Organization of the Department of Family Planning and Maternal and Child Welfare Central Administration

RETURN To REPORTS DESK RERet NoE PP-4b WITHIN '.Rpr o P4 ONE WEE]K Public Disclosure Authorized This report was prepared for use within the Bank and its affiliated organizations. They do not accept responsibility for its accuracy or completeness. The report may not be published nor may it be quoted as representing their views.

INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT

INTERNATIONAL DEVELOPMENT ASSOCIATION Public Disclosure Authorized

APPRAISAL OF A

POPULATION PROJECT

TUNISIA Public Disclosure Authorized

March 3, 1971 Public Disclosure Authorized

Population Projects Department CURRENCY EQUIVALENTS

Dinar 1 = US$ 1.905

US$ 1 * Dinar o.525

MEASURES

1 m 2 . 1.20 sq. yd. or 10.76 sq. ft.

1 Km2 = 0.38 sq. miles 2.47 acres

GLOSSARY

A. Abbreviations

GDP Gross Domestic Product GNP Gross National Product IUD Intrauterine Device KAP Family Planning - Knowledge, Attitude and Practice Study MCH-FP Maternal and Child Health and Family Planning RMC Rural Maternity Center SIDA Swedish International Development Authority USAID United States Agency for International Development WHO World Health Organization

B. Definitions

Maternity Hospital: Hospital providing obstetric and gynecologic services including maternity beds, prenatal and postnatal care facilities.

Rural Maternity Center: Clinic in a rural area to provide beds and a delivery room for uncomplicated cases, and to provide prenatal and postnatal care, child welfare and family planning services.

Maternal and Child Health Center: Health Clinic which provides prenatal and postnatal care, child welfare and family planning services.

Rural Dispensary: Health center in the rural areas providing basic elementary medical care through nurse-assistants. TUNISIA

APPRAISAL OF A POPULATION PROJECT

TABLE OF CONTENTS

Page No. BASIC DATA

SUMMARY AND CONCLUSIONS i-i

I. INTRODUCTION ......

II. THE POPULATION PROBLEM AND GOVERNMENT POLICY ..... 1

A. The Population Problem ...... 1 B. Family Planning and Public Policy ...... 2

III. THE FAMILY PLANNING PROGRAM ...... 3

A. Evaluation and Present Organization ...... 3 B. The Present Program ...... 5

IV. THE PROJECT ...... 7

A. Project Components ...... 8 B. Cost Estimates ...... 11

V. IMPLEMENTATION AND DISBURSEMENT ...... 13

VI. SOCIO-ECONOMIC ANALYSIS ...... 15

VII. RECOMMENDATIONS ...... 17

This appraisal report is based on the findings of a mission that visited Tunisia from May 19-June 2, 1970. It was headed by Mr. D. Miller and included Mr. N. Faltas, Mr. G. Bury (Consultant), and Dr. R. Castadot (Consultant). Mr. Faltas re-visited Tunisia from July 25-August 7, 1970. A mission, composed of Messrs. R. Springuel, head of mission, S. El Fishawy, S. Julin, and L. Currat visited Tunisia December 2-9, 1970. This report was prepared by Messrs. G. Zaidan, D. Miller, N. Faltas, and L. Currat. Mr. G. Baldwin lent his assistance to the group. -2-

ANNEXES

1 - ADMINISTRATION OF PROJECT AND PROGRAM

1-1 Duties and Responsibilities of the Project Administrator 1-2 Duties and Responsibilities of the Project Architect and the Project Accountant 1-3 Family Planning Program - Central Administration 1-4 Family Planning Program - Regional Administration

2 - DEMGRAPHIC DATA

2-1 Population Projection--Four Series (1967-1985) 2-2 Estimate of the Natural Rate of Population Increase for the Intercensal Period (1956-1966) 2-3 Projected Number of Women in the Age Groups 15-49 and 20-44 (1967-1974)

3 - FAMILY PLANNING PROGRAM PERFORMANCE

3-1 Provision of Family Planning Services--Number of Facilities by Province (1969) 3-2 Maternity Facilities by Health Region--Annual Number of Deliveries per Bed and Average Stay (1968) 3-3 Family Planning Consultations in MCH Centers (1969) 3-4 Commercial Sales of Contraceptives (1967-1969) 3-5 Distribution by Sanitary Region of Postpartum Educators, Maternity Beds, and Average Monthly Deliveries (1969) 3-6 Family Planning Acceptances by Method and by Month (1969) 3-7 Postpartum Family Planning Program Coverage, Acceptor Motivation, and Rate of Acceptance by Sanitary Region (1969) 3-8 Maternity Facilities Medical Activity Data (1969)

4 - FAMILY PLANNING BUDGET AND PERSONNEL

4-1 Budgeted Personnel Positions (1970) 4-2 Preliminary Projection of Family Planning Personnel (1970-1974) 4-3 Actual Disbursements for Family Planning Operating Expenditures (1968) 4-4 Actual Disbursements for Family Planning Operating Expenditures (1969) 4-5 Actual and Projected Family Planning Expenditures (1969-1974) 4-6 Family Planning Dinar Budget (1970) 4-7 Estimate of Operating Costs for Project Facilities -3-

5 - PR)JECT PARAMETERS

5-1 Demographic Data on Existing and Proposed MCH Centers 5-2 Number of Medical and Paramedical Positions (1970) 5-3 Projection of Paramedical School Graduates (1970-1973) 5-4 Paramedical Personnel Needs (1970) 5-5 Need and Utilization of Obstetrical Beds by Province (1969) 5-6 Graduates in Midwifery and Personnel Needs for the Health Ministry and IDA Project (1970-1980) 5-7 Location of Facilities 5-8 Project Capital Cost Estimates 5-9 Contingency Allowance 5-10 Family Planning Project Implementation Schedule

6 - THE DEMOGRAPHIC EFFECT OF THE PROJECT

7 - DESCRIPTION OF PROJECT FACILITIES

MAPS

1 Proportional Distribution of Population 2 Maternity and MCH Network 3 MCH Network Utilization

TUNISIA

BASIC DATA

Area 164L,000 km2

Population (1970) 5.2 million Urban Population 2.0 million Annual Rate of Growth (1967-70) 2.8% Crude Birth Rate (per 1000 population) h Crude Death Rate (per 1000 population) 16 Women in Age Group 15-49 1,079,000 General Fertility Rate 212 (number of births per 1000 women aged 15-49) Infant Mortality 110 (number of deaths of infants under 1 year of age per 1000 live births)

Gross Domestic Product (1970) uS$1,065 million (at current factor costs)

GDP per capita US$ 205 GDP Annual Rate of Growth (1965-70) 3.6% (1966 prices) Industrial Origin of GDP (1966 prices)

Agriculture 14.3% Mining, Water and Power 8.5% Manufacturing 15.2% Construction and Public Works 8.8% Transport and Communication 8.6% Services 25.3% Government Wages and Salaries 19.3% External Debt Public Debt outstanding (1969) US$700 million

Bank/IDA Position (US$ million) December 31, 1970

Bank loans (net of cancellations) 70.1 Repayments 2.3 Total loans outstanding 67.6 IDA credits (net of cancellations) 40,0 Total Bank/IDA T7.6

TUNISIA

APPRAISAL OF A POPULATION PROJECT

SUMMARY AND CONCLUSIONS i. In 1964 the Government of Tunisia initiated a limited, experimental program of voluntary family planning operated through the Ministry of Health. Two years later the Government expanded the initial experiment into a national program and established within the Ministry a new Directorate to provide education, service, and evaluation in family planning. ii. The project would strengthen the Government's program through a series of measures designed to increase substantially the number of acceptors of family planning and to retain more of them as practitioners for longer pe- riods of time.

The Project consists of the following:

(a) the construction and equipment of:

(1) four new maternity hospitals in Tunis, Sousse, Sfax, and Bizerte, with a total of about 500 beds;

(2) two new Rural Maternity Centers with a total of about 25 beds;

(3) twenty-nine Maternal and Child Health Centers; and

(4) the extension of the Avicenne Paramedical Training School and its Postgraduate Training Section.

(b) three technical assistance components:

(1) provision of consultants to design and recommend a system which would ensure an optimum use of the resources at the disposal of the family planning services and to help the Government implement the system;

(2) provision of experts to assist in teaching at the Avicenne Paramedical Training School and at its Postgraduate Training Section and provision of fellowships for training key paramedical personnel;

(3) provision of two external review missions of two to three experts scheduled for the Fall of 1972 and 1974 to assess the progress and efficiency of the national family planning program. - ii -

The total cost of the project will be US$7.7 million.

iii. The present family planning program, after six years of operation, reaches only about 2.5% of the eligible women in the fertile age group each year. This poor performance is attributable to:

(a) inadequate staff time given to family planning work as a result of the present staffing pattern and organization of the health services;

(b) overcrowding in the large urban maternity hospitals; and

(c) ineffective family planning work in the MCH1 centers because of poor scheduling of family planning services and inadequate functional design of the centers. iv. The project's foreign exchange component is estimated at US$4.8 million which would be met by the IDA credit, except for the part of fellowships and technical assistance costs related to training which may be met by other agencies. All local currency costs would be met by the Government, except for the services of local management consultants. v. As a result of the project, the targets of program achievement by the mid-1970's can be set much higher than recent performance. The number of consultations with potential acceptors is estimated to rise from the recent level of approximately 125,000 p.a. to more than 400,000, and the number of acceptors practicing contraception from just over 21,000 to more than 76,000 p.a. Finally, the number of births averted is estimated to rise from 6,000 p.a. to more than 21,000 p.a. vi. A Project Administrator would be appointed within the Ministry of Health to supervise the project. Contracts for civil works and procurement of materials, furniture, and equipment would conform to the Bank/IDA guide- lines on international competitive bidding. Domestic manufacturers of furniture and equipment would be accorded a preferential margin equal to 15% of the cif costs of competing imports, or the existing rates of import duty, whichever is lower. vii. The project would have important socio-economic benefits. These consist of improved maternal and child health, higher living standards for families practicing family planning and for the population in general, savings on the Government budget and an eventual contribution to reducing the rate of unemployment. viii. Subject to the provisions in paragraphs 7.01-7.02, the project is suitable for an IDA credit of US$4.8 million. I. INTRODUCTION

1.01 A Bank economic mission visiting Tunisia in March-April of 1969 first discussed the possibility of Bank Group assistance for the family planning program. The Minister of Planning subsequently requested the Bank to review the family planning program and to determine whether Bank assistance would be appropriate. This request was confirmed by the Governor for Tunisia at the Annual Meeting in September 1969.

