Document of The World Bank Public Disclosure Authorized

FOR OFFICIALUSE ONLY

Report No: 21320-KM

IMPLEMENTATIONCOMPLETION REPORT

Public Disclosure Authorized (2553)

ONA

CREDIT

IN THE AMOUNTOF SDRs9.2 MILLION(US$ 13.0 MILLIONEQUIVALENT)

TO THEREPUBLIC OF COMOROS

FOR A POPULATIONAND HUMANRESOURCES PROJECT Public Disclosure Authorized

December 21, 2000

HumanDevelopment 4 AfricaRegion Public Disclosure Authorized

This documenthas a restricteddistribution and may be used by recipientsonly in the performanceof their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCYEQUIVALENTS

(ExchangeRate Effective1993)

CurrencyUnit = ComorianFranc (CF) CF 1 = US$ 0.003663 US$ = 273'CF

FISCALYEAR January l-December31

ABBREVIATIONSAND ACRONYMS

AIDS AcquiredImmuno Deficiency Syndrome CDSF CommunityDevelopment Support Fund EPI ExpandedProgram of Immunization FADC Fonds D'Appuiau DeveloppementCommunautaire GDP Gross DomesticProduct IDA InternationalDevelopment Association IEC Information,Education, and Communication ILO InternationalLabor Organization (of the UN) MERCAP MacroeconomicReform and CapacityBuilding Project MOH Ministryof Health NGO Non-governmentalOrganization OAU Organizationof AfricanUnity PNAC NationalAutonomous Pharmacy of Comoros PPF Project PreparationFacility SAR Staff AppraisalReport UNDP UnitedNations Development Program

Vice President: CallistoE. Madavo CountryManager/Director: HafezM. H. Ghanem SectorManager/Director: ArvilVan Adams Task Team Leader/TaskManager: MalongaMiatudila FOR OFFICIAL USE ONLY

IMPLEMENTATION COMPLETION REPORT COMOROS: POPULATION & HUMAN RESOURCES PROJECT CR. 2553

CONTENTS

Page No. 1. ProjectData 1 2. PrincipalPerfornance Ratings 1 3. Assessmentof DevelopmentObjective and Design,and of Qualityat Entry 1 4. Achievementof Objectiveand Outputs 4 5.Major FactorsAffecting Implementation and Outcome 7 6. Sustainability I1 7. Bank and BorrowerPerformance 10 8. LessonsLearned 12 9. PartnerComments 14 10.Additional Information 14 Annex 1. Key PerformanceIndicators/Log Frame Matrix 15 Annex 2. ProjectCosts and Financing 19 Annex3. EconomicCosts and Benefits 21 Annex4. BankInputs 22 Annex5. Ratingsfor Achievementof Objectives/Outputsof Components 24 Annex6. Ratingsof Bankand BorrowerPerformance 25 Annex7. List of SupportingDocuments 26 Annex 8. BeneficiarySurvey 27 Annex9. Borrower'sContribution 31 Map # IBRD 26074

This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not be otherwise disclosed without World Bank authorization.

ProjectID: P000596 ProjectName: POP & HUMAN RESOURCE Team Leader: Eileen Murray TL Unit.'AFMMG ICR Type: Core ICR Report Date: December 21, 2000

1. Project Data Name: POP & HUMAN RESOURCE LIC/TFNumber: 2553 Country/Department: COMOROS Region: Afiica Regional Office Sector/subsector: HT - Targeted Health; SA - Social Funds & Social Assistance

KEY DATES Original Revised/Actual PCD: 10/21/1990 Effective: 06/29/1994 06/29/1994 Appraisal: 03/01/1993 MTR: 06/01/1996 11/01/1996 Approval: 12/14/1993 Closing: 06/30/1999 06/30/2000

Borrower/Implementing Agency: GOVT./M1N.OF HEALTH/EDUCATION Other Partners:

STAFF Current At Appraisal Vice President: Callisto E. Madavo Edward K. Jaycox Country Manager: Hafez Ghanem Francisco Aguirre-Sacasa Sector Manager: Arvil Van Adams David Berk Team Leader at ICR: Eileen Murray, Malonga Amolo Ng'weno, Daniel Viens Miatudila ICR Primary Author: Jdr6me Chevallier

2. Principal Performance Ratings (HS=HighlySatisfactory, S=Satisfactofy, U=Unsatisfactory, HL=Highly Likely, L=Likely, UN=Unlikely, HUN=Highly Unlikely,HU=Highly Unsatisfactory, H=High, SU=Substantial, M=Modest, N=Negligible) Outcome: U Sustainability: UN Institutional Development Impact: SU Bank Performance: S Borrower Performance: U

QAG (if available) ICR Quality at Entry: S S Project at Risk at Any Time: Yes

3. Assessment of Development Objective and Design, and of Quality at Entry 3.1 Original Objective:

The broad objective of the project was to strengthen regional and community involvement in population and human resource development, through improving the delivery of basic health services, and stimulating complementary community development activities. The project was designed to: (i) help establish efficient health regions and other supportive services capable of providing comprehensiveand cost-effective health care, includingfamily planning services and AIDS prevention,through community participation, self-management,and cost recovery; and (ii) support complementiuyinitiatives in communitydevelopment to develop social infrastructureand grassroots participation in small-scaleproductive activities. In addition to its social development objectives,the project was also expectedto stimulate economic growth.

The objective was clear, and a detailed set of performance indicatorswas defined for monitoring the outputs and outcomes of the project at appraisal, mid-course (1996) and completion (1999). The objective was realistic,the project sought to build upon a strong tradition of self-help and community participationto improve the health condition of the Comorian population. The project was important for the Comoros in view of a high incidenceof preventable illnessesand a strong populationgrowth rate (3.1 percent per annum) in a highly densely populated country,with a high level of unemployment. The project was consistent with the country assistance strategy (CAS) discussed with the Board in December 1993. The CAS focused on economic reform, human capital development,and protecting the Comoros' fragile eco-system. The project was one of three projects included in the five-year lending program, together with an Education project and an EnvironmentProtection project.

A credit to support economic reform and capacity building (MERCAP) had been approved in December 1992. The reform program emphasized resource mobilization,the streamliningof an over-extended civil service, the restructuringof public enterprises, and the implementationof a new accounting system for both public and private enterprises. The project review was consistent with the reform program through its focus on enhancingthe efficiency of the civil serviceand relying on local communities to improve the delivery of basic services.

3.2 RevisedObjective:

The objective of the project has not been revised.

3.3 OriginalComponents:

The project included two components, namely:(a) the improvementof health services, and (b) the establishmentof a Social Fund. The first component included: (i) strengtheningand developing program planning and monitoring capacities at the regional level, and stimulatingcommunity participationin health and populationactivities; (ii) conducting a series of training activities to increase the productivity of regional health workers; (iii) strengtheningthe capacity of MSPP to provide adequate technical and operational support to regional staff in the implementationof health activities; (iv) partially rehabilitating a number of health care facilities; (v) designing multi-media,well-targeted Inforrnation, Education and Communication (IEC) strategies and formulating other population and DIV/AIDSactivities; (vi) equipping about 20 laboratories to improve their diagnostic capabilitiesfor purposes of fertility and HIV/AIDS control services; and (vii) ensuring regular supply required to carry out fertility and HIV/AIDS control activities, as well as monitoring the impact of such activities.

The second component was designed to support: the rehabilitation of basic infrastructure,including rural roads and bridges, primary schools, water supply and health care facilities; (ii) income generating activities;(iii) activities which promote the well-beingand developmentof women; and (iv) training of communitiesand groups in appropriatetechnologies, and in resource and project development and management.

-2 - The two componentsof the project were highly complementary. The development of the health services componentrequired a strong involvementof local communities. By supportingthe developmentactivities initiatedby local communities through the social fund, the project was expected to empower local groups and improve the conditions for the deliveryof health servicesto the population. The two componentswere designed to achieve the project's objectives.

Both componentswere designed taking into account past experience.The Social Fund component was developedtaking into account the lessons from experience in other African countries and elsewhere in the world. The Social Fund was designedto finance projects submittedby local communities,especially for the rehabilitation of social facilities and other key infrastructure. A manual of procedures setting up the criteria for project financing was agreed upon during negotiations. The contribution of local communities to the cost of sub-projectswas expectedto be no less than 20 percent. Non governmentalorganizations (NGOs), local and international,were closely associated in the design of the Social Fund. A first batch of projects, of which 20 for the rehabilitationof primary schools and 12 for improving water supply, was prepared for fnancing during the first year of project implementationunder funds made available through the on-going Second Education Project at the time. The Social Fund was also expected to finance income-generatingactivities in close association with an ongoing program supportedby the UNDP and ILO. Finally the Social Fund was to focus on training for local communities,with particularemphasis on women's groups.

With regard to the health component, lessons were drawn from experience gained under several activities financed by the donor communityin the health sector in the Comoros. In the early 1990s,the UNDP supported a pilot program,which aimed at improving the administrativeand financial managementof the health center located in Misoudje. The Pilot program was highly successful. The success has been mainly attributed to close involvementof the local communityin constructionof the building, and in the management,financing and maintenanceof the facility.

Prior to the UNDP-assistedproject, the Bank had approved its first health project in the Comoros. The project was launched in 1982 and completed in 1991, and was instrumentalin establishingfamily planning services in most health centers and in improving the attitudes of religious and other leaders on the issue. With regard to the pharmaceuticalsub-sector, the project succeeded in establishing PNAC (Pharmacie Nationale Autonome des Comores) as an autonomous agency charged with the procurement and distributionof essential generic drugs in the countiy. This agency enabledthe populationto have easier access to essential drugs.

