. ., II . ; ...... -. •
II •• &IIe • ••• ,...... ,.' ..... ~.¥."'O."'CIoI"
'!IOJIC:T 'APER '· ~ ··"'·ET I ,. 'co< ,. f,. I 1 [ • ." ...... '~::..."'"~~ ! " r 1}8~08 J !FR , '- JIl • .. I"
... , '.'.. , .... " ! " ,WO 1 • , 1 ' , " , "",,weill ' . 1 , I - • •L I ,.,T 3.900 l,ObJ 0 .... , 1\ 2~ , . . • •• • n •••• c. a"" ...... 111., _11111... ,111" TEC)). :C=' I. 'IT ""~ ... ''''0 n".19. , ~ ~ IJ ...... 0- •... ·\,j.~SC ~ln"TIO. c . •••• ,. .... ~~ CCl~. l o . .. 0." " ~.""1' t a. ",::I •• "'. .. ".. ,. ... 2,000 '" J"! 53C 533 '" '" 1 ' ... "
~.. f2l ..•• .::; L..:J ~·.II'
/ I&:.QIII G~Iif'Y'HG """,el el.,,,,,,,,,.Cl ( .-? ;".)~l , T~ANSACTION CODE
Add I PIC PROJECT IDENTIFICAT!()rJ DOCUMENT FACESHEET ·:.:r.ange I: OO~UM~I\jT CODe D~I_tl' ______~ ______--~----.------~l------J COUNTRY t~TITY 14 DUCLiMENT REVISlu~ NliMS:H 1--'1 ~IGER i LlJ
5. PROJECT ·~UMBER 11 aU/HI) , L.2..-!UREA.U'O~FIC-;..;E;..... __i I ;JROJEC7 TITlE Imu""u," 40 ct:.r.crlN"fl 1 A. Sv,.,ccl 1 B Coo. 1 r- -, ~83-O208 ] ! .AFR I ~ 1 := i L - s, PROPOSeD NEXT DIJCL:MENT \10. i:STi'v1A.TED COSTS
2· PRP MM YV ,:SOuO or eOwlvalfnt, 51· 2!.;.5 CFA A. 3 B DATE [JJ J • PP 11111 717t ~.______F_U_N __ D_IN_G~S_O~U_R_C_E ______+-I~~~'~~K~~~:_ • AID ApprOPriated I 13,541 9. ESTIMATED FY OF A.UTHORIZATIONI9BLIGATION b .11 I OTHERr~------~------ us 12. c. Host Country a. 1"'4ITIAL Fv IIJ§J C. FINAL ~v ~ o. Othltf Donorl~j
II. P~OPCSED 9UDGET AID .4PPROP~IA.TED i'\.JNOS 'SOoo) B PRIMARYI A. A.FPRQ· PRIMARV TF.CH. CODE E. FIRST ;:Y liFE OF PROJECT PURPOSE '[ I I PAIATION I CODE C. Grant 0 Lo." F Grant G Loan I H. Gr~nt I L~n -ll-!--~Pf~:----~~5~3~O--~I------~~2,~------~------~------1 I 121 I (JI i! E ~------~------~------~------~~~~------~------TOTAL 2,000 ., I 12. S~CONDAAY TECHNICAL ,:OOES r",.xlmum WI cod., a~ "If" pOSHlon, ~~f11
533 1J. SPECIAL CONCERNS CODES (murmum six codrt of four ,;Josltlon, tHlCIIJ SECONDARY [" PURPOSE COOE BRnIG 15. PI=lOJECT :::;OAL Im"',(1)lIm :UO ,nlJr..t:r.rrl
r- To imprvve at low cost the quality of life al'ld ·... orking capacity of ::-.e L r'..tra.. ;o,ulatic~ (9,000 villages). 3y 19·32, t:, prav:'da 3500 vill~s wi th-.J ______~b~a~s~~~'~c health care services, 16. PROJECT PUR,IOSE (mu'mum 480 c";'nK:~rrl r- To establish ~ viable r~~ health deli7~ry system which demonstra~es ~ thp. va.'.ue of prevention, early diagnosis, tiltely curati.va interventicn a"ld proper refen-al.
L ~ 17 PLANNING RESOURCE REC.!JIREMENTS (uaft/funds; D"!sig!'"~ Team- Leader, Public Health Physioian, Publ.!.c Health Nurse, Logistics Manpower Sp. 'cialist, Economist, En~ineer, Sociologist
_____---:~,~ 18 ORIGINAT NG OFFICE CLEARANCE 19 Dare Documenr ~f.'Cel_ec In AIDIW. or lor A I DIW Documen t5. D. te of Dlltrll)Uhon Slqnalure 7 A y+t:~~.~"'-~~::.....-../ _~_ T,tle Regional Development Officer
AID 1J30-2 (J-761 IMPROVING ffiJRAL nEAT rT'1f{ ( 68 3· 02 c8 )
T~b~e of Conten~2
Part I. Summary an:: ?ecommer:s.ati.GI1s 1
A. Fa.ce Sheet 1 B. Recommendations 1 C. Project Descri~t:on 1 D . ~ \.U!lIIl.a.ry F i:1di.ng .:; 1 E. Project I.5sues 3 F. 611 (a) Determination ;
Part II. Project BackgTour.d and Detailed Descriktion 4
A. The Historical Basis of the GON Rural Health Strategy 4 B. Detailed :ie;;l:riyi.il.:IJ. 5
Part III. 11
A. Tec.hnir.:al Analysis ( 11 B. Financial Analysis and Plan 22 C. Soc.ie.l Analys is 47 D. Economic Analysis 61 r..r- ." r_ l '( ! Itt 4 : ~A Part rv. 67
A. Adlll..:L."J.~.strati ve AlTange:m.ents 67 B. Im1?l=mentation ?lan 72 C. IrJ.plementation Scnedule 74 D. :r.:valuation Al":-angements 77
Anne:ces
A. Main Causes of DeRth 85 B. Major Diseases Trea.ted try Ar!'ondissement 86 C. Health Care by Circumscri?t1on - 1976 88 D. Hauth i.f.anpower Availaoili ty 90 E. Niger Health Personnel and Board 91 F. Eealth Personnel Needed in Oreer to Fulfill Objectives of Tr..ree Year Plan 92 G. Personnel in Trair~ng Outside of Niger 93 H. Af!'icare and its Relationsh!p to the Imrr~~g R~~ Health Project 94 I. Breakdown of Urba.'1 P.:::'ll th Budge-::' 95 ;. Con'tl~ct1on Costs 96 K. Recurrent Costs Proj~ct~~ns to GON 97 L. DispensaI1P E.:a.uipment List 99 M. Drug Li.:;t 10C N. Ya.ccine List lOl O. Cold Chain Equipment 102 P. Eq'\lipruent Lists for Ga.rages and Me-:ical Equipment Workshop 108 Q.. Educa.tional a.r.d Audio-Visual Materia.J.s 111 R. logica.l.-:;Yar::e'N"ork .Yf.a-:r:.x lJ2 S. Other:Jc _.:lr A.ss:'stan:e 119 T. Check.L.s-::f St atu"tory Cri :,eria 132 G. Iaitial ~lvirorxe~tal ~xam:'natiGn 143 v. r;raft Gra:-_t A6reer::ee}t 150 W. The F9JIl:'.ly :iea.l.th Car,=, Report; Ru.ral :1ealth :?oJ.i.cy 158 and Vi.:J.~e Hea.l~h 3er"!:.ces in ~r:"ger: 'I'ech."l:!.~al Analyses md Prcgra..'Cl Recot:l.'":".enda"t~cn.s for an AID Project Paper, Volu.me II: A;:pencices, November 14, 1977:
1. Niger Hei~th Sector Assessment
2. ~-i1_!rlstry of :IeaJ.th, Summa.ry of Three- Year Plan
II PeI-sp!ct1ves, "
4. Village :-:eal:':h Teams
SecOUI:'st~ JOD I..escription, Trai.ning Schedule and Conte:..ts O:,~ ET..a.rr:..acy K:!. t
• Matrone J-Jb Descripti::m, TrllI'.i.ng Schedu.l~ and contents of Pha.rmacy Kit
Curricula. of Health Tra:'!Jing Institutions:
• ENICAS E:!lSP • ESSM (Summa.r'J, Years 1, 2 and 3)
6. other D::nor ~ogr3.mS ie} the Healt"j Sector in Niger
7. Village Health Tea.m.s: :Documents Helating to Supervision and the Rol; of the Certi.fied I1urse
8. Ministry of Health Items ,]oUI'nees d I Etudes de 113. Sante, Tahoua, July 1976 (Second National Level Health Conterence)
10. Job Descriptions f'Jr Long-Term Techn:cal Assistance Personnel
ll. Tables
• Village Health Teams, August 1977 Hea.lth Facilities in Niger, AUgJ~t 191i
Glossa.ry TABLES
'table 1 Niger: Central Gove~ent Revenues & Expenditures, 1971-1977
Ta.ble 2 Niser: PeI'centage Share 'bf National Budget ?ece.i ved by Selected M1n:'stries or Services, 1977
Table 3 29
Table 4 S1.m'tIlarj Cost f.s:im.ate WI::' Financial Plan 42
Table 5 CostL'1g of OutputS/Input3 43
Table 6 Budget-Ir:rproy';-!:.g Rurs.l Health 44
Ta.ble 7 Nursi.r.g ?r-ogr3lIl Summary • 62 I. Project Sc:!Ilar"l and ?ecomme:ldations
A. Facesheet (Attached)
B. Recamrler:dat;ions
This Project ?aper recommends that:
AID as.ist the Goverr~ent of Niger (GON) in the strengthenL~ and irr~roving its rural health delivery system with grant :funds in the amount of $13,541,000 for the life of the projec"t.
Assis~ance De ad~lis"tered over a five-year period of time (FY 78-IT 82), :::~ocusir.g on t'1l0 essential areas of health programming:
1. Human Resources Development
2. Institu"tional Support
AID approve the 'Ilaivers and conditions in the Implementation Section. T..rhicn are cons idered essen"tial to successful projec~ i=plem~~tation.
~. Project Descript;ior.
In order "'co meet the 'Ja3ic he:lJ.th needs of a growing rural population, a,t a reasor-able cost to the GaN, this project has oeen design,,:d to ass::'st the >1ir.is"tI"'J or' Health to ievelop its village health ~ program (v':1'"T). ~ conc.::rt "..,ri th c:he (JON the proj ect, over fi.ve years, "rill 2cr.centra-ce on tr:e ":rainir:g of "r..ey vO::!..'.zlteer villa.ge health workers alld :pro'liiing them "..rj::h physical and. personnel in:=astr'.1ct"..U'e .. The activ~ties of the project will be carried out by ~he ~~OH Nith constan t ~\Upport and :r.oni toring by the Mis sion :hrough i t.s ,raj ect ID.S.Ilager and se:"ected technical personnel. The specific inputs enumerated in the project paper ha.ve been selected on the basis of their rele~'ince, uti.lity~ and. replicability in the ongoi~g development processes of the rural tealth pr8gr3.E. It is projected that the investment in manpower developnent, a major item in the project, will result in a more expansive health cov2rage and thus curtail the need and usage of cos"tly secondaI-:,' and tertiary health modalities. The ultimate goal of the project is the prevention of disease and the promotion of health with tne eventual outcome - a higher quality of li~. -2-
1. S~=c1fic Project Activities
a. _Human Resource Develonment-6___ __
1. third-countl"'J training - theory and technology ot rural health delivel"'J systems ~ ~or ministeri~ level personnel, medical instructors, and health log1~tics/rna~~tenan~e prafes~ionals.
2. i..'1-country tr6.ining for pro£pective village health workers as WIll as advanced train,tng for bona ~ members of the ~n.llage hea.l.th team.
3. in-countl"'J continuing education grograms for health personnel at r..a-cional and depar..;mental levels.
4. tra.i.n.ing of certified and Sl:ate m:• ..rses ·,.,rhe -,lill be responsible for the treatment, ~raining, and supervision of v~ag~ health workers.
5. field training experience in rural J:l'2d.icine for medical student.s so as to givt:! them the necessa.1"'J skills for health intervention in a non-urba.'1 envirOIJ!l1.ent ~
6. el:.vironmental heaJ. th r,Jork~r training progra::n for a sele~t group who ,~ teach and monitor 3aQital"'J programs t~~oughout the rural area.
7. instruction and technical consultation in ~he areas of automec:-.anics, medical equipment repair and environmental sanitation.
b. Institutional Smmort ~.
8. procurement of vehicles for supervisory purposes and other supportive activities.
9. procurement of equipnent and supplies needed to reinforce and J:lobilize health operations througt:.out sl~lect rural areas.
10. construction and renovatior. of health care and support facilities in order to provide a substar,tial base of operations and control center's for the village health wo:r:-kers and their supervisors.
D. Summary FL"l.1ings
While scientifically valid data regar'ding the impact on morbidity and mortality of village health tearu, is not presently -3-
available, it ~~ highly probable that the VETs are having a significant impact on the h=9.lth of the populations they serve. Moreover, it also seems higb:y probable that a VHT system is the only feasible way by which resource-scarce countries such as Nig~r C?-n e~end health services to their village 90pulation at feasible cost. 7he project inputs and activiti;s ?ropos-ed :ill this PP have been designed to add the least possible recurren~ cost burdens to the ~r budget. The nature and funding levels of these project inputs and activities h~ve been discussed wEh the Secretary-General of the ~tinistI""iJ of Heal-:h and Social Ati'airs and ~e acceptable to the Ministry.
Rapid approval of the Pro.~<::!ct Paper (Jmu.ar'J 1978) and completion of a Grant Agreement in ~ebruarJ 1978 wculd allow resource now to begin in mid-1978. Th:' s is important so as to 'cake advantage of the Illomentum of t.he c1.l.l'rent i·fOIT 3-year -:;lannir...g ::j~cl.e, 2!:d. because much of the Mall' 5 proj ections fer the ne}:t; !)lanning cycle have been based on assumptions of forthcoming USAID support at t~~s orier of ma.gr..i tude. This has been discus sed with GON by AID/Niger after AID Washington IS ap!)roval of the intE':ri:n. report and health sector assessment in mid-1977.
The project meets all 8.};:plicable st,~tutor"! cri-<:eria and is re3.cly for i!mnediate impl,:mentatton.
E •.Projec"': I3SUf:S
The P;U:, F..s.A and interim report revie~'m by AJIJ/Tfl r!lise~ do~bts about the GON's capacity to manage a health sector grant, dfid about the reliance on SHD8 (md Africare) to prov:.d-:: th: major technical assistance in the fields of management, planring, .'1ealth ltanpower development, Dudgeting sta~istics, and epidemiological surveillance.
Hhile the ,goal 'l~d pUrpOSE! of the PP !'e!r.a:tn broe~dly unchanged, "':he ::najor differences in the design of the PP includc~: the revision of the ~ to a clearly-targeted nu~al health project rather than a health sector support grant; ~~ emphasis on e;Qa~riate assistance in technical fields; and· some revisions 01 the t~rgetsJ especially the lowering of the original plan for 5,000 VET's by 1982 to a more realistic 3,500~ (Project issues are accc~ted for in the project background and detailed description and the technical analysis section. ) F. 611 (a) DetelT:lination Although a 611 (a) determination for the two departmental headquarters to be constructed with the initial year IS fu..."1ding have been valida.ted by BEmO engineers (Abidjan Ca.ble #10042, Oct. 13 1977), additional construction activities progrmnmed under this project for dispensaries are scheduled fo~ furlding under the allotment of funds for the second year, i.e. Fi 79. A separate 611 (a) determination for the dispensaries will be provided prior to the ADO/Niamey's request for the second year allotment and obligation of tLese funC'~ through grant agre~==~ ~endm~nt. II. Project Background and £etailed Descrinti0j!
A. The Historical Basis _of the GON Rural. Health Strategy
In order ~o understand the GOri's nealth strategy as projected into the future, and v:!..ewed against the backgroand of existing health a.'ld :iisease condi·tions and the available health infrastructure and services, it is instructive ~o look back at the past history of Nigerien health policy and perfoI"'tlallce. There is a clear and consistent trend of GON perspective that is quite impressive relative to other Afric~~ states.
At :i.ndc;pendence, the Re'public of Niger fo'md itself in the position of other land-locked Sahelian countxies, 'Nith demographi~/ disease patterns, lack of effective infrastructure and lack of reSOUlces ::"r. "the h:alth sector that have bee:} dE:sGribed in preyious program documer.ts ':c.f. Rural Health Services PRE, 1976; Health Sec~or Assessment., 19TI). 3.ea.lizing that a basic and far .. reaching refor:n of the health sector was necessar'J if the GON was to urldertake the s-pread of r.ealth services to the mass of the population, the GON prepared in 1964, a Ten-Year Persoecti~ on the DeveloDIDent of Health Services (1964-1973). This major s~udy rtlas financed by usA.ti) and. had the tec~~cal collaboration of the T~0. Dl his preface t~ the publi~h~d study, the then - ~1iniste.r of Health underlined the rlE.'ed for a ba3ic refom that would "penni t the transformation and progr,:ssive abandonment of the str~ctures of the colonial pericd tc the benefit of an organizaticn designed and a.dapted to the needs and capabil i ties of the Republic of Niger."
The Minister :':ientified the ~-lO greatest ccnstr,~ints "':0 t~is refoI"!!l to be "the lack of qualified. personnel, and the :.no:: ufficiency of financial rescurces. II
III the text of the 1964 study, the three highest priorities chosen were: (1) "medicine de masse", i.e. public health, preventive, and Simple curative services to be provided. to the rural popluation; (2) health education -- especially regarding MCH, (mother and child heal. th ) nutrition, and village hygiene; and (3) training of Nigerien health workers. Significantly, and quite d.ifferently from many other African countries, much lower priority was placed on the further development of hospital-based services in urban areas.
At about the same time, and continuing to the present, the GON placed emphasis on the development of health auxillary training at the village lev~l. The concept of the village "secourj ste" had bee~ developed throughout th~ French colonial health sy3tems in Africa. This person acted mainly in first aid and as a liaison with -5- the mobile ser-rices of the Servi:e des Grandes F..ndemJes. But begi!llur..g in 1959 in TahO"l3., an~ ,ieveIOping m'O'5-C strong2..y :b :-larad..i thr~ug::'out the 1960 IS (see 3elloncle ud Fournier, Health me Develo"C!ller.-c :.:: the Rural Afric~~ Context), ~he ccncept of ~h= Village ~ea1~h ~e2~ (VHT--Frencn ac!'cnym z.sV), ccnsistL1.g of a S2~Gur:~~ wi t·n expa!lded prevent:.ve and curative :'u..l'J.c-cions, md 3. re-:r:ti!led 'tradi 1:i.:nal l"-ii wife (matr.·or.e), gaL-:ed ::lomentum. These seccuris-:es and !:l3.-crones were embodied i:l 3. village structure of communi:y pa... '+:icipation in selection and 3'..:.ppcrt, and supervised by HirdstI"'J of Health personnel from arrondisseme3, (the most peripher3.l. dispensaI"'J level :n the MOR system), ~r".:3sript:ior. !!ledical (~ealth center) and denartmen-caJ. (!!lost pp.ripr.craL pnysician) levels. This concept developeci prcgressively with MOH ~upport far ~eyond wha: was to be found (or for t::'at matter, beyond '"hat is st~ to be found) ~ otb.er Saheli.s.n cour..tries. Hcwever, there '"e!'~ ::.l ...... ays, m1 s-:ill re!!lai!J, .significant !1roble:ns i.'1 ~lemen:'ir..g this ~s-cem of VHTs: log:..;;tic problems in sU?ervision ar.d. sU'f.'ply:, resource con.;;traint~, lack of adequate numcers of persor~el and relev3nt training and rr.ctivation of supeI""risor'J per::or.r.el, ?roblems cf sus-cair..i.ng volunteerism a-c :he viLage level and special problems ir..v<...'lved. in serr.-ng the :lCr:la.dic popu.l3.tion. In addition 'the VHT de'relo;:nent ',.;as uneven betw'een, and witr.:'....:J., ·iifferent depar':mem;.;;, bur, tne critical poi.."1t is that the GON has (a) 3. lor.g histo=ical expe::-:Lmce 'Iii th the develo!Eel1t and :..mplementation cf v:l:a.ge-based r'JIll health systems, and (b) a de!r.cns~T3ted ccqnni ::mer.t to peripheral rural neal th sE'rvices as a major priority in its he3.l:h strategy.
T'{i -:h the change of gov~.IT'.. .i'nent :'11 ::'974, and the ne',.; acim.L"i3tration '3 thr.lSt to deyelop 3. broad base of support L'l t::e FJIal are3.S, c::his priority emphasis on the further d.evelo-prc.e!:,: of medicine de ~asse through the vehicl-: of the V'5Ts g3.i..'l'J.~d 3.dded """''PcY'':a.'1ce .?:-.:e !!.ost major constr3.ints r~a~ed :he s~e as 'these of-l96~ - the lack of tre.:..ned personnel. and the laCK 0f fir:anci::.l re.;;.::U,!"ces. '~ese overshadowed otter i:::rponant ":echnical ccns·trai::ts .'3uc!J. as logi.:tics, and tcchnica2. considerations reg3.rd.::.ng ~he :la"CUl"e of -:t.e t!'2..i!l:'::g function and the supel"'risicn of secolL'is-:,::s :L.'1d ::la:rGnes. rie'Ter-::heless, the GON's basic policy and .strategy has l''2!!lai..'1ed consi.;;:en:, ~"ell thcught-out, aad actualiz·;,j, lJy priority in the allocation of available scarce r~sources.
B. Detailed Descrintion
The developt:ent of 3IrY health delivery system requires: (1) a recognition of the environmental., social., eccnoo.ic3.l, and. cultural factors ""hich influence the state of health, and (2) the ability to utilize, effectively, per~onnel and material resources to prc~ote and maintain health, prevent illness, and treat overt ii.3ease. L'1 order to ::e effect:.ve, the health deliver'J system must be 3.v:lila'::le, accessib~e~ and acceptacle to the population which it serves. -6-
Ac..::ering to these basic principles, the GOU b~s esta~lished a v-.~"T. l"".ll'al health delivery systeI:l. designed to meet the health needs of the rural poor. ~~e ultimate go~_ is to improve 1;..t low cos~ "':ie ~e9.1th statt.:s of I"':r3.l Nig~ri~s and thero:>by .
inc._""'ase "'\0..:.;...... a ,,,,l';ry .. :;.w...J...v~.... f""I' i~l~'"• _ Ii.=.) • _41 1';'-'"__ '_ QV'T'\Qc_ ... '\.0..; __ ...\J;.I.,L"\,,~, "."roy ..~,.,~'a.nt_ ...... '" mo _'"...... ali":-y)\,J and their c3.~aci,:-r to ~·lort:.. Recogniz';ng "the Lllrlitaticns of "tbe existing health delivery system, the HOl{ 1:.3:3 developed a. Three-Yea.: Plan (1976-78) which ~phasizes the folla~ing objectives:
a) st;engthen the existing health system cOll.!ponentsj
b ) ex~and the geographic coverage and. the population served by this health system.
Consistent with these obj ectives, this pro.ject T..r...ll a~si 'it the MOH ;n establisr~~g an ~proved, integrated health ~rste~ appropria.te to Niger I s resources and rural popula.tion needs. At the time of this ·~iting, the MOR is planning objec"tives for the next five-year period (1978-1982). A"t the end of this period, the Ministr;r projects that the V1rl's ~·lill be functioning in 3,500 villages (3910 of the rural population). Thesp. villages should show scme increase in ~ife expec~anry, iecrease L~ L~fant mortality, and decrease in worker incapacity. • 2. Prl.Jj ect Pt.u::'::los e
The ~urnose af this nroject is to SUDDOrt the MOH's 'greser:t st;ateg'L to i'?'relo"O 3. v1.ab 1 e r'.t!'-ll health· delive:q ::;-,.::; cem ·,.,hich de!:lons"trates the v:L.ue of nreventian, early diagnosis, timely curative ir;:::e!"'rention, 2.Ili vroper referral. Thi3 pro.ject ',rill concentrate its eftOr1:3 L~ ~,o/'O oroad ca~ories: human resource dev~lopment and institutional support.
!n support of the :,leH IS he a.: ~h 3trategy, this proj ect proposes "to: (a) L~c~ase the nunber of health Dersonnel at all levels, and (b) strengthen the pr.esent institutianal system by providL~g additional drugs ~d supplies for VETs, resources required to sustain and support VET activities (i.e. dispensaries and health centers), and resources required. to link the various levels of the system together.
Although the project inputs may be v~ewed as two separate components, the expected outputs ~ill integrate these components to serve t~e project purpose and the MOH's health strategy goals ~hich are targeted for 1982. T5y this date, better trained and more strongly supported V:{I's will render improved. basic health ca.:e to 3,500 villages. -7-
3. OUt..,uts
a. Human Resources -~~ Health P~rsonnel
1) There will be 1,500 trained VF.1s (6,000 persons) ~iho will provide simple '~rev€!ntive, promotive, and cura.tive ~erv1ces at the village leve1.. In addition 13,500 (total number- of vi~lage workers) ~(ill receive retr~ling relevant to the village healtt needs. The increased tecb.nical ability and geographic expansion :)f the VHTs will help the GON ;rcvide 3% cf the village population w:'tn. basic health services by 1982.
2) There will be 500 academically trained health professionals -- trained in-country and/or in third-countrJ institutions - - WOl'king at aD. leyels (national, depa..rt::nen:t, country, village) of the rural deli-:ery system. In addition, 1,100 health professionals will a.cq,uire new skills and Ip.arn ne1-l theories relevant to the needs of the community through continuing edu.caticn programs.
3) The MOR ".dl.l have a group of health and auxilarJ support personnel trained by short-term American consultants III such areas as health administration and plar~g, driver education, budgeting and epidemiological, s~reillance.
b. Institutional SUTIDcrt
The institutional support system (i.e. logistical services and equipment, drtlgs and. supplies, and ~ea.lth care and support facilities) will be streng~hened and expanded throughout the countlj.
1) A functioning 'transportation system, supported by 48 additional vehicles and 200 mobylet~e3 provided under this project, will be responsive to the distribution of goods and supervision tetween the VETs and the health professionals and health care facilities. In additiop, 50 Nigerien auto mechanics and 25 medical repair tec~~icians tra~~ed by U.S. technical assistance personnel will increase the operational efficienC"'J of vehicles and medical equipmen'c by 10;0.
2) 3910 of the rural population will receive improved health car,~ serv:tces due to drugs and equipment provided to ¥iIT's with refer':als to 470 new and/or improved health care faciliti~s.
3) Mobile health units which service all departments will have increased diagnostic and communicabl~ disease prevention capabilities, enhancing the GON's ability to control the spread of communicable disease in Niger. -8-
4) Health and nutrition education programs will functicn in all health centers, PMIs, rural dispensaries and villages served by VHTs.
5)A national environmental sanitation program will function throughout the country and ~-1.l be i!zJplem.ented by 75 Nigerien sanitarians trained by U.S. technical assistance personnel.
4. Inputs,
The followi."lg inputs are required to produce the outputs outlined above.
a. Human Resource Develoument
1 ) Training - $4, 708 , 000
Although the pr~J focus of training is on the development of VHTs, this project will also provide financial support for the development of all health personnel, especially those individuals who are responsible for the supervision and management compone:tlts of the rural health .system.
a) Under the provi~ions of the project, 1,500 \rATs (6000 persons) '..nll be trained to provide 3im:ple preventive and curative services relevant to the needs of their villages. In addition to the initial training session (10-15 days), this projec·; -Hill provide funds for the retraining of all VHTs ever'] t-W'o years (i. e., 1/2 of all available workers 'Hill 'oe retrained per year). Retrai."ling sessions (10 days) ,;.;i.J..::;. serre as refresher courses and will provide an opport1.mity to assess md augment skills and knowledge.
b) This proj ect will provi('!e the opportunit".{ for 25 senior-level ~ifOH personnel (teachers, publ.';.c health officials, etc.) to receive specialized training in third-co~ntrJ institutions in Africa.
c) This project will support continuing education programs for MOH health personnel by.sponsoring one national seminar per year for five years (120 persons for 10 days/yr.) and two departmental conferences per year in each dep~ent (100 persons/ department for four days/yr.). These sessions will ~'rovide participants with additional training in public health care manage.ment and admin.\stration, and techniques 'to upgrade communicatilm and supervision skills.
d) This proj ect 'Hill support ~he academic education costs for: 100 state nurses at the School 01' Public Heal:~h (ENSP-3 y~. progr~); 200 certified nurses at the National School for Certi:f'ie1 Nurses and SociaJ. Aides (ENICAS - 1 yr. program); -9-
and 75 enviro~~ntal health workers at the new one year course at ENICAS. In ad.J:.. tion, the proj ect will provide f'u.."1ds for 175 medica.l students at the :rational School of Medica.l Scien~~ to receive field experience in I'U!'al health care. Funds will also be ayCi.i.lable for the medical school faculty to do operational field research.
2) Technical Assistance for Insti!utiol1e.l~ Support S.Y§~ $3,529,000
a) Th1s proj ect will provide both long and short-tem technical as sistance in the following areas:. 2 auto mechatdcs !ler year will wOl'k under t!le direction of MOH to set up a garage in Zinder and Agadez. They will provide direct service as well as tra:1Jl Nigerien counterparts in garage maintenance and V'ehicle service and repair.
b) One medical equipment technician per yf.~ar ~-11 work with Nigerien and exratriate technicians to set u!l a medical equipment workshop in Agadez and Zinder. Tn addition to provid.i.:lg direct service, he 'NUl train Nigerien counterparts.
c) Two sanitary engineers per year 'Hill assist il'l the development of the MOE' 5 enviror..mental health program. In addition, they will participate in the tra~ing pro~ram for sanitarians at ENICAS.
d) The MOH has requ~sted shor~-te~ consultants (30 man-months) to provide assistance in specific areas such as heaJ.th administration, logistics, etc. The MOH will transmit its specific needs as t~e project progresses.
3) Institutional Sup~ort Syste~ $5~303,000
These project :i.rrpl.:t3 ",·till .3trengt!:~en operational components of t.he VHT ruraJ.. be£1.lth deliV'ery serrice. 'fue basic thrus"t is to support (a) rescuxcesiDr VETs, (t) re!3ources required to sus"tain and support V3T activities (i.e. Qispensaries and health centers), and (c) resources needed to lJ.Ilk various levels o~ the system together for logistiC, supervisory and service p~~oses.
a) Resources of VHT~
This p!'oject will. provide3.ll VHT drug::: and equipment for medical b:Jxes for five years. In 3.ddition, each team will receive educaticnal end aucliovisual materi:.U to be USE,:l for health and nutrition education programs in the villages. T1"..is D.Laterial will be replaced yearly ~ All sllpp0rting hEalth faci.Lities will also be supplied with simple teaching aids on a yearlJ~ basis. ·.10-
b) Resources to Sus'taL"! ar..d SUDDort VHT Activities
(1) This proj ect 'tl:J.l -provide f1lllds to renoyate 220 existing health centers and d.ispensar:'es. This Lrl'put ...... -11. occur in the first year of the project ~~d will ret~nish an~ re-equip existing facili t:j,(.s.
(2) Finances will be p.roviier,: far environmenta.1 sani tation im:provemen+.s in 250 heal tb cer..ters "'_'ld dispensaries. These improvements will be spread out during the fiYe years of the project.
(3) Seven new dispensaries THill be constr~cted iuring the second and third ye~r of the project.
(4) ~HO de~~rtmental centers "~ll be constructed (Agadez 9.D.d Zinder). These ce~te\s "Hill house garages and medical and. oi'fic~s. ,I repair work.3nops, trai.ni.ng centen., libraries DDS 'I
c) Resources to !.ink Various Levels of System Together for Logistic, SUDe~riso.~ ~d Se~~ice PQrDoses
(1) T'..renty-f::ur 4-wheel drive yebicle~ (including spare l?arts at 25% of the cost) 'tl::n be d2.stribU1:ed. betw"een 5-6 denartments as needs indicate. Tbese vehicles w~ be replaced in th~ 4th year rr,6k:.ng a total :i.nput t)f 48 vehicles. The~e ;ehicles Ttlill be '..lsed to transport Jcads 9.!1.1 provide su:pervisoI'Y visits from department to health cen"'::ers, rtll'ril dispensaries and ·riilages. The project "..rill also :?ro'v"icie 100 mobyle"t"'ces to rural dispe"1sary perscTIn"el durin,; tr:e f:'rst proj ect Y'=8.r 'Hi ';h replacemen"t input in the founa year. The GON estic:la.tes that mocylettcs can be used ir. 5C"/o of the coun"tr.r ~o proviie supe~r:,so~J visit3 from "the certified nurses in the !'Ilrd.l dispensaries to YHTs i....",. the villages.
