign training institution. This training program, which started in June 1997, is covering: the new administrative organization and management modalities and procedures of the health system; proficiency in health care priority programs; IEC tools, methods and practices; laboratory techniques; and use of computing for management and health statistics. The objective of this component is to eliminate certain key elements impeding on the reform process and to upgrade the skill mix of MOH staff. This will include the provision of: (a) further training of MOH and health center staff; (b) specialized technical assistance in management, Project Appraisal Document Annex 2: Page 11 of 13 Country: Islamic Federal Republic of the Comoros Project Title: Health Project programming, health sector finance and select public health programs such as malaria; (c) long- term technical assistance in health sector management; (d) equipment and supplies in order for MOH to properly operate; and (e) funds to study mechanisms to put in place a health insurance scheme which corresponds to the country's demographics as well as the financial situation of the population. Expected Impact The component is expected to enable various MOH units to operate in accordance with their responsibilities under the health sector reforms and to increase the professional competence of health facility personnel for the delivery of quality health care. It will also prepare the ground for the introduction of some form of health insurance. Description (a) Training of MOH and Health Facility Staff (base cost: US$ 1.5 million, to be financed by IDA). The training program will complement the training provided under the ongoing project and will strengthen technical competencies at all levels. It will develop clinical, preventive and health care and IEC skills of health facility personnel, and MOH staff skills to manage the health system. The program will continue to be based on in-country short-term as well as longer-term training. For long-term training, diplomas will be awarded in order to increase the number of staff with post-baccalaureate diplomas. The staff of MOH central units will receive short-term training in techniques for supervision (tutelle), planning and programming, administrative management, IEC, as well as legal aspects and issues of the health sector and personnel management, and computing for the production and management of national health and epidemiological statistics. The staff of MOH regional directorates will receive short-term training in techniques for delegated supervision, and integration, planning and monitoring of priority programs, as well as in the collection and processing of health and epidemiological data at the regional level, and the production of IEC materials also at the regional level. MOH staff in both central units and regional directorates will receive long-term training in: (i) economics and management of health and social institutions; (ii) law and regulations on administrative, health and social matters; and (iii) public health, community health, epidemiology and statistics. Six staff of MOH central units will also receive long-term training in the pedagogy of health sciences (training of trainers). The personnel of health facilities will receive short-term training in public health and on-the-job training in medical techniques (doctors, midwives and nurses), as well as practical training in IEC in health centers and health posts. Long-term training will involve the specialization (similar to an initial basic training) of health care personnel: nurses in anesthesiology, operating room technicians, surgical instruments assistants, and pharmacist assistants. Project Appraisal Document Annex 2: Page 12 of 13 Country: Islamic Federal Republic of the Comoros Project Title: Health Project More than 400 staff will be trained (mostly in 1999 and 2000), with the following distribution by category and over time: MOH MOH Health Total central regional facilities units units By the mid-term review short-term training 40 18 210 268 long-tern training 26 3 40 69 Sub-total 66 21 250 337 At the end of proiect _ short-term training 40 1 8 210 268 long-term training 46 9 88 143 Grand total 86 27 298 411 (b) Logistical Support to MOH's Central and Regional Directorates and to PNAC (base cost: US$ 0.7 million, to be financed by IDA). In order for the central and 3 regional directorates to be able to fulfill their mandate of properly following up on the reform process at the level of health facilities, a vehicle, a motorcycle and basic office equipment will be provided for each regional directorate. The Pharmacie Nationale Autonome des Comores, or PNAC, will also be provided with some essential equipment. Finally, this sub-component includes technical assistance for a total of 48 person/months. (e) Mutual Health Insurance Scheme (base cost: US$ 0.1 million, to be financed by IDA). The project will finance operational research in mutual insurance mechanisms for health coverage. This will include the development in selected sites of Anjouan and Moheli of community based health insurance scheme taking into account lessons learnt from a UNDP financed project in the health district of Mitsoudj&Hambou. On the basis of lessons learnt, a proposal will be made at the time of the mid-term review to replicate the most appropriate scenario nationwide. Implementation Arrangements Training Activities will be implemented through the MOH's training center, Centre National de Formation et de Recherche en Sante Publique (CNFRSP). MOH's Training and Research Division will be responsible for reviewing curricula to ensure that it is consistent with its general orientations. The CEP will be responsible for inviting proposals from short-listed firms and making recommendations for the selection of a specialized training institution from abroad which will be responsible for long-term training activities. This training facility will have to be able to award diplomas. Regarding the logistical support to MOH's Central and Re gional Directorates and to PNAC, the CEP will be responsible for the procurement of the vehicles, motorcycles and office equipment and for ensuring their proper delivery to the three Regional directorates; it will do the same for the equipment to be provided to PNAC. As to the technical assistance, the CEP will recruit the Project Appraisal Document Annex 2: Page 13 of 13 Country: Islamic Federal Republic of the Comoros Project Title: Health Project consultants and consulting firms on the basis of terms of reference prepared in consultation with the users of that technical assistance. For the mutual health insurance scheme, the CEP will recruit an international consulting firm with prior experience in health insurance schemes in developing countries. In this context, it will be responsible for finalizing the terms of reference with the Secretary General of MOH, preparing the short-list of potential consulting firms, review proposals and recruit the most suitable firm. In addition, three nationals with experience in health sector management issues will work with the international team in order to provide the Comorian perspective. They could also be utilized as resource persons when the agreed upon health insurance system will actually be put in place. Note: A Project Implementation Manual prepared by MOH, which includes more details on the project's objectives, description, timetable and modalities of implementation as well as costs, can be found in the project file. This document will be used as a basis for field supervision during the project implementation phase. Project Appraisal Document Annex 3: Page I of I Country: Islamic Federal Republic of the Comoros Project Title: Health Project Annex 3 Health Project Estimated Project Costs (in US$ million) Project Component Local Foreign Total (1) Rehabilitation of Selected Health Facilities - 2.6 2.6 (2) Control of malaria 0.3 3.2 3.5 (3) Institutional Strengthening _ _2.2 2.2 Sub-total Project Components 0.3 8.0 8.3 Project Implementation Unit 0.5 0.1 0.6 Total Baseline Cost 0.8 8.1 8.9 Physical Contingencies _ _0.3 0.3 Price Contingencies 0.1 0.7 0.8 Total Project Cost 0.9 9.1 10.0* * Excluding USD$ 700,000 for duties and taxes. Project Appraisal Document Annex 4: Page I of 14 Country: Islamic Federal Republic of the Comoros Project Title: Health Project Annex 4 Health Project Financial and Economic Analysis I. Introduction The project development objective is to reduce the mortality from common diseases, particularly malaria, by ensuring a better utilization of health facilities for the delivery of quality health care to the vast majority of the population and by organizing mosquito control activities to reduce the incidence of malaria. The principal outcome / impact of the project will be a reduction in the under-five mortality rate from 100 per thousand in 1996 to 90 per thousand by the mid-term review and to 75 per thousand by the end of the project; also, the number of deaths due to malaria among under-five children is expected to decrease from an estimated 800 per year at present to 700 per year by the mid-term review and to 500 per year by the end of the project. This annex examines the following aspects of the financial analysis and economic justification of the project: (a) economic and sectoral context; (b) financial analysis of the health sector; (c) cost- effectiveness analysis for the rehabilitation and equipment of selected health facilities; (d) cost- effectiveness analysis for the control of malaria; and (e) cost-effectiveness analysis for the institutional strengthening. II. Economic and sectoral context The Federal Islamic Republic of the Comoros is one of the poorest countries in the world, with real per capita income of about US$ 460 (1996) and an estimated human development index of 0.331. Independent since 1975, the country suffers from a weak administrative apparatus and a shortage of qualified personnel on all levels of the public administration and the private sector. The technical and administrative constraints are compounded by growing foreign trade imbalances (with the drop in the prices of vanilla, ylang-ylang and other export crops, and the increasing imports of food stuff, particularly rice), inadequate basic infrastructure, lopsided national income distribution, the inappropriate framework of institutions, laws, and regulations, and the adverse effects of population growth. Under these conditions, the drastic measures taken in the context of the structural adjustment program to bring about macroeconomics reforms have been unable to reverse the pattern of sluggishness and social regression observed in recent years. On balance, the results of the reforms have been very modest although they have led to a substantial reduction in the budget deficit and stabilized inflation. However, these results have been obtained through sacrifices, extremely high social costs, and stagnation in investments. The country's health sector has been hardest hit. Its budgetary allocations represent about 5% - 6% of the country's consolidated budget, a far cry from the 10% recommended by the WHO. Those allocations have been to a great extent theoretical since operating subsidies are not paid to health facilities (exceptionally, 1995 allocations were paid in 1996) and the payment of salaries to civil servants is very irregular. The inadequacy of this government financing is in complete contrast to the official policy that gives priority to the social Project Appraisal Document Annex 4: Page 2 of 14 Country: Islamic Federal Republic of the Comoros Project Title: Health Project sectors. On the other hand, the contribution of the population to the operating costs of the health sector has been increasing substantially in recent years. Over the last five years (1993-1997), annual spending on health in Comoros represented on average about US$ 14 per capita, or about 3% of GDP. The project has been designed taking into account the quickly changing economic, sociological and political environment and the important changes in the distribution of responsibilities in the