( & (' , -7 I)ocument of The World Bank FOR OFFICIAL USE ONLY Report No. 12405-CD STAFF APPRAISAL REPORT REPUBLIC OF CHAD HEALTH AND SAFE MOTHERHOOD PROJECT MAY 13, 1994 MI CROGRAPHICS Report No: 12405 TD Type: SAR Population and Euman Resources Operations Division Sahelian Department Africa Region This document has a resbited drb2Hhdon and nmy be used by redpiub oaly in the perfonmanoe of their officid dutes. Its contents may no othewise be disdosed without Wodd Bank authorzation. CURRENCY EQUIVALENT Currency Unit = CFA Franc (CFAF) I US$1 = 597 CFAF ABBREVIATIONS AND ACRONYMS AGETIP Executing Agency for Public Works (Agence dExecution des Travaux dIrnt*rt Public) ATETIP Executing Agency for Public Works (Agence Tchadienne dx'&cution des Travatx dVntlrit Public) BCE Bureau de Cooperation et Etudes BELACD Bureau d 'Etude et de Liaison dAction Caritaive et de DOveloppemenr BSPE Bureau de la Sfatistique, PlanlJ;cation et Etudes CPA Cen;ral Purchasing Agency (Centrate Pharmaceuuique dAchats) CMA Contract Management Agency CNSF National Family Health Center CPAR Country Procurement Assessment Repert CPSF Office for Promotion oi Girls' Education/(Cellule de Promotion de la Scolarisation des FiUes) CTS CeUule Technique de Suivi do la Table Rondo SectorieUe DG General Directorate of the Ministry of Heilth(Direcion Gneralk de la Sante) DNPP National Declaration on Population Pulicy DPS D6l6gud prefectoral de la sante EDF European Development Fund EDP Essential Drugs Program ENASS Ecole Nationale des Agents Sociaux et Sanitaires FED Fonds Europe'en de Diveloppement FP Family Planning GTZ German Corporation for Technical Cooperation/(Deasuche Gesellscha_fi fr Technische Zusammenarbeit) HIEU Health Information and Education Unit ICB Intemational Competitive Bidding IEC Information-Education-Communication KAP Knowledge, Attitude and Practice KfW Bank for Reconstruction/Kreditanstalftr Ufiedraa#brau) LCB Local Competitive Bidding MCH Maternal and Child Health MOC Ministry of Commerce MOF Ministry of Finance MOPC Ministry of Planning and Cooperation MOPH Ministry of Public Health/(Ministere de la Santi Publique MSF Midecins sans Frontlires NRH National Referral Hospital NHDP National Health Development Plan NDPP National Declaration of the Population Policy NGO Non-Governmental Organization NDP National Drug Policy NHIE National Health Information and Education Strategy PADS Projet d'Actions pour le de Diveloppement Social PASP Phannacie dA'pprovisionnemem du Secteur Public PHC Primary Health Care PCT Project Coordination Team PHARMAT Pharmacie Tchadienne RMO Regional Medical Officer SDA Social Dimensions of Adjustmenit SECADEV Secours Cathofique et Diveloppement SSA Sub-Saharan Africa STDs SexuaUy Transmitted Diseases TA Technical Assistance TFR Total Fertility Rate UNAD Union Nanonale des Associations Diocisaines de Diveloppement UNICEF United Nations Chilaren's Fund USAID United States Agency for International Development VNU Volontaires des Nations Unies (United Nations Volunteers) WHO World Health Organization Fiscal Year January 1 - December 31. FOR OFFICIAL USE ONLY REPUBLIC OF CHAD HEALTH AND SAFE MOTHERHOOD PROJECT TABLE OF CONTENTS Page N' CREDIT AND PROJECT SUMMARY .............................i I. INTRODUCTION . ............................ II. SECTORAL CONTEXT ...................1......... A. Background .... ..........1............... B. Macro-Economic Context and Medium-Term Prospects ............ 2 C. Demographic, Health and Nutrition Sectoral Context .... ......... . 3 1. The Demographic Situation ................................. 3 2. Health and Nutritional Status ............................... 4 3. Organizational and Management Structure ....................... 5 4. Cost and Financing ...................................... 7 5. Sector Development Issues .................................. 8 D. The Gove.nment's Strategy ..................... 11 E. The Bank Group's Role ................... ..................... 13 III. THE PROJECT . ...................................... 15 A. Project Objectives, Scope and Description .......... .................. 15 B. Project Cost and Financing Plan ................................... 25 IV. PROJECT IMPLEMENTATION .................................... 26 A. Status of Project Preparation and Readiness ......... .................. 26 B. Project Coordination and Management . ............................. 2-,' C. Monitoring and Evaluation ...................................... 6 D. Procurement ..................................... 27 E. Disbursements ................................ 31 F. Accounting, Auditing and Reporting ............................... 32 V. PROJECT BENEFITS AND RISKS .............. ..................... 33 A. Benefits ................................ 33 B. Risks ................................ 33 VI. AGREEMENTS REACHED AND RECOMMENDAONS .................. 33 This report is based on the findings of a pre-appraisal mission and an appraisal mission that visited Chad in Januay 1993 and in November 1993 comprising of MmeslMessrs. Eva larawan, Mission Leader, Anwar Bach-Baouab, Population Specialist, Myrina Hams, Projects Assistant; (AFSPH); Bemard Abeill6, ArchitectlProcurement Specialist (AFTCB); Etienne Alingue, Program Offtcer (AF5CD); Michele Lioy, IEC Specialist (AF3PH); Jean Perrot (WHO-Consultant); Marie-Paule Fargier, (Consultant- Pharmacy Specialist). Report processing was funalized with assistance from Janine Leygonie (Sr. Staff Assistant/AF5PH). Ms. Katb-zrine Manhall and Mr. Birger Predriksen are the Department Director and Managing Division Chief, respectively, for the operation; Messrs. R. Bulatao (PHN) and C. Pannenborg (AFIPH) are the peer reviewers. This document has a restricd distnbution and may be used by ecipients only in the performane afctheir official duties. Its contents may not otherwise be disclosed without Wodd Bak authorizadoti LLSr OF ANNEXS Annex 1-1 Basic Data Sheet Annex 2-1 MOPH New Orgaational Chart Annex 2-2 Le Syst2Wh de D lsit SatTairesThe District Hiealth System Annex 2-3 Le#v de Politwe de Sant PubliqueALetter of Sector Development Policy and Quantified Monitoring Indicators Annex 3-1 Progmwwae de Constcton dt de RabiliaonlConstruion and Rehabilitation Program Annex 3-2 Project Cost Estlmates Amnex 4-1 Project Monitoring and Supervision Plan Annex 4-2 Procurement Arrangements Annex 4-3 Disbursement Profile Annex 4-4 Docments in the Project ile Note: Detailed worldng papers describing the following project components wil be included In the bnplementation Manual: 1. The EEC Progm 2. Redeployment and Training of Health Personnel 3. Terms of Reference for the Project Coordination Team 4. District HospitlHealth Centers Flnancing Plan 5. The PharmaceutIcal Sector Map: IMRD 2SS29 IBRD 2SS30 ILBRD 25531 CHAD HEALTH AND SAFE MOTHERHOOD PROJECT CREDIT AND PROJECT SUMMARY Borrower: Republic of Chad Benefidaries: Ministry of Public Health Credit Amount: SDR 13.1 million (US$18.5 Million equivalent) Terms: Standard IDA terms with 40 years maturity Project Objectives The Government of Chad has developed a National Health Plan (1993-2000) and and Description: launched the process of developing a population policy and its associated plan of action. The central objective of the health program is to increase access of the population to quality basic health care focusing particularly on the mc,t vulnerable groups of the population - children and women of child-bearing age. A number of donors are already supporting, or plan to support this program. The proposed project would complement these efforts to improve the health status of the Chadian population, giving particular emphasis to reducing both maternal and infant/child mortality. Parallel to this project, IDA is preparing a Population and AIDS Control Project to support implementation of the Government population policy as well as the development and implementation of an aggressive AIDS prevention program. Within the above framework, the present project would support the development and implementation of policies and investments designed to: 1. Strengthen capability at thentral level to suopr rgional health eyrces by: (a) improving the budgetary process at central and regional levels; (b) developing skills-upgrading modules for regional and district health personnel; (c) developing and implementing a nationwide IEC program; and (d) reinforcing Government capacity to plan, coordinate and implement donor-financed projects. 2. Provide assistance for health, nutritional and FP services to the regions of Guira and Tandjilf by: (a) establishing a network of district health facilities; (b) implementing skills upgrading programs for health personnel; and (c) promoting community participation in local health services planning, implementation, and monitoring. 3. Support the development and implementation of a National Drug Poliye by: (a) developing the planning and management capacity of the Division of Pharmacy, and (b) creating a Central Purchasing Agency (Centrale Pharmaceutique d'achats) for essential and generic drugs. Benefits & Risks: By the end of the project, the increased efficiency of the health system would result in increased access to and improved quality of health, nutrition, and FP services, even within the framework of existing limited sectoral resources. For the regions of Guera and Tandjile, the project will intervene directly to extend the capacity of the health care system, and proposed activities would directly benefit about 750,000 people (more than 12% of the population), mostly women ii and children, who would gain access to basic services. Increased availability of low-cost essential drugs, together with intensive retraining of health personnel is expected to enhance the quality of health services throughout the country. Sec- tor-wide restructuring measures will also help establish a basis for a more responsive administration and for a more efficient and sustainable program. The implementation of an EEC strategy is expected to increase community participa- tion in its own health development. The steps taken to improve access to quality MCH/FP services would put in place the basic infrastructure necessary for attaining the increase in family planning service delivery required to implement the Government's planned population program. This program, to be supported through the proposed IDA-funded Population and AIDS Control Project, is expected to contribute to increasing the contraceptive prevalence rate from the present 1% to 10% in the year 2000. There are three main risks: First, the implementing capacity of the central Government is weak. This risk would be minimized by: (a) up-front implemen- tation of key policy reforms such as personnel redeployment; (b) relying heavily on stakeholder commitment through local management and community participation; and (c) obtaining assistance from UNICEF, WHO, and ATETIP in the implementation of the project. Second, the Government's chronic financial constraints may affect counterpart funding, as well as salary payments. This risk would be mitigated through: (a) annual discussions of project and sector perfor- mance, budgetary allocations, and Public Expenditures Reviews; (b) redeploym- ent of existing health personnel to staff new infrastructures created through this and other donor-financed projects; and (c) gradual introduction of cost recovery to promote increased cost-sharing by the communities. Third, implementation of the national drug policy focusing on the use of essential and generic drugs may face opposition from the private pharmaceutical sector. To address this risk, the private sector will be given a place in the new system, allowing them a profit margin on essential drugs in generic form higher than on specialty drugs. Also, through IEC, the public will be taught that inexpensive generic drugs are as effective and safe as expensive brand name drugs. .O Environmental No environmental risks are foreseen. Economic Rate Not applicable of Return: iu ESTIMATED PROJECT COSTS AN) FINANCING PLAN (US$ MILON)' ESTIMATED PROJECT COST 2 LOCAL F-R1EIGN TOTAL (US$ MTLLION) Strengthen capability at the central level to support regional health services 0.2 3.4 3.6 2. Provide assistance for health, nutritional and 7P services to the Regions of Guda and Tandjil6 1.6 11.8 13.3 3. Support the development and implementation of a National Drug Policy 0.9 3.7 4.6 Total Base Costs u 18.9 21.5 Physical Contingencies 0.2 1.5 1.7 Price Contingencies 0.9 1.6 2.5 TOTAL PROJECT COSTS Zj2 2Q 7 FINANCING PLAN (In US$ million) IDA 18.5 Govenmemnt 1.0 Communities 2.6 UNDP 1.3 UNICEF 2.3 TOTAL 25.7 ESTIMATED CREDIT DISBURSEMENTS (IN USS MILIUON) ID-A FY 1M i229 iM 1221 129 22 Annual 1.5 2.0 5.5 6.0 2.0 1.5 Cumulatve 1.5 3.5 9.0 15.0 17.0 18.5 Totals may not add up due to rounding. 2 Net of taxes and duties. REPUBLIC OF CHAD HEALTH AND SAFE MOHERHOOD PROJECT 1. IN DUCTION 1.1 The Government of Chad has requested IDA's assistance in financing a project designed to help implement its National Health Development Plan. The proposed project would assist Chad in increasing access of the population to quality basic health, nutrition, and FP services, focusing particularly on the most vulnerable groups of the population - children and women of child- bearing age. Within this framework, particular emphasis would be given to reducing infant/child mortality and maternal mortality. 1.2 The project would be IDA's first free-s anding health project in Chad, though the ongoing Social Development Action ProjectUProjet d 'A ctons pour ke D4eloppement Social - PADS (Cr.2156-CD) includes a component supporting the improvement of Primary Health Cace and Social Services (PHCSS) in N'Djamena and to a limited extent in the Tandjile area. The policy measures and investments included in the project have been developed through dialogue with the Chadian authorities and are based on the Government Development Plan (Plan d'orientadon: Le Tchad vers "an 2000), prepared by the Ministry of Plan; the National Health and Social Affairs Alan (January 1993); and extensive discussions during the preparation of the Bank's sector report entitled "Chad Population, Health and Nutrition: Summary report", The World Bank, December 1992, the supervision of the health component of the PADS as well as during the course of project preparation. The interventions under this project would be complemented through a second parallel IDA operation to support implementation of the Government's population policy as well as development and implementation of an aggressive AID.3 prevention program. The basic data sheet and comparative indicators are found in Annex 1-1. 1.3 Total project costs are estimated at US$25.7 million (net of taxes and duties), with a foreign exchange component of US$22.0 million. Project financing would include US$18.5 million from IDA, a UNDP contribution of US$1.3 million, a UNICEF contribution of US$2.3 million, a Government contribution of US$1.0 million, and a community contribution of US$2.6 million. The project has been developed in close cooperation with the other major donors contributing to the development of the health sector in Chad (para 2.49). H. SECTORAL CONTEXT A. Background 2.1 Chad is a landlocked country with a population of over 6 million in 1993. It is one of the poorest countries in the world. Per capita GNP in 1991 was US$210 (compared to the US$635 average for Sub-Saharan Africa (SSA)); life expectancy is 47 years (compared to 52 years); female adult literacy is 18% (38%); and total adult literacy is 30% (49%). Chad's most intractable constraint is non-economic: recurring political instability and domestic strife. Subsistence farming is the mainstay of the population and generates 35-40% of GDP. The industrial sector (20% of GDP) includes a large cotton parastatal, public and para-public medium-scale enterprises, and informal micro-enterprises. The service sector (40-45% of GDP) includes a large informal trading sector. 2 B. Macro-Economic Context and Medium-Term Prospects 2.2 During most of the 1980s, the Chadian economy faced severe difficulties. These stemmed from a combination of armed conflicts, civil war, drought, political turmoil, and declining competitiveness. During 1987-90, there were three annual arrangements with the IMF under the Structural Adjustment Facility, and IDA approved the Financial Rehabilitation Credit. The adjustment program focused on improving public resource management and efficiency in the cotton sector, and also addressed efficiency issues in transport, livestock and trade. Important progress was made in reviving key sectors of the economy. Substantial growth was recorded in 1988-89, and this was accompanied by rising fiscal revenues, which permitted investment to double to the still modest level of 10% of GDP. 2.3 The December 1990 coup led to a renewed period of political and military uncertainty, with a consequent impact on economic developments. Indeed, until April 1993, and the completion of an eleven week "National Conference" leading to the creation of a new transitional government, economic issues took a back seat to pressing military and political reforms. The interim period saw sharp increases in military spending and declining capacity to collect revenues, and the fiscal targets of the Third Policy Framework Paper were missed by a wide margin. No new adjustment programs have been supported by the Bretton Woods institutions since the end of 1990. The Financial Rehabilitation credit was suspended in June 1991, the undisbursed amount was then cancelled, and the credit closed in December 1992. 2.4 The Chadian economy tlvrefore alternates between periods of severe instability associated with economic decline, and periods of serious development efforts to exploit Chad's long term potential. However, these cycles have had a devastating cumulative effect on both the public and private sectors. Within the public sector, revenue collection ability has suffered drastically, with total revenue now only 9% of GDP. This has led to both external and internal payment arrears, and to the inability of the government to meet its wage and salary bill regularly. This in turn, has led to strikes of public servants - including in the school and health systems - and to severe loss of morale, causing further worsening of the performance of the public sector. Economic difficulties and political uncertainty caused the closure of much of the private sector, and government payment arrears have caused severe liquidity problems for much of what remains, while the significant amounts of economic, physical, social and administrative infrastructure destroyed during civil strife have yet to be rebuilt. 2.5 These domestic problems were compounded by twin external problems. Export performances have been adversely affected by the fall in world market price for cotton, the main export crop. The appreciation of the real effective exchange rate generated also major losses for the cotton sector, and especially for the processing and marketing parastatal, COTONTCHAD. The real appreciation has had also an impact on livestock and other agricultural exports, as well as on manufacturing activities. At the same time, the country's inability to stay the course of its economic reform program led to declining intemational and lower flows of assistance. Domestic investment fell to below 10%, external arrears have grown, and Chad has exceeded its credit position at the BEAC, its central bank. 2.6 In the wake of the 50% devaluation of the CFA (in foreign currency terms) on January 12, 1994, Chad embarked on a stabilization program with the Bank and the IMF to restore equilibrium in public finances and address some key issues to improve the macroeconomic framework. Among them, the necessity to restore an operative administration appears paramount. 3 The improvement in Chad's external competitiveness should give economic growth, in particular in the agriculture s. i-, a renewed impetus. Accompanying measures included i. the program would provide greater chancps of success to achieve economic growth and inflation control. A specific set of measures on pric; .sf socially sensitive groups and increased public expenditures in health and education sectors will contribute to alleviate the adverse effects of the devaluation on the most vulnerable groups, and provide the basis for durable improvement in standards of living. 2.7 The main focus of Bank's assistance in Chad will continue to be poverty alleviation through investment in the human resource sectors, including education and health, the promotion of private sector activities, in particular export-oriented activities, notably through restoration of transport infrastructures. The proposed health project forms a key element in this Country Assistance Strategy. The expanded access to health services would contribute to improve standards of liviag for the most vulnerable groups, such as women and children. The investnrent would be supported by increased budgetary allocation to the health sector and a restructuring of expenditures in the Ministry of Public Health in favor of basic health care services. C. Demographic, Health and Nutrition Sectoral Context 1. The Demographic Situation 2.8 Data sources on Chad's population are scarce and unreliable. Although the first population census was successfully completed in April 1993, data available are preliminary and are being analyzed further. In the meantime, the mortality and fertility estimat-s derived from partial demographic surveys done in 1964 and 1968 will continue to provide the basic data for population projections. 2.9 Chad's population has doubled since 1960. At present, the average annual growth rate is 2.5% (3% for SSA). The country's crude birth rate has remained at 45 per thousand since 1965, while the crude death rate has decreased from 28 to 19 per thousand (compared to 16 per 1,000 in SSA). Although, the estimated total fertility rate (ITFR) in Chad (5.9 live births per woman) is very high by world standards, it is among the lowest in the region where the average is 6.6. There is a seemingly high prevalence of sexually transmitted diseases (STDs) and sterility might explain the country's lower fertility status. It is expected, however, that improved health and socioeconomic conditions and the resulting decline in mortality will cause fertility to increase, resulting in a rate of 6.6 TFR by the year 2000. 2.10 Rapid population growth has produced an age structure that is heavily weighted towards infants, toddlers and women of reproductive ages. The proportion of children aged from 04 years has risen from 9.9% in 1970 to 17.3% in 1990. With more than 50% of the population under the age of twenty, larger cohorts of women of childbearing age, and a TFR projected to further increase, there is a built-in momentum of accelerating population growth. Current estimates, based on Bank standard projection assumptions, suggest that the total population would increase to 7.4 million by the year 2000 and would double over the subsequent twenty years. 2.11 The pressure of the country's demographic expansion is further exacerbated by the population distribution pattern. Although the average population density is low (an estimated 4.2 inhabitants per km2 in 1988), it is nevertheless high in relation to arable land and water resources. At the same time, the population is unevenly distributed and varies from 0.2 inhabitants per km2 in the desert northern provinces, to 42 inhabitants per km2 around Lake Chad and along the rain-fed south/southeastern parts of the country where nearly 70% of the population live. Pinally, the 4 pressures of drought, war, political instability, and deteriorating economic conditions are rapidly reinforcing this pattern. Further demographic pressure will place large population segments into food insecurity. The urban population counts for over 20%, one of the highest rates in the Sahel. While this trend towards urbanization might result in smaller families due to the classic break with traditional behavior occurring when people migrate to cities, the impact on the rate of fertility would remain minimal, given the universality of marriage, polygamy, and continued low literacy among women. 2. Health and Nutritional Status 2.12 Available data suggest that the health situation in the country is precarious. Infant mortality is at 124 per 1,000 live births (106 in SSA). The principal causes of mortality and morbidity are infectious and parasitic diseases (including most of the tropical diseases), pregnancy- related conditions, and malnutrition. Fever, usually an indication of infectious or parasitic disease, cough, muscular and articular pains, traumas, and diarrhea continue to be the principal reasons for consultations in health facilities. At the age of one year, only 3.3% of children are fully vaccinated. Total vaccination coverage for 12-23 month old children, has dropped froma 15% in 1990 to 6% in 1992. 2.13 Pregnancy-related Problems. Maternal mortality is the main cause of deaths among women of reproductive age. It is one of the highest in the world. A study of the N'Djamena National Referral Hospital (NRH) has reported an average maternal mortality ratio of 811 per 100,000 live births for the years 1986-1989. These are hospital data and do not reflect the real situation in the country which is likely to be worse. About 1,000 deaths per 100,000 live-births have been reported in rural areas of the South. The NRH study revealed that among the direct causes of maternal deaths are hemorrhage/anemia (29%), eclampsia (18%), and post-partum and post-abortum infections (13%). Many indirect causes contribute to maternal mortality: (i) adolescent pregnancy is a serious problem in a country where more than 5.5% of pregnant women are less than 15 years old; (ii) difficult access to antenatal, obstetric and postnatal care: only about 30% of pr-gnant women have antenatal care, less than 15% of deliveries are attended by trained health personnel, and postnatal care is almost nonexistent; (iii) lack of child spacing; (iv) clandestine abortions: although data are not available, anecdotal evidence shows that a large number of pregnancies, both within and outside a marital union, are unintended; (v) lack of hygiene; and (vi) low literacy among women. 2.14 Female genital mutilation is widespread among many ethnic groups. While it is not associated with any religious belief, it is deeply rooted in the Chadian culture and traditions and is considered as a mandatory passage to maturity for 6 to 14 year old girls. Excision, the second most severe of the three basic types of female genital mutilation, is reported to affect an estimated 20% of the female population. The most severe type of mutilation originated and is practiced in the regions bordering Sudan. It is not as widespread as excision. A UNICEF study showed that 77% of women favor excision; 80% of mothers under 45 in the Moyen-hari said they themselves had been excised. In rural areas where the procedure is done in unsanitary conditions, the health risks are serious and could lead to infections, tetanus, hemorrhage, urine retention, sterility, dysmenorrhea, and difficult childbirth. It was with this in mind that a National Committee was created in 1988-89 to fight against traditional practices which have a negative impact on the health of women and children. The committee, which was expected to organize public awareness campaigns and elaborate legal texts to prevent this practice, has been practically inactive. 2.15 Nutrition-related Conditions. Iron deficiency is highly prevalent among pregnant women with rates at the central hospital reaching 70%. Among children 0-5 years old, malnutrition (less than 80% weight for height) is highly prevalent especially during the rainy season prior to the harvest. The prevalence of malnutrition roughly follows a geographic pattern from north to south, with the lowest rates in the Sudan southern provinces. Rates of severe malnutrition of 5-10% are routinely recorded in some rural areas even during years of 'normal" rainfall, Increasing to 15% and higher in years of drought or conflict, such as in 198485, and 1991. Although there is little data to support this conclusion, the prevalence of chronic, as opposed to severe, malnutriticn among children is also believed to be high and it is by no means confined to rural areas. In N'DjamEna, the CNNTA has estimated that 11 % of children between the ages of 6 months to 5 years are malnour- ished. Vitamin A and iron deficiencies are widespread throughout the country, affecting a significant number of children and adults. Malnutrition is attributed not only to household food insecurity but also to conditions that can be readily targeted including poor weaning practices, lack of clean water, and poor sanitation and hygiene. 