71 DEPARTMENT OF STATE AGENCY FOR INTERNATIONAL DEVELOPMENT WASHINGTON. D.C. 2053
UNCLASSIFIED AID-DLC/P-2237
August 23, 1977
MEMORANDUM FOR THE DEVELOPMENT LOAN COMMITTEE
SUBJECT: TUNISIA - Rural Community Health
Attached for your review are the recommendations for authorization of a loan/grant to the Government of Portugal ("Borrower") of, not to exceed Four Million Dollars ($4,000,000) - Loan in the amount of Three Mill.lon Dollars ($3,000,000) and Grant In the amount of One Million Dollars ($1,000,000) to enhance the quality and coverage of health services in two rural provinces.
No meeting has been scheduled for consideration by the Development Loan Staff Committee; however, your concurrence or objection is requested by close of business on Tuesday, August 30, 1977. Ifyou are a voting member, a poll sheet has been enclosed for your response. -Development Loan Comittee Office of Development Program Review Attachments: Summary and Recommendations Project Analysis Annexes A-G I. TRANSACTION Coot AGENCY Owa SMERNATN& OEVwILn @4iNT I.A R00 pp PROJECT PAPER FACESHEET C c . Docu-CI CODE 3. O tJNrRY / N TITy CUNISIA 3 TUNISIA 4.OOCUMENT REVISION NUMMER
MOROJECT MUiMER (I dl4s) Si. 8UR[AU/OrprIlC E 7.PROJECT TITLE (Maimum 40 characters) 564-0296 A80. 0UO. CODE NE 4 FURAL COMMUNITY HEALTH S.ESTIMATED IFY Olt PROJECT COMPmLTION *.ESTIMATED OATE OF OULIOATI0N
A. INITIA,,oQUARTERVV ° ..
C.C1 FINAL. IFY (enter 1. 2. or 10. ESTIMATED J, 4) COSTS (S00. OR'EQUIVALENT SI - A. FUNOING SOURCE FIRST FY LIFE OF PROJECT . C. t.'C 0. TOTAL. wx III L.G. TOTAL, AID APPROPRIATED TOTAL 3 355 ______3r. 4.-6/C ILOANI _. __oT__ __ .355, -I1-' I .3.o2OOww ---*-O - 355--- I n- 3---7 1-4-0--0 1 __s~~m )-'----,0-.0 -1- 1
mOST COUNTRY "____._n 96 _ _400 OTNER ONONISo, L______oo_.
TOTALS I6 O 1 4.315 --- II. PROPOSED SUOGET 1. 5.400t APPROPRIATED FUNDS (5000) A. APPRO. . PRIMARY PRIMARY TECH. cooE E. ,ST Y.I7 H. 2ND PRI ATION FY 8 K. 3111 _7 PURPOSE ~ .*- coDE C. CRAN? 0. _____ 6.0AN U NN 3AN I GRANT I) Health J. LOAN 6.GRANT M. LO0AN 533510 -"---8-0 --5 '-1 3,000 325 320 -.-_ ---- _
141 - TOTALS 3,000 325 "2-- 3
N. 4TH FY- -0. STH PY A. APPROPRIATION I.LIFEOF PROJECT 12. IN-DEPTH EVA. - - UATION SCHE--UL Z o. ,RANT P. L.OAN R. GRANT "illHe alth S. L.OAN ". GN,.1T U. LOAN III . - 1,000 3,000 (33
141 0117 TOTALS - 10 1i. DATA CHANGE FACESHEET IKOICATOR. WERE CHANGES MAOE DATA. BLOCK 12' 1 YES. IN THE PIO FACESHEET DATA, BLOCKS ATTACH CHANGED PIO FACESHEET. IZ, 13. 14. OR 15 OR IN PRP
D t = NO
y its
14. ORIGINATING OFFICE CLEARANCE 1S. DATE DOCUMENT RECEIVED ._.._ Per' TuniLsSIGNTUREMINTS. 5T12 IN AIoDW. OR FOR AIO/W OOCU . DATE OF TITLEEDATE SIGNED . s A = O DISTA16UTIONa T * ur0 ,, ,.0,,... .IA IIA00 1 II ( m10 .~0IT l RURAL COMMNITY HEALTH SILIANA AND SIDI BOU ZID PROVINCES
TUNISTA
TABLE OF CONTENTS
Part I. Project Summary and Recommendations
A. Recommendations .... ****** *.**** 2 B. Descriptioh of the Project.. 2 C. Sunmary Findings ...... ,,...... 5 D. Project Issues ...... g 6 Part I. Project Background Rationale and Detailed Description A. Backgroud,.., ,, . • , 8 B. Detailed Project Description ...... 37 Part III. Project Analysis
A. Technical Analysis ...... ,...... B. Economic 42 Analysis ...... v ...... 69 C. Financial Analysis and Plan ...... D. Social 73 Analysis ...... , ...... 87 Part IV. Implementation Planning A. Administrative Feasibility ...... 95 B. Implementation ...... 1. 97 Technical Assistance...... 98 2. Capital Assistance ...... C. Evaluation Plan ...... 103 D. Foreign .112 Donor Coordination . 114
Annexes:
A. Project Design Summary: Logical Framework B. Critical Performance Indicators Chart C. Checklist of Statutory Criteria D. A.I.D. Director 611(e) Certification E. GOT Application for Assistance F. Environmental Impact Statement G. Siliana and Sidi Bou Zid Maps H.K PRP - Rural Community II. Design Health Study II: Integrated Rural Health Services Siliana in and Sidi Bou Zid Provinces (Family Health * J. Tunisia: Siliana Care, Inc.) and Sidi Bou Zid Integrated Health Services Susan Christie-Shaw • K. Social Soundness Analysis * Annexes i thru K are available in NE/TECH and USAID/Tunis for review. -1-
TABLE I
TUNISIA SELECTED IND ICAT0R-
Borders: North.and East: Mediterranean Sea South and East: Libya South and West: Algeria 3 Population: 5 ,6 18 ,5 72 Population Density: 94 Persons/Square Mile Infant Mortality Rate: 106/1,000 Live Births- Annual Population Growth Rate: 2.3% (2.65% if emigration excluded) Number of Years to Double: 30.5 (26:5 if emigration excluded) Life Expentancy at Birth (in Years): 53.5 (Males); 54.4 (Females) Sex Ratio (M/F): 1.03 Population Below 15 Years of Age: 43% Population Between 15 & 64 Years of Age: 54.3% Population 65 Years and Over: 3.7% .Population in Rural Areas: 53% Population in Very Dispersed Rural. Areas: 35% Literacy Rate: 55%i. 4 Hospital Beds: 2.42/1,000 People - 4 Physicians (1975): 1/4,553 People 4 Physicians (Projected in 1985): 1/2,151 People- GNP Per Capita (Current Prices): $78z=- Health Expenditures Per Capita $23,507- (3.0% of GNP) Annual Inflation Rate: 6.0% (Consumer Prices) (Averages for 1973-1976) 10.5% (Investment Prices) Rate of Exchange: U.S. $1.00 - 0.43 dinars (curirent)- U.S. $1.00 - 0.42 dinars (1976)
1. Source: The FHC Report "A Program Proposal for Integrated Rural Health Services in Siliana and Sidi Bou Zid Provinces, Tunisia,".February 1, 1977. 2. Unless otherwise indicated, all data are from Ve Plan de Development Economique et Social, 1977-1981, Volume 1, Le's Projections Globales, Republique Tunisienne, August 1976. 3. 1976 estimated, Ministry of Public Health working documents. 4. The Family Health Care Report "A Review of Health Services Development in Tunisia," March 10, 1976. 5. U.S. Department of State. Development Assistance Plan 1975; citing a 1966 survey. 6. World Bank estimates. 7. Estimate in Chart III of Appendix A (The Family Health Care Report, 2z. stt.) revised to account for lower (than anticipated" then) MOH 1976 budget. 8. 1976 rate of exchange of 0.42 dinars is used in this report. - 2 -
Part I. PROJECT SUMMARY AND RECOMMENDATION A. Recommendation The Rural Community Health Project Paper requests the following authorizations: - Grant $1,000,000 - Loan (from Development Assistance under the following terms: 30 years, lO-year grace period 2% interest, and 3% thereafter) $3,000.000 Total New A.I.D. Obligations $4,000,000
B. Description of the Proect Project Synopsis. This project is designed to enhance the quality and coverage of health services in two rural provinces through: a) a restructured health manpower system for non-physician per sonnel b) the integration of preventive and curative primary health services (including family planning) c) an expansion in the outreach components of the primary care system d) expansion and improvement of the facilities and equipment for primary care If successful the project will contribute significantly to the setting of replicable national standards for the broader use of non-physician personnel and establish a field practice setting where medical students can be educated in the principles and practices of rural conmmunity medicine. - 3 -
A.I.D. will be funding as a grant a technical assistance team comprised of a physician, a non-physician practitioner and a health services administrator, a small amount of partici pant training, project support equipment and local costs for training and innovative field tests. A.I.D. will be flnancing a fixed amount'reimbursable loan to construct, renovate and equip a number of primary care facilities in the two concerned provinces. Working with Tunisian counterparts, the principal tasks of the technical assistance team will be: A. Restructuring the Role of Front Line Workers --- analyze existing functions and training of non-phlysician personnel in relation to total preventive and curative health care needs --- designing and organizing short training courses that will equip these paramedicals to undertake additional priority tasks --- assisting the newly trained field workers to carry out these broadened tasks in an operational setting B. Training the supervision of primary care workers and orienting community leaders. C. Organizing and implementing an expanded outreach program for preventive services. D. Upgrading the management of the health system and the mainten ance of patient records. E. Designing and managing a clinical and public health field training program for interns assigned to the two provinces. - 4 -
F. Designing and testing innovative approaches to health services delivery in the provinces. G. Designing a project evaluation covering both technical and capital assistance components of the project. The capital assistance portion of the project will finance the renovation and equipping of 19 and the construction and equipping of 21 primary care health centers in Siliana and Sidi Bou Zid. These facilities both expand and upgrade the field coverage of the rural health program. Their design is geared to their staffing and use by non-physician personnel as primary health care providers and to service the integrated curative and preventive functions to be carried out at the centers. This project is only in some aspects a new effort - as it builds on prior work with paramedicals by the Dutch, the Belgians and Project Hope working in collaboration with the Preventive Medicine Department of the MOH. What this project is attempting is to operationalize in a sizable field setting a restructured rural health system that will progressively train for and expand the respohsibilities of the non-physician staff, backed up by support facilities that give credibility and confidence to both providers and consumers. When this project is completed, the Ministry of Health should have a good start on implementing a rural program that is con siderably less physician dependent, and have the capacity to analyze, train and monitor the performance of non-physicians as they undertake wider responsibilities. The U.S. technical assis tance component will make it possible for the Tunisians to carry out these tasks more efficiently than would be the case without our help. On the capital side, the project will leave behind a pri mary care infrastructure that is appropriate to the setting, can be replicated elsewhere with Tunisian resources, and can be managed with a minimum physician input. A.I.D. will contribute approximately $ 1,000,000 as a grant to cover the technical assistance portion of this project and $3,000,000 to cover the capital components of the project. The GOT $1,390,850 will contribute/covering 25% of construction/renovation costs, acquisition of land,. and local operating costs.
C. Summary Findings The technical analysis (contained in Section II and in III A) concludes as follows: a) that the GOT is prepared to support a wider use of non physician personnel in primary care and to support training programs that will achieve that end, and will purposefully pursue the application of new skills by non-physicians in an operational setting. b) that the technical assistance strategy which involves the assignment of a small U.S. team to the concerned provinces to assist in carrying out the training and implementation goals is appropriate and supported by the GOT. c) that an expanded and upgraded network of health facilities are necessary to improving the quality and coverage of the rural health program, that these facilities are appropriate to the settings and can be constructed in Tunisia by local contractors. - 6
d) that A.I.D. should monitor the progress of the construction process, approve final building plans and cost estimates and reimburse the GOT an agreed amount not exceeding 75 of the con struction cost of each center when the centers become operational. On the basis of a review of the project by Susan Christie-Shaw, Rural Health Facilities Architect-Consultant to A.I.D., an initial environmental assessment was prepared that resulted in a negative determination. It is contained in Annex F. The economic and financial analysis highlight the limitations of the traditional cost benefit analysis techniques in relation to health projects, confirms the government's capability to sus tain a program of this cost and points up the cost savings that can result when non-physicians can be successfully used to replace doctors. The project meets all applicable statutory criteria. The statutory checklist is attached as Annex C. The A.I.D. Director has signed a 611 (e) determination indi cating that Tunisia has the capability to use and maintain this project. This certification is found at Annex D.
D. Project Issues At the time the PRP was reviewed and approved the following were identified as areas where more analysis was needed before PP completion: a) The development of "functional programs" for each type of health facility to be assisted. This involved a better defi nition of the range and volumes of services to be provided, - 7
the staffing requirements and the equipment requirements. b) a fuller agreement with the GOT on the scope and content of the retraining programs c) facilities designs that were compatible with the new functions to be carried out at primary health centers; reasonable estimates of construction costs. d) confirmation of the capacity of the government to repli cate the Siliana-Sidi Bou Zid system in other parts of the country. A follow on project design consultant team visited Tunisia in June. Their report (Annex I) provides satisfactory planning and productivity assumptions for each facility being con structed. Agreement has also been reached with the GOT on the scope and content of training programs to be carried out that will broaden the skills and responsibilities of non-physician personnel. A rural health facilities design consultant assisted the mission and the GOT in developing reasonable cost estimates for facilities construction and building designs that are suitable for the range and volume of services being provided. These consultant reports are appended as Annexes I and J and their findings are summarized in the body of this paper. The financial analysis and Section VI Operating Cost Im plications of the consultant Report, Annex I provide satisfac tory evidence that the additional costs of this program are within the capacity of the government to replicate. - 8 -
Part II. PROJECT BACKGROUND RATIONALE AND DETAILED DESCRIPTION A. Background and Rationale The Tunisian Health System Following independence When the Tunisians became independent a little more than twenty years ago, they inherited a health system that was in adequate for their needs. The bulk of the health facilities were urban in a country that was predominantly rural; they were entirely dependent upon foreign trained doctors as there was no capacity to train physicians in Tunisia; the rural people were reached only through the infrequent mass preventive campaigns and relied heavily on traditional practitioners for personal health services. The'system in place was geared to serve the foreign and Tunisian urban advantaged, and largely ignored the health needs of either the urban poor or predominantly rural majority. Over the past twenty years much has been done to redress this situation. A nationwide network of clinics and hospitals have been established providing some access to minimal basic curative services in all provinces, health services are provided to the bulk (and poorest segment) of the population at no cost. Training facilities for all categories of health workers have been established including three new medical schools to train Tunisian physicians. A preventive-health service has conducted active and largely successful campaigns against the major commun icable diseases. A national water supply organization has an active and growing program to provide safe water in small towns -9
and villages. A national pharmaceutical wholesaling and dis tribution system has proirided ready access to drugs at reason able prices in all parts of the co'atry. A national health insurance system has been established for industrial workers. Over the same period, malaria and typhus have been elim inated, infant mortality has dropped from more than 200 to a little more than 100 and general life expectancy'has increased by ten years to about 55. It is not surprising that the Tunisian initiatives in health since independence have been this numerous and significant. The responsibilities of the government to provide health services to the peopleare spelled out specifically in the constitution. This responsibility is also an important tenet of the socialist philoso phy and program of the Neo-Destourian political party which has led the country continuously since independence. Currently, about 8% of the government's operating budget is spent on Ministry of Health activities. This, coupled with private sector spending, amounts to an estimated $23.50 per capita expenditure on health; roughly 3% of the GNP.
The Rural Disadvantage As in most countries - both developing and developed - the rural areas have not fared as will as the cities in the distribu tion of health services.
-- the health system that has emerged since independence is largely an adaptation of the wstern mode. It is physician dependent, technology oriented and curative centered. - 10
-- priority has been given to the development of expensive specialized medical centers over less expensive and less professionally challenging primary care. -- resources - both people and money - have flowed to the more sophisticated elements in the health system. -- preventive and rural services have had little success in attracting even minimal Tunisian physician personnel and have been dependent since their inception upon foreign contract doctors. The net result of these difficulties is a very limited primary care system in the rural areas -- that is curative centered and crisis oriented; that is led by a clinic based foreign professional staff; that often has an inadequate command of French or Arabic; that treats vast numbers of patients in a hurried and impersonal setting in a society that values verbal communication; that depends only minimally and delegates few substantive functions to the bulk of the non-physician personnel. While the government system is heavily used, it is not particularly well-regarded, and those who have a choice - the better off or those with relatives in the city - often prefer to consult privately and/or bypass the provincial medical structure to consult at the major medical centers in Tunis, Sfax and Sousse. A WHO evaluation of the system conducted in 1974 judged that the quality of care and coverage of the rural system was dLstinctly less accessible and of lower quality than that available in the cities. - 11 -
Tunisian Efforts to resolve the-Physician Manpower and Distribution Problems
The Tunisian Government has been sensitive to the equity issues associated with the provision of health services in the rural areas but like most developing and developed coun tries has been less than successful in finding a solution. Because of the dependence of the system on physicians, the principal limiting constraint in expanding and upgrading services has been availability of doctors - both the total numbers and their distributions around the country. Four initiatives have been tried to solve the doctor problem. -- Shortly after independence the government nationalized all health care, essentially abolished private medical. practice and required all physicians to work full time for the government at assigned locations. This scheme quickly encountered severe implementation difficulties and was subsequently abandoned.
-- three (two new) medical schools have been established to vastly expand the number of physicians on the theory that market forces will force the new graduates to practice out side the large cities. These new physicians are to eventu ally replace the foreign contract physicians in the public sector health system. -- a period of obligatory service (1 year ) following comple tion of medical training at government assigned posts is to be required. - 12
-- medical students are being selected in a way that insures that a substantial percentage come from outside the large cities.
Few, if anyone, believe that these measures will provide
a long term solution to Tunisia's physician manpower supply and distribution problems. The professional and economic attraction of the medical specialties; the limited professional, economic and social opportunities for physicians in the rural areas; the absence of first-rate schoois for their children; the limited social life for their wives have worldwide drawn well qualified and well motivated physician families from rural service. Tunisia is an unlikely exception. The best that can be hoped for is that during the next five years a sufficient number of Tunisian physicians can be recruited to replace the foreigners now on contract. Many observers suggest that even this will not be accomplished without financial or administra tive inducements. What this means is that for the short term (5-10 years) it is unlikely that the substantial physician production underway will materially add to the numbers avail able in the rural areas.
Broader Use of Non-Physician Personnr"
Almost all informed observers - both Tunisian and foreign believe that a large measure of the short and long range .splu tion to Tunisia's primary care health services delivery prob lems lies in the broader use of non-physician personnel - both in preventive and curative roles. However, many of the same - 13 constraints that have limited their use in this country apply in Tunisia. Health systems managers are concerned about the quality of care non-physicians can in fact provide; the perceived acceptability by consumers of services delivered by non-physicians; the adequacy of their supervision, their potential as economic competitors to the MD's for the private sector health expenditure, their capacity to absorb additional training, their sense of responsibility in dealing with patients and the existing legal constraints to their broader use. International experience - including the U.S. - suggests these concerns are not well founded. Well trained non-MDs treat 90-95 of primary care cases, they are well accepted by consumers, they are highly responsible in their dealings with patients, they have the capacity to absorb and apply additional skill training. Moreover, the non-physician usually considers it an opportunity to serve in the locations that are unattrac tive to physicians. Furthermore, the highest paid non-physician in the system (with a potential primary care productivity capacity that is 90% of the physicians) usually draws only one third the wages of the doctors. The Tunisian medical leadership is aware and in large measure intellectually accepts all of the arguments that support a broader use. They understand that non-physician medicine doesn't have to be second class (and in primary care may well be superior to that which a physician can provide). They have seen the wide range of functions non-physicians can and do per form in the U.S. and other countries. Nevertheless they are - 14
understandably cautious about any widespread application of foreign experience in such a sensitive area to*Tunisia, citing the general higher levels of education abroad and the favorable management and supervisory setting as factors that are making an important contribution to this success elsewhere. What A.I.D. hopes to accomplish with this project is to help establish the.credibility of a primary care system where physicians provide essential technical backup and supervision to well qualified paramedicals rather than serve as the central focus of the system.