functioning of the health system. The consequences of this rapid socio-economic evolution are reflected in the choice of the objectives that have been selected to define the project components, which have also been influenced by the constraints facing the sector. It would be unrealistic to expect that the Government could make any significant contribution to the financing of the sector. The shift away from Government towards user financing seems irreversible; it should be encouraged and facilitated, together with the promotion of measures to develop savings, solidarity and social protection. Realistic and pragmatic economic objectives are, therefore, absolutely necessary for the project. They can be summarized as follows: (a) to strengthen the productive capacity (for preventive as well as curative care) of the health system; (b) to support the central units of MOH to enable them to exercise their new responsibilities for supervision (tutelle), planning and evaluation; (c) to give the priority to investments capable of: * generating additional financial resources (rehabilitation of health facilities, improvement of the quality of health care through training, etc.); * reducing expenditures (control of malaria); * promoting the development of a local economic activity (financing of new equipment for PNAC, etc.); and * facilitating the establishment of a mechanism for the financing of health insurance and the development of savings. The contents of the project have been carefully selected on the basis of the following criteria: (i) Government's priorities and its concern for national reconciliation; (ii) the socio-economic and political context; (iii) the performance of the health system and of the MOH; (iv) the results and impact (or lack thereof) of past experiences; (v) the implications of the different components regarding the needs for operation and maintenance and the nleans (available or to be provided) to cover those needs; (vi) the components' impact on development, and on the revenues of health facilities as well as on the health of the population; and (vii) the financing that could be provided by other donors in the context of other projects or programs. Project Appraisal Document Annex 4: Page 3 of 14 Country: Islamic Federal Republic of the Comoros Project Title: Health Project III. Financial analysis of the health sector To address the many problems in the sector, the country adopted in 1991 a national health development plan - revised in 1993 - which sets out the main priorities for the country's health policy to the year 2010. This was done in response to the 1978 Alma-Ata Declaration, the 1987 Bamako Initiative, and the three-phase health development scenario (Lusaka-Zambia, 1985), which the country has adhered to. In parallel, Comoros initiated comprehensive reforms of its health system, with the introduction of more or less complete autonomy for the health facilities and of community participation in the financing and management of those health facilities. The design and implementation of those reforms were supported by the ongoing Population and Human Resources Project. The proposed project (physical rehabilitationand equipment of health facilities, malaria control and institutional strengthening) is consistent with the country's priorities and will continue to support the reforms. The present section analyses the financial situation of the health sector. Overall, the sources of financing of health expenditures - which represent the different players involved in health services spending - can be grouped into four main categories: . The Government's budget: ordinary and special budget items covering operating and investment costs; * Official foreign aid: (grants and loans) included in the public investmentprogram (PIP); * Unofficial foreign aid: (grants only) not included in the PIP; and * Community financing: user fees and revenues from the sale of drugs. Table 1 presents an overall picture of the financing of the health sector over the last five years (1993-1997). The following paragraphs discuss the government budget and community financing, and attempt to present in Tables 6 and 7 a forecast for the financing of the health sector for the next five years (1998-2002). Project Appraisal Document Annex 4: Page 4 of 14 Country: Islamic Federal Republic of the Comoros Project Title: Health Project Table I Financing of the Health Sector (1993-1997) (in thousands US $) 1993 1994 1995 1996 1997 Investment Costs 840 1,212 1,387 1,010 1,087 Financing Government Budget Loans 238 367 415 340 366 Grants 442 682 770 631 680 Communities - 38 20 - NGOs 160 125 182 39 41 Total Financing 840 1,212 1,387 1,010 1,087 Operating Expenses of MOH, including priority programs 2,359 2,765 2,590 2,445 2,501 Financing Govemment Budget 545 532 512 248 400 Loans 425 7t82 802 769 735 Grants 1,389 1,451 1,276 1,428 1,366 Total Financing 2,359 2,765 2,590 2,445 2,501 Operating Expenses of Health Facilities 3,099 2,933 3,743 2,573 5,442 Financing GovernmentBudget 1,165 1,'138 1,088 527 1,100 Loans 234 183 266 152 728 Grants 434 339 493 281 1,353 Communities 758 876 1,319 1,219 1,847 NGO 508 397 577 394 414 Total Financing 3,099 2,933 3,743 2,573 5,442 Total Financing of the Health Sector 6,298 6,910 7,720 6,028 9,030 Project Appraisal Document Annex 4: Page 5 of 14 Country: Islamic Federal Republic of the Comoros Project Title: Health Project A. GovernmentBudget Trends in budget allocations Budget allocations for health were virtually stagnant from 1993 to 1997 (Table 2), growing only at about 1% a year, which is lower than growth in GDP (1.3% a year) or the population growth rate (3.1%). In 1996, the government allocated US$ 2.28 million to the health sector, or about 5.4% of the national budget. Of this allocation, 71% was to be spent on salaries, 7% on goods and services, and 22% on subsidies (Table 3). In 1997 the budget assumes an increase of less than 1% over 1996 (US$ 2.29 million), with 78% to be spent on salaries, 5% on goods and services and 17% on subsidies. Table 2 Trends in Budget Allocations for Health (In US$ million) 1993 1994 1995 1996 1997 Health Budget 2.26 2.27 2.20 2.28 2.29 Governmentbudget(total) 33.82 37.67 39.97 42.18 41.18 Allocations for Health as % of total budget 6.7% 6.0% 5.5 5.4% 5.6% Table 3 Theoretical Distribution of Health Expenditures (in US$ million) 1993 1994 1995 1996 1997 $ M. % S M. % $M. % $M. % $M. % Personnel 1.58 70 1.50 66 1.56 71 1.62 71 1.79 78 Goods and services 0.57 25 0.70 31 0.16 7 0.16 7 0.11 5 Subsidies 0.11 5 0.07 3 0.48 22 0.50 22 0.39 17 Total for Health 2.26 100 2.27 100 2.20 100 2.28 10o 2.29 100 Budget execution: difficulties and prospects Table 4 below summarizes data regarding the execution of the budget from 1993 to 1996 and provides an estimate for 1997, whereas Table 5 shows the percentages of realization by categories of expenditures. Project Appraisal Document Annex 4: Page 6 of 14 Country: Islamic Federal Republic of the Comoros Project Title: Health Project Table 4 Execution of the health budget (In US$ million) 1993 1994 1995 1996 1997 Health budget 2.26 2.27 2.20 2.28 2.29 Execution of Health Budget 1.71 1.67 1.60 0.78 1.50 Percentage of Execution 76% 74% 73% 34% 66% Table 5 Execution of the Health Budget by categories of expenditures Percentages of Realization 1993 1994 1995 1996 1997 $M. % $M. % $M. %/0 $M. % $M. % Personnel 1.58 100 1.50 100 1.15 74 0.78 48 1.50 84 Goods/ 0.11 20 0.15 21 0 0 0 0 0 0 services Subsidies 0.02 18 0.02 29 0.45 93; 0 0 0 0 Total Health 1.71 76 1.67 74 1.60 73 0.78 34 1.50 66 Clearly, Goverm-nent experienced great difficulties to execute its approved budget. In practice, since 1991 budget execution is more or less limited to the payment of salaries of civil servants, and even those are not always paid on time. Arrears have started to accumulate in 1995 and have been particularly important in 1996, so that at present cumulative arrears represent about ten months salaries. Regarding the operating subsidies for health facilities, the amount actually paid has varied between 0 and 20% of the budget allocation. The only exception has been the year 1995, the first year of implementation of the financial and budgetary autonomy of health facilities, when operating subsidies were paid in full at the beginning of 1996. In 1997, no health facility has received any operating subsidy, but on the other hand the performance of the Government for the payment of salaries for the first nine months has been better than in 1996. The estimate of US$ 1.5 million equivalent for government financing (budget realization) for 1997 would represent about 15 percent of the total financing for the health sector as a whole (Table 1). B. CommunityFinancing The current reform of the health system is betting on cost recovery from the community, and is on its way to winning the bet judging from the results obtained in hospitals and health districts. If the system is not fully satisfactory yet, it is not because of the inability of the communities to pay but rather the result of poor structural organization in the sector and the fact that adequate financial management systems are not fully operational in all health facilities. Project Appraisal Document Annex 4: Page 7 of 14 Country: Islamic Federal Republic of the Comoros Project Title: Health Project An analysis of cash generation by health facilities undertaken recently in connection with the introduction of new management tools indicates that one can be reasonably optimistic about the ability of those facilities to raise revenues since even the most optimistic forecasts have been exceeded. Table 1 shows a very substantial increase in revenues from communities over the past five years; those revenues include both user fees and receipts from the sale of drugs. In particular, cost recovery in 1997 is estimated at the equivalent of about US$ 1.85 million, an increase of about 50 percent over the revenues collected in 1996. In 1997, community financing would represent about 20 percent of the total financing for the health sector as a whole and would cover about one- third of the operating expenses of health facilities. C. Financing of the Health Sector for the next five years (1998-2002) Financial forecasts for the next five years shown in Tables 6 and 7 are based on the following assumptions derived in part from past experience in the health sector: * Government contribution to the financing of the health sector (in the range of US$ 1.7 million per year) will cover essentially the salaries and other personnel costs of civil servants working in the MOH or in health facilities. Of course, the Government will also have to service the debt incurred for the health sector, but this debt servicing is not included in the financial forecasts shown in Tables 6 and 7. * Government will mobilize the necessary financing, in the form of loans and grants, from donors to cover all of the investments costs and part of the operating expenses of the sector, including major rehabilitation of structures, equipment replacement and training of health personnel. * Health facilities will be able to generate enough revenue to operate and maintain their structures and equipment, even if they do not receive operating subsidies from the Government. Project Appraisal Document Annex 4: Page 8 of 14 Country: Islamic Federal Republic of the Comoros Project Title: Health Project Table 6 Financing of the Health Sector for the five-year period 1998-2002 (in M. US $) % InvestmentCosts 4.6 Financing GovernmentBudget Loans 3.5 Grants 0.9 Communities NGOs 0.2 Total Financing 4.6 10 Operating Expenses of MOH, including priority programs 13.2 Financing GovernmentBudget 2.1 Loans 4.0 Grants 7.1 Total Financing 13.2 30 Operating Expenses of Health Facilities 26.2 Financing Government Budget 6.4 Loans 4.0 Grants 3.8 Communities 10.0 NGOs 2.4 Total Financing 26.6 60 Total Financing of the Health Sector 44.4 100 Project Appraisal Document Annex 4: Page 9 of 14 Country: Islamic Federal Republic of the Comoros Project Title: Health Project Table 7 Summary of health sector financing forecast for 1998-2002 inM.US$ % Governmentbudget 