(2) The project "Htil equip tm gara.ges a..'ld ~Ho medical repair workshops in "'::he Lepartment Centers ~ Zinder and Agadez.
(3) This project ·..rill equip mobile health units with vaccine sufficient for 100,000 persons/yr, laboratory diagnostic equipment, and cold chain equipment. The labs ~'1d cold chain equipment 'Hi~ be provided the second year bnd allocated as needed over the next three years. It is &nticipa.ted that the \raccine program will begin during the second year of the project, bu"'c a final decision will be made u~on completion of an ~ssessment of the mobile medici::e progra.I:l during the fiI;t Y3ar of the project. -11-
A. Technic:a.l .Analysis of the G~;eUI!le!lt of Niger's Rural Healti: Strs.~: St!'eng:,ns ar'.d Cor:s"':~~
1. Strengths - ":3ottams Un ?ocus_"
It s eeI:lS pro0<"'I.J.e that the GCN, under exi.stL'1g and future conditions of resource scarcity, has chosen the nost (and perhaps the~) feasible broad strategy for providing/expanding basic heal.th serv1c~s to a far-fllUlg rura.l population. 'The M.OR appea.rs to have a realistic;perception of +he constraints actiug upon it, and a willingness to be self-critical and "c::qer=...:n.ental" in designing appropriate responses to these constraints. Members of tt.e team. have been struCK with 'tne appClren"': 'r seriousness of :?~ose" at 9.11 lev,,::ls in the MOH system., compared to other na:ticnsL'1 si::l.ilar circumstances. This factor ot· '';fill'' appears -::0 mirror s. 3er..u.:L"'!.~ COIlIll".i tment of the current government to ~phas:ze in?raved 3e~ces to tte r~al population. Many nations, :n Africa and elsewt.ere, ~e cur!'er..t~:z espousing the rhetoric of develoIJing broadly-distriGu'ted ::;as::'c health serv:.ces at feasible cost and with available human resources; ":he GON has 3. genuic.e c:ommitrnent to its own version of :'1'.is approach.
Alongside this se!'icus~1es s iJf ;lU... ","?ose, one has to place a high value on the almost tvo j-ecades of :::rpe:-:'ence T;,Ihi:::h the HOH has had in designi..'1g and :..r:.pl~ent::":lg v"i.l2.~ge-b3.3ed ~es.lth activities. While one ca..'1 take i3SUS or. indiviiual -t:.ecr.:J.i:al pci:rts iiith aspects of the aIJproac!1, it is e"rident that Nige:- has a ':Jres.ith and cep'th ct.' relevant experience that is JO: orten found ,~ o'ther .~:-icar. ~o~'1tries, nor ill the tecb.!u.cal er..:ert:'3e of extems.l dOEors.
The HOH has set 3. clear "l.!::i cons:"s ten:' :;Joli~y 2om'se; there are strong argu:n.ents for s'J.:;;portin,; -:he :·1ir.i.3:rj' alcr.g ::he !'oad that it has chosen, eVetl if -::h:'s 'T.ea...J.s ::::li.r:i:n.izir:.g :h.::: mount Cif well-meanin.g (EU:d ':)ossi'o12 accu:c-a::2'ind :-elevant) dcr-or adyice me. technical 3.ssistance to :.h'2 ::!l.oc.es't levels ·tlhich :he ;:'!OH ::..s prepared to accept. The consensus of the team is thac: Niger presen'ts the best opportuni";y in the West Afri.can health secto!' for AD to iemcns:rate its willingness to 5Upport :he impl~e~tation of s. indiger.ous government's own health strategy.
An important difference between the s:.tuation :.n Nig,=r and the other Francophone West African states lies in the fact that the GOI-T has al.!'eady carried out the underlying policy and administrative reform that is a prereQuisite to the effective development of village based rural health services. -12-
Tl:~'.l.gh there are severe manpower constraints a.t all levels of the MC:1;, theiesign team "Nas :.rn.pres sed ~.,ri th the competence of top managem.er.-:. "Wi thin the ~1inist.r'J. Evi.;ience of this includes the "at.-fing~rt:':;:s" knowledgeability of ser.ier >lCH officials ·,.;ith tec.h..:'l1c8,1 9.Ild buc.geta.l'Y :':1ta., and -:..he ri~orou.s schedule:)f field visits (out t~ :he '00 level) t:lB.intained by senior ~10H persor.nel, starti..'1g ,.;ith the Minister himsel':.* L'1 ad.dition, the team ·"as impressed by the competence and motivation of health ~orkers encountered in th~ field. Despite their heavy workloads, DDSs and nurses were enthusiastic about accompanying ~he team since it ga7ethem extn. opportunities to visit VR'I's. T.le team 2...lso obse.rveci one DDS take great time and care to instruct and er.courage several seccruristes while testing their grasp of what they had learned.
At the operational level, ther= a.re additional factors which seem to re~resent strengths '..;1 thi!l the GON health ::;ystem. The first is a significar.t degree of decefitralization ~d local authority at the depart~ental level in such areas as the traL'1ing curricula of VETs) priorities wit~ service c:.eliver'J, etc. 'Eu.:; d.ecentralization fosters innovation and 1."'1.i tia ti 'les fer constructive cl"lar:ge. The design team, during field visits, encountered sever~ exampl~s af such local ~ovatian as traL"'1~ f~ale secouristes, ~'1d de2i~'1ir.g an ir.novative local cir'J.g resupply system for VIITs using "market villages" instead of the dispensarJ_ V3T tr~ining curricula ~e reexamined on a fairly ·~ontinuous basis in :L.ght of loc3.1 r.eeds.
'This iecentralizati.cn f~ctor is ccmbined with an abiJ.ity of the :·10H to be .seU-evaluative and self-critical and to change tl!o..;tics -,.;hen field experience dictates the ·..,risdom of dOing so, Tahoua conferer.ce** ind.!.cates a re13.-'Cively open environment "..d.thin the MOH fox self-evaluation arld r~3ultant charge, The ~rcposed project ~~pu~s related to support of regul~ and frequent Depar~~enta1 and :National semina.rs a.re intended to fur"':her strengthen this atmosphere.
Finally, the fi!'!ll Dolicy of :he ~10H not to ~mgage in demonstration pilot :?roj~cts s while p.reserring locaI flexibility
* The Family Health Care Report: VolUI!le II, Appendices 3 and 8
** The Family Health Care Report: Volume II, Appendix 8 -13-
and variation, ~pressed the design team. ~~ is a real stren~h of the NigeriE:!l he3.l th sys"tem. It reflects a commi tmen"t "to the broad distribution of3e~ces at feasible levels of resource aJ..location.
2. Constrair.ts
T:l.e.re are a ',,;id.e ·J'ariet-J of constrair:t s at various levels that 1'. .1r,der the (':II.:)~; from fu.lly i.J::J.planenting its rural health ,pulicy; the mo~t important of these will be described in thi section of the report. It is the 9pinion of the team that the rtlr!U health strategy chosen by the MOli, and the specific project activities and L~puts proposed for ~ assistance to the MeH in carry~g out its plan, represent the most realist:..c and feasible 'Nay of ameliorating the'";e cor.straints.
I't. Magni ":ude of Heel. th Prcblems
A firs": order of constraint consi3ts of the sheer :nagnitude of the health and nutrition.u problems of rUger's rural popul3.tion. This cont~x: has been d.escribed in previous program documents, especially "the Health S~ctor Assessment*. The overall rural health strategy of the CON re~r~sent3 3. r~al.istic attempt to d.eal wi.th the existing and projec"tec health problems j~ a mzr~er ccnsistent -Nith resource avs.il.abili ty (oath donor a'1d na :ional. reven'..le i'Llr'.ds), and with a delj verj mode wbich reflects societ.al r.orms and C1.lstop"s • • b. Geographi::::/Log~.3tic Constraints.
The vast Lmd are3. of Niger, the scattered village and ncmadic populaticn, "the difficult Sahelian and desert terrain and climate, and the poorly developed c~~ications and trensport infrastructure pose severe obs"tacles to the develo:pment and maintenance of an effective and effi,.:ient heal:h sy3tem~ Personnel C3.;.'1 became isolated frr::n tec~..nica.l and m.a-r:i yational suppor:; vehicles r..ave an extre.:mely 3horl '..lSE:_ ul li.fe; 10gi3tic support and supply char~els ~re diff:cult to create and sustain. In the case of sandy areas, nurses may have to travel by horse, camel, or foot to reach VHTs; duxing the rainy season in other areas, village access routes are impassable. All these constraints are familiar throughout the Sahel. The GON policy of placing emphasis on simple health activities that can be carried out by VHTs at the village level '"ould seem to be the most appropriate and :_... ~ible response to these awesome problens.
c • Sociocultural. Constrain.ts
This important set of issues is discussed in depth in the ~ocial Analysis Section of this report. Although the design of the
*The FW1.y Health Care Report: Volume II, Appendix 1 -14-
VET health d.e1iY~ry system is g~er9.11y thoroughl,y compatible with the socioc'..lltu..r~ m.ilie'l of c;he populaticn, sr:ecial constra:m:s arise in the application of the system to the nomadic populations. It ~as ~IS ini:ial unders"t~~~g that tte GON ~as desirous of a separately iesi&led. project cf :1.ealth care for tl1e .lomads. rtoweve ..:, GON officials !llal.e i"t. cl:::ar to the team that their c'J..rrenc; policy i.s G.ot to progr8lIllJl8. ticall:; s e grega te teal ':h activi 1:i es !'elated to the :1. arn.ad s-:- Rather, they hope to work out "t.he challenges posed by health problems among these migratory gruups as part of the overall nati~nal rural health effort, with,arPropriate attention to r~quirements of local va..rl.a. t ion.
Histcrica.l2.y, there is a cultural and poll tical dis~a.o.ce ·;/ruc..:h ~t!f'8..!·e:.tt:=~ tt..e T"c..a..rs~ 5.l~~ -:1':8 :!:e·~ :'=~:: =.a.:::r 2..S~z:ts 'Jf the GONts establis~ed 30cial service sys"tcms. Because of their ~gratory pattern of l!fe, the ext.ension aI' any t'J1.)e of goverr;men-: service to the nomad.s is both difficult and. costly to i;:nplement. Therefc:;re, health services for these people will. be slowel' to deve:"op and smaller L'1 scale than ~ong the sedentarJ populations. However, it shculd ce emphasized that constraints of tt.e VHT healt!" delive!"'J 3ystem. for the nomads relate more to the :''!lple!:l.entation of the system than to ar;;'1 iuherent social. or cul't1lral i.'::ccmpatibili ty .
Financial ConstraL~ts: Current ~~d ~ecurren~
The additiona.:!.. i!lput of $13.5 !!l.illior- to the ~10H budget aver a five-year ?eriod ra.ises seyeral f:...r:ancial and economic issues of concer.1 to <:he r:roj ect. First of all is 'N'hether +:le central Hinistry personnel can plan, 20ntrol, and implE'men t the j.nter'rentiotls proposed :'n the PP. 'I'lhi:'e the Ministry is short in the nUI:J.bers cf trained high level persormel, panicularly those -.vith ba.ckgroundll in health planning and financing, those pe!'sons who are avai.lable appear to be compete!l-: ':J.n::! nard-work:....'1i. 'T:le design team enco1..U1tered r..c evidence that !"'unis are 'J.Sed :~or purposes other :tan those for ..,,'"hi-ch they are ~te~ded.
The proposed prc:ect activities are all ~ areas where the MOR is presently iIrvol'led. No new budget categories or programs are being created. Presumably, since the MOH has been able to handle diverse financing ranging from centralized ordering and :.r.porting of drugs to student scholarships, none of the interventions proposed will create special financial management problemE.
Rather, 3. small nULlber of the finanCial/management issues will get delegated from the central Ministry level to the Departmental level or below. Decisions relating to personnel, the selection of ~t~dents for health traL'1ing, and the allocation of vehicles - 15 -
by department are ::uade by .:; eniC'r 3.dm:!..nis-:ra tive offic ia.ls of' the :·10H. The dec:"3ior.s r-ade ~": lower l-::vels SUCh::'3 the use of particular vehicles fer ~lg ,:3t~ibution, the timi~~ cf retraL~ing courses, and local. 3upervisio:l of ·constr'J.ction or renovation pro~ect.:; 10 not inVolve 1..IDusual -:asks or pr'2sent of'ficia..l3 with finmcis..l iecisions -.. hL:h they hav:: not ::'2al: 'nth :.n th2 past.
'!':lese constraints, along -..'i th a des i:c~ not to aid to an existing recurrent cost problem, have "played an important part in the ies ign of the "project. ~{!ost of the financing fa.lls und.er human resources developmen·;~. About half of this 'N"ill be for lo~g-term technical a3sistance. D1U'ing that ~er:'od, .?~"':icipants should.. be iientif'ied, sen-: for third-count~J tra.in~~, ~d i-: i3 ho~ed they will eventual.ly replace the expatriat.::;;>. ;{CTwe-rer that '..... i:;..: :1ii, ::.1: most, five senior technicians to :h2 ~1CH payroll "by the ::nd of t~·;o :.rears. Staff' ::.t the lccal 12vel :':1 the DIS offic2 is :let ex::ected -:0 increase in order to hanile the slight::.y h_~her volUl!le of' logist:.c and supervisory tasks. Moreover, a.n :':1crease is :probably not needed. The ma.jor supervi.:;or'J responsibility will clearly fall en the nurses a~ -:he dis"pensrurJ level. The ~1CH decisicn to dcub12 the number of nurses per dis"pensary 'N"as made ,rior to the design of this projec-+:', 2l1d its recurrent cost i.mplications are clearly :for~seen by th:: :·1inis tr'J. The only addi tiona.l recU!"rtmt costs will '.:Ie thos e :'..nvolved TN"i th th2 logistics of reech":'ng VETs for cu;:er"Vis ion.
The assistan:e in the area af logis~ics proviied by additional foU.!'-wneeJ. cI"i';e vehiC':'es m:i mobylett.es '..rill resuJ.t in i.."1crea.s::d reCU!'re~t~os L..:i :;:'or tr.eir mainter.a.nce and cperation . Additional. ~lF.Ts w-i2...l n(,lt add Lrect.::.y to the 01CH "payroll; the e:·:tra cos~s incurred are :"or their "':;ra:....~L'1g, .3uperri.3ion, md ?rG~_sion of supplies. The latter item is r~~he~ ~~~r 3~ce the pati2n~s i:1 ~ost areas pay for Dar: of the cost of the :-.:.ed.:.cations. In -:::e southern areas, the C °hc.arge a.t:lC:l.ln t-...... ,.0 5 C'7~__'"I." (U .::J,-?Jc..'!' ~~) ..._ o r ---0~',{ 91", ...... S ••'lec.-'c' :. a t,'_0 ns ::!ore in t.he northern regions.
e. Centr~ ;·ICH Ca'Cabili ties
While the design ~e~ is impressei ·,.;ith the competence and ser10~ness of senior MOH staff, there are clearly both ~uantitative and q,uali tat:ve :onstraints at the central HOH level. Skilled senior and. middle management "persor.nel are :'.'1 short sUP"Ply, as are lower level per~onnel needed to carry out routine a::m:.nistrative "':asks. The personnel list for the central services and cabinet level positions includes only 20 positions. 'r'dO dore physicians in the "AJ "* category and one each in categories "A2," "A3," and "Bl." The latter category
* These altihabetical notations renresent standard civil service l.evels 'N"i th ","," being the highest and liD" the lowest. -16-
would include t=~th ~ersGnnel Nho hav~ received additional training at CUSS in Y:lour. ie or CESSI :.n. Dakar. ?:'ve ;osi'cions are li.s-:ed at the "B2" level wbicl:. ',.;ould inc2..ude :ti.6..·.n:re.s and st.a-r.e-certified nurses. As far as the ies ign team cou.::..d c.e-cer"..:l.me, paper flow and adminLtl-a.tive routines func"tion reli:~t:'vely effici-=n"~ly. Senior illCH persor..nel, frCl!l. the M.:.nister to :.he DI~pa-rtJIl.en"t Di.!'ectors, make :wpressive efforts to keep in.f'or:ned and i!1 contac-: with health ',;orkers in the fi'2ld by a system of regular md. freq,uent visits that ieeep them on the road several. weeks at a tj.me (the team was shown several detailed. reports of field trips oade~·by sen:'or health officials).
The efficiency of actual policy, planning, and management ::,!'ccesses at centr3.l levels is mor~! :ii.fficult to assess. 'There ap-peu...:..: t\J be a :-ea.J.. eff::;r:. :lad.e to '..!r.d.(~r"':3.k~ "bQttom-l~p" planning and oper~ess of decisionm~g by the use of such oechanisms as field visits, Deyartmental and National Ccnferences, rotation of senior departmental staff :illto central Hinis"7:.r'J positions, de..:ent.raliza :.ion of operational authori~:f, etc. The cur:~ent ~tinister of Health appears well infor.ned about t.achr.ical m~t.ters m,l operations. In conversatior.s ,vi th the Secretary-General, the :Cepu~.f Secre:a~r-General, a:J.d the Division Directors, the team..ru.s impr-:ssed "..nth their :notivati( and ser.se of cammi tment to ~ational gaals.
The team is less certain, but has no definite basis of criticism,. in the areas of financial plannL'lg and 3.C;,,~ ni~.J.ration and logistic supply and support. The n~{ Division of Administraticn and Finunce ·.... as C!reated in January 1977. It is sup1?osed to hand' e planni.!1g 3.I1d pro~ramm.-:ng, 9.c:::!01.l..'lting 2J."1d. .mpp2.ies; personnel, :9Urchasiner and ph::3.-"':l:B.cy. The ~10H has tradi tior... a.lly performed its own feI"'Nard planni.'1g and financL"lg f'JDc"tions, and has shown :nore ability to cond.uct tl::es e f1.lIlctiGns than many other Hi.. ustries in the GON. The f:'nancial planning 3. ..rld "::udgeting process that 'Nas e:qlained. too us invol'res the :10H first alloc3 ti~g it: own avai2.abl-2 reS::lurces against des ired. obj ectives, and. then ,;eeking to fj' 1 ou"'c gaps by requests to external donors; th:'s seems to us to be ~'l approp11ate 9roced~e. (Th~ functions of other divisions -,.;ithin the :1CH are discussed at some length in toh? previous AID Project Review Paper).
Two additional Ministries !'lave roles which have an impact on the ?roject. The Ministry of Finance is pr~ily responsible for the overall Nigerien budget, and pays special atten~ion to the balancing of financial reS01.:..l'ces among a.l.l the Ministries. It sets salar'J scales for Government employees and controls :persoIUlel ceilings for each HiD.istr'J. The MinistrJ of Finance also mmi to::s inputs for specific projects involr...ng foreign financing, and pays speci1ll attention to any i tem:5 entering thr= countI"'J dU~.f-free.
The Ministr'J of Plan was responsible for the d.evelopment of the curren'~ Tr.rs:e-Year ?lan* and is currently working
*The F8l!lilY nealth Care Report: Volume II, Append::tt 2 -17-
on the next Fiv,:--Year Plan. This Ministry ~s technically responsihle for coordination of all exte~nal aii des~ined fer any ytinlst~J. It probably plays a weaker role 'W'i th respect to the HOH than !3om.!: other Mini,stries due to the strong central i,Jlanning carried out by the Secre'tary General of the :.'1CH. In add.i tion, !'esponsibility fo:: coordination of all ~uma.n re.5o'.u-ces plus addi-:ional aJ:eas rests on one individual in the Ministry of Plan. The liaiscn wi ~h both the Ministries of Plan and Finance and the MOR will be handled in future by the newly formed Div: sion of Programming, Planning and Statistics (DIS). The rrew Divi2ion of Finance and Administration "NUl prepare and admiriister the detailed hea.lth budget.
?ersonnelrecruitrnent md adm:i.:list!"ation is hmclled through the gener3.1 Ci"n.l Se!"V1.ce; all posi'tions are buageted for before health w·orkers enter training. VlITs, of course, are not part of the goverm:len't ~e.l:'SoIL';.e:" system. One problem., common throughout :he Sahel, iIrvolves large sal~Jiiff'3rentia1s bet-ween the ,:;over::ll!lent and the private sectors, especially for mechanics and ted'_'1icians. There is a serious leakage into the private sector of these persoI1..nel trained at government expense. A sir.ri.lar problem. does n0t exist -Hi th respect to physicians and r.urses, as the private medical sector in lriger is so small as to be negligible, and private p~actice is not permitted for MOH physicians. • Logis~ic and transport planning at th~ central MOH level (including central control of vehicle and equipment repair) appeared to the team to be a less smoothly functioning area than those discussed above. ~10H officials are aware of this, a fact ~~·b.ich underlies their r~quest for long-tern tecr.nica.l assi.:;tance in the -"ehicle and medical equipnent areas.
t-linistry capabili tie s in :he e.rea of health in.i'orm:;:.tion syst~ cur~ently represent problems thEY ~re tr;ir.g act~vely ~o r'esol""e. Ministr'J ?e!'sonnel and ex,?atri3.te technical assistance perse~'1el (Belgian, Africare) are working to improve collection and utillzation of diseas'= reporting and epidemiologic surveillance. A recent step forward has been the rev1~ion of reportable diseases fram 150 to a more useful and manageable 60 conditions. Examples of use of health a..'1d diE;ease data are attached L'1 Arpendix 9 of the Family Health Care Report, Volume II, Appendix 9 (1976 Annual Report).
It is important that AID recognize and understand MOH policy regarding technical assistance at the central Ministry level. The ~tinistrf is quite clear in discouraging donors from placing resident advisors ~ithL'1 the policy-planning-managecent precess. Stated reasons include: -18-
(::..;; The desire of GON off:"cials to be ill cCIn!;llf:!te control of these precesses;
(2) ~e transient na~~e and ada~tive ?roblems (lingu1s~ic md cul:':.1l.r3.l) of expatriate persennel; a.c.d.
(3) The problems of bala.c.cing d.:i..fferent technical systems and approaches among ad"Tisors of multiple nationalities.
~e MOH is more receptive to technical ad71sors--non-poli~--at • M1nist:y level and ex&:'~ssed a priority for advisors who C&D. concentrate on tra1 ni og Nigeriec ~~lacements for th~elves. ~c;erience of other donors, hO",.;ever, :.nc.:.cates that the "counterpa...'"t problem" is a sie;n!f!cazr: c::e aI:.d. :b.at !.:l tt.e -::a.st, er-at!'iate te-::::"'''lici~s b..9.ve most often =ee~ used in a replac~entis~bst1t;tion ~ol=.
Because of this tec!mical assistance constraint issue, the approac~ ?ropesed in this report ~sts on fcur princ:ples: .
(1) Respecting ~10H concerns and sensitivities about avoidicg the fo~r Censeiller !ectr~aue dependen~J in policy areas.
(2) Providing resident t,echnicaJ.: advisors in specified areas tl:at' the MCH r..as reques~ed -nth ag..""ee!D.ent on stressing the trajn.iog funct:"cn.
(3) Providing ample f'ur..d.s fJr .3hort-te..~ consul tan"': ~~sors to perfor.n .3pecif~c tasks requeste~ by the ~OH, part!cularly in a:eas such 3S logistics, a~istrative and ~~ag~en~ processes, and :nan±;lC",.;er d.eyelo!=!Ilel:l"t:.
(4) Utilizbg the USAID ?r'J~j ect :nanager, res:'d.ent i:l :Uamey, ":0 foster o-pen ~cmmunica"t;:'cr: c~el:; oet",.;een USAID 'l.'J.c. the ~!CH, and ':0 "Hcrk ":0 ::IB.:dmize ":he relevance and iz:::pact cf avai.la.ble lo.c.g- and shcrt-ter!:l. assi..,tance.
t. Ocerat1cnal Health SysteI:l Cor:stn:n1:s
Although the MCH is making an effort to increase the n1lmber of heaJ.th personnel at every level of the health delivery system, the supply' of health professional, pa..ra,..med!cal., and support personnel is still tar below that required to meet national health demands J particularly concerning the r'J.ral population. In response to this shortage, tbe :<10H bas desiglled the VET syste::l to function as an extension of the health services in the rural areas. Trained to provide s~ple p~rentive and curative ~ealth at the village 1 e"'le 1 , the VETs could nave a major impact on the health sta"tUs of the -19-
rural populatio~. Eowever, the performance of the:le teaJrJ3 is tota.lly dependent upon t~e capability and availability of ~he ~ealth professionals ~ the health centers ~d rural dis~ensaries. Appreciating the potf!ntial :ragi1i~J of this system, th~ ~OH is expanding Doth the c:~n~ity (:;0110 nurses per heal ':h center md per:i::..spensary) md the quality (revised ~lSP cU!"ri2'.Llum) of the health profess:'onals.
Based on the information in the Health Sector A$sess ment and a review of curriculum materials*, the technical tra:.nin~ of ~ secouristes and'matrones seems to be relevant to the heal.th needs of the village, and seemi"to require only those slnJ.l.s ·lIhicb can feasibly be hanlled by the ·fHTs. :Iowever, the 'ril~e workers must. be :ont~ually assessed in terms of ~ua1ity of perfo~ce and :he rele,,:mce of their skills to the Yill~e r..~e'is.
Accordi.'1g to the curricula at E?HCA3 and ~NSP** the nurses ~e tecrnically ~ualified to work in the health cen~ers and rura.l dispensa.:.-:'es. Both schools offer courses L'1 -;.mblic health theo~J and practice. The certlfied nurses are taught basic theories of cOIllIIl'Unity health and hygiene, L'1cluding health and. nutriticn eci.ucation. By contrast, tte course at ENSP i3 mo~e ~tailed ~d. comprehensive and includes courses in public health administration, :TI.e'Chodclogy, statistics and demography.
In addition to their responsibilities at the health c~lters anQ dispensaries, both the certified and state nurses participate in ~..b.e training and supe!"vision of the VHTs. it see!!lS essential, therefore, tl::a",:; they receive additional train=-ng it they are to be :ffec:ive tr~i~ers and supe~risors. Equally ~portant is their ability to motivate, encourage, and psychologicall:;· .support ",:;he 'rillage health '.;orkers. Although some nurses appear :0 be highlY:!l.otivated and. anxious to .support the IlHTs, this may not al:·rays be tte case. As a.n. eY..ac:rple of' these ext:'emes, the tee.ID obserred one nurse ·,iho wa.s modifj~~g logistical .strategies L~ order to L~crease the efficiency of his VETs. HmTever, another nurs e ".... as interrie-r... ed yiho demonstra~ ve!"'.{ lit~l~ i:l.terest or sensi tivi ty "::0 the needs of his VHTs. He cri tized shortcomings in perfornance without attempting to uP6.rade the skills of the secouristes. Certainly, any defic1encie~ in the nurses' ability
* The Family Health Care Rep Jrt : Volume IT, Appendices 1 and 4
** The Family Hea.l th Care Report: Volume II, Appendi:( 5 -20-
to train and su-;:ervise ~"'ould seriously affect the effiden::y and success of the '.:IT program. The nurses could most 9.ppr~9ria-:ely receive additicn~ :~~i1ing in all of the aforemen~~oned areas during the de~art'...II:ental \"'vr~shops a.nd. seI!li..'1ars .