The Project Purpose We will be collaborating with the Tunisians in improving the quality and coverage of the primary care health system in an operational setting and in a defined area. Specifically, we will be working on: -- a broadened use of non-physician personnel in both preventive and curative services and family planning services delivery; -- the improved management of the health system and supervision of the personnel;
-- organizing and expanding preventive out-reach services
-- organizing and managing an effective clinical and public health training program for interns assigned to the two provinces; -- integrating curative and preventive services; -- upgrading and adding to the primary care facilities to a degree that reasonable coverage can be provided to 80% of the population and at a standard that can reasonably be replicated - 15 by the GOT; -- aes2gnlng and testing innovative approaches to health services delivery in the two concerned provinces. ThLs is only in some respects a new project initiative since it builds on work carried out by the Dutch, the Belgians and by Project Hope with the Preventive Medicine Department of the MOPH. What this project is attempting to do that is new is operationalize in a sizable field setting an upgraded primary care program that -- progressively trains and expands the role of nor-physi cians in both curative and preventive health care (past work has been with preventive services only) -- addresses opcrational problems associated with the application of new skills. -- provides support for facilities that will make the new workers roles more credible. The technical assistance and capital inputs for this project are planned over an initial three year period. No significant additional capital inputs are contemplated to augment facilities in this geographic area. It is unlikely that the technical assistance tasks will be completed in three years. However, this time span will be a suitable point to evaluate the degree to which this project has achieved its objectives; the utility of U.S. technical assistance and the desires and opportunities on both sides for further collaboration. Over the past year, A.I.D. teams have examined the national health system and in particular the two GOT designated project sites in Sidi Bou Zid and Siliana provinces. - 16 -
The Project Sites - Sidi BouZid and Siliana Provinces Siliana and Sidi Bou Zid are adjacent provinces in central western Tunisia. They each have one modest sized town and several large villages. The major town and the larger villages are on paved roads which for all practical purposes remain open year round. The balance of the popu lation (over 80%) live on dirt roads, tracks, paths and in household units ranging from 10 to 18 people. These houlshold units (two to three buildings each) are widely dispensed around the countryside and their location is depen dent upon proximity and convenience to traditional fields. This pattern of settlement makes it very difficult for government to provide services to the people. Each has a population of roughly 200,000 persons. The principal occupation in both provinces is agriculture but patterns in Siliana and Sidi Bou Zid are different. The predominant pattern in Siliana is small holder cultivation. There are some larger holdings in Sidi Bou Zid; principally orchards that require large amounts of seasonal labor. Both Siliana and Sidi Bou Zid were formed recently (1973:1974) by partitioning larger areas, in part to allow the government to focus development assistance on what they felt was consid erable unmet need. By almost any standard these two provinces could be considered highly disadvantaged. The Tunisia govern ment census cites Sidi Bou Zid as the province with the highest percentage of their population isolated (85%); Siliana is third (60.4%). Sidi Bou Zid has the lowest percentage of school age - 17
children in school (36%); Siliana is fourth lowest with close to half (47%). Sidi Bou Zid has the second lowest literacy rate in the country 31%; Siliana is fifth with 35%. Siliana and Sidi Bou Zid have the two highest fertility rates in the country and it is suspected that under-reporting masks an even higher birth rate. Only 5 percent of the people in both provinces have electricity; 2 to 9 percent of the people have access to running water.
The Existing Health Services Network A detailed analysis of the existing health services network and what we know of its productivity in Silianr.and Sidi Bou Zid provinces is contained in Family Health Care Report, Feb. 1, 1977, pages 17-49. In summary, from the rural areas to the center health services are presently structured as fn11nwa. Household level workers Aid Stations Dispensaries MCH (pM) Centers Circumscription Hospitals Rural Provincial Hospitals Household Level Workers
There are two types of household level health workers; governmental and non-governmental. The governmental include itinerant malaria control workers; special vaccination cam paign workers; family planning mobile teams; and social/health workers. The principal non-government workers are the tradi tional midwives (matrons) who are implicitly sanctioned by the - 18
government but not included in the government system and the traditional healers who are strongly discouraged by the government, are said to be declining in numbers and in fact operate illegally. There are approximately 177 govermental workers engaged in these functions in Siliana and Sidi Bou Zid.
Aid Stations These are free standing facilities staffed by one per son who changes dressings and dispenses medicines on the pre scription of a physician. The itinerant government physicians rarely visit these facilities. There are 11 Aid Stations in Siliana and none in Sidi Bou Zid.
Dispensary. The dispensary is the first line facility that is visited by the itinerant physician. Each usually has one full time resident worker. It is at this facility that the bulk of the out-patient visits take place. They are usually located in exis ting villages or new regroupments. Typically, a dispensary is very busy when the doctor visits one or two times per week seeing 20 50 patients per session. The balance of the week dispensary activity is very slow or non-existant. Patients sometimes walk one to two hours to seek medical care but most travel no more that 4 - 6 kilometers. There are 20 dispensaries in Siliana and 35 dispensaries in Sidi Bou Zid. - 19 -
MC (PMI) Canters There are two types of MCH centers; those with and without beds. Those with beds (5-10) have a delivery room. The MCH centers are generally well equipped and well staffed by 2-3 nurse midwives. The centers dispense pills, condoms, family planning information and insert IUDs. They provide rather com plete pre-natal and post-natal care, immunizations and care of common gynological problems. Because of the limited clientele they serve and their dependence on the physician for diagnosis, these facilities are usually underutilized except during the brief periods when a physician is in attendance. There are 3 PMI centers in Siliana and 5 in Sidi Bou Zid.
Circonscription "Hospitals"
There are 3 circonscription "hospitals" in Siliana and 1 i Sidi Bou Zid. They are located in delegation centers and are the focal point from which the physician serves the MCH centers and dispensaries. Observers that have visited these facilities suggest they would be better described as custodial care facili ties or "dormitories with medicines" since they lack almost all the staff assiciated with modern medicine. They lack X-ray capacity, laboratory, surgical capacity and means of sterilization (other than for syringes and needles). They are usually underutilized occupancy rates of 10 20% are not uncommon. The pharmacy is the best equipped part of the hospital. In addition to serving the hospital, it serves as the pharmaceutical supply center for the dispensaries, some PMIs and aid stations. - 20 -
Rural "Provincial" Hospitals In addition to the above, there are two rural provincial hospitals. There are in fact small circonscription hospital facilities (30 and 49 beds) that were redesignated "provincial" at the time the provinces were created.. Some additional investments in X-ray and laboratory equipment have recently been made since designation as provincial facilities. Siliana has no surgery; Sidi Bou Zid has a small surgery unit but no facilities for ster. ilization of equipment. Neither facility has a surgeon. The availability of larger physician staff in Sidi Bou Zid has re sulted in a more productive use of this facility. There are hopes of constructing a provincial hospital in each center. However, as funding for this is not included in the plan it is very likely that these facilities will serve as the provincial referral centers for at least five more years.
New Tunisian Initiatives onthe Integration of Prima e In an effort to improve the efficiency and access for the people to health services, the MOPH has adopted and begun to implement a policy that will integrate all primary health ser vices into one delivery system. This means that single purpose staff and categorical facilities will ultimately disappear, and that the artificial line between curative and preventive services will be removed. The first implementation of this plan will take place in Siliana and Sidi Bou Zid provinces. This decision has provided the GOT with four important challenges: -- to develop program assumptions that are the basis for the - 21
range and quantity of services that will be demanded and supplied; to adapt through retraining and through the acquisition of additional staff the capacity to deliver the expanded range of services; to design facilities compatible with the new program design; to.assure the resources exist to sustain the planned levels of services. The integration of ,aerviceshas also provided A.I.D. with a hospitable setting for this project. The curative and preventive services that are to be inte grated are: 1. Adult routine basic clinical care for minor illness,. chronic illness, minor trauma and emergency fir.st-sid, stabilization of major tratkma; 2. Pre-natal, labor and delivery, post-natal care, gynecology; 3. Pediatric routine basic clinical care as indicated in item I above; 4. Family planning; 5. Nutrition and hygiene education; 6. Immunizations/vaccinations; 7. Environmental education; 8. Malaria screening; 9. Water supply testing; 10. Inspection of publLc and commercial places, and 11. Dog control. - 22 -
In connection with designing this project, A.I.D. consultants have participated in the development of planning assumptions, retraining needs and facilities design. Their detailed observations on this process are contained in their consultant reports. 1
Under the integration of services policy, salles de soin, MCH centers, maternity centers and the smaller circonscription hospitals will be redesignated as "Basic Health Centers" Type A, B, or C and all new facilities constructed and put into operation in the delegations and below will follow the new program prin ciples.
In sumnllary the program principles provisionally agreed to are as follows.
Outreach Health Services in the Community
1. Community Services
The outreach services described below will be provided by workers in Types A, B, and C centers as appropriate. "Community":
Home Environmental education including burn and poissoning pre vention; waste disposal and protection/purification of drinking water; nutrition and family planning education;
1 Design Study II; Family Health Care, July 28, 1977 Tunisia: Siliana & Sidi Bou Zid Provinces - integrated Health Services - 23
identification and treatment of conjtuctivities and ringworm; maternal education re: dietary regimens appro priate for the home management of mild diarrhea;,provision of family planning supplies (condoms and pills); immuniza tions (not routinely); identification, education and referral of pregnant women, particularly high risk mothers; malaria screening as needed; management and monitoring of chronic con ditions as tuberculosis, arthritis/rheumatism, diabetes.
Commercial and Public Areas (1) * Sampling for analysis drinking water supplies -- piped and well * Treatment of wells by the method of the jar * Field testing for residual chlorine Inspection and control of slaughtering points Inspection and control of retail establishments, particularly re: stores selling perishable foods, and hotels * Advising on the protection and improvement of existing water sources * Advising on the transport and storage of water from the source to the point of consumption
"Schools Nutrition education; case finding of pregnant women through the children in school; environmental education akin to that offered in the home; identification and treatment or referral of condi (1) AJll J.Isted services are provided Services by a technician sanitaire. indicated by an asterisk may also centres de sante be provided by de base workers on an out reach basis. - 24
tions common-in schoolchildren; immnmizations;.management of chronic conditions such as tuberculosis and diabetes."
2. Type C.Centers The Type C center provides integrated (curative and preventive) ambulatory services and is intended to serve a population of from 2,000 to 5,000 people. Minimum staff con sists of one frcnt-line worker. "The type C center is proposed in two sizes. A smaller size is fully suitable for intermittant physician visits but planned to initially operate without physician services or midwife services. This first level of facility is staffed by an entry level integrated preventive and curative worker (e.g., recyclea malaria worker or aide soignant recycled or aide sanitaire recycled). The only differences between small and large Type C centers are physical size, population srrved and the presence of itinerant physician services." Siting criteria for the Type C centers are as follows: 1. In an existing or proposed regroupment; 2. In a village or other agglomeration; 3. In an area which is reasonably approximate to an existing or planned primary school; 4. In places where year-round water supply can be assured through some mix of wells, rain water collection, and haulage by tanker in the dry season; 5. Within the catchment area of a Type A or B center and thus accessible by road or track most of the year for purposes of supervision and resupply; and - 25
6. In areas serving a population of 2,500. Services provided from the Type C center include: 1. School health 2. Home health 3. Commercial and public area 4. Provision of routine and continuing care as prescribed by a physician--distribution of oral medications, injections and dressings 5. Definitive treatment of minor trauma 6. Stabilization and referral of major trauma (trauma should be read to include burns) 7. Identification and initial treatment of common skin disorders and minor illnesses 8. Identification, temporizing treatment, consultation or referral as appropriate, of serious illnesse.s.(acute pulmonary infection with high fever, fever and stiff neck, moderate and severe diarrhea) 9. Provision of selected pre-natal services (list to be expanded in the case of female provider). Services suggested do not require physical contact/exam of the pregnant woman beyond cursory overall visual inspection and palpation of the ankles for edema, risk assessment by history, determination of hemo globin, provision of prophylactic oral iron, nutrition education. 10. Provision of family planning information and supplies (pills and condoms) with referral IUDs, sterilizations and social abortions. 11. Laboratory services are limited to hemoglobin determination.*" - 26
* Hemoglobins will be done at the Regional Hospital laboratory using the bench type of spectrophotometer--also used for several other procedures. Hemoglobins in the centre de sante de base will be done by a method such as the method of Lovibond (described in Maurice King's A Medical Laboratory for Developing Countries) (Bibliography #19) - 27
3. Type B Center
The type B center is intended for larger regroupments and areas where population density warrants, and is generally lo cated on all-weather roads. The center is fundamentally an ex pansilon of the Type C center described above (an integrated ambulatory care facility) supplemented by up to 10 maternity beds and a very minimum laboratory capacity. Minimum staff includes one midwife and one integrated front line worker and the center is to be visited by a physician at least one-half day per week. The population served is between 5,000 and 10,000 people. "Basic Health Center (Centre de sante de base):
Includes all Type C services and, in addition, a full range of pre-natal, normal delivery, post-natal, and family planning services that fall within the capacity of the sage-femme. Laboratory services limited to non microscopic urinalysis of protein and sugar and determin ation of hemoglobin by method as in Type C centers. In cludes 5 to 10 maternity beds."
4. Type A Center The Type A center is situated in a delegation seat and serves a population of 10,000 or more. This center provides basic integrated preventive and curative services and some referral services--maternity services and in-patient infirmary type services in the areas of pediatrics and mekticine. Such a center is staffed by at least one physician and one midwife and - 28 -'
provides basic laboratory services, v-xcluding bacteriology. The bed compliment will not exdeed 15, of which up to 10 beds are for maternity, 5 for pediatrics and adult medicine, and 5 to be used as "swing" beds for maternity, pediatric, or adult services as needed. "Basic Health Center (Centre de sante de base):
Type A All Type B services plus 5 to 10 general medical/pedia tric beds for the definitive treatmtnt of non-surgical, acute illnesses requiring short-term in-patient care; casting of simple fractures; minor surgery that can be accomplished on an out-patient basis under local anaes thesia. Lab services include complete urinalysis including microscopic, white blood count and differential, blood urea and nitrogen, blood glucose, hematocrit, hemoglobin, erthrocyte sedimentation rate, collection of sputum specimens for acid fast staining and culture. It is recommended that space be provided now for later expansion of laboratory functions and eventual installation of radiography or radioscopy." 5. Equipment, Service Capacity, and Staffing Patterns 1. The equLipment lists for Types A, B, and C centers respec tively are shown in Appendix I. Initial (minimal) and future (more desirable) staffing patterns for each type of center follow in Table 2. 2. The projected annual ambulatory capacity of retrained front-line workers, midwives, and physicians is shown in Table 3. - 29
3. Table 4 shows the projected annual visit capacity of centres de sante de base Types A, B, and C, as well as the derivation of the projected capacity. 4. The location of existing facilties, proposed new con struction and renovation, and the final system by type of facility and capacity are summarized in Tables 5 and 6. (see also Maps - Annex G) 5. The projected initial ambulatory capacity of the restruc tured delivery system is shown in Table 7. 6. The geographia-distribution of centers and their esti mated relation to population is shown in Appendix 2.of the consultant report, Annex I. - 30 -
TABLE 2
STAFFING PATTERN
TYPE A CENTER INITIAL Physician FUTURE (on-site and also doing Type B 2-3 and C visits) Midwife (on-site and also doing Type C I2-3 visits) Front-Line Workers 4 6-8 Clerk I I Lab Technician- 1/2 1 X-Ray Technician' 1/2 Pharmacy 1 I I Custodian I I Cook I 1 Cook Helper - Econome I - I Driver L 2
12 20-24
1. One technician could be trained to do both functions. - 31 -
TABLE 2 (Continued)
STAFFING PATTERN
TYPE 6 CENTER INITIAL FUTURE
Front-Line. Worker 1 1-2 L Physician 2 blocks/week 2-4 blocks/week
Midw!fel 3 blocks/week 5 blocks/week
Midwife Assistant I
Maintenance/C leaning I
Cook I/Z 1/Z
TYPE C1 CENTER (Large)
Front-Line Worker 1 1-2
Physician I block/week 1-3 blocks/week
Midwife I block/week 2-3 blocks/week
TYPE C2 CENTER (Small)
Front Line Worker 1 1-2
Physician - 1-2 blocks/week Midwife - 1-2 blocks/week
I. See planning assumptions concerning the definition of "blocks" on page 24 and Table 3 following. Essentially, one block is equivalent to a facility visit (1/2 day for physicians and I day for midwives). - 32 -
TABLE 3 HEALTH WORKER PRODUCTIVITY PROJECTIONS
Front-Line Worker
25 visits/day-I x 5 days2 x 48 weeks - 6,000 visits/year
Midwife
30 visits/4-hour block x 6 blocks/week x 48 weeks 8,640 visits/year
Physician
! 60 visits /4-hour block x 6 blocks/week x 48 weeks - 17,280 visits/year
I. Includes visits conducted in a centre de sante de base and in the community. 2. Four full days, plus two 1/2 days. 3. Substantially higher than the United States visit rate, but substantially lower than many current visit rates, which may approach 40 visits/hour. (NOTE: It is Important that physician time is available in clinic settings for supervision of front-line workers.) - 33 -
TABLE 4 PROJECTED INITIAL AMBULATORY VISIT CAPACITY OF CENTRES DE SANTE DE BASE TYPES A, B, AND C
TYPE A
4 front-line workers x 52 weeks-Lx 125 visits/week - 26,000 visits/year 3 physician blocks/week x 52 weeks-x 60 visits/block - 9,360 visits/year 3 midwife blocks/week x 52 weeks-l x 30 visits/block - 4680 visits/year 40,040 visits/year
TYPE B I front-line worker x 52 weeks-Lx 125 visits/week - 6,500 visits/year I physician 1 block/week x 52 weeks--x 60 visits/block - 3,120 visits/year 2 midwife blocks/week x 52 weeks-L x 30 visits/block - 3,120 visits/year 12,740 visits/year
TYPE C I front-line worker x 52 weeks-x 125 visits/week U 6,500 visits/year I physician block/week x.52 weeks-x 60 visits/block - 3,120 visits/year I midwife block/week x 52 weeks-Lx 30 visits/'lock 1 560 visits/year 11,180 visits/year
1. Assuming coverage arrangements (and overtime) allow year-round (52 week) staffing and operation. - 34 -
TABLE 5
SUMMARY OF EXISTING, PROPOSED, AND FINAL SERVICE NETWORK. SI LIANA
EXISTING Sa lie Delegation de Soins Dispensary Maternity PMI Hospital El Krib 4 Gafour 1 5 1 1 Bou Arada 2 1 1 1 1 Siliana 5. 1 Robaa 2 Maktar 5 2 Rohia 3 1 Tr 20 -T -3 PROPOSED NEW / RENOVATED NEW / RENOVATED
Delegation Type C Type B Type A El Krib 1/1 1/ Gafour /1 Bou Arada /2 Stliana /] 1 / I /I Robaa Maktar /I 1 Rohia /1 3/1 /
UNALTERED EXISTING 1 TYPE C CENTERS- AFTER COMPLETION OF THE PROJECT, BY DELEGATION El Krib 2 Gafour 4 Bou Arada 2 Siliana 3 Robaa I Maktar 3 Rohia 1 Total 17 FINAL NETWORK Delegation Type C Type B Type A El Krib 4 1 Gafour 4 1 Bou Arada 4 Siliana 1 5 1 Robaa I Maktar. 5 Rohla 5
I. Currently referred to as either dispensaries or salles de soins. - 35 - TABLE 6 SUMMARY OF EXISTING, PROPOSED, AND FINAL SERVICE NETWORK SIDI BOU ZID
EXISTING SalIIe Delegation Other- de Soins .Dispensary Maternity PHI Hospital Jelma a Sidi lou Zid 2 5 1 1 1 Ouled Haffouz 3 Er-Regueb 4 1 Si. Al Ben Aoun 6 Maknassy 2 4 1 ! 1 Mezzouna 5 20 35 _2 5 -2 PROPOSED NEW / RENOVATED NEW / RENOVATED Delegation Jelma Type B -7 -1 17 Sidi Bou Zid 2/i Ouled / Haffouz 1I I//l Er-Regueb 2 ll Si. All Ben Aoun 2 / 1 Maknassy 2/2 Mezzouna 1l l3 - l
UNALTERED EXISTING TYPE C CENTERS-AFTER COMPLETION OF THE PROJECT, BY DELEGATION Jelma 6 Sidi Bou Zid 3 Ouled Haffouz I Er-Regueb 2 Si. Ali Ben Aoun 3 Maknassy 0 Mezzouna I Total .17 FINAL NETWORK Delegation Type C TypeB Jelma Type A 7 1 Sidi Bou Zid 6 1 Ouled Haffouz 3 Er-Regueb 1 4 1 Si. Ali Ben Aoun 5 ! Maknassy 4 1 Mezzouna 4 I
I. Sidi Bou Zid Regional Hospital includes a free-standing tuberculosis clinic and a separate family planning 2. Currently center. referred to as either dispensaries or salles de sons. - 36 -
TABLE 7 AMBULATORY CAPACITY SUMMARY AFTER PROJECT COMPLETION
SILIANA Type A- Type B Type C1 6 x 40,040 visits/year + I x 12,740 visits/year + 28 x 11,180 visits/year equals 240,240 + 12,740 + 313,040 equals 566,020 vlsits/province/year 566,020 visits 5 2.73"visits/person/year3 - 207,558 persons2 or, if only 80% of the population is served, 2.73/.8 - 3.41 visits/person/year
SIDI BOU ZID Type 1 1 A Type B Type C 7 x 40,040 visits/year + I x 12,740 visits/year + 33 x 11,180 visits/year equals 280,280 + 12,740 + 368,94o equals 661,960 visits/province/year
661,960 visits t 248,326248,26persons-ersos 4 2.67 visits/person/year3
or, if only 80% of the population is served, 2.67/.8 - 3.34 visits/person/year
1. See Table 4 for derivation of projected initial visit capacity. 2. Based on 1975 population of 192,668 with a net growth rate of 1.5% per year for five years. 3. Please refer to current estimated capacity of 1.39 and 1.38 visits per person per year on page 1.4 of the FHC February report. 4. Based on 1975 population of 230,511 with a net growth rate (corrected for out-migration) of 1.5% per year ,or five years.. - 37 -
B. Detailed Project Description The A.I.D. Project
As indicated earlier in this paper the proposed A.I.D. project will improve the quality and coverage of health ser vices in two predominantly rural provinces of Tunisia (Siliana and Sidi Bou Zid) through technical assistance aimed at re structuring the health manpower system and the integrated rural health delivery system and through capital assistance to upgrade the facilities and equipment used by the health system in those facilities.
