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 project would support expansion of quality primary health care coverage to an additional 3 million people by establishing 9 rural districts in the Center, East, West and Far North provinces and 9 urban districts in Yaounde and Douala. The objectives of the project include reducing maternal mortality by 30 percent to 50 percent in those districts, increasing vaccination coverage for the main target groups from under 40 percent to 60 percent to 80 percent, increasing the contraceptive prevalence rate from less than 5 percent to between 10 percent and 20 percent by the year 2000, and enhancing the nutritional status of the most vulnerable population groups. The project is also expected to improve the overall efficiency and effectiveness of PHN sector operations by strengthening sector management and coordination and by enhancing the productivity and improving the quality of services provided by MOPH personnel. Increased availability of low-cost essential drugs, contraceptives and vaccines would raise the credibility and acceptance of PHN services by the public, increase utilization of services, and reduce mortality and morbidity from preventable and curable diseases.

Risks: Because of the relatively recent (1992/93) adoption of the population and health policies, some difficulties and potential delays should be anticipated in translating policy orientations into clearly defined institutional mandates and relationships and an overall strategy into implementable programs. Specifically, the existence of firmly entrenched distortions and rigidities in the health care system and MOPH's generally weak coordination of activities may prove difficult to overcome in a first project. The possiblc lack of continued Government commitment to new PHN policies poses another risk and the commitment will be closely monitored to ensure adherence. Government has established the legal basis for the community participation structures and their relationship to MOPH. During project implementation, internal coordination would be strengthened by restructuring MOPH's management and formalizing coordination links within the TCC. Short-term specialist consultant services and staff training would be provided under the project to assist GOC agencies in its implementation. Finally, previous project experience indicates that while the proposed reforms are generally supported by providers and consumers, they are complex and require an extensive and continuous effort to educatc the public. The project would support the Health Education Unit of MOPH which is responsible for these information activities.

Economic Rate of Retum: N.A.

Maps: IBRD nos. 26348, 26349 and 26350 dated October 1994. v

REPUBLIC OF CAMEROON HEALTH, FERTILITY AND NUTRITION PROJECT

Summary of Project Cost Estimates (including taxes and duties, in US$ million)

PROJECTCOST ESTIMATES: Local Foreign Total A. ASSISTANCEIN DEVELOPMENTAND IMPLEMENTATIONOF NATIONALPOPULATION POLICY AND FP/IECSTRATEGY 1. Supportingthe Activitiesof the NationalPopulation Commission 0.49 0.33 0.82 2. ImprovingDemographic Data Collectionand Dissemination 0.72 0.29 1.01

B. ORGANIZATIONALAND ADMINISTRATIVEREFORMS OF MOPH 1. StrengtheningMOPI's Servicesand Structures 0.24 1.00 1.24 2. DevelopingHealth ManagementInformation Systems 0.13 0.18 0.31

C. EXPANSIONOF PHC COVERAGEAND SERVICEQUALITY IMPROVEMENT I .Supporting PHCServices throughDecentralized Health Districts 4.03 18.83 22.86 2. ImprovingFamily Planning and Maternaland Child Health 1.22 1.10 2.32 3. StrengtheningNutrition Interventions 1.12 3.65 4.77 4. StrengtheningTraining and Retrainingof Health SectorStaff 0.94 0.50 1.44 5. SupplyingEssential Generic Drugs, Vaccinesand Contraceptives 0.15 2.38 2.53 6. ExpandingCommunications Program through IEC 0.31 0.57 0.88

D. PROJECTPREPARATION ADVANCE -- 0.60 0.60

TOTALBASE COSTS 9.35 29.43 38.78

PhysicalContingencies 0.83 2.43 3.26 PriceContingencies 2.86 3.18 6.04

TOTALPROJECT COSTS: 13.04 35.04 48.08

FINANCINGPLAN:

IDA 8.03 34.97 43.00 Government 5.01 0.00 5.01 Communities 0.00 0.07 0.07

TOTAL 13.04 35.04 48.08

ESTIMATEDIDA DISBURSEMENTS: IDA FISCALYEAR FY95 FY96 FY97 FY98 FY99 FY2000 FY2001 Annual 0.7 8.6 6.7 8.0 7.6 7.8 3.4 Cumulative 0.7 9.3 16.0 24.0 31.6 39.6 43.00

EconomicRate of Retum:Not Applicable

PovertyCategory: Program of TargetedInterventions

REPUBLIC OF CAMEROON

HEALTH, FERTILITY AND NUTRITION PROJECT

I. INTRODUCTION

1.1 Despite its middle-incomestatus, Camneroon'spopulation and health indicators resemble thoseof low-incomecountries in Africa. The populationis estimatedat 12 millionand is growingat the rate of 3 percentper year; the total fertilityrate is 5.8. Life expectancyis 54 years; the infint mortalityrate is 65 per 1,000 live births; and the under-fivemortality rate is 126 per 1,000 live births. Faced with a deepening economiccrisis and politicaluncertainties, Cameroon will likely see these indicatorsworsen in the coming yearsunless significant remedial actions are taken.

1.2 Reinforcedby continuing IDA dialogue with the Government, many of these remedial actions are underwayand have been incorporatedinto formal statementsof populationand health policies adoptedin 1992/93. The populationpolicy abandonsthe Government'straditionally pronatalist stance and, inter alia, authorizesall health centers and hospitals to deliver family planning services and information. Cameroon'shealth policy formalizesmany measures alreadyundertaken to reorientits primary health care systemon the basis of integratedservices, decentralized management of resources,and the organizationof higherquality and sustainablehealth services at the levelof the newlycreated health district.

1.3 IDA has been actively involved in the developmentof both the population and health policies. The Governmentof Cameroon,recognizing the need for continuedinvestment in human resource developmentduring this criticalperiod, has requestedIDA assistancein the implementationof these policies. The proposedproject would providebroad-based support for the followingobjectives: (a) to promote the institutional and organizational reforms needed to decentralize health services; (b) to strengthen the managementof health sector resources; and (c) to improve health sector performance through the establishmentof 18 fully operationalhealth districts.

1.4 The project would be the first IDA-financedoperation for integrated developmentof population,health, and nutrition activities,although previousprojects, includingthe Social Dimensionsof AdjustmentProject and the Food SecurityProject, have separatelyaddressed some of these issues.

1.5 IDA assistanceto GOC is justified by several factors, including:(a) successfuldialogue on significantpopulation and healthissues; (b) clear policystatements providing a frameworkfor and indicating a commitmentto programimplementation; and (c) need, based on Cameroon'seconomic difficulties and on the importanceof continuingto investin humanresources. 2

II. SECTORAL CONTEXT

A. Background

2.1 Country Description. Administratively, the Republic of Cameroon is divided into ten provinces with widely varying ecological and climatic conditions, ranging from semi-arid Savannah in the North to rain forest in the South. Socio-culturally, the country is equally diverse, comprising more than 200 ethnic groups and Christian, Muslim and animist faiths. French and English are the two official spoken languages, but bilingual abilities vary significantly between provinces and within provinces and about a third of the adult population speak neither French nor English. See Annex I for Basic Data on Cameroon.

2.2 Economic Conditions. Can.vroon is among the countries of Africa with the greatest development potential. It is richly endowed with tropical forests, coastal fisheries, mineral deposits (petroleum, bauxite, natural gas), fertile agricultural land, and a largely favorable climate. The country's economy is served by a well-developed infrastructure and communications network, and until the mid-1980s a well-functioning financial system. From Independence in 1960 until 1985, this potential was realized, and real economic growth averaged about 7 percent a year throughout the period. Agriculture was the main source of growth and foreign exchange earnings until 1978, when oil production started and became the cornerstone of economic growth.

2.3 A sharp terms of trade loss and an appreciating real effective exchange rate combined with the onset of declining oil production dragged the economy into a steep depression in 1985/86 following seven years of oil-driven economic growth. Cameroon launched an adjustment program in 1988/89 with support from the IMF and the World Bank to address the mounting economic disequilibria; this program sought to: curtail the growth of public expenditures; strengthen and broaden revenue collection; reform the civil service; liberalize the trade regime; liquidate, privatize and restructure the parastatal sector; and restructure the commercial banking sector. However, the program failed to address certain fundamental problems in the economy and the economic decline continued unabated. A major change occurred on January 12, 1994 when the parity of the CFA franc was realigned from 50 CFAF/FF to 100 CFAF/FF. To take advantage of the positive effects brought about by this action, the Government, with assistance from the IMF and IDA, quickly adopted and started implementing a program of economic measures and structural reforms covering three key areas: (a) downsizing and strengthening the efficiency of the public and parapublic sectors; (b) improving the incentives framework for productive and production-supporting sectors; and (c) adopting poverty alleviation measures. An economic recovery credit was approved in June 1994 and a structural adjustment credit is under discussion in close collaboration with the International Monetary Fund.

B. Demographic Situation

2.4 Estimated at 8.7 million in 1980, Cameroon's population is now estimated at 12 million. The annual growth rate has increased from 1.6 percent (1950-1955) to the current 3.0 percent, due in part to significant declines (about 30 percent) in the crude death rate from 1976 to 1987. Annexes 2 and 3 provide additional details on Cameroon's population.

2.5 The 1991 Demographic and Health Survey (DHS) found that women give birth to an average of 5.8 children during their lifetimes, which represents a 10 percent decline since 1978. This figure masks a significant urban/rural differential: average parity for women in Yaounde and Douala is estimated at 3

4.4 children, while for rural women it is 6.3. Knowledge of modem methods of contraception has increased from 29 percent to 66 percent of women in union during the period 1978-1991, but the 1991 DHS found that only 4.3 percent of these women were using such a method.

2.6 If current demographic indicators remain constant, Cameroon's population will reach 15.5 million by the year 2000 and 21 million by the year 2010. Using alternative population growth scenarios prepared by the Futures Group yields the following results:

* Projection A: Fertility declines to 4.0 by the year 2010 and reaches 3.0 in 2025 with corresponding populations of 17.9 million in 2010 and 24 million in 2025.

* Projection B: Fertility declines to 3.0 in 2010 and 2.2 in 2025 with corresponding populations of 16.3 million in 2010 and 20 million in 2025.

If mortality rates continue to decline and emphasis is not placed on reducing fertility, Cameroon's population will double every 22 years, with corresponding increases in the demand for social services, including health and education.

2.7 With a total surface area of 475,000 km2, the average population density in Cameroon is only 25 inhabitants per square kilometer. Significant variations in population density exist among provinces: the West province averages 107 inhabitants per square kilometer, while the East province averages five.

2.8 The rate of urbanization is also increasing: from 28.5 percent in 1976, to 37.8 percent in 1987, to an estimated 42 percent in 1991. If the current rate of urbanization continues, Government estimates that 50 percent of all Cameroonians will live in cities by the year 2000. The major cities of Douala (1,094, 100 inhabitants) and Yaounde (955,300 inhabitants) are growing at rates of 5 and 6 percent per year respectively, due to the influx of young Cameroonians (under 25 years of age) seeking education and employment opportunities. By the year 2000, Yaounde and Douala will each have about 1.5 million inhabitants. Annex 3 estimates the populations of Yaounde and Douala from 1993 to 2025.

C. Health Status

2.9 Overview. The principal causes of reported morbidity and mortality in Cameroon are listed in Annex 4. Malaria, intestinal parasites, skin diseases, and respiratory infections comprise almost 75 percent of morbidity; malaria and anemia account for almost 50 percent of mortality, with respiratory infections, neonatal tetanus and malnutrition adding an additional 25 percent.

2.10 AIDS is currently a health risk throughout Cameroon, including rural areas. The principal transmission method is heterosexual intercourse. Of the 2,488 AIDS cases reported from 1985 to June 30, 1993, 70 percent are in individuals between 20 and 39 years old, and about 5 percent are among children younger than five years old. About 80,000 to 100,000 people, including about 2 percent of the sexually active urban population, are estimated to be HIV positive. Prevalence rates vary by risk group and by province. Projections for AIDS in Cameroon show that the disease will become increasingly prevalent in the next decade. By the year 2005, it is expected that there will be between 140,000 and 220,000 seropositive individuals and between 10,000 and 14,000 new cases of AIDS.

2.11 Maternal Health. A high maternal mortality rate, estimated at 430 per 100,000 live births, indicates the precarious health situation of women of childbearing age. Overall, the two main causes of 4 maternal mortality are obstetric hemorrhage and sepsis (infection), both of which can be complicated by prevalent conditions such as malaria and anemia. Nationally, 64 percent of all deliveries occurring in the five years before the 1991 DHS survey took place in health facilities. Twenty-one percent of deliveries were assisted by friends or relatives, 12 percent were assisted by traditional birth attendants, and 4 percent were unassisted.

2.12 The level of maternal health varies significantly among provinces and between urban and rural areas. Provincial level data on maternal mortality range from 900 per 100,000 live births in Maroua (Far North province) to 250 per 100,000 live births in Bamenda (Northwest province). The DHS survey found that in Yaoun&/Douala, mothers received ante natal care for nearly all births (99 percent), and the majority of mothers (86 percent) were vaccinated against tetanus. In rural areas, however, only 71 percent of the births involved ante natal care and tetanus toxoid was given in only 61 percent of pregnancies. See Annex 5 for more detailed information regarding maternal health.

2.13 Child Health. Children under five years of age are at a significant health risk in Cameroon. The infant mortality rate is estimated at 65 per 1,000 live births and the under five mortality rate is 126 per 1,000 live births. The 1991 DHS study found that in the two weeks preceding the survey, nearly I in 5 children had had an episode of diarrhea, I in 10 children under five had suffered from coughing and rapid breathing, and I in 4 children under five had had a fever. Only 41 percent of children with fevers and 50 percent of children with diarrhea were taken to a health facility for treatment.

2.14 The DHS study found the main causes of death among children under five to be (in descending order of importance) diarrhea, malaria, measles, respiratory infections, and undernutrition; 60 percent of malaria deaths occur in children in this age group.

2.15 Although vaccine-preventable diseases did not figure prominently in the causes of mortality and morbidity for Cameroon as a whole, these diseases are apparent at the provincial level. MOPH data on measles (Eastern, Littoral, Northern, and South provinces) and neonatal tetanus (Central, Eastern, Far North, and North provinces) confirm UNICEF findings that these diseases are the most significant causes of death for infants less than one year old, accounting for 34 percent of all infant deaths in 1986. UNICEF also estimates that less than 40 percent of Cameroonian children were fully vaccinated by their first birthday against childhood (EPI) diseases (tuberculosis, diphtheria, whooping cough, tetanus, polio, and measles). See Annex 6 for vaccination coverage by type of vaccine and by province.

2.16 Nutrition. Results from the 1991 DHS, presented in Annex 7, indicate significant nutritional problems: 24 percent of children under five suffer from moderately to severely chronic undernutrition (height-for-age measure); 3 percent suffer from moderate to severe acute undernutrition (weight-for-heightmeasure), and 14 percent are underweight (weight-for-age measure). Comparison of these results with the 1978 National Nutritional Survey indicates the seriousness of the problem in the provinces of Adamaoua, North, Far North, and East, where chronic under nutrition has increased from about 15 percent to 25 percent and acute undernutrition from I percent to 4 percent.

2.17 The DHS found a clear age-specific pattern in the prevalence of undernutrition in Cameroon, from less than 2 percent incidence of stunting, undernutrition, and wasting in infants aged I to 6 months to over 33 percent stunting, 20 percent underweight, and 10 percent wasting between the ages of 18 and 24 months. The survey concludes that inappropriate infant and child feeding practices are strongly associated with the high levels of undernutrition found in Cameroon. Annex 8 presents data on feeding practices by age for the different provinces. 5

2.18 The nutritional status of women also raises concern. The 1978 National Nutrition Survey showed that pregnant women suffered from deficiencies of iron, calories and lipids and gained only one-third the normal weight gain during pregnancy. As a result of poor maternal nutritional status, 13 percent of babies in Cameroon were born with low birth weights in 1985.

D. Health System

2.19 Public Health Sector Organization and Management. The Ministry of Public Health (MOPH) is Cameroon's principal governmental agency addressing health issues, although the National Social Security Fund (CNPS) also provides services through its network of clinics. Other agencies involved in health research, education, and communication include the Ministries of: Higher Education and Scientific Research (medical training), National Education (school-based health programs), Social Welfare and Women's Affairs (health, family planning, and nutrition education to women's groups), Agriculture (health education to women's agricultural groups), and Economy and Finance (consideration of population variables in the national development planning process).

2.20 The current organizational structure of the MOPH was established by ministerial decree No. 89/011 in January 1989. This decree established six central directorates. The Directorate of Hospital Medicine is responsible for planning, administering and supervising all public hospitals; it also oversees private hospitals. The Division of Training and Cooperation manages the paramedical training institutions. The Directorate of Preventive and Rural Medicine is responsible for epidemiological surveillance, control of endemic diseases, and execution of the Expanded Program on Immunization (EPI). The Directorate of Pharrnacy is in charge of planning the supply of drugs to all health facilities, assuring their quality, and inspecting all public and private pharmacies. The Directorate of Studies. Planning and Health Statistics plans and executes capital investment projects; and performs data collection and analyses which include planning, monitoring, and evaluating health facilities. The Directorate of General Affairs is in charge of general administration, personnel, finance, and health facility management. The Directorate of Family and Mental Health is responsible for the promotion of mother, child, and juvenile health which includes family planning, nutrition, and information, education, and communication (IEC). See Annex 9 for the organigram of the Ministry of Public Health.

2.21 Ministerial decree No. 89/011 also organized the provincial health system to reflect the administrative divisions of the country. Health delegations were established in each of the ten provinces. Headed by a provincial delegate who reports directly to the Minister of Public Health, the provincial health delegation comprises six services (corresponding to the central MOPH directorates) and supervises all health activities in the province including hospitals, pharmaceutical supply, planning and statistics, training, and administration. Provinces are sub-divided into departments under the authority of the departmental public health service, which has responsibility for hospitals and health centers as well as for preventive and rural health services.

2.22 Co-management of the health system, linked to both decentralization and cost recovery measures, has been promoted since June 1990 when the Minister of Public Health signed a lettre circulaire authorizing the creation of community health and management committees at the village, health center and sub-divisional levels. Health committees (called COSA) for each catcbment area (aire de sante) are being established and will have responsibilities for planning activities and expending resources made available to the community health facilities; a sub-committee of the COSA (called COGE) would be responsible for managing the funds obtained through cost-recovery. At the district level, COSADI are being established with similar responsibilities. 6

2.23 The Declaration of Health Sector Policy (Annex 14) organizes health services at three levels comprising: (a) local health centers, usually staffed by certified nurses and providing preventive and basic curative care to the surrounding population; (b) district and departmental hospitals (of 100 to 150 beds), usually staffed by at least one physician and providing first referral services for the health centers; and (c) provincial and central level hospitals (of more than 200 beds) providing specialized medical services.

2.24 As a result of a rapid expansion of health facilities in the late 1970s and early 1980s, Cameroon today possesses an important network of health structures. MOPH lists 1,031 government- operated health facilities which include I teaching hospital, 2 referral hospitals, 3 central hospitals, 8 provincial hospitals, 38 departmental hospitals, 132 district hospitals, and 847 health centers. Coverage remains a problem in both rural and urban areas; while there are competing facilities in some areas, large segmnentsof the population do not have access to care. Urban areas are underserved by public sector health services; even doubling the WHO-recommended ratio to one health center per 20,000 people, Yaounde and Douala both lack about 45 health centers. While the availability of private services is clearly greater in urban areas, the issue of financial accessibility remains.

2.25 Facility maintenance and equipment repairs are a growing concern. No overall policy governs equipping and maintenance of health centers, and the annual budget allocates less than I percent of the estimated amounts for repairs. In addition, within the Ministry of Public Health, coordination and planning of maintenance activities is divided between the Directorate of Hospital Medicine (responsible for biomedical equipment and its maintenance) and the Directorate of General Affairs (responsible for maintenance of health facilities and transport).

2.26 Private Health Sector Organization. Non-profit religious missions and for-profit clinics constitute the bulk of private providers of health care. There is also a growing number of non-governmental organizations involved in health activities. Numerous traditional practitioners provide services to the population, but because they are not licensed and their operations are not subject to well-defined standards or quality control, their activities remain largely undocumented. For-profit facilities represent about 5 percent of the 539 private health facilities identified by MOPH; they are located in the major cities of Yaounde, Douala, Garoua, Maroua, Bafoussam, and Bamenda. MOPH estimates that in 1992 there were 322 physicians (including 78 in the confessional sector) and 39 pharmacists in the private sector.

2.27 Religious health facilities, organized by the principal denominations, make up the majority of the private health system in Cameroon. The Catholic health services (SCS) comprise 179 health facilities (including 8 hospitals) and 1,315 personnel. SCS data estimate about 1.5 million consultations performed in 1991-1992. About half of these consultations took place within the Diocese of Yaounde (including the surrounding rural villages) and half in the other Dioceses of Douala, Bamenda, and Garoua. In addition, SCS operates two training schools (in Yaounde and Bamenda) which train nurses and nurses' aides.

2.28 Protestant health services (FEMEC) comprise 122 health facilities (including 24 hospitals) and 2,633 personnel (including approximately 80 expatriate staff). FEMEC estimates the number of consultations at about 2 million for 1991. The Ad Lucem Medical Foundation operates 7 hospitals and 11 health centers, totaling about 2,000 beds, in four provinces (West, Central, Littoral and South). In addition, Ad Lucem is involved in the importation of essential drugs for the non-profit private sector (see para. 2.39). 7

2.29 Formal mechanisms for cooperation between private non-profit/confessional service providers and the government-run services have generally been ineffective, although the government has until recently very modestly subsidized the health services of these groups. Collaboration at the level of service delivery is similarly informal, and the modalities for establishing working partnerships between these two sectors in each health district need further development.

2.30 Health Personnel. In February 1993, staff working in Cameroon's different health structures in numbered 19,027, of which 4 percent were physicians, 31 percent trained or "assimilated" (i.e., trained on the job) nurses, and 26 percent nurses' aides. As with most other Sub-Saharan African countries, this personnel is inequitably distributed and insufficiently and/or inappropriately trained.

2.31 Central province has the highest ratio of physicians to population with about 15 per 100,000 inhabitants; at the opposite extreme is Far North province, with 2 physicians per 100,000 inhabitants. Even within Central province, 230 of 293 physicians may be found in Yaounde where the Teaching, Central, and General Hospitals are located. Yaounde itself has a ratio of 23 physicians per 100,000 inhabitants. The situation for nursing personnel is similar: Central province has 70 nursing personnel per 100,000 inhabitants while Far North has only 17 nursing personnel per 100,000.

2.32 Personnel norms are being developed, and redeployment of existing staff will remain a critical issue for the sector. As in virtually all other African countries, however, personnel are reluctant to be posted to rural areas where working conditions are more difficult. The problem is more acute between regions rather than within regions, but within regions excess personnel are particularly prevalent in facilities in provincial capitals. While formal mechanisms for personnel transfers between and within regions are well defined, the actual process may require significant negotiation among the parties involved.

2.33 Poor allocation is linked to another significant personnel issue, the low productivity of staff, one study of nurses' use of time found that over 70 percent of their day was spent in nonproductive activity. Reasons for this low productivity of medical and para-medical staff include inadequate training and supervision, insufficient continuing education, a lack of incentives for good performance, and insufficient work input such as drugs and equipment. There is an urgent need to experiment with both financial and non- financial incentives for health facility staff.

2.34 Essential Drug Supply and Distribution. ONAPHARM was created in 1985 to ensure both the supply of pharmaceuticals to the public and private non-profit sector and the quality of all imported and locally produced drugs. Accorded financial autonomy (though MOPH retained oversight responsibilities), ONAPHARM received both an initial capital of US$9 million (CFAF 2.5 billion), to establish a distribution system and purchase its initial stock, and annual subventions. By 1988, however, ONAPHARM had accumulated such debts to its suppliers that it was forced to drastically reduce its supply activities.

2.35 In 1989, MOPH created the Directorate of Pharmacy (para. 2.20) which is responsible for the formulation, coordination, and supervision of pharmaceutical policy. Roles and responsibilities between the still existing ONAPHARM and the Directorate of Pharmacy with respect to quality control are unclear. In addition, because ONAPHARM is bankrupt and the Directorate of Pharmacy has not been given resources for drug supply, public sector acquisition and distribution of essential drugs in Cameroon are virtually non-existent. 8

2.36 Supply functions, where they exist, have been taken over by external donors with the objective of implementingtheir specific projects. GTZ (German Technical Cooperation Agency) established the first provincial drug supply system in Bamenda (Northwest province) in 1986. The system operates as an importer and wholesale distributor for public and some non-profit private health care facilities in the province. Drug prices include the actual cost of the drugs plus an average mark-up of 195 percent to cover management costs (salaries, incentives, consultancies, training, administration, maintenance, consumables, quality control, losses, and depreciation of buildings and equipment). Turnover in 1990-91 was about US$800,000 with a surplus of US$230,000. This surplus was redistributed to member communities for improvement of health care facilities. GTZ no longer provides financial assistance to the supply store or to health facilities for cost recovery in the Northwest province. These facilities depend entirely on recovered revenues through drug sales to finance their non-wage operating costs and to obtain drugs.

2.37 Structures identical to the Northwest province's drug supply system have been organized, with GTZ's assistance, in the Southwest and Littoral provinces. Similar provincial drug supply systems (CAPPs) are being established with help from other donors in Adamaoua, the South, North, and Far North provinces. Areas not supported by a donor generally rely on private pharmacies for their pharmaceutical needs, making essential drugs prohibitively expensive for many poor Cameroonians.

2.38 In January 1993, the EU (with GTZ technical support) began to re-organize the basis for a national supply system with the establishment of CIAME (Centre Interimaire d'Approvisionnement en Medicaments Essentiels). To date, CLAME has provided three types of services: (i) importing and selling drugs from stocks; (ii) acting as a purchasing agent; and (iii) providing a tendering service only. For purchasers able to meet CIAME's financial conditions, this agency has successfully filled the gap left by ONAPHARM's difficulties (paras. 2.34-2.35), and it was anticipated that it would eventually become the national structure for drug importation. During appraisal, MOPH proposed the creation of a national purchasing agency for essential drugs (CENAME) to replace CIAME and to serve as a purchasing agent for the provincial drug supply systems. Discussions of these alternative approaches for national drug supply are continuing (para. 3.22). Until a new drug import system is adopted, MOPH would continue to rely on CIAME as the interim Central Drug Supply Store.

2.39 Ad Lucem Medical Foundation represents another approach to drug supply, catering both for its own health facilities and for those of other confessional health facilities in Cameroon. Currently, Ad Lucem is experiencing severe financial difficulties and diminishing revenues. Nevertheless, revenue from drug sales in 1992-93 totaled US$3.8 million and is estimated at US$5.0 million for 1993-94.

E. Health Expenditures and Financing

2.40 Cameroon's public health care system is financed by the national budget, revenues from the (recent) authorization to retain the proceeds from cost recovery at the local level, and external aid. The current status and future prospects for financing Cameroon's health sector from these sources are analyzed in Annex 10 and summarized in Table 6 of that annex.

2.41 Government Financing. The Government finances health service delivery through: (a) the use of buildings and land ceded to the Ministry of Public works; (b) civil servant medical and para-medical staff salaries paid by the Ministry of Finance; and (c) investment and operating support provided by the MOPH. Overall Government spending for health has never substantially exceeded 5 percent of the national budget (compared with 10 percent recommended by WHO) but did attain approximately US$12 per capita (35.8 billion CFAF, or 8% of the national budget) in 1985-86. The economic crisis forced deep budget cuts 9 in 1986-87 and 1987-88; since 1988-89 the budget has remained relatively stable both as a percentage of the national budget and in absolute terms while obviously declining in real terms.