8.5 19 Loans 11.5 26 Grants 11.8 26 Communities 10.0 23 NGOs 2.6 6 Total 44.4 100 The assumption that health facilities will not receive any operating subsidies is realistic in view of the deplorable track record of the Government. It is also realistic to assume that health facilities will be able to collect from communities the equivalent of about US$ 2.0 million per year and to operate even without operating subsidies from Government provided, however, that: (i) health facility personnel who are civil servants are paid regularly by Government; (ii) the cost of training health personnel is financed by Government or donors (ii) major physical rehabilitation of structures and equipment replacement are financed by Government or donors; (iii) health facilities are managed and operated correctly and efficiently; (iv) health facilities can manage and operate their own pharmacies; and (v) certain parameters (such as the percentage of health services provided free to those who cannot pay, and the invoicing based on lump sum amounts) remain within acceptable limits. In the absence of operating subsidies to health facilities, the regular payment of salaries to civil servants working in those health facilities is particularly important. If salaries are not paid, the collected user fees and proceeds from the sale of drugs are likely to be diverted to provide some form of compensation to personnel to enable them to survive, instead of being used for the purchase of drugs and the operation and maintenance of the facilities. The financial forecasts show that a substantially higher level of expenditures for health (close to US$ 18 per capita, compared to about US$ 14 on average for the last five years) could be achieved and financed through a reasonable mix of budgetary allocations, grants and loans, and community contributions. It is worth noting that for the next five years the community contributions would represent about 23 percent of the total financing for the health sector as a whole, but about 38 percent of the operating expenses of health facilities. IV. Cost-effectiveness analysis for the rehabilitation and equipment of selected health facilities The component to rehabilitate and equip public health facilities is part of the reform of the national health system launched three years ago, which is based on community participation, autonomous management of health facilities, user fees for medical care and procedures, sales of drugs, and decentralization. The effort to rehabilitate and equip is based on the repeatedly-observed fact that the public is always willing to pay whenever quality care is offered and delivered. Project Appraisal Document Annex 4: Page 10 of 14 Country: Islamic Federal Republic of the Comoros Project Title: Health Project The rehabilitation and equipment of the Hombo hospital and the Domoni medical and surgical center in Anjouan, the Mitsamiouli medical and surgical center in Grande Comore and of selected facilities in Moheli are intended to facilitate the delivery of good quality health care to the population, which will also have a favorable impact on cost recovery by those health facilities. The component is estimated to cost the equivalent of US$ 3.1 million, including contingencies. This component, together with the training of health personnel included in component 3 on institutional strengthening, is expected to increase the beneficiary satisfaction with the services provided and, therefore, to increase the utilization of health facilities, as measured by the number of curative visits per capita per year, which would increase from an estimated 0.4 at present to 0.8 at mid-term and to 1.0 by the end of the project. The component has been designed taking into account the condition of existing structures and equipment and the necessity to adopt the most cost-effective solution, through least-cost rehabilitation and limiting new constructions (the cost of rehabilitation usually vary between 45 and 65 percent of the cost of a new construction) and through the purchase of appropriate equipment (i.e., the least expensive equipment, but also the one that is the easiest to operate and maintain). Intended to strengthen the capacity for preventive and curative care, the component aims at ensuring better case management and at allowing for the hospitalization of patients with a minimum of comfort, hygiene and cleanliness. Most importantly, the design of the component has taken into account its direct impact not only on the health of the population but also on the revenues of the health facilities. During project identification/preparation, two options have been discussed for the rehabilitation and equipment. The first option consisted of a minimum package of rehabilitation and equipment with revenue-earning potential and assumed that the health facilities will be able to operate satisfactorily even if the Government does not provide them with any operating subsidy. The second option included also additional rehabilitation and equipment that could be justified only if the Government commits itself to pay operating subsidies. The adoption of this second option would imply operating costs too high to be covered only by user fees paid by beneficiaries. In view of the deplorable track record of the Government f-or the payment of operating subsidies to health facilities, the minimum package of rehabilitation and equipment has been selected. The main objective of the component, as now designed, is to ensure that those health facilities are capable of charging fees for quality services rendered and are financially self-sustaining. Experience shows that hospital revenues are mainly derivecl from the dispensary, the clinic which has individual more luxurious rooms, the maternity, the radiology department, and the pharmacy. For each health facility, the selection of the specific units to be rehabilitated and equipped has been based on this analysis. This will ensure that the health facilities will be able to generate enough revenue to subsidize their less profitable units and operate even if they do not receive operating subsidies from the Government provided, however, that the conditions listed in paragraph 20 of this annex are met. The income from user fees and from the sale of drugs has been an indicator of the capacity of health facilities to self-finance their activities. Despite the many shortcomings in hospital services and the Project Appraisal Document Annex 4: Page 11 of 14 Country: Islamic Federal Republic of the Comoros Project Title: Health Project absence of government financing, all the health facilities have been able to maintain a reasonable level of activity. In this respect, the KMF 21 million, KMF 10 million, and KMF 25 million in revenues collected respectively at Hombo, Domoni, and Mitsamiouli in 1996 are indicators of the potential of these health care facilities. At present, the fees introduced in 1995 are only partially applied in public establishments because of equipment shortcomings and the lack of means in certain hospitals, especially for hospitalization. Also, activities at Hombo were disrupted during all of 1996 owing to construction works within the hospital grounds and the unexpected departure of some doctors to pursue specialized studies, while activities were curtailed at Domoni and Mitsamiouli mainly because of the absence of a physician. With regard to the regional hospital at Hombo, many patients from Anjouan are still forced to travel to Grande Comore at considerable expense if they require special x-rays or an ultrasound which can only be performed at Moroni. If these tests could be performed in Anjouan, the financial burden on these patients of finding the money for transportation and accommodation would be alleviated. Improvements in the availability of equipment and in conditions for hospitalization at the regional hospital in Hombo and in the medical and surgical centers in Domoni and Mitsamiouli, would result in a significant increase in the volume of activity at these facilities. It is also likely that an improvement in the quality of health care would result in increased use of services by the population. There is no doubt that the rehabilitation and equipment of a number of units at Hombo, Domoni and Mitsamiouli will lead to a considerable increase in the income they earn, so that they will no longer be dependent on hypothetical government subsidies. On the basis of the fees in effect in the different health facilities, the regional hospital in Hombo can be expected to earn between KMF 60 million and 80 million per year, and the medical and surgical centers at Domoni and Mitsamiouli between KMF 30 million and 40 million per year. V. Cost-effectiveness analysis for the control of malaria The Comorian Government has included control of malaria and Bancroft's filariasis among its top priorities. In its view, malaria is one of the greatest obstacles to the country's socioeconomic development. No precise data are available on morbidity and mortality in Comoros. Still, incomplete hospital statistics suggest that malaria could be responsible for 20% to 25% of hospital admissions. The magnitude of endemic malaria demonstrated by different parasitological studies suggests that its incidence is similar to the general estimates for tropical Africa among children under five, and accounts for 10% to 20% of all deaths in that age group. Parasite studies conducted between 1950 and 1989 show that the parasite index among children under five ranges from 30% to 80%. The indirect impacts of chronic malaria generally include anemia, low birth weight, and higher maternal morbidity and mortality. Moheli is known as one of the largest focuses of filariasis in Africa, with an overt infection rate of 20% in adults (Blanchy & Benthein, 1989). The debilitatingeffects of this disease are large. The malaria control component is expected to decrease the number of deaths due to malaria among under-five children from an estimated 800 per year at present to 700 by the mid-term review and to 500 by the end of the project. In addition to case management, the component will support activities directly related to mosquito control, thus breaking the cycle for the transmission of the parasite. Specific activities include: (a) case management at all levels of the Project Appraisal Document Annex 4: Page 12 of 14 Country: Islamic Federal Republic of the Comoros Project Title: Health Project health services; (b) indoor residual house spraying (RHS); (c) treatment of breeding areas of anopheles with larvivorous fish or larvicides; (d) supply, distribution and impregnation of bednets with insecticides; (e) IEC campaigns to increase community participation in the control of vector-borne diseases; and (f) strengthening MOH's division for vector-borne diseases - Service de Lutte contre les Maladies a Transmission Vectlorielle - SLMTV. The total cost of the component is estimated at US$ 3.9 million, including an important contribution of US$ 0.9 million by beneficiaries for the purchase and impregnation of bednets. The reliance on an integrated program coordinating the activities of health services and communities and developing complementary vector control as required is the most efficient and cost-effective. The selection of the specific activities is based on the characteristics of each island which allow for different approaches with great variances in costs (it is worth noting that the cost of treatment of breeding areas of anopheles with larvivorous fish or larvicides -- a very effective form of vector control for Grande Comore -- is negligible). Malaria has tremendous direct and indirect costs for governments (ministries of health) as well as family economies, placing a strain on tight family budgets. The direct costs generated by malaria are basically the expenditures for treatment. Treatment might include drugs, diagnostic tests, attention from a doctor/nurse/healer, transport and associated out-of-pocket expenses in seeking treatment (for patient and whoever accompanies him/her) and possibly additional food -- food losses occur because of the increased rate of