The project is expected to be carried out over a three-year period starting in FY 1978 and will require a $ 1,000,000 grant for technical assistance and a $ 3,000,000 loan for capital assistance, which will be supplemented by an estimated $ 1,390,850 contribution from the Tunisian Government. The bulk of the grant funds for technical assistance will provide for nine person-years of resident technical advisors, one person-year of short-term consultants, and short-term training in the United States for five Tunisians. 'he technical assistance package is designed as five distinct but complementary components. They are: Technical Assistance (Grant Funded) 1. Job restructuring and the retraining of frontline health workers. 2. The detailed conceptualization and design of both the system management and the patient record system to support newly integrated preventive and curative services for rural areas. - 38
3. The training and orientation of rural delivery system supervisors and managers, as well as the orientation of co-munity leaders. 4. Support for improved clinical experience in medicine and public health for interns assigned to Siliana and Sidi Bou Zid.
5. Design and i"rlementation of a program of research and evaluation c~mponent covering the technical and capital assistance areas mentioned in this summary. Capital Assistance (LoanFunded) The capital assistance activities include: The design, renovation, construction and equipping of 40 health facilities which will provide integrated primary health services at the delegation, regrcupment and village level. An estimated $617,000 is needed for the renovation and equipping of the existing facilities: 8 Type A, 1 Type B and 10 Type C centers in the two provinces. The remaining money will be applied for financing the construction of new health facilities: 6 Type A, 1 Type B, and 15 Type C centers. Although firm cost estimates have been established, planning for these facilities has been complicated by rapidly increasing construction costs within Tunisia. Design specifications have been developed to accomodate the functions of the centers with expert outside assistance.
2. Logical Framework Narrative
The project forsees as its goal improving the quality and coverage to primary care health services in Siliana and Sidi Bou Zid provinces. - 39 -
Indicators of impact on the goal will be increased productive capacity of the health centers and changes in morbidity/mortality patterns. Both of the above can be verified by program operations statistics. The adaptation of a problem oriented medical records system will facilitate detection of changesorbidity and mortality. The prime assumption is the maintenance by the GOT of its present high level of interest in rural health. The project purpose is to restructure the non-physician health manpower component of the primary care system, train them for broader functions and operationalize the new system in an expanded network of new and renovated facilities. At the pro ject' .completion (EOPS) -- a curriculum of retraining will be designed for each category of workers -- all categories of non-physician personnel will have completed some retraining
-- retrained workers will be carrying out their new roles on the-job -- a network of new and renovated facilities will be commpleted and equipped
-- a model field training experience for preventive medicine in terns will be established.
These conditions can be verified by project records, obser vation of non-physician practitioners in action, observation of facilities, an- examination of the field training program for in terns. - 40 -
The following are the citeria assumptions upon which these accomplishments depend -- the continued sustained interest by the MOPH in.broadening the functions of non-physician personnel. -- the availability of adequate GOT support of an expanding rural health program (people to train; funding to support them) -- the availability of qualified U.S. technical assistance team resident in the two provinces. -- the acceptability of expanded services delivered by non physicians to consumers. The planned outputs of this project are: a curriculum for training non-physician health workers in new duties -- 250 retrained workers, supervisors, and local officials -- renovation and construction of 40 new primary care facilities -- an operating field training program in rural health for interns
-- an improved patient record and management system. These outputs depend upon the availability of the U.S. technical assistance team, adequate numbers of workers enrolled in training courses, timely awarding of construction contracts by the GOT, and prompt contractors execution by Tunisian contractors. The U.S. inputs to the project will provide $2,675,000 as reimbursement to the GOT for construction and renovation costs, $ 325,000 for equipment and $ 1,000,000 for technical assistance. This will consist of a three person TA team and some participant training. - 41 -
The GOT will share in the project costs by at least 25% - through a direct cash and in-kind contribution to the construc tion costs and then budget to ongoing and expanded rural health opera,-ions in the two concerned provinces. The Logical Framework Matrix is at Annex A. - 42 -
Part III. PROJECT ANALYSIS A. Technical Analysis Technical Assistance Program 1. Job restructuring and retraining of front line workers The restructuring of tasks, the training in new skills and the application of new skills in an operational setting will be the most important technical assistance assignment that will be undertaken as a part of the project. The gen eral strategy that will be used is to assess in the field the capacities of existing front line workers, compare these capacities with the needs of the population for primary services, train workers to fill some of these gaps, and pro vide supervision and support in the application of the new skills until they become fully operationalized.
There has been considerable discussion between the MOPH and A.I.D. on the scope and content of the retraining program and we have reached agreement on a program that would upgrade the skills and broaden the functions of the front line workers. There are five general categories that will be considered for retraining and continuing education. 1. Non-physician, predominantly clinical personnel now staffing aide stations and dispensaries (e.g., aide soignants and aide sanitaires) 2. preventive health workers (service d'hygiene) 3. midwives and midwife assistants 4. environmental health technicians 5. supervisors at the delegation and provincial level (e.g., physicians) - 43 -
Table 8 indicates the activities that workers in cate gories 1, 2 and 3 presently perform (It does not indicate what they have been taught during their pre-bervice training programs but are not generally used). The table also illustrates the goals of the retraining program for workers in categories 1, 2, 3 and 4. These have been agreed to by the MOPH and repre sent attainable objectives during the life of this project. The training program will be field based that is the training will be carried out by MOPH personnel with the assistance of the A.I.D. TA team. Where possible regional MOPH personnel should serve as the instructors both in the classroo-.. and the field-practice (clinic and community) settings. Instruction will take place in 3 stages: 1. periodic short courses focussed around a particular new skill or augmentation/refresher training of old skills 2. reinforcement and continuing education through supervision on the job.
3. Periodic updating (12 months later) after basic retraining is completed. It is expected that classes will include 5 to 15 workers. It is important that during the early stages of the project all supervisory personnel, including MDs, participate in a struc tured training experience. The supervisors should be exposed to the goals of the overall project, the new roles that retrained workers will be expected to play, their own modified duties and responsibilities and their vital role of supervision if the potential of the front line workers is to be realized. - 44 -
TABLE 8.
CURRENT AND PROPOSED SKILLS: INTEGRATED FRONT-LINE HEALTH WRKERS I CURRENT SKILLS PROPOSED SKILLS SKILLS WORKI R C;AT--GORY "ORKE CATEGORY 1- 2 3 162 3 4 Family Planning: Pills - x Condoms + +- IUDs - + + Social Abortions x + - + Nutrition Education: Adults Children x + + + Pregnant Women, Mothers x + + x Use and + + Distribution of SAHA and/or Instruction in the Preparation and Use of Other Weaning Foods + + Immnunizat ions: Routine (e.g., DPT) x (x)* x + + + Episodic (e.g., Rabies) x x + + Prenatal Care: Casefinding Initial Risk Assessment + + Education x + + x + + Management (Minimum 3 Prenatal Visits) - Interview &Observe ______X ______+ + + - Lab + + Physicai Exam x + Labor and Delivery: x + Postnatal/Child: Acute Post-Birth Care (Airway, Etc.) x + Post-Birth.Preventive Treatment & Exam (Eyes and Hips) W.- (x) + Postnatal/Mother: Family Planning - Advice/Education -Supplies x + +
x + + - IUD Insertion - x - + Child Care Education - Breast feeding x + + - Hygiene and Cleanliness x + - Treatment of Mild Diarrhea + x + + Clinical Care: Diagnosis and Emergency Treatment/Rererral of Diarrhea - Mild x - (x) - Moderate + + + + - Severe + + () Indicates that some workers do these procedures, some do not. TABLE g (Continued) - 45 -
CURRINT SKILLS PP KLl C 1 WORKER CATEGORY WORKER CATEORY SKILLS r 7 2 3 192 3 Clinical Care (Continued): Common Skin Disorders (x) (x) + + Conjunctivitis Wx + Otitis Media + + Sympton Recognition & Emergency Treatment - High Fever with Chest Findings x) + +
- High Fever with Stiff Neck -x) + + - High Fever with Diarrhea ) + - Anemia Identification & Prophylaxis + + Treatment of Visible Stool Parasites + +. Trauma - Minor (Abrasions, lacerations and burns--first and some second) x + + Trauma - Major (Maintain airway; stabilize fractures; transport of patient; identi fication, temporizing treatment and referral of some second and all third degree burns) + + Common Gynegologic Disorders x + Poisoning - Identification and Referral + + - Lavage +? +7 Identification of High Risk Infants and Children: x + + + Treatment Through Education of Family x + + + Treatment Through Food Supplement + + + Referral + Environmental Education: Water, Poisoning, Burns +. + + Malaria Screening: Active x + + Passive W x + + Water Supply: Wells: Physical assessment, testing & recom mending improvements (x) + + Home: 'Transport, storage & purification ) + + Piped: Testing Wx) + + Inspection of Establishments: Restaurants + + Slaughtering Points + Butcher Shops + Hotels + + Factories & the Work Place: "+7 Dog Control: Owner Education- + + Eradication + Invnunizat ionsJ +
* () indicates that some workers do these procedures, some do not. - 46 - TABLE '8 (Continued)
CURRENT SKILLS PROPOSED SKILLS. -WORKER CATEGORY WORKER-CATEGORY S 2 3 112 3 1 4 Miscellaneous Skills: Drawing Blood I - Finger Stick *(x) x (x) + + + - Venapuncture (x) (x) + + Specimen Collection: Acid Fast Material Wx) Intravenous - + - Infusions + Clysis + + Collecting Stools for Culture or Micro scopic Exam (x)
() indicates that some workers do these procedures, some do not. NOTES: I. Administrative skills (e.g., recordkeeping, clinic management and equipment maintenance) need to be, as appropriate, included in the skill goals list and formally addressed in the training programs. 2. The proposed skills for workers in Categories I and 2 assume that these workers will remain predominantly male. Therefore, common gynecologic dis orders are excluded from the proposed skill list for such workers. Should, as would be desirable, women become available for this role, then some revision, in the skill list would be appropriate. - 47 -
Workers in categories (1)and (2)will undertake a short term training process that will enhance, refresh, or add skills sufficient to allow them to serve as the core staff for the basic health center, Types A, B, and C. Workers in category (3)will expand their skills to include the identification and treatment of common childhood illnesses as well as non-obstetric/ gynecologic illnesses commonly occurring in women of child bearing age. Workers in category (4)will develop an increased capacity and depth of knowledge through the practical field application of their current skills in community and environmental sanitation. They will also be provided with limited orientation to the con cept.of integrated curative and preventive services and super visorial skills relevant to their rote vis-a-vis personnel in categories (1), (2), and (3). Supervisors in category (5)will be appraised of the role and change of responsibilities of the front-line workers, as well as the rationale for integrating curative and preventive services. They will be assisted in the development of effective supervisorial techniques which actively foster the successful implementation and maintenance of integrated preventive and curative services. At the present time, approximately 100 workers in Siliana and 75 workers in Sidi Bou Zid fall into categories (1), (2), and (3)and would be candidates for retraining. The skill goals shown in Table 8 represent an initial service needs assessment of the population. This will be updated as the GOT/US technical team gains experience. - 48 -
With the expanded functions of the front-line worker and the integration of preventive and curative services, the single provincial surveillant general who is now largely responsible for the supervision of dispensary workers will be heavily most burdened. During the earliest phase of the project, realistic a assessment should be made of how much one surveillant general can do. An assessment should also be made of what strators admini assigned to small hospitals (e.g., Maktar) and ultimately to all Type A facilities, can do in the way of direct field supervision. Optimal use of these supervisors, as well as physicians of trained to support and guide the front-line workers in the utilization of their new skills, will be essential if the training investment is to result in a permanently improved service delivery capacity.. Short term training will take place largely in the cities Siliana of and Sidi Bou Zid. On occasion, other sites within the two provinces may be used for relevant demonstration and field experiences. However, no significant amount of training will be planned for sites outside of the two provinces. The end result of this training process will be the functional integration of preventive and curative services, including family planning. The benefits should be immediate in that more workers will be delivering more needed services, and services will be of higher quality. 2. Management Systems and Patient Records The integrated rural health delivery system requires management a system that allows resources applied (money and - 49
people) to be related to the services provided to a defined population. This capability, when linked to an ongoing assess ment of morbidity patterns as partially revealed by a review of medical records, allows an aesessment of the relevance of outputs from the rural health service programs to the needs of the'pop ulation. Though changes in patterns of morbidity can, at most, be attributed only in part to any health program, changed mor bidity patterns do require a changed delivery capacity, and they can euggest the changes needed in the content of training programs. This will be particularly true in areas such as Siliana and Sidi Bou Zid where escalation in the rate of economic and social development can reasonably be projected. In the face of such development rates, particularly when coupled with improved pre ventive and curative services, it is reason-hle that there will be changing pattern of illness over the next 10 to 20 years and, therefore, a requirement for new or modified preventive and curative interventions. Therefore, a management and medical records component to the project is included. It has the following objectives: a) Develop and implement a simple manual system for identifying all fiscal resources (capital and operating) devoted to provin cial health programs nd allocate these resources to program elements by cost category. b) Identify managrialily useful program elements. Specific program elements at this time can only be illustrated, as the definition is dependent upon the completion of Job restructuring and systems redefinition described elsewhere. However, an - 50
illustrative program element might analyze the comparative costs of inpatient services or dispensary services. Cost categories couon to all program elements might include personnel, supplies, pharmaceutical supplies, and travel. c) Define and identify the population base and the population served, grouped by age, sex, and geographic area. Relate the population served and population not served to estimates of unmet need and to the associated costs of delivering ser vices needed by the uncovered population groups. d) Adapt a problem oriented style patient medical record, probably housed at the dispensary level, which relates to family, household unit, and community. This record might build on the existing malaria census and household numbering system. Such a record is to allow for: (1) The planning and recording of the results from individual and mass preventive activities--e.g., immunizations and pre-natal care. (2) The recording and ready identification of major individual health problems, "therapeuticinterventions, and ultimate resolutions. (3) The assessment of services delivered for individual health care needs. (4) The assessment of the perceived needs of the population, the diagnosed ills of those who seek care, and the dis covered needs of those identified in screening programs. (5) The planning for the initial, as well as periodic, modi fications of training programs for front-line workers and other preventive, prpmotive, and curative programs. - 51 - The specifics of this activity will have to be worked out by the MOPH and the TA team.
3. The Traininx and Orientation of Supervisors and Managers and Orientation of Community Leaders. The restructuring of roles for front-line workers and the integration of services requires the following: 1) Understanding of and agreement to the roles by the supervisorial/managerial hierarchy. 2) Change in the supervisor's role, and to a lesser extent the manager's role, which will derive from any change in roles and responsibilities for front-line workers. Specifically, immediate supervisors may well have to acqu.ire additional skills or familiarity with new tech nical areas in order to be able to adequately supervise workers who may oe trained to do taskc outside the experi ence and training of the supervisor. 3) Official approval--by the Ministry of Public Health and by other concerned ministries--of any changes either in the job descriptions of front-line workers and of their supervisors or in the responsibilities of higher levels of managerial and technical supervision. 4) Understanding and support of the needed changes in health personnel, particularly those relating to the front-line worker, by those parts of the provincial government struc ture which are outside the Ministry of Public Health admin istrative channels. a) The regional offices and staffs of other ministries and - 52
and relevant agencies, e.g., Social Affairs, Agriculture, and SONEDE (the first is responsible for the social/health worker, and the lazter two have responsibilities for water resources and drinking water quality). b) The political structure at and below the regional level--delegues, omdas, etc.-- and its administrative support structure. These individuals will play a key role in gaining the people's acceptance of a changed service pattern. c) The Governor's office: This office, with its broad administrative program and political responsibilities, must be fully aware of, approve, and support all program activities, but particularly those associated with job restructuring.
4. Strenghening of Preventive Medicine Internships There are two components to this activity: (1) providing public health internships, and (2) strengthening medical library resources. 1. Public Health Internships One key to improving and maintaining the quality of rural health services is the training of a small but reasonably stable cadre of physicians who are professionally challenged by the opportunities in public health, preventive medicine, and primary care. It is essential that a hospitable work and, to the extent .feasible, social environment be structured to allow the physician with an interest in rural services to pursue further training and - 53
finally to find rewarding employment in rur,l areas. In any case, a set of educational experiences--ideally starting with the medical school selection process, continuing through medical education, and building to the six-month preventive medicine obligatory stage of internship--are necessary steps. The internship is typically the last and most critical point at which a decision to enter residency training in public health and preventive medicine can be made. To complement this stage of the educational experience, this project intends to develop and implement in Siliana and Sidi Bou Zid a model clonical experience in public health and preventive medicine.
The general strategy will be as follows: a. Determine the number of assignees likeiy per province per rotation. (It has been estimated that 100 interns could be assigned nationally to preventive medicine every six months; if they are assigned to all provinces equally (an assumption that may not be true or desirable), then an estimated four to five interns would be assigned every six months to each province.) b. Determine the desirability of naming Siliana and Sidi Bou Zid as special elective sites that could be requeted by potential interns. c. Develop a short orientation for all pre-internship students to aquaint them with the Siliana and Sidi Bou Zid option in order to attract particularly good students. d. Conduct small-group seminars for interns on principles of practice in public health, preventive medicine, and primary - 54
care, and covering such topics as: 1. Approaches to primary care 2. Practical epidemiology and health program planning 3. Health Manpower--techniques of supervision, delegation, and consultation 4. Health manpower--alternative roles for physicians and non-physicians 5. Principles of program management and budgeting 6. Cost-effectiveness analysis 7. Current morbidity and alternative approaches to morbidity and alternative approaches to morbidity control 8. The rural problem oriented medical record--a tool for patient care, program approaches 10, The development, management, and testing of rural drinking water supplies 11. Waste disposal in rural areas
i) sewage
b) solid waste
12. The food chain--protection of the consumer and promotion of productivity 13. Nutrition and health -- the role of public health programs 14. The delivery of maternal and child health services 15. Trauma maz-gement in rural areas 16, The organization of referral, emergency, and specialty - 55
services needed by the rural population e. Structure field work for interns, including:
1. "Research" projects chosen by students, designed to foster relevant problem identification and the development of realistic (affordable and effective) responses, including simple measures of program effectiveness
2. Selected clinical experiences at the level of:
(a) dispensary and home
(b) integrated family health center
(c) in-patient management at the rural hospital 3. Participation in the training and field supervision of front-line workers to expose the intern to curricu lum development as well as to didactic and supervisorial techniques
4. Program management: Attendance and participation in selected management meetings and management functions at the level of the provincial health administrator and the Regional Health Inspector. - 56 -
The development of the program will be carried out conjointly by the U.S. contract physician assigned to the project, working under the overall guidance and within the framework agreed to by the Director of Preventive Medicine from the Ministry of Public Health, and the Chairman of Preventive Medicine at the Faculty of Medicine, Tunis. The Regional Health Inspectors, designated as field supervisors/instructors, are critical resources for the development of the intern's clinical experience. Additionally, physician staff should be identified in the University and MOPH systems whose interests in public health are such that they can contribute to the development of implementation of this component of the program.