1.02 An identification mission consisting of Mr. D. Miller (Economist) from the Bank and Dr. G. Povey (Consultant), visited Tunisia in November and December 1969. The mission's recommendations included the preliminary identification of a possible Bank project comprising the expansion of three maternity hospitals in Tunis, Sousse, and Sfax; the construction of several rural maternity centers with delivery beds (RMC's) and several maternal and child health centers (MCH's); and the expansion of the paramedical training school in Tunis.

1.03 An appraisal mission visited the country in May 1970. It was headed by Mr. D. Miller, Economist, and included Messrs. N. Faltas, Economist, G. Bury, Architectural Consultant, and Dr. R. Castadot, Medical Consultant. Mr. S. Julin lent his assistance to the mission. Mr. N. Faltas revisited Tunisia in July 1970. A mission, headed by Mr. R. Springuel, and composed of Messrs. S. El Fishawy, S. Julin and L. Currat visited Tunisia in December 1970 to brief the Goviernment on the major aspects of the project.

II. THE POPULATION PROBLEM AND GOVEVNMENT POLICY

A. The Population Problem

2 2.01 Tunisia, with an area of 164,000 km had a total population of 5.2 million people in 1970. Forty-five percent of these people live in the four provinces 9 f Tunis, Sousse, Sfax, aad Bizerte. Population density averages 100 per km in these northlastern coastal provinces, as opposed to less than 20 inhabitants per km in the southwestern interior regious (Map 1). The rate of population growth increased from less than 2% around 1930 to about 2.3% by 1960. By 1968 the rat-e of growth had further increased to 2.3%, with an estimated birthrate of 44 per thousand and a death rate of 16 per thousand. Unless the rate of population growth is reduced, Tunisia will double its population over a period of 25 years, reaching a level of 10.4 million in 1995. With a high fertility rate and an average death rate, there is a favorable prospect that reduction in fertility will be reflected in a reduction in the rate of population growth. Since over half of the married women are concentrated in 4 of the country's 13 provinces, the logistics of delivering family planning services are relatively favorable. The urban/rural distribution of the population by province is shown in Map I. Other pertinent demographic data are contained in Annex 2. - 2 -

2.02 The Tunisian real GDP grew at an average annual rate of 5.5% in the early 1960's. Due to bad weather and consequently poor harvests in 1966 and 1967, the rate of economic growth was about 3% during the second Four-Year Plan (1965-68). The target of the third Four-Year Plan (1969-72) is a 6% growth rate. In 1969 per capita GNP was US$230. During the first Plan, investments accounted for about one-quarter of GNP and they are expected to remain close to that level during the present plan. Given the present rate of population growth and the high capital/output ratio, almost half the resources invested in the present plan will be necessary to maintain the per capita income of the population at existing levels.

2.03 Unemployment is a large and growing problem in the country. Although labor force and employment statistics are difficult to interpret, unemployment is probably not less than 15% of the labor force, and may exceed 20%. Thus, in 1968 the number of unemployed was about 270,000. The problem is particularly severe among rural men (over half of Tunisia's labor force) and among the youth of the country. The Government has established special work programs to try to reduce the problem through public works, and these have benefited a relatively large proportion of the unemployed. In the long run, however, the Government looks to its new population policy as one way of reducing the economic, social, and budgetary pressures generated by mounting unemployment.

B. Family Planning and Public Policy

2.04 The Government recognizes the burden that the rapidly increasing population is imposing on Tunisian economic growth, thus the third Four- Year Plan (1969-72) explicitly calls for a reduction in the rate of population growth. The Ministry of Planning has turned to voluntary family planning to improve the economic and social prospects of the country, while the Ministry of Health has viewed the family planning program as a means of improving the health of mothers and children. The program has received the active support of President Bourguiba, the ruling Socialist Destourian Party, and the National Union of Tunisian Women.

2.05 The launching of the Government's experimental family planning program in 1964 has not been the only attempt to reduce fertility. In the same year a law became effective that established 19 as the minimum legal age of marriage for men and 17 as the minimum legal age for women. At approximately the same time the Government stopped making social welfare payments for any child beyond the fourth one. The family planning program included provision for free social abortions and tubal ligations, both of which were performed for women upon request, with necessary safeguards and explanations, provided they had a minimum of 5 living children. These positive policy measures are being reinforced by increasing the educational levels and by continuing the process of female emancipation. - 3 -

III. THE FAMILY PLANNING PROGRAM

A. Evaluation and Present Organization

3.01 An experimental public program was initiated in 1964 by the Tunisian Ministry of Health, with financial and technical assistance from the Ford Foundation and the Population Council. A national survey of knowledge, attitudes, and practice (KAP study) was conducted in the same year; it indicated that there was a large demand for family planning services. The Government responded to the study by the institution of a pilot program under the Ministry of Health; during the period 1964-66, medical and paramedical personnel were recruited and trainAd, evaluation procedures were established, and 30 centers were opened within the health organization.

3.02 The experimental phase was expanded into a national program in June 1966 with the addition of mobile teams to the services currently being provided by the large urban hospitals. But the general lack of adequate follow-up after initial consultations, the inadequate quality of service, and the exercise of coercion in some isolated instances, created a popular backlash which led the Government to temporarily withdraw its original unqualified political support for the program. This hesitancy has now been overcome and Government support is again open and strong.

3.03 The third phase of the program began in early 1968 with the reor- ganization of the Family Planning Services. Family planning activities were merged with the Maternal and Child Health Services and set up as a separate directorate within the Ministry of Health. It was during this phase that USAID first began providing substantial operating funds to family planning services in Tunisia, thus enabling the expanded program to be implemented.

3.04 In 1969 a large part of the administrative and financial control of the program was decentralized from the Directorate in the Ministry to the 16 regional health administrators who became responsible for all health services in their region. The central Directorate retained control with regard to personnel (recruitment, training, and assignment to regions) and overall medical aspects of the program. It did, however, lose control over personnel utilization after assignment. This division of responsibility between the regions and the central Directorate weakened the program due to the possibility of diversion of personnel from family planning to health activities. It is desirable that the Directorate of Maternal and Child Health and Family Planning (MCH-FP Directorate) in the Ministry of Health be re- stored with the powers necessary to control the administration and budgets of the MCH and family planning centers (now held by the regional health administrators). 1/ The MCH-FP Directorate would then control its financial, personnel, and technical policies. The proposed redistribution of program authority has been accepted by the Government. Another important reason for the program's poor performance to date is administrative weakness within the MCH-FP Directorate. The staff is competent and well motivated. However, the distribution of responsibilities has not been well defined, and the personnel of the Directorate has been insufficient to handle the program. Consequently, such necessary functions as the distribution of contraceptives to MCH centers have not been adequately scheduled or implemented. Personnel policies and recruitment have been neglected, and since 1968 about one-half of the family planning budget has not been utilized. The project will attempt to remedy these administrative defects by providing management consulting services to assist in designing and introducing a system of management appropriate to the family planning program.

3.05 The Ministry of Health is organized by departments, divisions and directorates. Until the summer of 1970 the Directorate of Maternal and Child Health and Family Planning was responsible to the Division of Preventive and Social Medicine in the Technical Services Department. In addition to running the Directorate of MCH-FP, Directors normally held other responsibilities which diluted their attention from their primary Directorate, which was itself fairly well down the Ministry hierarchy. Day-to-day administration of the family planning program was, in effect, in the hands of an Administrator who reported to the Director. This Administrator did not carry sufficient weight within the Ministry, both because of the location of the Directorate and because he himself was not a doctor. On July 22, 1970, changes in administrative arrangements were made which should increase the prestige of the Directorate within the Ministry and strengthen the authority of its Director. A leading woman gynecologist, with a distinguished career as head gynecologist at the largest maternity hospital in Tunis, was appointed head of the MCH-FP Directorate, with no other responsibilities. She now reports directly to the Minister of Health. If the increased authority of the Directorate (as recommended in 3.04) is matched by an efficient administration of the delivery of family planning services, the effectiveness of the program can be greatly increased. It will be the role of the management consultants to make specific recommendations in this respect (para 4.12). The Government agreed that for a period of five years, it would consult with the Association prior to the appointment of subsequent Directors and Administrators of the family planning program, and in case of future changes in the organization of the Directorate.

1/ Active consideration has been given by the Tunisian Government to the creation of an autonomous public Institute of Maternal and Child Health and Family Planning; such an Institute, if established, would reach the objectives proposed by the Association in its recommendation regarding the centralization of the personnel and budget control for family planning activities in the MCH-FP Directorate. - 5 -

E. The Present program

The Family Plannn De3Jvey yse

3.06 The program depends upon counseling women on the advantages of family planning and offering acceptors a wide choice of contraceptire methods. It is dependent on family planning consultations at the 5 maternity hospitals, 52 rural maternity centers, 89 MCH centers, and 189 rural dispensaries in the Miiry's network. At all of these, family planning consultations and services are free.

Services at MCH Cen-ers and Rural Di earies

3.07 Outside the largcr trban 'hy spit Ra, family plani, consultations and serviccs are offered by specialised mobile teams intended to operate on a fixd 5chcdnle. Thce teams conist of n gy7ecologist (generally an Ear- 'urpean physician o cotIact) a midwife, an assistant nurse, and a d-7 Ideal , the nobile tem ia preceded (for nhe first few times, at least) by the regional health educator who visits the local Party cell or the village cafe and projects cducational fi The7. health educator is accompanied by family planning motivators who visit families with young children. The work o the rgional edcator's, the local mass media campaigns, and the local Party cells are the main methods of enlisting the support of the male population.

3.08 The reliance oT mobile teams to enlict new acceptors has not worked well. The average number of hours these teams are scheduled to be available to each MCH center and rural dispensary has been less than 3 per week, a small fraction of the time most clinics are open. The ability of the teams to meet their announced schedules has been unsatisfactory since the nationwide shortage of doctors frequently leads senior medical officers at the teams' base hospital to divert family planning doctors to more pressing tasks of curative medicine at the hospital. Five hundred fifty of the country's 800 doctors are foreigners, a fact which increases the problem of keeping medical posts filled. This irregularity affects follow-up services as much as initial consultations and results in many more women dropping out of the program than should do so.