.mother consideraoleconst'L"aint lies in the area of logistics e..nd transport. The rural heU":'r, ieliver'J system rep.tesents a cont1nuo~l.S circu.:. t :flowing between the 'Jepar'tment heads and the village te&u. Supervision and support p~ss from the Departmental Health Director to th.e state and certifiE: Distances ~re often grea.t, road~ are poor and in many areas nonexistent. The lack of appropriate vehicl=s at all levels, and of trained mechanics to maintain and. repair vehi::les, plus the high .::ost of gasoline, seriously hampE:.L' the necessarJ support linkages in the present syste:J.. The need to integrate the nCI!lads into the rural health deliverJ system poses particular problems wb~ch the MOH will have to • address at same point. Even if Vlrrs are trained and ?laced, retra.ining) provision of drugs and supplies, snd. superr_sion wi11 still be difficult due to the migratory ?atterns of noma.ds. (for further detail on this issue, see the social 301.l.."1.Cness chapter of this report.) The :wo national hospi -:als (~riam.ey and Zi.'1c.er-) are the best equipped facHi :ie5 in ~Iiger and. g,dmi t patients refer!'ed from all regi~ns. However, these t',.;o hcspi":al.s '.l:'i.lize 30 percent 'Jf all available heal:h ~ersonnel i.1. the count!""J and 15 percen:. of :he cperating budget. The fi.'le other depar":lD.ental hospi~al.3, al:hough rf.:El.2onaoly -,'iell .staffed a.r:"/er, there are eyi;;odic deficiencies in flow due to the problems in management, finance, and transport. The d~sire of the Ministry to remain in con:.rol of its O~1lll direction ;:as led to a reluctance to accept long-term assistance in such areas as health policy formulation, management) and. program. -21- evaluation. Ho~::ver , extensive donor inpu:.3 have been concentrated in such capita: L~tens:ve areas as hospital-based services. Since there is a shortage oi Nigerien physicians, the Ministr! has been more aIINmable to a :-.igh=r leye: of -risibili't'! for donors in this area than in those considered less capital intensi'le. Fina.lly, donors' desire for easily identifiahle projec~s has led to specialization by either geographic areas or service areas, creating the potential for isolation and lack of coordination of donor activities with the overall GON ~fstem. 3. Summar! of Strengths and Constrain~s' The project team has attemp~ed to list the constraints of the preser..t health deli~er"J syste1Il. in Niger -,ii th a fair degree of specifici -t-J, aliuN'ing the reader an o:9portunit"J for infor::J.ed opinion. Many of ~he constr~~~ts contain oitiga:ing statements; these should not be interpretec. ~s apologia. They do reflect, ho-..rever, +;he convL::tion of the tea.... that :hese constraints are not disabl~g, nor do they preclude an investment by AID which can lessen than considerably while ~t the same t~e stre~gthening the GON's capacity ~o extend health services to more people. As viewed by the team, the major strength of Niger's health ielivery system. is the administrative refor:n ,..,hich has allowed a village based str~Hegy to be ~ple:men~ed. ~fni::"e this refor:n is 1:1 national strength, it. could ::e vie~.;ed direct policy/program -influence through the placement of expatriate technic~~ perso~~el. Present strategies in most W~st ft1rican countries, a3 Ne~ as in ~any other less developed countries, are based on the classical concept of pyramidal organization structures in -..rhich res:90nsibility, decisicl"'.J:l.e.king and action rest -..nth the top md :1ot the oo-ctom of ':he pyramid, causj.ng a phenomenon of cOI:.~entr3.tion ane:. centralization. TIl:"., is in fac': dimi...'1i.shing Ii ttl: by little in most ccun~ries. A tendency :oward. increased decen-:raliza~ion icplies ~hat the per~eived needs of the population and the~~ prioriti~s are determlr.ed as a ~~ction of services and personnel having theoretical and technical expertise. The team emphatically feels that this administratj,ve reform is '",hat oakes heal. th deli very in Niger different than in ~r other countries; it makes possible the extension of heal.th services to a dispersed, ~~ral population TNithin the societal value structure of Niger. AID can play 9. signal role as a donor by supporting the applice.tion of this refonn and then streng':hening the GON's cammi tmer.t to equity in service delivery to all its citizens. -22- B. Financial Analysis and Plan --Int l'O duct i on The financial. s01mdness of this project is based on a number of issues. The cost-effectiveness of ~e specific inputs and the project as a. whole ar~ shown in the economic anaJ.ysis. 'The cost estimates tor inputs and outputs are summa.rized in the tables at the end of this section. , Because this is a non-revenue producing proj ect and contributes only indirectly to increaseci prcductivity through improved health, the most critical financial i~lsu~ fo!' the project is how the GON will continue to fund the recurren~ cost. The analysis of the abUi t"'J of the government to support this proj ect and continue to fund the recurrent cost after the official termination date is based on t':le financial ~oundness of the GON budget in general and the health budget in pa.":ticuJ.ar. 1. Niger's P.~blic Fino.nce 8itllation a. Revenu~s and Exnp.ndi tures During the drought period in Niger from 1971 to 1974, total pL',blic expenditures declined in real terms from the prior' period .. By the 1975 fiscal year increases in uranium revenue and other taxes due to the post-drought economic recovery had increased total c~'rent revenue by almost 50 percent. The Treasury was then able to restore IiL~ds dra~\ down from its deposits with the Central Bank. By the next fiscal year, 1975/76 expenditures grew more rapidly than revenue, resulting in a decline of the overall government surplus, to 1.5 billion CFA from 3.6 billion CFA the prior year. The TreaswrJ was able to retain a healthy position of 3.1 billion CFA as reserve. . Total central government revenue grew from. 13.5 bill.ion in 1971/72 to 34.2 billlon eFA in 1976/77, or at an average annual rate of growth of about 17 percent. Growth in reven.ue tended to keep pace with the economy but without ~~ actual decline during the drought years due to the external budgetary assistance during that period. Eighty-six percent of total revenue came from taxes in the 1977 fiscal. year. The 1f.l.I'gest component cC'nsisted of taxes on goods and services, the second-largest of taxes on income and profits, and the other large item of taxes on international trade. Non-tax revenues consisted mainly of property l!lcome. -23- During the fiye years, 1971 t<.) 1976, central government curr~~~ expendit~es g~ew at an average annual rate of 15 pe=ceni:;. As wi"'::::' revenues, expenditures increased most ~a.pj.dJ.y during the last two years of the period. The present government has adopted a conservative fiscal policy, maintain~ng the ~at~ of growth of current eX?endit'..u-es below that of current rev~n"l.e in order to increase t.u.:.- gov,,=rnmenT. contribution 1:') investment financing. A ±i..m.ctional analysis of the breakdown of current expenditures ls shovm in the following ·;:able. The sector receiving the largest L'1.crease in allocations over this t:ime per~od was education, wi":h part~.cu.la~ ~phasis en higher education. Health is receiving SOI!l.e share of this s:L."lce the recent establishment of the HedicB~ School ~t the wniversity of Niamey. It should be n~ted that while health has been receiVing about eight percent of the cur:rent expenditures throughout the period, the -.'mount increased from 970 million to 1,883 Tll.lilion CFA, al~ost doubled during the six-year period. The half of central governme!lt expendi tu.res going to general public se:rrices is higher t;,;an J:cs share in othe:c Saheli.a.n countrie~. About 80 percent of tbis goes for gene.tal administration (or n.on-sectoral ministries and activities), the remainder fo~public order e..D: . .1 safety. Relative to other 313.b.elian cotmtries) the percentage deyoted to defense is 10',0/". An economic analysis of the centr~ government· expendi tures c.uring the period 1971 to 1977 revealed that the m(lst rapiclly growing expenc.i. ture i te::lS ~o{e~e subsidi~s and other curre;l"t transfers, mainly due to support of the parastat1.J. sector. The largest item in the econcmic bre~~d~~ is expenditures on goods and services. The major item in this categorJ is for ~erscr~.el, and the ~hare for personnel has actually declined as a perce:rt of total cur:rf;!nt cxpend.:l tures aver the six-year perioc.. Civil ser'rants onl:r r~~,:~~ived one pay .caio:e. in Januar"J 1975. tebt service has increased f=om 379 million CFA to 1,499 million CFA and now compriSeS eight percent of the total cur~ent expendit~e. Hcwever, reports of 1977 estimated that only a quarter of this consisted of external deot serv.tc~ng sj,nce most foreign aid has been as grants or low-i~terest loans. -24- TABLE 1 NIGER: CENTRAL GOVEF.NMENT REVENUES &: EXPENDITURES 1971 - 1977 (In Billions of CFA E'rancs) 1971L,g, 1972/3 !mi~ 1974/5 1975/6 !,976/7 Total Current , RevenJ.e 1~.1 :2·9 13 .3 20.0 24.7 31.8 Total. Current Expendituxes 11.5 12.3 13.3 15.3 20,0 23.3 %by Functional Classification Gen,;~ral Public Services 51 48 49 45 47 50 Defense 7 7 6 8 8 7 Education 15 16 18 20 20 18 Health .8 8 8 8 8 8 Comm. & Soc. Serv1.ce~ 1 1 1 1 1 1 Economic Services 8 8 7 8 7 7 Un~oca.b1e 10 II 10 10 -2 8 Total %* 100 101 99 99 99 99 Plus r:entra.l Govt. InYestment Exp en cJ i ture 12.4 2.8 2.7 3.5 5.4 10.9 Total Budgetary F.xp~ndi tuZ'es 13.9 1.5.1 16.0 l.B.8 25.4 34.2 *Rounding Error -25- The 1977 na:tional budget fer iIiger has been broken iown Oy the amo~: l:stEc :0= each ~i3~~J er office. ~e ?erce~tage share received. ty aach ministrJ cr effic,: is shewn ~ the fcl2.o·.... i.."1g table. The large sm.ount aJlocated. ':('1 the YJ...."li.s1:!'Y of Finance is because it includes thl~ followi.::.g Dud.ge1:3.I"J ca:,egcr:"es: Fonds National Dr I.."lvesti.s.:: ement (?NI) SalariE:s for a1.l mid.dle ani lower-level ;'governmen t· wor~ers Purcl:.ase of certa~ ·rehicles bel.l"'I'lging to v~ious ~~3tries Construction and. upkeep of certaL"l governme:lt buildi..:';.gs Public debt Contributions "'.-0 international bf')di~~s Support costs for e}..l'atriate technicians .J) 1 L"l FY 197 , the MinistrJ of He~th received 1,162,900,000 CFA $4,746,530) fer llO fo~ign tec1:.:."licians. The GON average in this categoI"J fer. FY 1976 was 1,168,750jOOO eFA ($4,770,408). -26- UBLE 2 NIGER: PERCENTAGE SHARE OF NATI0Ni.L BUDGET RECEIVED BY SELECTED MINISTRIES OR SERV!CES, 1977* -Item %of Total ~~t Received Finance Education 12.2 Public Works 8.1 In.terior 5.8 Health 5.5 Defense 5.1 Rural Development 3.4 Forei.gn Affairs 3.2 Plan 3.0 President's Office 1.6 Sub-total 89.6 Other ML~istries and Offices** 10.4 100.0 34.2 billion CFA *Source: Niger National Budget for 1977, pg. li. ** Ministries and offices each receiving less than one percent of the budget include Con~eil National Developpemen.t, Commtmi ty Affairs, Information, Youth and Sports, Justice, Public Affairs, Economic Affairs, PrI' and Mines. -27.. b. Investm~'nt Ex:::endi tures « ~-1cst centr---1 government investment excendi tures are disbursed through the iTatic.na..:. L'westment Fund (FNI). A proced.ure of ea.r.narking specific reyenue sources for the FNI was used until 1976; since then the policy has b\~en to tr-a.c.,sfer from the general budge"t to the FNI an amoun"t of resc.1urces equivalent to the revenue derived from uranium. Large-scale mini.r:g of uranium was started in Niger in 1971. Uranium production and. receipts have increased steadily since then. Receipts which amcllnt~ld to 1.1 billion CFA in 1974 rose to about 4 billion C?A in 1976 and to about 8 billion in 1977: and a recent report estimated revenues could reach 12 billion CFA i!J. 1978. In 1978 the FNI appropriations were eJ~ected to reach 13 billion CFA, an increase of 63 percen-: over -::he prior "'lear. The total bild.get for 1977/78 '.ias proj ~cted to reach 43.4 billion CFA, r:.a.king the FNI proportion about 30 percent of "the general budgt~t. It ':'bould. Leo nutt:~ tli.d.t pr'.:ij-:::ct3 dir~ctly financed fram foreign aid sources are not included in the central govern:nent investment expe~ld.i tures as shown in "the prior tabl:.. The distribut:.on of investment among sectors has shown considerable stability ove.r the six-year period. About ~O percent has been spent on infras"tructuxe: roads, bridges and water supplies. Human resources s~cn as ed~cation, health"and community amenities has been receiving on increasL~g shau'2, from 11 percent in 1974 to 26 percent 1.'1 1977. Admi..'1i3trative infras"tructure has received about 20 gercent, and the remaincler has gone to yarious projects in pa..voticipat:"on with foreign aid loans. c. Future PYOSDeC~s « 'The grossiorc.est::.c product of Niger de!,ends hilivily on the rura2 sector; 3.gricul tur'= ar..d ncmadic lfcrestock raising provi:ie a livl'?:ihocd for rr:.os-: ·of the population and account for about half of the gross domestic product. Under ,10r.nal weather ccnditions agricultural. prodnction proviie:. more than half of the ccuntI"J's export earnings. Witllou-: any dramatic climatic changes the agricultural situation should remain s'f:able. External as s istane~! has long been an important component in Niger's balance of pa.yments. The largest component is given in the form of grants. Investment aid. and technical assistance are particularly important ~ Food aid was important during the drought but was almost phased out by 1976. The principal development aid providers have been Trance, West Germany, Canada" the European Community, 1J.NDP and raRD/IDA. Arab countries have assumed increasing importance recently, as has the United States. External as,3istance is of great importance to the health sector as ~...J.1 be seen short~. -28. The future cut~ook for the GONls financial position seems qui~e op~~-"sti~. ~e ~~cr=asing procu:tion and revenue fram uranium and ~xte.r::al d.ssis~a.r.c'? iave cre'l.l:ed. f:,s:ll sti...""Pluses. This has enabled the Gove~~ent to adopt a more liber~ :'~ves~en~ program tc trj to increase procuc:ive expen~~ures anc :0 re~s~ribute incam~ to lower-income !5ro1;.PS, :!:: ~an be e:qJected that the ratl".er conservative financial manag~ent polici~s will be conti.r..ued. '"i. th current expenditures beL~ kept in l~~e ~ith currer-t revenues exclud~g those revenues derived. from uran:~. Ex0ernal. debt se!"V'icing should not be a problem in the next few years ',.;i ~h continuaticn of similar f::""'1.ancial. policies. The question appears to be more whether the GON can carrj out the planned expendi :ures under the ~TI with the 3ubsta.r..tial growth L'l the inves-:mcnt bu~et ',.;hic!J. has occured. ::....~ the last two years. 2. The Rea:. th Bl.:daetg for Nizer• a. The Hea.l:.n Budpe~ ?.~la~iye to "the Ha:.ional. Budget During the five-year period 1973 to :'977, the health budget for the :VICR ~creased i.~ size by 05 percent frsm 1.018 billion eFA to 1.882 biD.ion, cut re!O.a...i..ned. a s1:ab1~ c~~ of total current government ~xpendi~ures ir. a breakdry~ by functional c~assificat~cn. The role '.ihicn the ?NT 9lays in the total health budget is rapiq becoming r:J.ore ~por:an-c. In 1973 only 5, oeo, GOO CFA or 0.4 percent of the budget for heal~h came from the fl'IT. In 1976 the ?!n allocated 120,~5C,OOO eFA ~c the MOH. ne nIT 3.l.2.ocation for health is expected to L~cr'2as e in 2.977 to 451 rr.i.ll:"on CFA ~ or more than a threef:1d. ::""J.crease in one Jea~. ~'lost of tt.e FNI fu:r:ding is to be used for rur3.l-based cons:ruction ofiispensar:"es, '3.rrondis3ement medical centers and :natena2. ani ci:"li health c~n1:er (::¥...I'.3). 'i'he ir..creasir.g proportion of the ~1U f'J.1lding ',.;hi,,!J, is being gi 7~n :0 the ~'IOH establ:"shes a certain gov~rnnen:al _ .:"ority. I':le 1977 allocation is 5.6 pe~cent of ~he total ~IT allocation. If the n:TItJudget a.llocations rema.i.. ..1. at the 13 billion CFA foreseer. fo~ 1978, and :'f the ~IOH continues to receive 6 percent, it can expect to receive about 780 million eFA 1.1. 1978. b. Other Denor Assistance Outside aid to the health sector plays an extremely important rol.e in the Nigerien health d,c:liver"'j systeI!l.. The amotmt, source, and brief description of all exteI'rJal donor assistance is shown in the tables in Appendix S. The projec~s listed on the tables have been differentiated into th~se targeted maL'lly towards rural or urban areas, and also into multilateral versus bi1ate~al assistance. External :lonor ac~iYities which started and ended in the early se'lfent1es have been ami tted from the tables. The 'Talue of ~~lc~e proj ects amounted to le3s :han $30, COO. Of the external (1976) aid one-third -29- was in tJ::e fem of bilateral assistance and two-thirds was multilatel'aJ. as~:'stance. External assistance totalling $78.7 million is listed for various funding periods, the earliest date shown being 1963 and same ru.""..d.ing being carried for:.,ard to 1982. It is not possible to arrive at a specifi~ amount for 1977; ~~wever, the fi~~e of $13 million, which was the to~al for 1976, is not an unreasonable one to carry fOrNard per annum, and thE' trend 3.ppears to be fer external. funding to be increasing rather than decreasi.'1g. '!ABLE 3 External AID to Health Sector Summary Table (See Annex S for detailed lists) Amount Total Amounts RuraJ. Are as 1276 $' s Ob1isated* ~ BilateraJ.. aid 4,310,560 l22, 746 ,216 Multilateral aid 2 z701:236 46:3872154 Sub-total. 7 zOl1~ 796 162:1332370 Urban Areas Bilateral aid 727,362 3,325,927 Multilateral aid 5 :8'T5,4C6 11,961 2974 Sub .. totaJ. 6,602:748 15,287,901 GF.A..~ TOTAL 13:614,564 184,421 , 271 (1) Rural Health External Aid Of the $13.6 million coming from external. sources in 1916, about halt was allocated to projects affecting rural areas. This does not reflect the same emphasis as the nationaJ. hea1tn budget where two-thirds is estimated to be snent on rural heal:'h. services. In the ruraJ. sector J a.l:nost $3 milli;n of t:.e total of $4 oj 1 J ion came from three bilateral projects. German aid is being given to provide personnel including five doctors who are essentially based at the hospital but who also work ...ri th village health teams in the Ta.houa *(unspecified time periods involved, but all on-going) -30- Department. ~e French gave almost $1 million for staff assistance (mainly to :-1obi12 Medicine), equipment and scholarships on a national basis. Beeinni:J.g in 1976 Canadian Universities I technical services (sueo) assisted tee medical center at Zinder ·~th persor~el and commodities ·~.th almost $1 million. Multinational assistance to the rural areas amounted to $2.7 million, over $2 million o~ which came from FED for construction in rural areas, both of dispensaries and arrondissement medical centers. All of the rural assistance with the exceution of the Africare Project~in Diff~ Department can be looked upon- as com:plementarJ to the inputs proposed in the PP. In the Africare Project three components overlapped 'Nith those listed: the technical assistance for automobile maintenance, repair and ~tenance of medical equipment and the vehicle component. The PP has defined its inputs as beL~g cor1ined to the other sL~ Depa-~p.nts. L"l the rural a!'eas, OXFAM gave assistance in 1976 to the establi~rrment and training of VHTs, but the money was for a ~ingle year, was not continued in 1977, and there have been no indications that future funding is contemplated. (2) Urban Health External .~id • External aid to primarily urban project areas totalled $6.6 million, of Ttfhich only 11 percent came from bilateral aid, the rest from multilateral projects. Therefore in 1976 aid to urban areas appeared to attrac~ about the same amount of money from external donors as rural health projects. The GONls priorities are currently clearly more in favor of rural health expe."'1ditures. External aid obligated frc..'IIl all souz'ces for f'uture expenditures is heavily concentrated in rural projects. Two large multi:ateral projects prov~ded the bulk of the urban funding. The Ai'rican Development Bank g3.ve $4.8 million ~o be used for the construction of the Medical School buildings at the University of Niamey. About $1.4 !:lillion cam from FED and was allocated toward buildings for the National School of Public Healtl" in Niamey and hospitals in Maradi and ZL'1der. Coordination of external aid projects with the PP should be carefuJJ.y worked out since several areas could be camplementar'J to the planned inputs. Tne role of the Secretary-General in the Ministry of Health includes coordination 0:: all external aid and he spends a considerable runount of time and effort on this activity. Even beyond the formal Ministry coordination, some dovetailing of specific activities in such areas as nutrition education could enhance the size and quality of several donor programs. -31- c. TotaJ. Suo'Oort to the HeaJ.th Sector Identif"Ji.ng the total amount going to the total health sector budget is not easy. In the 1976/77 fiscal year the MOH budget fi~~e given ~as 1.8f~ billion CFA. To this should be added on FNI planned investment of ... 51 million CFA for rural. health buildings. The budgetary item of 1.163 billion CFA for support for expatriate health personnel did not appear in the MOH budget and is pres,umec. to be addi tive. Of the l2l million CFA for the School of Med:.cal Sciences 86 pi] J j on appeared in the Ministry of National Fdur::ation (MNE) budget, but should be added to the health sector support. The analysis of the other donor assistance for 1976 gave a total of $13.615 million or 3.4 billion CFA. Of this admittedly about 60 percent ·wa~; going to building programs ra.ther than to the operating budget . .lUI the above extJenditures add to a total of 6.865- 1 billion CFA going to the public uealth s~ctor budget during one year. The size of the private health sector was not estimated but is tlnlikely to be over 10 percent of the public s~ctor. d. Analysis of Health Exnenditures The breakdown of the NOH budget into personnel versus materj.al and operating costs shows that personnel has taken about half of thf~ budget during the period 1973 "to 1977. The most recent figure was ~6 percent. An analysis of the health budget for Togo for that year showed personnel costs amounting to about three-quarters of the total health budget. In Senegal. usa the proportion a!Jsorbed by person.'1el costs is much higher . With only hal.f the health budget going to personnel, the MOH L'1 Niger has more flexibility than same other Sahelian countries. The total amount s~ent on administration (which includes the cabinet and central administra.tive s€,rrices) was ve.rJ modest, only 46 million CFA. Of this about L~O percent constituted personnel costs, and slightly more than that for transport, reflectir..g the hifh costs of supe.rrising a large geographic area with mainly low population densities. It should perhaps be noted that salary levels for senior !tinist.rJ personnel in the MOH are modest, the highest paid official earning under $9,000 per annum, and the second highest under $5,000. Of the 24 persons who make up the professional staff of the Cabinet, only ten earn ,salaries of aver $2,000 per a.nn1.ml. Expenditures list~(c_ in the hee.lth budget for paramedical training are for the National School of Public Health (ENSP) and the National School for certified Nurses and Social Aides (ENICAS). For both schools the total annual expenditures amounted to 51,126,000 eFA -32- or a modest 3 pe~cent of the health budget. The Medical School at the 'University 0:' Niamey :'s the eXIJensive item for the heal'th education progr..m. For the :'976/77 fiscal year, the ~IIOH contribu'ted. about 35 million CFA or about ~O percent of the budge't. rne MNE was paying the ~a..lance of acout 26 mil..:.ion, gi~-Lg the School of Hedical Sciences a to'tal budget of 3.bout; 121 miiJion CFA. T::e figures for the 1977/78 fiscal year involved. a planned budget of 43 !D..i.lli.on froIL. ~10H and 70 :nillion CFA from the MNE or a total of liS m.1llion. The Medical School budget is still comparatively modest, but experience in other Saheli~~ countries would suggest that it can be expected. ~o i~crease rapidly and use a substa:J.tial proportion of the nat:'onal health budget s Expenditures for medicine in the he3.lth budget for 1977 amounted to 476,700,000 CFA or 20 cents ~er capita for medicine, about 40 percent of which was used in the ~wo n3.tional hospitals 3.t Niamey and Zinder . Hospital se~ces, ilOwever 'tMe a modest percentage of the health budg~G compared with oth~l' West African cOill1tries. Bxpanditures for transport were also relatively modest, 207,950,000 CFA and most of this consisted of the expenses of delive~-fig care to rural areas. while personnel costs only accounted for about half of the total MOH budget, a lower amount than for many Sahelian countries, this does not present the total personnel picture. Only 28 of t~e 129 dGctors and dentists employed by the MOH are Nigeriens. Another 30 are foreigners employed by the MOH on contract, 12 of whom '.fork ::n the bro national hospita.ls. Seventy-one foreign physicians and dentists are provided through foreign technical assistance, and thus a.re not listed. on the MOH budget but do appear on exter:'lal donor assistance tl') the health sector. Support costs for expatriate techniciar..s to ::over housing !,".=nta.:..s, i'urnish:"ngs , utilities 3!ld transport are :najcr :.. t2.:!lS ef E~xpendi ture fer the GON. Support cost,s for expatriate tech..'1icians were first listed in GON f:"scal year 1976 when the MOH ~as allocated 1.163 billion CFA. Senior MOH of!icia.ls stated that support costs for foreign physici~'1s located i!J. N:am.ey aJ.tl.ounted to about $40,000 each. It is clear that P,':"O"v"iding tecr..nical assistance without support services is extremely expensive to the GON. Every attempt to accelerate the p9.ce at which Nigerien health personnel can take over from expatriates means much lower costs per health service rendered. Urban vs Rural Expenditure 5 The internal MOB: budget is weighted in favor of more rural expenditures, reflectL~g the general pclicy commitment of the Goverm:J.ent. of Niger. Uroan expenditures are defined to include the cabinet and administrative overhead, all medical and nursing school expendi tuxes, and the t-..ro national hospi taJ.s at Niamey and Zinder which can be considered the tert:"~J care centers. Similar guidelines are u,'Jed to differentiate rural and urban expenditures by -33- foreign donors. Eawever, it is not possible to ~ake a clear distinction betweo:u. urban ac_-:' !"Ul'al heal tn eX?encli tu!'es. It should. be recc~ized that must stud.en,:s graduate and go to ~.;ork in r'J.!'al areas, urban people !'eceive care atiispensa..!'ies loca"ted in "the urban 9..!'eas, and rural persons often get referrei ':0 ur-oan facilities. e. Reaurrent Cost Recurrent costs have to be of concern to a country where signii'icant dC.!J.or assistance and large numbers of expatriate personnel have been necessar'j to develop and sustain a functioning health ,:'eliveI"j system. E:zteI'!1al tecr..nical tid has been J:.ainly at the most senior 1e,el, usually physicians. neplac~en"t 'Ni:l be gradual, bu~ ',olhen the GON h2.s to sustai..'1 an 3.rulual support cost per tech."lician of around. $40, COO, and. '.. hen the highest-paid ~OH physici.an has a sala.ry of $9,OCO, the transition shouli ::o't :place fi!1a.r..cialcurdens '..rhich the ~'10H can not afford. Suppose that; at the end of five years the GON could repl:lce all 110 foreig!1 technicians with Nigeriens at an average salazy of $6,000. T"'~s ',fQuld actual.ly result ~ a net per ca:;Jita sav"~g of around ~34,000 per annum, since suppcrt costs for MOH officials do not include 'the ver'J expensive housi..'1g compcnent. Personnel costs at the aid-level for nU.!'si..'1g staff '.-Till increase over the life of the :project but not by large sums of money. At the VHT level the persor~el 9..!'e working on a =ainly vol~'1taI"J basis (c~tcmalY gifts may be donated 'rJy pati~nts), but they do not ac.d a financial bU.!'den tc the MOH except for traL~'1g and retr~ing costs, both of ~hich are modest. ~e expec'ted recU.!'rent expenditures ~hich will be incurred by the rv1inistr'J of Health i.r.. I'Tiger for tve ye'd.r follm-ri..'1g the phase-out of this project are detailed ~~ T~ble 3, Pnnex H. At that time, there -..till be 6, ceo te~ ·... arkers half of ·..rhcm '..rill requi.r.e a..'1Ilual retraining. In ac.diticn, there T..rill be ar.pro:c..ma~ely 20J graduateS from ~TICAS, a.1.l o~ ,.;heI!). are assUIlled to be ~-rorking in t':e rur3.l. areas. This ;-rill be suff:!.cien't to 3.l.J.ow for two nUl'ses in each of the 2.70 ~.spensaries. There '.-Till be an additional fift;y graduates from 'i~he School of Public Health who wi:l possiblY be placed ~ rural hea.l~h centers ~d in maternities. The new categorJ of sanitarj engineers being trained at ZNICAS shows about 75 stUdents who will be .serving to upgrade envircnmental sanitation cf1..iefly :i.n the rural areas. The total additional cost c,f the personnel trs.ined under the project during the sixth year amcunts to 263 million CFA. The additional personnel would constitute about 30% above the present personnel budget (includ.ed in both the MOH and MOF Qudgets) of 863 million CFA. The sum of 863 million CFA represents combined personnel costs. -34- Some simplif'lJi,.'lg ~.ssumptions have been made. .4.11 @:r~ .. t.1 a. tes und.er "C~e proj E!ct are as sumed to be ~-lorking exclus i vely i= -+:'1.: rur3.l. areas. It is C\lso a..:;;sumed t~at there will be no dr'Jp outs from any -par"': of the training program prior to compl~tion of project activities. Furthertlore, 3.ll graduates trained will ';:Ie given average sal.aries r'Jughly comparable to those at present. A moc.est 5% can be expected to' oe promoted in the system or go on for furth~~r training. Ivshould be noted that the extra 1,500 villag'.! health te~ trained under the project should more than double the present number of ~-1lage health teams (1,263). The new coverage afforded under the project should reach over 35% of the rural population. With the only ~ual costs being training, estimated to be 15,000 CFA p,er team :nember, this II'.?thod is clearly the lowest cost of delivering h·e3.l th C:i.re to these 1 - ':":'g in the r'J..!':ll areas. Salaries to the 'lIlTs ':'0 not constitute "" ,L'ecurrent cost as VHT mE:Il:.bers serve on 3. -roltmtarJ basis .. The technical assistance proposed under the project is modest. Therefore, there will be only modes"j~ increases 1.'11 personnel costs upon completion of the project. If the auto-mechanic trainers can train three or four senior auto technicians or those more s.enior, their annual salaries can be exp~cted to average about 600,000 eFA ($2,450). They will not incur the overhead . e}"pens es occasioned by utilizing expatriatest Support costs incurred L'l utilizing expatriates generally averages over $45,000 per technician and are included in the budget of the Mil'listry of Finance. The medical equipment repair counterparts will earn similar salaries but the costs of sendi...'lg s\~ch equipment by air to Abidjan, Dakar or Europe for repair ~.,rould bt? avoided. The sanitary engineers will ha.ve at least t-..ro counterparts follOW'"-Ilg completion of the project. These -Hill be able to i..'1cur the double I'Uncticn of teaching the 15 students in the special sanltation/ ellvironmental program at EllICAS and provide guidance to the Minist:-y of Health for implementing its new prograI:!. in sanitation. At the conclusion of their tours, the sar~tarJ engin.eers should leave behind a cadre of trained stUdents and counterparts. It can be conjectured * It should be noted that AID tec.hnicians require minimum overhead support from thP. GON. PersonaJ. support costs such as housing are borne by AID. -35- that the beginnir.g classes at ENICAB !!lay contain qualified Nigeriens who can utilize ad.di tional tra:ini..'1g following completion of their cou..rses at ENICAS, tb'.lS the MOH may incur same addi ~ional training costs w~ich are not anticipated at this tine. Hcwever, the Government of N~ger ha.s begun budgeting for just such an eventuali t:'J beginning in FY 1982. A great deal of other dcnor assistar.ce is in the areas of building and construction. The edt:.cational buildings are alrea.dy staffed tr:r teachers 0 No big hospital buildbg program is planned. There :1.s currently a./lull in the dispensary bu1l.ding program. The building program, once completed, is unllkely to make major recurrent cost demands for personnel, and upkeep costs are modest on new buildings. The area of transport mEY be of same'lI'hat more concern. Few donors ~~pear to be interes~ed in major tr~1sport inputs. Recurrent costs are extremely high with short vehicle lire, expensive gasoline, .4J-4 ~ .. ,~ .. .(,.., "''ht~i:'1g ,."' ..... e -" ... +~ and "'oero/'J ..... a.; ... ". ... ,..,,,,,,h,,, ... "; " ... dif•• '""'~""'J .-..... v.., ~,tJ...... l:"u.o.. \JW, .t'..."" ~ .... '-u. "'"""'_"- ...... "-w with a high turnover rate. Yet the transport cOl~. -'lent is vital to the supervision of the rural-based system. If the MOH uas to pick up both the ve'~cle purchase and operating cost componen~s for an enlarged transport system, this .~ greatly increase beth the size and proportion of the total MOH budget going for transport. The procw"en:.ent c.f vehicles, mobylett':.Q, dxug!~, and educational aUd."to-visual material are all designed to bE! supportive of the health de1ivery system being pursued by the C'rover:J.J.llent of lUge? at the lowest level, Le. the village health team, The .:::lodest construction elements proposed undel the project also are designed to support these personnel or to assist with their tra~ning. Other dOD.or support t'J the health sector 'ru~ likely continue at about the same level. Alre5:.dy i'unc..s 3.r.f! programmed ahead by SCJllle donors to 1982 or beJond. It is Lmrealistic to think that they '..rill suddenly c:lrJ up. The MOR has done a good job of directing funds into a health system. which is low ce::.;t. Urban health has received a lowe I' priorit;y than in m~y Sahelim countries, and high-cos-c tertiar.r h03pital components of the .r..~a:.th system are not over-emphasized. Delivery of health services at the 10': Gi ven a contin.uation of the present boom in uranium revenues and continua.tion of the GONis increaSing support to the health system detailed earlier in this section, the MOH can manage the ~d1 tional recurrent costs generated by this proj ect. This is not to say that donor assistance will not be required at the end of this project. At that time health services are projected to reach only 39% of the rural population and external assistance will stiJ~ be required to eXDand and :il!lprove health services. -36- 3. Prcg!":l:1 Buget Data: Uni t Cost Calcalations a. Eu:an Resource Development (1) Tzoa.i!licg (a) Third-country pa...