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The World Bank Public Disclosure Authorized Documentof The World Bank Public Disclosure Authorized Report No. 12348-CM STAFF APPRAISAL REPORT Public Disclosure Authorized REPUBLICOF CAMEROON HEALTH, FERTILITY AND NUTRITION PROJECT FEBRUARY7, 1995 Public Disclosure Authorized Public Disclosure Authorized Population and Human ResourcesDivision Central Africa and Indian Ocean Department Africa Region CURRENCY EOUIVALENTS The rate of CFA francs 572 to the US dollar was used for cost projections as of late January 1994 The CFA franc (CFAF) is tied to the French franc (FF) in the ratio of FF I to CFAF 100 WEIGHTS AND MEASURES Metric System ABBREVIATIONS AND ACRONYMS AIDS Acquired Immune Deficiency Syndrome CAPP Centrale d'approvisionnementspharmaccutiques provinciale CHU Centre hospitalier universitaire CFA Communaute financiere africaine CHS Catholic Health Services CHW Community Health Worker CIM Centre d'instruction medicale de Maroua CPR Contraceptive Prevalence Rate CSD Centre de sante developpd CSE Centre de sante elementaire CUSS Centre universitaire des sciences de la sante CY Calendar Year DAG Direction des affaires generales DCF District Clinical Facility DEPS Direction des etudes de la planification et de la statistique DHS Demographic Health Survey DMH Direction de la medecine hospitaliere DMPR Direction de la medecine prdventive et rurale DP Directorate of Planning of the Ministry of Economy and Finance DPH Direction de la pharmacie DPS Delegue provincial de la sante DSFM Direction de la sante familiale et mentale ED Essential generic drugs EU European Union ERC Economic Recovery Credit FEMEC Protestant health services FF French franc FP Family Planning FY Fiscal Year GOC Government of Cameroon GTZ German Technical Cooperation Agency HD Health Districts HEU Health Education Unit of the Ministry of Public Health HFNP Health, Fertility and Nutrition Project HMIS Health Management Information System HSP Health Sector Policy ICB International Competitive Bidding IBRD International Bank for Reconstruction and Development IDA Intemational Development Association IEC Information, Education and Communication IHC Integrated Health Center JHPIERH Johns Hopkins Program of International Education on Reproductive Health LCB Local Competitive Bidding MCH Mother and Child Health MINASCOF Ministere des affaires sociales et de la condition feminine MINEDUC Ministere de leducation nationale MEF Ministry of Economy and Finance MIS Management Information System MOPH Ministry of Public Health MSR Medical and Surgical Requisites NGO Non-Governmental Organization NPC National Population Commission NPP National Population Policy OCEAC Organisation de coordination pour la lutte contre les endemies en Afrique centrale ONAPHARM Office national pharmaceutique ORT Oral Rehydration Therapy PHC Primary Health Care PHN Population, Health and Nutrition PPF Project Preparation Facility PTD Personnel and Training Department SAL Structural Adjustment Loan SAR Staff Appraisal Report SCS Catholic Healh Services SDA Social Dimensions of Adjustment SMC Social Marketing Company STD Sexually Transmitted Disease TBA Traditional Birth Attendant TCC Technical Committee for Coordination and Follow-up of Health Sector Projects TFR Total Fertility Rate UNDP United Nations Development Program UNFPA United Nations Fund for Population Activities UNICEF United Nations Children's Fund USAID United States Agency for International Development VAT Value-Added Tax VHC Village Health Committee VHW Village Health Worker VSC Voluntary Surgical Contraception WHO World Health Organization FISCAL YEAR July 1- June 30 HEALTH, FERTILITY AND NUTRITION PROJECT TABLE OF CONTENTS Creditand Project Summary ................... iii I. INTRODUCTION .I II. SECTORAL CONTEXT .. 2 A. Background .2 B. Demographic Situation .2 C. Health Status .3 D. Health System .5 E. Health Expenditures and Financing .8 III. NATIONAL POLICIES AND PROGRAMS .. 10 A. Population Policy.10 B. Health Policy 12 C. IDA's Role and Sector Lending Strategy.15 IV. THE PROJECT .. 17 A. Project Summary .17 B. Detailed Presentation of the Project .18 C. Project Cost and Financing.28 D, Environmental Considerations .. 30 V. PROJECT IMPLEMENTATION .. 30 A. Preparation Status .30 B. Project Implementation.30 C. Project Coordination.32 D. Procurement.32 E. Disbursement, Accounts and Audits.37 F. Monitoring, Evaluation and Supervision .39 VI. PROJECT BENEFITS AND RISKS .. 40 A. Benefits.. 40 B. Risks .. 