2. Library Resources
There is a need to strengthen the preventive medicine libraries at the Faculty of Medicine, Tunis and to provide modest library resources at the two project sites. The Tunis Library should; iLLUiUae basic text and reference works on preventive medicine, public health, health, health planning and epidemi6logy, as well as for selected series of multi-year subscriptions to relevant journals. - 57 -
In Siliana and Sidi Bou Zid hospitals, there is no question that a small working library -- containing basic clinical medical texts, public health preventive medicine texts, and a few selected journals--should be provided. At present, there is no way for either contract physicians, Tunisian physicians and non-physicians or proposed contractor technical assistance staff (physician or non-physician) to draw on recorded experience in medicine and health. The providion of a small basic library resource (a portion of which should be tailored to non-physician interests) will contribute substantially to the improvement of the professional environment in each province.
5. Evaluation Design and Implementation The A.I.D. financed technical team will need to collaborate with the GOT and USAID in the design of a project evaluation. During the early stages of the project the contract team will also need to reach agreement with the MOPH and USAID on the specifics of a research and evaluation program that will insure that:
-- adequate records are kept on the impact of the training and capital aspects of the project in relation to levels of ser vices, changea in morbidity patterns, consumer perceptions of the system, etc. -- there is a funded mechanism to test new ideas and approaches -- there is a means to test the results of services integration against provinces where the old system is still in place. Some subjects that have been identified as promising are the following: - 58
the possibilities for expanding the role of women in extending preventive services capitalizing on their better access to the home
-- ways to motilvate the non-physician workers to a higher standard of work performance
-- methods to improve the morale and reduce the sense of isolation of health workers -- ways by which the community volunteer can be constructively involved in the health program
CAPITAL ASSISTANCE PROGRAM
This project will finance the following additions to the rural health services primary care network in Siliana and Sidi Bou Zid provinces:
-- Construction of 5 Type A health centers, 1 Type B health center and 15 Type C health centers -- Renovation of 5 Type A health centers, 1 Type B health center and 10 type C health centers
-- Equipping 4 Type C centers Three maps showing the existing network, proposed additions and completed network are attached as Annex G. The program description of each type of facility is summarized on p of this report and is discussed more completely in the Christie-Shaw Report, Annex J. In analyzing the capital assistance component of this project, five principal issues have been considered. These are: 1. The program coverage of the expanded system. 59
2. The suitability of the buildings to the range and volume of tasks to be performed. 3. The capacity of the GOT to staff the facilities. 4. The structure and costs. 5. The Environmental Impact.
1. The Program coverage of the expanded system As indicated above, Tables 5 and 6 show the system in place and the additions that will be made to it. Tables 9 and 10 show the physical facilities in relation to program coverage. Some preliminary analysis by the expert consultants provides an estimate of the reasonable productive capacity of the expanded health system and gives a fair idea of the amounts of client contact that the new network can produce. According to these estimates the system has the capacity to provide services to 100% of the population at the rate of 2.67 contacts per year. If the system reaches only 80% of the population (which is likely because of distances, lack of interest by consumers, etc.), the number of patient contacts increases to 3.34 per year. We have no precisely comparable data on the exi4ting coverage in Siliana and Sidi Bou Zid. An earlier consultant study suggested the present contact rate in Siliana was between 1.39 and 1.58 visits per year. Rates of provider-consumer contact in W. Europe and the U.S. are about 4.0 per year. Provided the Tunisia estimates are close to accurate, the capacity of the Tunisian rural system to provide access to health care will at minimum increase by more than 30% and perhaps approach standards in developed countries. While this data provides only gross - 60 - TABLE 0 HEALTH CENTERS IN RELATION TO POPULATION
PROVINCE: SILIANA
LOCATION OF RESIDENT FINAL NETWORK POPULATION DELEGATION SECTEUR POPULATION FACILITIES SERVED El Kr|b Hammam Bayadha 4,735 C 3,788 Bordj El Messaoudi 4,959 C 3,967 El Abassi 3,938 Ain Achour 3,933 Bou Rouis 4,440 C 3,552 El Krib Commune 2,408 A 9,132* El Krlb • 2,537 Ed-Dkhania 3,100 C 2,480 30,050 22,919
Gafour Abbad 2,215 Gafour Banlieu 4,211 Gafour Commune 6,046 A 9,312* Fourna 5,044 C 4,035 Lagsab 1,782 C 1,426 El Akhouat 3,716 C + C 2,960 23,014 17,733 Bou Arada El Aroussa 4,625 C 3,700 Bou Jlida 2,340 C 1,872 El Fetiss 4,840 C 3,872 Bou Arada Commune 5,487 A 8,880* Bou Arada 3,087 Henchir Roumaine 3,946 C 3,157 Tarf Echna 4 o4
*This figure does nut include referrals from Type C.or B centers. - 61 - TABLE 9 (Continued)
HEALTH CENTERS IN RELATION TO POFULATION
PROVINCE: SILIANA
LOCATION OF RESIDENT DELEGATION FINAL NETWORK POPULATION SECTEUR POPULATION FACILITIES SERVED Robaa Robaa Commune 2,110 B 7,997 Ouled Fredj 4,682 Sidi Said 4,039 Ed-Dija 1,087 Bargou et B'Hirlne C 1 911 2,30 9908'
Siliana El Arab 2,434 Jamaa 4,325 C 3,460 Siliana Commune 6,982 A 10,492* Sejja 2,620 Sidi Mansour 4,757 Massouj 3,828 C 3,062 El Khalsa 1,488 Ain Dissa 855 Marj El Mokaddem 1,552 C 2,414 Sidi Hamada 2,141 C. 1,713 Sidi Morched 5,667 C 4,534 Es-Sfina 2,855 39,504 25,675 Rohia Rohia Commune 1,181 .A 3,674* Rohia 3,411 M'Sahla 1,033 C 826 El Haria 2,398 C 1,918 Es-Smirat 2,444 C 1,955 Ej-Jmilat 1,608 C 1,286 Hababsa 4,965 C 3,972 __13X3_17,0- *This figure does not include referrals from Type C or B centers. - 62 -
TABLE 9 (Continued) HEALTH CENTERS IN RELATION TO POPULATION
PROVINCE: SILIANA
LOCATION OF RESIDENT FINAL NETWORK POPULATION DELEGATION SECTEUR POPULATION FACILITIES SERVED
Haktar Beze. 4,'23 C 3,778 Beni Hazem 2,050 Sadlane 2,286 C 1,829 Ras El Oued 1,805 El-Louza 2,231 C 1,785 Soualem 3,132 Kessera 3,895 C 5,432 Foudhoul 1,620 El Gueria 2,243 Mansourah 4,131 C 4,426 El Gara 2,510 Maktar Commune 6,068 A 9,965* Sayar 3,691 427,215
TOTAL POPULA- TOTAL POPULATION: 9., TION SERVED: 140,562
PERCENT OF POPULATION SERVED: 73%
.*Thls figure does not include referrals from Type C or B centers. - 63 - TABLE 10
HEALTH CENTERS IN RELATION TO POPULATION
PROVINCE; SIDI BOU ZID
LOCATION OF RESIDENT FINAL DELEGATION NETWORK POPULATION SECTEUR POPULATION FACILITIES SERVED Jelma Labiod 3,306 C 2,645 Baten El Ghazel 2,834 C 2,267 Celta 4,049 C 3,239 H'Ghilla 4,948 C 3,958 Cebalat Askar 1,822 C 2,652 Essed. 2,674 C 2,139 El Amra ?,387 Jelma 4,449 A 4,762 El Haouia unknown C unknown Guedir Ez-Zitoune 2,406 ZU7-5 21,662 Sidi Bou El Hameima 2,955 C 3,089 Zid Bennour 2,898
El Makarem 3,849 C 4,343 El Amra 5,054 Lassouda 4,112 C 4,015 Sdakia 5,274 Sidi Bou Zid Comm. 8,843 A 10,654* Faied 6,040 C 4,832 Garaat Hadid 2,410 Gammouda 2,116 El M'Zara 5,410 C 5,512 Ez-Zitouna 2,890 Hichria 4,599 C 4,859 Et-Touila 4,638 Oum Ladham 3,947 3,158
*This figure does not include referrals fron Type C or B centers. - 64 -
TABLE 10 (Continued)
HEALTH CENTERS IN RELATION TO POPULATION
PROVINCE: SIDI BOU ZID
LOCATION OF RESIDENT FINAL NETWORK POPULATION DELEGATION SECTEUR POPULATION FACILITIES SERVED Ouled Ouled Haffouz 7,877 A 6,302* Haffouz Sidi Khlif 6,542 C 5,234 (new delegation) Dhouibet unknown C El Hania (k.102) unknown C 141 1753
Er.-Regueb El Kcham 3.305 C 2,644 Es-Salda . 7,305 C 5,844 Ksar El Hammam 7,000 Er-Regueb 5,642 A 9,909* Gouleb 3,789 Redaa 3,962 C 3,170" Ez-Zitouna** C 3,500 31,003 25,067
Mezzouna Mezzouna 4,312 A 4.C 3,450* El Founi 3,442 C 2,754 Bou Hedma 4,423 C + C 3,538 12,177 9,742
Sidi Ali Bir El Hfal 4,781 C' 3,825 Ben Aoun Bir El Amarna 5,451 C 4,361
Er-.Rabta 5,061 C 4,5Ze El Mansourah 3,043 C 2,434 Si.Ali Ben Aoun 3,436 A 5,329* El Karia unknown C Es-Sahla 3,785 26,157 20,478
*This figure does not include referrals from Type C or B czrers. *Ez-Zitouna is within the delegation of Er-Regueb. However, the FHC team is unsure of its exact location. - 65 - Table 10 (Continued)
HEALTH CENTERS IN RELATION TO POPULATION
PROVINCE: SIDI BOU ZID
RESIDENT FINALLOCATION NETWORK OF DELEGATION SECTEUR POPULATION FACILITIES POPULATIONSERVED
Maknassy El Kassira 4,912 Hachana 1,828 C 3,918 Bir Badr 3,857 t 3,086 Jebbas 3,921 Maloussi" 4,104 Gheriss 2,624 Henchir Kaliel 3,488 Menzel Bouzaiane 4,555 B 6,331 El Omrane 1,886 El Mech 3,197 C 2,558 Maknassy Commune 4,478 A 8,906* Maknassy 1,965 C 1,258 ;0,815
TOTAL POPULA- TOTAL POPULATION: 211,511 TION SERVED: 159,942
PERCENT OF POPULATION SERVED: 73%
*This figure does not include referrals from Type C or 8 centers. - 66
approximations, and implementation depends upon exploiting the non-physicians in the system, it is useful as a reference point to demonstrate the potential capacity of the expanded network to reach the rural people with services.
2. Suitability of Buillings to the Range and Volume of Tasks to be performed
The Bureau employed program design consultants and an architect with specific experience in the design of rural health facilities to address this problem. Working collabora tively, the architect developed schematic design studies that are tailored to the functional and services volume requirements of the facilities. Three alternate designs were developed for Type C centers; two alternate Type B centers and two alternate designs for Type A centers. Within each facility space is allo cated by function. Consideration was given to the possible addition of an augmented staff in future years. The detailed findings are at Appendix J. We are satisfied that the facilities proposed can be designed to fulfill the functions and service volume of the system. We are also satisfied that the equipment selected is appropriate to the functions of the centers. During the building design process, A.I.D. should continue to make TA available and should approve the final product.
3. The capacity of the GOT to staff these facilities. Sufficient front-line workers (e.g., service d'hygiene personnel and dispensary agents of various types) are already employed (in Siliana about 77; in Sidi Bou Zid about 100) to - 67
meet the minimal staffing needs projected htor all Type C centers and to substantially contribute to the minimum staffing required for Type A and B centers. The minimum number of physicians required for each province are: Siliana seven and Sidi Bou Zid eight. Currently, there are seven or eight physicians in Siliana, one in each delegation seat and two (possibly three) in Siliana City. All physicians are in government service except for one physician in private practice in Siliana City. In Sidi Bou Zid, there are either seven or eight physicians distributed as follows: six government physicians in Sidi Bou Zid.City, one private physician iT Jidi Bou Zid City and one government physician in Maknassy. In Sidi Bou Zid, some redistribution of physicians aswell as the acquisition of a few new physicians would provide minimally adequate coverage of the province. For instance, it might he reasonable to move two physicians from Sidi Bou Zid City to Ben Aoun and Er-Regueb, and at a later date acquire new physicians for Jelma, Ouled Haffouz, and Mezzouna. Thus, in aggregate, only three additional physicians are needed for both provinces to meet the minimum staffing criteria for supporting a rural delivery system (one physician per delegation seat); none are required immediately. As over three-hundred graduates from Sousse and Sfax Facilities of Iedicine will be available within three years, it is not at all unreasonable to assume that, by virtue of government policy and competitive pressures, these three positions can be filled by Tunisian physicians. Further, some of the foreign contract physicians will be replaced within the next 2-5 years by Tunisian physicicians. It is our judgment that the GOT - 68
will not have difficulty in staffing the added facilities. Nevertheless, we should include staffing as a component of FAR reimbursement certification using the "initial staffing pro jections outlined in the program description for each facility.
The Structures and the Costs The rural health facilities specialist examined the capital component of the project; a) to establish reasonable cost estimates for the facilities to be built b) to determine the type of construction methods most suitable and
c) to verify that local contractors exist that are capable of constructing the types of facilities proposed for financing. The detailed fundings are at Annex J. In summary, they are as follows: a) Cost Estimates: During the past year, the construction industry has experienced significant cost increases (40%. labor, 50% concrete, 30% cement, 30% reinforcing steel). Assuming construction were to begin in 1978 cost estimates were as follows: Type C 2 (small centers) $21 per sq. ft. C 1 (large centers) $21 per sq. ft. Type B $32 per sq. ft. Type A $32 per sq. ft. b) Type of Construction: the architect strongly recommended that the conventional traditional construction techniques as approved by the Ministry of Equipment be used for these facilities vs. prefabriacted systems recommended by some con - 69
tractors. SER/ENG has certified the preliminary architectural plans and cost estimates meet 611(a) (1) requirements (See Annex D). The Er'-ironmental Impact: An initial Environmental Examination was completed by the rural health facilties architect. It was this technicians conclusion that the general positive impact of this project would far outweigh the minor inconveniences that would take place during the construction process.
B. Economic Analysis Measures As has been demonstrated by the Rand Corporation studies performed under contract to the Department of H.E.W., it is very difficult, if not impossiblf, within the capitalist countries to define those health status conditions that are measurable in economic terms. However, some Western Socialist countries such as Sweden, Australia, and Yugoslavia appear to have developed measures which are principally applicable to ur banized, full service areas. In Tunisia, the population addressed is principally'rural and under-served. For purposes of analysis a more general approach highlighting the costs versus non-mon etarily quantifiable benefits, and the marginal returns for investment, as well as a rather general cost-effectiveness approach are used. Economic Descriptors Of the '76 MOH budget of $96,861,600 ($17.23 per capita), $65,000,000 goes for operating costs ($11.57 per capita). In the combined Sidi Bou Zid/Siliana area $571,132 is estimated as spent on operating costs or only $1.39 per capita. In the FHC report current visits per person per year are - 70
estimated at $1.39 which would work out to $1.00 per visit (under the alternative method of calculation, p.44, of the February report which yields 1.58 visits/person per year, the figure drops to $.88). In the proposed project, in non-deflated dollars, the cost drops to $.57 per visit at 2.70 visits per capita.
From a slightly different point of view, using the same current figures, 1.58 visits per year, the proposed program would increase the number of possible visits from 649,662 per year to 1,227,980 or an 89% service increase at an annual operating increase of 23%.
In terms of either the total MOI budget or of the operating budget for 1976, the incremental cost for Sidi Bou Zid/Siliana opdration represents .3 of 1% and .4 of 1% respectively. Since the operating budget has been increasing at a rate about 47. faster than inflation per year there should be no difficulty in financing the operating costs.
Cost effectivness
If one makes the assumptions: (1) that increased services at the level of 2.70 visits per year is a satisfactory goal and (2) that the current workers will continue to be employed, the maximum cost option, presuming the same facilities and non salary operating cost requirements, can be calculated by es timating a primarily physician deliverer system. If the increased number of visits (578,318 per year) were executed by a physician the operating costs would increase as follows: - 71 -
One physician can deliver 17,2801 visits per year, there fore:
578,318 ; 17,280 - 33 physicians 33 X $14,429/yr + 548,757 $548,757 salaries 96.428 non-personel costs incremental operating cost Ratio of roosed system 4 5..38 physician system 645, 285 This ratio sets an upper bound, i.e., the proposed system is about 40% as expensive as shifting to a heavily physician dependent system (which would, however, retain current workers). At the opposite end of the scale is the use of entirely non physician personnel. Even presuming that the Tunisians were will ing to accept such an approach, the following calculations in dicate that very little savings would be achieved by el'Iminating the three additional physicians who are proposed:
3 X 17,280 visits per year - 51,840 visits 51,840 t 8640 (midwives visits) - 6 midwives i.e., Operating costs of $216,431 vs 246,315 proposed.
C2a .al Costs The loan financed capital costs of the project have not been included in the above analysis. The loan is proposed for thirty-year repayment, ten-year grace, two percent interest during the grace period and three percent thereafter. On a non-deflated basis this will cost the government $60,000 per year
1 p 26, FHC July Report - 72 over the first ten years of the project. This will be covered by the Ministry of Finance under the five year plan for investment. The approximately $333,000 per year ($ 1,000,000 over three years) for construction costs, including materials, will come from the Ministry of Health's capital budget, currently running at $32m in 1976. B. Repayment Prospects The Tunisian economy remains very susceptible to the vagaries of weather and changez in the world market. Yet, as hs1 been demonstrated in the past two years, when excellent crops and a tourism boom mitigated the effects of a slump in phosphate and olive oil exports, there is a degree of diversification which gives Tunisia's economy greater protection from outside forces than many developing countries have. Moreover, Tunisia's low debt service ratio and its responsible financial management give it a good credit rating for commercial borrowing, as well as making it attractive to foreign investors. These sources, to gether with continuing availability of concessional assistance, should assure the financial resources needed for implementation of what is shaping up as a quite ambitious Development Plan for the period 1977-1981, one which, according to the GOT, is intended to accomplish the country's take-off and end its dependence on foreign assistance. Foreign debt outstanding at the end of 1975 is estimated at $1.1 billion compared with $1.0 billion in 1974, equivalent to about 25 percent of GDP in either year. In'contrast, this relationship was at 40 percent in 1970. The relative burden of - 73
debt servicing slightly increased in 1975, but r;-mained below 10 percent of export earnings compared with some 22 percent in 1970. This significant change in the debt service ratio is mainly due to the sharp increase in export earnings following the changes in world market prices in 1973-74, but it also reflects reduced borrowing and especially the Government's efforts to change the structure of the foreign debt by borrowing more from public sour ces on concessionary terms. This is reflected in the average effective rate of interest payment on the disbursed debt outstanding at the beginning of the year, wbich in 19/5 was only about 4.2 percent. Tunisia no longer qualifies for borrowing on AID's most concessionary terms, and this loan will be extended on inter mediate terms, i.e. 30 years repayment, including a 10 year grace period, with interest at 2% during grace and 3% thereafter. Given Tunisia's overall debt position and economic outlook, repayment prospects for the proposed loan are good.
C. FINANCIAL ANALYSIS AND PLAN A.I.D. support in this project covers thru grant funds, the cost of the U.S. contract technicians, U.S. training of Tunisian trainers, library materials, vehicles, and local costs of some field trails. Thru loan funds, the project funds 75% of construc tion/renovation costs and laboratory equipment. The Tunisian Government will assume the remaining construction/renovation costs, acquisition of land for new clinic sites, salaries of front line and supervisory personnel, transport for the outreach workers, operating costs for the hospitals and health centers and administra tive support for the U.S. contract team (office space, drivers, - 74
clerical support, etc). The Economic Analysis discusses the capability of the Tunisian Government to meet the operating costs of this system. The con struction/renovation costs are derived from the report of Architect Susan Christie-Shaw (Annex J). Ms. Shaw, working with a Tunisian achitect, traveled with the project design team. A full description of how costs were determined is contained in her report. USAID and the GOT have reviewed this report and concur in its major conclusions. The following summarizes those conclusions.
During the past three years., the construction industry in Tunisa has experienced significant cost increases; e.g., 40% in labor, 50% in concrete, 30% in cement, 30% in reinforcing steeL. In January, 1977, a general wage and price increase of about 15 20% was decreed. There was indication from the Ministry of Equipment that construction costs hould begin to level-off and stabilize -- at least for the next several months. As of June, 1977, 7% was the acceptable rate of escalation in overall con struction costs. These resulted from discussions with various representatives involved in some aspect of the health/medical construction industry. They include representatives from the Ministry of Equipment, Ministry of Health, private contractors, private Tunisian architects, and a World Bank architect. In addition to discussion on the general status of the construction industry in both rural and urban Tunisia, the
1There was general consensus that there should be no significant difference between construction in the urban and rural The setting. expected saVings in labor (36-40% of construction costs) in - 75
the question of cost estimating was raised.