~icipa.nt training (in Africa) $10,000 per ~~-year x 5 persons per year x 5 years; 1~ 1I:l:f'lation per year. (b) In-CO'lmtrj contin~ education for MOE personnel National S~'1ars: 120 persons x $20 :!?er day ;;( 12 days xl seminar per a.r.nUI:l for 5 years; lO1o ini'latio.a per year. Deuartmental conie!"ences: 2 conie!"ence ger year x 7 Dep~en-cs x ;0 persons per conference x $10 per person-day x 1+ days per conference x 5 years; lO% inflation per year • • . (c) VETs Initial tra.i.r..i..'1g: 300 teams per year x 4 persons per -Ceam x $10 per ~ x l5 days x 5 years; lO% inflation per year. Rec"!cla.ge: Year Cost/Year* # Students** 1 $10 l,500 2 II 2,100 3 12 2,700 4 13 3,300 5 l4 3,900 (d) Practical nurse training (ENICAS) 40 students per year x $2,000 per student year x 5 years (1. e. increase from 80 to 120); lO% 04 ¥lop, ,,+04,.,... '.'Q'" 1~Q"'" * 10% !.nflation per year ** One-half of total VET workers -37- (e) Diploma nurse traiIU.ng (ENSP: 20 students per year x $2,500 per '3tudeut year X 5 years; 1010 il".Ll"la tion per year. (f) Rural L.~alth tra.i."ling for m.edical students (ESSM) $50,000 pvr year X 5 years; 1010 inflation per year (for deye10pmer't of r'J.ra.l he a.::. th training of medical students and for eValuation of VHT system) • (g) 'Tra"ning of environmental. health workers (ENICAS) 15 students per year x $2,000 per student year x 5 years; 10% inflation per year. (2) Technic!li Assistance: Long-term -(a) Auto mechanic trainers 2 (b) Medical equipment repair trainer 1 (c) Sanitary engineers 2 Five persons for 4 years to start a.t $110,090 with 10% Del' aD...'1um inflation after ye~ 1, and 15% per annum contir.gency. Contracts to start mid-year 1, finish mid-year 5, Per F~rson Ccm:;uta'tion Year 12345 Grand Total Basic cost 110 Plus 1~ per annum inflation 121 133 146 161 Plus 15% per annum contingency 16 18 20 22 24 Total 126 139 153 168 185 1/2 year 1 and 5 63 92 Total person cost 63 139 153 168 92 615 Related Costs: In-country air travel at $2,000 per year per person for 5 persons; training materials and supplies at $3,OCO pe~ person per year for 5 persons. Year 1 234 Grand Total Final Cost Per Person 65 144 158 173 95 635 Technical Assistance: Short-tenD. consultants. =38- (d) Senior-level consultants in such areas as management, logi~tics, d~ography, etc. 30 person-months at $~O,OOO per month (as per Niger Range and Livestock PP) with 10% inflation per annum after Year 1: 10 person¥·months Year 1 $100 5 person-months Ye>:J.r 2 plus 10% inflation $55 5 pe;:oson-lll.Onths Year 3 plus 10f0 inflation $60 5 person-months Ye3.r 4 plus 10% inflation $66 5 person-months Year 5 plus 1010 in.f:.ation $73 b. Ir.sti tntional Support (1) Transport (a) Veh1~le - 4-wheel Drive 4 vehicles per Department x 6 Departments x 1 replacement aycl~ (vehicles will not be given to Diffa Department) and three addi tionaJ. vehicles will be used for local office and technician support. (Replacement of vp.hicles once during life of project). Per vehicle - err/Niamey $10,500 25% spare parts 2,625 Total $13,125 Total Cost/Vehicle Other Year 1 $13,l25 $4,000 Year 2 plus l~ p.a. 14,438 4,400 Year 3 plus 10% p.a. 15,882 4,840 Year 4 plus lo-~ p.a. 17,470 5,324 Year 5 plus 1010 p.a. 19,217 5,856 (b) Mobylettes 100 ~obylettes x 2 (i.e., 1 replacement cycle in 5 years) - 200 Per mobylette: $1,000 purchase plus spare parts Per m-:>bylette: $200/year operating costs -39- Total Cost/Mobylette Cost of Ooerating Year 1 ~1,200 $200 Year 2 plus 1~ p.a. 1,320 220 Year 3 plus 10% p.a. 1,452 242 Year 4 plus 1~ p. a. 1,597 266 Year 5 plus 1~" p. a. 1,757 293 (2) Equipm~t and Supplies (a) Dispensal"'J and Health Center Equipnent and Furnishiags: $1,000 per dispensarJ - 170 dispensaries $2,000 per health center - 20 health centers (b) Drugs for VHT.3 and Vaccines $50 per VHT kit per year for 5 years -Year # of VHTs ~:ost!K1t 1 1,500 $50 ·2 1,800 55 3 2,100 60 4 2,400 66 5 2,700 73 (c) Vaccines for 100,000 personJyear :( $2 per person for 4 years: Educational Material and Audiovisual. Aids: $10 per VHT per year for 5 years Year # of VHTs Cost!vm Total. 1 1,500 $10 $15,000 2 1,800 II 20,000 3 2,100 12 25,000 4 2,400 13 31,000 5 2,700 14 38,000 -40- Plus $25 fer each of 170 dispensaries and 50 health centers fo? 5 years: -Year ~& H.C.s Cost/~. & H.C. Total 1 220 $25 $5,500 2 220 27 5,900 • -:. • 3 220 30 6,600 4 220 33 7,300 5 220 36 7,900 (e) Laboratory and Cold Chain Equipment for MobUe Medical Units: $100,000 to be purchased ~ Year 2 and allocated as needed over next 4 years. (f) wcal office support (Niamey) including personnel, equipnent & supplies: ., Year Total Cost 1 34 2 19 3 20 4 21 5 (3) Constructic.n and Renovation (a) Departmental Headquarters: $157,500 per head~uarters at Agadez and Zinder including DDS offices, training center, workshops and furnishings, plus 2~ contingency for buildings. (b) Equipment for medical repair workshop and garage automobile maintenance shop $40,000. (c) New dispensaries (including attached hou~'ing as per standard plan): -41- $80,000 per (lispe~sarJ curre~tly, 10% i~~ation per ye~ and 15% contingency. Construction ,;,f 4 l..'1 second year of prcj ect and 3 in third year to be placed one in each Department. Funds are also provided for the digging of wells and puttir.,g ',-later in ove_"!1ead tanks. Cost Year 1/ Cos't Year 2/ Cost Year 3/ Dispensary Di~)ensary Dis'Pensary Basic ccnstruc~ion $80,000 $80,000 $80,000 Plus 1~ inflation sa,ooo 96,000 Plus 15% contingency 101,000 110,400 Yo 4 x 3 405 331 (d) Environmental sani.tation improvement at 50 health centers and 170 dispensaries at $1,000 per health center and dispensary: -Year # of H.C. & Dis~. Cost/Unit 1 50 $1,000 2 50 1,100 3 50 1,210 4 50 1,331 5 50 1,464 TABLE 4 Summary Cost Estimate and Financial Plan (In $000) AID Host COlIDtry other Donors Total. Uses ot Funds FX W FX -xc- FX LC Training 3,537 1,280 19,948 1,328 2,930 29,023 • Technical Assistance 2,811 25 5,500 12,242 3,094 23,672 Transport 1,200 . 43 3,025 1,020 1,015 5 6,308 Equi pnent & Supplies 1,658 167 3,033 200 3,250 1,092 9,400 construction & Reconstruction 360 690 3,500 17,600 900 7,055 30,105 Inflation & Contingency Factor 2,220 855 1,000 245 2,920 31 7,2'71 11,786 1,755 11,863 44,513 21,655 14,207 HYj,779 TABLE 5 Costing of Outputs/Inputs (In $000) Project #683-0208 Improving Rural Health Project Inputs Project Outputs Y No. 1 No.2 No. 3 No.4 No. 5 No. b No. '1. No. B Total AID 2,780 1,929 3,529 1,510 2,024 1,321 162 286 13,541 GON 15,000 6,228 5,570 4,045 12,300 18 15 13,200 56, <,r(C Other Donors 1,635 2,623 15,365 1,020 13,954 1,250 , 5 35,862 Total. 19,415 10,780 24,464 6,575 28,288 2,589 177 13,491 105,779 -- Percent 1~ 1~ 23~ 6~ 27J, 2~ 13~ l.tJ1- -- I !I Project Output as follows: 1. Increase in number of trajned and retrained VHTs. 2. Increase in number of academically trained health professiorlals. 3. Functioning cadre of support 'personnel trained in health admin., planning, driver educatiou, etc. 4. Functioning transportation system for supervision and distribution of supplie~ and equipment. 5. Improvement of rural service cadre including drug and supply inventory. 6. Increase in control and surveillance of communicable disease. 7. Functioning health/nutrition education program in all health centers, PMIs, rural dispensaries and villages. 8. Functioning environmental sanitation program. -44- TABLE 6 Budget - ImDroving Rural Health (Tl $000) Category 1 2 3 4 Total Human Resources 1. Training a. 3rd country participant 50 55 60 66 73 304 b. In-country continuing edu cation for MOH personnel 57 63 69 76 84 349' c. VHT training 180 193 218 240 264 1,100 VEf retraining 150 231 324 429 546 1,680 d. MICAS 80 88 97 105 115 485 e. ENSP •50 55 60 66 73 304 f. ESSM - Rural Health 50 55 60 66 73 304 g. Environmental health - MNICAS 30 33 36 40 44 183 2. Technical Assistance a. Auto Mech. Trainers 130 288 316 346 190 1,270 b. Med. Equipment Repair Trainer 65 144 158 173 95 635 c. Sanitary Engineers 130 288 316 346 190 1,270 d. Short term consultants 100 -60 -66 73 354 Sub-total - Human Resources 1,072 1,553 1,774 ,019 1,820 8,238 -45.- Budget 2 ($000) 1 2 4 1 5 Total Institutional Support 1. Transport Vehicles - 4:wheel drive 158 92 326 112 438 1,126 Mobylettes 110 22 145 27 29 333 2. Equipment & Surmlies Dispensary & Health Center Equipment 141 116 60 60 - 377 Drugs for VHTs 65 99 126 158 197 645 Vaccines - 220 442 245 293 1,200 Educational & Audio Visual Equipment 20 36 32 28 46 162 Laboratory and Cold Chain Equipment -0 100 - - - 100 Local Office' 34 19 20 21 21 115 3. Construction & Recon struction Departmental Hdqs. 310 - 310 Equipment for Med. Equipment Repair & Garage 4o - - - - 4o Dispensaries - 263 289 33 24 609 Sanitation Improvements 50 80 61 67 28 286 Budget Cate gory Program Year 1 2 3 4 5 Grand Total Human Resou-ces Development 1,072 1,553 1,774 2,019 1,820 8,238 / Institutional Development 928 1,47 1,501 751 1,076 5,303 Total 2,000 2,600 3,275 2,770 2,896 13,541 -47- C. Social Analysis Introduction Like most developing countries Niger confronts the basic problem of establishing relativwly uniform bureaucratic systems among dispersed and differing peoples. This problem applies especially to the extension of the rural health delivery system to two ecologically differing groups - the sedentary farmers and the pastoral nomads. Generally this syste& "fits" better among the farmers than among the nomads despite some adaptations which are made in the system. What follows are two separate analyses which describe these adaptations and which show, despite the diiffering ecological contexts, how Niger is trying to extend the health system to all peoples in a just and uniform fashion. However, there are unique problems involved in the extension of the health system to the nomads. Therefore the second section on the nomads will depart from the usual format for social soundness analysis (i.e. treatment of the socio-cultural fit between the project and the beneficiaries, the spread of the project interventions, and how the beneficiaries will make successful use of these interventions). Instead it will attempt to identify aud describe these problems, which in the case of the nomads are formidable, and to indicate how the rural health delivery system must be especially adapted to the nomads. Part A - Social Analysis of the Rural Health Delivery System Among the Sedentary Farmers Part B - Social Analysis of the Rural Health Delivery System Among the Nomads Part A - Social Analysis of the Rural Health Delivery System Among the Sedentary Farmers 1. Introduction A crucial linkage in the rural health delivery system is the village health tei= (VHT). Five million of Niger's inhabitants are dispersed throughout a vast country with 8 Co living as sedentary villagers in the agricultural lands of the south and 20% living as pastoral nomads in the arid north. Tae most effective way to reach these inhabitants with curative and vreventive medicine is to extend a health system through a trained vilage health team. This team links the villagers with the national health system by providing basic health care with the support and surerv7ision of the local dispensary. Since AID's efforts are primarily to as.cist in the expansion of the number of VHls and the health support system, ihe social soundness analysis will focus on the operation of these -village-basedteams within this system. The village health team, as a vertical linking unit, deals with two groups: villagers and MOH personnel. It provides villagers with basic curative and preventive medicine for common Sahelian illness, with rudimentary treatment, and with Jreven ive medical techniques. The team, including a health worker (secouriste), mid-wife (matrorie), and administrative cc=ittee (co.it de etin), consists entirely of villagers, but they are trained and retrained by nurses in a dispensary and are supervised periodically by these nurses who travel in the countryside to visit them. This section will focus on the operhtions of the VHT as it relates to the rillagers and to MOH personnel. Three basic social soundness questions wiiill guide the analysis: a. How does the VI= system fil. sociocultur-ally within the existing structures. processes and values in the village? b. Will the VW system spread successfu~yfrom 1,270 villages in 1977 to 3,500 villages in 1982 and later to all 9,000 villages? c. Will the villagers actually benefit from tae VJ system in the way in which they are intended to? The following three sections address themselves to these questions, and the order of the questions corresponds to the respective sections. -49. 2. Sociocultural Fit 1 Generally, the VET system not only fits in with the village structure but it reiafcrces its existence. This is a result of three factors: Villagers themselves elect the VHT; village leadership supports it; and the incentives for VHT members reinforce underlying values. The formation of a VHT is from the "bottom up", for it is the -lllagers themselves.who select the members of the team. A nurse and a rural development-officer (animateur) visit a village and explain to them the purpcse and operations of the VMT. If the villagers want to have a team, the government officials return and supervise the election of the members. They stress to the villagers that they should choose people who are trustworthy, respectable and reliable, and who 2 can be exrected to remain in their villages throughout the year. Villagers do this and occasionally select existing leaders, such as a chief or marabout to be a secouriste or to be on the administrative comittee. Almost always they select a traditional matrone to become a trained one. The VHT positions carry with them prestige in the eyes of the villagers, and they bring scarce resources to the village, so the existing leadership supports them. Tae chief, especially, helps the VHT by calling meetings for secouriste and matrone to teach preventive medical techniques and by exhorting villagers to practice them. By thus allying himself with other leaders, he reinforces his own position as a leader, Literate people in the village, such as a teacher, marabout or merchant, will often assist the VEf by reviewing records of medicines distributed, because they, too, enhance their own status by doing so. 1 Village is used here in the broad sense to refer to the maximal residential group of both sedentary farmers and pastoral nomads. Among the nomads, however, this group, the campement, is a much smaller group consisting of a few families. Nevertheless the processes discussed here as they relate to VHT operations are more or less the same for both groups. Significant differences between the two will be specified in Part I. 2 The latter criterion is important, since slack season labor migration to Nigeria, Ivory Coast, Libya and elsewhere is increasing. -50- VHT members receive no salary and are supposed to give their services voluntarily. They do so and for the most part do it effectively, because the prestige of having been chosen by their own kinsmen and neighbors carries with it sufficient rewards. The imderlying value of "group solidarity" (Faulkingham 1970: 178) reinforces their services, for villagers are expected to help one another. Moreover the Islamic religion to which virtua.ly all Nigerien vilagers belong reinforces the donation of goods and servrices; it is believed the donor will get his reward later in 2.ife for "God Sees what you are doing" (IriCoy go no - Djerma expression). Occasionally villagers themselves reward the VHT members with small gifts ("cadeaux") or provide services such as repairing their houses, which is also deeply rooted in the village tradition of gift-giving (Faulkingham 1970: 159). Villagers will also help the secouriste till his fields during the agricultural season. The VHT system does not conflict with traditional village health care, and to a certain extent blends in with it. Few villagers believe in a germ theory of disease, and although they hypothesize a variety of physical causes of cisease, mostly they associate disease incidence with supernatural causes such as the actions of spirits or witches inflicted upon then. Consequently they rely.upon traditional curers such as a marabout or Islamic holy man, a diviner, or a fetish curer to intervene for them by performing riturals to overcome the supernatural affliction. Nevertheless, villagers do recognize the efficacy of basic curative medicines such as aspirin or mercurochrome or malaria suppressants. Inspections of VHT medical supplies and records, and the heavy demand on western medical facilities, amply testify to this. Consequently the medi dine and treatment of VHT members are constantly sought after, and in the eyes of the villager are one more curing serri;z which he can use in addition to those .f the traditional curer. In fact, v_!lagers often seek the services of both. For example, one might seek paregoric from a secouriste for d arrhea and also seek a charm from a curer for the same sickness to insure good health. The roles of the VM relate in IfLerent ways to those of the traditional curers. In tha case of Lhe matrone it is very compatible; every village has traditional matrones, and villagers usually imderstand that by under-zoing training the matrone 'bil! become even more effective. The role of the secouriste is hrcvver, less clearly understood, and potentially rore competitive with established roles. Insofar as the secouriste delivers first a.d for wounds and the like, he adds clear -aew services. As a minor disease curer he competes more directly with the herb5 and remedies of the Ladrisseur, whose livelihood will in the long ran be treatened by the spread of western medicine. -51- For the more serious diseases and for mental ills, the Muslim medico religious profes-ionals (Marabouts, boka, etc.) are likely to adapt and maintain their positions, for western remedies are not always quick and sure. The village curer's reaction to such potential competition from the secouxiste has also been variable. In some cases marabouts theselves have become secouristes, thus blending the systems. In others the marabouts argue that villagers would claim that it was the free government melf'cine which had cured them, and would refuse to pay; these marabouts keep the seccuriste at arm's length. Finally the VETs fit in well with the overall rural health delivery system and are a logical extension of this system to Niger's disperkd population. Eveyr VdT is supported by a dispensary, ,).d nurses visit each neighbori ng team at least once even. couple of months. They inspect their pharmacies, replenish them when necesspary exlain the use of new techmiques or medicines end question the secouriste or matrone in their use of existing ones. in addition the dispensary serves as a referral point for cases which the secouriste or matrcne cannot handle; and with the cooneration of the chief or ouher villagers, they can notify the dispensar by courier to dispatch a vehicle to pick up the sick or inj-red person. Desnite this general congruity of VHT operk,.tim-s with both village life and the rural health system, there are a few con-trainits. In a few cases the incentive of prestige for VHT members is not enough and they either abuse their position by demanding g4.ts or become lax in their duties. This apolies more to the secouriste than. to the matrone, the role of the latter being firmly entrenched in village life while that of the former is new m d not clearly perceived. MOH personnel recognize this as a problem and would like to retrain and suTport the secouriste more than they do at present. The radio, which broadcasts in several indigenous languages, carr.es occasional health programs, and reaches to the farthest corners of the cotutry, could be a powerfu!l means of reinforcing tle WET's role, of assuring that norms for their beharior are publicly known, and of sharing prestige of successful village programs. Secondly, the VH system is more congruent with the life of the sedentary villager than with that of the migrating nomads. It is more difficult to supervise and support the latter because their migrator routes and schedules are subject to climatic conditions and hence are not highly predictable. Nevertheless, like the villager they do recognize the efficacy of modern medicine and will make use of it through the VhTs or the dispensaries. See Part II to this analysis for a uller discussion of nomad health services. -52 3. Spread Effect At least two factoro will enable the VHT system to expand and operate in 3,500 villages by 1982: the motivation of the vllagers themselves and the special attention which the MOH gives to the village health teams. Villagers want very much tvo have a VHT in their villages. Their recognition of the efficacy of modern medicine was mentioned above, and they would like to have medicine and basic"treatment readily available. For remote villages, travel to a dispensary is too d4ficult and often seen as a last resort when traditional cures are ineffective. Ideally sedentary villagers would like to have a diszensary in their own village but are quite satisfied with a 1M. Village chiefs, especially, want to have a ViT in their village. It was mentioned above that the chief allies himself with other leaders to reinforce his own nosition. This is because chiefs work through important village personalities in order to get villagers to agree on an action or to accept an innovation. In this way the chief maintains and increases his village support (Faulk2ingham 1970, Stoller, 1977). Since the VHT as a government-trained unit has status in the eyez of the villagers, the chief is vezry likely to support its establishment in the -rl'age with the hopes that it in turn will reiznforce his rw status. Finally the VT is a source of status for aspiring inO-iividuals. These individuals are likely to make it known to other villagers before the elections that they want to be elected. Large villages require several secouristes, matrones and comittee members, and so the VHT serves as a modesz outlet for upward mobility within the village. Within the rural health system, specific people are responsible for the expansion of the VT systems. As noted earlier certified nurses and mid-wives train the secouristes and matronei for a two-week period at the dispensary. T4e training is intensive and covers an understand.ng of causes, symptoms and cures of common Sahelian diseases as well as basic curative and preventive techniques. Instruction is practical with much demonstration and application. In addition there is i.struction of basic nimerical skills to enable VHT members to keep rudimentary records. When the team returns to the village, nurses follow up the training with questions and advice as they inspect the medicine box. Finally, both secouristes and matrones are retrained back at the dispensary once every two years. There are, however, some constraints on this expansion. The most obvious and difficult ones to overcome are the vast distances and problems of travel in Niger. This is especially the case among the nomads where 00 11 8W 09f"~~~ 4- 4 OA t414, ~ rw~V----It U 1Mt bI -U two*~~~~~A 14t A lt 4"7RW7 fX1 VWX restvo t ahvwI-O e putcytotytq ~W.~~4 h, SeWmbor arvuoas th=01VOO VU9 are repete. and lite oo and t V9 Uk~ t~o r4gs633,1 tU4 p g44 VtUqger Vzo#t so s~~~~t4Ot vvw1 ey40,qwepo~b As noted Owsq, tb4 Y~ersf QbIQQ# theV omeo 94 tr thov aen * U4m.tsftte wt the p9oQf4~Q9 Q Q4 h~q the by elotg 1ew members, with the assits1ance of M4QR pe~rsnae, They also exr som coto ove the distribution ot medlctu VUlaer =st, bqr cer944V meicne suchAas~#~asrin or vti for whc they5pay 4~nomina t, W4namthe cetfe.orstate nurse viit YWth TPpsi*revwlws4th reors$ mdup supply. ad amout o .~e moe uUa~ inQ he..szfI 4* shotage offzs odon n4( h H 0~4Cf MAO a~rgood41~ Sooutugs Caoe 40Q21 the~~tvilae t±4ef vbo en pressue on th.e 4g memy brs) or~ 1 tey do noact, n.h nrs mar1 tak bactei mecine uppl whichnot givuen frly tthevillaer up= *ata Qshmnt~ o =.Rpreeio4it. the nientsenste.t aoe iC'nicte tatvilagozsse ime te a.eklms~.i up tearh of agT tsr wan adi M ncour1ae responsibe ph.aicipion thoa ~evel~ to Insis forlarea~s stalteboeMdine . L±.ajt d o an pzwnpte*edcin srtm @ t#h,,cosrintsc metioe above, f(Besuoe oamiguus th slghty oleof ,th securitea fw dver ,atninelehr n r ntAalb o sistne... They i may ~ttr cocenrateonouseolddutes a th expnseof scouist duties or ma vnlaeteaxa salyi eac fwg dbr 5. Conclusion Despite the constraints on the T,7 system, it is an effective way of meeting the health needs of the rural poor. It does this through a linkage of local participation with a national health system. This linkage insures a minim=m disruption of existing local structures and processes and a compatible mixture of traditional arzd modern beliefs and practices. In addition this linkage caui be expanded throughout the cotmtry as the MOH continues to try to insure adequate delivery of basic health services. -55- Part B - So-ial Analysis of the Rural Health Delivery System Among the Nomads Sunmaj: Despite repeated recognition by all parties during the early phases of project develorment that the vast pastoral zone needs special attention to assure that benefits of the VHT system spread to Niger's nomadic population, this section concludes that the nomads will be touched less significantly than will be the rural sedentary population. The project ought not to be delayed by such a fining, however, because the GON is strongly committed to serve the majorihy .f the latter population, 1. Background As many as 20 percent of Niger's rural people spend some or all of their time in nomadic encampments, securing their living by moving their animals to the best available areas of grass and water, while concentrating at certain seasons near some fixed resource such as dry season wells, late drj-seascn dgricultural lands, or wet-season saline vegetation. The northern most Department, Ag'dez, is the most thoroughly noa'.dic area: perhaps two-thirds of the population (or 70,000 people) i _n Tuareg and Peul nomad camps. But in fact larger numbers of nomads live in the other, more southerly, Departments (77,000 in Maradi, 90,CX0 in Niamey, e.g.) in varying relationships to the settled village end toiwn agriculturalists: some are members of agricultural families -ihc tran.hume with their animals part of the year, some are livestock dertndaent people livihg in camps at the margins of agricultural zones, andt some are fuly nomadic in the drier areas of these Departments. 1h terms of absolute wealth, many of these nomads may not be the "pcoresz of the poor" in Niger. Their herds represent substantial i. Jg capital, although there is no accurate way to calculate their total value in market terms. Further, the nomads may have a somewhat better nutritional status due to their higher i-atake of proteins, specifically m and milk products. On the other hand they are clearly the population least integrated into the national political entity, least serviced by national institutions, and least involved in decisions in the broader economy that affect their own lives. Given that the capacity for producing change lies largely in government hands, their continued margi-nality threatens to destroy their way of life, which at one time was at least co-equal to, and sometimes even dominant over, that of the settled villagers. Recognizing that the pastoral zone posed special problems and that its development should enhance the lives of the nomads themselves, the GON Serrice d'Elevage and USAID have embarked on the Niger Range and Livestock Project. With similar concerns, the development of the present -56- TLIral Health Prcect early on stressed the willingness of AI to consider special efforts to serve the nomads' human health needs. As the A= Niger Health Sector Assessment stated: "the delivery of health services to the nomads represents a vexinmg problem for the Ministry of Health, iwhich7 has requested A!D to provide a social anthropologist to investigate ways and means by which this task might be performed morE efficiently and successfully" (p. 35). 2. Existing Health Services for Nomads At present, gover.-ment health service delivery to nomadic people is split to two parts. First, the central chain of hospitals, medical centers, dispensaries and WTs occasionally reaches near or even into nomad caLps. ome dispensaries are in .arket towns at which nomads appear or to wich they can and do ride or animal-back in emergencies. A small number of secouristes are located in smaller permanent settlements around a school or oasis (e.g. i Agadez Department at Marandet, Teguidda-N-Tessoim, Aderbissinat), where at least some nearby nomads gain access to their services despite their not being members of the secouriste's "own" community. And an uncounted but small handz'ulcfrxmad ae reported to have been trained as secouristes or matrones and to be working in their own camps. Second, during th: late wet-ses-on especially around the InGall axea, whtre "Le cu-e s=le6 .ttracts thou-sands of nomads from both north and south, mobile medical teams (4quipes mobiles) from the Service de Medicine Mobile normally make a month-long tour of nomad camps dispensing both vaccination and curative services for as long as their supplies last. So far the mobile teams have had no direct relation to the normal rural health serices and so they do not play a role in anima.ting, supplying, or superrising the VHTs. This spasity of goverrent services leaves most medical practice (except for some Ehuropean pills, notably aspirin, which can be bought in the markets) in the hands of traditional practitioners. Births take place under the care of older women in the camping group, but both Peul and Tuareg deny that there are specially recognized women who might be obvious choices for training as matrones. Neithror is the role of gurisseur or herbalist highly specialized among nomads, although scmetimes a person with a particularly strong record of success with a single ailment gains a local reputation. Rather, every camp shares general knowledge of the use of plants, minerals, and other ingredients for remedies. The Tuareg, for example, recognize over one hundred plants with medicinal properties, and have a complex theory of disease and treatment based on body humors, Arabic magic, and community therapy. Among both Tuareg and Peul, the medico-religious role of the marabout is strongly defined and rewarded. Whole sub-tribes of -57 maraboutic status (e.g., the Kel es Suk Tuareg), and famous individual marabouts who oiten have distant origins but are attached to powerfluJ camp groups, practice mixed religious and secular systems of misfortune prevention, security enhancement, healing (especially of nervous and mental conditions), and general advising, all to clients who pay in cash, kind and/or services for their consultations. The marabout is the one party with a strong personal and financial interest in nomadic health service deliverj. 3. Receptivity tb Changing Medical Practice Despite the elaborateness of traditional medical practices, nco.ads are highly receptive to western medical services. If anything, they believe shat western medicine probably has a pill or an injection for every malady. in a recent five days of travel in Peul and Tuareg nomadic camps, the social analyst was besieged br requests for medical aid for ills which included fevers, headaches, chronic earaches, conjunctivitis, gastro-intestinal disorders, badly-set fractures, facial ulcers, swellings, infected wounds, skin disorders, progressive blindness, and impotence. In many cases the nomads knew that there was a western medicine for such ailments, and among the Peul the demand for "maganin a nassara" (Hausa for European medicine) almost grew menacing, as people werd expecting the 6quine mobile. In cases of • serious .llness and injury, the analyst heard repeated reports of recent attempts to evacuate the affected by camel or donkey to the nearest medical post. It is clear that although there are indigenous ideas that will conflict with western medicine, there is much that can be done now to relieve nomads' health problems. Most important, many nomads had at least a hazy knowledge of the seccuriste/matrone system. When it was described fully, and when it became clear that literacy was not a prerequisite for the VHT, enthusiasm for the idea was combined with a wave of visible relief that such an efficacious system was within their capacity if not their grasp. 4. Special Elements of a VHT System for the Nomadic Zone In general, the GON-VBT system could be extended to the nomadic zone without significant modification. Recruitment, training, community responsibility, and the "voluntariat" would remain constant. It is only in the specifics of a projected network of VHTs and the logistics of their animation and supervision that adaptations need to be made to the physical and social milieu: a. What kind of network of VHTs would be feasible in the nomadic zone? (i) Most campements are too small in population to plan realistically for each campement to have a VHT. On the other hand -58 tribal fractions under a designated chief are often too large and dispersed around the landscape. Depending on hjw many VETs seem consistent with the proportion of nomads in the national populatimi, planners would need to collect population and migratory route information and to assess what level unit might be used for the optimum VHT community of responsibility. Nomads themselves express willingness to choose someone who not only will remain at his job but who spends most of his year centrally located within the region used by his subtribe. (ii) Peul and Tuareg VHrs probably need to be created separately, since migration patterns vary and difficulties of trust and co~mnication between them exist. The result could be that two different VT might be physically nearer one another than sheer spatial planning might warrant, at least at some points during the year. b. How can VHrs be animated and supervised? The difficulties of travel and communication in the nomadic zone mst not be understated. (i) At present only three animators (Ministry of Plan) serve the whole of Agadez Department. Unsystematic recruitment of VHTs would almost surely create maldistribution of services on the grcund. An augmented anition capacity should be merged with the supex-risory system noted next. (ii) For a practical nurse with other duties than to oversee VH1, a supervisory role would be an exhausting task. Vehicles can bog down for days at a time; nurses are, so far, mainly southerners with little enthusiasm fcr the rigors of overland travel and camping. Instead, special permanent teams along the lines of the new temporary 4cuires mobiles - fully equipped, experienced, and committed to bush work - are the only probable way to overcome these obstacles. (iii) Neither motorcycles nor American four-wheeled overland vehicles will be satisfactory for the nomadic zone. The only vehicle with enough special equipment available, parts possibly available, and local expertise in repair throughcut all the Nigerien territory north of about the 15th parallel is the British Land Rover. Other vehicles cannot stay maintained and moving in the physical and supply conditions of the area. -59 5. The Constraints Against VHTs for Nomads Although early ccmmitments were made to extend the VHT system to nomadic connnmities, the PP team enzountered a complete shift in attitude on the part of the GON. It ncw rejects "special treatme" for the nomads, though it recognizes verbally the special logistic problems that are involved. But is an identical system with particular adaptations "special treatment"? TSA-D has not proposed a special institutional buildup nor a favored treatment in term of numbers of dispensaries or VHTs. Nonetheless, the GON has insisted that no special reference of any sort be made to "nomads". All, it says, are "Nigeriens". Under these c.ircumstances Trs are likely to spread much more slowly to the nomadic zone than among the sedentary population, despite statements from individual DDS's that they plan to recruit more nomad ViTs. a. 