2.42 The structure of the MOPH budget, the process of budget formulation and adoption, and the procedures for expending authorized amounts are typical of francophone Africa. MOPH's budget is dominated by salaries (for some 19,000 personnel): for FY 93-94, the wage bill, despite reductions both n salaries and benefits, consumed almost 90 percent of the total operating budget; for FY94-95 additional reductions in salaries will reduce the wage bill by about a third. At the same time, the government has proposed to increase non-wage current expenditure budget appropriations by 30 percent for 1994/95.

2.43 Govemment financing is also hampered by a very centralized budget preparation process and slow disbursement procedures. The budgeting process is conducted essentially by the Ministry of Economy and Finance; no input is sought from communities, health centers, provincial health authorities and hospitals, and very little even from the MOPH, with the result that the process has become increasingly arbitrary. Once allocated, tardy spending authorization, inflexible line item management, and lengthy procurement procedures represent formidable obstacles to efficient execution of budgets. These administrative complexities, compounded by a lack of funds, have since 1991 reduced actual investment and non-salary operating expenditures from 71 percent to 50 percent of authorized expenditures, representing an additional de facto reduction of 30 percent. To make sure that budgeted expenditures for 1994/95 are actually held in full, the President has instructed the Ministry of Finance to assign first priority to these outlays in its execution of the Treasury cash budget. Further increases in the national health budget agreed upon during negotiations would raise the share of the health sector from 5.0 percent in FY 93/94 to 7.0 percent in FY 96/97 and 10.0 percent by the end of FY 99/00.

2.44 Community financing. Since 1964 all health facilities have been authorized to charge fees for services which, except for a percentage retained by consulting physicians as incentive payments, were retumed to the treasury. Laws passed in 1990 and 1992 are designed to significantly increase financial resources available to meet operating expenses. The Drug Financing Law of 1990 authorizes public health care facilities to establish community-managed drug revolving funds through which drug sale revenues can be retained locally; the Hospital Financing Law of 1992 authorizes selected tertiary-level hospitals to retain 50 percent of fee-generated revenues. Additional regulations regarding the application of these laws are under review.

Table 1: Estimates of the potential for cost recovery under different scenarios (in millions of CFAF)_ l______1994195 1995/96 1996/97 1997/98 1998/99 1999/2000 2000/01 l______Ctrs Arnnt. Ctrs Anit. Ctrs Amnt. Ctrs Amnt. Ctrs Amnt. Ctrs Amnt. Ctrs Amnt. HC/Slow 319 909 383 1,092 460 1,311 552 1,573 662 1,887 662 1,887 662 1,887 HC/Medium 447 1,274 627 1,787 807 2,300 807 2,300 807 2,300 807 2,300 807 2,300 HC/Fast 447 1,699 627 2,383 807 3,067 807 3,067 807 3,067 807 3,067 807 3,067 Hospital 9509S 1,169 1,389 = 1,611 1,836 1,836 1,836

2.45 The existing systems of cost recovery in Cameroon (confessional health centers; bilaterally funded projects; and private non-profit health facilities) exhibit a wide variation in the kinds and amounts of costs to be recovered, in the approach for individual payment, and in the methods for collecting and managing revenues. Preliminary results from the functioning cost recovery systems indicate that substantial amounts can be generated for non-salary expenditures. While the lack of standardization may potentially be a source of misunderstandings and abuses, it is far less important than consensus on: (a) the fundamental issues affecting the viability of cost recovery, including the availability of essential drugs, an equitable 10 pricing policy, and common approaches for dealing with chronic under utilization of health services; and (b) the continuing importance of the MOPH budget. Table I depicts the potential for cost recovery in the health centers (HC) based on three scenarios: slow, medium and fast construction of health centers.

2.46 External Financing. The principal sources of external support to Cameroon's health sector include the traditional multilateral donors (WHO, UNFPA, UNICEF, EU, etc.); a wide range of bilateral donors, several with many years of experience in the country (Germany, the United States, Belgium and France), and a significant non-profit sector comprising both international non-governmental organizations (NGOs) and local confessional groups. Germany (GTZ) is involved in the development of the decentraized health districts in the South West and the North West provinces. USAID financed maternal and child care programs in the Adamaoua and South provinces. France is providing assistance in hospital management in the North and Littoral provinces. Annex 10 provides the commitments of donor by year, Annex 11 contains a map with the locations of the major donors by administrative district.

2.47 As the table below indicates, the sources and amounts of external assistance have increased in recent years. Between 1990-91 and 1993-94, commitments from all sources (multilateral, bilateral, and NGO) to the health sector increased from approximately US$1 per capita (3.01 billion CFAF) to US$2.75 per capita (8.3 billion CFAF) in 1993-94.

Table 2: Donor commitments by type of donor (in millions of CFAF)

Donortype/ 90/91 91/92 92/93 93/94 94/95 95/96 96/97 97/98 98/99

Y ear______Multilateral 64 342 1,147 1,820 1,866 2.733 2,729 2,729 2,224 Bilateral 2,121 4,884 7,010 6,159 5,302 4,325 3,639 3,433 2,750 NGO 826 1,042 1,226 365 170 18 9

2.48 Annex 10 presents the current status and future prospects for financing Cameroon's health sector. Table 6 in the annex summarizes current and projected future costs of the priority programs and estimates internal and external sources of financing. Based on a number of assumptions concerning the internal sources of funding (growNthof the Government's national budget, MOPH's share of that budget, and the success of cost recovery) and the level of foreign assistance, the table indicates that the period 1994-1999 will be critical and that the proposed IDA credit would fill a funding gap. Financing of sector activities by a combination of increased Government budget, cost recovery revenues and forcign aid is considered sustainable under present conditions.

Ill. NATIONAL POLICIES AND PROGRAMS

A. Population Policy

3.1 Background and Content. Cameroon's traditionally pro-nataiist population policy has been changing since 1989, when the MOPH created the Directorate of Family and Mental Health and began promoting birth spacing as a part of maternal and child health services. With financial and technical assistance from the World Bank and UNFPA, a national population policy was formulated and published in March 1993. The policy authorizes all health centers and hospitals to provide family planning services to offer a wide range of contraceptive choices. I1

3.2 The policy considcrs family planning as part of an overall strategy to improve the well-being of families and couples in general and of women and children in particular. Among a wide range of proposed actions, the policy seeks to: (a) facilitate access to voluntary family planning services, especially in rural and per-urban areas- (b) ensure availability of information and educational programs concerning contraceptive methods (modem, natural and traditional), STDs (including AIDS), and causes of sterility; (c) promote responsible parenthood through educational efforts; (d) strengthen girls' education to increase levels of education and age at first marriage- and (e) improve research and coordination to ensure efficient implementationof the policy and increased participation of the entire population. Excerpts from the National Population Policy are providcd in Anncx 12.

3.3 Family Planning Services. The new policy provides an important framework for action, but much remains to be done to control population growth. Attitudes towards family planning are generally favorable: 85 percent of respondcnts in a 1991 survey of five urban areas believe that women should control reproduction. Further, 12 perccnt of women surveyed in the DHS study wanted no more children, and about 33 percent of women wanted to wait at least two years between births. If these family planning needs were met and these unwanted births were avoided, the total fertility rate would drop to 5.2 from the current rate of 5.8. Rural women arc less favorable to family planning.

3.4 Demand for family planning services is increasing, but the availability of accurate information and adequate services remains a major problem. In 1991 8 in 10 provinces were offering FP services, 12,541 clicnts werc registered, and 42.3 percent among them were new acceptors. An MOPH study on contraceptive use in 1992 revealed that slightly more than 27,000 people used a modern method of contraception during 1992. The most frequently used method was pills (47 percent), followed by injectables (33 pcrcent), IUDs (12 pcrcent), and tubal ligations and condoms (4 percent each). Use of methods varied according to urban or rural location: only 3 percent of rural women used a modem method compared to 12 percent of women in Yaoundc/Douala See Annex 13 for detailed information on attitudes toward family planning and on contraceptive use by province and method.

3.5 Issues. The National Population Commission (NPC), an interministerial body under the leadership of the Ministry of Economy and Finance (MEF), is responsible for defining population policies and overseeing implemcntation of the National Population Policy (NPP). MEF's Directorates of Planning (DP), Census (DRG) and Statistics and Studies (DES) provide technical support to the NPC but they lack sufficient technical and financial means to formulate detailed operational strategies for implementing the NPP.

3.6 Several factors in Cameroon have had a negative impact on the promotion of family planning. These include: the assumption that women need the husband's consent before receiving contraceptives (83 percent of male respondents and 75 percent of female respondents make this assumption); concerns about the safety of modem contraceptive methods (only 30 percent believe that modern methods are safe); and the perceived hostility of family planning service providers (44 percent of respondents indicated that nurses were rude and disrespectful towards family planning clients). Information campaigns aimed at both men and women about family planning are necessary, as well as training programs for service providers.

3.7 Sources of family planning information and frequency of exposure to such information vary. The 1991 DHS found that almost no women were exposed to such messages in the month preceding the survey. A 1992 study by Population Communications Services (PCS) focused on urban areas and determined the following as important sources of family planning information: radio (64 percent), television (46 percent), newspapers (24 percent), and songs (23 percent). Nationally, exposure to television and radio 12 vanes according to province: in the Adamaoua, North, and Far North provinces only 23 percent of mothers with children under five years of age listen to the radio and only 13 percent watch television. Traditional methods of communication are also frequently used for transmitting family planning information; 75 percent of respondents reported using conversations to communicate such information.

3.8 The Health Education Unit (HEU) of MOPH, located in the Directorate of Family and Mental Health, is responsible for creating radio and television programs, plays, posters, and booklets relating to health. Currently, this service is underutilized, and other ministries have begun their own IEC efforts. A strengthened Health Education Unit could act as coordinator of ongoing IEC activities, collecting ideas and lessons and initiating training for leaders of grassroots women's groups about disease prevention and family planning. Potential beneficiaries include: the Groupes d'animation rurale and the Maison de la femme (Ministry of Social Welfare and Women's Affairs) and the Agents de developpement communautaire (Ministry of Agriculture).

3.9 The limited number of public and private health facilities offering family planning services as well as the quality of the services provided represent significant constraints for the increase of contraceptive prevalence rates. The Directorate of Family and Mental Health (DSFM) is currently implementing a program to integrate family planning services into the minimum service delivery package of the health centers. Based on recently adopted guidelines and service protocols, the program emphasizes the quality of clinical services and counseling, the availability of (a limited range of) contraceptive supplies, and accurate reporting of results. Future development of services will need to emphasize a wider range of contraceptive choices, increased outreach services, and improved supervision.

B. Health Policy

3.10 Background and Content. Even before the Alma-Ata Conference (1978) on primary health care, Cameroon experimented with different ways to expand health services beyond the existing hospital system to reach the community level. The Public Health Development Zones pilot project, located in six areas, used mobile outreach teams from the Departmental level to visit villages and conduct sessions on health education, treatment of minor illnesses, and provide referral services. From the experience, the MOPH concluded that: (a) communities were willing to participate and organize themselves in order to improve health services in their area; (b) health activities could be carried out at the community level and community members found these activities desirable; (c) the mobile approach was not cost-effective; and (d) coordination of this program with other health activities carried out by the MOPH was extremely difficult.

3.11 Beginning in 1982, the MOPH sought to bring health services to communities on a continuing rather than intermittent basis. Policy emphasized the need to integrate primary health care activities into the overall strategy and activities of the MOPH and to create formal mechanisms to facilitate community participation, including Village Health Committees (VHCs), Village Health Workers (VHWs), and Traditional Birth Attendants (TBAs). Under this approach, community funds provided (through construction or renovation) a health hut as a base for the CHWs and TBAs as well as an initial stock of medicines for the village pharmacy (propharmacy); the MOPH trained and supervised the Health Workers and the Traditional Birth Attendants. By 1987, the MOPH concluded that: (a) health centers were not integrated into the PHC system and were unresponsive to changing local needs; and (b) communities were unable to sustain their initial effort with the result that most health huts and committees ceased to function effectively. In response to these criticisms, the National Primary Health Care Committee was formed in June 1987 to review Cameroon's PHC policy. 13

3.12 In 1989, MOPH reorganized its strategy for primary health care delivery; thereafter, with assistance from the World Bank (and other multilateral and bilateral donors), MOPH formulated its health sector policy which was approved by the Government in December 1992. The PHC strategy endorses the principles of (a) decentralized health service delivery and management; (b) co-financing of the costs of health care; and (c) implementation of an essential drugs policy. The three principles embodied in the new PHC strategy are being successfully tested in a number of bilateral donor-sponsored projects including the primary health care project in South West province supported by GTZ and the integrated urban health center at Soboum, Douala funded by Swiss Cooperation. The proposed project would build on these experiences. Annex 14 summarizes the national health sector policy.

3.13 Increased decentralization would clearly establish responsibilities at each level of the health care system: (a) the Central Lcvel of MOPH, responsible for policy-making, standard setting, training and cxtemal aid coordination, (b) the Provincial Level Health Authority, responsible for supervision, technical support, and coordination of all PHC activities in a province , and (c) the Operational Level Health District, comprising the health centers and dispensaries located within the district, the community including the health committee (representing the villages or neighborhoods served by the health center), and the District Hospital (DH) serving the role of referral/counter-referral facility for the surrounding health centers.

3.14 The Health Center would provide a minimum package of integrated services (preventive, promotive, and curative) at the center and in the surrounding community through outreach activities. Included in this package are: pre- and post-natal maternal care; under fives growth monitoring; immunizations; family planning; nutrition and health education, diagnosis and treatment of prevalent diseases (malaria, respiratory infections, etc.); and local control of endemic diseases. Management of the health center would be based on a continuous exchange of views between the beneficiary communities and the health services and would result in a more efficient and effective use of available resources.

3.15 While the primary health care policy clearly emphasizes rural areas, the principles would also be applied in urban areas where certain health problems are worse than in rural areas: the 1991 DHS shows that acute under nutrition among children under 5 years old is four times more prevalent in urban areas; nearly half of infants aged 6 to 9 months in Yaounde/Douala are fully (and prematurely) weaned; affordable pharmaceuticals are also difficult to find, since urban residents must depend on private pharmacies; and the population per health center ratio is higher, with resultant crowded facilities, decreased quality, and long waiting time.

3.16 Co-financing has been instituted on the basis of legislation passed in 1990 and 1992 (para. 2.44). Community financing, generated and managed locally, would be used for the operation of the health facility; non-community financing (from governmental sources and international assistance) would fund salaries, training, construction and equipment, and purchase of an initial stock of drugs.

3.17 Components of an essential generic drugs policy are being formulated. A national list of essential drugs for public sector health facilities was signed on June 15, 1993. The decree also states that only drugs on this list can be prescribed and that revisions may be made as needed. Legislation on the importation, control, and distribution of drugs is being formulated.

3.18 Sector Development Issues. Donor support for the Government's health sector policy and PHC strategy has provided the means for initiating many of its elements on a national scale by MOPH, including definition of the elements of a health district approach, experimentation of alternative cost recovery mechanisms, and testing of an autonomous purchasing agency for essential drugs. These field-tested 14 approaches form the basis of the activities to be financed by the proposed project. However, the de facto organization of donor support by province (Annex 11)and the relative autonomy allowed thus far to projects has contributed to certain regional inequities which may in turn pose problems for coordinated development and implementation of the national health policy. For this reason, the project will both correct regional imbalances and support efforts to coordinate health scctor activities.

3.19 Currently, sector coordination and management is the responsibility of the Technical Committee for Coordination and Follow-up of Health Sector Projects (TCC). Composed of senior MOPH personnel and organized largely on an ad hoc basis, the TCC has accomplished much. Continued progress will require broader participation (through the inclusion of representatives of other key ministries involved with PHN issues), more formal technical support (through a strengthened permanent secretariat), and a clearly defined and mandated role for policy and program development.

3.20 Effective operationalization of the health district approach will require the establishment or reinforcement (at all three levels of the health pyramid) of systems to manage human, material, and financial resources. Certain of these management issues are currently under review by the Government, including: revision of the health management information system, improved management and redeployment of personnel, analysis and coordination of sector financing (including cost recovery and external aid), and strengthened budgeting and accounting practices. Other management issues crucial to the success of the health district concept are at different stages of development, including staff training, essential drugs, and appropriate infrastructure and equipment.

3.21 Most advanced is the definition of appropriate infrastructure and equipment and their link to staffing and activities of the health centers and district hospitals. National seminars in Bertoua (1992) and Bafoussam (1993) have identified the location of the health districts (specifically, the district health services and hospitals) and defined activities, space and equipment needs, and required staffing of a functional health district. Two major issues remain. First, because implementation experience is limited to a few functional health districts (heavily supported by externally funded projects), questions of technical feasibility and financial viability have only been addressed partially (based on data from operating sub-districts) or theoretically (on the basis of districts operating in other countries). Second, experience in implementing urban health districts is very limited both in Cameroon and elsewhere. The proposed project would be thc first in Cameroon to contribute to the creation of functional health districts in both rural and urban areas.

3.22 The chronic shortage of drugs in public health facilities and the high cost of drugs in commercial pharmacies (exacerbated by the 1994 devaluation of the CFA franc) have combined to limit access to adequate medical treatment for the majority of Cameroonians. Government remains committed to overhauling its drug policy, and consultations involving Government, the pharmaceutical sector, and donors have established a consensus on the general content of the needed reforms. Donors (including the IDA) have agreed that the European Union and WHO would take the lead in the dialogue with the Government on drug policy formulation. Donors and Government have agreed that the new Central Drug Supply Store would be a flexible, efficient structure, act as a purchasing agent for the provincial drug supply centers using recognized competitive bidding procedures, and maintain only a minimum buffer stock for emergency purposes.

3.23 Development of key elements of an essential drugs policy and procurement system is underway but needs to be systematized. MOPH has established its list of essential drugs, but it has not yet been distributed and explained to health facilities nationwide; quality control measures both for licensing the import of generic drugs and for sampling and chemical testing are currently inadequate, and the existing provincial drug supply systems need to be reviewed and integrated with the national system to reduce costs. I5

In addition, the commercial and social roles of thc private pharmaccutical sector must bc more clcarlv defined and a more comprehensive regulatory framework adopted conccniing issUes such as gencric drugs, pharmacist training and pricing With support from WHO and thc European Union. thc Govcrnmcnt has established a committee composcd of MOPH officials and the pharmaccutical Industry representatives to prepare recommendations for Governmcnt action which should include refonms of the drug supplv and distribution system, financing of drugs and quality control mcasuires

3.24 Training of medical and paramedical personncl has not kept pace with citller tcchnical or managerial developments in the field Cameroon has onc mcdical school, the Yaounde-bascd Centre universitaire des sciences de la sante (CUSS), wvhichtrains about 60 to 70 ph\sicians per year The curriculum must be updated and adapted to include the Governmcnt's reoricntation of primary health care and health system management, including supervislon of hcalth personnel ln-scrxice training to incrcasc physicians' knowledge and skills is insufficient Paramcdical pcrsonnel have bccn trained in the 34 nursing schools located throughout the country, but the majority of these schools arc now closcd because of prolonged hiring freezcs. Medical and paramcdical training has cmphasized ciirativc rather than prevcntive health care and has virtually ignored managcment of decentralized healtlhservicesh anv rcorganization of the health system including preventive health, outrcach and familv planning also \\Ill rcquilrcadditional training in those areas for existing health personnel.

3.25 Finally, the decline of more than 10 pcrcent In actual cxpcnditurcs since l (9)0-(l and the poor economic prospects for the country posc problems for the sustainability of the proposed Investments. During project implementation, the financing plan (para. 4 67) makcs minimal demands on the Government (less than US$1 million per year. mostly taxes). To cover the recuLrrcltcosts generated by the projcct, assurances were obtained at negotiations that: (a) GOC' would take all necessary mcasures to increase progressively the share of the health budget in the total governimcnitbudget from thc currcnt level of 5.0 percent to the level of 7% bv FY 1996/97, 8% by FY I 99X/99,and to I 0%)Iobv the end of FNYI (99/2000 and allocate such increases to non-salary expenditurcs until the cornplctionlof the project 'I'he project would monitor the timelv availabilitv of these budgeted increascs Project activitics would also improve the efficiency of budget expenditures.

C IDA's Role and Sector Lending Strategy

3.26 Related Bank-Financed Assistance. The Health. Fertility, and Ntutrition Project would be the first freestanding Bank Group opcration in the hcalth scctor in Camcrooni UIindcrthe Social Dimcnsions of Adjustment (SDA) Project, the Bank contributed US$2 1.5 milllionwith additional cofimancingfrom nine other sources to finance activities in the arcas of education, training, and( cmplo\ ment, women in development; community development-economic planning. and hcalth Poor project pcrforinaiicc, however, led the Government and the Bank to cancel the health componcnt and latcr the cntirc project

3.27 Within the framework of SDA, a Japanesc Government grant (adminlistercdby the Bank) has since 1991 financed activities to: (a) formulatc and publish national hcalth and population policies, (b) develop operational strategies for their implementation- (c) rc-equip and revitalize basic health care facilities and strengthen serviccs for the poor (emphasizing maternal and child health. but also control of sexually transmitted diseases, including AIDS), and (d) strengthcn the insttutLionalcapacitY of thc MOPH in strategic planning, programming and budgeting, financial and personniielmanagcmiita and coordination of sector operations. 16

3.28 Lessons Learned. This would be the Bank Group's first freestanding operation in the PHN sector. Experience with other Bank projects suggests that project execution activities should be integrated into MOPH's existing departments and technical services and that the timely availability of counterpart funds and the budget approval/expenditure process should be closely monitored to minimize delays. The experience gained from the implementation of the Japanese grant, the recommendations of the 1993 country implementation review (CIR), and the conclusions of the recent country procurement assessment report (CPAR) have also been incorporated into the proposed project. Specifically, project implementation would be integrated into the ministerial structures of MOPH and MEF (para. 5.5) to ensure the internalization of management skills. Counterpart funding for incremental recurrent costs would be included in future budgets of both ministries (para. 3.25). Project activities address recommendations of the latest country portfolio review (CPPR) for improving financial management and increasing donor coordination while reducing the use of (foreign) technical assistance. Measures for improving procurement procedures were discussed during appraisal and IDA credit negotiations and include strengthening ministry and provincial capabilities, international competitive bidding and introducing standardized bidding documents (paras. 5.13-5.19).

3.29 IDA Country Assistance Strategy/Rationale for IDA Involvement. The most recent country assistance strategy (CAS) discussions took place in June 1994 during the Board presentation of the Economic Recovery Credit (ERC). The Cameroon CAS emphasizes the development of the human resources sector and strongly focused interventions to alleviate poverty, including improvements in the delivery of social services to low-income groups. In the health sector, Government policy emphasizes the strengthening of family planning activities, the improvement of primary health care services and the establishment of programs to combat nutritional deficiencies. The CAS provides that IDA will support the implementationof this policy through the proposed health, fertility and nutrition project. Through a Japanese Grant for Population and Health administered by IBRD and the PPF-finaneed preinvestment studies, IDA has played an active and key role in the successful PHN sector policy dialogue with GOC, which has produced major shifts in health and population policies in Cameroon. With coordinated donor support of the PHN policy, GOC now wants to move to an implementation phase of the new policies and needs the financial support of IDA to translate policies into operational programs. IDA assistance complements the activities of other donors, and is focused on geographical areas where no other donor support is envisaged. The proposed project would: (a) contribute to the strategic reorientation of the PHN sector by completing the policy formulation/testing phase and consolidating these advances legislatively and organizationally; (b) establish the requisite technical and managerial conditions to increase the productivity of investments in the PHN sector; and (c) finance the rapid expansion of health service delivery in geographical areas (both rural and urban) not currently envisioned by other donors.

3.30 As an active participant in the ongoing population and health sector policy formulation and implementation dialogue, IDA would support measures to: (a) promote institutional and organizational reforms (including increased decentralization of health services), (b) strengthen the management of health sector resources, and (c) improve sector performance of health and family planning service delivery and support programs. As a new donor in the PHN sector, IDA would promote both multisectoral coordination and donor cooperation to review policy and coordinate program implementation. Under the proposed project, IDA would assist the Government to establish an organized framework (consortium of key donors) for regular consultations with major donors and all relevant ministries (including Planning, Social Welfare and Women's Affairs, Agriculture, and National Education Ministries). 17

IV. THE PROJECT

A. Project Summary

4.1 Project Objectives. The project would help the Government implement key components of its population and health policies. The basic objectives of the project are to: (a) provide institutional support for continued development of the national population policy and rapid implementation of a national FP/IEC strategy; (b) promote complementary organizational and administrative reforms needed to strengthen the management of health sector resources and advance the decentralization of health services; and (c) expand the coverage and improve the quality of primary health care coverage to underserved, low-income populations.

4.2 The project Action Plan (Annex 15), refined during appraisal and confirmed at negotiations, provides a strategic framework organizing the remaining policy decisions, prerequisite implementation actions, and anticipated outputs. It would serve as a tool for monitoring progress of sectoral reforms. An overall project implementationmanual has been prepared and was discussed during negotiations; provincial implementation manuals would adapt this strategic framework to local conditions and priorities during project execution.

4.3 Proiect Description. The project would assist the Government through the year 2001 with a combination of national-level support to reorient and reorganize primary health care delivery; and intensive regional-level assistance to decentralize and strengthen basic health care services in 18 health districts not currently receiving external financial aid. Nationally, the project would provide assistance to implement the 1993 population policy ; develop public PHN services; train MOPH managers and service providers; supply essential generic drugs, vaccines, and contraceptives; and expand communication activities. Regionally, the project would support the expansion of quality primary health care coverage to about 3 million people through the establishment of 18 fully operational health care districts out of about 130 districts projected over the next 10 years. The 18 districts selected are low-income districts with high concentration of the poor and currently lack of adequate services. Coverage would be divided between rural and urban areas, with Bank assistance to nine rural districts in the Center, East, West and Far North provinces and nine urban districts in Yaounde and Douala.

4.4 The specific components of the project are as follows:

(i) Assistance in the Development and Implementation of the National Population Policy and the FP/IEC strategy (US$1.8 million or 5 percent of base cost), by supporting the activities of the National Population Commission and improving demographic data collection and dissemination for population policy-making and operations;

(ii) Organizational and Administrative Reforms of the Ministry of Public Health (MOPH) to Strengthen the Management of Health Sector Resources and Promote Decentralization of Health Services (US$1.5 million or 4 percent of base cost), by supporting the strengthening of MOPH's health services and management structures and developing health management information systems; and

(iii) Expansion of Primary Health Care Coverage and Improvement in the Quality of Health Service Delivery (US$34.7 million or 90 percent of base cost): Expanded coverage would be assured by supporting PHC services through decentralized health districts; improving family I

planning and maternal and child health services. and strengthcning Nutrition Interventions. Quality of servicc dcllvcr wotuldhc assured by strengthening the training and retraining of health sector managcrs and hcalth serNice providers at all levels including community health workers for outreach actiNities. supplxin g sscltiall gelneric drugs, vaccines, and contraecptives to the public and private non-profit hcalth scrvicCs. and introducing multisectoral approaches to strengthen the Health Education lUniitof MOPII and cxpand communication programs through IEC.

Component (i) \illIC carricd out b M FF and components (ii) and (iii) by MOPH.

B Detailcd l rsciitat ion of the Project

4.5 Support the Activities of the National Population Commission (NPC). The project would provide institutional support to the National Population Commission (NPC) to: (a) continue building a national consensus on1the necd for. and the econiomic and social benefits of, family planning and child spacing. (b) gather aind dissemiin1ateinfornmation necessary to develop population action plans, and (c) develop sectoral stratcgics antd progranmsto implementthe National Population Policy.