The questions were grounded in the following assumptions given to the factors that effect cost estimating: 1. Assume construction to begin early 1978 in rural provinces of Siliana and Sidi Bou Zid. 2. Size of facility: assume 200 m2 ( 2,225 ft. 2+) 500 m2 ( 5,500 ft. 2+) 1000 m2 (11,000 ft. 2+) 3. Shape of configuration of building: assume relatively simple shapes, simple spans 4. Building use/type: assume out-patient facility (ex. dispensary) and in-patient (ex. PM with beds) 5. Type of construction: assume conventional, traditional the Ministry techniques as approved by of Equipment (stone construction or reinforced concrete columns with brick cavity tem of walls, built-up roof sys hollow tiles (hourdi) or conventional arches/vaults prevalent in new and recent construction in both urban and rural areas. 6. Quantity and quality of systems/services: assume electricity, hot and cold running water, natural ventilation, local heating (not central), flush toilets 7. Quality of construction as effected by contractor: assume experience is good 8. Availability of construction materials (proximity to and scarcity of): assume substantial local supply 9. Availability of local contractors and tradesmen: the rural area is usually off-set materials'(60-70% by the generally high r 1osts of of total construction costs). This for Types A and B. 'ezld be truer However, Type C may reflect a sagas if process is developed.for local contribution. a - 76
assume existing 10. Formal bid process vs mutual agreement with local contractor: assume more formal process 11. Type of facility development process (time is money): assume relativity formal process with delays, official approval by several offices, etc. 12. Inflation between time of cost estimates and actual time of bids. 13. Recent experience with projects similar to those in question. The resulting answers -- largely emphasizing recent experience in similar building type, similar construction system, and degree of formalization of the facility development process indicated the following ranges for the three proposed buildings in question; (Ms. Christie-Shaw identified both a formal and informal process for design and construction. We have listed only the formal pro cess costs which is the higher of the two.) Formal Process Dinars Dollars Proposed Type C3 80-100/m 2 $17-21/ft2 *200m2 (2225 ft2) Proposed Type B3 140-160/m2 $30-34/ft 2 +500m2 (5500 ft2) Proposed Type A3 2 t1000nm2 (11,000 ft2 ) 140-160/m2 $30-34/ft2
2 $1 - .424 TD; TD 1 - $2.36 U.S. i Sizes of proposed types were further defined since the interviews. - 77 -
Initial analysis resulted in two figures: 100 TD/m2 ($21/ft2) for new construction for out-patient facilities, and, 150 TD/m2 (32/ft2) for in-patient facilities. These figures were checked and rechecked against recent experience in the provinces as well as in Tunis with government officials, (Director of Buildings and Equipment, Ministry of Health and Deputy Director of Construction Section, Ministry of Equipment), contractors and architects. It was agreed that they were reasonable figures but that with a local contractor building a small building in a rural area, the Type C facility should be buildable for approximately 80 TD/m2 or $17/ft 2 , and the Type B facility for 1.5 times the amount or 120 TD/m2 or $26/ft2 . New Construction
Formal Process Type A a) 10,000 2 2 ft @ $32/ft - $320,000 +10% contingency 13 500
b) 900m2 @ 150 TD/m2 - TD 135,000 +10% contingency TD 13500
Type B 2 a) 5400 ft @ $32/ft2 " $172,800 +10% contingency 17 280
b) 486m2 @ 150 TD/m2 - TD 72,900 +10% contingency 7 290
Type Cl/Large a) 2200 ft2 @ $21/ft2 " +10% contingency $ 46,2004 620
89 - 78 -
Formal Process Type Cl/Large (continued)
b) 198m2 @ 100 TD/m2 - TD 19,800 +10% contingency 1,980
Type C2/Small with lodging 2 a) 2000 ft @ $21/ft2 - $4io +10% contingency 4,200
b) 180 m2 @ 100 TD/m2 = TD 18,000 +10% contingency 1800
Type C2/Small without lodging 2 a) 1500 ft @ $21/ft2 - $31,800 +10% contingency 3 180
b) 135m2 @ 100 TD/m2 - TD 13,500 +10% contingency 1,350
The cost estimate figures-assume construction is begun Ln early 1978, t-iat the starts are simultaneous and that there are no time elays. The figures show a 10% contingency included in the totals, but do not include architectural fees, site acquisition or equipment. The figures answer this question: What would it cost to build the proposed facilities within the next few months? The chart below demonstrates the answer for the proposed project in Siliana and Sidi Bou Zid provinces: New Construction: Formal Process Siliana Sidi Bou Zid Totals Type A @ $352,000 (2) $704,000 (3) $1,056,000 (5) 1,760,000 Type B @ $190,080 (1) $190,080 ----- (1) 190,080 Type C1 @ $50,820 (3) $152,460 (5) $ 254,100 (8) 406,560 Type C2 @ $46,200 (31 138,600 (4) 184,800 (7) 323,400 Totals: $1,185,140 $1,494,900 $2,608,040 - 79 -
Location of New Construction Siliana Province Type A: El Krib, Rohia Type B: Robaa Type C: Jama (optional), Ed-Dkhania, Sadiane, Es-Smirat, M'Sahla, El Haria Sidi Bou Zid Province Type A: Jelma, Ouled Haffouz, Mezzouna Type B: -- Type C: Lassouda, Zaafriaa, Ec-Zitouna, Es Saida, El-Hania, Bir El Amama*, El Mansourah*, Er Milia, El Kerma * possible community contribution of some materials and labor, figures show no donations. Estimates for Renovations The regional hospitals in Siliana and Sidi Bou Zid need expansion and/or renovation to accomodate the space required for laboratory services, for educational facilities for retraining existing personnel, and for space for the new x-ray equipment at both sites. Due to the constraint of time, it was virtually impossible to carefully analyze the existing use of space, to measure the buildings, to generate enough information to carefully analyze the existing use of space, to measure the buildings, to generate enough information to substantiate a specific recommendation for changes in all of the existing facilities including the two regional hospitals. In order to expedite the process, it is strongly urged that an architect be consulted to develop renovation schemes based on space use analysis in light of the policy of integrated ser vices. The survey of the existing facilities included a general plan sketch of the major use areas, general condition of the facility and preliminary needs. - 80 -
The preliminary renovation cost estimates1 are broken into minor renovation and major renovation. Minor renovation includes painting and general finish work with insignificant relocation of walls. Major renovation includes significant demolition and reconstruction as well as finish work. Preliminary Cost Estimates for Renovations and/or Expansions Siliana Province Type A Bou Arada @ $ 25,000 Gafour 25,000 Maktar 25,000 Siliana 150.000 $225,000 Type B Type C Sidi Morched $ 10,000 Bou Rouis 10,000 El Aroussa 10,000 Bou Jlida 10,000 Kessera 10,000 EJ-Jmilat 10,000 60,000 Total Renovations Siliana Province $285,000
Sidi Bou Zid Province Type A Sidi Ali Ben Aoun $ 10,000 Er-Regueb 10,000 Maknassy 10,000 Sidi Bou Zid 150,000 180,000 Type B Menzel Bouzaiane $110,000 i0000 Type C M'Ghilla $.10,000 El Hameima 10,000 Battoumet 10,000 El Mech 10,000 40,000 Total Renovations for Sidi Bou Zid Province $330,000
1 The $10,000 figure given to renovation of dispensaries is generous unless new construction for expansion is involved. - 81 -
D. Combined Facility New Construction and Renovation Cost Estimates --- a Sunnary for Both Provinces
Formal Process Type A Siliana Sidi Bou Zid Totals new construction $ 704,000 $1,056,000 $1,760,000 renovations 225,000 180,000 405,000 Type B new construction $ 190,080 ... $ 190,080 renovations --- $ 110,000 110,000 Type C1 (1 & 2) new construction $ 291,060 $ 438,900 $ 729,960 renovations 60,000 40,000 100,000 Sub Total $1,470,140 $1,824,900 $3,295,040 Minor Equipment 1 --- 2 000 2,000 Grand Total 11,70,14U $IT826,900 3,27,040
1 NOTE: 4 proposed Type C facilities in Sidi Bou Zid'need equipment. They are Dhouibet, Haddej, Ferjane, El Founi. $500 has been allocated for each site. This $2,000 appears in grand total in theconstruction estimate breakdown. . 82 -
Equipment
The loan will also include approximately $323,345 in laboratory and health center equipment. This will include such equipment as: examination tables, waiting benches, pharmacy cabinets, sterilizers, Hemoglobinometers, Storage cabinets, beds, baby scales and bassinettes, tubes, etc. A specific list of equipment for each type of center and price estimates are attached as Annex 7 to the FHC Design Study II. This list has been re viewed by the MOPH and USAID. However, a final review will be con ducted by the U.S. contractor and the MOPH during the first 90 days of the project prior to placing the final order. None of the individual equipment items will exceed $2,000. All equipment will be purchased in the U.S. or Tunisia. Conclusions:
Based on the project design reports, the following tables summarize U.S. and GOT contributions. 0
BUDGET SUMMARY
U.S. Contribution: Grant $1,000,000 Loan Total 3 ,000,00 $4,000,000
GOT Contribution: $1,390,850 83
TECHNICAL ASSISTANCE BUDGET
FY 77 FY 78 FY 79 Total Resident Staff: Physician 47,000 47,000 48,000 142,000 Health Practitioner 30,000 32,000 34,000 96,000 Health Administrator 30,000 32,000 34,000 93,000 U.S. Project Coordinator (1/3 time) 10,000 10,000 10,000 30,000 Short-term Consultants ($200 per day x 3 mo. per year) 12,000 12,000 12,000 36,000 Overhead, Fee, G&A for Con tractor 74,000 75,000 75,000 224,000 Allowances: Living Quarters ($1000 per mo. x 3) 27,000 36,000 36,000 99,000 Temporary Quarters ($780 per mo. x 3) 7,020 7,020 Post Allowance $685 x 3 2,055 2,055 2,055 6,165 Shipment of 700 lbs Unaccom panied Baggage 3,150 -- 3,150 6,300 Shipment of POV $4,000 x 3 6,000 Shipment -- 6,000 12,000 of HHE 5000 x $1.38 x 3 10,350 -- 10,350 20,700
Communications, in-country per - diem for long-term advisors, etc..1,810 1,780 1,980 5,570 Travel: S-round trips @ $1200 5,400 -- 5,400 10,800 3 consultant visits x 21 days x $55 per diem 3,465 3,465 3,465 10,395 3 round trips year one $1200 3,600 3,600 3,600 10,800 Training: 5x 1200 Air Fare (3 FY 77; 2 FY 78) 3,600 2,400 6,000 5 x 90 days x $35 per day 9,450 6,300 15,750 5 x $200 (U.S. Travel) 600 400 1,000 Training Fee 5 x $500 1,500 1,000 2,500 Vehicles: 3 vehic es x $8,000 24,000 24,000
Library Rerrces : 8,000 8,000 Local Training Costs: Materials and per diem 10,000 10,000 10,000 - 84 -
FY 77 FY 78 FY 79 Totals Field Trials: U.S. Consultants/Tunisian Researchers/data processing materials, etc 25,000 50,O00 25,000 Totals 355,000 325,000 320,000 1,000,000 - 85 -
CAPITAL ASSISTANCE BUDGET SUMMARY
U.S. INPUTS: Facility Renovation $ 461,250 New Construction 2,011,530 * Equipment 313,345 Contingency 203.875 TOTAL $3,000,000
* Represents 75% of material, labor and transport costs. - 86 -
GOT Budget Sumary
Construction/Renovation: 0 25% of Materials, Labor, Transport $ 824,220 Design of Plans/Administration of Construction Contracts 20,000 Acquisition of Land 1 Incremental Oerating Costs for New or Substantially Expanded Centers: Personnel Costs $149,887 Non-Personnel Costs 96,428
Year 1: $ 80,105 Year 2: 160,210 Year 3; 246.315 Total : 486,630 Support to U.S. Contract-Team: Office Space, supplies, clerical and administrative support, drivers x 3 years 60,000 Classroom facilities (In kind)
TOTAL $1,390,850
1 If location of new health centers requires land acquisition, GOT will assume this responsibility. - 87 -
D. Social Analysis A project social analysis was conducted by an expert consultant in June, 1977. The principal recommenda tions as they relate to project design and development (and the comments of the project design team) are as follows: The Project must not only concern itself with training non-physicians in added skills but with the application of these skills.in an cperational setting. We agree with this finding. The focus of this project is to operationalize non-MD's with a broader range of skills. A principal task of the Technical Assistance team will be to assist .in overcoming the program and administrative obstacles that have prevented prior attempts at this from being realized. The project should make thebroadetpossible use of traditional practitioners to insure the best chances ofproject spread and survival. We do not believe this recommendation can or should be implemented. The technical assistance team will need to deal with this entire subject with caution and sensitivity. First, the practices of traditional medicine.is against the law. The GOT appears to accept the role of the traditional midwife. It does not accept the other - 88
traditional healers and will not agree to activities that strengthen their position in health services delivery. Vigorous support of traditional medicine by this project could not only cause the TA team problems with the GOT but could compromise the willingness and the capacity of the Ministry of Health to implement a broader role for the non-physicians. After the TA team is settled in the issue of working with the traditional midwife and the use of other community resources should be explored. The project should not reouire the GOT to supply large numbers of physicians as they cannot do so. There are at present 12 doctors in Siliana and Sidi Bou Zid. We are seeking three more by the completion of the project. This the GOT says they can supply from the 300 plus that should be graduated. We believe they can do this. We do not wish to have a large increase in the numbers of physicians for this project as their presence will tend to support continuation of the physician centered system. The groject should have a strong research comonent. We agree. $100,000 in TA grant funds is reserved to finance local costs of field trials in new methods of health delivery. This will be administered by the TA contractor in collaboration with the GOT. - 89 -
The importance of the role of women in preventive medicine outreadT. We agree that more women should be engaged in outreach activities. The contractor will be directed to pursue this objective in program implementation.
A complete social analysis based on extensive fiAd notes is appended to this PP. The chief findings are summarized here: Compatability concerned two social systems; the dispersed rural populations of Siliana and Sidibou Zid; and the provincial delivery system of the Ministry of Public Health. Because of deficiencies of personnel, equipment, and budget allocations, the rural health care system does not work well and does not enjoy the respect of the rural inhabitants: Those who can circumvent the system by going to Tunis where they seek private care. Others rely on the indigenous system of health care as well as the rural system of the Ministry. Ministry field personnel are almost totally occupied with curative services. Efforts to operationalize an integrated preventive health program utilizing redesigned curriculum for auxiliaries, restructured job descriptions, and retrained malaria workers have not been realized - 90
anywhere in Tunisia. The proposed AID program, there
fore, should not simply improve or augment the existing
curative system, but must concern itself with implemen
tation of a rural preventive program. Since this has
not been done before, precise guidelines cannot be pre
sented and an innovative, research oriented technical
assistance program, limited in geographical scope and
concentrated in effort is recommended.
Secondly, it was felt that the program's best
chances for achieving spread and survival beyond donor
assistance lay in establishing a strong infrastructure
of auxiliary workers cooperating with indigenous personnel.
A potential contractor should be aware chat there are
divided opinions on this within the Tunisian medical
community and care, tact, and good judgment are necessary
in this effort. The quality of indigenous practitioners
and the efficacy of various practices vary widely.
Decisions will have to be made according to cases, and
trials should proceed as research and experimentation.
The more the program has to rely on doctors, the
less chance of success it will have. While it would be
desirable for the Tunisian Ministry to supply counter part physicians, program assumptions should not consider
them indespensible. Furthermore, the lack in implemen - 91
tation of a preventive health program in this area has nothing to do with the intelligence and good intentions of the Ministry, but rather with lack of means. There fore, it is recommended that caution be exercised in
using the project to require the GOT to promise what they cannot deliver. It is suggested that a realistic assessment of Ministry problems and resources should be made. A cooperative effort for addressing these would be the most productive approach.
These limitations suggest two emphases. One is research. It is suggested that a standard morbidity and mortality survey which could be replicated periodically could serve as an orientation to focus effort and resources, and as an evaluation tool. The other emphasis has to do with improving the quality of care, the outreach of services, the enlistment of local participators. Efforts in this regard should be care fully tested and monitored, suggesting an ongoing research component of anthropology-epidemiology. Since the program would have to depend on auxiliaries, several means of upgrading skills (on-the-job training, overseas training, creation of libraries) morale (career advancement opportunities, team work, better supervision), and recruitmedt are recommended. The - 92
dispersed population particularly for a preventive program, casts doubt on the adequacy of stationary facilities. The spotty record of mobile teams suggests a new approach for maximizing personnel time. Experi mentation with the concept mobile team in place personnel was recommended. This would then be compatible with, ultimately, the most crucial aspect of insuring survivability, the enlistment of indigenous personnel.
Various ideas such as training traditional mid wives, recruiting village medical assistants and expanding the role of agents sanitaires should be tried and evaluated. Women enjoy an exclusive relationship with infants and small children and thus are the key to intervention's concerning nutrition and infectious diseases. They have also exclusive domain over the household, and thus can control various sources of contamination. On the other hand, cultural circumstances have made access to women difficult. This situation demands special attention from a contractor. The language of women'is arabic. Only carefully designated males have the right to speak to women or enter their homes. It is important, therefore, that the recruitment and training of female auxiliary and indigenous workers should beencouraged in every way. - 93 -
The present administrative system is designed for a system of curative care based in stationary facilities. This system is designed to provide doctors with the personnel and means for carrying out curative services. A preventive program depending heavily on auxiliaries and attempting to reach beyond the confines of hospital and dispensary will have far different administrative requirements. It was suggested that trial and experimentation be conducted in this relm. The structure of hospitals is authoritarian. A preventive program demands more autonomy and initiative than an authoritarian system can achieve. Doctors and supervisory personnel who can establish collegial working relationships with auxiliaries will be most useful. Auxiliaries will also need to be sensitized to the culture of villages. Staffing of the technical assistance team should follow careful program definition and realistically reflect needs. This team will have the difficult task of commanding the respect of the highly sophisticated medical community of Tunis, the auxiliary workers, and finally, the villages of Siliana and Sidi Bou Zid. It is suggested that the team leader be an M.D. with an MPH or Ph. D. Relevant experience in a franco - 94
phone country would be bigly desirable. Because of the experimental and innovative nature of the program, he or she should be able to demonstrate an ability to understand research. The emphasis on preventive medicine suggests a sanitarian expert. Personnel with experience with on-the-job-training would be
desirable. The importance of women clients and auxiliary personnel suggests that at least .one member of the team should be female. All personnel should speak French and be willing to undertake a program in Arabic.