Little progress was made in other componentsfor a number of reasons. The project was prepared in the Ministry of Planningwith minimal involvementof officials from the Ministry of Health, which was expected to implementit. Moreover, the project was too complex for the recently-createdMinistry of Health. It was also designedto support vertical programs with no attempt to address systemic issues of the health sector. Finally, it neglected the fiscal environment of the project at a time when the country's public finance situation was strained.

The shortcomingsof the First Health Projectwere taken into account in designing the health component of the Population and Human Resource DevelopmentProject (PHRD) under review. PHRD was prepared in close cooperationwith the Ministry of Health,and the detailed technical specificationswere agreed upon during negotiations. The health component of PHRD took into account the lessons from the Mitsoudje pilot project (a UJNDP-financedhealth facilitywhich tested cost recovery schemes for community-based health facilities). PHRD sought to give increased supervisoryresponsibilities to regional health teams, organize on-the-job training for staff, and promote community participation in the managementof health

- 3- facilities. Performance indicatorswere established for each regionalteam. Health centers were given increased autonomy in staff administration,price setting for services and resource management. It was expected that reforms supportedby MERCAP would result in more regular budget allocationsto the health sector, and to project facilities in particular.

The central services of the Ministry of Health were to be reinforcedto enable them to better dischargetheir responsibilitiesin planning, norm setting,training and monitoring and evaluating performance. Health centers were to be rehabilitated,taking into account a set of priorities. Before any rehabilitation,however, local communitieswere expected to commit their support to the cost of investment and maintenance of the facilities. The Social Fund, established under the second component of the project, was expected, inter alia,to help local communitiesmeet their commitmnent.

A health sector policy letter was agreed upon during negotiations. It summarizedthe basic principles of the 1991 National Plan for the Developmentof Health, and provided a set of guidelinesfor the managementof health facilities in close association with local communities. It also indicated that, starting in late 1994, three-year rolling expenditure programs establishedjointly by the Ministries of Health and Finance, would be reviewed annually by IDA. At least 20 percent of annual budgets would cover non-wage costs.

3.4 Revised Components:

The project was not restructured during implementation.

3.5 Quality at Entry:

The quality at entry of the PHRD is rated satisfactory. The project was fully consistent with the country assistance strategy and the reform program initiated by the Government with support from the Bank in 1991. The health component of the project was in keeping with the National Plan for the Developmentof the Health Sector enacted in 1991. The project took into account the lessons from past experience in the Comoros and in other parts of the world. Its two components were mutuallyreinforcing. Both components were carefullydesigned in close association with local groups and NGOs. Detailed specificationsand procedureswere agreed upon in the course of project preparationand processing. Sub-projectswere available for Social Fund financing before project start-up. This is mainly due to the Canadian NGO, CECI's successfuljob on the communitymobilization side. A training program was also formulated. Performanceindicators were defined for mid-term and project completion. The French bilateral aid agency was expectedto finance a system for collectingand processing health statistics.

The risk section in the Staff Appraisal Report (SAR) was appropriate, particularly when compared to similar sections of SARs prepared in the early 1990s. The three risks envisaged were the lack of appropriatefunding, the low capacity of the government administration,and political instability. Mitigation measures included the strengtheningof communitymanagement for health facilities,granting autonomy to the management of the Social Fund, the training of staff, and provision of technical assistance. Eventually, the project suffered from the lack of appropriatefunding and political instability.

4. Achievement of Objective and Outputs 4.1 Outcome/achievement of objective:

From 1994 to 1996, the project was successful. In the last three years of project implementation,the

-4 - social, economic,and political situation deteriorated,and thus project activities were at a standstill. In 1997, the populationof the island of Anjouan, the poorest and most densely populatedisland in the three-island country,decided to secede. The Organizationof African Unity (OAU) imposed sanctions on the secessionistisland, including an embargo,resulting in a heavy toll on the well- being of the population, particularly its poorest segments. In view of these developments,the projects overall outcome is rated unsatisfactory.

In August 1998, the accumulationof arrears by the Comoros, led to the suspension of disbursements. The suspensionwas lifted, but in January 2000, only. The worsening of the fiscal situation resulted in an increased irregularity in the payment of wages to civil servants,with negative consequenceson staff morale, includingin the Ministry of Health. The progress made under the project before the crisis was seriously compromised, as a consequence. Since early 1999,the project has been consistently rated unsatisfactoryfor developmentobjective and implementationprogress.

The political crisis is in the process of being resolved. With recent improvements in economic management and national reconciliation,it is expected that some of its achievementsmay have a lasting impact on the well being of the Comorian population.In addition,the governmentshowed its commitmentto working with the Bank by settling the IDA arrears late 1999. The Bank, as a result of this positive step, undertook a full-fledged CPPR in March 2000, where objectives and activities for all on-going projects were re-visited to take into account the new socio-economiccontext.

Outcome/Achievementof Objective. Despite an overall environmentnot conduciveto the implementation of developmentprograms, the project achieved its overarchingobjective, which was to strengthenregional and community involvementin populationand human resource development. Communityparticipation in the managementof health facilities and in the preparationand implementationof projects supported by the Social Fund was particularly robust. On the other hand, contrary to expectations,the project had no significantimpact on economic growth, which was negative during most of the period of project implementation. The project also had little visible impact on health indicators,which have remained poor.

Achievementof the project development objectives is rated unsatisfactory,because the project has not improved the health status of the population.

4.2 Outputsby components:

Managementof the Ministry of Health. Up to 1997, the managementof the Ministry of Health had considerablyimproved. In 1994, the Ministry established a national committee for the implementationof sector reforms and launched a major informationcampaign to discuss the basic principles of reform with the staff and the representativesof the population. The principleswere communityparticipation in the financing and managementof health facilities, and the delivery of health services through the 17 health districts under the responsibility of regionalteams. Two laws and 8 implementingdecrees were enacted to irnplementthe reform. The reforms included: (i) the reorganizationof the Ministry of Health with more emphasis on the regional directoratesand a redefinition of the role of the central units; (ii) conversion of public hospitals and health centers into public establishmentswith administrative and financial autonomy, or into not-for-profitprivate organizations,with board of directors and managementcommittees, including representatives of the population; and (iii) introductionof cost recovery. Managers of most health facilities,with the notable exception of the main hospital in Moroni, the capital city, were selected in consultationwith the boards of directors. A total of about 500 poorly qualified staff was declared redundant. A programto lure back Comorian doctors living abroad was successfully implemented. An ambitious and comprehensiveprogram to train health staff within the country using as much as possible

- 5 - Comorian nationals was designed, but administrative and bureaucraticinefficiencies prevented about half of the planned training activities from proceeding.

Despite temporary paralysis of the health system in recent years and the deteriorationin staff morale, achievement under the first sub-component is rated satisfactory. The scope and depth of the reforms supported by the project are unique in sub-SaharanAfrica.

Rehabilitationof health facilities. The project financed the rehabilitationand equipment of two regional hospitals and three health centers. Works were carried out by local enterprises and were considered satisfactoryoverall. Works were completed in one hospital on Moheli island and in one health center on Grande Comore. Works in two health facilities in Anjouan were halted during the recent crisis. Works did not even begin for one health center in Grande Comore (Fomboni),because the Governmentdid not want an opposition leader who had won the contract to benefit. In addition, at the time of credit closing, the planned equipment had not yet been put in place in most facilities. The persistent lack of funds for the maintenance of rehabilitated health facilities is a major drawback. Overall, this sub-component is rated unsatisfactory.

Promotion of population and AIDS prevention activities. Family planning activities have been included in the basic health care package of the Ministry of Health. Health center staff have been trained in family planning issues. IEC campaigns using both modern communicationsmethods and traditional networks have been supportedby the project. The latest demographic survey conducted in 1996 showed that the modern contraceptiveprevalence rate has increased to 8 percent, from 3 percent when the project was prepared. Much more remains to be done, however, in view of the high population growth in a country, which is already highly densely populated. The HIV prevalence rate remains low at less than 1 percent. The strong traditional values of an Islamic society are an obstacleto promoting modem family planning, as well as activities to curtail the spread of the HIV/AIDS epidemic. The sub-component is rated satisfactory.

The Social Fund component. This component has been successfulin mobilizing local communities for the implementationof infrastructure. Schools have been by far the investmentfor which the demand was the highest. A total of 215 classrooms in 90 schools have been built. Water supply and sanitation projects came next, with a total of about 40 projects completed. Thirteen health posts and ten training and women development centers have been built with the support of the Social Fund. Local infrastructure,such as rural roads and bridges (8) and markets (8), has also been supported by the Fund. Out of a total of 219 projects completed, 107 were carried out in Grande Comore, 72 in Anjouan, and 40 in Moheli. It is estimated that about three quarters of the country's population has benefited directly or indirectly from projects implementedwith the support of the Social Fund.

Initial difficulties in procurement,construction standards, inadequateperformance of some local enterprises,cost overruns, and insufficientsupervision of works were gradually overcome. Two technical audits were carried out and found that works on the whole were of good quality and procurement procedureswere followed. The auditors made specific recommendationsthat were for their most part directed at making best use of local resources, including local consultants and contractors, and establishing standards and systems for updating unit costs of sub-projects. To address the issue of inadequate maintenance of new facilities, it was agreed during negotiationsthat the up-front contribution of beneficiariesto the cost of new investmentin water supply would be increased from 20 to 25 percent of total cost.