3.09 The project will change the distribution of family planning services by relying on the gradual involvement of pediatricians and general practitioners in family planning activities and on specially trained midwives who will reside at the MCH centers. The Government of Tunisia agreed that pediatricians and other physicians attached to MCH-FP Centers and other family planning facilities, and general practitioners would be gradually in- volved in supporting family planning activities on a part-time basis, and that special training courses for doctors and medical students will be given in the field of family planning. The salary structure of midwives will be adjusted to ensure that they will accept these resident positions. Midwives presently engaged in family planning activities already receive a premium over the salary paid to midwives not connected with family planning. It would be -6- necessary however to pay an "isolation allowance" to midwives working in the rural areas to permit adequate staffing of the centers distant from the main cities. Assurances were given by the Government of Tunisia during negotiations that this recommendation will be implemented. Project centers are intended to be open 40 hours per week for both MCH and family planning services. As a general rule, it is expected that the centers' regular physicians or a gynecologist will perform the initial medical consultations with new acceptors, initially prescribe pills, insert IUDs and perform other nonroutine functions. Routine service functions would be performed by the specially-trained midwives.

Postpartum Program

3.10 The postpartum component of the program depends on counseling women in maternity hospitals during the days immediately following childbirth. Women indicating interest are then referred to an MCH1 center in their neighborhood. In 1969 the postpartum program accounted for about 3,750, or about 18% of the program's 21,300 new acceptors. This number is much lower than it should be for two main reasons. First, the proportion of women who deliver in hospitals (30%) is relatively low. Second, the proportion of acceptors to the number of women who deliver in hospitals is far below that experienced in many other countries -- 6% as compared to an average of 25-30% in other postpartum programs. Several factors explain the relative inefficiency of the postpartum program: many health-educator posts in the hospitals have not been filled; and, as noted, there are frequent shortcomings in the family planning services available at the MCH centers to which women are referred. The project will increase the number and proportion of institutional deliveries by increasing the number of maternity beds, it will improve the operation of MCH centers, and train more paramedical personnel for health and family planning work (paras 4.04 to 4.09).

Contraceptive Methods

3.11 Six methods of contraception are offered in the program: IUD, pill, condom, cream, tubal ligation, and social abortion. Of the 21,300 acceptors in 1969, 9,200 chose the IUD, 7,800 chose the pill, 2,800 had social abortions, (of whom 1,100 also had tubal ligations) 2,400 requested and obtained tubal ligations, and 200 used other methods. Thus at present, the IUD method prevails although there are pronounced variations among regions. These variations mainly reflect the preferences and training of doctors in the region and the availability of supplies. High turnover in the predominantly foreign medical staff and inadequate organization of contraceptive supplies have contributed to erratic shifts in dominant methods in some regions. It is also worth noting that the volume of pills sold commercially outside the government program exceeds the volume currently being distributed through the program.

Results Attained

3.12 After nearly six years of operation, one can only conclude that there is great room for improvement in the effectiveness of the program. - 7 -

Only about 2-1/2% of the eligible women (equal to 80% of the women in the 15-49 age group) have accepted family planning services in the national program. In 1969, the number of eligible women increased by 36,000 while the number of new acceptors was 21,300. The 21,300 new acceptors in Tunisia in 1969 compare with 28,000 in Jamaica and 35,000 in Singapore for the same year, countries with a little less than one-half of Tunisia's population. The generally disappointing performance of the program to date is attributable to the shortcomings in the design and staffing of the family planning delivery system (paras 3.07-3.08) and to the inadequate administration of the MCH-FP Directorate (para 3.04-3.05). There is no concern about the demand for family planning services; indeed, there has been some holding back on educational programs through the mass media for fear of stimulating more demand than the system could handle.

Program Financing

3.13 The availability of program funds has outrun the ability of the program to use them. In 1968 and 1969 the family planning budget was set at US$1.14 million and US$0.96 million, respectively. These figures represent operating costs only, as no capital costs have so far been charged to the family planning program. However, only about 50-60% of the budgeted funds have been disbursed. This reflects the program's inability to generate the level of activities -- from recruitment and training to the delivery of services and supplies -- intended by the budget. As a result of improvements stimulated by the project, it is expected that by 1974 the existing program will be able to spend operating funds of approximately US$1.0 million per year (Annex 4-5). The additional facilities represented by the project will impose on the government budget additional operating costs (including health, training and family planning expenditures) of approximately US$1.1 million; however, only part of the operating costs of the new project facilities will be charged to the budget of the family planning program, the remainder representing health and training expenditures.

3.14 The Government has been financing only about 25% of the costs of its family planning program; the rest has been financed by external grants. The shares of various sources of finance for the 1969 program were as follows: Government of Tunisia (21%), USAID (dinar budget 34% and US dollar budget 20%), Swedish assistance (17%), the Population Council (7%). A detailed breakdown of disbursements by type of expenditure and by source of funds can be found in Annexes 4-3 to 4-5. Dependence on foreign funding of operating costs may diminish in the future but the transition is likely to be gradual.

IV. THE PROJECT

4.01 The project is intended to increase the capacity and effectiveness of the family planning program by (a) adding new facilities and equipment; (b) training the needed personnel; and (c) providing technical assistance for the introduction of needed administrative changes which should permit more - 8 -

effective evaluation and control of the program. Project components can be described under two sets of physical facilities and three technical assistance activities.

A. Project Components

Physical Facilities

4.02 The project consists of the construction or extension of the following facilities:

(1) Medical Facilities

(a) Construction of four new maternity hospitals (in Tunis, Sousse, Sfax, and Bizerte) with a total of approximately 500 beds;

(b) Construction of twenty-nine maternal and child health centers;

(2) Educational Facilities

Extension of the Avicenne Paramedical Training School in Tunis including its Postgraduate Training Section.

Technical Assistance

4.03 The project has three technical assistance elements:

(1) Provision of consultants to design and recommend a system which would ensure an optimum use of the resources at the disposal of the family planning services and to help the Government implement the system;

(2) Provision of experts to assist in teaching at the Avicenne Paramedical Training School and in its Postgraduate Train- ing Section and provision of fellowships for training key paramedical personnel;

(3) Provision of two external review missions of two to three experts scheduled for the Fall of 1972 and 1974 to assess the progress and efficiency of the national family planning program. -9-

The Urban Maternity Hospitals

4.04 Three 140-bed hospitals (in Tunis, Sousse, and Sfax) and one 80- bed hospital (in Bizerte) are to be built (Annex 7). Of the total 500 beds, 360 will constitute net additions to the present number of maternity beds in the country and 140 will be replacements for maternity beds which had been borrowed from other hospital departments. These hospitals are needed in order to increase the number of deliveries in facilities where effective postpartum family planning counseling can take place, to satisfy an increasing demand for social abortions and tubal ligations, and to provide adequate training facilities for the medical and paramedical personnel required by the family planning program. Although there would not now be sufficient medical and paramedical personnel to staff these facilities, the training components of the project would ensure an adequate supply of paramedical staff by the time the hospitals are ready for use (Annex 5-10). The urban maternity hospitals in Tunis, Sousse, and Sfax will be built on Government-owned property; the site in Bizerte has not yet been selected, but it is understood that the hospital will be built on Government-owned property.

The MCH Centers

4.05 The 29 MCH centers will provide integrated MCH and family planning services on a full-time basis (approximately 40 hours per week). Seven of these new centers will replace existing structures that are so dilapidated they have become unusable; the center locations (Annex 5-7) have been agreed upon with the Ministry of Health on the basis of need and population to be served (Annex 5-1). About one quarter of the proposed MCH centers are located in the provinces where the new maternity hospitals are proposed. The design of these project centers will differ substantially from that of the ministry's existing MCH centers. To ensure continuous delivery of family planning services, they will include quarters for a midwife-in-residence and family planning consultation and examination rooms that are separate from those used for pediatric services.

Rural Maternity Centers

4.06 Two rural maternity centers will be constructed in locations justified by population needs. These centers will also serve as pilot centers for this kind of facility in rural areas. They will provide a total of 25 additional delivery beds. One (on the island of Djerba) will be a maternity unit addition to an existing rural hospital; the other (in Sedjenane) will add maternity facilities to an existing MCH-FP center. Sites for the two clinics are owned by the Government.

Avicenne Paramedical Training School

4.07 Tunisia lacks paramedical personnel trained in midwifery. To meet these needs and those of the project, there are at present three training facilities in the country offering midwifery courses in Tunis, Sfax - 10 -

and Sousse. The Tunis school now has a capacity to graduate annually about 120 nurses and nurse-assistants, and about 25-30 midwives. It appears feasible to expand the school by about one-third, to a capacity of 200; at this size it would graduate 60 midwives annually. This level could be reached by 1975 with an increase in enrollment starting in September 1972.

4.08 The project would generate a need for about 90 additional midwives (Annex 5-4). The Government of Tunisia gave assurances that this number of midwives will be assigned to the project facilities according to a schedule agreed upon during negotiations. To avoid the risk of staffing the new facilities at the expense of the existing family planning facilities, the Association asked, and received assurances from the Government, that at least the present level of staffing be maintained in the existing facilities.

Avicenne Postgraduate Training Section

4.09 The country lacks instructors and supervisors (moniteurs) to handle the training of the additional midwifery personnel needed. A section for training such personnel would therefore be created within the Avicenne Paramedical Training School. Its capacity would be 20 graduates a year which would approximately double the present output of instructors and supervisors from occasional special courses. This level could be reached by 1973, with an increase in enrollment starting in September 1972.

Sites

4.10 A detailed description of the sites of all project facilities would be submitted to the Association. The Goverrnment of Tunisia gave assurances that it has or will have land titles to such sites in time to enable the work to start according to the schedule in Annex 5.10.

Technical Assistance

4.11 The three technical assistance components are designed to ensure the efficient use of project facilities and to increase efficiency in other parts of the program.

4.12 Management Consultants. The engagement of a management consulting firm is necessary to remedy the present serious administrative weakness in the family planning program. The program does not presently include any systematic Procedures for evaluating the various components of the program in terms of their contribution to the desired objectives; for determining the operating costs of these various components; for projecting program activities and resource requirements over an adequate time horizon; for revising objectives, programs, and budgets in the light of experience and changing circumstances; and for designing a further expansion of the program. The development of such a system has been partially hampered by the inadequacy of the established accounting procedures which do not clearly differentiate between family planning activities and other functions of - 11 -

the Ministry of Health. The need for such a monitoring system is apparent, since, for 1969 the cost per acceptor appears to have been in excess of US$30, a high figure by world standards.