40 VII. AGREEMENTS TO BE REACHED AND RECOMMENDATION .41 VIII. ANNEXES Annex 1 Basic Data Annex 2 Demographic Indicators and Population Distribution Annex 3 Population Projections for Yaounde and Douala Annex 4 Causes of Morbidity and Mortality in 1992 Annex 5 Pre-natal Care and Assistance during Delivery Annex 6 Vaccination Coverage Annex 7 Nutritional Status of Children Under Five Annex 8 Feeding Practices by Age and Province Annex 9 Organigram of MOPH Annex 10 Financing for the Health Sector Annex 11 External Donors by Province Annex 12 Declaration of the National Population Policy Annex 13 Attitudes toward Family Planning Annex 14 Statement of Cameroon's Health Sector Policy Annex 15 Action Plan Matrix Annex 16 Contraceptive Requirements Annex 17 Nutrition Program Annex 18 Training Needs Annex 19 Project Cost Tables Annex 20 Implementation Schedule - Calendar of Activities Annex 21 Implementation Schedule - Estimated Annual Contractual and Other Payments and Technical Assistance Annex 22 Project Performance Indicators Annex 23 Estimated Schedule of IDA Disbursements Annex 24 IDA Supervision Input into Key Activities Annex 25 List of Key Documents in the Project File Maps IBRD Nos. 26348, 26349, 26350 dated October 1994 This report is based on the findings of a Bank pre-appraisal mission, comprising eight members,which visited Cameroonfrom June 21 throughJuly 12, 1993. The mission memberswere: Mr. Loso K. Boya, Task Manager and Mission Leader; Dr. Liliane Metz-Krencker,M.D. (Johns Hopkins School of Public Health), Family Planning Specialist;Dr. Bruno Dujardin, M.D. (Prince LeopoldInstitute of Tropical Medicine, Antwerp,Belgium), Primary Health Care System Specialist; Dr. Guy Kegels, M.D. (Prince Leopold Institute of Tropical Medicine, Antwerp, Belgium),Health Organization and Pharmaceutical Sector Specialist; Mr. Peter Bachrach (Consultant,Planning AssistanceInc., Washington, D.C.), Economist and Financial Analyst; Mr. Kingson Apara, OperationsOfficer, Bank ResidentMission, Yaounde; Ms. MarylouBradley, Operations Assistant and Ms. Jill Rodieck,Summer Intern. The projectwas appraisedin May/June1994 by a Bank missioncomprising Mr. Loso K. Boya(Mission Leader), Dr. Remo Melony (GTZ), Mr. Peter Bachrach (Financial and Management Analyst), Mr. Francesco Sarno (Senior ProcurementSpecialist), Mr. Thierry Brun (Senior Nutritionand Food Specialist),Mr. Joseph Ntangsi, (Economist, Bank ResidentMission, Yaounde), Ms. Fran,oise Genouille(Operations Assistant), and Mr. Patrick Najman (Drug PolicyConsultant). Mmes. J. Christiansenand L. Ptito, Mr. F. Bonnaire,Ms. K. Li Tow Ngow and Ms. A. Anglio assisted in the preparationof the report. Messrs. Francisco Aguirre-Sacasaand David Berk are the Department Directorand ManagingDivision Chieffor this operationrespectively. iii REPUBLIC OF CAMEROON HEALTH, FERTILITY AND NUTRITION PROJECT CREDIT AND PROJECT SUMMARY Borrower: Republic of Cameroon Beneficianres: Ministry of Public Health and Ministry of Economy and Finance Amount: SDR 29.5 million (US$43 million equivalent) Terms: Standard with 40 years maturity Project Description: The project supports the implementationof the Government's population and health policies and seeks to: (a) consolidate these policies both legislatively and organizationally; (b) establish the requisite management and technical conditions for rapid expansion of health service delivery; and (c) finance reform measures and field operations in rural and urban areas not currently covered by other donors. Over the period 1995-2001, the project would: a) provide institutional support for continued development of the national population policy and rapid implementation of a national family planning and information, education and communication strategy by: (i) supporting the activities of the National Population Commission; and (ii) improving demographic data collection and dissemination for population policy- making and operations; b) promote complementary organizational and administrative reforms needed to strengthen the management of health sector resources and advance the decentralization of health services by: (i) supporting the restructuring of MOPH's health services and management structures, including selective improvement of its physical facilities; and (ii) developing health management information systems; and c) expand the coverage and improve the quality of primary health care services to underserved low-income populations by: (i) reinforcing health services delivery through the establishment of decentralized functional health districts (including rehabilitation of district-level facilities), increasing the availability of quality maternal and child health and family planning services, and systematic introduction of nutritional interventions to improve nutrition for children under five, pregnant women, nursing mothers, and female adolescents; and (ii) strengthening key support programs through training for PHN personnel, the supply of essential generic drugs, contraceptives and vaccines, and the expansion of communication programs through information, education and communication activities. iv Benefits: The
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