The administrativecost of the Social Fund has been consistentlymuch higher than initially anticipated. In the early years, the Social Fund administrationhas been involved in the day-to-day supervision of project

-6 - activities, resulting in a high overhead cost Eventually,an increasingpart of the supervision activities was contracted out to local consultants. This did not reduce cost substantially,however. Disbursementsfor operating costs of the social fund represented 31.5 percent of disbursementsfor sub-projects, compared to 22.5 percent estimated at appraisal. The high cost of air travel between islands has been a contributing factor to high administrativecost.

Income-generatingactivities supported by the Social Fund started in 1998. Small credits in an amount of less than the equivalent of US$200 each were extended through the developmentbank of Comoros, mutual funds and local committees.A total of approximatelyUS$200,000 was extended for the financing of 42 sub-projects.

A beneficiary surveywas carried out in 1997. The survey revealed that local committees including,the elders in the communities,the youth and women, were all highly satisfied with the supportthey received from the fund. In most villages, beneficiariesdid not mind participatingin the cost of the works, but some villages, mainly in the poorer islands of Anjouan and Moheli thought that the 20 percent contributionwas too high. Over 75 percent of the communitiessurveyed indicatedthat they wanted the social fund to provide increasedtraining. Most local communities were clearly committedto the sustainabilityof their investmentsas maintenance schemeswere in place by 85 percent of them. A summary of the survey's findings is in Annex 8.

The Social Fund component is rated satisfactory.

4.3 Net Present Value/Economicrate of return:

N.A

4.4 Financialrate ofreturn:

N.A.

4.5 Institutionaldevelopment impact:

The institutionaldevelopment impact was substantial. The Ministry of Health is now functioning a little better due to the re-deploymentof staff to the regions. In parallel, health facilities were rendered autonomous, and due to the cost-sharingmechanisms that were put in place, these facilities are functioning much better now.

On the social fund side, the institutionis perceived by the Government,the population,and donors as the key mechanismfor communitydevelopment activities in the three islands.

5. Major Factors Affecting Implementation and Outcome 5.1 Factorsoutside the controlof governmentor implementingagency:

Political instability, includingseveral coup attempts and frequent changes in governmnentaffected project implementation. The decision by Anjouan leaders in 1997 to secede from the Comoros,and the resulting political chaos was a major obstacle to the completion of project activities. The inability of that government to bring about a solution to the Anjouan secession sparked riots in Grande Comore. On April 30, 1999 the army staged a bloodless coup and promised improvedmanagement and a return to civilian rule. In December 1999 a civilian Prime Minister was appointed with the support of 22 out of the

-7 - Comoros' 30 political parties. Intense negotiations in July/August2000 between the government and the Anjouaneserebels resulted in ajoint declaration calling for the reunificationof the country with a large degree of autonomy for each island.

The devaluationof the Comorian franc by 33 percent in foreign exchange terms in January 1994 contributedto increasingthe competitivenessof the Comorian economy, but was not sufficient for setting it onto a sustainable growth path. The Comoros continued to rely for its exports on a small group of commodities,with highly volatile world prices. Tourism, which was a growth industry in the late 1980s and early 1990s,was affected by political instability, and hotels' occupancy rates dropped to below 50 percent in recent years. Under MERCAP, the ratio of governmentrevenues to GDP was expected to increase from 14.2percent in 1991 to 17.8 percent on average for the period 1998-2002. Actually it is estimated to have declined to 13.8 percent in 1999. Under these conditions,the Government proved unable to implementits recurrent budget. At end- 1999, accumulatedwage arrears were about twice the annual wage bill. The rate of execution of non-wage expenditures in the social sector was below 30 percent in 1999.

5.2 Factors generally subject to government control:

External factors had a negative impact on growth and fiscal revenues, but successivegovernments were, for most of them, not stronglycommitted to reforms. Revenue mobilizationefforts were short lived and public expenditure control remained weak throughoutmost of the project implementationperiod. The failure of the Government to provide adequatefunding to health facilities, which were scheduled to be rehabilitated under the project, delayed the program of civil works under the health component. Such funding was a condition of disbursementfor the civil works under that component. The condition was met, but in December 1995 only. Following this initial funding, however, health facilities had to rely on a high level of cost recovery to make up for the lack of operating subsidies from the Government. Lack of counterpart funding has been a perennial problem during project implementation. Accumulationof arrears to civil servantswas also a recurrent phenomenon,which created serious morale problems, particularly toward the end of project implementation.

Political instabilitybrought about frequent changes in the staffing of key positions within ministries. Sometimes,the Government interfered in the procurementprocess or the supervision of works. In one instance, the contractor for the rehabilitation of a hospital was prevented from completingthe works for about ten months, because he was consideredto be a political opponent by the government in place. In another incident,for the same reason, wings of an existing health center were demolished to give room to new structureswhich were not erected up to credit closing on June 30, 2000. The project management unit (PMU) was the only unit, which was not affected oy the frequent changes in staffing. This significantly reduced the negative impact of political instabilityon project implementation.

5.3 Factors generally subject to implementing agency control:

Factors generally subjectto implementingagency control. The two project implementationagencies did their best under difficult circumstances. They managed to implementthe project despite inadequate government financial support.

-8 - 5.4 Costs andfinancing:

Cost and Financing. The table below shows the categories of disbursementby componentsas initially scheduled and as actually paid in thousands US dollars.

Categories A B B/A Initial disbursements Actual (%) disbursements

Health Equipment 1,830 474 26 Civil works 1,760 1,437 96 Training 1,150 999 87 Consultants 420 924 220 Operating costs 450 741 165 Special account (38.8)

Sub-total 5,610 4,575 82

Social Fund Sub-projects 5,450 5,150 94 Operating costs 1,170 1,620 138 Special account (123.3)

Sub-total 6,620 6,770 102

PPF 800 726 91

Grand Total 13,029 12,071 93

Disbursementsfor the Social Fund component were higher than initially expected, but lower for the health component. The devaluationof the Comorian franc in 1994 resulted in a higher amount available from the credit in local currency. This increased amount was mainly used to finance a larger number of activities under the Social Fund component than initiallyexpected. Disbursementsfor operating costs were 38.5 percent higher than expected at appraisal. This resulted from the under estimation of operating cost, particularly for the Social Fund, as well as from the failure by the Government to provide sufficient counterpart funding.

On the health component, the low disbursementrate for equipment is basically due to the fact that project activities were at a standstill since August 1998, when disbursementswere suspended for an eighteen-monthperiod. Even though the bidding process took place for this equipment,the Ministry of Health was unable to award the contracts, and make the purchases due to this eighteen-monthsuspension of disbursement.

In spite of problems encountered during implementation,including the delay in meeting the disbursement condition for the rehabilitation of health facilities, there has never been a significant lag in disbursements.

-9- 6. Sustainability 6.1 Rationalefor sustainability rating.

Rationale for sustainabilityrating. Most facilities built or rehabilitated under the project have operated to the satisfactionof the beneficiariesin spite of a chronic absence of government funding. The people have developeda strong tradition of community participationand self-help. The project has successfully built upon this tradition and, as a result, health centers are managed by local communities, which ensures, among other things, that many health issues are discussed locally and promptly dealt with. Local infrastructuresub-projects supported by the Social Fund are fully under the control of the local population. For instance, most schools built with project funding operate with teachers directly paid by the local communities. Contributionsfrom the local population are complementedby considerabletransfers from the large Comorian communityliving abroad.

The recent crisis has demonstratedonce again the resiliency of Comoros' local communities. Continuous under-fundingby the Government of its operating expendituresin the social sectors, including the wage bill of civil servants, seriously weakens the sustainabilityof large facilities financed by the project. Funds generated by cost recovery in the health sector have been reported to be used to pay for salaries of health workers, making it difficult for local communitiesto meet other operating expenses, including for the maintenance of facilities.

In 1999, the new Government has made efforts to re-establishfiscal discipline, including the payment of arrears to IDA, which enabled IDA to lift the suspensionof disbursements in January 2000. For the project to be sustainable,however, these efforts are to continue over the long-term.

6.2 Transition arrangement to regular operations:

In FY98, IDA approved two follow-up credits,the first one to support continuation of the social fund activities for the rehabilitation or construction of communal infrastructureand the creation of micro-enterprises,and the second one to consolidatethe results achieved under the health component of the project. Implementationof both projects has been seriously disrupted by the recent crisis and the suspensionof IDA disbursements from August 1998 to January 2000.

Nonetheless,recent development in Comoros augur well for the resolution of the conflict with Anjouan and improvedeconomic management. With the deteriorationof social services and increase in poverty in recent years, IDA is working closely with other donors, including the EU, UNDP, and the RMF,to provide comprehensiveassistance to combat poverty. Following the settlementof arrears in January 2000, IDA lifted the suspension and resumed project activities in key social sectors.Moreover, the Board approved an Interim Support Strategy in November 2000 to assist the Government in its efforts to strengthen economic management, achieve national reconciliationand fight poverty. The Government'smedium-term program of reconstructionfocusing on the improvementof social services and living conditions for the poor as one of its key pillars. These factors thus strengthenthe likelihood of the sustainabilityof this project, but sustainabilityrests with government maintaining fiscal discipline.

- 10 - 7. Bank and Borrower Performance Bank 7.1 Lending:

The performance of the Bank in the identification,preparation and appraisal of the project is rated satisfactory. On the Bank side, the project was fully consistentwith the country assistance strategy. On the Government side, it was consistentwith the Government's plan for the health sector. The project was well designed. It soughtto strengthenregional and local involvementin the development of human resources, and build upon a strong tradition of communityparticipation. It adhered to the Bank's safeguard policies.

