Document of THE WORLD BANK Public Disclosure Authorized
Report No. 17396-MAR,
PROJECT APPRAISAL DOCUMENT
ON A Public Disclosure Authorized
PROPOSED INTERNATIONAL DEVELOPMENT ASSOCIATION CREDIT
IN AN AMOUNT OF US$24 MILLION
TO
THE ISLAMIC REPUBLIC OF MAURITANIA
FORA
Public Disclosure Authorized HEALTH SECTOR INVESTMENT PROJECT
February 24, 1998 Public Disclosure Authorized
Human Development II Africa Region CURRENCY EQUIVALENTS
(Exchange rate effective as of December 22, 1997)
Currency Unit = UM I UM US$0.006353 US$1 157.41 UM
FISCAL YEAR January I to December 31
ABBREVIATIONS AND ACRONYMS
AfDB - African Development Bank AIDS - Acquired Immune Deficiency Syndrome ARI - Acute Respiratory Infections BCI - Budget consolide d'investissements (Public Investment Budget) BHA - Better Health in Africa CAS - Country Assistance Strategy CDC - Center for Disease Control CGP - Comitetde gestion du programme (Program Management Committee) CHN - Centre hospitalier national (National Hospital Center) CPF - Centre de promotion feminine (Center for the Promotion of Women) CPP - Commission de preparation du PASS (Project Preparation Committee) CSA - Centre de sante cate,gorieA (Health center category A) CSB - Centre de sante categorie B (Health center category B) CSPD - Commission chargee du suivi et de la mise en oeui re du Plan Directeur 1998-2002 (Sector Policy Implementation Board) DAAF - Direction des affaires administratives etfinancieres (Directorate of Administrative and Financial Affairs) DALY - Disability Adjusted Life-Year DGI - Direction de gestion des investissements (Directorate of Investment Management) DHR - Direction des ressources humaines (Directorate of Human Resources) DHS - Demographic and Health Survey DPCS - Direction de la planification, de la cooperation et alela statistique (Directorate of Planning, Cooperation and Statistics) DPM - Direction de la pharmacie et du medicament (Directorate for Drugs) DRASS - Direction regionale de l 'action socio-sanitaire (Regional Health Directorate) ENSP - Ecole nationale de la santepublique (National School of Public Health) EPI - Extended Program of Immunization EU - European Union FAO - Food and Agricultural Organization of the United Nations FDI - Foreign Direct Investment FGM - Female Genital Mutilation FPU - Family Planning Unit GDP - Gross Domestic Product GOM - Government of Mauritania GTZ - German Agency for Technical Cooperation HIV - Human Immuno-deficiency Virus HP - Communal Health Post HSIP - Health Sector Investment Project IBRD - International Bank for Reconstruction and Development IAPSO - United Nations Inter-Agency Procurement Services
Vice Presidents Jean-Louis Sarbib and Callisto Madavo Country Director Hasan Tuluy |Sector Managxers :Ok Pannenborg /Nicholas Buniett Task Team Leader :Sergiu Luculescu. ICB - International Competitive Bidding IDA - International Development Association IEC - Information, Education and Communication IMR - Infant Mortality Rate KAP - Knowledge, Attitudes and Practice (survey) MCH - Maternal and Child Health M&E - Monitoring and Evaluation MEP - Manuel d'execution du programme (Program Implementation Manuel) MF - Ministere des finances (Ministry of Finance) MMR - Maternal Mortality Rate MSAS - Ministere de la sante et des affaires sociales (Ministry of Health and Social Affairs) MP - Ministere du plan (Ministry of Planning) QAG - Quality Assurance Group NGO - Non-Governmental Organization ONS - Office national des statistiques (National Bureau of Statistics) PASS - Projet d'appui au secteur de la sante (HSIP) PDIS - Plan de developpement des infrastructures de sante (Health Infrastructures Development Plan) PDRH - Plan de developpement des resources humaines (Human Resources Development Plan) PER - Public Expenditure Review PFP - Policy Framework Paper PHC - Primary Health Care PHRD grant - Policy and Human Resources Development grant POAS - Plan d'operation annuel pour le secteur (Annual Operational Plan) PPF - Project Preparation Facility PRCI - Plan de renforcement de la capacite institutionnelle (Plan for institutional capacity strengthening) PTHG - Plan triennal a horizon glissant (Three-Year Rolling Plan) RH - Regional Hospital SECF - Secretariat d'etat a la condition feminine (Executive Secretariat for Women Promotion) SBD - Standard Bidding Document SDR - Special Drawing Rights SIP - Sector Investment Project SOE - Statement of Expenditures STDs - Sexually Transmitted Diseases TB - Tuberculosis TSS - Techniciens superieurs de sante (Senior Health Technicians) UM - Unite monetaire (Ouguiya) UNFPA - United Nations Fund for Population Activities UNICEF - United Nations Children's Fund UNIPAC - UNICEF Procurement and Assembly Center (Centrale d'achat et de stockage de l'UNICEF) USAID - United States Agency for International Development WDR - World Development Report WHO - World Health Organization
MAURITANIA Health Sector Investment Project
CONTENTS
A. Project Development Objective ...... 2...... 2
1. Project development objective and key indicators for development outcome/impact.. 2
B. Strategic Context...... 3
1. Sector-related CAS goals supported by the project ...... 3 2. Main sector issues and Government strategy ...... 3 3. Sector issues expected to be resolved before project effectiveness...... 4 4. Sector issues to be addressed by the project and strategic choices ...... 5
C. Project Description Summary ...... 6
1. Project components ...... 6 2. Key policy and institutional reforms supported by the project ...... 6 3. Benefits and target population ...... 7 4. Institutional and implementation arrangements...... 8
D. Project Rationale ...... 10
1. Project alternatives considered and reasons for rejection ...... 10 2. Major related projects financed by the Bank and/or other development agencies ...... 10 3. Lessons learned and reflected in the Program design ...... 11 4. Indications of borrower commitment and ownership ...... 13 5. Value added of Bank support in this Program ...... 13
E. Summary Project Analyses ...... 14
1. Economic ...... 14 2. Financial...... 15 3. Technical...... 15 4. Institutional ...... 16 5. Social ...... 17 6. Environmental assessment ...... 17 7. Participatory approach ...... 17
F. Sustainability and Risks ...... 18
1. Sustainability ...... 18 2. Critical risks ...... 19 3. Possiblecontroversial aspects ...... 21
G. Main Credit Conditions ...... 22
1. Conditions...... 22 2. Legal Covenants ...... 23
H. Readiness for Implementation ...... 23
I. Compliance with Bank Policies ...... , 24
Annexes
Annex 1. Program Design Summary Annex 2A. Detailed Program Description Annex 2B. Donor Activities in the Health Sector Annex 3. Estimated Project Costs Annex 4A. Cost-Effectiveness Analysis of the PTHG 1998-2000 for the Health Sector in Mauritania Annex 4B. Economic Analysis Annex 5. Financial Summary Annex 6. Procurementand DisbursementArrangements Table A. Program Costs by Procurement Arrangements Table B. Thresholds for Procurement Methods and Prior Review Table C. Allocation of Credit Proceeds Table D. Estimated Disbursements of IDA Credit (1US$million) Annex 7. Program Processing Budget and Schedule Annex 8. Documents in Project File Annex 9. Statementof Loans and Credits Annex 10. Country at a Glance Annex 11. Letter of Sector Policy
Map: IBRD 29419 Mauritania Health Sector Investment Project Project Appraisal Document Africa Regional Office AFTH2 Date: February24, 1998 Task Team Leader/Task Manager: SergiuLuculescu Country Manager/Director: Hasan Tuluy Sector Manager/Director:Ok Pannenborg/NicholasBurnett Project ID: MR-PE-35689 Sector: Pop. Health & Nutrition Project Objective Category: PovertyReduction LendingInstrument: Sector-wideInvestment Credit (SIP) Program of Targeted Intervention: [X] Yes [ ] No
Project Financing Data [] Loan [X] Credit [ Guarantee [ ] Other [Specify)
For Loans/Credits/Others:
Amount (US$m/SDRm):US$24 million / SDR 17.8million Proposedterms: [ ] Multi-currency [] Single currency, specify Grace period (years): 10 [x] Standard Variable [ ] Fixed [ LIBOR-based Years to maturity: 40 Commitmentfee: 0% Service charge: 0.75%
Financing plan (US$m): Source Local Foreign Total Government 75.8 0 75.8 Cofinanciers 0 72.4 72.4 IDA' 0 24.0 24.0 Beneficiarycontribution 19.4 0 19.4 Total 95.2 96.4 191.6
Borrower: Governmentof IslamicRepublic of Mauritania Guarantor:NA Responsible agency(ies):Ministry of Health and Social Affairs
Estimated disbursements(Bank FY/US$M): 1998 1999 2000 2001 2002 2003 Annual 1.0 4.7 5.1 5.7 5.9 1.6 Cumulative 1.0 5.7 10.8 16.5 22.4 24.0
For Guarantees: NA [] Partial credit [ ] Partial risk
Proposed coverage:NA Project sponsor: NA Nature of underlying financing:NA Terms of financing: Principal amount (US$) Final maturity Amortization profile Financing availablewithout guarantee?: NA [] Yes [ No If yes, estimatedcost or maturity: Estimated financing cost or maturity with guarantee:
Project implementationperiod: 5 Expectedeffectiveness date: 05/15/1998 Expectedclosing date: 6/30/2003
OSD PAD Form: February24, 1998 Project Appraisal Document Project Title: Health Sector InvestmentCredit Country: Mauritania Page 2 of 24 A: Project Development Objective
1. Project development objective and key performance indicators:
On the basis of the new sector policy (Plan Directeur 1998-2002) and the Plan triennal e horizon glissant (PTHG) 1998-2000, a broad Health Sector Investment Project (HSIP) is proposed to support the implementation of the GOM's Program for the health sector during the period 1998-2002. The overall objective of the Program is to improve the health status of the population in general (and of underserved groups in particular) through the provision of more accessible and affordable quality health services. The Program's specific objectives are to: (a) improve health services quality and coverage; (b) improve health sector's financing and performance; (c) mitigate the effects of major public health problems; and (d) promote social action and create an environment conducive to health. HSIP will provide financial support to achieve all of these objectives. Additional agreements reached with Government ensure that the project will also contribute significantly to the strengthening of sector capacity by: (i) promoting government leadership in the formulation and implementation of a coherent sector policy; (ii) establishing sound planning and budgeting practices; (iii) improving sector administrative and clinical performance; (iv) helping decentralize decision-making in the public sector; and (v) helping MSAS to institute an effective coordination mechanism to channel donor and NGOs resources for the achievement of sector policy. Further to the GOM's request, the project will also support: (a) the collection of demographic and health data, by contributing to the funding of a demographic and health survey and of a population census, and (b) the sector to monitor a set of key health indicators, thus enabling the Government to continuously assess the progress made in the implementation of its Program for the sector.
Key indicatorsfor developmentoutcome/impact (see Annex 1)
GOM's new sector policy was prepared by the Ministry of Health and Social Affairs (MSAS) with the involvement of central and district health staff, with specific input by relevant personnel from other sectors, and in collaboration with donors and NGOs. Specific indicators to evaluate the outcomes and impact of the sector policy include:
(i) vaccination coverage (to increase to 85% in 2002);
(ii) expenditures for primary and secondary health care (to be maintained at same levels as in 1995 i.e., at least 40% of total expenditures);
(iii) health facilities utilization rates (to increase to 80% in 2002);
(iv) infant mortality rate (to be reduced to 80/1000 in 2002);
(v) under-five mortality rate (to be reduced to 90/1000 in 2002); and
(vi) total fertility rate (to be reduced to 5.5 in 2002).
Monitoring indicators, to be used in the annual progress review reports, are listed in the Letter of Sector Policy (Annex I 1). ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Page3 of 24
B: Strategic Context
1. Sector-relatedCountryAssistance Strategy (CAS)goal supportedby the project (see Annex 1):
CAS documentnumber: 16595 Date of latest CAS discussion: 05/21/1997
The CAS specificallymentions, among its strategicelements: (a) poverty reduction;(b) increase of human capital; and (c) improvement in the access and quality of health services (by means of developing basic and referral health services with emphasis on remote geographical areas), and development of adequate reproductive health services. Moreover, the proposed project will also contribute to other CAS areas of interventionsuch as developmentof the rural sector, modernizationof the public sector and gender supportingactivities. The CAS mentions among its "Triggers for Bank assistance program" the achievement of quantified vaccination rates. All these elements are fully consistentwith GOM policy for the health sector and with the HSIP objectives.
2. Main sector issues and Government strategy:
The recently adopted health sector policy continues GOM's reform process, which was initially outlined in the Plan Directeur 1991-1995/6 and supported by the Bank's current health project. An evaluation of the Plan Directeur 1991-1995/6 indicated substantial progress in the areas of health services delivery (with the extension of health facility coverage to 75% of the population and the availability of essential drugs at the health posts), health systems administration (particularly with respect to decentralization and sector financing through the introduction of cost recovery), and participatory management. In addition, Bank analysis of GOM's public expenditures (conducted in 1995 and 1996) demonstrated sustained commitment to increasing the Government's financing of the health sector, imrprovingthe allocation of resources (toward developing primary health care services and increasing the non-wage portion of the recurrent budget), and developing effective cost recovery arrangements.
While substantial progress has been made, significant sectoral issues and constraints remain, including: (i) insufficient access to quality health services, particularly preventive services and services for newly emerging health needs and problems such as STD/AIDS, water-borne diseases, etc.; (ii) inadequate planning and management capabilities for administering resources at the various levels of the health system; and (iii) weak structures for promoting intersectoral coordination and participatory decision-making on vital health concerns. Specific sectoral issues and the Government's response include:
(a) Low access to services: While steady progress has been made in the development of health infrastructure, the existing health facility network is not fullyaccessible: 25% of the population still must travel more than five kilometers to reach a health center or a health post, while 10% must cover more than ten kilometers to reach the nearest health facility. During the preparation of the proposed project, a comprehensive Plan de de'veloppement des infrastructures de sante (PDIS) containing standardized building requirements, equipment lists, etc. has been adopted and will guide decisions on future services over the next five years.
(b) Poor quality of care: Development of human resources has been characterized by weak personnel management, inequitable allocation of the various categories of staff, and inadequate training and motivation contributing to the poor quality of services. During the last five years, MSAS has consistently pursued a staff deployment/redeployment policy with the following results: (a) a computerized staff register has been set up, (b) training of health personnel, and in particular of staff working in referral hospitals and health centers, has become a priority; and (c) a Plan for human resources development for the period 1988-2002 (PDRH) is being developed. Project Appraisal Document Project Title: Health Sector InvestmentCredit Country: Mauritania Page 4 of 24
To ensure appropriate staffing and training, this document (PDRH), takes into account the new staffing norms per category of health facility, the projected development of health infrastructures, and the skills needed to improve the quality of services.
(c) Inadequate drug supply: While the introduction of cost recovery at the health post and health center levels has significantly improved the availability of essential drugs, drug procurement and distribution continue to pose problems. Complementary interventions by the proposed project (to strengthen procurement capabilities) and by the African Development Bank (to reinforce the management capacities of the Direction de la pharmacie et du medicament (DPM) and drug distribution) should improve the availability of drugs. In addition, the introduction of cost recovery at the district hospital level will ensure the availability of drugs. A comprehensive review of cost-recovery arrangements will take place, during the first year of the project, to ascertain, among other things, that enough funds for providing the public health sector with drugs to will be available during the Program.
(d) Insufficient emphasis on prevention: Although the sector policy emphasizes prevention, preventive activities represent only 20% of the cost of services provided by the public sector. The introduction of cost recovery has contributed to this situation by creating incentives for providing curative rather than preventive services. The new health sector policy seeks to correct this situation (75% of activities now being proposed have high cost-effectiveness ratios and 25% medium cost-effectiveness ratios); measures to introduce incentives to motivate health providers in preventive care are also being developed.
(e) Weak sector management and administrative capacity: The pertinence of the current administrative and management arrangements to the tasks and requirements of thePlan directeur 1998-2002 has been analyzed and a Plan de renforcemnen de la capacite institutionnelle (PRCI) has been agreed upon. This will result in substantial changes in the organizational structure of MSAS. Regarding the MSAS' abilities (in the areas of policy development, planning and budgeting, financial management, procurement and resource management) current efforts to evaluate the previous sector policy, to adopt the new policy and to finalize the PTHG 1998-2000, have helped strengthen central capacity. Needs for skilled management personnel are even more acute at regional and departmental levels. The recent empowering of the Direction regionale de l'action socio-sanitaire (DRASS) with personnel management tasks, and GOM's commitment to substantially increase district discretionary budgets are among the solutions to the problem.
(f) Relations with donors and NGOs: Project preparation work conducted by MSAS has also contributed to the strengthening of relations with donors aLndNGOs, and other sectors, since all major policy documents have been developed in close consultation with external and internal partners. The recently developed PTHG 1998-2000 presents, for the first time in Mauritania, a comprehensive picture of all sector activities and of their source of funding. The PRCI foresees specific measures to build up capacity in many areas among which the MSAS' donorlNGO coordination function is seen as a priority.
3. Sector issues expected to be resolved before the proposedproject's effectiveness:
A number of sectoral issues will be resolved before the proposed project's effectiveness. In particular:
(a) MSAS' Study on health facilities utilization and equipmenit needs and the PDIS provide a sound basis for expanding health services coverage over the next five years. Endorsement by all donors ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Page5 of 24
of the overall sector policy and of the PTHG has already taken place and will ensure effective implementation and standardized infrastructure design.
I(b) The implementation of the human resource development plan will contribute to the resolution of personnel distribution and training problems.
(c) Drug procurement and maintenance shortcomings are also being addressed, e.g., the Directorate for drugs (DPM) and the Maintenance service at MSAS are being strengthened; private firns have been involved in medical equipment maintenance; and GOM has decided to develop a maintenance strategy for the sector.
(d) The PRCI-centrally, in regions and districts-will be finalized before credit effectiveness. This plan is being carried out with support from the current IDA project, a PHRD grant, and a Project Preparation Facility (PPF), and it will continue to be implemented after credit effectiveness with support from the proposed IDA project. A preliminary analysis of this plan shows that about 70% of the first year's disbursements from the proposed IDA credit will be made for institutional strengthening.
(e) Decentralization of decision-making to sub-national levels and especially to DRASS's is in process and will be further supported by means of the PPF. Strengthening of donor coordination activities conducted by the MSAS has also started (e.g. PTHG meetings were jointly chaired by the ministers of planning and health), but work will need to continue after credit effectiveness.
4. Sector issues to be addressed by the project and strategic choices:
Government's strategic choices are clearly spelled out in the new sector policy and include decisions related to:
(a) expanding coverage by providing health facilities capable of treating a high proportion of cases, thereby significantly reducing the referral to more specialized levels and abroad;
(b) using cost-effective options such as development of primary health care and preventive activities;
(c) further decentralization of decision making to districts (DRASS's) and below;
(d) consensus building (under MSAS leadership) with donors, NGOs, central programs, and regional and district health units; and
(e) sustainable financing of the costs of improving health service delivery and health systems administration. Project Appraisal Document Project Title: Health Sector InvestmentCredit Country: Maurtania Page 6 of 24
C: Project Description Summary
L. Programcomponents (see Annex 2 A &B for a detaileddescription and Annex 3for a detailed cost breakdown): Component Category Cost Incl. % of Bank- % of Contingencies Total financing Bank- (US$M) (US$M)financing * Improve health services Infrastructure, 86.4 45.1 3.1 12.9 quality and coverage. equipment consultants. * Improve health sector's Consultants, 37.4 19.5 1.8 7.5 financing and equipment, inst. performance. capacity, operating costs. * Mitigate the effects of Drugs, 56.5 29.5 1.3 5.4 major public health equipment, problems. training, operating costs. * Strengthen social action Institutional 11.3 5.9 0.2 0.8 and create an environment capacity, conducive to health. operating costs.
* To be allocated during the 0.0 0.0 17.6 73.3 3rd, 4th and 5th program year. Total 191.6 100.0 24.0 100.0
IDA will support this Program-by means of the HSIP-acti.ng as a last resort lender. As described in detail in Annex 2A and 6, activities to receive financial support from the credit have been identified for the first two calendar years of the Program. The remainder of the credit (73%) is to be allocated during the 3rd, 4th and 5th program year. Modalities for allocating this part of the credit are presented under Section 4 below (see Annual Planning and Budgeting.)
2. Key policy and institutional reforms supported by the project:
The policy reforms summarized in the Plan Directeur 1998-2002 are detailed in a series of specific documents prepared during project preparation (the PDIS, the PDRH, and the PRCI) and included (with estimated costs) in the PTHG. The project will continue to support policy reforms in these and in additional areas, including quality of care, information management, cost recovery (at hospital level), drug supply and distribution, and social action reform.
These sector reforms will be accompanied by institutional reformns resulting from MSAS's increased leadership role in defining sectoral directions and its enhanced capacities for implementing its policy. Specifically, while donors will continue to play an active role in the sector, MSAS will be expected to take the lead for coordinating implementation of thePlan Directeur 1998-2002; periodically updating physical and financial progress; revising central and district plans and budgets; mobilizing internal and external funding; and evaluating impact. Revisions in the organizational structure of MSAS will be supported by the recruitmnentor transfer of additional staff and by technical and financial support for the following functions: planning and programming, public health administration, donor coordination, financial analysis and budgeting, procurement, accounting, auditing, monitoring and evaluation. ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Page7 of 24
3. Benefits and target population:
By strengthening sector performance, the Program will improve health status, particularly of women, children and under-served populations, including the populations living in the remotest geographical zones.
Sector performance will benefit from the Program's capacity building component which will improve administrative performance and service delivery, and will promote the involvement of regions, distiricts and communities in decision-making. The resource base for the sector will be strengthened by: (i) extension of cost recovery; (ii) introduction, where feasible, of pre-payment arrangements for health service provision at community level; (iii) growth of the private sector; and (iv) partnership between the public sector, donors and NGOs.
Specific sets of indicators to monitor progress and assess the degree of achievement of various objectives have been designed for each of the sector policy components. Analysis of prior health expenditures has demonstrated that the bulk of service delivery was already in primary and secondary care, thereby benefiting the poor and rural population. A study of cost-effectiveness and soundness of the sector policy and plans-based on the findings of the World Development Report (WDR) 1993 and the Better Health in Africa (BHA) study as bench-marks-has also been carried out. This study demonstrates that 75% of the activities proposed in the sector policy have high cost-effectiveness ratios and address large population groups.
It is envisaged that, during Program implementation, beneficiary assessments will be carried out at two-year intervals, to monitor progress and the degree of satisfaction at the level of users of services.
Though the Program is sector-wide and will address the entire population, it focuses mostly on providing accessible and quality health services with emphasis on the rural poor population, and women and children, thereby contributing to poverty alleviation. For this reason, this operation would be part of the Program of Targeted Interventions for poverty alleviation.
In summary, the Program will generate the following economic and social benefits:
* Improved health status of the poor, of women and of children leading to better school performance for children and increased productivity for adults.
* Development of primary health care and use of a cost-effective package of preventive and curative services to improve children's health, enhance school readiness, contribute to the development of human capital, and foster beneficial social behavior, thereby lessening social welfare costs and promoting community development.
* Reduced fertility rates resulting from family planning, reproductive health and IEC activities, thus lessening the burden on the poorest families and contributing to economic growth.
* More efficient utilization of financial resources (internal and donor contributed) available to the health sector.
* More equitable geographical distribution of health services promoting both health gains and economic development in the population of remote areas. Project Appraisal Document Project Title: Health Sector InvestmentCredit Country: Mauritania Page 8 of 24
4. Institutional and implementation arrangements:
Implementation period: Five years: 1998-2002
Executing agencies: Ministry of Health and Social Afifairs(MSAS)
Program coordination: The MSAS, through its central directorates and district health administrative units, will have overall responsibility for the management of all Program activities. More specifically:
(a) The Minister of Health will provide policy guidance and oversight. He/she will receive technical support from the Secretary General and central directors., and from the Comite de gestion du programme (CGP). The Ministry of Planning will continue to monitor donor programs, but will also substantially involve MSAS in this activity.
(b) In order to coordinate activities, build consensus, and involve donors, NGOs and other line ministries, the Commission de preparation du PASS (CPP) currently operating under the chairmanship of the Secretary General of MSAS and composed of central-level program directors, representatives of other sectors, donors and NGOs, will be converted into a Commission chargee du suivi et de la mise en oeuvre du PlarnDirecteur 1998-2002 (CSPD). The Technical Secretariat of the CPP will be converted into a Comitf de gestion du programme (CGP). A document stating the terms of reference of these bodies will be issued before credit effectiveness.
(c) Policy, planning, monitoring, evaluation and overall coordination work will be carried out by MSAS Direction de la planification, de la cooperation et tes statistiques (DPCS) at the central level, and by Directions regionales de I 'action socio-sanitaire (DRASS) in districts.
(d) Financial management of GOM budget for the sector, human resources management and personnel matters will be carried out by the Direction des cffaires administratives etfinancieres (DAAF). A newly-created Direction de gestion des inves,tissements (DGI) will, using current expertise built under the PSP, complement DAAF activities by handling all procurement operations financed by donors and from the GOM budget. In the beginning, the DGI will handle IDA funding to the sector; during Program implementation it is expected that, gradually, other donors will also channel their funds through the MSAS. This will also make it possible to progressively develop common implementation arrangements to be used for GOM and donor funds. All of these coordinating functions will be further developed and supported in accordance with the PRCI, currently being developed and agreed with Government. Program coordination requirements will be also addressed in the Program Implementation Manual.
Annual planning and budgeting: The DPCS will prepare annual operational plans, and annual progress reports (based on the results of Program monitoringcarried out with the assistance of all central directorates and DRASSs), and organize mandatory review meetings with donors and NGOs to reach a consensus on these documents. These meetings will constitute the main mechanism for: (i) Program review, adjustment and rolling of the PTHG, (ii) agreement with donors and NGOs on the annual plan and budget for the next fiscal year, and for (iii) identifyingIDA funded activities (with the exception of the firsttwo fiscal years for which activitieshave already been identified)from the activity list contained in the PTHG (by selecting activities in line with the health sector's policy and priorities for which no source of financingwas available). ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Page9 of24
As the SIP approach might make it necessary to use IDA funds in program areas traditionally not targeted by IDA investment projects (such as secondary and tertiary care, if sufficient resources for primary health care are provided from other sources), the sector Program and plan have been thoroughly analyzed to ensure compliance with cost-effectiveness criteria and Bank's policy for the health sector. Similarly, during project implementation, the relevance of annual plans and budgets and their compliance with the sector policy will be reviewed yearly, before a decision is made as to which activities will receive financial support from the credit. Lastly, in order to ascertain that investments in infrastructure and equipment are made in accordance with mid-term objectives set forth in the sector policy and plan, and that investment expenditures are matched by commensurate recurrent funds, the PDIS 1998-2002, including adequate provision for maintenance and supplies, was prepared by Government and agreed upon by IDA, donors and NGOs. This will allow the preparation (well in advance of the annual consultations with donors and NGOs on the sector plan and budget) of bidding documents for infrastructure and equipment, thus shortening the time necessary for their procurement.
At the end of these consultations, donor commitments to various Program components for the fcllowing year will be stated, thus enabling IDA to act as a last resort financier and allocate money for gaps in identified priority areas. It is expected that IDA funding will be, on average, relatively small, i.e., about 12.5% of the total Program cost.
Accounting, financial reporting and auditing arrangements: The DAAF and the DGI will be responsible for Program administrative and financial management, and reporting. The financial mLanagementsystem used for the current IDA credit has been analyzed and found adequate. However, given the complexity of the Program, the financial management system at MSAS will be further irmproved. Financial management will be based on a computerized system that will be installed at DAAF and DGI which will include: (i) accounting based on: (a) Project Chart of Accounts to group expenditures by project component or activities; (b) disbursement categories and source of funds; and (c) appropriate accounting standards and reporting periods and formats; (ii) recording of monitorable physical and other performance indicators including comparison with related costs, and explanation of variances; (iii) procurement contract management information; and (iv) internal control arrangements to ensure proper segregation of duties, documented procedures for authorizations, levels of supervision etc. This system will also allow to monitor recurrent and investment expenditures by region and level of care. Records will be kept for all project-related expenditures and financing, following regular budgetary procedures. A special account for the IDA credit will be opened and maintained with a commercial bank acceptable to I]DA. This account will be managed by the Director of the DGI.
An independent auditor, acceptable to IDA, will audit IDA funds, including the IDA special account and statements of expenditures. Audit reports will be submitted not later than six months after the end of the financial year. The auditor's terms of reference and selection will be agreed with IDA during Negotiations, and the appointment of the auditor will be a condition for credit effectiveness. Under the Program, MSAS' financial management system will be strengthened and computerized to allow proper monitoring of expenditures per level, geographical area, and budget line. MSAS will be strengthened-inter alia-by receiving technical assistance in accounting, financial management, and financial management information.
Monitoring and evaluation arrangements: Under the overall guidance of the Minister and the Secretary General's direct supervision (supported by the CSPD and the CGP), the Directorate for Planning, Cooperation and Statistics will monitor and evaluate Program implementation. The DPCS will also prepare annual progress reports (based on the results of Program monitoring carried out with the assistance of all central directorates and DRASSs), propose annual operational plans, and organize the annual mandatory discussion with donors and NGOs on these documents. ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Page10 of 24
Indicators(based on the logical framework)have been designed (see Annexes I and I1) and will be used to measurethe general progress of the Programand its outputsand, where possible, its outcomes. A beneficiary assessment has already been carried out; similar surveys will be repeated at two year intervalsafter credit effectiveness.
A mid-term review of the Programwill be carried out in the year 2000 in accordance with the terms of reference and monitoring/evaluationindicators agreed with IDA and the donors (Annex 11). Within six months of the closing of the IDA credit, an ImplementationCompletion Report (ICR) will be prepared by IDA, with MSAS contributingits own evaluation of the Programto the ICR. The ICR will analyze both the success of the overall sector Program and the results of the IDA contribution to the sector.