4.6 T[he NPC. an iutcrmiinlistcrialbodx supported by the Ministry of Economy and Finance (MEF). is responsible for population policy planning and monitoring. The project would assist the NPC and its technical secretariat, the Directorate of Planning (DP), to carry out this mandate by financing training of DP staff and consolidating its offices, and initiating a work program (in collaboration with technical Ministries) to prepare the operationialstrategies for fertility reduction. The project would finance seminars, logistical expCensCsassociated N ith the}mectings of the NPC and the costs of printing and distributing the population policx docuLments.

4.7 Additional training would bc pro\ ided for NPC demographers and managerial staff; DP would idcntifN candidates and prcparc training schcdules for IDA review before implementation. Local training institutions \\ould be used to the extent possible, since both the University of Yaounde and the Institute of Demography 'Training anld Research (IFORD) offer appropriate courses of study.

4.8 Improve D)emographic Data Collection and Dissemination. To formulate detailed operational stratcgics for imuplcnemeitationof the National Population Policy, NPCs population planners would need additional inf'ormailtiollon issues such as the fastest growing populations (and the reasons why), region-specific determinants of fertility, and Culturally appropriate approaches to fertility reduction measures. Withl projcct support. the Directorate of Census of MEF would carry out a series of fertility surveys. Agreenmcntwas reached v\ith GOC during negotiations that a fertility survey would be carried out everv two \,ears and a contracepti%cprevalence survey would be carried out annually, starting in CY 1996, both in accordancc x\ith termlsof refercrce acccptable to IDA, and that the results would be furnished to IDA for comments In addition, the Dli \ould also rcview the impact of population growvthon the environment through periodic rcgionialstudies

4.9 Under thc project. the staff and scope of work of DP would be expanded to enable it to assist the technical Ministrics of GOC to develop and implcment sector-specific population strategies GOC gave assurances at negotiations that it would submit to IDA by June 30, 1996 for review and comments a plan of action to develop sectoral strategies for thc implementation of the National Population Policy as part of ongoing dialogue Onpopulation issues, and im1plementthe plan, 19

4.10 As one strategy, the project would finance dissemination of the National Population Policy through (a) training and awareness-raising seminars for the provincial and district health teams and (b) sensitization campaigns, seminars and workshops to inform community leaders, opinion-makers and couples of the benefits of family planning.

4.11 With project financing, the DP would establish in Yaounde a national information center on issues related to population and development. The population and development information center would collect reading materials on population issues in the country and organize periodic seminars for youth, political and opinion leaders and women's groups. IDA assistance would include the provision of books, materials and equipment.

4.12 Support the Strengthening of MOPH's Health Services and Management Structures. The project would support ongoing efforts to (a) reorganize MOPH; (b) introduce/improve management systems and tools (personnel management; finance, budgeting, and accounting; etc.) needed to improve the efficiency of MOPH operations; and (c) decentralize health service delivery by increasing local control of health service operations.

4.13 Certain central functions of MOPH would be strengthened and expanded, including (a) PHN policy formulation and monitoring; (b) service delivery norms and standards, including training of health personnel; and (c) planning and management of sector financial resources, including investment planning and external aid coordination. To improve the internal administrative efficiency of MOPH, the project would finance appropriate office equipment and training as well as minor rehabilitation and upgrading of services (telephone,electrical and paint work) for selected MOPH central offices in Yaounde and in the participating provinces.

4.14 The project would improve strategic management of MOPH by increasing the role and reinforcing the technical capabilities for policy formulation and monitoring of the Technical Committee for the Coordination and Follow-up of Health Sector Projects (TCC)(para. 3.19). The TCC would become a permanent oversight body of MOPH, chaired by the Minister and responsible for PHN sector policy and strategy definition, program planning and external aid coordination and monitoring of sector operations. The TCC would be enlarged to include representatives of the ministries in charge of planning, finance, social welfare, women's affairs, education, and agriculture.

4.15 Currently, MOPH proposes that the TCC create subcommittees (standing or ad hoc as needed) to oversee implementation of specific aspects of the health policy; the secretariat's role would be limited to administration and support of these subcommittees and of the full TCC. During appraisal, the mission agreed with MOPH on the specific role of the TCC with respect to the implementation of the proposed project. The project would support the activities of the subcommittees and the secretariat, assist with publication and dissemination of TCC's documents, and support both the TCC's sector coordination activities and its project coordination responsibilities. At negotiations, an initial set of sectoral issues for discussion by the TCC and a proposed approach for addressing these issues were discussed.

4.16 The TCC would also play an important role in coordinating the Technical Directorates' justification of, and search for, external assistance. In the short term, the project would support basic policy analysis activities which: (a) cut across provincial and individual donor-sponsored project boundaries including data collection staff training, and program supervision, (b) emphasize common policies, norms and service standards to be applied in the national health system, and (c) permit MOPH to clearly articulate its position to donors through the TCC. In the longer term, the project would promote a consortium of key PHN donors, 20 as a means for organizing regular consultations between the Government and the major donors; these would include semi-annual Government/ Donor/IDA joint supervision missions for field operations.

4.17 At present, the general principles of the new health policy often lack the supporting details needed to translate them into fully operational programs throughout the country. To establish effective norms and standards, the project would (a) provide technical support for drafting additional legislation and regulation; and (b) promote (through the TCC) simplification and increased flexibility in managing of MOPH's human, material and financial resources. Ministerial decrees have been adopted, authorizing the establishment of the health districts, and specifying the roles and responsibilities of central and provincial structures, and the internal functioning and rclationship of the various health committees.

4.18 During appraisal, measures were idcntified for reinforcing MOPH's authority in matters of personnel management: hiring, transfer, promotion and discipline, etc. While existing civil service regulations are sufficient, their application is inconsistent and ineffective. At negotiations, GOC indicated measures and means for applying them to ensure equitable geographical distribution of staff and improved internal management of civil scrvice personnel assigned to MOPH and gave assurances that it w,.>uldtake necessary measures. The project would improvc the administrative procedures and practices for managing staff at the central, provincial and district levels and strengthen the planning process for staff recruitment and dcployment in the sector. The project would finance the costs associated with the implementation of the proposed organizational changes, including the cost of printing and disseminating new job descriptions and internal procedures, and relocation costs for staff redeployed.

4.19 Financial planning and management of the sector would focus both on the investment and recurrent budgets. Investment planning and budgeting for the health sector would be strengthened at all levels; the project would provide financial and technical assistance for: improving medium-term (three year) health sector planning; strengthening project preparation capabilities at the central and provincial levels; and providing additional assistance to provincial health authorities in preparing investment projects for their respective health districts. Assurances were obtained at negotiations that the Government would review with IDA in June of each year: a) all investment expenditures made in the health sector in the previous year and planned for the coming three years, with particular attention given to their recurrent cost implications; and b) expenditures of the non-salary recurrent budget across existing programs and services to cover at a minimum their estimated annual operating costs for materials, fuel, maintenance, etc.

4.20 The project would support MOPH efforts to improve the methods and procedures for formulating and executing the operating budget. The project would help MOPH to: (a) restructure its budget at the different levels through a need-based estimation of required resources (more objective criteria, size of populations served, standard of physical plant, etc.); (b) increase the share of the national budget earmarked for non-wage operating costs; and (c) reduce spending delays by simplifying procedures for accessing budgeted resources. During negotiations, the Government agreed that it would submit to IDA not later than April 30 of the year evidence that the previous year's budget was spent as originally intended, and prepare and discuss the proposed operating budgets for the subsequent year.

4.21 Effective decentralization would establish the provincial health authorities and train the district health teams as the managerial units of field operations and both would have additional responsibilities concerning: planning and program management; use of approved budgets and available health personnel; and acquisition and distribution of drugs as well as the use of recovered revenues for drug resupply activities. The provincial level will also have a variety of program coordination functions, including technical support, training and supervision of the decentralized health districts. 21

4.22 Staffing of the different positions of the provincial health authorities is underway, and the Government has provided assurances that all key positions in the provincial health authorities supported by the project would be fully staffed at all times. To improve the working conditions of the provincial authorities, the project would finance minor building repairs, appropriate office equipment, and vehicles.

4.23 Project support to the provincial health authorities would initially focus on improving their abilities to assist the districts in the preparation of the health district development plan for extending the coverage and quality of services. Assistance would include training, logistical support for organization of planning workshops, and short-term technical assistance where needed. The project would also finance provincial efforts to implement improvements in the health management information system (HMIS) and in personnel management (supervision, perforrnance evaluation, and training).

4.24 Because of the delays anticipated in implementing decentralization, project support to the provincial health authorities would allow for alternative approaches and permit flexibility in the use of resources to establish the basic components of the health district. Estimated timetables for full implementation of the health district were prepared during appraisal with central and provincial staff and indicate a minimum of approximately three districts per year. To reduce the costs of supervision and to promote the sharing of experiences, districts would be established collaboratively with other donors and, where feasible, contiguously.

4.25 The project, in close collaboration with the Ministry of Economy and Finance, would establish a permanent system of financial accounting and auditing of income deriving from cost recovery on drug sales and medical visits. An independent accounting firm has been selected to assist with this effort. During appraisal, terms of reference were agreed to for assistance to develop requisite accounting procedures. At negotiations, the Government presented a satisfactory institutional and regulatory framework, agreed to by the Ministry of Finance, for collecting revenues from drug sales and medical visits and accounting and financial management of costs recovered by the health centers and district clinical facilities, and gave an assurance that it would maintain a system acceptable to IDA. The project would finance the costs associated with the implementation of the technical tools needed for accounting and financial management. The Government has given its assurance that financial officers would be appointed on each provincial team and at the central level to oversee the cost recovery operations and audit the related accounts.

4.26 Develop a Health Management Information System (HMIS). The project would support development and expansion in the covered areas of MOPH's proposed HMIS currently being tested with the support of several projects. The proposed HMIS would provide information to MOPH managers at the district, provincial and central levels on the basis of agreed-upon indicators reflecting epidemiological trends, morbidity and mortality trends, service delivery (utilization rates and service ratios), and resource use (status of health infrastructure, staffing needs and training requirements; budgets and revenues; and pharmaceutical, contraceptive, and vaccine supplies.

4.27 The project would assist the statistics section of the Planning and Studies Directorate of MOPH in the design and production of statistical forms to be used in the country, in providing on-the-job training and periodic supervision of health statistics staff at all levels, and in the centralization of processed data for annual publication and dissemination. The project would finance the introduction of methods to increase local use of collected data and to improve feedback to field staff on the quality and meaning of data received. Included in the project are costs for training workshops/seminars for MOPH statistics staff, data processing equipment for provincial and central level personnel, and publication and dissemination of the collected information. 22

4.28 Support PHC Services through Decentralized Health Districts. The project would finance the expansion of primary health care (PHC), maternal and child health (MCH) services, and family planning (FP) services in half of Cameroon's provinces (Center, Littoral, West, East, and Far North) and its two principal cities (Yaounde and Douala). Between 1995 and 2000, 18 fully functional decentralized health districts (HDs) comprising 150 integrated health centers and 18 first-referral clinical facilities (district hospitals) would be made operational with active beneficiary community involvement and support. The following rural and urban districts have been selected by the GOC:

Rural: Yokadouma and Mouloundou (East province); Foumban, Malantouen, and Mbouda (Wcst province), Eseka and Ntui (Center province); and Kousseri and Makari (Far North provincc)

Urban: New Bell, Log Baba, Cite des Palmiers, Deido, and Bonaberi (Douala), and Bivemassi, Nkolndongo, Cite Verte and Djoungolo (Yaounde).

Within the proposed urban districts, depressed areas and "bidonvilles" would be targeted in order to address rapidly the very low health, fertility and nutrition status of the poor.

4.29 Under the project, a health district (HD) would serve a population of about 100,000 people and would respond to the majority of health problems encountered by its defined community. Each fully functional health district would comprise: (a) a network averaging six integrated health centers (IHC); (b) a district clinical facility (DCF) providing first referral and counter-referral services; and (c) a district health team responsible for operating the health district. GOC has adopted appropriate texts and regulations to: (a) establish the legal basis of the health districts in Cameroon, and (b) specify the modalities to ensurc decentralization of management responsibilities within the public health system.

4.30 The definition of staffing norms, spatial needs, and standard equipment lists is well underway. Based on current pilot health districts in the Littoral, North-West, South-West, and Far North provinces as well as in the Soboum urban health center in Douala, implementation plans (with re- ,ponsibilitiesand estimated completion times) for establishing the IHCs, DCFs, and district health tcams are defined in the implementationmanual. With existing implementation capabilities at the district and provincial levels, the time required to establish a fully functional health district is estimated at approximately thrce years. The project would finance the proposed activities during each phase of these plans, including mobilization of the population, creation and training of the local management structures, facility rehabilitation and re-equipping, management and technical training, and drug supply. Under the terms of reference agreed upon during appraisal, an infrastructure consultant reviewed the technical norms for facility rehabilitation ar.a has prepared recommendations for the project's 18 health districts.

4.31 Improve Maternal and Child Health and Family Planning Services. The project wvould support and expand MOPH's efforts to integrate the entire range of MCH and FP services into the newly formed health districts. Objectives would vary for each rural and urban district supported by the project but by the year 2000 the project, in the areas covered, would: (a) reduce matemal mortality by 30-50 percent (from 430 to 250 per 100,000 live births): (b) raise the vaccination coverage for the main target groups from under 40 percent to between 60 and 80 percent; (c) lower morbidity and mortality for children under fivc, (d) enhance the nutritional status of the most vulnerable population groups (expecting and nursing women, children under 5 and young girls); and (e) reduce current levels of fertility among women of reproductive age by increasing the modem contraceptive prevalence rate from less than 5 percent to betwcen 10 percent and 20 percent. 23

4.32 Services would be aimed principally at mothers and children and emphasize low-cost preventive health care, family planning, and nutrition services. Each IHC would be expected to provide a minimum package of integrated services including: (a) prenatal, intra-partum and postpartum care; (b) neonatal and under-five consultations, vaccinations and disease control (pneumonia, malaria, diarrhea and anemia); (c) juvenile and adolescent health services; and (d) family planning services.

4.33 Obstetric and pediatric services would be strengthened at the IHC and DCF levels. The project would finance a strategy combining outreach activities and health promotion with improved clinical interventions and training of personnel.

4.34 The immunization strategy would include social mobilization and would strengthen institutional services (schools and women's groups). The project would support: (a) training (basic and refresher training, cold chain maintenance, IEC/ motivation); (b) purchase of vaccines; and (c) maintenance and replacement of cold chain equipment. Reporting systems would be improved, and MIS data collection and processing would be emphasized.

4.35 Basic family planning services would be provided as a component of the minimum package of integrated PHC services. At negotiations, GOC gave assurances that it would submit to IDA before December 31, 1995 a national program for expanding family planning services over the 1996-1999 period, and implement the program. This program would emphasize the quality of FP services and increase access to clinical services and counseling, ensure regular contraceptive supplies, and improve reporting systems.

4.36 Recently adopted MOPH policies and guidelines for improving the quality of MCH/FP service delivery ("Protocoles des services de planification familiale" and "Politique et standards des services de sante maternelle et infantile et planification familiale") would be printed and distributed to all health centers. They would serve as a basis for training personnel, including the traditional birth attendants (TBAs) and other potential community development agents.

4.37 All supervision activities organized by the health districts would be based on the Protocoles et Standards des Services de SMI/PF. MOPH has adopted a supervision system with schedules, responsibilities, supervision session plans (for the districts), and criteria for evaluating staff performance. At the central level, supervision would emphasize: (a) compliance with norms and standards of services and (b) centralize and process provincial HMIS data for planning future operations. Overall supervision of the FP program would be located at the provincial level which would become the logistical base for materials, training, and technical assistance. Physicians at the district level would be responsible for supervising the nurses and midwives, and occasionally, the outreach health staff. They would receive training at designated training sites, as would the nurse/midwives. The nurse/midwife supervisors located at the health centers would be responsible for the supervision of TBAs and other development agents within the communit.

4.38 Supervision would emphasize: (a) guidance and training to health staff; (b) assistance with resources and logistics; (c) monitoring and evaluation. Supervisors would be trained in interpersonal skills, counseling, and clinical skills. Tools such as reporting forms, budget coefficients, etc. would be developed to facilitate the supervision work, and the project would share GTZ and USAID experiences and lessons learned through their projects. Service indicators would be selected and standardized, and special forms would be used to collect information. Short-term technical assistance would be provided to the health districts for the implementationof the supervision activities. Evaluation would be based on the results of the fertility and contraceptive prevalence surveys referred to in para. 4.8. 24

4.39 The project would help GOC reorganize and standardize MCH/FP in all 150 integrated health centers and 18 district clinical facilities proposed for financing. Rehabilitation of MCH/FP services within the IHC would be financed as well as equipment, materials, and supplies. In conformity with nationally established norms, access to family planning services would also be improved by diversifying the mix of available FP methods: (a) IHCs would provide Type I methods (condoms and spermicides), injectables, and (where equipment and staff expertise permit) IUD and Norplant insertion/removal would be carried out; and (b) voluntary surgical contraception (VSC) would be performed only at the district level clinical facilities, on a referral basis. District physicians would provide obstetrical care and treatment for referred clients and would perform consultations for infertility and VSC services if they have becn trained to do so.

4.40 Supervised by the IHC head, outreach services would be provided by both IHC staff and other sources such as the village health committees, TBAs, and community development agents (supervised by the ministries of social affairs and agriculture). The project would train and equip these service providers to perform a number of community-based functions comprising: (a) general PHC work (including nutrition information), (b) information on the benefits of family planning and available methods (as well as the dangers of sexually transmitted diseases), identification of potential clients, and referral to appropriate services; (c) distribution of Type I contraceptives (condoms and spermicides); and (d) referral of women with side effects or complications requiring medical attention. This would be the beginning of a community- based distribution system of contraceptives to be extended to the rest of Cameroon in future years.

4.41 Contraceptive needs have been estimated for the period 1994-99 (Annex 16) on the basis of population projections, current contraceptive prevalence rates (CPR) by modern method, and anticipated increases of 3 percent per year over the i)roject period. The project would strengthen MOPH's management of contraceptives by: (a) improving the data base and methods for more accurately forecasting demand by method, (b) reinforcing procurement and distribution in country, and (c) regularly monitoring supplies and supervising personnel.

4.42 Strengthen Nutrition Interventions. Given Cameroon's different socio-ecological systems, nutrition interventions would require multiple strategies based on the characteristics of each region; the project would finance surveys of the extent and location of the specific nutrition problems as a basis for developing such strategies. The project would support several types of research into the nutritional problems faced in Cameroon. Baseline surveys would be conducted to determine the anthropometric status of children and the weaning practices of mothers. Operational research would also be carried out first to test (on a pilot basis) new weaning foods using locally available foods and then to monitor child growth after introduction and promotion of the new foods. The Centre de la Recherche en Alimentation et Nutrition (CRAN) under a contract with MOPH would carry out studies to assess the acceptance rate and effectiveness of the actions and the nutritional status of the target populations. The project would train a team of Cameroonians for the management and coordination of nutrition programs and would finance costs associated with the collection, analysis, and dissemination of the research results. Annex 17 provides a detailed discussion of the nutrition component. The project area includes regions of contrasted ecology, food habits, nutrition and health status. In each sub-region, specific health and nutrition strategies will be developed and specific objectives will be selected. The project will adopt a two-pronged approach to the reduction of the four major nutritional deficiencies: protein-energy malnutrition, iron-deficiency anemia, vitamin A deficiency and iodine deficiency disorders: 25

- Routine prevention and treatment of patients and users of health centers. - Outreach activities of eradication of parasitic and nutritional disorders organized at three to six months intervals in villages and slum areas located around the participating health centers.

4.43 The first year of the project will be used to organize and prepare the materials necessary for the campaigns: IEC, base-line studies, equipment and drugs for the participating health centers, monitoring and evaluation of impact strategies. The prevention and treatment strategy will include direct nutrition services through the 150 integrated health centers. In these centers the staff will ensure a close linkage between health and nutrition activities (growth monitoring, education, micronutrient deficiency eradication, etc.). This would broaden the effect of health interventions and enhance their cost effectiveness.

4.44 Outside the health center, health teams will encourage or seek participation of local communities with the support of private institutions or NGOs to carry out nutrition activities beyond the health centers in their respective areas of responsibilities but in coordination with them. Village committees would include nutrition workers responsible for specifically implementing nutrition and nutrition-related activities. The objective is to extend the influence of the centers beyond the immediately accessible populations and promote a preventive approach to reducing malnutrition through empowerment of local community. This would be done by supporting nutrition workers to implement child growth monitoring, nutritional supplements distribution and other nutrition-related activities. The program would be decentralized at the village level under the responsibility of a community worker selected by the village.

4.45 The Nutrition Service of the Ministry of Public Health and the Center for Nutrition attached to the Ministry of Higher Education and Scientific Research would participate in the training of health center/NGOs field staff in cooperation with UNICEF under the overall supervision of the training coordinating consultant. Regular nutrition education and supervision would enable the community nutrition agents to pursue their malnutrition control activities with minimal support from the project and therefore increase the sustainability of the component. The project implementation manual spe'ifies in a simplified way all the tasks to be conducted by the nutrition workers and the different steps required for proper implementation of nutrition activities at all levels.

4.46 Nutritional activities including growth monitoring, identification and referral of malnourished individuals, and nutritional education of mothers (promoting breast feeding, better weaning methods and foods for infants), improved feeding practices for young children, and administration of micronutrient supplements to high risk groups would be part of the minimum package of services to be provided by all 150 integrated health centers of the project. Mapping and baseline surveys would be carried out to document the locations, types and extent of specific nutritional disorders by province.

4.47 With respect to micronutrient problems (including vitamin A, iron and iodine deficiencies), the project would target children under five, pregnant and lactating women, and female adolescents. These high risk groups would benefit from project-supported actions for food supplementation, distribution of iodized salt, vitamin A capsules and iron tablets, and education of mothers at the health centers. Cameroon already iodizes salt for its own use and for export (though quality control needs strengthening); and iron tablet distribution to expectant mothers at risk would be instituted as part of prenatal care in the project health facilities. 26

4.48 In districts with a high incidence of protein-calorie malnutrition, the project would support selective establishment in district clinical facilities of nutritional recovery services for acute cases. However, given the low level of acute malnutrition in Cameroon, this type of intervention would be very limited.

4.49 Strengthen the Training and Retraining of Health Personnel at all Levels. During project preparation, training needs were identified for implementation of the PHC strategy by type of health personnel and by level of the health service delivery system (Annex 18), and available training capabilities among MOPH staff were reviewed. During appraisal, agreement was reached with the Government that a training coordinating consultant be retained to finalize the training objectives, carry out a detailed inventory of local training institutions and to develop an action plan. The project would expand selected training facilities in Maroua, Douala and Ayos. The project would (a) develop selected training sites to support the implementation of the district-based PHC strategy; and (b) renovate, equip, and finance the initial operating costs of the training centers.

4.50 At the central and provincial levels, the project would emphasize management and supervision skills for approximately 150 MOPH managers in public health, health services planning, health economics, systems management and supervision skills. With IDA approval, MOPH will select appropriate candidates and identify specific training courses, emphasizing locally available training resources and institutions (see para. 4.51 below). At negotiations, assurances were obtained that GOC would evaluate annually the technical and management training activities undertaken during the previous year, and furnish to IDA (for its review and approval) by March of the subsequent year detailed plans based on that cvaluation. A limited number of scholarships would be provided for overseas training (up to a year's duration). About 10 scholarships would be provided for specialized physician training during the 1995-2000 period.

4.51 At the health district level, the 18 newly created health district management teams (each comprising 2 physicians, 10 nurses and 10 auxiliaries) would receive initial instruction on their responsibilities under the decentralized health district system at the Centre d'mnstructionmedicale in Maroua (CIM) and practical training at the Soboum IHC in Douala or in other functional IHCs. The training activities programmed during project implementation include about 20 three-month sessions for at least 40 district physicians and 400 nurses. Each district team would be trained together to improve interpersonal relations between physicians and nurses and to foster collaboration and team spirit. In agreement with GOC and Belgian AID, the project would help CIM expand its intake capacity, including: (a) extension of classroom space and (b) additional short-term assistance to conduct the training sessions. Different curricula used by other projects in previous training sessions would be revised and integrated. Training will includc one month of theoretical training and two four-week practical training courses in the health centers, with supervision and follow-up technical assistance in applying the training received.

4.52 Health center personnel delivering FP/MCH services in the project areas would receive intensive training to update and improve their clinical knowledge and skills. The course content and curricula currently used in Cameroon would be updated and strengthened on the basis of an analysis of the tasks which each team member will be required to carry out; theoretical training would be offered in schools designated by MOPH, and clinical training would be organized by the OB/GYN departments of designated hospitals. After completion of training, participants' service delivery skills would be monitored and facilitation visits would be organized to help them use their skills and knowledge. The project would also organize ex-post evaluation of the impact of training on service delivery.

4.53 Training of health center clerks responsible for funds recovered from the sale of essential drugs would be provided by other experienced drug clerks drawn from other parts of the country. Training 27 would be offered locally at the health district office, and clerks would be supervised by the district team members.

4.54 Health committees at the local and district levels would receive training on the principles and operations of the new health delivery system.

4.55 Given the limited training capabilities at central and provincial levels, agreement was reached and terms of reference prepared during appraisal for the recruitment on a competitive basis of a training coordinating consultant to: define an overall training plan for implementing the PHC strategy, prepare specific training modules (based on existing documentation), establish procedures for the selection of candidates, and organize the training venues. At negotiations, Government confirmed its choice of selected consultant, training objectives were finalized, an inventory of potential training institutions was examined, and a training action plan was agreed upon.

4.56 Supply of Essential Generic Drugs, Vaccines and Contraceptives to the Public Health Facilities. The project would support measures to strengthen Cameroon's policy on essential drugs as well as actions to implement a program to increase access to quality, low cost drugs. At negotiations, IDA obtained assurances that before disbursing SDR 690,000 (US$ 1 million equivalent) worth of drugs for the health districts, GOC would take measures to: (a) adopt and publish appropriate legislation concerning pharmaceutical policy (including lists of essential drugs by level of care); (b) adopt regulations instituting the Central Supply Store for Essential Drugs and organizing its management and operations; and (c) propose measures for ensuring the quality of imported generic drugs (including licensing, chemical control, and inspection).

4.57 Initial project activities would emphasize information and awareness about the nature and use of essential drugs as well as specific staff training in the management and control of distribution systems and revolving funds. The project would fund formal and in-service training courses in coordination with other donor-sponsored projects implementing the drug policy. It would also support initiatives to improve the quality of prescriptions (such as treatment protocols and publication of a prescription guide). Information and training seminars would be organized to familiarize IHC health committee members, HD management committee members, and the community at large with essential generic drugs.

4.58 Until adoption of legislation acceptable to IDA instituting the Central Supply Store for Essential Drugs, project financing at central level would support MOPH's existing drug distribution structure (CIAME) whose operating procedures were reviewed by the appraisal mission and found acceptable; subsequently, the project would support efforts to: (a) acquire low cost generic drugs, vaccines and contraceptives through bulk purchasing and international competitive bidding; (b) assure the distribution and improve administration of these materials throughout Cameroon; and (c) improve systems to recover (partially) the costs and renew the supplies of the consumed drugs and other materials.