The Government was committedto the project, as evidenced by the courageousand far-reaching reforms implementedin the health sector in the early years of project execution. It was expectedthat the Governmentwould be able to finance recurrent expendituresin the social sectors, as a result of the implementationof its economic reform program supported by MERCAP. The implementationcapacity of the Borrower was properly assessed. The project was a simple one, with two components,which were expected to be mutually reinforcing. About 45 sub-projectswere prepared for Social Fund financing before Board presentation. Some of them were in the process of being implementedwith financing from a PPF advance. Experience showed that expectations in the SAR for the Social Fund componentwere achievable

Project risks were clearly identified. The risks of inadequate counterpartfinancing and political instability materialized,but to an extent, which was, in both cases, beyond expectations. The project design proved to be robust, however, as the objective and most outputs were achieved. The appraisal report included an iinpressive list of performance indicatorsfor the health component. The French bilateral cooperation had an arrangement with the Government to establish a system for monitoring health indicators. However, the system never became operational,making it impossibleto assess progressin meeting the performance indicators set forth in the SAR.

7.2 Supervision:

The performance of the Bank in the supervision of the project is rated satisfactory. There was a remarkable continuity in the staffing of the Bank team. Following a project launch workshop in May 1994, two supervisionmissions visited the Comoros each year. A mid-term review took place in 1996. It highlightedthe need to make greater use of local consultants and promote the development of local enterprisesthrough training. It also emphasizedthe need to put increasedfocus on the maintenanceof facilities and made recommendationsto that effect.

Supervision missionswere issue-orientedand sought to assist the implementingagencies execute the project with diligence. Reporting was timely, accurate and informative. The ratings were generally adequate, except in 1997, when the project was rated highly satisfactory for implementationprogress and development objective,despite serious problems encounteredwith counterpart financing. Supervision reports were adequatein discussing the achievement of development objectives. Actions to establish a system for monitoring performnanceindicators in the health sector were not taken by the Borrower and its partners. This is partly due to extremely weak capacity in the country and also to political instabilityand insecurityduring the early years of project implementation. In the absence of most achievement indicators,

- 1 1 - Annex 1 shows the baseline of various indicators at appraisal, the actual indicators achieved (available in few cases) and the target agreed upon during negotiations.

7.3 Overall Bank performance:

Overall the performance of the Bank is rated satisfactory.

Borrower 7.4 Preparation.

The performanceof the Borrower in the preparationof the project is rated fully satisfactory. The teams in charge of project preparationwere highly motivated. They made a significantcontribution to a sound design of the project. They were closely in contact with the stakeholdersand listened to their concerns.

7.5 Government implementationperformance:

Despite the delay in meeting the condition of disbursementfor the rehabilitationof health facilities, the Govermmentsperformance in the execution of the project was satisfactory early on. It implementedan ambitious program of reforms in the health sector and helped put the Social Fund on a sound footing. In the final years of project execution,however, the governmentperformance deteriorated. The government failed to provide the minimum required for counterpart funds and for recurrent expenditures in the health sector. The inability of the Government to address the serious poverty issues facing the population of Anjouan resulted in an open crisis, which has taken a heavy toll on overall economic and social performance. Overall the performance of the Government is rated unsatisfactory.

7.6 Implementing Agency:

The two implementingagencies were effective in implementingtheir components, despite recurrent difficulties with counterpartfunding and frequent governmentinterference in the procurementprocess. The Social Fund administrationdemonstrated that a lot could be achieved when projects were prepared and implementedwith the close participationof the beneficiaries. It made the necessary adjustmentsto take into account lessons from experience, recommendationsmade by technical audits and suggestionsmade by beneficiaries. The Social Fund administrationwas able to deliver a large program of works without any technical assistance,which is highly commendable. The performanceof the implementingagencies is rated satisfactory.

7.7 Overall Borrower performance:

The overall performanceof the Borrower is rated unsatisfactory,in spite of the achievements brought about by the project in the field. The Governmentwas unable to set the country on a growth path. Economic and social conditions deteriorated,and poverty worsened in past years, in spite of the services provided by the facilities rehabilitated or built under the project.

8. Lessons Learned

As already indicatedin the project completion report for the first health project issued in 1992, conditions

- 12 - prevailing in the Comoros for implementingdevelopment projects are difficult. Major obstacles include a stagnating island economy,extremely weak public institutions,government incapacity to remunerate adequately its civil service, and a strong tradition of village politics leading to politicaland social instability. On the other hand, local communitiescan be easily mobilizedto channel their energies and resources towards the achievementof common goals. Lessons from the project should be seen in that context.

The first and most important lesson is that projects in the social sectors in the Comoros should be designed so as to reinforce the dynamism of local communities. Even if the Comoros makes sustained progress on the path of sound fiscal management,the country will be unable, for a long period of time, to mobilize the resources needed to pay an expanding number of civil servants in the social sectors. The populationhas demonstratedits willingnessto pay the local teachers hired to teach in the schools built with Social Fund support. Direct payment of teachers and health workers by the beneficiariesis more efficient than collectingtaxes for that purpose. The Comoros should envisage reforms that would reduce the need to maintain an ever expanding civil service, and rely instead on the dynamism of local communities. Other countries,which have also great difficulties increasingthe ratio of government revenuesto GDP beyond 15 percent, should also consider such reforms, and the Bank should be prepared to assist.

The second lesson is that testing different approaches for sub-project preparation, financing and supervision before committing a large amount of resources,as was done with the Social Fund before Board approval of the project, is highly desirable. The Social Fund component was well prepared and its implementationwent smoothly. Adjustmentswere made during executionto take account of the lessons from experience. Technical audits and beneficiary surveys were conductedwith project funding to help the Social Fund correct deficienciesand better meet the concernsof the population.

The third lesson is that the share of operatingexpenditures in total cost for a newly-establishedSocial Fund in a context such as the Comoros is bound to be high. It takes time to develop the local enterprise sector, which is expectedto carry out and supervise a large number of works spread across several islands. In the meanwhile,the Social Fund administrationhas to step in and use its resources to help local communities implementtheir projects. In addition, beneficiary surveys indicated that the population insisted on getting appropriatetraining to better manage their projects. This legitimate demand increased administrative costs, which eventually represented about 31.5 percent of sub-project cost, compared to 22.5 percent estimated at appraisal. Under the follow on project, this share is expected to be 24.5 percent.

The fourth lesson is about cost sharing and therefore the population's willingnessto pay for services delivered in health. Cost sharing from the beneficiarypopulation enabled the health system to continue to operate despite the lack of governmentfunding, even for health worker salaries. This has enabled the Board of Directors and managementcommittees of health facilities to function adequately since they were empoweredby the population, due to the new cost sharing schemesthat were put in place by the project.

The fifth lesson is that adequatemethods need to be developedto monitor the health status of the population. Experience has shown that relying on the Government to produce statistics on time is not a viable solution. Local communities should be endowed with the capacity to collect and analyze simple sets of data. Representativesof the population should be given appropriatetools to monitor performance health activities and make adjustments as appropriate.

Finally, in countrieswith weak central institutions,but strong local communities, the flexibilityin moving funds rapidly to support communities' projects may be a productiveapproach. In countries prone to political instability, such an approach may yield positive development results.

- 13 - 9. Partner Comments (a) Borrower/implementingagency:

This ImplementationCompletion Report prepared by the Bank on the Population and Human Resources Project reflects the reality in the country. The Health component'sobjective was to improve health services and the second component'sobjective was to put in place the Fonds D'appui au Developpement Communautaire(FADC). These 2 componentswere complementary. They both tried to involve Comorian populationgroups in community developmentactivities. Regardingthe first component, the project tried to seek communityinvolvement as a means for improving health services. The second component'smain objective was to help communities implementcommunity-based development activities that were meaningfulto them.

The continuity of Bank staff in Project supervisionwas very much appreciatedby the Comorian Government. It is unfortunate that political events in Comoros, these past few years, have caused delays in project implementation. At many instances,during project implementationthe Governmentwas not able to pay its civil servants in time nor to finance operating expendituresof health facilities that were rehabilitated by the Project. However, the Comorian Government has made big efforts recently to improve public finances.

(b) Cofinanciers:

N.A. (c) Otherpartners (NGOs/private sector):

N.A. 10. Additional Information

-14 - Annex 1. Key Performance Indicators/LogFrame Matrix

OBJECTIVE/STRATEGY/ACTIVITY/ Endof PERFORMANCEINDICATOR Proiect Baseline Actuals Target

1. Ensurethe developmentof humanresources

Women'slife expectancyat birth (years) 56.00 56.00

Globalfertility rate (per 1,000women aged 15- 216.20 110.00 44) Totalfertility rate 6.60 5.00 Crudebirth rate (per 1,000population) 44.50 40.00 Grossmortality rate (Per 1,000population) 13.60 10.00 Maternalmortality rate (per 1,000live births) 460.00 100.00 Infantmortality rate (per 1,000live births) 91.90 60.00 Under-Fivemortality rate (per 1000) 131.50 75.00 Meanbirth interval(months) 36.00 Numberof cases of neo-nataltetanus (peryear) 10.00 Numberof deathsfrom malaria among children 2,200.00 700.00 aged lessthan 5 years(per year) Numberof deaths fromdiarrheal diseases 1,800.00 600.00 amongchildren aged less than 5 years (peryear) Prevalenceof Iodinedeficiency among women aged 15 years and above(per 1,000) Percentof children0-49 monthswith more than two standarddeviation below the reference medianfor weight for age Annualgrowth rate of HIVsero-positivity 0.00 amongpregnant women Sero-positivityrate for humantreponema 22.20 2.00 pallidumtype A amongpregnant women Contraceptiveprevalence rate amongwomen 3.00 8.00 10.00 aged 15-44