D: Project Rationale
1. Project alternatives considered and reasonsfor rejection: (a) A classical investmentproject based on the design of the current PSP project was consideredas an alternativeto a SIP and discussed both at review meetings in Washingtonand with the GOM. Such a project may yield more immediatebenefits, disburse IDA funds more promptly,and offer the possibility of funding activities in sectors other than health (i.e., population activities conductedby the MP and gender and nutritionactivities developedby the Secretariatd 'etat a la conditionfiminine). However,the drawbacksof such a project outweighits advantagesas it: (i) will extend the life of the PSP project unit to the detriment of a more harrnonious sector strengthening;(ii) will continue an undue reliance on donor-initiateddecisions; (iii) may delay and detract from MSAS's policy developmentwork, and may not be the best vehicle for sector reform; and (iv) will providenarrower sector and health status benefits. (b) A large project combining: (i) an integrated sector-wide investment Program for the health sector; and (ii) an inter-sectoral project to address delerminants of ill-health requiring interventionsby sectorsother than health,with emphasison nutrition,was also discussed. Such a project was deemed too complex and cumbersome, especially from a management and mnonitoringviewpoint. As a result, in additionto the proposeclhealth sector investmentproject, a free-standingnutrition project has been identified and will support those nutrition strategies necessitating actions by other sectors, such as agriculture, fishery, women affairs, rural developmentand planning. This latter project will be presented to Board in FY98.
2. Major relatedprojects financed by the Bank and/or other development agencies (completed, ongoing andplanned): (a) The health sector in Mauritaniais being supportedby the Health and PopulationProject (PSP; Cr. 231 I-MAU), the first IDA credit to the sector, which is scheduledto be closed August 30, 1998. Designed as a regular investrnentoperation, it has financed: (i) population activities developed under the coordination of the Human Resources Directorate of the MP; (ii) gender activities conducted by the Secretariat d'Etat a la condition fiminine; and (iii) health activities organized by MSAS to support health service delivery in two regions in addition to Nouakchott, and the strengtheningof key technicalprograms such as family planning, MCH,IEG, and STD/AIDS. (b) A free-standingNutrition and Social Participation project has recently been identified, as a complementaryproject to the present HSIP. This project will provide financial support to nutrition activities at grass-root level and will involve NGOs and ministries other than MSAS, such as the Secretariat d'Etat a la condition fiminime, Agriculture, Fisheries, Rural development. (c) Other donors currentlyactive in the health sector in Mauritania include,besides the UN agencies, the EU, the French and GermanCooperations, the SaudiDevelopment Fund, the Islamic Bank for PrqjoctAppraisal Document Proect Tite: HealthSector Investment Credit Country:Mauritania Page 11 of24
Development,and the AfDB. Their activities and programs are described in Annex 2B is presented,in summary,in the followingtable.
Sectorissue Project LatestSupervision (Form 590) Ratings ImplementationProgress DevelopmentObjective (DO)
______._ _ .__ (IP) Bank-financed Health,Population, Gender Healthand Population Lastform 590:November Improvehealth statusby (Credit 2311 MAU) 199?;rated satisfactory provision of basic health services;help developa populationpolicy; assist developmentof gender activities. Nutrition Nutritionand social At pre-appraisalstage Improvenutrition status by action developinggrass-root activities. Education GeneralEducation Last form 590:June Assist educationsector (primary (Credit2706-MR) 1997; and secondaryed.; improve -rated satisfactory quality and resource VocationalEducation -ratedunsatisfactory mobilization)and (Credit252 1-MR) (crrrentlyunder intensive rationalizetechnical and supervision) vocational training. Other developmentagencies' EuropeanUnion Rehabilitationof Satisfactorily Tertiaryand secondaryhospital NationalHospital Center implemented(1993-1995) development. & Aioun Hospital ECU 8,000,000 Service decentralization Satisfactorily Secondaryhospital and primary in Gorgol District implemented; health care development. (1991-1995); ECU 8,500,000 AIDSISTMSupport Satisfactorily Capacitybuilding and program implemnenteduntil 1996. supportfor AIDS/STM. Suspendeddue to disagreementon project coordinator; ECU 600,000 AfricanDevelopment Bank PrimaryHealth Services Implementedwith delays, Strengtheningdrug Strengthening since 1994(effective procurementat centrallevel; since 1992); Developmentof PHC in 2 UCF 10,000,000 districts;and Supportto maintenanceservice. French Cooperation StructuralAdjustment Current;relatively Developmentof PHC and first successful; referralhealth facilities. FF13,000,000 Health System Implemented;relatively Decentralization; Restructuring successful;during 1992- Districthealth services; 1995 AIDS/STD;and ______FF12,000,000 Health personnel development.
3. Lessons learnedand reflected in the Programdesign:
(a) The current IDA-assistedHealth and PopulationProject (PSP) originally intendedto encompass many donors (AfDB, CFD, UNICEF and UNFPA). This arrangement was never fully implemented, as the respective donors ultimately preferred projects of their own or made effective their funds with considerable delay. In spite of PSP's complexity, the project is
'A detailed description of the health sector's donor-funded projects is available in Annex 2B ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Page12 of 24
successful (disburses well, will reach all objectives, will be closed as scheduled, and has received adequate counterpart-funding). While the results of the PSP prompted both the Bank and the GOM to consider a similar project design for the next credit (Section Dl), this option was discarded in favor of a sector-wide investment operation. The investment in staff and equipment made in the PSP management unit will not be lost, however, as most of this staff will be used to strengthen the institutional capacity of MSAS.
(b) Implementation of PSP has shown GOM to be a committed partner which pursues a sound sector policy and observes agreements. On the negative side, "PSP has not sufficiently enhanced MSAS's management capacity and has not significantly contributed to the strengthening of donor coordination activities (which have continued to be performed by the MP with little technical support from MSAS).
(c) The PSP has also demonstrated GOM's willingness and capacity to approach complex societal problems (for instance, the switch from the country's former pro-natalistic policy to the present population policy and action plan, the willingness to prevent the spread of HIV/AIDS epidemic and reduce STDs, the progress made in improving the status of women, and the success of cost recovery). It has also helped launch sector institutional reform and has improved sector financing and management. On the negative side, implementation experience suggests the need to be cautious about: (i) an over-reliance on timely donors financial contributions; (ii) complex and overly ambitious project goals; and, particularly, (iii)overly optimistic assumptions concerning the time needed to reach consensus on politically, socially or religiously sensitive questions. The integrated sector-wide approach proposed to support this Program addresses these concerns through an active and comprehensive involvement of all stake-holders, such as donors, care providers and beneficiaries in the development of the sector's policy and plans. All of these partners will be involved in the annual sector performance review, planning and budgeting exercises, and in Program implementation.
(d) Approaches used by donors vary (some prefer to operal:e, hands-on, in relatively small geographical areas-such as the KfW/GTZ-some are interested in specific program areas- such as Nutrition in the case of the Spanish Cooperation, or Nutrition, Immunizations, etc., in the case of UNICEF, while others are more interested in broader issues-for instance WHO, the EU and the French Cooperation). There is, nonetheless, consensus among donors concerning the need to strengthen health sector capacity in Program implementation, financial management and donor coordination. However, while donors have been involved actively in the development of the new sector policy, PDIS, PTHG 1998-2000, etc., and have clearly expressed their commitment to further support the sector, most of the donors are not able to commit themselves in a formal manner (regarding their financial input), and have not finalized their work programs for the next two years. This situation has led to the proposecl project's features which imply a Program led by GOM, common planning and evaluation mechanisms with donors and NGOs, strengthening of MSAS implementation and donor coordination capacity (to allow proper utilization of Government and IDA funds at project effectiveness, with the intention to only progressively incorporate other donor funding and develop common implementation arrangements).
(e) Out of the two current projects in the education sector (Projet cd'appuia I 'enseignementgeneral, Cr. 2706-MR, and Projet d'appui a V'enseignement technique et a la formation professionnelle, Cr. 2521-MR), the former is successful. The latter was recently analyzed by QAG and continues under intensified supervision. Similarly with the PSP, these proijects also point to the fact that, in Mauritania, where the MP coordinates all donor-funded actilvities, the Ministry of National Education is insufficiently involved in donor coordination and is, generally speaking, ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Page13 of 24
administratively weak. Considering this situation, the proposed HSIP lays emphasis on the strengthening of MSAS' institutional capacity, including its donor coordination function.
4. Indications of borrower commitment and ownership:
GOM has demonstrated its commitment to sector reforms by takingappropriate measures aiming at improving health care quality and accessibility, by proposing strategies and activities with high cost- effectiveness ratios, and by decentralizing decision-making at district levels. GOM has also: (i) developed its own policy and planning documents with relatively little support from expatriate consultants and by involving all intemal and extemal partners, (ii) involved the office of the Prime Minister, MP, and other ministries in the consensus process set up for health sector program development and IHSIPdesign, and last-but not least- (iii) designated the health sector among the country's priority sectors in its most recent policy documents.
The results of public expenditures reviews carried out in 1995 and 1996 illustrate best GOM's commitment to the sector and to its policy. GOM has constantly increased the health sector's share of the public budget; the health sector's budget allocation has been almost fully disbursed, with primary and secondary care services receiving distinct priority and the recurrent non-salary expenditures receiving adequate funds. GOM also successfully pursued and committed itself to cost recovery and its extension to secondary care facilities.
Recently, both Ministers of Planning and Health stated their commitment to the strengthening of MSAS institutional capacity and to the Plan Directeur (1998-2002) (see Annex 11: Letter of Sector Policy).
5. Value added of Bank support in this Program:
IDA's first Health and Population Project provided the means for GOM to adopt measures on a number of critical sector issues (including population policy, staff redeployment, decentralization, sector financing, cost recovery) and to initiate the development of health infrastructure, human resources, management capacity, and maintenance services. Nonetheless, PSP will probably reach its objectives without entirely meeting all of GOM's present needs. This will happen because:
(a) GOM's new objectives for the sector are more ambitious and, in some cases, such as family planning and nutrition, the consensus-building process has taken more time than originally anticipated.
(b) GOM's strategy for the sector has changed, as in the cases of: (i) training (where GOM recently decided to rely upon its own training facilities for medical post-graduate training in general specialties); (ii) the search for new financing modalities (where the establishment of pre-payment arrangements is being considered); (iii) the consolidation of service delivery capacity at district level (where the district hospitals' role is being expanded to cope with logistic difficulties and minimize patient referral); and (iv) maintenance (where GOM needs to more clearly define its strategy and find best ways to use private sector's services) .
The proposed IDA project would, therefore, be fully justified as a means to build on PSP's achievements, and especially to improve overall sector performance and donor collaboration. The sector- wicle budget support from the credit will respond, in an efficient manner, to new priorities for the sector and to the need to strengthen its planning and management capacities. Lastly, but very importantly, the sector-wide integrated approach will put the Government in the driver's seat, and strengthen its donor coordination function. The credit will be used to ensure funding in high-priority program-areas identified ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Page14 of 24 in the new sector policy and in the annual plans, for which there is broad consensus among Government, donors and NGOs.
E: Summary Project Analyses (Detailed assessments are in the project file and in Annex 8)
1. Economic (supported by Annex 4-A;4-B):
[ ] Cost-Benefit Analysis: NPV = NA ERR = NA [xl Cost-Effectiveness Analysis: [x] Other (Economic Analysis):
Cost-Effectiveness Analysis: The SIP approach does not lend itself to assessing the rate of return of the IDA input to the national health sector Program because: (i) the IDA level of funding and the breakdown by expenditure categories are to be determined on an annual basis; and (ii) IDA funds are fungible-and will be used as a last source of financing. It is therefore not feasible to prospectively quantify project costs and benefits. For this reason, an analysis of the soundness of the entire national sector Program, as presented in the sector policy, was carried out. This analysis has encompassed: (1) the sector policy (Plan Directeur 1998-2002), recently approved by the Government; (2) the data presented by MSAS in its PTHG 1998-2000; and (3) available cost-effectiveness ratios for health interventions in Africa. Furthermore, the consistency of the GOM policy for the sector with the minimum package of care described in the World Development Report (1993) (WDR) and Better Health in Africa (BHA) was also analyzed.
The analysis (presented in Annex 4A) demonstrates that 75% of the interventions proposed in the Health Sector PTHG 1998-2000 are highly cost-effective, i.e., they cost less than US$100 per DALY saved. This group of interventions comprises infectious disease control and prevention activities. The remaining 25% of interventions are moderately cost-effective, i.e., cost between US$250 and US$999 per DALY saved, and belong to activities in the area of non-communicable diseases. None of the interventions proposed in the PTHG falls under the category of low cost-effectiveness. Furthermore, these interventions correspond to the priority actions included in the "minimum package of care" of the WDR and BHA, target the main public health problems of the country, have important externalities and address very large population groups.
EconomicAnalysis: An economicanalysis (Annex 4B) to assess the soundnessof the HSIP was conducted. It examinesmatters such as the economicand sectoralconitext, health sector expendituresand financing, equity, risks, and capacity. It emerges from this analysis that the HSIP is consistent with the recent CAS and PFP for Mauritania,that public interventionand finaznceof health care are justified, and that the sector policy framework is adequate. Furthermore, the trends and structure of health sector expendituresduring the last years were promising and clearly support a SIP. Concerningthe financial plan, the Governmentand beneficiary contributionswill increase faster than donor contributions,which will stabilize towards the end of the period. IDA contributionwill ibesmall (about 12.5 % of the total Program cost). The Government will continue to depend on external funding but it will strengthen its own contribution. Beneficiarieswill play an increasingly importani role. Furthermore, the HSIP will promote equity. The likelihood of identified risks to occur is modest. Finally, there is a strong commitment to strengthening health sector's management and administrative capacity, and to substantially decentralizing decision-makingto districts, which in turn will lead to better resource utilization and more rational decision making. Projeci:Appraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Page15 of 24
2. Financial (see Annex 4B): NPV = NA FRR = NA
The total cost of the five-year health Program is estimated at US$191.6 million, distributed equally between investment costs (49 %) and recurrent costs (51 %). Government would finance US$75.8 million (39.5 % of the total). Moreover, through cost recovery, beneficiaries would contribute US$19.4 million (10 %). Finally, donors (excluding IDA) would finance US$72.5 million, (37.8 %), while IDA, as the lender of last resort, would finance US$24 million, (12.5 %).
For the sector to receive adequate funding, MSAS budget-as a share of Government's total budget-is assumed to steadily increase until it reaches 8.5 % in the year 2002. This is a conservative assumption compared with GOM's formal commitment to attain 10 % by the year 2002. Present budget execution rates are assumed to be maintained, in the future, at close to 100%.
Projections regarding donor investments are also conservative; they assume that donors' financial contribution to the sector will be stationary, in real terms, at the level of the year 1995 (IDA contribution to the present HSIP not included).
Furthermore, cost recovery assumptions made are not substantially different from the present performance of the cost recovery system. At primary level of care, it is assumed that cost recovery will apply to 80% of the population (instead of currently 75%), and that an average amount of UMI 18 per capita and per year will be spent for drugs. At secondary level of care, 80% of the recurrent expenditures (salaries not included) is assumed to be financed from cost recovery and an average amount of UM73 per capita and per year to be recovered during the entire period of five years. At tertiary level, 80% of the non-wage recurrent expenditures are assumed to be financed from cost recovery, and an average amount of LIM122 per capita and per year to be recovered during all years projected.
Fiscal impact: This Program will not lead to modifications of tax instruments. Nonetheless, beneficiary contributions towards the cost of the Program will be substantial. However, as described above, the cost and affordability of services in the public sector will be constantly monitored. Cost recovery for drugs will continue along the lines of the present arrangement which proved to function well and was able to provide drugs of good quality at affordable prices. The indigent population will also continue to be protected. Affordability of services and consumers' willingness to pay will be constantly monitored, aiming to make the under-served groups the gainers of this Program. During the five years of the sector's Program, the Government will better manage donor inputs (which are expected to remain important but to slightly decline toward the end of the period) and beneficiaries will be increasingly involved in decision-making and in financial support to the sector. Decentralization will also play a substantial role in efficiency gains and a more rational sector development.
3. Technical:
The policy for the health sector is technically sound. The issues of quality, access and equity are addressed systematically. The recent CAS, which was the result of a broad participatory process, also emphasizes poverty reduction as the main objective for the country and for its collaboration with the World Bank, and stresses the importance of the health sector. As the second Plan Directeur continues the policy launched by GOM in 1991, there is also ample evidence that the sector policy is being consistently applied, is appropriate for the country, and has started to have an impact on the health status. This is evidenced by all three PERs carried out in 1995 and 1996, which have demonstrated regular improvement in financial resources (contributed by GOM, donors and beneficiaries), and rational use of resources (emphasis on primary and secondary care, right ratios between investment and recurrent expenditures, and between recurrent and recurrent non-salary expenditures, a continuous effort to decentralize service delivery and decision-making, etc.). As mentioned in Annex 4 A, 75% of health ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Page16 of 24 interventions proposed for the Program 1998-2002 fall in the category of high cost-effective interventions and the remaining 25% in the medium cost-effective category. Other documents (e.g., PTHG 1998-2000 and PDIS) show that, in regard to health infrastructure development, GOM will continue to strengthen health delivery capacity at the outreach. While the new Program is not proposing radical changes to the sound process of sector restructuring and reform started in 1991, it does contain innovations. For instance: (i) in sector financing by promoting the set up of pre-payment arrangements, (ii) in training of health providers, hereunder, local training to specialize general practitioners is now carried out in Mauritania, (while under-graduate medical training will continue to take place abroad); (iii) in health care delivery, by the set up of self-sufficient secondary hospitals to minimize referral. All main health status problems, for which cost-effective interventions are available, are also systematically addressed e.g.: sexually transmitted diseases and HIV/AIDS; family planning; nutrition, IEC and communicable diseases.
4. Institutional:
(a) Executing agencies: MSAS will be the HSIP executing agency. All of MSAS directorates and services and the DRASSs will be involved as appropriate, as well as all MSAS'spartenaires au developpement. Regarding the demographic and health survey and the support to population census, these two rather specialized activities will be entrusted to ONS and FNUAP respectively. While MSAS has demonstrated its capacity to develop and pursue a sound sector policy, to date it has only managed GOM's recurrent non-wage budget allocation for the sector (the budget allocation for salaries is managed by MF and the investment budget contributed by donors and executed by various project units is managed by MP). Hence, the HSIP emphasis on health sector capacity building and the new management arrangements being proposed.
(b) Program management: The management of the Program will rely upon two substantially strengthened MSAS units (i.e., Direction des affaires administratives et financieres-DAAF- and Direction de la planification, de la cooperation et de la statistique-DPCS) and a newly created unit (i.e. Direction de gestion des investissements-I)GI). This last directorate will be in charge of all procurement operations, and of the financial management and accounting of all investment funds channeled through MSAS. The th[ree units will manage Program implementation under the supervision of the Minister and Secretary General and with the support of all MSAS directorates and DRASSs. The main instrument used for Program management will be the annual Program review and planning exercise which will take place towards the end of each fiscal year. With this opportunity, GOM will present to donors and NGOs: (i) a progress report on the performance and achievements during the respective FY, and (ii) an updated version of the PTHG (the first year of which will be a detailed activity plan for the respective year). These documents will mention all activities planned to take place in the health sector and their source of financing. The IDA financed activities will be identified, every year, based on the proposals contained in the PTHG. These activities will be discussed with all partners, and, after receiving IDA agreement, will be used to develop annual Procurement and Disbursement Plans.
While the MP will retain its donor coordination function, it is also being proposed to transfer the more technical, Program-specific tasks to MSAS, and to strengthen the collaboration between MSAS and MP. Several other arrangements to allow the participation of other sectors and to coordinate MSAS various services are also proposed (e.g., Sector Policy Implementation Board and Program Management Committee. See also paragraph C4). Moreover, the PRCI will be implemented, key positions for successful Program implementation have been identified, job descriptions written and GOM has committed itself to staff these positions in a phased manner. MSAS will also be supported with ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Page17 of 24 equipment, computers, and technical assistance. By pursuing the decentralization of decision-making, district staff will increasingly become involved in Program execution. Similarly, donors and NGOs, which have already participated in the development of the new sector policy, will increase their role in the implementation of the Program. It is anticipated that GOM will entrust them with the management of specific Program components (e.g., WHO with the tropical disease program and sector policy matters, UNICEF with the nutrition program, UNFPA with the family planning program), as it has already been decided for the demographic and health survey, and in the case of population census activities which will be executed by ONS and FNUAP.
5. Social:
The Program will have a positive social impact, since it will help achieve the ultimate objective of improving the health status and well-being of the population of one of the poorest countries in Africa. The Program will also promote equity as: (i) it will rely upon strategies which positively discriminate the rural population, women and children; (ii) it will assure the provision of good quality health care services to the majority of the population, reaching out to remote geographical areas; (iii) it will use best cost- effective interventions; and (iv) it will support the development of primary care and of effective first referral services which will be able to address more than 90% of health conditions. Information camipaigns, grassroot-level actions, and user involvement in the management of health facilities and beneficiary assessments will reinforce the social acceptability of the Program.
6. Environmental assessment: Environmental Category [ I A [ B [x] C
This is a category C project, since no environmental risks are foreseen. Any conistruction/rehabilitation of buildings will be done in accordance with acceptable standards. Promotion of hygiene will have a positive environmental impact. There would be no displacement of people. Measure to ensure appropriate disposal of hospital waste will be taken with the opportunity of civil works.
7. Participatory approach:
(a) Primary beneficiaries and other affected groups: Primary beneficiaries are already involved in health matters, as they: (i) contribute to the financing of recurrent costs in health facilities at all levels (primary, secondary and tertiary); and (ii) participate in the decisions made regarding the use of resources generated through cost recovery. Beneficiary assessments have also been carried out with the opportunity of the current IDA credit to the health sector, and at the preparation stage of the newly-proposed Program. In Mauritania, there is also a genuine commitment to decentralization. District elected leaders (walis) and district health administrations (DRASS) can already make a large array of decisions (regarding, for instance, the management of financial and personnel resources in their respective geographical areas), benefit from specific budget allocations from the public budget, and retain locally the funds generated through cost recovery. They have been consulted with the opportunity of the evaluation of the first sector policy and the launching of the new sector policy which further pursues decentralization. This implies institutional strengthening and a more discretion to DRASSs, more involvement of political and administrative leaders in health matters at wilaya level, and more community and beneficiary involvement (by giving more authority to the Comites de developpement socio-sanitaire and Comites de gestion). The PTHG 1998-2000 was prepared based largely on proposals made by district staff. The selection of sites for new health services and for rehabilitation works has been made on the basis of criteria of accessibility and health needs from the lists of requests submitted by local health administration (which also ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Page18 of 24
included a signed commitment of the respective communities to effectively contribute to the respectiveworks).
(b) Other key stake-holders: Both the recently-discussed Country Assistance Strategy for Mauritania-as well as the preparation of the new sector policy and of the proposed Program- have been carried out in a participatorymanner, and with the involvementof beneficiaries,local health staff, district political leaders, NGOs, and donors. From the central level, the Prime Minister's office was representedand all relevant other sectors have been involved. The MP and the Secretariat d'Etat a la condition feminine were particularly active.
F: Sustainability and Risks
1. Sustainability:
The Program proposed by GOM for the health sector for the period 1998-2002is built on and developsfurther the policy for the health sector launchedin the early '90s under the Plan Directeur 1991- 1995/6(and supportedby the first IDA credit to the health sector). The 1995-96PER conductedby the World Bank, as well as two other health expenditures analyses carried out during Program preparation, have provided evidence that the GOM's health policy has indeed been implemented, that resources have been used in accordance with its requirements, and that the financirng of the sector has steadily been improved. It is worth quoting in this regard that: (i) the share of recurrent health expenditures of total recurrent expenditures has increased from about 5.3% in 1993 to 6.40/%1in 1996; (ii) salaries have been maintained at less than 65% of the recurrent health budget; (iii) total expenditures for primary and secondary care have accounted for more than 40% of total health expenditures; (iv) recurrent budget execution has been about 100%; (v) donor funding and expenditures have steadily increased; (vi) cost recovery for drugs and services has been remarkably well implemented; (vii) allocations for districts, specifically mentioned in the budget, have been increased by 6% annually; and (viii) the decentralization policy has been pursued. Important consensus meetings (e.g., Journees de reflexion sous la Khaima in 1995), and agreements reached during the discussions of the Country Assistance Strategy have also demonstrated GOM's commitment to reduce poverty and to further develop social sectors. At the launching of the Plan Directeur 1998-2002, GOM committed itself to increase the share of the health sector budget to 10% by the year 2002, and demonstrated its willingness to hold a transparent dialogue with donors, NGOs, other sectors and beneficiaries. Beneficiary assessments carried out under the current IDA credit and the preparation work for the proposed credit also show grass-root interest in GOM's objectives for the social sectors, including the policy goal of developing affordable, good quality, primary health services. The participation of donors and NGOs in Program preparation and execution will also contribute to Program sustainability. Consultants and private contractors will conduct studies, and execute construction and rehabilitation works. IDA financing amounts to US$24 million and represents about 12.5% of the Program's total cost. During the first years of the Program, IDA contribution will be used, with priority, to strengthen the health sector's institutional capacity (N.B. IDA funds will not be used for civil servants' salaries). It is expected that IDA financing will decline towards the end of the Program, as the Government takes on an increasing share of Program financing. However, in spite of the Government's commitment to increasing levels of funding for the sector, and of foreseeable economic growth, external support will continue to be necessary to sustain health and other social services for some years after the end of the Program.
'Not includingthe "depensescommunes". ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Maurtania Page19 of 24
2. Critical Risks (reflecting assumptions in the fourth column ofAnnex 1).
Risk Risk Risk Minimization Measure Rating
Annex 1, cell "from Outputs to Development Objective" 1. Cultural and behavioral "barriers" (e.g., cultural, N * Education reforms, already being lack of knowledge, costs) may prevent increased implemented, will increase literacy levels. utilization of services. * The Secretariat d'Etat a la condition feminine (SECF), has established Centres de promotion feminine (CPF) at district level (wilayas), and revenue-generating microprojects with a functional alphabetization program to increase literacy and awareness at grass-root level. * Cost of health services will be monitored, and service affordability and consumer satisfaction with services will be periodically assessed. 2. Low literacy levels may have an adverse effect N * GOM is committed to increasing public on health status and on services utilization. spending for education. * Education sector reforns which started in 1987 will expand access to primary education, improve the quality of primary and secondary education, reduce illiteracy, and strengthen job-oriented vocational training; these reforms will be continued and further strengthened. 3. Problems of poor access to water, sanitation, and M * Implementation of rainfed Natural Resources electricity may not be solved and may maintain Project (with IDA support). causes of ill health. * Review of Policies, Strategies, and Traditional Energy Sector Programs (RPTES) will build local capacity through a mix of policy and operational support to Traditional Energy Sector. * Continuation of IDA and other donors' support to GOM to assist sound investment programs for water, sanitation, and electricity, and increased private sector investment. 4. Inadequate weaning foods and lack of nutrition N * IEC program will be strengthened to raise education may slow down the improvement of awareness as to the benefits of health services, health status. with emphasis on prevention and nutrition. * A free standing nutrition project is also being developed to support nutrition activities in other sectors than health. ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Page20 of 24
Annex 1, cell "from Componentsto Outputs" 1. Poor economicperformance may hinder GOM's M * Promotionof strongsupply response from the capabilityto implementits overall development private sector. plan and provide adequatefunding to social sectors. * Facilitationof accessto servicesand credits. * Exploitaticinof new marketopportunities. * Developmentof financialintermediation, lowerproduction costs, and increasedprivate sector participationin the deliveryof public services. * ForeignDirect Investment(FDI) to upgrade diversityand raise the technologicalbase in the rural, fisheries,mining, and publicutility sectors. * OngoingPublic Resource Management Credit (FY 1996) and capacitybuilding programs will support effortsto an efficientmarket oriented public sectorapparatus. * Fiscaldecentralization will improveeconomic managementand public expenditure management. 2. Poor geographicaccessibility may hinderservice N * Health post networkwill be expanded, utilization. equippedand staffed. * Selectivehealth centerswill be rehabilitated and upgraded,and the minimumpackage of servicesrevised, thereby reducingthe need for referrals. * Road netwoirkwill be further extended,with betteravailability of transportation. 3. Lack of policyframework to enhancesocial M * Formulationand endorsementof new policies action. for social issueswill be carriedout and regularlymonitored, so that the SocialAffairs Directorateof MSASwill accomplishits mandate. * Good record in regardto commitmentto social sectorswill be maintainedby including regularlythe social issuesin the dialoguewith the WorldBank and donors. 4. The MSAS'sweak capacityto implementthe M * Implementationof the PRCIwill be closely programmay cause delays. monitored. * SIP approachwill allow the Programto be adjustedto new needs, changesin performance and variationsin sector's resources. * Main donors to the sectorare also committed to improvehealth sectoradministrative performance. * Annual sectorperformance reviews will take place. 5. Donor fatiguemay leadto decreasein support. M * Increaseddonor coordinationin MSAS (in additionto MP efforts). * Intensifieddonor participationin all aspectsof planningand imanagementof health programs. ProjectAppraisal Document ProjectTitle: Health Sector Investment Credit Country:Mauritania Page21 of 24
Overall RiskRating: M * Properproject planning, and strengthened The overallrisk that the Program could fail to supervisionat all levelsduring Program achieve its developmentobjectives is rated as implementationwill ensurethat bottlenecksare modest. recognizedand correctedin a timelymanner, thereby facilitatingthe achievementof Programobjectives * SIP mechanismsof annualprogress review, planningand budgetingwill allow to adapt to unforeseeablechanges and cope with contingencies.
RiskRating: H = High Risk; S = Substantial Risk; M = Modest Risk; N = Negligibleor Low Risk.