4.59 In each province supported by the project, the project would (a) strengthen the management and contribute to the buffer stocks of the provincial drug supply stores Centrales d'approvisionnements pharmaceutiques provinciales (CAPPs). Through material support and possibly technical assistance, the project would establish and/or strengthen the CAPP (headed by a pharmacist and a financial officer and responsible for distribution of essential drugs, contraceptives and vaccines, and small equipment), which would process and manage the drug orders from the health districts. Warehousing facilities for the drugs would be rehabilitated by the project. Pick-up of drugs and their subsequent distribution to the health centers would be carried out by the concerned health district office. 28

4.60 The CAPP would supervise cost recovery operations and audit drug cost recovery accounts in the province. It would also constitute and manage the provincial drug fund to finance bulk purchases of drugs abroad in collaboration with the other provinces. Such a fund functions independently in Northwest province and is being successfully operated in Southwest and Littoral provinces with German cooperation, similar funds are operating in South, Adamoua, and Extreme North provinces, with support initially from USAID and now from UNICEF.

4.61 At the district level, the project would provide initial stocks of essential generic drugs as well as contraceptives and vaccines for the 150 health centers and 18 health districts, equivalent to three years' requirements (valued at CFAF 1.2 million or US$5,770 per health center and CFAF 5.0 million or US$11,540 per district clinical facility).

4.62 Strengthen the Health Education Unit of MOPH and Expand Communication Programs through IEC. The project would finance the development of an IEC strategy comprising (a) audience research, (b) message development and delivery costs, and (c) evaluation. In addition, the project would train HEU personnel and service providers involved in communication and would promote coordination of all agencies concerned with message delivery to ensure the complementarity of interpersonal, group and mass media approaches.

4.63 MOPH would be responsible for organizing IEC training seminars for health personnel and for maintaining contacts with outside agencies for the preparation of IEC material for use by the district teams. The project would fund equipment and specialized assistance for developing communication tools and IEC materials; but, apart from small materials (photos, videos, and recordings) which would be done in- house, actual production of IEC materials (posters, plays, films, songs, etc.) would be contracted out to other Government agencies, such as the Cameroon Radio and Television Corporation (CRTV), or the private sector. The project proposes to fund non-salary costs of the IEC program activities for a period of six years.

4.64 At the district level, the project would provide a supply of IEC materials for each integrated health center and distnrct clinical facility. In the community, health committee members would act as contact persons for organizing information-discussion seminars on health. Home visits would be incorporated into the activities of the IHCs in an effort to detect high-risk cases or to recapture patients with whom contact has been lost. Two PHN education seminars would be organized each year in selected schools with a special focus on nutrition, STD/AIDS prevention, and the dangers of smoking and alcoholism.

C. Project Cost and Financing

4.65 Cost. The total cost of the proposed project is estimated at US$48.08 million, with a foreign exchange component of US$35 million or 73 percent of total project costs. The foreign exchange component is calculated on the basis of estimated foreign exchange proportions as follows: (a) civil works 89 percent; (b) equipment and furniture 90 percent; (c) vehicles 52 percent; (d) medical supplies 96 percent; (e) consultant services 100 percent; (f) training and scholarships 24 percent; and (g) research 2 percent. Project cost tables are summarized in Annex 19. 29

Table 3: Summary of Project Cost Estimates (including taxes and duties, in millions of USS)

Local Foreien Total A. ASSISTANCEIN DEVELOPMENTAND IMPLEMENTATIONOF NATIONALPOPULATION POLICY AND FP/IECSTRATEGY I. Supporting the Activities of the National Population Commission 0.49 0.33 0.82 2. Improving Demographic Data Collection and Dissemination 0.72 0.29 1.01

B. ORGANIZATIONAND ADMINISTRATIVEREFORMS OF MOPH 1. Strengthening MOPIHs Services and Strictures 0.24 1.00 1.24 2. Developing Health Management Information Systems 0.13 0.18 0.31

C. EXPANSIONOF PHC COVERAGEAND SERVICEQUALITY IMPROVEMENT 1. Supporting PHC Services through Decentralized Health Districts 4.03 18.83 22.86 2. Improving Family Planning and Maternal and Child Health 1.22 1.10 2.32 3. Strengthening Nutrition Interventions 1.12 3.65 4.77 4. Strengthening Training and Retraining of Health Sector Staff 0.94 0.50 1.44 5. Supplying Essential Generic Drugs, Vaccines and Contraceptives 0.15 2.38 2.53 6. Expanding Communications Program through IEC 0.31 0.57 0.88

D. PROJECT PREPARATION ADVANCE - 0.60 0.60

Total Base Costs 9.35 29.43 38.78 Physical Contingencies 0.83 2.43 3.26 Price Contingencies 2.86 3.18 6.04

TOTALPROJECT COSTS: 13.04 35.04 48.08

FINANCINGPLAN: IDA 8.03 34.97 43.00 Government 5.01 0.00 5.01 Communities 0.00 0.07 0.07

TOTAL 13.04 35.04 48.08 4.66 Base costs are in mid-1993prices. Physicalcontingencies of 10 percenthave been included for rehabilitationworks and goods. Price contingenciesare estimatedat an average of 3 percent for local currencyand at 3.9 percentfor foreignexchange costs, which is consistentwith the averageprojected MVV Indexbetween CY1990-CY2000.Cost estimatesfor other expendituresare based on recent experienceof other Bank-financedprojects in Cameroonand on quotationsfrom suppliers. Nationalstaff salary estimates are basedon civil servicepay scalesand UNDPlocal pay scale.

4.67 Financing. IDA's creditwill be US$43 millionequivalent, representing 90 percentof total projectcosts. Over the six year project implementationperiod, this amount constitutesadditional resources of about US$0.60per capita per year (basedon the current estimatedpopulation of 12 million).

4.68 The Governmentof Cameroonwould finance up to US$5 million, or 10 percent of total project costs. Beneficiarycommunities would finance up to US$0.6 million (about 1.4 percent of total project costs), primarilythrough existing cost recoverymechanisms at the health center and district clinical facility levels. 30

D. Environmental Considerations

4.69 The proposed project was determined to be in Category C, which indicates projects not expected to have a negative environmental impact. Rather it should have positive effects via reduced fertility and rehabilitated health facilities. No environmental analysis has been prepared therefore for this project.

V. PROJECT IMPLEMENTATION

A. Preparation Status

5.1 With support from two PPF advances of US$340,000 (approved March 21, 1991) and US$260,000 (approved June 30, 1992), MOPH initiated both a series of organizational reforms and a number of special studies. Studies were conducted and proposals made in the areas of urban primary health care delivery, nutrition, pharmaceutical policy, and health sector resource management (personnel, finance and budgeting, and infrastructure and equipment maintenance). Organizational reforms included the establishment of the Technical Committee for the Coordination and Follow-up of Health Sector Projects (TCC), which oversaw formulation of the health policy, proposed a new structure for MOPH, and recommended measures (based on the results of the studies) to strengthen health sector management at the central level and to integrate health services at the local level. A list of documents in the project file may be found in Annex 25.

5.2 With Japanese grant funds for population and health, the Government undertook short-term consultancies to prepare project implementation plans in the areas of accounting (para. 4.25), staff training (para. 4.55), and health infrastructure rehabilitation (para. 4.30).

5.3 MOPH has prepared a project implementation manual which establishes (a) schedules, responsibilities, and coordination mechanisms; (b) procurement guidelines; and (c) decisions on outstanding issues. A draft manual was agreed upon at negotiations and will be finalized before project launch.

B. Project Implementation

5.4 Based on the number of districts to be established and the amount of time required to achieve complete coverage in each district, project implementation would occur over a six-year period (1995-2001). The Action Plan (Annex 15) and the Implementation Schedule (Annex 20) provide details of the calendar for execution of the project activities.

5.5 Implementation of the Health, Fertility and Nutrition Project would be the responsibility of the relevant departments and technical services of the Ministry of Public Health and of the Ministry of Economy and Finance. For the Ministry of Public Health which would implement the bulk of project activities, certain precautions are being taken to ensure a smooth execution of the project. First, there will be a strong decentralization of activities to the provinces away from Yaounde. This would permit beneficiary participation and local control of the operations by the village-level and district-level health committees which have already been formed. Second, supervision of more complex components such as training and infrastructure rehabilitation works would be sub-contracted to private sector firms following competitive bidding. Third, advance preparation work has been carried out for the infrastructure component by a consultant who assessed the implementation capacity at the district level, identified the sites, prepared 31 architectural drawings and designs, and estimated the costs, material quantities and completion time needed. Taken together, these actions would go a long way towards facilitating project implementation.

5.6 Assistance in Development and Implementation of National Population Policy. The Directorate of Planning (DP) of MEF would provide support to the National Population Commission; organize the training for demographers (identifying institutions, preparing schedules, and reviewing them with IDA), coordinate the other regional population studies, and supervise the activities of the national information center on issues related to population and development. The Directorate of Census would implement the periodic fertility and CPR surveys. DP would submit to GOC and IDA through the TCC semi-annual reports on the progress of the population component.

5.7 Organizational and Administrative Reforms of MOPH. The TCC would have overall responsibility for monitoring sectoral reforms and recommending additional legislative and regulatory proposals. The Directorate of Studies, Planning and Statistics of MOPH would coordinate implementation of the health management information system, proposed improvements in planning medium-term sector investment, and the programmed expansion of health infrastructure. The Directorate of General Affairs of MOPH would be responsible for implementing budgeting and accounting reforms and for coordinating improvements in personnel management.

5.8 Expansion of PHC Coverage and Improvement of Service Quality. The provincial health authorities would be responsible for planning and monitoring the establishment of decentralized health districts in their respective provinces. They and the district medical directors would be responsible for planning, organizing, and launching the PHC activities of the integrated health centers and district clinical facilities. They would supervise implementation of project activities and prepare progress reports for the TCC. A Financial Officer would be assigned to the provincial team of each participating province to supervise the cost recovery operations, carry out periodic audits of the health district accounts, and train the drug clerks in handling revenue collection from drug sales. A procurement specialist would be added to the provincial teams and the central project office to assist with procurement issues. Since the project would be implemented by the same departments and technical services of MOPH, technical assistance personnel currently available in ongoing projects would be called upon to assist the provincial health authorities in designing and implementing plans for setting up decentralized health districts. The project would finance additional short-term technical assistance to the provincial health authorities as needed to reinforce their implementationcapabilities (including procurement) and strengthen project management.

5.9 MOPH would provide technical support to the provincial health authorities in the areas of training, pharmaceuticals, and IEC. In collaboration with the coordinating consultant for training, the Training Division of MOPH would schedule and organize training for MOPH managers, provincial staff, and district team health personnel. The Training Division would also manage the scholarship program in consultation with the other technical departments of MOPH. During negotiations, GOC provided assurances that for all scholarships funded by the project, it would (a) submit for IDA approval the proposed candidate, training institution, and course of study, and (b) take all necessary measures to ensure that successful candidates bind themselves to serve for at least three years in posts for which they were trained. The Directorate of Pharmacy would coordinate the introduction of legislation and regulation to strengthen pharmaceutical policy. The Health Education Unit (HEU) of MOPH, with support from other agencies including the Cameroon Radio and Television Corporation, the Ministry of Social Welfare and Women's Affairs and the Ministry of National Education, would coordinate the communications program. 32

C. Project Coordination

5.10 The Technical Committee for Coordination and Follow-up of Health Sector Projects (TCC) has been enlarged (paras. 4.14 and 7.1 (i)) to include representatives of other ministries concerned with PHN issues and would coordinate and oversee the implementation of the HFN project (and all other projects in the sector) under the overall control and guidance of the Minister of Public Health, who would consult periodically with the Minister of Economy and Finance. With PPF assistance, the TCC is now operational and meets regularly both to discuss important sectoral issues internally and to maintain contacts with donors.

5.11 At appraisal, the role of the TCC Secretariat was agreed to and includes liaison with the operating departments of MOPH and MEF involved in the project and with the donors. The TCC Secretariat would include a full-time experienced Project Coordinator (whose appointment was confinned at negotiations) in charge of the project, principally to oversee the preparation of technical and financial reports to the Government and IDA. Nomination on terms and conditions satisfactory to IDA of other key project management staff namely, 6 procurement specialists and 6 financial officers (I for the central level and I in each participating province) and of additional personnel to the TCC for specific technical areas (e.g., a Financial Officer whose task would be to supervise the implementation of cost recovery operations nationally, to monitor progress, and to carry out internal audits of the financial operations in the provinces) would be a condition of IDA credit effectiveness. Short-term consultant services would continue to be made available to the TCC Secretariat, as needed. At negotiations, GOC gave assurances that the TCC Secretariat would remain fully staffed throughout project implementation.

5.12 Annual work programs and corresponding budgets would be prepared by the project implementing agencies at central, provincial, and district levels; these plans and budgets would be consolidated by the Project Coordinator, reviewed and approved by the TCC or one of its sub-organs, and submitted to IDA for review and non objection at the beginning of each fiscal year. Funding has been included in the project to enable these agencies to improve their planning and budgeting. Funding has also been included to help the Secretariat monitor the project, manage its consolidated accounts, and prepare semi-annual progress reports for the GOC and IDA. The Secretariat would manage the agenda of the consortium of key donors to PHN to be created under the project (para. 3.30), organizing its meetings and follow-up action.

D. Procurement

5.13 Table 4 below summarizes the project elements, their estimated costs, and the proposed methods of procurement. Additional details may be found in Annex 21. Following the recommendations of the Country Procurement Assessment Report issued in April 1994 which concluded that procurement practices in Cameroon were inadequate, and to enable a satisfactory procurement process, the following measures were discussed and agreed upon during negotiations: 33

For ICB

• Advertisement to be made through Development Forum, local newspapers and embassies located in Cameroon. * Minimum of 45 days to be allowed between availability of bidding documents to bidders and bid submission date. * Precise quantitative and/or monetary criteria are to be used for bid evaluation and post qualification criteria, * Contract must be awarded to the lowest evaluated responsive bidder. * The two envelope system of bid presentation would be discontinued. * Registration, income tax and social security clearances for bidding would not be requested from foreign bidders. * Bid guarantees should be allowed from any acceptable Bank of member countries. . The obligation for bidders to use a Cameroonian shipping/insurance company should be discontinued. • There should be no negotiation between bid-opening and contract award decision. * A provision must be added in the bidding document for international arbitration. * Payment for import of goods shall be made by letter of credit.

For LCB

* All bid openings shall be public, allowing bidders or their representatives to attend. * Precise quantitative/monetary criteria must be used in bid evaluation. * Contract must be awarded to the lowest evaluated responsive bidder. * There will be no negotiation between bid opening and contract award decision.

For Consultants

* The short-list shall be a minimum of 3 and a maximum of 6 firms with no more than 2 firms from the same country. * The practice of requesting bid and performance securities shall be discontinued. * Quality shall be the main criterion for the selection of consultants.

Additional procurement arrangements are outlined below; these arrangements were reviewed with the Government at appraisal.

5.14 Project Procedures. All civil works, goods and services financed by the project would be procured in accordance with IDA guidelines. To the extent practicable, all contracts for works and goods would be grouped into bid packages estimated to cost the equivalent of US$ 100,000 or more.

(i) Civil Works. All major civil works for the reconstruction and rehabilitation of health centers and clinical facilities totaling US$19.6 million would be carried out through contracts in bid packages estimated to cost US$100,000 or more and awarded on the basis of ICB in accordance with Bank Guidelines for Procurement under IBRD Loans and Credits (May 1992). Local firms participating in ICB for civil works would be granted a 7.5 34

percent preference. Contracts estimated to cost the equivalent of less than US$ 100,000 per contract, up to an aggregate amount of US$ 0.5 million may be procured under contracts awarded on the basis of competitive bidding, advertised locally, in accordance with procedures satisfactory to IDA. Standard bidding documents would propose a reference price and indicate unit prices and quantities.

(ii) Goods. Contracts for vehicles, cquipment, medical supplies, materials, drugs, contraceptives and vaccines would be awarded in convenient packages of US$100,000 or more according to international competitive bidding (ICB) procedures in accordance with Bank Guidelines for Procurement of IBRD Loans and IDA Credits (May 1992). Exceptions to ICB would bc for small contracts spread over a period of time in which foreign firms would not bc interested. These would include contracts with a value of less than US$100,000 and not exceeding US$0.5 million in the aggregate, each of which would be awarded after LCB according to procedures acceptable to IDA; and small value items costing US$20,000 or less per contract and aggregating to US$0.25 million which would follow prudent international or local shopping procedures involving quotations from at least three reputable suppliers. A preferential margin of 15% or the applicable customs duty, whichever is less ovcr the c.i.f. prices of competing goods for all ICB procurement, would be given to domestic firms, if any. and

(iii) Consultants' Services. Intemational and local consultants' services financed by IDA (US$1.4 million equivalent) would be contracted in accordance with the Bank's Guidelines for the Use of Consultants (August 1981). The model letter of invitation and standard form of contract for appointment of consultants as developed by the Bank would be used. The services include training, technical assistance, contract management services, architectural serviccs for the design and supervision of the rehabilitation works and other specialist services in the area of procurement, auditing and accounting. The Government would contract design and supervision of civil works to private firms selected in accordance with the Bank's Guidelines for the Use of Consultants (August 1981).

5.15 Procurement Arrangements under the Proiect. For the proposed project a number of activities are planned in order to cstablish local capacity in the area of project coordination and implementation:

(a) A Project Coordinator has already been identified. The Project Coordinator would work under the TCC and coordinate the activities of all the departments and services of the Ministry of Economy and Finance, and the Ministry of Public Health involved in the project.

(b) A detailed implementation schedule (see Annexes 20 and 21) for works, goods and services to be procured under the project has been prepared and was reviewed during negotiations and wvould be updated,annually, during implementation for discussion with the IDA supervision missions. This would contribute to ensuring timely processing of all required actions. During implementation, all bid evaluation reports transmitted to IDA for review would contain an updated copy of the implementation schedule and a Form 384. 35

5.16 The Department of Planning of MEF would be responsible for procurement of works, goods and services for component (i) or Part A of the project. The Directorate of Studies. Planning and Statistics of MOPH (DSPS) would be responsible for procurement of works, goods and services for components (ii) and (iii) or Part B and C of the project. However, in addition to six full-time procurement specialist positions (I central + 5 provincial), DSPS would have access to support from independent procurement specialists (consultants), as required (estimated at two man-months per year during the first two years of the project and one man-month per year during the rest of the project). The Directorate of Studies, Planning and Statistics under the guidance of the TCC would ensure that standard bidding documents for the projects including those for all civil works and goods for the first year of the project, are prepared and found acceptable to IDA prior to credit effectiveness.

5.17 DSPS, with assistance from the full-time procurement specialist, would also collect and record procurement information as follows: (a) Prompt reporting of contract award information; and (b) Comprehensivemonitoring reports to IDA (on a semiannual basis and at time of submission to IDA of each bid evaluation), indicating: (i) revised cost estimates for individual contracts and the total project, including best estimates of allowances for physical and price contingencies; (ii) revised timing of procurement actions, including advertising, bidding, contract award, and completion time for individual contracts; and (iii) compliance with aggregate limits on specified methods of procurement.

5.18 Review by IDA. IDA-financed contracts for works and for goods above a threshold of US$100,000 or more each, and the first five contracts procured under LCB, would be subject to IDA's prior review procedures. Selective post-review of awarded contracts below the threshold levels would apply to about one in three goods contracts. In the case of consultants, prior review by IDA would be required for all consultancy contracts.

5.19 During negotiations agreement was reached on the proper monitoring of the procurement, as well as the use of Bank Standard Bidding Documents for ICB, and standard procurement documents for LCB to be developed and reviewed by and agreed with IDA. At negotiations, the Government reviewed with IDA: (a) an updated procurement plan; (b) a procedural manual for management and procurement; and (c) draft bidding documents for the infrastructure rehabilitation program and major equipment as well as draft letter of invitation for consultant services. The Government gave assurances that it would apply the procurement procedures and arrangements outlined above. 36

Table 4: Procurement Methods and Disbursements Procurement Arrangements (US$ '000)

Procurement Method International Local Competitive Competitive Consulting Project Element Bidding Bidding Servicesa Otherb Total Cost

Civil Works 16,665.4 2,941.0 - - 19,606.4 (16,665A4) (627) - (16,665.4)

Vehicles 3,307.3 - - 3,307.3 (2,819.6) - - - (2,819.6)

Medical & other imported equipment 4,162.7 - - - 4,496.7 (4,162.7) - - - (4,162.7)

Materials - 18.3 - - 18.3 - (15.7) - - (15.7)

Furniture - 502.4 - - 502.4 - (452.6) - - (452.6)

Drugs Yrs 1-3, Vaccines & Contracep. 3,616.5 - - - 3,616.5 (3,570.4) (3,570.4)

Drugs Yrs. 4-6 689.3 - - - 689.3

Short-Term Consultancy - - 1,399.3 - 1,399.3 - - (1,399.3) (1,399.3)

Fellowhip/TrminingAbroad - - 620.1 - 620.1 - - (566.1) (620.1)

Local Trng./Seminars/Studies - - 3,893.4 250 4,143.4 (3,893.4) (250) (4,143.4)

Operation/Maint.IGen.Oper. Costs/Superv. - - - 8,469.2 8,469.2 (7,833.4) (7,833.4)

Incrementalsalaries/Redeploymt. costs - - - 518.9 518.9

PPF Refinancing - - 600.0 - 600.0 - - (600.0) - (600.0)

TOTAL 28,441.2 3,461.7 6,603.3 9,238.1 48,080 (27,218.0) (1,095.3) (6,603.3) (8,083.4) (43,000)

Employmentof consultants would be in accordance with IDA guidelines. b Includesminor items (repair contracts, office supplies, etc.) costing US$20,000 or less which would be procured internationally or locally on the basis of price quotations from at least three reputable suppliers. - Non ICB/LCB Aggregated as Other Note: Figures in parenthesis are the respective amounts financed by the IDA credit. 37

E. Disbursement. Accounts and Audits

5.20 The IDA credit of US$43 million would be disbursed over a six-year period; consistent with the country disbursement profile; a schedule for estimated disbursements is presented in Annex 23. Major project components would be completed by December 31, 2000, and the closing date for the IDA credit would be June 30, 2001. The IDA credit would be disbursed according to the components and categories in the percentages indicated in the following table:

Table 5: Withdrawalof the Proceedsof the IDA Credit

AmountXUS$0 Percentageof Categories MOPH MEF Expenditures l ______Total to be Financed 1) Civil Works 16,600 100 16,700 100% foreign; 85% local

2) Equipment, Furniture, Materials and 7,100 400 7,500 100% foreign; 85% Vehicles local

3) Drugs, Contraceptives and Vaccines (a) Generic drugs, Contraceptives and Vaccines 2,600 (b) Drugs for health centers and district clinical facilities 1,000 3,600 100%

4) Consultant Services 1,400 1,400 100%

5) Training, Workshops and Studies 3,700 1000 4,700 100%

l6) Operating Costs 2,900 600 3,500 100% foreign; 95% Local

7) Operations and Maintenance of 1,800 200 2,000 95% Build, Veh. and Equ.

8) Refunding of PPF 600 600 Amount Due

9) Unallocated 3,000--

Total 43,000

5.21 The project would finance initial supplies of essential, generic drugs at 100 percent; subsequent supplies would be purchased with the revenues generated by community financing through the cost recovery system. Imported contraceptives and vaccines would be financed at 100 pereent. Operating costs financed 38 at 100 percent (foreign) or 95 percent (local) would include mission travel and subsistence allowances for local and expatriate staff involved in the project, fuel and office supplies. Operations and maintenance of buildings, vehicles and equipment would be financed by IDA at 95%. Past Bank experience with disbursement in Cameroon indicates that counterpart funds are made available with considerable delays. Assurances were obtained at negotiations that GOC would take necessary corrective action (para. 3.25).

5.22 To expedite disbursements, two special accounts would be opened in conmmercialbanks in Yaounde, managed by MOPH and MEF and used for all categories of expenditures. One special account would be established for MEF for US$100,000 equivalent until disbursement and special commitments reach SDR 700,000 and a ceiling for the amount of CFAF I 10 million (US$200,000 equivalent). The other special account would be established for MOPH for US$600,000 equivalent until disbursement and special commitments reach SDR 3.5 million and a ceiling for the amount of CFAF 660 million (US$1,200,000 equivalent), each representing four months of operating expenses. These amounts were confirmed during appraisal. Five second generation accounts would be opened under the MOPH special account, one in each of the provinces included in the project, in a branch of the same commercial bank, or the local branch of a correspondent bank in those places where no local branch exists. Advance payments covering four months of estimated expenditures would be made to these second generation accounts by MOPH from the main special account on the basis of realistic budgets of anticipated expenditures proposed by the provincial health authority and authorized by the Minister of Public Health. MEF would exercise its normal review and control of expenditures and accounts through its provincial financial controllers stationed in each of the provinces. The signatories for withdrawal of second generation accounts would be the provincial financial controller (Ministry of Economy and Finance) and the provincial health delegate, acting together.

5.23 District clinical facility renovation, bulk equipment purchases, vehicle purchases, and consultant services would be excluded from second generation accounts. Provincial accounts with supporting receipts would be submitted monthly by the local branches (including the branches of correspondent banks) to the Directorate of General Affairs of MOPH with copies to the TCC Secretariat. The special accounts would be replenished by IDA against documented expenditures and upon receipt of withdrawal applications supported by bank statements from the special accounts and all second generation accounts. Small expenses related to project administration and miscellaneous operating costs, training workshops and seminars, airline tickets, fuel, and contractual services valued at less than US$50,000 equivalent would be reimbursed against certified statements of expenditures for which documentation would be kept at the Secretariat of TCC for review by IDA supervision missions and project auditors.

5.24 GOC would establish adequate accounts for all project operations in accordance with sound accounting practices. During negotiations, GOC gave assurances that it would furnish annual audit reports to IDA on the project accounts and that these audits would be carried out by independent auditors selected on terms and conditions acceptable to IDA. Certified copies of the accounts and the auditors' reports would be forwarded to IDA for review within six months after the end of each fiscal year. The appraisal mission reviewed with GOC a short list of firns from which one would be retained to audit project accounts based on a multi-year contract. The selected firm would establish project accounts, train the accounting staff and carry out periodic financial and technical audits on the basis of a multi-year contract with the Government. Signing of the auditing contract would be a condition of IDA credit effectiveness. An audit firm has been recruited by the Government to assist in establishing the accounting and financial management system and to verify compliance with the procurement and disbursement arrangements under the IDA Credit Agreement and the Implementation Manual. The audit firm would also review the financial statements, the performance of the cost recovery system and of financial management, and help evaluate the impact of the project. 39

F. Monitoring. Evaluation and Supervision

5.25 To increase the independence of judgmcnt and objectivity of the evaluation process, monitoring and evaluation should be conducted by separate institutions. Monitoring of the implementation of the project would be responsibilities of the Ministry of Public Health and the Ministry of Economy and Finance, whereas the evaluation of its impact would be carried out by a combination of beneficiary community assessments, NGOs and research institutions (for nutrition indicators for example). At negotiations the Government and IDA reviewed and included in the documents mechanisms for beneficiary voice, feedback and incorporation of their concerns (such as satisfaction with the services provided, participation in the decision making process, etc ..), to reduce dependence on Government. Also, performance indicators were agreed upon to measure overall progress of the project. (See Annex 22).

5 26 Monitoring would bc the responsibility of the Ministry of Public Health and the Ministry of Finance and Economy based on rcports from participating services and departments and "ad hoc" surveys requested when necessary from consultants. The information obtained from the provinces would be analyzed and mapped so as to permit appropriate planning. The information generated would be consolidated by the Ministry of Public Health and used for the preparation of its semi-annual progress reports.