Finally, it was noted that capital inputs were being made prior to implementation of a preventive program which must by necessity operate without precise guidelines. In order to afford compatability with the experimental and innovative nature of this program, it was recommended that a portiou of capital develop ment funds be reserved for the descretion of the technical assistance team. - 95 -
Part IV. IMPLEMENTATION A. Administrative Feasibility The administrative arrangements outlined in this PP have been reviewed by the project design team and concurred in by the Ministry of Health. There are, however, several areas of this activity which may create administrative problems. These include: (1) relationship and flow of iLformation between the two provinces and officials in Tunis; (2) experience of other donors in securing counterpart personnel; (3) relation ship of project personnel to the existing Tunisian and foreign physicians 'in the two provinces; (4) difficulty of contractor operations in two rural provinces. 1. Flow of Information: The Government of Tunisia has identified the provinces of Siliana and Sidi Bou Zid for this project activity. However, as discussed in the PRP and other project development documents, the current health system in Tunisia is dominated by services, facilities and educational institutions in Tunis. The proposed project for integrated rural health services delivery in these two provinces is in the nature of a demonstration. If it is successful, then the Ministry of Public Health may plan to extend this program into other provinces. Therefore, this program should serve to create and institutionalize a process which permits effective access to the knowledge gained, allowing it to be applied toward the extension of health services in rural areas through out Tunisia. Project success and potential replicability will - 96
depend on the ability of the U.S. contract team to keep close relations with officials in Tunis. The visit of Tunisian MOPH officials to the U.S. in November, 1976, has established some momentu in this regard, and Dr. Taoufik Nacef, Director, Division of Preventive Medicine, Ministry of Public Health has been designated by the GOT as Program Director for this project. However, in order to insure a capability in the MOPH/Tunis to carry out expansion of this system and to insure regular access to this individual by the contract team, Dr. Nacef should be requested to identify a member of his staff to serve as counterpart to the U.S. contract team. 2. Counterpart Personnel As noted above, designation of appropriate counterpart personnel is a key factor to project success. The Social Soundness Analysis reported that other donors undertaking similar health activities in Tunisia have experienced difficulty in securing counterpart personnel to work with the project teams and carry on activities following completion of the project. The need for such counterparts has been discussed with the MOPH and will be a part of the project agreement signed by USAID and the GOT. However, the MOPH should be requested to identify counterparts in the provinces and in Tunis prior to arrival of the U.S. contract team. - 97
3. Physicians Currently in Siliana and Sidi Bou Zid As discussed in the PRP, the number of Tunisian physicians in,these two provinces is very low. Siliana Hospital has on its staff a full-time French physician and a Tunisian preventive medicine intern. There are also two Tunisian physicians in the city in private practice. Sidi Bou Zid has seven contract physicians from Bulgaria and Palestine. The GOT is currently attempting to place more Tunisian physicians in the rural areas. However, the role of the foreign physicians in relation to this project should be assessed by the U.S. contract team early in the project. 4. Contractor Operations There are numerous administrative difficulties which may arise by having the contract team split between two rural provinces. A good French language capability is essential and some Arabic or willingness to learn Arabic will be required in selecting the contractor. Project success will depend upon selection of an experienced contract team with overseas experience, flexibility in living conditions and the ability to work as a team although each individual will have considerable independence. B. Implementation Plan At all stages during the project design process, the active participation of responsible GOT officials has been an - 98
asset to project development and their suggestions are included in the narrative. Therefore, once the project is approved, implementation should move quickly. If the funds are available, a Loan/Grant agreement should be signed by September 30, 1977. Contractor selection and negotiation for the technical'assist ance services portion of this project will take approximately four months.
The key performance indicators in the implementation of the project, beginning with the signing of the Loan/Grant Agreement through to the anticipated final evaluation, are listed in Annex B. The capital assistance portion of the project which finances construction will be carried out on a Fixed Amount Reimbursement basis. 1. Technical Assistance Imp lemenation A.I.D. technical inputs are designed to assist th( GOT and the province of Siliana and Sidi Bou Zid design and implement a restructured health manpower system. A contract team composed of three long-term advisors (a physician, a non-physician practitioner and a health services administrator) for 3 years each and approximately 9 work months of short-term consultants is planned. The Chief of Party should be a physician trained and experienced in preventive medicine and public health, familiar - 99
with planning and itAlementing rural delivery systems. Overseas experience is also required. Other team members should include a non-physician practitioner with curriculum development and training experience and a health services administrator with an MPH or MBA or equivalent and experience in evaluation and design of health services research, and in planning rural health systems. The team will be stationed in the concerned provinces. Frequent exchange visits will be required and a plan of operation for distribution of the team's skills and time in the two provinces and Tunis will be required as a part o'f the first work plan to"be submitted after the team's arrival.
These logistical arrangements necessitate a conttact team with strong French language capability, previous overseas experience, a willingness to live in a provincial town and ability to function independently but cooperatively. Working with Tunisian counterparts the principal tasks of the technical assistance team will be: A. Restructuring the Role of Front Line Workers -- analyze existing functions and training of non-physician personnel in relation to health care needs designing training courses that will equip these paramedicals to undertake additional priority - 100
tasks (see list of workers to be trained and skills ,'o be taught - Table 8). -- assisting the newly trained field workers to carry out these broadened tasks in an opera tional setting B. Training and supervision of primary care workers and orienting country leaders C. Organizing and implementing an expanded outreach program for preventive services. D. Upgrading the management of the health system and the maintenance of patient records E. Designing and managing a clinical and public' health field training program for interns assigned to the two provinces. F. Designing and testing innovative approaches to health services delivery in the provinces G. Designing a project evaluation covering both technical and capital assistance components of the project H. Strengthening the capabilities through on-the-job training of the Regional Hospital Administrators, Regional Health Inspectors and MOPH Program Director who will assume the responsibility for this program at the end of the A.I.D. project. - 101 -
It is difficult at this point to define which types of short term consultants will be required. Precise needs should be identified when work priorities are established. However, each consultant must have a defined time-limited scope of work which supplements and complements the work of the contract team. Short-term consultants in the following fields are anticipated:
-- Architectural/engineering advice on health center construction
-- Health manpower
-- Curriculum training specialist
-- Environmental health
-- Budged planner
-- Medical records
-- Health Management systems
-- Health planning.
The project also funds a short-term non-degree training program in the U.S. for several key provincial trainers, supervisors or counterpart personnel. Within the first six months, the contractor will recommend to USAID appropriate individuals and type of training program to be'undertaken. Following A.I.D. and GOT approval, the contractor will be responsible for setting up the U.S. program. - 102 -
Within 90 days after arrival in Tunisia the contractor will develop, in consultation with the GOT counterparts, a de tailed Plan of Work for the subsequent year for USAID approval. This Plan will cover the anticipated scheduling of key actions and inputs, including estimated phasing of short-term employees. The Work Plan should be based on a revalidation and refinement of the health worker functions and productivity assumptions made as part of the project design (See Table 8). Based on this review, the Work Plan must address the following project components:.
-- Retraining programs for non-physician personnel (including short courses, on the job training, and updating skills); -- Plan for use of preventive medicine internships; -- Upgrading of management records systems; -- Plan for training and orientation of community leaders; Type of research/evaluations to be carried out in the course of this project, taking particular note of issues identified in Social Soundness Analysis and this PP; -- Evaluation timeable/design. Contract funds are also included to cover costs of training materials and the innovative field tests/evaluations. - 103 -
Annex B identifies the key project performance indicators in implementation of the project. The following time schedule indicates key contractor actions during the first year: 10/77 - RFP released
1/1/78 - Contractor Selected
2/1/78 - Contractor Arrives Tunisia 4/1/78 - Work Plan for Ist year due 4/1/78 - Equipment list reviewed with GOT/USAID 4/1/78 - Site selections for new centers and renovatiDns reviewed with GOT/USAID 5/1/78 - Completed job analysis report submitted redefining roles to GOT 5/31/78 - GOT/Contractor agreement on new job definition as basic training program design 8/1/78 - First Semi-annual report due including report on field tests to be undertaken, in particular tests to recruit female participation 11/78 - First Evaluation conducted by USAID with AID/W participation. 2. Capital AssistanceImolementation The loan portion of this project ($3 millioro will fund: -- Construction of 21 new basic health centers -- Renovations and/or expansions to 19 existing facilities -- Equipment for these facilities. A.I.D. intends to disburse loan proceeds by reimbursing the GOT under a fixed amount reimbursement (FAR) procedure - 104
whereby pre-construction agreement is reached on a fixed Dinar amount per type of center, equivalent to 75% of the estimated construction contract amount, any cost overrun being borne by the GOT. In June 1977, Ms. Susan Christie Shaw, Rural Health Facility Planning and Design Consultant, visited Tunisia with the project design team to develop functional design and preliminary architectural schematics for the facilities and establish current and projected cost estimates. Her report dated July 15, 1977 provides a full description, schematic design, costing, etc. of the proposed construction. Construction and renovation will include three Health Center designs:
TnaC_: Two type C centers are proposed; the differences are the size of the service area and the presence of an itinerant physician. Type Cl/large will serve between 2,500 - 5,000 people. Type C2/small will serve an area of approximately 2,500 people.
Type C centers will be located in some regroupments as well as in sector seats and will provide ambulatory care only. - 105 -
Type Cl/large shall be designed to allow for future ex pansion for maternity in-patient services should the need and demand occur. Type Cl becomes a Type B with the expanded maternity services.
Type B: These :fi.ters will serve a population of 5 - 10,000 and will include all the integrated services of Type Cl, plus a full range of prenatal, delivery, post-natal, gyn, and family planning services. The facility requirements are a Cl basic health center for out-patients with expansion to include 5 - 10 maternity beds with the appropriate support areas. Type A: These centers will serve a population of over 10,000; assumed location is in delegation seats. The pro gram of services is the same as Type B, plus 5 - 10 short term in-patient beds for general medical and pediatric patients. Space in Phase I should be provided for future X-ray and expanded laboratory services. The out-patient facilities are larger in a Type A center than in a Type B or Cl, where they are the same.
The regional rural hospitals are existing facilities in the provincial capitals. The program of integrated services, both for in-and-out patients, will be the same as those programmed for the Type A basic health center, plus radiography and expanded laboratory capacity. - 106 -
Improvements at this level include X-ray, laboratory, library, classroom and office space for recycling the existing workers and continuing education, and expanded out-patient services.
Location and Site Selection: In order to accommodate the integrated services proposed for the rural provinces of Siliana and Sidi Bou Zid, workers will be retrained or recycled and facilities will be con structed or renovated. A complete inventory was made of existing facilities, visits were made to all facilities in all capitals and delegation seats along with several sector seats, other small towns and regroupments. The recommendation, resulting from in-depth discussions in the provinces with representatives who know priorities, resources and needs, is for the design and new construction of twenty-one (21) basic health centers (Types A, B, and C) and nineteen (19) renovations and/or expansions to existing facilities.
These new and renovated basic health centers, proposed to provide both out-reach as well as out-patient/ambulatory care, and, in some cases, in-patient care, have been preliminarily located in accordance with the following siting criteria: 1. Assuring health services to population with limited or no access to basic health care (preventative and curative); - 107
2. Providing a framework for supply, supervision and referral;
3. Proximity to roads or "pistes" that are passable; 4. Complementing and reinforcing che economic and social development priorities in the provinces (regroupment); 5. Assuring that physicians are available for Type A centers; 6. Assuring resident mid-wives for Type B, along with a part-time physician, and; 7. Assuring itinerant physician is available for Type Cl/large. The agreed upon list of proposed construction and renova tion for the forty (40) sites is demonstrated in the chart below:
Location by Town or Sector and Facility Type
SILIANA SIDI BOU ZID New Construction
Type A El Krib Jelma Rohia Ouled Haffouz Mezzaouna Type B Robaa Type C Jama El Kerma Ed-Dkhania Lassouda Sadiane Zaafri.a Es-Smirat Ec-Zitouna M'Sahla Es-Saida El Haria El Hania Bir El Amama El Mansourah El Milia - 108 -
SILLNA .SIDI BOU ZID Renovation' and/or Exp-ansion Type A Bou Arada Sidi Ali Ben Aoun Gafoud Er-Regueb Maktar Maknassy Siliana Sidi Bou Zid Type B --- Menzel Bouzajane Type C Sidi Morched M'Ghilla Bou Rouis El Hameima El Aroussa Bouttoumet Bou Jlida El Mech Kessera EJ-Jmilat Along with the programmatic basic criteria for locating the health centers in the respective communities, was given to the following preliminary factors for assessing the proposed tracts of land/sites: 1. Topographic and geological characteristics of land in terms of drainage, surface soil characteristics, integrity of land to provide for a structurally sound and economic construction: 2. Exposure to sun and prevailing winds; 3. Adequate supply of potable water (in some instances there may be a problem with year-round water supply but if required, potable water can be provided by means of a large tank); 4. Storm water and sewage disposal connections. (Central sewage systems are not available in most cases. Adequate septic or closed systems with drainage field can be pro vided as required depending upon the nature of the particu lar soil's capacity to drain.); - 109
5. Proximity to the center of the community for pedestrian as well as vehicular traffic; 6. Proximity to other health delivery facilities; 7. Free from noise and air pollution; 8. Availability of electricity and other services (in many cases non-existent but forthcoming); 9. Availability of the land, and; 10. Size and shape of the proposed tract. In conversations in the provinces, no significant problems were noted. As to the availability of land. In most instances, but not all, there was land designated or available for new construc tion. The exact location of proposed new construction and/or expansion and renovation should be again verified in terms of the aforementioned factors and in terms of adequate size along with available services with respect to the proposed facility to be built.
Cost
The financial analysis section of this PP discusses how the cost estimates were arrived at by Ms. Christie-Shaw. Both USAID and the GOT have reviewed her report. Table 13 provides a breakdown of the renovation and construction costs by type of center. These cost estimates are based on schematic designs. Final drawings will be prcpared by the Ministry of Equipment for the MOPH and carefully reviewed by A.I.D. Engineers. Subject to inspection by the MOPH and USAID Engineers and certification that the construction and/or renovation meets agreed standards, - 110 -
USAID will pay 75% of the construction costs. Site Selection: The sites identified herein must be confirmed by the MOPH and USAID following review of the design plans and based on site selection criteria, site priorities and service provided from the center or defined in this PP. Each site will be jointly certified by the MOPH and USAID based on a site visit. Construction Schedules: Upon completion of the site certifications in each Region, the MOPH will make arrangements for construction contracts. Construction should begin as soon as possible but not later than 120 days after site certification. Construction Monitoring Construction will be monitored both by MOPH and USAID personnel. At lease one visit will be made to each site while con struction is underway. A final site visit is required by USAID to certify the building is complete and meets agreed standards. This is necessary but not sufficient condition for FAR payment.
The Operational Basic Health Center The Project Agreement signed between USAID and the MOPH should describe the criteria to be met by a health center to qualify for reimbursement by USAID of 75% of the agreed upon direct construction costs: materials, labor and transportation. Each center will have a minimum staff of qualified personnel, each of whom will receive additional, in-service training. For a Type A Center, minimum staff will include: one physician and one midwife.. Type B minimum staff: one midwife, on integrated front line worker and scheduled visit by a - 111
physician at least one-half day per week. Type C minimum staff: One integrated front line worker.
Operational Criteria: 1. Staff must be 2ssigned to the Center and have completed in-service training or be scheduled for such training. 2. Each clinic will have the necessary supplies (ledgers, charts, etc.) necessary for the maintenance of a complete clinic record system. 3. Each BHC will have the minimal medical equipment for the services to be provided. 4. Each BHC will have sufficient drugs, medic.Lies, dressings and other supplies sufficient for three month's operations. 5. The leadership of each village within the center catch ment area will have been visited by an employee of the MOPH and been advised of the date the center is to open and of the kinds of service it is to be prepared to depense. 6. Each BHC will bave been inspected jointly by USAID and the MOPH prior to, during and upon completion of construction and be certified for adherence to site, design and construction specifications The above criteria will be met before the USAID project advisor and USAID's Engineering and Controller staff will certify a Center "operational" and eligible for FAR payment. To insure this system proceeds in an orderly and timely fashion will require continuous and careful monitoring by MOPH and USAID staff. Coor dination of all project components -- personnel, ttaining, con struction, supplies reporting -- must be carefully maintained - 112
and schedules adhered to.
C. Evaluation Plan From the outset of the project, special efforts should be made to develop and refine baseline data on health status in the two regional provinces. A key function of the contract team will be to upgrade the maintenance of patient records. The logical framwork and Performance Tracking Network set out a time schedule of the outputs. Formal evaluation sessions should be held annually be USAID using these evaluation bench markers, with participation from AID/W, the contractor and the GOT as deemed appropriate. In addition, the contract team, possibly with the assistance of a consultant, will develop a design for an eval uation of the project at its conclusion, covering both technical and capital assistance components of the project. This evaluation should assess not only the success of this project, but also examine the conditions for success of similar efforts. Questions which should be addressed include: 1. Do the Siliana and Sidi Bou Zid rural health improvement programs make sense? 2. Should they be continued? 3. Should they be expanded to other provinces? 4. How might they be modified? 5. What can we learn from these experiences? 6. Have the programs contributed to meeting the health needs of the population any better than unrestructured programs in other provinces? - 113
7. If so, is the additional cost worth the benefit? These questions fall within the purview and reseprch interest of the Department of Preventive Medicine at the Faculty of Medicine, Tunis and the MOPH. The Ministry of Public Health should be encouraged to collaborate in the evaluation process with the Faculty of Medicine. - 114 -
D. FOREIGN DONOR COORDINATION The social soundness analysis made extensive use of foreign donor experience in formulating recommendations. Continued communication with the personnel of other health projects will be carried out by the technical assistance team. Both collegial contact and lessons learned can enrich the project. Some donor projects are complimentary. Project Hope has worked closely with the Ministry of Public Health to restructure curriculum, job descriptions, and to formulate an integrated preventive health strategy. An on-going dialogue with Hope personnel would be mutually beneficial in terms of testing assumptions about the training program, the strategy, and, finally, the problems of recruitment of auxiliary health workers. UNDP-WHO is sponsering a Belgian MD. who will begin sometime in late 1977 a course of instruction for monatrices, or teachers for the nursing schools (at present there are only twenty monatrices in Tunisia). Contact with this program would likewise be mutually beneficial.
Although the future of the Dutch program in LeKef is uncertain at the time of this writing, it deserves attention. A number of innovative ideas were put on trial in this project which could be instructive. The director, Dr. Vanderstraaten, worked closely with an anthropologist, Dr. Jungmans. Together they studied the indigenous system of health care, formulated a range of taks which could be performed by auxiliary workers, - 115
and began recruiting village medical assistants. Each was
a pioneering effort. The Dutch program also worked out a close relationship with the U.S. Peace Corps which was highly sucbessful. The Belgian project at Cap Bon has
also a considerable fund of experience worth drawing on. The Belgians were the first to make imaginative use of aids sanitaires, or malaria workers. They have success
fully incorporated research projects into their public health program, effected a close link to the nursing
school at Nabuel, and evolved an effective strategy. The HOPE project at Monastir under the direction of Dr. Stephen
Simons will be an attempt to implement che comprehensive
and ambitious strategy developed at the Ministry. The progress of this effort will certainly be instructive.
There are some public health projects which could be drawn
upon for direct cooperation. CARE has a modest program to develop uncontaminated water sources in remote areas. The Peace Corps program in Tunisia has detailed volunteers
for similar work and has emphasized auxiliary health
personnel volunteers. Samir Zogby, the Peace Corps Director in Tunisia, has already expressed his desire to cooperate with the AID project. It is possible that these donors could contribute not only work and qualified personnel,
but methods of dealing with some of the morale and administra
tive problems which have plagued attempts to draw more young auxiliaries into service in remote areas. - 116 -
Additionally, A.I.D. is proposing a Family Planning Services Project beginning in FY 78 (664-0295) which will develop an effective low cost family planning delivery system to provide supplies and services to a large portion of the population in reproductive age. Project emphasis will be on villages and households in the most rural areas. This Family Planning Services project also includes training of medical and para-medical personnel. There are obvious inter-relationships between the two activities and USAID should make every.effort to assure close coordination. ANNEX A
PROJECT DESIGN SUMMARY LOGICAL FRAMEWORK
(for ease of reference - see facing pages) AID m--,,a.vu PROJ ECT DESIGN SUMMARY Life of Poi1
LOGICAL FRAMEWORK FromFY ____o TeIsl U. S. FMon _3FY 40L Proec Ttale &HMs. Rural Comnity Uealth - Silisn and Kid' gnnu 24A XP.Ipea - Tunisia - 0296 Dot. Piepord: * n177 NARRATIVE SUMMARY OBJECTIVELY VERIFIABLE INDICATORS MEANS OF VERIFICATION Program IMPORTA4I ASSUWTIOHS w Stow Gol: The a&der ojeclIve te Measures .1 Goal Achievement: Asum t achueving gal targets: ubb tlis project caneribeuqs: Improve quality and coverage of I primary Increased percentage of population Utilization care in iliana and Bid Son Zid data, ongoing management COr maintains high level using services. audit; including of sampling of patient interest in rural health. Changes in morbidity/mortality patterns.