4.13 The consulting firm engaged would be expected (i) to design and recommend a system which would ensure an optimum use of the resources at the disposal of the family planning services, and (ii) to help in the implementation of such a system after reaching an agreement with the services of the Ministry of Health. An evaluation of the study undertaken by the Con- sultant-Group may be asked by the Association at various time intervals in the course of the study. Reorientation steps may be taken at that time if deemed necessary.

4.14 The Government has been requested to nominate a consulting firm for approval by the Association. Terms of reference for the firm's work were agreed upon. The appointment of the consultants would be a condition of credit effectiveness.

4.15 Advisory Services for Nurse-Midwifery Training: Provision is made for the engagement of experts to assist in midwifery training, since Tunisia lacks such personnel. Some of the postgraduate students and other personnel may also require a period of training abroad in population and family planning. An allowance of up to US$50,000 is included in the credit for these purposes. It is expected that part or all of the cost of experts and foreign scholarships may become available from other external sources; in this event the allocation for technical assistance would be correspondingly reduced and the balance available for cost over- runs in other parts of the project.

4.16 External Reviews: The third and final element of technical assistance consists in the provision of two small teams of international experts (2-3 men each) to evaluate the overall progress of the program, and to make recommendations as to the further expansion program, in the Fall of 1972 and 1974. The members of the review teams would be appointed by the Government with the assistance and approval of the Association. Terms of reference for these missions would also be subject to mutual agreement.

B. Cost Estimates

4.17 The total project cost is estimated at US$7.72 million. The major components of the project are listed in the following table. (Annexes 5-8 and 5-9 give additional details on these components.) - 12 -

Cost Estimates

% of Dinars (Thousands) US$ (Thousands) Total Local Foreign Total Local Foreign Total Exp.

I. Construction and Equip- ment Costs

Maternity Hospitals 739.6 1,153.0 1,892.6 1,408.9 2,196.5 3,605.4 46.7

Maternity Centers 24.3 54.3 78.6 46.3 103.4 149.7 1.9

MCH Centers 410.9 753.2 1,164.1 782.8 1,434.8 2,217.6 28.7

Extension Avicenne Paramedical Train- ing School 94.5 119.2 213.7 180.0 227.1 407.1 5.3

Total Construction and Equipment Costs 1,269.3 2,079.7 3,349.0 2,418.0 3,961.8 6,379.8 82.6

II. Technical Assistance

Management Consult- ants 19.5 88.5 108.0 37.2 168.6 205.8 2.7

Advisory Services for Training Schools 6.6 19.6 26.2 12.6 37.4 50.0 0.6

External Review Missions 3.9 11.9 15.8 7.4 22.7 30.1 0.4

Total Technical Assistance 30.0 120.0 150.0 57.2 228.7 285.9 3.7

III. Contingencies 214.2 339.9 554.1 408.1 647.5 1,055.6 13.7

Total Project Cost 1,513.5 2,539.6 4,053.1 2,883.3 4,838.0 7,721.3 100.0 - 13 -

4.18 Construction cost estimates are in line with recent costs for com- parable construction in Tunisia. Furniture and equipment costs are based on detailed lists and recent suppliers' quotations. Professional fees and technical assistance for the design and supervision of the physical facilities have been calculated on the basis of 4% of construction and fixed equipment costs. Technical assistance costs have been estimated by the Bank Group.

4.19 Contingency allowances amount to 16% of total project costs before contingencies. The allowance for unforeseen factors (other than inflation) are estimated at 8.5% of total costs, the allowance for price increases at 7.5% (Annex 5-9).

PLect Financin

4.21 Exception made for the possible financing of part of the local costs of the management study, the IDA credit of US$4.8 million will cover the project's total foreign exchange costs. The balance of US$2.9 million equivalent in local currency will be provided by the Government of Tunisia.

V. IMPLEMENTATION AND DISBURSEMENT

Project Administration

5.01 A Technical Committee, in charge of proposing the general policies in the field of family planning, would ensure the broad coordination and supervision of the project. To help this Committee in its task of coordination and supervision a Project Administrator will be nominated in consultation with the Association. A detailed list of his functions is given in Annex 1-1. The appointment of the Project Administrator would be a condition of credit effectiveness. In the performance of his duties, the Project Administrator would consult with appropriate members of the MCH-FP Directorate, the Ministry of Health, and the Ministry of Public Works. He would work in close contact with the project architect and the project accountant. Assurances were received from the Government that adequate supporting staff (including the Government project architect and the project accountant mentioned above) will be provided to allow the Project Administrator to satisfactorily perform his duties. It should be noted that the duties of the Project Administrator will be terminated upon completion of the project facilities.

Professional Services

5.02 The need to evaluate and establish proper environmental and con- structional standards for the project, and to closely supervise all aspects of implementation requires the retention of professional advice, beyond the existing resources within the Government. Therefore, the Government has agreed to retain a firm of architects satisfactory to the Association, spe- cialized in hospital design, referred to as the hospital advisor, on terms - 14 -

and conditions acceptable to the Association. The schematic and detailed designs for all the project components would be prepared by the hospital advisor and would be acceptable to the Association.

Implementation

5.03 The proposed project would be implemented during 1971-75, construction starting in 1972. The architectural and engineering firm(s), appointed by the Government on the recommendation of the hospital advisor, would be responsible for the production of working drawings and details, specifications, bills of quantities, preparation of all contract documents and calculations necessary to obtain the contract sum, by competitive tendering or other agreed procedures, adjudication on the contractors' bids and provision of supervisory services, all in agreement with the Project Unit and the approval of the hospital advisor.

Procurement

5.04 All procurement would be based on contract documents and bid packages prepared by the hospital advisor and approved by the Government and the Association. Tendering for the facilities will be on the basis that any domestic or foreign contractor approved by the Ministry of Public Works may bid for any one or more of the facilities; evaluation will be on the basis of choosing that combination of bids which yields the lowest evaluated overall cost. The hospital advisor would also conduct tendering procedures, adjudicate and recommend the award of contracts for the construction, supply, and installation of furniture and equipment. Domestic manufacturers of furniture and equipment would be accorded a preferential margin equal to 15% of the cif costs of competing imports or to the existing rate of duty, whichever is lower.

5.05 All the buildings in this project will be regularly maintained in accordance with a manual of maintenance to be prepared by the hospital advisor.

Disbursements

5.06 The Association would disburse:

(a) 55% of the cost of civil works and locally produced furniture and equipment;

(b) the cif costs of imported equipment and furniture;

(d) 75% of the cost of the hospital advisor's fees; - 15 -

(e) 60% of the cost of professional services for locally appointed architects and engineers.

These percentages would be adjusted as necessary to disburse the US$4.8 million equivalent or 62% of the project cost, whichever is lower, over the estimated project implementation period of 4-1/2 years. Undisbursed funds would be cancelled.

VI. SOCIO-ECONOMIC ANALYSIS

6.01 The Government has recognized the burden that the rapidly increasing population is imposing and the Third Four-Year Plan (1969-1972) calls for a reduction in the rate of population growth. The Government has been particularly concerned with the high and increasing rate of unemployment (paras. 2.03 and 6.07), and it regards the spread of voluntary family planning programs as an important method for the long-term alleviation of this problem. The project would improve the scale and effectiveness of the family planning program and provide important social and economic benefits. Although the economic and social benefits cannot be measured precisely, they are substantial and can be described in specific terms.

6.02 On the social side, the provision of better maternity services and fewer pregnancies would improve the health of mothers and children. Maternal mortality, one of the main causes of death for women of child-bearing age, would be reduced. The availability and more extensive use of contraception would reduce the number of unwanted pregnancies which result either in in- duced abortions under unsafe conditions (and often lead to death) or in unwanted children. Parents of smaller families can give greater care to their children, resulting in better health and lower infant mortality. Among the impoverished sections of the population, fewer children would mean less malnutrition. This fact is particularly important in the case of young infants, when malnutrition can have permanent crippling effects on their physical and mental development. Family planning services would thus lead to an improvement in the quality of life, particularly among the low-income sections of the population. Finally, the family planning program would gradually affect demographic trends; these changes in turn would have important economic implications.

6.03 On the demographic side, the project should add 55,000 new acceptors to the 1970 level of 21,300 resulting in a total of 76,300 new acceptors a year by 1976. This would result in about 21,300 averted birth per year in 1979, of which 15,300 are attributable to the proposed project alone. This estimate is based on the following assumptions:

(a) The distribution of acceptors by method remains the same as in 1969; therefore, out of the 76,300 new acceptors in 1976, 61,000 will use the pill or have -- 16 -

IUD insertions, 8,500 will have tubal ligations, 6,100 will have social abortions, and 700 will use other methods.

(b) For IUDs and pills, 40% of acceptors continue using family planning methods after one year, 16% after two years, 6.4% after three years, and none after four years. This is a very conservative estimate as compared to the experience of other countries.

(c) In the case of tubal ligations, five such operations avert one birth in each of the three subsequent years. This follows from the fertility level of the population which is about 200 per 1,000 women in the child bearing age, that is, one child is born each year to every five women in the child bearing age.

(d) In the case of social abortions, four operations prevent one live birth.

6.04 On this basis, 76,300 new acceptors in a given year avert 13,000 births in the following year; 18,100 after two years; and 21,300 after three years. Thus, going from the present level of 21,300 new acceptors per year between 1970 and 1975, to a level of 76,300 new acceptors per year between 1976 and 2,000, the total number of averted births will reach 551,000 by the year 2000. The effect of this family planning program would be to make the population about 4.6% smaller than otherwise in the year 2000, while that of the project alone would beto make it 3.2% smaller than otherwise. The impact of the project is likely to be larger than this for two reasons. First, the previous assamptions (para 6.03) were conservative. Second, the project, through its technical assistance component, will increase the efficiency of the overall program; the magnitude of this effect is difficult to estimate, but it may be substantial.

6.05 Between 85-90% of the 55,000 additional acceptors resulting from the project will be contacted through the new MCH centers (and the few rural dispensaries) while only 10-15% will be contacted through the post-partum program of the 4 maternity hospitals and the 2 RMCs. The cost of the MCH centers is approximately one half that of the hospitals and the RMCs. This may suggest that the MCH centers have a much ereater cost-effectiveness than the maternity hospitals. Such a conclusion is unjustified since the components are not separable and cannot be treated as independent alternatives. A strong attraction of the MCH-FP centers to many women is their connection with the maternity hospitals. Equally important, .the hospitals provide in- service training opportunities for family planning medical and para-medical personnel. Finally, hospital services are needed to satisfy the increasing demand for social abortions and tubal ligations. Thus a project restricted to MCH centers only would not be technically appropriate. - 17 -

6.06 The size of the demographic trends discussed in paragraph 6.04 determines the economic benefits. In the short-term, living standards will improve by changing the age structure of the population and thereby reducing the number of consumers in relation to the labor force. Each child must be fed, clothed, cared for medically, and educated. A smaller number of children means that the same resources are available to a smaller population. At the family level, more food and clothing, etc. is available to each member of the smaller family. For the Government, resources that would have been needed to educate and provide medical services for the additional population are now freed for other uses. Both Government and family benefits are large in relation to the costs, which moreover include a large health component.