'he American vehicles to be purchased under the project will function primarily in the southern (agriculture) tier of the c ountry;, b. The motorbikes to be purchased for VHT supervisors will be useless in northerly terrain. c. The anticipated diminution of the role of Animation Rurale will increasingly leave recruitment of new comunities to self-animation, biasing expansion toward those areas where the VHT ccncept is already taking root. d. The problems of higher rates of fuel consumption, longer distances, shorter vehicle life, and other "special" logistic problems - all plainly recognized in the field but not fully realized or umsympathetically viewed in Niamey - can only leave the north and the nomads short of all the material on which the VHT system depends. e. The support and supervision of nurses over nomadic health teams is inadequate in the vast pastoral zone. In addition VHs run out of medical supplies during migrations and can only replenish them when they happen to pass by one of the dispensaries which are few and widely dispersed. 1 See, for example, the elaborate system of joint animal-human, health teams proposed by the GON for the nomadic population of Tchin Tabaradin arrondissement in Tahoua Department, pp. 25-29 of the WHO report on the Conference/Workshop on Primary Health Care held in Niamey Jan 13-21, 1977. -6o f. Finali.., the lack of personnel able to address Tuareg and Peil in their own languages, t1he degree to which services are staffed so far by better educated southerners, and other larger sociopoliticPl factors of nomad-government relations, all add up to a kind of non-persona.11y motivated but institutional discrfminaticn against the nomadic population. To offset these constraints the MOH distributed medicine freely to nomad VHTs whereas VHTs among the sedentary farners must pay for them end. in turn receive payment from the farmers. 6. Conclusion The foregoing analysis is meant to be frank and honest, not accusatory. In AID guidance on the analytical description of .he poor majority, it is recognized that sometimes the poor cannot be reached by the programs we support for such reasons as political will, cost efficiency, or technical capacity. In some measure all these factors apply to the present jituation, although the second anqd third of them could be overcoue with external assistance. In any event, the pro-bable inability of this project to impact significantly on nomadic counities cezrtainly does not - .litate against the project as a whole. Niger is committed to the VHT system, the system is effective, and its growth with AID support will help many thousands of rural NigerItas, including some nomads who will be reached trader the -urrent staadard modes of recruitment and expansion. Within the MOH itself, and between the MOH and O/Niamey, there will be a continuing dialogue as to how to improve the system. Ln the middle run we are confident that question of deiivezx of services to the nomads ,will arise again and will begin to be addressed. In the meantime only some nomads will benefit, while the large majority will be no worse off than they are nor. References Fauilkingam, Ralph, "Political Support in a Hausa Village" Phd. Dissertation, Department of Anth-rcpolocy, Michigan State University. Stoller, Paul, "Backg-,ound Paper on Politics and Medicine Among the Djerma-Songhai", ADO/Niamey, Niger D. Economic Analysis It is our.conviction that this project is the most cost effective approach -o the formulation of a rural health delivery system in Niger. The cost-effectiveness for the total project is based on the cost-effectiveness analysis of each component which follows: . Training This it the most important component of the project, with a total of $4.7 million being spent over the five-year period. The analysis of this category of support would suggest that in gross terms it will benefit the entire ruLral population but should be allocated over a longer time period than the project life. However, even if we consider just the population covered during the five-year life of the project - about 2.1 million people - the cost per inhabitant is only $2.241. The first two items, third-country participant training and national seminar, will probably offer most assistance to the miisterial and educational staff and wil improve their capacity to disseminate information and directions to lower levels of health professionals and paramedical personnel. Over the five-year period, ten teachers -d ten senior MOH officials and five logistc/maintenance ,will receive third country training. There is little question that the third-country participant training in African schools or universities is a lwer-cost n:thod than similar training in the U.S. It is likely that the courses are better adapted to Africs conditions. In addition the national seminars have proved to be effective two-way channels of communication for senior MOH officials. Uiamey-based personnel have been able to state their riews on fature pollcy and planning, and senior local officials have been able to voice their concerns. In a country where travel is both costly and difficult, a concentrated discussion among senior MOH officials for ten days is much more cost-efficient than spending funds for individual travel and consultations. In-country seminars are to be held in each department twice a year, and will focus on managemant and planning issues. Since each DDS has a certain amount of local autonomy in managing his rural health delivery system, since disease patterns vary by region and since logistical problems differ widely from north to south, the departmental level seminars provide a low-cost solution to the problem of continuing education. The next three categories in-volve support for students in training to .,rkin rural areas. The environmental health workers will be enrolled in two new nursing programs. The programs are summarized below: -62- TABLE 7 Length No. of Cost/ Nursing of Grads. Student No. Receiving program Location Program Per Annum Per Annum Support State Niamey 3 years About 4o 480- 20 (ENSP) 500,000 CFA Certified Zinder 1 year About 80 350- 40 (ENICAS) 46o,ooo CFA It is clear that support of the host country training programs, which were judged to be effective and relevant for nurses working in dispensaries, will be the least-cost solution to increasing rural health manpower. With the desire of the MOH to place two nurses i each dispensary instead of one, there is an immediate need for approximately 170 nurses. A recent publication cn health needs stated that about 40 to 45 will graduate per year to be assigned to dispensaries. This means that it will take about four years to fully staff all existing dispensaries. Therefore, one must consider increasing the size of the student body in nursing training. It should be recognized that while a higher percentage of certified nurses work in dispensaries, the work of the state nurses at the arrondissement health centers is also essential to supervise the work of the certified nurses and to provide on-going training. Since both are necessary to a rural-based system involving VHTs, the project support for 60 students is modest. This number will be involved annually as an additional part of the health delivery system for rural inhabitants. 1he new prcgram to train 15 environmental health workers per annum will provide a whole new cadre of professionals. Currently nurses do not have sufficient time to devote to patient care and to teaching let alone time to involve themselves in sanitation education. In addition, their teaching has not been sufficienctly oriented toward this area. Again, having an established educational facility and a new curriculum seems the lowest-cost solution to providing needed skills. Higher-level technical assistance will aid in curriculum development, planning for qualifie-d teachers and assisting the country-wide policy for optimum use of this new category. Medical students are currently doing some training in rural areas. The success of their individual placement depends on many factors such as the orientation, interest and time of both student and supervising physician and the availability of transport and research funding. The financial support given in this category should provide maximu flexibility. Desirable areas for research studies are aspects of VET work, how medical students can reach remote areas, and means of trying additional drug or educational programs in -63 specific geographic areas. Such small studies may provide the MOH with valuable research data in areas where they currently have neither the extra manpower or flexible funding to gather data for future plarming and decision-making. 'ne training of new VHTs and the retraining of existing VHTs on a biennial basis is the core of the entire rural health program to be undertaken by the Ministry of Health. It should not be overlooked that these VETs work on a voluntary basis, and are not added to the civil de--vice payroll; therefore they provide the lowest cost solution to the delivery of simple health services. Since there has been no research conducted, there are obvious questions of their efficiency and effectiveness. Personal conversations during field trips revealed that the number of visits by patients to dispensaries from villages having VHTs was about half that of villages without VHTs. This would suggest that VHTs do provide a saving to the alternative of giving rural populations health care from dispensaries staffed by MOH paid nurses. This also raises questions which can only be answered by some well planned research. The short training cycle for VHTs and the modest cost estimated by MOH officials of 15,000 CFA per annum for training or retraining VHT workers p robably makes their work the lowest-cost solution to providing a minimal level of care. Unanswered questions which would have a substantial impact on costs and effectiveness of VHTs will be answered with the assistance of medical students during the course of the project. They include: a. What are the current drop-out rates of the matrones and secouristes? Why do they drop out? Are the rates execessive? b. Is the present training appropriate and effect Should matrones receive training in health services for women a children presently being given to secouristes? c. Are male secouristes as effective as femal. -cou: What are the relative advantages and disadvantages? d. Are two matrones, two secouristes and two cr- de gestion members the optimm number for all villages? For delivery of services in a timely and cost-effective manner? e. What are the most effective and cost-efficient ways to distribute the .limited number of drugs? Should secouristes share a box of drugs? What is the most reliable and inexpensive way to ensure restocking of supplies? - -,W '.. -'"i-/' -. :, 4%4,w C.. Where a-Ads Op retaiin befl gie?.4 ff C t War perF~ sWIJ0444r supoveT At2 o AUWmn$ to tue above quwatt4.vs, V=-- provtd. Wa4ton t~oU*~qth 4qgOtg of th hath 4.vq7 system at the -a~ee rm project to base4 O the desig teams ec4usQn tht . ystem S4l1m* to tbe prsent YHT delivery siple health oer~v4coes to the lowoowt and most effective solc f'or the Sael4. The present healtU cPa syt= at the village lee 14. cQP.4ttet ith the asattp' A h4th being-purg4 t by- the Club-.du Sahel* 2 , Tekiwa-eiAssioaba. Wve~ba~4bIs~W~4 (I WrN~the projeet to Assist the Minitryz of ffesth to rediu4 QOst of a4 to'improve the I~tapozt&t4.on os4Ua. ,Vah4cles in certa.1a areas las two years or less anid 'Qftem-, brvak d=w due to lack o4 1 V~tivey ma4t4fl4Qe, l-o mechafis"=43P assist inthe development of preventive maintenmnce capabit:,and tri personnel to provide ongoing primary maiatenumca,repair' * and driver education. The tefttcal assistane for medical eqtuipnent repair is being irv~ to enable, the 1404 to make Ynm~U9O tue .1ed equip~ent vasilable toax =ispenaztes , health, centers and hospitals. This assistance will also include the training..±' 140Hi personnel to maintain 2uLpnent at the end of the project. Two sanitary engineers are provided by the project to assist the MO0H improve its lln.ess-prevention capability, This is critical to the d.,4olent oe'the least-cost health delivery system as Ineas p(=yjl serally recognized as being more cost effective than trodif onal western curative programs. Vehicles provided 'under the project have been selected to give the MOH the' cheapest transportation possible to meet minimum *needs. The project provides f9U~r vehicles to six departments for assistance ith provision of silplic\s and supervision to the rural health delivery system. There are areas of the country where local travel can be done by mobylette and therefore 200 were provided in the project. -65- These are operable at lower cost than 4-wheel drive vehicles where they can be used. They are mainly appropriate for use at the dispensary-to-VB linkage. rn many areas health workers will continue to rely on horse and camel travel to carry out their duties. 4. Equipment and Supplies Dispensary and health center equipment and furnishings are planned for all 220 existing facilities, New purchases of equipment will be limited to replacements of worn-out items and purchases of needed furnishings to bring dispensaries and health centers up to mini=mun standards. A list of dispensary,/health center funiishings and equipment is given in Annex L. Because the MOH secures drugs from a variety of sources the selection of drugs to be purchased with project funds will be left to the senior MOH personnel to assure that minimum needs are met without duplication. Another rea of discussion and planning was educational materials and audio-visual aids. Additional visual aids are required to improve .the effectiveness of training programs at the village level. Only a minimum of visual aid are currently used; therefore, short-tarm assistance will be prvvdcd to develop audio-risu-- aid materials. Materials provided will be of a durable nature and will be issued only once to all VHTs. Laboratory and refrigeration equipment for the mobile medical units aa-e necessary in order to serve isolated areas as well as reduce the amount of equipment needed in more densely populated areas for i=aunization programs. Use of mobile medical units enable the MOH co diistribute the cost of this relatively expensive equipment over a large percentage :f the population, thus reducing the cost per person for vaccination programs. It should be noted that both cold chain equipment and vaccines will not be provided until year two of the proposed project after further evaluation of the efficacy of these inputs. 5. Construction and Renovation The construction of departmental headquarters at Agadez and Zinder -- including administrative offices, training centers and workshops for maintenance of vehicles and medical equipment -- is necessary if the delivery system is to work and have the capacity to expand and offer additional health services. Since Agadez has about 100,000 persons in a territory of 63L4,000 square kilometers, any -66 health iatervn-7.ion is going to have a relaGively high cost per unft in compari;on with more density populated area. Zinder, with over a millicn people in an area of only 145,000 square kilomete'rs represents a complete contrast in unit costs. Bui~ding costs in Agadez are probably double those in Z4.-der. Hcvevar, headquarters facilities are necessar in both departments, and the GON is dedicated to providing similar levels of health services nationwide. The seven proposed dispensaries will serve 70 villages or a. potential patilent population of almost 30,000 persons not currently covered by fixed facilities. These dispensaries offer mo:. than patient care, for they serve as the control focus for supervision and training of VRTs. They serve as both house and office for a nurse who may not be attracted to this area of social service in a village setting without such a status symbol. The final item in the proposed project is funding for envronmental sanitation improvements to selected dispensaries. This sum will allow latitude in needed improvements and make for better working conditions and more sanitary facilI ities for the patient population. Teaching sanitation is difficult when the dispensary has no funds to construct a latrine. 6. Conclusions This project addresses itself to many inadequacies of the existing health delivery system by supplying inputs of varying types throughout the different levels. The project attempts to find low-cost Solut4 s to particular bottlenecks or ga7s in the expansion of the existing system. Indiv-idual DDS personnel continue to introduce various alteniative methods of delivezy of health services. These vary from use of a central market village for restocking drug supplies to ten VH1s to training female secouristes. Promising alternatives should be systematically evaluated and the MOH should be commended for allowing this degree of innovation. Funds for medical students to assist in such evaluation are included in the project paper. Based on the above analysis it is felt that the project is economically sound in terms of the benefits expected to be d ,livered to the rural population, and the selection of the moit cost-effective means to deliver these services. Ymproved health and increased productivi ty are always hoped for but cannot be quantified until the hard data, to be compiled by this project, can be analyzed. -67- IV. Imlementation Planning A. Administrative Arrangzments 1. Government cf Niger - Ministry of Health and Social Affairs a. Administrative Units The Ministi-y of Health, in July 1976, after many months of formal h&.rings and in-depth planning meetings, adopted the following structure as the means of offlclating Niger's country wide health system. It represents a giant step from the centralized hospital-oriented system of curative medicine which has traditiona.Jy been practiced in Niger. The implementation program will follow and utilize the lines of authority described below. Minister of Health - Makes all major policy decisions with the tdv-.ne of the cabinet. Directly responsible to the President and the Su'reme Military Council regarding all health matters. Delegates luthority on matters such as the Improving Rural Health Prctyect. Office of Ser.retary General - Operatej under the general supervision of the Minister of Health. Responsibilities include tie operation, coordination, supervision and administration of the entire health system. All technical divisions of the Ministry (Division of Hygie;ne and Mobij e Medicine excluded) fall under the puzrriew of this office. The Secretary General's Off-.ie is also the clearing house for all contacts at the central and pripheral levels. Divisional directors report directly to the Secretay7 General. The Secretar General will provide the leadership and couthority for the implementation of the Improving Rural Health Project. He has been actively involved in all phases of design and plamUing. Divisions: The Division of Programming, Planning and Statistics Headed by a Nigerien with an advanced degree in health administration and planning, this division has been delegated the responsibility by the Secretary General to coordinate the administrative activities of all Divisions in the Ministry of Health - with particular emphasis on liaison with other ministries such as Finance and Plan. The Ministry recently created an Assistant Secretary General position to add force and direction to this division while at the same time facilitating direct 3nd immediate access to the Secretary General's Office. -68- A health statistics section, presently manned by two "agents s-atistiques", has been comissioned to collect, analyze and report the results of weekly epidemiological bm,_rveillance data emanating frcm the 38 arroncissements. A additional seven "middle-level" statisticians will join this section upcn completion of their training in 1978. The health statistics section disseminates findings on co~amicable diseases, major pestilential diseases, and causes of death to specific audiences via a series of monographs and bulletins. Africare has signed a contract with the GON to supply technica.l assistancd in statistics and epidemiology to this Division of Programming, Planning and Statistics. The project will work quite closely with this division during a1 phases of the project evaluation program. The responsibility of establishing a logistics section which will plan and direct a central garage has also been delegated to the Division of Progra=ing, Planning and Statistics. Equipped and staffed with trained mechanics, the garage will maintain and repair all Ministry of Health vehicles. In time, its scope of work wil2. be expanded to include medicaLl equipment repair which at present is performed in Abidjan and Europe - at great cost to the Government. Project personnel will give technical support to the formulati6n and operation of this progrun .. he National Bureau for Pharmaceutical and. Chemical Products This division, a mixture of government and private interests, provides pharmaceutical products and miedical and surgical supplies to popular pharmacies, depots of medical supplies, and ~tllage pharmacies. The organigram of the Ministry of Health and Social Affairs shows this division as having direct line responsibility to the Ministry of Health. It will be necessary to coordinate drug purchases outlined In the project with this division. Since only the initial supply of drugs to VHEs will be made by the project a simple ad hoc retwork will be established. Divlion of Health Facilities The two na4-ional hospitals (Niamey and Zinder), seven departmental hospitals, and the smaller arrondissement hospitals fall under the authority of this division. The MOH does however, intercede directly on all budgetary matters. In general all hospital services are free of charge to Nigeriens. It is important that these services be operational and accessible to patient referrals from primary and secondary health facilities. Division of Sociel Affairs and Maternal ChilV Health This division serves to direct social affairs, maternal and child health services, education cl' women and the coordinati( of efforts with tne private seoT~or of the health care system. It too makes all its budgetary requests directly through the Ministry. It will be necessary to coordinate the project's health education inputs with this division to ensure program continuity and consistency. Division.of U[iene and Mobile Medicine Through the seven departmental centers this division focuses on the problems of communicable diseases. It is charged by law with control and epidemiological surveillance of camuaicable diseases including smallpox, yellow fever, measles, cholera, TB, leprosy, polJLo, schistosomiasis and venereal disease. The Government has also given this division legal authority for the enforcement of health and sanitary regulations. The evaluation program of the project will rely quite heavily on information from this division. Program effectiveness can only be ascertained by having reliable baselinie information throughout the project. Subunits Deriving its directions from the divisional entities, the follcwing subunits account for direct patient services: Central Medical Centers There are approximately 38 medical centers which provide general hospital and maternity care at the arrondissement level. These centers are suDervised by a licensed state nurse and staffed by certified nurses and auxiliary personnel. The maternity section of the center is usually directed by a state midwife who also provides PMI services. The centers are given the responsibility of training the village health teams and supervising certified nurses working in rural dispens.aries. Supervision of the personnel at the center faJls to the department health director and his assistants who visit at least one a month. The major responsibility for the training of the 1,500 VH~s indicated in the project will be delegated to these subunits. Maternal - CIhild Health Centers This section falls under the responsibility of the central medical center. Its p;ime goal is to extend MCH services (prenatal care, deliveries, post-natal care, infant nutrition programs) to all dispensaries. Ms are staffed by trained midwives, social assistants and aides who direct the health/nutrition education program -70 and provide literacy and sewing education fcrwcmen. The educational program designe-. in the project will align itself to the ongoing activities of th:is division to avoid duplication of effort. Changes will be negotiated as needed. Rural Di s-nensaries The present contingent of dispensaries (167) is staffed by certified nurses who in turn are supervised by state nurses from the arrondissement- 'Dspensaries are visited at least once a month by these supervising personnel. On the average, the dispensary attends 75 to 100 people each day. Basic medicine is practiced at this level with problematiL cases being referred to central medical centers. As is noted throughout the project the dispensary is the primary back-up service to the VET program. The efficacy of the VHT system is dependent upon the efficiency and competency of the dispensary. Village Health Teams The central focus of the rural health delivery system is the village health team (VHT). It is usually one of the first contact points which are available to villagers for basic health services. The basic potential of the VHT lies in its preventive pursuit, that is, to treat and refer before an illness progresses to secondary and tertiary symtcmological levels. VHEs are generally trained and superuised by dispensary and health c~nter personnel. The major share of project funding is devoted to their training and retraining. b. Analysis of Management Capacity It is felt that the administrative stracture described above will enable the MOH to insure a successful project. The added technical input at the operational level and the considerable infusing of training and resource assistance adds further strength. With limited financial resources, equipment, supplies and manpower, the MOH has brought health services, however limited, to approximately 1263 villages. Such an acc'omplis1ment would not have been possible had there not been a viable and effective cadre of leaders in the ministry. It is therefore reasonable to assume that the same leadership will influence the successful implem-ntation of this project. Con sequently it is necessary to identify key positions and describe their relationship to the overall program. They include: (1) Secretary General (2) Departmental Health Director (DDS) (3) Turses (4) Village Health Teams -71- Secretary General Given the present administrative organization, the Secretary General directs the entire health system. All major decisions -- thcse considered policy -- must be cleared and sanctioned by him before any changes are made within the health ministry. A consensus exists among the EDO and the many technical teams who have visited, that the newly appointed administrator exemplifies e ll the qualities of leadership needed for an effective, efficient, and responsive health system. His health orientation and special interests are in concert with those espoused by AID -- directing preventive and promotive health care to the rural poor. DepartmentUal Health Director (DDS) The DDS =nder general guidance of the Secretary General is allowed to develop programs within his jurisdiction to the extent of his creativity and professional know-how. They vary accordingly. In most instances the effectiveness of the programs under his command cora-elate with the number of his personal contacts with subordinates. Those programs which have a higher frequency of supervisory visits tend to function more effectively. Therefore, it is extremely important that the standards for the selection of the DDS remain high and that tht decentralized policy of implementation continue to prevail. Equally important, the DDS must have continual ]_ogistical support -- distances, lack of equipment and untimely delivery of materials can substantially detract from a potentially effective program. In addition the DDS must have a reasonable talent pool from which he may select his direct contact personnel who are responsible for the day-to-day medical outreach, namely, state nurses, certified nurses and VHTs. Nurses A receptive health system is a must if the promotion of health is to be reality. The system must respond to physical needs, recognize attitudinal biases, and be accessible and reliable. It is evident that the existing cadre of nurses and VHs are intellectually well aware of the role they play in the development of a receptive health system. They are often, however, stymied by a lack of supervision, updated skills and general mobility. With the projected input, spelled out in the project paper, it is anticipated that this group will perform nearer to its capacity and subsequently have greater impact in realizing the goals of the rural health project. There are no administrative barriers which preclude or interfere with our quest to strengthen this area of the rura" health program. -72- Village Health Tesms (VHTs) .s with the nurses, the VHTs have the qualities necessary for the development of a highly effective health program. They too, however, need c:ose supervision and a more enriched training program. At the present time their responsiveness to the target population ii not of major administrative concern. This is perhaps due to the self-selection process. VI~s serve at the pleasure of the population and when they aye deemed to oe no longer functional by the people a replacement is sought -- by the people. 2. AID Administrative Arrangements for the Project No unusual role for AID is foreseen for this project at this time. It is possible, however, that changes might occur as a result of the monitoring and evaluaticn of the project. AD wiLI disburse funds for local costs on a reimbursable voucher system following procedures spelled out in the Project Agreement. B. Implementation Plan The successful completion of this rural health project rests heavily with the timing and sensitivity of the logi-stical support system. For the human resource development sectors this mezans dew.loping a viable transport system to get trainees and trainers :o their appointed destination and arranging for a receptive environment for learning and living. For the instituticnal support sector, logistical arrangements must focus on proper procurement, storage and delivery of goods and supplies. Given the present situation, the system has the capacity to fulfill logistical needs. The additional workload, caused by the rural health project, does not appear to put a strain on the system however, special attention will be given to this area and appropriate changes will be suggested as experience is gajied and needs surface. Monitoring The monitoring and general liaison work associated with the project will be dine by the project meaager -- an experienced health administrator. Monitoring -will take the form of a continual scrutiny of a mutually agreed-upon series of project activities in order to ascertain timeliness and thoroughness as well as to identify potential problems areas. Accordingly, the project manager will: 1. Mwaintain continuous lia.ison with key personnel in the GON involved in project implementation. -73 2. De-velop close working relationship with key personnel is MOH and Social Affairs, and advise AID and the GON on the efficiency of'project inputs as -,ell as what steps should be taken to cor :!E-t any deficiencies. 3. Review Niger's progress towards established performance targets, advising GCN and AID whether the progresss is adequate and on schedule. 4. Review all project reports. 5. Communicate suggestions to the EDO and MOH for the correction of problematic areas. 6. Conduct personal inspections, upon conferring with MOH, at selected project sites, particularly with VHEs throughout the departments. 7. Participate in evaluations of the project. 8. Be available to the i4istn- of Health for technical assistance throughout implementation. 9. Maintain liaison with all other donors who might have impact on the health project. In addition, back-up support will be supplied at the Mission. Coordination with Other Projects Other projects being financed by external donors will require coordination with the PP activities and will be additive in nature if well planned. The French assistance to Mobile Medicine will mean that they should be consulted in any equipment purchases which are designed to maintain the cold chain. The Peace Corps' involvement in nutrition education could be extremely useful: for example, in assistace with designing visual aids and the development of a nutrition program for village matrones. The SETS program received unanimous approval from the participating countries at the recent WHO meeting at Brazzaville. However, the individual country programs (including that for Niger) have not as yet been specified. Coordination will be required in at least two areas, the vaccine input and any inputs designed to strengthen the MOH central planning and management capacity. -.he FED program tc construct or renovate about 13 dispensaries before the end of 1978 will complete the current building program of the MOH. The additional construction of 7 dispensaries under this proposed project will come after the current FED assistance and will complete the en-ire rural building plans for the MOH. ne new priority of the M0H is the training anzd staffing of all dispensaries with two nurses each. UNICEF has teen providing some small amount of funding for ugs used in rural dispensaries, but there are indications that this assistance might not be continued in the near future. Unresolved I sues Da"y-to-ddy decisions related to implementation will be the responsibility of the MOIl -Amddesignated personnel. The project manager will be responsible for the annotation and approval of all U.S. inputs into the project. Qualifications for the MOH personnel assigned to the project have yet to be drawn up. In the event that implementationai problems and issues cannot be resolved th-rough the infozmal collaboration of AiD-MOH project personnel, special meetings will be convened between appropriate AID staff and MOH officials. Past records infiicate this arrangement to be effective and acceptable to both organizations. Local Involvement From its inception, selection of VHT membership (the heart of the project), as indicated above, has rested with local inhabitants, and thery have exercised their authority to mouitor and replace members of the VHT when the situation demands it. This level of accountability has accorded them an opportunity to influence and pattern a system which responds to their unique needs. According to the Ministry, the Three-Year Plan, and projections through 1982, there will be no change in this procedure in the foreseeable future. Thus, this same direct involvement ill prevail throughout the life of the proposed project's no additional arramgements are deemed necessary, Imrlementation Schedule Date Action Agency Januarj 1978 Review and Agreement on PP RDO/GON January 1978 PP Submission to AM/W RDO February 1978 Identify Project M-.ager Counterpart GON February 1978 PP Approval AID/W February 1978 Grant Agreement and PIO/C Signed RDO/GON February 1978 Initiate Evaluation Process RDO/AID/W/GON -75- Date Action Agency February 1978 Recruit Technicians AID/W February 1978 Accounting Procedure Developed and implemented EDO/GON March 1978 Vehicle and Mobylettes Ordered RDO /GON March 1978 Drugs for V!as Ordered RDO/GON March 1978 Audio and Visual Aids Equipment ordered DO /GON March 1978 Language Trainin f T ,hriia Assistance Persf uiuei (i.f needed) AIDiW April 1978 Warehouse, Transport System Augmented to Accommodiate Expansion GON April 1978 Develop Stude -- Recru .tment Process GON a. 3rd countr- parti pants b. In-'ountry training for health pez :nnel April 1978 Develop Plan 'for Fx!panded h11 Training &)N April 1978 Develop Retraining >;cles for VH~s GON April 1978 Develop Curricula.. Dates and Participart List for Conferences and Seminars GON April 1978 Develop Training Sites qnd Review GON Logis tics April 1978 Plan Rural Field Program for Medical Students GON April 1978 Construction Sites Identified GON April 1978 Sites for Sanitation Improvement Identifi ed GON April 1978 Technical Assistance Job Descriptions and Sites Assigned GON/Rt)O May 1978 Nominations =ade for Training GCN a. 3rd country participants b. In-country training for health personnel -76- Date Action Agency May 1978 Housing Arrangements Completed for TA person.