5.27 Monitoring of Compliance with Financial and Procurement Covenants. The Ministry of Public Health and the Ministry of Economy and Finance would set up an analytical accounting and financial managemcnt system to monitor costs by activity and by site, to develop standard costs of works, goods and services and maintain their level at competitive standards.

5 28 Evaluation of Impact. Since the project aims at delivering health, family planning and nutrition services the evaluation will focus on (a) access and use of health services, (b) availability and use of essential generic drugs and contraceptives and (c) nutritional status, anthropometric indicators, health of participating populations, etc. The objective of the evaluation is to assess whether the project has improved the information and practices of household regarding health and birth control, their nutritional status and in general the quality of life of the beneficiaries inside and outside the direct intervention areas. The project may have a spill-over effect beyond the targeted communities. The indicators used would also include non quantitative features, such as community participation, access to information, mobility, preservation of valuable skills and traditions, status of women and other variables which would be part of the evaluation scheme.

5.29 Supervision. Because of the project complexity and MOPH's relative inexperience with IDA procedures, IDA supervision would be intensive during the early stages of project implementation. Semi- annual revieNwsof progress in the field are planned, and supervision inputs into key activities have been programmed (Annex 24).

5.30 MOPH has recently established guidelines, procedures, and schedules for monitoring and supervising implementation of the health districts by the central and provincial levels as well as by each of the main programs. In addition, baseline surveys would be carried out by the Government, for example for the nutrition component. Provincial health authorities would prepare semi-annual progress reports to be submitted to the TCC and to IDA. The reports would assess progress (physical, institutional, and budgetary) against agreed annual programs and targets. In addition, based on MOPH's list of HMIS indicators, IDA and MOPH reached understandings during appraisal on a set of service indicators, reflected in the draft Project Implementation Manual and Annex 22, to measure the project's population and health outcomes and impact. At negotiations, the Government gave assurances that it would carry out annual beneficiary 40 assessments based on the agreed indicators. These would provide additional information on the quality of service delivery.

5.31 A comprehensive mid-term review of the entire project would be carried out jointly by GOC and IDA not later than June 30, 1997. The review would: (a) evaluate progress on the project's outcome objectives; (b) identify additional measures, if necessary, to accomplish these objectives; and (c) adapt the Action Plan Matrix in accordance with the capacity and performance of the various GOC departments involved. The review would specifically focus on performance concerning: (a) the functioning of the key PHN sector management structures (the TCC and its Secretariat and the Directorate of Planning of MEF); (b) progress on cost recovery measures and their impact on health care service quality and utilization; (c) progress in delivering quality primary and referral health services under the decentralized health district system; (d) progress in implementingthe training activities to improve the performance and productivity of staff, and (e) the performance of the consultants.

5.32 Finally, the Government gave asssurances at negotiations that an implementation completion report detailing the project's progress in achieving its objectives, its sustainability and outcomes, and IDA and GOC's performance would be submitted to IDA within six months of the closing date, along with a plan for future operations of the project which would be carried out thereafter.

VI. PROJECT BENEFITS AND RISKS

A. Benefits

6.1 Through the establishment of nine rural districts in the Center, East, West and Far North provinces and nine urban districts in Yaounde and Douala, the project would support expansion of quality primary health care coveragc to approximately 3 million people. Within these 18 districts, project objectives are: (a) to reduce maternal mortality by 30 to 50 percent; (b) to increase vaccination coverage for the main target groups from under 40 percent to between 60 and 80 percent; (c) to increase the modern contraceptive prevalence rate from less than 5 percent to between 10 and 20 percent by the year 2000; and (d) to enhance the nutritional status of the most vulnerable population groups. The project is expected to improve the overall efficiency and effectiveness of PHN sector operations by strengthening sector resource management and coordination and by enhancing the productivity and improving the quality of services provided by MOPH personnel. Increased availability of low cost essential drugs, contraceptives and vaccines would raise the credibility of PHN services, increase utilization of services, and reduce illness and premature deaths from preventable and curable diseases.

B. Risks

6.2 Because of the relatively recent adoption of the population and health policies, some difficulties and potential delays should be anticipated in translating policy orientations into clearly defined institutional relationships and an overall strategy into implementable programs. Specifically, the existence of firmly entrenched distortions and rigidities in the health care system and MOPH's generally weak coordination of activities may prove difficult to overcome in a first project. The possibility of a lack of continued Government commitment to new PHN policies poses another risk that will be closely monitored to ensure adherence. Govermmentfulfillment of conditions prior to negotiations and Board presentation has established the legal basis for the community participation structures and their relationship to MOPH. During implementation, internal coordination would be strengthened by restructuring MOPH's management and formalizing coordination links through the TCC. Consultant services would assist GOC agencies in 41 implementingthe project while permitting build-up of local capacity. Finally, previous experience of other projects indicates that while the proposed reforms are generally supported by providers and consumers, they are complex and would requirc an extensive and continuous effort to educate the public. The project would support the Health Education Unit of MOPH which is responsible for these information activities.

VII. AGREEMENTS TO BE REACHED AND RECOMMENDATION

7.1 Before credit negotiations, GOC agreed to:

(i) expand the membership of the Technical Committee for Coordination and Follow-up of Health Sector Projects (TCC) to include representatives of the Ministries of Public Health, Economy and Finance, Social Welfare and Women's Affairs, Education, and Agriculture (para. 4.14); and

(ii) nominate the Financial Officers for the five provinces covered by the project and the Financial Officer for the central level, on terms and conditions satisfactory to IDA (para. 4.25).

7.2 Before Board presentation.,GOC agreed to:

adopt legislation decentralizing management responsibilities within the public health system, establishing decentralized health districts in Cameroon, and specifying the modalities for district management and operations (para. 4.29);

7.3 Before the Credit becomes effective, GOC would:

(i) prepare and finalize the standard bid documents in form, substance and format acceptable to IDA, including the bid documents for all the civil works and goods for the first year of the project (paras. 5,16 and 5.19).

(ii) appoint the key project management staff including the Project Coordinator, 6 procurement specialists and 6 financial officers, under terms and conditions satisfactory to IDA (para. 5.11);

(iii) enter into a multi-year contract with an auditing firm under terms and conditions satisfactory to IDA (para. 5.24); and

(iv) sign the contract with the training coordination consultant (para. 4.55).

7.4 Before disbursement against the category related to drugs for the health centers and the district clinical facilities (category 3 (b)), GOC would:

(a) adopt regulations instituting the Central Drug Supply Store and organizing its management and operations; (b) finalize and publish appropriate legislation, or decrees as the case may be, conceming pharmaceutical policv and regulations, and (c) propose satisfactory measures for ensuring the quality of imported generic drugs (para. 4.56). 42

7.5 Assurances were also given at negotiations that GOC would:

(i) take all necessary measures to increase progressively the share of the health budget from 5.0 percent of the total Government budget FY 1993/94 to 7.0 percent by FY 1996/1997; 8.0 percent by FY 1998/1999; and 10.0 percent at the end of FY 1999/2000; and allocate the increases to non-salary expenditures until the end of the project (para. 3.25),

(ii) carry out a fertility survey every two years and a contraceptive prevalence survey annually starting in CY 1996, both in accordance with terms of reference acceptable to IDA, with the results to be fumished to IDA for comments (para. 4.8);

(iii) submit to IDA before June 30, 1996, a plan of action to develop sectoral strategies and programs for the implementation of the National Population Policy (para. 4.9) and implement the plan;

(iv) take necessary measures to ensure equitable geographical distribution of staff and improved internal management of civil servicc personnel assigned to MOPH (para. 4. 18);

(v) review with IDA in June of each year: a) all health sector investment expenditures made in the previous year and those planned for the next three years, with particular attention to their recurrent cost implications; and b) the expenditure of the non-salary recurrent budget across existing programs and services. (para. 4.19);

(vi) submit to IDA not later than April 30 of each year evidence that the previous year's budget was spent as originally intended, and prepare and discuss the proposed operating budgets for the subsequent year (para. 4.20);

(vii) maintain a system acceptable to IDA for cost recovery accounting and financial management of health centers and district clinical facilities.

(viii) submit to IDA by December 31, 1995, a national program for expanding family planning services over the 1996-1999 period and implement the program (para. 4.35);

(ix) evaluate annually the technical and management training activities undertaken during the previous year and furnish to IDA for its review and approval by March of each year detailed plans based on that evaluation (para. 4.50);

(x) Keep the TCC Secretariat fully staffed, and key staff appointed with terms of reference, qualifications and experience acceptable to IDA throughout project implementation (para. 5.11);

(xi) for all scholarships funded by the project, (a) submit for IDA approval the proposed candidate (including his/her functions and qualifications), training institution, costs and course of study; and (b) take all necessary measures to ensure that successful candidates bind themselves to serve for at least three years in posts for which they were trained (para. 5.9); 43

(xii) furnish annual audit reports to IDA carried out by independentauditors selected on and conditionsacceptable to IDA, and furnish certified copies of the accounts and the audit reportsto IDA within six monthsof the end of each fiscal year (para. 5.24);and

(xiii) carry out annual beneficiaryassessments based on the agreedservice indicators(para. 5.30); and, jointly with IDA, hold a mid-termreview of the entire project not later than June 30, 1997 (para 5.31).

7.6 Recommendation.Subject to the above conditions,the proposedproject would constitutea suitable basis for an IDA credit of SDR 29.5 million (US$43 million equivalent) on standard IDA terms with a maturity of 40 years.

AF3PH February 7, 1995 44 Annex 1 REPUBLICOF CAMEROON

HEALTH, FERTILITY,AND NUTRITION PROJECT

BASIC DATA

|25 - 30 | 15 -20 |Most recent |yearsao yearsago estimate (1991) Area and Population Total area (thousands of square kilometers) 475 475 475 Total population (thousands) 5,825 7,439 12,000 Urban population as percent of total population 16.40% 26.90% 42% Per capita GNP (US$) ...... $850

Population Growth Average annual population growth rate 1.90% 2.90% 3% Projected population for year 2000 (millions) ...... 15.5 Projected population for year 2025 (millions) ...... 32.5 Total Fertility rate 5.2 6.3 5.8 Retention .... 43 42 Crude death rate (per 1000) .... 14 12 Age structure of population 0 - 14 years ...... 44.70% 15 -64 years ...... 51.60% over 65 years ...... 3.70% Life expectancy (years) 42 47 55

Health Infant mortality rate, 0-1 year(per thousand live births) 143 109 65 Under five mortality rate (per thousand live births) .... 198 126 Maternal mortality (per 100,000 live births) ...... 430 Babies with low birth weight ...... 13% Population per physician 26,720 13,700 11,998 Population per nurse 5,831 3,800 2,000

Family Planning Percent of women wanting no more children ...... 12.40% Percent of women wanting two years between births ...... 34.70% Percent of women using any method of contraception ...... 16.10% Percent of women using any modern method .... 2.00% 5.00%

Education Total illiteracy rate (% of population) 81% 59% 46% Femaleilliteracy rate ...... 50% Percentageof age group enrolled in school Primary 94% 97% 101 % Secondary 5% 13% 26% Tertiary .... 2% 4%

Sources: Social Indicators of Development 1993; World Development Report 1993: Cameroon Demoaraohic and Health Survey 1991; Ministry of Public Health 1993. 45 Annex 2 REPUBLICOF CAMEROON HEALTH,FERTILITY AND NUTRMON PROJECT POPULATION DATA

dtMOG*AP41 IM-4cT6hRS v

v978 - 1987: 1991 Crude Birth Rate( per thousand) 45 41.2 42 Crude Death Rate (per thousand) 20.4 13.7 12 Infant Mortality Rate (per thousand) 156.5 82.9 65 % less than 15 years of age 43.4 46.4 44.7 % between 15 and 64 years of age 52.9 50.2 51.6 % over 65 years of age 3.7 3.4 3.7 Informationin first two columnsIs from 1976 and 1987 censusesin Cunoroon. Informationin third columnis from 1993 World DoevloprnmntReport.

DSfiSLT)t~OFHEPOPULATION

Adamaoua 63,701 554,000 8.80 Center 65,420 1,851,000 27.00 East 109,002 578,000 5.30 Far-North 34,263 2,110,000 61.40 Uttoral 20,229 1,521,000 75.20 North 66,090 931,000 13.80 Nonhwest 17,409 1,391.000 80.40 West 13,883 1,500,000 107.30 South 50,752 424,000 9.10 Southwest 24,709 927,000 34.70 Total 465,458 11,787,000 (mean) 24.80 Source: Minist of Public Wealth,Cameroon. 46 Annex 3

REPUBLICOF CAMEROON HEALTH, FERTILITYAND NUTRITION PROJECT POPULATION PROJECTIONS

POPULATION PROJECTIONS FOR CAMEROON

40.00 o35.00 30.00 25.00 20.00 15.00 U.. *210.00 0. 0.00 o .00 1990 1995 2000 2005 2010 2015 2020 2025 Assumespresent growth rate of 3 % and Year other indicatorsremain constant.

POPULATION PROJECTIONS FOR YAOUNDE AND DOUAILA

7.00 Assumesa 5% annualincrease for Douala 6.00 - and 6% for Yaounde 5.00

44.00 -- *-YAOUNDE

.~3.00 -X- DOUALA j2.00 1.00

0.00 - i I t l 1990 1995 2000 2005 2010 2015 2020 2025 Year 47 Annex 4

REPUBLIC OF CAMEROUN EEALTH, FERTIITY AND NUTRrITON PROJECT CAUSES (IF MORBIDITY AND MORTALITY IN 1992

LIST OF FIRST TEN CAUSES OF MORBIDITY

Causes

Malaria 41.79 Intesnnal Parasites 13.15 Skin Diseases 11.21 Broncho-pneumonia 8.18 Cold/Sore Throat 7.36 Anemias 4.19 STD Infections 7.65 Diarrheal Infections 3.27 Mouth Diseases 3.21 Source: Minstry of Public Healh and Mission'sEstmate

LIST OF FIRST TEN CAUSES OF MORTALITY

Causes 9

Malaria 34.84 Anemias 12.95 Respiratory Diseases 8.63 Neonatal Tetanus 8.43 Malnutrition 8.12 Meningitis 7.71 Pneumonias 6.78 Diarrheal Diseases 5.96 Hypertension 3.49 Intestinal Occlusions 3.08 Source: Minstry of PublicHealtn and Mission'sEsFimates 48 Annex 5

REPUBUCOF CAMEROON HEALTH.FERTIUTY AND NUTRmON PROJECT PRE-NATALCARE AND ASSISTANCEDURING DEUVERY

Pre-natal Care in Cameroon

Don't Know 4% No visits_ .21%

4 visit or more 49%

1 visit 3%

2-3 visits 23%

Assistance During Delivery

None 4% Relatives/Fnends 21%

Nurse/midwife 52% TBA 12% NursesAi 5% Doctor 6%

Source: 11St1Demograpti0 end H.alth Survey Annex 6

REPUBLICOF CAMEROON HEALTH,FERTILITY AND NUTRITIONPROJECT VACCINATIONCOVERAGE

National Vaccination Coverage 1992

60 50a 40 0 Q 30 c 20

Vaccine

ATo refers to Anti-tetanus Vaccine.

Vaccination Coverage by Province for 1992 .~~~-UL B3Ja 70 60- 150 *BCG 0 40 20 ~~~~~~~~~~~~0DPT3/P3 30 nii~u M easie 20 10 Q ATV 10

U. Province

Source: DivImonof Ruraland PreventiveHealth. PArsariyof Pubic Health. Camerooft Annex 7

REPUBLIC OF CAMEROON POPULATION, FERTILITY AND NUTRMTON PROJECT NUTRITIONAL STATUS OF CHILDREN UNDER FIVE

Percensge of chiddren under 5 couidered Ls under nourisbed using andhropoaetricmeAremmmu of -atritioul fnaw.

Height for Age (S) Weigh&for Height (S) Weight for Age (S)

Less thaa Les than Lest than Las. tha 1.es ta LAs tdan Characteniscs (-3D) (-2SD) (-3SD) (-2SD)' (-3SD) (-2SD)l Number

Ag* of child less than 6 mnths 0. 1.7 0.0 0.5 0.0 1.0 253 6-11 months 2.4 t.9 0.2 3.4 3.2 10.9 334 12-23 mothst S.6 2S.5 0.8 7.3 5.2 21.2 549 24-35 arxths 12.9 313 0-3 1.9 3.0 16.6 424 36-47 wmohs 12.6 30.4 0.0 123 2.6 13.0 411 43-59 months 11.9 33.2 0.3 0.8 1.6 11.0 382

Se. of chad Male 8.5 25.4 0.3 3.1 23 12.4 1195 Female 9.3 23.4 0 2.S 335 14.9 1162

R-nk of nild 1 8.2 22.9 0.4 3.6 3.2 13.7 432 2-3 7.7 72..6 0.4 2.6 2.2 11.7 760 4-5 10.0 233 0.2 1.6 2.9 14.5 556 6 and over 9.8 28.7 0.7 4.0 3.6 15.2 609 BiutbiJ Ftrst borm 8.4 23.1 0.4 3.6 3.2 13.9 435 LAs ths 24 moau 8.2 23.0 03 2.1 3.4 14.6 379 24-27 momh 9.7 2535 0.4 2.7 2.9 14.1 1238 48 monthand over 7.0 23.4 0.4 3.4 1.9 10.0 306

LIT* svi,nimnt Yaoundi/DouaLs 2.1 8.9 0.2 1.0 035 5.1 351 Other cities 7.0 21.5 1.1 4.2 3.4 14.7 609 Urbtanto'al 5.2 16.9 0.8 3.0 2.4 11.2 960 Rual 11.4 29.6 0.2 2.9 3.3 153 1397

Yaoundr/Douala 2.1 8.9 0.2 1.0 05 5.1 351 A4am&oua/Nor/EL North 11.t 21.9 13 6.S 6.0 243 679 CegartlSanh/Ee 8.4 25.1 0.0 1.8 3.9 14.3 494 Wesiti/ll 9.7 26.2 0.2 145 1.0 635 421 Noeth-Wea=/SCO&Wm 9.4 27.6 0.0 1.1 0.7 9.2 413

Edncatam kvd of mw Norm 133 32.2 0.6 4.7 4.6 21.4 769 Prinwy S.6 24.2 0.5 2.3 2.4 10.4 1039 S.coadaryor bthir 3.1 13.9 0.1 1.7 1.5 1.1 550

Total of children 3.9 24.4 0.4 3.0 2.9 13.6 2357

Note: This table is baed on thechildren born within te 1-59 s prior to the fuey. Ech ndicatm is uxprmd in units of the sandard deviation (SD) from the median of the Population of In zteLkwAlRhewue used by NCHS/CDCAWHO.Th childre aje under nuruhed if tbey fnd the lves a&less tha -2 SD (-2SD ead -33D) of th medisaof th refiere

'The childn at less tha -3SD an inchhded in this aegory.

Soume: Cmeroo Demtonphie Lad Healt Survy, 1991. 51 Annex 8

REPUBUCOF CAMEROON HEALTH,FERTILITY AND NUTRITiONPROJECT FEEDINGPRACTICES BY AGE AND PROVINCE

Feedin PracticesBy Age (percent)

< 2 10 9 56.1 5.4 16 1292.7 0 5 2 to3 41 41 538 93 4 4 to 5 0 166 22411 2 77 6 to 7 1 15?9 0.4 0 67.9 6.7 8. 1 8 to 9 1.7 9.9 .t 1.7 63.9 13.6 8.2 10to 11 1.2 9.8 0.9 2.3 70.6 7.6 7.7 12 to13 2.5 6.1 2.7 1 56.9 12.1 18.7 14 to 15 , 0 5.9 1.3 1.3 57.3 8.4 25.7 16 to 17 1.1 6.4 1.7 1.3 43.6 3.1 42.7 18 to 19 0 5.5 1.8 0 34.1 3.6 55. 1 20 to 21 0 2.1 0 0 26.9 3.1 64.9 22 to 23 0 2 1.2 0 26.2 6 64.6 Source:1991 Cameroon D.mogreptic ad HUelthSurvey

Initiation of &essffeding Immediately <24 hrs > 24 hns (percent) (percent) (Prcnt) Adamaoua/North/Fur-North 14.9 8.8 76.3 Center/South/East 8. 1 18.3 73.6 WestALittoral 10.7 24.8 64.4 North-West/South-West 14.4 30.7 54.9

Introduction of Complemeny Foods(orcen) Adamaoua/North/Far-North 77 Center/South/Est 76 WestAittoral 70 North-West/South-West 79

Reasonsfor Weaning Matemal Child rime to Factors Factors Wean Adamaoua/North/Far-North 19.5 4.9 75.7 Center/South/East 25.5 12.7 61.7 West/Littoral 14.4 9.7 75.9 North-West/South-West 12 7.6 80.4 Maternifactors inehde lneas. nipple or breaMotobwn. nomilk. woiwng.becare pr.mt Chid factorsincluod Ilneas or refduedto sucWl. Source:1991 Caneroon DemogrepNe and Heath Survey Organigramme simpifIe du Minist6re de la Sante Publique

i~~~~~ hb |- Eap- b1s I.. C." a- F£o Co o co...|

F..M-B..& -60 , .. A~ yr 4~.To4... MQ. id. w o du.. i

Lu'. F...M .' ftub ~~~ , 64 6

I {" F S 6e s B u o H _M& | {WV.

S.| ,Srbu. XO_ _ D_,II 4I I MZ 53

Annex 10 Page 1 of 7

REPUBLIC OF CAMEROON HEALTH, FERTILITY AND NUTRITION PROJECT FINANCING CAMEROON'S HEALTH SECTOR

II. GovernmentFinancing

While governmentspending for health in Cameroonhas never approachedthe 10% advocatedby the World Health Organization,it had reachedhistorically high levels by 1985/86.As Table 1 indicates, followingdeep budget cuts for 1986/87 and 1987/88, the Ministry of Health's budget has remained relativelystable in absoluteterms whileobviously declining in real terms.

Table 1: Ministryof Health budgetsduring the economiccrisis

86/87 : 87/88 : 88/89 : 89/90 : 90/91 : 91/92 : 92/93 : 93/94

Investment : 8,008: 5,014: 2,265: 3,225: 3,365: 3,220: 3,150: 3,150 Operating 27,809: 25,622: 23,976: 25,641: 22,731: 24,362: 25,837: 24,329

Total Health : 35,817: 30,636: 26,241: 28,866: 26,096: 27,582: 28,987: 27,479 % of Total : 4.8% : 4.7% : 4.5% : 5.2% : 5.1% : 5.1% : 5.3% : 5.0%

Though the above table clearly documentscontinuing government support to the health sector duringespecially difficult times, further analysis suggeststhree fundamentalproblems with the Ministry's budget:

- the rigid budget structure and centralized preparation process which leave little room for negotiation; - the lack of a quantitativebasis justifyingMSP's additionalspending needs; and - the difficultiesof spendingthe amountsfinally approved by the variousministries and the National Assembly.

While this report discusses all three problems, solutions to the first and last problems require intenninisterialdecisions beyond the sole responsibilityof the Ministryof Health.

Budgetstructure and process

As in other Africancountries and in other Cameroonianministries, the MOIHswage bill essentially consumesthe entire operatingbudget. The followingtable summarizesbudgeted and expendedamounts for personnelas a proportionof the total operatingbudget. 54

Annex 10 Page 2 of 7

Table 2: Budgeted and expended MOH personnel costs as a proportion of total operatin, costs : 1990/91 1991/92 1992/93 1993/94 Budgeted personnel costs 84% 80% 83% 80% Expended personnel costs 91% 87% 88% -

As the table indicates, previous efforts to control personnel costs have been mostly unsuccessful: Despite the earlier elimination of certain indemnities and the more recent imposition of salary reductions (ranging from 4-20%), economies have been small and of short duration.

A recent study has identified 1.500 staff (of almost 17.000) as redundant, but even if they were all released, the net effect would probably be about a 5% reduction in personnel costs. And even if such savings were financially attractive (and politically feasible), the budgeting process would not necessarily ensure that the gains would be reallocated to other uses in the health sector.

The proposed project will focus on the issues of equitable distribution and improved quality of staff rather than on the reduction of the numbers of health personnel. The project will also promote measures to inform personnel of their rights and responsibilities as health personnel and to consolidate the power of the Minister to transfer and to discipline his staff.

In many respects, the budget process is as rigid as the budget structure. Annex 3 describes the different steps of the process (for the investment and operating budgets) as well as the principal actors. What is clear is that the highly centralized nature of the process has removed virtually all input from the local and intermediate levels and even most from the Ministry itself.

Ouantitative justification of needs

Even if more flexibility were introduced into the budgeting process, it is not clear for a number of reasons that the Ministry is prepared to take advantage:

- With the decline in available resources to respond to demonstrated needs, budgeting norms and instructions (which reportedly existed into the early 80's) have given way to the routine inscription of the previous year's amount, increased by some percentage. - Allocation of amounts approved by the National Assembly has the objective of providing some resources to all central and external services but the amounts are often determined arbitrarily. - Existing disbursement methods and accounting procedures do not permit adequate justification of past expenditures.

The proposed project will finance management tools for the the reintroduction of budgeting and allocation norms based on service performance and standardized methods for estimating costs. In addition, dispersion of accounting responsibilities (among different directions in Yaounde and by services outside Yaounde) as well as the payments by the Ministry of Finance (and the Treasury) mean that the MOH has great difficulties justifying past expenditures. In the proposed project, accounting personnel and procedures will be organized to improve the Budgeting Sub-Direction's ability to monitor MOH expenditures. 55

Annex 10 Page 3 of 7

Disbursement procedures

Once the budget is adopted by the National Assembly, the authority to spend is delegated to all services. Permission to spend is often delayed, however, and along with a lack of flexibility among line item expenditures and the lengthy procedurcs required to effect the purchase represent obstacles to efficient execution of the budgets.

Annex 3 details the various steps for procurement of goods and services, depending on the amount of the procurement and the level (central, intermediate or local) by which it is to be acquired.

Table 4 below demonstrates the impact of these disbursement procedures by comparing budgeted and actual expenditures for investment and non-salary operating costs.

Table 3: Comparison of budgeted and expended MOH budgets (millions of constant CFAF)

1990/91 1991/92 1992/93 1993/94

Investment Amount budgeted 3,365 3,220 3,150 3,150 Amount expended 2,607 1,640 766 - 77% 51 : 24% -

Operating (non-salary) Amount budgeted 3,701 4,818 4,415 4,783 Amount expended 2,408 2,974 2,983 - 65% 62 : 68% -

The results of this table indicate that while the investment budgeting process is becoming an increasingly fruitless activity, preparation of the non-salary operating budget remains a useful exercise.

Possibilities for increasing either or both investment and non-salary operating budgets, even in the medium-term, are so remote that the project should probably focus only on insisting that budgeted amounts be spent and that expenditure procedures be eased; these measures alone would double non-wage expenditures in the sector and justify proposed project efforts to improve budget estimates based on real need.

In the near-term, introduction/extension of cost recovery mechanisms represents the health sector's single best hope to establish a solid financial base capable of generating sufficient resources to reestablish and maintain minimum leveis of quality in its facilities.

III. Community Financing

Cameroonians have always paid for health care, both through the payment for medical services and for the purchase of drugs:

- A household budget survey of decade ago estimated household expenditures for health at 100 billion FCFA (US$ 400 million). (DesRochers, 1990) 56

Annex 10 Page 4 of 7

A more recent study estimated total private spending on drugs alone at 67.5 billion FCFA (US$ 270 million). In 1988/89, hospitals collected more than I billion FCFA from patients, of which 850 million were returned to the Public Treasurysand the rest shared among medical staff (DesRochers, 1990, para. 18)

What has changed more recently. as a result of the economic crisis and the obvious impossibility of maintaining "free" government health services, has been the Government's willingness to accept the principles of cost recovery and (implicitly) decentralized management of locally generated revenues.