2.16 Seoually-transmitted Diseases (STDsa including AIDS. As mentioned before (para 2.9), the total fertility rate of 5.9 is well below the average 6.6 for SSA. While it is suspected that this is due to the prevalence of STDs, the unavailability of statistics makes it difficult to substantiate this supposition. AIDS is increasing rapidly, but its widespread impact is largely underestimated by both Government and the population. The number of AIDS cases has practically doubled each year from 1986 to 1992. The AIDS program suffers from an overall poor community awareness of the seriousness of the problem, poor skills among personnel, and a shortage of resources at the level of health facilities (particularly supplies for blood tests); the program's effectiveness is also hampered by logistical constraints with respect to follow-up and supervision. With IDA support, the Government is undertaking a rapid assessment of the AIDS situation and will be using the results of the assessment in the preparation of the future IDA-financed Population and AIDS project. 3. Organizational and Management Structure 2.17 Organization of Health Services. The MOPH is responsible for formulating health policies and providing most national health services. It underwent in 1991 a major reorganization allowing it to support decentralized and integrated health, nutritional and FP services (Annex 2-1 presents the new orgarigramme). Although the new organization was officially approved, the transition has been slow and difficult. It is a three-tiered system (central, intermediate and peripheral) linked by a referral system such that each health facility provides a minimum package of activities, the complexity of which increases the higher the level of service delivery. While responsible for policy-making, health planning and control, as well as resource allocation, the central level does not execute activities, either centrally or locally. An important feature of the central level is the creation of a deputy directorate general responsible for overseeing, supervising, and coordinating all the health regions. Responsibility for the national health budget, procurement, personnel management, and training remains at the central level. At the regional Cmterrediate or prefeCture) level, the Regional Medical Officer (RMO) is responsible for overseeing the planning, management, and supervision of all health activities in the region. Finally, at the peripheral level (district), the District Medical Officer (DMO) reports to the MOPH through the RMO. His responsibilities include: administration of the district hospital, management of human and financial resources and health information in the district, ensuring the supply and distribution of drugs and materials for the district; securing proper management of funds generated through community participation, and overseeing the proper implementation of the district-health plan (para 2. 18). Training of personnel is carried out at all levels, its site being determined by the type of training and the personnel to be trained. Coordination among divisions throughout the levels is ensured through administrative committees (Conseils de sanuS et des Affaires sociakes). Legislative instruments including proposed staffing levels, have already been approved (Decree no. 5191PR/91). 6 2.18 The District Health System. To implement the new heath system, and to improve access to basic health services, the MOPH has established a district-health plan (Plan de couverture sanitaire). According to this plan, the 14 administrative regions (Prefecaures sanitaires) remain the functional administrative units. Based on geographic and demographic criteria, the 14 regions (prefectures) are divided into 46 health districts which do not necessarily correspond to an existing administrative-political structure. Each district is expected to cover a population of 100,000 to 250,000 people and to include a district hospital and a social center. Each district hospital is responsible for the supervision of health centers which, in turn, have a well-defined zone of responsi- bility. There are 633 responsibility zones, each one comprising a population of about 10,000 to be served by one health center. The planning and coordination of all health activities in each of the regions is the domain of the regional team, while district teams focus on the execution and supervision of health activities in the district. At each level of the pyramid, a baseline and norms for equipment, personnel, and activities have been defined (Annex 2-2). 2.19 Although the division of the country into health districts is officially effective, not all districts are functional. Using three minimum criteria namely, the presence of a building for the district hospital, the presence of at least one physician, and the continuous supply of essential drugs, one notes that only 24 out of the 46 districts are functional. Of the 22 districts who do not meet those criteria, 13 do not have a district hospital. The situation is worse at the lower level of the pyramid where more than half of the "Responsibility Zones" do not have a health center as expected in the plan de couverture sanitaire. Of the total 431 health facilities currently available throughout the country, only 31 could be considered referral (9 hospitals and 22 health centers). The rest are infirmaries, dispensaries, and health posts. About 65% of these infrastructures are operated by the public sector, 24% by NGOs, and 11% by private organizations, mainly industries. There are also 23 social centers, mostly in urban areas, that are operated by the Ministry of Social Affairs and that provide nutrition and immunizadon services. However, given Government's strategy which focuses on integration of services at the level of a health center, the role of these centers is expected to change and to focus more on community development. Table I shows the distribution of health infra- structure by type and affiliation. Table I H__fWth Infrastrucwre Ho_ital - - = -_O =O m - _ eC= 81V MM I Pet"r -0aI4 Public 6 18 22 206 5 2 - Is 22 Church-related 3 4 4 72 20 I S 1 Private I - 1 30 2 3 1 UNICEF - - - 11 - . . . Tota 9 22 27 308 38 S 2 20 23 *S _ _ 199a. m 2.20 The N'Djamena National Referral Hospital (NRH) of 600-700 beds is presently the only hospital structure in Chari-Baguirmi. (A Chinese-funded district hospital is in the pipeline, as are other hospitals to be built by the PADS). Yet, it is expected to play a referral role not only for the capital city and the region of Chari-Baguirmi, but also nationwide. Currently, the NRH functions largely as a primary care and outpatient facility, thereby wasting scarce technical and financial resources. The Government budgetary allocations for operating costs is insufficient, and there is an acute shortage of basic and essential drugs and supplies. Hospital personnel, like all other civil 7 servants, have not been paid for several months. Recently and with the new organization of the MOPH, the NRH has been given the status of a National institution and therefore, a certain degree of administrative and budgetary autonomy. However, it continues to suffer from very poor management and limited funancial resources. The French Cooperation which has been providing some technical and financial assistance to the NRH, is now trying to strengthen the management system. They are continuing to provide financial assistance (drugs and medical supplies) and will train hospital personnel. 2.21 The private sector is very limited in Chad. A recent survey indicated that there were only 9 physicians practicing private medicine, all of whom are in N'Djamena. While the role of the private sector is minor in the delivery of services, it plays a significant role in the distribution of contraceptives. Traditional practitioners exist in virtually every village and town of Chad. Very little information exist on their numbers, their availability, or the nature of their services. 2.22 The pharmaceutical sector comprises of: a prosperous private sector and a public sector which relies almost exclusively on donors. The private sector is represented by the Pharmacie Tchadienne (PHARMAT) which holds a drug import and distribution monopoly. It does not comply with the essential drugs list or generic classifications for its procurement. The public sector is represented by the Phanmnace d'approvisionmementdu secteurpublic (PASP) which, according to the new organigramme of the MOPH, should be an autonomous national institution. However, given the weak budgetary allocation to this sector, the role of the PASP has been mininal. The Division of Pharmacy at the MOPH is being reorganized to fill a policy-making and quality assurance role. It is currently very weak and ineffective. The public sector relies heavily ou donors who generally adhere to the essential drugs list and provide drugs for the zones in which they work. The June 1992 National Seminar on essential drugs and the January 1993 Round Table meeting resulted in adopting a National Drug Policy (NDP) with a general consensus among donors and the Government to strengthen the Division of Pharmacy at the MOPH and to create a Central Purchasing Agency, la Centrale pharmaceutique d'achats (CPA), which would have the status of an autonomous, private, not-for-profit organization. The Government policy clearly states that this CPA would not have a monopoly on drug imports but would be exempt from taxes. The strategy in the long-run is to develop a strong, open market involving both the public and private sectors. All donors have agreed to support this policy. The Government has set up an ad-hoc committee to work, with representatives from the MOPH, MOPC, Ministry of Finance (MOF), MOC, and bilateral and multilateral agencies, on the legal status and establishment of the CPA. 4. Cost and Financing 2.23 Financing of the health sector is characterized by: i) an extreme dependency on external assistance and, consequently, a relatively small share of financing from the Government; ii) Government funds favoring curative health services; and iii) actual public health expenditures consistently lower than budgeted amount (contrary to other Government expenditures). 2.24 While the absence of accurate financial data makes a precise analysis difficult, recent trends indicate that the share of the Government budget allocated to health has been around 4% over the past few years. Ihe sharp increase in budgetary allocation to health in 1991 to 5.8% is a reflection of the fusion of two ministries, Public Health and Social Affairs/Women, into the MOPH and does not reflect an increase in real allocations to health. It is also attributable to a large increase in the salary, rather than non-salary expenditures. In 1990, the Government spent about US$1 per capita on health while allocations from external sources were about US$3.5. The source of almost all investment in the health sector in Chad is international aid; in 1990, total foreign aid was 8 estimated at 7.07 billion FCFA (US$27 million). Though difficult to estimate, expenditures by households for the purchase of services, and medications on the private market, are estimated at US$1 per inhabitant. Therefore, Chad spends about US$5.5 per capita on health for recurrent as well as investment expenditures. This is far below the average $12-13 per capita total cost of a public health and essential clinical services package recommended both by the Better Health in Africa study and the 1993 World Development Report. 2.25 The principle of free health care for all is losing ground in Chad. Results of the 1991 household survey for N'Djam6na and of a rapid rural assessment in the region of the Guera, conducted in 1993 as part of the Bank's Poverty Assessment, confirm the community's willingness and even financial ability to share health costs. The process of setting up a cost recovery system is only starting. A decree instituting such a system was enacted in October 1990. This system is however restricted to projects falling within the national Primary Health Care (PHC) program (supported by EDF VI, UNICEF/WHO, and PADS); it does not cover the projects of church- affiliated groups or other NGOs. This decree has now been revised in order to generalize cost recovery. Experiments are underway in different parts of the country, but the individual approaches are often different. With the help of Medecins sansfirontires (MSF), pilot public pharmacies have been set up in the districts of Fianga, Pala, and Mandelia to sell generic medications to patients of the public health facilities with a certain margin of profit. Preliminary findings show that their prices are 25% lower than private pharmacies. Other experiments initiated by EDF VI, PADS and church- affiliated Bureau d'Etudes et de Liaison d'Action Caritative et de Ddveloppement (BELACD) have shown that no matter what payment system is used, it is possible to recover at the level of the health center, not only the costs of medications, but also most operating costs excluding personnel and maintenance of equipment. Costs recovered are expected to replenish stocks of medications and cover about 45-50% of the operating expenditure (excluding wages). While experiments and individual approaches are often different, there does seem to be a consensus with respect to pricing and a need to establish a general and coherent framework for the system being adopted. The Government has prepared a plan for financing health services for the period 1990-2000. It includes the expected contributions from both Government and clients and shows that, apart from financing of the private for-profit sector, the community would finance up to 10.5% of total health expenditures by the year 2000. 5. Sector Development Issues a. Weak Institutional Capadty 2.26 The weak managerial capacity generally characterizing the Chadian administration is particularly acute in the health sector. The MOPH has weak institutional capacity to ensure implementation of the National Health Plan. Like many SSA countries, Chad has made little progress in changing the overly centralized administrative structures (both geographically and hierarchically) of the health system inherited from the colonial regime. Although the MOPH has undergone a major reorganization (para 2.17), deeply entrenched problems cannot be resolved over-night. The old organizational lines with rigid partitioning, and a nearly total lack of coordination, between directorates have not completely disappeared. Furthermore, financial and human resources required to manage the financing and provision of public health services are depleted. There is a dearth of skills required to translate policy into implementable projects and programs particularly in planning, programming and budgeting. At the same time, inter-sectoral cooperation is often neglected despite the fact that public services for health require interventions that go beyond the reach of the health sector alone. 9 2.27 Weak capacity is also manifest in the IEC Division which is responsible for the implementation of the National Information, Education, and Communication Strategy (NIEC). This unit has been barely operational and has accomplished very little since the strategy was developed. IEC activities of national health programs such as the FP program or AIDS/STD program are generally designed to fit the narrow objectives of each vertical project rather than health priorities of the country. Their messages are fragmented (in some instances contradictory) and of poor quality, and because of lack of monitoring and evaluation, their impact is unknown. Data on media coverage, credibility, and acceptability are scarce and their quality difficult to assess. Little research has been done on the knowledge, attitudes, beliefs, and practices of the target population (particularly in FP and AIDS). There are practically no IEC activities at the peripheral level and the potential benefits of IEC programs for change in health-related behavior at the household level are hardly being exploited. 2.28 Decentralization of decision-making and authority is viewed by many as a viable means of achieving greater efficiency and equity in health. However, to be successful, decentraliza- tion requircs definition of the specific objectives sought, a clear delineation of functions at each level, mechanisms for communication and coordination among the various levels, and sufficient training to enable full assumption of decentralized responsibilities. According to the new mandate of the MOPH, central and regional staff have to re-orient their work from exercising control as direct supervisors to emphasizing policy formulation, strategy development, resource allocation, and technical backstopping. As mentioned in para 2.17, the region is expected to be the locus of decision-making and activities coordination. However, in spite of the written mandate of the MOPH and the government's strategy in favor of decentralization (see para 2.38), there is much work to be done in order to move the health system in that direction. The regional units have a weak managerial capacity and do not control the resources necessary to undertake their functions. Even if legal authorities are assigned to local authorities, the de facto structure of financial incentives and responsibilities for salaries and careers continue to remain with central ministries. Through training and technical/financial assistance, donors (the European Union in particular), have been focusing on reinforcing the skills of the Regional Medical Officer in health services planning and management. However, the issue of decentralized budgeting and financial regional autonomy has not been addressed. b. Limited Access to Basic Health, Nutrition and FP Services 2.29 Limited access is primarily related to the insufficient supply of services and the inadequate geographical distribution of health facilities throughout the country. Only 30% of the population has access to a health facility within seven miles. There are about 0.06 referral facilities per 10,000 inhabitants (compared to the WHO-recommended I per 10,000). A referral facility has at least one medical doctor, a nurse anesthesiologist, an operating room, and equipment for blood transfusions. The estimated ratios: 1,316 persons per hospital/health center bed and 16,000 persons per PHC infrastructure, are the least favorable among Sahelian countries. Even when physically accessible, most public health facilities, particularly in rural areas, require major repairs: only about 40% are classified as 'in good condition"; only 36% have a water supply within the building; and only about 9% have electrical power. Equipment is in disrepair at all levels of the system, particulaily ia PHC facilities where basic equipment such as baby scales, measuring apparatus, and sterilization equipment is unavailable. In order to address this issue, the Government has undertaken a systematic analysis of infrastructure needs and presented it to donors for support as part of the National Health Development Plan (NHDP) (paras 2.18 and 2.37). 10 c. Degradation in the Quality of Basic Health, Nutrition and FP Services 2.30 In addition to this state of disrepair and lack of sanitary conditions, several factors limit the access to basic services and contribute to the critical degradation in the quality of health facilities. First, shortage of qualified and motivated personnel is a major constraint to effective management of the sector. A national study conducted in 1993 shows that insensitivity of medical and para-medical personnel is an important barrier to women utilizing health facilities. Second, scarcity and inappropriate use of drugs severely limit adequacy of treatment. Tbird, the low levels of operating budgets for health facilities limit the supply of essential materials (other than drugs). Each of these three factors are discussed in more detail in the following paragraphs. 2.31 Health Personnel. According to 1993 MOPH estimates, the public health sector employs 3,339 persons. While quantitatively the overall number of personnel (4,301 including NGOs and private) may seem sufficient, it is important to note the following: (a) low health care worker/population ratios: there is one physician per 35,000 inhabitants (9,000 in SSA), one registered nurse per 34,000 inhabitants (2,000 in SSA); (b) negative attitude and low qualification of existing personnel: 35% of present personnel are classified by the MOPH as "non-qualified personnel"; (c) heavy bias towards central administration as more than 650 persons work at the central MOPH; (d) severe regional disparities: more than 30% of total health personnel (108 of the 164 physicians (or 66%) and 56 of the 88 midwives (64%)) work in N'Djamena; and finally, (e) quality of training: most nurses and other auxiliary health personnel are trained at the Ecole Nationale de la Santd Publique et des Service Sociaux (ENSPSS). While the ENSPSS trains an adequate number of personnel, the quality of the training is very poor. In preparing the health plan, the MOPH did a detailed analysis of personnel requirements by administrative level, by prefecture and by category of personnel. The analysis showed that additional health personnel needed for the implementation of the plan totals about 500 persons by year 2000, mainly registered nurses, pharmacists, and technicians (laboratory, dental). 2.32 Absence of low-cost essential druss. The public pharmaceutical sector is disorganized, non-operational and impoverished. On paper, the national budget for drugs is FCFA 40 million which represents about 5% of total expenditures on drugs. In reality, even those very limited resources have never been allocated, and the role of the PASP (para 2.22) in supplying drugs to the public sector has been minimal. As a result, public hospital pharmacies and health facilities rely almost entirely on donors for their pharmaceutical supplies and regions where donors do not intervene suffer from chronic shortages. Despite some institutional strengthening offered by EDF VI and EDF VI to the PASP, the latter remains very weak. As a result, while using the PASP facilities for storage, donors continue to manage their own stocks of pharmaceutical and distribute them to the regions where they intervene. Some have started introducing cost recovery for drugs with quite encouraging results (para 2.25). 2.33 Specialty drugs that are found in the private market do not meet the health needs of the population and are financially beyond the reach of the majority of the Chadians particularly in the rural areas (more than 1,500 brand name drugs sold in Chad are not essential drugs). As prescriptions are written for brand name medicines, there is no incentive for distributors to shift to generic equivalents which could be sold at much lower prices. A number of pharmacists however, are aware of these problems and willing to participate in the development of a National Drug Policy that will improve financial and geographical accessibility of the population to essential drugs. 11 d. Lack of Integration of Activities and Programs in the PHC System 2.34 Following reorganization of the MOPH in 1991 and the creation of a three-tiered health system with a district focus, Chad has decided to move from the vertical, project-based approach to service delivery, towards an integrated approach. Accordingly a health care provider is expected to link preventive and curative care, and to provide health, nutritional and FP services at the same facility. With the exception of a few health centers, this transition has been slow and the integrated approach remains theoretical. In 1992, there were reportedly eight public health facilities providing contraceptive information and services. All eight facilities are located in urban areas so the rural population remains unserved. One of these is the National Family Health Center (CNSF) recently established in N'Djamena, with assistance from United Nations Fund for Population Activities (UNFPA). The CNSF functions as both a reference clinic and a training site for medical and para-medical personnel. Nutritional interventions have traditionally taken place at social centers (para 2.19) rather than at health facilities and consist essentially of food distribjtion and rehabilitation rather than child growth promotion, nutrition education, and micronut. ent supplementation. Nutrition programs continue to be operated with a vertical approach. Furtherntore, in the few centers where FP and nutrition interventions are currently integrated in health centers' activities, they are given low priority among health workers. 2.35 While Government's policy focusing on integration of basic services at the level of the health center is sound, it should not be a panacea, i.e. a successful integration of activities is possible only if the health facility is functional, i.e provides a minimum array of services. For example, the integration of vaccination activities in the health center is successful in improving vaccination coverage only if such centers are geographically accessible and acceptable to potential users, namely women and children. e. Heavy Reliance on External Aid 2.36 External aid represents about 80% of the country's total (recurrent and investment) health and social affairs expenditures which places Chad in a situation of extreme dependency. In 1990 external aid to health-related operating expenses was estimated to be more than three times greater than Government outlays for this purpose. The source of almost all investment in Chad's health and social affairs sector is international aid. Apart from investment support to renovate and equip facilities, donors are financing essential drugs, operating needs, and training. Some of them are also providing assistance in management and operation of health facilities. Given the serious resource constraints and the unmet demand for services, donors are expected to play a major role in the health sector in Chad for some time to come. D. The Government's Strategy 2.37 Government's focus on the social sectors is indicated in the Development Plan (para 1.2) where priority is given to: (a) education and prevention activities as well as strengthening basic curative services; (b) establishment and operation of a health system based on health districts; and (c) decentralization of decision-making to the regional level. The plan aims to ensure widespread availability of services, especially for the most vulnerable groups, particularly mothers and children. Priorities in the health sector for the 1995-2000 period are spelled out in a "Letter of Health Sector Development Policy" including quantitative performance indicators (attached as Annex2-1). The Government, through a January 1993 UNDP-led Round Table has defined policy measures and set operational targets to the end of the century. The document presented at the Round Table meeting was revised to take into consideration donors' comments and an action plan was prepared that 12 includes an assessment of budgetary needs for investment and recurrent costs. It represents an important milestone in the sector, and is spelled out in two volumes: Vol.1 Diagnostic et Strate'gie and Vol. 11 Programmes d'actions which constitute the National Health Development Plan (NHDP). An overall donors' commitment to support this plan was obtained at the January 1993 Round Table and the Government has set-up a UNDP-financed technical unit (Celliue Technique de suivi de la Table Ronde Sectorielle) at the MOPH to follow-up on the recommendations of the Round Table meeting. 2.38 The thrust of Government's current health strategy as spelled out in detail in Annex 2-3, is to improve significantly the coverage, accessibility and quality of basic health services. Accordingly the key objectives of the health strategy are: (a) developing and strengthening the three- tiered health care pyramid by promoting decentralization and integrating activities and programs; (b) carrying-out the district health plan (plan de couverture sanitaire); (c) ensuring accessibility to low- cost essential drugs; and (d) increasing community participation in the management and financing of primary health services. 