-:± EDO May 1978 Identify Technical Assistance Personnel Counterpaozts GON June 1978 Drugs, and Audio Visual Materials Arrive RDO/GON June 1978 Technical Assistance Personnel Arrival and Posting RDO/GON June 1978 order Constraction Equipment RDO/GON a. Equipmeu and furnishings for health center ad dispensary b. Sax _tary equipment c. Materials for department centers july 1978 Project rv-iew RDO/GON August 1978 Determine 'Vehicle Distribution GON August 1978 Land AvaiJ.able and Cleared for Construction GON. August 1978 Construction Contracts Signed GON September 1978 Vehicles Arrive RDO/GON September 1978 Construction Equipment Arrives at Sitos CON October 1978 Construction of Department Centers Begins -- Agadez, Zinder GON October 1978 Sanitation Improvements Begin GON November 1978 Recycle Project Plan and Schedule RDO/GON January 1973 Order Cold Chain Equipment RbO/GON February 1979 Vaccines Ordered RDO/GON Februarj 1979 Construction of Dispensaries Begins GON April 1979 Arrival and Distribution of Cold Chain Equipient RDO/GON MaY 1979 Vaccines Arrive RDO/GON -77- C. Evaluation Arrangements Ongoi.L.g evaluation studies will be an integral feature of the project from the onset. The evaluation process will center around: the assessment of quality and status of outputs, program significance, and the verification of scheduled activity completion. Recommended changes and modifications will be developed from these activities in order for the project to real±ze more fully its stated goals. The results of the evaluation will also serve as a tool for assessing the transferability of the project to other parts of the continent - espec:ally those countries experiencing similar health problems. 1. Collaborative Efforts Strategy for the evaluation process wYill emerge from joint meetings between the MOH and AID during the initial stages of implementation. Evaluation will relate to purposes associated with the overall goal of improving at low cost the quality of life and working capacity of the rural population (9,000 villages). 2. Periodic Collection The first full-scale joint evaluative y-will take place at the end of the second year of the project. ecommendations emanating from this end-of-second-year formal evaluation will be the topic of an AID-MOH conference where participants will suggest adjustments in the final portion of the project. A final evaluation will be performed six months before the end of the project. This final activity will pass judgment on the success of the project as well as chart direction for future health efforts. Joint reveiws, in addition to continual mcnitoring by the project manager and his Nigerien counterpart, will be held during years one, two, and three of the project. The purpose of these reviews is to examine performance targets, progress made and general project management considerations. 3. Goal Indicators Improvement in health status in the rural areas is difficult to demonstrate and requires a long lead time before any meaningful change occurs and can be measured. The formal portions of the evaluation study will be carried out by AID/Washington (Office of Development Program Review and Evaluation fPC/DPRE7) and a select number of Nigeriens. This group will initially attend to some of the more basic purpose issues including: -78 a. Increased number of village health teams. Measure - Beginning of project status (BOPS) compared to end of project status (EOPS) or time of evaluation status using the target number of 3,500 at project ccpleticn as a referent. Activity - Review end-of-month status reports at MOH as well as make periodic visits to the seven departmental headquarters for record assessment. Compare progress with pre-arranged schedule of activity (to be forzlated with MOH). Deviations are to be noted and analyzed, and activities adjusted accordingly. b, Improved and expanded training and retraining of managerial and health personnel at all levels. Measure - Course content and scope; nunbers of enrollees, graduates and counterparts, skill and knowledge attainment levels. Activity - Visit training centers to review and record course content and length of course; monitor registration records and graduation certifications, and review pre and post-course examination results. Construct a pre and post-seminar questionzaire to be given to select personnel engaged in training and retraining. c. Improved and expanded logistical support system. Measure - Numbers of active vehicles and functioning medical equipment; numbers of supervisorj visitations over a selected period of time; and an inventory of basic medicines on hand. Activity - Visit select departments for record assesment; review records of dJspensaries and villages within these deparlrments in order to compare recorded visits, vehicle and equipment usage, and general condition of variois pieces of medical equipment. d. Improved and expanded rural health .acilities and departmental centers. Measure - Work space, caseload, personnel and equipment. Activql - Inspect blueprints as well as make site visitations; check MOH records and establish a referent atte-dance matrix to make appropriate comparisons. Make periodic inventories of all usable eqSUpment e. Strengthened environmental sanitation program at National, Departmental and Village levels. -79- Measure - Numbers of trained sanitary workers; curriculum enrichment; and operating programs at all levels. Activity - Review registers and curriculum at training centers, and make field visits to selected sites to observe and record program progress. f. Fstablished health/nutritional educational programs at health centers, dispensaries and villages. Measure - Knowledgeable and skilled personnel, and operational programs and patient charts of health/nutriticaal adequacy. Activity - Review MOH records for changes in appro priate health indicators; review credentials of personnel functioning in tLis area; and make field visits to selected sites to review charts of adequacy. g. Increased surveillance and control of communicable diseases. Measure - prevalence; incidence; .and contacts. Acivitf - Review records at MOH and appropriate agenc~es; field visits for record compaxison.. 1, Baseline Data for Pu-ose Indicitors In addition to direct involvement in technical procedure formulation during the early stages of implementation, the evaluators from AID/W will instruct third-year students at the medical school offering an indepth course in the principles and methodology of evaluative research. Field work associated -with this anticipated course wll serve as a means of collecting baseline health information in order to facilitate before and after health. studies in matched villages. In order to insure that this student medical group will attend sctro of the more critical and complex health-related issues, it will be necessary to train them on an intensive basis, in sampling techniques, questionnaire construction, statistical analyzis and research design. 5. Sample Areas of Investigation a. Background Variables (1) Village perception of VETs (2) Impact of volunterism on health delivery (3) Drop-out rates, social mobility and supervision of VIEs -80 (4) Traditional-modern medicine program integration (5) Langtage choice and impact on training (6) Social n-lass, age, and village status of VHTs b. Worker Characteristics and Per-formance (3,) Motivation and worker effectiveness (2) Wozker-p4tient attitudes toward prevention, heaLlth, &rd i2ll.e:.s (3) Social status and frequency of usage of health services c. System Effectiveness (1) General effectiveness and conmitments of VHTs (2) Specific duty effectiveness cf VHTs (3) Team ccmposition ad level of progr= effectiveness (4) Cost benefit analysis 6. Output Indicators Outputs can be measured from project records. No special baseline data should be needed. D. Conditions Precedent and Covenants It is the intent of ADO/Niamey to include the following conditions precedent and covenants in the project grant agreement. These guiding principles, mode.led after previous grant agreements with the GON, will assure implementation according to project design. 1. Conditions Pr 'cednt a. A senior level Niger-en, to be stationed in Niamey, will be nmaed director of the project. b. The GON will submit a statement of procedures for semi-annual reeiew meetings of the Improving Rural Health i'rojeci. c. Notification that a special account has been established in a bank of the government's choice for the transfer and deposit of advanvtt against local expenditures. 2. Secial Covenant The GON will furnish a work plan and an accompanying budget breakdown for the first year's activities in conformance with the general project outline and financial plan. E. Procuxement Plan 1. Responsibility Given the nature of this project it is proposed that primary responsibility for procurement be assigned to the GON. The GON has indicated that it has at oresent the capacity to implement the necessary local procurement through its own agencies. The ADO agrees that GONs undertaking procurement actions is probaoly the most expeditious way to proceed. In carrying out this responsibility the GON will request the advice and assistance of the ADO/Niamey as needed. 2. Equipment anc Comrodities List The detailed listing and cost estimates for the vehicles, mobylettes, equipment and ccmodities.to be purchased under this project is given in the financial annex. Project needs may result in some shifts between the line items but these Shifts will not oe major ones. 3. Source and Origin The authorized source and origin for cc odi -.,aced try AID -"nder this project is the United States. While maxldn1 effort will be made to mirchase all suitable materials ?nd eauipment in the United States, the practicabil ty of the project will require that many of the items shown in the equipment list, particularly those Items relating to construction, must be purchased from Code 935 scyrce and origin and Code 941 countries. In addition, some ir.g items, such s Nivaquire and Flavoquin, and Mobylettes may not be available in the United States, thus necessitating off-shore procurement (See item 8 below.). 4. Method of Procurement Procurement of U.S. zc'urce equipment will be conducted according to AID Handbook l competitive solicitation (IFB) procedures. The procurement of non-major equipment and materials undertaken in this project, when the estimated cost for delivery in Niger under a single transaction is less than $75,000, is exempt from formal ITB requirements and may be conducted on the basis of good ccmmercial practices as well as reasonable, informal solicitation offirs. Local or third country purchases, when authorized, will be conducted in accordance with good commercial practices and, as far a. practicable, on the basis of ccmpetitive solicitation of offers. 5. Shelf Item Procurements Authcrization for local cost shelf item pr.ocurement is requested in accerdance with AID Handbook 15, Sections 11 B 3 and 31 B 4, of comodities which are ncrmallv imported into the Republic of Niger, and kent in stock in the form in which they are impoited, for sale to meet a general demand. Shelf items of Code 899 origin, but not of U.S. orgin, are eligible for financing, providing that the total cost of these purchases does not exceed 10 percent of the total local costs financed by AID or $10,000, and the unit price of goods purchased as shelf items does not exceed the local currency equivalent of $2,500. 6. Technical Services Procurement a. Long-term ADO/Niamey will request AID/Washngton to contract vith individuals or organizations for long-te= technical services in the areas of. automotive mechanic training, medical equipment repair, and sanitary engineering. b. Short-term ADO/Niaxey will assume the responsibility for contracting short-term technical sexrices as specific 3reas of need are identified anri requested by the G0N. PrelJ.inac- talks with the GON !rve indicated a possible need for assistpnce in areas such as planning, training management, administration, finance and demography. 7. Procurement of Construction Services GON will contract with a local construction -firmfor the construction of 7 dispensaries and 2 departmental headqaarters. Afl/Nimey with the assistance of REDSO engineers will review and approve all construction plans, IFBs, and contracts. -83 8. Waivers A waiver of AIDs somrce and origin requirements is necessary for the procurement of Nivaquine and Flavoquine. The justification fur this waiver is that anti-malarial drugs currently being used and distributed by VFTs in Niger are limited to Nivaquine and Flavoquine. The popularity of these two drugs has been greatly enhanced through extensive advertisement on the radio and th ough colorful and grapnic posters strategically plaied in rural villages. Furthex-mcre it is important to keep dosages familiar and consistent. While this iz generally true of all drugs, it is especially true for anti-malarial drugs rhere the relative difference between a prophylactic dose and a toxic dose is so close. Other Waivers: a. Code 935 procurement of mobylettes--motorized bicycles ($200,000). b. Code 935 procurement of a portion of the construction iaterials financed under the project ($60,000) Mobylettes--This forn of transportatiou has proven itself to be a most effective and economical meaas of travel- especially for supervisory pu:rposes--in aver fifty percent of the country where passable roads exist. The operation of these vehicles is simple and requires a mi:nium of instruction. Another factor in favor of the mobylezte is the ease and availability of repair services. Mobylettes and spare parts are locally available. They are not manufactured in the United States. Construction materials--Tae majority of the construction materials financed under the project will be of local origin or from neighboring code 941 countries A small percentage (approidmately 7%) of the required materials are not available from 941 countries but, are regularly imported into Niger from code 935 cowntries. A waiver is requested allowing code 935 procurement of these construction materials because the volume Pad type of items to be procured at any one time would render imnortation from the United States completely impractical. -84- P. Negotiation Status Me Dproving Pural Health project, as described in the project paper, is based on a GON ten-yeer health plan. The project design, which focues on specific program area:, has been developed in collaboration with the health ministry. We have the concurrence of its officials with respect to project inputs and anticipated outputs. The goverent has expressed a desire to see a more rapid implementation of the progru but ADO believes that the schedule outlined is more feasible. - 85 - Annex A Main Causes of Death Data a/o August 31 1977 for period JanuaX 1976-March 31, !977 (by percen ) Nane of Disease Thrban Areas Rural Are u. Tuberculosis 5.63 7.03 Baci3.ary Dysentary & Amoebiasis 6.15 9.57 Malaria i$.03 15.32 Meningitis 9.13 10.62 Peptic Ulcers, intestinal obstructions, hernias 2.13 .1.69 InfectiTe and Parasitic Diseases 12.23 1.4.04 Complications of Pregnancy & Child Birth • . 2.07 3.62 Congenital. Anomalies, Birth Injury Difficult Labor, Accidents/ Violence 15.64 15,,03* Unimwn Causes 32.99 23 •05 Total - All Causes 100.00 100,100 • Estimate Source: MOH/WHO/Niamey MJur Disea ,e Treat.±,. by Arrundiu.cm.- t Amsex b Janu ry 190 - AusutL 31, 1977 Waales Whooptlg 112!I! bipLthvria TPt-:us iul tscwYlt tu malaria Me,,naltis problcms Juundice ______39 10: 144 12 15 5806 116 612 6 PlImp. NA 13 1 2 2 i9 32 . Arl IL 23 10 1 3 1 1939 26 1603 Jffdrilne 12 25 2i 3 63 12 162 Total for Dupartnunt 71, 171 8 19 21 010 1A6 2377 6 N3:s__o 169 7I 2 26 9 14 60w: 29 136 98 lki,,yc 503 11.2 - 15 Dcogosdukitchl - 7560 58 163 -, 1973 369 - 18 8 8 Gaya 5 2 19 1)15 29 299 137 - 9 - 1,9 3 23 212 82 19g 397 8 -1 1.463 fl9 TotAl for PJpartmc.nt 3513 1122 9 76 114 05300 2( 237L 2'16 Muradi 2639 296 - 6 9 Agu j t 16693 86 1893 29 602 29 2 - Dakoro 3 7115 15 129 9 516 139 - 3 - ('aldan. 619S6 18 1,8' 1! Routidji 863 159 - 32 adua'ostuf 696 - 1)6 21 95 6 4.2 - -- .91.5 139 .ay,,hi163 139 - 1.i - -/6 29 9 29 Tttuoua 259 19- 21 15 1 14693 9 -116 13 TotAl for Duartment ,5738 1001 2 56 13 61.1131 297 2$% 134 NI Ely 54218 1L048 1591 1.h' 6t "45 1 &)5u 44 F1I1igue .429 223 9 3 Ouallam 2 11223 - Th9 79 161 43 3 9 236L1 6 27 9 Say 229 1;29 - 12 41 17562 22 2 " 13 Tera 263 52 - 9 3 38 271 57 Til1abery 2 9 2 6 31 12003 7l 16J 49 Total for Department 68!0 1593 29 130 224 .8187,16 3?5 10136 651 Tahoua 615 213 2 23 9 13238 Bi rni n'Konni 11323 21 1329 9 257 - 19 - 12623 29 1i3uza 21.5 58 1W8 69 4 21 3 162 9 903 Ilhia 139 9 - 23 23 - 8264 9 216 - Keita 39 11 - 9 Madaoua - 7515 23 396 3 343 139 9 11 36 14oo6 Tci iitabaraden, 129 69 1207 - - 2 - I 96 6 Total fur th'parLm'ist 3333 721 5 632 .. 9-015 Prz M II 1 Intestinal Measles Whooping Cough Viptheria Tetanus Polioquylitus Malaria Meningitis problems Jaundice Zinder 6 1703 197 52 32 - 183 296 629 37 Gpire Goure 132 49 - - 2 1629 15 193 19 Magaria 6 529 58 3 - - i03 21 1123 29 Matameye 62 23 - 13 - 6273 43 39 9 Myrriah 263 139 6 15 3 829b 15 1363 - Tanout 3 _42 -1 2 4136 18 329 Total for Department 2732 50B 61 63 7 4743 408 2976 103 GRAND TOTAL 22289 5119 124 452 327 366585 1574 27460 1.274 Source: LNICEF Regional Office Abidjan 10/4/77 - 88 - Annex C Health Care by Circumscrintion - 1976 Data a/o August 31, 1977 Department/ Arrondissement Consultations 1No. of Patients Days Deliveries I. Agades 20,361 NA NA NA Arlit 22,361 92 110 1,128 Iferouone 62 1) 92 NA il1ma 233 10 96 NA Sub-total 43,017 113 98128 II. Diffa 24,631 62 1,061 1,762 Bosso 9,361 NA NA NA Maine Seroa* 33,132 1,106 25,703 262 N'Guigmi 30,361 482 3,87.6 361 Sub-total 97,485 1,650 30,580 2,385 Ill. Dosso* 210,601 615 NA 762 Bobye 213,132 236 852 183 Dogondoutchi 526,361 752 10,391 716 Gaya* iL5,031 336 2,106 345 Loga 102,631 252 1,519 169 Sub-total 1,197,756 2,191 14868 2,175 IV. Maradi 299,796 716 NA 323 Aguie. 179,362 496 3,297 225 Dakoro 110,796 379 2,746 416 Guidan Roundji 104,673 625 3,297 456 Madarouna 139,800 309 1,915 97 Mayahi =2,387 326 2,147 189 Tessaoua 218,3C6* 397 3,238 826 Sub-total 11105,120 3,248 16,640 23532 V. Niamey (Arrord) 195,000 1,523 3,063 1,132 Niamey (City) 690,000 721 9,132 367 Filingu6 186,623 600* 4,403 387 Ouallam* 75,032 310 2,607 310 Say 88,596 235 1,510 225 Tera 182,043 652 7,506 575 Ti llabevy 244,601 523 4,302 625 Sub-total 1,661,825 4,564 32,523 33621 VI. Tahoua 161,289 626 2,306 4-12 Bi.cni N'Konni 151,361 620 2,603 1,420 Bouza 209,463 185 1,307 210 I-lela 137,603 221 2,203 275 Keita 83,407 326 1,800 142 Madaoua 563,707 513 3,462 615 Tchintabaraden 133,000 228 1,537 111 Malbaza 45,762 252 1,378 179 Sub-total 1,485,592 2,971 16,596 3,384 *Estimate - 89 - Departen/ Arrondissement Consultations No. of Patients Days Deliveries VII. Zinder 105,637 1,62 3,632 1,132 Gour4 99,487 368 NA 341 Mangaria NA 323 2,803 423 Matameye 45,147 313 1,587 515* Myrriah 167,461 247 4,173 200* Tanout 82,501 462 4,Ioo 252 Sub-te;al 500,233 2,875 16,295 2,863 TOTAL 6,091,098 17,612 127,800 18,088 *Estimate Source :MOH Annex D Health Manpower Availibillty - Availability of Trained Nigerien Health Personnel, August 1977 Qualif. Dept Dept Dapt Dept Dept Dept Dept In Serv. Det6 Susp. On Niamey Dosso Tahoua Zinder Maradi Agadez Diffa Temp. Serv. from Leave Total Practice MOH Assign ment Physiclans 12 - 1 3 - 1 4 3 - - 25 Dentists - - 1 - - 3 - - 6 Pharmacists 7 . -..- I - - 8 License in nurs, care 2 ------2 Hlth assis. techn. 17 2 2 5 2 2 1 2 1 - - 34 State nurse 104 30 14 30 31 10 14 10 6 - 3 252 Chief nurse 14 3 - 4 ------21 Cert. nurses 164 48 57 55 35 23 25 - 1 8 1 417 State mid wives 35 5 5 9 .5 3 1 2 2 1 - 68 Chief mid wives - - - - 2 - - - - - 2 Soc. assis. 5 - - - 1 * - - 1 - - - 7 Soc. assis. techn. 3 ------M 3 Soc. assis. helpers 16 2 - 3 2 3 3 - - - - 29 Extension Supervisor 2 - - 3 1 - - - - 6 Extension Auxiliary 1 - 2 - - - - 3 Sanitation Techn. 1 - - 1 - -.. 2 Electrical Techn. 1 - .....- 1 Health Nurse 4 - - 6 10 Supplied by the World Health Organization (WHO) Representative, Niamey, Niger - 91- Annex E NIZR HEALTH PERSONNEL ON BOARD a/o AUGUST 31, 1977 Foreign Technical Type Nigerien Contract Assistance Total Doctors 25 15 69 09 Dentists o 3 15 2 20 Pharmacists 6 2 3 11 Licensed Health Practicioners 3 2 - 5 State Nurses 292 13 12 317 Health Assistants 23 1 1 25 Nurses (Brtvtds) 35 1 2 38 Certified Nurses 537 2 3 542 Mid-wives (State) 64 - 4 68 Mid-wives (short-term training) 2 - 1 3 Social Assistants 1 1 2 Technical Social Aides 1 1 1 3 Assis. Technical Social Aides 1 2 6 9 Social Aides 30 1 2 33 Health Educators 19 - 2 21 laboratory T-chnicians 3 2 5 Sanitary Engineers 1 1 2 Hygenists -" - 1 1 Nutritionists 1 - 1 Garage/Transport Person 7 3 10 Interpreters 1 - - 1 Dietician 2 - 1 3 Total - All Sources 1056 56 117 1229 Source: WHO/Niamey - 92 - Annex F PERSONNEL NEEDED II- ORDER TO FULFILL THE OBJECTrES OF MM T,= YEALiR PIAN Data as of 31 August 1977 (Excludes Participants in Training Outside of Niger) Type of Personnel Niamey Dosso Tahoua Maradi Agadez Diffa Zinder Total Dent Dept Dent Dent Dent Dent Dent Dent I. Medical Personnel Generalist 12 2 2 2 4 4 4 30 Public Health Sp. 13, 5 5 12 5 5 5 50 Cardiologist 11 3 2 3 2 2 3 26 Pediatricians 12 3 3 2 3 4 4 31 OBGY: 7 2 2 3 3 2 6 25 Oral S,rgeons 7 1 2 2 2 1 7 22 Opthalmologist 3 1 1 1 1 1 2 10 Gastro-Internist 3 1 1 1 1 1 2 10 Eye,Ear,Nose,Throat 2 1 1 1 2 1 2 10 Neurologist 2 1 1 2 1 1 1 9 Psychiatrist 1 1 1 1 1 1 2 8 Radiologist 3 1 1 1 1 1 2 10 Urologist 3 1 1 2 2 1 2 12 Anesthesiologist 4 1 2 1 1 1 3 13 General Surgeon 13 4 14 2 4 4 7- 38 Hemotologist 2 1 1 3 1 1 1 10 *Proctologist 3 1 1 2 1 - 2 10 Bio-Therapist 3 1 1 1 1 2 3 12 II.Para Medical Personnel (Non-Traditional) Dentists - 3 1 2 1 4 3 14 Pharmacists 1 3 2 2 2 4 4 18 State nurses 43 78 63 64 65 70 69 503 Chief Nurses 15 2. 32 14 26 35 32 175 Certified Nurses 146 156 182 143 138 145 178 1CP8 State Midwives 22 28 20 26 39 23 29 185 Chief mid-wives 21 23 22 22 21 16 18 143 Social Assistants 4 4 2 1 4 5 4 24 Assis. Social Aides 3 2 2 3 2 4 3 19 Sanitary Engineers 4 4 5 5 6 7 2 33 Laboratory Tech. 5 18 17 25 10 25 26 100 Med. Equip. Repair 9 4 6 l1 9 7 3 46 Source: WHO/Niamey and Ministry of Public Health and Social Affairs - 93 - Annex G Per.onnel in Training Outside of Niger Tyme of Place cf Year Training will be completed Personnel Training Total 1977 1978 1979 1980 1981 1982 Physicians (48) Dakar 9 - 3 3 1 1 1 AbidJan 5 - 1 - . 1 2 Nigeria 3 - 1 1 1 - - Algeria 6 --- - 2 4 Other Africa (Gabon, Zaire, Emt) 3 - - 1 - 1 1 France 7 -- - 1 -- usOther (Belgiun, Fracer e12 - 6 - 6 QCuba) ) 3 1 - 1 1 - - Phiysicians (Spec) Physical Theray Canada 1 1 . - . . Opthalmology France 1 2 - Cardiology France 1 - 1 - . . OBGIYN France 2 - 1 - . . Surgery France 1 - -- 1 -- Dentists Dakar 1 --- - Abidjan 2 - . .. . 2 Pharmacists (Spec) France 2 2 . K~iesthera-y Algeria 5 3 2 - . . Laboratory Per- Togo 15 5 3 7 - - sonnel Algeria III -- 1 -- - Anesthesiologist Algeria 3 - - 3 -- - Assis. Social Aides Ivorzj Coast 7 - - 7 - -- Social Workers France 3 - 3 - . . Medical Secreta- France 4 - - L -- ries TOtaLS 206 19 21 34 15 7 10 Source: Ministry of Hea.th and Social Affairs September 1977 Amex H Afrizare and its Relationship to the Improving Rural Health Project Specific program activity which has evolved out of the experiences of the Africare project tb= far centers around two areas: 1. Involvement in the Diffa Department in a program similar to that which the Improving Rural Health projer.t has designed for the remaining six departments. 2. Special research activities in the MOH, Niamey. Throughout the design phase of the Improving Rural Health project, AID personnel and project team members consciously avoided a cctflictive relationship between the two programs--given the scarcivy of resources. The subsequent relationship can be described as follows: Ccmlementary--a mutual role exists in the overall goals of the two projects. However, whereas the Africare project directs its resources to strengthen the rural health delivery system in the Diffa Department, a concentrated region, the Improving Rural Health project is more national in scope, covering the entire country. Dissimilar-Africare is heavily involved in formulating an epidemiological research progrem and developing laboratory procedures for the 2entral ministry. The Improving Rural Health project has no similar designs. Coorerative--Potential overlap, such as curriculum develol~mnt for in-service education has been averted through personal contact and turned intc a cooperative relationship. A common training program, excluding regioral nrerequisities, is being used throughout th country. The objectives contained in the project paper are the result of joint planning meetings with the Ministry of Health and reflect the wishes of the government and the professional judgment of an experienced project paper team. Unless some unforeseen exigencies develop, we expect to carry out the program to full realization. - 95 Annex I 7) (000 CFA) Amiaistration (Cabinet and Central Administration) Personnel 18,961 Material 4,055 Telephone (incl. service DDS) 3,670 Transport 19,320 46,036 Education Personnel ENSP ENICAS 30,791 Material ENSP 2,805 ENICAS 2,145 Utilities ENSP 6,000 MICAS 605 Tood and clothing for students 8,780 • 51,126 Hospital Services Niamey Personnel 145,900 Material 18,500 Technical supplies 6,855 Utilities - Water and electricity 29,700 Telephone 3,300 Food for Patie;ats 49,500 Medicines, Lab. supplies 130,000 Trawt-port l65o 385,405 Zinder Personnel 39,131 Material 4,620 Technical supplies 2,750 Utilities - water and electricity 8,800 telephone 1,100 Food for Patients 19,800 Medicines, Lab. supplies 62,528 Transport 1 100 T39,829 TOTAL: Hospital Services 525,234 Annex J -96- GEAL BuDGET COSTRUCTI0N AND RENUVATION Dollar CFA Catego: ost Cost A. DDS Facili ties-Agades and ZnLder Guardians Housa 35,122 2,625,000 0Oi.Lces and Training Center 65,755 16,110,00 Garage and Medical Equipment Repai; Workshop 59,951 14,688,000 Sub-Total (Fazilit7) 156,828 38,423,000 Price for two facilities ncluding 10io iation cer year and 2Cj cont "ngency 313,660 76,846,00o0 B. Dispensaries - Se-en at various towns in Niger each 53,061 13,000,000 Sub-Total for seven icluding inflatLng and coningency 371,430 90,O00,OO C. Sanlitaxy hstllations Fifty Healths Centers 50,000 12,250,000 Two hundred t-Ien-y Dispensaries 220,000 53,900,000 Sub-Total 270,00 66,50,CCC Grand-Total 955 090 2?2,996,Ccc Or l,000,0CO 245,OC0,000 Drafted: Harrell/M.J. Morgan Abidjan October 4, 1977 Cl: Anata Mackie (In Subs) Armez K - 97 - Recurrent Budget Projections .ManpowerComponent l(e). DiplomA Nurse Training (ENSP) 20 students per year x $2,500 per student year x 5 years. 10 percent inflation per year. 2 year program. Year Entering Year Leaving # Manpowrx Grade 32 x salary starting 1. 19 8 1980 20 700,000 CFA 3. 1980 1982 20 5. 1982 1983 10 Year Grads. on Payroll x salary B2 Total Cumulative Expenditure 000's 700,000 CFA 3. 1980 20 700,000 CFA 14,000 4. 1981 20 " 14*000 5. 1982 40 " 28,000 6. 1983 50 " 35,000 l(d). Practical Nurse Training (ENICAS) 40 students per year x $2,000 per student year x 5 ears. 10 percent inflation per year. 1 y.ar program. Year Entering Year Leaving A Manpower Grade 02. r startiag salary 1. 1978 1979 40 300,000 CFA 2. 1979 1980 40 3. 1980 1981 40 4. 1981 1982 40 5. 1982 1983 40 Year Grads. on Payroll x salary D2 Cumulative 2. 1979 40 300,000 CFA Totas.xpenditure 0 s U A 3. 1980 80 24,000 4. 1981 120 36,000 5. 1982 160 48,000 6. 1983 200 60,000 - 98 1(g). Environmental -ealth Workers (ENICAS) 15 students per year x $2,000 per student year x 5 years. 10 percent inflation per year, 1 year program. Year Entering Year Leaving 1. 1978 19/9 15 2. 1979 1980 15 3. 1980 1981 15 4. 1981 1982 15 5. 1982 1983 15 Year Grads. on Payroll x salarv Dr Camlative 300,000 CFA 00 s CFA 2. 1979 15 4,500 3. 1980 30 9,000 4. 1981 45 13,500 5, 1982 60 18,000 6. 1983 75 22,500 (c) VHT's. Total of 1,500 teams x 4 persons/team z 6,000 trained Total of 13,500 V workers retrained Total im operation in year 5 - 1982 - 6,000 - 13,500 a 19,500 Number requiring retraining in year 6 = 1/2 x 19,500 = 9,750 From Wright's Perspectives, paragraph 2, Item 1.6. Cost of recycling momber of VRT per annum = 15,000 CFA. Cost of recycling additional VHT workers year 6 = 9,700 x 15,000 CFA = 145,500,000 Total Additional Cost for Manpower Component by Year 6 (1983) Item Co,,. byAYear 6 l(c) VHT's - Recycling 1/2 additional members L45,500,000 l(d) 200 additional ENICAS grads. 60,000,000 l(e) 50 additional ENSP grads. 35,000,000 l(g) 75 additional ENICAS grads. (sanitary eng.) 22,500,000 Total 263,000,000 - 99- Annex L Dispensar Ecuiment List Quantit Item 2 Metal storage cabi.-_t for medications 1 Medical weighing scales 1 Portable metal medical bag 2 Sterilizer - rustproof - 4.51 cm 2 Water basin 30 cm (rustproof) 5 Kidn4ey shaped table ( _"tnroo) 2 Rustproof water pail 1. Examining table 1 Square treatment table 2 Round treatment table 70 x 60 cm 2 2-burner portable gas stove 1 Stool - two rollers 2 Metal waitin benches - 2 meters in length 500 Assorted hy-podermic needles 100 Syringes - 2, 5, 10, 15, 20 c 6 Medical shears - rustproo 6 Bandage shears - rustproof 6 Hemostatic pliers - no points 6 Mayo scissors 6 Surgeon shears 2 Blood pressure kits, including stethescope (enclosed in bag) - 100 - Annex M Drug and Miscellaneous List 1. Alcobol. of iodine 2. 1 opthrlmic ointment 3. Sulfaguanidlne tablets (Ganidan) 4. Adpirirn Tablets' 5. Blue Methyline for mouth wash 6. Flavoquine/Nivaquine- anti-malarial mredicines in pills anrepowder 7. Mezcurochrome 8. Scissors, bandage, straight and curved 9. Bandages--all types 10. Compresses 11. Absorbent cotton 12. Medical thermometer - 101 - Annex N Vaccine List Dos Z Proposed by Year Tye1979 1980im BCG - Anti-TB 500,000 500,000 500,000 Me sles 800,000 800,000 500,000 Chole.-a 200,000 200,000 200,000 Yellow Fevt.r 3,000,000 3,000,000 2,000,000 Meningitii 1,000,000 1,CO0,000 1,000,0CO Poliomyelitis 2,500,000 2,000,000 1,500,000 Smallpox 700,000 500,000 500,000 Tetanus Toxoid 3,000,000 2.000,000 1,000,000 Tetracoq (DiptAeria/Tetanus) 250,000 . 250,000 250,000 - 102 - Annex 0 Cold Chain Eouilment Quantity Item 10 Portable Ice-Making Machines--to be opere.ted from car batteries 30 Ice boxes suitable for storage of vacciLes 15 Refrigerators--small -103 - Annex P EZuprment List for Garage Maintenance Shops Agades and Zinder SPECIFICATION This specification is for the procurement of cne lot of hand -ools and eqiipment. Items should be those sold by Snap-on Tools, Kenosha, Wisconsin; MzMaster Carr, Chicago; Black and Decker, Towson, Md., or eqcjal. Catalogue numbers shown are those in snap-on catalogue "EL"; Maaster Carr No. 81, or Black and Decker PE-4. IT4# Z DCRIPI ON CAT # EST UNIT PRICE (R1OB) 1. Black & Zecker 1 2 Drill, electric, 1/2" cap. 2.6 continuous 220V AC 1335 $ 75.00 2 2 Bench grinder, 61 1/3 HP continuous daty 220V AC 4310 50.00 3 4 6" grinding wheels, 2/4" wide, 1/2" hole A 60 grit. 15314 10.00 4 4 6" grinding wheels, 3/4" wide, 1/2" hole, A 46 grit 15313 10.00 5 4 6" wire wheels, I" wide with 1/2" adapter, 30 gauge 39012 4.00 6 6" wire wheels, " 'wide with 1/2" adapter, 33 gauge 27004 4.00 2. Snan-on 7 2 Face shields GA224 7.00 8 2 sets H S drill bits, English 1/16" to 1/2" by 32 nds. DBII5A 4ooo 9 2 sets H S drill bits, metric, 1 = to 13 mm DB125A 70.00 10 2 Tool set, basic, Engisl 3/8", 1/2" drive and chest 5088GSB 550.00 U1 2 Standard length metric sockets, 6 point l/2' drive 10 m to 19 mm 310TWMY 3Q.00 - lO4 - IE DESCRIMI0N CAT # EST UT PRICE (FOB) 2. Snap-on (cant) 12 2 Vacuum and fuel pymp gauge set MT14B $ 50.00 13 2 Files, round, 7/32" diam. x 66P 1.50 14 2 Files, mill flat 6" 6MA 2.00 15 2 Files, mill, flat 8" 8MA 2.00 16 4 Files, triangular, 5 1/2" 6T 2.00 17 10 Handles for above GA98 2.00 18 4 Knife, utility, with extra blades GA169 4.00 3. McMaster Ca--r M# . DESCRIPTION CAT PAG EST UNI PRICE (FOB) 1-9 2 Mechanic's vise, 5" Jaw 5310A4 1281 45.00 and anvil 20 4 "C" clamp, forged 8" medium weight 5028A5 1272 26.00 21 4 "C" clamp, forged, deep throat 6" light weight 5027A15 1272 12.00 22 2 Oil drum dispensing pump 1318N16 281 35.00 23 8 Grease gun, hand lever type 18 oz 1053Ki 276 25.00 24 2 Sharpening stones, Al oxide two grit 4506A2 1241 5.00 25 2 Tire pressure gauge pencil type 5469K2 881 8.0 - 105 - ITEM WQY DESCRIPTION CAT PAGE EST UNIT - PRICE (FOB) 3. MaMaster Carr (cont) 26 4 Suction gun, 16 oz cap with flex. hose 10501C2 281 12.00 27 3 Oil fiter wrefich 688oo. 1361 5.00 28 2 Battery hydrometer, temp erature compensated. Read specific gravity 4057i11 745 8.Ou 29 2 Battery terminal puller 6700D11 1359 6.00 30 2 Battery post cleaner 6636D12 1359B 2.00 31 2 Battery tester and case 12 V 72631L 1005 25.00 32 2 • Battery jumper cables #3 wire 25 ft. with clamps, heavy duty 7234x17 980 35.00 33 1 Abrasive cloth, A 10 x 1 1/2" zoll, 100 grit, 50 yds. 4687A17 1256 7.00 34 1 Abrasive cloth, A 10 x 1 1/2" roll, 180 grit 50 yds. 4687A14 1256 7.00 35 2 Flash light, 2 cell, rubber fiber case, with batteries 1050D21 419 4.00 36 2 Battery lifter 6681A2 135913 3.00 37 4 Tire pump, hand 1 1/4" dia. x 14" 9954n3 798 5.00 38 2 sets Tire changing tools 6691D1 1359D 125.00 39 2 Tire changing stands 6856D. 1359D 225,00 40 2 Cross rim lug wrench 6679A2 1359D 12.00 41 2 Hydraulic sei-rice jack 1 1/2 ton 29o8Y4 180 250.00 42 2 sets Jack stands (pair) 1 ton cap. each. adj. ht. 12" x 17It 8059T2 185 50.00 - 1o6 - ITM QTY DESCRI=T!ON CAT # PAGE EST U'I PRICE (FOB) 43 4 raavanized comnb. dispenser/ funnel. 1 pt. 4362-1 65A 3.50 44 4 Galvanized comb. dirpenser/ funnel. 