6.07 Another important benefit is the project's long-term effect on unemployment. This is a problem that has caused the Government particular concern, since the rate of unemployment is not only high (15-20%), but con- tinues to increase. The Government regards the spread of voluntary family planning as one important method for eventually lightening the burden of this major social and economic problem. To this end the Third Four-Year Plan (1969-72) calls specifically for a reduction in the rate of population growth. After the project is implemented, the present program is estimated to result in a labor force in the year 2000 that is 2.3% smaller than otherwise; of this, 1.6% would be the direct result of the project. These estimates are conservative for the same reasons given in paragraph 6.04.

6.08 In summary, the project will improve the conditions under which deliveries are performed and make for a more effective family planning program. Such a program will have important social benefits, consisting of improvements in the health and welfare of mothers and children. It will also lead to better living standards and will help alleviate the long- run unemployment problem.

VII. RECOMMENDATIONS

7.01 During negotiations, agreement was reached on the following princi- pal points:

(1) The administration of the family planning facilities and personnel would be centralized (para 3.04);

(2) All family planning facilities would be provided as soon as possible with adequate staffing (para 3.09);

(3) The salary and employment conditions of the midwife would be attractive enough to ensure that the personnel will accept resident positions in the MCH centers (para 3.09); - 18 -

(4) The Government would submit a specific schedule for involving more doctors in the family planning program and delegating to the extent feasible family planning functions to paramedical personnel (para 3.09);

(5) Family planning services would be delivered on a full- time basis at the MCH centers included in the project by specially-trained midwives (para. 3.09); for this reason the MCH centers would include a residence for the midwife (para. 4.05);

(6) The Government would meet the recurrent expenditures of the project and would at least maintain the present level of staffing in the existing family planning facilities (paras 3.13, 3.14 and 4.08);

(7) Paramedical training would be expanded between 1972 and 1975 (paras 4.07 and 4.09);

(8) For a period of 5 years the Government would consult with the Association prior to the appointment of subsequent Directors and Administrators to the family planning program, including the Project Administrator, and in case of future changes in the organization of the Directorate (paras. 3.05 and 5.01);

(9) The final design of all project facilities should be acceptable to the Association (para 5.02);

(10) The Management consultants, and the hospital advisor should be acceptable to the Association and appointed on terms and conditions approved by the Association (para. 4.14, and 5.02).

7.02 The appointment of the management-consultants and the project administrator is a condition of credit effectiveness (paras. 4.14 and 5.01).

7.03 Subject to the above conditions, the project is suitable for an IDA credit of US$4.8 million to the Government of Tunisia. ANNEX 1-1

DUTIES AND RESPONSIBILITIES OF THE PROJECT ADMINISTRATOR

1. Initiation of arrangements for selection of consultant/architects, approval of their terms of reference, and administration of their agreements.

2. Making of necessary arrangements for briefing of consultant/ architects and for the review and approval by the appropriate authorities of the Borrower of plans, reports, specifications, and other material submitted by the consultant/architects.

3. aking of all necessary arrangements for calling bids and awarding contracts relating to the project in relation with the Ministry of Public Works.

4. Preparation, administration, and consultation with the appropriate authorities of the Borrower in the design and supervision of the construction of civil works and of the technical assistance pertaining to program design and administration.

5. Direction and supervision of the project administration supporting staff.

6. Liaison with the Association and other foreign aid agencies and all appropriate authorities of the Borrower (i.e. Directorate of MCH-FP, Ministry of Health, Department of Training and Education, Ministry of Public Works) in matters relating to the implementation of the Project, and

7. Preparation of quarterly progress reports to the Project Committee and to the Association.

ANNEX 1-2 Page 1 of 2

DUTIES AND RESPONSIBILITIES OF THE PROJECT ARCHITECT AND THE PROJECT ACOOUNTANT

A. Project Architect

1. Assembling of all information relating to site conditions of the project institutions.

2. Assistance in preparing schedules for constructing, furnishing, and equipping project institutions.

3. Preparation of the architectural brief relating medical specifications to realistic costing and functional design.

4. Technical advice to consultant/architects to ensure that brief referred to in paragraph 3 above is fully understood.

5. Checking of the architectural drawings to see that space provisions and medical specifications are interpreted correctly so as to minimize changes during construction and after tenders have been accepted and approved.

6. Ensuring that furniture is designed and manufactured to specifications.

7. Ensuring the timely procurement of furniture and building material and their availability as required by the Project.

8. Processing and expediting of all constractors certificates of payments submitted through consultant/architects, and

9. Visiting the project works and evaluating the progress of the Project.

B. Project Accountant

1. Setting up of an accounting system as required for by the implementation of the Project.

2. Overall supervision, maintenance, and verification of any special project accounts of the Association.

3. Ensuring that funds are available in relevant accounts as required to meet payments to contractors.

4. Taking of prompt action as required to expedite disbursement of the loan including preparation of withdrawal applications.

5. Ensuring that a detailed account is maintained with respect to each contract for procurement of goods and services for the Project. ANNEX 1-2 Page 2 of 2

6. Preparation of such interim evaluation and financial statements as required under the credit agreement.

7. Preparation of letters of credit, if any, and signing or counter- signing of checks.

8. Ensuring that financial regulations are complied with by all staff with respect to receipt and payment of public and other funds. ORGANIZATION OF THE DEPARTMENT OF FAMILY PLANNING AND MATERNAL AND CHILD WELFARE CENTRAL ADMINISTRATION

TECHNICAL DIRECTOR

PROGRAM ADMINISTRATOR

COMMUNICATIONS TRAINING AND RESEARCH ANDADMINISTRATIVE_AND DIVISION EDUCATION DIVISION EVALUATION DIVISO OPERATING DIVISION

PREPARATION EDUCATION STATISTICS AND PERSONNEL EVALUATION

SUPPLIES AND PRINTING SHOP PROMOTION RESEARCH EQUIPMENT ACCOUNTING

ALCN TRAINING _ DATA PROCESSING CASH ACCOUNTING

DISTRIBUTION LIBRARY I z m

IBRD - 5263(R)

ORGANIZATION OF THE DEPARTMENT OF FAMILY PLANNING AND MATERNAL AND CHILD WELFARE FP REGIONAL ADMINISTRATION (ACTUAL)

DIRECTORATE OF MCH-FP mmm.DEPARTMENT OF FAMILY .. ... NATIONAL INSTITUTE (PERSONNEL AND SUPPLIES) PLANNING AND MATERNAL FOR CHILD HEALTH AND CHILD WELFARE FAMILY PLANNING PILOT CENTER _fREGIONAL PUBLIC HEALTH HOSPITALS ADMINISTRATORI II II

MC ETERS T I I I I

REGIONAL EDUCATOR REGIONAL SECRETARY GREGIONAL REGIONAL PEDIATRICIANS ______J ~ ~~GYNECOLOGISTS RGOA EITIIN

MATERNAL AND MATERNAL AND CHILD WELFARE PERSONNEL EINTERGTED EDUCATION C EGT CHILD WELFARE

HOUSE VISITS SUPPLIES AND MOBILEHOSPITAL EQUIPMENT ACTIVITIESSERVICES

SOCIAL WORK STATISTICS

z z MATERNITY ( EDUCATION

I BRID - 5261 (R)

ANNEX 2-.

TUNISIA POPULATION PROJECTION - FOUR.SERIES

Year Series A Series B Series C Series D

January 1, Population (OOO1s)

1967 4,820 4,820 4,820 4,820 1968 4,962 4,962 4,962 4,957 1969 5,107 5,107 5,107 5,087 1970 5,257 5,257 5,257 5,212 1971 5,413 5,413 5,411 5,331 1972 5,574 5,574 5,569 5,449 1975 6,104 6,104 6,075 5,814 1976/I 6,299 6,299 6,256 5,940 1980 7,197 7,197 7,032 6,475 1985 8,647 8,602 8,144 7,238

Birthrate per 1,000 /2

1970 44.3 44.3 44.3 38.0 1975 45.0 45.0 43.0 34.0 1980 47.3 47.3 41.1 32.6 1985 48.8 46.6 38.8 32.6

Deathrate per 1,000 /3 1970 15.3 15.3 15.3 14.6 1975 13.9 13.9 13.7 12.5 1980 12.4 12.4 11.7 11.0 1985 10.5 10.3 9.7 9.4

Annual Rate of Natural Increase

1970 2.90 2.90 2.90 2.34 1975 3.11 3.11 2.93 2.15 1980 3.49 3.49 2.94 2.16 1984 3.83 3.63 2.92 2.32

/1 Census year.

/2 Assumed Fertility Decline: A - No fertility decline; B - General fertility rate decline 1980-2000 = 30%; C - General fertility rate decline 1970-2000 -50% and D - General fertility rate decline 1967-1991 50%. Assumed /3 Mortality Decline: Identical for Series A, B, C, D, Coale-Demeny "South" Model Life Tables, level 14-22, 1967-2007.

Sources Internptional Demographic Statistics Center, U.S. Bureau of the Census, unpublished projection, December 1969. Based on 1966 Census with adjustments for 2.7% underenumeration. ANNEX 2-2

ESTIMATE OF THE NATURAL RATE OF POPULATION INCREASE IN TUNISIA FOR THE INTERCENSAL PERIDD 1956-1966

Implied Average Annual 1956 1966 Growth Rate (00-5) (000's)

Census count of population 3,783 4,533 1.8

Estimate of foreigners in Tunisia 341 70

Tunisians 3,442 4,463 2.6

Estimated underenumeration of Tunisians 16o 124

Tunisians onlyadjusted for underenumeration 3,602 4,587 2.4

Tunisian net emigration 1956-1966 66

Total Tunisians 3,602 4,653 2.6

PLAN ESTIMATE of total Tunisians 3,602 4,529 /1 2.3

/1 Includes Tunisian emigrants and excludes foreigners.

Sources: Secretariat d'Etat au Plan et " 1'Economie Nationale, Direction Generale du Plan, Service des Statistiques D'mographiques, Recensement General de la Population et des Logements, 3 Mai 1966, Population par age, sexe et 6tat matrimonial.