2.39 With respect to developing and strengthening the three-tiered health care pyramid, the Government has reorganized the MOPH along a system characterized by three levels of responsibility and a referral system (para 2.17). The cornerstone of this restructuring is the establishment of functioning health districts and a clear definition of responsibilities at each level. Accordingly, the central level is supposed to specialize in policy development, the intermediate level is expected to adapt those policies to the region and to coordinate all activities in the districts under its jurisdiction, and the peripheral level is required to coordinate all activities in all of its zones of responsibility. A minimum package of health services is delivered at each level of the system. At the health center, the package includes curative consultations, vaccinations, nutritional information, pre-natal consultations and normal deliveries, dealing with chronic diseases, family planning and outreach community services. Back-up for more complicated problems and overall supervision are provided by the district hospital where the package of services is catled a complementary package, including referral from the health centers as well as medico-surgical emergencies, complicated deliveries, and diagnostic services. Under this strategy, the N'Djamena National Referral Hospital (NRH) is expected to provide technical back-up, perform rarer interventions, and support for training health personnel. With the help of the French Government, the Government is exploring ways to enforce the referral system at the level of the NRH. 2.40 Reorganization of the health system will require the upgrading and construction of health facilities, the training and redeployment of health personnel, and the implementation of an appropriate policy for the supply and distribution of low-cost essential drugs. For two years, a team of Government officials with technical assistance financed by the Africa Development Bank, have proceeded with regional teams to the development of the district health plan, including detailed information on the number of infrastructures, their site and architectural norms, as well as personnel norms. With respect to health personnel, the Government has prepared a national training plan and a redeployment plan that take into consideration the needs at each level of the system. As elaborated, the district health plan serves as the basis for orienting any external aid to the sector. 2.41 The constraints of the country in personnel as well as in material and financial resources have been taken into account in the preparation of the district health plan. Despite its limited resources, the Government has stated its commitment to spend about 10% of its budget on health by the year 2000. This seems ambitious given the economic constraints facing the country at this point in time. The Government concedes that it will not be able to meet its obligations in the health sector without the assistance of donors. The Government has stated also its intention to work 13 towards an improved coordination with all organizations and agencies that intervene in the sector. Particular attention would be given to the promotion of private medicine. 2.42 The pharmaceutical policy developed to support the health strategy advocates the promotion of generic essential drugs, which must be made geographically accessible as well as affordable. Accordingly, in consultation with all donors, the Government has chosen to create a Central Purchasing Agency (CPA) for essential drugs for the public as well as the non-profit sectors. This not-for-profit CPA would have financial autonomy with an external audit system, would be privately managed and would have significant participation of community representatives and donors on its management board. Chad has adopted an official list of essential drugs with necessary mechanisms for periodic revision. These measures will be accompanied by the strengthening of the Division of Pharmacy at the MOPH to enable it to fulfill its mandate of policy-making and quality assurance, and by approved legislation that generalizes cost recovery to allow health centers to retain the funds they collect from the sale of drugs and provision of health services. These funds would enable them to establish revolving funds for essential and generic drugs. E. The Bank Group's Role 2.43 Lessons Learned from Previous Projects. This would be the first free-standing, IDA-financed health project in Chad. The Social Action Development Project (PADS), effective April 17, 1991, and scheduled to close June 30, 1996, has a health component which aims at improving health and living conditions of disadvantaged groups in N'Djamena and the Tandjil6. Operationally, the project has been successful as a pilot test by studying various cost recovery schemes and sensitizing the population to the importance of community participation and cost sharing. While the component aimed at providing credit and technical assistance to small and micro-enterprises has been a success, the infrastructure and health components have experienced difficulties mainly in the design of civil works to be executed, lack of adequate supervision, and procurement delays. Timely implementation has been a serious problem, and PADS along with other projects in Chad and the Africa region have offered several lessons pertaining mainly to project implementation and supervision. 2.44 The most important lesson learned in Chad and other African countries pertains to the insufficient capacity of the concerned Government agencies, including the Project Coordination Team (PCT), to carry out ambitious projects. In the case of PADS, weak managerial capacity has led to serious start-up delays in execution, particularly for the civil works component. To address such deficiencies, the Health and Safe Motherhood project would incorporate the following measures: (a) the use of the ATETIP as the executing agency for the complex civil works component; (b) training and capacity building would be at the center of all components; and (c) frequent supervision would be planned. 2.45 Another lesson learned is that policy reforms need to be addressed up front, prior to negotiations. Emphasis on securing an adequate health infrastructure would accomplish little if complementary changes in health care policy are not torthcoming. Under this project, difficult issues, such as drug procurement, cost recovery, development of district health plans and plans for redeployment of health personnel have been addressed during project preparation and agreed upon before appraisal. 2.46 Another lesson learned from Sahelian projects is that, to improve utilization rates of existing health infrastructure, the quality of services needs to improve. In turn, this requires availability of affordable drugs. This is addressed in this project through creation of the Central 14 Purchasing Agency (para 3.30). Finally, to have an impact, a health and safe motherhood project should respond to the needs and the demand of the community. Beneficiary assessment have been done as part of the preparatory work for this proposed project to ensure pertinence of proposed activities to the needs as expressed by the community. 2.47 Rationale for IDA involvement. IDA's Country Assistance Strategy was presented to the Board on May 25, 1993 and is fully explained in the Memorandum of the President for the Chad Basic Education Project (Cr. 2501-CD). The strategy supports the objectives of alleviating poverty and improving the prospects for long-term growth by: (i) increasing the accessibility and quality of basic social services; (ii) increasing incomes through productivity increases and improved services (including transpornation) to the agricultural sector where the majority of the population lives and works; (iii) improving basic infrastructure which serves to increase competitiveness and improve welfare; (iv) promoting employment generation and entrepreneurship by encouraging the provision of services by the private sector; (v) supporting the reallocation of public expenditures towards development purposes; and (vi) promoting a coherent strategy for tapping the potential of the energy sector. The assistance strategy is flexible and designed to build on Chad's positive attributes, to continue the policy dialogue and to adjust rapidly to an improvement in country conditions. IDA is implementing a Core Program of support to alleviate poverty, to place minimum demands on Government administration and finances, to make maximum use of non-Government capabilities and to improve the prospects for long-term growth. 2.48 This project constitutes an important element of the above strategy, especially with respect to objectives (i), (iii) and (v). From the sector work preparation stage and throughout the ensuing dialogue with Government and donors, the Bank has been a key partner in the development of the National Health Plan. The project reflects the importance given by IDA to safe motherhood and to the decline of maternal mortality and infant and child mortality. IDA would be the lead partner to support the much needed health reforms to improve the quality of health services, specially through training of health personnel and restructuring of the pharmaceutical sector. 2.49 Donor Assistance and Coordination. The health sector is supported by many donors (para 2.36) who until very recently, have not coordinated their efforts in an effective way. The Round Table meetings and the resulting National Health Development Plan supported by the Bank, has provided a framework for coherent policy commitment and interventions. This permitted for the first time a coordinated donor support to the sector. The EDF VI program took the initiative, providing technical assistance, annual national training seminars for the regional health directors, and technical training for selected members of regional staff. Ihe EDF VII is continuing this role and supporting the development of MOPH services at the regional level in 8 Sahelian regions (about 36% of the total population). The Swiss Development Corporation is providing similar support in the peri- urban areas of N'Djarn6na and Chari-Baguirmi (about 22% of the ta population). Other donors are providing (or plan to provide) such assistance in the remaining regions. The African Development Bank has provided much needed support to the cental level of the MOPH and would be supporting three regions (about 25% of dhe total population). In regions where more than one donor are present, their interventions are complementary. Apart from IDA, support to the sector is provided by France (FAC), Germany (GTZ and KfNW), UNFPA, UNICEF, USAID and WHO. The non-governmental community is quite active in service delivery and includes the Belgian Medecins sans frontieres, Union Nauonale des Associatons Dioc&saines de DSveloppement (UNAD), BELACD, Secours Catholique et Developpement (SECADEV), and other NGOs. 15 M. THE PROJECT A. Project Objectives. Scope and Description 3.1 Obiectives. The project would assist the Government in implementing its long-term strategy for increased access of the population to quality basic health, nutritional, and Family Planning services. It would support Government's efforts to: (a) enhance capability at the central level to support regional health services; (b) improve access to basic health services in the regions of Guera and Tandjile; and (c) ensure accessibility of the population to low-cost essentW drugs. The Government's health policies and programs are defined in a pelicy report which includes a five-year action plan with quantitative targets for years 1995-2000. It is summarized in a Sector Development Policy Letter which was finalized during negotiations and adopted by Government as a condition of Board presentation. Progress made towards the project objectives would be measured according to a set of monitoring indicators and annual targets agreed upon during negotiations and annexed to the letter of Sector Development Policy (Annex 2-3). 3.2 Project Scoe. The project would provide support for the strengthening of the health sector by increasing accessibility to basic health, nutritional and FP services, particularly for the most vulnerable groups. Within this framework, particular emphasis would be given to reducing infant/child mortality and maternal mortality. The scope of some investments (components 1 and 3 in the table below) would be nation-wide, i.e their impact is not limited to particular geographical regions of the country. Other investments (component 2) would specifically targ. - wo of Chad's 14 regions, selected for support through this project because no other donor has been forthcoming to provide urgently needed assistance to develop two regions' health system. PROJECT SUACMMY (TOTAL COST US$25.7 MILHON) 1. Strengthen Capability at the Central Level to Support Regional Health Saees (US$4.2 Mlon) al (a) improving the budgetary process at central and regional levels (US$0.2 Million) (b) developing skills upgrading modules programs for regional and district health personnel (US$1.1 Million) (c) developing and implementing a nationwide ImC program (US$1.6 Million) (d) reinforcung Government capacity to plan, coordinate, and implement donors-financed projects (US$1.3 Million) 2. Provide Assistance for Health, Nutrional and EP Services to the Reglons of Guera and Tandjil (US$16.2 Million) a/ (a) establishing a network of district healh facilities (US$7.2 Milion) (b) implementing skills upgrading programs for heallh personnel (US$1.0 MilLion) (C) promoting conununity pafricipation in local health services planning, implementation, and monitor- ing (US$8.0 Million) 3. Support the Development and Implementation of a National Drug Policy (US$5.3 Million) a/ (a) developing the planning and management capacity of the division of phanracy (US$0.6 MiUion) (b) creating a central purchasing agency (Centrake d'achats) for essential and generic drugs (US$ 4.8 Million) Note: a/ Includes base costs and contingencies. Totals may not add up due to rounding. 16 3.3 Pro3ect Description. The proposed project would support the development and implementation of policies and investments designed to: t. Strengthen Capability at the Central Level to Support Regional Health Services (US$4.2 Million) (a) improving the budgetary promess at central and regional levels (US$0.2 Million) 3.4 Scope and Obiectives. The objective of this component is to support Government's efforts to decentralize decision-making and management authority in the health sector to achieve greater efficiency and equity in the provision of health services. Although a cornerstone of the Government's health strategy, successful decentralization is however conditional on factors some of which are beyond the scope of this project. Activities envisaged in this component are not sufficient to ensure successful decentralization but they are necessary initial steps in that direction. They are designed to reinforce the roles of regional medical officers. These roles have been redefined to give them responsibility for regional health planning and program monitoring, coordination of public and non-governmental regional health activities, monitoring of public sector health personnel, supervision of district health teams, and provision of logistical support to district health teams. Accordingly in many regions of the country, a number of important activities are expected to be done regionally, particularly coordination of external aid, and definition of priority interventions. There is clearly a need to put in place a financial and budgetary management system in the regions with two parts: (a) budgetary preparation enabling each region to propose a budget grouping the estimated needs of all health infrastructures of the region. These budgets would adopt a "functional" presentation that allows the identification of all activities, and a "consolidated" presentation showing the contributions of all donors. These budget proposals would be the basis for discussions with the Ministry of Finance; and (b) budgetary implementation: each region would be responsible for implementing its own budget as voted. This functional and consolidated presentation of the budget would also have to be adopted at the central level to replace the current presentation which is done according to the nature of the expenditure and does not allow an - .ialysis of the activities of the sector. 3.5 Project Support. To assist Government in the implementation of this component, the project would finance: (a) six man-months of specialist services in accounting and financial manage- ment (international). In the first year of the project, the TA (1'echnical Assistance) would assist the MOPH at the central level to: (i) revise/adapt its budgetary nomenclature, in conformity with other ministries; (ii) establish procedures of budgetary follow-up to the regions; and (iii) train personnel in the MOPH and MOF on the new measures. In the second year of the project, the TA would train regional and district medical officers in the elaboration, execution, and follow-up of budgets. Subsequently, each region would organize a meeting grouping the District Medical Officers to prepare the region's health budget which would be presented to the MOPH central level; and (b) office equipment (computer and printer). Separate budget entries for drugs and other recurrent expenditures for the 14 health regions would be entered in the Government's budget. During negotiations, the Government gave assurances that it would maintain a separate budgetary chapter for two separate categories - drugs and operating costs (excluding personnel) for each of the 14 health regions through the end of the Project. 17 (b) developing skills-upgrading modules for regional and district health personnel (US$1.1 Million) 3.6 Scope and Objectives. The objectives of this component are: (i) to support the development (nation-wide) of managerial and technical training programs for district health personnel (In addition to this nation-wide developmental activity, the project supports the implementation of training programs in the two regions of the project (para 3.20)). In addition to upgrading the skills of health personnel, the project would help consolidate various donor-supported training activities. A standard set of modules would be developed for use in all district-training activities throughout the country and would build on ongoing training activities, particularly those supported by EDF VII, IDA/(PADS), UNICEF, and USAID; and (ii) to support the use of already developed modules for updating curricula in basic training courses at the ENASS (Ecole Nationale des Agents Soclaux et Sanitaires). 3.7 The new modules would focus on pre- and post-natal care, deliveries, referral of high- risk pregnancies, FP, child nutrition, and communicable disease control. Particular emphasis would be given to STD/AIDS prevention. In accordance with Government's policy, FP education and contraceptive services, as well as nutrition monitoring and management of nutritional problems, would be fully integrated into the public health facility. Health staff would provide iron and Vitamin A supplement at both clinical sites and at district locations where local authorities have identified serious nutritional problems. While some initial testing of communicable diseases would be done at the health center, other more complicated or confirmatory tests would be done at the district hospital. Special attention would be given to staff supervision, task management and work routines. IEC would be at center stage of these activities and training modules would be designed accordingly. Given the increased responsibility of the district level and the establishment of a cost recovery system, a radical change in the customary behavior of health personnel would be required, particularly in: (a) managemnent: managing the money collected at the health facility, forecasting the needed drug supplies, estimating expenditures; (b) communication: all cost recovery programs stress the need for joint management by health workers and the people's representatives; and (c) essential drugs and diagnostic/treatment strategy: health workers would need to be trained not only in the use of essential drugs but also in diagnostic and treatment schemes which would result in a more controlled pattern of prescribed drug consumption. Accordingly, a guide on the proper use of drugs (stategies plaintes - d6cisions) would be elaborated and would serve as the basis for the training of district health personnel on strategies to follow in problem resolution. 3 R Background. During the January 1993 Round Table meetings, both Government and donors expressed concern with the concentration of personnel at the central level and with the low quality of, and serious disparity among, training programs for health personnel. It was unanimously agreed to prepare National Plans for redeployment and training of health personnel, and in its mandate the Round Table follow-up Task Force (Cellule Technique de Suivi de la Table Ronde Sectorielle) (CTS) at the MOPH has been asked to give the preparation of the two plans a top priority. Preliminary plans were discussed during appraisal and Government is working on a revised version based on a conceptual framework which shows the link between planning, management, initial training, continuous training and redeployment of health personnel. Both plans were discussed further during negotiations and the adoption of such time-bound action plans, agreeable to IDA, is a condition of credit effectiveness. As discussed during appraisal, the time-bound plan for the redeployment of health personnel would include practical incent, 'es as well as necessary regulatory measures. During negotiations, the Government gave arances that the training and redeployment plans would be implemented according to time-tables agreed upon during negotiations. 18 3.9 Uroject Sppo. As described in para 3.7, this component would support the development of a series of short-term training programs and would facilitate the transfer of competencies to local trainers at the ENASS and at the regional level. Once developed, the modules would be piloted, as a project activity, in Guera and Tandjild. The project would finance: (i) specialist services (5 person-months local and 10 person-months international to develop training modules, to train the regional trainers and teachers from the ENASS on the utilization of modules, and to evaluate the training activities; (ii) production of training materials and operational guidelines; (iii) cost of participation in in-country training seminars; (iv) short-term local training of 20 teachers of the ENASS in the utilization of modules; and (v) a two-year training for one person in the pedagogy of health sciences. The Government has requested the assistance of the WHO for the implementation of this component. According to the agreement, WHO would senrv as the executing agency and would work closely with the Training Division of the MOPH. Before negotiations, the Government submitted to IDA a draft convention with the WHO for the management of this component. A signed convention, satisfactory to IDA, would be a condition of credit effectiveness. The objectives, organization plan, and implementation calendar for this component are detailed in the implementation manual. (c) developing and implementing a nationwide IEC program (US$1.6 Million) 3.10 Scope and Qbjective. The objective of this component is to strengthen the capacity of MOPH and its IEC Division to develop and implement IEC programs with respect to improving health and contraceptive behaviors of the Chadian population and to support district, health, nutrition and FP services. To this end, the project would: (a) reinforce the MOPH capacity to plan, coordinate, and control the quality of IEC activities; (b) conduct training programs in IEC, interpersonal communication, and social mobilization; and (c) conduct quantitative and qualitative studies on the basis of which the IEC strategies and messages would be developed. 3.11 Background. Although IEC techniques have been recognized by G. .,ament as important tools to empower the population to take charge of its own health, efforts in this regard have been limited to uncoordinated actions in donor-financed vertical health programs (para 2.27). The NHIE Strategy developed in 1987 needs to be updated to reflect realities and health priorities as established in the context of the new National Health Plan. With the help of an international consultant (IEC), the Government has reorganized the Health, Information, and Education Unit (HIEU) into a Division of IEC and the National IEC Task Force has prepared an action plan on which the IEC subcomponent of this project is based. According to the plan, the Division of IEC would be strengthened and staffed to carry out a well-defined role of coordination, conceptualization, and supervision/control of quality. Its activities would focus on key messages developed on the basis of the research results and focusing on nutrition, FP, maternal and child health problems, genital mutilation, AIDS/STDs prevention, and other communicable diseases. It would also look at the possibility of integrating the traditional sector in primary care delivery. Project activities to strengthen IEC activities are determined on the basis of this plan and described in the implementation manual. During negotiations, the Government gave assurance that the Division of EEC would operate with the terms of reference agreed upon with IDA during appraisal. 3.12 Prject Suppon. The project would finance: (a) training of personnel at the central level for the national IEC staff, in order to develop the IEC unit's capability to develop and implement IEC activities and to train regional staff. This includes: a two-year training external in IEC for one person from the IEC unit; and short-term training outside Chad, preferably in Africa (13 19 person-months); (b) KAP and qualitative studies that would be used for IEC strategy and message development. In addition, the KAP survey would provide baseline data for the evaluation of the IEC sub-component; (c) the production and dissemination of IEC materials to target communities; (d) a minimum of audio-visual equipment to be used to inform/educate decision- and policy-makers as well as for training activities; (e) vehicles (two cars and seven small motorcycles) to make it possible for the EEC specialist of the Central IEC Unit to supervise IEC activities and carry out training; (f) some IEC activities for priority areas that are not financed by other donors; (g) two years of a resident specialist services (UNDP financing of a UN Volunteer): past experience shows that the success of IEC activities depends crucially on the support of well-trained IEC specialists. At present there are no IEC specialists in Chad. Therefore, this position would initially be filled at the international level while a Chadian is being trained under the project to assume these responsibilities, and (h) short-term technical assistance for specific tasks for which no Chadian expertise exists. (d) reinforce Government's capacity to plan, coordinate and implement donors' financed projects (US$ 1.3 Million) 3.13 Backgrnd. The MOPH's coordination office (Bureau de Cooperation et Etudes - BCE) is under the MOPH Director General (Annex 2-1). A Project Coordination Team (PCT) within the BCE has been responsible for coordinating the preparation of the proposed project. This team would be strengthened to enable it to coordinate implementation of the proposed project. This is a functional way to group under the Director General, the Round Table Follow-up Task Force ( (CTS, see para 3.8)) with the coordination functions related to implementation of this proposed project. Coordinators of respectively the CTS and the PCT report directly to the Director General. The two teams have collaborated closely during the project preparation phase and are expected to continue to do so throughout the implementation phase, particularly with respect to ensuring that inputs provided by donors contribute to the MOPH's development objectives. 3.14 Proiect Coordination Team. With responsibility for managing all construction contracts delegated to an agency such as the ATETIP, the PCT would focus on: (i) overall coordination of project activities; (ii) facilitating implementation; (iii) providing professional guidance to implementation agencies; and (iv) monitoring and evaluating project outcomes. The PCT currently staffed with a Coordinator and necessary support staff (secretariat, driver, watchmen), would be reinforced with an administrator in charge of coordinating the preparation and the follow-up of annual programs and budgets for all components, an accountant and a procurement officer. The accountant and procurement officer would be recruited locally from the private sector. All staff would be recruited on a competitive basis, under terms of reference satisfactory to IDA and would be appointed subject to IDA's approval. Agreed upon terms of reference for the key positions in the PCT are in the implementation manual. As a condition of credit effectiveness the PCT would be fully established, with the Coordinator and the three senior professional staff in post. The Government gave assurance during negotiations, that it would operate the PCT under the, agreed terms of reference (including staffing) and that these key staff persons would not be replaced without IDA's prior consent. 3.15 PrQi1ect Spport. The project would finance the investment costs associated with the strengthening of the BCE to coordinate project implementation, including office rehabilitation, equipment, vehicles, and furniture, supplies and incremental operating expenditures, salaries of local staff recruited for this project, including an administrator, an accountant, (2) secretaries, an administrative assistant and a chauffeur, and about 22 person-months of short-term professional assist&a;.e in the areas of accounting, auditing, preparation of procurement documents and other 20 technical areas if necessary, under service contracts subject to IDA's review and approval. Civil servants seconded to the PCT would be financed by the Government. 