1 qt. 4362T2 65A 4.00 45 4 PLmp oiler, 7/8 pint 6" spout 1250K5 281 4.50 46 4 Polyethylene :nel 1/2 qt 4360T3 57 3.50 cap 47 2 Battery charger 10 Amp. 12V DC automatic trickle, 1171 inrut 7182K12 981 40.00 48 2 Transformer, 120/240 Volt. AC. 50-60 Hz 500 watts 6980K6 983 35.00 49 4 Battery filler 2 1/2 qt. 4428T1 65 7.50 50 4 Gasoline can, safety cap. 4303T5 63D 14.oo 5 gal. 20 gauge 51 2 Air compressor, cap. 2.3 CFM @ 100 ISIG free air; wheel mounted; prtable; aircooled; 220 V, 50 RZ single phase motor with overload protection, con plete with receiver built to meet ASME code; quick coupler: air chuck; 25 ft. air hose; drain; safety valve; air gauge and unloader 4309Ki1 800 35.00 52 1 lot Spare parts for above to 15% of the value of the ecuipment, The composition should be bared on the normal usage of parts 4309Kli 800 50.00 and filters in the first year 's operation and on the total number of units to be supplied on this order - 107 - ITM # y DESCRPTIION CPJT# PAGE EST UI PICE (FOB) 3. McMaster Carr (cont.) 53 2 Literature: English - one 4309IM 10.00 copy, French two copies. Operator's Manual Spare parts list overhaul. manual Armex P - lo8- Medical Equipment Repair Shop . : Quantity Item Price Total Per Unit Price JTK-17 MID Molded Case Model with Meter $ 297.00 $ 891.00 4 JTK-17MM (Metric Tools Model with Meter 322.00 1,288.00 2 15 Piece Service Kit 15.95 31.90 4 Leather Service Case 96.00 384.00 2 Triplett Model 60 V.O.M. 99.00 198.00 2 Triplett Model 60 Case 25.00 50.00 2 3" Triggered Oscilloscope Oscilloscope Less Probe 399.00 798.00 2 3" Triggered Oscilloscope Probe 29.50 59.00 2 3" Triggered Osci-ll-scope Frotection Case 12.95 25.90 2 Model 464 Portable Digital Multimete- 259.00 518.00 2 RF Signal Generator 234.00 468.00 2 Hookon Prrbe 3,95 7.90 2 Five :1_ace Electronic Screwdriver Set 7.35 14.70 2 5-Piece Phillips Driver Set 8.50 17.00 2 Inch and Metric Hex-Driver Sets Inch Set 12.95 25.90 2 Inch and Metric Hex-Driver Sets Metric Set 12.95 25.90 2 Slip Joint 6" w 3/41 jaws 2.85 5.70 2 Slip Joint 66B385 10" w/l 1/2" jaws 4.50 9.00 2 Cable Cutter - 8" length plastic covered handles 16.95 33.90 2 Heavy Duty Wire Cutters Nickle Chrome Steel 7.50 15.00 2 Titani'm Tweezers Type TW805 13.25 26.50 2 X-Acto Kaife Chest 7.95 15.90 - 109- Quantilar Item Price Total Per Unit Price 2 Electricio.a Knife Dri~vr $ 5.25 $ -10.50 2 Curved Scissors - Cut Length 3 7/8" 11.95 23.90 2 Che-Lab Kit 27.95 55.90 4 WD-40 - 16 oz aerosol can 2.30 9.20 2 Sila-Spray 2.25 4.50 6 Corrosion-inhibitor Lubricants 16 n%. cam 2.39 15.54 3 Ultrasonic Ciei . r-,Model LP-I-HD 96.00 2.08. oo 3 Soft-faced Hammers w/tips (soft-tip, meditm Q, tough tip, medium-hard tip, hard tip, e-ra-hard tip) 15.50 47.70 3 Straight Claw Hammers 11.95 35.85 3 12 oz. Ball-pein Hammers 4.70 l4.io 2 Carbide Rod Saw Blade 12" 2.35 4.70 3 Heavy Duty Hack Saws w/12" blades 5.60 16.80 3 3/8" Cordless Dril-Screw-driver w! Charger Unit (Charger for 210-,225 Volts) 39.99 119.97 3 Engravers for use 220 volts AC 14.95 44.85 50 Wire Cup Brushes 2 3/4" diameter 2.95 147.50 3 Variable Speed Moto-Tool 62.00 186,00 2 12-Piece Carbide Cutter Set 63.00 126.00 2 12-Piece Emery Wheel Sets 14.50 29.00 2 1/4" Drill - Variable Speed from 0-2100 rpm 24.95 49.90 2 Vertical Drill Stands 15.95 31.90 2 Horizontal Drill Stands 3.50 7.00 2 3/8" Drill - 1/3 horsepower motor 3.2 amps 54.99 lO9.98 2 1/2" Drill - 1/3 horsepower 3.4 amp. 59.99 119.98 - 110 - Price Total Quantity Item Per Unit Price 6 Workmate All-Purpose Work Center and Vise $ 89.00 $534.00 2 10-Piece Metric Hex Key Set 3.40 6.80 3 Foldup Hex Key Sets Inch in Metric - Medium Inch 2.75 8.25 3 Foldup Hex Key Sets Inch in Metric - Small Inch Set 2.25 6.75 3 Foldup Hex Key Sets Small Metri; Sets 3.20 9.60 3 Foldup Hex Key Sets Large Metric Sets 4.95 14.85 2 Nutcrackers 10.95 21.90 4 each Aaiastable Wrenchs - sizes: openings 1/2', 3/4'", 5/'16"" 1.1/8" 90.60 2 Acelylene Cylinder Welders incl. Starter and Regulatcr, and Oxygen-capable of 500 hours operation 319,95 639.90 2 Desoldering Tools - "Model Hotvac" 21.35 43.10 15 "Kwik-Draw" resin core solder 1.20 15.50 4 Swing Lamps - extending to 24" for 220 volts 30.85 123.40 15 Replacement Bulbs 1.40 19.60 6 Magnifying Glasses 2" dia. 3.40 32.40 6 Magnifying Glasses 4 1/4" dla. 10.00 60.00 3 Vaco Pow Rivets-Kit 31.95 95.85 4 Vaconnector Kits 30.00 120.00 6 Tool Containers for Shop 700.00 4,200.00 6 Workbenches 3,000.00 18,000.00 - ill - Annex Q Elucationa! and Audio-Visual Materials quantity Item 7 Orerhead projectors - 220 volts 7 White screens 7 Small printing presses 3 Mimeograph machines 5 Xerox machines - small 3 Collating machines - hand-operated 5 Staple machines A ,,i,-x E PitOJEC r DE,' LGN '1 UR1. Y Project Title & Numhr: Improving Rural Health LkXbICAL kkIAML'WORK Lafe uf PrJ.eCt: From FY 78 to FY 8 Total U.S. Funding 11-.5 Date Prepare I.LSt .'_r_ 1_ 197 NARRATIVE SRMMARY OBJP'kIVWLY VEIFI-ABLEI-NDICATORS MEANiS OF VERIFICATION IMkiOHT'w- A r:;;IM'IIow;_ Progrm Goal: The broader object!ve to M.a; ires of G,,al Acl,-v,iment Crncerrin., oag_v_'i- vt-au, _,,V irgrami/project which this project contxibufes: Goal: To improve at low cost the Inetcased life expectancy, de- Special "tudic-": I) Other f'i:tors ,ifo n,,t po'.'vit t,, okutwtigh quality of life and working capacity crua:d Infant irotel' ity mod 1) DImographit utudit7; Birth- effects of improv-Vi h.alth :;vrvic -s, i., . of the riural population (9000 villages). decreat;e in w,)rk, r Incainicity death ratee; life exl)(ectancy, drought. in all ruiiA viii :g's. '2) Epidml ogoeial s tudi e::. 2) GOi eOi'. :nuet to adieqj:tt, 1) ruppi'rt 'h, (Incidnce mortality due- to present polici,'s and ttrat. pi,; tIt dt:v, lolmjunt S-bgoal: By 19)8P, to provide 3500 Increa;e ii IIfe', ,xp'ctwicy, major c nunicable disease ) aLd improvem.'z ufth-, rut h-alth tservices villages with basic health care decrease . infant mortality, 3) Socio-ecnrtic studi,'t ,, V stem. se rvices decrease in work r incapacity workr productivity. i) (ON contlint-G to :;upm,ri IItr, ,i iA in a-ll v:!l] s4 servi.,v -I y activitie8, i ... H4 ' I , Ir 1;]t41-tuti1)n, ViPr's. water supplies, ,tc. Project Puityose: PoP-o:iroCondition:3 iOat will indicate Affecting port--ti-ga l ik: ha; 'ien achi,-vAt: End of' ,roJ:ect status. A viable rural health delivery system 1) AnrLual numb1er of prevenutable 1) Review of health rec-nrds. Allowances will be matd,- fo'r*" :;purious which demonstrates the value of illns ss ulcr.a:e by 15, i.e., effects of improved rel-,l'itnf' and cone prevention/early diagnosis/timely malaria, mfi:;ls diarrhca, finding. curative intervention/proper referral. TD, etc. 2) Secondary, & T(rtiary :) Review of health records. medical symptons; d,_rca:iu by lO0Iannual. 3) 2Up intrease in medicines 3) Survey records of VIITs on constueu at the villaWe Itv,.l. sampling basis. 4) Increase] vllages awar,:- 4)tield observations of VHTs ne;s of prv-int ly halth care and evaluation of knowledge tcchs. and practices of health pro motion, dlisease preventlon and curative care. 5) By 1 982 at least 1/3 of rural 5) Site surveys in selected population within 10 miles of areas a medical station. Outputs: Manitude of Outputs necessary Affecting outnut-to purpose link: and sufficirut to achieve purpose. A. Trained health personnel 1) Increase in the ntumber of trained 1) 1500 (6,000 persons) trained 1) Census of VHT. 1) The "I will give highest priority to and retrained VHiTs. VETs 13,500 VI1workers retrained, training of managerial and health personnel at all levels, - P) Increase in 1h nlkaber of 2) 25 - (L'nchers/renior P.ll. 2) MOil reords including &cadm*csally 2) The MOll will be capabl, an d responlible trained hen.ath professionnias offila2 ) vehicles and medical equtie-nt for maintaining the logistical stilox)rt Byntom. workin at all levels for rural health 200 -Certified nurses reco-do and field ob~aervations delivery system. 100 - rtnte nursea an reports. 175 - medical students 75 - ruiltari,-nn a) tlhese halth professionals wi1l a) 1100 persons particIpetted cotit1ilue to acquire now skills and new MOH conferences and rcminars. th -ores relevant to healthlneeds of onrmuilty hirough continulng education pro rnm:i. 3) MOl will hav- a group of health and 3) 5-1(0 trained sptecialist in auxillary support personnel trained in specific health or related areas. 3) 14M1 records und field obser- 3) The MOlt such areas as will insure staffing and equipping health administration and vations. planning, driver of new construction. education, etc. h*) WHOt recordr; field observa- h) The MOH will give high pritrty to planning tien and evaiuatioi, of curricula. and implementation of envi onmeintal Gazitation efforts. 5) O1 records nd field ohl. rva- 5) V'llagers will continu, to react favorably tion . to VHT. 6) (At records wEd field els, rvr- f) VIIT members will perf,,rm as expected. tions. 7) The MOH will emphastiz,- halth/nutrition education an a ctimponent of health aervices for the rural population. 8) The MO1l will give high priority to the t urveillance and control of comunicaile H. Institutional support Institutional Support d s 1) Functioning. transportation system 1) '12 fuctionin i-wheel drive responsive to supfrvisory visits and vehicles. distribution of gnods and services between 200 sobylettes for supervisors the VIITs and health proferssionals and between dJipeisary and villages. health care facilities, a) 45% tncr-'ane in supervisory visits. b) 30% lncreace in op-rational efficiency in all vehicles. 2) 35% of nrre votpulation will receive 2) a) 3500 Virrr eiuipped with improved drugs and supplies. dnigs and ruppilea. .b) Estahlished and Functioning: - 7 new dir.,pennres - 2 Departm-inL C-nters (Agariez, Zinder) wLh two gargefs and repair workshops,. - 2 'O existing heAth facilitiers newly fuirnlrh.d and equipped. - Sanitation improvements made In 220 health fncllitics. 3) Increase in the control and 3) 80%rural population Immunize&. surveillance of communicable disease in Niger. 14) FunctilunIn heulth/nutriLon 4) 3500 Virr aiud uupportina health education program in all health centers, p.ofeu'luaul givlig health and IM4I, rural dipen inria sad villages lutritiun progrtw. served by VIr. 5) FunctJoning environmental 5) At laAt b% of rural popu sanitation program in rural area.. latiou provid-1 with sanitary education prgrau . Inputai: Activities and T.xs of Resources levl of ETfort/E.pditure for Affectlng input-to-output (Total by link: 19B2- each activity. (Total iby 19) " A. misn Pe'ourcea DevClolUmen,. Truining for Health Personnel Peoplu/Students i) 3rd coutxiry participant training in 1) 25 1) Orders and receiving reports. 1.)Uman Africa or Lurope for t-achura for academic heuources Dcvvlojaeant health iftitutionas, a.nior MAl public a) That We W)H will establish sound criteria for the acleetiun of health orfILI&IS, etC. types anid numbera of peraoauel to be triained/ro.trained 2) Incountaty training for Mo1 health 2) at all levels. 2) TechnicaL Asusitaiee personel a) VHIT In training/retraining for all a) 6,ooo a) That qualified Freuch speaking VIrr -forkeru. 13,500 b) Certified nurses in training at b) 200 technicians are available. b) That the MM will rovide qualified ENICAS. counterparta. c) State nurses in training at EM4P. c) 100 d) Rural Health field training for 4 175 medical students from ESS4. a) 75 Technical Assistance Trainers Trainers (persoi/yeara) I) Auto mechanica 1 8 2) Medical equip repair 2 14 3) Sanitary engineer I4) Short-term consultant 2.S B. Institutioal Support 1) Logistics Eiup 1) Vehicles Logistics a) 11-wheel drive vehicles and parts., a) 42 and Equiment a) That all cmenoditi can be totally aborbed b) mobyletteaa. b) 200 and utilized by the M ai. b) Qualified pursomel will be available and trained to maintain and operate equipment and transportation provided. c) That the GONwill contribute admiietra tIve and operative costs from budgeting resources. 2) Equipment and supplies (back-up level 2) for VIers. a) Drugs fur VIITs. a) Teams equipped b) 2Ti3 Educational materials and audio b) Teams equipped visual for Viir's, health centers and 3500 dispensaries. Health centers and diapen- Sarie 1)00 c) Equipment and furnishings for c) 220 IC and dispensaries existing health centers and dispensarles. d Equipment for garages and medical d) 2 garages equipment repair workshops in Zinder and 2 workshpa Agadez. e) AlI) equipment and cold chain e) 21 o)bIle units equipment for midblle health units. f) Vaccines for mobile health unit. f) 500,000 peoule 3) Construction/Renovation of health 3) care and supporting facilities. . a) Department centers in A#gadez and a) 2 centers Zinder. b) New dispendariee b) 7 dispensaries c) Onvironmental sanitation improve- c) 220 health centers and ment of existing dispensaries and health dispensaries centers. , l ?4Ii;fI £8 (Yi1'0I, AW c 3 :'1 V. iju A_ --- At4cur 4 4N AID IOse-Is tl-ut PROJECT DESIGWI SUMMARY Life of Poj4.c/ LOGICAL FRAMEWORK FvomFY "__ to FY __& otei U.S Fudndir - P ,d.! 12- 1977 Projen riIIINum Institutional Support (sutrtume) NARRATIVE SUMMARY _ OIE-C--Tv4IELY-V-RiFIA:BuIE INDICATR-S- MANS OF VERIFICATION IMPORTANT ASSUMPTIONS Propam o, SectmorGoal The bqoarlarobjecli to Meisu of Goal Achiienean: Asurmnptknmfor lrhisggng"I lerptsr L. Other fa torn do ni(t prn-vitt o which thisproictcontribules: Invreu::e'i I Il',i cx 1 .irtiy, ] Crflced Lt dlt': Frgrt.Ti, or ,'2ctor 'l, l, r Infant mrt'l I ty 'utldcra::i ii (I) Nt!%rtriiphic c2tdiis h~rth-d,:at.h outw, gh efft, if ijtlrovd heailth h.J,,'tivo to witich tti:, r jt cLttt.,'tut,:. dit-it. ' iritj]i'1ty itt :t citt r.t, lifc cxcLs:,=. servcit. (;+a+.: TD inprov:u at 11,w ,O:;L tt ti-t it,/ viqiW li' t-cI'::, in Lil'- ,Xl-cLucy (,. I htk n i); (]Oi' tNci,+ 2.U.OdPt ct nitnui; Lo ad-iliq nt,-Ly isuopurt. of lJl er:d working, ctpia+iLy of Ll' r "i-Al dt-crane It, illit IMn, 'j, lt'! t- st, m tIt ty of .tl't. l" CL:;9hl:iv'rIlk, l * I: the pr,-st,it polt-i t nl ::ti'L&U-pirs for 1 l.ul'itian (,XxO-x vitlucen) Ill wrk,.r ]iv.-:it.j itn all vliags ($) ,-'_ii-ecotcnii' itudle2 on w)rk-r develnoe.n.t arid improvcyernt if tht ;,-rv,-i by VII''. j tuti l.c L y. rut-l heall.h , -rvi('t- zyrtmI. Projict Purpose: Contditions that will indicte pui pose has been Asumplbns fo schitvtq pupose: .ct,.ed. End at ptolett ,latutl Fy ILI 810 81 F2__ Inputs (cont'd) (b) Educational materials plus yearly (b) 1500 1800 2100 2Ii00 27OO MCI and will contiue to be replacement for: Centers effectuated after departure of (1) vYir 220 220 220 220 220 American personnel. (2) Health centers & dispensaries (c) Fquip. fc, 2 gnages and 2 medical repair wor. shope I ...... (d) Lab equir. cold chain and vaccine for mobite health unit (1) Units 21 21 21 21 25 (2) Vaccine (e) Furnisidngs & equip, for existing Facilities health facillties 220 ...... 3. Construction and/or Renovatlon of health care and support facilities Center (a) Department centers at Agadez I Zinder (includes garsge and med. equip. repair workshop, training center, library and D.D.S. office) 2 (b) Jew dispe;:,cries -- -t 3 -- - () Envirotnental sanitation improve mente "itcxIsting dspencaries asf health centers. 50 50 50 50 50 -119- Annex S Analysis of Other Donor Assistance Outside aid to the health sector plays an extnemely important role in the Nigerian health delivery system. The amount, source, and brief description of all external donor assistance is shown in the table in Annex S. The projects listed on the tables have been divided into those targeted mainly 'toward rural areas, and multilateral assistance. External donor activities which started and ended in the early seventies have been omitted from the tables. The value of these projects is less than $30,000. In 1976, the national health budget for the MOH ih Niger amounted to $6.8 million. For that year the total for external donor assistance amounted to $13.3 million, or about twice the amount of the national health budget. Of the external aid one-third was in the form of bilateral aszistance and two-thirds as multinational assistance. External assistance totalling $78.7 million is listed for various funding periods, the earliest date shown being 1963 and some funding being carried forward to 1982. However, the figure of $13 million which was the total for 1976 was not an uinreasonable one to carry forward per annum and the trend appears to be for external hnuding to be increasing ratner than decreasing. External Aid to Health Sector Summary Table (refer to page 126 for detailed lists) - 120 1. Rural Areas Amount Total Amount Obligated 1976$s (unspecified$ fs times bu o .ng A. Bilateral aid 4,310,560 122,796,216 B. Multilateral aid 2,701,236 46,387,i5 Sub Total 6,751,805 169,183,370 2. Urban Areas A. Bilateral aid 727,362 3,325,927 B. Multilateral aid 5,875,406 1,961,974 Sub Total 6,602,468 15,287,901 3. Rural Areas - subtotal 6,751,805 169,183,370 Urban Areas - Subtotal 6,602,768 15,287,901 Grand Total 13,354,573 184,471,271 1. Rural Health External Aid Of the $13.3 million coming from external sources in 1976, about half was allocated to projects affecting rural areas. This does not reflect the same emphasis as the national health budget where two-th.rds was spent on rural health services. In the rural sector, almost $3 million of the total of $4 million came from 3 bilateral projects. German aid is being given to provide personnel including 5 doctors who are essentially based at the hospital but who also work with village Health Teams in the Tahoua Department. The French gave almost one million dollars for staff assistance (mainly to Mobile Medicine), equipment and scholarships on a national basis. Beginning in 1978, the French will support the rural health strategy of the Government of Niger by providing credits totally $103,000,000 for rural health education and for the construction of four medical centers and 20 dispensaries. It is now planned that this phase of the French program will terminate in 1979. Also beginning in 1976 Canadian Universities' technical serv-ices assisted the medical center at Zinder with personnel and comodities with almost $1 million. Multinational assistance to the rural areas amounted to $2.7 million, over $2 million of which came from FED for construction in rural areas, both of dispensaries and arrondissement mrdical centers. All of the rural assistance with the exception of the Africare Project can be looked upon as being supportive to the inouts being proposed under the PP. In the Africare project three components overlapped wit'i those listed, the technical assistance for automobile maintenance, repair and maintenance of medical equipmint and the vehicle component. The PP has defined its inputs as being confined to the other 6 Departments. In the rural areas, OXTAM gave assistance in 1976 only to the establishment and training of VHTs, but the money was for a single year, was not continued in 1977, and there have been no indications that future funding is contemplated. Other projects being financed by external donors will require coordination with the PP activities and will be additive in nature if well planned. The French assistance to Mobile Medicine will mean that they should be consulted in any equipment purchases which are designed to maintain the cold chain. The Peace Corps involvement in nutrition education could be extremely useful in assistance with designing visual aids and development of a nutrition program for village matr8nes. The SHDS program received unanimous approval from the participating countries at the recent WHO meeting at Brazzaville. Hvwever, the individual country programs (including -122 that for Niger) :ave not as yet been specified. Coordination will be required in at least two areas, the vaccine input and any inputs designed to strengthen the MOH central planning and management:. cap-citf. The FED program to construct or renovate about 13 dispensaries before the end of 1978 will complete the current building program of the MOH. The =all additional'total of 7 dispensaries covered under the PP, will come after the current FED assistance and will cover the entire rural building plans for the MOH. T1e new priority of the MOH is i he 'raining and staffing of -l disnensaries with two nurses. Ui-TIC, has been providing some small amount of funding fc r drugs 2sed in rural dispensaries, bur tlere are indications that this assistance will not continue beyond mid-1978. 2. Urban Health External Aid Thternel aiA to primarily urban project areas totalled $6.6 million, of which only 11 percent came from bilateral aid, the rest from multi lateral projects. Cf the national health budget, one-third or about $2.3 million was aliocated for urban health services. Therefore in 1976 aid to urban areas appeared to attract about the same amount of money from a.ternal donors as rural health projects. The GON's priorities were currently clearly more in favor of rtral health expenditures. External aid obligated from all sources, much of which is for future expenditures, is heavily concentrated in rural projects. Two large multilateral projects provided the bulk of the urban funding. The African Development Bank gave $4.8 million to bt used - 123 for the construc:ion of the Medical School buildings at the University of Niamey. Ano-her $1.4 million came ii-om ME and was allocated towards builings for the "lationa.a School of Public Health in Niamey and. hospitals in Maradi and Zinder. The breakdown of the Africare funding for 1976 into about one quarter of the total $550,C00 for rural programs and the rest for urban expend-.tures such as the epidemiological l& oratory was given by the organization. However, it should be recognized that such an expenditure will a-lso ultimately benefit rural areas. German aid funds were used to improve the water supply and sanitation in the cities of Niamey, Maradi and Zinder. The People's Republic of China listed a very modest sum of $44,*000 to cover the services of about 20 physicians who were stationed in the hospitals of Niamey and Maradi. St~h4APY ,D -0O'V= TSTON,9 The national budget for Tiger in 1976 allocated $6.8 million to the MOH. This budgetar fi4gnure did not incluce any external aid; nor did it include some items such as housing and support services for foreign technicians such as physicians working under external funding. This is normally provided by Niger. A MOH official stated that the cost for housing and utilities for a foreign technician was about 7,962,500 CFA per annum. Other support services cost 1,857,500 CFA for a total of ?,820,000 CFA or about $40,000. With at least on hundred foreign technical assistance personnel working i-.the MOH, this sum alone would amount to $4 million, making the total health budget add to $10.4 million. Even with this Jidition the amount paid - 2 4 for health serII:es by the GON would appear to be less than the the number or type $13.3 million given by external donors. Probably of exnatriate Personnel working in the health field will not change during the next few years. External donor assistance in 1976 was approximately equally divided between projE cts benefiting primarily rural and urban areas. The internal MCH budget was weighted more heavily in favor of more of the ruara exnenditu.res, reflecting the general policy commitment grcund). Government of ITiger, _-scussed in Part V of the PP (FroJect azk urban However, it is not possible to make a clear distincTion between and rural health expenditures. As noted in the economic analysis, urb.an expenditures were defined to .include the cabinet and administrative two overhead, all medical and nursing school expenditures, and the the national hospitals at Ni amey and Zinder which could be considered graduate tertiar-j care centers. It should be recognized that students and go to work in rural areas, urban people receive care at dispensaries to located in the urban areas, and rural persons often get referred urban facilities. Similar guidelines were used to differentiate rural and urban expenditures by foreign donors. Some expenditures for the was Maradi hospital were included in urban expenditures since it not possible to separate them out. Cocrdination of external aid projects with the PP should be to carefully worked out since several areas could be complementary the planned inputs. The role of the Secretary-General of the Ministry of Health includes coordination of all external aid and he spends a beyond considerable amount of time and effort on this activity. Even - 125 the formal Mristry coordination, some dovetailing of specific activities in such areas as nutrition education could enhance the size and quality of several donor programs. - 126 ,.,MR DONOR PROMPUIS - HEAZa'H SECTOR 1. Health Projects in Ru--a. ±reas A. Bilateral Funding Amount Total Amount Project Activity Source 1976 ($) Jn ding Period_ Description Basic HeaLth Setnrices Africare 118,000 2,800,000 Delivery Project Ile 1977-7 Personnel to be pro vided include 1 epidemiologist, 1 surgeon, 1 public health physician, 1 OB/GYN, 1 auto mechanic specialist, and 1 medical equip. repair technician. The surgeon, OB/GYIT, automechanic spec. & Med. equip. trainer will be based in Diffa. Sponsorship of Conference 25,000 Conference held in on Family Health Care USAID £an.Z 1977] Niamey focused on how to effectively deliver health services to rural areas. Primary Health Care Peace 174,573 219,840 ,wo nurse educators, Delivery Corps (1974-1979) nine laboratory technicians, 16 health nutrition educators Rural Health Project Fed. Rep 833,333 7,500,000 Personnel (5 doctors Tahoua Dept. of Germany 1 mechanic) commodities, (4 Landrovers, drugs for rural dispersaries) provided in Tahoua Dept.. mainly mobile medicine) staff, equip., tech. assistance, scholar ships, construction (4 medical centers, 20 dispensaries). -127- ITIM DONOR PROGRAMS - HEALTH SECTOR 1. .-Health Projects in Rural Areas A. Bilateral Funding Amount Total Amount Project Activity Source 1976 ($) Funding Period_ Description Rural Health Care Belgiud 485,486 1,087,424 A medical team, 3 Assistance (1976-1982) doctors, one auto mechanic trainer, and drugs for rural dispensaries in Dosso Asat. to Ministry of Netherlands 47,000 80,000 Medical personnel Health consisting of two doctors provided for the Niamey Dept. (working in rural areas only) Medical Ast. in CXFAM • 36,080 36,080 Two nurse/midwives Tchintabaraden/ (1976) provided for training Tahoua Dent. in Tchintararaden Arrondissement Assistance to Med. SUCO 998,896 3,999,896 Tahoua Dept. Two Center, Zinder (i976-1979) nurse educators, 1 lab technician, commodities. Training of Secouristes/ 07AM 30,080 30,080 Financing part of Matrones (1976) training costs for VHTs Assistance to Galmi SIM 305,868 N.A. 2 doctors, 4 nurses, Hospital (indefinite) 1 dentist/oral surgeon, 1 dental hygeinist Asst. to Leprosy Hospital SIM 15,570 N.A. in Maradi (indefinite) Personnel (4); equip, for operating rooms Assistance to Guescheme SIM 305,868 N.A. Four nurses, equip. Hospital (indefinite) for operating rooms - 128 - 1. Health Projects in R'zal Areas A. Bilateral Funding Amount Total Amount Project Activity Source 1976 ($) ZFunding Periog Description Dispensary at Goudel EEK 6,056 17,896 1 =urse, drugs, 1 N.A. & supplies Dispensary at Karma E.M 3,750 N.A. 1 nurse, drugs and supplies Sub-total 4.,310,560 122,796,216 -... t. .. .. , ll ! :tVa II I- TotalAmq i Am't =F/=(1974-1979) nae_ fot i!t thr"hu the n fo ua-rg CE .o 4 Drp ndsuple Dis7Qenarvi ,9 (1Iw4- 9,4) Sub-total 297012236 46t367.,15 Foo /fo t_.end" 10,(19,1M , 00food the,,! H~ Rr eath *i Areasd betos ture Fooufr-totalCJ Wr, 701 1.. 1681Foo5ai Regional Project -,Niger portononly rural services. - 130 11. Health Projects in Urtan Areas A. Bilateral Funding Amount Total Amount Project Activity Source 1976 (Funding Period) Description Basic Health Services AERICARE 432,000 2,800,000 An epidemiologist Delivery Project (OQ ) has recently been appointed in charge of epidem. lab. for MOH. A public health physician is participating in curr. design for VIT training Improvement of Water Fed. Rep. 236,962 481,927 loan for improvement Supplies of Germany (1973-1977) of water supply and sanitation facilities in Niamey, Maradi and Zinder Medical and Hospital USSR 14,400 NA Medical personnel Equipment (1975-1979) and hospital equip ment for Niamey and Maadi Assistance to Hospitals People's 44,000 I,0004 22 Physicians Niamey and Maradi Rep. of (1976) China Sub-total 727,362 3,325,927 - 131 - B. Multilateral Funding Amount Total Amount Project Activity Source 1976 (-niding Period) Description Cormstruction of Medical ADB 4,800,000 4,800,000 Construction School, Univ. of Niamey (1976) materials and labor for bio medical science building and administrative block Health Facilities Construe- FED 1,361,779 3,429,530 Funds have been tion (1972-1977) provided for the National Public Health School Building in Niamey and Hospitals at Maradi and Zirner Health Science School/Riamey ADF 24,197 66,234 Funds have been used to expand buildings at the Health Sciences School, Nat'1 School of Public Health National School of Public UMDP 164,612 565,-10 Funds were used to Health/Niamey (1972-1976) provide personnel, training materials and laboratory supplies Hospital Assistance WIP 150,518 1,816,800 Provision of food for hospitalized patients at the National Hospitals in Niamey and Zinder respectively Assistance to the Faculty WHO 308,100 796,000 Two midwife in of Medical Sciences, Univ. (1975-1979) structors have of Niamey been provided Scholarships for Health WHO 66,200 488,300 Scholarships Science Study in Europe (1975-1978) for graduate study in Europe Suba t c tals 6,875,406 11,961,974 Sthe onor Assistance 7,6022768 15)287,90l ub-1o' urban areas (health sector - 132 - Annex T Checklist of Statutory Criteria A. BASIC AUTHORZ FAA Sec. 103;!04;!C5;106. Is grant being made a. For agriculltare, rural No. development or nutrition? b. For population plarning Yes, for health. or health? c. For education., public Yes, in part for human administration, or human resources development. resources development? d, For the following activities: 1. Programs of technical No. cooperation and development. 2. Programs to help recipient country alleviate energy problems. 3. Programs of researcb. into, and evaluatiu.n of the progress of economic develolment or into the factors of development activities and development assistance. 4. Programs of reconstruction following natural or man made disasters. The following abbreviations are used: FAA - Foreign Assistance Act of 1961, as amended. FAA, 1973 - Foreign Assistance Act of 1973. App - Foreign Assistance and Related Programs Appropriations Act, 1975. MMA - Merchant Marine Act of 1936, as amended. - 133 - B. GEAL CRIT=A FOR PROJECT 1. App. Unnum'bered; FAA Sec. 653(b). (a) Describe how Committees By Congressional Presentation and on Appropriations if Senate Congressional Notifications when and House have been or will appropriate. be notified concerning the project. (b) Is assistance within Yes (Operational Year Budget) country or international organization allocation reported to Congress (or not more than $1 million over that fig'ire plus 1,)? 2. FAA Sec. 6ll(a)(l). Prior to (a) Yes obligation in excess of $100,000, will there be (a) engineering, financial and other plans necessary to carry out the assistance and (b) a reason- (b) Yes ably firm estimate of the cost to the U.S. of the assistance? 3. FAA Sec. 6 11(a)(2). if No further legislative action will further legislative action be necessary within recipient country. is required within recipient country, what is basis for reasonable expectation that such action will ba comnleted in time to permit orderly accomplishment of purpose of the assistance? 4. FAA Sec. 611(b); App. Sec. 101. Project deals with the delivery of If for water or water-related basic health services at the village land resource construction, has level and is not a water or water project met the standards and related, resources project. criteria as per Memorandum of the President dated Sept. 5, 1973 (replaces Memorandum of May 15, 1962; see Fed Register, Vol 38, No. 174, Part III, Sept. 10, 1973)? - 1314 5. FAA Sec. 611(e). If project Yes. A 6 11(e) certific".-nn i is capital assistance, (e.g., attached to this project paper. construction), and all U.S. assistance for it will exceed $1 million, has Mission Director certified the courtry's capa bility effectively to maintain and utilize the project? 6. FAA Sec. 209,619. Is project Project is not susceptible of' susceptible of execution as execution as part of regional part of regional or multi- or multilateral project. lateral project? If so, why is project not so executed? Information and conclusion whether assiStance is for newly independent country, is it furnished through multi lateral organizations or plans to the maximum extent appro priate? 7. FAA Sec. 601(a); (and Sec. This project will deal prizarily 201(f) for development loans). with the delivery and upgrading of Information and conclusion health services to 3,500 villages whether project will encourage by 1982. These services are delivered efforts of the country to: under the direction of the Ministry of (a) increase the flow of inter- Public Health; the use of cooperatives, national trade; (b) foster credit unions, anrd saving and loan asso private initiative and come- ciations is not envisaged to be a part tition; (c) encourage devel- of the delivery of health services. opment and use of cooperatives, Free labor unions do not function in credit unions, and savings and the MOH. loan associations: (d) dis courage monopolistic practices; (e) improve technical efficiency of industry, agriculture and commerce; and (f) strengthen free labor unions. 8. FAA Sec. 601(b). Information As the project"is ultimately aimed at and conclusion on how project the delivery and upgrading of health will encourage U.S. private services, it will neither encourage trade and investment abroad nor discourage private U.S. trade and and encourage private U.S. investment except to the extent that participation in foreign as the rural economy grows, demand for assistance programs (includ- goods and services will grow. ding use of pri.vate trade channels and the services of U.S. private enterprise. - 135 9. FAA Sec. 612(b); Sec. 636(h). Describe steps oaken to assure that, The project is primarily dir to the maximlum extent possible, the ected at the upgrading of the couitry is contribut;ng local curren- delivery of health services at cies to meet the cost of contractural the village level. The GON and other services, and foreign currently contributes a size currencies owned by the U.S. are able budgetary allotment to utilized to mert the cost of con- --chieving this same objective tractural and other services, and indications are that the percentage of this budgetary allotment will increase during the life of the project. The U.S* assistance wil help finance additional budgetary resources to reach an ever larger nm=ber of villages. 