3. Possible Controversial Aspects:
Female genital mutilation (FGM) is still practiced in Mauritania and the Board has made clear its concern regarding this issue in Africa. The matter has been discussed, both with MSAS and with the Secretariat d'etat a la condition feminine. According to the information provided by GOM, "Notwithstanding the fact that genital mutilation in Mauritania affects relatively less women's health than is the case in other Sub-Saharan African Countries (as it concerns smaller population groups and uses less traumatic techniques) this issue is already on the political agenda and was addressed recently -inter alia- at a national seminar organized by GOM and UNDP". A national NGO (L 'Association Mauritanienne pour la Promotion de la Famille) is active in this area, has held a national consultation (on the FGM and other "pratiques nefastes 'a la sante de la femme") in November 1997, and it is currently working, in close collaboration with the SECF, to reach consensus and to elaborate an action plan. As a condition for Negotiations, the Government has stated, in its Letter of Sector Policy, its commitment to reduce the frequence with which FGM is practiced and to address the FGM's detrimental effects on the health of women. The HSIP will support the implementation of specific measures to reduce the health consequences of FGM and educate the user of health services.
There is also concern regarding the infectious diseases morbidity and, in particular, with the water and/or vector borne disease epidemic (schistosomiasis, malaria, hepatitis) which might increase further as a result of civil works carried out on Senegal river. This issue was specifically discussed with Government and donors and, as a result, a task force, led by WHO, was set up. The current IDA financed project has supported activities in this area, and the GOM policy for the health sector for the next five years continues to address the issue. HSIP will finance activities related to: (i) the set up of an effective diisease surveillance system, (ii) supervision work and strengthening of district teams to act promptly in case of epidemic, (iii) procurement of specific drugs for case management and chemoprophylaxis and (iv) IEC. More generally, the extension of the health delivery system, in particular at the primary health care level, improvements in the quality of services and the emphasis on prevention should also mitigate thie effects of the epidemic and reduce disease incidence. Furthermore, Mauritania coordinates its infectious disease activities with the other two countries (Senegal and Mali).
Both issues were re-analyzed with the opportunity of technical discussions held during N'egotiations. Actions foreseen in the PTHG and their respective cost estimates for the components dealing with reproductive health (and in particular with FGM) and with infectious diseases have been reconsidered and the credit increased by US$2.6 million. With the same opportunity GOM restated its commitment to reduce the "pratiques nefastes a la sante' de lafemme" and its concern with reproductive health, tuberculoses, water-borne diseases, and the strengthening of sector capacity. ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Page22 of 24 G: Main CreditConditions
1. Conditions:
As conditionsof Negotiations,
(a) the Government has transmitted to IDA the following documents, which were discussed and agreed upon at Appraisal: (1) A signed Letter of Health Sector Policy stating (i) GOM commitmentto finance the health sector from its own resources, donor funds and beneficiaries' contributions;(ii) the main thrusts of the health sector policy and the priority areas to be protected in case of unexpected financial stringency; (iii) GOM commitment to reduce the practice of female genital mutilation;and presenting(iv) a matrix of monitoringindicators for the Program; (2) The final versions the PDIS 1998-2002and of the Health SectorPTHG 1998-2000; (3) An outline of the Program ImplementationManual (includingan ImplementationPlan and the model of the bidding documentto be used for nationalcompetitive bidding for goods and civil works); (4) A document describing the organizationalchanges at the MSAS (includingthe creation of the Direction de gestion des investissements and stating the functions to be carried out by DPCS,DGI, and DAAF); (5) The list of posts of the DPCS, DAAF,DGI and DPM; (6) The Procurementplan for IDA financedactivities for 1998-1999; (7) The terms of reference and the consultantcontract for a Study on the cost recovery in the health sector. (b) The Governmenthas appointedthe staff in charge of the Procurementunit and of the Accounting unit at the DGI, and staffed the director posts at the DP'CS,DAAF and DGI, in a manner acceptableto IDA. As conditionsof credit effectiveness,the Governmentwouldl: (1) Deposit into the project account the initial amount of Governmentcounterpart funds for the first year of the Program; (2) Submitthe final version, acceptableto IDA, of the MEP (program implementationmanual) (3) Submitthe approvedPRCI for 1998-2002; (4) Appointan independentauditor acceptableto IDA; (5) Staff, in a manner acceptableto IDA, two accountantposts and the post of chief procurement officer at DGI, an additional accountant post at the I)AAF, and appoint the directors of DAAF, DGI and DPCS. (6) Install a computerizedfinancial monitoringsystem at the DGI and the DAAF. (7) Submit to IDA bidding documents for works and goods to be purchased in 1998 using IDA funds. ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Cojntry: Mauritania Page23 of 24
2. Legal covenants:
(1) The Letter of sector policy and its monitoring and evaluation indicators (Annex 11 of the PAD), as well as the Plan Directeur 1998-2002 will guide all sector activities to be developed during the period 1998-2002. (2) MSAS will present and discuss with donors and IDA, by October 31 of each year, a progress report on the first three quarters of the respective fiscal year and a proposal for a Annual Operational Plan (POAS) and budget for the health sector for the next fiscal year. Upon reaching agreement on these documents, the POAS will constitute the first year of the respective PTHG and will be used to guide MSAS, DRASSs and donors work in the sector. (3) By the end of each year, MSAS will discuss and agree with IDA, which activities of the POAS for the next fiscal year will be funded from the proceeds of the project and will develop an annual procurement plan which will encompass all IDA funded activities for the respective fiscal year. (4) Annually, Government will review the progress made in the implementation of the PRCI (Institutional Strengthening Plan), the PDIS (Health Infrastructures Development Plan) and the PDHR (Human Resources Development Plan), and will update and implement these plans. (5) By 31 October 1999, MSAS will develop a Maintenance strategy for the public health sector and will implement it during the Program with support from the private sector, donors and IDA. (6) Annually, Government will make available adequate counterpart funds. (7) During the year 2000, Govemment will carry out a mid-term review of the Health Sector Investment Project and of its Program. (8) During the year 1999 and 2001, Government will carry out beneficiary assessments to evaluate consumer satisfaction with Program implementation and to identify measures to adapt the health sector's Program to consumer needs.
H: Readiness for Implementation
[ ] The engineering design documents for the first year's activities are complete and ready for the start of Program implementation. [x] Not applicable.
[x] The procurement documents for the first year's activities are complete and ready for the start of Program implementation.
[ ] The Program Implementation Plan has been appraised and found to be realistic and of satisfactory quality. (to be discussed at Appraisal; NB It will be part of the Program Implementation Manual).
[ ] The following items are lacking and are discussed under credit conditions (Section G): Project AppraisalDocument Project Tifle: Health Sector Investment Credit Country: Mauritania Page 24 of 24
I. Compliancewith Bank Policies
[x ] This projectcomplies with all applicableBank policies.
Task Team Leader SergiuLuculescu
Sector Managers Ok Pannenborg/ NicholasBurnett
CountryDirector Hasan Tuluy ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Maurtania Annex1- Page1 of 5
Annex 1 Program Design Summary
Narrative Summary Key Performance Monitoring and Critical Assumptions Indicators Evaluation Sector-related CAS Goal: (Goal to Bank Mission) Poverty reduction * GOM will continue to through: implement the designed Economic and Financial (1) rapid broad-based 1.1. Decrease urban 1.1.1. Integrated Recovery Program, growth and income unemployment (currently Household Study (to be especially in the major generation; 26%; 20% in 2000, 15% in repeated in 2002). sectors like agriculture, 2002). fisheries, mining, banking, public (2) increase in human 2.1. Increase adult literacy 2.1.1. Annual (and enterprises, insurance, capital; (currently 31%; 40% in 2000, other) education sector education, and health. 60% in 2002). reports. * Private sector involvement will be 2.1.2. Same as (1.1.1.) enhanced. above. * GOM's debt burden will be addressed. (3) interventions targeted 3.1. Increase vaccination 3.1.1. same as (1.1.1.) * World prices for to the vulnerable groups; coverage (currently 65% for above. principle exports like infants; 75% in 2000, 85% in iron ore and fisheries 2002). will not decrease markedly. (4) strengthening the 4.1. Increase accessibility to 4.1.1. Same as (1.1.11.) * Intemational aid capacity to design and water and electricity above. dependency will deliver pro-poor, pro- (currently 50%; 60% in 2000, decrease. growth policies; and 75% in 2002). * No extreme adverse climatic conditions (5) Strengthening of 5.1. Maintain expenditures 5.1.1. Monitor public (draught) will occur. sociaLIsectors. for primary and secondary expenditure in the health In the event that health care at the levels for sector. economic performance 1995 (i.e. at least 40% of total improves, or at least expenditures). 5.1.2. Set up remains satisfactory, this computerized financial program should monitoring system, contribute markedly to allowing monitoring by the CAS goal of level and program "Poverty Reduction", component. which coincides with the Bank Mission of "PovertyAlleviation." Project Appraisal Document Project Title: Health Sector InvestmentCredit Country: Mauritania Annex 1 - Page 2 of 5
ProgramDevelopment (Objectiveto Goal) Objective: Generalobjective: To 1. Increase health facilities 1.1. Routinereporting * The economic support health sector utilization rates (currently system. performance will development thus 60%; 70% in 2000, 80% in improve, or at least will contributing to the 2002). continue at the same improvement of health level. status by the provision of 2. Reduce Infant Mortality 2.1. Special * The main accessible and quality Rate (currently 118/1000; demographic studies. employment/ income health services. 95/1 000 in 2000, 80/1000 in generating sectors of the 2002). economy will be expanded to 3. Reduce Underfive 3.1. Same as (2.1.) accommodate an Mortality Rate (currently above. increasingly healthier 182/1000; 140/1000 in 2000, work force. 90/1000 in 2002). * The population growth rate and rural- 4. Reduce Total Fertility 4.1. Same as (2.1.) urban migration will Rate (currently 6.5; 6.0 in above. decline. 2000, 5.5 in 2002). * Political climate facilitating the implementation of sector policy will remain stable. * Expansion of other social services like education, transport, communications, water, and electricity will continue. * Poverty alleviation programs and activities will be targeted to vulnerable groups and geographic areas.
Outputs: (Outputs to Objective) 1. Improve health 1.1. Develop health facilities 1.1.1. Annual sector * Increased utilization services quality and according to PDIS. report on PDIS. of improved, expanded coverage; services in spite of 1.2. Increase number of 1.2.1. Routine reporting "barriers" (e.g. cultural, health posts fully functional system. lack of knowledge,and and supervised (currently costs). 208; 350 in 2000, 443 in 1.2.2. Health sector * Householdfood 2002). reports. security will improve. ProjectAppraisal Document ProjectTitle: HealthSector InvestmentCredit Country::Mauritania Annex1 - Page 3 of 5
1.3. Increase primary health 1.3.1. Same as (1.2.2.) * The problem of care coverage, i.e., above. inadequate weaning geographical accessibility foods will be addressed. less than five kilometers from * Problems associated health center or health post with Nutrition Education (currently 65%; 75% in 2000, will be addressed. 80% in 2002). * Adult literacy will increase. 1.4. Increase consumer 1.4.1. Beneficiary * Accessibility to water, satisfaction with health assessment survey sanitation and electricity services (from qualitative (repeat in 2000 and will increase. assessment in Beneficiary 2002). Assessment Study).
2. Improve health sector's 2.1. Increase (or at least 2.1.1. Budget and PER financing and maintain) donor financing of analyses. performance; the health sector (at least, in constant prices, at the level of 1995).
2.2. Increase percentage share 2.2.1. Same as (2.1.1.) of recurrent budget for health above. (currently 6.5%; 7.5% in 2000, 8.5% by 2002).
2.3. Extend cost recovery to 2.3.1. Same as (1.2.1.) secondary health facilities (by above. 2000).
3. Mitigate the effects of 3.1. Increase contraceptive 3.1.1. Routine reporting major public health prevalence rate (currently system.. problems; and 2.5%; 5% in 2000, 10% by 2002).
3.2. Increase antenatal care 3.2.1. Same as (3.1.1.) rates (currently 35%; 50% in above. 2000, 75% by 2002).
3.3. Increase postnatal care 3.3.1. Same as (3.1.1.) rates (currently 22%; 40% in above 2000, 60% by 2002).
3.4. Decrease under-five 3.4.1. Nutrition surveys malnutrition rates (currently (in 2000 and 2002). 30%; 25% in 2000, 15% in 2002). ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex 1 - Page4 of 5
4. Promote social action 4.1. Formulateand endorse 4.1.1. Policydocument. and create an environment policy for social action conduciveto health. (currentlynone; availablein 2000,revised by 2002).
4.2. Numberof studies 4.2.1. Reports available. conductedon underserved groups (at least one annually).
4.3. Formulateand 4.3.1. IEC reports. disseminateIEC messagesto raise demand for modem contraception(currently none).
Program (Componentsto Outputs) Components/Sub- components:(see Annex 2 for Program description) 1.1. 1. Budget and PER * Geographic analyses. accessibilitywill start I. Improvehealth services US$86.4million improvingthrough the quality and coverage. extensionof roads and availabilityof 1.1. Build 235 health transportation. posts (153 by IDA). * Donor dependencywill decrease,lessening the 1.2.Equip 263 health risk of donor fatigue. posts. * Domesticresources will increase. 1.3.Upgrade 12 health e Capacityof GOM to centers from grade B to implementoverall grade A. economicplan will improve. I.4. Upgrade 14 health * Needed policy changes posts to grade B health will be effected. centers. * Programs and activities in related sectorswill be 1.5. Rehabilitate5 health implemented centers grade A, 14 health concurrently. centers type B, and 52 health posts.
1.6.Rehabilitate and strengthenperformance of all 11 district hospitals. ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex1 - Page5 of 5
II. Improve health US$37.4 million sector's financing and performance.
11.1. Strengthen the I. 1.1. Same as (I. 1.1.) management, planning, above. and administrative performance of MSAS.
11.2.Decentralize.
11.3.Improve health sector financing.
III. Mitigate the effects of US$56.5 million major public health problems.
111.1. Integrated 111.1.1. Same as (I.1. 1.) Management of above. Childhood Illnesses.
III.2. Extended antenatal, delivery, and postnatal Care.
III.3. Common ailments (inciludingcommunicable diseases control).
111.4.Information, Education, and Communication.
IV. Promote social action US$11.3 million IV.1.1. Same as (I.1.1.) and create an environment above. conducive to health.
IV. 1. Situational analysis.
IV.2. Policy formulation.
IV.3. Information, Education, and Comnmunication.
ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex2A - PageI of 5
Annex 2A Detailed Program Description
Overall health sector Program priorities and their estimated costs are presented, respectively, in the Plan Directeur 1998-2002 and the PTHG 1998-2000. The Plan Directeur 1998-2002 comprises four mnajorobjectives: (i) improving the quality and coverage of health services at primary and referral levels; (ii) strengthening the performance of health sector resource planning and management; (iii) mitigating the effects major public health problems; and (iv) creating an environment conducive to the promotion of health and social action. The PTHG comprises plans for each of the Ministry-level directorates and services, for the Etablissements autonomes (i.e., tertiary care facilities), as well as comprehensive plans for all twelve regions. Another document, recently discussed and agreed upon by donors and NGOs, is the PDIS 1998-2002. Based on this plan, besides the needs in civil works, equipment and human resources needs are estimated, and respective activities planned.
Together, these documents provide the framework within which annual operational plans will be developed. Towards the end of each fiscal year, the Government will present, at an open meeting with donors and NGOs, a progress report on the activities conducted during the respective year, and a proposal ifor an activity plan and budget for the next fiscal year. At this meeting, GOM, donors and NGOs will reach an agreement on future activities and their sources of financing, thereby allowing IDA to perform iits lender of last resort function and to identify which activities will receive financial support from the proposed credit. In order to qualify for IDA support, activities should be: (i) consistent with the health sector policy; (ii) included in both the PTHG 1998-2000, and the proposed Annual Operational Plan; (iii) considered relevant and timely by the other donors and NGOs; and (iv) unfunded by GOM, beneficiaries, or donors. This sub-set of the activities (derived from the PTHG 1998-2000, and the Annual Operational Plan) will constitute the Activity plan for IDA financing for the respective fiscal year (based on which an IDA Procurement and disbursement plan will be developed).
Program Component 1: Improve health services quality and coverage US$86.4 million
Given Mauritania's specific geographical conditions, inadequate transportation infrastructure, and lack of communications, the Program emphasizes health facilities capable of treating a high proportion of cases, thereby significantly reducing the referral to more specialized levels and abroad. The overall Program aims to ensure the availability and financial accessibility of quality primary and referral health services for at least 80% of the population and to increase utilization rates to 80%.
This component comprises the following elements: 1) Expansion of health service coverage, with specific objectives for primary, secondary and tertiary services; 2) Improvement of health services performance, which includes staffing, equipping & maintenance, supply of essential drugs; 3) Improvement of health facility utilization rates; and 4) Quality assurance measures. ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex2A - Page2 of 5
Over the period 1998-2002, the Program seeks to increase coverage through: (i) construction and/or refurbishing of 148 health posts, 17 Category B health centers and 6 Category A health centers; (ii) upgrading of 14 health posts to Category B health centers and 10 Category B health centers to Category A health centers, along with the provision of qualified staff and equipment for general surgery; and (iii) construction of I new district hospital and renovation of 7 other district hospitals.
During the first eighteen months, the project will finance alrchitecturalstudies and the preparation of tendering documents for all civil works. IDA will also finance construction of I CSA, 3 CSB, and replacement of 19 health posts. The Program will also provide medical equipment and transport for 38 health posts constructed with French Cooperation financing.
Diagnostic capabilities will be introduced at primary level and strengthened at all referral levels. Surgical capabilities will be made available at all district hospitals. Staff from the tertiary hospital in Nouakchott will also perform supervision in the field and regularly take care of more complex cases by carrying out regular visits to district hospitals; the IDA credit will finance these visits.
Concurrently with the geographical extension of services, ithe Program will support improvement of the quality of services through : (i) development of norms and standards comprising a clear description of functions to be performed by each health facility category (minimum package of care); (ii) implementation of a human resources development plan to ensure appropriate staffing, training, and supervision of health personnel; (iii) continued improvement of systems for supplying essential drugs at the primary level and introduction of adequate drug supply systemrsat the referral level; and (iv) proper maintenance and health facility hygiene.
Program preparation activities have already defined minimum packages of activities by level of services, and during annual planning process these packages will be reviewed. Program preparation funds are also financing a human resources development plan, and the credit has tentatively identified as a priority area for support the newly created institute for specialized care (emphasizing training in general surgery) and the existing nurse training school. Refurbishment of :facilities and equipment, development of a more coherent curriculum, and development of pedagogical skills are envisioned in the first eighteen months.
Continuing on the initial IDA project efforts to strengthen drug supply systems, the new credit will initially support ministry efforts to extend the cost recovery system to the district hospital level. The project has tentatively identified support for consultant services to design the system and develop the requisite management and treatment supports; initial stocks of drugs for the hospitals will also be purchased.
Program Component 2: Improve health sector's financing and performance US$37.4 million
Over the next five years, the Government is committed to strengthen health sector financing by: (1) increasing health's share of the total public budget to 10%; (2) expanding cost recovery to secondary health care level (primary and tertiary care facilities already recover costs for drugs and services); (3) mobilizing private resources; and (4) increasing donor funding. Combined with implementation of an ambitious infrastructure development program and planned iimprovements in human resource development, drug supply, and facilities maintenance, MSAS capabilities to plan and manage its resources will be severely tested . ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex2A - Page3 of 5
This component comprises the following elements:
(i) Strengthening of planning, management, and administrative performance of the MSAS; (ii) Decentralization of decision-making to districts and health facilities; (iii) Strengthening of the coordination of external (donors and NGOs) and internal partners; (iv) Improvement of health sector financing including an increase of GOM's contribution, donor funding, and community and beneficiary participation (and also strengthening of community and beneficiary participation in management decisions concerning Program priorities and resource allocation); (v) Implementation of an effective health information system and of an epidemic surveillance system at central and district levels; and
(vi) Improvement of health personnel management.
Over the initial 18 month period, the Program will emphasize the strengthening of central and regional-level planning and management capabilities. At central level, the credit will finance refurbishment, equipment, and transport for the key directorates of Planning (DPCS), and Finance and Administration (DAAF). Key additional posts for each of these directorates have been identified and job descriptions prepared; the project will not finance salary costs of civil servants to be redeployed or recruited. However, the proceeds of the IDA credit could be used for consultants to fill vacant posts, should civil servants could not be recruited or redeployed for some of the incremental positions. The project has also tentatively identified additional funding for technical support in the areas of planning, management information systems; financial management; tendering; and internal and external audits.
In particular, during the initial phase of Program implementation, the project will continue to finance strengthening of the PTHG process (introduced during preparation), the coordination of donor financing and the interventions of other sectors, and the organization of the annual sector review. More efficient mechanisms for donor coordination will increase donor participation in the achievement of the sector policy; these mechanisms will include adoption of national norms and standards (e.g., equipment, infrastructure, staffing, etc.) for health service development, closer monitoring of donor funded activities, and the organization of regular meetings with donors and NGOs. The Program will also address staff performance by improving personnel management, monitoring staff performance, establishing an equitable incentive/disincentive scheme to reward good performance, and decentralizing human resources management to districts
At the regional level, the overall Program aims to improve regional management and administration of the DRASS, to increase the involvement of political and administrative leaders (Walis) in health matters at wilaya level, and to strengthen community and beneficiary involvement (by giving more authority to the Comites de Developpement Socio-Sanitaire and to theComites de Gestion). Among the tasks to be decentralized are: drug logistics and stock management (to be performed by the Regional Pharmaceutical Depots); human resources management (including deployment and re-deployment of health personnel; training and supervision); and planning and budgeting (using resources from cost recovery, the public sector's budget and donor contributions).
The Program will initially support the District Health Teams--composed of DRASS staff, district hospital directors, and Moughata chief medical officers--by financing the operating costs associated with the newly decentralized tasks. Subsequently, priority areas identified by region during the three-year ProjectAppraisal Document ProjectTitle: Health Sector Investment Credit Country:Mauritania Annex2A - Page4 of5 planning process will provide the basis for annual funding.
Program Component 3: Mitigate the effects of major public health problems US$56.5 million
The principal public health problems included in the overall Program for the period 1998-2002 comprise:
(a) infant and child mortality, where the Program would reduce the IMR from the current 118/1,000 live births to 80/1,000 in the year 2002 and the under-five mortality rate from the current 182/1,000 to 90/1,000 in 2002);
Program interventions to reduce infant and child mortality will focus on measures to: (i) reduce neonatal (0-28 days of age) mortality; (ii) reduce the incidence and severity of infectious diseases in children (by applying-inter alia-the WHO/UNICEF/CDC-Atlanta package for Integrated Management of Childhood Illness); (iii) further strengthen the Extended Program of Immunization, and (iv) establish a strong child nutrition program.
Initially, the project will finance efforts to evaluate currenit diagnostic and treatment practices for diarrheal and respiratory diseases and to produce written protocols for use in the health facilities. The project would also train technicians in the maintenance of the cold chain and finance the annual evaluation of vaccination coverage.
(b) maternal mortality, where the Program aims to reduce MMR from the present level of 940/1000 to 600/1000 in the year 2002;
Program interventions to reduce maternal mortality will include measures to: (i) reduce the risks related to pregnancy and delivery by providing quality ante-natal and delivery care to at least 80% of pregnant women in rural areas and to 100% of pregnant women in cities; (ii) identify at risk pregnancies organize subsequent referral in a timely manner; (iii) intensify training and supervision of health personnel; and (iv) strengthen IEC and family planning activities including purchasing and distribution of contraceptives and measures to decrease the importance of FGMs.
Over the first eighteen months, the project will focus on studies to determine the current obstacles for accessing reproductive health services and the quality of pre and postnatal care.
(c) nutritional status where the objective is to reduce by 25°%the severe and moderate malnutrition in children under five years of age;
Program interventions to improve nutritional status will emphasize measures to: (i) reduce iron, iodine and vitamin A deficiencies in children and in pregnant and lactating women; (ii) identify and provide care to children at nutritional risk; (iii) strengthen health sector capacity in nutrition monitoring and surveillance; and (iv) develop nutrition education activities;
Initially, the project will finance studies to develop applied nutrition surveillance and research and to plan a Program of micro-projects to promote improved nutrition.
(d) preventive care and infectious diseases (quantified targets are presented in Annex 1). ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex2A - Page5 of5
Program interventions to reduce the morbidity and severity of communicable and non- communicable diseases will address: (i) tuberculosis and leprosy; (ii) parasitic diseases such as malaria, schistosomiasis, intestinal and Guinea worms; (iii) sexually-transmitted diseases and AIDS; as well as (iv) behavioral-generated conditions, injuries and accidents (including diabetes, obesity, cardiovascular diseases, smoking and smoking-related conditions, and route accidents).
Initially, the project would support national-level institutions with existing, successful programs: the psychiatric hospital, the orthopedic rehabilitation hospital, the TB hospital, and the national laboratory. As national strategies (currently underway for many of the above diseases) are adopted for the various communicable and non-communicable diseases, the project will finance appropriate parts of the strategy. The project will, in particular, support the programs for water-borne and vector transmitted diseases control.
Program Component 4: Promote social action and create an environment conducive to health US$11.3 million
Many important pre-requisites for the success of health programs are the responsibility of other sectors, including: general education, poverty alleviation, control of Mauritania's too rapid urbanization and of population growth, empowering of women, water and sanitation, and concern with health ccinsequences of developmental projects. In addition, the social component of efforts to promote preventive measures and to increase utilization rates is often neglected. The overall objectives of the Program are to encourage a public environment supportive of the implementation of the health sector policy and to promote social policies in favor of the poor and other vulnerable groups.
Overall Program interventions aim to reinforce the role of social services as an integral part of health service delivery and include measures to: (i) revise national policy; (ii) conduct household research to determine the most pressing needs and the means for addressing such needs; (iii) conduct a demographic and health survey, (iv) promote appropriate legislation to protect society's most vulnerable gr-oups;and (v) provide services and assistance to the poor and under-served.
The project tentatively proposes to provide both financial assistance for the operations of the Social Action Directorate and technical support for revision of the social policy adopted in 1989. In addition, the project will finance a study of current and future procedures for addressing the issue of indigence and the provision of health services. The project will also continue implementation of regional health communications strategies and intends to finance an evaluation of current IDA financed activities in Hodh El Gharbi and Nouakchott and their extension to two additional regions.
Further to Government's request expressed at Negotiations, the credit will also support the forthcoming population census. The population census is an activity conducted under the coordination of the Ministry of Planning and executed by the ONS (under the overall technical supervision and coordination of the FNUAP). IDA will finance US$1.4 million out of the total estimated cost of US$6 mrkillionof this operation, the remaining funds being provided by donors and Government. The executing agency for the sub-component financed by IDA will be the FNUAP.
ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex28 - Page1 of 16
Annex 2B Donor Activities in the Health Sector
Analyse et legons a tirer des projets finances par certains bailleurs de fonds dans le secteur de la sante en Mauritanie
I - UNION EUROPEENNE
Durant la periode 1990-1996, correspondant au 6eme et 7eme FED, le montant total des engagements de l'Union Europdenne dans le secteur de la sante en Mauritanie se chiffre a 3 488 795 000 UM. Parmi les instruments utilis6s figurent les projets nationaux et r6gionaux, les fonds de contre partie de l'ajustement structurel ou de l'aide alimentaire, le cofinancement des ONG ou l'aide d'urgence. Les projiets execut6s sont analyses ci-apres.
1-1 Projet de rehabilitation du Centre hospitalier national et de l'H6pital Regional d'Aioun
L'objectif du Projet etait d'ameliorer la qualite des soins donnes au Centre hospitalier national (CHN) et a l'h6pital r6gional d'Aioun par la rehabilitation des infrastructures, la foumiture d'equipements m6dicaux, la formnationdu personnel medical et, pour le CHN, l'appui a la gestion. Le cofit du Projet a e 7 888 670 ECU sur une prevision de 8.000.000 ECU. L'execution du Projet, entre 1993 et 1995, a permis au niveau des deux etablissements d'ameliorer l'environnement de travail, de renforcer le plateau technique et la capacite de prise en charge des patients. Au niveau du CHN, le developpement d'un systeme de gestion plus performant a e entrepris avec la mise en place d'une cornptabilit6 analytique et d'une comptabilite matiere. Des reflexions ont dte menees sur les besoins en medicaments et consommables. Un systeme d' information informatise a et planifie et un systeme de recouvrement des cofits mis en place. Les resultats obtenus sont satisfaisants.
Cependant, avec le recul, plusieurs remarques peuvent etre faites a propos des travaux effectues. La rehabilitation du service des urgences et la construction d'un service de porte n'ont pas ete integrees dans les activites de remise en etat des infrastructures du CHN. II s'ensuit un engorgement de l'h6pital par les patients et les accompagnants, et des difficultes dans la prise en charge des urgences. La programmation des equipements et les garanties de maintenance ont et insuffisantes. Divers problemes d'ecoulement des eaux, de climatisation et d'61ectricite demeurent non resolus notamment au niveau des urgences, du laboratoire et du bloc operatoire. La restructuration de l'h6pital regional d'Aioun est incomplete. Le bloc operatoire est mal concu. Le service des urgences, les services generaux et les infrastructures complementaires (chateau d'eau, groupe electrogene) ont ete omis dans la renovation, reduisant la fonctionnalite de l'h6pital. La livraison des equipements (instruments chirurgicaux, materiels de laboratoire, etc.) s'est faite avec retard. Certains equipements livres etaient incomplets, de mauvaise qualite ou ne sont toujours pas utilis6s faute de personnel qualifie comme au laboratoire. Ces elements constituent autant de contraintes au bon fonctionnement des structures concernees.
1-2 Projet d'appui a la d6centralisation des services de sante dans la region du Gorgol
Mis en oeuvre entre 1991 et 1995, ce Projet visait i ameliorer l'acces des populations de la region du Gorgol a des soins de base appropries par un appui aux differents niveaux du systeme de sante regional. ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex2B - Page2 of 16
Cet objectif s'integrait dans le processus de d6centralisation engage par le MSAS. Le Projet a, ainsi contribue au developpement des soins de sante primaires dans la region par la formation des Unites Sanitaires de Base (USB), la construction/ rehabilitation de 25 formations sanitaires primaires, la mise en oeuvre d'un systeme de recouvrement des coOts dans 4 centres de sante de Moughata, le soutien au programme SMI notamment dans sa composante PEV et l'initiation de la lutte contre la dracunculose. Au niveau secondaire, les batiments de l'h6pital regional de Kaedi ont e rehabilites et le systeme d'information reorganise. La faisabilite d'un systeme de recouvrernent des cofits a ete etudiee et un appui donne au fonctionnement de l'hopital. Enfin les batiments de la Diiection regionale de l'action sanitaire et Sociale et du Dep6t Pharmaceutique Regional ont ete construits. Le montant des engagements est de 3.625.000 ECU.