2. Provide Assistance for Health, Nutritional, and FP Services to the Regions of Guera and the Tandjil6 (US$16.2 Million) 3.16 Following discussions with Government and major donors, the regions of Guera (total population 295,000) and Tandjile (total population 452,000) were selected as focal areas for this project because of (i) the particular low status of health services delivery in these two regions; and (ii) the fact that no other donor has been forthcoming to provide urgently needed assistance. One reason explaining this lack of donor interest is the fact that these two regions are less accessible than most other regions, particularly during the rainy season. The only donor-activity in Guera is EDF VII and its support is limited to training and technical assistance for the regional medical officer and support of health care services in one central district of the region. Two other districts remain completely unserved. A rapid appraisal (done in the context of field work on Poverty Assessment) confirms the seriousness of health services delivery problems and the beneficiaries' unmet demand for basic health services. Similarly, while the Tandjile had been identified by the PADS team as a target area, only technical assistance to the Regional Medical Officer (RMO) (one administrator and one physician) is provided through the PADS. Due to shortage of funds, UNICEF has limited its interventions (rehabilitation of infrastructure, health personnel training, and introduction of cost recovery) to the district of Kelo (in Tandjild) but has expressed interest in collaborating with IDA to expand coverage of services to other districts. Together, these two regions comprise 12% of the total population. (a) establishing a network of district health facilities (US$7.2 Million) 3.17 Scope and Objectives. The objective of this component is to provide assistance for the establishment of a network of health facilities in the regions of Guera and the Tandjile. The needs of the two regions in infrastructure rehabilitation, construction, equipment and supplies, and maintenance have been determined in accordance with the national norms for coverage and services as specified in the "plan de couverture sanitaire" (Annex 2-2). According to this plan, the health center is the entry point to the health system. There should be one center per responsibility zone (about 10,000 inhabitants). The district hospital would be responsible for supervision of district health centers (about 30 to 50 per district) and is expected to serve as a referral facility. The objective of the component would be to restore those facilities that are currently in poor physical condition. There would also be construction and equipment of new health facilities. Sites have been sclected according to the national norms of coverage and have been agreed upon during appraisal. 3.18 Staffing of the newly-constructed or renovated health facilities would be done according to norms defined in the National Health Development Plan; a health center would have a total of 3 staff (1 nurse, 1 orderly and 1 maintenance staff) while a district hospital would be staffed by 22 people (2 medical doctors, 4 registered nurses, 4 technicians, 3 midwives and other technical and administrative staff). Information on actual number of health personnel by category and health infrastructure shows a gap in both regions. At the Tandjil6, there is an additional need for 2 physicians, one midwife, 37 nurses and 37 paramedical personnel. Available information for the Guera shows an estimated additional need for 4 physicians, 34 nurses, and 38 paramedical personnel. The gap in personnel would be filled through redeployment from one region to another or within the same region, from the central district to the periphery. Prior to negotiations, the Government presented a time-bound plan for redeployment of personnel. As mentioned in para 3.8, adoption of 21 a plan agreeable to IDA is a condition of effectiveness. Assurances regarding the implementation of the personnel redeployment plan were given by the Government during negotiations (para 3.8). 3.19 Ur ject Suppor. The project would finance the rehabilitation of 14 health centers and three district hospitals and the construction of 44 health centers and one district hospital, and related facilities. Facilities for the regional and district health teams would also be rehabilitated or constructed. In Tandjile, the project would finance the construction of a regional office and one district office, and the rehabilitation of a district office. In Guera, the project would finance the rehabilitation of two district offices. Equipment and related professional activities are included in all construction and rehabilitation. The proposed civil works program is described in Annex 3-1. Staffing of all constructed/rehabilitated facilities would be ensured through redeployment of health personnel according to a time-bound action plan (para 3.18). Construction management would be delegated to a Construction Management Agency (such as ATETIP). The Government submitted a draft contract with a CMA which was discussed during negotiations. Signature of a contract, satisfactory to IDA, with a CMA would be a condition of effectiveness. (b) implementing sldlls-upgrading programs for district health personnel (US$1.0 Million) 3.20 Scope and Objectives. The objective of this component is to upgrade the skills of health personnel who would be deployed in health centers and district hospitals, and enable them to deliver adequately the minimum package of health, nutrition, and FP services. Training needs have been identified and the content, scope, and time-schedule of the training programs were discussed in detail during appraisal and were reviewed during negotiations. Several types of training are envisaged: (i) a two-year training in public health for one physician per region in an African country; (ii) short-term clinical training in Cameroon or Ivory Coast for physicians (in surgery, internal medicine, ob-gyn) and paramedical technical staff (anesthesia, radiology, etc.,), and for every region, one person from the regional health team who is responsible for IEC activities in that region; and (iii) local regional training for health personnel. Local training is expected to start in Project Year 2 following the development of training modules (para 3.6) and would be coordinated by the Division of Human Resources in the Regional Health Team in close collaboration with the EDF VII in one district of Guera, and UNICEF for all other districts of Gudra and the Tandjile (para 3.23). A revised version of a training plan was transmitted to IDA as a condition of negotiations. The plan was discussed during negotiations and its adoption will be a condition of effectiveness (para 3.8). 3.21 Troject Supoort. The project would support: (i) training activities: seminars (36 one- week sessions), 3-months abroad clinical training (training sessions for 14 medical and pararnedical personnel), one month training abroad in IEC for the 2 IEC regional focal persons, and 2-year training in public health (one physician per region); and (ii) means to coordinate and supervise training activities in the regions. This would include providing training materials and funds for training sessions. (c) ..amoting community participation in local health services planning, implementation, and monitoring. (US$8.0 Million) 3.22 Scope and Objectives. A major objective of this project would be to contribute to an improved health system sustainable over the long-run. As mentioned earlier (para 2.25), medical cost recovery schemes have been introduced in different parts of the country with considerable success. A cost recovery system organized and managed through local health committees would be implemented in the Gu6ra and the Tandjile. These committees are composed of elected community 22 representatives and health personnel. In health centers, the system is expected to recover the cost of all essential drugs and most operating expenditures with the exception of wages, which will be covered by the Government. The experience of the MSF in the Mayo-Kebi shows that between 45- 50% of all non-wage recurrent costs can be recovered. Prior to negotiations, the Government signed a decree generalizing cost recovery to the whole country. It also adopted regulations providing for the creation of health committees. 3.23 The cost recovery system would be introduced gradually in concert with the infrastructure construction-rehabilitation program and the essential drug program. Given the weak capacity of the local government in social mobilization and in the creation and support of health committees (at the level of districts and health centers), the Government has decided to request the assistance of UNICEF in the overall management of this component, thus benefiting from UNICEF's extensive experience in social mobilization and the introduci;.on of cost recovery. Accordingly, UNICEF would be asked to play a key role in mobilizing the community to form health committees, training district-level health personnel in coordination with the regional health authorities, supporting the day-to-day management of the health facilities, and conducting operational research. Given its wide experience in monitoring cost recovery efforts, UNICEF would also be asked to play a key role in establishing a monitoring system as of the first year of the project and to assess the results of cost recovery efforts during the mid-term review. Throughout this process, UNICEF would be paying particular attention to building the capacity of regional and district health teams who in turn would continue to be in charge of planning, coordinating, and managing all health activities in their regions. Prior to negotiations, the Government transmitted to IDA a draft convention with UNICEF. During negotiations, this convention was discussed and UNICEF parallel co-financing confirmed. As a condition of effectiveness the Government would submit a signed contract with UNICEF satisfactory to IDA. 3.24 The financing plan of district hospitals and health centers in the two regions of the project shows a sharing of estimated costs among Government, the comnmunity and M)A in order to ensure that resources needed to adequately operate health infrastructures are available at all levels. The human resources required would be secured through redeployment (para 3.18). There is no need for additional long-term TA at the level of the region as it is provided in the Guera, through the EDF VII and in the Tandjile, through PADS. UNDP has agreed to finance one United Nations Volunteer per district in the four districts which require technical assistance while health personnel to be redeployed there, are being trained. As te incremental operating costs, they are shared by Government, IDA and the community for the duration of the project with IDA's support decreasing with time and Government's and community's contribution increasing with time. 3.25 ject Sumpp: The project would finance: (a) an initial stock of essential drugs and supplies for the two regions. This would help establish the revolving fund for drugs at the level of each health infrastructure. In addition, as the utilization of health facilities is expected to increase, there would be a need for supplemental stocks of drugs throughout the duration of the project. Micronutrients for the duration of the project are also including in the pharmaceuticals; (b) incremental non-wages recurrenc costs; and (c) one motorcycle per health center. As the executing agency, UNICEF would manage the funds and materials allocated to this component. UNICEF cofinancing was finalized during negotiations. 23 3. Support the Development and Implementation of a National Drug Policy (US$5.3 Million) 3.26 This component would support Government's efforts to implement its newly adopted National Drug Policy (NDP) (para 2.22) to ensure overall geographical as well as financial accessibility of the population to essential drugs as a prerequisite to the successful implementation of cost recovery. The NDP is based on the introduction of an Essential Drug Program (EDP) as a means of reducing the high cost of basic treatment due to the very high prices charged for brand- name drugs. It is also based on the selection of the drugs essential for dealing effectively with at least 90% of the curative and prophylactic needs of the majority of the population. An essential drugs list has been officially adopted and is being used in several projects. Before negotiations, the Government revised the existing list to include drugs such as vaccines and STD medications, used in national programs. 3.27 The project would assist the MOPH in defining its plan of action with respect to planning and management of pharmaceutical programs, drug procurement and logistics, drug quality assurance, and rational use of drugs. These efforts would be coordinated with existing donor- financed projects. There are two subcomponents which require IDA's assistance: (a) develop the planning and management capacity of the Division of Pharmacy; and (b) create and support the operations of a Central Purchasing Agency (CPA). A detailed description of this component, including the terms of reference for the technical assistance, costs, timetable, and monitoring indicators is given in the implementation manual. (a) developing the planning and management capacity of the division of pharmacy (US$0.6 Milion). 3.28 Scope and Objectives. The objective of this component is to develop the capacity of the MOPH Pharmacy Division to elaborate a strategy and a program of action in order to operationalize its NDP and to adequately supervise the pharmaceutical sector. To this end, the project would help: (a) develop a Pharmaceutical Plan (Plan Directeur Pharmaceudque) that defines a strategy for the next three years in the pharmaceutical sector as well as the detailed plan of action and budget. It would represent the terms of reference for the Division of Pharmacy. During negotiations, the Government gave assurances that a three-year pharmaceutical plan, agreeable to IDA, would be adopted no later than January 3 -96. The plan will be transmitted to IDA one month before the annual review meeting (para 4.. tnd would be discussed during the meeting; (b) conduct a review of the pharmaceutical regulatory framework in order to ensure that it is in line with the new policy; (c) establish a system of drug registry to ensure adaptation of the drug market to actual epidemiological conditions. This implies taking stock of all drugs that are in the market Oegal) for pharmaceutical, and defininig the criteria for allowing drugs into the market: pharmacological, therapeutic, economic, epidemiologic, and quality assurance criteria; (d) undertake a revision every two years of the list of essential drugs according to the minimum package of services for health centers and district hospitals; (e) strengthen the Pharmacy inspection and quality assurance procedures; and (f) creation of an information system on appropriate utilization and promotion of Essential Drugs. Time-bound plans for the completion and implementation of each of these activities are in the implementation manual. 3.29 oectSup . To assist Government in implementing this component, the project would finance: (a) specialist services to assist in reviewing the regulatory framework and in the pre-aration of the pharmaceutical plan (14.5 months, international; 16 months, local); (b) training 24 and workshops; (c) office rehabilitation and equipment; and (d) incremental operating cost including office supplies. The Government has requested assistance of the Drug Action Program of WHO/Geneva to provide assistance in the implementation of this component. A draft contract between this organization and the Chadian Government has been prepared and was discussed during negotiations. The signature of said contract, acceptable to IDA, is a condition of effectiveness. Long-term TA would be provided outside the framework of this project by the French Government who has agreed to reorient its current long-term TA from drug procurement to planning and management. It was also agreed that the assistant's letter of mission presented by the French Government to the GOC, will specify that the assistant would work within the framework defined in this proposed project. (b) creating a central purchasing agency (Centmie phannaceuaque d'achats) for essential and generic drugs (US$4.8 Million) 3.30 Scope and Objectives. This component would support Government efforts to ensure adequate and timely supply of essential drugs and medical supplies to all health facilities (public and NGOs) at prices the commnunities can afford, through the establishment of a Central Purchasing Agency (CPA). The CPA would be developed as an autonomous, not-for-profit institution, for the whole country. It would ensure economies of scale and bulk purchases of essential drugs in generic forms to be sold to health facilities (public and NGOs). The Government has established an ad-hoc committee to work on the operational status of the CPA to promote management and financial autonomy. The CPA would meet the following criteria: (i) be responsible for purchasing all national list essential drugs requested by authorized health facilities; (ii) purchase high quality essential drugs at the lowest possible price through competitive bids on the international market (possible long-term contracts with annual deliveries advised); (iii) have a small staff and enjoy full management and financial autonomy; (iv) be not-for-profit; (v) be completely self-financed (including salaries) by applying a fixed wholesale margin (maximum of 20%) on the orders it processes; and (vi) keep operating costs at a miinimum. The CPA would not be granted a monopoly on public health facility drug purchases (i.e health facilities are not under the obligation to get their supply of drugs through the CPA. They would choose to do that because the CPA would have competitive prices). Prior to negotiations, the Government submitted to IDA a draft document describing the operational status of the CPA which was discussed and agreed upon during negotiations. As a condition of effectiveness the Government would establish the CPA with operational procedures satisfactory to IDA. 3.31 Under the project, the following functions of the CPA would be developed: (a) purchasing and supply aimed at getting the lowest price through international competition; (b) inventory management to ensure continuous availability and avoid losses due to expired drugs; (c) financial and administrative management necessary to guarantee sound pricing and minimum costs. An accounting system would be put in place with regular bi-annual financial audits; (d) distribution: this function would be minimal as the CPA would not be responsible for distributing drugs, and health facilities would make arrangements to receive their specific orders. This function would be reviewed after two years of operation; and (e) quality control: given the unavailability of laboratory controls in the country, a simple system for ensuring high quality of purchased drugs, such as WHO certification, would be adopted. 3.32 Given the importance to project success as well as the complexity of this component, important safeguards need to be introduced to ensure successful implementation: (i) given the heavy reliance on donors for the provision of drugs, their support and participation in the CPA is essential. At the January 1993 Round Table meeting, donors confirmed their willingness to purchase drugs through the CPA (para 2.22). Their commitment was again renewed during a meeting on this sector 25 organized during project appraisal; (ii) a close monitoring of the CPA's activities is key to successful implementation. A Management Board would oversee the establishment of the CPA and its operations. It would comprise representatives from the MOPH and other relevant ministries. "Clients" of the CPA, particularly the regional and district health committees would be largely represented; and (iii) during negotiations, Government gave assurances that semi-annual management audits of the CPA would be done by the management audit firm selected according to IDA's procedures. This audit would look at the cost and selling prices of essential drugs and compare them to an international average. It would also examine operating costs, availability and quality of drugs, and assess efficiency of CPA management. Details of activities, timetable, and monitoring indicators are described in the implementation manual. 3.33 The project would support the operations of the CPA during the first three years because it is estimated that it would take three years for the CPA to be fully financially viable on its own. During those first three years, the project would finance: (a) rehabilitation of a building to house the CPA. Prior to negotiations, IDA received Government's commitment to provide the CPA with the physical space currently occupied by the PHARMAT and the PASP (para 2.22). As a condition of effectiveness the Government will provide the CPA with sufficient facilities for the start- up phase of its operations and adopt a facilities expansion plan for the CPA, each satisfactory to IDA. During negotiations the Government gave assurances that the CPA will occupy, not later than June 30, 1995, the facilities discussed and agreed upon with IDA; (b) equipment and 3 vehicles; (c) an initial supply of essential drugs and medical supplies. This initial stock would be sold to the district health teams in the first year and would constitute the revolving fund for the CPA; (d) specialist services: a long-term pharmacist administrator (3 years), 18 person-months of short term technical assistant (commercial law, data processing, accounting audit, procurement specialist). While donors' support for the CPA is essential, it is important for the CPA to keep its autonomy not only vis-a-vis Government but also vis a vis donors. Accordingly, the recommended long-term TA for the agency would not be sponsored and recruited by any particular donor but rather would be recruited through a competitive process following IDA procedures. Terms of reference for the TA and a description of proposed training are in the implementation manual. The recruitment of the TA is a condition of effectiveness; (e) training: in computers and management information systems for the CPA staff, and a 9 month training in management for the national director of the CPA; and (f) salaries for the CPA staff which includes the national director, accountant/administrator, assistant accountant, secretary, pharmacy technicians (3), stock room clerks (3), drivers (2), guards and cleaning staff. B. Project Cost and Flnancing Plan 3.34 The total cost of the project, net of taxes, is estimated at about US$25.7 million, with a base cost of US$21.5 million, and a foreign exchange component of US$22 million. Price contingencies, estimated at US$2.5 million, assume an annual domestic inflation rate of 30% in Project Year 1, 6% in Project Year 2 and 2% for the remainder of project's years. A Foreign inflation rate of 2.5% is assumed for the total duration of the project. Physical contingencies are estimated at US$1.7 million (7% of base costs). IDA would finance about 72% of total project costs (US$18.5 million). UNDP and UNICEF would contribute US$1.3 and US$2.3 million respectively. Government would contribute about US$1.0 million equivalent, including budgetary allocations for drugs, materials, and incremental sectoral management. Communities would contribute through participation in the management of health facilities and cost-sharing of health services (US$2.6 million). Detailed project cost estimates are given in Annex 3-2. 3.35 Incremental Recurrent Costs and Project Sustainability. Considering Government's severe budget constraints, the project is designed to have minimal recurrent cost 26 implications. As personnel would be redeployed from the central to the regional levels, incremental personnel costs would be minimal. The major part of incremental costs of the project would go to activities which would stop or slow down after the project period, including development of health, nutrition, and FP training materials, and initial stocks of medications, and medical supplies. The successful introduction of cost recovery in the two regions of the project would result in increased cost-sharing by the community and project sustainability. However, despite the increased community participation and Government efforts and stated intention to devote 10% of the budget to health, Chad is likely to remain heavily dependent on foreign aid in the health sector in the foreseeable future. IV. PROJECT IMPLEMENTATION A. Status of Project Preparation and Readiness 4.1 Throughout project preparation, discussionas were regularly held with the Chadian preparation committee, the technical staff of the MOPC and the MOPH (including regional staff) to agree on priorities within the health sector strategy. IDA has actively worked with Government and donors in the preparation of the UNDP-led Round Table meeting that resulted in the adoption of a National Health Development Plan, and the ensuing framework for policy commitment and interventions. Working papers for all project components have been prepared. Site selection and architectural standards and designs for basic health centers and referral services and a procurement schedule were developed by pre-appraisal and updated during appraisal; to the extent possible, the remaining documentation for civil works, including draft bid documents, were prepared after the appraisal mission and reviewed and agreed upon during negotiations. All preliminary procurement actions for the first year of operation would be completed at the time of credit effectiveness (para 4.15). 4.2 Training needs have been identified and the content, scope and time-schedule of the training programs were discussed in detail during appraisal and finalized during negotiations. B. Project Coordination and Management 4.3 Day-to-day management and implementation of each project component would be the responsibility of the concerned unit at the Ministry of Public Health, as follows: the component on strengthening capability at the central level to support regional health services would be the responsibility of corresponding technical units of the MOPH; assistance to the regions of Guera and Tandji}l would be the responsibility of the regional health teams under the direction of the RMOs; and the NDP component would be implemented by the Division of Pharmacy at the MOPH for the first subcomponent and the ad-hoc committee (para 3.30) for the CPA. The PCT would be responsible for project monitoring and evaluation and would also coordinate procurement and distribution. 4.4 The Bureau de Cooperation et Etudes (para 3.13), which includes the Project Coordination Team (PCI), would be strengthened and would coordinate implementation of the proposed project. The PCT would: (a) coordinate the preparation of annual work programs and budgets for all components; (b) procure goods and services and recruit consultants when needed; (c) review implementation progress reports prepared by the coordinator of components; (d) maintain and consolidate all project accounts including special accounts and accounts kept by the Construction Management Agency (para 3.19) with the assistance of a private accountant; (e) prepare the necessary documentation for withdrawal of proceeds from the IDA Credit; (f) make arrangements for the audit of project accounts, and SOEs; (g) prepare, as required, semi-annual and annual progress reports for 27 IDA, the Government, and cofinanciers; (h) organize annual and mid-term reviews of project implementation; and (i) maintain an effective dialogue with key donors and agencies in the health sector. C. Monitoring and Evaluation 4.5 Monitoring and evaluation of project performance - including investments and policies - would be carried out by the respective implementing units and coordinated by the PCT. Special efforts would be made to measure the impact of project investments on qualitative improvements by assessing key indicators that were identified and agreed upon during negotiations. 