10. FAA Sec. 612(d). Does the U.S. The U.S. owns no applicable own excess foreign currency and, foreign currency. if so, what arrangements have been made for its release? C. FJqD=NG CRtTERA FOR PROJECT 1. Develo.ment Assistance Project Criteria a. FAA Sec. 102(c); Sec. lll; l.ae(a). The project is aimed Sec. 281a. Extent to which 100% at improving the quality activity will (a) effectively of life among the rural poor by involve the poor in development by improving the quality of health extending access to economy at care which is afforded to them. local level, increasing labor- Any funds directed to health intensive production, spreading facilities in the urban areas investment out from citics to will ultimatel,j be directed to small towns and rural areas; and the achievement of improving (b) help develop cooperatives, health services for the rural especially by technical assistance, poor by the training of to assist rural and urban poor to additional health personnel who help themselves toward better life, are involved with the delivery and otherwise encourage democratic of these services. levate and local governmental institutions? (b) No cooperatives will be es tablished unde, this project. - 136 b. FAA Sec. 108, 103A. Is The project is aimed at assistance being made available: providing training to health for agriculture, rural development workers who will deliver or nutrition; if so, extent to which health services at the village activity is specifically designed to level. increase productivity and inccae of rural poor; if for agricultural research, is full account taken of needs of small farmers? c. FAA Sec. 1.10(a)i Sec. 208(e) A waiver is being requested based on Niger's status as one of Is the recipient country willing to the "rel'tively least developed". contribute funds to the project, and Nonetheless, Niger is already in what manner has or will it pro- contributing '.5.%of project costs vide assurances that it will provide and is expected to continue to at least 25% of the cost of the pro- do so -throughout the life of the gram, project, or activity with respect project. to which the assistance is to be furnished (or has the latter cost sharing requlirement been waived for a "relitively least-developed" country? d. FAA Sec. L1Ob). Will grant Grant capital assistance will capital, assistance be .disbursed for not be disbursed over more than project over more than 3 years? If 3 years. so, has justification satisfactory to Congress been made, and efforts for other financing? e. FAA Sec. 207; Sec. 113. Extent to The project is aimed at fostering which assistance reflects appropriate the development of the Village emphasis on; (1) encouraging develop- Health Team which is selected ment of democratic, economic, political, by Villav Councils throughout and social institutions; (2) self-help the country, The village is in meeting the country's food needs; accountable for the activities (3) improving availability of trained of the village health teams. worker-power in the country; (4) Women already are involved because programs designed to meet the country's part of the project's efforts health needs; (5) other important will be to improve the services areas of economic political, and social delivered by the traditional mid development, including industry, free wife, the matrone, who will pro labor unions, cooperatives, and vide information on pre and on Voluntary Agencies; transportation and post-natal care. The project is communications; planning and public designed to increase the matrone's administration; urban develorment, ski.lls and modernization of existing laws; or (6) integrating women into the recipient country's national economy. - 137 f. FAA Se:. 28l(b). Describe Project is ftnly cognizant extent to J-nich -rogram reccgnizes the of the needs and desires of particular needs, desires., and capa- the peop2le of the country bi..Lities of the people of the country and is designed as to deter utilizes the country's intellectual mine their capacity for longer resources to encourage institutional termi development efforts; Host development; and supportz civic educa,- government personnel and tion and training in skills required organizations be used in the for effective participation in govern- evaluation and monitoring of mental and pojitical processes essential project activities and the to self-gove*,nment. design of future activities. Project will be implemented by host goverrent services, and will train host country per sonnel to staff and/or surer vize Village Health Teams. g. FAA Sec, 201(b)(2)- (4) and This activity does promise to -(8); Sec. 201(e); Sec. 211(a) contribute to the development 1)-(3) and - &). Does the of economic resource, pro dictive capacity, and self-sus activ-ity give reasonable promise taming economic growth by of contributing to the develop- improving the quality of life ment; of economic resources, or among 1iger's rural peoples. to the increase of productive it is related to and consistent capacities and self- sustaining with the GON' s development economic growth; or of education- program, and the Sahel Develop al or other institutions directed ment Program. The PP shows toward social progress? Is it that the project is economi related to and consistent with cally and technically sound. other development activities, and will it contribute to realizeable long-range objectives? And does project paper provide information and conclusion on an activity's economic and technical soundness? h. FAA Sec. 201(b) (6); Sec, 211(a) Project will have no adverse (5),= 6 information and con- effect on economy or areas of clusions on rossible effects of the surplus labor in the U.S. with assistance on U.S. .. nczy, with the exception of waivers for special reference to areas of sub- off-shore _murchase of vehicles, stantial labor surplus, and extent local purchases and construction, to vhich U.S. con=odities and all coodities will be pur assistance are furnished in a manner chased from US source suppliers. consistent with improving or safe guarding the U.S, balance of payments position. - 138 - C. C0U? RY FMFC4,AI:CE Progress Towards Country Gcals Food production is a major focus of Niger's development 1. FAA 201, Describe the extent effort. The project is not to which country is (1) makin related directly to increasing appropriate efforts to increase food production. However it food production. may be assumed that a healthier rural population will produce more ford. FAA 11-6(a) Has the Secret .ry of Yes State made a determination that the recipient country does not engage in a consistent pattern of gross violations of internationally recognized human rights? FAA 620 (o) Fishermen' s Protective Not applicable Act c-5. if country has seized or imposed any penalty or sanction against any U.S. fishing vessel on account of its fisUing activities in international water. a. Has any deduction required by Tbt applicable FIshermen's Protective Act been made? b. Has comnplete denial of assistance Not applicable been considered by A.I.D. Administrator? B. REIATIOS JITH U.S. GVE£ ZIMT AND OTI NATIONS 1, FAA 620(a). Does recipient country Niger has no trading furnish assistance to Cuba or fail relationship with Cuba to take appropriate steps to pre- nor does the aircraft vent ships or aircraft under its under its flag carry cargoes flag from carrying cargoes to or to or from Cuba. from Cuba. - 139 - FAA 620(b,. If assistance is to a The Secretary of State has goverzmernt, has the Secretary of determined that 'iger is not State determined it is not con- controlled by the Inter trolled by the International national Communist Mavement. Communist Movement? FAA 620(f) Is recipient country No a communist country? FAA 620(i) Is recipient country in No any wLy involved in (a) subversion or military aggression against,the United States or any country receiving U.S. assistance, or (b) the planning of such subversion or agres sion? FAA 6 20(j) Has the country permitted, No or failed to take adecuate measures to prevent, the damage or destrction, by mob action, of U.S. property? FAA 6 20(n) Does recipient country Not applicable furnish goods to Noi h Vietnam or per mit ships or aircraft under its flag to carry cargoes to or from Dorth Vietnam? FAA 620(t) Has the country severed Diplomatic relations with diplomatic relations with the Uni-ed the United States have never States? been severed. FAA 620(u) What is the payment Niger is not delinquent in status of the country's U.N. any obligation to the United obligations? If the countr is in Nations. arrears were such arrearages taken in to account by the AID administration in detering the current AID Opera tional Year Budget? FAA 481. Has the Government of No recipient country failed to take adequate steps to prevent narcotics drugs and other controlled sub stances (as defined by the Com prehensive Drug Abuse Prevention and Control Act of 1970) produced or processed, in whole or in part, in such counw-y, or transported through such country, from being sold illegally within the jurisdiction of such counry to U.S. Gavernment personnel or their dependents, or from entering the U.S. unlawfully? FAA 666 Does the government of recipient No country object to the presence of any officer or employee of the U.S. who is present in the country for the purpose of carrying out economic development assistance on the basis of the race, religion, national origin or sex of such officer or employee? Milit ary a-Lenditure s FAA 620(a) What percentage of country budget is for military expenditures? How much of foreign exchange resources spent on military equipment? How much spent for the purchase of sophisticated weapons systems? FAA 6 20(g) What provision is there Disbursement procedures against use of subject assistance to will be included in the compensate owners for expropriated or grant agreement to pre nationalized property? vent use of the funds for purposes other than those intended. FAA 901 Has the country denied to its No citIzens the right or opportunity to emigrate? FAA 115 Wil country be furnished, in No the same fiscal year, either security supporting assistance, Middle East peace funds? If so, is assistance for population programs, humanitarian. aid through international organizations, or regional programs? FAA 653 (b) Zf this assistance within Yes the country or intcrnational organi zation allocation for the fiscal year reporting to Congress (or not more than $1 million over that figure plus 10%)? - 141 - FAA 662 Will arrangements preclude Yes use of funds for CIA activity? E. STANDARD ITv! CHECI=ST Procurement FAA Sec. 602. Are there arrangements Yes to permit U.S. small business to participate equitably in the furnish ing of goods and services financed. FAA Sec. 6 04 (a) Will All ccmmo-lity pro- Yes cuiement financed be from the U.S. except as otherwise determined by the President or under delegation from him? FAA Sec. 604(d) If the cookprating Niger does not discriminate country discriminates against U.S, against U.S. marine insurance. marine insurance companies, will agree ment require that marine insurance be placed in the'U.S. on commodities financed. 6 FAA Sec. 0(c). If offshore procure- There will be no offshore ment of any agricultural commodity or procurement of agricultural S)duct is to be financed, is the'e commodities under this health any provision against procurement when project. the domestic price of such commodity is less than parity? FAA Sec. 608(a) Will U.S. Government Yec excess personal property be utilized wherever practicable in lieu of pro curement of new iteras? MAA Sec 901(b) (a) Compliance with Yes requirement that at least 50 per centtu of gross tonnage of commodities (computed separately for dry bulk carriers, dry cargo liners, and tankers) financed shall be transported on privately-owned U.S. flag commercial vessels to the extent that such vessels are available at fair and reasonable rates. - 142 - FAA Sec 6a. If technical assistance Yes to both questions. is finalced tillI such assistance be furnished -o the :ft lest extent prrocticable as goods and professional and other se-vinces frm private exerprise on a contract basis? if the facilities of other Feder-al agencies will be utilized, are they particuLarly suitable, not competitive with private enterprise, afid made available without undue interference with domestic programs? International Air Trnsnort Fair Cmretitive Practice Act, L977, ii' air transportation of persons or prorerty is financed on a grant basis "ii_ pro'zicn be =! -. that U,S. flag carriers will be utilized to the extent such service is available? - 143 - Annex U October 4, 1977 INITIAL ENVIRONMENTAL EXAMINATION PROJECT LOCATrON: NIGER PROJECT TITLE: IMPROVING RURAL HEALTH FUNDING: IEE PREPARED BY: M. J. Morgan Engr. Adv. REDSO/WA - October 4, 1977 ENVIRONMENTAL ACTION RECOMqENDED: A Negative Determination is recommended. See page 3, para 7. RDO/Niamey ASSISTANT ADMINISTRATORS DECISION Date: APPROVED: Asst.Admin.,AID/W DISAPPROVED:__Date: - 14+4 - I, EAMINATION OF NATURE, SCOPE AND MAGNITUDE OF ENVIRONMENrAL IMPACTS A. Project Description The purpose of this project is to support the GON's health strategy goal projected for 1982. Specific ally stated: within the next five years the MOH (Ministry o' Health) plans to establish and strengthen the VHT (Village Health Team) rural health delivery system in 3500 villages -in order to provide a greater percentage of the rural poor with basic health care services. This project will assist the MOH to achieve this goal by addressing tw major categories: human resource development and the institttional support system. Project inputs will focus on the development of trained VHTs and the strengthening of the infrastructure required to support and sistain VHT activities. As a result of this project support there should be: 1) an increase in the number of trained VHTs providing basic health services at the village level; 2) an increase in the number and technical ability. of health personnel as well as improved health facilities to support the VHTs; and 3) a stronger institutional system linking the various levels of the system together. The project will finance the construction of two D.D.S. (Direction Ddpartementale de la Sant6) facilities, seven dispensaries and improvemient of sanitary facilities at 220 locations. The only effect on the environment will be from this construction, which will be minimal during the construction but will offer improved health facilities and maternal/child care to the rural poor thereby improving their health and overall well being. B. Identification and Evaluation of Environmental Impacts Land Use The impact of the proposed construction on land use will be minimal. The two D.D.S. facilities are to be constructed at Agadez and Zinder. Both will use electricity and water from the municipal systems. Each facility consists - 145 of an office building of 1700 square feet, a guardien's house of 800 square feet and a garage/workshop facility of 2580 square feet. Sanitary facilities will consist of a flush toilet in the office and pit privies at the guardien's house and the workshop. When the drain field for the flush toilet and the pit privies are cortructed the contractor will insure that they are at least 150 feet from any source of potable water. Percolation tests will be made before the sanitary facilities are constructed to insure the drainage of the soil is adequate. The plans for the construction of the seven dispensaries, which have a floor area of 2325 square feet, call for provision of flush toilets. Water for their operation will come from a well on the premises. The contractot will be required to place the septic tank and its drain field at a minimum of 150 feet from the well. Percolation tests will be made to insure that the infiltration is adequate for the septic tank and its drain field. The sanitary facilities at the 220 locations consist primarily of pit privies. The contractor will be required to locate them at least 150 feet from any potable water source. Water Quality There will be no environmental effect on the water quality. Atmospheric There will be no environmental effect on the atmosphere. Natural Resources The constzuction sites are not large, being appro ximately 2 hectares (5 acres) for each of the D.D.S. facilities. The dispensary sites will be less than 1/2 hectare each. The sites will have to be cleared of sparse semi-arid shrubs. - 3A6 - When construction is completed ornamental shrubs and trees will be planted. The effect on the natural resources will be minimal. Cultural There will be no impact on cultural environment of the villages where the facilities are located. Socio-Econknnic There will bo no socio-economic environmental impact other than the short term ef'ect that the construct ion will have on the local labor fotce. Health The facilities to be constructed will offer improved health and especiall-., maternal and child health services to the rural poor. The dispensaries will provide a central rural base out of which the nurse can operate and deliver health care services to patients, and edu cational programs and support services to the VET's. The D.D.S. facilities provide somewhat similar service . on a broader and higher administrative level as the dispensaries come under their jurisdiction. The improvement of the health of the rural poor is expected to be accelerated with the proposed construction. RECOMMENDATION: Since there will be minimal effect on the environment, as discussed above and shown in the attached evaluation form, a negative declaration is reconmended. - 147 - IMPACT IDENTIFICATION AND EVALUATION FORM Impact Identification and Impact Areas and Sub-Areas Evaluation A. LAND USE 1. Changing the character of the land through: a. Increasing the population ...... N b. Extracting natural resources ...... N c. Land clearing ...... L d. Changing soil character ...... N 2. Altering natura7, defenses ...... N 3. Foreclosing important uses ...... N 4. Jeopardizing man or his works ...... N 5. Other factors N B. 'WATER QUALITY 1. Physical state of water ...... N 2. Chemical and biological states ...... N 3. Ecological balance ...... N 4. Other factors N IMPACT IDENTIFICATION AND EVALUATION FORM C. ATMOSPHERIC 1. Air additives ...... N 2. Air pollution ...... N 3. Noise pollution ...... N 4. Other factor s N D. NATURAL RESOURCES 1. Diversion, altered use of water ...... N 2. Irreversible, inefficient commitments .. N 3. Other factors N E . CULTURAL 1. Altering physical symbols ...... N 2. Dilution of cultural traditions ...... L 3. Other factors N F. SOCIO-ECGn!OMIC 1. Changes in economic/employment patterns N 2. Changes in population ...... L 3. Changes in cultural patterns ...... L 4. Other factors N - 149 - IMPACT IDENTIFICATION AND EVALUATION FORM G. HEALTH 1. Changing a natural environment ...... N 2. Eliminating an ecosystem element ...... N 3. Other factors _N H. GENERAL 1. International impacts ...... N 2. Controversial impacts ...... N 3. Larger program impacts ...... N 4. Other factors N I. OTHER POSSIBLE IMPACTS (not listed above) N N - No environmental impact L - Little environmental impact M - Moderate environmental impact H - High environmental impact U - Unknown environmental impact See attached Discussion of Impacts. - 150 - Annex V AMPLIFE DESCRIPTION AND FANNCIAL PLAN OF THE PROJECT k. Project Design In order to assist the Government of Niger to fulfill its national health program as outlined in the Three Year Plan, (1976-1978), the following rural health project has been designed. It represents a cooperative effort towards realizing the country's goal to offer the rural population an appropriate, low cost health system - that is, a system which is responsive to the many health problems of the rural poor. Further, the project will assist the government to bring about broader ccaerage by extending health serv-ces to a greater number of its villages over the next decade. After careful study and deliberation, a five year program is offered which emhasizes two key elements Li the national program -- Human Resource Develorment and Insitutional. Support. Program emphasis in these .two areas will generate a viable rural health delivery system which demonstrates the value of prevention, early diagnosis, curative intervention and proper referral. Given the existing conditions, it is projected that by 1982, through the efforts of the project and through continued support from other donors, o timum health cov.erage will extend to approximately 39% of the rural population. B. Project Activities I. Human Resource Development a. Training 1. Third Country Participant Training As Niger continues to move beyond simple curative health care delivery, it is important that certain personnel receive advance training and be informed of current health information. Recognizing the limitations of in-country health training provisions have been made to select personnel for special courses and training centers in African countries such as Senegal, Togo, and the Cameroons. Thoce selected for training will be senior level personnel in the Ministry of Health, teachers of health for ESSM, ENSP, ENICAS, and logistic and maintenance personnel in government operations for health. 2, In-country Continuing Education Opportunity for annual country-wide conferences is planned. The Minister of Health and the Secretary General will have - 151 the ultimate responsibility for planning and conducting these meetings. These conferencez are planned to give MOH personnel the opportunity to share information and to discuss pertinent issues. The conference is also seen as a forum for ccntinued health planning and a source for timely feedback on project grogress and develoiment. Provisions have also been made for deoartmental level semar_. These seminars are to be organized around problem solving and information sharing regarding regionQl, issues. 3. Cetified Nurses in Training To meet the need of the increasing number of dispensaries as well as to allow at least two nurses to be stationed at each, the project allows for the training of approximately 40 certified nurses each year for the next five years. At present dispensaries must close when supervisory visits are made to the village health teams (VHT). 4. State Nurses in Training Training is provided for approximately 20 State Nurses. State Nurses are responsible for the operation of the Medical.Center and the supervision of dispensaries throughout the country. As dispensary level staff and VHTs increase in number it will be necessary to keep an appropriate balance between supezrisors and supervisees.. 5. Medical Students in Field Training In order to prepare Nigerian trained doctors to be more responsive to the medical problems of the rural areas advanced medical students will be given field experienc at designated rural locations. The curriculum will center around biomecical and medicosociological problems of people without access to mod.=rn medical facilities and appropriate health education. In additi-n to this practical educational experience these medical students will assist in the collection of baseline health data and participate in the initial phases of program evaluation. 6. Environmental Health Workers in Training To promote awareness and to introduce proper techniques of environmental sanitation training will be made available for approximately 15 environmental health candidates at ENICAS each year for the next five years. Upon completion of their training, these workers will be expected to give direct service to villages and to provide basic training to indigenous health workers. 7. Village Health Team Training In order to provide health coverage to 3,500 villages by 1982 the project will allow for the training of approximatelyl5 0 0 teams - 152 (4 members each.'. For the next five years and in keeping "itb existing program procedure s, the project will support a 15 day training program. As indicated above it is suggested that the service membership of the team be expanded to four people, namely, two matrones and -wo Secouristes. 8. Continuing Education and RetraIning of Village Health Teams (VT) In addition to training rec±'.its the project proposes to retrain VHTs. Every second'year, the MOH will convene one half of the VH~s at convenient; lcations where they -will undergo advanced supervised training and rece;.ve updated health information. The emphasis will be on primary preven ive information throughout this training period. b. Technical Assistance 1. Automobile Mechanic Trainer Over a five year period of time, two auto-mechazic trainers will train approximately 50 Nigeriens in the field of automotive. maintenance and repaYr. In addition, these technicians will assist in the development of a country wide driver education program. They will be stationed in Niamey but will be available ftr consultation to cther departments. 2. Medical Eauinment Renai: Trainees To improve usage and to decrease tfte voLume of impaired medical equipment, trainers will instract approximately 5 people per year in the care, servicing and maintenance of basic medical equipment. In addition, these tec~hnicians will assist in procuremen planning for medical equipment suitable for rural Niger. They will be stationed in Niamey but will be available to other departments for consultation. 3. Sanitary Engineers In concert with MCHs effort to introduce and institutionalize the concept of primary prevention as a community function, two sanitary engineer technicians wrll train approximately 35 Nigeriens each year for five years. The training program should equip its graduates with the necessary skills and knowledge to initiate and implement community programs in the area of vector control, sewage disposal, well maintenance as well as other elements of ccmunity sanitation. They will be stationed in Niamey but will be available to other departments for consultation. 4. Short Term Consultants As experience is gained during the implementation of the rural health project, provisions wil be made for the contracting Asnod /ro Vrx~p 4rY4A=U e4 all9gV' of ....to ....ci,4aat (u P,-mh) Tug , Lgs.d c al Mate ste 'co9 any e ch h enh pe~rso t 1 ey eme t ...... delver-pste-* AoGares d 2, EL~gt an SQ43lie i::': "iTA reew1T #dca~oa addtionnorne t theirqtenald train ng,giv V res ed w=4 mobe rUt.hUed the wit aadquate Umpl Qf drug;s, This is not intended to replace ieu t sourcese thent itn'as. spplementior boe,. 3. Educational Materials with Rehlacementa " Of hes Aond ,-yltt. T adtto tdees veies should fac=etob .~~~h ptimelree_ i r sof anupplten aced o zual, h ealh;ca ;0n01=_p, " periodic changes in heah Preogram techises ae miformtin equie that Vs, iealth ckeen audi dispenies reive timelyr and relevnt euceion mateias t be usedfrmedistructin < ine4 preventive- health PQl~Wqsa E c drtions..QJQ~O.4fctions. .e~and". the' serv b ill wo accompany each shipment,eQ when per "Q4-ttact t po.,,bl,. 4Ecui~ent for Garages To support and sustai a viable transportation system the pz'ojeqt maes provisions for a tally eqipped garage in~ two ar'eas of the country - 144z =d Under. use gar",s All be responl.e:. for preventive and customa maintenance for all 94th vyehicles in their arta. In additi.on to regular' servicing, it is ezpocted that the equipment will be used in the training program menti.oned above. 5 4 Equipment for Medical Repair Worksho-o For the Agadez arnd Uinder' headquarters, provsi.ons are made for medical equipment' repair. Inkeepin6 with the automotive program, the center is expected to maintai.n and repair medical equipment Al in area health stations.* As a secondaryr function to the servicing program,, service tools will be u~sed for-,training purposes. - 154 6. Laboratory Eauinment. Co"l Chain and Vaccines for Mobile Health Units A complement of cold cha.n equizment and supply of vaccines will be prograned into the rroject during the second year. Allocation and distri'cution rill be contingent, however, on first year evaluation reports. 7. Furnishing andEquipment for Existing Health Facilities Upon completion of an inventory at the existing 220 health facilities -- dispensaries and health centers -- the project will replace needed furn-ishings and equipment. In addition to the replacement program the project will provide seminars on facility care and maintenance. b. Construction and/or Renovation of Health Care and Support Facilities 1. Denartmental Centers Construction of departmental health headquarters is planned at Agadez and Zinder. These facilities dll include: a garage and medical equirmen,: workshop, tr aining center and offices for departmental health officials. These complexes will serve as central training sites and outlets for automotive and eairent repair. 2. Dismensaries In keeping with the GONs desire to develop health facilities at a pace commensurate with the availability of trained manpower, seven dispensaries are planned. Actual constriction will begin during the second year of the project. Completion is expected during the third year of the project. 3. Environmental Sanitation Improvements at Elxisting Dispensaries and Health Centers At each health center and dispensary provision will be made for proper waste disposal, procurement of water (with proper storage) and appropriate vector control. Emphasis will be on clean and sterile environment at all health facilities so as to provide an exemplary atmosphere for villagers. C. implementation The major activities of the project will take place over a five year period of time in accordance with the schedule of events detailed - 155 below. The schedule consists of three Parts: (1) the date which denotes the apprcximate time the event will take place; (2) the activity itself -- described in general terms; (3) designation of responsibility. Implementation Schedule Date Action Agency January 1978 RFviev and Agreement on PP EDO/GCN January 1978 PP Submission to AID/W RDO Februar- 1978 Identiy Proj ect Manager Counterpart GON Februai y 1978 PP Approval AID/W February 1978 Grant Agreement and PIO/C Signed . RDO/GT February 1978 Initiate Evaluation Process RDO/AID/W/GON February 1978 Recruit Technicians AID/W February 1978 Accounting Procedure Develped and Implemented RDO/GN March 1978 Vehicle and Mobylettes Ordered RDO March 1978 Drugs for VHTs Ordered RDO March 1978 Audio and Visual Aids Equipment Ordered RDO March 1978 Language Training of Technical Assistance Personnel (if needed) AID/W April 1978 Warehouse, Transport System Augmented to Accommodate Expansion GON April 1978 Develop Student recruitment Process GON a. 3rd country participants b. In-country training for health personnel April 1978 Develop Plan for Expanded VHT Training GON April 1978 Develop Retraining Cycles for VHTs GON April 1978 Develop Curricula and Dates and Participant List for Conferences and Seminars GON - 156- Date Action Agecy April 1978 Develop Training Sites and Review Logistics GON April 1978 Plan Rural Field Program for Medical Students GON April 1978 Construction Sites Identified GON April 1978 ites for Sanitation Improvement Identified GON April 1978 Technical Assistance Job Descriptions and Sites Assigned GON/RDO May 1978 Nominations Made for Training GON a. 3rd country participants b. In..countr-y traini:g for health iersonnel May 1978 Housing Arrangements Conpleted for ! Personnel RDO May 1976 Identify Technical Assistance Personnel Counterparts GON June 1978 Drugs, Audio Visual Materials Arrive EDO June 1978 Technical Assistance Personnel Arrival and Posting RDO June 1978 Order Construction Equipment EDO a. Equipment and furnishings for health center and dispensary b. Sanitary equipment c. Materials for department centers July 1978 Project Review Auust 1978 Determine Vehicle Distribution GON August 1978 Land Available and Cleared for Construction GON August 1978 Construction Contracts Signed GON September 1978 Vehicles Arrive EDO September 1978 Construction Equipment Arrives at Sites GON - 157 - Date Action Aen October 1978 Con-struction of Department Centers Begin -- Agadcz, Zir.der C-ON Cctober 1978 Sanitation Improvements Begin GON November 1978 Recjcle Project Plan and Schedule FDO/GON January 1979 Order Cold Chain Iqtipment RDO January 1979 Const.ru;tion cf Dispensaries Begins GON February 1979 Vaccines Ordered RDO April 1979 Arrival and Distribution of Cold Chain Ecraipment PFO/GON 4 -~ 4 ft eU i) - V .. imnl ...... b ...... ,, ...... ' I. ,i LI -.. rUri ;7 I5 h L:A 0 2 t u vILI, ! , -, F~e ,t ''r 4' - 159 - Glossary Aides Sociales Social workers Arrondissement Comparable to a district Campement Group of families among nomads who migrate - together; maximal residential. group among nomads Canton A cluster of villages CESSI Centre d'Enseignement Superieur des Soins Infirmiers - Located in Yaoundd - trains middle level health personnel CHD Departmental Hospital Center which services entire Departement Circonscription A group of five or more arrondissen6nt Medicale Medical Centers comprise a circonscription medicale CMS Supreme Military Council Cure salee Annual gathering of nomads with their animals in Ingall area of Niger. Purpose is: to replenish animals with nutrients as a result of restored pasturage; to renew kinship ties; to meet with government agents; to revalidate core values through rituals CUSS Centre Universitaire des Sciences de la Sant (University Center for Health Sciences) located in Yaoundd DDS The chief medical officer for a Department (comparable to a state) Djerma Djerma group who live in West Niger. Comprise 20% of population of country. ENICAS National School for Certified Nurses and Social Aides (Ecole National d'infirmiers (es) certifids (ES) et d'aides assistants de l'Action Sociale de la Republique de Niger located in Zinder - 160 - ENSP National School of Public Health - trains nurses, and mid-wives; located in Niamey Equipes Mobiles Mobile Medical Units - the operational personnel of the Division of Mobile Medicine ESSM School of Medical Sciences, University of Niamey Fetish curer Traditional curer (charaten) GON Government of the Republic of Niger Grandes Endemies The endemic disease service; in 1976, the name was changed to the Division of Hygiene and Mobile Medicine Guerisseur Traditional healer who uses herbal medicines as main source of curative intervention HC' Health Center Infirmier certifig Certified Nurse; comparable to a licensed Vocationdl Nurse in the United States Infirmier d'dtat A nurse licensed by the state; comparable to a Registered Nurse in the United States Marabout Traditional healer who uses spiritual incantations as main source of curative intervention Matr8ne Traditional midwife (could also be trained) Medicine de basse Basic health delivery system employed by the Ministry of Health Mobylette A motorized bicycle MOH Ministry of Public Health and Social Affairs ONPPC Office National des Produits Pharmaceutiques et Chimiques - National Bureau for Pharmaceutical and Chemical Products which provides government health estab lishments, local communities and public establishments with pharmaceutical products and surgical supplies - 161 - Peulh Nomadic group (Fulani in English) who migrate in pastoral zone and comprise 10 of population Pharmaci2 Populaire The local pharmaceutical representative of the National Bureau for Pharmaceutical and Chemical Products (Office National des Produits rharmaceutiques et Chimiques) PMI The maternal/child health division of the Ministry of Public Health & Social Affairs PP Project Paper Prefect The Chief of a Department unit--a unit of government comparable to a state Recyclage Retraining Sage Femme Mid-wife (trained and certified) Secouriste Male member of village health team- responsible for basic treatment- sc-,times traditional healer Service d'animation Community Development branch of the rurale government SHDS Strengthening of Health Delivery Systems - A WHO/AID-supported regional project with headquarters in Abidjan Trousse The medical kit provided to Village Health Teams--contents vary by Department and whether the kit is given to a securiste or a matr8ne Tuareg Nomadic group who migrate in North to Central Niger. Comprise 107. of population VEM/ESV Village Health Team (Equipe de la Sautd Villagoise) generally comprised of two se;ouristes; two atrones and a management committee (comitd de gestion)