Les resultats obtenus sont globalement satisfaisants si l'on en juge par le niveau de fonctionnalit6 des structures sanitaires primaires et I'augmentation progressive du taux d'utilisation de l'hopital, seule formation sanitaire de ce type A avoir beneficie de l'affectation d'un chirurgien mauritanien. Cependant certains problemes constates entravent le bon fonctionnement des formations sanitaires. Au niveau de l'h6pital regional, ces problemes concement la mauvaise isolation des salles de malades, le manque de solidite A certains endroits des materiaux locaux utilises, I'dquipement insuffisant des services de laboratoire et de radiologie et la faible capacite de maintenance. Au niveau des formations sanitaires de base, le manque de solidite des mat6riaux locaux utilises dans Ia construction des batiments oblige A envisager A breve 6cheance de nouvelles operations de renovation. De plus, le taux d'attrition des USB est eleve, atteignant 50% et des difficultes persistent dans l'approvisionnement en medicaments, les quantites livrees A la region etant inferieures aux besoins du fait de I'augmentation du nombre de structures sanitaires A ravitailler. A tous les niveaux, les effectifs en personnels de sante sont insuffisants bien que la region du Gorgol soit l'une des regions les mieux dotees du pays.
1-3 Appui au Programme de lutte contre les MST/SIDA (PNLS)
L'appui de l'Union Europeenne au programme national de lutte contre les MST/SIDA (PNLS) se fait d'une part a travers le volet national du programme regional de lutte contre les MST/SIDA, d'autre part, directement au PNLS dans le cadre d'une convention signee le 15/9/94 pour une duree de deux ans d'un montant de 350.000 ECU. II est axe essentiellement sur le renforcement de la prise en charge des patients atteints de MST et de leurs partenaires.
Le volet national du programme regional visait: i) A creer et renforcer le developpement de centres de reference nationaux constitues par le service de dermatologie du CHN et le centre de sante de Sebkha a Nouakchott, ii) a developper la recherche operationnelle. A partir de 1994, I'appui direct, au programme national de lutte contre les MST/SIDA, s'est fixe pour objectif, la d6centralisation des activites de lutte au niveau de 8 centres situes dans les villes de N4ouakchott,un centre de sante dans chacune des villes de Nouadhibou, Kiffa et Kaedi par le renforcement de ces centres de sante grace A la rehabilitation des bAtiments, la fourniture d'equipements de laboratoire et de reactifs, la formation du personnel medical, I'information/ education des patients sur les MST. Un appui etait aussi prevu a la Soci6te Nationale des Industries Minieres (SNIM) pour le d6veloppement d'une politique d'entreprise concernant les MST/SIDA en collaboration avec le PNLS. Le Projet prevoyait enfin, le renforcement des capacites techniques du PNLS et des etudes visant l'amelioration du ionctionnement des services.
Malgr6 les retards, certaines actions planifiees ont ete r6alisdes, telles la mise en place des structures de reference, l'etude sur les etiologies des ecoulements genitaux qui a permis d'6tablir des protocoles therapeutiques et d'elaborer un manuel de formation A l'intention du personnel de sante, l'organisation de sessions de formation, 1'elaboration et la diffusion( de materiels IEC. Par contre tous les ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex2B - Page3 of 16 laboratoires des centres de sante n'ont pu etre 6quipes faute de personnel qualifi6, ce qui n'a permis d'intervenir dans un premier temps que dans 2 centres de sante de la peripherie de Nouakchott. Un marche de reactifs a ete passe avec une societe mauritanienne prevoyant des livraisons fractionnees en fonction des besoins et du niveau d'activites des centres. Le manque de coordination entre les volets du programme appuyes par d'autres bailleurs de fonds et les autres services (SMI/PF, tuberculose, maladies transmissibles) diminue la coherence de l'intervention et limite l'integration des activites au niveau p6riiph6rique.Malgre ces insuffisances, la mission d'evaluation, conduite par la <
* F'amelioration des connaissances sur les MST; * la definition de strategies de lutte claires contre les MST; et * Ia resolution de certains problemes constates lors de la mise en oeuvre du plan A moyen terme.
Malheureusement ces acquis sont actuellement compromis par le blocage du financement par la D6l6gation de l'Union Europeenne depuis fin juillet 1996, y compris le marche des reactifs en cours, suite A des malentendus. Les discussions sont engagees en vue de relancer tres prochainement les activites. Les fonds disponibles sur le Projet national sont de 240.000 ECU. La totalite du budget du Projet regional a et entierement utilisee, soit 272.790 ECU.
1-4 Appui au programme de lutte contre la cecite
Le Projet d'appui au programme de lutte contre la cecite represente le volet national d'un programme regional couvrant les pays membres de l'Organisation Commune de lutte Contre les Grandes Endemies en Afrique de l'Ouest. II est gere A partir de Bamako par l'Institut d'Ophtalmologie Tropicale Afiicaine (IOTA), et localement par un coordonateur nomme par le MSAS. Le Projet a pour but de reduire les c6cit6s evitables par le developpement des actions de pr6vention et les cecites curables par le developpement des soins ophtalmologiques.
Durant la premiere phase de mise en oeuvre, de 1993 A 1996, le programme mauritanien a beneficie de divers concours qui se sont traduits par (i) la formation de 2 medecins et 4 infirmiers, (ii) I'acquisition de stocks de materiels destines A l'equipement d'un centre fixe, en l'occurrence l'antenne regionale d'ophtalmologie de Nouakchott sise A la PMI- Pilote, et A l'organisation de missions de chiirurgie avancee A l'interieur du pays, (iii) la mise place d'un systeme de communication par satellite. Dans I'attente de leur affectation, les 6quipements sont stockes dans les magasins du MSAS. Une nouvelle convention de financement a ete signee recemment couvrant la periode 1997-1998 en vue de poursuivre les activites de formation des personnels medical et infirmier localement et A l'etranger, de sensibilisation, de renforcer la supervision des antennes regionales. Les locaux affectes A la Division des maladies cecitantes 2 medecins seront rehabilites et equipes. En outre, on prevoit de mener, avec l'aide de l'L.O.T.A., une enquete descriptive sur le trachome dans ies regions du nord du pays et une enquete de prevalence de la cecite en Mauritanie. Le cofit du Projet est de 1.162.500 ECU dont 655.555 ECU sont engages au titre de la premiere phase. Le montant de la nouvelle convention pour 1997-1998 est de 35.588 ECU.
1-5 Appui au processus d'ajustement structurel
L'appui de l'Union Europeenne au processus d'ajustement structurel a d6marre en 1993. Dans le domaine de ia sante, il a revetu deux formes: (a) appui budgetaire au secteur de la sante pour la realisation de certaines d6penses et (b) appui technique A la Direction du budget et des comptes en vue de l' introduction d'une nouvelle nomenclature budgetaire pour le secteur sanitaire. Le montant total des ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex2B - Page4 of 16
engagements, tous secteurs confondus, a 6te de 20.145.000 ECU pour le programme 1993-1995, et de 13.300.000 ECU pour le programme 1995-1996. Le montant des decaissements effectues sur les fonds de contrepartie au profit du secteur sanitaire s'est 6leve entre 1993 et 1996 A 7.395.388 ECU soit 1.257.250.000 UM.
L'appui budgetaire au secteur de la sante a ete utilise pour financer l'entretien des equipements par le service de maintenance, la construction, 1'equipement de sept Directions r6gionales A l'action sanitaire et sociale (DRASS) et la fourniture de consommables et de produits pharmaceutiques a ces structures et pour ameliorer le fonctionnement des directions du MSAS. Les allocations faites au CHN ont servi pour l'achat de medicaments, le secours aux indigents et l'apurement des dettes de l'Etat envers l'etablissement. Un soutien est apporte depuis 1996 au Programme Elargi de Vaccination, dans le cadre d'un Projet regional d'appui A l'independance vaccinale. Couvrant une periode de trois ans, l'objectif de ce Projet est d'assurer la transition de la prise en charge des op6raltions de vaccination (achat de vaccins et de materiel de vaccination ) vers le budget de I'Etat.
L'appui A la Direction du budget et des comptes (comprenant le financement d'une cellule d'appui et une assistance technique internationale) a aboutit A des resultats satisfaisants. II a permis d'ameliorer la programmation des recettes et la programmation budgetaire. II a contribue au deroulement de la revue des ddpenses publiques en 1995. Dans le secteur de la sante, cet appui visait plus particuli6rement l'introduction d'une nouvelle nomenclature budgetaire (budget programme).
Le soutien au Programme Elargi de Vaccination et l'appui A la Direction du budget et des comptes pour la mise en place du budget programme sont les seuls volets en cours d'execution sur les fonds de contre partie. Pour le soutien au PEV, un montant de 36 millions UM vient d'etre alloud au titre de 1'exercice 1997. Un montant similaire est prevu pour 1998. Par contre aucun financement n'est pour le moment mis en place pour soutenir le processus de mise en place du budget programme qui pourrait requerir des fonds suppilmentaires.
Pour P'annee 1997, la notification des activites prises en charge sur fonds de contrepartie est parvenue au MSAS durant le troisieme trimestre, suite au retard intervenu dans la r6partition intersectorielle de 1'enveloppe. Outre le soutien au PEV, les engagements de l'Union europeenne, d'un montant de 21,6 millions UM, porteront sur l'informatisation de la DPM, la mise en place du systeme de recouvrement des couts dans les regions de l'Adrar et de l'Inchiri, I'acquisition du materiel orthopedique pour le CNORF, et l'achat de filtres pour le programme national de lutte contre le ver de Guinee.
On remarquera le risque de duplication entre les deux premieres activites relatives A l'informatisation de la DPM et A la mise en place du systeme de recouvrement des couts dans les regions de l'Adrar et de l'Inchiri et des volets du Projet de renforcement des soins de sante primaires supporte par la Banque Africaine de Developpement.
D'autres demandes de financement sur les fonds de contrepartie sont en cours d'examen au niveau du Ministere du Plan et de la Delegation de l'Union Europeenne. Il s'agit de la mise a disposition de Volontaires des Nations Unies pour travailler comme chirurgiens dans les hopitaux regionaux (47 Millions UM ), de la poursuite de l'appui aux operations de maintenimce et d'equipements (144 Millions UM), de la maintenance des infrastructures sanitaires (30 Millions UM). ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Coiuntry:Mauritania Annex2B - Page5 of16
1-6 Cofinancement des projets des ONG
Differentes ONG beneficient d'un cofinancement de leurs projets de la part de l'Union Europeenne. Les financements les plus recents ont et alloues au Groupe de Recherche et de Realisation pcur le Developpement Rural dans le tiers monde (GRDR) et A <
1-7 Aides d'urgence ECHO
Cet instrument a ete utilise pour financer l'assistance, en 1993 et 1994, aux populations ddplacees du Mali et l'appui aux Centres de Rehabilitation et d'Education Nutritionnelle (CREN) de Nouakchott. Par l'interm6diaire des ONG <
1-8 Conclusion
Les appuis communautaires s'inscrivaient dans l'ensemble dans les priorites sectorielles telles que decrites dans la politique nationale de sante, notamment apres 1'adoption par le MSAS du Plan Directeur 1991-1995/6. Une complementarite et une synergie etaient souvent recherchees avec l'action d'autres bailleurs de fonds comme la Coop6ration Francaise ou la Banque Mondiale. 11 en est ainsi de I'appui A la decentralisation dans la r6gion du Gorgol ou des tentatives de mise en place d'un systeme de gestion des medicaments essentiels et de l'introduction du recouvrement des couts dans le secteur hospitalier.
Les projets finances par l'Union Europeenne etaient pour la plupart geographiquement limites. Le secteur hospitalier en a ete le principal bdneficiaire, qu'il s'agisse du CHN ou des Hopitaux regionaux de Kaedi et d'Aioun El Atrouss. Orientes surtout sur les investissements lourds, ils ont consiste en la renovation d'infrastructures, et la foumiture d'equipements. Cependant, les actions realisees ont souffert cl'insuffisance dans la preparation et la conduite des operations d'infrastructures, et/ou de retard dans la programmation et la fourniture des equipements. Les capacites de maintenance ne garantissent pas un entretien correct des equipements installes dont certains sont tres sophistiquds. Ces insuffisances expliquent en partie que tous les objectifs n'ont pas et atteints. Elles justifient l'inscription dans le programme de d6veloppement des infrastructures du PASS de certains travaux de r6habilitation devant 6tre executes au niveau de ces etablissements hospitaliers et de certaines formations sanitaires primaires (le la region du Gorgol. Le manque de definition par le MSAS d'une strategie hospitaliere, A un moment oa la priorite se situait plutot au niveau des soins de sante primaires et l'insuffisance de personnels f7ormrssont aussi responsables de la faible operationalite de certaines des structures appuyees. ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex2B - Page6 of 16
Les autres formes d'assistance de l'Union Europeenne utilisant les fonds de contrepartie etaient sous-tendues par une logique d'ajustement structurel. Les appuis de ce type sont en general concus comme des aides limitees dans le temps. Leur poursuite est conditionnee par l'atteinte d'un certain nombre de resultats, par exemple la mise en place au CHN des systemes coherents de gestion des medicaments essentiels et l'elaboration d'une politique de prise en cliarge des indigents ou l'extension du systeme de recouvrement des cofits A certains actes de prevention. L'insuffisance de competences nationales dans le domaine de la gestion et de l'6conomie de la saznt a freine l'execution des actions financees sur les fonds de contrepartie du fait du non-respect par le MSAS des diverses conditionalites. L'absence d'un programme pluri-annuel pour l'utilisation des fionds ne permet pas de donner la coherence souhaitee par le bailleur de fonds aux actions qui lui sont soumises pour financement.
On observe donc une diminution progressive des engagements entre 1993 et 1996, surtout perceptible pour les fonds de contre partie, voire a un arret du financeementde certaines activites comme l'appui A la lutte contre les MST/SIDA. La convention de financement du 8eme FED signee recemment ne prevoit aucun financement en ECU sur le Programme indicatif national (PIN) pour le secteur de la sante, bien que theoriquement celui-ci demeure un des secteurs prioritaires d'intervention de l'Union Europeenne. Seule une partie des fonds de contrepartie pourra etre allouee, directement et/ou par le biais d'autres organismes d'execution pour financer des projets soumis par le MSAS. La programmation de ces fonds, initialement prevue en Mars 1997, pourrait se faire en Octobre.
L'absence de toute pr6vision de financement sur le PIN de Lome IV bis et le faible nombre de projets inscrits dans le portefeuille en 1997 ou en 1998 et au-dela, pourraient provenir de plusieurs causes: a) baisse de l'interet porte au secteur par l'Union Europeenne en depit de la priorit6 affichee, b) insuffisance des capacites du MSAS dans les domaines de la programmation et du suivi de l'execution des projets, et c) absence d'un dialogue continu et constructif entre les services du MSAS et la Delegation de l'UE.
BANQUE AFRICAINE DE DEVELOPPEMENT (BAD)
Le Projet de renforcement des soins de sante primaires represente l'action la plus importante soutenue dans le secteur de la sant6 en Mauritanie par le groupe de la BAD. II constitue une partie du <
* renforcer les soins de sante primaires par la mise a la disposition des formations sanitaires peripheriques des medicaments essentiels;
* ameliorer la capacite du secteur pharmaceutique central et dans 4 regions en matiere d'acquisition, de conditionnement, de controle de la qualite, de stockage, de gestion et de distribution des medicaments essentiels;
* renforcer les prestations sanitaires peripheriques dans les regions de l'Adrar et de l'Inchiri;
* assurer une maintenance continue des equipements et des infrastructures faisant partie de l'intervention.
Le coOt initial du Projet, soit 12, 266 Millions UCF (1.231, 01l5 Millions UM), est couvert par un pret de la BAD equivalant A 10 millions UCF et un apport du Gouveimement Mauritanien qui supporte 18% des d6penses du Projet, essentiellement en monnaie locale. ProjectAppraisal Document ProjectTitle: Health Sector Investment Credit Country:Mauritania Annex2B - Page7 of 16
Prevu initialement en 1992, le demarrage effectif n'a eu lieu qu'en 1994 a cause du retard dans les procedures d'approbation tant nationales que celles de la BAD.
1. Execution physique
Au bout de quatre annees, le niveau d'execution est relativement bas comme le demontre le bilan de 1'execution physique des differentes composantes.
Composante de renforcement du secteur pharmaceutique central et dans 4 regions
La construction de 4 depots regionaux (Adrar, Inchiri, Brakna, Hodh El Gharbi) est achevee. Une partie des vehicules a ete acquise. Environ 54% des depenses pr6vues pour le fonctionnement de la DPM et la formation A l'utilisation des medicaments essentiels ont e effectuees. La totalite des medicaments a ete fournie. Le nombre d'activites residuelles est tres important. II s'agit en particulier de la renovation de la DPM (bloc administratif, dep6t central, atelier, garage) et de la construction du laboratoire de controle de qualite des medicaments, de la fourniture des equipements et du mobilier, de la realisation des Vrd et travaux exterieurs, du reamenagementlextension du dep6t central. Un lot complementaire de vehicules doit etre fourni et une assistance technique mise en place aupres de la DPM pour 18H/mois. Un important volet de formation est aussi prevu au profit des personnels des services pharmaceutiques du niveau central (Directeur, chefs de services, inspecteurs, pharmaciens d'approvisionnement et de distribution, responsable informatique, technicien biomedical) et du niveau decentralise afin d'ameliorer les competences dans les domaines de la gestion des services pharmaceutiques, de l'approvisionnement et de la distribution des medicaments. 11est indeniable que ces retards ont eu des repercussions negatives sur la performance du secteur pharmaceutique qui n'a pas ete capable de suivre les reformes engagees durant la periode couverte par le Plan Directeur pr6cedent.
Composante de renforcement des soins de sante primaires dans les regions de I'Adrar et de l'Inchiri
La quasi totalite des etudes a ete realisee. Quelques vehicules ont ete livres, ainsi que des filtres pour le programme national de lutte contre le ver de Guinee, et des mobiliers pour l'Ecole Nationale de sante publique et le programme national de lutte contre le ver de Guin6e. La DRASS de I'Adrar a recu tine petite dotation de medicament. Les activites de formation ont concerne des techniciens de laboratoire, des personnels infirmiers et sages femmes, et des agents du programme national de lutte contre le ver de Guinee. Les travaux de construction des postes de sante de Tawaz et de Benichab sont acheves.
Dans la Wilaya de l'Adrar, il reste au titre du genie civil A achever les travaux de:
* construction de la DRASS, du centre de sante de Ouadane, et de postes de sante dans les localites de Terabane, Toungad, Laghleitat, Idechane, Timinit, Wokchada;
* reamenagement/extension de l'h6pital regional d'Atar, de la PMI du centre de sante Atar; et
* renovation des locaux de l'Unite de maintenance situee dans la cour de l'h6pital, des PMI d'Aoujeft et de Choum, des postes de sante de Ksar Torchane, Ain el Taya et Kenawal.
Dans la Wilaya de l'Inchiri, les travaux en cours concernent la construction de la DRASS et le reamenagement/extension du Centre de Sante de type A. Celui-ci comprendra 12 lits d'hospitalisation et ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex2B - Page8 of 16
une petite salle d'operation dont le rajout a ete decide recemment, anticipant ainsi sur la programmation du PASS. Cependant la construction de cette salle se heurte A l'exiguite du site d'implantation choisi qui, bien que de position centrale dans la ville, n'offre que peu d'espace pour l'extension de l'infrastructure. Aussi a-t-il fallu delocaliser la DRASS vers un autre emplacement. Une unite regionale de maintenance sera 6galement construite.
La plupart des travaux de genie civil ci-dessus enumeres sorit en cours d'execution ou vont tres prochainement demarrer. En meme temps, sera lance l'appel d'offre pour I'acquisition des equipements/ mobiliers de toutes les infrastructures rehabilitees ou construites par le Projet et pour l'acquisition de 5 vehicules. 11restera A fournir une dotation de petits materiels et de medicaments essentiels et A executer le volet de la formation. Celui-ci comporte toute une serie de s6minaires ateliers A l'intention de diverses categories de personnels (DRASS, medecins chefs de Moughata, medecins, infirmier majors, techniciens de laboratoire, agents de maintenance, chefs de postes de sante) daris les domaines aussi varies que la gestion, le systeme d'information sanitaire, la sante publique, les techniques de laboratoire et les specialitbs medico-chirurgicales.
Composantede creationde l'Unite de maintenance
Outre la dotation en micro-ordinateur, le service de maintenance a ete assiste par un specialiste de la maintenance appartenant A une firme de consultants pendant 12 mois. Un seminaire a ete organise pour les medecins chefs pour les sensibiliser aux problemes de maintenance. Les appels d'offre sont en cours pour les travaux de genie civil et pour l'acquisition des equipements et mobiliers. La formation de 10 agents de maintenance reste un objectif du projet. Un montant de 53.078 UCF non engage doit servir aux frais de fonctionnement de I'Unite de maintenance.
ComposanteBureau d'execution du projet
Cette composante est la seule entierement executee A ce jour. Les locaux du bureau d'execution du projet ont ete renoves et equipes. L'Assistance technique pour la supervision et le contr6le des travaux est en place. Trois agents ont recu une formation en management, comptabilite et informatique.
Etudesarchitecturales de 11h6pitalde Nouadhibou
Ces etudes techniques et architecturales ont pour but d'evaluer les cofits lids A la reprise des travaux de construction de l'h6pital regional de Nouadhibou. Elles pourraient s'achever au debut de l'annee 1998, A cause d'un retard li au bureau d'etudes. La capacite envisagee est de 100 lits repartis entre les servicesde medecine,de chirurgie, de pediatrie et de maternite. Une unite de psychiatrieet une de contagieuxainsi qu'un service d'urgence sont egalementprevus. Couitdes etudes: 107.761UCF.
2. Executionfinanciere
La situation financiere du projet reflete celle des activites. Les engagementsne represententque 28,5% des ressources et les decaissements 18,7%. Toutefois, si on ajoute au montant engage le cofit estimatif des travaux du lot genie civil (1.298.207 UCF) et des equipements medicaux et divers (1.244.278UCF) dont l'appel d'offre sera lance incessamment,le taux d'engagementdes ressources du projet augmentesensiblement (51%). En ce qui concernel'utilisation des ressourcesdu prat FAD, le taux de decaissement est de 21,8%. La repartition des decaissements par categorie de depenses revele un depassementau niveau des etudes et des medicamentsessentiels. ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex2B - Page9 of 16
3. ProblImes de mise en oeuvre
L'enum6ration des activites r6siduelles et le faible taux de d6caissement temoignent des difficultes rencontr6es dans l'execution du projet. Non seulement le retard initial de demarrage de 18 mois n'a pas e rattrap6, mais d'autres facteurs de ralentissement se sont surajoutes. Ce sont entre autres, les lenteurs dans le processus d'execution et d'engagement des ressources, dans le lancement des appels d'offres et le traitement des dossiers, la non-liberation des locaux de la DPM, la non-implication des services centraux et regionaux du MSAS dans la planification et l'execution des activites, la supervision insuffisante des chantiers. L'eloignement du bailleur, qui n'est pas represente en Mauritanie, ne favorise pas non plus le dialogue et la prise de decision. La derni&remission de suivi et d'evaluation de la BAD a de ce fait recommande d'adopter une nouvelle strategie d'execution du projet afin de rattraper le retard et de garantir l'efficacit6 des realisations. Parmi ces recommandations, qui concordent avec les objectifs du PASS, figurent l'elaboration d'une politique pharmaceutique nationale, l'evaluation du systeme de recouvrement des cofits, la definition d'un paquet minimum d'activites pour tous les niveaux de la pyramide sanitaire, la necessite de mener une r6flexion sur la prise en charge des frais de fonctionnement du laboratoire de contr6le de qualite par ses clients et d'affecter le personnel requis dans les formations sanitaires renovees ou construites par le projet.
COOPERATION FRANCAISE
Presente dans le secteur depuis l'independance, la Cooperation francaise est la plus ancienne de toutes les cooperations dans le secteur de la sante en Mauritanie. Entre 1982 et 1994, la Cooperation Framnaisea investi 251, 896 MF dans le secteur de la sante, dont 88,8% au titre de l'assistance technique et des bourses, 10,4% au titre des conventions FAC et 0,7% par la Caisse Francaise de D6veloppement. L'aide dans le secteur de la sante represente 7,7% du volume global de l'aide apportee par la France a la Mauritanie Atravers ses differents organismes de cooperation au developpement.
1. Evolution des orientations de la Cooperation Franqaise dans le secteur de la sante en Mauritanie
On peut identifier trois periodes d'evolution dans les moyens et les modalites de la cooperation francaise. De 1982 A 1986, les credits FAC qui sont annuels sont polarises d'une part, sur le renforcement du fonctionnement et de l'6quipement des hopitaux, principalement le CHN et les h6pitaux regionaux de Atar, Kaedi, Nouadhibou, malgr6 la denomination de certaines conventions faussement intitulees < Appui A la sante publique »>, et l'appui logistique aux assistants techniques d'autre part. Mais, en l'absence d'une politique hospitaliere clairement definie et de la faible articulation des h6pitaux avec les autres niveaux du systeme de sante, l'impact des projets sur I'amelioration de la situation sanitaire reste globalement faible. Le nombre des assistants techniques est eleve, partiellement compense par des programmes de bourses.
Entre 1986 1991, les projets visent autant le secteur hospitalier que les soins de sante primaires. Le Projet d'amelioration de la situation sanitaire de la region du Gorgol, cofinance par le Fonds Europeen de Ddveloppement, et executd par l'Association Fran,aise des Volontaires du Progres (AFVP) en est une illustration. Ses activites sont orientees vers la formation, le recyclage et la supervision d'agents de sante communautaires, la disponibilisation de medicaments essentiels a faible cofit aupres des populations, le renforcement des moyens humains et materiels et du systeme de gestion de la DRASS et de l'h6pital regional. En meme temps, la programmation des credits FAC devient pluriannuelle et de nouveaux insltruments d'assistance voient le jour, en l'occurrence l'aide budgetaire dans le cadre de l'appui au ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex2B - Page10 of 16 processus d'ajustement structurel.
Entre 1992 et 1995, l'objectif est de restructurer les systemes de sante. La reorientation de I'assistance technique d'un r6le de substitution vers un r6le de conseil, latente au cours de la periode precedente est reaffirm6e. Les recentes conventions de financement visent quant A elles I'autonomie des systemes de sante mauritaniens.