4.6 To effectively coordinate project monitoring, the PCT would: (a) transmit to IDA progress reports on project implementation and outcomes twice a year (in April and October), starting in 1995, using the format developed in the ongoing Chad education projects (Cr. 1950-CD and 2501- CD); (b) organize, no later than November 30 of each year, starting in 1995, a joint IDA/Govern- ment review of project implementation, based on the progress reports, annual work programs, and budgets for the next year; and (c) carry out a mid-term review of project implementation-based on financial and technical audits-jointly with IDA, no later than May 1997. Details of IDA's supervision plan and of annual and mid-term reviews are provided in Annex 4_-. Within six months of the Credit closing date, the PCT would also transmit to IDA a completion report, prepared in accordance with terms of reference satisfactory to IDA. The Government gave assurances during negotiations that these requirements would be met. D. Procurement 4.7 Table 2 below summarizes the project elements by category, estimated costs, and proposed procurement methods. No special exemptions, permits or licenses need to be specified in Credit documents for International Competitive Bidding (ICB) as Chad's procurement practices allow IDA procedures to take precedence over any contrary provisions in local regulations. However, a note on procurement was discussed during negotiations to draw the attention of implementers to procurement advance precautions for ICB such as: (a) to refrain from using restricted lists of suppliers and contractors; (b) to leave the choice of insurance company to the suppliers or contractors; (c) to ensure sufficient advertising; and (d) to discontinue the use of the two-envelopes system for submission of bids. Procurement schedules and the packaging of works and goods are given in Annex 4-2. 28 Table 2: Sumrary of Proposed Procurement Arrangements (US$ million equivalent including Contingencies) Methods of IDA financing CATEGORY OF EXPENDITURES ICe LCB Other *.S.F. Total Cost 1. CIVIL MOKS 1.1 Construction/Rehabilitation (Hospitals) 1.4 - - - 1.4 (Excluding Parts A and C) /c (1.4) - - (1.4) 1.2 Construction/rehabilitation - 3.4 Ia - 0.6 /b 4.0 (Excluding Part A) - (3.4) - (-- (3.4) 2. wOaDS 2.1 Vehicles 0.3 - - 0.3 (0.3) - - - (0.3) 2.2 Equipment 3.4 0.2 0.1 - 3.7 (3.4) (0.2) (0.1) (3.7) 2.3 Furniture 0.1 * 0.1 (0.1) - (0.1) 2.4 Pharmeceuticals 3.2 - - 2.8 /c 6.0 (Excluding Part A) (3.2) - () (3.2) 3. CrSULTAKCIES 3.1 Professional Fees - - 1.0 /d - 1.0 (ExcLuding Part A) - (.0) - -1.0) 3.2 Specialist Services (Short Term) - - 1.2 - 1.2 - - (1.2) - (1.2) 3.3 Specialist Services (Long Temn) - - 0.7 2.3 /e 3.0 ~ - (0.7) - (0.7) S. TRAINING AND TRAINING hATERIAL 4.1 Fellowships - - 0.8 - 0.8 - -*(0.8) (0.8) 4.2 Local Seminars - - 0.4 - 0.4 - - (0.4) (0.4) S. NISCELLANEMXS 5.1 Operation & Maintenance - - 1.3 1.5 /f 2.8 - - (1.3) 0..) (1.3) 5.2 Salaries - 0.4 - 0.4 - - (0.4) - (0.4) 5.3 TraveL Allowances - 0.6 - 0.6 - ~ ~ ~~- £0.6 -06 Total Costs 8.3 3.7 6.5 7.2 25.7 Total Financed by the IDA credit (8.3) (3.7) (6.5) (-) (18.5) NWte * Figur In parenthese re th respectve amounxs financd by the IDA edit. NS.F.: Not Sank-Financed. 'Footnotes with smal letrs Indicate amount financed by Government nd other donon proured unds thW procedures: te: Snmall Contract not excoeding USf260,000 I Tho follow capital ltters show the projet components: (bl: Land & Building Acquisition by Governenwt Part A Capaoity Building at centr voel. (a): Pharmacwutioas purchased by beneficanes and Pert 8: Assistance to Heath. Nutiton and FP In two rgions. UNICEF. Part C: Ntoinal Drug policy. (dl: Design/Supervislonandconstruction contracts maage- ment. Figurte mny not add-up due to rounding tel: VNUs finnrerd by UNWP and UNICEF. if): Finanocd by UNCEF, Government and benfidaries. 4.8 Civil works. The proposed civil works program (totaling US$4.8 million net of taxes and duties and including contingencies) includes in two regions (Guera and Tandjil6): (a) construction of about 44 health centers and one hospital for referral services and related facilities (US$3.4 million); and (b) rehabilitation of 14 health centers and three hospitals for referral servic.s (totaling US$1.4 million). Of the civil works component of the Project, IDA credit would finance 100% of the construction costs net of taxes and duties. Through the introduction of cost recovery, communities would finance operating costs and maintenance of health centers. The Government would finance the operating costs for the referral services. 4.9 Construction and rehabilHtation. Construction management would be delegated to a Contract Management Agency (CMA) such as ATETIP, a non-governmental Chadian Construction Management Agency that was ertablished with support from the successfil Faso Baara project in Burkina Faso. Civil work contracts financed by IDA for the remodeling of three district hospitals and the construction of one district hospitals, including offices and staff housing (totaling US$1.4 million) would be awarded through ICB in accordance with the Bank's GIwdein:for Procurem 29 under JRD Loans and lDA Credits (May 1992). Standard bidding and contract documents developed by the Bank would be used. 4.10 The remaning civil works contracts financed by IDA for rehabilitation and construction of 58 basic health centers which would not exceed US$100,000 each (totaling US$3.0 million) and for the remodeling of the warehouse for the CPA (totaling US$0.4) would be awarded through LCB in accordance with procedures acceptable to IDA and described in an implementation manual (similar to that introduced for the basic education project in Chad), as agreed with Government during appraisal. The CMA would maintain a roster of registered contractors eligible for Local Competitive Bidding (LCB), would permit additional applications at any time, and would not preclude large or foreign firms from participating. No preferential margin would be given to domestic contractors when LCB is used. Standard bidding documents would propose a reference price and indicate unit prices and quantities. Contractors would be invited to bid by way of discounts either on the total or on the unit prices. Contracts would be awarded to the lowest evaluated bid based on criteria specified In bidding documents. The contract award committee of CMA would open bids in public and have full authority to contract. I would justify, however, in writing and prior to signing the contract and with reference to the bidding documents' criteria, any decision not to select the lowest evaluated bid. For conacts with fewer than five bidders, for contracts greater than or equal to US$250,000 equivalent, or for rejection of the lowest bid, the award committee would request IDA approval prior to signing the contract. Where necessary, particularly in remote areas, the CMA would be allowed to select qualified NGOs as contractors for carrying out construction programs. These NGOs would be selected through prudent international and local shopping, based upon price quotations (not to exceed US$65,000 per basic health center) obtained from at least three reliable NGOs, provided that the aggregate amount does not exceed US$500,000. 4.11 Goods. Goods financed by IDA (totaling US$7.3 Million), including equipment, office supplies, vehicles, and pharmaceuticals, would be grouped into packages of at least US$250,000 each and procured through IC in accordance with the Bank's Guidelines for Procuemnent wider IBJR Loans and MA Credits (May 1992). Standard bidding and contract documents developed by the Bank would be used. A preferential margin of 15%, or the applicable customs duty, whichever is less, over the c.i.f. prices of competing goods for all ICB procurement would be given to domestic firms, if any. Furniture and goods would be procured through LCB, provided that the aggregate amount of such procurement does not exceed US$0.3 million. Procurement of small items (e.g. office supplies and spare parts) which cannot be grouped into bid packages of at least US$30,000, will be done on the basis of prudent international and local shopping, based upon price quotations obtained from at least three reliable suppliers, provided that the aggregate amount of such procurement does not exceed US$200,000. 4.12 Consultants' services. International and local consultants' services financed by IDA (JS$2.9 million equivalent) would be contracted in accordance with the Bank's Guidelines for the Use of Consultan (August 1981). The standard form of contract for appointment of consultants as developed by the Bank would be used. The services include training, technical assistance, contract management services, architectr services for the design and supervision of the construction program, and specialist services in the area of procurement, auditing and accounting. The construction management services would be contracted to a CMA such as an ATETIP on a sole- source basis provided the price, terms and conditions of contract are acceptable to IDA. In the event that negotiations with ATETIP are not satisfactory to IDA and the government, a firm would be selected from a short-list in accordance with The Bank's Guidelines for the Use of Consultants (August 1981). The CMA would contract design and supervision of construction to private firms 30 selected in accordance with 7he Bark's Guidelwnes for the Use of Consultans (August 1981). Technical assistance for the preparation of training modules would be contracted to WHO on a sole source basis. Also, the capacity building in the two regions of the project would be contracted on a sole source basis to UNICEF. Thesw two institutions have a comparative advantage because of the unique expertise they built in developing countries (since the Bamako Initiative) in the area of cost- recovery and use of essential drugs in basic health care. They also combine this advantage with the fact that part of the costs of their services would be a grant from their insttutions and UNDP representing their contribudon to the project. 4.13 Prom ment staus of ongoing projects in Chad. A Country Procurement Assessment Report (CPAR) was completed in August 1993. For this project, findings of the CPAR remain valid. In general, Chad's current procurement laws and regulations do not conflict with IDA Guidelines. The disbursement lag under certain ongoing IDA-funded projects in Chad is partly the result of Insufficient procurement skills and poor procurement practices (i.e., poor planning and slow progress in civil works due to inadequate management capability). 'he capacity of project units to plan and closely supervise IDA-financed procurement has been a major constraint to the tinely execution of project activities. However, recenty, due to closer supervision and the emphasis on project implementation, substantial improvements have been observed in Chad. 4.14 Procurement arraents under the proposed project. For the proposed project a number of activities are planned in order to establish local capacity in the area of project coordination and implementation: (a) One project coordinator has already be recruited. Past experience in project manage- ment and procurement was taken into consideration in the selection process, and the project coordinator has already demonstrated his capacity. (b) A detailed implementation schedule for works, goods and services to be procured under the project was prepared at time of appraisal; it was reviewed and updated, where necessary, during negotiations. This schedule would contribute to ensuring timely processing of all required actions. During implementation, all bid evaluation reports transmitted to IDA for review would contain an updated copy of the implementation schedule and a Form 384; and (c) Based on the scope of the construction program agreed at appraisal, schematic designs and specific accommodation requirements have been submitted to IDA for review and found acceptable at negotiations. Design, preparation of bidding docu- ments, and supervision of civil works have been contracted out to a consulting firm selected in accordance with IDA Guidelines before negoiati and all design and bidding documents necessary for the first year of project implementation for the health centers would be ready before credk eftiv_nes; 4.15 The project coordination Team would be responsible for procurement. However, in addition to the fill-time procurement specialist position, it would have access to support from independent procurement specialists (consultant), as required (estimated at two man-months per year during the first year of the project and one man-months per year during the rest of the project). The coordination team would ensure that bid documents for civil works, goods, and drugs required under the Project for the health centers be prepared and found acceptable to IDA gtir tocredit effectiveness. 31 4.16 The coordination team, with assistance from the futl-time procurement specialist, would also collect and record procurement information as follows: (a) Prompt reporting of contract award information; (b) Comprehensive monitoring of reports to IDA (on a semiannual basis and at time of submissionto IDA of each bid evaluation), indicating: (a) revised cost estimates for individual contracts and the total project, including best estimates of allowances for physical and price contingencies; (b) revised timing of procurement actions, including advertising, bidding, contract award, and completion time for individual contracts; and (c) compliance with aggregate limits on specified methods of procurement. 4.17 Review by :A. IDA-financed contracts for works and for goods above a threshold of US$250,000 equivalent each would be subject to IDA's prior review procedures. The review process would cover about 38% of the total value of the amount contracted for works, and about 95% of the total value of the amount contracted for goods financed by IDA (Annex 4-2 page 2 of 5). Selective post-review of awarded contracts below the threshold levels would apply to about one in three goods contracts. In the case of consultants, prior review by IDA would be required for all consultancy contracts for individuals above US$50,000 and for firms above 100,000. However, this exception would not appply to the terms of reference for such contracts, single source hiring of firms, assignments of critical nature as determined by IDA, and to amendments of contracts raising the contract value to US$100,000 equivalent for firms and US$50,000 equivalent for individuals, respectively. 4.18 During negotiations agreement was reached on the proper monitoring of the procurement, as well as the use of Bank Standard Bidding Documents for ICB, and standard procurement documents for LCB to be developed and reviewed by and agreed with IDA. At negotiations, the Goverment furnished IDA with: (a) an updated procurement plan; (b) a procedural manual for management and procurement; and (c) draft bidding documents for the ( istruction program and major equipment as well as draft letter of invitation for consultant set, . The Government also gave assurance at negotiations that it would apply the procurement procedures and arangements outlined above. E. Disbusements 4.19 The project is expected to be completed over a five-year period; the IDA credit would be disbursed over 6 years (according to the categories shown in Table3 below). The estimated disbursement profile is shown in Annex 43. Disbursement of the Credit would be fully documented except for contracts and expenditures valued less than US$20,000 equivalent which would be made against Statements of Expenditure (SOEs). Documentation for withdrawals under SOEs would be retained at the PCT for review by IDA supervision missions and for semiannual audits. To facilitate disbursement, the Government would open a Special Account (SA) in a commercial bank to cover IDA's share of eligible expenditures managed by the PCT. The authorized allocation for the Special Account would be US$500,000 and would be only for making payments against contracts estimated less than US$250,000. At the request of the Borrower, IDA would make an initial deposit of that amount from the proposed Credit upon credit effectiveness and would replenish the SA upon receipt of satisfactory proof of incurred eligible expendiures. Replenishment requests would be accompanied by up-to-date bank statements and reconciliations of the SA. Given the availability of the special Account, the minimum application for direct payments, reimbursement or requests for special commitments would normally be for the equivalent of US$20,000 equivalent. The amov ss to be financed by IDA under each category are shown below. 32 Tablg3 Allocaion and Disbursement of the IDA Credit (IJS$ million) Category of expenditure Proposed IDA % of Expenditure Allgoaign Financed by IQDA 1. Civil Works 4.3 100% 2. Goods 4.0 100% 3. Pharmaceuticals 2.9 100% 4. Consultants" services 2.4 100% 5. Training and training miaterial 1.0 100% 6. Incremental Operating Costs 1.9 100% 7. Unallocated Z& - Total 18.5 * Except pharmaceuticals and training material F. Accounting, Auditing and Reporting 4.20 The PCT would be responsible for the financial management of the project and would maintain, with the assistance of a private accountant, consolidated project accounts in accordance with International Accounting Standards (lASs). Project accounts, including the SA, would be audited annually in accordance with International Standards on Auditing (ISAs) by auditors acceptable to IDA. The project accounting system should be capable of producing, on a timely basis, information used by management to plan, evaluate and control within the project use of, and accountability for, its resources. This should include the regular production of financing situations for all loans and credits, showing funds utilized, committed and available by category of expenditure and project component, in the currency of the respective agreement. It should also include information to enable management to compare and control costs with appraisal estimates. SOEs would be accepted as basis of disbursements only if the intenal control and accounting system and auditing arrangements are satisfactory. If the absence of auditors absolutely precludes this practice, then disbursements under SOEs would be audited semiannually. The annual audit report would be submitted to IDA within six months of the end of each fiscal year; the semi-annual audit reports would be submitted to IDA within three months of each period; the Government would submit a short-list of independent auditors, including the related draft contract and terms of reference. The Government gave assurances during negotiations that it would submit to IDA audit reports of reasonable scope and details within: (a) six months of the end of each fiscal year in the case of the annual audit report; (b) and three months of the end of each semester in the case of the SOEs. The appointment of an independent auditor under a multi-year contact acceptable to IDA would be a condition of credit effectiveness. The auditor should be appointed under an 'open' contract and his mandate re- confirmed each year. Project management should be encouraged to prepare the financial statements for audit as early as possible in each year so as to advance the date of the audit and permit early re- confirmation of the auditor in time for him to carry out the interim audit of the current year. As a condition of L Atveness the accounting and financial management system will be operational. The system will have been developed with the help of an internationally recognized accounting firm. 33 V. FPO.ECT BEINEl i- ANI IS A. Benefits 5.1 By the end of the project, the increased efficiency of the health system would result in increased access to and improved quality of health, nutrition, and FP services, even within the framework of existing limited sectoral resources. For the regions of Gudra and Tandjile, the project will intervene direcdy to extend the capacity of the health care system, and proposed activities would directly benefit about 750,000 people (more than 12% of the population), mosdy women and children, who would gain access to basic services. Increased availability of low-cost essential drugs, together with intensive retraining of health personnel is expected to enhance the quality of health ser- vices throughout the country. Sector-wide restructuring measures will also help establish a basis for a more responsive administration and for a more efficient and sustainable program. The implementa- tion of an IEC strategy is expected to increase community participation in its own health development. The steps taken to improve access to quality MCH/FP services would put in place the basic infrastructure necessary for attaining the increase in family planning service delivery required to implement the Government's planned populatior. program. This program, to be supported through the proposed IDA-funded Population and AIDS Control Project, is expected to contribute to increasing the contraceptive prevalence rate from the present I % to 10% in the year 2000. B. Risks 5.2 There are three main risks: Eimr§ the implementing capacity of the central Government is weak. TMis risk would be minimized by: (a) up-front implementation of key policy reforms such as personnel redeployment; (0) relying heavily on stakeholder commitment through local management and community participation; and (c) obtaining assistance from UNICEF, WHO, and ATETIP in the implementation of the project. Secon, the Government's chronic financial constraints may affect counterpart funding, as well as salary payments. This risk would be mitigated through: (a) annual discussions of project and sector performance, budgetary allocations, and Public Expenditures Reviews; (b) redeployment of existing health personnel to staff new infrastructures created through this and other donor-financed projects; and (c) gradual introduction of cost recovery to promote increased cost-sharing by the communities. Ihird, implementation of the national drug policy focusing on the use of essential and generic drugs may face opposition from the private pharmaceutical sector. To address this risk, the private sector will be given a place in the new system, allowing them a profit margin on essential drugs in generic form higher than on specialty drugs. Also, through EEC, the public will be taught that inexpensive generic drugs are as effective and safe as expensive brand name drugs. VI. AGREEMENTS REAC AND RECOMMENDATIONS 6.1 The Government met the conditions of negotiations and furnished the following documents for discussion and finalization at negotiations: a. A draft letter of health sector development policy and an accompanying action plan; b. A National Plan for training of health personnel; c. A National Redeployment Plan for health personnel; 34 d. Draft contract agreements between the Govement of Chad and: (i) the WHO for the technical assistance in training at the central level; (ii) UNICEF for the management of health activities in the regions of the project; and (iii) the WHO/Gen- eva for technical assistance to the Division des Pharmacies; e. Ministerial decrees (arre&S ministEriel) regarding: (i) the organization and staffing of the IEC Division; (ii) the amendment to the composition of the Task Force on IEC f. A shortlist of internationally-recognized institutions in the field of IEC research; and a draft contract and terms of reference defining a proposed twinning arrangement between the MOPH and the institution. g. A ministerial decree on cost recovery and one on the bylaws of the 'comitds de gestion' for the health facilities; h. A written commitment of the Government to put at the disposal of the CPA the buildings occupied now by the PASP and the PHARMAT; i. A ministerial decree establishing the list of Essential Drugs; j. A ministerial decree fixing the 'droits de visa' of pharmaceutical specialties, and the right of the Division des Pharmacies to keep the revenues; k. A draft document regarding the operational status of the CPA; 1. CVs and drafts of negotiated contract for the recruitment of procurement specalists for the preparation of bidding documents for drugs and for other goods; M. An implementation plan and a procurement plan; n. The confimtion that an agency (such as ATETIP) has been selected for the management of the construction/rehabilitation component; o. A document indicating the choice of construction/rehabilitation sites for the health centers and district hospitals; p. Signed contracts with consulting finns who would be in charge of preparing technical documents for civil works and equipments; q. Letters of invitation regarding: (i) key posts in the PCT-coordinator, adminir, procurement specialist, accountant; (i) the auditor for the duration of the project; (iii) installation of the accounting and financial management systems. 6.2 During negotiations, the Government gave assurances that it would: a. Maintain a separate budgetary chapter for two categories - drugs and operating cost (excluding personnel) for each of the 13 health regions (pr6fecures sankares) through the end of the project (para 3.5); 35 b. Implement the National Plan of Redeployment of health personnel and the National Plan for training of health personnel according to the timetable agreed upon during negotiations (para 3.8); c. Operate the Division of IEC with terms of reference (including staffing) acceptable to IDA (para 3. 11); d. Operate the PCT under terms of reference (including staffing) acceptable to IDA and would not replace any key staff without IDA's prior consent (para 3.14); e. Adopt, following consultation with IDA, a three-year Pharmaceutical Plan not later than January 31, 1996 (para 3.28); f. Conduct semi-annual management audits of the CPA as stated in para 3.32; g. Ensure that the CPA would occupy, not later than June 30, 1995, the designated facilities as agreed upon with IDA (para 3.33); h. Submit to IDA progress reports on project implementation and outcomes twice a year (in April and October), using the format developed in the on-going education project; organize no later than November 30 of each year, starting in 1995, a joint IDA/Government review of project implementation; Carry out a mid-term review of project implementation-including financial and technical audits-jointly with IDA, no later than May 1997 (para 4.6); i. Apply the procurement procedures and arrangements agreed upon at negotiations (para 4.18); and j. Submit to IDA annual audit reports of all project accounts within six months of the end of Government's fiscal year and, semiannual audit reports of the SOEs within three months after the end of each audit period (para 4.20); 6.3 As a condition of Board presentation, the Government would give IDA a signed version of the letter of Health Sector Development Policy (para 3.1). 6.4 As conditions of credit effectiveness, the Government would: a. Adopt by ministerial decree, a time-bound National Plan for redeployment of health personnel and a time-bound National Plan for the training of health personnel, satisfactory to IDA (para 3.8); b. Have entered into two agreements with WHO, each in form and substance satisfactory to the Association, for carrying out activities in the Training component tpara 3.9) and the Pharmacy Component (para 3.29); c. Establish the PCT, under terms of reference satisfactory to IDA, with the Coordina- tor and the three senior professionals in post (para 3.14), and the accounting and financial management system in place (para 4.20); 36 d. Enter into an agreement with UNICEF and a construction management agency such as the ATETIP, satisfactory to IDA (paras 3.19 and 3.23); e. Establish the CPA with operational procedures, satisfactory to IDA (para 3.30); f. Recruit long-term technical assistance for the CPA (para 3.33); g. Provide to the CPA sufficient facilities for the start-up phase of its preparation and adopt a facilities expansion plan for the CPA, each satisfactory to IDA (para 3.33); h. Prepare bidding documents satisfactory to IDA, for the procurement of the list of major civil works and goods agreed upon with IDA (para 4.15); and i. Employ an independent auditor under a multi-year contract acceptable to IDA (para 4.20). 6.5 Recommendation. Subject to the above terms and conditions, the proposed project would be suitable for an IDA credit of US$18.5 million to the Republic of Chad on standard IDA terms. amReL4 37 Annex 1-1 Page 1 of 1 REPU8LIC OF CIUO HEALTH AND SAFE MOTHERHOOD PROJECt BASIC DATA SEEEET sum RegiaWlncomgrom '~~~o -- - -s------------------------_-____ 2-30 15-20 recent Ssh- Next Unit of 7eat yeR* etimt. Sakeran Lou- biter mhasure age oe (We) Africa Inr icm grow HUWI RESOURCES Size growth. structwe of pm3utatii Total population (wre a 1993) miliwts 3-33 4.03 6.28 4.f MM 629 14 and under X of pop. 40.8 41.7 41.9 35.3 37.3 tS-64 55.5 54.7 54.5 60.3 57.8 Age dependency ratio uilt 0.8 0.83 0.84 0.66 0.72 Percentage in urban areas X of pop. 8.9 16 29.5 38.7 58.6 Females per 100 males Urban rsber - Rural I- Population growth rate annul X t.8 2 2.5 3 2 2 Urban - 6.1 8.1 5.2 4.9 5.4 3.2 urban/rural growth differential difference 4.8 7.2 3.8 2.6 5.9 2.4 Projected population 2000 dIll one - 7.42 6.69 3672 769 Stationary population " - 27.91 - oeterminArts of poptation growth Fertility Crude birth rate per thou.pop. 45.3 44.3 43.7 45.9 29.4 29.5 Contraceptive prevalence births per woman 6.03 5.93 5.96 6.46 3.72 3.74 Child (0-4) /woman (15-49) ratf0 X of women 15-49 5- - 6.2 Urban per 100 women Rural U Mortality Crude death rate per thou.pop. 27.6 23.8 18.5 15.6 9.? 