metabolism during malaria attacks. The indirect losses from malarial illness include time lost as a result of temporary disability during the acute illness stage, debility following disabling malaria which may reduce the efficiency of workers, and the longer-term effect on future labor supply resulting from. impaired educational achievement in children as a result of missed schooling or reduced performance in school. Indirect losses may be incurred not only by the patient but also by others who are caring for the patient (particularly in the case of ill children) or who substitute for the patient. In addition to the expenses associated with treatment and the opportunity cost of "lost" or reduced value of time, there are so called "psychic" costs resulting from the pain, anxiety or loss that accompanies illness or death. The threat or risk of malaria also generates costs which can be conveniently grouped into the same categories of direct, indirect and psychic. Direct costs can include the outlays made in chemoprophylaxis (with its possible risks of side effects as well as its protective role), bed nets, screens, repellents, and vector control (with its possible negative environmental or health consequences). Indirect costs can be of two rather different kinds: there are costs associated with strategies to reduce the risk of getting malaria and costs associated with strategies to ameliorate the economic consequences should malaria strike. Both the direct and indirect costs of malaria are always difficult to measure or estimate in most countries, and Comoros is no exception. The best that can be done is to provide an order of magnitude of the costs involved. On the basis of 1996 data, the direct health costs linked to malaria (hospitalization, medical consultations and procedures, and drugs) have been estimated at KMF 1.0 billion (US$ 2.5 million equivalent) per year on average during the project period. It is expected that, as a result of the project, there will be a saving of 20% of overall health spending on malaria, or KMF 200 million (US$0.5 million equivalent) per year. The total savings for the four-year period of the project would be US$ 2.0 million equivalent. Project Appraisal Document Annex 4: Page 13 of 14 Country: Islamic Federal Republic of the Comoros Project Title: Health Project On the economic front, the Government views malaria as one of the main causes of absenteeism from work and school. People are hardest hit by the effects of the disease during the period when farm work is heaviest and the result is a significant reduction in productivity and economic growth. At present, however, Comoros has no data to provide a basis for quantifying its economic losses attributable to malaria and evaluating the extent to which they impede its development. Some preliminary studies on this subject have recently been conducted in other countries in the region (Burkina Faso, Cameroon, Chad, and Congo). Malaria research (Lemox, R. W., Vector Biology and Control Project, Arlington, VA, USA) throughout the African continent as a whole reveals that while the effective economic cost of malaria at both the individual and household levels is still largely unknown, significant costs are incurred with respect to time loss, transport to obtain health care, early death, and health care services. Although some of these factors are measurable, the extent of under-employment and the seasonal nature of work in rural areas make it difficult to determine the actual impact of this disease on productivity and development. The malaria studies conducted in Cameroon, Chad, Congo, and in particular Burkina Faso, assess the direct costs of treating the disease and carrying out control activities, and the indirect costs associated with work time lost and early death. These measures have allowed the economic impact of malaria to be measured and extrapolations to be made as a basis for estimates covering sub- Saharan Africa as a whole. The value of a productive day is estimated at US$ 0.82. The average case of malaria results in the loss of 11 work days, or a cost per individual of US$ 9.02, or around 2% of per capita GNP in Comoros. Given the low per capita income (currently equivalent to about US$ 460 annually), which is increasing at a lower rate than the population, the indirect losses from malarial illness will therefore be important. Assuming 100,000 thousands cases of malaria in the adult population per year, the indirect losses would amount to about US$ 900,000 per year, or about US$ 3.6 million for the four-year project period. The proposed malaria control measures will help mitigate these losses, or possibly reverse them, owing to their positive effect on total working time. By putting particular emphasis on prevention and the use of bednets as a means of disease control, the proposed project will provide a notable opportunityto reduce indirect losses. It would not make sense to attempt to compute a rate of return for the malaria control component on the basis of very rough and incomplete estimates of savings in direct costs or indirect losses that could be avoided. However, in assessing whether it is appropriate for Comoros to spend US$ 3.9 million for malaria control, one should consider the potential savings in direct health costs of US$ 2.0 million and the indirect losses of US$ 3.6 million that could be mitigated or avoided. There is no doubt that a reduction in the incidence of malaria will improve the quality of life of Comorians and benefit the Comorian economy as a whole, through lower absenteeism and higher productivity. It will also have an impact on the tourism market, since tourists will be less apprehensive of contracting the disease. Project Appraisal Document Annex 4: Page 14 of 14 Country: Islamic Federal Republic of the Comoros Project Title: Health Project VI. Cost-effectiveness analysis for institutional strengthening Although the institutional strengthening component (total estimated cost of US$ 2.4 million) includes three sub-components (training, logistical support to MOH, and health insurance scheme), the cost-effectiveness analysis deals only with training (estimated cost: US$ 1.5 million). Training will be in-country, and short-term as well as long-term. More than 400 staff will be trained. Long-term training will benefit about 55 MOH staff and about 90 health facility personnel. Short-term training will accommodate about 60 MOH staff and about 210 trainees from health facilities. The choices made for the definition of the training program are based on an analysis of the training needs of MOH staff and of health facility personnel. The training program under the ongoing PHR project covered urgent needs in the areas of administrative and financial management, reorganization of the central units of MOH and operating modalities of the new health system. Under the proposed project, training activities will focus on: (i) long-term training of MOH staff to increase the number of staff vvith post-baccalaureate diplomas; (ii) short-term training of MOH staff to teach them new techniques and practices necessary for the proper functioning of the health system (supervision, strategic planning and management, personnel management, IEC, legal issues of the health sector, health statistics etc.; and (iii) long- term and short-term training and skills enhancement (for dliagnosis and care) for doctors, health care staff and medical technicians. For long-term training, diplomas will be awarded. A conscious choice has been made to continue to develop a local capacity for training in the Centre National de Formation et de Recherche en Sante Publique (CNFRSP) in Moroni. All training, whether long-term or short-term, will be in courntry, with the participation of foreign training institutions. One advantage of this approach is that most of the moneys spent will remain in Comoros. It is also the most cost-effective way of upgrading the skills of MOH staff and health professionals. For example, it is estimated that the long-term training of a person in Comoros will cost from US$ 3,000 to US$ 6,000 per year, as compared to about US$ 20,000 per year for training abroad. For short-term training, the cost differential is even greater. In addition to the cost aspect, training in Comoros will also have a number of important advantages compared to overseas training: * it will allow the staff to continue to exercise their professional activity, without prolonged interruptions; * it will permit the adoption of a curriculum focused on local practices and the solution of the health problems of Comoros or of the problems of health facilities; and * it will limit the risks which are inherent in overseas training: difficulty to adapt the acquired knowledge to deal with local problems; possibility that the trainees will not return home or, if they do return home, will not be assigned to posts with the functions and responsibilities which the training was supposed to help them carry out. Project Appraisal Document Annex 5: Page I of I Country: Islamic Federal Republic of the Comoros Project Title: Health Project Annex 5 Health Project Financial Summary Years Ending December 31 (in US$ million) Implementation Period Calendar Year 1998 1999 2000 2001 2002 Total Investmnent costs 1.2 2.3 3.4 1.4 1.1 9.4 Recurrent costs 0.1 0.1 0.1 0.2 0.1 0.6 Total 1.3 2.4 3.5 1.6 1.2 10.0 Financing Sources (% of total proiect costs) IDA 65 88 92 80 77 84 WHO 5 4 3 7 4 4 UNICEF 2 1 1 2 3 2 Government 2 1 - 1 2 1 Beneficiaries 26 6 4 10 14 9 Total 100 100 100 100 100 100.0 Main assumptions: See detailed cost estimates in the Project Implementation Manual. The IDA credit will finance 100% (net of taxes) of expenditures for components I (rehabilitation and equipment of selected health facilities) and 3 (institutional strengthening to facilitate and support the increased utilization of quality care by the population and the further implementation of the health sector reform), as well as for parts of component 2 on the control of malaria (i.e. the indoor residual house spraying, the treatment of breeding areas with larvicides, the strengthening of MOH division for vector- borne diseases, and the initial batch of impregnated bednets). For the remaining parts of component 2 on the control of malaria, WHO will finance case management, UNICEF will finance IEC to increase community participation, and beneficiaries will pay for impregnated bednets. Project Appraisal Document Annex 6: Page 1 of 6 Country: Islamic Federal Republic of the Comoros Project Title: Health Project Annex 6 Health Project Procurement and Disbursement Arrangements Procurement Procurement methods (Table A) This project is a follow-up to the health component of the on-going PHR Project. The project implementation unit (Cellule d'Execution du Projet - CEP) is staffed with a competent local procurement specialist who has also been trained in Bank procurement procedures, and procurement performance under the on-going project has been satisfactory. Goods and works financed by IDA would be procured in accordance with the Bank's Guidelines for Procurement under IBRD Loans and IDA Credits published in January 1995 and revised in January and August 1996. Consultancy services would be procured in accordance with the Bank's Guidelines for Selection and Employment of Consultants by World Bank Borrowers published in January 1997. Civil Works. Civil works contracts exceeding $100,000 per contract for the rehabilitation of hospitals and medical and surgical centers will be procured under ICB procedures in accordance with the Bank's Guidelines. Civil works contracts costing more than $30,000 but less than $100,000 in aggregate would be paid through NCB procedures acceptable to IDA. Rehabilitation and construction of small health infrastructure, including the MOH's training center and concrete tanks for larvivorous fish for the malaria component, which are expected to cost the equivalent of or less than $30,000 per contract for an aggregate amount of $70,000 will be procured through obtaining at least three bids from small, experienced local contractors. Goods. Contracts for goods such