Project purpoe: Conditios "t will indicate pupose has been Assumptims for Ietructure mon-physician achieving puIpose: primary care and operationalisecomponent of achieved: End of project status. new - training curriculum for non- Project system in expanded network of records; - continued interest physician practitioners observation by COT facilities. of non-MD's in actions in broadening functions established observation of of facilities; non-MD's - a1 categories completed some examination of training training for interns. - availability of GOT support for expanded - retrained workers carrying out program (peoph roles on the Job a money)end valability of US TA team. - network of new facilities will be completed -field tr1ling C,; . ._-Z Magnitudee t of1 Outputs: . I ] system for interns - Carriculm for mo-phyaician. Assumptions - Operational U1/78;fnalized 8180 Project for aclievming oupus: - 250 retrained Manager certification - adequate workers supervisors and - By 8/79 100; By 8/80 250 numbers of workers local officials available for training Project records - renovation and costruction of 40 - 20 facilities completed courses am facilities by 5/79 comrse 40 facilities completed by 8/80 Inspection - operating field training program - Designed tiely selection by GOT of for interne elered by HOPH by 3/79 con str In operation by 1/80 Observation - improved patient tineli, construction of record sad management - Being tested 11/78; operational 8/8 Gystm. facilities by GOT contracts. - equipmst Examination of System in place and utilized for 2 hospitals by 11/78; 50Z training and of treatment centers by 2/80; lO0 by 8/80. &A 1in"#lN PROJ ECT DESIGN SUMMARY We soP.iqq W".. FYF LOGICAL FRAMEWORK T*W.V. 9L L Foodes 3t- %=- - 11 I SoeTide A 16 m 4a lr0 Cgeael tw Noolih-- 1 A A -a - TTunisa Risa " 0i Das NARRATIVE SMA.R OBJECTIVELY VERIFIALE INDICATORS MEANS OF VERIFICATION " PORTANT ASJUPTIONS p-a IWpammhe. Tasapl (Type and Qmatyj) Asas.ptils I puIwdig hils e ll prjamcii 911 TA ge ms Review of Irecords - availability US TrA team pide ai ad funding mal Aveekas practittooot - availability.- ca o balth AdImisrator tuads for project -consultant& (9m) -IPartlclpant training - reovation o acilities - onruction of m facflities - gUlmeaft let centers local Costs of reaarcb program
- e1=a to 251 coestruction sad remsattoo - dAsises - suprvisio costructioe - lIiashiq tralnin facilities - e lies operating costs lares cowa gparts m Irt of coui act cam - tra"rt alines .- _---lzi"Itranspert onsusachars per d.lm tira esa oeratig comtes f ealth system ANNEX B COUNTRY PROJECT NO. jPROJECT TITLE |DATE ORIGINAL APPROVED T Rural Community Health REVISION PROJECT PURPOSE (FROM PAP FACESHEET) 7. 4/78 Completed job analysis Restructured health manpower report submitted system through redefining roles to GOT by Contractor (USAID/ the requisite administrative, management, GOT) and capital development support mechanisms. 8. 4/78 Contractor work plan due 9. 5/78 GOT/Contractor agree on new job defini tion as basis training program design (USAID) HroSCRIPtiOn 10. 6/78 Construction contract signed for 50 Prior Actions (enough for trainees in early training prog- rams)(USAID) Pre project analysis functions rural health workers in place (contract) 11. 8/78 Construction team mobilized on sites Specs for lab and health center equip. w/equipme;, working on 50 of centers (USAID) agreed to (AID/W) 12. 10/78 Adequate funds covering training, opera CPI Descriptions: tional cost centers in GOT budget with funds available training now (USAID) 1. 9/77 ProAg signed (GOT/U5AID) 13. 11/78 Interim evaluation underway (USAID) 2. 12/77 Lab and health center equip. reviewed 14. 11/78 Training design completed per CPI 8 with USAID and AID/W and ordered USAID; (GOT; (USAID) AID/W) 15. 11/78 Equipment installed in 2 project hospi 3. 12/77 List of sites submitted by GOT and tals to support training program (USAID) approved by USAID. GOT plans for centers USAID (USAID/GOT) 16. 1/79 Training programs using new curriculum 4. 1/78 TA contract signed (AID/W) underway with students (USAID) 17. 1/79 Construction contract signed for 5. 2/78 TA team on duty at agreed field remaining 50 (USAID) sites (USAID) 18. 5/79 50 of centers - 6. 2/78 TA team working construction complete; with designated GOT equipment in place - staff assigned (USAID) counterparts on job definition (USAID) 19. 8/79 Last training program starts per CPI 15 ,(USAID) 40& WIN CRITICAL PERFORMANCE INDICATOR (CPU DESCRIPTION COUNTRY ~PROJECT NO. jPROJECT TITLE 'DATE OIIA Tunisia 1 664-0 O i Rural Community Health IBREVI.sON. CPI Descriptions (cont'd): 20. 11/79 Evaluation (USAID) 21. 1/80 50% of centers in operation (construe tion complete; staff in place; equipment operational; budget available )(USAID) 22. 2/80 Outreach programs operational for 200,000 people (USAID)
23. 2/80 Evaluation scope of work agreed by GOT, USAID and contractor (USAID) 24. 8/80 Functional Rural Health System in 2 Provinces.
- Better health care to 200,000 people - Outreach increased (programs - coverage Trained people - 85% of construction completed and operational per CPI 19. - Lab and other equip, in 2 rural hospitals and new health centers utilized for training and treatment - Redefined rules operational and acceptable - tested by evaluation
- Replicability of program in other parts of Tunisia (tested by evaluation's indices agreed CPI 23) - GOT budget for Rural Health in 2 Provin _-toeat, evel continue program AD Ma CRITICAL PERFORMANCE INDICATOR (CPI) DESCRIPTION COUNTRlY IROJECT NO. ROETTITLE DT IOIGNALSRGNLAPOE .. POVED Timisi a r 664-0296 R 1I Commmiunlty Heal h OATE RF anFY
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AIGALYISEElCaUVII FINANCIAL
AID III& 67 CRITICAL PERFORMANCE INDICATOR (CPl) NETWORK A4NNEX C
STATUTORY CIMECKLI STS
I Country Checklist :enteral! Criteria for Councry
1. FAA Sc. J16. Cai it be demon-. Yes. Project will 3trtetd that coniLcniplated extend assist- health services to the poor ance will directly, benefit the of two rural provinces needy? rT not, has of the Department Tunisia - Siliana of and Sidi State decermined that this govern- Bou Zid. ment has engaged in consistent pat tern of gross violations of inter nationally recognized human rights?
2. FAA Sec. 481. Has it been deter- No. mined that the government of recip ient country has failed to take ade quate steps to provent narcotic drgs and ocher concrolled sub :Lanevs (as dofe d by the Conpre Ih.isive Drug Ahuse Prevention and (:,,itrol. AcC or IQ70) produced or 'irL'uss'd, iii wh tc or in part, iln lt'llLrV, or Lrati.porccd throu,,gh such councry-, from being sold ille gally within the jurisdiction of such country to U.S. Government per sonnel or their dependents, or from entering the U.S. unlawfully? 3. 6 0 FAA Sec. 2 (a). Does recipient No. country furnish assistance to Cuba or fail to take appropriate steps to pre vent ships'or aircraft under its flag from carrying cargoes to or-from Cuba? 4. FAA Sec. 60(b). If assistance is to Yes. a government, has the Secretary of State determined that it is not con trolled by the international Cormnunist movement? 5. FAA Sec. 620(c). If assistance is to No. goverrmaent, is the goverwenc liable as debtor or unconditional guarantor
or servLecs furnLhed or ordore.d wi're (a) such cti..il ha exhausted avail able lc-aL retimdies and (b) debt is not tlniied .or coiltotscd by suchi goverunmcnt?
6. FAA Sec. 6 20(c). If assistance is to No. a government, has it (including govern ment agencies or subdivisions) taken any action which has the effect of nationali.'z ing, expropriating, or otherwise seizing ownership or control of property of U.S. citizens or entities benefically owned. by them u-ithout taking steps to discharge its obligations toward such citizens or cutitics?
7. FAA Sec. 620(f); App. Sec. 108. Is No. recipient couwlry a Conmunist country? Will assistance be provided to the Ik, ocratic Ropublic of Vietnam (North VitLiiam), SouL11 VEtan)ir, C.'mbodia or
X. FAA Se'c. (20(i). Is recipict co'untrv No. in any way involved in (a) subversion of, or military aggression against, the United States or any country receiving U.S. assistance, or (b) the planning of such subversion or aggression?
9. FAA Sec. 6 20(j). Has the country per- No. mitted, or failed to cake adequate measures to prevent, the damage or de scruction, by mob ac..tion, of U.S. pro perty?
10. FAA Sec. 620(1). If the country has Tunisia has an investment failed to institute the investment guarantee program with the guaranty program for the specific United States. risks of expropriation, inconverti bility or confiscation, has the AID Administrator within the past year considered denying assistance to such governmnct for this reason? ANNE.X C Jaie. 3
11. FAA Sec. 620(o); Fisheri4n's Protective Tunisia has taken no such Act, Sec. 5. If country has seized, or action. imposed any penity or sanction against, any U.S. fishing activities in inter natilonal waters,
a. has ny deduction required by Fisher ne11's Protectivc Act beten made?
b. has complete denial of assistance been considered by AID Administrator?
12. FAA Sec. 620(g); Aoo. Sec. 504. (a) Is Tunisia. is current in loan the governmient of the recipient country payments except for two in default on interest or principal of underpayments which are any AID loan to the country? (b) Is presently being negotiated country in default exceeding one year between AID and that Govern on interest or principal on U.S. loan ment. tinder program for which App. Act appro priatus funds. unless debt was earlier disitiod, or apliproprL tt: steps takeri I cu're deft[ilL.
I 1. FAA So.'." bO2((s. Wlit percttt:'g of ArounJ 5'1'. of the country's v'ttilLry I'udget hs f r military axpctidi- budget i.s for military ex Liarv's? How much of fQreign exchange penditures. This has not resources spent on military equipment? been determined to be an H1ow much spent for the purchase of excessive amount. sophisticated weapons systems? (Con sideration of these points is to be coordinated with the Bureau for Pro- gram and Policy Coordination, Re gional Coordinators and ilitary Assistance Staff (PPC/RC).)
14. FAA Sec. 620(c). Has the country Tunisia has diplomatic re severed diplomatic rela'ions with lations with the Unites the United States? IL so, have they States. been resumed and have new bilateral assistance agreements been negotiated and entered into since such resumption?
15. FAA Sec. 620(u). What is the payment Payments are not in arrears. status of the country's U.N. obliga tions? If the country is in arrears, were such arrearages taken ihto ac count by the AID Administrator in due:r..ning the currcnt AID Opera tional Year Budget? ANNEX C
I. FAA So.-c. 620A. Has tc CoutILrV No. granted sanctuary from prosecution to any individual or --roup which has commit.ed an act of inter national terrorism?
17. FAA Sec. 666. Does the country No. object on basis of race, re liion, national oriiLn or sex, to the presence of any officer or employee of the U.S. there to carry out economic development programn under FAA?
18. FAA Scc. 669. Has the country No. delivered or received nuclear repro cassing or enriclvnenc equipment, materials or tcchnology, without specified arrangements on safe guards, etc.?
19. FAA Sec. 901. Has. Ehe country No. denied its citizens the right or opportunity to emigrate?
Funding, Criteria for Country
I. Develoorw.nt Assistance Country Criteria
a. FAA Sec. 102(c),(d). Have cri- The Government of Tunisia ceria been established, and taken has performed sophisticated into account to assess cormnitment social science research on and prot-rcss of country in effec- nutrition and dietary pro tively involved the dor in de- blems, income distribution, velopment, on such indexes as: and population growth. Fin.d (I) small-farm labor intensive ings have been incorporated agriculture, (2) reduced infant into ongoing GOT programs
mortality, (3) population --rowth, . in health and population. (4)ohUnemployment is a serious (4) equality of income distribu- domestic problem, the re tion, and (5) unenloyment. duction of which has been a principal objective of the current Five Year Plan. A major thrust of the new Five Year Plan is to address re giot.al imbalances in the access to social services, in particular medical care and education. AID monitors these Tunisian efforts to assist the poor and Lnvolve them in development. ANNEX C Page 5
b.. FAA Sec. 01(b)(5).(7) & (S): Sac. 208: 211(a)9 4 ),(7). Describe excenc co which country is:
(1) Making ppropriatce efforts to In- The GOT has undertaken major crease food produccton aind improve integrated crop production for it.ans food storage and dis- programs in wheat, the staple tribution. food, during the past five years which have resulted in a doubling of production. Research to adapt new prac tices is being strengthened. Grain sto'age needs have been closely watched. Although capacity has been judged ade quate in the past, the U.S. is now reviewing a GOT request for construction of new storage capacity and improving grain .handiing facilities.
(2) Creacing a favorable climate Tunisia has launched an ag for foroi;,i ad domestic pri- 1ressive policy of accraccing •vaCe unLorprise andeinvest- foreign private and %ncourag isnt., inS doinestic private inve-c mcnt. The national invcstirmnt promotion agency, API, has been very successful in at traccing new foreign invest ment to Tunisia. last year, API approved over 500 appli cations for investment pro jects. Domestic investment has been channeled into such sectors as tourism, which has witnessed phenornenal ex pansion over the last decade. (3) Increasing the public's Through a wide variety of role in the developmental programs aired at youth, wcmen, process. rural populations, and urban poor, the GOT seeks to provide educational and other oppor-' tunities to expand the partici pation of the public in the developmant process. ANNEX c .Pa e 6 (4) (a) Allocating availaLle bud- Tunisia boasts an ir. aetary resources to developmenc. presstvely hi-h savings race, and has financed mos:i of the inves.ir.nt which over the last five years has underlain a rate of 1;rowt.h avcraging q per year. Covevrnment progrrmts are concentratcd on developmental programs. (b) Divcrting such resources Tunisia maintains a mili for unnecessary military ex- tary establishment which is penditure and intervention in very.modest in relation to affairs of other free and in- i'ts defense needs. Tunisia dependert nations, has not engaged in or in directly supported inter ventionist actions in foreign nations. (5) aking economic, social, and Tunisian economic policies political reforms such as stress private business tax collection improvements initiative and foreign in and changes in land tenure vestment. arrangements, and makinG pro gress toward respect for the rule of law, freedom of expres sion and of the press, and re cognizing the importance of individual freedom, initiative, and private enterprise.
(6) Otherwise responding to the Among nations of the third vital economic, political, and world, the GOThas an im social concerns of its people, pressive record of economic and demonstrating a clear de- growth during the last five termination to take effective years. High rates of eco self-help measures. nomic growth have been ac companied by si-nificantly improved diets, falling birth races, and reduced infant mortality. The great bulk of the investrrent which has permitted -rowth has come from domestic sav ings. Inflation has been kept under control. Economic policy has stressed compara tive advantage, stressing tourism, light industry, nid mineral resources. A ,inji-r effort to aclticvef. . susCailting gruwLh is Lo lo. launched with the new Fivt: year Plan this year. ANNEX C Page 7
Co FAA Sac. 201(b). 211(a). is Yes. the country amonil the 20 countries in which devolopmenc assistance loans may be made in this fiscal year, or among the 40 in which development assistance grants (otlher than for self-help projects) may be made? d. FAA Sec. 115. Will country No. he furnisled, in same fiscal year, ci eoar.ecurfty supporting as siLtance, or Mliddle East poace funds? If so, Is assistance for population programs, humanitarian aid throuIh f.nternational organiza tions, or regional programs? Pane 8
STATUTORY CHECKLISTS Ir Project Checklist A. General Criteria for Project
1. AM. Unnumbered; FAA Sec. 653(b) Included in AID's Con (a) Describe how Comnittees an gressional Preientation Appropriations of Senate and House for FY 1978 at *3. 830. have been or will be notified million.Congressional noti concerning thd project; fication will be needed to (b) is assistalco within (Opera- shift to FY 1977 and revise tional Year Budget) country or inter .the amount. national organization allocation re ported to Congress (or not more than $1 million over that figure plus 10%)?
2. FAA 6 Sec. 11(a)(1). Prior to ob- Yes; see Part II and II of ligation in excess of $100,000, Wll PP as well as Anne.es G and H, there be (a) engineering, financial, and ocher plans necessary to carry out the assistance and (b) a reasonably firm estimate of the cost to the U.S. of the assistance? 3. FAA Sec. 611(a)(2). If further legis- No further legislative action lative action is required wi'hin 're- within the recipient country cipient country, what is basis for will be required. roasonable expectation that such action will be completed in time to permit orderly accomplishiment of purpose of the assistance?
4. FAA Sec. 611(b); Aoo. Sec. 101. N.A. If for water or water-related land resource construction, has project met the standards and criteria as per lemorandum of the President dated Sept. 5, 1973 (replaces hemorandwu of hay 15, 1962; see Fed. Register, Vol 38, No. 174, Part I1, Sept. 10, 1973)? ANNEX C Page 9 5. FAA Sec. 611(e). If project is capital Yes; see Annex D. assistance (e.g., construction), and all U.S. assistance for it will exceed $1 million, has Mission Director cer tified the country's capability effec tively to maintain and utilize the project?
6. FAA Sec. 209, 619. Is project sus- No. This is a sall rural health ceptible of execution as part of re- project limited to two rural gional or mutlilateral project? If provinces. so why is project not so executed? Information and conclusion whether assistance will encourage regional development programs. If assistance is for newly independent country, is it furnished through multilateral or ganizations or plans to the maximum extent appropriate?
7. FAA Sec. 601(a); (and Sec. 201(f) for (a) thru (f) N.S. development loans). Information and conclusions whether project will en courage efforts of the country to: (a) increase the flow of internation al trade; (b) foster private initia tive and competition; (c) encourage development and use of cooperatives, credit unions, and savings and loan associations; (d) discourage mono polistic practices; (e) improve tech nical efficiency of industry, agri culture and connerce; and (f) strengthen free labor unions.
8. FAA Sec. 601(b). Information and The project area and its economy conclusion on how project will en- are too small to have effects courage U.S. private trade and in- outside Tunisia initially. If vestment abroad and'encourage pri- the project is successful, the vaete U.S. participation in foreign Government of Tunisia will vateU.S pariciatin inforignhave to increase its purchase of assistance programs (including use ha to ies its purchaenof of private trade channels and the medical supplies and equipment. services of U.S. private enterprise). Annex C Page 10
9. FAA Sec. 612(b); Sec. 636(h). Des- See PP text cribe steps taken to assure that, to Part III and IV. the maximum extent possible, the country is contributing local cur rencies to meet the cost of contractual and other services, and foreign cur rencies owned by the U.S. are utilized to meet the cost of contractual and other services.
10. FAA Sec. 612(d). Does the U.S. own ex- As of the close of FY 77 cess foreign currency and, if so, what Tunisia will cease to be arrangements have been made for its an excess currency coun release? try.
B. Funding Criteria for ProJect
1. Development Assistance Project Criteria This project will make a. FAA Sec. 102(c); Sec. 111; Sec. 281a. health care available Extent to which activity will (a) ef- to small towns and rural fectively involve the poor in develop- areas which do not ment, by extending access to economy now have access. at local level, increasing labor intensive production, spreading in vestment out from cities to small towns and rural areas; and (b) help develop cooperatives, especially by technical assistance, to assist rural and urbzn poor to help. themselves toward better life, and otherwise encourage democratic private and local governmental institutions?
b. FAA Sec. 103, 103A, 104, 105, 106 Is assistance being made available: Einclude only applicable * paragraph - e.-. a, b, etc. -- which corresponds to source of:.funds used. If more than one fund source is used for project, include relevant paragraph for each fund source.]
(1) [103] for agriculture, rural develop ment or nutrition; if so, extent to which activity is specifically de signed to increase productivity and income of rural poor; [103A4 if for agricultural research, is full ac count taken of needs of small* farmers; AIMM[' C Page 11 (2) [104] for population planning or Project will achieve this health; if so, extent to which purpose. Thru upgrading iiCtiVity vxUt.i iow-cotL, Wil- skills of non-physician tera~ttl do Iivery sLtemgs LO pro- health wo;kers and providing vide 1Ial0l1 ammd (Mni ly platining appropriate rural health services, especially to rural facilities. areas and poor;
(3)£105] for education, public ad ministration, or human resources development; if so, extent to which activity strengthens nonformal education, makes formal education more relevant, especially for rural families and urban poor, or strengthens management capability of institutions enabling the poor to particinate in development;
(4) [106] for technical assistance, energy, research, reconstruction, and selected development problems; if so, extent activity is:
(a) technical cooperation and develop ment, especially with U.S. private and voluntary, or regional and inter national development, organizations;
(b) to help alleviate energy problem;
(c)research into, and evaluation of, economic development processes and techniques;
(d) reconstruction after natural or manmade disaster;
(e) for special development problem, and to enable proper utilization of. earlier U.S. infrastruJture, etc., assistance;
(f) for programs of urban development, especially small labor-intensive.en terprises, marketing systems, and fi nancial or other institurions to help urban poor participate in economic and social development.
'U" ANNEX C Pa.ge (5)[1071 by grants for coordinated private effort to develop and disseminate Intermediate tech noloLes appropriate for deve lopment countries. c. FAA Sec. 110(a); Sec. 20(e). Is Yes. The Loan/Grant Agreement the recipient country willing to con- will provide for at least tribute fuit. to the project, and in 257. contribution to pro what mainer has or will it provide as- ject costs by the recipient surances tlmia it will provide at least country. 25% of the prograin, project, or acti vity with respect to which the assist atice is to be furnished (or has the latter, cost-sharing requirement been waived for a "relatively least-developed" country)?
d. FAA Sec. 110(b). Will grant capital assistance be disbursed for project over more than 3 years? If so, has justifi cation satisfactory to Congress been made, and efforts for other financing?