These principles have long been accepted by Cameroon's private, confessional health centers and hospitals which provide some 35-40% of health scrvices to the population (see Annex 1). Until the onset of the economic crisis, the Government provided very modest (1-2% of operating budgets) but symbolically important subsidies to these health services, for the past several years even these amounts have not been paid, and the confessional health centers and hospitals have had to recover virtually all of their costs, relying on gifts and donations to finance the gap. Among public facilitics the experience is much more recent, and until 1990 was expressly limited to specific projects (GTZ in the Northwest and the Southwest, CIM in the Extreme North, and USAID in the South and Adamaoua).

Legislation has recently been passed permitting health centers to rctain all revenues generated by their activities (1990) and allowing hospitals to retain half of their rcvenues (1992). Additional regulations providing for the application of the laxv have not yet been adopted, and a number of approaches are being tried, virtually all within the contcxt of a project. While cost recovcry has been accepted, its implementation is occurring in a context marked by significant dcclines in per capita incomc from 240.000 FCFA in 1986 to 140.000 FCFA in 1991 and by important remaining issues concerning the principlcs of cost sharing and the potential for cost recoverv.

Cost sharing

The national health policy states that non-community funding shall, as a matter of priority, be directed towards staff training (scholarships, in-service, etc.), construction, equipment and salaries as well as to the purchase of an initial stock of basic generic drugs, whereas community funding shall especially be used to run health services. As a practical matter, the introduction of a policy of cost sharing is usually preceded by an analysis of the structure and variance of health center and hospital costs and by a decision (with corresponding objectives) on the kinds and proportions of costs to be shared by the various partners.

Analysis of health service investment and operating costs is at an early stage in Cameroon" a recent study by Medicus Mundi Belgium in Bogo District (Maroua) represents one of the first efforts to present expenditures systematically by type, source, and amount. While differences among the public experiments are usually minor, major differences exist betwveenthe public health services and private non-profits (medical/paramedical staff salaries, amortization, etc.).

The resulting lack of objectives raises both equity and measurement issues. The proposed project would establish a focal point within MOH for financial analysis of the sector and strengthen capabilities for developing financing options and monitoring cost sharing. 57

Annex10 Page 5 of 7

Cost recovery

Whether by default or design, differentapproaches to cost recovery are being promotedat the health center level. Annex 4b providesan idea of the amounts involvedfor the different cost recovery systems.What seemsapparent is that significantsums are beinggenerated in the absenceof cleardecisions on a numberof importantpoints:

- determinationon how and at what levelprices are establishedand periodicallyadjusted; - organizationand administrationof the cost recoverysystem; and - adoptionof a calendarfor the introductionof cost recoveryon a nationalscale.

While there are benefits to testing differentapproaches, minimum guidelines on a numberof important managementissues needto be adoptedto avoid eventualmisunderstandings and abuses whichmay threaten expansion of the idea. The proposed project would support improvedfinancial managementat central, intermediate,and local levelsto ensurethe integrityof cost recovery.

Some idea of the potential for cost recoverycan be made by combiningthe results of the MMB studywith certainassumptions concerning implementation.

Table 4: Estimatesof the potentialfor cost recoveryunder different scenarios

1993/94 1994/95 1995/96 1996/97 : 1997/98 1998/99 Ctrs : Amnt Ctrs : Amnt Ctrs : Amnt Ctrs : Amnt Ctrs : Amnt Ctrs : Amnt

HC/Slow 266 758: 319 909: 383 : 1,092: 460 1,311: 552 : 1,573: 662 1,887 HC/Medium 266 758: 447 1,274: 627 1,787: 807 2,300: 807 2,300: 807 : 2,300 HC/Fast 266 1,011: 447 : 1,699: 627 2,383: 807 3,067: 807 3,067: 807 : 3,067 Hospital 385: 950: 1,169: 1,389: 1,611: : 1,836

This table indicatesthat, when combinedwith estimatesof hospital revenues(DesRochers, 1993), cost recoveryat the health centerand hospitallevels could contributesubstantially to non- salary expenditures. All of these assumptionswould be radicallyaltered if the cost of drugs wereto increasesignificantly.

DonorFunding

External financingof Cameroon'sPHN activities is characterizedboth by the large number of donors and by the kinds and amounts of support provided.The principal sources of supportinclude the traditionalmultilateral donors (WHO, UNICEF, UNFPA, EEC, etc.), a wide range of bilateral donors (severalwith many years of experiencein the country),and a very significantnon-profit sector comprising both intemationalnongovemmental organizations (NGOs) and localconfessional groups (in particular). 58

Annex 10 Page 6 of 7

As Table 5 below indicates, both the sources and the amounts of external assistance have increased dramatically in the last few years.

Table 5: Donor commitments by type of donor (in millions of CFAF)

: 90/91: 91/92 92/93 : 93/94: 94/95: 95/96 96/97: 97/98 98/99

Multilateral (excl. IDA): 64 342 1,147 1,820 1,866 2,733 2,729 2,729 2,224 Bilateral : 2,121: 4,884 7,010 6,159: 5,302: 4,325: 3,639: 3,433: 2,150 NGO 826: 1,042 1,226: 365: 170 18: 9

Including proposed IDA funding, the amount of foreign aid available to the health sector for the period 1994/99 would be in excess of 30 billion FCFA. These estimates do not include details on the proportion of investment and recurrent cost financing or on the amounts for technical assistance. 59 Annex 10

Page 7 of 7

Table 6: Projected Costs for Current and Future Priority Programs/Summary of EstimatedExisting and Future Funding (in millions of CFAF)

Total 90/91 : 91/92 : 9293: 93/4 : 94/95: 95/9 : 96797: :* 971:9

1. m z AcrtA: 90/91-93/94/Projecticm: 94/95%-" 2609: Z7.582: 28.e7: Z7.479: 27.575: 27.673: 27.872: 28.131: 2B.457: 139.7M

1r?~estwrt bjF~ t : 3.365: 3.2Z: 3.150: 3.150: 3.150: 3.150: 3.150: 3.150: 3.150: 15.750 jratirg bugt 22.731: 24.362: 25.S7: 24.329: 24.425: 24.523: 24.722: 24.91: 25J07: 123.958:

PersaTl. salaries ar brfits 19.030: 19.544: 21.4Z2: 19.546: 19.250: 19.000 9.0: 19.OtD: 19.C00: 95.250 ft'rs8lky CPOtir cots 3.701: 4.818: 4.415: 4.73: 4.879: 4.977: 5.176: 5.435: 5.761: 26.228 Paerswat savirgs : 296: 546: 546: 546: 546: 2.48 x mort-salar 16 24X: 17X: 2At 21X : 22X : Znx: 24X : 25X:

ENC : 2.m:: 2.M: 2.858: 2.S& 2.M:8 2.858: 2.88: 2.L: 2.lM: 14.490 FEC : 4.83 4.MB: 4.13: 4.158: 4.MB: 4.a3B: 4.18: 4.18: 4.18: 24.190 Ad Lu : 1.458: 1.458: 1.458: 1.458: 1.458: 1.458: 1.458: 1.458: 1.458: 7.2W

3. Ermmm cct f prcity pw Diret service Dti w::y : 2.625: 2.625: 2.625: 2.62Z5: 2.6525: 13.125 p seeric : : : 1.W2: 8.168: 9.792: 10.085: 11.733: 12.747: 54.357

4. r r' URO ca :2 3|5. 3Li7?11 31LI llSl: a 7nc U c 49.M: 4K9. M 511M mfi 25 1-30

5. mm EwMtlm ActL.u: 90/91-92M/Projctiar: 93/%-96 : ZB.054: 3.016: 3.121: 3.a61: 26.M: 27.673: 27.l72: B.131: 28.457: 138156

Irmumt hi : 2.607: 1.640: 766: 1.532: 2.295: 3.150: 3.150: 3.150: 3.150: 14.8M rratirg buet : 25.447: 23.376: 24.35: 24.3: 24.425: 24.53: 24.722: 24.981: 25.307: 13.958

6. f iPrgfitCnVmsian EradUa CENC: ZAMR: 2.891: 2.9tl: 2.- l: 2.89: 2.AMl: 2.898: 2.M9: 2.a%: 14.490 F9fC : 4.=1: 4.13: 4.13: 4.3: 4.1C : 4.1B: 4.l3: 4.0t: 4.13: 24.190 Ad L.r : 1.458: 1.458: 1.458: 1.458: 1.458: 1.458: 1.458: 1.458: 1.458: 7.290

7. Cxt rtwy R1_/Ntwit3ls : : : : ~~~~~~~~~~~~3l5:950: 1.169: 1.399: 1.611: I.M6: 6.955 Qei./)4smLUthcwntam (mediumho_mis) : : : : 758: 1.274: 1.7W7: 2.3m: 2.300: 2.300: 10.719

. Fi.wcl.i w Wuit refons/qiw ct riw.wy (5*6*-7.4) : : 2.566: 3.866: 2.307: 9.421: 9.461: 9.M1: 10.447: 11.236: 49.58

W.. FINANCING

9. Finw:irg in ?wd iArtiLatoraL (excltdirg IDA) : 64: 342: 1.147: 1.820: !.&6: 2.733: 2.729: 2.729: 2.Z24: 12.31 j' .arera :_.21: .. 3: 7 .010: 6.159: i.30: *.;3: 3.*N: 3.. : Z., 19- *9 : 8b: 1.DL2: 1.226: 365: 170: 18: 9: : : 197

TOCt : 3.0M1: &.2W 9.: 834: 7..3 7.Mc 6-Wr 66.16 4.974: 31.97

10. Firwcir "d ji. reWor odiLt costrw y(9.8) 2.: 325 : -. 2: 6.262: 17.59

l-. i,m .M fiKt :-: : MO. 1 JV: 32V5: 2.05: 1.9M-: 'o W5 An ne x11

F=04FR -rTE: P4 A I FR EESa

F>,oOR N,,l.,

f>FROV~~~~~ ~~~~ . .C......

~~~~~~~~~~ ... US. .D:. . ..

,s,zbord~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~Oue .. . .--......

~~~~~~~M -tr- rals

p ~ ~~~UICEF - CEE

\:::- - ...... g.: . SAI...... ~~~~...... -' Annex 12 61 Page 1 of 4

REPUBLIC OF CAMEROON

EALTTH,FRTUITY AND NTRITON PROJECT

DECLARATION OF TEE NA1IONAL POPULATION POLICY

NATIONALCOMMISSION ON POPULATION

(March 1993)

so laIa - I&= AM i - the i,ua aptia tar the eautsz ,u d L

Smeb a Policy Ls pw.oessd withia the ftwinan as.saLe, i.aL&L &a1 peUtX^l aLtuatLas by &a_

-j te inLtinm and the gaaam EgwauLeUaLuL 9zpg seek with a eleb mLtuzsL heLi*S inLalybaind sa the upmtoa the bi bei a" an t L, .. ULdarty

- th pusaataJ±a at"ti.ud at the gima esalmWhia

er 5hIdga l with ha i_ r th p* Gn to jeop"Azdse the b.aJth of ebil1drs and ineW%m theuuw tee

-w oclaationLe of Lni.ai±ia.l and sellinti.Yv b.bavt.l yta-&-via the a1.untygo"S whieb iuuLts LS the 2ads1 - OeYrsheaat of an Lopar. parties at the popnlatim I 62 Annex 12

- th social ctange Causad by modernization, rapLd Page2 of 4 U=-b" tioa, tbA LZLCSC- Ln ducatiZUAloeL 6OSWbos- IMtAc o0 d_qraph±e behawiaur of the scielty is te loss of *I lo ou culturzal value, the ehorarinq of beast! 04A4n9 periods causing the Latazvals betven deol±eriae to bqpca sht*s. the coping vith ox=sal*t&l rolationsh±ps an an incease in tAe risks of unwanted p?r3Da1ci±s teenager

- p areptLble d.velop t towards advanm dacy reltinq into the eete±an up of a yetsm of poUtic" pluL_l and the aft fzaation of a f*.idm of SxP3S5±D iupring the t-i'kL into aca of pubai opi.in t hA man" c of the nation a a falz I

- a fzLl fooddelf-suffic±.y and a psp.At.a' a feed senritr wlch Us gtml t1 bobe mi ±thw*.aa dUfialt situatiAn coep.ded by the snin a crisis.

Zs th Uqh of the fmgag, the EatLmai PW.J.atJa f.Ucy rule out amy e.mi.w. maux.n wbi.a may yzivnwn i JYLdm" Alad inlss fim Livelr d;edA an th m of Cebtdm the vtU to heW. NULl zm lat Si" beLa right to th.L spcuin WA to be _uffiBJitly 6t6d a" L3s" - Lesm_ rel"Atin to aWp.WLatAe rimYlu La that reIspest

mm -w-. olths pauley JILLae theo I mmsh.lbLTy of imaWdLiA.L. And CeuplAe to ensur, a ing to th*ir mame te twtPrs wlfm ef aq chid they idSSe to ha,. asn vel as the resposuibLUIr aO the Stat and of YSwr citias With so"" to th h-am" dof th mihy, th 3atiin. and the whele MashLad.

The agw,rwt is printing te amemse as a"l ottsama to inf smautl. a--r-priate maemoW and mie se esano to usable thus to fully examiuu mWmthe bvtoimm" rigtas am to ramm aUlloLg" batara likely, torswut umfm r 5"y parmng thexiz UusJ la" bjecUYsS with Zsg&Ii to

no ULatUea ftp.latlaim PuLLey aUe reepam the tuadnmata prineipl.e wa" rigt. of the muomA.a Peple, as Pr&Lajs" i the puveble of the a'mtit att Cinuin Whieb aftti Its attasbmm to the b"asi 63 Annex 12

Page 3 of 4

r ino-6bdL. La t.Te CIV.ruSl Dc1sxatioa of Ruasa pqttS z4 bA td MAtions crta r, totly the foLUow±.q Yx4Aples I

"er* h quas ciqs a lLt±os. SS Stati andeaiz=s to Assure for Its citl±ze tei eoa4Ltioas necussrr fot L devolomaat".

?uCr`.A:Tzu, r:spcadoq toa the apa.a eonain" LA the Lagos Plan of Actiam a4apta4 by rican Beads of Sta and tWhCh calls fez th. f@xIAt1O of Plplatia policie, the gowe s.aLso adesa tha S_dktADA cOMZaLA"dLa thu Actico PI&ns adovtd at tAs Wwl4P0ku.LatLe CoaSMrS (lUCUMM La 1974, Mexic La 19", ALub in 1964. &Wtwd_ La 1989), it being uaimtag that ±tu s0j.ang cacia" in dalg With PJP, laCe iseus thzuqf An £ tgraX%d aempdab of Caeo'n 4oia nad ecomta dew.J.ara:.

a - a 0 A &

Gerally BP*a",, Camrons EatimaL. Is LatLm LUy aim at raisig the leve an Laprsoi the qua.y at tho We. of th ppeiat±i, v1tW.± th limits of teA rsecexnm avalLable, i u wit h e dLuiLty And the tundamema.l hinna :±qbtu, na.ly by oowigt aaow the popeltLaa' s bA us (he.lth, fiood, 0doati, _LqS, bmml.a . . ).1

a - ______

za gald to achiae" the ebo 's. godl* the fe.LLminq g04A.L be pursued. And specLf±ico. >1 t-ahjecuujys i 9. chaL~z

a) To LaVuye - the boealth malditL.= ot the popalatim La gsocata and that of inuthe and C.L1dzesu La pastirAUWs I

b) to stxm fself-sug±icy and peicSe _ood

a) to pint. basc .cac± for all and esiaLLy fod gil I

4) to -ts and develop quaLfid bea xeinUn es wUla seeking ihipsLilty between trainngand wqlcymntj 64 Annex 12

*) to prO ad d..lop the w_ll-bienq of faLsj sd and Page40ofs4

f ) to pFZOe "4 enaur an integrated and hasmzn±os deiowdelpt of cities end te coum ruLA wb-LLopsz$viq th oavmiz t I

g) to p:ote ressaaz La the S I.d of atio.

e.2 - DcXC O3.~mm

2. to low MUA.ity levels La m L am& itezuL and chLA

2. ts wt us anl/r qiwp, helth faaLLLt±e. ssprnLa.r theus of 1±axI7 helt cars saYtea thzmaoua thu aatLmaJ. trritor I

3. to paa responsible pon all asestime of the POPWAJtion.anc4&dA, to helSoLLe few LasfU i edcatiLos on fa&iJy l f i, _ .irati.am em ul UaF =dmeatLoI Of the eMssWmyof Mminsat.L .

-dsmsat±imn MJsLLy US, car soo a" AeE ussCLa

4. To prine etL faw &U. thragh Wm satLa up A the 5qSiLaLq of saU"ionaL IAZLAfzaSwUcmz aid tAbmh adem"ia eshesl- curriemlAF to she rval asies .5 the so eeC aatLUms&L

S. to tL* aquina maLet fLee utawiuty La ed to _ _ cuples Whovieb to have eKLLdrm g.

6* to printe Nand sxm~ St-ls,e' .at.m aid esbl mrs2mmt end &Jsm- a" eayOM bup-ow" La Is gaLlS theiR law" of sidcatiem theirgbtage. at th fIesmarag

m'utee" wish a ytin" O ring the inumy Of LersiLsy Ja.l' thewq* the saetin up et thee mm la-thmubst th natinsl ts_ar espeeag La mal, are" ad Am aaeas with :gaa Utiininat i I 65 Annex 3 Positive Attitudes Toward Family Planning PageI of 3

A'titudes '"'''''''';'' '''' Agree DIsagree, Attitudes -(-P- s - fPercentVt IPercent' '(Percenti

Women shculd control reproduc:ion 84.9 12 3

Family planning is better than atcrticn 83.7 16.3 4.7

Use precaution to avoid pregnancy 83.5 11.6 4.8

Modern family planning methods are ineffective 23 64.5 12.4

Perceived susceptibility to pregnancyif fp methods are not used. 58.6 33.8 22.9

Unplanned pregnancy could cause seriousproblems 47.6 26.3 26.3

It is better to be pregnant than to use fp methods. 31.8 57.3 10.9

Ne ative AttitudesToward Family Plannin

Woman needs husband's consent to use fp methods 75.9 20.2 4

Family planning methods are safe 27.9 55.1 17

Nurses are rude and condescending 44 49.4 6.7

,Religion is againstcfamilv planning .42.5 43.6 13.9 .~~~~~~~~~~~~~~~ Reported Reasons for Not Using Modern Methods

Afraid of side effects 28.9 51.2

Want to get pregnant 13 12.2

Husband refused 5.9 7.3

Lack of information 24.3 4.9

Against religion 4.6 4.9

Method inaccessible 5.4 2.4

Sexually inactive 4.2 2.4

Inferzile 2.5 4.9

Currently pregnant 1.7 2.4

Dan't Know 9.6 7.3

5et o^. t .re aeiSr.senne 1991. JhU$PCS and MOPH. 66 Annex 13 Page 2 of 3

REPUBLICOF CAMEROON HEALTH,FERTILITY AND NUTRITION PROJECT DESIREFOR CHILDREN

Desire for More Children (Currently Married Women 15-49)

Want child, undecided when Want no more 7% children %Want child after 2 12% ~~~~~~~~~~~~~~~years 35% Undecided 4%

Declaredinfertile 9% Steriiized -- -_ 1% Want child within 2 years 32%

Source: Caneroon ODmgrapSc andHedth Suey

Source: Caneroon Demograpic and Health Survey 1991. 67

REPUBLICOF CAMEROON Annex 13 HEALTH. FERTILITYAND NUTRITlON PROJECT Page 3 of 3 MODERN CONTRACEPTIVE USE

Modern Contraceptive Use in Cameroon in 1992

Condoms Tubal Ligations

IUDs_ 12%

Pills I___~ _ - r47%

Inj 33%

Current Contraceptive Use by Province (measured in number of users) Province Condoms lmplants Injectables, lUDs - Pills-- t Spermjicides | .ubLcationsr| Total Adamaoua s ___ 16 2 82| 1| -enter 159 2 5,630 1,531 6,238 74 214 13.848 Far-North 9 7 1 26 1 44 Littoral 326 23 2.129 548 2,944 19 58 6.047 North-West 340 12 609 629 1,049 121 573 3.333 North 59 20 43 412 20 554

South 1 _ 6 8 113 4 1 133 South-West 128 377 208 1,423 2 85 2.223 West 102 113 221 288 1 11 736 Total 1.124 37 8,907 3,191 12,575 241 943 27,018 Source: Deparunnt of Farily andMental Health, MNistry of Puc,ic Heolth. Cameroon 68 Annex 14 + O R K * ,3< > Pagel of5

, -Z

Republic of Cameroon

STATEMENT OF SECTORLALHEALTH POGTYC

DECEMBER 1992 Annex 14

Page 2 of 5

S U M M A R y

An analysis of the health situation and the progress made since indeoendence shows that the health sector in Camoroon still suffers from serious set-backs owing to the non precise definition of a health policy and to the economic crisis.

This document attempts to define a sectorial health policy for Cameroon and provides in its appendix tho statement of a National Policy towards the reshaping of Primary Health Care ind a series of priority programmes for the reconditioning of the health system. These priority programmes are essential to tho operational strategy of this policy.

The Sectorial Health Policy aims at improving the state of health of the population through an increase in accessibility to integrated and quality care for the entire population alongside its participation.

Th* main aspects of this policy include

- The integration of health care at all levels of the system, taking into account priority programmes and specific actions in all health institutions;

- The rationalisation of the management of equipment, infrastructure and staff by setting up efficiont information systems for effective planning, taking into consideration the results obtained, the needs and the objectives of health servicss; - The drawing up of a drug policy to render essential drugs available on a p.rmanont basis at all levels; - The contribution by public health to the setting up of a national solidarity systmSm:

- The adoption of regulations to enhance decentralised managementof health services with a view to bringing management and financing closer to conMunities. These proposals constitute a reference document for all involved in the health sector, be them public, peravublic or private, national or foreign. 70 70 ~~~~~~~~Annex14 Page 3 of 5

4. 1 BASEC PRrNCIPL-ES

The health sector cannot on its own establish an acceptable health level to 411 Cameroonians by the year 2000 - such a result can only be achieved through to political will, together with the joint effort.s of the health and health-related sectors. Health development contributes to the improvement of the socio-economic situation. It also flows from it. Health policy must therefore be part and parcel of a global development policy and should reflect the socio-economicgoals of the government, so as to meet the expectations of the population.

The basic principles of -this declaration can be stated as follows: - The governmentmust maintain its responsibilitywhich is to ensure health to the population, the fundamental right of any individual; - The right and the obligation of everyone to take part individually or collectively in the handling of health; - The responsibility of the government to ensure solidarity, equity and social justice; - The respect of the right to information, the integrity of the individual as well as his freedom in health-related issues.

4.2 PURPOSE

rhe main purpose of our sectorial health policy is to contribute to the improvement of the state of health of the peopli.

4 3 ORJECTIVEI

1 ) Render'quality health care accssible to all the population by enlisting t:; j;a;Ion;' : 14

2) Establish comm,uni,yaarticipation at all live.- c! planning, execution and assessment of health pro9rUM:ss;

3) Increase population access to preventive, curative promotional and rehabilitative care;

4) Oevolop manpower, qualitatively and quantitatively;

5) Organize a working national health information system directed towards the efficient and effective running of management of the Health services; Annex_14

71 Page 4 of 5 6) OevelOO the nat iOnal health map within the framewoat of a functional health information system beneficial to Cameroonians.

7) Restructwre the Health services at all levels in order to ensure the rational decentralisation of the decision making structure and facilitate efficient management.

8) Draw up and apply rules and regulations propitious to the liberation and management of financial resources and the decentralised management of all or part of the funds thus raised by health establishments.

9) Improve the efficioncy and eff*ctiveness of the health system especially through t.ho rationalisation and decentralisation of managemont, a better mastery of planning and cost reduction at all levels.

10) Define and apply a pharmaceutical policy capable of ensuring a permanent availability of quality drugs in all health institutions in tho country.

11) Redueo the mortality rate of children bolow 5 years by one third by the year 2,000.

12) Reduce mother mortality rate by half by the year 2,000. 13) Reduce morbidity and mortality linked to diseases that can be provented by immunization. 14) Promote and ease the use of th family planning services with a view to significantly reducing mother mortality and protect children and adolescents' growth and health.

4*4 LSTRATEGrEL

4.4.1 The training of staff on the techniques of organising and managing health services at various levels.

4.4.2 The carrying out of studios on major fields with a view to using the results to meet the aims here stated. 4.4.3 The activation of the Health Technical Coordinating Ccmmitte to sisaolethe experiences of all and - sundry to be shared for the imorovement of t i- -s _~. ., Ann r 14 72 Page 5 of5

4.4. The integration of major health programmes within present and future health structures in order to ensure efficiency, effectiveness and duration.

4.4.5 The reorganisation of structures and the definition of thhe functions thereof in the health systtm.

4.4.6 Prawing up and promulgation of legal and statutory texts needed to promote an efficient health system.

4.4.7 The intensification of interministerlal coordination on health related problem's.

4.4.8 The systematic involvement of the community in the management and assessment of health activities of which they are beneffciaries.