-15 - 1.1. Improve the delivery of basic health services

Total number of new out-patient visits per year 50.00 200.00 and per 100 residents

Value of pharmaceuticals distributed annually 70,2 147.75 by public institutions (in FC milllion)

Percentage of pregnant women with more than 25.00 90.00 two pre-natal visits Births correctly assisted (per year) 27.20 60.00 Family Planning visits (per year) 18,253.00 50,000.00

Contraceptives used (Couples-Years of 7.40 18.00 protection per 100 women aged 15-45 years, per annum) Percent of children 12-23 months completely 85.00 90.00 immunized 1.1.1 Improve the management of the Ministry of Health

Cumulative number of MOH Staff trained under 0.00 864.00 230.00 the project Cumulative number of functioning regional 0.00 3.00 health teams Cumulativenumber of health facilities with 0.00 18.00 20.00 Managing Associations Cumulative number of Hospitals with 0.00 8.00 3.00 fonctioning Boards of Directors Cumulative number of health facilities headed 0.00 23.00 by a trainedmanagers . Cumulative person-months of training provided 2,095.00 357.00 .to MOH staff by the project 1.1.2 Rehabilitate health facilities Cumulative number of health facilities made 0.00 5.00 fonctional by the project Cumulative number of health facilities 0.00 5.00 7.00 rehabilitated by the project Cumulative number of health facilities equiped 0.00 0.00 5.00 by the project

-16 - Dosesof vaccinesadministered annually by the EPI program(Thousands of doses) . 20000 Condomsdistributed per year (Thousandsof 287.90 1,200.00 _ _ units) Contraceptivesother than condomsdistributed 7,131.00 17,490.00 annually(Couples-Years of protection) 1.1.3Promote Population and HIV/AIDS prevention Iactivities Cumuiativenumber of aboratories equiped for 1.00 17.00 17.00 EHlV/AIDScontrol activities Cumulativenumber of healthcenters provided 18.00 0.00 with LECequipment by the Project Cumultativenumber of surveysconducted in 3.00, 6.00 the areasof FamilyPlanning and Population Number...of .-- V. .-test. . performed. . per year. ---_--l ------Numberof HIV tests performedper year __ ~~Number of Syphilistests performnedper yearX 1.2. Supportcommunity development initiatives

Populationbenefiting from classrooms built by 0.00 1459532.00! the projectbet from F Populationbenefiting from health posts built by 0.00 45,723.00 the project Populationbenefiting from water supply 0.00 66,226.00 systemsbuilt by the project Populationbenefiting from feeder roads built 0.00 8,971.00 l lbythe project ...... tPopulationbenefiting from centres de 0.00 7,733.00

promotionf&minine built by the project - iPopulationbenefiting from centres de 0.00 23,149.00 promotionprofessionnelle built by the proiect1 Populationbenefiting from the sewerage 0.00 10,651.00 systembuilt by the project i jPopulationbenefiting from anti-erosion 0.00 956.00 structuresbuilt by the project

- 17 - 1.2.1 Support rehabilitation/renovation of basic social infrastructure Cumulative number of classrroms built under 0.00 215.00 200.00 the project Cumulative number of Health posts 0.00 11.00 built/renovated by the Project Cumulative number of water systems 0.00 33.00 Cumulative number of local markets created by 0.00 5.00 the project petits systemes d'irrigation 0.00 1.00

Cumulative number of small-scale fisheries 0.00 1.00 organized under the project Cumulative number of kilometers of feeding 0.00 roads built by the project Cumulative number of sewerage structures built 0.00 6.00 by the project Cumulative number of anti-erosion structures 0.00 3.00 built by the project 1.2.2 Support income-generating activities 180.00

SCumulativenumber of loans granted by the 0.00 50.00

|project 1.2.3 Support the training of members of Community Committees Cumulative number of Community Pilot 0.00 177.00 180.00 Committees made operational by the Project

Cumulative number of Community Pilot 0.00 288.00 Committees created by the Project Cumulative number of members of the 0.00 4,134.00 5,731.00 Community Pilot Committees trained by the Project 1.2.4 Support special programs for women |Number of Centers for Women's Development 0.00 4.00 created by the Project Number of Centers for Professional Training 0.00 5.00 created by the Project

- 18 - Annex 2. Project Costs and Financing

Project Cost by Component (in US$ million equivalent)

Project Cost by Appraisal Actual/Latest Percentage of Component Estimate Estimate Appraisal USS million US$ million Health 5.61 4.75 91.27

Social Fund 6.62 7.07 117.83

PPF 0.80 0.72 90.54

Total Project Costs 13.03 12.54 96.24

Project Costs by Procurement Arrangements (Appraisal Estimate) (US$ milion) Expenditure Category ICB LCB Other Total Costs 1. Goods 1.27 0.56 1.83 l ______= _ l (1.27) (0.56) (1.83) 2. Civil works 1.76 1.76 I ______l l_____(1.76) (1.76) 3. Consultants 0.42 0.42 ______(0.42) (0.42) 4. Training 1.15 1.15 1=______(1.15) (1.15) 5. MOH Oper. Costs 2.44 2.44 (0.45) (0.45) 6. CDSF Inc. Op. Cost 1.19 1.19 (1.19) (1.19) 7. CDSF Sub-Projects 4.93 1.52 6.45 (4.93) (0.50) (5.43) 8. Refinancing PPF 0.80 0.80 (0.80) (0.80) TOTAL 1.27 6.69 8.08 16.04 (1.27) (6.69) (5.07) (13.03) Note:Figures in parathesisare amountfinanced by IDA

-19 - Project Costs Financed by IDA by Procurement Arrangements (Actual/LatestEstimate) (US Miflions) Expenditure Category ICB LCB Other Total Costs

1. Goods 0.322 0.34 0.118 0.474

2. Civil works 0 1.437 0 1.437

3. Consultants 0.106 0.134 0.684 0.924

4. Training 0 0 0.999 0.999

5. MOH Oper. Costs 0 0 0.741 0.741

6. CDSF Inc. Op. Cost 0 0 1.620 1.620

7. CDSF Sub-Projects 0 2.500 2.650 5.150

8. Refmancing PPF 0 0 0.726 0.726

TOTAL 0.428 4.105 7.536 12.071

PROJECT FINANCING BY COMPONENT (TNUSS THOUS, EOUIVATLENT _NDS Component Appraisal Estimate Actual/Latest Estimate Percentage of Appraisal

IDA Govt. Benefi- IDA Govt Benefi- IDA Govt Benefi- ciaries ciaries . ciaries A. Supportto 5,610 1,990 0 4,575 - 82 Health Sector

B. Community 6,620 1,017 0 6,770 94 Development Support Fund

C. PPF 800 0 0 726 1,162

D. Unallocated

TOTAL 13,030 3,007 0 12,071 94 1,162

-20 - Annex 3: Economic Costs and Benefits Not Applicable

-21 - Annex 4. Bank Inputs (a) Missions: StageCy~No.of~roo of Perons ard Specialty P fr a~ (e.g.2 Economists,, I MS,etc.) ... l . . ..t .. , .- o m E Month/Year Cut speiat Ojctv Identification/Preparation 07/1991 2 Economist I Health and Population Specialist I Education Specialist 11/1991 1 Consultant (Sociologist) 05/1992 1 Economist (Task Manager) 1 Engineer 10/1992 1 Economist (Task Manager) I Engineer I Public Health Specialist 05/1993 1 Economist I Community Development AppraisallNegotiation 03/1993 1 Education Specialist I Public Health Specialist I Specialist in Community Dev. I Implementation Specialist I Economist I IEC Specialist I Consultant 05/1993 1 Economist (Task Manager) I Community Development

Supervision 01/1994 1 Task Manager HS HS 05/1994 1 Task Manager/Economist S S I Public Health Specialist I Procurement Specialist I Financial Specialist I Consultant 11/1994 1 Task Manager/Economist S S 1 Public Health Specialist 1 Financial Specialist 1 Consultant 06/1995 1 Task Manager S S 12/1995 1 Task Manager HS HS I Community Development 07/1996 1 Task Manager HS HS I Public Health Specialist 11/1996 1 Task Manager HS HS Economist Public Health Specialist IEC Specialist 06/1997 1 Task Manager HS HS 1 Public Health Specialist

-22 - 11/1997 1 Task Manager S S I Public Health Specialist 07/1998 1 Task Manager S S I Public Health Specialist 10/1998 1 Task Manager U U 11/1999 1 Task Manager U U

ICR

(b) Staff

Stage of Project Cycle ActalLatest Estimate No. Staff weeks USS(,XO0) Identification/Preparation 160.2 422.2 Appraisal/Negotiation 93.4 261.2 Supervision 111.4 390.2 ICR 6.37 18.2 Total 371.37 1091.8

-23 - Annex 5. Ratings for Achievement of Objectives/Outputsof Components (H=High, SU=Substantial, M=Modest, N=Negligible, NA=Not Applicable) Rating l Macro policies O H O SU O M O N * NA O Sector Policies O H OSUOM ON O NA a Physical O H *SUOM O N O NA 0 Financial O H OSUOM O N * NA O Institutional Development 0 H 0 SU 0 M 0 N 0 NA O Environmental O H OSUOM O N * NA

Social O Poverty Reduction O H OSUOM O N O NA E Gender OH OSUOM O N * NA O Other (Please specify) O H OSUOM O N O NA 0 Private sector development 0 H O SU O M 0 N 0 NA 0 Public sector management 0 H O SUO M 0 N 0 NA El Other (Please specify) O H OSUOM O N O NA

-24 - Annex 6. Ratings of Bank and Borrower Performance (HS=HighlySatisfactory, S=Satisfactory, U=Unsatisfactory, HU=Highly Unsatisfactory)

6.1 Bank performance Rating

nOLending OHS OS OCU OHU O Supervision OHS OS OU OHU O Overall OHS OS C U O HU

6.2 Borrower performance Rating

nlPreparation OHS OS C U O HU O Government implementationperformance O HS O S 0 U * HU O Implementationagency performance O HS OS 0 U 0 HU Ol Overall OHS OS * U O HU

- 25 - Annex 7. List of Supporting Documents Staff Appraisal Report, Federal Islamic Republic of Comores, Population and Human Resources Project. November 19, 1993.