as hospital, medical and laboratory equipment, an initial supply of mosquito nets, spraying equipment for insecticides, vehicles and office equipment costing more than $100,000 per contract will be purchased through ICB procedures in accordance with the Bank's Guidelines. Contracts for goods and office equipment available locally which cost more than $30,000 but less than or equal to $100,000 per contract, for an aggregate amount of $200,000, will be procured through NCB procedures acceptable to IDA. Small quantities of goods and office equipment expected to cost less than $30,000 per contract, up to an aggregate amount of $200,000, would be procured through national shopping based on price quotations obtained from three reliable suppliers. Purchase of anti-malarial insecticides under four annual contracts for a total amount of $900,000 will be arranged through the procurement services of the WHO. Consultant Services. These types of services, for an aggregate amount of US$ 3.0 million, will be for: (a) design and supervision of the rehabilitation and equipment of hospitals and medical and surgical centers; (b) technical assistance for the implementation of health sector reform and management; (c) supervision of the anti-malaria spraying program; (d) health insurance studies (e) training program for MOH and health workers; (f) local contractual staff of the project Project Appraisal Document Annex 6: Page 2 of 6 Country: Islamic Federal Republic of the Comoros Project Title: Health Project implementation unit - CEP; and (g) annual financial audits. Consultant selection will be generally addressed through competition among shortlisted firms using the Quality and Cost Based Selection (QCBS). For the annual financial audits ($75,000), which will involve intemationally recognized accounting firms, the least cost selection will be used. Consultancy services for the implementation of the health sector reform, management, and supervision of the anti-malaria program and general project support, whichl would involve individuals for an aggregate amount of $500,000, will be selected on criteria based on qualifications, experience, and competence for their assignments. Prior review thresholds (Table B) IDA financed contracts above the threshold of $100,000 and $50,000 for works and goods respectively will be subject to IDA's prior review. All other contracts will be subject to post review. Prior IDA review for consultants will be required for: (a) all contracts for individuals costing more than $30,000 per contract; (b) all contracts for high level local staff of the project implementation unit, including the executive director, the accountant and the procurement specialist; (c) all contracts for the financial audits; and (d) all contracts with firns costing more than $50,000 per contract. All other contracts will be subject to post review. For all contracts with a consulting firm exceeding $50,000 per contract but up to $100,000 per contract, where the selection is based on the evaluation of technical and financial proposals, the recommendation for selection, together with the combined technical and financial evaluation reports, will be transmitted to IDA for non-objection prior to the negotiation of the contract. For other contracts with a consulting firm exceeding $100,000 per contract, the technical evaluation report will also be sent to IDA for non-objection prior to the opening of the financial envelopes. Disbursement Allocation of loan proceeds (Table C) The credit closing date is December 31, 2002, although most of the credit will be disbursed by June 30,2002, i.e. in four years. The 100 percent (net of taxes) financing by the IDA credit for all disbursement categories is justified by the fact that beneficiaries will contribute about 10 percent of the cost of the project through the purchase of impregnated bednets, and will also pay for services rendered by health facilities in order to cover their operating and maintenance costs. Category 4 (operating expenses for the project implementation unit - CEP) includes expenditures for (i) local contractual staff salaries, benefits and other incidental employment costs; (ii) travel costs and allowances; (iii) insurance, operation and maintenance of vehicles and equipment; (iv) banking charges; and (v) office rent, supplies and utilities, and communication charges. Project Appraisal Document Annex 6: Page 3 of 6 Country: Islamic Federal Republic of the Comoros Project Title: Health Project Use of statements of expenses (SOEs) A simplified format will continue to be used for SOEs in which expenditures are summarized by category. The documentation for withdrawals under SOEs would be retained at the project implementation unit (CEP) for review by IDA staff during supervision missions and for annual audits. SOEs will be used for payments of contracts of less than US$ 50,000 for goods and works and consultant contracts of less than $50,000 and $30,000 for firms and individuals respectively. Special account A special account in Comorian francs will be opened and maintain in a commercial bank; the maximum amount or authorized allocation will be an amount equivalent to US$ 800,000. Audit An independent auditor acceptable to IDA will audit the use of all IDA funds, including the special account and statements of expenditure. Project Appraisal Document Annex 6: Page 4 of 6 Country: Islamic Federal Republic of the Comoros Project Title: Health Project Table A: Project Costs by Procurement Arrangements' (in US$million equivalent) Expenditure Category Procurement Method Total Cost (including contingencies) ICB NCB Other N.B.F. 1. Works Civil works 1.5 0.1 0.1 1.7 (1.5) (0.1) (1.6) 2. Goods Equipment, mosquito nets 1.9 0.2 1.2 0.9 (l) 4.2 insecticides, vehicles (1.9) (0.2) (1.1) (2) (3.2) 3. Services TA, Training & Studies 3.0 0.5 (3) 3.5 (3.0) (3.0) 4. Miscellaneous Operating Costs 0.6 0.6 (0.6) (0.6) Total 3.4 0.3 4.9 1.4 10.0 (3.4) (0.3) (4.7) (8.4) Note: N.B.F. = Not Bank-financed (includes elements procured under parallel cofinancing procedures, consultancies under trust funds, any reserved procurement, and any other miscellaneous items). The procurement arrangement for the items listed under "Other" and details of the items listed as "N.B.F." need to be explained in footnotes to the table or in the text. Figures in parenthesis are the amounts to be financed by the Bank loan/IDA credit. (I)This amount comprises $900,000 worth of mosquito nets to be purchased by households/beneficiaries. Note that the initial batch of mosquito nets financed by IDA is being procured under ICB. (2)This amount comprises $900,000 worth of insecticides to be procured through WHO procurement methods in four annual purchases. (3)This total amount of $550,000 is financed by WHO ($400,000) and UNICEF ($150,000) for training activities. 'For details on presentation of Procurement Methods refer to ODI 1.02, "Procurement Arrangements for Investment Operations." Details on Consultant Services can be shown more easily in the Table Al format (additional to Table A, where applicable). Project Appraisal Document Annex 6: Page 5 of 6 Country: Islamic Federal Republic of the Comoros Project Title: Health Project Table B: Thresholds for Procurement Methods and Prior Review' Expenditure Contract Value Procurement Contracts Subject to Category (Threshold) Method Prior Review/Estimated Total Value Subject to Prior Review 1. Works Rehabilitation of >$ 100,000 ICB All / $ 1.4 million Hospital and medical and surgical centers Rehabilitation of >$30,000 and NCB None Moheli Facilities <$100,000 Minor Rehabilitation <$30,000 obtaining at least 3 None bids 2. Goods Equipment, vehicles >$l00,000 ICB All 1$ 1.9 million and mosquito nets Small equipment & >$30,000 and NCB >$50,000 / $ 0,1 supplies <$ 100,000 million Office supplies <$30,000 Shopping None Insecticides >$100,000 Direct Purchase (WHO None Procurement) 3. Services Consultants and Firms QCBS, LCS >$50,000 / $ 0.8 training million Individuals Short-list >$30,000 / $ 0.4 million CEP contractual staff Short-list All / $ 0.2 million Financial audits LCS All / 0.1 million 4. Miscellaneous Operating costs N/A Total value of contracts subject to prior review: $ 5.0 million Note on selection method for consultants: QCBS = Quality- and Cost-Based Selection. LCS = Least-Cost Selection. 'Thresholds generally differ by country and project. Consult OD 11.04 "Review of Procurement Documentation" and contact the Regional Procurement Adviser for guidance. Project Appraisal Document Annex 6: Page 6 of 6 Country: Islamic Federal Republic of the Comoros Project Title: Health Project Table C: Allocation of Loan Proceeds Expenditure Category Amount in US$ million Financing Percentage Civil works 1.5 100% of total costs Equipment/vehicles/supplies 3.0 100% of total costs Training, technical assistance, studies 2.8 100% of total costs Operating expenses 0.5 100% of total costs Unallocated 0.6 Total 8.4 Project Appraisal Document Annex 7: Page I of I Country: Islamic Federal Republic of the Comoros Project Title: Health Project Annex 7 Health Project Project Processing Budget and Schedule A. Project Budget (US$000) Planned Actual (At final PCD stage) Bank Budget 48 48 PHRD Grant 372 200 B. Project Schedule Planned Actual (At final PCD stage) Time taken to prepare the project (months) 6 months 6 months First Bank mission (identification) 12/05/96 12/05/96 Appraisal mission departure 11/01/97 11/08/97 Negotiations 12/01/97 12/29/97 Planned Date of Effectiveness 07/01/98 Prepared by: Ministry of Public Health and Population (MOH) Preparation assistance: PHRD Grant Bank staff who worked on the project included: Name Specialty Core team members: Eileen Murray, AFTH2 Task Team Leader Bertrand Ah-Sue, AFTS2 Senior Procurement Specialist Malonga Miatudila, AFTH2 Public Health Specialist Raj Soopramanien, LEGAF Country Lawyer Hilda Emeruwa-Creppy, AFTH2 Task Team Assistant Laura McDonald, AFTH2 Task Team Assistant Extended team members: Pisei Eap, AFTM3 Economist Manorama Gotur, AFC08 Operations Analyst Philomene Lai-Cheong, AFTC2 Budget Officer Myrina McCullough, AFTH2 Program Assistant David Freese, LOAAF Disbursement Officer Cecilia Kennedy, LOAAF Disbursement Analyst Lead Adviser: Maryse Pierre-Louis, MNSHD Senior Public Health Specialist Peer Reviewer: Qaiser Khan, MNCYE Principal Economist Consultants: Pierre Cornillot Public Health Specialist Paul Geli Implementation Specialist Jose Najera Malaria Specialist Project Apprsisal Document Annex 8: Page I of 11 Country: Islamic Federal Republic of the Comoros Project Title: Health Project Annex 8 Health Project Letter of Sector Policy REPUBLIQUE FEDERALE ISLAMIQUE DES COMORES MINISTERE DE LA SANTE PUBLIQUE ET DE LA POPULATION Moroni, le 10 ddcembre 1997 A l'attention de Monsieur Michael N. SARRIS Directeur des Operations pour les Pays de l'Ocdan Indien - R6gion Afrique Banque Mondiale - Washington D.C. Objet: Politique de d6veloppement Sanitaire aux Comores Monsieur le Directeur, 1. Nous avons I'honneur de porter a votre connaissance par la presente, les politiques et les strategies que le Gouvernement de la Republique Fed6rale Islamique des Comores entend poursuivre afin d'accrottre 1'efficacit6 des actions men6es dans les domaines de la sant6 et de la population. 2. Depuis son accession I la souverainete internationale en 1975, le pays s'est fix6 comnme objectif d'assurer un niveau acceptable de soins de sante pour tous ses habitants. Aussi, notre politique sanitaire de ces dix dernieres annees a-t-elle et6 axee sur les soins de sante conform6ment a l'esprit de la declaration d'Alma-Ata, nos orientations privil6giant prioritairement: * Ia restructuration et le renforcement des structures de pilotage de la politique sectorielle; * Ia r6habilitation et 1'6quipement des infrastructures sanitaires; * I'appui aux programmes prioritaires de sante publique (Programme Elargi de Vaccination, Sante Maternelle et Infantile), le renforcement de la lutte contre les grandes enddmies, les Maladies Sexuellement Transmissibles et d'autres affections; Project Appraisal Document Annex 8: Page 2 of ll Country: Islamic Federal Republic of the Comoros Project Title: Health Project * I'arnelioration des conditions d'assainissement et d'hygibne du milieu; * 1'amnlioration de la gestion des ressources humaines, matdrielles et financieres par la mise en place de cadres adaptes, la formation permanente du personnel et la participation croissante de la population aux frais de santd. 