8.5 Infant mortality rate per thou. tive births 183 158.8 124.6 107.3 66.9 49.5 UInder S mortality rate U - - 209.8 166.8 166.6 79.5 Life expectancy at birth: overall years 36.4 40.2 47 S0.6 62.1 65.3 femtle 38 41.8 49.2 52.4 62.8 67.9 Labor force (15-64) Total labor force millions 1.28 1.5 1.97 198 1413 238 Agriculture X of labor force 92.2 86.7 Industry U 2.8 4 Female a 23.2 22.7 21.1 37.6 35.6 32.3 Females per 100 males Urban number Rural 40.6 Participation rate: overall X of labor force 38.4 37.1 34.8 41 49.4 40.6 female * 17.5 16.6 14.5 30 34.6 25.6 Educational attairment of labor force School years completed: overall years - - male u NATURAL RESOURCES Area thou.sq.kmn 1,254 1,284 1,284 23,066 37,780 22.765 Density pop.per sq.bn 3 3 4 21 79 27 Agricultural land Z of land area 37.3 37.4 37.5 38.3 38.5 40.9 Agricultural density pop.per sq.km 7 8 11 54 206 66 Forests and woodland thou.sq.km 149 139 128 6,677 8,944 6.174 Oeforestation rate (net) annual 2 .0.7 -0.7 -0.6 -0.4 -0.3 -0.5 Access to safe water X of pop. - 26 - 36.2 67.8 Urban a - 43 - 7S.5 64.5 78.2 Rural n 23 24.1 79.5 46.9 Rurt1 HOPH NEW ORGANIZATIONAL CHART . CENTRAL LEVEL CONSEIL NATIONAL SANTE L TERE ........... ...... .......... | CABNET CONSEIl OE CABINET ION DIRECTION GENERALE BUREAU OES I ~~~~~~~~~~~~~~~~~~~~~~SECRETARtIAT NATIONALES BUREAU OE COOP. ETUOES CCMITE DE EIRECTION I~~~~~~~ DI41RECATIO PAFCTON NOIRECIONETABLISSENENTSI DIRECTION DES ACTIVITESJ SANITAIRES SAFNITAtIRES .2.. I .: w CONITE DE DIRECTION CONITE DE DIRECTION ICOITE DE DIRECTION B CONITE DE DIRECTION DIVISION PLANIFICATION DIV. RESSUCES HUAIN. DIVISION FORM ATION DIV. RESSCCES FtNA. DIVISION fORNATIONS DIVISION SMI/YEFNUTRITEION 3Qj SANI ITAIRES DIV. RESSOURCES INFRM DIVISION MALADiES TAANSMISS. DIVISION LASORTOIRES DIV. LEGISLATIVE DIVISION O LITE DIES SOINS DIVISION RECHERCHES p S10-NEDICALES DIVISION ASSAINISS. El HYGIENE DU MILIEU DIVISION DE PHARIACIE DIVISION DE MEDECINE SCOLAIRE UNIVERSITAIRE ET TRAVAIL PREFECtJRES SANITAIRES MOPH NEW ORGANIZATIONAI CHART - PREFECTURES LEVEL CONSEIL PREFECTORAL PREFECTURES SANITAIRES DE LA SANTE CONITE DE DIRECTIONj DIV.PLANIFIC.PROGRAMMATION CONSEIL DE DISTRICT DISTRICTS SANITAIRES DISTRICTS SANITAIRES HOPITAL PREFECTORAL SAUTE EO COMITE DE DIRECTION:] - DIVISION RESSOURCES/ |PROGRAYVATIONI CONSEIL SANITAIRE ZONES DE RESPONSASILITE ....................... r CHEFFERIE ZONES DE RESPONSABILPIE TAL DE DISTRICT ZONES DE ZONES DE ZONES DE ZONES DE RESPONSABILITE RESPONSABILITE RESPONSASILITE RESPONSA8ILITE 'r, aq o N) MY I- Annex 2-2 Page 1 of 6 40 REPUBLIC OF CHAD HEALTH AND SAFE MOTHERHOOD PROJECT THE DISTRICT HEALTH SYSTEM PYRAMIDE SANITAIRE ADMINISTRATION ET FORMATIONS SANITAIRES * * * ** ** ** ** ** ** ** ** ** ** ** ** ** ** ** * ** NINISTRE * ** SECRETAIRE 0'ETAT ** .* ** ** ** DIRECTION ** GENERALE IVE ** ** QIIRL ** * ** DIRECTION ** ** GENERALE ADJOINTE ** ** a* ** D-* IRECTIONS INSTITUTIONS * C CENTRALES RATIONALES * _ * ** IVEU ** ** INTERWEDIAIRE ** DIRECTIONS HOPITAUX ** * PREFECTORALES PREFECTORAUX ** ** (14) ** ** ** ** ** NIVEW ** DIRECTIONS HOPITAUX ** PifIPHERltE ** DISTRICTS ** ** (46) ** ** ** RESPONSABLES ZONES DE RESPONSABILITE ** * ZONES DE RESPONSABILITE (CENTRES SANITAIRES) -- ** (633) ** ADMINISTRATION FORMATIONS SANITAIRE SANITAIRES 41 Annex 2-2 Page 2 of 6 LE PLAN DE COUVERTURE SANITAIRE 1. Dans le cadre de l'adoption par le MSP/AS du "Scenario en trois phases" de developpement de ses services sanitaires, il a etd procede a l'elaboration d'un plan de couverture sanitaire. Ce plan a ete rdalise par une dquipe composee du BSPE et du PERI/BAD. Pendant deux ans, cette equipe s'est deplacee sur le terrain et a procede, avec les equipes prefectorales de la sante et les autorites administratives et traditionnelles locales, au decoupage des Prefectures en 46 districts sanitaires. Les equipes prefectorales ont ensuite procede au decoupage des districts en 633 zones de responsabilitd. * Les Prefectures sanitaires. Les 14 prefectures sanitaires du pays reposent Sur les 14 prefectures administratives du Tchad. Outre l'administration prdfectorale de la sante et des affaires sociales, chaque Prefecture doit posseder un hopital prefectoral de reference et un Centre Social. * Le niveau peripherique est compose de Districts et de Zones de responsabilite. * Le district regroupe une population comprise entre 100.000 et 250.000 habitants. Son aire geographique correspond generalement a la sous-prefecture administrative. Le district comprend les locaux administratifs du district, I'hopital de district, et dans certains cas, un centre social ou un jardin d'enfants. * La zone de responsabilite regroupe une population d'environ 10.000 habitants. Son aire gEographique correspond a un rayon de 10 km ou de deux heures de marche (sauf dans leg rEgions a faible densite de population). Cette zone doit etre equipde d'un centre sanitaire. Les details de ce plan de couverture peuvent Wtre consultes pour chacune des zones et les renseignements ont ,te reportes sur des cartes geographiques pour l1ensemble du pays. Le tableau suivant en e nne la synthese: Infrastructures sanitaires - Niveaux intermddiaire et pfriph6rique A CONSTRUIRE A REHABILITER TOTAL Directions prdfectorales 6 8 14 HMpitaux prefectoraux 1 12 13 Centres sociaux 37 15 52 Jardins d'enfants 16 8 24 Directions de district 26 10 46 Hopitaux de district 10 24 34 Centres sanitaires 279 174 453 Ensetnble 375 251 626 Afin d'atteindre la realisation complete de ce plan de couverture sanitaire, des prioritds sont dtablies pour: rendre operationnels des districts sanitaires ainsi que les directions prefectorales; donner la priorite a la rEhabilitation des structures existantes avant d'en construire de nouvelles. 42 Annex 2-2 Page 3 of 6 Afin de realiser ce plan au niveau intermediaire et peripherique, il faut donner au niveau central les moyens de coordonner la mise en application de ce plan: cellule d'appui aux constructions et rehabilitation, et service de maintenance des equipements. LE PLAN D'EFFECTIFS 2. Le plan d'effectifs permet de chiffrer les besoins en personnels au bon fonctionnement des structures de santd prevues dans le plan de couverture sanitaire. L'approche qui a ete adopt6e est normative: elle s'appuie sur les tAches et activites menees par chacune de ces structures. Le tableau suivant donne les besoins optimaux pour chacune des structures. j | Par entite geographique Ensemble du pays | NIVEAU CENTRAL 1 120 personnels NIVEAU ENTERMEDAIRE (14 Prefectures) - Direction prefectorale 19 personnels 266 personnels - H6pital prefectoral 50 personnels 700 personnels - Centres sociaux et jardins d'enfants comptabilises au niveau district - Total 966 personnels NIVEAU PERIPHERIQUE District - Direction du district 7 personnels 322 personnels - H6pital du district 22 personnels 1 012 personnels - Centre social 8 personnels 368 personnels - Jardin d'enfants 6 personnels 276 personnels Sous-total 43 personnels 1 978 personnels Zone de responsabilite - Centre sanitaire 4 personnels 2 532 personnels -Total 4 510 personels I TOTAL 5.596 personnels LES ACIIVIIES AU NIVEAU PERIPHERIQUE 3. L'adoption des soins de sant6 primaires et son execution par les districts sanitaires, mais aussi la prise en compte des ressources limitdes qui pouvaient Wre mobilises I cet efet (faibles ressources financieres, faible qualifications des personnels de sant6), ont conduit le Tchad I definir les activitds minimales qui devraient Wtre mises en oeuvre au niveau des services de sant du district sanitire. Le 43 Annex 2-2 Page 4 of 6 district sanitaire est compose de deux echelons complementaires qui doivent chacun garder leurs speciftcites pour constituer les deux premiers echelons du systeme de r0fdrence. Pour ce faire, il fallait definir les activites qui doivent Otre realisees A chacun de ces Echelons. - Le Paquet Minimum d'Activit_s (PMA) definit les activites des Centres sanitaires presents dans les zones de responsabilite; - Le Paquet Complementaire d'Activites (PCA) definit les activites des H6pitaux de districts. A. LE PAQUEr MINIMUM D'ACTIVITTs 4. Le PMA est l'ensemble des activites curatives etprAventives offertes a une population definie dans des conditions telles que chaque activite, dotee d'une efficacite satisfaisante, est delivree a un individu qui en a besoin A un moment approprie. 11 est un ensemble standard d'activites attendu dans tous les Centres sanitaires du pays. lt suppose des soins globaux, contniws et inz6grgs. 11 s'agit du PMA du Centre Sanitaire, c'est-adire: - il comprend a la fois des activites sanitaires et des activites sociales; - il est execute par des personnels sanitaires et des personnels sociaux; Si le PMA est bien developpe au niveau du Centre sanitaire, il doit resoudre 90% des problimes de sante des populations. II ne s'adresse pas seulement aux personnes malades qui se pr6sentent I la consultation, mais a l'ensemble de la population. 5. Le PMA comprend les activitds suivantes: * Consultation curative primaire * Depistage des pathologies sociales * Consultation des enfants sains de 0-4 ans, y compris: - Vaccinations - Depistages des malnutris * Prise en charge des femmes enceintes et en Age de procreer, soit: - Consultations prenatales Accouchements TMnormaux" - Bien-tre familial * Prise en charge des malades chroniques, malmntris, tuberculeux et lEpreux * Education sanitaire intgree aux autres activites et communication avec les populations 44 Annex 2-2 Page 5 of 6 Activites de d6veloppement communautaire SystQme de reference/contre reference pour lea malades ne pouvant pas 8tre pris en charge au ler echelon. 6. n s'agit des activit6s mlnimales dans la mesure oli un centre sanitaire assure completement ces activites, U peut en inclure de nouvelles s'il y a les capacites (par exemple, activites de laboratoire). B. LE PAQUEr COMIPLg MNAIRE D'AcrTIVIS 7. Le Paquet Compldmentaire des H6pitaux de District. Le PCA de Hopitaux de District est 1'ensemble des activitEs devant Wtre offertes par les services du 2eme echelon, k savoir l'H6pital de District. Ces activit6s sont complementaires a celles du ler echelon qui ne peut pas les offrir pour des raisons d'ordre technique et economique. L'H8pital de District regoit les malades referes par les Centres sanitaires. II ne doit par consequent plus exercer les fonctions des services de la zone de responsabilite oti il est implante. 11 est prevu qu'il regoive entre 7% et 10% des consultations curatives du ler echelon. 8. Le Paquet Complementaires d'Activites des H6pitaux de District se compose de: 3 Prise en charge des urgences mEdico-chirurgicales * Prise en charge des accouchements compliques * Hospitalisation * Fonction diagnostic de laboratoire * Fonction diagnostic de radiologie * Consultation de reference. 9. Ce n'est que dans un tres petit nombre de cas que les malades doivent Ote rds i I'H6pital prefectoral. Le Paouet Complementaire des Activites des Centres Sociaux. L'analyse des activirEs actuelles des Centres Sociaux fait ressortir que les activitds purement sociales ne representent que 47% alors que les activitds medicales representent 53% des activites. Or l'esprit du nouveau modele de fonctionnement et d'organisation du Minist're de la Sante Publique et des Affaires Sociales veut que les fonctions et/ou les activitds de m0me nature soient int6grees dans une meme strucure sanitaire. Cela implique que les Centres Sociaux vont progressivement se dessaisir des activitds de santd et dEvelopper les activites purement sociales. 10. Le Paquet d'ActivitEs des Centres Soclaux se compose de: DeEveloppement communautaire Promotion famuliale * AAlphWaS isation 45 Page 6 of 6 * Enseignement mdnager * Protection familiale et rbglement des conflits conjugaux RAinsertion sociale de: * Personmes handicapdes * Jeunes ddlinquants * Alcooliques * Personnes du 3eme Age abandonnes Reference des Centres Sanitaires et des HOpitaux de District 46 Page I of 10 REPUBLIC OF CPAD HEALTH AND SAFE MOTHERHOOD PROJECT LEITER OF SECTOR DEVELOPMENT POLICY REPUBLIC OF CHAD Ministry of Planning and Cooperadon Division Chief, Population and Human Resources Operations, Sahelian Devartment The World Bank, Washington, D.C. Public Health Policy Saement 1. The objective of this Statement is to describe the Governmen of Chad's health policy; its plans, projects, and development saegies for the health sector. I. CQNTI 2. the Transition Charter of the Republic of Chad, product of the National Sovereign Conference held in January 1993, guartees the right to good health. 3. Tne Government's health policy adheres to the broad principles advocated by the World Health Or,anization, of which Chad is a member, and is consistent with the country's socioeconomic and cultural realities. It is based on the principle of universality which recognizes health to be a fundamental right of every Chadian and on the precept that health programs are instances of social action arising from the united efforts of the cental government, the local government, and the individual. 4. The state of public health in Chad continues to be characteized by: persistan high morbidity and mortality rates, especially of pregnant women and infants; and - a high incidence of infectious, parasitic, and nutritional diseases. 5. These conditions are exacerbated by: poor health coverage; lack of equipment In health care facilities; lack of medicines and medical supplies; lack of management skills with regard to human resources, supplies, and finances; inadequate integration of activities; 47 Annex 2-3 Page 2 of 10 cutbacks in public health expenditure; and - insufficient, unqualified, unmotivated, and geographically unbalanced staff. II. FOCUS 6. Chad's National Development Plan (plan d'orientation) states that its top priority is to ensure the development of the population towards an adaptation to the cultural, social, economic, and technological changes the country will inevitably face. Tbis is an absolute prerequisite for development. 7. Health, like the Social Services, is an essential contributing factor to the welfare of the nation. Therefore, priority is placed on preventing pain and suffering. The role of public agencies in resolving health problems is a major one in a country where the majority of the population has no means of access to private services (themselves still under development). The welfare of the people also depends on preventive family health care. Accordingly, this policy aims at providing the population with the means of living in a healthy environment: with clean water, sanitation, and control of the main vectors of disease and epidemics. 8. Where development is concerned, health is sine qua non. Social sectors such as education and health must be considered as factors of development and be allocated the necessary resources. 9. Good health is one way to ensure balanced and harmonious development in Chad. An equitable distribution of health services can help create a balance between urban and rural areas by providing rural communities with necessary health services, thus enabling them to remain in their villages and be gainfully employed there, instead of swelling the ranks of the urban disadvantaged. 10. The policy herein described focusses on resolving a twofold problem: the present health level of the Chadian population is very low, and access to public health services, which are of poor quality, is very limited. 11. Implementing this policy priority comes down to establishing and developing public health districts in which first-level public health centers deliver a minimum package of health care services (vaquet minimum d'act1vltis-MPA), and district hospitals deliver a complementary package (vaquet complbnentaire d'acdvltds-PCA) of health care services. IM. HALTH OlIJY BEClMl 12. The key objective of Chad's health policy is to provide the population with quality basic health services, as espoused by the WHO goal of Health-for-All as soon as possible. 13. The accomplishment of this objective will depend on the implementation of the following intermediate programs: (a) Maternal and child health measures and blmunzation agains major iWfeatous diseases to reduce the infant mortality rate from 180 to 120 per thousand; to increase the detection of risk-prone pregnancies; 46 Annex 2-3 Page 3 of 10 to reduce the maternal mortality rate; to increase vaccination coverage to 60% per annum by the year 2000 and 80% by the year 2005; to use oral rehydration therapy (ORT) to treat 90% of all diarrhea cases. (b) Nutrition promotion measures - to reduce the number of infants with a birth weight of less than 2.5 kg; - to increase growth monitoring of infants up to age 5 and treaunent of malnutrition cases. (c) Availability of essential drugs - to ensure that essential drugs are available in all public health facilities on a not-for-profit basis. (d) aean water and sanitation - to provide 50% of the population with clean water by the year 2005 and 70% by the year 2015; - to increase the number of households and public facilities (schools, dispensaries) equipped with latrines. (e) Prevention and control of local endemic diseases to reduce mortality and morbidity from malaria, leprosy, tuberculosis, onchocerciasis, trypanosomiasis, dracontiasis, SlDs/AIDS. (f) Family well-being - to increase the contraceptive prevalence rate from 1% to 10% by the year 2000 and to 30% by the year 2015. IV. NATIONAL HEALTH DEVELOPMENT STRATEGY 14. Chad's health development strategy is based on the concept of primary health care adopted by the Alma-Ata World Conference in 1978. 15. In order to accelerate the establishment of primary health care, a five-part strategy has been instituted- (a) Development of the three-tier health system proposed by WHO was adopted by Chad in 1988 (to be developed in three phases). Ibis system moves the concept of the health pyramid from a hierarchical and administrative one to a multi-level one, differeniating between operational, support, and directional levels. The health district constites the operational level and is responsible for putting policies into effect. The regional level, where national policies are adapted to the regions, suppors the districts in technical matters. The central level (responsible '49 Annex 2-3 Page 4 of 10 for policy formulation, monitoring, and evaluation) makes decisions regarding investments and functions of the sector. It prescribes standards based on principles of effectiveness, efficiency, equity, and workability. And finally, it endeavors to mobilize fiscal revenue at home and resources from donors abroad for the financing of quality health care, accessible to all. (b) The second part of the strategy involves the introduction of a public health coverage plan for the entire country based on norms derived from a selected model concerning drugs and financing, and on the analysis of existing resources. Non-public entities (NGOs, denominational groups, cooperatives) play a crucial part in the coverage plan and have the same responsibility as the departments of the Ministry of Public Health. (c) Where pharmaceutical goods are concerned, Chad has adopted an essential drugs policy and has produced a national list of pharmaceutical products. Accessibility to such essential products depends on a series of measures including reform of the Pharmaceutical Supplies Authority (a public-sector entity), reorganization of the supply system, and cost recovery of drugs. (d) Community participation in the management of the system is to be strengthened so that individuals, households, and communities will take responsibility for their own health. Despite their limited purchasing power, communities can contribute gready to the survival of their children and reduce the incidence of disease. To further ensure accessibility to health care and to information on health improvement, beneficiaries will be associated with the administration of health services at the operational level (district and service zones). (e) The final part of the strategy is based on a new mode of operation for the national health system characterized by decentralization in planning, accountability, participation, and integration. This strategy has been prepared in collaboration with the country's partners-in- development, who are committed to supporting it. Implementation of the National Health Development Strategy 16. In order to improve the health status of the population in general and the maternal and infant population in particular, the Government's future strategy is to: (i) improve access to health services, i.e. increase care delivery coverage and utilization rates; (ii) improve the quality of health services; and (iii) enhance the development of health districts through rational and efficient use of resources (staff, medicines, funding, etc.); and (iv) through an ongoing information/education/comrmunications campaign, organize and elicit community participation in the financing of the health sector. 17. Improving accessibility: In order to increase coverage and utiization of health care services, the Government will emphasize the development of health districts through a process of decentralized planning, organization, and management centered around the following principles: (a) The administratve delineation of the country has already been accomplished: the regions have been divided into 46 health districts, and those health districts have been divided into 633 service zones (zones de responsabiIk), according to the concentration of population in the respective areas. 30 Annex 2-3 Page 5 of 10 (b) Specialization at each level of the system between first-level facilities and the district hospital to which those facilities refer users. (c) Rehabilitation or construction of a simply-built, first-level health center (with maternity ward) in each service zone, and a second-level facility (the district hospital) affording a wider range of technical capabilities (emergency, radiology, laboratory, matemity, in-patient, referral consultation). (d) Organization of community participation in the management of the health centers through: (i) the creation of health committees; and (ii) the use of an information/education/communication campaign focused on community participation. 18. Improved quality: The Government has defined "packages' of health care services to be provided at each level of the system, for both basic and referral care. Particular attention will be given to training and supervision of staff and to ensuring availability of essential drugs at affordable prices throughout the nation. 19. Management: The health committees will be responsible for, and ensure the management of, the health facilities. These commitees will guarantee basic health care for the target communities, provided the communities agree to share some of the responsibility for meeting the operating costs of their health centers. 20. Finacing: In addition to the community's participation, the Government's strategy in this arena is aimed at (i) reorganizing the funding of the public health sector so that maximum advantage is taken of all possible economies; and (ii) increasing available funding in general. 21. Community participatiou in health costs: The Government will ensure that the costs of community participation will not hinder its access to health care or interfere with the development of health services. The health policy framework, plans, and strategies, designed to this end, shall focus on the mobilization of external resources. Efficient use of such resources depends on their being coordinated with those of the government and the community. Coordination of external aid will therefore be the subject of joint annual consultations between the Government and donors. 22. Government funding of health care: It is recognized that budget expenditure on health ought to increase by 10% annually. Given Chad's annual population growth rate of 2.3%, this is equivalent to an increase in real terms of 7.7% per annum - an ambitious goal, since health expenditure would have to rise from 4.2% of the budget to 10.4% within ten years. These figures give the full measure of the test: the Government alone, however great an effort is made, will not be in a position to guarantee health for all by the year 2000. 23. External aid with health expenditure: Despite a substantial effort in the health sector, then, Chad will be unable to meet even the most basic health needs of its population by the end of the decade if it has to do so alone. Thus the Public Investment Program is based on the assumption that external aid should not only continue but be expanded, also at an annual.rate of 10%. The Government, fiuly cognizant of its financial weakness, recognizes that it must rely on external donors to meet a substantial proportion of its health system funding needs - not that 51 Annex 2- Page 6 of 10 donors should be regarded as replacing the Government temporarily, but rather as providing a necessary supplement to enable the population to reach an acceptable health status. 24. Personnel: Th.e implementation of both the training and redeployment plans are of top priority to the Government. A program to place personnel in health centers, based on these plans, will be carried out according to a carefully scheduled calendar. 25. Pharmaceuticia: To ensure the availability of essential and usable drugs in the health centers, the Government has begun the process of setting up a central agency to purchase essential and generic medicines. The agency will be autonomous and not-for-profit. The process includes: (a) the adoption of statutory instruments embodying the articles of incorporation of the central purchasing agency and the list of essential medicines, which are to be exempt from Customs duties and charges; (b) the establishment of official arrangements for monitoring the quality of essential medicines and inspecting pharmacies. 26. Health sector assets: The health infrastructure strategy emphasizes extension of health care coverage through, on one hand, the rational development of health centers based on the subdivision of the country into health districts and service zones and, on the other, the integration of treatment and prevention activities and the formulation of building/equipment standards and staffing norms. 27. Private health sector: Convinced that health care coverage and the efficacy and quality of health services can be increased by opening the public health field to private enterprise, the Government has taken steps to promote development of the private secor. It has endowed Non Governmental Organizations (NGOs) with the responsibility of coordinating the health activities in certain districts, and is encouraging the creation of private health centers. 28. Family well-being: Although several ministries intervene in this arena, the Ministry of Public Health is responsible for family welfare matters. Here, the Government's strategy is to pursue an integrated development of family planning services, family welfare activities, and promotion of women's affairs, through: - formulation and implementation of a full-scale policy on women's development; - information campaigns to create awareness and changes of attitude that will lead to improved conditions for women. CONCLUSION 29. This health strategy is presented in fill in the Health Development Plan (January 1993) and certain elements of it have already been implemented. Full implementation of its measures can be expected to enable the health sector to obtain a higher yield from its services and to achieve the major objective of the Government's health policy as soon as possible. 32 Annex 2-3 Page 7 of 10 30. The health policy set out in this Statement can be expected to lead to such specific results as a general renewal of confidence in the country's health services, mobilization of the population, general participation in operation of the health care delivery system, an improved availability of essential drugs, increased utilization of health and family welfare services, and broader public health service coverage. 