Secretariat d'Etat au Plan et ' 1'Economie Nationale, Plan de D6veloppement Economique et Social, 1969-1972, Rapport de Synth se, Tunis, 1969, p. 28.

Robert J. Lapham, The Population Council, Family Planning and Fertility in Tunisia, September 1969. ANNEX 2.-3

TUNISIA MJLECTED NUMBER OF WOMEN IN THE AGE GROUPS 15-49 and 20-L FOR 1967-1974

Women Yearly Women Yearly First of Year 15-49 Increment 20-44 Increment

1967 978,845 - 683,094 -

1968 1,009,159 30,314 695,44 12,350 1969 1,042,957 33,798 709,655 1h,211 1970 1,079,355 36,398 726,090 16,435 1971 1,117,596 38,241 745,034 18,944

1972 1,157,661 ho,o65 766,661 21,627 1973 1,199,750 42,089 791,175 24,514 1974 1,243,785 44,035 818,367 27,192

Source: International Demographic Statistics Center, U.S. Bureau of the Census, unpublished projection, December 1969.

ANNEX -3-1

TUNISIA

PROVISION OF FAMILY PLANNING SERVICES

NUMBER OF FACILITIES BY PROVINCE, AND SCHEDULED NUMBER OF

HOURS PER WEEK FOR SELECTED FACILITIES, 1969

Hospital RMC MCH Centers Rural Dispensaries

Scheduled Scheduled Scheduled TOTAL Hours Hours Hours No7T Province No. Per Week No. No. Per Week No. Per Week Facilities

1. Tunis 3 30.5 .5 16 44.0 11 19.5 35

2. Bizerte - - 5 7 23.5 17 18.0 29

3. Beja - - 6 7 17.0 12 18.0 25

4. Jendouba - - 4 5 9.5 16 18.0 25

5. Le Kef - - 2 4 9.0 22 24.8 28

6. Kasserine - - 1 4 17.5 10 20.0 15

7. Bafsa - - 3 4 13.5 10 3.0 17

8. Gabes - - 1 7 17.0 17 16.0 25 9. Sfax 1 10.0 3 6 15.0 20 26.5 30

10. Sousse 1 1.5 9 11 17.0 15 19.0 36

11. Kairouan - - 1 1 4.0 23 13.0 25

12. Nabeul - - 9 14 47.0 4 16.0 27

13. Medenine - - 3 3 6.0 12 18.5 18

TOTAL 5 42.0 52 89 240.0 189 230.3 335

Sources Ministry of Health.

Page 1

TUNISIA MATERNITY FACILIES By HEALTH REGION -- ANNUAL NUXBER OF DELIVEIEthS PER BED AND AVERAGE STAY FOR 1968

Annual No. of Deliveries Average Bed Sanitary Maternity Facilities No. of Per Bed Stay Utilization Begion and RM0s Beds (1968) (Days) Ranking A

1.Tunis 1 Hop. Charles Nicolle 70 77 4.7 6 2 Hop. Azia Othmana 63 88 4.1 5 3 Hop. H. Thameur 74 67 5.4 10 4 Arrana 16 38 9.6 21 5 La Marsa 25 63 5.8 12 6 La Manouba 17 33 11.0 24 7 Pont de Fahs 3 0 36.9 39 8 Zaghouan 8 44 8.3 18 276 69 5.3 III

2.Bizerte 9 Tabourba 4 93 3.9 3 10 Hop. de Bizerte 18 95 3.8 2 11 Hop. de Ras Djebel 8L 10.7 23 LO79 4.6 1 14 3.Menzel 12 Hop. M.I. Bourguiba 28 55 6.6 13 Hop. de Mateur 14 19 19.2 31

2 43 VIII 18 4. Beja 14 Hop. de Beja 32 44 8.3 15 Hop. Medjez El Bab 8 18 20.3 37 16 Teboursouk 7 45 8.1 17 17 Bou Arada 6 28 13.0 26 18 Testour 15 14 26.1 34 19 asafour 6 0 36.9 39 74k 31 11.8 III

5. Jendouba 20 Hop. Jendouba 18 67 5.4 10 21 Bou Salem 10 40 9.1 19 22 Ain Draham 8 4 8.3 18 23 Ghardimaou 8 5 73.0 38 24 Tabarka 10 7 2.1 37 54 42 8.7 II

6. Le Kef 25 Le Kef 30 40 9.1 19 26 Makthar 8 45.6 34

810.7 xI

7. Uaserine 27 Hop. Kasserine 8 53 6.9 VI 15 ANNEX 3-2 Page 2 Annual No. of Deliveries Average Bed Sanitary Maternity Facilities No. of Per Bed Stay Utilization ... ag9 _ and RMCs Beds (1968) (Days) Ranking /

8.0afaa 28 Hop. Gasfa 14 57 6.4 13 29 Tazeur 15 27 13.5 27 30 Gammouda 15 10 36.5 36 III

9. Medenine 31 Hop. Medenine 18 22 16.6 30 32 Djerba 10 68 5.4 9 33 Tataouine 10 11 35

10. Gabes 34 Hop. Gabes 20 67 5.5 IV 10 11. Sfax 35 Hop. Sfax 52 92 4.0 4 36 Djebeniana 4 39 9.4 20 37 Mahares 6 22 16.6 30 38 Kerkennah 5 17 22.0 33 17 II 12. Kairouan 39 Hop. Kairouan 33 29 12.6 XIII 25 13. Sousse 40 Hop. Sousse 53 73 5.0 7 41 Enfidha 7 29 12.6 25 42 Kalaa-Kebira 0 36.9 39 4 U V 14. Mahdia 43 Hop. Mahdia 8 63 5.8 12 44 EL Djem 15 14 26.1 34 U1: U7T III

15. Nonastir 45 Hop. Monastir 18 69 5.3 8 46 Moknine 12 23 15.9 29 47 Ksar Hellal 13 24 15.2 28 48 Djenal 9 45 8.1 17

16. Naboul 49 Hop. Naboul 14 117 3.1 1 50 Hanamet 10 24 15.2 28 %1 Grombalia 8 61 5.7 11 52 Soliman 7 45 8.1 17 53 Korba 15 22 16.6 30 S4 Kelibia 18 36 10.1 22 55 Menzel Temine 12 53 6.9 15 56 Beni Khalled 12 53 6.9 15 57 Mensel Bou Zelfa 6 7.0 16 102 51 _r_2 VII

TOTAL 966 52 7.0 Weion rling is indicated in roman numerals and district ranking in arabic numerals. ANNEX 3-3

TUNISIA

FAMILY PLANNING CONSULTATIONS IN MCH CENTERS IN 1969

Family Planning Number of Family Planning Consultations Province MCH Centers Consultations per MCH Center Rank

1. Tunis 16 29,933 1,871 2

2. Bizerte 7 15,870 2,267 1 3. Beja 7 7.373 1,053 4

4. Jendouba 5 4,219 843 7

5. Lekef 4 2,337 584 10

6. Kasserine 4 2,982 746 8 7. Gafsa 4 3,498 875 6

8. Medenine 3 1,441 480 11

9. Gabes 7 5,017 717 9

10. Sfax 6 8,824 1,471 3

11. Kairouan 1 178 178 13

12. Sousse 11 10,662 969 5 13. Nabeul 14 6,617 473 12

TOTAL 89 98,951 1,112

Source: Ministry of Health. ANNEX 3-4

TUNISIA

COMKMRCIAL SALSS OF CONTRACEPTIVES Unit Unit Cost CIF42 Cost CIF/2 Contraceptive 1268 Dina Dollars Pills

Lyndiol 2.5 mg. 5,400 724o0 66,000 0.228 0.43

Ovulene 1,700 9,100 16,000 0.285 0.54

Norscyline 22 6,000 16,000 0.196 0.37

Anovlar 4.0 mg. 12,000 0.261 0.50

TOTAL CYCLES 57,100 87,500 110,000 0.236 0.45

Condoms TOTAL MONTHLY SUPPLIES 350,400 100,800 243,000 0.018 0.03

Based on figures for first 9 months. Central Pharmacy putehase price.

Source: Central Pharmacy. ANNEx 3-5

TUNISIA POSTPARTUM FAMILY PLANNING PROGRAM: DISTRIBUTION BY SANITARY REGION OF POSTPARTUM EDUCATORS, MATERNITY BEDS, AND AVERAGE AtDHM DELIVERIES FOR 1969

Average Postpartum Maternity Average Monthly Sanitary Educators Maternity Beds Monthly /1 Deliveries Region Actual Repuired Beds per PPE DeliverieT- per PPE

1. Tunis 10 22 280 28 1,611 161

2. Bizerte 3 3 26 9 166 55 3. Menzel . Bourguiba 2 2 42 21 150 75 4. Beja 3 3 74 25 118 39

5. Le Kef 3 1 38 13 109 36

6. Kasserine 3 1 8 3 35 12 7. Gafsa 2 3 44 22 114 57 8. Medenine 3 2 38 13 99 33 9. Gabes 2 2 20 10 111 55

10. Sfax 3 6 67 22 431 166 11. Mahdia 2 1 23 12 59 30

12. Monastir 2 3 63 32 187 94

13. Sousse 3 5 65 22 339 113 16. Nabeul 5 5 96 19 409 82

15. Kairouan 1 1 33 33 79 79

16. Jendouba 4 3 54 13 190 48 TOTAL 51 63 971 19 4,207 82

/ Based on 1968 data.