Development Credit Agreement, Federal Islamic Republic of Comoros, January 18, 1994.

Aide-memoires of preparation, Appraisal, and supervision reports of Bank missions.

-26 - Additional Annex 8. Beneficiary Survey

BeneficiarySurvey (Summary of the survey)

The objective of the survey was to assess the perceptionsof communitiesconcerning the Social Fund, its procedures,its results, the changes broughtabout by investmentmade, and the nature of projects required. To that end, forty committeeswere contacted:twenty in GrandeComore, fifteen in Anjouan,four in Moheli, forty independentbeneficiaries, forty elders, forty youths and twenty women associations. During field interviewssteering committees,elders, includingthe village chief in most cases, womenbeneficiaries, and youths were present. Each interview lasted for about two hours.

List of villaees

Grande-Comore

Village Project Population Cost Community Comments (ComF) Participation

Koimbani Rehabilitationof 2,150 5,745,950 473,000 Communityshare not Washili a womentraining entirelypaid center

Maoueni Road 900 16,866,715 3,197,900 (after evaluation) Itsandra insteadof 2,383,290

Bangoi la Constructionof a 1,655 19,644,426 5,335,100 Hambou school

Wella Health center 4,000 16,617,536 3,233,850 Mitsamiouli

Bandamadji Constructionof a 715 18,043,485 4,233,000 Itsandra school

Mvouni Completionof 3,800 14,237,803 3,607,236 two classes

Moindzaza Water supply 250 11,595,548 1,407,650 Djoumbe

Bangoi Kouni Water supply 2,848 52,527,147 12,921,500

Ndzaouze School 1,536 8,782, 005 2,561,150 rehabilitation

Wella Rehabilitation 1,941 21,566,321 6,373,750 Itsandra and construction

Zivandani Constructionof a 978 9,186,624 2,696,580 school I I I

-27 - Mramani Rehabilitation of 3,188 27,730,050 7,314,447 a school

Tsembehou Construction of a 8,096 23,218,646 4,480,300 Two projects were market financed in this village Hachinpenda Construction of 916 11,188,251 3,196,800 rain water drainage system

Chandra Construction of a 3,511 34,139,207 5,644,450 school

Mahale Rehabilitation of 1,531 8, 634,760 2,113,625 water supply

Barakani Rehabilitation of 5,000 16,839,014 2,483,489+ a school 525,500

Koki Construction of 3,066 18,266,256 3,069,820 water supply

Ouani Rehabilitation of 7,134 36,097,231 6,491,200 health center

Patsy Water supply 932 7,586,789 1,761,225

Moh6Ii

Village Project Population Cost Community Comments I ______|(ComF)______participation Wallah 2 326 4,420,636 1,458,960

Hoani 728 2,130,773 697,305

Mbatse 767 4,112,106 909,325

Banar Salama 634 13,107,981 3,822,300

-28 - Results

1. Degree of satisfaction:45% very satisfied, 42.5% satisfied and 12.5% less satisfied (of which 5% of total who have encountered serious problems). Relationships between the Social Fund and villages are good even in cases where serious problems were encountered.

2. Procedures: 70% found them efficient, 15% relatively efficient, and 15% not efficient. Communities had no difficulty accepting that they have no direct access to funds. Excessive administrative delays were encountered by 15% of communities. All communities insist on being fully informed on all operations concerning them.

3. Project preparation: 82% were fully satisfied with technical preparation of projects; 17.5% were not satisfied. In the latter case technical problems were encountered during works, particularly as concerns roads or bridges. 90% would like the Social Fund to provide training to one or two people in the community on project preparation. Several communities had to hire people to help them prepare projects. Committees were generally unhappy when they had to deal with enterprises, as they felt that they were kept in the dark.

4. Needs: 96% found that the Social Fund met their priority needs; they indicated, however, that they had a lot of priorities, but were asked to select only one. Only one community found that the project, which was promoted by an NGO, was not their top priority.

5. Community participation: 425% found that community participation to the financing of projects was about right, and 57% to high. In Moheli, all communities found that the participation required was too high; this was the case for 80% of the communities in Anjouan. Both islands are poorer than Grande Comore. 62.5% of communities found that their contribution was much higher than the 20% required. Contribution in kind was the preferred mode of participation.

6. Nature of projects: First priority includes school, road, and water supply; second priority, sanitation; third priority, markets; fourth priority, health post; fifth priority, women training center and library. All communities insisted on the need to include as top priority income generating activities and credit. Most communities are highly concerned with unemployment of youths. Communities would like to benefit from short-term professional training. 30% of communities were in favor of electrification.

7. Benefits: all communities found that the projects have contributedto improving their living conditions. Schools have contributed to an increase in schooling rates; children's motivation has increased; success rates have improved. Water schemes have contributed to reducing time spent and to improved health conditions. Roads have contributed to improved trade and faster evacuation of sick people. Health posts have contributed to the reduction of infant mortality.

8. Training: 77% found that training provided was to the point, but far too short.

9. Maintenance: 87% have taken steps to ensure sustainability of investment made, including fees. Communities have proved highly inventive as concerns resource mobilization. Committees have remained highly involved in project operation and maintenance.

-29 - Conclusion

The Social Fund is an excellent mechanism for helping communities meet their priority needs. It should be enlarged and continue to put emphasis on community participation and technical training.

The Social Fund is considered the best project ever in the Comoros. Even villages, which have not benefited from social fund support, praise its merits. The project is the first to take account of people's needs. The project has contributed to restore dignity, because it helped communities realize that they were able to actively participate in the development of their village with their energy and willpower.

Problems were not encountered during implementation, however, but these problems were not insurmountable. In most cases, solutions lie in better supervision of works, enhanced capacity in the management of the fund, and increased transparency in accounting.

Communities' needs are so numerous that it seems impossible to meet all of them. Over the past four years, each village has benefited on average from one project only. Only a happy few were able to get a second one. In view of the extent of requirements,the volume of financing available should be greatly expanded.

A most positive point has been the creation of village steering committees, in which all categories of the population are represented, including the poorest segments, such as women and youth. These committees have helped establish a consensus and are most involved in the operation and maintenance of facilities.

- 30 - Additional Annex 9. Borrower Contribution

MINISTERE DE LA SANTE Republique des Comores

RAPPORT D'ACHEVEMENT DU PROJET POPULATION ET RESSOURCES HUMAINES (Credit IDA 2553-K1M)

- 31 - A l'attention de: Monsieur Hafez Ghanem, Directeur des operations pour les Comores

Objet: Projet Population et Ressources Humaines (Cr. 2553-KM)

INTRODUCTION

Par ce rapport d'achevement, le Gouvernementde la Republique Fed6rale Islamique des Comores (RFIC) voudrait mettre en exergue les points forts du Projet Population et Ressources Humaines (PPRH) ainsi que les difficultes rencontrees au cours des six ans de sa mise en oeuvre, ce qui sous-entend que les objectifs du projet n'ont pas tous et pleinement atteints.

Depuis son accession a la souverainete intemationale en 1975, la Republique Federale Islamique des Comores (RFIC) s'est fixee comme objectif d'assurer un niveau acceptable de conditions de vie pour tous ses habitants. Dans le domaine de la sante, la politique des vingt derni&es annees a dte axee sur les soins de sante primaires,mettant l'accent sur la disponibilit6a l'echelon le plus p&ipherique,d'un ensemble de services de sante prioritaires,conformement a l'esprit de la Declaration d'Alma-Ata.

En mai 1991, soit deux ans avant l'identification du PPRH, la RFIC se dota d'un Plan Sanitaire qui definissait les grandes orientations et les axes prioritairesde la politique Sanitaire dans la perspective de l'an 2000. Il fut decide que les activites et les programmes prioritairespoursuivraient les memes objectifs que par le passe, a savoir : la promotion par l'infornation, I'education et la communication,des comportementsfavorables a la sante, la prestation des services de sante matemelle et infantile, y compris les vaccinations, la surveillancepre- et perinatale et la planification familiale, la lutte contre les endemies et les epidemies,en particulier le paludisme, les infectionsrespiratoires aigues, les maladies diarrheiques,les maladies sexuellementtransmissibles et le SIDA ; et enfm l'approvisionnementet la fabricationlocale de medicamentsessentiels, notamment par le developpementdu reseau des pharmaciesmises en place selon la strategie de l'Initiative de BAMAKO. Afm de faciliter la mise en oeuvre de ce plan et parer aux graves difficultes de fonctionnementqui caracterisaientle secteur public, le Gouvememententreprit une profonde reforme institutionnelleet statutaire de ce secteur. Un accent particulierfut mis sur la rationalisation du systeme sante et sur la souplessede fonctionnementet d'adaptation necessaire a une evolution rapide de la demande et des techniques et i une adaptation aux realites socio-economiquesnationales. En decembre 1992, un decret autorisant la gestion autonome des recettes des h6pitaux fut publie.