A, 73 Annex 15 Page 1 of 2 Action Plan MatrLx Issue area Policy dec sions/actions lientation preregjisite5 - Inestrrnt srt

Population Policy SectoraL strategy for iRpleienta- Oisseminarion of NPP Pop.ulation Inforumtion Center tion of the Wational Pop Policy Sersi:ization canJigna CP/Deograhic/Ferti lity surveys

Mealth Policy CodificatiaVDiffusion Adoption of r8?Bining rtqired Diffusicn/Inform,tion of health legislation persaomel comcerninr the policy Training of NZN a9gers

Coordin tion T:c legislation/proceures/es Spport to the secretariat Dacr crsortiuu Establishent of secretariat

Decentralized IataaenIt Provincial Support : Katerial/FiramiaL spW.rt for Firncial, logisticql eid technical deveelopnt of district health sirt to the 04l6gatiins plans Siuprvision costs

District Organization Adoption of text definirn district Sertsibilisation des viltags/Orga- Finwcing of district health deve- Etaboration of methodology for nization of the carte swnitaire :lpir t progri (infrastrcture, establishirg the aires de sante ELaboration of cdiue term district: equipm. , vehicules, training, Adption of process for apinoving health developet pgroS drugs etc.) district helth dcevelopmt plan

Dialogue Str%ctures at Estabtsi5nt of rules/regulation5 Dissemination of r*glientation Systemtic training of ccmitt de the Local Level re fuctioning inttrieur gestion

Information (tHlS) Inforution need by level Ifflementation action plan Equipint purchases Appel d'offre for eq.uipnt Proution of form5, etc. Training

RESCURCE SZLIZATICNAND XANAGE?ENT

Issue area : Policy decisiors/actiors _ Invleientation prerequisites Investmient su.prt (Years 0-1) (Years 1-2) (Ycars34)

Persornne Planning/Nanagmit : Staffing norms Prepagration of redepioynt/re- PaAaent of nev personnel category :Inventory of currert persaw l cr-ui tisat plan (1S0 persorves) Definition of redepLoyrnwt incen- f inrncing of redeploewant tives tIproved ainistrative procd res Persorriel maneqna t proceires Training of persanvel managant for mn_ging persorrnil nmnel staff

Motivutiin Greater ministerial authority over Persornel magemen t procedres hiring, tranafers and proutiors : mAel Decentralized personrwl perforce evalution criteria Proposals of wasures to further career development

; i nance Policy analysis : Clear policy on cost sharing marmonisation of cost recovery Three year invesoment/recurrent AgreQnwIt on Goverrmint b.dget in- systeim : cost planning creases for non--wge operatiomns Iproved ecornmic/finrcial aaly- sis capabilities

8udgeting/Accounting Agreement on a decentralized and Budgeting mi,sl'/orms aid costs Training participatory budgeting process Agreciwnt on streamlined proceulres 38tgeting nln. Anrual buigeting exercise for sperding budgeted mney Adoption of tests/tools Devetcament of tools/ethods to Purchase of necessary equip=Int impro'e ministry accounting Annex 15 Page 2 of 2

PROUN PERFOUUaNCE

Iss orea Paoicy decisions/ectieg Imletmentation orerenjisites Istnr swovorr Service del i very

HeaIth Definition of norm _/stan tarh(e.g.,: Distribjtion of WM guide(ines Hospirat referrat system minim. peckage) Strengthd EPI progre

Nutrition Approahes re rutrition Rase(ine surveys

PvputatimtVFP matiorul progr ftor a ing FP Distribution of FP guidelines £ d FP services (rw'vution, services De. aop_nmt of outreach worker/Cfi contracptiw mix, erc.) progrm Swrt serwC

Training Adinistrative reform re training Cansotid./Rehrbishing of schools Systimtic retraining/in-se.vice wd_ recort:fication/iwetgintt Training of t_dchrs training of heaLth persiaewl : Neds sassa_ment : Curricueu revision/Testing 94*rvision (logistics/perdium) :Adoption of ptan for retraining Agrenfl with CIN to train? :Recruitm_nt criteria (.., wt : tfor rural heatth canten)

Infratrqcture ard tatiarutimation of infrmtstture :Irwntory of needs Rervtion/tchabilitation Equipnt PLww type/Stardard eqipunt list Preratien of terering dSa_mnts Arr.nt evatuation of coverage ts i ntnce

Essentiat drs Decision re ONAPHWA*/CAM EvatlLtiorn ot r Drug urciases : Lgislation re lirtation bv Agre,t on apt doffre prced. Distrituticn and storm" : verie_ actors (iret. Ad Lurm) vetity camtrol/Licwing/Sapting :Oistribution of list of *suntiat fors_tion des prescripteurs : dsby evetl : Agreed won precription practie s/ : treatuant protocols

IEC Strategy develomnt Definition of icWte rds ap- Production/Diffusion of messages prapriate msages, m , etc. Monitoring/Evltuation of ipact Participsting agery coordiru tin Training of persormL mchanmism 75

Annex 16 Page 1 of 4

REPUBLICOF CAMEROON HEALTH,FERTILITY AND NUTRITIONPROJECT CONTRACEPTIVEREQUIREMENTS (1994-99)

FORECASTING CONTRACEPTIVES NEEDS: Forecasting contraceptivesneeds for the next five years in the Bank-financed project districts, considering that the Contraceptive PrevalenceRate (CPR) for all methods will increase from 5% to 20% will be based on population estimates and dernographic information. The current annual natural population increase being 3.0 %, we can assume that the population of Cameroon will present around a 330,000 population increase per year. In this initial projection, the contraceptive prevalence rate by method for 1992 will be used as a basic indicator, but at this stage the provincial preferences and differences will not be taken in consideration. In addition, for each method, the calculation will be different depending on whether the client is a new or a continuing user. Quantity of contraceptives to be ordered should include an additional amount for wastage. These estimates are only guidelines of the arnount of contraceptives needed per couple for a twelve month period and they are based on the average length of time that family planning clients actually use each method - their potential product effectiveness is longer - for example the Copper T 380 A is effective for up to 8 years and Norplant for up to 5 years. Although it is not possible to predict changes in client demand or interruption in supply accurately, a further careful analysis of past supply and use patterns during the project will enable a closer calculation; that is why contraceptives needs should be forecast at least annually and reviewed quarterly.

CALCULATION:

Total Population to be served:

DOUALA 5 Districts (urban) 850,000

YAOUNDE 4 Districts (urban) 790,000

In 5 Provinces 9 Districts (rural) 996,600

TOTAL 18 Districts 2,636,600

According to the natural population increase of population of 2.9 % the total population shouldbe:

In 1994 2,428,915

In 1995 2,499,353

In 1996 2,571,834

In 1997 2,646,417

In 1998 2,723,163

In 1999 2,802,134 76

Annex 16 Page 2 of 4

WOMEN OF REPRODUCTIVE AGE:

We assume that the total female population represent half of the total population in the project districts:

In 1994, 2,428,915 . 2 = 1,214,457

The Unicef 1991 Women and Children situation analysis estimated that the number of women in reproductive age represented in Cameroon 22.7 % of the total population of women. In 1993 only approximately 5% of these women were using contraceptives, but obviously in the remote areas of Cameroon the CPR might be even lower than the average 5 %. In 1992 the national CPR by method was:

Pills 40.5% Injectables 29.2% IUD 17.3% Condoms 6% Spermicides 1.6% Implants 0.4%

Example of calculation for pills:

In 1994, the continuing users will be 275,681 x 5 % = 13,784 Among these continuing users, 40.5 % are taking Pills: = 5,582

In one year each continuing user uses 13 cycles

Number of cycles per year needed: 72,566 cycles

New Users The CPR is supposed to increase 15% in 5 years, this means that we can assume that it will increase approximately 3% a year, but according to our experience usually the rise is slower in the first two years of a project. But in forecasting we will assume and use the 3% per year figure. So the first year and every following year we will have to add 3% of new acceptors-which method will prevail, we do not know, but we will be able to accurately forecast the by method rate after quarterly reviews and careful analysis of distribution and services: 275,681 x 3 % = 8,270

Among these new users, 40.5 % will accept pills = 3,349

Number of cycles needed: 3,349 x 6,5 = 21,768

Total of pills to be ordered: 72,566 + 21,768 = 94,334

Total pills to be ordered if we add 10 % for wastage: 94,334 + 9,433 = 103,767 77 Annex 16 Page 3 of 4

First year of the project (1994-95) CPR from 5% to 8%

I.:l3 Non-hber C;-nt r,.. r., . cycles. Methods uIs I. urits/dcu.es Total

Pills 2 1 .7-3 94.334 In]ectables: 1. Depoprovora 2/3 . i 3.21o 13.994 Noristerat 1/3 1.11 2.4;_ 10.458 IUD . 7t 2.14S 6.913 Condoms !:: 24.H' 107.500 Spermicidcs lI. . 1: 396 1.716 Implants 26O 356

Second year of the project (1995-96) CPR from BB to 11%

Nl.' r t Number ot C t, t I Ft.ll;.I r"; 1 cycles/ Methods i;r 2; I :;: - uni ts/dnics Total

Pills .1-1 1hq.41 4. 2.S22 142.005 Injectables:t . . Depoprovera 2/3 i.41, 1. : 3.34-4 21.003 Noristerat 1/3 2.I25 13.4R 2.S08 15.756 IUD .6:i 2..2.2C3 10.060 Condoms .3< I.'<17 25.500 161.600 Spermicides 5 l Is is 4 0E 2.566 Implants . 1 300 427

Third year of the project (1996-97) CPR from 11% to 14%

N ITTL- I Number of C.. IMr1IhI Y I:-. I 1 t cycles/ Methods toe rL .-`. N.'w -I..- 3 unitn/doies Total

Pills I Oi4- .- - t23.1iP 192.770 Injectables: 9 .. Depoprovera 2/3 S. 1I 4 3.506 2B.50S Noristerat 1/3 .7i 2.631 21.361 IUD .l. 4t 4 1IS;. S9 2.337 13.381 Condoms 1.3.r1 -2.64r 27.070 219.600 Spermicides l1i34. 432 3. 510 Implants 4.100 350 577

Fourth year of the project (1997-98) CPR from 14% to 17%

Njtmber f Number o0 .- ntjnu?n. r.i3. cycles/ Methods 1501 | se- | 1 TI:n | uriits/doses Total

Fifth year of the project (1990-99) CPR from 173 to 203

Number of Number of Continuing cycles/units/ cycles/ Methods users doses New users units/doses Total

Pills 21.279 276.627 3.755 24.407 301.034 Injectables: 15.342 2.707 Depoprovera 2/3 10.228 40.912 1.804 3 .608 44.320 Noristerat 1/3 5.114 30.684 902 2.706 33.240 IUD 9.089 18.177 556 27.800 343.000 Condoms 3,152 315,200 556 27.800 343.000 Spermicides 840 5.040 148 444 5.484 Implants 1.154 577 500 650 1.227

The pills that women are currently using in Cameroon are imported by both UNFPA and USAID. USAID imports LO-FEMENAL (Blue lady) and OVRETTE (low Estrogen-Pink Lady) - both have a shelf life of 5 years and are distributed through the public and the private sectors (the social marketing program.). UNFPA imports MYCROGYNON-MICROLUT and EXLUTON they also planned to order EUGENON.

The pills are called combined oral contraceptives or Progestin only contraceptives depending on their composition. The combined pill is the most common and effective contraceptive method widely used in the world because it is extremely safe and has numerous health benefits and an excellent reversibility. It contains Estrogen and Progestin. There are two dosage levels of combined pills used in Cameroon. The classification of the combined pills is made according to the dosage of estrogens, having a normal dose of 50 microg or a low dose of 30 microg and the steroids can be given in an even daily dose (monophasic) or increased in 2 steps (biphasic) or in 3 (triphasic) along the month. The progestin only pills (POPs - sometimes referred to as minipills) contain different kinds of progestins at different dosages.

Which pill to prescribe? In many public family planning settings, this decision is made on the basis of which low dose Oral Contraceptive (OC) is available to the program at the lowest price. In this way, local and national bids for OCs clearly determine which pills are available for the clinician to prescribe in a given setting. However if all the present brands of OCs were to be available to a clinician and to his or her patients at the same cost, one approach is to prescribe the very lowest dose OC first. Providers should consider several factors when selecting which pill to prescribe for a given woman: a) the pill prescribed should minimize a woman's risk of major and minor side effects. b) oral contraceptives have been demonstrated to have major non contraceptive benefits; c)smoking increases a woman's risk of developing a number of the most serious pill-related complications; d) if a women has been successful using an oral contraceptive with 30 mcg estrogen, is pleased with it and is experiencing no complications, then it is appropriate for that women to remain on the same combined pill. Progestin only pills are particularly desirable for lactating mothers and women who want to use an oral contraceptive but have contra- indications to OCs like severe headaches and hypertension. But we must keep in mind that they have lower effectiveness, more breakthrough bleeding and fewer contraceptive benefits than combined OCs. Their prescription needs much more counseling. In conclusion, a large choice of oral contraceptives should be made available to the clients and to the providers who could better adapt the prescription to the woman's personal case and to her preference.

Before the start of the project, it is highly recommendedthat a careful selection of types of contraceptives' responding to the clients needs and preferences be made by the providers with the help of a scientific committee including the OB/GYN department at the CUSS. 79

Annex 17 Page I of 4

REPUBLIC OF CAMEROON

HEALTH, FERTILITY AND NUTlRITION PROJECT

Nutrition Program

A. Background informationl

The project area includes ecological zones which are very different: the Far Northern Province where staple foods are sorghum, millet and to a lesser extent maize and rice, the West, Center and East Provinces where roots and tubers, together with plantain bananas anid maize are the staple foods. Because of their contrasted ecological environment (Sahelianin the North and hulmid forest in the South), the two target areas of the project call for different strategies. Exposure to parasitic infestations, causes of micronutrient deficiencies and protein-energy malniutritioniare usually differenit in the North and the South. The high prevalence of iodine deficiency disorder in the Eastern Province, for example results in part from the consunption of insufficientlyprocessed bitter cassava. The presence of thiocyanate in the cassava-baseddiet impairs the utilization of iodinie and causes endemic goiter, growth and mental retardation in children. Although some pockets of iodine deficiency are founIdalso in the Far North (Table 2), the prevalence of iodine deficiency appears in general lower and muchl mlore localized. It could result both from the low content of iodine in the soils (hence in the food grown locally) and from the isolation of the populations. The present chapter will first introduce some data on food intake and nutrition at a national level for Cameroon, then review some specific characteristics of the project a-eas relevant to nutritional interventions.

National and regional dietary intake

The diet of a large portion of the population of Cameroon is monotonous, low in protein for growing children, poor in critical vitaminis, essential fatty acids and minerals, causing widespread iron deficiency anemia, localized iodine deficiency disorders and vitamin A deficiency in specific areas. At the national level, the mean dietary energy intake of the population calculated from food availability is around 2,200 Kilocalories, therefore slightly above energy requirements. Average protein intake is 55g of protein, which could be adequate but this average intake hlides large variations of intake between individuals because of large socio-economic differences and unequal intra-household distribution resulting in low levels of intake for a large proportion of consumers. Marked seasonal fluctuations in food availability inflict in certain years, severe food restrictionis on some groups of inhabitants of the populated Northern regions.

B. Objectives and Strategy

The project will adopt a two-pronged approach to the reduction of the "big four" nutritional deficiencies: Protein-energy nmalnutrition, iron-deficiency anemiiia,vitamin A deficiency and Iodine deficiency disorders: 80

Annex 17 Page 2 of 4

- Routine prevention and treatment of patients and users of health centers. - Outreach activities during four years of eradication of parasitic and nutritional disorders organized at six monthly intervals in villages and slums areas located around participating health centers. The first year of the project will be used to organize and prepare the materials necessary for the campaigns: IEC, base-line studies, equipment and drugs of participating health centers, monitoring and evaluation of impact strategies.

Whereas the Ministry for Public Health will be responsible for routine prevention and treatment, the outreach health campaigns will be entrusted to an autonomous agency. The contract of this agency will be renewed annualy upon evaluation of the results obtained in the field. The Center for Nutrition, attached to the Ministry of Higher Education and Research, will be the lead agency in the evaluation of the nutrition impact of both routine and outreach campaigns.

The routine prevention and treatment strategy of this component will provide direct services in nutrition through the 150 health centers. In these centers ensure a close linkage between health and nutrition activities (growth monitoring, education, micronutrient deficiencies eradication). This would broaden the effect of health interventions and be a more cost effective approach. Moreover, nutrition activities would benefit from the medical structures already in place for the health and population planning.

Outside the health center, health teams will encourage or seek participation of local communities with the support of health-specialized NGOs to conduct nutrition activities beyond the direct access of health centers but in coordination with them in their respective areas of responsibilities. Village committees would include nutrition workers responsible for specifically implementing nutrition and nutrition- related activities. The objective is to extend the influence of the centers beyond the immediately accessible populations and promote a preventive approach to reducing malnutrition through empowerment of local community. This could be done by supporting nutrition workers to implement child growth monitoring and nutritional supplements distribution. The program could be decentralized at the village level under the responsibility of a community worker selected by the village. Regular nutrition education and supervision would enable the community nutrition agent to pursue its preventive malnutrition control with minimal support from the project and therefore increase the likelihood of sustainability.

E. Eradication of deficiency disorders

In project areas of particularly high prevalence of deficiency disorders (iodine, Vitamin A, and iron), the Nutrition Service of MOPH would also implement eradication campaigns together with other specialized institutions. This would include: a) mapping the prevalence of iodine deficiency disorders (IDD); b) selecting for each zone or village, the most appropriate method of intervention: iodized salt, intramuscular injection of iodized oil, oral intake of iodized oil, equipment of village wells with silicone Elastomer releasing iodine in drinking water; and c) implementing and monitoring the impact of such interventions in areas of high prevalence of IDD.

TraininR

Training of Health centers/NGOs staff and supervisors in nutrition activities 81 Annex17 Page 3 of 4

The Nutrition Service of the Ministry of Public Health and the Center for Nutrition would participate in the training of health center/NGOs field staff in cooperation with UNICEF, under the overall supervision of the Training coordinationconsultant. This would consist in training sessions twice a year, (five days each time) in community nutrition interventions. It would include assessment techniqueson the impact of poor nutrition and poor health, comparativeimpact of alternativestrategies to reduce malnutrition, cost effectivenessin the reduction of mineral and vitamin deficiencies(iron, folate, iodine and vitamin A deficiencies), use of nutrition surveillance for intervention design and nutrition planning. This training will be as decentralized as possible and include practical field experienceand short visit to villages.

The project implementationmanual will specify in a simplified way all the tasks to be conducted by each party in the implementationof the communitynutrition program and the different steps required for proper implementationof nutritionactivities.

Specifictasks of nutrition workers

Village nutrition workers includedin the IHC team, thanksto frequent and pertinent training, would be able to undertakethe followingtasks:

- Growth monitoringof children0-5 years - Use of cereal-pulsesmixed flour as weaningfood - Oral rehydration against diarrhea - Promotion of breast feeding - Reduction of parasite infestation - Reductionof iron deficiencyand folate deficiency - Reductionof iodine deficiencydisorders - Reduction of vitamin A deficiency - Referral of most severe cases to nearest health center or nutrition rehabilitationcenters - Group discussionof causesof malnutrition - Identificationof incomegenerating projects - Reductionof the prevalenceof malaria

Tar-getsand objectives

The table below indicates the targets and objectives of this component in terms of coverage and reduction of malnutrition. The community nutrition program would directly monitor the growth of about children between 0 and 5 years of age and follow-up about lactating or pregnant women. Through these interventionsmalnutrition rates in project areas are expected to decline from 14% to about 8 % (or a relative reductionof 43 % from the current malnutritionrate).

|Targetsindicators 1995 19 i 1997 18 19l .. 20 a) Number of Centers 10 20 60 100 140 150 b) Population served by 150 centers 100,000 200,000 600,000 1,000,000 1,400,000 1,500,000 82

Annex 17 Page 4 of 4 c) Children 0-5 years( 19 %/ ot h) 19,0(N) 38,0(X) 114.(N)0 190,000 266,000 285,000 d) Nbr.wasted children (4, o)f 760 1,520) 4,560 7,6(X) 10,640 11,400 e) Nbr.underweight chillr. (14 % (it ci 2,f66) 5,320) 15,960 26,6(N) 37,240 39,900 f) Nbr. underweight children in grovth surveillance t30% o4 e) 798 1,596 4,788 7,98() 11,172 11,970 g) Nbr prevented cases of rualnut~ by nuitr. surveil. (35 4of f) 279 559 1,676 2,793 3,910 4,190 h) Nbr. children refered to nut rehah cetnters (15',I% 4f f) 121) 239 718 1,197 1,676 1,796 i) Nbr.children in supplem feeding in centers (1()' (itfI) 81) 160 479 798 1,117 1,197 j) Nbr prevented cases 4tnialintlit.h supplcril teediIg & rehah ccntcrs 359 718 2,155 3,591 5,1)27 5,387 (g+i) _ k) Total Nbr. prevented cases ot malniit 359 1,077 3,232 6,823 11,850 17,237

I) Prevalence if rnaltmtr in proiject impacit ireas (ck mi percent ift ci 12% 11% 11% 10% 1(% 8% m) Overall reductioni nt mIalnuLitFoittin (I pctcCIt ot to tal nIr. 13 % 20% 20% 26% 32% 43% underweight children, n) Estimated nFhrwi menii prcgnaltt icit tiig 3 i I 1ti 3.1)1)1) 6 ,()00 18,(XX) 30,0X0) 42,(X)0 45,000 o) Womenri in iaternit\ tfllw up 3 olt n 9(U) I,8(N) 5,400 9,(XX) 12,6(X) 13,500 p) Women in lactation folIoss -li (22' It 111 661) 1,321) 3,960 6,6(X) 9,240 9,900

(q) Prevalence if anefimia 35)' ioffi 35.h)))) 7(),()() 21(0,(XX) 350,0(X) 490,000 525,000 r) Prevalence it iodiiie deficicrics 27(ir oif hl 27,1)0) 54,0)()) 162,000 270,0(X) 378,000 405,000 s) Prevalence of vitarainn A LlUcitejici tf 'iit 61t)()) 12,(000) 36MAX)0 60,(XX) 84,001) 90,000

Note: Indicators q,r,s refer to the estflmated numiiberof cases of anemia, iodine deficiency and vitamin A deficiency in the populatioln served by the 150 centers, but those indicators do not reflect the expected reduction in prev.alence. It is ntot possible at this stage to speculate on the magnitude of the reduction wlhiclhcani he aClhieved. 83 Annex 18

Annex 18 Training ed tfor Inptswfnting the Reorientation of Primary HeastnCare lwbre MWbrede Miveau/Tyo d foriution * FS Ders./FS Personmetconcerne totat Ourre Centre de Sante

-Persorret du CS -Politique de reorientation des SSP 960 3 IDE/IS,AS (2) 2.8a0 pH -Formistion technique 960 2 IDE/IS, AS 1.920 3 mois -Structures de dialogue Gestion des recettes 960 1 Cois 960 3 sm. -COSA/COGES 960 3? H:mr s 2.8W 2 sm.

Rdoital de District -PersomrwLde L'ID -Politiqu de riorientation des SSP 120 45 : M4dfcel/ParcntdicaL 5.400 PM -OrganisationCGestion de LIND 120 : 5 : NC, SurveiLl./Econoe, 600 3 smc. major,CaOE -foFrmtion coMinentaire -Obstttrie 120: 1 : ddscin 120 A ditrn. -Pddiatrie 120 1 : n6dscin 120 A d6t6ru. -Laboratoire 120 : 1 : Laborwntin 120 A detrnn. -Planning Flitial 120 : 2 : MC, Sage F : 240 1 mais -0entist6rie, opthtaUmologie, etc.

-RecycLagsen maintsrce/uMtretien/propritt -Mnipulation des aWereiLs 120 : Tchnici. PM -*aintsnsnce/EntretienVPropret* PM -Structures de dialogue -Gestion des recettes/dep -n 120 1 : Rigis r spicial 120 1 mois? -COOE 120 8 : rbr 960:s

Eauiae di Service de Sant* de Ofstrict -Persorret de lIES5 *Politique de reorientation des SSP 120 8 : NC (2), Chefs bur. (2) 960 PM Autre (4) -Forimtionmtchmiqua 120 4 :C (2), Chefs bur. (2) 480 3 mois -Gestion financi6re/CptabiLitd 120 1 Chef Bur. Acein/Finance: 120 :A ditefr. -Techniqus de sLpervision 120 5 :IC (3) Chefs buretm 600: 3 sm.

-Structures de dialogue -COSADI/SICEDI 120 : Mbres ?

D4lkation ProvinciaL. de Santi -Polfitiq_ de rorlitation des SW 10 : 10 : OPT, Chtfs aese/bur. 100 :P -Managamint/Ptanific ation des serVics 10 4 nPS,Chef s acs 40 :A dittru. -Gestion du district 10 : 5 : Chefs bar., psrs. tech.: 50 : 3 mois -Gestion finwicirt/C*p itit: 10 : 1 : Chef See. Ain/Finace: 10 :A ditcr. -Techniqus d suparvision 10: 4 oPI, Cheftsces 40: 3 sm. wivesu Cnrtral .Politiqa de riorientation du SS : PM -M4aagant/Ptwwnification den serice 50 Oir, S/Dir, Chfs sces 50 A diter.. -Techniqus de stpsrvision -Formotion complmntaire REPUBLIC OF CAMEROON HEALTH, FERTILITY AND NUTRITION PROJECT Project Cost Summary

% % Total (CFAF '000) (USS '000) Foreign Base Local Foreign Total Local Foreign Total Exchang Costs

A. Assistance in Development and Implementation of Population Policy Support the Activities of the National Population Commission 264,916.5 179,000.8 443,917.3 488.8 330.3 819.0 40 2 Improve Demographic Data Collection and Dissemination 385,144.9 158,205.9 543,350.8 710.6 291 9 1,002.5 29 3 Subtotal Assistance in Development and Implementation of Population Policy 650,061.4 337,206.7 987,268.1 1,199.4 622 2 1,821.5 34 5 B. Organizational and Administrative Reforms of MOPH Support the Strengthening of MOPHs Services& Management 126,455.8 541,335.5 667,791.3 233.3 998.8 1,232.1 81 3 Develop a Health Management Information System 70,128.0 96,403A4 166,531.3 129 4 177 9 307 3 58 1 Subtotal Organizational and Administrative Reforms of MOPH 196,583.8 637.7389 834,322.7 362.7 1,176,6 1,539.3 76 4 C. Expansion of PHC Coverage and Service Quality Improvements Support PHC Services through Decentralized Health Districts 2,183,098.5 10,202,484.1 12,385,582.6 4,027.9 18,823.8 22,851.6 82 59 Improve Family Planning & Maternal & Child Health Services 663,715.3 594,913.7 1,258,629.0 1.224.6 1,097.6 2,322.2 47 6 m Strengthen Nutrition Interventions 605,425.0 1,978,536.2 2,583,961.2 1,117.0 3,650.4 4,767.5 77 12 -1 Strengthen Training & Retraining of Health Personnel 506,563.2 273,500.8 780,064.0 934.6 504.6 1,439.2 35 4 Supply of Essential Generic Drugs, Vaccines & Contraceptives 77,849.8 1,291,915.1 1,369,764.9 143.6 2,383.6 2,527.2 94 7 Strengt. the Heafth Educat. Unit of MOPH and Expand Comm. Prog. thru IEC 169,458.4 309,077.7 478,536.1 312.7 570.3 882.9 65 2 Subtotal Expansion of PHC Coverage and Service Quality Improvements 4,206,110.2 14,650,427.6 18,856,537.8 7,760.4 27,030.3 34,790.7 78 90 D. Project Preparation Advance (PPF) 116,567.1 226,658.3 343,225.4 215.1 418.2 633.3 66 2 Total BASELINE COSTS 5,169,322.5 15,852,031.4 21,021,353.9 9,537.5 29,247.3 38,784.8 75 100 Physical Contingencies 347,214.4 1,421,087.2 1,768,301.6 640.6 2,621.9 3,262.5 80 8 Price Contingencies 1,551,992.3 1,716,760.3 3,268,752.6 2,863.5 3,167.5 6,030.9 53 16 Total PROJECT COSTS 7,068,529.2 18,989,878.9 26,058,408.2 13,041.6 35,036.7 48,078.2 73 124

Cs I>o O I. REPUBUCOF CAMEROON HEALTH,FERTIITY AND NUTRITIONPROJECT ProjectCmponent by Yer - Total indudi ContIngencIs (US$ W0)

TotalsInckuding Contingences 963 M7 97/98 913 31900 00/01 Total A. Asisance In Develpnmentnd hknpbmntatlonof PopulationPolicy Supportthe Actvies of te NatonalPopuAtion Commission 403.2 140.3 115.9 149.5 124.2 159.0 1,092.1 improveDemogan DataColection and Dissemhation 447.1 142.3 219.4 157.3 234.4 166.7 1,367.3 SubtotalAssidance In Develwmentand nplernentatonof PopulationPolicy 850.4 282.6 335.3 306.9 358.6 325.7 2,459.5 B.Organiational and Adninistrative Refonmsof MOPH supportthe Sbwrtegn of MOPH'sServces &Management 710.7 351.8 1158 90.2 92.6 95.1 1,456.3 Developa HealthManagement Information System 186.7 71.0 688 17.6 18.1 18.6 380.8 SubtotalOrganizatonal and Adninistrative Refonmsof MOPH 897.4 422.8 184.6 107.9 110.7 113.7 1,837.1 C. Expnion of PHCCoveage and Servke Quality hnprovenents SupportPHC Services through Deczed Health Dstrics 3,065.6 3,252.6 6,273.2 6,457.2 6,866.3 2,102.2 28,017.0 ImproveFamily Plannng & Maternal S ChidHealh Serces 331.2 952.8 518.8 465.0 389.9 400.6 StrenUwgenNutrion Intrvention 3,058.3 1,474.5 902.1 883.1 872.1 877.2 826.7 5,835.7 StrewgenTrain & Retain of HealthPesonnel 228.1 407.3 428.2 410.8 286.0 232.0 1,992.4 Supplyof EssentalGeneric Drugs, Vacches & Contracepties 502.6 586.1 603.7 477.1 449.6 460.9 3,080.0 Serngt.theHeethEducat.UnitofMOPHandExpandConmn.Prog.tirulEC 421.6 127.6 133.6 137.9 141.6 145.5 1,107.8 Subtotl Expansionof PHCCoverage and ServiceQuat knprovaeents 6,023.6 6,228.5 8,840.7 8,820.0 9,010.6 4,167.8 43,091.2 D. ProjectPrepartion Advance(PPF) 690.5 - - - - ' 690.5 Tota PROJECTCOSTS 8,461.8 6,934.0 9,360.6 9,234.8 9,479.9 4,607.2 48,078.2