Source: Ministry of Health. ANNEX 3-6

TUNISIA FAMILY PLANING ACCEPTANCES BY METHOD AND BY MDNTH FAMILY PLANNING PROGRAM, 1969

TUbal Sociai q Pill: Ligation Abortid Condon/ Cream / IUD Wo.of New Number of Number Monthly Monthly Month InaertionaLl/ Acceptors Operations of Operations Supplies Supplies

Jan 1,022 (59) 869 242 198 1,815 266 Feb 722 (51) 671 165 191 1,238 167

Mar 968 (48) 575 262 271 1,590 305

Apr 1,049 (33) 736 250 235 1,652 364

May 1,055 (65) 619 319 310 1,440 324 Jun 884 (50) 699 240 269 1,654 283

Jul 781 (40) 526 160 231 1,385 321

Aug 517 (25) 404 99 241 1,601 264 Sept 591 (26) 730 141 213 1,601 255

Oct 542 (30) 631 241 252 1,384 302

Nov 548 (30) 603 164 209 1,608 328 Dec 520 (51) 718 141 161 1,882 253

TUL 9,199 (508) 7,761 2,424 2,781 18,850 3,432

I Numbers in parentheses indicate reinsertions and are included in adjacent column with primary insertions 3/ Includes 1100 women who have also had tubal ligation 3/ Each person receives a monthly supply of 12 condoms 4/ Includes creams, aerosols, and foam ANNEX 3-7 Page 1 TÙXISIA

POSTPARTUM FAMILY PLANNING PROGRAM FR 1969: MEASURES OF PROGRAM COVERAGE, ACCEP1OR MOTIVATION, AND RATE OF ACCEPTANCE BY SANITARY REGION

A1 /2 13 A~ /4 5/6 Sanitary Maternity No. Deli- Abor- Confie- 4pts. Caver- Apts. Mota- Aoqe, Accept- Region Facilities of veries tions mente Made age Kept tion ances ance PPE Ratio Ratio Ratio

1) Tuanis .1 Hop. Charles Nicolle 5,402 37 5,439 815 - - 2 Hop. Azia Othmana 5,797 2 3414 8,141 1,521 129 128 3 Hop. H. Thameur 5,456 1 747 7,203 1,348 398 397 1 Ariana 630 0 630 0 0 0 5 La Marsa 1,696 o 1,696 419 40 40 6 La1(anouba 601 0 601 272 - - 7 Pont de Fahs - - - - - 8 Zaghouan 461 20 481 0 0 0 Total TUNIS 10 20,043 -,7 24,191 4,375 i- ~37 7 7 (2,419) 2) Bizerte 9 Tabourba 356 3 359 0 0 0 10 Hop. de Bizerte 1,609 493 2,102 1,275 227 218 11 Hop. de Ras Djebel 261 161 422 269 _ 45 37 - Total BIZERTE ~ , 2 67 2,93 1,5,¯ 272 17•F ~ž5* T (961) 3) Menzel 12 Hop. M. 0. Bourguiba 1,915 496 2,411 994 207 207 13 Hop. de Mateur 73 18 91 54 29 4 Total MENZEL 2 ~1798 5"Z 2,502 1,07 Z-- ~ 23 2 211 U~T~ (1,251) 4) Beja 14 Hop. de Beja 1,450 265 1,715 908 403 390 15 Hop. Medjez El Bab 72 0 72 0 0 0 16 Teboursouk 281 6 287 191 52 46 17 Bou Arada 223 43 266 0 0 0 18 Testour 212 10 222 0 0 0 19 Gaafour 36 2 38 0 0 0 Total BEJA 3 2,274 ~32 2,600 1,099 7-3 -7 47, 3 6 (867) 5) Jendouba 20 Hop. Jendouba 963 86 1,049 317 101 100 21 Bou Salem 709 74 783 134 101 57 22 Ain Draham 338 5 343 58 28 28 23 Ghardimaou 335 3 338 50 - - 24 Tabarka 194 10 204 0 0 0 Total JENDCUBA 2,539 178 2,717 59 20.6 230 ~ TB (679) 6) Le Kef 25 Le Kef 1,467 64 1,531 632 112 110 26 Makthar 112 31 143 93 - - Total LE KEF 3 1579 95 1,674 725 4-7 11= 1. 110 ~ (558) 7) Kasserine 27 Hop. Kasserine 3 458 178 636 153 24.1 25 16.3 24 3.8 (212) 8) Gafsa 28 Hop. Gafsa 799 300 1,099 107 25 24 29 Tazeur 429 76 505 96 14 13 30 Gamouda /7 221 125 346 26 4 4 Subtotal 2 1,4h9 501 1,9=0 229 7. ~3 lb 1.3

Total GAFSA 2,512 736 3,248 - - - - (1,624) ANNEX 3- 7 Page 2

/1 /2 /3 / A /6 Sanitary Maternity No. Deli- Abor- Coxtn- Arps. Cover- Aps.. Madm- Acept- Accept Region Facilities of veries tions ments Made age Kept tion ances ance PPE Ratio Ratio Ratio

9) Medenine 31 Hop. Medenine 492 168 660 270 - - 32 Djerba (Houmt Souk) 628 114 742 29 14 9 33 Tataouine 33 0 33 0 0 0 Total MEDENINE 3 f17 2d2 T13 299 2 0. T I7 9 T0 (478) 10) Gabes 34 Hop. Gabes 2 1,511 50 1,561 776 49.7 322 41.5 300 19.2 (780) 11) Sfax 35 Hop. Sfax 5,154 10273 6,427 2#014 581 565 36 Djebeniana 0 0 0 0 0 0 37 Mahares 169 11 180 171 42 22 38 Kerkennah 48 3 51 15 - - Total SFAX 3 3T371 1,2d7 6 R 2, 200 33.0 62O 2 38 T (2,219) 12) Kairouan 39 Hop. Kairoaan 1 1,055 341 1,396 361 25.9 68 18.8 68 4,9 (1,396) 13) Sousse 40 FIop. Sousse 3, 906 1,140 5,046 524 - - 41 Enfidha 152 36 188 184 - 42 Kalaa-Kebira 38 1 39 SE0 0 0 ToalSOSS 3 4,96 1,77 5,7- 707 13.4 0.0 0* =O (1,758) 14) Mahdia 43 Hop. Mahdia 599 514 1,113 375 116 101 44 El Djem 229 23 252 77 - - -7 Total MAHDIA 2 62 57 1,35 E 3. TT$ 25.7 101 7. (682) 15) Monastir 45 Hop. Monastir 1 454 500 1,954 1,174 78 68 46 Moknine 356 167 523 320 88 88 47 Ksar Hellal 496 113 609 491 26 24 48 Djemmal 541 5 546 376 181 181 Total MONASTIR 2 2,847 7 3,2332 13 0 17.7 3 1 9.9 (11816) 16) Nabeul 49 Hop. Nabeul 1,626 619 2,245 730 170 170 50 Hammamet 309 0 309 238 42 42 51 Grombalia 543 90 633 221 9 9 52 Soliman 328 0 328 253 - - 53 Korba 339 7 346 0 0 0 54 Kelibia 664 172 836 265 120 120 55 Menzel Temine 653 94 747 700 151 151 56 Beni Khalled 165 1 166 0 0 0 57 Menzel Bou Zelfa 380 0 380 230 - - Total NABEUL 7 37007 953 I7 3,990 70 92 TT 492 =2 /g (1,196) GRAND TOTAL 51 55,487 12,274 67,761 19,526 28.0 3,949 20.2 3 745 5.5 (1,329)

/1 PPE (EPP) = postpartum educators. 77 Include therapmtic abortions as well as social abortions. 73 Equivalent to the summation of columns B and 0. Data in parentheses represent confinements per postpartum educators. /4 Ratio of Column E over Column D Ratio of Column G over Column E 75 Ratio of Column I over Column D 77 Does not include data from four facilities -- Metlaoui, Redeyef, M'dhilla, and Moulares -- which do not have postpartum coverage. 8 Number of appointments made by patients after delivery or abortion. 9 The number of deliveries may vary depending an the source used; the discrepancy may reach 2000.

Source: Ministry of Health; data assembled by IBRD Mission. АÅ¸ЕS 3- е TUiJISIA

MATERNITY FACILITIES MEDICAL А¡¢М ¢£ А¢А IC1R 1969

Neonat ³ l Abortlons 5t111born Mortality Deliveries Maternity Hoapltals and per 10 о L1ve Maternlty ре³ 1,000 ре³ 1,000 Ре³l »аt а l w/5urgical Rura1 Maternlty Centexs Abortione Deliveries Dellveries Hlrths St111born Mortality Live Blrthe L1ve Birthe Mortality Aselstance