31. The Government's health strategy is part of a long-term health develop- ment process. It will provide a frame of reference for all domestic and external interventions whose aim is achievement of the ultimate objective of health for all. GIVEN in NDJAMENA on the ..... day of ..., 19 For the GOVERNMENT OF THE REPUBLIC OF CHAD Ibni Oumar Mahamat Saleh Minister of Planning and Cooperation QUANTIFIED MONITORING; INDICATORS QUANTIFIEI) IND)ICATORS PER YEAR Objetive Itndiatos 1995 ,9 1. Strengthen capability at Central level to support regional health services through: (a) inproving PFnctional and con- Budgdary nomencla- Regional health Regional and Regional and Regional and budgetary process at solidated presentation tur revised; proce- budget presented central heakh central health central healh central and regional of Govenment bud- durs of budgeary according to the new budgets prsented budgets presented budgds presented level get as descibed in follow"up to the regions nomenclature according to the according to the according to the the Implentation established; Staff from new nomencature new nomenclature new nomenclature Manual the MOP nd MOPH country). wsined. (b) developing skls. Number and dute of 20 peron trined in Testing of moduls Modus rvised upgrading modules for seminan held; num- modules deveopment; achieved; folowing regional and district ber of paticipants in trainer from ENASS evaluation heath personnel tJe seminan; Train- 20 modules developed; sent on training; ing material 20 regional trainers developed; trained in utilization of modules (c) developing and Studies completed; Contractual for the Results of KAP tudy One qualitative One qualitative One qualiative implemaeting a ICAP study recruited; available; study complted study compteed study competed nationwide IEC technical asistants one person in LT one person in LT U' program recmited; training; training; Three persons in Three perons in Three perons in two qualitative studies trining (shoa- training (short- training (short4erm traning achieved; completed Two qualitative term outside term outside outside country). studies completed. coury). appite EC VNU reuiited material produced. Thre penm in Three persons in training (sbortterm taining (short4Irm outide country). outside country)_ (d) reinfor¢ing Annual program of Annual program of Annual program of Annual program of Annual program Annual program of Govermen's capacity action; Semi-annual action; Semi-annual and action; Semi-nnal action; of action; Semi- action; Semi-annual to plan, coordinate, and annual; audit annual audit reports st- and annual audit Semi-annul and annual and annual and annual audit s 3 and inplement donors' reports satisfatory isfactory; Pogress repots satisfactory; annual audit audit reports reponts satisfactory; o finanoed projects. Pgress reports; repors; Annual review Progress repors; rpor satisfactory; Progress repots; Annual teview meeing rports; Audit Annual review satisfatory; Progrss reports; Annual review meetings-reports; reports. meeting reports; Progress repors; Annual review meetings-reponts; o Audi reports. Audit reports. Annual rview mcetings-reports; Audit reports. mecdng reports; Atudit rports. Audkt reports. ObjectIves I Indicnanor 1995 1996 1997 1996 1999 2. Provide assastance for Health, Nutritional and FP Services h the Regions of Gudra and TandjiM by: (a) estabhng a piee of one Ahtctl studis for Half the Al oonstucion- netwok of district hea cenler per one health inftastut constuctionlrbabilk rehabiliation heallh fiiies; IFIsmilyn compleod; ation psrm program omplised and one hospta per coompld nd all dbUK, inf are AN completd saffed. Halh facilis infrastruf are affd accding to fully d peronnd noms. (b)implemen sdillss Wo*rwp by district upgading programs and by peromel for distict health calgpo; pesonne Number of people in each ciica worhhop; Number of people in training. 4' (c) premoting Availability of dmgs; Order of dgs reeived Drugs available in at Drugs available in Drugs available in Dmgs available in comm-nW health infinstucur. all health all healfth all health paicipatin in local Pr oete of centers Treant schedules *astructe. i . infanstute healh services supevised at let prepared One supervision per Planning, once during the month for exing Treatment Treatment Tremnt iniplementaton, and pmvius month. 50% of staff in place. health ceners. schedules schedules scebduls available. monioing avilabbe. availabl. Avaiabiliy of Teamt sceodules 100% of staff in treatm schedules available. 70% of staff in 80% of staff in plac. for spcifi diseaes. place. place. 60% of doff in plce. 100% of HC have a Staff peece. 40% of heath 60% HC have a managamnt All diri hospo oaters bve a maootomuninee. x manaeento have a an_agmet ma_nagent committee . I commitee in pce. _ commitwt ommittee. 0 _ . ' 5 ~~~~~~~~~~~~~~Annex 2-3 01 | L ~~~~~~~~~~~~~~Page 10 of 10 I I _ tS~~~~~~~ a a 1. 1iIii 1 tS~~Ljp 56 ANNEX 3-1 Page 1 of 13 REPUBLIC OF CHAD HEALTH AND SAFE MOTHERHOOD PROJECT PROGRAMME DE CONSTRUCTION Er DE REHABILrlATION 1. Le projet prevoit dans les deux r6gions du projet (Tandjile et Guera) un programme de construction et de rehabilitation qui vise a completer les programmes d6ji en cours ou acquis sur d'autres sources de financement. Le programme comporte la rehabilitation de trois h6pitaux de district (Kelo, Lai et Melfi), et la construction de celui de Bitkine, ainsi que leurs infrastructures administratives et le logement des medecins chefs. Concernant les CSS, le programme intervient sur 58 zones de responsabilite, comportant la rehabilitation de 14 CSS et la construction de 44, dont 8 CSS du secteur priv6 dans le district de Bere pour pallier le deficit actuel en CSS -- voir le tableau intituld programme des infrastructures sanitaires. 2. Les normes des locaux et des equipements repondant au paquet minimum de soins ont ete elaborees en concertation avec les divers acteurs - spdcialistes de sant6 publique du ministere, bailleurs de fonds operant au Tchad et membres de la mission d'evaluation de la Banque mondiale. Ceux qui ont participe a cet exercice ont manifest6 d'ailleurs leur int6ret A voir ces normes connaitre une large diffusion au Tchad. Ces normes sont assez analogues A celles recemment definies pour des projets similaires dans la sous-region - notamment au Mali et au Senegal. 3. L'estimation de ce programme est basee sur les normes ainsi d6finies, ainsi que sur des coets constates dans de recents r6sultats d'appel d'offres pour des realisations de nature similaire au Tchad ou dans la sous-region. 4. Le calendrier des actions a ete etabli en tenant compte que la selection des bureaux d'etudes et la preparation d'un contrat de delegation de maltrise d'ouvrage I passer avec un Agence d'execution chargee de la gestion des contrats (du type ATETIP) seront suffisamment avances au moment des negociations pour permettre de disposer de dossiers d'appels d'offres avant la mise en vigueur du credit. 5. Les tableaux ci-dessous donnent les details necessaires pour la rdaLisation des etudes et la mise en oeuvre du projet. Ces tableaux comprennent: (a) Les normes (b) Le programme de construction (c) La liste des equipements (d) Liste des infrastructures par district ANNEX 3-1 Page 2 of 13 CHAD - PROGRAMME INFRASTRUCTURES SAUITAIRES (NORMES) TYPE D'INFRASTRUCTURES: CENTRE SOCIO-SANITAIRE TYPE 1 (ZONES RURALES) SURFACES ET UTILISATION DES LOCAUX PROGRAMME ARCHITECTURAL 125 280 ACTIVITES PERSONNEL LOCAUX ........................... .......................................... ...... .......... _................................... .. ....... .......... _............. ... ... _ ............................................... .. __ ..... SURFACES NETTES SURFACES COUTS BASE N'DJAMENA CAPACITE NOUBRE TYPE NOMBRE 12;/PLACE 2/UNITE TOTAL BRUTE EN DESCRIPTION PROFESSIONNELLE PERSONNEL LOCAL UNITE 142 le2 12 FCFA X1000 USS ............ .... ........ ............... ................................. .......................... ........................................... _....... ...................... .......... ...............................___...._.._ ACTIVITES NIINIMALES (A) ........................... CONSULTATION CURATIVE IDE I SALLE DE CONSULTATION 1 16 16 16 20 2,500 58,929 D&PISTAGE/PROVENTIF INFIRIIER DIPLOME CONSULTATIONS 0-4 ANS O'ETAT CONSULTATIONS PRtENATALES EDUCAtION SOCJO-SAITAIRE CONSEILS SOINS/PANSEMENTS IA 1 SALLE DE SOINS 1 6 6 6 8 938 53,348 REHYDRATATION (ISOLEHENT) IINFIRIIIER COIN ISOLENENT 1 4 4 4 5 625 $2:232 VACCINATION/PIQORES AUXILIAIRE SALLE VACCINATION PICU 1 6 6 6 8 938 $3,348 CONSERVATION VACCINS (FRIG. PETROLE EMPLACENENT ISOLE 1 4 4 4 5 625 52,232 AVEC VARIANTE SOLAIRE) ACCOUCHENEWTS/REPOS ; SALLE ACCOWCHEIEENT 1 12 12 12 15 1,875 56,696 DEP6r PHARNACIE (CONITt GEStION) - OVWPt PAIMACEUT14UE I - 8 8 tO 1,250 54,464 + GUICHET ' - GUICHET 1 - 4 4 5 625 S2,232 ATTENTE - - VERANDA 1 - 18 18 23 2.813 510,045 RESERVE PETIT NATERIEL PERSONNEL ENTRETIEN I NAGASIN 1 - 4 4 5 625 52,232 SANITAIRES n - LATRINE/DOUCHE 1 - 4 4 5 625 S2,232 (TRADITIONNELS AVEC FOSSE VENTILEE) .... ---- ......... ....... - ..................... 3 11 29 86 108 13,438 547,991 ..........----s.:.s=.-=a ............. ======= =========e= NOTE: LOGEIENT INFIRMIER (COPORTANT DEUX PIECES) a 32 1H2 SOIT LOGENENT INFIRNIER: 4,000 t14,286 ANNEX 3-1 Page 3 of 13 CHAD - PROGRAJNE INFRASTRUCTURES SANITAIRES TYPE D'INFRASTRUCTURES: CENTRE SOCIO-SANITAIRE TYPE 2 (ZONES URBAINES) ACTIVITES PERSONNEL LOCAUX ..,., ........................ ..................... ........................................ ..... ........ ,............ ....................... .................... ............................... .... _.......... . SURFACES NETTES SURFACES COUTS BASE M'DJANENA CAPACITE NOMBRE TYPE NOY8RE N./PLACE ../UNITE TOTAL BRUTE EN EN DESCRIPTION PROFESSIONNELLf PERSONNEL LOCAL UNITE M2 le H' No FCFA XIODO USS _,........................... ..................................................... ............................. ............................................... .......... ........................... ...... .......... ... ................. ACTIVITES ELARGIES (B) ........................... CONSULTATION CURATIVE IDE I SALLE DE CONSULTATION 1 (A 16 16 16 20 2,500 $8,929 OtPISTAGE/PREVENTIF INFIRMIER DIPLNE- CONSULTATIONS 0-4 ANS D'ETAT EDUCATION SOCIO SANITAIRE CONSULTATIONS PRiNATALES CONSEILS ACTIVITES PREVENTIVES PROGRAMNE ' - SALLE POLtYVALENTE 1 - 12 12 15 1,875 $6,696 SOINS/PANSEMENTS IA I SALLE DE SOINS 1 6 6 6 8 938 $3,348 RtHYDRATATION (ISOLEMEHT) INFIRNIER COIN ISOLEMENT 1 - 4 4 5 625 52,232 VACCINATIONS/PIQORES AUXILIAIRE SALLE VACCINATION I - 6 6 8 938 $3,348 CONSERVATION VACCINS EMPLACENENT ISOLE I - 4 4 5 625 52,232 DtPOT PHARNACIE (COHITE GESTION) - DEPOT PHAANACEUTIOUE I a 8 8 10 1,250 54,464 *GUICHET - GUCHET 1 - 4 4 5 625 S2,232 ATTENTE - - VERAHDA 1 - 20 20 25 3,125 S11,161 RESERVE PETIT NATERIEL PERSONNEL D'ENTRE I MAGASIN I 4 4 5 625 52,232 SANITAIRES - LATRtNE/DOUCHE 1 4 4 5 625 S2,232 3 11 29 88 110 13.750 549,107 ..A) .AVE O SAL ECOSLAIO ILN.....U....X.IN. SAL cEa CONSUTIO SI, LA ZONE DesRE ASSe-1.0HAIAT (A): AVEC DEW MEO SALLE DE CONSULTATtON St LA ZONE DESSERVIE OEPASSER 12.500 HA8tTANTS ANNEX-1 Page 4 of 13 TYPE D'INFRASTRUCTURES: NOPITAL DE DISTRICT (REFERENCE 1ER *CHELON) ACTIVITES PERSONNEL LOCAWX ._......................,._. .......................... ............................................................................................. SURFACES NETTES SURFACES COUTS QUALIfICATION --------------------------- ---- ------------- PERSONNEL NOISRE TYPE NOWSRE PLACE UNITE TOTAL BRUTE EN EN DESCRIPTION RESPONSABLE PERSONNEL LOCAL UNITE le N2 N2 m2 FCFA xIOOO USS _. . ... .. .. .. .. .. .. . . ........ ........................... . . .... .... ... .. .. _.. .. .. .. . ..... .................... .. .. . .. . . ._....... ................... . ... .........................,..... ._..................... ADNtNISTRATION _ _ . .................................. _ .. BUREAU ItOECIN CHEF IEDECIN I BUREAU 1 20 20 20 25 3,125 S11,161 GESTION/CONPTABILISt GESTIONNAIRE/CONP 2 BUREAU GEST./CONPT. 1 6 12 12 15 1,875 $6,696 SECRtTARIAT SECRtTAIRE 2 BUREAU SECRtTAIRE 1 6 12 12 15 1,875 56,696 AFFAIRES SOCIALES ASSIST. SOC. 1 BUREAU ASSIST. SOCIALE 1 12 12 12 15 1,875 S6,696 NYGINEt IDE SPEC. I BUREAU HYGIENE 1 12 12 12 15 1.875 S6,696 ARCHIVES/STATISTIaUES - SALLE DES ARCHIVES 1 - 9 9 11 1,406 $5,022 RtUNION/DOCUMENTATION - SALLE DE RMUNION 1 20 20 25 3,125 511,161 STOCKAGE FOURNITURES - - MAGASIN 1 6 6 8 938 S3,348 SANITAIRES - BLOC SANITAIRE 1 12 12 15 1,875 T6,696 CONSULTATION . .... ...... __.... . _.. _.. TRIAGE INFIRNIER AUKIL. I SALLE ATTENTE/TRI 1 20 20 25 3,125 S11,161 ENTitES . FICHIER/CAISSE 1 - 10 10 13 1,563 $5,580 CONSULTATION NED. GEN. NEDECIN I SALLE DE CONSULTATION 1 16 16 16 20 2.500 S8,929 CONSULTATION GYNECO/OIST. - SALLE DE CONSULTATION 1 16 16 16 20 2.500 S8,929 SOINS IDE 1 SALLE DE SOINS t - 24 24 30 3.750 $13,393 ORTHOPtDIE * SALLE INTtGRitE AUX SOI 1 9 9 11 1,406 *5,022 un RtHYDRAT./R9CUPER. NUTRITION - SALLE D'ISOLENENT 1 - 12 12 15 1,875 56,696 ID BLOC TECHNIOUE . ... _.. .. . .. _.... URGENCES IDE - SALLE SEPTIOUE a * 12 12 15 1,875 S6,696 RADIOGRAPHIE + LABO DiVELOP. bDECIN - SALLE RADIOGRAPHIE 1 26 24 24 30 3,750 S13,393 PRtPARATION SCOPIE - . VESTIAIRE 1 * 3 3 4 469 S1,674 CHIRURCIE ft0ECIN - SALLE D'OPtRATION 1 - 28 28 35 4,375 $15,625 STABILISATION INFIRNIER AUXIL. I SALLE DE STABILISATION 1 * 9 9 II 1,406 $5,022 PREPARATION - SALLE DE PREPARATION 1 9 9 11 1,406 $5,022 RtVEIL/POST OPtRATOIRE a - SALLE POSTOPtRATOIRE 1 - 9 9 11 1,406 55,022 ACCOUCHEMENTS DIFFICILES "wDECIN * SALLE D'ACCOUCHENENT 1 20 20 25 3,125 511,161 TRAVAIL/ATTENTE SAGE FENNE 1 SALLE DE TRAVAIL 1 * 9 9 11 1,406 $5,022 DOUCHES/SANITAIRES - - B BLOC SANITAIRE 1 - 12 12 15 1,875 56,696 PHARNACIE/LABORATOIRE - ..... .......... ............ TRAVAIL ADNINISTRATIF TECN. PNARNACIE I BUREAU 1 * 9 9 11 1,406 $5,022 PRgLkENENET - ZONE PRtLtVENENTS 1 6 6 8 938 $3,348 ANALYSES - LABORATOIRE 1 - 6 6 8 938 S3,34a PREPARATION/STOCK. FRtOD a - SALLE PREPARATION 1 - 6 6 8 938 S3,348 STOCKASE IbECA£NET P - NASAN (NOPITAL + OIS 1 - 12 24 30 3,750 $13,393 ANNEX-3-1l Page 5 of 13 TYK D INFRASTRUCTURES: NPITAI DE DISTRICT (REFERENCE tER tCNELON) ACTIVITES PERSONNEL EOCAJX ........................... ........................................ .......................... ..................................................... ...................................................................... .__. SURFACES NETTES SRFACES COWTS GUALIFICATPON .--_------- *---. PERSONEL NISRE TYPE NNRE PLCE UNITE TOTAL RRITE Es EN DESCRIPTtON RESPONSASE PERSONNEL LOCAL UNITE N2 l2 N N2 FCFA X1OOO usS ........................... .......................... ........................................... ........................................ ..................... ........................................................ ............_. NIOSPITALtSATION (CAPACITt 33 LITS) ............................................. HOSPITALISATION NMDECINE (FE . SALLES DE 6 LITS 1 36 36 45 5,625 S20,089 NOSPITALISATION MDECINE (NO - SALLES DE 6 LITS I 36 36 45 5,625 520,089 OSPITALISATION PeDIATRIE - SALLES DE 6 LITS I - 36 36 45 5,625 $20,089 lOSPITALISATION CHIRRGIE - SALLES DE 4 LtTS 2 32 64so 10,000 $35,714 ISOLEMENT/SOINS INTEWSIFS - SALLES 2 LITS 2 - 12 24 30 3,750 $13,393 REm ACCDUCNtE - - CIAI DRE EREPOS 1 9 9 11 1,406 $5,022 NOSPITALISATION ACC0UCNtE SALLE DE 6 LITS 1 - 36 36 45 5,625 $20,089 GARDE - 2 SALLE DE GARE 2 6 6 12 15 1,875 $6,696 LOCAtIX ANNEXES .............. .................... ......._ CUISINE (PAR FANILLES) - ABR - 20 20 25 3,125 $11,161 STOCKAGE VIVRES - - MAGASIN 1 9 9 11 1,406 $5,022 RIPARATION/ENTRETIEN PERSONNEL ENTRETI 2 ATELIER ENTRETIEN I 12 12 1$ 1,675 s 6,696 LAVAGE/ISUDERIE ' - IUANERIE i - 12 12 15 1,875 $6,696 STOCKP.GE LINGERIE - LINGERIE I - 9 9 11 1,406 S5,022 Nt8ERGEMENT DES FAMILLES * ABRI (NORS PROGRAOE) - - - - - SANITAIRES/OOUCRES B LOC SAMITAIREMOUCHES 2 - 10 20 25 3,125 $11,161 INCtN6RATION U . INCINtRATEUR I - 6 6 8 938 %3,348 OSPOT ODURES ABRI I - 6 6 8 938 $3,348 YORCUE (LAVAGE/HABILLAGE) - MORGUE I - 10 10 13 1,563 S5,580 GROUPE ELECTROGENE I ASRI GROUPE 1 10 10 13 1,563 .,,580 STOCKAGE CARSUR^ANT . LOCAL CARMURANTS 1 - 9 9 11 1,406 S5,022 RESERVE EAUA - CNATEAU D'EAU 1 - I . - 600 $2,143 LOGENENT ........................... LOGENENT HtDECIN CHEF - - NAISON NED. CNEF I - 90 80 100 12,500 $44,643 LOGEWEJT GARDIEN - LOGE ARDtEEN I 20 20 25 3,125 S11,161 ......... ......... ......... ......... .......... ......... ............ la ST 120 884 1,10S 138,72S K ff,446 ...........................5= _,5rSgA 2S2== 5wX=5m5=5555= A1NEX 3-1 Page 6 of 13 SLUREA PIFECnt (ME ICALE . . ...................... ..... ...... ............ .................... ... ... .. .. ... .. . . . .. . ........................... .. ... .... ............ ACTIVITES PERSONECL LOCAX ....................... ................................ .................................... ......... ................. ...... .......... ................................ ..................................................__.__._ SURFACES NETTES SURFACES COUTS CAPACtTE NONURE TYPE NONBUE N/PLACE N'/;W3E tOTAL BRUTE Es EN DESCRIPTION POFlESSIONNELLE PERSONNEL LOCAL tWITE N2 N2 Ne N' FCf KItOO USS ........................... ........................ .......................................... .......... ACTIVITES NINIIALES (A) .......................... SANTt PUSL[GUE NEDECIN CHEF 1 8UREAU 1 20 20 20 25 3,125 S11.161 SECRtTARIAT SECNETAIRE 2 SECRETAtIAT 1 6 12 12 IS 1,875 f6,696 RiUNION- - SALLE DE RiUNION/FORNA I 16 16 20 2,500 f8,929 PLANIFI CATIGN/PROGRAMNATION .......................... PLANIFICATION PLANIFICATEIM I UREMA 1 12 12 12 15 1,875 f6,696 GESTION DE LA FORATION ADM. COORD. I tUREAU 1 8 8 a 10 1,250 $4.464 STATISTICUES STATISTICIEN I UREAU 1 8 8 8 10 1,250 S4,464 DIVISION RESSOURCES _ _ .. .. .. .... . _. . GESTION DU PERSONNEL ADNINISTRATEUR 1 BUREAU 1 8 8 a 10 1,250 S4,464 GESTION FINANCIERE ADNINISTRATEUR I BUREAU I a a a 10 1,250 54,464 RESERV E AtRIEL PERS. ENTRETIEN 1 NAGASIN 1 20 20 4 5 625 S2,232 SANITAIRES - BLOC SANITAIRE I - 8 8 10 1,250 54,464 0' ~~~~~~~~~~~~~~~~~. .. _..... ...... .. . . ....... ......... ... ___.. ___.... ........... 9 10 12 104 130 16,250 558,036 ......................... .................... ANNEX -1 Page 7 of 13 CHDO - PROAIE INFRASTRIJCTUJRES SANITAIRES 280 OMRENU PREf HOP. PREf BUIEAUX DISTRICT NOP. DISTRICT CSS RUAL CSS UIRlAIN ........ ...~~~~~~~~~~~~~~~~.......... ........ ................ ................._.......................... SURFACES N': 130 log 1,200 112 144 112 961 HI 108 110 se (CAXIIM) FCFAXIOO/N2 ESTIMATION El NILLI01S DE FCFA ............... ............................ ............................................................. ......................... ...................................................................................... ..................... 158 CONSTi. C: 20 190 23 tSZ 17 t1 63 RENABIL. R: 8 76 9 61 7 7 EOUIPT. EC: 5 60 5 45 4 3 NIlRE N: PREFECTURES DISTRICTS ZONES DE RESPONSABILITE SUREAUX lOPtTAJUX BUREAUX HOpITAUX REF CSS PREFECTURES/ POPULATION. ---------------- ----- .--------------- --- DISTRICTS HA81t41TS M C R E tt C R E3 0 C R E0 N C R E Z 11 C R EO TAODJILE EXIST 458,240 1 - - 0 - - - 3 - - 53 26 . . . PRIVE PUBLIC 1 . . . . 3E3E EXIST 61,072 I0 - - 11 3 - - PRIYE 3 7 -8 PUBtLIC--. KELO EXIST 222,148 - - - 0 0 - 1 18 9 - - - PRIVE.5 . . . PUBLIC- - - 9 4 9 LAI EXIST 75,020 - - 1 - - - * - 24 14 - . PRIVE -10 - - - CO0JTS DE BASE EN HILtIONS ptlc .- --11 - - 1 I - 10 3 18 -------------------- , ............ ................ -..................... ---------------- .............................. C R EQ tOTAL TOTAL 1 458,240 1 0 1 0 0 0 1 1 2 0 2 2 26 8 35 ----.--- .----.-- --- ---- FCFA NILLIONS u=Sumu 20 0 5 0 0 0 23 9 10 0 121 90 469 56 105 512 186 210 909 US X 1000 73 0 18 0 0 0 81 33 36 0 434 321 1,676199 375 1,830 665 750 S3,245 Z: NO1113E DE ZONES DE RESP01NSABILITE 1: 110118OE DE CSS EXISTANITS ANNEX 3-1 Page 8 of 13 CKAD - PROGAME INFRASTRUCTURES SANITAIRES 280 SUREA PREF N 3 PRE0 NBtREAUX DISTRICT HOP. "ISTRICT CSS RURAL CSS LtRIH SURFACES W.: 130 M 1,200 C 144 '961 W log ml 110 N (MAXIMUM) FCFAXIOOQIN2 ESTIMATION EN MILLIONS DE FCFA 158 CONSTR. C: 20 190 23 1S2 17 17 63 RENABIL. R: 8 76 9 61 7 7 EQUIPT. EO: 5 60 5 45 4 3 NOHBRE N: PREFECTURES DISTRICTS ZONES UREAUX HOPITAUX BUREAUX NOPITAUX REF CSS PREFECTURES/ POPULATION DISTRICTS X1OOO N C R EQ C R EQ N C R EQ N C R EQ Z N C R EQ GUERA EXIST 229 I - - 1- - - 3--- 2 - -3013 -1 PRIVE - - FED FED - FED FED - PUBLIC . . . - BITKINE EXIST 76 - - - 1--- --- 10 6 - - - PRIVE '4 - - PUBLIC. - - 1 1 - 1 - 1 - - 4 2 6 NELFI EXIST 41 - - - - - 1- 1 - 7 2 - - - PRIVE..1'- PUBLIC . - t 1 - 1 - - 5 1 6 NOGO EXtST 111 - - - - - - - ED) - - 13 5 - - 'PIVE 1 - - COtUTS DE BASE PUBLIC ...... 8 3 11 TOTAL 1 228 0 0 0 0 0 0 0 22 2 1 2 I? 6 23 FCFA MILLIONS 0 0 0 0 0 0 018 10 152 61 90 290 41 92 442 102 200 744 US X 1000 0 0 0 0 0 0 0 65 36 542 217 321 1,036 146 329 1,578 363 715 2,656 u.u.uuuuu.ua Uwagt.s-gu.Cm uon =umawcum Buwcm = a=== == ======= Z: NOMBRE OE ZONES DE RESPONSABILITE N: NOMBRE OE CSS EXISTANTS 64 Page 9 G' 13 LISTE DES EQUIPEHENTS POUR UN CSS QUANTITES DEFINITION 20NE RURALE ZONE URBAINE PARAVENT I 1 LIT STANDARO METAL 4 2 TABLE CHEVET MfTAL 4 2 TABLE EXAMEN STANDARD 1 1-2 TABLE SOINS/EXAMEN 1 t MARCHE PIED 2 t TABLE INSTRUMENTS 60X40 2 1 CHARIOT SOINS I 1 ETAGERES MURALES STOCKAGE MEDICAMERT 12 12 ARMOIRE MtDICAI4ENTS 2 PORTES (120X40 3 2 BRANCARD 1 1 POTENCE PERFUSION 2 1 BUREAU 120X80 METAL 1 1-2 TABLE 120X60 METAL I1 ARMOIRE 2 PORTES MtTAL 1 1-2 CLASSEUR 2 TIROIRS NtTAL 1 1 TABOURET FIXE 3 4 TABOURET AJUSTABLE 1 1 SANC (PREVOIR SUR LOT GERIE CIVIL) PM PR CHAISE OROITE MtTAL 6 6-9 ETAGERE KIOULAIRE NMTAL C12OX2OM) 3 3 ARMOIRE VESTIAIRE (40X40X180) 1 1-2 PATERE FIXE 3 3-4 PESE PERSORNES 2 2 PESE EBEtS 2 2 NtTRE RUBAM 2 2-3 ST&tHOSCOPE 2 1-2 TENSIOMEtRE 1 1-2 STETHOSCOPE (OBSTtTRIQUE) 1 1 TABLE ACCOUCHEMENT 1 - SEAU DECHETS 4 4-5 OTOSCOPE 1 1 SPECULUM (REGLABLE) AVEC BOITE NMTAL 2 2 MICROSCOPE MORO 1 - ENSEMBLE COLORATION 1 - JEU VERRERIE LABO I - CENTRIFUGEUSE 1 I STERIL.VAPEUR 6L 1 I RtCHAUD PETROLE I I ARTICLES NETTOYAGE 1 1 TROUSSE A OUTILS 1 I CORBEILLE BUREAU 1 1-2 POUBELLE A COUVERCLE 3 3 LAMPE TEMPETE 2 2 TORCHE tLECTRIQUE 2 2 BASSIN LIT 1 0 BASSIN RENIFORME 2 2 URINAL I I PORTE THEROMtTRE 2 2 PLATEAU INSTRUMENTS 3 2-3 BOITE INSTRUMENTS 3 2-3 BOITE SERINGUES 2 2-3 BOITE AIGUILLES 2 2-3 BOITES INSTRUMENTS I I PISSETTE 3 3 BROSSE A ONGLES 2 2 ACCESSOIRES BUREAU (KIT) 1 1 BROSSE A INSTRUMENTS 2 2 BOITE INSTRUMENTS PANSEMENTS 3 3 CISEAUX PANSEMENTS 2 2 BOITE PETITE CHIRURGIE 2 2 PINCE A TAMONS 2 2-3 CUPULES 2 2 BOITES A COMPRESSES 4 3 INSTRUMENTS DIACCOUCHEMENTS 1 - AfAISSE LANGUE NtTAL 1 1 TOILE CIRCE 7 6 GARROTS 2 2 6"j ANNEX 3-1 Page 10 of 13 HOPITAL DE DISTRICTS/LISTE DES IQUIPEMENTS LOCAL PAR LOCAL SALLES DES URENCES LABRATOE TABLE D'EXAMENS I C1NTRIFUGEUSE&LECTRtQUE I tAmpE OPARAT. MOBILE I CENTRIFPUEUSEMANUFLLR I BOlT PEI CHIRURGIE I CENTRIFUGEUSE MICROHE- E5CABEAU I MATOCRtTE DMN-MARIE I SALLE DWACCOUCHEMENTS MICROSCOPE BINOCiUJ LAIRB+1BLOCK LUMIERE I TABLE D'ACCOUCHEMENT/ BALANCE I RAANIMATION PRiNATALE I ETUVE UNtVERSELLE30 1 1 LAMPS OPERATOIRE MOBILE I AG1TATEUR VIBREUR VORTEX I PEss-BtE§5 I COMPTEUR A TOUCHES MONO- VENTOUsE OBasTCOMPLIkr i TOUCHE I sTtrHoscOPE DE PINARD I COMFTEUR A TOUCHE5 MUL- BOITE ACCOUCHEMENTS I TITOUCHE I BOTE CURETAsE I APPAREILWESTERGREN(vr.s&)I- BOhr FORCEPS I MENT.) I DtECWTEUR DE POULS FORTAL I HAEMOLOIBINOMfrTRE (COLORI1 AMBU NOUVEAUX.NtS 1 aou PHor. A PRkCI) I THtSUSCOPR I SALLE WOPERATIONS MiNUTERIE I CoLoRIMfIRE(A PRWa1lE) I TABLE D-OPEQATIONS I LAMPE A ALCOOL I LAMPe OPERATOIRE TYPE FITREA EAU plAFONNIER I PRODUTS RENOUVELABLe 1 ASPIRATEUR CHIRUROICAL (&ECTRIQUEET A PEDALE) I SALLE D'EXAMV RADIOL BISTOURI kLECTRIQUe I CONCENTRATEURD'OXYGENE I uNrTB DR RADIOLOIE DR BASE I TABLE A INSTRUMENTS (GRAND PARAVENT EN PLOMB I MODBU3) I LOT D'ARTICL1S EN PLOMB TABLE A INSTRUMENTS (PErmf (TABLER.OANTS,CACHIU) 1 moDkE) I SUPPORT TABLIER TABLE A HAUTEUR VARiABLE I JEU DE CASSEIrrS I SCEAU A PANSEMENTS (SANS JEU DR CADRES COUVERCL) I FaMS Tr PRODUITS R&ACM I BOITE ABDONMNALE I BOtTE AMPUTATION I CHIMBRE NOIRE eOITE CtsARIENNE I BOtTE OPERATOIRE UYN*CO UNITt DE DVELOPPEMMENT BASSE I MANUEL I BOTTe HERNIE I ENSEMBLE &IAURAOE CHAMBRE TAMBOUR 314 1 1 NOIRE I TAMBOUR6 I MEUBLEDE CHsANC ENT I PORTE-S&RUM I CHARIOT PORTE-CIVI1RERCl- LOCAL h1rERJRESERVE VIE.RE 1 BotTE CYSTOSTOMIE I TABLE DE TRAVAIL I BOUGIE UR§TRALE (BENIQUfS I CHAISs NtOATOSCOPE I STERILISATION ARMOIRE DE RANGEMENT I AUTOCLAVE VERTICAL MIX I POUPINEL ARMOIRE MtTALUQUE 66 ANMX3-1 Page 11 of 13 PltFECTE pU cthRA DSCTICr De MONCO. CHEF UEU DE PREFE=URE NOM | APPARTENANCE STATUT | APPtI EWCERJEUR H6PtTAL DE MONGO MIN. S.P. CIS'FANT FED Z.R. MONGO OUEST MN. S.P. I SEUL CS A CREER FED ZR. MONGO EST MIN. S.P. EN THORS EL'OPN. LZR. N1EROUI MN. S.P. EXSTANT Fl51,_ t Z.R. EREF MN. $.P. SEOANT IED iZ. MANOALME MIN. S.P. EXISTAIW FED 7.R. BARDANGAL MN. S.P. A CREER Z.R. ABRECHE bMN. S.P. A CREER Z.. DIOUKOICO KOU MIN. SP. A CR_E_ ZR. KATALGO WN. S.P. A CRBER 2R. AMaARKOYE MNN. S.P. A C3_E_R Zi. BDITCHOTCI MN. S.P. AC3EER ZR. KOUBSA IWN. S.P. A_ __ ZR. BARO CATHOtlQUE EDaSrNT DiTSRicT DP BllXU jl _ NOM APPARTENACE | rSTATUT AifPtI WTIRLIR H6PMTALDERIIKINE MIN. S.P. |EANSTt? PROIE ZL. BITIJNE biN. S.P. EXISTANT FED - PROlEr Z.R. ABrOUYOUR |WMN. S.P. EXISTANT FEM . FPaol Li. KOUI AADOUOOUL hem. I.P. A CRMR PROW !R. SARA-ABASE MIN. S.P. A CREgR13 PROW Z.L. DIIMI MIN. S.P. A CREfE PRO ZL. GASSAitA hN. S.P. A CRn PROW ZR. BITXINE MoB. M. ImaISTAfN ZJL. DADOtAR CATHOUJQUE WSTANT LR. MOUKOULOU MID. B.M. UGZTANT LR. KOR3 MID. M.K BUANT DISIRICT OH MELa NOM A|PPARTEENCE STATUT APPUI ENfEJEUR H6FFAL DE MEIMI MIN. SaS. TESANT PRWOff ZL MElfl MN. 5.p. WANT FM- PROT ZL. MOFI baN. &5. Ap ClER ROJ LR. SNINOL MIN. 5.P. A CR. PROIT ZL. MANAM MIN. SLP. A CRIM POiT ZL. DIANA MIN. S.P. AdE PROJBI ZL. SAMICAROUM MN. &P. A CRrER rn ZL 0o0M! AL C.T ISUMAr '7 ANNEX 3-1 Page 12 of 13 PREFECTURE DU GUERA PROJET EVENTUEL.EENT. EVeNELLENT. EN COMPLEMENT EN COMPLEMENT DU DU FED SECrEUR PRIVE - 9OPITAUX: * A REHABIUTER/CONS- 2 TRUIRE 2 * APPUI AU FONC(MONNE- MVENT - CErNTRES DE SANTE- * A REHABIUTER 3 4 5 * A CONSTRUIRE 9 7 * APPUI AU FONCFIONNe- 12 . MENT PREFEOURE DE LA TANWILE DISTRICT DE LAW CHEF LIEU DE LA PREFECTURE NOM APPARTENANCE j rAT tF r APPt EXTIEURM HOPITAL De LAi MIN. S.P. EWSTANT PROJET Z.R. LAI VERS HOPITAL MIN. S.P. A CREER PROJET ZR. LAI AVION MIN. S.P. A CREER PROJET ZR. LL NOUNOOU MIN. S.P. A CREER PROJEF 7ZR. DOMOUOOU ,UN. S.P. EXUSIANT PROWT ZR. DONO.MANOA MEN. S.P. EaSTANT PROJET ZR. MOUROUM-TOULOU NON. S.P. EXISTANT pRoJEF Z.R. sOUMOU NUN. S.P. A CREER PR08T ZR. NDAM WDN. S.P. A CREeR PROJBT aR. DORMOU MIN. S.P. A CReER PROJEF ZR DARBE MIN. &XP. A CRsE IPROIET Z.R. NxAMANaO hON. S.P. A CREER PROST ZR. MANGA0ouDoU bMN. S.P. A CReER PROIET ZR. OABRI-NOOLO MIN. S.P. EXaSTANT PROMST ZR. _UIDAI _ CATHOUQUE EXISTANT ZR. DERESSIA AS. C.T. EXISTANT Z.R. KOBIAGUE MJS. LU. EXISTANT ZR. KIMRE MIS. MU. eXsTANT ZR. MRBIUE Ur NINGA MIS. LU. EISTANTS ZR. k ISIRE AS. C.T. EXISTANT ZR. TCHA KANDnLI AS. CT. EXISTANT ZR. TCHAGUILENOOLO MIS. E.U. EWaSTANT ZR. TER MIS. LU. EXSTANT ZR. GANA PRIve EXISTANT 60 MmNE 3-1 Page 13 of 13 DISTRICT DH K-LOZ E ~~~NOM |APPARTNMANCE | StATU | APPU MIUil | HOPITAI - D8 KE NON. S.P. E)CSTANT PROtou ZR. MONoaoYE MN. S.P. EMSTANT PROJET 2.R. DOOU MIWN. S.P. EXISTANT PROE?r ?.R. BOLOOO bDN. S.P. EXISTANT PRO1 2.R. M'SAIA EB.T 8IaSTANT ZR.BAKTCHORO ;BMACD EXIStANT Z.R. KROUMLA AS.C.T. EDaSTANT 7.R. MBTIKIM8 E.B.T. EXISTANT ZR. NANOASSOU BUEACD EXISTANT Z.R. BAYAKA MIN. S.P. EXISTANT PROJT |ZR. DAFRA NAN. S.P. A CRIER PROJEr Z.R. BERTE NON. S.P. ACREER PRO Z.R. BEtO NORINDIM MIN. &P. A CREER PRO1I ZR. MABABOU NUN. S.P. A CREER PROIE hZR. MANOSE BEMBOH bNN. S.P. A CREE PmOIE ZR. KELO A (DJENORENQ) MIN. &P. A CRIER PRO;IB ZR. KELO B (BONOMBYOV) MIN. S&P. A CREER PROI ZR. KELO C OMNDINNA MUN. S.P. A CREER PR1KT 2R. KELO D (BARDADJE 1) MIN. S&P. A CRI P1t D*-RCT DE BERE NOM | APPARTUNAIE [ STATUT A IYUIrERER HOPMTAL DE RERB ADVENSTS STANTr Z.L KOLON &ON. S.P. 8XISTANt ZR. amB aE:r. EXISTANT ZR. DEL81AN tE T. 8XISANT__ ' _ ZL BER18R1 MIN. S.P. A CRIER ZR.MANDI WUN. S.P. A CRIER ZR. KOLON I WN. &P. A CRA ZR. S_HDOU5-DADn aE.T. EISTA1IT ZR. KOUMk WN. S.P. A CRR ZR. ORINGA WUN. S.P. ACRER ZR. TAMYO.NOOLO NUN. S.P. A CREER ZR. DALI he4m. S.P. A CR_ A.M..6 SANTE ET NATERI4ITE SAMS RISQUES 3aMeaditaxe "Counet.smed (US$ '0000) Cant. Rase Plus Costs + Price ease Cost Physical Conting"nc ies Price Contingencies Total cIne. cont. Pr ice Cant. Local Duties Local Duti.s Local Duties Local Duties Cont. on For. (Exci. a 1For. (lxcl. & for. (Exad. 6 Foe. (Fxal. a on Base Physical Exch. Taxes) lTaxes To-tal Each. Taxes) Taxes Total Each. Taxes) Taxes Total Exch. Taxes) Taxes Total CO.sts Cant. A. wtwool. CL,l1 Consstruction 2,041 1,161 - 3.202 204 67 - 271 176 409 - 585 2.421 1,637 4.058 3,747 313 Rehabilitation 833 272 - 1.105 83 27 - I1I 62 103 - 166 979 403 -1,382 1,256 126 Subtotal toao. Civil 2.874 -1,43-4 -i,3-09 287 -94 - 383 239 -512 - 751 3.400 7;0 - 5,,-440 -5,003 -4 3 B. Vehicules/Equipment 3,404 - . 3,404 318 - 318 263 - - 263 3,985 - 3,985 3,644 341 C. Nobilier 32 1 - 33 3 0 - 3 1 0 - 2 37 2 - 39 35 4 D. Nedicanents 5,073 - - ,073 S07 - - 507 443 - - 443 6,023 - 6,023 5,476 548 X. Seavlse do Bwaolal.te. 1. esloess intesuatloeaw International-LT 2,618 - -2,618 131 - - 131 230 - - 230 2,978 - -2,978 2,837 142 International-CT 877 32 - 909 44 2 - 45 63 11 - 75 99 45 - 1,029 980 49 Albtotal SesLVo.. lntesaatlomssm i?4s 3_2 - 3-52-7 -175 -2 - 176 -293 -11 - 304 1 39-63 -45 -4,007 3.816 191 2. National 136 - - 136 7 - - 7 9 - - 9 151 - - 151 144 7 3. Nonoraires professionnels _ 464 365 - 028 23 18s 41 35 129 - 164 522 512 - 1.034 985 49 Suetota Sa"loe do Vpoialat. 4,094 -397 4-4,91 -205 -20 - 225 -337 14 - T 4,636 557 - 5,193 -4,94 6 247 Vr. 110901tion, Locale 236 85s 321 12 4 - 16 21 32 - 53 269 221 - 390 372 19 laterne 607 104 III1 30 5 - 36 44 37 at8 681 147 - 827 788 39 S*btetaRIftmasm 043_ 189 - 1,032 -42 -9 - 52 -65 -69 -134 950 260 - 1,218 1.160 s8 tota Ioweemnt Costa 16,32 2,021 - 84 13-63 123 - 1, 486 1T,3-48 7_22 0-70F 19,031 2,866 - 21,897 20,264 12,634 St. Beauggeat coats A. 06)4 veh. & Equip. 