2. Analyse des programmes soutenus par la Cooperation Fran 2-1 Convention pour l'utilisation des fonds de contre partie le I'aide budgetaire 1990. L'aide budgetaire consentie en 1990 a permis de rembourser la dette de la Mauritanie aupres des h6pitaux de Paris (5 MF ) et d'acheter en devises des medicaments pour le CHN et pour le systeme de recouvrement des couits. Les fonds de contrepartie resultant de la vente de ces medicaments, d'un montant de 4,2 millions FF soit 92 Millions UM, devraient etre utilises pour appuyer: a)- la decentralisation dans le Trarza A travers la mise en conformite des infrastructures sanitaires de la Region, dont la construction/ rehabilitation du batiment de la DRASS, de I'h6pital regional, d'un centre de sante par Moughata et de postes de sante par Commune. Cout: 60 Millions UM; b)- le developpement du systeme d'information sanitaire et de l'analyse epidemiologique dans les regions A travers la formation et la supervision des personnels de sante exercant u niveau des DRASS. Cout: 32 Millions UM. La lenteur dans la reconstitution des fonds de contrepartie g,neres par cette aide budgetaire n'a pas permis encore d'executer les actions enumerees ci-dessus. 2-2 Aide A l'ajustement structurel de 1992 D'un montant de 13 MF, les fonds de contrepartie de l'ajustement structurel ont e utilises pour la construction de 89 postes de sante, 1'extension de 13 CS, de maternites et de structures hospitalieres, et la rehabilitation partielle du CHN. Les travaux de genie civil concernant le niveau primaire constituaient une partie du ( Ce projet a largement contribue A l'extension de la couverture sanitaire de base. Cependant tous les postes de sante construits ne sont pas implantes dans les localites les plus peuplees, des criteres objectifs n'ayant pas toujours prevalu lors du choix des sites d'imp]lantation. L'execution des travaux a connu des retards du fait de la lourdeur des procedures. La qualite des infrastructures realisees a souleve des reclamations notamment pour les postes de sant6 bien qu'un plan type ait et6 utilise. Les postes de sante construits presentaient en effet, de nombreuses malfa,ons au niiveau des maconneries, du systeme d'approvisionnement en eau, des revetements de sol et des toitures. La conception du plan type, les faibles competences des entreprises de construction et le mode et la qualite de la supervision des chantiers, impliquant l'Etat, etaient responsables des defauts constates. Le programme de construction n'etait pas accompagne d'un programme de rehabilitation/remplacem,ent des equipements dont la qualit6 est mediocre. Les effectifs des personnels de sante s'averent insuffisants en maints endroits. Certaines infrastructures construites sont de ce fait peu fonctionnelles ou restent longtemps fermees. Dans le cadre du PASS, il est prevu d'elaborer un plan de developpement des infrastructures sanitaires precisant notamment les criteres objectifs de localisation des formations sanitaires de base et de prendre en compte les implications de ce plan d'infrastructures sur les dotations en personnels et en equipements. 11est aussi prevu de r6viser le plan type des postes de sante qui sera utilise par tous les intervenants et de revoir les ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex2B - Page11 of 16 modalites de selection des entreprises de construction ainsi que celles de la supervision des travaux. 2-3 Projet d'appui a la restructuration des systemes socio-sanitaires mauritaniens (Convention FAC 1992-1995) D'un montant de 12MF, if s'agissait du premier FAC pluriannuel. Le projet comprenait 5 volets. Le volet 1, intitule appui A la decentralisation a permis de financer: i) la formation de 20 cadres medecins directeurs r6gionaux de l'action sanitaire et sociale (DRASS), ii) la formation A distance pour 15 cadres du niveau central, iii) la foumiture de micro-ordinateurs destines A 1'6quipement des DRASS. Cout: 3,4 MF. Le volet 2 d'appui au d6veloppement sanitaire regional etait destine A renforcer les programmes de vaccination par la fourniture de chaines de froid photovoltaYques,et d'hygiene publique au niveau des r6gions, par le contr6le de 1'eau et des aliments, la lutte antivectorielle et l'hygiene hospitaliere. Ce volet a et execute en collaboration avec les ONG: Gret/Alizes, Pharnaciens Sans frontieres, Medecine Aide Presence-Perpignan, et la Direction internationale des hopitaux de Paris. Un complement de rehabilitation de l'h6pital d'Atar a e realise sur ce volet dont le montant total a e de 2,5 MF. Le troisieme volet, oriente vers la formation et le recyclage du personnel de sante visait A appuyer le dispositif d'assistance technique detachee au CHN (11 cooperants sur 19) en vue de reorienter leurs activites vers la formation des personnels de sante sur 1'ensemble du pays, a creer une bibliotheque medicale et infirmiere, A financer diverses actions de cooperation inter-universitaire et de jumelage inter- hospitalier. Il a soutenu en plus, des formations qualifiantes pour des personnels d'encadrement et l'achat d'equipements de laboratoire pour la formation de 12 Techniciens Superieurs de Sante. Ce volet a ete complete par le projet Sante Population de la Banque Mondiale qui a finance des formations qualifiantes en anesthesie et les stages de perfectionnement des cadres mauritaniens charges d'encadrer la formation. Montant: 2,5 MF, Le quatrieme volet a appuye la lutte contre les MST et le Sida. Execute en collaboration avec le Fonds Europeen de Developpement et le projet de la Banque Mondiale, ce volet a contribue A definir et mettre en oeuvre des programmes de prevention des MST/SIDA. Il a permis d'organiser la transfusion sanguine, de developper le contr6le des MST, de mener des etudes sur les MST, d'ouvrir un laboratoire de reference MST au CHN pour la recherche, de developper un reseau de laboratoires pour le diagnostic biologique et la s6curite transfusionnelle dans des hopitaux regionaux, d'assurer la formation des personnels en soins specialises. Le montant de la contribution fran,aise etait de 2 MF. Le volet 5 visait la diversification des systemes de sante. Il associait des actions de protection sociiale et de facilitation de l'acces aux soins de certaines couches de population demunies. Avec les ressources mises a sa disposition, l'ONG Caritas qui etait un des operateurs a reussi A developper un centre de sante de type prive a but non lucratif dans le Departement Dar Naim a Nouakchott fonctionnant de fa9on entierement autonome, et a completer le financement de son projet d'ecole m6dico-pedagogique pour enfants handicapes. Montant 1,5 MF. Par l'intermediaire des ONG, I'AFVP et le GRDR (Groupe de recherche et de realisation pour le developpement dans le tiers-monde), un autre projet de ce volet a aide la DRASS et des communes du Guidimaka A coordonner les flux financiers generes par les migrants pour les services de sante et la protection sociale. ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex2B - Page12 of 16 2-4 Autres projets finances par la Cooperation franqaise 5-1 Enquete de mortalite maternelle: Un credit de 350.000 FF a et alloue pour la realisation d'une enquete de morbidite maternelle (MOMA) dans deux zones urbaines de Nouakchott et pour la structurationdu serviced'action sociale de la DRASS. 5-2 Appui aux refugies du nord Mali: Un credit FAC de 1,5 MF a et octroye aux ONG Medecins Sans Frontieres et Medecins Du Monde et A l'Association < 2-5 Cofinancementdes ONG Les actions de cofinancement se sont surtout developpees A partir de 1991 avec differentes ONG de droit fran9ais ou mauritanien. La plupart des volets des projets FAC sont desormais executes avec le concours des ONG. Inversement, apportant une part du financement de leurs projets, la Cooperation apparait comme un des principaux bailleurs des ONG intervenant sur le terrain. Les dossiers presentes doivent recevoir un agrement du comite de pilotage installe au Ministere de la Cooperation et du developpement. Les principales ONG concern6es sont: Association Fran9aise des Volontaires du Progres, Pharmaciens Sans Frontieres, Sante Sud, Medecins Sans Frontieres, Medecins Du Monde, Caritas, Gret/Alizes, Credes, Raoul Follereau. 2-6 Cooperation d¢ralisie A c6te des ONG, d'autres acteurs non gouvernementaux collaborent avec la Cooperation fran9aise dans la mise en oeuvre des projets d'appui au secteur de la sante parmi lesquels figurent les jumelages intercommunaux, la cooperation decentralisee, les echanges inter-universitaires et inter- hospitaliers. Nous presentons ci-dessous quelques actions realisees par les jumelages et la cooperation decentralisee, les universites et les h6pitaux. 6-1 Citees Unies France: par l'intermediaire des ONG Gret et Caritas, Citees Unies France a developpe un projet d'appui aux villages de la region du Brakna. 6-2 Appui de la commune de Vitrolles A la ville de Kiffa: sur la demande de la commune de Vitrolles, I'association Sante Sud a developp6 sur un financement de la Cooperation francaise (800.000 FF en 2 phases) un programme de renforcement des structures de soins de sante primaires de la ville de Kiffa par des missions d'appui intermittentes aux personnels de sante mauritaniens. A noter que ONG a ben6ficie de subventions du FED pour ses interventions dans la meme region. 6-2 Syndicat d'agglomeration nouvelle de S6nart: Le SAN de Senart et des communes fran,aises et mauritaniennes s'investissent dans le secteur de la sante depuis 1988. Cette cooperation etait d'abord concentr6e sur l'hopital de Rosso, dont les locaux ont e renoves et equipes. Le systeme de gestion de l'h6pital a et renforce en meme temps que l'introduction du recouvrement des couts. Le montant des interventions entre 1988 et 1996 s'etablit A 2,45 MF dont 1,15 MF apportes par le SAN de Senart. L'evaluation en 1994 de la mise en oeuvre de ce volet d'appui a la gestion par le recouvrement des couts, a conclu A un encouragement des actes de diagnostic au detriment de la qualite des soins qui laisse A desirer, tandis que la phase therapeutique est mediocre. Cette evaluation a donc recommande d'ameliorer la qualite professionnelle des agents par des encouragements financiers. II est prevu de poursuivre ces interventions dans le cadre d'une nouvelle convention couvrant une periode de 4 ans de 1997 a 2000. (cf. infra). ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex2B - Page13 of 16 3. Projets nouveaux ou projets dont l'execution doit se poursuivre sur la periode 1998-2000 3-1 Projet FAC d'Appui a I'autonomie des systemes socio-sanitaires mauritaniens: ce projet, dont la convention de financement a ete signee en 1996, est en phase de demarrage. D'un montant de 16 millions FF, la dur6e d'execution est en principe de 4 ans soit de 1997 A l'an 2000. La plupart des actions se d6rouleront A l'int6rieur du pays, centrees sur le renforcement des h6pitaux regionaux, la lutte contre certaines maladies et l'operationalisation des services sociaux regionaux. 11comprend 3 composantes qui sont: * Composante 1, appui a la planification regionale et aux h6pitaux regionaux; coat: 8 MF * Composante 2: programmes prioritaires de sante publique; coat: 4 MF * Composante 3: programmes mobilisateurs de developpement social; coat: 4 MF Les actions identifiees par composante telle que retenue par le comite de pilotage du 27 mai 1997 sonlt decrites ci-apres. Elles s'inspirent toutes des objectifs retenus par le nouveauPlan Directeur 1998- 2002 dont elles representent une des premi&restentatives de mise en oeuvre. 2-1 Composante 1: Appui A la planification regionale et aux h6pitaux regionaux Cette composante comprend les activites suivantes: (i) le suivi des medecins DRASS : l'objectif est de renforcer les capacites de gestion, de planification et de supervision des medecins DRASS et de celles des medecins-chefs des Moughata, et d'ameliorer la collecte des donnees du systeme d'information sanitaire regional. Des moyens logistiques et du materiel de bureautique seront mis A disposition pour completer l'equipement dejA fourni par la Cooperation fran,aise aux DRASS et permettre la realisation des missions sur le terrain. Cofit: 1,25 MF. (ii) le renforcement des DPR et des pharmacies des hopitaux regionaux par la mise en place des outils d'information de gestion dans les 13 DPR et les pharmacies hospitalieres et la formation et le suivi de leurs responsables. Ces activites constituent les prealables A l'introduction du systeme de recouvrement des coats qui est envisage au niveau de 4 hopitaux regionaux des zones d' intervention de la Cooperation francaise que sont le Tagant, le Trarza, le Brakna et Dakhlet Nouadhibou. (iii) la formation des chefs de services regionaux d'hygiene et d'assainissement durant 15 mois dans differents domaines, tels l'epidemiologie, la lutte contre les maladies transmissibles et la salubrite de l'environnement. Cofit: 1,25 MF. (iv) le renforcement des capacites de diagnostic, de traitement et de gestion des h6pitaux regionaux de Rosso, Aleg, Tidjikja et Nouadhibou pour leur permettre de jouer efficacement leur r6le de reference. Dans ce cadre les hopitaux regionaux de Rosso et de Nouadhibou seront equipes de blocs operatoires pour les urgences chirurgicales et obst6tricales. Des outils de gestion et de supervision seront elabores et des consommables fournis afin de tester la mise en place d'un systeme de recouvrement des cofits. La formation occupera, cependant une grande place dans ce volet tant celle des medecins que celle des paramedicaux (majors-surveillants des services hospitaliers, surveillants generaux, sages-femmes de matemites hospitalieres). Par ailleurs la formnationde medecins specialistes en chirurgie, pediatrie, medecine polyvalente et urgences sera ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex2B - Page14 of 16 assuree par l'Institut Nationaldes Specialites Medicales( INSIM) afin de combler le manque de specialistes dans les HR. Des missions d'encadrement des activites medico-chirurgicales decentralisees seront organisees en collaboration avec le C(HN avec l'appui du FAC. Un programmede formationcontinue des m6decinsexercant dans les h6pitaux regionaux et dans les centres de sante notammentdans le domaine de l'urgence sera finance, ainsi que la bibliotheque et le centre de reproductionde l'INSM. (v) la formationde 12 techniciensbiomedicaux affectds dans les regions. 2-2 Composante2: Programmesprioritaires de sante publique Dans cette composante,on envisagede financer: (i) la fourniture d'equipements, de consommableset la formation des techniciens des laboratoires d'analyses biomedicalesdes regions du Trarza, du Brakna, du Tagant, de Dakhlet-Nouadhibouet de Nouakchott. (ii) la formation des 9 medecins-chefsde centres de sante de Moughata de Nouakchott en SMI, nutrition, lutte contre les MST et en sante publique; la meme formation pouvant etre propos6e secondairementaux medecins-chefsdes 4 regionsciblees. (iii) la formation des personnelsde la zone test du programmenational de lutte contre la lepre et la tuberculosedu Trarzaavec extension ultdrieureA Nouakchott. (iv) le suivi de l'enquete MOMA et l'appui au programmede maternite sans risque par l'61aboration d'un plan d'action par les medecins-chefset les obstetricienset l'organisation d'une session de formationcontinue pour les sages-femmes. 2-3 Composante3: Programmesmobilisateurs pour le developpementsocial Les objectifspoursuivis dans le cadre de cette composantevisent a: * rendre pleinement op6rationnels les services regionaux charges de l'action sociale par la formationdes chefs de services a l'action socialedes DRASS; * cadrer dans une premiere etape le champ de la protectionsociale en Mauritaniepar l'organisation de Journees de reflexionsur le financementde la protectionsociale et le risque maladie;et * lutter contre la pauvrete par l'organisation de 4 aires de sante dans un quartier de Nouadhibou, dans les communesde Tidjikjaet de Boghe et dans la communauli6de Idini. 3-2 Convention pour l'utilisation des fonds de contre partie de l'aide budgetaire 1990. A ce jour, la totalite des fonds de contrepartiecorrespondant a l'aiide budgetairede 1990 n'est pas constituee.Sur les 92 millionsUM prevus, le montantdisponible est de 53 millions UM. II est envisagd de les allouer au projet d'appui a la decentralisationdans le Trarza(cf. supra). ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex2B - Page15 of 16 3-3 Utilisation des fonds de contrepartie de la subvention d'ajustement structurel de 1994 Un budget de 10 millions FF, sur fonds de contrepartie de la subvention d'ajustement structurel de 1994, est alloue A la construction d'une centaine de postes de sant. Les sites sont en cours d'identification en fonction des resultats de l'etude sur la couverture sanitaire. S'inspirant des lecons apprises lors des operations anterieures similaires, I'accent sera mis sur l'utilisation de la main d'oeuvre locale sous la supervision des collectivites locales et d'operateur(s) independant(s) du type bureau d'etudes ou ONG choisi(s) conjointement par le maltre d'ouvrage qu'est le MSAS et le bailleurs de fonds. L'equipement sera mis en place par l'IDA. 3-4 Assistance technique La Cooperation Francaise continuera de mettre des assistants techniques de divers profils A la disposition du MSAS. L'effectif des assistants techniques, actuellement de 17 personnes, est reparti entre le niveau central (5 agents ), la DRASS de Nouakchott (I'agent), le CNH (I agent) et le CHN (10 agents). L'adaptation de l'assistance technique aux besoins prioritaires du pays passera par differentes dtapes au cours des prochaines annees: (a) diminution progressive de l'effectif A raison d'une personne par an environ, (b) reorientation de la fonction par le passage d'une assistance de substitution A une assistance technique conseil, (c) redefinirions des profils. Aussi, les assistants techniques travaillant au CHN interviendront pour la moitie de leur temps dans des activites de formation hors de cet etablissement. La duree du projet est prevue pour 4 ans de 1997 Al'an 2000. 3-5 Cooperation decentralisie Tout comme dans la precedente convention FAC, il est prevu que des acteurs de la cooperation d6centralisee, comme l'Assistance Publique/ h6pitaux de Paris et l'Universite d'Aix-Marseille interviennent dans l'execution de la convention FAC 1997-2000. Selon le nouveau protocole d'accord recemment conclu, couvrant la periode 1997- 2000, le Syndicat d'agglomeration nouvelle de Senart poursuivra egalement et etendra ses interventions A d'autres communes des Regions du Trarza et du Brakna dans le cadre d'un projet d'amelioration de la sante maternelle et infantile. Seront finances dans le cadre de ce projet : (a) la reconduction de l'aide au fonctionnement l'h6pital de Rosso pour soutenir les echanges de personnels infirmiers, suivre la gestion et corriger les insuffisances constatees dans la mise en oeuvre du systeme de recouvrement des couts, fournir des consommables de laboratoire et de radiologie; cofit: 65.000 FF par an; (b) la construction d'un poste de sante dans la commune de Bababe, la renovation du centre de sante de R'Kiz et l'equipement d'un petit laboratoire, la renovation/extension du centre de sante de Mederdra par la construction d'une PMI neuve, la renovation du poste de sante de Tiguent et de sa maternite, la prise en charge partielle de la rehabilitation/ extension du centre de sante de Boutilimit prevoyant la construction de 2 salles d'hospitalisation, la renovationl extension du centre de sante de Keur Macene; cofit: 434.500 FF sur deux ans; (c) la formation des personnels charges des soins de sante maternelle dans les centres de sante de R'Kiz, Mederdra, Tiguent, Boutilimit, Keur Macene par une equipe mixte de formateurs infirmiers et sages femmes; coot: 365.500 FF sur 4 ans. 4. Conclusion La Cooperation francaise est un des principaux et des plus anciens bailleurs de fonds du secteur de la sante en Mauritanie. Elle a joue a ce titre un r6le important dans l'amelioration de la situation sanitaire du pays par l'importance de ses financements et par ses conseils a la mobilisation des autres acteurs fran9ais (ONG, jumelages, cooperation decentralisee). Aux c6tes d'autres partenaires comme la Banque Mondiale ou l'Union europ6enne, elle a contribu6 au renforcement du dialogue avec les autres Project Appraisal Document Project Title: Health Sector Investment Credit Country: Mauritania Annex 2B - Page 16 of 16 partenaires exterieurs d'une part, a la rationalisationet au developpementdu systeme de sante d'autre part. Les interventionssont elles aussi de plus en plus int6greesavec celles d'autres bailleurs de fonds, s'inscrivant dans les orientationsdefinies par le programmedu Gouvernement. Elle a entrepris depuis quelques annees de reorienter ses actions vers de nouvelles priorites en vue de s'adapter Al'evolution de la situation sanitaire du pays, accroitre son efficacite et la viabilite de ses interventions.Initialement confinees au secteur hospitalier A cause de 1'expertisequ'elle a dans ce domaine, les actions financees par la Cooperationfran,aise tendent A se generaliser A l'ensemble du systeme de sante selon une approche de sante publique,tout en visant une plus grande responsabilisation des collectivites locales dans le financementet l'organisation des soins. Malgre ces efforts d'adaptation, I'efficacite de I'aide francaise pourrait etre limitee par l'extension du champ d'intervention a l'interieur du secteur de la sante sans augmentation equivalente du volume de financement. La durabilite des r6sultats pourrait 8tre compromise par la preponderancede l'assistance technique dont les nouvelles modalitesdestinees Aaccroitre le transfert de competences ne sont d'ailleurs pas clairement definies, et par les proceduresde gestion qui ne responsabilisentpas assez les acteurs locaux. Les autorites mauritaniennespourraient, de leur c6te, prendre certaines mesures pour accro"itre 1'efficaciteet la perennit6de l'aide francaise.Ainsi une nouvellemethode de programmationdevrait etre mise en place qui permette d'avoir une vision plus etendue et eviter de travailler au coup par coup. L'elaboration du Plan Directeur 1998-2002 et du plan triennal glissant et d'autres documents de politiques et de programmes sous sectoriels devrait y contribuer. Certaines relations, dans la mise en oeuvre des projets, pourraient etre contractualisees avec des operateurs independantsde maniere A separer les fonctionsregaliennes de l'Etat avec celles d'execution par d'autres institutions.La definition d'un statut des personnelsmedicaux permettantde valoriser les formationset de faciliterle deploiementa l'interieur du pays, I'amelioration de l'utilisation des recettes du recouvrementdes cofits, et une plus grandecelerite tant dans la mise en oeuvre des activites que dans la resolutiondes difficultesde travail au quotidien,constituent quelques unes des autres mesures d'amelioration des resultats des projets finances par l'aide fran,aise dans le secteur de la sante. ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex3 - Page1 of 1 Annex 3 Estimated Program Costs Program Component Local Foreign Total ------US$ million------1. Improve health services quality and coverage 29 43 72 2. Improve health sector's financing and performance 22 9 31 3. Mitigate the effects of major public health problems 33 14 47 4. Promote social action and create and environment 7 2 9 conducive to health Total 91 68 159 Total BaselineCost Physical Contingencies 5 3 8 Price Contingencies 14 10 24 Total Program Cost 110 81 191 Project AppraisalDocument ProjectTitle: HealthSector Investment Credit Country: Mauritania Annex4A - Page 1 of 6 Annex 4A Cost-effectivenessAnalysis of the PTHG 1998-2000 for the Health Sector in Mauritania A. Health interventions ranked by cost-effectiveness Definitions Cost-effectiveness in health care: * measured in dollars per disability-adjusted life-year (DALYs). * corresponds to the net gain in health or reduction in disease burden from a health intervention in relation to cost. Disability-adjusted life-year (DALY): * a unit used for measuring both the global burden of disease and the effectiveness of health interventions, as indicated by reductions in the disease burden. . calculated as the present value of the future years of disability-free life that are lost as the result of premature deaths or cases of disability occurring in a particular year. Methods / Sources of data 1.. References * World Development Report 1993: Investing in Health, (table B.6 and B.7, p. 222-223). * Better Health in Africa: experience and lessons learned. R.P. Shaw and E. Elmendorf, The World Bank, 1994. * PTHG 1998-2000, P. Bachrach, 1997. * StaffAppraisal Report, Rep. of Mozambique, November 1995. * Jha, Ranson and Bobadilla: Measuring the Burden of disease and the Cost-Effectiveness of Health Interventions: A Case Study in Guinea. (World Bank Technical Paper # 333). * Le developpement social en Mauritanie. Olivier Degreef, UNICEF/RIM, 1995. N.B. The 76% of the target population for communicable disease, especially for malaria, correspond to the adult population (56%) and the under-five children (20%). The 54% of the target population for nutritional and endocrine condition interventions include children under the age of five (20%), school-age children (24%), and pregnant and lactating women (10%). The percentage of pregnant and lactating women has been calculated, taking into account the crude birth rate for Mauritania and assuming that the majority of mothers are breast feeding for about 2 years. 2- Methods The table is divided into 3 components: * Interventions that can be substantially controlled with high cost-effectiveness: less than US$ 100 per DALY saved. * Interventions that can be partially controlled with moderate cost-effectiveness: US$250 to US$999 per DALY saved. . Interventions that cannot be controlled in a cost-effective manner: US$ 1,000 or more per DALY saved. There are few or no interventions in the range of US$100 to US$250 per DALY saved (WDR 1993, p.222). The ratio between cost and effect, or the unit cost of a DALY is called the cost-effectiveness of the intervention; the lower that number, the greater the value for money offered by the intervention. There are thousands of health care interventions, but only about 50 of them have been analyzed in the WDR 1993. However, these 50 interventions deal with more than half of the world's disease burden. The implementation of the 20 most cost-effective interventions could eliminate 40% of the total burden and three-quarters of the health loss in children. Table I deals only with the basic package of health care inputs, included in the 50 interventions studied in the WDR 1993. The cost-effectiveness of interventions aiming at strengthening the health delivery system was not determined. ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex4A - Page2 of 6 Table 1: Health Sector PTHG 1998-2000 (Mauritania): Health Interventions Ranked by Cost-Elfectiveness Cost- Nature of interventions Costof US'per life-year Costas a Targeted effectiveness interventionin saved(2) proportionof total populationas a UM'000 (1) expendituresfor proportionof total ratios of thehealth population(%) interventions package(/) High cost- (1)- Communicableand perinatal: 67011 16.46 18 20 effectiveness: Diarrhealdiseases, ARI, Childhood cluster:pertussis, polio, measles, underUS$100 per tetanus DALY saved Tuberculosis,leprosy 78,825 50.50 22 56 (2)- Maternal: 30,714 29.43 8 21 Pre andpost deliverycare, delivery care.In patientcare: Obstetrical and Gynecological (3)- Family Planning: 2,850 1.07 1 21 Provisionof contraceptives.Outreach family planningservices (4)- Nutritional and endocrine: 12,075 15.90 3 54 Under5: Protein-energymalnutrition, Vit. A deficiency Pregnantand lactatingwomen: nutrition,anemias School-agechildren: Iodine deficiency (5)- Communicablediseases 84,891 26.01 23 76 STD/HIV,Malaria Total (1-5) 276,366 NIA 75 N/A Medium cost- (6)- Noncommunicablediseases (cardiovascular,diabetes, obesity) and effectiveness: unintentional injuries US$250to US$999 per DALY saved Total(6) 90,256 045.70 25 56 Low cost- None effectiveness: US$1000or more per DALY saved _ GRANDTOTAL 366,622 N/A 100 N/A (1): Datafrom PeterBachrach: Report on the GOM Three-YearPlan 1998-2000(July 1997) (2): Ratiosfor Africancountries collected from literature(WDR 93, BHA,Staff Appraisal Report# 14373-MOZ,Jha, Ranson,and Bobadilla:Measuring the Burdenof Diseaseand the Cost-Effectivenessof HealthInteriventions). Project Appraisal Document Project Title: HealthSector InvestmentCredit Country: Mauritania Annex 4A - Page 3 of 6 Conclusions Most of the interventions are highly cost-effective since interventions with cost-effectiveness ratios under US$100 represent 75% of the total cost of the program. The other 25% of the budget will be spent on interventions with medium cost-effectiveness ratios. It is worth mentioning that the Health Sector PTHG 1998-2000 is not proposing any intervention falling into the category of low cost-effectiveness. The basic package of health is highly cost-effective, especially the outreach family planning services, outpatient care for diarrheal disease and immunization. Many of the most cost-effective health interventions are preventive in character. However, five groups of clinical services are highly cost-effective and address very large disease burdens. These include pregnancy-related services, family planning services, control of sexually-transmitted diseases, tuberculosis control and care for the common serious illnesses of children such as diarrheal diseases, acute respiratory infection, measles, malaria, and acute malnutrition. The moderately cost-effective interventions proposed in the Three-Year plan are related to non- communicable diseases. Cardiovascular diseases are divided as follows: ischemic heart disease (US$250-US$999 per DALY saved); cerebrovascular diseases (US$1,000 per DALY saved) and peri-, endo-, and myocarditis (which have a low occurrence and have not been evaluated for cost-effectiveness). Diabetes: the cost-effectiveness of those interventions is evaluated at under US$100 per DALY saved. Obesity: the cost-effectiveness of that intervention-which is related to a specific cultural context of Mauritania-can be affected by the incidence and prevalence of this disease, and the probability of dying from its complications. Empirical data to evaluate cost-effectiveness of this type of interventions were not available. Injuries are divided into unintentional, such as motor vehicle injuries and falls, which have cost- effectiveness ratio between US$250 and US$999 per DALY saved, and intentional, such as self-inflicted, homicide, viiolence and war, which have not been evaluated for cost effectiveness and are rather infrequent. In summary, 75% of the interventions in the area of disease control and prevention are highly cost- effective, i.e., under US$100 per DALY saved. The remaining 25% are moderately cost-effective, i.e., between US$250 to US$999 per DALY saved. None of the interventions proposed in the Three-Year Plan falls under the category of low cost-effectiveness. Project Appraisal Document Project Title: HealthSector InvestmentCredit Country: Mauritania Annex 4A - Page 4 of 6 B. Cost-effectivenessof interventions by type of health problems and consistencyof GOM health carepackage with BHA and WDR 1993 Methods/ Sourcesof data 1- References * Better Health in Africa (1994). * World Development Report, (1993). * Peter Bachrach: Preliminary Report on the GOMHealth Sector Three Year Plan 1998-2000 (July 1997). 2- Methods Africa's households and communitiescould become much healthier through three mutually reinforcing improvementsthat would enhancethe effectivenessof each dollar spenton health, i.e.: packageof basic health care inputs; decentralizationof health care delivery;and improvedmanagement of the essential inputs to health care, such as pharmaceuticals,health sectorpersonnel and health sector infrastructureand equipment. The cost-effective"packages" of servicesare designedto deal effectivelywith the most commonhealth problems. Its purpose is to provide better health at the lowest cost. The basic h-ealthcare should be complementedby (1) supporting services, and by (2) intersectoral interventions. A basic package of health care inputs, supporting servicesand intersectoralinterventions are essentialfor maximizingcommunity effectiveness. In Table 2, the GOM Health SectorPTHG 1998-2000is divided, similarlyto Better Health in Africa, into the followingcomponents: (1) Basicpackage of health care inputs EPI, ante and postnatal care, treatment of maternal morbidity',control of sexually-transmitteddiseases, family planningoutpatient care, tuberculosiscontrol, commonserious illnessesof children(diarrheal disease, acute respiratoryinfection, measles, malaria and acutemalnutrition). (2) Supportingservices Information,education and communicationto improve screening for diseases and diagnostic accuracy, providercompliance and patient compliance. (3) Intersectoralinterventions Safe drinkingwater and sanitation.They constituteimprovements to the enablingenvironment for health. (4) The interventionsnot included in the three components of the package of basic health care are presented in section D as Other interventions. (5) Some of the interventionsincluded in the Plan Directeur 1998-2002,which do not have any cost, are not includedin the tables. Most of these interventionsare related to the strengtheningof socialactions. ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex4A - Page5 of 6 Table 2: Cost-Effectiveness of Interventions per Type of Health Problem and Consistency of GOMHealth Care Packagewith "Better Health in Africa" and WDR93 Descriptionof interventionproposed in GOM HealthSector PTHG BHA WDR93 Realcost of Costas a Target 1998-2000 package package intervention proportionof population and/or (UM' 000) total (%) priority (2) expenditures (1) for health ______package (%) A- Basic package of health care inputs Diarrhealdiseases, acute respiratory infections, childhood cluster Y Y 67,011 18 20 (pertussis,polio, measles, tetanus) Pierinatal/Maternalcauses Y Y 30,714 8 21 Nutrition/Feedingprogram: proteinenergy malnutrition, iodine Y Y .2,075 3 54 deficiency,Vit. A deficiency,anemias FamilyPlanning (outreach FP services) Y Y 2,850 1 21 Communicablediseases: STD, HIV/AIDS,Malaria Y Y 84,891 23 76 Tuberculosis,lepra Y Y 78,825 22 56 Noncomm.dis.: Cardiovascular,obesity, diabetes, injuries Y Y 90,256 25 56 Subtotal 366,622 100 N/A B- Supporting services Geographicand financialaccess to basic healthservices to at least Y Y 5,092,926 83 80 80%of the population Availabilityof well trainedpersonnel in healthcenters Y Y 6,234 0 80 Qualityof healthcare at all levels Y Y 745,116 12 80 Innproveduse of preventiveservices Y Y 113,372 2 80 Strengtheninghuman resources planning and management Y Y 37,174 1 80 Resumethe processof decentralizationof decision-makingand Y Y 18,490 0 80 management Developa healthinformation system Y Y 32,701 1 80 Provisionof soundhealth information Y Y 60,643 1 80 Subtotal 6,106,656 100 N/A C- Intersectoral interventions Assuringsafe water,sanitation and food qualitycontrol Y Y 52,755 83 Irnprovesectorial participation in sanitarydevelopment Y Y 10,650 17 Subtotal 63,405 100 Cl-Other interventions Reinforcingsocial action: Settingup an adequateinstitutional framework 49,070 48 Assuringan adequatefinancing of the socio-sanitarysystem: Irnproveresources allocation Y Y 37,517 36 Financialresources mobilization Y Y 16,514 16 Subtotal 103,101 100 (1): Y signifiesthat the interventionis also recommendedby BetterHealthin Africa and/orWDR 1993 (2) Data from Peter Bachrach: Report on the GOM Three-Year Plan 1998-2000 (July 1997). ProjectAppraisal Document ProjectTitle: Health Sector Investment Credit Country:Mauritania Annex4A -Page6 of6 Conclusions (1) Basic package of health care inputs See conclusionsin Table 1. (2) Supportingservices Supporting services help maximizethe value of personal.health care. The IEC component is highly cost- effective. For example,the cost-effectivenessof the AIDS educationprogram is US$1.67per life-yearsaved, of the tobacco legislation/warningfor 10% of the population, it is US$0.31 per life-year saved and of the mother's education on respiratoryinfections, it is US$0.40 per life-year saved. (Data for African countriescollected from literature.) A detailed cost-effectivenessstudy using data for African countries on supporting services (such as training, providerand patient compliance,etc.) was not available. (3) Intersectoralinterventions It had been calculated(Mozambique) that the cost per life-year saved for the constructionof pit latrines, is US$0.33 per household. Safe water supply is US$0.62per life-yearsaved per household. Basic package of health care inputs, supporting services and intersectoral interventionsare essential for maximizing community effectiveness(Better Health in Africa). In this aforementionedpackage, some of the interventionshave not been studied completely in terms of cost-effectiveness;however, the package has been emphasizedby BHA as very important since "it has reduced total hospital admissions in some communitiesin Africa by up to 50% and has cut hospital admissionsfor such illnessesas measles,tetanus and diarrheaby up to 80%No." In summary, the interventionspresented in the PTHG 1998-2000 correspondto the priority actions mentionedin both the World Development Report 1993 and Better Health in Africa. Most of them are highly cost-effective(less than US$100per DALYsaved). ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country: Mauritania Annex4B -Page 1 of 13 Annex 4B Economic Analysis I. Introduction The Health Sector Investment Program (HSIP) is based on a new sector policy (Plan Directeur 1998-2002) and a Three-Year Rolling Plan (PTHG 1998-2000), prepared by the Mauritanian Government in collaboration with donors and NGOs. The policy aims to provide accessible and quality health services for the entire population, with emphasis on the rural poor population, women and children. The HSIP will provide financial support to GOM's policy for the health sector. Resources will be provided by GOM, beneficiaries, donors, and major NGOs. IDA contribution to the program will be about 12.5% of the total program cost. This analysis examines the following aspects of the program: (i) economic and sectoral context; (ii) health sector expenditures and financing; (iii) cost-effectiveness; (iv) equity; (v) risk; and (vi) capacity. It is based on data from the: WB Public Expenditure Review, April 1994 (#10973); WB Public Expenditure Review 1995/1996 (text not yet released); Gilles DesRochers: Public Expenditure Review for the Health Sector, 1996; Marlene Abrial: the Cost Recovery Study, 1996; CAS for Mauritania (#16595), PFP for Mauritania (1997-99) and the Health Sector PTHG 1998-2000 and other data provided by the country economist. II. Economic and Sectoral Context Macroeconomic framework Over the last three decades, and until recently, economic performance in Mauritania has fluctuated widely. This is largely a result of droughts, declining international prices of the country's principal exports (over the last 10 years, Mauritania's terms of trade decreased by 12 %, equivalent to an annual loss of about 0.6 percent of GDP) and weak economic management. Since 1985, a series of ambitious programs have been launched, to redress imbalances and restructure the economy on the basis of free market principles. Under these programs, the Ouguiya (UM) was devalued and key structural reforms in trade, pricing, taxation, public expenditure, civil service and social sectors were implemented. Mauritania's shifting performance during this period demonstrates the degree to which the economy has remained vulnerable to exogenous factors. Of these, the most significant have been: (i) fluctuations in the world prices for principal exports, i.e., iron ores and fishery products; (ii) adverse climatic conditions (drought and desertification) and related plagues (desert locusts); and (iii) variations in international aid. Mauritania's debt burden has also been a significant factor. Among the endogenous factors are Mauritania's narrow resource base (limited to iron ores and fisheries and to agriculture which has poor prospects) and the insufficiently developed private sector. Demographic factors have also contributed, as there is important population growth and excessively rapid urbanization. Despite this vulnerability, during the last ten years, Mauritania has successfully managed a major transition to economic and political liberalization. As a result, public finances have been stabilized, and structural reforms, as mentioned above, largely completed. Mauritania's GDP has grown by about 4.6 percent per annum over the last five years. Moreover, as a result of economic growth and of a conscious effort to reorient public resources to the social sectors, many education and health indicators have started to improve. ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex4B - Page2 of 13 Just as economic growth has been fundamental to the general health gains, the converse also increasingly appears to be true. There is a growing body of evidence that health gains in Mauritania have contributed to development and particularly to the economic enrichment of the lowest income groups. Strengthening and further developing Mauritania's health system are, therefore, important to supporting a progressive economic reform. Links to CAS As stated in the eight PFP 1997-99 for Mauritania, of July 2, 1997, the Government's strategy for the medium term is to improve the standards of living and reduce poverty through private sector-led growth. The Country Assistance Strategy (CAS) for Mauritania (#16595), presented to Board in March 1997, fully supports the Government's efforts in reducing poverty, and its key strategies (objectives) to achieve this goal, i.e., to increase human capital. Actions and progress benchmarks, mentioned in the CAS, are: (i) tc develop basic and referral health services (with emphasis on remote areas); (ii) to make available adequate reproductive health care services and increase the use of modem contraceptive methods; and (iii) to develop preventive services (the CAS specifically mentions immunization rates and nutrition). The health sector strategy and the proposed project are identified in the CAS. Rationalefor Public Intervention and Finance The characteristics of the health care market may prevent private providers to render all, or the majority, of services needed by the population, as :For many services there may be important market failures. In Mauritania, imperfect information, limited access to services, problems with affordability, and lack of knowledge in consumers regarding health matters contribute to market failures. This is generally the case of health services of benefit to the community as a whole (i.e., public goods, such as safe drinking water and sanitation) and of services with significant externalities for which there is low consumer demand and high price elasticity. Disease prevention is an example of such latter service. For example, immunizations against infectious illnesses protect the immunized persons but also decrease transmission of infectious diseases to the remaining population. The demand for such services is generally low, especially in low-income countries. As a result, the private sector usually does not provide immunization services; the public sector does it, and because of consumer's little willingness to pay, excludes these services from cost recovery (to protect the entire population from the risk of infectious diseases). Consequent to this situation, the private sector's role in many developing countries, including Mauritania, is limited to the provision of curative care to the better off urban population. In sub-Saharan Africa, strong solidarity among the members of large families, palliate this situation, as-in many cases-a relative will pay for the sick person. However this applies, more often than not, to curative care. The public sector, therefore, has an important role to play in providing basic health services to the needy. In the context of Mauritania, public interventions in the health sector have a strong rationale because of: (i) poverty; (ii) a weak private sector, which charges unaffordable prices (drugs in private pharmacies cost eight times more than similar drugs in public sector) and which is mostly concentrated only in two relatively developed cities; (iii) low demand for preventive services and public health goods; (iv) strong seasonality of revenues for the rural population; and (v) important problems of accessibility. The public sector's medium-term goal, (i.e., to ensure affordable and adequate basic services to the entire population and especially to the poor) is, therefore, timely and relevant. It should be noted that the public sector in Mauritania is being ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Maurtania Annex48 - Page3 of 13 extensively and increasingly funded from private resources through cost recovery (which operates at all levels of the health delivery system). Revenues generated through cost recovery are managed by the respective health facilities, and consumers and local administrative authorities, are increasingly involved in decision on the use of these funds and-more generally-in decision-making about health in their respective geographical areas. As already mentioned, the sector policy also supports the development of the private sector, which has recently started to grow in the capital city. The gradual set-up of pre-payment arrangements, is also opening a possibility to subcontract with the private sector part of the service delivery. Adequacy of the Sector Policy Framework Since the beginning of the 1980s, the Government's sector strategy has been oriented towards the provision of preventive and primary care services to the population. Over the last years, the government has been taking the lead in defining the sector policy and has issued two sector programs. The Plan Directeur 1991-1995/6, has been recently evaluated and a new Plan Directeur 1998-2002 has been launched. The main strategies include: (i) improvement of health services quality and coverage; (ii) improvement of health sector's financing and performance; (iii) actions to mitigate the effects of major public health problems; (iv) strengthening of social action programs and promotion of an environment conducive to health. This new sector policy is a continuation of the strategies launched with the opportunity of thePlan Directeur 1991-1995/6 (see also PAD part B paragraph 2). The Plan Directeur 1998-2002 and its operational framework, the PTHG 1998-2000, are the products of widespread consultations and have received the endorsement of numerous stakeholders, including the donor community. The program is comprehensive and visionary, has well defined sector priorities, and addresses issues of service provision, quality, efficiency, and equity. Financing mechanisms and overall financing problems are also addressed. Under this framework, the government maintains its leading role in health sector reform and has strong ownership of the program. The role of MSAS is clearly defined as being one of policy making, financing, and monitoring and regulation, while health care itself is being provided by a network of decentralized services. Private provision of care, including use of traditional medicine, is also envisaged. The harmonization of multiple donor projects into a sector-wide approach, under the leadership of MSAS will gradually reduce the duplication brought about by the coexistence of various donor-driven projects and will strengthen local capacity in health services planning and management. Lastly, monitoring and evaluation instruments have been designed and will be used in annual program reviews and evaluations. The analysis of the PTHG (presented in Annex 4A) also proves the adequacy of the sector policy to the health problems of the Mauritanian population and the user of cost-effective intervention strategies. III. Health Sector Expenditures and Financing To assess the affordability of the national health sector investment program, the Government has carried out analyses of MSAS budget and expenditures, donor aid, and of beneficiary financial contributions. Moreover, projections were made for costs likely to be generated by the activities planned under the program. A summary is presented below (see table 1). ProjectAppraisal Document ProjectTitle: Health Sector Investment Credit Country:Mauritania Annex4B - Page4 of 13 Trends and structure of health sector expenditures While budget allocationto the health sector duringthe last five years has fluctuated,there has been a high execution rate (90 percent in 1993, 66% in 1994, and 99% in 1995). This has translated into expendituresper capita which compare well vvithother low-incomecountries (in nominalterms from US$5.37in 1993 to US$9.49 in 1995). The situation of the recurrent budget was also encouraging,as the share of the health sector's recurrent budget compared to total governmentrecurrent budget has been increased from 5.27 percent in 1993 to 6.42 percent in 1996 (or to 7 percent, if one takes into account the NISAS share from the "depenses communes"). Furthermore,with the exception of 1995, the recurrent budget executionrate was over 90 percent. In addition, the share of salary expenditure was controlled since non-salary recurrent expenditures were constantly maintained over 35 percent of total recurrent health expenditures. For the health investment budget (the Budget consolide d'investissement (BCI)), the situation has been somewhatdifferent. The internally-financedpart of theBCI has increased (with the exception of the year 1996, when it decreased drastically),while the donor-financed part, which has representedbetween 85 and 98 percent of the 13CI,has fluctuated. The execution of the health investmentbudget (with the exceptionof 1994)was modest, and indicatesa need for stronger commitmentfrom both Governmentand donors and better donor coordination. To this end, a sector investmentprogram seems to be the answer. ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex4B - Page5 of 13 Table 1. Mauritania - Health public sector budget and expenditures 1993 1994 1995 1996 Allocated Executed Allocated Executed Allocated Executed Allocated Totalpublic health (MSAS) 1535 1393 2836 1871 2836 2804 2243 Currenthealth 1057 1027 1242 1241 1315 1494 1357 Salaries 682 638 705 719 792 914 767 Non-salaries 375 389 537 522 523 580 590 Investmenthealth (BCI) 478 366 1594 630 1521 1310 886 Externallyfinanced 439 339 1481 533 1331 1145 846 Internallyfinanced 39 27 113 97 190 165 40 Total publicgovernment 37789 37486 38797 34624 41198 36658 43093 Total recurrentgovernment 20058 19482 19207 19573 20098 20240 21142 Salaries 6441 6436 6700 6700 6968 6970 n.a. Non-salaries 13617 13046 12507 12873 13130 13270 n.a. Total investmentgovernment (BCI) 17731 18004 19590 15051 21100 16418 21951 Externallyfinanced 16031 1494 17871 1689 19100 1653 18077 Internallyfinanced 1700 16510 1719 13362 2000 14765 3874 Population 2147778 2147778 2211473 2211473 2277766 2277766 2341543 Exchangerate (1990=80.6UM/US$) 120.81 120.81 123.58 123.58 129.77 129.77 137.2 GNPdeflator (1990=100) 125.97 125.97 134.03 134.03 139.93 139.93 144.69 GNP nominal 113919 113919 125446 125446 140343 140343 152322 Total health exp.fGNP (%) 1.35 1.22 2.26 1.49 2.02 2.00 1.47 Total healthexp./total gov. exp. (%) 4.06 3.72 7.31 5.40 6.88 7.65 5.21 Currenthealth/Current government (%) 5.27 5.27 6.47 6.34 6.54 7.38 6.42 Investmenthealth/Investment gov.(%) 2.70 2.03 8.14 4.19 7.21 7.98 4.04 Health exp. per capita (nominal) UM 715 649 1282 846 1245 1231 958 Health exp. per capita (nominal) US$ 5.92 5.37 10.38 6.85 9.59 9.49 6.98 Healthexp. per capita (real)UM 567 515 957 631 890 880 662 * * Finally, it should be mentioned that donors have financed many activities in the health sector, without channeling their funds through the public sector budget (they provided for instance, financial support to NGOs). Such funding supports a mix of investment and recurrent expenditures. During the period 1993-1995, donors have spent over and above their contribution to BCI on an average UM639 million per year. This is an important contribution and raises expenditures per capita in nominal terms by US$1.55 in 1993 (up to a total of US$ 6.92 per capita) and US$2.09 in 1995 (up to a total of US$11.58). * * ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex4B - Page6 of 13 Health expenditures analyses also demonstrate that the budget was used to pursue GOM's objectives for the health sector, i.e., to deliver services for the benefit of the poor and the rural population and to develop primary health care. During the period 1993-1996, the budget spent on primary and secondary care represented about 40% of total health expenditures, and expenditures for tertiary care and administration were stationary at levels which compare well with Sub Saharan African countries. Furthernore, with the help of moneys generated through cost recovery, adequate funding for drugs and maintenance has also been provided. Finally, in Mauritania, the health sector's budget specifies budget lines for each of the districts. These funds are discretionary. They have constantly been increased (by 6% a year) and will be further increased, alongside district management and financial capacity improvements. Table 2. Health sector expenditures per level of care (%) Level of care / Year 1994 1995 Primary level 35.4 32.5 Secondary level 6.0 8.8 Tertiary level 33.0 28.7 Administration 25.6 29.9 Total 100.0 100.0 Cost Recovery Since 1992, the Government moved away from a health care system exclusively financed by the state, unsustainable financially, and with little beneficiary involvement (in cost recovery and in decision making). The present system is based on: (i) sale of essential drugs prescribed during consultations in public facilities and (ii) cost recovery for services rendered. It applies to primary and tertiary health facilities and it is estimated to enc:ompass more than two thirds of the. population. Secondary care facilities practice cost recovery, but solely for drugs. At present, the Government is studying the possibility for extension of cost recovery to services rendered also in district hospitals. For drugs, the profit rate is over 100 percent of the purchasing price. The funds generated from cost recovery are retained at the point of collection and used for the replenishment of drug stocks in health facilities. The remaining 100% complements the Government's recurrent budget with regards to the maintenance of health facilities (30%), provides financial incentives for health personnel (30%) and constitute a "security fund" to provide drugs for the indigent population and/or finance various activities such as supervision, immunizations etc. (40%). Decisions taken regarding the security fund need to be approved by the MSAS. In 1996, cost recovery collected in primary health care facilities reached about UM276 millions (about US$1.9 million), and represented about 50% of the recurrent expenditures for primary health care during that year. Tertiary care establishments have along been engaged in this process for several years. This is the most advanced and better regulated part of the health delivery system. In 1996, income generated from cost recovery at the tertiary care level reached an amount of UM286 millions in 1996 (about US$1.97). The existing cost recovery system has proved to be a success. The new program envisages to improve its performance at all levels and to expand it by introducing cost recovery for services at secondary care level. However, to ensure the viability of the system, certain ProjectAppraisal Document ProjectTitle: HealthSector Investment Credft Country:Mauritania Annex4B - Page7 of 13 weaknesses will to be dealt with such as the: (i) irregular replenishment of drug stocks; (ii) imperfect accounting of revenues and expenditures; (iii) increase in the average cost of drugs (about 8 percent yearly); (iv) poor knowledge about MSAS current expenditures at district level; and (v) large variations in the average cost of treatments among health facilities. Financing of the program To project the financial resources of the health sector for the period 1998-2002, the following assumptions were made: (i) the MSAS budget, as a share of total Government budget, was assumed to steadily increase until it reached 8.5% in year 2002. This is a more conservative assumption than GOM's formal commitment to the sector which is to attain 10 percent by year 2002. Budget execution is assumed to be close to 100%. (ii) projections with regard to donor investments were conservatively made assuming that donor financial contributions to the sector (excluding the proposed IDA investment) will remain stationary in real terms, at the level of FY95; (iii) at the primary level of care, it was assumed that (1) cost recovery will concern 80 percent of the population (instead of 75% currently); (2) a yearly amount of 118 UM per capita will be spent and recovered for drugs; (iv) at the secondary level, it was assumed that (1) cost recovery for services will start in 1999; (ii) that 80% of non-wage recurrent expenditures will be financed through cost recovery, and (iii) a yearly amount of UM73 per capita will be used for drugs; (v) at the tertiary level of care, it was assumed that (i) 80% of the non-wage recurrent expenditures is financed by cost recovery, and (ii) a yearly amount of UM122 per capita will be spent and recovered for drugs; and (vi) IDA's contribution to the program was calculated by subtracting the contributions of GOM, donors and beneficiaries from the cost of the entire health sector program for the period 1998-2002 (the cost of the program was calculated on the basis of the PTHG 1998-2000, and by extrapolating expenditures for FY99 and FY00). (vii) An amount of US$ 6 million is specifically ear-marked a population census to be carried out in the period 1998-2000 (see annex 2A (Detailed Program Description) component 4. Project Appraisal Document Project Title: Health Sector InvestmentCredit Country: Mauritania Annex 4B - Page 8 of 13 Table 3: Financial resources for the health sector 1995 1996 1997 1998 1999 2000 2001 2002 GOM Recurrent 1494 1630 1723 2020 2190 2350 2517 2861 Investment 190 40 19 83 96 110 126 143 Total GOM 1504 1397 1742 2103 2286 2460 2643 3004 Donors excl. IDA 1739 1980 2102 2135 2200 2266 2334 2402 IDA 0 0 0 390 900 990 830 640 Total donors 1739 1980 2102 2525 3100 3256 3164 3042 Beneficiaries 285 450 462 610 627 645 663 682 Sub-total 3528 3827 4306 5238 6013 6361 6470 6728 Pop. census GOM 16.6 49.8 16.6 Donors (excl.IDA) 132.8 415 132.8 IDA 49.8 132.8 49.8 Total pop. census 199.2 597.6 199.2 Total 3528 3827 4306 5437.2 6610.6 6560.2 6470 6728 Exchangerate 129.8 137.2 142.1 148.6 153.7 167.6 167.5 178.1 Population 2277766 2341543 24071072474506 2643792 2615018 2688238276360 9 Expenditure/habitant(UM) 1549 1634 1789 2117 2364 2432 2407 2435 Expenditure/habitant(US$) 11.93 11.91 12.59 114.24 15.38 15.43 14.37 13.67 Millions of current UM. * The period 1995-1997 includes IDA contribution through the current PSP project. This category iicitudes donors contributions to BCI and their contributions "hors BCI". Figure 1: Donor, IDA and MSAS recurrent expenditures plus beneficiary contributions to the health sector 4000 ______3500 .Donors re2500 - o 2000 ~' -. I~~u~~lDA(HS P) .2 E1500 E1500 Va:er:i- Gov.reccurrent X02 500 ;*-----....* g : ; < ;; : + cost' ,expenditures 0. . ~~~~~~~ ~ ~~~~~~~~~~~~recoveryI 1995 1996 1997 1998 1999 2000 2001 2002 Year j Project Appraisal Document Project Title: Health Sector Investment Credit Country: Mauritania Annex 4B - Page 9 of 13 Figure 2: Total investment and MSAS recurrent expenditures plus beneficiary contributions to the health sector 4000 3500 3000 -g =u + Total iniestment E 2500 - (incl. GOM) 32000 E1500 - Gov. recurrent 1000 expenditures + cost recowry 500 , ,. ,.'_ _ _ 1995 1996 1997 1998 1999 2000 2001 2002 Year The following trends can be observed from the above table and figures: (i) the increase of GOM and beneficiary contributions is steeper than for the donor-contributed budget; (ii) donor contributions will stabilize towards the end of the period; (iii) IDA contribution will be: (a) small (about 12.5% of the cost of the total program), (b) very modest in FY98, since the program's expected effectiveness date is May 1998 and the MSAS capacity will not be fully in place by that date, and (c) expected to decline after the year 2000. This demonstrates that the Government will continue to depend on external funding but it will increase its contribution. Beneficiaries will also play an increasingly important role. Fiscal Impact and Cost Recovery This program will not lead to modifications of tax instruments. Nonetheless, beneficiary contributions towards the cost of the program will be substantial. However, as described above, the cost of services in the public sector will remain affordable. Cost recovery for drugs will continue along the lines of the present arrangement which proved to function well and to be able to provide good quality drugs at affordable prices. The indigent population will also continue to be protected. Affordability of services and consumer's willingness to pay will be constantly monitored, aiming to make the under-served groups the gainers of this program. During the five years of the sector's program, the Government will better manage donor inputs (which are expected to remain important but to slightly decline), and beneficiaries will be increasingly involved in both decision-making in, and financial support to, the sector. Decentralization will also play a substantial role in efficiency gains and is a more rational sector development. IV. Cost-Effectiveness Analysis An analysis of the soundness of the entire national sector program, as presented in the sector policy, was carried out. This analysis has encompassed: (1) the sector policy (Plan Directeur 1998-2002), recently approved by the Government; (2) the data presented by MSAS in ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex4B -Page10 of 13 its Health Sector Three-Year Plan 1998-2000; and (3) available cost-effectiveness ratios for health interventions in Africa. Furthermore, the consistency of the GOM policy for the sector with the minimum package of care described in the World Development Report (1993) (WDR 1993) and "Better Health in Africa" (BHA) was also analyzed. The analysis (which is presented in annex 4A) demonsitratesthat 75% of the interventions proposed in the Health Sector PTHG 1998-2000 are highly cost-effective, i.e., cost under $100 per DALY saved. This group of interventions comprises infectious disease control and prevention activities. The remaining 25% of interventions are moderately cost-effective, i.e., cost between $250 and $999 per DALY saved and belong tc, activities in the area of non- communicable diseases. None of the interventions proposed in the Three-Year Plan falls under the category of low cost-effectiveness. Furthermore, the interventions presented in the PTHG 1998-2000 correspond to the "minimum package of care" of the WDR and BHIA. They have important externalities and they address large population groups. V. Equity Analysis The Mauritanian health system promotes equity in the following manner: The public budget for the sector is preferentially being used to finance expenditures at the primary care level. A Public Expenditures Review (G. DesRochers) demonstrates that over 30 percent of the expenditures in the sector has been spent on primary health services (i.e. health posts, health centers in categories A and B) and that expenditures for tertiary care (27 percent in 1996) have decreased during the last four years. The Plan l)irecteur 1998-2002 is pursuing equity as it foresees that public revenues be distributed with priority to: (i) social sectors; (b) high cost-effective interventions; (c) primary health care; and (d) services in rural and remote areas. In other words, the sector policy is of benefit to the sick and poor segments of the population. In Mauritania, cost recovery for services and drugs involves all levels of the health delivery system (contrary to the other African countries in which, more often than not, cost recovery is developed at primary health care level). As a consequence, the better off population, which, in Africa, tends to be the primary user of tertiary care services, pays more, as services rendered in tertiary facilities are more expensive. Conversely, the poor, who usually are the users of outreach services, pay less and still have access to affordable services of an acceptable quality. The GOM's strive to improve the quality of primary health care facilities also contributes to enhancing equity. The cost recovery system has also succeeded in keeping drugs accessible to the poor. For instance, despite the fact that essential drugs are sold in the public sector at about two to three times their procurement price, they are of a better quality and seven to eight times cheaper than the drugs sold in private pharmacies (since the private sector is currently purchasing drugs from many producers and wholesalers without being able to perform quality control, and it is using inappropriate procurement methods). Analyses carried out are showing that annual average expenditures per capita for primary care were about 145 UM and that cost recovery did not deter the poor from making use of public facilities. Cost recovery is not being practiced for preventive services and for curative services needed in relation to conditions such as tuberculosis, leprosy etc., which have strong public ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit laountry: Mauritania Annex4B - Page11 of 13 benefits. As these conditions affect more frequently the poor, the health system also promotes equity. There is potential to convert cost recovery for services into pre-payment arrangements. Pre-payment will allow for discharging of more preventive services, better protect the poor (as the affluent groups contribute more to cost recovery), and improve the management of funds. The objective of introducing pre-payment arrangements is mentioned in thePlan Directeur 1998- 2002, and has-to a certain extent-started to be implemented. For instance, pregnant women buy a carnet de sante which gives them access to pre-natal (preventive) health services and natal care. Indigent mothers are exempted from payment. VI. Risk Analysis Risks which may hamper the achievement of the objectives of the Plan Directeur 1998- 2002 fall into two categories: (a) risks due to financial shortfalls mainly as a consequence of possible weak overall economic performance and donor fatigue; and (b) weak management capacity at various levels of the health service delivery system. The likelihood of one or both of these risks occurring is modest, as, from a macro-economic perspective, Mauritania's performance has been promising during the last years and, generally speaking, donors are satisfied with their projects in the social sectors and do not plan to reduce their support. Furthermore, there is a strong commitment to strengthen health sector's management and administrative capacity and, also, to substantially decentralize decision-making to districts. See also PAD, part F-Sustainability and Risks-and critical assumption in annex I-Program Design Summary. Possible risks include: Future economic performance may not improve as projected, and may hinder GOM's capability to implement its overall development plan and to provide adequate funding to social sectors. Fluctuations in Mauritania's economic performnance in the last decade demonstrate the degree to which the economy remains vulnerable to exogenous factors. Of these, the most significant are: (i) variations in the world prices for the country's principal exports: iron ores and fishery products; (ii) climatic hardship (drought) and related plagues (desert locusts); (iii) variations of international aid, particularly important given Mauritania's high dependency on aid for investments; and (iv) Mauritania's significant debt burden. The stabilization and liberalization processes implemented since 1985 have reversed the decline that the Mauritanian economy experienced in the 1970s and 1980s. The budget balance and Mauritania's situation on the intermational market has improved, exports have grown, and-due to encouraging results in sectoral reforms-a certain reduction in the incidence of poverty has taken place. The GOM expects to complete its stabilization program by December 1997. The central objective of the next phase of GOM's reform program, as stated in Government report on the Journees sous la Khaima and its Priorites du Developpement pour 1997-99 document, is to reduce poverty through accelerated, private sector-led growth and emphasis on social sectors. The GOM has set a target of 5-6 percent annual growth of GDP for the period 1997-2000. The strategy to attain this goal consists of: (i) encouraging a stronger response from the rural sector; (ii) developing basic urban infrastructure; (iii) promoting private sector development; (iv) improving the environment to foster employment creation and poverty reduction; and (v) restructuring and modernizing the public sector. Based on the country's good record in the '90s ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex4B - Page12 of 13 and considering the Government's commitment to poverty reduction, this risk, although important, seems less likely to occur than in most Sub-Saharan African countries. Future budgetary allocation for the sector may not be adequate and the program may be underfunded. The proposed financial plan is based on conservative projections. It considers an increase of the MSAS budget share of total Government buudgetto 8.5 percent by 2002 ( while GOM has committed itself to increase the health sector's slhare to 10 percent by 2002). As already mentioned, GOM's record regarding financing of the health sector has been excellent and the budget execution has improved). Projections with regard to donor investments are also conservatively assuming that donor financial contribution to the sector will be stationary, in real terms, at the level of the year 1995. However, donor commitment is strong and discussions with donors pointed out to the fact that there is no intention, at present, to reduce external funding. The SIP approach foresees to monitor and annually evaluate sector performance. If needed (although highly unlikely) the program will be down sized to a core-program. The Letter of sector policy mentions specifically criteria for priority setting to be used in case of unexpected budget shortfall. In addition, cost recovery is a success and il: will be expanded. Furthermore, both Government and the Bank have indicated their willingness to maintain social sectors in the center of their dialogue. Decentralization policy may not be implemented as scheduled. Mauritania is genuinely committed to decentralizing not only service delivery but also decision making. The decentralization policy has been consistently pursued, and in 1997 the country is well beyond the point of no return. Significant political and administrative power has already been entrusted to walies. In the health sector, important progress have been made with the set-up of district health administration and district plans. The country's budget specifies allocations for each of the districts. These funds are discretionary, and will be increased in the future alongside district management and financial capacity improvements. Moreover, districts have the right to retain the funds generated by cost recovery and use them, at the level of the respective health unit, to contribute to recurrent expenditures, provide incentives to the health personnel, replenish drug stocks and subsidize services for the poor. There is also significant community involvement in health facility management of, and in decisions regarding, the use of financial resources (Comites de gestion). The program foresees close monitoring of the budgetary allocation to districts and support to decentralization. Lastly, overall macroeconomic improvement will contribute to political stability and encourage Government to continue to decentralize decision making. MSAS's insufficient capacity to implement its sector program may cause delays. At central level, especially with regard to matters such as policy development, budgeting, planning, management, financial management and procurement, the health sector's capacity is indeed still weak. At present, the sector has launched a new policy and it has finalized the PTHG 1998-2000. This work has helped strengthen central capacity. Concomitantly, a Plan for Institutional strengthening has been developed by Government. The implementation of this plan, which will receive support from Government, IDA and donors (in particular the French Cooperation and EU), will be closely monitored. With financial support from the current IDA credit, a PHRD grant and a PPF, actions to strengthen sector capacity are being implemented. Specific measures taken by Government include the filling of key management posiltions in the MSAS, the setup- within MSAS-of a DGI and consultant support. The steps agreed upon with GOM also constitute conditions for credit negotiations and effectiveness. The SIP approach will allow the program to be periodically evaluated and adjusted. Health sector's administrative performance will be a central piece of the annual review process. ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex4B - Page13 of 13 The quality of services may not substantially improve, especially due to problems with availability of drugs. MSAS capacity to purchase essential drugs through international competitive bidding and to manage drug stocks will be strengthened. This issue is among the problem areas identified in the PRCI. Essential drug policy will be periodically reviewed and updated. Drug stock and utilization will be included in the Management Information System and monitored monthly. Specific quality assurance actions will be implemented, and supervision of health facilities strengthened. Beneficiary assessments will be carried out at two-year interval to gauge consumer satisfaction with services rendered by public facilities, but also to explore alternative solutions and the use of the private health sector and traditional medicine. VII. Capacity analysis Part of this issue has also been addressed under point VI on Risk Analysis. At present, the health sector in Mauritania is weak in respect of matters such as planning, budgeting, financial management, and donor coordination, since most of these activities are entrusted to MP (donor coordination and the management of the BCI), to MF (recurrent wage salary), and to various donor project units (procurement through ICB, for instance). The question of whether MSAS will be able to manage a comprehensive sector program is, therefore, of outstanding importance, and has been recognized as a critical point by Government. As answer to this, actions to strengthen sector capacity are currently being implemented (see also the paragraph concerning MSAS's insufficient capacity under Risk Analysis). The work conducted at program preparation stage has offered an opportunity to start strengthening MSAS's analytical capacity (with the opportunity of the evaluation of the Plan Directeur 1991-1995/6, of the Study on Needs and Utilization of Health Facilities, Beneficiary Assessment Survey, etc.), its planning perfornance (as a new sector policy, a PTHG 1998-2000, a PDIS, a Human Resources Plan were developed, using MSAS staff with support from local and some international consultants), and its donor coordination function (since donors and NGOs have been involved in most of the work). The MP and the MSAS also agreed on an intersectoral committee (involving main donors and NGOs as well) to be used for program preparation work, and on the main actions necessary to improve health sector administrative performance. The office of the Prime Minister has also shown interest and participated at meetings. At the program preparation stage, three consultant missions were carried out and the PRCI was developed. Based on this Plan, the Government committed itself to creating a number of new positions, and to gradually strengthen central capacity. In parallel to this effort, decentralization of decision-making to district, is also being pursued and will receive adequate financial support. IDA has supported capacity-building activities technically, and an PHRD grant and PPF have been made available to finance the steps agreed upon to take place before credit effectiveness. The proposed program will continue to lay emphasis on capacity building, and the sector performance will be monitored and evaluated annually. ProjeictAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex5 - Page1 of 1 Annex 5 Financial Summary Years Ending (Indicate currency, units and base year) ImplementationPeriod Operational Period 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Program Costs Investment Costs 15.71 19.25 20.28 19.82 19.19 17.27 15.54 13.99 12.59 11.33 Recurrent Costs 17.04 20.57 19.24 19.16 21.34 23.90 26.77 29.99 33.58 37.61 Total 32.75 39.82 39.52 38.98 40.53 41.17 42.31 43.97 46.17 48.94 Financing Sources (% of total Program costs) IDA 1.38 3.25 3.27 2.61 2.01 1.75 1.77 1.82 1.84 1.80 Cofinanciers 7.13 8.22 7.54 7.34 7.55 5.96 5.57 5.32 5.25 5.41 Govemment 6.66 7.34 7.79 8.31 9.44 8.87 9.69 10.57 11.54 12.60 User Fees/Beneficiaries 1.92 1.97 2.03 2.08 2.14 1.91 1.98 2.05 2.12 2.19 Total 17.10 20.78 20.63 20.34 21.15 18.50 19.01 19.76 20.74 21.99 Main assumptions: Assumptions for investment period: - Total Government budget for 1995 - 1999 and health budget for 1995 - 1997 are given. - Total government budget increases 7% annually after 1999. Equally for investment and recurrent budget. = Total health budget as a share of total Government budget increases steadily until it reaches 8.5% in year 2002. - Donor investments: Projections are made on the basis of donor investments in 1995 assumed constant (corrected for inflation). - Exchange rate: US$1 = 166 UM • Data relative to foreign aid are collected from the donors and are based on real expenditures in the period 1993-95. Thereafter donor investment is projected. As share of GNP it is assumed to remain stable: 1.4%. Cost recovery assumptions: -- at primary level of care, cost recovery applies to 80% of the population. An amount of UM 118 per capita is projected until 2003. -- at secondary level of care 80% of the recurrent expenditures(salaries not included) is financed by cost recovery. An amount of UM73 per capita is projected until 2003. % -- at tertiary level of care 80% of the recurrent expenditures(salaries not included) is financed by cost recovery. An amount of UM 122 per capita is projected until 2003. Assumptions for Operational Period: * Investment costs will be decliningby 10% per year in nominal terms. • Recurrent costs will be increasing by 12% per year in nominal terms. * This will give us a total cost that increases in average4.42 which is less than the average increase during 1998-2002 (which is 5.86%). Financing sources: -- IDA - will spend in average US$ 4 million per year. -- Government - will increase by the same percentage rate as the average increase during 1998-2002. -- Beneficiaries- maintainthe level of 2002 in real terms (inflation rate 1.035) Project AppraiisalDocument Project Title: Health Sector InvestmentCredit Country: MaLritania Annex 6 - Page 1 of 9 Annex 6 Procurement and Disbursement Arrangements Procurement No special exceptions, permits, or licenses need to be specified in the Credit documents for International Competitive Bidding (ICB), since Mauritania's procurement practices allow IDA procedures to take precedence over any contrary provisions in local regulations. Procurement of works, goods and consultant services financed by the IDA credit will be carried out in accordance with the Guidelines: Procurement under IBRD Loans and IDA Credits (January 1995, revised in January and August 1996) and Guidelines for the Selection of Consultants by the World Bank Borrowers published in January 1997. National Competitive Bidding (NCB) advertised locally would be carried out in accordance with Mauritania's procurement laws and regulations, acceptable to IDA provided that: (i) any bidder is given sufficient time to submit bids (four weeks); (ii) bid evaluation and bidder qualification are clearly specified in bidding documents; (iii) no preference margin is granted to domestic contractors and manufacturers; (iv) no eligible firms is precluded from participation, regardless of nationality; (v) award will be made to the lowest evaluated bidder; and (vi) prior to issuing the first call for bids, draft standard bidding documents are submitted to IDA and found acceptable. IDA's Standard Bidding Documents (SBD) will be used for all ICB procurements. Bidding documents agreed upon by IDA and used for National Competitive Bidding (NCB) in the Population and Health Project (PSP) will be used for National Competitive Bidding (NCB) procurements under the program. The Bank's Standard Request fcor Proposal (SRFP) forms will also be used for the procurement of consultant services. One ICB contract document and one NCB document for procurement of civil works and goods have been reviewed and approved by IDA during appraisal and will be approved during negotiations. As part of the Program Implementation Manual, the MSAS is preparing a draft procurement/disbursement plan for the first two program years (which actually covers a period of 18 months assuming credit effectiveness in May 1998); it will be reviewed by, and agreed with, IDA and other donors during negotiations. Further plans after the implementation period of two years will be reviewed and updated at least one month prior to the start of each program year. When other donors will gradually (ref. para C.4.d.) become involved in the program financing, it is expected that NCB will be used without any difficulties as demonstrated in the current operation. Civil Works' total cost is estimated at US$ 7.2 million for the whole five year-program. Civil works contracts financed by IDA during the two first program years, estimated to cost US$ 1.8 million are for the construction and rehabilitation of health facilities and other infrastructures in the regions, including Nouakchott. They are estimated to cost less than US$300,000 per contract, up to an aggregate amount of US$1.1 million, and would be procured through NCB procedures. Contracts for small works estimated to cost less than US$50,000 per contract, up to an aggregate amount of US$ 650,000, may be procured under lump-sum, fixed price contracts awarded on the basis of quotations obtained from three qualified domestic contractors invited in writing to bid. The invitation shall include a detailed description of the works, including basic specifications, the required completion date, a basic form of agreement acceptable to IDA, and relevant drawings where applicable. The awards would be made to the contractors vvho offer the lowest price quotation for the required work, provided they demonstrate they have the experience and resources to complete the contract successfully. These contracts would mostly be for vvorks relating to small constructions such as health posts and replacement or rehabilitation of existing facilities in rural areas. Goods' total cost is estimated at US$ 8.0 million, of which US$ 2.2 million financed by IDA during the first two program years, include health equipment kits, hospital furniture, equipment and ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex6 - Page2 of 9 supplies, training center equipment and supplies, warehouse stacking and operational equipment, transport vehicles, pharnaceuticals, laboratory reagents and medical supplies, books and learning materials, as well as office furniture, equipment and consumable. Procurements will be bulked where feasible into packages valued at US$ 100,000 or more and will be procured through ICB. Procurement of drugs valued at US$ 100,000 or more may be made through LIB, up to an aggregate total of US$ 1.01 million, from non-governmental organizations which specialize in drugs supply, can ensure the quality of drugs at all levels of the supply cycle, and have due authorization from primary drugs manufacturers to supply their products. This procedure tried under the PSP proved to be cost effective and ensured quality. The Government would have otherwise to rely either on a firm to carry out the required testing or to make available costly equipment and highly qualified staff in the country. Procurement of office furniture, vehicles and fuel valued at less than US$ 100,000 up to an aggregate total of US$ 0.22 million will be procured through NCB. Implementation of the program would require the purchase of relatively small, mainly consumable items, by MSAS local offices, regional authorities and communities around the country, which would be difficult and impractical to package and procure following NCB procedures. Thus, such items (mostly pharmaceuticals, contraceptives, medical equipment, vehicle, furniture and office equipment) which could not be grouped into ICB packages and costing less than US$100,000 per contract, up to an aggregate amount not to exceed US$ 0.10 million over the first two program years, would be procured through the UNICEF Procurement and Assembly Center (UNIPAC) and/or through the Inter-Agency Procurement Services of the UJNDP(IAPSO) and/or UNFPA; this would be the most economical and efficient way of procuring small quantities, in particular in case of emergency. Procurement of small equipment, furniture and vehicles spare parts costing less than US$20,000 equivalent per contract up to an aggregate of US$ 160,000 may be procured through prudent national shopping (for items available locally) up to US$ 90,000, or up to US$ 70,000 through international shopping (for those goods not available on the national market) oni the basis of quotations obtained from at least three qualified suppliers. Spare parts, operating expenditures, minor off-the-shelf items, pharmaceuticals and other proprietary items costing less than US$5,000 equivalent per contract up to an aggregate of US$ 50,000 equivalent, may be procured directly frcm manufacturers and authorized local distributors. Consultants' Services and Training financed by IDA during the first two program years would be for: (i) studies, preparation of bidding documents, works supervision, data collection, design and operation of accounting systems, audits and impact analysis; (ii) short term consultancies for specific technical matters such as planning, contractual services and training courses design; and (iii) training, locally and overseas, of health personnel staff. Consultants financed by IDA, totaling US$1.7 million, would be hired in accordance with the Bank's Guidelines for Selection and Employment of Consultants by World Bank Borrowers dated January, 1997. It will be acldressed through competition among qualified short-listed firms in which the selection will be based on Quality-and Cost-Based Selection (QCBS) by evaluating the quality of the proposal before comparing the cost of the services to be provided. For audits and services of a standard nature the Least-Cost Selection (LCS) will be the most appropriate method -- the firm with the lowest price will be selected, provided its technical proposal received the minimum mark required. Consultants services for assistance on drug procurement and logistics services and for revision and design of training curricula and modules (estimated at less than US$100,000 per contract up to an aggregate of US$ 220,000), would be based on Consultants' Qualifications (CQ), taking into account the consultants' experience and competence relevant to the assignment. Single Source Selection (SSS) will be exceptionally used for the management of civil works contracts, the performance of the Demographic and Health Survey (1998 DHS) and to carry out IDA financed activities of the Population census (scheduled to take place in 1999). The Government of 'Drugs, vaccinesand reagentsto be procuredduring the Project's first two years were estimatedto value US$0.2 million. However,since vaccinesand drug needsmight be more importantthan estimated,the aggregatetotal to be procuredthrough LIB from IDA funding is US$.1.0million. Project Appraisal Document Project rTie: Heafth Sector InvestmentCredit Country: Maunitania Annex 6 - Page 3 of 9 Mauritania proposed to select: (a) AMEXTIPEfor the constructioncontracts management,through a contract established in accordancewith a standard approved by the Bank -- this AGETIPE-typeagency created under the Bank financed "Public Works and Capacity BuildingProject" has successfullyproven its capacityto manage civil works contracts;(b) the Office nationaldes statistiques(ONS)-- which is the only local agency having the required qualificationsand which had proven its capacity to carry out services of the same kind under the on-going IDA financed Populationand Health Project; and (c) the UNFPA which is the overall coordinator of the census in Mauritania, is the UN technical agency for populationmatters and possesses the specializedpersonnel needed for this large operation.Services for short-term or ad hoc consultancies, lectures and small studies which can be delivered by Individual Consultants will be selected through comparison of qualificationsagainst job description requirements among those expressing interest in the assignmentor approacheddirectly. For training abroad and in- country,the program-- containingnames of candidates,cost estimates,content of the courses, periods of training, institutionselection -- would be reviewedby IDA annually. To ensure that priority is given to the identificationof suitable and qualified national individual consultants,short-lists for contracts estimated under US$100,000may be comprised entirely of national consultants if a sufficient number of qualified firms (at least three) are available at competitive costs. However, if foreign firms have expressed interest, they will not be excluded from consideration. The StandardRequest for Proposal (SRFP)forms as developedby the Bank will be used for appointmentof consultants. Simplified contracts will be used for short-term assignments,simple missions of standard nature i.e. those not exceeding six months, carried out by individual consultants or firms. The Government will be briefed during negotiationsabout the special features of the new guidelines, in particular with regardsto advertisementand public bid opening. ProjectAppraisal Document ProjectTitle: HeaKthSector Investment Credit Country:Mauritania Annex6 - Page4 of 9 Table A: Program Costs by Procurement Arrangements (for the first two program years) (in US$ million equivalent including taxes, duties and contingencies) Expenditure Category Procurement Methoc! Total Cost (incl. conting.) ICB NCB Other N.B.F 1. Works 1.14 0.65 1.79 (1.08) (0.62) (1.70) 1.1 health infrastructures - 0.94 0.52 - 1.46 (0.89) (0.50) (1.39) 1.2 other civil works - 0.20 0.13 - 0.33 (0.19) (0.12) (0.31) 2. Goods 1.44 0.22 0.51 2.17 (1.44) (0.22) (0.51) (2.17) 2.1 medical equipment 0.72 - 0.12 - 0.84 (0.72) (0.12) (0.84) 2.2 equipment/furniture, 0.72 0.22 0.19 - 1.13 vehicles (0.72) (0.22) (0.19) (1.13) 2.3 pharmaceuticals - 0.20 - 0.201 (0.20) (0.20) 3. Services 1.46 1.46 (1.46) (1.46) 3.1 CW engineer/arch, - - 0.80 - 0.80 management/computer (0.80) (0.80) consultancies and audit 3.2 Training, studies, - - 0.66 - 0.66 contractual services, (0.66) (0.66) short term consultancies 4. Miscellaneous 1.05 1.05 (0.99) (0.99) 4.1 operating costs - 0.65 - 0.65 (0.59) (0.59) 4.2 PPF refinancing - - 0.40 - 0.40 (0.40) (0.40) Total Costs 1.44 1.36 3.67 6.47 Total Financed by IDA (1.44) (1.30) (3.58) (6.32) N.B. To be allocated during the 3rd, 4th and 5th program year (17.68) Total IDA Credit (5 years) (24.00) Note: N.B.F.= Not Bank-financed.Figures in parenthesisare the amountsto be financed by the Bank loan/IDAcredit. Total may not add up due to rounding. 'Drugs, vaccines and reagentsto be procuredduring the Project's first two yearswere estimatedto value US$0.2million. However,since vaccinesand drug needsmight be more importantthan estimated,the aggregatetotal to be procuredthrough LIB from IDA funding is USS1.0million. Project ApipraisalDocument Project Title: Health Sector InvestmentCredit Country: Nlauritania Annex 6 - Page 5 of 9 IDA Review. All contracts for construction of civil works and purchase of goods above the threshold value of US$100,000 will be subject to IDA's prior review procedures. The use of IDA's SBD would considerably expedite the prior review process as IDA review would primarily focus on invitation to bid, bid data sheet, contract data, technical specifications, bill of quantities/schedule of requirements and other contract-specific items. The review process would cover about 65 percent of the total value of the amount contracted for goods and about 40 percent of the amount contracted for civil works. Selective post-review of contracts awarded below the threshold levels will apply to about one in three contracts. Draft standard bidding documents for NCB were reviewed by and agreed upon with IDA during negotiations. For consultant services, prior review will include the review of budgets, short-lists, selection procedures, letters of invitation, proposals, evaluation reports and draft contracts. Prior IDA review will not apply to contracts for the recruitment of consulting firms and individuals estimated to cost less than US$100,000 and US$50,000 equivalent respectively. However, the exception to prior IDA review will not apply to the Terms of Reference of such contracts, regardless of value, to single-source hiring, to assignments of a critical nature as determined by IDA or to amendments of contracts raising the contract value above the prior review threshold. For consultant contracts estimated above US$200,000, opening the financial envelopes will not take place prior to receiving the Bank's no-objection to the technical evaluation. For contracts estimated to cost less than US$200,000 and more than US$100,000 the borrower will notify IDA of the results of the technical evaluation prior to opening the financial proposals. Documents related to procurement below the prior review thresholds will be maintained by the borrower for ex-post review by auditors and by IDA supervision missions. The MSAS/DGI will be required to maintain all relevant procurement documentation for subsequent review by IDA. The MSAS/DGI will submit to IDA periodic procurement schedules detailing each procurement in progress and completed as part of the normal project reporting exercise. ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Maurtania Annex6 - Page6 of 9 Table B: Thresholds for Procurement Methods and Prior Review 1 Expenditure Contract Value Procurement Contracts Subject to Category l (Threshold) Methods Prior Review * Wrs';, < N'Sg04Pa'<;00i" ICB1G 0 '.... NCB $tS1...... -f:Other above US$300,000 X Prior IDA review above US$100,000 X Prior IDA review below US$100,000 X Post review. Aggregate above US$50,000 ____ amount: US$ 1,000,000 below US$50,000 X Post review. Aggregate amount: US$650,000 above US$100,000 X . Prior IDA review above US$100,000 LIB for Prior IDA review Aggregate procurement amount: US$1,000,0002 of dirugs below US$100,000 X _ Post review . Aggregate above US$20,000 amount: US$220,000 below US$100,000 IAPSO or Post review. UNIFPAC Aggregate amount: US$100,000 below US$20,000 X Post review aggregate amount for shopping: National: US$90,000 ______International: US$70,000 below US$5,000 direct X Post review. Aggregate purchase from amount: US$50,000 manufacturersor authorized dealers SelectionMethods _ ;; All TORs or sole source contractsare subject to IDA prior review Audit, civil works N/A Least Cost Selection Prior Review design/supervision L __ Firms Above US$200,000 Quality and Cost Based Selection Prior Review + Review of (QCBS) TechnicalEvaluation Report before opening financial proposal Above US$100,000Below Consultants' Qualifications Prior Review + (i) US$200,000 (CQ) notificationof Technical Evaluation scores, (ii) combined evaluation report Drugs logistics, Below US$100,000 Consultants' Qualifications Post Review Design/revise CQ training modules and curricula AMEXTIPE N/A Single Source Selection Prior Review ONS (for DHS) N/A Single Source Selection Prior Review Individuals Above US$50,000 Section V of Consultants Prior Review Below US$50,000 Guidelines Post Review I All thresholdsstated in this sectionshall be reviewedby the Borrowerand IDA on an annual basis. Modificationsmay be agreedupon based on performanceand actual valuesof procurementsimplemented. Amendments to the CreditAgreement would be requiredafter the implementationperiod of the frst two programyears. 