3. Des succbs significatifs ont 6te obtenus grAce I l'appui de la Communaute Internationale (PNUD, OMS, UNICEF, FNUAP, CEE, COOPERATION.FRANCAISE, APEFE, CARE, LIGUE ISLAMIQUE, BANQUE MONDIALE, BANQUE AFRICAINE DE DEVELOPPEMENT, etc.). Cependant, la sante de la population reste precaire notamment celle des femmes en Age de procreer et des enfants. En effet, malgre des efforts substantiels engages pour accroitre les infrastructures et les equipements hospitaliers, les taux de mortalitd (84% pour la mortalite infantile et 10,4% pour la mortalit6 generale) se trouvent encore a des niveaux inaccepeables en raison des faibles moyens dont disposent les services sanitaires, d'un cadre institutionnel faiblement exploite, et surtout de l'insuffisance de personnel qualifie. Pour faire face A ces nombreux problemes, et afin d'atteindre l'objectif de la santd pour tous mentionn6 plus haut, nous nous sommes dotes d'un certain rombre d'instruments fondarnentaux qui fonde notre strategie de developpement sanitaire: • d'abord un Plan National de Developpement Sanitaire (PNDS) adopte en mai 1991, qui arrate les grandes orientations prioritaires de la politique sanitaire du pays pour les prochaines annees. ensuite une nouvelle Loi portant cadre gdn6ral du systeme de sante et definissant d'une part les missions de la sante publique et d'autre part son systame organique; * enfin, un Code de la Santd Publique et de I'Action Sociale (comprenant en annexe le Code de Deontologie Medicale) qui enonce les regles juridiques applicables aux activites et aux structures de sante en charge de la protection et la promotion sanitaire de l'individu, de la famille et de la collectivitd. Le Plan National de Developpemerit Sanitaire 4. Revise en 1993 en collaboration avec l'OMS, le PNLD et l'UNICEF, le Plan National de Ddveloppement Sanitaire est l'instrument de gestion du secteur sanitaire de la Rdpublique Federale Islamique des Comores. 11 est fonde sur les principes de la d6claration d'ALMA-ATA (1978), du Scenario de developpement sanitaire en trois phases de Lusaka-Zambie (1985) et le l'Initiative de Project Appraisal Document Annex 8: Page 3 of 11 Country: Islamic Federal Republic of the Comoros Project Title: Health Project Bamnako (1987). II tient egalement compte des donnees socio-economiques du pays, des exigences du Programme d'Ajustement Structurel (PAS) et de la politique de d6centralisation administrative en cours. II arrete les grandes orientations et les axes prioritaires de la politique sanitaire des Comores jusqu'en 2010. Ainsi, les activites et les programmes prioritaires poursuivront les memes objectifs que par le passe, a savoir: renforcer et faciliter l'accessibilite de la population aux soins de sante primaires par la decentralisation des formations sanitaires et la responsabilisation de celles-ci en matiere de prise de decision; * offrir des soins de qualite par l'amelioration de plateau technique; * dynamiser la politique de gestion des ressources humaines par l'elaboration de plans des effectifs, de formation et des carrieres; * ameliorer l'accessibilite aux medicaments par le renforcement de la politique des mddicaments essentiels; • instaurer un systeme de recouvrement des coats par la mise en place de mdcanismes d'autofinancement, de gestion et de controle de l'utilisation des ressources, qui intkgre en aval les communautes dans la prise en charge et le controle des formations sanitaires de base; * enfin mettre en place des mecanismes de surveillance et d'evaluation des activites des differents programmes. 5. Pour lutter contre la forte croissance demographique des Comores (environ 2,7% par an) et influer sur la structure de la population (le rapport d'Age est trEs deplacd au b6ndfice des classes d'Age les plus jeunes), nous avons renforce la politique familiale avec l'appui de nos partenaires habituels; notamment le FNUAP, I'ASCOBEF, etc. Des resultats encourageants ont ete obtenus dans le contr6le et 1'espacement des naissances. Par exemple, l'indice synth6tique de feconditd est passe de 6,8 enfants par femme en 1991 a 5,1 en 1996. Cependant, les besoins dans le domaine de la planification familiale sont loin d'etre satisfaits. Aujourd'hui encore, environ 56% des naissances ne sont pas correctement planifiees, la difference entre le taux de fecondite et le besoin en nombre d'enfants reste positif et la densite de la population continue d'augmenter (241 habitants au km2 en 1991 contre environ 278 en 1997). Notre strategie en la matiare est organisde autour de deux axes: Project Appraisal Document Annex 8: Page 4 of 11 Country: Islamic Federal Republic of the Comoros Project Title: Health Project - d'abord, I'IEC ciblee sur des groupes sensibles (femmes de 15 a 49 ans et leurs maris, jeunes, leaders d'opinions) sera renforcee et elargie; * ensuite I'acces aux mdthodes modernes de contr6le des naissances et aux fournitures correspondantes sera gendralise. Parall lement, des actions de formation du personnel ont etd mises en chantier. Elles ont dte appuyees par I'6quipement des formations sanitaires en materiels de planification familiale, par l'approvisionnement en contraceptifs et enfin par l'organisation d'activites de maternite sans risque. Ainsi le Gouvernement Comorien s'engage avec l'aide des Bailleurs de Fonds a continuer d'appuyer ce programme de lutte contre la forte croissance d6mographique. Reorganisation du svstbme de sante 6. Au terme d'une periode de plus de quinze annees, les responsables politiques du pays on da prendre acte d'une dvolution irreversible de la demande de soins, de prevention des malades et de protection de la sante. L'augmentation continue des d4penses de sante, la volontd et la capacite de participation de la population A la resolution des problemes de sante imposaient une profonde reorganisation du systeme comorien. Pour des raisons qui tiennent a la fois des choix de societe effectues en Republique Federale Islamique des Comores et des capacites economiques et sociales du pays, il ;tait devenu evident qu'au cours des prochaines annees, la politique nationale de la santd devait s'appuyer sur le developpement concertd des secteurs public, prive et communautaire, le premier ayant vocation a constituer l'armature du systeme puisque l'organisation et le fonctionnement du systeme de sante relbvent de la competence de I'Etat. 7. Afin de faciliter la mise en oeuvre de ce developpement, le gouvernement a initie un ensemble de reformes institutionnelles qui concernent tous les niveaux de notre systeme sanitaire. Son objectif est d'offrir a l'ensemble de la population I'acces A des soins de qualit6 et a une protection toujours efficace, associant les possibilit6s combinees d'une accessibilitd independamment des ressources et du statut social d'une part, et d'un libre choix eventuel A l'initiative de l'utilisateur, d'autre part. La Loi n° 94-0161AF portant cadre general du systeme de sante et definissant les missions du service public hospitalier a ainsi ete votee le 17 juin 1994 par 11'Assemblee Federale. Elle definit les Project Appraisal Document Annex 8: Page 5 of 11 Country: Islamic Federal Republic of the Comoros Project Title: Health Project conditions dans lesquelles les secteurs public, prive et communautaire s'organisent et se developpent en fonction des besoins et des moyens du pays. 8. Parallelement, pour assurer le developpement coherent du secteur prive et communautaire, I'Etat a mis en place les organismes professionnels - notamment l'Ordre National des Medecins, Pharmaciens et Chirurgiens dentistes - charges d'organiser et de contr6ler la pratique des professions medicales (medecins, sages-femmes, inflrmieres, pharmaciens, paramddicaux) et a etablis les regles regissant les autorisations des Installations, des constructions et de l'acquisition des equipements. 9. Pour ce qui concerne le secteur public, le Gouvernement a mis un accent particulier sur 3'amelioration de la qualite des services fournis I la population. C'est ainsi qu'un certain nombre d'actions y concourant ont ete initiees au travers le Projet Population et Ressources Humaines en cours d'execution. II s'agit principalement: * de la rehabilitation de plusieurs structures sanitaires en difficulte et de la fourniture d'&quipements et de materiels essentiels pour garantir la cohdrence et la continuite des services prioritaires; * de l'ajustement des effectifs des personnels de la sante relevant de la fonction publique aux capacites des cadres organiques du Ministere de la Sante et de leur formation a la nouvelle organisation et aux nouvelles activites; * de la mise en place de procedures de surveillance, de suivi et d'dvaluation des activites des differents programmes retenus comme prioritaires. Reforme institutionnelle et statuaire du secteur public 10. Au terme de plusieurs annees de discussions sur la rdforme organisationnelle du secteur sanitaire, la R6publique Federale Islamique des Comores s'est dotde d'un systeme de sante mixte qui associe le secteur prive a l'Etat, ce dernier conservant cependant des obligations et des devoirs irrevocables, notamment le pouvoir reglementaire et un droit de regard sur tous les organismes de soin du secteur prive. Pour l'essentiel, la loi reorganise et decentralise la gestion des services de sante et met un accent particulier sur la rationalisation du systeme de sante et sur l'adaptation du secteur public aux rdalites ddmographiques et socio-economiques rdgionales. Elle organise les structures et les services Project Appraisal Document Annex 8: Page 6 of 11 Country: Islamic Federal Republic of the Comoros Project Title: Health Project de soins et de prevention relevant du Ministere de la Sante Publique en un dispositif hierarchise qui correspond au schdma de la subdivision administrative des Comores (Fdddral, Regional et Prefectoral): • au niveau central, le Ministere de la Sante Publique et ses directions gdnerales sont charges de la definition, de la coordination et de la planification nationale, de la mise en oeuvre des programmes nationaux et des politiques nationales de sante, de la surveillance epiddmiologique, de la formation des professionnels, de la coordination des aides et des projets, du financement des infrastructures et des equipements lourds, de la politique nationale du m6dicament, de l'exercice de la tutelle sur le fonctionnement, le financement et la qualite des soins, de la preventions et de l'information sanitaire; * au niveau regional, le Centre Hospitalier Regional represente le niveau de technicit6 medicale, soignante et medico-technique le plus eleve de sa rdgion. Ses missions principales sont l'accueil des situations de detresse et d'urgence, la realisation d'investigations diagnostiques complexes, la mise en oeuvre de traitements medicaux et chirurgicaux lourds, la prise en charge des situations obstetricales a risque. II coordonne son action avec celles des Centres Sanitaires de District qui lui sont referes par l'intermrdiaire des structures relevant de la Direction Regionale de la Sante. La Direction Regionale de la Sante est pour ce qui la concerne, I'autoritd de tutelle de l'ensemble des structures de soins de la region. Elle est organisee autour t'une equipe de sante, dirigee par un medecin, directeur regional. Cette equipe a pour taches specifiques: * de veiller a ]'application de la reglementation en matiere de la protection sanitaire de la population, de la pratique de la mddecine, de la vente des mEdicaments et la lutte contre les epidemies, * d'organiser, de lutter contre les epidemies et d'assurer la police sanitaire dans I';le, * d'organiser, d'impulser et de cordonner les activitds concourant au maintien et a l'arnelioration de la sante et du bien-etre social de la population de I'lle; * de superviser et de contr6ler le fonctionnement des services peripheriques de la sante, * de programmer, d'organiser, d'impulser et de coordorner les activites de la formation et de l'education socio-sanitaire, * d'organiser, de coordonner les activites de l'assistance sociale et de participer a la gestion des aides et dons qui leur sont destinEs, * d'impulser et de coordonner les activites de la promotion de la femme, * de collecter et de tenir a jour les statistiques sanitaires au niveau de I'lle. Project Appraisal Document Annex 8: Page 7 of 11 Country: Islamic Federal Republic of the Comoros Project Title: Health Project Au niveau nArinh&rique, le centre Sanitaire de District (Centre de Sante, Centre Medico-Chirurgical- Urbain selon les cas) est le principal pOle des activites sanitaires autour duquel gravitent les postes de sante de secteur qui lui sont referes, y compris la distribution des medicaments essentiels. 