2,132 246 -2.377 113 12 - 125 211 97 - 309 Z,455 355 - 2,820 2,670 140 S. Salaires personnel 204 129 - 332 10 6 - 17 19 47 - 66 233 182 - 416 196 20 C. Vrias de deplacements 225 224 - 449 11 11 - 22 22 83 - 105 259 318 - 576 549 21 lota seoezemat coat. 2,561 5980 5 -134 -30 - 164 -252 --227 - 47'9 eS47 85 AS,02 36 8 tota 18,88-01 2,6-19 - 1511,49 -153 - 1,650 1,599 99 5-4I 2197 37-21 - 569 23,878 -1,821 Thu May 05 15:25:02 1994 00 :3 o (* m, -j 1-1 Expenditure Aceounte Breakdo~m CHAD SANTE ET MATERNITE SANS RISQUES Project cost 8=nry * * Total (FCFA '000) 1US$ '000) Foreign Base Local Forelgn Total Local Foeign Total Exchange Costs A. nftorceent capacity au miAenw emntral pour qUpept mmn niveanx regLonmax 1. Decentralisation budgetaire 2,735 75,544 78,278 5 127 131 97 1 2. Developpement production modules 63,018 503,601 566,618 106 844 949 89 4 3. HisO en place programme IEC 20,575 822,546 843,122 34 1,370 1,412 90 7 4. Renforcer capaclte de qestion et coordination du projet 34,432 620,497 654,929 58 1,039 1,097 95 5 tubatal Penforcement capacity an nivean central pocr eqppert am nimeiax regionaux 120,759 2,022,187 2,142,947 202 3,387 3,590 94 17 *. AsJdstance anx retons pmr seavloes sante, nutrition et NW 1. Mlse en place reseau sanitaire niveaux districts 748,417 2,686,662 3,435,079 1,254 4,500 5,754 78 27 2. Programme formation pour personnel sante 84,809 404,352 489,161 142 677 819 83 4 3. Promotion de la Participation Communautaire 98,392 3,934,512 4,032,.904 165 6r590 6,755 98 31 ubtetal Assistance aux regions pour ervices ante, nutritlon et UW 931,618 7,025,526 7,957,144 1,560 11,768 13,329 88 62 C. A stance aise on place F@lltique Nationale Ptarmaceutiqu, 1. Division Pharmacie 3,545 312,761 316,305 6 524 530 99 2 2. Centrale d'Achat 507.746 1,911,678 2.419,424 850 3,202 4,053 79 19 Snbtotal Assistance dise en place Poltique )#ationale Pharmaceutique 511,291 2,224,439 2 735,730 856 3,726 4,582 81 21 total NAB# COStI -1i,563,660 11,272,152 12,835,820 2,619 18,881 21,501 88 100 Physical Contingencies 91,472 893,752 985,224 153 1,497 1,650 91 8 Price Contingencies 566 560 954,809 1,521.369 949 1 599 2,548 63 12 ttal CNSNO COS" 2,221,701 13,120,713 15,342,413 3,721 21,978 25,699 86 120 Mon May 02 1545:07 1994 C. N) IxA o 1 7-1 Project Coat sumary CHAD SANTE CT MATERNITE SAMS RISQUES Coopeneta by 1lnazclas (USS *000) The IDA UNICEF UNDP Government Cormmunautes Total Amount Amount Amount Amount Amount Amount &. Ren¢eeemet e paeotty Wu nuvet eenttal pour support aux niveaux ietalum 1. Decentrallsation budgetaire 146 - - _ - 146 2. Deveiloppement production modules 1,129 - - 1,128 3. Mine en place programne IEC 1,541 - 67 - - 1,608 4. Rentorcer capacite de gestion et coordination du projet 1,275 - - 7 1,275 S ebtota Pnnforent aapacIty au nlvo"u eentala pour eUppO euX nivaumx eglonaum 4,090 - 67 - - 4,157 . AsatetaCn aux regaon* pout sevteas sante, nutrltion et DM1 1. Mise en place reseau sanitaire niveaux districts 7,173 - - - - 7,173 2. Programme formation pour personnel sante 993 - - - - 993 3. Promotion do la Participation Communautaire 1,503 2,331 1,250 305 2,632 8,021 subtotal A"IStanc*e mmX geglao pour e vlces ante, nutrItion et NW? 9,669 2,331 1,250 305 2,632 16,186 C. Assistance mie an place Plltiq.e Nationale, ltazmaoeutlque 1. Division Pharmacie 592 - - - - 592 2. Centrale d'Achat 4,126 - - 637 - 4,763 Total DOSburueot 18,477 2,331 1,316 942 2,632 25,699 "on may 02 15:44:32 1994 _. mm 0Q o C 2-1 Coaponents by Financiero CHAD SANTE ET HATERNITE SANS RISQUES froject Coqonents by Year -- imnest ntjt/urent Costs (US$ '000) Totals Including Contingencies 1995 1996 1997 Q968 1999 Total A. UAnfoe_ ent capuaty ao niveaw entral pow support awX nivaux teglaiu 1. Deontralieati budgetair Investment Costs 74 68 0 0 0 143 Recurrent Costs 1 I 0 0 0 3 Subtotal Decentnsiation budgetaise 75 69 1 1 1 146 a. vmlqpomnt proeatcWAn m31.s Investment Costs 251 190 202 16S 69 898 Recurrent Costs 16 99 65 24 25 231 Subtotal Dewlqppent preodction modules 260 209 267 209 94 1,128 3. We* o plae psegeasu Yr3 Investment costs see 259 107 174 106 1,236 Recurrent Costs 69 74 73 78 77 372 Subtotal Vte en p_ac prcgo t23 656 334 10 252 105 1,608 4 *Anforew eapacite de jotlen et cooodinaUtin de projet Investment Costs 251 85 191 61 63 652 Recurrent Costs 112 132 118 136 124 623 Subtoa lfores capacite de gestien et coordination do projet 363 217 309 199 166 1,275 Refore_et capecity a nveam centra per suppot aux Aviaux r xeglO ux 1,364 909 757 662 466 4,157 D. Asistance ax eoons pour servsces $Mte, nAtrtIOn Ot NW 2. Wise an plae resea sanitaire niveaux dietrlets Investment Costs 175 3,397 3,601 - - 7,173 Recurrent Costs - Subtotal Was an place r esea sanitar nlveunx districts 175 3,397 3,6301 - - 7,173 2. Programmo feo tin pour personnel saute o Investment Costs 224 224 159 224 64 895 Recurrent Costs 4 23 23 24 24 97 Subtota Psogram fermation pour peronnel sante 228 247 182 248 68 993 3. Promatin dn d s a rtictipaten Commnatatre Investment Costs 651 1,245 1,355 1,421 1,547 6,224 Recurrent Costs 122 365 386 421 503 1,797 Subtotal Promotion de la Participation Communautalre 779 1,610 -T.74 1 84 2,050 80021 Subtotl Assistance aw regons pour sorvice sante, nutrition *t B33 1,181 5,254 5,524 2,090 2,138 16,186 e. Assitanoe alse en place toliLtque Vationale Pharmacoutique 1. Division bazaac Investment Costs 303 177 51 - - 530 Recurrent Costs 25 19 18 - - 62 Subtotal Divsiodn EtUrnal. 320 195 69 - - 592 2. cetralel d'tAuat Investment Costs 3,636 254 256 - - 4,146 m x Recurrent Costs 199 206 212 - - 617 w *ubtotal Centralo d'Achat 38835 461 468 - - 4,763 O W Subtotal ssistance Vlie en place Polltique Iationale 9harmaceutiqu 4,163 656o 537 _ - - 5,355 "^ Total PRDGBOC coeT 6,700 6,816 6,617 2,751 2,604 25,699 Total Investment Costs 6,159 5,900 5,921 2,066 1,851 21,897 Total Recurrent Costs 550 918 696 686 753 3,802 Hon May 02 5s4ss27 1994 9-1 Project components by Year -- Investment/Recurrent Costs CHAD SANTE ET MATERNITE SANS RISQUES E2xendeture Accounte by Components - Totals lncluding Contingencies tUss '000) Assistance aux regions pour services Renforcement capacity au niveau central sante, nutrition et BEF Assistance mise pour support aux niveaux regionaux Mise en en place Renforcer place Programme Politique Mise en capacite de reseau formation Promotion de Nationale Developpement place gestion et sanitaire pour la Pharnaceutigue Decentrallsation production prograime coordination niveaux personnel Part Iipation Division Centrale budaetaire modules IEC du proiet districts sante Conmuinautaire Pharmacie d'Actiat Total S. UnVetMent Costs A. Genie Civil Construction - - - - 3,421 - - - 637 4,058 Rehabilltation - - - - 1,114 - - - 267 1,382 Subtotal Genie Civil - - - - 4,536 - - - 904 5,440 8. Vehicules/Equipment 6 470 669 98 2,044 426 21 103 148 3,985 C. Mobilier - - - 11 - - - 1 16 39 D. Medicaments - - - - - - 3,870 - 2,154 6,023 3. Bezviaes de Bpecialistes 1. Services lnternationaux International-LT - - 67 - - - 2,198 - 713 2,979 International-CT 134 205 207 117 117 _ - 249 - 1,029 Subtotal $ewvican internationaux 134 205 274 117 117 - 2,19- 249 713 4,007 2. National - 8 - - - - 135 8 - 151 3. Honoralres professionnels - - - 367 475 - - - 192 1,034 subtotal services de 8peaialite. 134 213 274 494 592 - 2,334 257 906 5,193 I. WomotAon Locale 4 42 46 - - 251 - 45 2 390 Externe - 172 249 60 - 219 - 114 16 827 subtotia Veauation 4 215 294 60 - 469 - 159 17 1,218 *U Total Investment Costs 143 8989- 1,236 652 7,173 895 6,224 530 4,146 21,897 II. Recrret coats A. OM veh. 6 Equip. - 200 125 302 - 34 1,797 62 289 2,810 B. Salaires personnel - 19 - 269 - - - - 127 416 C. Frais de deplacements 3 11 246 51 - 64 - - 201 576 Total Aecurrent COsta 3 231 372 623 - 97 1*797 62 617 3.802 total VDJ)XCT COSTS 146 1,128 1,608 1,275 7,173 993 8,021 592 4,763 25,699 Taxes Foreign Exchange 140 978 1,559 1,193 5,327 789 7,781 584 3,628 21,979 Thu May 05 15:28:36 1994 E o to -I t 1-1 ExpendIture Accounts by Components - Totals Including Contingencies CHAD SATE ET MATERNITE SAMS RISQUES Jro3Jot Coet sumar I 8 Total (FCF'A '000) (US$ '00O0 Foreign ease _ Local Foreian Total Local Forelgn Total Exchange Costs I *umatmnt costs A. eosl Cvii Construction 693,346 1,219,430 1,911,776 1,161 2,041 3,202 64 16 Rehabilitation 162,470 497,450 659,920 272 833 1,105 75 S Subtotal Smile Clvil 855,816 1,115,880 2,571,696 1,434 2,074 4,300 67 20 B. Vehicules/Egqipment - 2,032,231 2,032,237 - 3,404 3,404 100 16 C. Mobilier 760 19,198 19,958 1 32 33 96 - D. Medicaments - 3,028,572 3,028,572 - 5,073 5,073 100 24 S. Suawla.. de Sgialalate, 1. sewloes lutenati naux Internatlonal-LT - 1,562,984 1,562,984 - 2,618 2,618 100 12 International-CT 18,990 _523,542 542,532 32 877 _ 909 96 4 fubtotal sezvtloe intea.atlaaux 10,990 2,006,526 2,105,516 32 3,495 3,521 99 16 2. National - 81,039 81,039 - 136 136 100 1 3. Honoraires professionnels 217 858 276,731 494,588 365 464 828 56 4 Subtotal Sezvica d Speldste 236,840 -2,444,296 2,661 144 397 4,094 4,491 91 21 r. rogmaten Locale 50,857 140,733 191,591 85 236 321 73 1 Externe 62,190 362,368 424 558 104 607 711 85 3 Subtotal lezmatten 113,047 503,101 616,148 189 843 032 82 5 tOtWl Iest ent Costs 1,206,471 9,743,285 10,949,755 2,021 16,320 18,341 89 85 It. Aoeuzwnt Costs A. O4 veh. G Equip. 146,651 1,272,695 1,419,341 246 2,132 2,377 90 11 S. Salaires personnel 76,009 121,671 198,480 129 204 332 61 2 C' Frain de deplacements 133,737 134,502 268,239 224 225 449 50 2 D. Per Diem _ ____ _ _ _ ___ total Se-uraent costs 357.198 1,528,868 1, 886 065 5798 2. 561 3 159 81 15 Total RAhoLINa COSn 1,563,666 11,272,152 12,835,820 2,619 18,881 21,501 88 100 Physical Contingencies 91,472 893,752 905,224 153 1,497 1,650 91 8 Price Contingencies 566 2560 954 809 1,521,369 949 1,599 2,548 63 12 Total "ROOaC= COBSS 2,221,701 13,120 713 15,342,413 3,721 978 25,699 86 120 Mon May 02 15:45:17 1994 00 e-I Project Cost Summary CHAD SANTE CT taTERN?IT SANS RISus ko_z6mat JAaow"t. b y ltanckers WS '000w The IDA UNICEF UNDP Government co^munautes Total Amount Mount 1ount aount Aount Mun-E A. On" Civil 06nstractlon 3.421 - - 637 - 4,059 Rebabilitation 1.382 - - - 1,382 ubteos s1o "Civl 4.603 - - 63754 5. Um Vbhicules 269 - - - 269 Equipment 4,169 21 - - _ 4,169 obiliter 11 - - - - 11 Nedicaments 3 231 1.148 - - 1 636 6,023 ubteeal 7 1,169 mo_ - T 36 10,492 C. Etude- - - - - D. saviem" de qrmaial.te 1. Honoradm prote.sIoenelo 779 - - - - 779 2. Notional 1,233 - - - - 1.233 3. ZabomaWima Intezntienal-L 135 949 10316 - - 2,401 Inteunational- 760 - - 6 _ *vb d_emA"S 949 ,1.-- 16 *. Vite Localo 534 - - - - 536 temn. 31 - - 391 1. Va* 4 _m _ am Voh. 4 BeNl 1,144 214 - 305 996 2,659 Selaitz peranmml 416 - - - - 416 real* de deplac_t 572 - - - - 572 ~o lftai. de O.W.g.imt M1111 31 -*F1U.-434 got"l la,477 2,33 13 - 9402 --2- B31fr Nob NeM 02 15:44:53 1994 5-1 fto_ment Accounts by naanciers 76 At 4:1 Page 1 of 2 REPUBLIC OF CHAD HEALTH AND SAFE MOTHERHOOD PROJECT PROJECT' MONrTORING AND SUPERVISION PLAN 1.1 IDA sunervision ingut. Reguar supervision needs are descried in Table 1 of this Annex. In addition, specific tasks such as review of progress reports, terms of reference, anmnal plans and audits, and procurement and disburement actions are estimated to require 8 staff weeks of various specialist inputs a year which are not included In Table 1. Borower's Contribution to Supervision (a) L would be submitted twice a year, In October and April. They would include a summary of implementation under each project component, financial statements on project expenditures, updated project implementation and procurement schedules, as well as the stats of contract advertising, bidding, awards and completion dates and compliance with aggregate limits on specified methods of procurement. ThePCF would collect inputs frm each responsible MSP D at and prepare the reports. (b) Joint annual reviews. Once a year, no earlier than October and no later dt November 30, the PCr will organize a joint IMA/Govement review of project implementaton based on: (i) the progress report in the above paragraph which, for the purposes of the anua review, would also include: (n) an annaal work program and budget for the next project year, (ili) a draft budget for the health sector for the next year; and (iv) the staus of policy and project monitoring indicators. (c) Mid-term rde. In addition, the PCr would canr out, jointly with IDA, and, to the extent available with other donors affiliated with the project, not earlier than April 1 and not later thanMay 31, 1997, a mid-term review of the progress made in carrying out the project. The review would cover all aspects of the project, and will be made on thebasisof a report prepared 90 days earlier by the PCT. Based on the review, the MSP shall promptly prepare an action plan, accepable to IDA, for the further implementation of the project and the program, and shall thereafter implement such action plan. (d) Ihe PCr would be responsible for coordinating IDA supervision missions and participating in them. (e) Prolect conmletion rep=rm Within six monts of the Credit clin date, a completion report, prepared in accordance with terms of refrence sasfactory to IDA, would be transmitted to IDA. 77 Annex 4I Page 2 of 2 ThliLL SUPERVISION PLAAN IDA FISCAL ACTIVITY SKILL STAFF YEAR (FY) REQUIREMENTS WEEKS AND APPROX. DATES ___ . FY95 PREPARATION FOR AND IMPLEMENTA- CIVIL wORKS, PROCURE- 6 NOV-DEC TMON OF PROJECT LAUNCH WORKSHOP MENT, DISBURSEMENT. 1994 AND FIRST SUPERVISION MISSION TO RE- HEALTH. AND PROJECT VIEW PROJECT START-UP AND PROCURE- MANAGEMENT. MENT. APR-MAY SUPERVISION MISSION CIML WORKS/IMPLEMEN- 6 1995 TATtON, HEALTH, PRO- JECT MANAGEMENT. FY96 1ST JOINT ANNUAL REVIEW MISSION: RE- PUBLIC HEALTHPFRAINING 6 OCT-NOV VIEW PROGRESS OF PAST YEAR PLAN CIVIL WORKS SPECS. 1995 AND BUDGET FOR THE NEXT YEAR. PROCUREMENT PHARMACEUTICALS SPECtALIST APR-MAY SUPERVISION MISSION SAME AS ABOVE 4 1995 FY97 2ND JOINT ANNUAL REVIEW MISSION SAME AS ABOVE 4 OCT-NOV 1996 APR-MAY MID-TERM REVIEW: COMPREHENSIE RE- SAME AS ABOVE + FI- 6 1997 VIEW OF PROJECT INPUTS, OPERATIONS NANCIAL ANALYST AND OUTCOMES AND RESTRUCTURE PROJECT IF NECESSARY. FY98 3RD JOINT ANNUAL REVIEW MISSION SAME AS ABOVE 6 OCT-NOV 1997 APR-MAY SUPERVISION MISSION SAME AS ABOVE 4 1998 FY99 4TH JOINT ANNUAL REVIEW MISSION SAME AS ABOVE 6 OCT-NOV 1998 APR-MAY SUPERVISION MISSION SAME AS ABOVE 4 FY2000 PROJECT COMPLEIION MISSION TO BE DETERMINED 6 NOV-DEC 20 00 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ----------- ---------------------- - - ----------- - ---- - --------------- -- -- -- -- -- - -- -- - -- -- -- -- -- -- * .t , I.- _ t o ------------- - 1. ^ @ r-----____--____----------------------_-_-_----_-_--_-----_-_-_---_-_---_-_-_-_---_-_- I~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~iW *! 4-4- 0 t 4 -_ o D @ ~* Y Y, 8~~~~~~ Ec a ," 23I FINA 10:293N 0~;sw 3.4. Stage Cestion Centrale Actaat CONlS TNOR: 12.9A i N 0194 T03.94 03.94 t0.94 (pirecteur pendant 9 mcit) INSTITUt O N1 w1x 3.5. Etuds Genie CIil (RENAl) 4s COnS OR: 12.93 NA NA 02.94 03.94 04.94 10.94 1 at prepration di OA. FIR" 1 0 0 3.6. Appul Protean" et Profile 11 CONS 12.9 03.94 04.94 S 0.94 0 6.94 06.94 tters phmme ldo postes + C sells on FIRMt1 a 09.94¢ recrut_ent persorem et AT I 502eMe phps*e # Elaboration do guide des 0 1 09.98 : ePredores * Audit TecbniqAe. ; 1 f 4 t0 3.? Ispecialiste Acquisition Nediael 54! CONS TOR: 12.93 j A NA 03.94 04.94 04.94 j 09. tiotal I.3 1 16!STITI a a i7otat A.3 162[___1....____i........t___ a LETTRE IWVITAT.II 1ESTINATIJETUODES SNORT LISTE I LAMKZIE PROPOITtO waNTTO. AT MTION I DE UNTRATS 1E1~~ ISNOOO1ASSAIDE APPL DO EES I PP D DEES NTRAT I GwEN TYPE DE COOMTS N tOSSM PASSAT APPEL TROAFSNEIS A OfU ICfTRT SBATlER JACNEVEINUT) ETCNPOSANTES f 0351 03STT 1TRAhSf1S A IDA joFFtERs OFFRES jILO IDA IPAM #IOA 'fl CoNTRAT 10U OUTRATI DE O CA)DATEDATEDATE TE(Cs) DT C AE()DT E . ......................... .. ..... --------- --------- ------- ----- ------ --------~*-- ------ ------ .1. Assistance a 10Organksation 366CN O:0.3 1 N A0.3 08.93 0893 119 de t('IEC au niveau centrat. I iDIV It1 :2: jSminuf re 7 NA NA NA NA N.9' 03.94N 11.93 :3Etude et preparatfon DA0pour 9 cCONSI 11.93 NA NA029 0394 t 03.94 106.94 *rmnovation Locaux de Suresux. ~ FIRM ItI .4.a Travaux de Renwvation Locaux j 95 LOC 07.94 08.94 109.94 10.94 NA 10.93 06.95 .5. Enquete ~~~~~47 CON TOR* 03.93 NA NA03.94 039 044 045 I IND~~~~~~~~~~IIVa .6. Formtfan a arsMairm4 ICNSTI TOR: 09.93 112.93 101.94 02.94 03.94 0.9 125 A4 TOTAL PRPARATION 6031 JPROGRANIE CONSTRCT ION CgsS .1. Travaux Hopi tow I 17 ice 11.94 12.94 02.95 03.95 NA 4,04.95 06.97 Travaux CSSJ 2.9231 LCD 11.94 112 94 02.95 03.951 NA 1,04.95112.97: .2. Equlpements Hopitaux et CSS 1.7321 Ice 10.94 101:95 103.95 04.95 M A 06.95 06.96 1 .3. Supervision Travaux & Equipt. 127 ICONS.FIRNJ 11.93.9 12.93 01.94 02.94 I03 94 a04.94 12.97 C .4. Gestion de Contrats 1 83 MCNS TOR: 12.9; NA MA 02.94 103:94 04.94 12.97 .5. Assistance asx dfstrfcts UNWICEF NATNETA0IP 694 0.4 69 Total 3.1 6,036aI DIVISION PHARNACIEaaa 11Aenseoeents deBureau 40 LD a 11.94 12.94 01.95 02.95 NA a04.95 03.96 :2 EquipeumLnt 1 112: CB01.95 106.95 09.95 ,10.95 MA 04.95 04.96 .3.Acquisition Documesntation 4 a CD 01.95 06.95 09.951 10.95 1 NA 049 ~04.96 .4. ~AssistSlo Ptanif./Administr .1 34 CONS TOR: 03.94 M A MNA 03.94 03.94 106.94 06.96 INSTIT a aS .5.INise a jour tiste medicmnents MAA099 a I~~~~~~~~~~~~~INSTtTI OMS$1 ,6. 10ours.. atw r a*Inspection Pharmncie 37 TO:O394MS- MA 03.94 0. 94 a69 ~: IRocumentation 8 I INSTSIT OHUS I I a t ,7. Stages Informatique (Local) I 4 CONS TOR: 0694 M A NAM MA a29 a3 9 s.aFIRM diFntomeet-aNAN A 1.9 39 A.lFrals, de fontionnement 72 ATtE1 NA M A M A M A NA MiA MA -I ,9. ICENTEALE P'ACNAT a a t jRtetsb. tureaa IL Nagslins 2201 LCD 10.94 a 12 94 ' 02.9 03.95 1 A 0.9 016 1 lOEqaIpemmnt £ Nebular 145~U i ce 12.94 049 0695 07.95 MA 08.95 12.95 ,111,Acquihittan Docuw btation 2 5 AUTRE I 3NA4 NA ~06.951 NA NA 108.95 1, 12.95 *t2lPrmwlection N.E. M A 2 PREQIA 0.94 06.94 08.94 109.94 M A NA M A 13a'Adsat N.E. A Contrwceptifs 1,900 lCD 10.94.94 12.94 02.95 03.95 a NA 105.95 12.95 1 :14,A.1. 810 ICONS.ID TOR: 03.9 OHVS NA 03.94 0.4 106.94 a12.97 .1S Personnael Centrale Achat J 30.- ICN.D TOR: 03.94 1 NA N A094 04.95 06.95 112.97 I ' 5 LETTRE IWYITAT. I I I t | 1 55 ~~~~~~~~TOMN IEfERE4rX II SOT LISTE LANCEIENT UOPOSITICN5 !ELsTENATIONIIETHODES / ONISULTATION I-TTREUUHN t TWPE DE aNNUAlS lE S pAS I OEDOSSIER cU REISE :OE O0TRAT 1 EXAJEU T PE DE 004TRATS JEH UESMMJOOPASSA%Tlh APPEL D'OFFRES APPEL 0', DES TRAMSRNS A tWD CONTRAT SIGATURE IACNEVENEWTI ET CoMATES CMffS I atNAT T MaNIS A IDA OSFftES O oFFRES L'IDA I'PA L'IDA ',u aCItAT'WU CONTRATI I DI B SE NW (A) DATE DATE DATE ATE (S) DATE (C) DATE () 3DATE CE) ._. ..... _..........._...... ...... _.... ..... .... ...... ------- ........... ------ .._.. ,_ ..*.. .... ._ 3. X I i 3. .Renovatlon atiment PADS . . t - - 3.2.1Equipei nt A 110.94 t A iA 01.95 04.95 3 3: Naterlel IEC 201 ICB 06.94 09.94 10.94 M NA i MA 01.95 104.95 t 3:4bA. T. 2431 CONS 1 03.94 N NA MA 09.94 1 tO.94 1 12.94 12.96 t | t t"~~~~~~~~~~ISTIT tUNICEFt:t5t 3.6. I prlawerle Nwmts IEC 45 5 LC j MZA | 09.94 t10.945 MA M NA t12.94 03.95 3.7.fFormation 22 CONS NA 508.94 110.94 MA MA 01.95 12.95 jTotal 3.3 520 | 4:1 Et abcwatlon du PA 1DS c MA MA MA NA } NA 03.94 Ofbnaue des Procedwees5ttt 4.2 Rise mn place ystem PADS CONS TOR: 02.94 03.94 04.94 05.94 1 05.94 t 06.94 5 09.94 gestion cowptable *t f inenci*rl INOIV tOtt * Appul coptable durant ; ; 06.98 t I'execution di prolet. t I I t 4.3 Audit dck ccaptes du projet 235 CONS 02.94 03.94 :04.94: 05.94 t 05.94 06.94 5 06.98 t 4.5 Spci tfo arches 60 COAS TDR: 03.94 K MA MA 06.94 t 09.94 5 06.97 4.6 SpecilIste. (testion1Coepte) 123 CONS TMO: 03.94 | NA NA 5 06.94 09.94 12.98 s~ ~~~~~13 cmo I TOO:t 0394 te * lt 4.? equipment et VehIcules 10? 1 1 TOTAL 3.4 " S 5 1 1 5 TOTAL 8140240S33 lJ..L814 - _ ! ! _ NAs Non applicabe; IDIsV Consultant I.ivi&duel; TR: Terus de reference. (a): IUTaInt.rnatfonul; LOCuLocal; QUOT3 quotations; CONSwConsultants (b): 60 jour. apr.. to date lifitt d'ouverture des otffres Cc): aewlimnt pou les contrats de consultnts (d): 60 jourw minimum qre I telex de non-objection do l'IOA e): 3-6 sols pour tea equipaments et 6 U1 mios pour los travaux. b A:114-2 Unl CHAD HEALTH AND SAFE MOTHERHOOD PROJECT DI smen Ptofbraofl de D.eboISernIt MA i9wuwe ntu P ofduI _ fulws 9 9s _ IDA h- fRe ye- -~ iui H@h ed Sif MctheAaodPrajct R AeglndSec. rof _.~~9 OUitU ci tv Cueit Sector Au _ h &a4Wi*e ra 100.00% a ID,4 a ouewms hWtd n*s, cC C,e* om&b (US ndlkonl (US$ tSkIn 1%1 Ml 1995 1 0.4 0.4 2.03% 0.00% 90.00% 2 0.4 0.a 4.056% 1.00% s;r 3 0.4 1.1 6.08% 2.00% Z 4 0.4 1.6 8.1S% 3.00% 80.OO% II)" I 0.5 2.0 10.81% 7.00% 2 0.5 2.6 13.51% 10.00% 3 0.5 3.0 16.22% 16.00% 7O.0% 4 0.5 3.6 18.92% 18.00% r 1997 1 1.4 4.9 2B.35% 22.00% i f 2 1.4 6.3 33.78% 27.00% 3 1.4 7.6 41.22% 30.00% f 4 1 A 9.0 48.65% 34.00% 1998 1 1.6 10A 58.78% 38.00% * < 2 1.5 12.0 64.88% 42.00% 3 1.5 13.5 72.97% 46.00% 4 4000% 4 1.5 15.0 81.0% 50.00% t tunO 1 0.5 15.6 83.78% 54.00% 2 0.5 16.0 80.49% 58.00% 30.0S 3 0.5 16.5 B9.19S 64.00% 19 ' 0% 4 0.6 17.0 91.89% 70.00% 2000 1 0.8 17.8 95.95% 70.00% 20.00% 2 0.6 18.6 100.00% 82.00% a~~~~~~ D 10.00% 0.00% - - hal~~~~b4 Yewr (Ezarcicel ___ Y "'~~~~~~~~~~~~___ 2 | a-D 84 Annex 44 Page I of 2 REPUBLIC OF CHAD HEALTH AND SAFE MOTHERHOOD PROJECT Documents in the Project File 1. "Plan d'Orientation, le Tchad vers l'an 2000", Ministere du Plan et de la Cooperation. 2. "Population, Health, and Nutrition", Africa Regional Series, December 1992, Report No. IDP-122. 3. 'Seminaire Preparatoire Sante/Affaires Sociales - Table Ronde", MSPIAS, N'Djamena 17-20 Juin 1992. 4. "Table Ronde Sectorielle, Reunion de Suivi de la Conference de Geneve Im - Diagnostic et Strategie, Tome I", MPC, N'Djamena, Janvier 1993. 5. "Table Ronde Sectorielle, Reunion de suivi de la conference de Geneve Im - Programmes d'action, Tome II", MPC, N'Djam6na, Janvier 1993. 6. "Annuaire de staistiques sanitaires du Tchad", 1988-92, MSP, Dicvision du systeme d'information sanitaire. 7. "Plans nationaux de formation initiale et de formation continue des resources humanies pour la sante, 1994-2000", MSP/Cellule technique de suivi de la table ronde sectorielle, Fevrier 1994. 8. "Rapport sur le redeploiement du personnel de santE", MSP/Cellule technique de suivi de la table ronde sectorielle, mars 1994. 9. "Renforcement et rdorganisation des Activites en matiere IEC pour la SantE," Programme Information, educadon et communication (IEC) pour la Sante, Consultant Report, 1994. 10. "Plan de financement des h6pitaux de district et des CSS", Consultant Report, 1994. 11. "Le secteur pharmaceutique," Consultant Report, 1994. 12. "Plan de financement du secteur de la sante 1990-2000 et des affaires sociales", Consultant Report, 1994. 13. "Cellule de Coordination projet sante et population," Dossier de consultation, Dec., 1993. 14. "Programme National SMI/BEF", MSP/Direction des activites de sante, 1993 85 Annex44 Page 2 of 2 15. *Assistance aux deux pr6fectures du Guera et de la Tandjile-, janvier 1994, rapport prepare par J. Perrot, WHOIICO, Geneva. 16. *Liste nationale des medicaments essentiels genkriques", MSP/Direction des etablissemnts sanitaires, Avril 1994. 17. "Etat d'avancement des travaux du groupe national de preparation et de suivi de la table ronde sante et affaires sociales", WHO Njamena, mars 1992. 18. "Extension de I'Ecole nationale de santE publique et de securite sociale - rapport de mission", 1992. 19. 'Etude sur la Couverture Hospitaliere de la vile de N'Djamena, PNUD, 1993. 20. "Conference nationale de reflexion sur les soins de sante primaires - rapport final" MSP/Direction des soins de sant6 primaires, 1991. 21. "Poverty Alleviation: a Necessary Means to Growth in Chad - Country Assessment and Policy Issues", UNDP, 1989. 22. 'Etude du secteur de la sante, vols. 1-10", CHEMA and SCET-TUNISE, MSP, 1989. 23. "Analyse economique et financiere du secteur de la santE au Tchad", J.Perrot, OMS/1CO, 1992. 24. "Contribution a la reflexion sur la mise en place d'un recouvrement des couts dams les structures sanitaires au Tchad", SECADEV, 1991. 25. *Recouvrement des coets", MSPlPrefecture Socio-sanitaire du Mayo-Kebi, 1992. 26. "La mise en place d'un systeme de recouvrement des coOts de la sante-, MSP1DG, projet Vleme FED, 1988. 27. "Etude du secteur sante au Tchad", F.Orivel, IRBDU - CNRS, 1991. 28. 'Apercu Nutritionnel", FAO, Tchad, 1991. 29. "Atelier de sante publique", MSP, VfIltae FED, 1990. 30. "Projet de smuts des comitds de santE", MSP/Cellule medico-sociale/PADS IBRD 25529 _._ *s %. s 21 bThe bo..dem.- coIors, othew Wnoooho,, shown CHAD o i, oo do TCHAD Sof on dOsri TCHAD I ~~~~~~~~~~~~~~~~~~~~~~~~LIBYA a -Zh HEALTH AND SAFE MOTHERHOOD SANTE ET MATERNITE SANS RISQUE PROJECT REGIONS N REGIONS DU PROJET N r 20- Project Regions Main Roads r Project Regions Routes Primaires Distric Hospitals to be built Secondarv Roads ' H6pithl de District a Construire Routes Secondoires E] Hospital Center Rivers Hopital Centrol Rivieres Exisfing Regional Hospitals Prefecture Boundaries ! Hopital de Prefecture Existanfts limites des prefectures Existing District Hospitals International Boundaries Q H5opit7l de Distrid Exist nts Frontieres Intemabonale rLOmTM 0 o so loo ISO 200 250 S ' ' I ' ' 1'' OllES O 50 100 5 ,/ ,_' iS / ' ' It;1 .1 ~~~~~~~~~~~~~~~~0~ ,oNkou IN I G E RX\ n@tO, Maussoro ~ ~ ordn 0 Chad ;<9Muss3k ~ % < SUDAN f / __^ > T ; h \ ° a "Di~~~~~~~~~~Oebrene - ii- / Ot ikam \ ( ~o~00x~KoSltwo 0 *- MOISSO Utbo / \CENTRAL AFRICAN y ,*z./t3:R XN REPUBLIC 544104 mc | p2p3p4cxx pu35TR F 16- 17 LIBYA *REPOF CHAD / TCHAD EGYPT REGION OF TANDJILE NIGr REGION DU TANDJILE ' HOSPITALS AND HEALTH CENTERS o 10 20 30 40 50 / CHAD ' HOPITAUX ET CENTRES SANITAIRES KILOMETERS ---- SUDAN NIGERIA P*S EXISTING REGIONAL HOSPITAL f HOPITAI PREFECTURE EXISTANT * EXISTING DISTR'ZT HOSPITALS .5, ' HOPITAL DE DISTRICT EXISTANT CE,TIAL/ _ EXISTING HEALTH CENTERS CHARIAFRCAN REPUBC ~ HEALTH CENTERS TO BE CONSTRUCTED I CHESLE DA CO ISTRICU OIOSNTIRE BAGUIRM I/ o3 SOCIO-SANITARY DISTRICT HEADQUARTERS CHEF-LIEU DE DISTRICT SOCIO-SANITAIRE:: O ZONE OF RESPONSIBIUTY HEADQUARTERS I CHEF-LIEU DE ZONE DE RESPONSABILWTE AO Golo 'e I SOCIO-SANITARY DISTRICT BOUNDARIES / A UM(TE DE DISTRICT SOCIO-SANITAIRE / 10- PREFECTURE BOUNDARIES / 10 LIMITE DE PREFECTURE INTERNATIONAL BOUNDARIES / / .MITES DE PAYS MAYO - *~* ~ Deress AO Koblogtu, 0Ndam KEBBI . mbolo \ Miss&r AODonogou \ _ Newmo / I N A . Tchdkondji / / 0lnktchoro )G Tingo^chirou. \D ,A Ningo 0oMAbigut ' ' , pMOnao Kroumlal MOYEN \ AO goMonogoy 0 / KdEolon 8$4Noungou M O YEN Au oln I pODarba KboAo,Bovka I ftKirbCHARI * Berth L8L& / Mangsi Bemboh B6rA KimrJ ,, 86Bero-Guidi- i ) \ Dormon Guidari OGama ~~Biro-Guidi' \~~~~~~~~~~ GPobri Ngolo 'L A~plat A t f | Dale Tamio-NgoioO J0A The boundories, colors, OA A ~ Mouroums TouilouLm Tzo Do Mag denons,nat,nn and any * Nanga uT BiollimeO DOlbion A0 § ango other information shown > .60 onassu n this mop do not al;Atou / AAGOmngo I imply, on the part of zr loooo AO,:;!-. ~~~~~~~~~~~~~~~~~~~~~~~~The WorI*.Bankc Group, i | Dafro wot I _,. Mango any jurnent on the legal w 0 D .,ouao' stus o?ayterritory, / Or aG ONE O CIDnTLLGNNorse oraccptanetof snutch - C~~~~~~~~~CfJr,cKJTAI ~~~~~~~~~~~~~~~~~~~~~~~~boundaries. LOGONE-ORIENTAL 1 18 191 LIBYA The boundorses. colonrs, RLP- t denominations and any B A T H A \ tYn other informotion shown / on this mop do not K... imply on the part of *- - NIGER i r The World Bank Group F j e.. *gmoI rany judIIment on the leo/ -{ status ot any territory, Amgorkoe or any endorsement Abrc CHA D or acceptance of such AbSUcAN boundaries, .-, SUDAN / \ Ss>EreF A MongoIme . ..... 1> NIGERIA, \Djoukoulkouli / 'N ONGO~~~~n ~~Boro /- 'N MONGO -2CENTRAL C H A R I - * Soro.Arob2, Kviorbro _EAE R O O AFRICAN REPUBLIC " B A G U I R M I / AbIouyour0 iiKoubo Adougoul / t i -12^ ` /t e Niergui '* 12 MoukouIouo Bordongol 0f log) CHAD /TCHAD j -_ /Djimj-Woia REGION OF GUERA * QMokofi /_ \*---> !REGION DU GUERA * !Maqnam I SALAMAT HOSPITALS AND HEALTH CENTERS f Magnam \>g HOPITAUX ET CENTRES SANITAIRES Ea Ggi'EXISTING REGIONAt HOSPITAt Gogmi s) .... f EXISTING DISTRICT HOSPITAL Ipo ,y4Amkorouma HOPITAL DE DISTRICT EXISTANT * ~ ~ ~ ~ ~ ~ ~~jina ~ tefi o DISTRICT HOSPITALS TO BE CONSTRUCTED ~~~~~Djona 0 ~~~~~~~~~~~~~~~~~~~~~~~~HOPITAL DE DISTRICT A COtNS TRUIRE EXISTING HEALTH CENTERS ; \ .... ^CSS EXISTANTS 1 1 A 3 ....HEALTH CENTERS TO BE CONSTRUCTED A CSS A CONSTRUIRE * 5000~~SCI-SANITARY DISTRICT HEADQUARTERS 1 ~~~~CHEF-LIEU GE DISTRICT SOCIO-SANITAIRE ZONE OF RESPONSIBIUTY HEADQUARTERS 0 CHEF-LIEU GE ZONE DE RESPONSABILITE I'*\ | ....... _ _ SOCIO-SANITARY DISTRICT BOUNDARIES Sphingul L UMITE DE DISTRICT SOCIO-SANITAIRE ** ¢,_ /8OShingil / 1 ....... ~~~~~~~~~~~~~~~~~PREFECTURE BOUNDARIES r \. _ ,. _ I Z. r~~~~~~~~~~~~~~~~~~~~~~~~LLIE DE PREfECTURE * -'-'' / ( ' INTERNATIONAL BOUNDARIES MOYEN - CHARI'i* ___I**/~~~~~~~~~~~~~~~~~~* / ~~LIMITESDE PAYS10 t~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~O I, ,. I MOYEN -CHARI K ItOMETERS X 1 1~ ~ ~ ~ ~ ~~~~~~~~~~~8° 19^ 20O'