2 Drugs, vaccinesand reagentsto be procuredduring the Project's first two years were estimatedto value US$0.2million. However,since vaccinesand drug needs mightbe more importantthan estimated,the aggregatetotal to be procuredthrough LIB from IDA fundingis US$1.0million. Project Appraisal Document Project Title: Health Sector InvestmentCredit Country: Mauritania Annex 6 - Page7 of 9 Procurement under the program will be handled by the Direction de gestion des investissements (DGI), newly created in the MSAS, to assist the Direction des affaires administratives et financieres (DAAF) and using skills and competencies built under the on-going project (PSP), with the support of short-term consultants as needed. The design and supervision of all civil works (construction and rehabilitation) financed by the IDA credit (and also by other donors interested in such arrangements) will be carried out by consulting firms. This arrangement will be the same as for the current project (PSP) which proved to be suitable for even a much larger infrastructure component. However, in case the construction program would expand significantly in scope and geographic coverage and become to heavy a workload for DGI's staff, the MSAS agreed to use AMEXTIPE on an "as needed basis" through agreement passed in accordance with standard approved by the World Bank. AMEXTIPE is the Mauritanian Agetipe-type non-governmental construction contract management entity, established under a World Bank credit. The DPCS in the MSAS and DRASS in the regions will be responsible for the overall activity planning, the identification and availability of land (if required), the preparation of equipment lists and any other information needed by DGI to prepare bidding documents for the procurement of goods, or terms of reference for the selection of consultants as well as the evaluation of their performance from the technical point of view. All technical specifications for medical equipment are currently being prepared by a specialized consulting firm and will be submitted to IDA for review before negotiations. Information related to civil works will be transmitted by the DGI to the firm(s) in charge of the preparation of detailed design and bidding documents for works. Also, to facilitate implementation, small and urgent procurement may be done through IAPSO and through UNIPAC or other non-govemmental organizations (as long as it is the least cost solution) -- in accordance with the provisions described below for the procurement of goods. For all other procurement handled by the DGI, the procurement methods described below and summarized in Table A will apply. Conditions for negotiations are mentioned in PAD - section G. During negotiations, agreement was reached on the proper monitoring of procurement, as well as the standard procurement documents to be used for NCB. The Government gave assurance at negotiations that it will: (a) use the Program Implementation Manual for Project Implementation; (b) use the Bank's Standard Bidding Documents for ICB; (c) apply the procurement procedures and arrangements outlined in the above documents; and (d) review the procurement plan and procurement arrangements each year (immediately after the annual review with IDA and other donors and before the beginning of the next fiscal year). During implementation, all bidding documents, bid evaluation reports, and draft contracts transmitted to IDA for review will contain an updated copy of the procurement planning. Procurement information will be collected and recorded as follows: (a) prompt recording of contract award information by the Borrower; and (b) semi-annual reports to the Bank by the Borrower indicating: (i) revised cost estimates for individual contracts and the total program, including best estimates of allowances for contingencies; (ii) revised timing of estimated procurement actions, including experience with completion time and completion cost for individual contracts; and (iii) compliance with aggregate limits on specified methods of procurement. A detailed procurement plan for works, goods and services to be procured under the two first program years was prepared and will be agreed during negotiations. It will be updated and reviewed on a regular basis during annual reviews. The Government gave assurance at negotiations that it will take the necessary measures to ensure that procurement phases do not exceed the following target time periods: Project Appraisal Document Project Title: Health Sector InvestmentCredit Country: Mauritania Annex 6 - Page 8 of 9 Maximum number of weeks * Preparation of bidding documents 4 (12 for large contracts) * Preparation of bids by bidders 4 (6 for IC13) * Bid evaluation 2 (4 for large contracts) * Signature of contracts 2 * Payments 4 Disbursement The proposed allocation of the credit is shown in Table C. The IDA credit will be disbursed over a period of five years (from 1998 to 2003), with a closing date of June 30, 2003. The estimated disbursement schedule is shown in Table D. All applications to withdraw proceeds from the credit will be fully documented, except for contracts not subject to prior review by IDA. For the rest, disbursements will be made against Statements of Expenditures (SOEs) certified by the Director of the DGI/MSAS. Supporting documentation will be retained by DGI/MSAS and will be available for review as requested by IDA supervision missions and program auditors. Table C: Allocation of Credit Proceeds ExpenditureCategory Amountin US$ FinancingPercentage rmillion 1. Works 1.70 95% 2. Goods (includingMedical equipment, drugs, 2.15 100%of foreign and 95%of local reagents,office equipment,vehicles, and expenditures furniture) 3. Services(including long term TA, short term 1.45 100% consultancy,civil works contractmanagement and training) 4. OperatingCosts 1/ 0.60 90% 5. To be allocatedduring the 3rd, 4th and 5th 17.70 programyear 6. PPF 0.40 Total IDA credit 24.00 1/ Operatingcosts includeincremental operating costs incurredon account of programimplementation, management and supervision, includingoffice supplies,office equipment and vehicles operation and maintenance,contractual services and travel and allowancesincluding those for trainersand trainees,but excludingsalaries of officialsof the borrower'scivil service. Project Appraisal Document Project Title: Health Sector InvestmentCredit Country: Mauritania Annex 6 - Page 9 of 9 TableD: EstimatedDisbursements of IDA Credit(US$ million) IDA 1998 1999 2000 2001 2002 2003 Fiscal Year Annual 1.00 4.70 5.10 5.70 5.90 1.60 Cumulative 1.00 5.70 10.80 16.50 22.40 24.00 Cumulative 4%! 24% 45% 69% 93% 100% A Special Account will be opened for the IDA credit and maintained with a commercial bank, acceptable to IDA. The maximum balance in the Special Account will be US$300,000, which will cover about 4 months of expenditures, to be disbursed from the Special Account. ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex7 - Page1 of 1 Annex 7 Program Processing Budget and Schedule A. Program Budget (US$000) Planned Actual (At final PCD stage) FY97 137.2 137.2 FY98 135.5 30.8 B. Program Schedule Planned Actual (At final PCD stage) Time Taken to Prepare the Program (Months) First Bank mission (identification) 06/1995 06/1995 Appraisal mission departure 11/1997 10/1997 Negotiations 11/1997 02/1998 Planned Date of Effectiveness 04/1998 05/1998 Prepared by: Ministry of Health and Social Affairs & Ministry of Planning Preparation assistance: PHRD Grant (US$400.000 equivalent); French Cooperation (six consultant missions fees); Belgium Trust Fund (one consultant mission fees). A PPF (US$400.000) is also available (not yet used). Bank Staff Who Worked on the Program Included: Name Specialty Sergiu Luculescu Public Health Slaheddine Ben-Halima Procurement & Implementation Astrid Helgeland-Lawson Health Economics Bernard Abeille Procurement, Implementation, Sector Capacity Ousmane Bangoura Public Health Souleymane Sow Implementation Miguel Saponara Economics Tom Merrick Lead advisor Theresa Ho Peer reviewer (Public Health) Jo Martins Peer reviewer (Health Economics) Wolfgang Chadab Disbursement Hans-Werner Wabnitz Legal Roselyne Leroy Staff Assistant ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country:Mauritania Annex8 - Page1 of 1 Annex 8 Documents in the Project File* A. Program Implementation Plan * Will be part of the Program Implementation Manual B. Bank Staff Assessments * Mission Aide-Memoires of November 1996, February 1997, June 1997 and November 1997. C. Other * Country Assistance Strategy for Mauritania (WB, May 1997, #16595); * Policy Framework Paper 1997-1999 (WB, July 1997, SecM97-581); * Rapport d'Evaluation du Plan Directeur de la Sante et des Affaires Sociales 1991 (2)-1994 (5) (MSAS, Version Finale); * Plan Directeur de la Sante et des Affaires Sociales 1998-2002 (MSAS, Version Finale); * Beneficiary Assessment; * Plan de Developpement des Infrastructures Sanitaires 1998-2002 (MSAS, September 1997); * Plan d'operation annuel 1998 (MSAS, September 1997); * Recapitulatif des interventions des bailleurs de fonds du secteur de la sante A l'exception des interventions de l'IDA de 1985-1997 (MSAS, September 1997); * Plan Triennal 1998-2000; * Plan d'Action pour le Renforcement de la Capacite Institutionnelle du MSAS (A. B. Sy); * Financements des Partenaires Exterieurs dans le Secteur de la Sante en Mauritanie pour la periode 1998-2000 (Dr.O.Bangoura, September 1997); * Revue des Depenses Publiques de Sant6 (Gilles DesRochers, September 1998); * Revue des Depenses Publiques de Sante. Recouvrement des Couits.(Marlene Abrial, Mars 1997); * Seconde Revue des Depenses Publiques (WB, Octobre 1996); * Public Expenditure Review (WB, April 1994, #10973); * Plan de developpement des ressources humaines et de la formation. (Jean-Pierre Manshande, November 1997) * Including electronic files. 0-U Status of Bank Group Operations in Mauritania IBRD Loans and IDA Credits in the Operations Portfolio L2 3 Difference Between expected Original Amount in US$ Millions and actual Loan or Fiscal disbursements a/ Project ID Credit Year Borrower Purpose No. IBRD IDA Cancellations Undisbursed Orig Frm Rev'd Number of Closed Loans/credits: 37 Active Loans MR-PE-1874 IDA28872 1998 MINISTRY OF PLAN PUBLIC RESOURCE MGMT 0.00 .40 0.00 .41 1.20 2.72 MR-PE-1875 IDA29650 1997 GOVERNMENT RAINFED NAT RES MGT 0.00 18.00 0.00 17.84 .32 0.00 MR-PE-46650 IDA29710 1997 OMVS REGIONAL POWER 0.00 11 .10 0.00 10.95 5.34 0.00 MR-PE-1874 IDA28870 1996 MINISTRY OF PLAN PUBLIC RESOURCE MGMT 0.00 20.00 0.00 10.61 1.20 2.72 MR-PE-34106 IDA28350 1996 ISL. REP. OF MTA INFRAST & PILOT DEC. 0.00 14.00 0.00 11.21 7.10 0.00 MR-PE-1857 IDA27060 1995 GOVT OF MAURITANIA GENERAL EDUCATION PR 0.00 35.00 0.00 21.64 8.20 0.00 CD MR-PE-38661 IDA27300 1995 FIN/PRIV.SCTR.CAPACI 0.00 7.20 0.00 3.72 3.28 2.51 MR-PE-1864 IDA25750 1994 GOVERNMENT AGRIC SERVICES 0.00 18.20 0.00 6.94 1.49 0.00 CD MR-PE-1870 IDA24550 1993 GOV'T OF MAURITANIA CONSTRUCTION CAPACIT 0.00 12.00 0.00 .79 .07 0.00 MR-PE-1872 IDA25210 1993 GOVERNMENT TECHNICAL/VOCATIONAL 0.00 12.50 0.00 7.48 6.80 0.00 MR-PE-1855 IDA23110 1992 GOVERNMENT ,POP HEALTH 0.00 15.70 0.00 1.60 .27 0.00 0 MR-PE-1867 IDA23890 1992 GOVT OF MAURITANIA WATER SUPPLY 0.00 10.50 0.00 3.91 3.57 3.57 MR-PE-1839 IDA21670 1990 ISLAMIC REPUBLIC OF MAURI P.E. SECTOR INST DEV 0.00 10.00 0.00 .01 -. 90 -. 91 Total 0.00 184.60 0.00 97.11 37.94 10.61 X tn 't Active Loans Closed Loans Total Total Disbursed (IBRD and IDA): 85.33 450.21 535.54 of which has been repaid: 0.00 157.34 157.34 Total now held by IBRD and IDA: 184.60 279.88 464.48 Amount sold 0.00 63.35 63.35 Of which repaid : 0.00 63.35 63.35 C Total Undisbursed : 97.11 0.00 97.11 -0 a. Intended disbursements to date minus actual disbursements to date as projected at appraisal. b. Rating of 1-4: see 00 13.05. Annex D2. Preparation of Impleimientation Suimiary (Fofm 590). Following the FY94 Annual Review of Portfolio performance (ARPP), a letter based system will be used (HS - highly Satisfactory, S - satisfactory, U - unsatisfactory, HU - highily uwisatisfactory): see proposed limprovements in' Project and Portfolio Performance Rating Methodology (SecM94-901), August 23, 1994. 10 Note: a. Disbursement data is updated at the end of the first week of the month. 9r c V' Project Title: Health Sector InvestmentCredit Projec:tAppraisal Document Annex 10 Annex 10 - Page I of 2 Country: Mauritania Mauritania at a glance 8/28197 Sub- POVERTY and SOCIAL Saharan Low- ._ Mauritania Africa income Developmentdiamond Population mid-1996 (millions) 2.3 600 3,229 GNP per capita 1996 (USS) 470 490 500 Life expectancy GNP 1996 (billionsUS$) 1.09 294 1,601 T Average annual growth, 1990-96 Population (%) 2.5 2.7 1.7 GNP Gross Labor force (,%) 2.7 2.6 1.7 per pnmary Most recent estimate (latest year available since 1989) capita N) enrollment Poverty: headcount index (' of populahon) 50 Urban population (% of total population) 54 31 29 Life expectancy at birth (years) 51 52 63 Infant mortality (per 1,000 livebirths) 96 92 69 Access to safe water Child malnutrition (% of childrenunder 5) Access to safe water (% of populatbon) 41 47 53 l Illiteracy (% of populationage 15+) 66 43 34 - Mauritania Gross primary enrollment (% of school-agepopulabon) 74 72 105 Male 81 78 112 Low-incomegroup Female 66 65 98 _ KEY ECONOMIC RATIOS and LONG-TERM TRENDS 1975 1985 1995 1996 Economic ratios GDP(millions USS) 475.9 683.2 1,067.7 1,093.8 Gross domestic investment/GDP 34.5 28.9 18.1 22.0 Openness of economy Exports of goods and services/GDP 39.0 60.8 50.4 53.6 Gross domestic savings/GDP 13.0 8.8 7.0 13.9 Gross national savings/GDP 19.1 9.6 9.3 17.3 Current account balance/GDP -13.3 -19.2 -8.8 -4.7 A Interest payments/GDP 1.1 4.0 3.0 .. Savings Investment Total debt/GDP 39.5 217.4 231.1 Total debt service/exports 22.1 24.3 19.8 . Present value of debt/GDP .. .. 157.8 Present value of debt/exports .. .. 288.8 Indebtedness 1975-85 1986-96 1995 1996 1997-05 (averageannual growth) Mauritania GDP 1.7 2.9 4.7 4.7 5.4 Low-incomegroup GNP percapita -0.9 0.7 1.3 2.1 2.9 Exports of goods and services 7.9 -0.5 12.6 7.1 2.5 1 STRUCTURE of the ECONOMY (% of GDP) 1975 1985 1995 1996 Growth rates of output and investment Agriculture 29.6 22.5 25.5 25.5 40 7 Industry 34.1 32.9 31.5 31.4 20 Manufacturing .. 12.9 10.9 10.9 Services 36.3 44.6 43.0 43.1 - 91 92 93 95 96 Private consumption 67.3 74.9 82.9 76.3 -0 General govemment consumpton 19.7 16.2 10.0 9.9 GOI 4GOP Imports of goods and services 60.4 80.8 61.5 61.8 | 1975-85 1986-96 1995 1996 (averageannual growth) Growth rates of exports and imports (%) Agriculture 3.4 2.6 5.0 3.5 z0 Industry 1.8 2.3 4.9 3.1 Manufacturing .. 0.2 10.4 8.9 10 Services 0.7 3.5 4.5 6.9 A Privateconsumption 2.4 2.3 1.5 -3.0 10 General govemment consumption -6.6 0.7 0.0 3.1 Gross domestic investment -2.0 -1.7 31.3 26.9 -20 Imports of goods and services 2.0 -3.0 14.8 3.1 - Exports Imporls Grossnational product 1.7 3.3 4.0 4.6 _ Note:1996 data are preliminaryestimates. Figures in italicsare for yearsother than those specified. The diamondsshow four key indicatorsin thecountry (in bold)compared with its income-groupaverage. If dataare missing,the diamondwill be incomplete. Project Appraisal Document Project Title: Health Sector InvestmentCredit Country: Mauritania Annex 10- Page 2 of 2 Mauritania PRICES and GOVERNMENT FINANCE ______1975 1985 1995 1996 Domesticpnces ~~~~~~~~~~~~~~~~~~~~Inflation(% (%/change) 15 Consumerprices .. 6.5 4.7 1. ImplicitGDP deflator 15.0 10.2 4.3 3.6 Governmentfinance (-A of GOP) Currentrevenue .. 24.5 24.0 28.8 9t 92 93 94 95 96 Currentbudget balance .. -4.9 6.1 11.2 *-GDP def. 4 CP Overallsurplus/deficit .. 14.6 0.1 5.3 TRADE ______1975 1985 1995 1996 (millionsUS$) Exportand import levels (mill. US$) Total exports(fob) .. 378 493 485 500, CommodityI - Ironore 10 17 27 4 Commodity2 - Fish .. 225 280 277 Manufactures 3 Total imports(cif) .. 334 417 435 20- Food .. 93 94 99 Fueland energy 4 0 3 0 Capitalgoods 8 5 6 Exportprice index (1987=100) .. 99 129 129 90 91 92 93 94 95 96 Importprice index (1987=1 00) .. 91 134 136 mExports Mlmports Ternmsof trade(1987=100) .. 109 97 95 BALANCEof PAYMENTS `1975 1985 '1995 1996 (millionsUS$) Currentaccount balance to GDPratio (%) Exportsof goodsand services 185 415 539 587 Importsof goodsand services 278 552 656 676 I Resourcebalance -92 -137 -117 -89 Net income -30 -52 -53 -56 -5 Net currenttransfers 59 58 76 94 Currentaccount balance, 0 beforeofficial capital transfers -63 -132 -94 -51 Financingitems (net) 10 12 1 Changesin net reserves 5 2 -3 0 1 M em o: ______Reservesincluding gold (mill. US5$) 48 63 90 145 Conversionrate (local/US$) 43.1 77.1 129.8 137.2 EXTERNAL DEBT and RESOURCE FLOWS______ (millionsUS$) 17 195 95 196 Compositionof total debt, 1995(mill. US$) Total debtoutstanding and disbursed 188 1,485 2.467 G A IBRD 0 53 11 8 Fs. 184 81 IDA 14 62 336 359 836 Total debtservice 42 102 116 .. C IBRO 9 10 3 3 100 IDA 0 1 4 4 Compositionof netresource flows Ofricialgrants 47 127 135 .. 0 Ofricialcreditors 14 54 43 1 Privatecreditors 8 2 0E Foreigndirect investment -123 7 3 16 Portfolioequity 0 0 0 World Bankprogram Commitments 8 31 72 35 A - IBRO E - Bilateral Disbursements 2 6 31 36 B-IDA 0 - Othermultilateral F - Private Principalrepayments 9 6 4 4 C -IMF 6 - Short-term Net flows -7 0 27 32 ______Interestpayments 0 5 3 3 Net transfers -7 -5 23 29 DevelopmentEconomics 8/28/97 Project Appraisal Document Project Title: Health Sector Investment Credit Country: Mauritania Amex I I Annex 1t - Page1 of 7 Letter of Sector Policy RWpublique islamique de Mauritanie llonneur-Fraternitc-Justicc A Monsieur Jean Louis SARBIB Vice-President de la Rigion Afriqtte Banque Mondiale - Washington Oblet - Lettre de Politique dc developpement du Secteur dc la Sante Monsieur le Vice-Prdsident, Lc Guuvernczneznt de la Republique Islamiquc de Mauritanie so fdlicite de sa collaboration fructueusc avec la Banque Mondiale et de l'appui que votre organisation lui a apporte dans la mise en oeuvre du Projet Sante Population (cr6dit 231 1 MAU), Ce projct constitue la premiere intervention financee par la Bainque dans Ic secteur de la Sant6 en Mauritanie. Exdcut6 avec un succes certain, il a permis d'accomplir les progrEs appr6ciables dans Ic fonctionnement du sectaur de la santd et d'ameliorcr l'etat de sant6 des populations. Cherchanit a rentabiliscr les investissements realis6s, notre Gouvernemeni a d&cidc A travers l'4laboration d'un Plan Directeur 1998- 2002 de mettrc cn oeuvre unc nouvelle strategie sectoriclle de d6veloppcinent sanitaire ct de requ&rir le soutien de tous scs parteniaires cxternes et intcrncs en vue de soni financement. La pr6paration de cc plan qui a connu une participation activc dc -toutes les partics concernees (Gouvernement, socidtd civile, partenaires extcnrcs, ONG, agents de sante) est niaintenant achevec. Cc document, qui vous a ete transinis par lettre officielle N° 000621 en daLe du 22 Septembrc 1997, guidera Ic developpement sanitaire et harmonisera les intervcntions de tous Ics partenaires opcrant dans le secteur. La prdscnte lettre a pour objectif de vous exposer succinctemnent les principales orientations contenues dans le Plan Directcur et de preciser Ics engagements du Gouvemnement en faveur du sccteur de la sante. I Project Appraisal Document Country: Mauritania ProjectTitle: HealthSector Investment Credit Annex 11 - Page2 of 7 En eflet, durant la p6riode couvelte par le plani, les objectifs du Gouvernement sont d'assurer le rncilleur etat de sante possible des populations ct de mettre Cll place les bases d'un developpement durable du secleur sanitaire. Pour ce faire, notre politique de sante sc fondcesur l'utilisation de stratigies a n-eilleur couia I efficacit6 tclles que la stratc6gie des soins de sante primaires et l'linitiative de Bamako. Elie se fondc ainsi sur les engagements intcrnationaux pris par le 'pays dans le domainc de la sante et dans les domaines connexcs. Elie complete ct renforce les dispositions pertinentes contenucs dans la d6claration de politique de population, dans la strat6gie nationale de promotion des fenimcs et dans ila strategie de lutte contre la pauvrete. Elle sc propose dc fairc acceder la majorit6 de la population mauritanienne aux soins essentiels dont ele a besoin. Dans le souci de r6pattir equitablerrent les fTuits de la croissance economique, les cibles principales en seront les femmnesct les cnfants et plus largeineit, les personnes et les familles defavorisdes ou en situationi de pr6caritd et celles vivant danisles zones reculees. Pendant la periodc quinquennale 1998-2002, l'une des priorites du Gouvernement sera de renforcer la couverture saiitair-c aux niveaux primaire, secondaire et tertiaire afin de garantir l'acces a au moins 80% dc la population aux services socio-sanitaires le plus pres de leur lieu d'habitation. Un plan dc developpement dcs infrastructures saiiitaires a ete elabore afin dc definir plis pr&cisernnt Ics besoins a satisfaire. Notre Gouvernement s'engage a poursuivre l'executioii dc ce plan et dc l'utiliser afin d'harnouiser les interventions de toUs lei parlenaircs au developpemcnt. Pour animliorer l'olfre et la qualite des services, il a 6t6 dcfini pour cliaque type de foimations socio-saniLaires un ensemble dc soins de sankt essentiels et de serviccs de santc publique et sociaux, selectionnes en fonction de Icur simplicitc el de leur coilt relativemilent faible en cornpar-aison avec Icur efficacitc. Des plans d'6quipemnents et de d6veloppement des rcssources hunaines sont cn cours de preparation. Leur mise en oeuvre sera synchlonis6e avec celle du plan d'infrastructures. Dans le cadre de ces plans, notre Gouvcnr.ment s'engage a doter toutes les formation s sanitaJires en personnels de santle qualifies et en nombrc convenable, a elaborer unc strat6gie dc niaintecnancepour accroitirc P'efficacit6 ct la durabilitt des equipeinents, de la logistiquc et des batiments. En compl6ment de ces mesures, des moyenis logistiqucs et des procedures addquates d'acquisition des mddicameints esscntiels seront dgalemcrnt mis en place de manierc a rendre operationnelles toutes les:infrastructures existantes ou qui seront creees. rIanis l'cventail des services qui seront offerts aux populations. Ic Gouvcr-nement a identifi6 certains domaines prioritaires auxquels il alloucra pr6f6rentiellement Ics fonds publics et qui sei-ont prot6g6s contre toute reduction imprevue de ressources. II s'agit dc la prevCntion et de la promotion de la sante et plus sp6cifiquement de La lutte contre les mlaladics transmissiblos (paludisme, diarrhees, infections respiratoires aigudis, tuberculose, etc...), de la lutte contrc les MS'ISIDDA, de la nutrition et de la planification faniiliale, toutes interventions susceptibles d'induirc utie aindlioration plus notable de l'6tat de sante de la population. Le Gouvernemcnt prendre toutes les dispositions approprikes pour assurer Ic fonctionnement ad,quat des 6tablissements de soins. Le Plan Directeur 1998-2002 renforcera les acqt'is du pr6cddent plan qui s'etait focalise sur les formations sanitaires du nivcau primaire. tl diveloppera aussi le roilc de ref6rence des hopitaux rkgionaux. Les etablissements du niveau tcrtiaire constitueront les points d'appui des centres et postes de soins de santd primaire. et dc des formations de soins du nivcau secondaire. Le Ciouvernemenit veillera ncanmnoinsa maintenir un juste 6quilibrc dans la repartition des ressources entre les soins curatifs eL pr6ventifs, R integrer harmonieusemcnt le fonctionnemcnt des dtablissements de 2 Project Appraisal Docutment Country: Mauprtania Project Title: Health Sector Investment Credit Annex 11 - Page 3 of 7 soins et a en contriler les coOts. 11 s'engage a elaborer a cette fin une politique de developpement et une strategie coh&rente de gestion des h8pitaux. Le Gouvernernent est conscient de la necessiti urgente de faire participer davantage les secteurs parapublic et privc dans Ie ddveloppemcnt sanitairc. Dans ce cadre il veillera a la promotion du secteur prive et associatif conformrment aux orientations definies en mati&e de privatisation et dans un esprit de complimentarite avec lc secteur public. Tout comnie dans lc sectcur public, lc Gouvernement vcillera a evitcr 1'explosion des couiaset a assurer une qualitl acceptable des prcstations. L a mise en oeuvrc du Plan Directeur requcrra davantage de ressources financi6rcs qu'il faudra mobiliscr en faveur du secteur de la sante. Ces ressources financieres proviendront d'un accroissenient des allocations budgetaires de lPEtat et des collectivites d6centrafisees, de la contribution des bdneficiaires a travcrs le recouvrement des couts qui a etd misc en ocuvre avec succes, et des contributions des partenaires externes. En confinnation de la priozite qu'il accorde au sectcur dc ia sante et des affaires sociales, notre Gouvememeti s'enjgage A augmenter Ic budget alloue au Ministere de la Sanid et des Affaires Sociales et aux 6tablissemenits autonoisies de sante et a porter progressivement la part du secteur datis le budgct de fonctionnement de l'Etat a au moins 6,5% en 1998, 7% en 1999, 7,5% en 2000, 8% cii 2001 et 8,5% en 2002. Tout en assurant une boinc execution du budget, le Gouvcrnement maintiendra un juste equilibre dans la structure de la depcnse publiquc de sante. de manicre a ce quc: * les d6penscs salariales nc depassent pas 60% des depenses de fonctionnemeni * les depenscs de fonctionnement pour les soins de sante primaires el sccondaires repr6sentce-ont plus de 45% des ddpenscs de fonctionnemenit du secteur. 11 est prdvu dl'tendre et de gdneraliser le systeme de recouvrement des couts pour les medicaments et les actes a l'ensemible des formations sanitaires du pays afin de mobiliser les contributions financi6res dcs beneficiaires. Cette action s'appuicra sur les r6sultats d'vnc 6tude qui sera pr6alablement conduite, les objectifs du Gouvernement resteit d'assurer l'abordabilitd dcs tarifs et de proteger les pauvres. L'utilisation des ressources generces par lc recouvremenl des coUtS scra reglementee a tous lcs niveaux de la pyramidc sanitaire. Les usagers contribuant dc plus en plus au financernent du secteur, leur engagement dans la gestion des fonds el dans la gestion des formations sanitaires (cogestion) sera promu grace a une implication plus poussce des repr6.sentants des populations dans la prise de ddcision. En vue de pallier a l'insuffisance des ressourccs nationales, le Gouvernemcmiimobilisera des ressources financieres additionnelles auprcs de ses partenaircs externcs: organismes de coop6ration bilat6rale, multilat6ralc et ONG. Etant donnr que les partenaires externes ont activement contribue, par le passe, au financement du developpement socio-santaire, la contribution attcndue de 78 millions de dollars americains parait realisable. I .e CGouvernemeni renforcera, A cct effet, Ics modalitds de coordination des partenaires extcrnes dans laquelle lc iMvlinist6rede la Sante et des Affair,, Sociales e.st appcld a jouer un r6le accTu et prendra touecs autres nesures utiles pour accroirrt-' 1'cfficacitd et assurer la perennite de leurs intervcntions. Teniant comptc du d6calage persistant entre les besoins sanitaires du pays et Ics ressources disponibles, le Gouvernement consid&re comme prioritaires lc renforcement des capacitds de gestion et I'am6lioration de l'efficacit6 et de la perfonnance du secteujr socio- 3 ProjectAppraisal Document ProjectTitle: HealthSector Investment Credit Country: Mauritania Annex11 - Page4 of 7 sanitairc. 11executera en cons6quenceIc plan de renforcement in.stitutionneldu secteur de la sante, qui a etc elabors pour la p6riode 1998-2002, prevoyant la reorganisation ct la restructuration du Minist&rede la Sante et des Affaires Sociales, la description de po.stes conf'ormes aux nouvelles taches, le recrutement et Ia formation des cadres, l'ulilisation d'assistat3s techniques pour des p&iodes dtfinies, la fowuniture d'un appui materic1 et logistiqueaux services centrauxet d6centralisds. n rcste entcndu que la ddcentralisation, largemcnt engag6e, scra poursuivie par le transfert d'utnc part de plus en plus importante de }'autoritel at des ressources vers les directions regionales A I'action sanitairc et sociale (DRASS) et vers les circonscriptions sanitaircs des moughataas (CSM). Les tachcs qui seront d6centralisies concernent en particulier la gestion des ressources hurnaines (deploiement, formation, supeavision, evaluation) , la mobilisation et la planificationi de toutes les ressources materielles et financi6res disponiblesdans la region, la budgdtisation des ressources ct la coordination des intcrveltions dcs parLenaires incrnes et cxtermes.Ces objectifs en matiOre de decentralisation justificnt q9U les fonds mis a la disposition des DRASSaugmetitent a un rythmc plus rapide quc celui du budget de fonctionnemnent du secteur ct que cette augmentation soit paraIllIe a un renforcemcnt de leurs capacites de gestion. Dans le cadre du renforcement des capacit6s nationaies, le Gouvernemcnt metIra cn place un nouveau systenmedc gestion du secteur socio-sanitaire base SUI': - un plan triennalglissant (et un plan ddtail16d'operation annucl) qui inctura toutcs lex- activites menees par le Gouveriement et par ses partcnaires internes ct Cxternes durant la periode couverte par les dits plans * une revue annuelle de suivi ct d'evaluation de 1'execution du plai triennal et du plan d'op6ration annucile avec la participation dcs partenaires iniernes et externes sur la base d'unc matrice d'indicateurs jointe a.cet1e lettre * Ia proposition d'un budget et d'un plan detaillc d'operations pour l'annee suivante at la mise a jour du plan triennal. I..cs mutations sociales extr-cmement rapides et les irnportants changenelits qui s'accomplissent dAans1'environnement du secteur impliquent d'autres types de mesures hors du champ traditionnelde la santc. TIs'agit en particulier de: * Ia lutte contre la pauvrete ct la precarit6, * la reduction de I'analphabetisine, de I'augmentation clu taux de scolarisation en paniculier des filles, * la lutte contre les pratiques nuisibles a la santd reproductive de la femme avec un acccnt sur les mutilations en particulier. I,c gouvernement a entamd un debat ouvcrt sur ces questions et est en train de finaliser des strate6giesd'action dans ces trois domaines, afin de poursuivre un d6veloppement social et iconornique harmonieux et promouvoir une meilleure sante de la femme. Ces actions constituent aulant de pre-requis pour le succes de la nouvelle politiquc de santA. Lo Gouvernemcnt elaborera une politique d'action socialc destin6c a promouvoir IA solidarit6nationale an faveur des personnes d6favorisAeset poursuivra ses efforts pour assurcr un ddveloppemenit dconomiqtueharmnonieux daans le cadre des politiquescn vigueur. 4 Project Appraisal Document Country: Mauritania Project Title: Health Sector Investment Credit Annex 11 - Page 5 of 7 lTelles soint, Monsicur Ic Vice-Pr6sident, la substance de la Politique de Sante de la Mauritanie ct les bases sur lesquellcs notre CGrouvernomentvoudrait poulrsuivre unc collaboration avantageuse avec tous ses partcnaircs et en particulier avec la Banque Mondialc pendant la pcriode 1998-2002. .~~~ Lee t / Le Miiiistre du Plan MO DAHMMNEKd'Ai1NEi Idd AMA` ...... S~~~~~~~~~~~I ProjectAppraisal Oocument Country:Mauprtania Project Title: Health Sector InvestmentCredit Annex 11 - Page 6 of 7 Marilce d'indicateurs de suivi de P'ax6cution du Plazi triennial. Listc des Indicatcurs A.n. es 1998 1999 2000 2001 2UJ2 Indlesteurs g6ndraux Population totale Taux do.crlssance d6mographique. Revenu piar habitant (S EU) Taux de croaisance du PlB Taux do scoyWt tion des fillks Taux d'oalphabrdisatdondes adultes Pourcenatae de la population totale ayaiut accas A 1'enu potable._ __ ludicateurs uldItat.deoab de laurcd populateelois Esptrance de oie iola n naissaIce pa t r s Taux de mortatb infrntile - Taux de mortalg iu deantdjuv onienic . d Taux de nonsali malesmellca Indicc synthdlIque de dfcondt oe o u i u ire Taux de privalence de la malnutritiou proEl:ino-calorique chez les enfants. _ Indlcateurs tie disponlbilW des ressotres pour le secteur PBudgedo..nta fodctbonuentld alloue par I'Etatu u sectuur (MSAS Etatblissements autonomes) 2 Mondtant M 13npourxentage du budget tptal de fonctiopuremcnitde l'Etat * Pourcr tage du budget de foncBionCienI du MSAS afrec(6 aux d*nonses non salariales * Pourcentage da budget de fonctioanemenl aslou6 uux niveaux piiamcaire aet econdaire * Pourcentageddu bidget de fonctionaentit allsucc aux DRASS Miontant de recettes provenaul du recouvremcnl des coats par niveau: I) Primairo ,- 2) Secondaire 3) Tertiaire Montait des fudanceoets atlou6srparlesparl atnouires expcrnes R inscrits dens lh BCI a nonparcditc daLisle BCI Nomdbre d'isuiastuclures samitaimcs las niveaux prie airc at secondsaire fonctionniellt s par type (PS, CS B, CS A, HR) Pourcentuap dquipeinent c bon otat Nonmbra d'agents de s.ant6 et r6parltifol p1aTcatbS,ories professoiuniclies et par nivoau. Ratio m6decint habitants Ratio parmmedicaV Elaltts l'aux de disponiibilith des medicarmeals essentiels (au niiveau du stock central):. 'raux de disponibilit6 des vaccins (au uiveau du stock central) FDonn6i:6facultatives Project Appraisal Document Country: Mauntania Project Title: Health Sector InvestmentCredit Annex 11 - Page 7 of 7 Liste d3esiuidlcateurs Aziraes 1998 1999 200u 2,001 2002 Indelcateurs d'aclUwvczlent des actliv'tli pillnll6es (au 30 Scpteinbre dc chaque annee) Execution du budget dc fonctioluien2ent du secteur * Montants d6caiss6s * Taux d'ex6cution du budgct (extrapolationi sur les 12 inois de l'ann6c) Infrastructures sanitairus NNombre d'infrastructures constnhites ou r6habilities par type Taux do r6alisation par rapport aux previsions Equipcrprnts *e Nombre d'"quipcrnents install6s par typo * Taux de rialisation par rapport aux pr6visions 1'ersonnel dNoNmbre do personnels funes par catcgorics professionnelles ' Taux de r6alisation par rapport anx prbvisions o Effectifs des personuils existalus ct tcaris par rapport auX nonrme d'allocation par Region et par niveau ludicatours do perfortnjunce du secteur (au 30 Septexibrf de chaque ann6e) Taux de rocouvremenut des rapports truinestriels des DRASS Nombrc de jours de supervisiou hors du clief lict de la RPglon par Cq91ipC DRASS Pourcentage de la populationi totale ayant acoes A une stnrcturL dc SSI' i nioins do 5 km. du domicile Taux de couverture vaccinale des enlfants do 0-11 niois par antigEnu: 13CG, DTC, Polio Oral, Rouvax Pourcentage d'cnfaiits coinplWternuit vaccinds tvavni le premier anuiiversaire Pourcentage de femrnies Cendge de procr6or vaccin6cs coiitre Io t6tanos (VAT2) Taux de couvertuxe prinatale (miiiiinutn 3 CPN/feo uinc) Taux de couverture postnatrile (minimuimi I CpN/fermrne) Noiibre total d'aQcoucheinents enregistc6s dains les £ormahioans sanlitaires Taux de couverture des accouchernezits assist6s" Nomibra de naissances vivantes Pourcentage des nouveau-nds de poids dce naiss8nce uwt inf6riecar a 25V0 granunies Pourcentago de d6c s p6rinataux Taux de pr6valence contraceptivo au niveai national et par k6gion Pourcentage des enfanIs de moiiis de 3 ans dont le poids cst infierur A la mnoyeane (2 ¢carts type) Pourcentage de la population syant accks aux m6dicaments essonlicls Coat moyen du traitement par Rt6gionet par niveau primnairc et sccondaire Utilisation des services curatifs . 'Taux d'utilisation des services curatifs par niveau * 'raux d'occupation moyen des lits des HMpitaux i4gionaux . Duree znoyenne de sejour daas les 1I6pitaux r6gionaux ^ Nombro d'interventious chirurgicales par Rdgion dout uombre d'interventions effectu6es par les missions clirurgicales itin6rantes * Nombre de cdsariennes (pourcentago) * Pourcentago de consultanits r6fir6s du niveon primaire vers le niveau sexoniaire MAP SECTION BIRD2941 9 ra< aK;nBenTilL \\ ALGE~~~~ALGRIA26 . ~~~~~~~~~~~~~~~~~~~~~~~~~~~3'-''' S PA! N I +S H ZEMMOUR z++4 L 24~~~~~~MA '~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ot ouin .6uc,ne n'mliun prs postio \~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~d G3p de lo B.qui - .st b 0S;~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~due,ti.-.,- ni -un S.tifi.t. o.v 3W~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~"'. -cpai de ce limites. > 3 S Lcnr u6r \2t'2^ Fchot°ChoumRIA W~~~~~~~ ~ ~~~~~~~~~~~~~~~~~~~~00 N.-,t 3~~~~~~~~ PSmA N IX H TA g oAguiloiFcllTamcssouth> gidiikia ~~~ZEMOURhi RG I 2ACH 3;33ej3tt3t.fi3¢j$33SAHARA t ,tK>, ; , S E N E G A L G~~~~~~~~~~~~~C)ouroyeIT )uMA Le r6 --trich Ck4° 1;" 0 1° td66 14 A~~~~~~~~~~~~~~~ERE D1998