Le PPRH fut prepare en mars 1993. A cette epoque, malgre des succes significatifs et l'appui important d'organismes d'assistance et de bailleurs de fonds de ia communaute intemationale, le pays etait encore loin d'atteindre les objectifs qu'elle s'etait fixee. Ses taux de mortalite se trouvaient encore a des niveaux inacceptables.La situation qui prevalait a cette epoque etait caracterisee par la precarite de l'etat de sante des populations,notamment des femmes en age de procreer et des enfants. La pathologie etait dominee par le paludisme, les infectionsrespiratoires aigues, les maladies diarrheiques,les maladies sexuellement transmissibles, ainsi que par d'autres maladies infectieuses et parasitaires.

Depuis plus de quinze ans, la RFIC, dont l'economie a connu une croissance relativement rapide au cours de la decennie 1975-85,fait face a de severes difficultes socio-economiques.A la suite d'une politique de gestion de gestion budgetaire lache, une mauvaise gestion des entreprisespubliques et une demande

- 32 - soutenue au niveau des importations,le pays fait face a une stagnationdu taux de croissance economique reel, une baisse des exportations,un deficit budgetaire (dons exclus) reste Aun niveau equivalent A24% du PIB ; un deficit du compte courant de la balance de paiements (dons exclus) ddpassant 20% du P.I.B. ; une accumulationd'arrieres de paiements interieurs et exterieurs; une deteriorationdes termes d'echange (faible competitiviteexterieure et faible rentabilite des exportations).

C'est dans ce contexte socio-economiquedifficile, que, le 14 decembre 1993, la Banque mondiale accepta d'octroyer aux autorites comoriennesun credit de developpementde 9,2 millions de DTS.

II. OBJECTIFSDU PROJET

L'objectif global du credit dtait de renforcer le developpementdes ressources humaines. Pour atteindre ce but, le projet devait (i) assurer la mise en place d'un systhmesanitaire efficace et rentable et (ii) promouvoir la participation des communauteslocales au developpementsocial et economique.Ce credit cadrait avec le programmedecrit dans le document cadre de politique economique pour 1991-93et 1994-96 et qui visait, entre autres choses, A accelerer la croissance reelle du PIB A3,5% en 1993 et A4,4% en 1996. Bien plus, il prenait le dynamisme communautairequi caracterisela RFIC.

III. REALISATIONSDES OBJECTIFS DU PROJET

Le projet a realise plusieurs de ses objectifs. En effet, nous pouvons affimer que, globalement,le credit a apporte une ameliorationsensible au systbme sanitairecomorien et qu'il a augmente la volonte et la capacite des communautesA participer aux efforts sectoriels de developpement, notammenten education et en sante. Sur six formations sanitaires soit deux hopitaux et quatre centres de santd- qui avaient ete jugees prioritaires,cinq ont ete rehabilitees dont une par lUnion Europeenne.Une formation sanitairen'a pu 6tre realisee pour des raisons politiques. Des Directions centrales du MSPP ont e equipdes. La Direction de 1' Education Sanitairea beneficie d'un appui particulier du projet dans le but d'assurer l'adhesion et le soutien social et de stimuler la demande des services de sante disponibles. L'education sanitaire individuelle a e combinee avec un effort de communicationde masse elargie par des seminaireset des programmes radiophoniques.Des modules de formation ont ete developpesafm d'aider les differentescategories du personnel du MSP A s'acquitter efficacement de leurs taches. De nombreux agents du MSPP ont beneficie de ces modules A l'occasion des sessionsde formation qui ont e organisees dans le pays par l'Ecole Nationale de Sante (ENS) avec l'assistance d'un bureau d'experts internationaux.L'organisation de ces formations dans le pays a permis non seulement d'augmenter le nombre des beneficiaires,mais aussi de renforcer les capacites institutionnellesde l'ENS.

Dans le secteur de la sante, les rdsultats les plus interessantset les plus perennes ont toutefois porte sur les reformes. Les services et les structures de soins et de preventionrelevant du Ministere de la Sante (MSP) ont et reorganisesdans un dispositif pyramidal hierarchise qui part des postes de Sante vers les h6pitaux regionaux et les unites centrales du MSP. La volonte d'etablir et de garantir l'efficacite de la gestion des formations sanitaires s'est materialisde,entre autres choses, par l'adoption de textes legislatifs et reglementaires appropries(au total deux lois et 8 decrets), par l'elaboration de meilleures regles et procedures administrativeset fmancieres pour le MSP et par la transformation de ces structures publiques de soins en Etablissements Publics Hospitaliersdotes de la personnalite morale, conformesaux dispositions des textes 1lgislatifsen vigueur. Les h6pitaux du gouvemementont et6 dot6s d'un Conseil d'Administration qui assure le contr6le direct du fonctionnementet de l'usage des ressources allouees et de recettes apportees par la tarification officielle des actes effectues. Ces conseils sont composes de trois categories de membres, A savoir: des representantsdes collectivitesterritoriales, des representantsdes personnelsde 1' etablissement et des personnalitesexterieures reconnues pour leur competence et leur interet dans l'un des

- 33 - domainestouchant au fonctionnementet aux activites des formationshospitalieres. Les representants regionaux du MSP assistent aux reunions du Conseil d'Administrationet y font entendre la voix et les observationsdu ministere, en particulieren ce qui concemera le budget de fonctionnement,les equipements et la politique de developpementsanitaire. Le Gouvernementa egalementdote ses Centres de Sante (CS), ses centres medico-urbains(CMU) et ses centres medico-chirurgicaux(CMC) du statut d'Etablissements prives sans but lucratifs avec des missions de service public. La gestion des Postes de Sante est confiee a des associationsvillageoises de soutien, qui se voient par convention,autorisees a percevoir le montant d'actes tarifes pour en couvrir les frais de fonctionnement.Toutes ces reformes ont permis de faire evoluer plusieurs cadres des directions centrales et regionales du MSPP du travail d'executant a celui de superviseur.Ce qui est tres interessantpour l'efficacite et l'efficience du systeme sanitaire national.

Grace au PPRH, la distribution des soins de sante par le secteur public s'appuie desormais sur une responsabilit6 accrue des communautes locales et sur leur participation directe a la gestion des structures, ainsi que sur un dispositif de fmancementqui peut combinerdes ressources locales a des financements assures par le budget de l'Etat ou par l'aide intemationale.Les el6ments critiques essentiels de cette participation communautairesont devenus la decentralisation,l'intensification des activites d'information, d'education et de communicationa tous les niveaux, la g6neralisationdu principe du recouvrementdes cofits, la dotation de toutes les formations sanitairesd'une autonomie de gestion financiere et administrative avec integrationdes representantsdes communautesdans les instances de deliberation et de decision. La populationest tres satisfaite d'etre revresenteedans les organes de gestion des formations sanitaires.

Le projet a pu ainsi accro:itrela disponibilitedes services du planning familial et le contr6le du SIDA; il a aussi ameliore la qualite des activites visant a accroitre la demande pour ces services.Le programme de populationet de prevention du SIDA a ete execute de facon satisfaisanteet a permis une augmentation sensible du taux d'utilisation des contraceptifsmodernes. On estime ce taux a 8 % aujourd'hui, alors qu'il n'etait que de 3% en 1990. Des campagnes d'information sur le fHV/SIDA ont permis de mieux sensibiliser la population sur les dangers de la pandemie. Elles ont sans doute contribue a maintenir le taux de prevalence de la seo-positiviteau VIH a de faibles niveaux (de l'ordre de 1%). Lors des dernieres epidemiesde cholera, les communaut6sont decouvertque le PPRH les a rendues capables de se prendre en charge et de participertres efficacement aux activites de contr6le des maladies.

Grace a sa composante<( FADC >>,le PPRH est consider6 par la population comorienne comme de loin le meilleur projet. Lors de l'enqu8te sur les beneficiaireseffectuee en 1997, les personnes interrogeesont affirme que le projet s'est soucie reellement de leurs besoins. La composante FADC a tenu ses promesses, parce que la grande majorit6 des villages de la RFIC ont pu beneficier d'au moins une r6alisation.Le FADC a rendu leur dignite aux populationsen leur permettantde realiser qu'avec l'energie, la volonte et 1'engagementardent de toute la communaute,elles etaient capables de participer activement au developpementde leur village. Des Comites de Pilotage (CP) ont ete crees pour formuler les besoins et r6aliser les projets. Ces comites beneficient de l'adhesion de la population.La compositiondes CP a pris en compte tous les mouvementsassociatifs qui existent au sein du village, qu'ils soient traditionnels ou modemes, ce qui permet d'aborder les questions avec un large consensus. Les categories defavorisees telles que les femmes et les jeunes y sont bien representees,ce qui a cree, dans de nombreux cas, une symbiose entre les CP et les communautes.