. FAA Sec. 207; Sec. 113. Extent to Major objectives of this which assistance reflects appropriate project include 3, 4 and 6. emphasis on; (1) encouraging development of democratic, economic, political, and social institutions; (2) self-help in 1K1Vting the country's food needs; (3) improving availability of trained worker-power iu the country; (4) pro gramsis desit.ned to mnect the coulitry's Iih'altih needs; (5) other Important areas of economic, political, and social development, including in dustry; free labor unions, coopera tives, and Voluntary .Agencies; transportation and cormiunication; planning and public administration; urban development, and moderniza tion of existing laws; or (6) in tegrating women into the recipient country's national economy. ANNEX C Page 13
.f. FAA Sec. 281(b). Describe ex- tent to which This project was developed program recognizes the in response particular needs, to a Tunisian desires, and capa- request and cities of the Tunisia Ministry people of the country; of Health utilizes the country's and provincial intellectual health officials resources to encourage have played institutional a major role development; in the project and supports civic edu- design. cation and training in skills re citred for effective participation in nov'rmllnltl and political. processes c'sseitl. ial to sel -Sover1lilt.
g. FAA Sti. 21())..(4) atd -W() Health .Sec. 201(e); resources in the S.c. 211(a)()-(3) and -(8). project Does the activity area are minimal. give reasonable pro- Project ise of contributing will assist the GOT to the development: to of economic resources, provide better health or to the increase care at lower of productive capacities per capita costs ana self- to the rural population. sustaining economic growth; or of educa- These goals are incorporated tional or other institutions directed in GOT development plans. -toward social progress? Is it related to and consistent with other development i activities, and will it contribute to realizable lo-ig-ranee objectives? And does project paper provide information aiid cotteltiusl, o i 1ni an activity's eCOilOic aid Lechnical soundness?
I. FAA 2 Sec. 11(a)(5), All iid((0). Information technical assistance and and conclusion on I commodities possible effects provided under of the assistance on t thLs project II.S. ecoitomy. Jith will be either special reference to t from U.S. areas of substantial or local (i.e. labor surplus, and " ;'unisian) sources. extent to which U.S. conmodities and i assistance are furnished in a manner consistent with improving or safeguarding the U.S. balance-of-payments position. 2. Development AssistanceProject Criteria (Loans only) a. FAA Sec. 201(b)(1). Information Financing and conclusion from other sources, on availability of fi- including nancing from other free-world private sources sources, within the [F.S., on oWier including private sources within U.S. than coffmercial terms is highly unlikely. Page 14
b. FAA Sec. 201(bL)(2);201(d). (1) See text Part III. Information and conclusion on (1) (2) Terms of the loan are capacity of the country to repay the both reasonable and legal loan. including reasonableness of under lava. repayment prospects, and (2) rea sotat'llness and legaltty (under laws ot eottotry and U.S.) of lending aisd retisding terms of the loan.
c. FAA Sec. 201(c). If loan is not Yes. See Annex E. made pursuait to a multilateral plan, uzsd thc amount of the loan exceeds $100,000, has country submitted to AID an application for such funds to.etlher with assurances to indicate that funds will be used in an economi cally and technically sound manner?
d. FAA.Sec. 201(f). Does project Yes. See texit Part I paper describe how project will pro- and II. mote the country's economic develop ment taking into account the country's human and moterial resources require ments and reLationship between ulti mate objectives of the project and overil 1 economic development?
L.. FAA. Sec. 2 0 2(a). Total amount of $2,650,000 equivalent 1i 't',' ssMader lomi which is goii d- will be paid, thru the rIt'LIy Lo hilvsL, eterprise. is goiii GOT, to private contraceors Lo iILLt,1I-kdiaILe r'diL istittitions or for construction. Balance. tLher," Lorroteors for"use by l1rivate on- of loan, or $350,000 L'rprise. is being used to finance in- equivalent will be paid thru ports from private sources, GOT to private enterprise for laboratory equipment. or is otherwise being used to finance procurements from private sources?
f. FAA Sec. 620(d). If assistance is This assistance is not for a for any productive enterprise which productive enterprise that will compete in the U.S. with U.S. en- exports goods/nervices terprise, is there an agreement by the to the U.S. r-cipiant country to prevent export to the U.S. of more than 207. of the enter prisc's annual production during the life of thc loan? mulm.-,,,m,.m m~mw..,. ANNEX D UN TED STATES OVERNENT Memorandum
TO : E/TECH, ft. John S. Alden .T E E:C DATE: August 11, 1977 FROM :ENGR/SP/GE,
SUBJECT: Rural Community Health - Tunisia - P.P.
The Office of Engineering has reviewed the preliminary Architectural and the Cost Estimates PILs for the proposed Rural Community Health project in Tunisia and finds that they are adequate to meet the requirements of Section 611(a) (1) of the Foreign Assistance Act.
&e-inBuy U.S. Saving: Bonds Reuglarly on the PayrollSavings Plan ANNEX D UITE SATES OP ANI kftsian Gpdole Amkrjo"m UPed MI@m for E@meesI )iJLnU ma*IL.yi do ,oopkqagqn Eonon . an Tom Cooperds 6mTecimiqu on 14, Avonu do Is Lbmt JtjiL--:FYI Tu . Tunisia
CERTIFICATION PURSUANT TO SECTION 'I~gITP611 (e)OF FAA 1961 As AMENDED
I, Hermon S. Davis, Jr., Director, the principal officer of the Agency for International Development in Tunisia, having taken into account, among other things, the maintenance and utilization of projects in Tunisia previously financed or assisted by the United States, do hereby certify that in my judgement Tunisia has both the financial capability and the human resources to effectively install, maintain and utilize the capital assistance project which consists of (a) rural regional hospital improvement and (b) ambulatory facility design and con struction of the components thereunder for the program of integrated rural health services in the provinces of
Siliana and Sidi Bou Zid.
This judgement is based upon general considerations discussed in the capital assistance paper to which this certification is to be attached.
August 11, 1977 - 7\:~.L ~ Hermon S. Davis, Jr. Director 1(?i 3LeZ -'rJG 77 :~*14~yTUNIS41 * 21F'2i "Z STT7 'ASHIDc I?'MUDIAT. 4 D':Cll TUIIS 411 5712 a
Si;.j: RUA C~aLTITY :17ALT *Ti:A)UNs )AL'Dr%-/ARSllAL MENO PAYEDi AUr.UST q, 1977 "'ISSIC"' HAS RMCIyE- flRAYT PP H!AND CARRITED ET DR. LUCAS. THE~ IIEEOO*RMTS Ifl ADDITIONj TO REFTTL A ARE SUB!IITTF7D. /_ * IS KC MNTION1 Or THE FAMILY PLANNINGS-EIRVIC? KJC *~ ~ N ITS~ ::.rCF PRCJZCTRE,%- .LATICAISHIP3954-0295 TO T!IS PRO~C "It r'.. IS TO PEV?10P M.TDIR~ECB',!NIG 7 'Ey YSi TO PROVID-F sUp?Llr ZFECTIV7 Low'79.TSJ(S-OCoST. AND SRVICES TO A LAD"T L":.y 'Nrl ?CUSERCLD I! TF2rMUOST It~~s T:~;.;or MV DIC4kL RURAL AR-AS. T;"IS FR0JECT AIND PAR4-DICAL PIPSCNNFL. *£iS ~:_PCRT 0O;.!SOCIAL I J21f SCU&;DklS5' DLCS*R3Lr~ .ND I3-Slcl. Ali? ""FLL AY?~Ox d{c AL;DRSS.A0 AM1D WifHIC PROjECT ~ - op7 IS DlESIGNED~ :- :CCSS T.?- THAT AID/Yl R7FVIF' PROCEED ASAP. AND APPROVAL T---ULAR, MATERIAL INCORPORATr]D IN%BODY OF PP BE AFTWXED A) KTARDI~f R-I URSFMENT OF -CU.C;oI. CAPITAL CCSTS, SUG'3EST 'J~..!,CT~ C. SUMRY FINDINGS ' III.A. NEY ?Iu.~ O CAPITAL COSTS AND F NARErfl AMOUNT NOT . .ENT, OF ZSTI:'IAT"D CCNSTRUCTICK 7xCELEDING COST OF EACH .CS3 OPEATIO NAL. CENTER *vI*r CENTER ).:III.-B. WIDERSTAAND $-!. MILLION' 0YEIR THIRTY YEARS. ;I7CIAL PEQUEIST FOR P.ROj:CT R3CEIVED TODAY FROMI 'OT. li ANNEX F THRESHOLD DECISION BASED ON
INITIAL ENVIRONENTAL EXAMINATION Project Location: TUNISIA Project Title: RURAL COMMUNITY HEALTH
Funding (Fiscal Year and Amount): Loan: FY 77 - $3,000,000 Grant: FY 77-79 $i,000,000 Life of Proect: FY 77 - 79
IIE Prepared By: Susan Christie-Shaw Date: July 10, 1977 Architectual Consultant
Environmental Action Recommended: Negative Determination
Bureau for Near East Decision:
APPROVE#/~j DISAPPROVED:
DATE : ......
Clearances: NE/GC:GDavidsonC NE/TECH:JAlden Date: 7/7;, IDate: 6 NE/CD:PGuedet Date:140. SER/ENGR:JCabrer ate: INITIAL ENVIRONMENTAL EXAMINATION INTEGRATED RURAL HEALTH PROJECT FOR SILIANA AND SIDI BOU ZID PROVINCES IN TUNISIA.
As per AID requirement, attached please find a completed Inpact Identification and Evaluation Form along with discussion. GENERAL IMPACTS The only adverse impact anticipated will be during actual construction and will be minor and temporary in nature and will include: 1. Inconvenience in traffic.near and on the construction site. 2. Inconvenience of noises due to construction and machinery. 3. Inconvenience due to storage of materials.
The objectives of this project will far outweigh any minor inconveniences caused during construction. Providing access to integrated health these very rural care in provinces is worth the minor adverse consequences of a few months. Culturally and socially, the impacts anticipated are significantly positive: 1. Reinforcement of the policy of regroupment by coordinating the location of small basic health centers with the centralization other of social and human services as per the recent policy by the Government of Tunisia. 2. Augmenting the policy of the Ministry of Health to integrate the curative and preventative services in the homes, schools, places public as well as within the walls of the proposed basic health centers. 3. Providing/suggesting separate waiting areas for men and women (with or without children) at all new basic health centers. Repeatedly, we were told in both provinces that the reasons provincial the lounges in the hospitals were empty is that there is only one, not two. In reviewing existing Government of Tunisia schemes for existing "dispensaries", the verification of respecting this cultural attitude was emphasized. The recent policy of the Tunisia Government of on humanization in hospitals was further indication that the facilities need to accommodate (separate lounges) the activities available that respond to the needs of the total human being. 4. Restructuring or recycling of the front-line workers as a more efficient means for use of existing personnel is indeed of social benefit along with the creation of new positions. LAND USE With few, if any, exceptions the proposed sites for new construction are designated by the municipalities for health services. No significant uses of land should be foreclosed. Improvements to the sites should result from the construction -- maintenance of grounds, landscaping will result in a visually more attractive place. In the area of sandy soil, a certain degree of stabilization is anticipated.
WATER QUALITY In every instance, precaution should and will be taken to assure that the effluent, after the sewage is properly treated, discharges into areas where there is no possibility of water contamination...'Storm and sewage disposal, whenever possible, will be connected to collectors from existing systems. Since the proposed facilities are relatively small, there should be no signi ficant adverse impact on the water quality either during or after construction.
ATMOSPHERE The use of equipment that would pollute the air and the production of polluting fumes or by-products is not anticipated.
NATURAL RESOURCES No diversion or altered use of water is foreseen. The natural and/or produced resources relevant to this project are the use of gravel, stone, cement, concrete, brick, tile, reinforcing steel and sewer pipe. These materials are inample supply in Tunisia and are locally available in the two provinces where the construction will occur.
CULTJRAL No possible adverse consequences are foreseen.
SOCIO ECONOMIC No significant adverse impacts are anticipated. Primarily, existing workers will be retrained in addition to a relatively small number of new workers trained. The impacts are favorable in terms of new employment and market utilization for foods and other products. The social impact is significant to the population being served.
HEALTH A highly favorable impact on the haalth of the peoples to be served is indicated. GENERAL No international or-controversial Impacts are foreseen.
OTHER A comparatively small increase in electrical energy as well as local water supplies is anticipated by the new basic health centers. IMPACT IDENTIFICATIONAND EVALUATION FORM
Impact Identification Impact Areas and Sub-areas and Evaluation1 A. LAND USE. 1. Changing the character of the land through: a. Increasing the population N b. Extracting natural resources N c. Land clearing N d. Changing soil character N 2. Altering natural defenses N 3. Foreclosing important uses N 4. Jeopardizing man or his works N 5. Other factors
B. WATER QUALITY
1. Physical state.of water N 2. Chemical and biological states N 3. Ecological balance N 4. Other factors
1 N - No environmental impact L - 'Tttle environmental impact M - Wo-idite environmental impact H - RT environmental impact - Uknown environmental impact IMPACT IDENTIFICATION AND EVALUATION FORM
C. ATMOSPHERIC
1. Air additives N
2. Air pollution N 3. Noise pollution N 4. Other factors
......
0. BATURAL RESOURCES
1. Diversion, altered use of water N 2. Irreversible, inefficient commitments N 3. Other factors
E. CULTURAL
1. Altering physical symbols N 2. Dilution of cultural traditions N 3. Other factors
F. SOCIO ECONOMIC
I. Changes ineconomic/employment patterns N 2. Changes in population N 3. Changes in cultural patterns N 4. Other factors IMPACT IDENTIFICATION AND EVALUATION FORM
G. HEALTH 1. Changing a natural environment N 2. 'Eliminating an ecosystem element N 3. Other factors
H. GENERAL 1. International impacts N 2. Controversial impacts N 3. Other factors
I. OTHER POSSIBLE IMPACTS (not listed above)
Prepared By: Susan Christie-Shaw Date: 10 July 1977
Project Location: Siliana and Sidi Bou Zid Provinces in Tunisia
Project Title: Rural Community Health Project of Integrated Services in Siliana and Sidi Bou Zid Provinces, Turisia Mee",,,e'n a.n Soo MAP NO.1 Anex G Tunisia Page 1
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1) Names of provincial capitaTs are underlined. 2) This map does not show the most recent provincial borders. 3) Siliana and Sidi Bou Zid. provinces, represented by shaded areas, are shown in larqer outline maps on the next two pages. Am Pl 2
MAP NO. 2 EXISTING HEALTH FACILITIES SI LIANA
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outiaprovin4ce. ah Lodll~lf iilll s o .[ MAnd[a Ar ntl MAP NO. 3 EXISTING HEALTH FACILITIES SIDI BOU ZID --,,,,K ey .4 VISPINSA4RY MI MA#/ I:j IUS Of SOINS La, FAIuLY f .tVsVIN CINrI .,: IMTI.-+ CALE, 9.. ,,,.. . C) .UuI LA N 9c"- IAS50 E "" /%" %Im s !0I" I . , o.,.~ EL,KAIIA ...... I, 41 R I-A -" / 'A I z._ ' A,* 'I - o.fWA" , ., --r. . ' j 664 e ll at. ." 4& I ..°, ,%.. .I" "' ' . SORE:O'n~to TnsaMn/tyo.A.ILPub.,i,1.,,ee.t NA 5 Loanffclce o egehciyeetbtae[. wit"n thei res.eciv'- t.,,. "" °" " r' ~ e " ! ...." K E Z O UNA ;" "" .ILWCm [ / .= .t=i114I 1 1' OK O0L9 GAT IO N LIMITIC 09 CH61IMdAr .. .0 It Id 1 GOUVIR NORAMT - EC1 I1 09i 0l go r APPROXIMATISCALJA:km ,, I0 200 ,5 c 11OUR"J[ GOverm"t Of Tunisia, Ministry of Public Health Ie~: Prov inc i a l bo unda r ie s do no t re f lec t t he m o st r e cen t add i ti on of now a l egst eml c t osl ts r f f 4 u Locationsoutsid the province om lctoswilteefrPa of fa cltes Noa. M"" and. M re not geographically exact, but are within their respeitlve setlrs, MAP NO. 4 PROPOSED FACILITY CONSTRUCTION/RENOVATION SI LIANA Ic~j l/.rpI.OI eKRD& %% A'- C- .... -~ ~ ~ ,,___CNRUTo I %TYPE A FACILITY I.Nu - I J RENOVATION TO ISW~SWJ 'I kSf~I sellM ITYPE A STANDARDS . ,:".., b-"l CONS"TRCTN OF %"% L J /. TYPE 8 FACILITY A ""- TYPE t,, TYPE CB FACILITYSTANDARDS sl " i...... [' RENOVATIOTYPE C STANDARDSN TO APPROXIMT, SCAL: . 9, i o =, 3*o ,O 5O SOURCE: Government of Tulsi, ilinistry of Public Htelth Motes: Provincial boudaries do not reflect the mest recant addition of nan delegations. SIm locations will therefore appear outside Locations of oil Type C facilities are not geogreghlcally emact but are within their The as does not differentiate between Type respective sacteur. C1 and Type C faclllties since final deteninatmi project lulnncation (See discusion In teOt). 2 wii be mede during early Am= Pap MAP NO. 5 PROPOSED FACILITY CONSTRUCTION/RENOVATION SIDI BOU ZID , M AIIT""" =,, - b l b>.eoi, "?* . &,gav It , ~~ ,,It, t ,S ' maOi % ou~I ide",ih prRovice IMI~~ 70tw RE O ATO TYP C ACIJ pr-. t d %1,." I.L.a.Ie n / , ---.EN3A,,.,.PROVSIO AFS %e Key35 ' ' It PWIC-l It#e m AnCONSTRUCTION Of om TYPE A FACILITYCOSRTINF 0 Is l RENOVATION TO CONSTRUC7ION OF TYPE C SrANDAROS TYPE 8 FACILITY I REINCVA TION TO ] PROVISION OFI TYPE 9 STANOARDS MINIMUM EQUIPMENTr lOWlCl: Covernmwi of Tunisia, ministry of Pubic ftelth Nlots: Prvincil boudrlIa do ot rflect the mostrecent dditionof nowdlgatons. onl Ilaions will hereforel seppwr outilde the province. The 6P doe not differentiate bet TypeI € ad Type I C2 falitieslo linch 'Inal 'etermlmation will be eade during early PrGJO,9 lNPlomtstlh. (I"dllcullio. Inl text.) hm@ Page 6 MAP NO.6 FINAL HEALTH SERVICES NETWORK SILIANA 0• , ... , &a 's'-'"s ..C'". 0140s C sJD .W -Ai.r- POOSDPRJC $mlaG", "Agggl ",asseBe Ke .ft HA., ... ,O rYEA appea outsde te proince APPRO"IMTE a, a..= sc , 'CATYPEkAtO ,=o oF. r5 R C fTwsa Mnsr ofABCbljc"",,,Gvrmn health, apKelso%the rovnce outside Locatli of all Type C faclllties are no: geograulically aeset but are within their respectivs seteura. Tha mp e. not differentiat~e betuse Type C end I Type C2 fadl lities ine final determination will b. ade during ealrly proJet limpintaton (Sea teat for discussion). A=ae 0 Pe ? MAP NO. 7 FINAL HEALTH SERVICES NETWORK SIDI BOU ZID ClCK a Ii.000 C % 64,10ILs - I CU %I- - A .PCR """.&.. S,,IE1 ,a,,9L ,,. A o"Awid the• ""CC -atence isA I~ Tol~.c mwe11.sllo "-,.6/.. I " c_:./I .,,..I-"A, , ..... o~o- _a. --A,' TYPA,LIA-161301ON C. 'A, ILPRC~l/ / %; A~~~C Its. R P~lfa Bsv S D R &..'a-JC 1°9 SA ii ...... c ,-.,,% "-7 , c CL I "ASMA % prjctIplmntto Se tstfo isusios ." M=,"IAKNA55Y otto.,,.N9 MEZZOUNA "It"a "4°.,.."I I Key f6 *.*^"a --1It- -'x l~el C.1$,.&T a~l~ws,_C3 POPOEDCONSTRUCTED PROJECT UNDER A B C RENOVATED UNDER C EQIMNMINIMUM ,,. ,*=.,=PROPOSED PROJECT " ONLY APPROXIMATE SCE: lu o ,1o ,o, o SOURCE: Government of Tunisia, Ministry of Public Health Notes: Provincial boundaries do not tef~oct zhe most recent addition of now deleations. Som locations will therefore appear outside the province. Locations of all Type C facilities are not geographically exact but are within their respective Iectours. wid* The me does not differentilate between Type CI and Type Ca facilities since final determination will be during early project ImplmGntetion (Sao text for discussion).