00 REPULLC OF CAMEROON HEALTH. FERTILITY,ND NUTRWTONPROJECT Comoe by Rnancer

RepubNlcof Local CAmeroon DA ComunItIes Total (Eid. Duties & Amount % Amount % Amount V% Amount S For. Exch. Taxes) Taxes k Assitance In Development and huplemerlIalon of Populaton Poliy SuppodtOw AcIeoftheNffclPopuatlonComnaion 185.4 17.0 906.8 83.0 - - 1.092.1 2.3 381.3 644.6 66.3 mprve Dwnoaplic DnabCoection and Daeni on 69.2 5.1 1,298.1 94.9 - - 1,367.3 2.8 335.4 979.8 52.2 Subtotal Assidance In Deveopment and Ia _lementktIof Population Policy 254.6 10.4 2,204.9 89.6 - - 2,459.5 6.1 716.7 1,624.3 118.5 B. OrganIzatonal and Administrative Refoms of MOPH SuppcontheStrengileningofMOPrsServices&Management 297.7 20.4 1,158.5 79.6 - - 1,456.3 3.0 1,154.6 144.9 156.7 Develop a HealthManagemmnt Information System 22.6 5.9 358.2 94.1 - - 380.8 0.8 204.2 154.0 22.6 Subtotal Organizatonal and Administrative Reforms of MOPH 320.4 17.4 1,516.7 82.6 - 1,837.1 3.8 1,358.8 298.9 179.4 C. Expansion of PHC Coverage and ServlceQuality Improvements Suppot PHC Se,vstvoughDecenalized Heath Distrits 3,487.5 12.4 24,529.6 87.6 - - 28,017.0 58.3 22,813.4 1,716.2 3,487.5 Iknpro Famly Plannl& haternal & Child Health Services 247.0 8.1 2,811.4 91.9 3,058.3 6.4 1,289.7 1,521.6 247.0 0C StrengthenNutrition Intereti 334.8 5.7 5,500.9 94.3 - 5,835.7 12.1 4.267.7 1,233.1 334.8 0' StrengthenTraining & Retrainingof Health Personnel - - 1.992.4 100.0 - - 1,992.4 4.1 604.6 1,387.8 Supplyof EssentialGeneric Drugs, Vaccineis& Contraceptives 52.4 1.7 2,338.3 75.9 689.3 22.4 3,080.0 6.4 2,886.8 140.9 52.4 Strengt.the Health Educat. Unt of MOPHand ExpandCornm. Prog. thru IEC 319.3 28.8 1,500.0 71.2 - - 1,107.8 2.3 664.9 365.4 77.5 Subtotal Expansion of PHC Coverage mnd Servce Quality Improvements 4,440.9 10.3 38,661.0 S8.1 689.3 1.6 43,091.2 89.6 32,527.2 6,365.0 4,199.1 D. Projed Prepartin Ad (PP) 0.0 - 690.5 100.0 - - 690.5 1.4 434.0 256.5 Total Disbursement 5,015.8 10.4 43,073.1 90.0 689.3 1.4 48,078.2 100.0 35036.7 8544.7 4,496.9

o -0 0' REPUBLICOF CAMEROON HEALTH, FERTILITYAND NUTRITION PROJECT Disbursements by Seedster and Governrent Cash Flow (US$ '000)

Costs to be Financing Available Financed Republic of Caneroon IDA Conrnunities Project Cunulative Arrount Armunt Total Costs Cash Flow Cash Flow 1 - - - 4,230.9 4,230.9 -4,230.9 2 3,806.5 3,806.5 4,230.9 424.5 4,655.4 3 3,806.5 - 3,806.5 3,467.0 339.5 4,315.9 4 3,114.2 - 3,114.2 3,467.0 -352.8 4,668.7 5 3,114.2 - 3,114.2 4,680.3 -1,566.1 -6,234.9 6 4,177.9 - 4,177.9 4,680.3 -502.4 -6,737.2 7 4,177.9 - 4,177.9 4,617.4 -439.5 -7,176.7 8 4,006.0 112.1 4,118.0 4,617.4 499.4 -7,676.1 9 4,006.0 112.1 4,118.0 4,739.9 -621.9 -8,298.0 10 4,099.6 114.9 4,214.5 4,739.9 -525.5 -8,823.5 11 4,099.6 114.9 4,214.5 2,303.6 1,910.9 -6,912.6 12 1,982.4 117.7 2,100.2 2,303.6 -203.4 -7,116.0 13 1,982.4 117.7 2,100.2 - 2,100.2 -5,015.8 X Total 43,073.1 689.3 43,762.4 48,078.2 - -7,116.0

* ~~~~~~~~0% REPUBLICOF CAMEROON HEALTH, FERTILITYAND NUTRITION PROJECT LocaUForeignlTaxesby Financier (US$ '000)

Republicof Cameroon IDA Comnmunities Total Amount % Amount % Amount % Amount % I Foreign 0.0 - 34,347.4 98.0 689 3 2.0 35,036.7 72.9 II. Local(Exci Taxes) 518.9 6.1 8,725.7 93.9 - - 8,544.7 17.8 III.Taxes 4,496,9 100.0 - - - - 4,496.9 9.4 Total Project 5,015.8 94 43,073 1 90,0 689.3 0,6 48,078.2 100.0

O _ \0 REPUBLICOF CAMEROON

HEALTH, FERTILITYAND NUTRITION PROJECT - ProcurementAccounts by Year (USS '000)

Totals IncludingContingencies 95/96 96/97 97/98 98/99 99/00 00/01 Total 1. CivilWorks 2,506.3 2,606.8 4,581.8 4,556.8 4,670.8 683.9 3. Vehicles 19,606.4 1,509.6 499.0 430.2 246.0 307.4 315.1 3,307.3 4. Medical & other imported equipment 1,005.0 689.7 862.4 883.9 904.3 5. Materials 151.4 4,496.7 2.6 2.8 3.1 3.2 3.3 6. Furnture 3.4 18.3 62.1 40.4 123.7 120.9 130.1 25.2 502.4 7. Drugs Yrs 1-3, Vaccines & Contracep. 656.5 732.6 720.3 511.4 524.2 471.4 8. Drugs Yrs. 4-6 3,616.5 - - - 224.1 229.7 235.5 689.3 9 Short-Term Cons./Supervision 747.9 783.5 790.8 805.2 828.3 852.1 4,807.8 10. FellowhiplTrainingAbroad 448 186.8 191.5 164.6 32.4 - 11. Local Trng./Seminars/Studies 620.1 708.6 662.6 763.4 686.3 683.4 637.1 4,143.4 12. Operation/Maint./Gen. Oper. Costs 455.3 648.9 806.8 940.1 1,073.0 1,136.5 5,060.6 13. Incremental salaries/Redeploymt. costs 72.8 80.8 86.7 90.2 92.9 95.7 518.9 15. PPF Refinancing 690.5 - - - - - Total 690.5 00 8,461.8 6,934.0 9,360.6 9,234.8 9,479.9 4,607.2 48,078.2

0 O _ 90

REPUBLIC OF CAMEROON HEALTH, FERTILITY AND NUTRITION PROJECT Annex 20 Implementation Schedule Page 1 of 2 Calendar of Activities

I C QuantltVy *r'SeQaationdesign. btdding/islection. etc.; x - uarter of IrrciementatlcIl

_r.. ' ~- - ",,JPvfe& Year Pr*ctc5Elemn t -- t Z L3 ... ±. st t

1. ASSISTANCE FCR DEW. AND IMPI. OF POP. PCL.

(A) SUPPORT THE ACTIVITIES OF NATIONALPOPULATION COMMISSION Pooulacion Round Toles x x x * Pooulanon Sensitization Camopign. . . x xx x xIx x xx x xx x xx x x x x Provinciai Workshops on Population x x x x x x x x x x x x x xxx xxx x x x x

iS) IMPROVE DEMOGRAPHIC DATA COLLECTICNAND DISSEMINATION Oemographc' Surveys .. x .. x x Studies x x x x x x - Population Oata Collection and Proesing x x x x x x PrintngidistKibuon ot Population documents x x x A x x *Seminaus for Domographers x x

2. 0O ttAMZATlOtALAM xMAMAGUICTE MS IMTHIZ IALT4 UCT

(A) MANAGEPAENTSTRUCTURES Creation of Technical Committa for Coordiwticn and Foibow-up (TCC) x Reahbilitainon of MCPH Offices x x x (a) (1I Implementation of organiztion changes witrin MOPH istatf training x x x x x I x x xx x x x x x x x x x x x x Oevelop manragementlacounting system .. x x x Update and disseminate PHN policy and otMir docunem x x x x x Print and disseminatg new job descnptions. intemaaorocedwes x x x x x Redeploymont of piersonnel ...... x x x x x x x x x x x x x x x x x x x x Carry-out annual audits of project x x x x x x Mid-Term Project Review x

(3) MEALTH MANAGEMENT INFORMATIOC SYSTMS - Seting uo ot management informaton system x x x xx Training of MOPH staff in statis . data collection and dissemination x x x x Oxsu Collection and Oisseminaton x x x xxx xxxx x x x x x x x x x Carry-out research studies x x x x x x Study Tour,HMIS x HMIS Sominats at district. provincial and eomtrislevs x x I x x x x x x

3. EXPANSIMOFPHCCO V!tAANQ JJAUTYPWxVEMEfM

(Al SUPPORT PHC SERVICES THRU HFALTH OISTRICTS ConstrucainoRenailitation of ISO Heahh Cantes ... x x x x x x x x I xx x x x x x x x x xi 101 (101 (101 (301 140) 1401 120) Construction/Renaiilitation of IS Clinical fFelities ... x x x x x x II x x x IC) (3) 13) 131 13 (31 31 M d7d .fm Rev,ew af eferral System _ x 91 REPUBLIC OF CAMEROON Annex 20 HEALTH, FERTILITYAND NUTRITION PROJECT Page 2 of 2 Implementation Schedule Calendar of Acvvit'os

la-.Ouaonty *Proearation, design. bidding/Iletlon. etc. x-Quarterto lmOlemmntationI

Ph,~ ~ Pvf~to Yaw

=:_-~~~~ -Z - -

(I) IMPROVE FAMILY PLANNING AND MATERNAL ANO CHILD HEALTH Study on Sate MotherMood xx xxx Study on CantracSootve Prevalanc,Frtiulity x x x x xx ixx x x x

Technical assist. on FP7MCE interventions x x x x x

4. STR FiiWT UTHmMO. -T-iTIVN Basekino Surveys x x x x x x Nutrinon StrategyFormulation x x x x x x National Sominars on Nutriton x x x x x x Workshops/Seminars on Nutrition Education,*includin xx xx xx xx xx x x

. STWStl11HE TRAWi AND iETMWU OFHEALTH PUNWIE. Rtraining ofHxas"t Oistnct Txm Members x x x xxxxxx x x x x x x x x x x x x x Traiang ot Community Workersfor OutreachActivritie x xx I xxxxxxxxxxxx x xx xx sx xsI RetrainingMOPH'x orovinciallcentra maagw x x x x xxxxxxxxxxxx x xx x x sx x - Scholarships x x x x x x -Training for Demographers x x *Scholarsliops fotDemograoherx x x x x

(A) SUPPLYING ESSENTIAL ORUGS.VACCINES AND CONTRACIPT IUVi - RehaSlitation of Orug Warshouess x x x x x x (Cl (11 121 121 I.ntixi Stock of Essential Ougs for 150 heM comentrs& S clinical facilitos x x x x xxxxxxxx xxix x x xx xxA x Oistribution of Vacctmes & ContrxcaQuvs x x x x xx xixxxxxixx x x x a Isxa I

*Trainingotlocaldrugclerlk xxxx xxxxxxxxixxxx x i xa a

(liEXPANDING COMMUNICATION PlOAM THROUGH IEC Trainingof IECSoecialietsJTr,n x x xxx x x xxix xxix xxx x xa t *Ovveloocid-testIEC meages xx xx x x x x i x xx IEC Worksiooa. Seminar aWd S aafon Camp ... x x x x x S Annual PHN Education Somimr x x x x x x x x xx xi ProductionOistrobution of heat &famtyplaninngeducation mat.wa . x x x xi xxx x x x x x xx . a x x x

* including food suppl. distribution 92

Annex 21

HEALTH, FERTILITY AND NUTRITION PROJECT Page 1 of 3 Implementation Schedule Estimated Annual Contractual and Other Payments (US$ million equivalent) (Q = Quantity)

Pre- Project Year _ Total Project Element Project I |2 3 4 | 5 6 Payment[ Remarks

CREDIT TIVIING (tentative dates) Effectiveness: (March, 1995) Close: 7th Year WORKS

Architects' Contracting x l 50 Health Centers - Design (Q) (10) (10) (40) (40) (40) (10) - Contracting (Q) (10) (10) (40) (40) (40) (10) - Construction (Q) (10) (10) (40) (40) (40) (10) (150) 0.21 0.22 0.89 0.92 0.94 0.24 3.42 ICB 18 Clinical Facilities - Design (Q) (3) (3) (4) (4) (4 - Bidding +Contracting (Q) (3) (3) (4) (4) (441 - Construction (Q) (3) (3) (4) (4) (4i (18) 0.44 0.45 0.61 0.63 0.65 2.78 ICB MOPH Offices - Design (Q) (1) - Bidding +Contracting (Q) (1) - Construction (Q) (1) (1) 0.21 0.21 LCB 5 Drug Warehouses - Design (Q) (1) (2) (2) - Bidding +Contracting (Q) (1) (2) (2) - Construction (Q) (1) (2) (2) (5) 0.06 0.12 0.12 0.30 ICB GOODS

Proc. Special Contractng Bidding Doc. Preparation x x x x x x x Bidding + Contracting x x x x x x x ICB (4x4 Veh. Vehicles 0.64 0.25 0.18 0.09 0.26 0.26 1.68 & ambulances) LCB (Cycles) Other Imported Goods (medical, office 0.49 2.08 0.79 0.80 0.83 0.13 5.12 ICB aid communic. equipment)

Local Furniture and materials 0.05 0.05 0.10 0.10 0.10( 0.04 0.44 LCB 93

Annex 21 Page 2 of 3 HEALTH,FERTILITY AND NUTRITION PROJECT g ImplementationSchedule EstimatedAnnual Contractualand Other Payments (US$ million equivalent) (Q = Quantity)

Pre- ProjectYear Total ProjectElement Project 1 2 3 4 5 6 Payment Remarks ESSENTIALDRUGS, VACCINES& CONTRACEPTIVES 150 Health Centers x 0.64 0.66 0.67 0.47 0.48 0.50 3.42 ICB 18 ClinicalFacilities x 0.21 0.22 0.22 0.65 ICB

SERVICES

TORs Short Lists x x x x x x Selection+ Contracting x x x x x x

Short-TermConsultants 0.55 0.60 0.59 0.60 0.62 0.63 3.59 IDA Guidelines Training Abroad/Fellowships 0.09 0.13 0.13 0.11 0.08 0.01 0.54

MISCELLANEOUS

Local Training/Seminars/Workshops 0.56 0.62 0.70 0.64 0.63 0.65 3.80 Operations + Maintenance 0.56 3.21 3.94 3.56 3.69 4.14 19.10 Rental Fee 0.01 0.01 0.02 0.02 0.02 1 0.02 0.10 IncrementalSalaries/Allowances 0.41 0.48 0.52 0.54 0.55 0.57 3.07 PPF Refinancing 0.33 0.33

TOTALS I [5.04 19.09 9.26 8.69 9.07 1 7.41 48.08 (IDA-Financed) 6.80 6.20 7.20 7.40 7.60 I 7.80 43.00 REPUBLICOF CAMEROON HEALTH,FERTILITY AND NUTRITIONPROJECT TECHNICALASSISTANCE

jV.'~ ~ ~ ~ ~ ~ ~~~

> S0%. itH|niS|jrj5,T9y,: 'iS|~~ . .J

olloAStMEA lt ANO t^KAttZOTl gWf0^_ IN 1HE HSA.T14 SICIOft

8 months h idIuai I1 tAOf,i .tpement -ttuooDewep bp, tm ed bsEolt. x K . . 11 x Accouetinng msd Moutgneed Syotem Ainwe1A Auh K . . .. .a e monthe fimb

hdIMu.j 2 H.aah en.gemenwnt hbmahmb Syste D0ev - H"s capMutdetrd x1 t month. -HUMS . d K e1 monwth

S. !IDXPAMg PHtCCOVERAaE AND QUAtIIV US ttl 1T

4 months kwdlIu&l t. Sup9oitMn fiC StvkoS UwSthh HXMU Dlotdt@cS MM-TomT P m of*etendo SVt40S a * StudV Wn pSpOctI kw *tnOAing K K x K 16atbonthe kdMwduai wb n ht.llt ~sm so dep eted

Gists.. so hepam I_st 1 *po xa I 5 2 monlhs kdJv4ual

2. 1114w4ul FuJy ftwwV - MtmtJ m_t ChM HeaRt Dewimp FrIMCH htAEW.Umw x x x x I 2 month. kidlv4dual

S. Ep*rWb CA 1e111 ttlW Sh IEC -D*M IpCbh _sr.tthiw x K k * K X 16 month. h.dt4du.I

TOTAL: 02 monih.

OQ (D r X

0 9ot 95

Annex 22

REPUBLICOF CAMEROON

HEALTH,FERTILITY AND NUTRITIONPROJECT

Project Performance Indicators

1. Coverane

1. 1. Curative coverage

1. 1. 1. Rate of use of health centers 1. 1.2. Rate of referral from health centers to/at the district hospitals

1.2. Preventive coverage

1.2.1. Coverage for BCG vaccination 1.2.2. Coverage for DTC3, Polio3 vaccination 1.2.3. Coverage for antenatal care

2. Health and family planninE services

2.1. Family planning: Couple-years of protection 2.2. Growth monitoring: Number of children weighed 2.3. Diarrhea: Rate of use of ORT 2.4. Occupancy rate 2.5. Number of maternal death per 100,000 2.6. Number of children under 5 and women (15-49 years) vaccinated.

3. Nutrition Services

3.1. Numbers of wasted children (% of population served) 3.2. Number of underweight children (% of 0-5 age group) 3.3. Prevalence of malnutrition in project areas 3.4. Prevalence of anemia (% of population served)

4. Oreanization and Administration of Services

4.1. Rate of shortages for the 10 most vital and essential drugs. 4.2. Rate of community participation in the financing of the functioning of health centers 4.3. Consumption rate of the allocated budget

Note: Project indicators will be measured against WHO-recommended norms and official Government standards. 96

Annex 23

REPUBLICOF CAMEROON HEALTH, FERTILITY, AND NUTRITION PROJECT

ESTIMATED SCHEDULE OF IDA DISBURSEMENTS (US$ million equivalent)

Country IDA Disbursement Disbursement Disbursment FY Semester in Semester Cumulative % of Total Profile

FY95 June 30,1995 1 0.7 0.7 2.0% 6%

FY96 December 31, 1995 2 3.6 4.3 10.0% June 30,1996 3 5.7 10.0 23.0% 14%

FY97 December 31, 1996 4 3.0 13.0 30.0% June 30, 1997 5 3.0 16.0 37.0% 26%

FY98 December 31, 1997 6 4.0 20.0 47.0% June 30, 1998 7 4.0 24.0 56.0% 46%

FY99 December 31, 1998 8 3.8 27.8 65.0% June 30, 1999 9 3.8 31.6 73.0% 66%

FY2000 December 31, 1999 10 3.9 35.5 83.0% June 30, 2000 11 3.9 39.4 92.0% 82%

FY2001 December 31, 2000 12 1.8 41.2 96.0% June 30, 2001 13 1.8 43.0 100.0% 100%

1/ Includes repayment of PPF 97 REPUBLICOF CAMEROON HEALTH, FERTILITYAND NUTRITION PROJECT Annex 24 IDA Supervision Input into Key Activities Page 1 of 2

EXPKCtEO sKUJ $TAFFINP VT PEREOD ACTIVITY REQUIREMENT IstaF al

FY95 Project Launch Workshop Public Health 2 Implementation Specialist 2 IEC Specialist 1 Health Facilities Planner 2

FY96 Supervision Mission Public Health 2 Implementation Specialist 2 Health Economist 2 Health Facilities Planner 1 Procurement Specialist 1

Supervision Mission Public Health 2 Population Expert 1 IEC Specialist 1

Other Resident Mission 2

Supervision Mission Public Health 2 Implementation Specialist 2 Institutional Development Expert 2

Supervision Mission Public Health 2 Implementation Specialsit 2 IEC Specialist 1 Health Facilities Planner 2 Population Expert 1 Health Economist 2

Other Resident Mission 2

Supervision Mission Public Health 2 Implementation Specialist 2

Other Resident Mission 2

FY97 Mid-Term Review Public Health 2 Implementation Specialist 2 Health Economist 2 IEC Specialist 2 Institutional Development Expert 2 Population Expert 2 FY98 Supervision Mission Public Health 2 Implementation Specialist 2 IEC Specialist 1 Health Facilities Planner 1

Supervision Mission Public Health 2 Implementation Specialist 2

Other Resident Mission 2 98 REPUBUCOF CAMEROON HEALTH,FERTIUTY AND NUTRITIONPROJECT IDA Supervision Input into Key Activities Annex 24. Page 2 of 2

FY _ SuDer.,sion Mssuon - Pubiic H-ath 2 impi.m.nUtotfonSpeciaaIt 2 IEC Specait 1 Health Facikies Fannwr 1

Su2*Msion Mission Public Heah 2 Impimntation Specilit 2 PopuLation Expert I

Othe Ftesiden Wssion 2

FY2000 Supervison Mission Public Hasth 2 Implementaion Spcalist 2 IECSpecalist 1 H-ath Facies PaRar 1

Supervision Mission Public Heaft 2 Imp peMalionSpecilist 2 Popuiation Expert

Qt- PoResideentmission 2

FY2001 PmoiwetCompletion Mission Public Healh 3 Implementation Specialist 3

Total: 101 99 Annex 25

REPIJBLIC OF CAMNEROON HEALTH, FERTILITY AND NqJTRITION PROJECT LIST'OF KEY DOCUMENTS IN PROJECT FILE

1. Statement of Sectoral Health Policy, Republic of Cameroon, December 1992.

2. Declaration of National Population Policy, Cameroon National Population Commission, March 1993.

3. Cameroon Demographic and Health Survey 1991, Ministry of Planning and Regional Development, December 1992.

4. 1987 Census Summary Report, Ministry of Planning and Regional Development, December 1992.

5. La Politique des Ressources Humaines du -tinisterede la Sante Publique du Camneroun, Rapport Definitif Fascicule 1, N.C. Counsulting, Fevrier 1993.

6. Financement et Gestion de Ressources dans le Secteur de la Sante du Cameroun, Cameroun, GTZ, Mars 1992.

7. Developpement des Soins de Sante Prinaires en Milieu Urbain, Bruno Dujardin, Institut de Medecine Tropicale, Antwerpen, Belgique.

8. Ia Politique Pharmaceutique du Cameroun, Sodgandji, 1991.

9. Essential Drugs Program, Guy Kegels, June-July 1993.

10. Nutrition of Infants and Young Children in Cameroon, USAID/Macro International Inc., March 1993.

11. Financing Carneroon's Health Sector, Peter Bachrach, July 1993.

12. Camneroon, Population and Family Planning Review, AFIPH, June 1991.

13. Detailed Project Cost Tabulation (COSTAB).

14. Rapport Final de l'Atelier de Formation des Formateurs en Nutrition, Care International Carneroon, June 1993.

15. Final Report of the National Nutrition Survey, USAID, October 1978. 100

16 HEALTH MANAGEMENT STRUCTURE. Cameroon, Ministrv of Public Health and GTZ, May 1993.

17. Programme National de Lutte Contre le SIDA, Deuxieme Plan a Moven-Terme, 1994-98

18. Teachers' Guide in Health Education For Primary Schools in Cameroon, Ministry of Public Health and Ministry of National Education, July 1990.

19. Cameroon Baseline Survey 1991 - Child Spacing Promotion Project, Ministry of Public Health and Johns Hopkins University, March 1992.

20. Rapport sur le Projet Renforcement des Soins de Sante Primaires dans les Provinces du Littoral, du Sud-Ouest et du Nord-Ouest du Cameroun, GTZ, May 1992.

21. Education des Populations a la Parente Responsable, Strategie, MINASCOF and UNFPA, 1990.

22. Rapport de Mission de Preparation des Interventions de la CEE dans la Sante, Cameroon and GTZ, February 1992.

23. SMI/PF/Nutrition au Cameroun: Situation Actuelle et Integration dans le Systeme des Soins Int6gres, Lalla Toure, March 1993. Montn Febb harboudre, dn,,n, , denonm.nnionsond onyJ olb.r -normonP ho,n CAMEROON -m^ePhwoohly,- thfknpir ) HEALTH,FERTILITY, AND any ad n,enionhn I.nI NUTRITIONPROJECT .sn?o,o ony ke,r.kn,y. a-ony ndo-n, t YAOUNDEPROJECT LOCATIONS baaadors\\

) OLIGA V \ \ * PROJECTLOCATIONS

MAIN ROADS

/ . ---- \ RAILROADS/ STATIONS

B . ' fr/ A \ MEIALA RIVERS,CREEKS, AND STREAMS EUILT-UPAREAS I 973)

400 RTO 1200 1600 METERS V / < ~~~~~~ ~ ~~BASTOS|M;R

NKOM) -KA N- \TSINGA ND NA

/ :> - \ \ \ aR t V \1 | u~~~~~~~~~~~MFANDENA ( ADA ASCAR\ \) \\ N OETOA-MEKI

t< \ > \t,KOUDOU NOON\O \ ~~~~QU HAOUSSAsT

8CITE VERTE \

MESSA~ ~ ) NLONGKAKt ~ ~ ~ ~J ~ DOUGLD'11-' S O

MELEN k/ \ /, - < -- \ <~~~~~~~~~~~~~~~~~~~~~~~~~N O G;OOLOm

< t s- ), -'(.J/ t < X 0 -T 5ffit ~~~~NKONDONGO 0 9>& / \ <83tB . U~~NIVERS,iTY<~~~--,'IGO/ EKLE t< 2 S NKO N

EKOUNOU 00 co,o''.

MVOL E a

/ 1 t1 \ | Nou90vo/a\ K lUbo/soser{ )t tOTvGUNEa| GAEOdQ< CONGO '

o~~~~~~~~~~~~~~~~~~~~~~~~~TLaan\T/aMbaIn ,a,,ove

MA~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~Z,.... C h.4[''i4. __- N,.^.1 .... r'suvei S . ,>

-W HAHALC

SEN II

CA.MERO)ON~ \ }},?7 06r6 r 2LET-0 *0 60 80 062120 170 10

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