11 assure les soins essentiels de base et dans certaines conditions peut proceder a des hospitalisations k des interventions chirurgicales limitees et a des accouchements. 11. Enfin, il donne une autonomie de gestion financiere et administrative aux formations sanitaires et les dote d'un statut et d'un ensemble d'instruments juridiques conformes I leurs missions et a l'exercice de cette autonomie. C'est ainsi que les Centres Hospitaliers Regionaux ont ete transformes en etablissements publics autonomes. Conformrment aux dispositions de la loi, ils sont dotes d'un Conseil d'Administration qui assure le contr6le direct du fonctionnement et de l'usage des ressources allouees et des recettes apportees par la tarification officielle des actes effectuees. Le Ministere de la sante leur affecte annuellement les dotations necessaires a la remuneration des personnels relevant de la fonction publique, ainsi qu'une eventuelle subvention destinee a couvrir une partie des frais de fonctionnement. Pareillement, des dotation speciales leur permettent d'acquerir des equipements nouveaux ou de renouveler les 6quipements anciens. Cependant, en ce qui concerner la remuneration du personnel apres 1995, le Gouvernement ayant accumule quelques 11 mois d'arrieres de salaire, a decide de geler ces arrieres tout en continuant d'honorer regulierement les salaires de l'annee 1997. Et a ce jour le pari a ete tenu puisqu'en 1997 tous les mois ont ete paye en salaire. Pour l'avenir le Gouvernement s'engage: a) k rechercher aupres de ses partenaires exterieurs un Don Exceptionnel pour regler ces 11 mois d'arrieres geles; b) a continuer de regler chaque mois dl en salaire des fonctionnaires; c) et pour le prochain exercice budgetaire 1998-1999 commencer a mettre a la disposition de chaque ministere son propre budget comprenant a la fois les salaires des fonctionnaires du secteur, mais egalement les frais d'un fonctionnement minimum de ce secteur. Par contre, les Centres Sanitaires de district ont ete dotes du statut d'Etablissement prive sans but lucratif avec des missions de service public. Administrds par des associations sans but lucratif crees a cet effet et agrees par le Ministere charge de la sante, ils disposent de moyens necessaires k leur fonctionnement par le biais de dotations en personnel et en credits provenant du budget de l'dtat et affectes par convention, et par le droit a percevoir le montant des actes tarifes. Project Appraisal Document Annex 8: Page 8 of I1 Country: Islamic Federal Republic of the Comoros Project Title: Health Project Les postes de sante qui leur sont referes sont geres par convention par des associations villageoises de soutien. L'Etat participe a leur fonctionnement a travers la prise en charge des travaux de construction ou de rehabilitation et par les moyens qu'il leur affecte au budget du Centre de Sante de reference. Les associations de leur cote sont autorisees a percevoir le montant d'actes tarifes pour leur frais de fonctionnement. A ce jour les centres sanitaires de district disposent de leur Association gestionnaire participant a leur fonctionnement quotidien. Par contre seul les formations sanitaires de NGAZIDJA disposent d'un Conseil d'Administration rdpondant aux normes de la Loi, et ce depuis cette annee 1997. Les problemes politiques du pays ayant empeches la mise en place de ces Conseils d'Administration I NDZOUANI et a MWALI; cependant le Gouvernement s'engage a y poursuivre leur mise en place des que la situation le permettra. Pour finir, l'ensemble de ces structures de sante integre les representants des communautes dans leur instances de deliberation et de decision et s'appuie dans la distribution des soins, sur la responsabilisation des cadres de la sante, et sur un dispositif de financement base sur le principe du recouvrement des coOts, combinant des ressources locales, nationales et exterieures I des financements assures sur le budget de l'Etat. Ainsi le Gouvernement s'engage: a) de poursuivre les reformes organisationnelles du systeme de sante restent en application en particulier de continuer ce dispositif de participation communautaire a la gestion et au fonctionnement des prestations de sant6; b) de continuer a doter chaque formation sanitaire de sa pharmacie autonome; c) de veiller k ce que les nominations des cadres superieurs du Ministere et des formations sanitaires repondent a la fois aux dispositions legislatives en vigueur, et au profil des cadres organiques (en particulier les directeurs generaux des CHR, les directeurs gdneraux de Ministre, et le Secretaire Gdneral du Ministere; d) et enfin veillent a la stabilite de ces memes cadres dans leur poste d'affectation. 12. Tels sont les 6I6ments essentiels qui caracterisent aujourd'hui le nouveau systeme de sant6 comorien dont la mise en place et en voie d'achavement, comme nous venons de le souligner plus haut. Avec l'appui des differents bailleurs de fonds, et dans le cadre de I'actuel accord de credit signe avec la Banque Mondiale, nous nous engageons mener 'a son terme cette entreprise nationale et satisfaire ainsi aux objectifs que nous nous etions assignes dans la perspective de la fin de I'annie 1998. Project Appraisal Document Annex 8: Page 9 of l1 Country: Islamic Federal Republic of the Comoros Project Title: Health Project En particulier, le Gouvernement s'engage a ce que la periode 1997 - 98 permette d'achever la mise en application des textes reglementaires encadrant cette reforme et de finaliser le fonctionnement des structures de soins selon les nouveaux modes d'organisation et de gestion. Mais d6j', l'importance, la variete et la qualite des resultats que nous avons obtenus et ceux qui sont previsibles I l'issue du premier projet Population et Ressources Humaines, nous imposent A rechercher pour l'avenir les conditions d'un effet durable et d'une consolidation de cette entreprise. Nos priorit6s futures privil6gient: * au niveau central, le renforcement des capacites de gestion et de management de Ia tutelle, * au niveau des structures perinheriques, le renforcement et l'harmonisation des capacites de soin et de prevention, * au niveau des collectivites, la consolidation de la participation des communautes au fonctionnement du systeme de sante et le renforcement de leur capacite contributive a son financement. 13. Pour l'essentiel, ces priorites sont les suivantes: Au titre du renforcement des capacites de gestion et de management de la tutelle La mise en place de Direction Generales du Ministere dotees des moyens et des equipement ndecessaires au developpement de leurs nouvelles activites issues de la reforme, notammnent la collecte et le traitement de l'information epidemiologique et statistique et la surveillance a travers le pays, des risques d'emergence d'affections a caractere epidemique jusqu'a la fin 1998. La reorganisation et le renforcement du Centre National de Formation et de Recherche en Sante Publique, en vue de constituer un centre de reference pour la formation initiale et continue des personnels de sante comoriens jusqu'a la fin 1999, La mise en place d'une Centre National de Production et de Diffusion IEC - Sante Au titre du renforcement des capacites de soins et de prevention I1 participation a la rehabilitation et a l'equipement m6dical et administratif des etablissements peripheriques pour l'an 2000. Ia poursuite des programmes de requalification des personnels, en particulier des cadres administratifs des services centraux et regionaux pour I'an 2000. Project Appraisal Document Annex 8: Page IO of II Country: Islamic Federal Republic of the Comoros Project Title: Health Project Le renforcement d'un programme national de lutte contre le paludisme, avec I'appui coordonne de differents bailleurs de fonds pour I'an 2000. L'organisation des dispositifs de production, de stockage et de distribution des produits sanguins en conformite avec les regles strictes de sdcuritd transfusionnelle et d'hemovigilance. Au titre du renforcement des capacites de participation de la population et d'opdrations integrees Sante-Population-Environnement La participation aux actions de protection et de lutte contre les vecteurs du paludisme pour I'an 2000. La participation a la lutte contre la diffusion des maladies sexuellement transmissible et les risques de transmission du virus du Sidal Le renforcement des implications de la population dans les actions de proximite en information-Education-Communication pour l'an 2000. La participation aux etudes de mise en place d'un systeme de mutualisation et d'assurance k l'initiative des collectivites peripherique pour l'an 2000. 14. Enfin, le Gouvernement s'engage a mener a bien des activites plus integrees dans differents programmes prioritaires de notre Plan National de Developpement Sanitaire 1993 - 2010. Dans cet esprit, nous considerons qu'une attention particuliere sera consacree a la maitrise de la fecondite et aux exigences d'une maternite heureuse et sans risque pour l'enfant, notre objectif etant de passer d'un taux de prevalence contraceptive de 8% en 1996 a 20% en 2001, de diminuer le taux d'abandon de planification familiale de 70% pour 1996 a 50% en 2000, de diminuer le taux de mortalite maternelle de 500 pour 100 000 naissances vivantes en 1996 h 250 en 2001, enfin de parvenir a un taux de 20% d'utilisatrices de moyens modernes cle regulation en l'an 2000. 15. Le gouvernement s'engage a realiser ces objectifs en maintenant son appui aux structures autonomes chargees de la distribution des soins et de la prevention dans le secteur public: a) par la mise a disposition d'un personnel qualifie, m6dical, soignant et administratif, r6mun&r6 sur le budget de l'Etat, et par la formation initiale et continue de ces personnels, b) par l'affectation de subventions specifiques, notammebnt pour l'acquisition de gros equipements autorises et pour les travaux d'infrastructure et par I'attribution de moyens Project Appraisal Document Annex 8: Page 11 of 11 Country: Islamic Federal Republic of the Comoros Project Title: Health Project spdcifiques destinds a la realisation d'activitds particulieres relevant des programmes prioritaires, c) par des mesures d'incitations sociales et l'amelioration des conditions de travail, d) par l'elaboration d'un plan directeur de la politique pharmaceutique nationale - afin d'amdliorer l'accessibilite au moindre coCt aux mddicaments essentiels dans 1'ensemble des formations sanitaires participant au service public hospitalier - e) et enfin, par l'instauration de mecanismes rigoureux de controle de l'utilisation des ressources financieres et ,matdrielles affectdes aux projets en cours d'exdcution. Le Gouvernement s'engage a veiller au strict respect et I la mise en application des dispositions Idgislatives soutenant la reforme du systeme de sante, notamment dans les directions centrales et regionales, et diligentera des actions pour parachever la reorganisation des services centraux et rdgionaux afin qu'ils soient en mesure d'assurer leurs nouvelles missions pour la fin 1998, si la situation politique se stabilise. Enfin, il prendra toutes les dispositions rdglementaires relevant de son autoritd, qui pourraient etre necessaires pour ce faire. Pour conclure, cette reorganisation de notre systeme de santd, ainsi soutenue et amplifiee, ne doit en aucun cas etre assimilee a un desengagement progressif de l'Etat, mais doit &tre replacde des a present dans la perspective de sa necessaire adaptation a la limitation des moyens disponibles. Nous sommes persuades que 1'effort historique entrepris par la collectivite comorienne pour am6liorer la qualite et la pertinence de son systeme de sante portera pleinement ses promesses et que seront ainsi confirmes les premiers resultats tres encourageants que nous avons obtenus tant sous l'angle economique qu'au point de vue de la sante de la population. Nous vous prions, Monsieur le Directeur, de bien vouloir agreer l'expression de notre tres haute consideration. Pour le Gouvernement LE MINISTRE LE MINISTRE DE LA SANTE PUBLIQUE DES FINANCES ET DU BUDGET ET DE LA POPULATION _22 o? g c -.