La composante FADC a apport6 un appui financier et technique pour la realisation des projets communautaires. Plusieurs infrastructures de base ont pu ainsi 8tre construites ou rehabilitees. Ces travaux de genie civil ont porte, entre autres choses, sur des salles de classe au niveau des ecoles primaires, sur des postes de sante, sur des ouvrages d'adduction d'eau, sur des routes d'accbs, sur des ponts, sur des marches locaux et sur des etablissementsde stockage des vivriers. Le choix des structures a rehabiliter etait toujours

- 34 - determine de concert avec les communautes.La preference a ete accordee aux travaux de haute intensite de main d'oeuvre qui etaientjuges techniquementet economiquementefficaces et susceptiblesd'offrir de grandes opportunitesd'emploi. Le FADC a collabore avec le Ministerede la Sante pour assurer la mobilisation et a la formation des communauteset, ainsi, faire participer ces dernieres a la rehabilitation et Ala gestion des formations sanitaires.La volonte d'augmenter la capacite des institutions locales a planifier et a executer les sous-projetsa conduit le FADC A mener plusieurs activites de formation. Ces formations ont beneficie Aenviron 1800 macons, 180 menuisiers,360 producteurs de meubles scolaires et 100 ateliers de montage. Le FADC a aussi aide techniquementet financierementles pauvres A lancer de petites activites viables et productivesdans les secteursou une demande des produits etait identifiee. En plus, le projet a apporte un appui Aplusieurs adjudicatairesdu marche de fabrication de mobilier pour les projets de rehabilitationfinances par le FADC. Des pr8ts ont ete egalement etd accordes a des membres des communauteslocales. Afin d'apporter une reponse approprieea la question des femmes, le projet a accordd la priorite aux activites qui sont generalementaccomplies par les femmes, qui font une discriminationdes avantages ou qui favorisent l'integration et la promotion de la femme. Dans cet esprit, le FADC a organise un programme feminin d'alphabdtisation,de formationen planning familial, en nutrition, en sante matemelle et infantile et en activites generatricesde revenus. Les femmes ont egalementbeneficie d'un encadrementspecial qui a aide plusieurs d'entre elles a formuler les projets, a organiser leur communaute et A faire des propositions aussi bien au FADC qu'A d'autres bailleurs de fonds, y compris dans le cadre des activites gendratricesde revenus.

Le projet a pu atteindre la plupart de ses objectifs grace A l'excellence des rapports de travail entre la Banque et le Gouvernement.Des amenagementsnecessaires A la bonne realisation du projet ont pu etre realises grace Aune bonne comprehensiondes problemes et a une forte volonte d'aboutir Ades solutions acceptables.La continuiteau niveau tant de l'equipe nationale que de celle de la Banque pendant toute l'execution du projet de sante et fonds social a contribue aussi au succes de cc projet.

II convient d'indiquer que le succas du PPRH n'a pas ete total: certains objectifsjuges importantsn'ont pas ete atteints. Plusieurs travaux ont ete interrompuspour l'une ou l'autre raison. Sur une formation sanitaire de la Grande Comore, les activites de rehabilitationont ete suspenduespendant une longue periode de temps, a la suite d'un differend avec l'entreprise qui avait gagne le contrat de construction. L'etablissement a ete detruit pour faire place Aun nouveau centre. Ce centre n'a cependant pas ete construit et les populations concernees ont manifeste leur grande deception.Le PPRH a fixd a 20% du cofut des ouvrages la contribution des communautesaux fmancementde leur projet. Compte tenu des faibles capacitees des communautes, il convient de fixer la participation communautaireA 10%. Si dans l'ensemble, les communautesont accepte le principe de cette contributionet ont mis tout en oeuvre pour mobiliser les ressources ndcessaires, les communautes les plus pauvres ont eu du mal Aremplir la condition mise a l'engagement des travaux. C'est surtout le cas A Anjouan et Moheli. Les evenements politiques aux Comores ces dernieres anndes ont causd quelques perturbationsdans P'executiondu projet. La crise ouverte en 1997par la declaration de secession d'Anjouan, n'a pas permis d'achever plusicurs activites prevues pour cette ile. Les formations sanitaires qui ont ete rehabilitees n'ont pas ete equipees, car la suspension des d6boursementsdes credits IDA aux Comores a freine le processus d'acquisition des 6quipements.Bien plus, les etablissementssanitaires n'ont pas obtenu les complementsfinanciers de l'Etat, dont ils ont besoin pour assurer 1'entretienet le renouvellementde leur patrimoine.Les centres de santd, dont la gestion a ete confiee a des associations sans but lucratif creees a cet effet et agreees par le MSP, ne disposent pas encore de moyens financiers et humains necessairesa leur fonctionnement.Les depenses engagees par le Gouvernementpour participerau financementde ce dispositif n'ont pas ete maintenus au niveau reel des engagementsreconnus pour 1992, soit au moins 800 millions de francs comoriens. La grande faiblesse institutionnellequi a caracterise la Fonction Publique, le Trdsor et d'autres services strategiquesde l'Etat n'a pas permis a l'Etat de s'acquitter correctement de s'acquitter de sa responsabilite

- 35 - dans la mise en oeuvre du projet, notamment en ce qui concerne la liberationdes salaires du personnel des formations sanitaires. L'instabilite politiquechronique (coups d'Etat, intrusions des mercenaires dans le pays, grande instabilitedes equipes de directiondes services publics) ont contribue enormement A limiter le succes du PPRH. Tout au long de sa vie, le projet n'a pas reussi Amettre en place un mecanisme de suivi et d'evaluation capable de lui permettre d'apprecier correctementl'iimpact des efforts investis dans le pays.

IV. CONCLUSION Le rapport d'achevement prepare par la Banque sur le Projet de Sante et de Fonds d'Action et de Developpement Communautaire(FADC) correspond bien Ala realite du projet sur le terrain. Les commentaires de la Banque sont dans l'ensemble pertinentset pour l'essentiel, notre analyse est concordante. Les points qui nous semblent les plus importantsdans le but d'ameliorer les performances des deux parties lors des futurs projets sont les suivants:

* Une bonne preparationdes projets est essentielle pour assurer l'addquation entre les credits alloues et le programme et eviter les conflits et certains retards au moment de l'execution; * II serait utile de reduire les delais entre l'evaluation du projet, sa mise en vigueur et le debut d'ex&ution. Ceci afm de limiter l'importance des changements; * L'amelioration des performances passe par la n6cessite d'avoir une structure 16gerede suivi et qui ne sera pas trop dependante des influences; * L'autonomie de gestion est eminemmentsouhaitable: elle devrait donc etre maintenue; a II est n6cessairede raccourcir les d6lais entre la demande de r6approvisionnementdu compte sp6cial et l'arrivee des fonds; * Il convient aussi d'ameliorer les communicationsentre la Banque et le gouvemement.Les transmissions des dossiers, meme expedies par courrier express, ne sont ni assez rapides ni assez fiables. Il serait utile que la Banque aide les projets As'affilier aux services d'Internet; * La stabilit6au niveau des 6quipes a e un facteur determinant A la bonne marche du projet; * La Banque et le Gouvemement doivent s'efforcer de garder des relations de confiance mutuelle tout au long de l'ex6cution du projet. Ceci a permis de trouver des solutions a toutes les difficultes rencontrees et ce, dans des d6lais raisonnables et dans l'interet du projet; : La Banque devra veiller tout particulierementA l'appropriation des projets par le pays. Ceci prend beaucoup de temps au depart, mais permet plus tard d'ex6cuter le projet sur une p6riode moins longue; * La Banque et le Gouvemement doivent s'efforcer d'int6grer, dans les projets, des mecanismes d' incitation ad6quate des agents charg6sd'ex6cuter le programme; * 11convient de poursuivre le programme de rehabilitation de l'infrastructure sanitaire de fa9on A am6liorer la disponibiliteet la qualite des services de soins pour la population et, ainsi, minimiser les evacuations sanitaires. Ce programme doit aussi int6grer I'H6pital El Marouf; * II faudrait poursuivreles actions de formationtant pour les cadres des ministeres que pour les membres des communaut6slocales, car ces actions ont et6 benefiques. La formation doit etre continue et 6volutive,mais il faudra veiller A ce que le gain de ces formationssoit r6el pour le pays. Des formations orientees vers l'acquisition de metiers sont aussi fortement essentiellespour permettre aux femmes et auxjeunes d'avoir des activit6s generatricesde revenus. II convient d'appuyer les communaut6s souhaitent qu'un accent soit mis sur la formation de leurs membres et d'organiser des formations techniques qui permettraient de mieux superviser la realisation de leurs projets et de prendre plus d'initiatives en faveur du developpementde leurs villages; * II faut veiller Ace que les activit6s de formation soient d6finieset planifi6espar une assistance technique qui est bien int6greedans les 6quipes nationales et qui connait, avec precision, les besoins prioritaireset les motivations des candidats.Cette methodologie doit etre poursuivie dans les futurs projets, car elle assure I'efficacit6 des activit6sde formation; * II faudrait realiser que les communaut6saux Comores sont extremement demunieset que leurs besoins

- 36 - sont considerables.Ces communautesrisquent de se decourager si elles doivent attendre plusieurs annees pour realiser leurs projets prioritaires.Pour cela, il faut accelerer la realisation de leurs projets prioritaires. * II importe aussi d'oeuvrer dans le sens du renforcementdes Comites de Pilotage (CP) en accordant a leur fonctionnementtoute l'attention necessaire. Car 1'engagementdes beneficiairesen faveur de 1' execution des activites et de la conservationdes ouvrages fmances est un incontestableatout pour la transparence de la gestion et la perennite des resultats des projets; * II convient d'adapter la part que les communautesdoivent apporter au fmancement des projets aux capacites des ces communautes.Les communautes les plus pauvres ont eu cependant du mal a remplir la condition mise a l'engagement des travaux; * II convient enfm d'oeuvrer dans le sens de la mise en place d'un systeme efficace de monitoring et d'evaluation pour assurer un bon suivi et une evaluation satisfaisante des projets.

Pour le Gouvernement,

MonsieurAhmed OULEDI, CoordinateurNational Projet Sante II

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