-( .. , . ..' Project Appraisal Document Annex 9: Page 1 of 2 Country: Islamic Federal Republic of the Comoros Project Title: Health Project Annex 9 Health Project Documents in the Project File* A. Project Implementation Plan (1) The Ministry of Health and Population has prepared a Proiect Implementation Manual in French (Manuel d'Execution du Projet) dated June 1997, which includes the following sections and annexes: I. General presentation of the health sector and issues related to health financing. II. The Project For each of the three components (Rehabilitation and equipment of health facilities, control of malaria and institutional strengthening): - context and objectives; - detailed description; - costs; - financial and economic analysis; - risks and risk minimization measures; - implementation modalities and timetable; and - monitoring and evaluation. III. Description and tasks of project implementation unit (Cellule d'ExJcution du Projet - CEP) - terms of reference of higher level staff of the CEP (executive director, procurement specialist and accountant). (2) Detailed cost tables. B. Bank Staff Assessments (1) Aide-memoire of the Bank supervision mission for the midterm review (Nov/Dec 1996) of the ongoing PHR project. (2) Aide-memoire of the Bank preparation mission for the Health Project (Mar 1997) (3) Aide-memoire of the Bank preappraisal mission for the Health Project (June 1997) C. Other (1) Note d'Information sur la Reforme du Systeme de Sante aux Comores (Mai 1996) - Direction Generale de la Tutelle, des Structures et des Moyens & Cellule d'Execution du projet Population Project Appraisal Document Annex 9: Page 2 of 2 Country: Islamic Federal Republic of the Comoros Project Title: Health Project et Ressources Humaines "Composante Sante" Annexe I: Politique de developpement sanitaire aux Comores - lettre du Ministere de la Sante Publique a la Banque mondiale, en date du 9 novembre 1995 Annexe II: Loi no. 94-016 du 17 juin 1994 portant cadre generaL du systeme de sante et definissant les missions du service publique de la sante Annexe III: Decret No. 95-053/PR portant statut et organisation administrative et financiere des dtablissements publics d'hospitalisation en application de la loi no. 94-016/AF du 17 juin 1994 Annexe IV: Decret No. 95-054/PR portant statut, organisation et fonctionnement des centres sanitaires de district et des postes de sante en application de la loi no. 94-016/AF du 17 juin 1994 Annexe V: Decret No. 93-156/PR portant organisation et missions des directions regionales de la sante et des affaires sociales Annexe VI: Arret6 No. 93-038/MSP fixant la carte sanitaire des Comores Annexe VII: Arret& interministeriel No 95-203/MFB instituant les formations sanitaires en *tablissements prives sans buts lucratifs avec mission de service public Annexe VIII: Arrete No. 94-300/MSP portant la mise en piLace des pharmacies a but non-lucratif dans les structures de sante Annexe IX: Arrete conjoint No. 95-378/MSP/MFB instituant les formations sanitaires en etablissements prives sans buts lucratifs avec mission de service public. Annexe X: Schema, la nouvelle organisation du systemne de sante en Republique Federale Islamique des Comores Annexe XI: Schema, nouvel organigramme du Ministere de la Sante Publique Annexe XII: Schema, organisation administrative et fonctionnelle des h6pitaux Annexe XIII: Schema, organisation budgetaire et financiere des h6pitaux Annexe XIV: Schema, organisation administrative et fonctionnelle des centres sanitaires de district Annexe XV: Schdma, organisation budgetaire et financiere des centres sanitaires de district *Including electronic files. Project Appraisal Document Annex 10: Page I of I Country: Islamnic Federal Republic of the Comoros Project Title: Health Project Annex 10 Status of Bank Group Operations in Comoros IBRD Loans and IDA Credits in the Operations Portfolio Difference Between expected and actual Original Amount in US$ Millions disbursements a/ Loan or Fiscal Project ID Credit No. Year BotTower Purpose IBRD IDA Cancellations Undisbursed Orig Fnn Rev'd Number of Closed Loans/credits: 9 Active Loans KM-PE-603 IDAN0310 1997 GOVT OF COMOROS EDUCATION III 0.00 7.00 0.00 6.98 0.00 0.00 KM-PE-604 IDA29310 1997 GOVERNMENT AG SERVICES PILOT 0.00 1.60 0.00 1.51 1.68 0.00 KM-PE-596 IDA25530 1994 GOVT. POP & HUMAN RESOURCE 0.00 13.00 0.00 3.29 3.15 0.00 KM-PE-606 IDA26320 1994 GOVT OF COMOROS SMALL ENTERPRISE DEV 0.00 5.10 0.00 3.01 2.95 0.00 KM-PE-593 IDA22070 1991 GOVERNMENT ROAD MAINTENANCE 0.00 6.60 0.00 .30 .14 0.00 Total 0.00 33.30 0.00 15.09 7.92 0.00 Active Loans Closed Loans Total Total Disbursed (IBRD and IDA): 18.46 49.80 68.26 of which has been repaid: 0.00 2.18 2.18 Total now held by IBRD and IDA: 33.30 44.13 77.43 Amount sold : 0.00 0.00 0.00 Of which repaid : 0.00 0.00 0.00 Total Undisbursed : 15.09 0.00 15.09 a. Intended disbursements to date minus actual disbursements to date as projected at appraisal. b. Rating of 1-4: see OD 13.05. Annex D2. Preparation of Implementation Summary (Form 590). Following the FY94 Annual Review of Portfolio performance (ARPP), a letter based system will be tised (HS highly Satisfactory, S satisfactory, U unsatisfactory, HU = highly unsatisfactory): see proposed Improvements in Project and Portfolio Performance Rating Methodology (SecM94-901), August 23, 1994. Note: Disbursement data is updated at the end of the first week of the month. Project Appraisal Document Annex 11: Page I of 2 Country: Islaamic Federal Republic of the Comoros Project Title: Health Project Annexe 11 Comoros at a glance 28/08/97 Sub. POVERTY and SOCIAL Saharan Low- Comoros Africa Income I Developmentdiamond Populafion mid-1996 (mnillions) 0.5 600 3,229 GNP per capita 1996 (USSJ 460 490 50 LifeXepectancy GNP 1996 (billions USS) 0.2 294 1,601 ! T Average annual growth, 1990-96 Populafion (96) 2.6 2.7 1.7 GNP Gross Labor force (96) 2.8 2.6 1.7 per p mary Most recent estimate (latest year available since 1989) capita enrollment Poverty: headcount index (% of populafion) Urban populafion (X oftotal population) 28 31 29 Life expectancy at birth (years) 56 52 63 Infant mortality (per 1,000 lve births) 87 92 69 ! Access to safe water Child malnutrition (96 of children under .) Access to safe water (96 of population) 48 47 53 Illiteracy (X ofpopulation age 15+) 43 43 34 1 Gross primary enrollment (9% of school-age population) 75 72 105 -Cororos Male 81 78 112 Low-income group Female 69 65 98 KEY ECONOMIC RATIOS and LONG-TERM TRENDS 1975 198l6 1995 1996 E = = t == Economic ratios^ GDP (milDons USS) 114.5 233.2 229.7 Gross domestic investment/GDP .. 32.8 17.1 17.2 ! Openness of economy Exports of goods and servicet GOP .. 17.0 19.3 18.4 1 Gross domestic savings/GDP .. -0.3 -7.9 -5.9 1 Gross nafional savingsrGDP .. Cunrent account balance/GDP .. -12.7 -12.9 -9.8 Interest paymentslGDP .. 1.3 0.2 0.7 Savings Investment Total debt/GDP .. 117.2 87.2 Total debt service/exports .. 8.9 1.7 Present value of debt/GDP .. 0.0 47.2 Present value of debt/exports .. 0.0 181.5 .. Indebtedness 1975-85 1986-96 1995 1996 199705 (average annual growth) Comoros GDP 4.5 0.9 -2.3 1.0 .. GNP per capita 1.7 -1.5 -4.7 -1.2 .. Low-mcome group Exports of goods and services 15.6 5.3 11.2 1.0 STRUCTURE of the ECONOMY 1975 1985 1995 1996 Growthratesofoutputandinvestment(%) (% of GDP) Agriculture .. 36.1 38.7 40.0 20- Industry .. 14.1 12.8 13.6 o Manufacturing .. 3.7 5.3 4.8 0.2 Services ,, 49.8 48.4 46.4 -20 Private consumption .. 72.7 86.7 88.9 .40 General govemment consumption .. 27.5 21.2 19.1 jGDI _O_Gp Imports of goods and services .. 50.1 44.4 41.5 GP 1975-85 1986-96 1995 1996 (average annual growth) Growth rates of exports and impdrts (%) Agriculture 4.3 1.7 1.5 2.2 so. Industry 4.1 2.9 1.0 2.0 40I A Manufacturing 4.4 3.9 1.0 2.0 Services 4.8 -0.2 -8.3 -0.4 20 Private consumption 3.7 2.7 0.3 -1.2 93 35 General govemment consumption 3.4 -3.4 -4.2 -6.4 _ .2_ 1 Gross domestc investment 3.9 -4.4 -3.4 8.8 40 Imports of goods and services 4.3 1.2 8.6 -4.0 Exports Imports Gross national product 5.7 1.1 -2.3 1.2 . . Note: 1996 data are preliminary estimates. The diamonds show four key indicators in the country (In bold) compared with its income-group average. If data are missing, the diamond will be incomplete. Project Appraisal Document Annex I1: Page 2 of 2 Country: Islamic Federal Republic of the Comoros Project Title: Health Project Comoros PRICES and GOVERNMENT FINANCE 1975 1985 1995 1996 - Domestic prices Inflatlon (%) (% change) 25 - Consumer prices .. .. 0.8 2.1 20 - Implicit GDP deflator .. 7.1 7.0 0.0 10- Government finance _ (% of GDP) -s- 91 93 94 95 95 Current revenue .. 37.4 20.8 20.5 -10 - Current budget balance 19.5 -3.9 -0.2 GDPdf. -;-CI Overall surplus/deficit -16.5 -10.6 -*6.0 TRADE 1975 1985 199p 1996 (millions US$) Export and Import levels (mill. US$) Total exports (fob) - 16 11 6 ao - Vanilla .. 10 6 3 Girofle .. 3 0 1 s0o Manufactures 3 0 0 0 Total imports (cif) 37 68 62 40 : Food .. 4 18 12 Fuel and energy .. 3 8 4 20 Capital goods _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Export price index (1987=100) 70 79 75 90 91 92 93 94 95 9a Import price index (1987=100) 67 80 78 at imports Terms of trade (1987=100) 104 98 96 BALANCE of PAYMENTS 1975 1985 1995 1996 -_- (millions US$) Current account balance to GOP ratio (%) Exports of goods and services .. 20 45 42 Imports of goods and services .. 64 104 95 Resource balance .. -44 -58 -53 Netincome .. -1 1 0 90 91 92 93 94 95 98 Net current transfers .. 31 27 30 Current account balance, before official capital transfers .. -15 -30 -23 Financing items (net) - 21 26 32 Changes in net reserves .. -6 4 -9 -15 - Memo:_ Reserves including gold (mill. US$) .. 12 37 39 Conversion rate (locakUJS$) 214.3 449.3 374.4 383.7 EXTERNAL DEBT and RESOURCE FLOWS (millions US$) Composition of total debt, 1995 (mill. USS) Total debt outstanding and disbursed 5 134 203 IBRD 0 0 0 0 G IDA 0 20 64 68 13 B Total debt service 1 2 1 .. E64 IBRD 0 0 0 0 35 IDA 0 0 1 1 Composition of net resource flows Otficial grants 14 0 0 Official creditors 1 22 9 1 C Private creditors 0 0 0 */ 3 Foreign direct investment 0 0 2 *D Portfolio equity 0 0 0 *8 World Bank program Commitments 0 0 0 0 A - IBRD E - Bilateral Disbursements 0 6 10 6 B - DA D- Other multilateral F - Private Principal repayments 0 0 0 0 C - IMF G - Short-term Net fows 0 6 9 6 _ Interest payments 0 0 0 0 Net transfers 0 5 9 6 Development Economics 8128/97 MAP The botundaries, colors, d'enominations T AN ZA N IA 48Gan and any othernfomtion shown on > _Grand this map do not imply, on the port of > Comore ,iJsamsouu~ \The World Bank Group, any judgment 12 Anjouon on the legal status ofoany terriory orMhei ' rny endlorsenset or acceptance of Mcel such boundaries. COMOROS <>Mayole 1ay \6 M ,,M Z MBIQEBeni Fr) Hnhop) tK E :6566 e uM'6eni J 4, ~~~~~~KILOMErERS ) hn nf,) li!tJ| 0 ! 1I'f >e qX j o oI2100 00 MA DAGASCAR 16 NGAZ IDJA MILES - !'.21 S ? S -- 44' kant y~(4~~ N,. (GRANDE 36 00 4 8 2 Mitsou~~e COMORES 'I4aumbouni ROADS 0 TOWNS PATHS CONTOURS (elevotions in feet) -4- AIRPORTS * SPOT ELEVATIONS (in feet) PORTS REEFS 120 1 N _~~~~~~~~~~~~~~~~~~~~~~~~N *rW" NZWAN I 4 ( E ''At, uareu> ( ' ANJOLIAN) Muitsasd MWALI Sao (MOHELI) N, M4,j,3_~mbo Pomn )min MirinDomon Quoltafib ~~~~~~~~~~~' ~~~~> M oy~~~~~~~ Remani 5 0 25643 i t I I I | ~MIL1ESI125f, ..........., 5 0 25 i(ILOMETERS 10~~~~~~~~~~~~~~~~~~~~~~~~~~~ 4A