1. ¡nа³lе²ÅlÁоÆа ·7 5,·99 о.7 5,·1о 1³6 9 ·· 34 ±7 е.о ³. Ï³lа otraaa ¿a ³,344 5,797 40. а 5,632 ³³± 17 4о ·± 76 ·. е . Н. Â¿аÂе¸³ 1,747 5,45 ¬ ³о 5,753 26 29 45 9 54 3 о 4. А³³l а¿а о 63о - 6³± 4 15 6 7 1· о. ³ 5. ьа Marea о 1,696 - 1,65 ³ 4³ 6 24 11 35 о5 6. La Ма¿о¸¬а 0 601 - 597 9 16 15 0 15 0. ³ 7. Pont ´е Faha ------8. Zaghouan 20 461 4. W³9 13 2³ 28 4 2 0 2 Tota1 TUNIS 1 20 0 0 2о.0 20 о1 73 1 3 23 9 9. ¢аÊо¸³ьа 3 3 3 2 2 19 о . 1о. Blaerte 493 1,±о9 о. о 1,565 ео ·1 51 15 ±± ±.о 11. Raa Djebal 161 261 « . о 246 15 1,о ±о 16 76 3 о 12. Menzel Bourguiba 496 1,915 25.0 1, В31 В4 21 45 22 ±7 1.0 13. Mateur _18 2. о ¬ 2 16 1 1 h6 1.4__ Tota1 BIZERTE 1 171 21 27.0 0 1 ³2 1 3 3о . е а 2 1, 1.0 1,3 о 3 9 73 2о 15 Medjez Е1 Bab 0 72 - 68 4 1S 58 14 7³ 1.4 16, Âeboursovk ± ³В1 ³. о 278 6 3S 21 о ³1 о.3 17. Во¸ Arada 4 223 19. о 21z 11 47 51 9 ¬О 0 1В. ¢е²t о¸³ 10 212 4 0 204 8 49 39 4 4 о5 19. Áаа³о¸³ ³ 36 .о 35 1 ³9 _ ³8 о 28 2.8 Tota1 32 2 272 1.0 2 1 7 11 2 5i´ 1 1.0 ³о. Âе¿Êо¸ьа 9 9.о 99 71 1 9 .0 21. Но¸ salem 74 7о9 1. о ¬Во ³8 14 41 17 58 ·. о 2³. Ain nra ¿am 5 338 1. о ·27 1о 3о о 18 48 03 ³·. Chardl »,aou · ··5 08 ·о z ³9 5 11 1ь о.· ³4. Âаьа³ºа 1о 194 5.0 19о 4 5³ ³7 5 ³± о.5 Tota1 1 2 9 7.0 2 10 20 1 3.0 25 Le Ке £ 1, 7 .0 1,3 113 71 2 11 2.0 26. ¼аºth а³ 31 Æ 2 27. о 1 о9 В 91 7 9 8 ³ 5. о Tota1 9 1, 79 -1 73 121 2 2.0 27 azae .ne 17 B. -I '- ÂоÁаl 1 - Г38-'-Ei- . ³2 Ii2 1³2'7 2 12³ 2.³.' ³ . Áа²£а оо 799 ·7 о 7 о 9о 1о 11 2 1 .0 ³9. ÂаZе¸³ 76 429 17о 426 19 ³· 44 11 55 о³ 30. Gammouda 12 z³1 56о 21z 1 19 « ³е е9 о.4 Âоt аl о1 1, 9 .0 1 ³, 1 122 . о 31. е´е¿l »е 1 ГÃ2 - ´ .0 Æ 3 - 1 2 1 1 ·³. ¿3е³ьа 114 62е 18. о 575 4· а± 7h 4о 114 11.0 33. Tataoulne о 33 о 5 33 167 3 · 200 3.0 Tota1 ³ ³ _ 1,1 3 . о 1 о 1 1 2 . о 34. ÁаÊе² 5о 1 Æ ·.о 1,2 о 91 2 Æ 1. о _ Tota1 0 1 11 3 1 20 91 2 21 1.0 3. sfax 1, ³73 ,9 3 ³ о ,93 ³1 2о 7 1 ³. о 36. Djebeniana - - - - - ·7. Manarea Æ 169 ±.о 16о 9 6z 56 18 74 о. ± 38. ºе³ºеn¿а¿ 3 48 ±.о 43 5 ³· 19 о 119 2.о Tota1 39. Каl ³о¸а¿ 3 1 1 0 1 32.0 9 7 1 7 121 .0 Tota1 3 1 1$1 32.0 9 7 1 7 121 Æ 0 So ase 1,1 о 3,9 о 29.0 3,9 2 1 1 13 9 -0 41. Е¿£lаьа 36 152 2.о 146 6 ±е 41 ³о 61 о.± 42. Ка1аа Кеªi ³а 1 38 ³ .0 38 7 26 ³± 0 26 43. ¼а¿´lа S14 599 85. о 567 4о 17 7о 1³ 82 ³.о 44. Е1 D, em 23 299 1о ,0 219 14 45 6 36 99 43. о 45 Monastir 5оо 1,454 34.0 1,42 о 1´3 n ·о 1z 4³ z.o b6. Moknine 167 356 46, а 374 9 26 24 1о 34 о.· 47. Kaar½ еÆ аl 113 496 22. о 1´94 2 ³о 4 0 о.2 В notea ¼ , 4 . al 0;9 5 1 18 18 _ 1 _ 36 o.z 2 84i ·1 о 9. Nabeul 9 1, 2 3. 1, 3 1 5о. Hammamet 0 3о9 307 4 3³ 13 3 16 ¡.3 51. Gromballa 90 51´3 16.0 S31 14 18 26 1S « 0.2 52. Soliman о 328 - 3³о 8 31 25 18 43 о. · 53. Ко³ªа 7 39 2. о 334 7 29 2о е ³8 о. 54 ºе11ь1а 17z 664 z5.o 648 17 15 ³± 1³ 38 о.1 5S. Ме¿³еl Tlmine 94 653 14.0 627 25 15 39 19 S8 0.1 $6. Deni Кh аll е´ 1 16$ 0.6 1S3 10 65 6S 26 91 0.6 57 Menzel Во¸ Ze1fa _ о 33 о 319 11 1 34 0 34 0.3 Tota1 983 19.0 77 193 12 0 12 2 2. GRAND 10TAL 12 039 2 22. 3 о7 2 2 1 .0

/1 The ¿¸Âªе³ о: deliveries ÂаÃ v а¿ dependiag о¿ t.he source used the discrepancy Âа} reach 2000.

ANNEX 4-1

TUNISIA FAMILY PIANNING SERVICES

BUDGETED PERSONNEL POSITIONS FOR 1970

Headqurters External Total Staff Total

FT PT FT PT FT PT

Division PO V PO V P0 V P O V P 0 V P O V P O V

1. Management 9 - - 16 0 16 X X X X X X 9 - - 16 o .6 25 - -

2. Administrative Services 18 - - X X x 16 14 2 21 21 0 34 - - 21 21 0 55 - -

3. Research & Evaluation 26 - - XX X X Xx X I X 26 - - X X x 28 - -

4. Training 10 - - XX X 92 65 27 34 2 32 102 - - 34 2 32 136 - -

5. Communication 24 - - x x x x x x x x x 24 - - x x x 24 - -

6. Medical Services 3 3 0 X XX 82 62 20 60 22 38 85 62 20 60 22 38 145 87 58

Subtotal 92 - - 16 - 16 190 141 49 115 45 70 282 - - 131 45 86 413 - -

TOTAL 108 30 113 13

Medical Services

Medical Counselors 1 1 0 XX X X X X 1 1 1

File Clerks 2 2 0 X X X X X X 2 2 0

Gynecologists MT X XX 23 21 2 X I X 23 21 2

Midwives MT XX X 18 15 3 60 22 38 78 37 41

Nurse Assistants MT xX I 18 12 6 X X X 18 12 6

Chauffeurs MT XXX 18 14 4 IX X 18 24 4

Lab Chief X X X 1 0 1 X XX 1 0 1

L ab W o r k er s X X140 04 X X X o

Subtotal 3 3 0 82 62 20 60 22 38 145 87 58 TOTAL 3 15 1142

(FT) = Fll-Time. (MT) = Mobile Team. (PT) = Part-Time. (-) = Information unknown. (X) = Information not applicable. = Zero. - Positions = Occupied = Vacant Source: Ministry of Health. ANNEX 4-2

TUNISIA FAMILY PLANNING SERVICES

PRELIMINARY PROJECTION OF FAMILY PLANNING PERSONNEL, 1970-1974

1970 1971 1972 1973 1974 Dision FT PT FT PT FT PT FT PT FT PT

1. Management 14 15 16 17 18

2. Administrative Services 32 21 33 21 35 21 37 21 38 21

3. Research and Evaluation 27 31 31 31 31

4. Training and Education 26 69 31 90 32 107 34 120 35 146

5. Comimnication 24 24 24 24 24 6. Medical Services 59 39 97 45 110 52 117 57 148 77

Subtotalt 182 129 231 156 248 180 260 198 294 244 TOTAL 311 387 428 458 538 Foreign Advisers 5 6 6 6 6

/1 Only 34 positions are authorized for the 1970 Budget. FT - Full-time. PT - Part-time.

Source: Ministry of Health. AINMX 4-3

TOW~ISIA FAMILY PLAN~NING SERVICES

19W ACTUAL DISBURIS19ENTS FOR FAMILY PIANNING OPERATING EXPENDITMRES (in 000's Dinars)

US AID US AID Diar Dollar Peace Description Govt.a Buclget Budget PC/FF Corps SIDA TOTAL % By Function 1. Management------0 2. Administration - 21 - 25 46 13 3. Research & Evaluation - 2 - 134 - M1 5 4s.Training - 10 10 29 4- 52 15 5. Communications - 3 - l14 - 21 38 11 6. Medical' Services 65 5 4 16 - 31 198 56

2ITa D65 DB1 D50 D98 D4~ D52 D350 100$

1.Saaries 55 35 9 26 14 37 166 147 2. Salary Supplement - - - 146 - - 145 13 3. Contractual Services - 39 - 214 -- 63 18 4. Travel &Per Diemu - - 1 1 -- 1 0 5.. Research & Evaluation ------0 6. Printing & Prodiction - 1 - - 5 7 2 7. Seminars - - - - 0 8. F?A - 2 - - -2 1 9. Medical Supplies 10 - 40 1 - 10 62 18 10. Administration - 14 - 14 1. TOTAL D65 D81 D50 D98 D14 D252 D2350

% of Total 19 23 114 28 1 15 100%

SCoat for tubal ligations and abortions not included.

Source: Data from each agency compiled by IBRD Mission. ANNEx 4-4

TUNISIA FAMILY PLANNING PROJECT

1969 ACTUAL DISBURSEMEWTS FOR FAMILY PLANNING OPERATING EXPENDITURES (in 000's Dinars)

US AID US AID Dinar Dollar Peace Description GOrt.1 Budget Budget PC/FF Corps SIDA TOTAL % BU Function 1. Management - - - . - - - 0 2. Administration - 29 5 15 - - 49 16 Research 3. & Evaluation - 14 - 7 - - 21 7 4. Training - 24 12 - 3 - 39 13 5. Conmunications - 7 3- - 21 63 20 6. Medical'Services 66 31 10 - 31 138 4 TOTAL D66 D105 D62 D22 D3 D52 D310L 100% By Type 1. Salaries 66 37 1 16 3 37 160 51 2. Salary Supplement - 9 - 6 - - 16 3. Contractual 5 Services - 22 6 - - - 28 9 4. Travel & Per Diem - 8 29 - - - 37 12 5. Research & Evaluation - 2 16 - - - 17 6 6. Printing & Production - 6 - - 5 11 4 7. Seminara - 2 - - - - 2 1 8. FPA - 8 - - - - 8 2 9. Medical Supplies - 2 10 - - 10 22 10. Administration 7 - 9 - - 9 3 TOTAL D66 D105 D62 D22 D3 D52 D310A. % of Total 21 34 20 7 1 17 100%

L2 Costs for tubal ligations and social abortions not included. (2 Costs for renovation of premises not included.

Source: Data from each agency compiled by IEND Mission. ANNEX 4-5

TUNISIA FAMILY PLANNING SERVICES

ACTUAL AND PROJECTED FAMILY PLANNING PR MINAR EXPENDITURES, 1969 - 1974 For the Facilities Existing in 1970 (in 000's dinars)

Actua.LL Estima I ed

Description 1969. 1970 1971 1972 I 1974

By Function

1. Management - 13 16 18 19 21 2. Administration 29 43 48 53 58 62 3. Research and Evaluation 1F. 25 37 40 43 45 4. Training 24 65 94 107 117 135 5. Communication 7 31 39 41 45 45 6. Medical Services 97 115 163 184 191 242

TOTAL D171 D292 D397 D443 D 473 D550

By Type

1. Salaries 103 161 223 249 267 308 2. Salary Supplement 9 8 10 11 11 12 3. Contractual Services 22 24 36 40 43 53 4. Travel and Per Diem 8 12 17 19 21 24 5. Research and Evaluation 2 9 14 15 16 17 6. Printing and Production 6 15 18 20 22 22 7. Seminars 2 10 11 12 13 14 8. FPA 8 8 8 8 8 8 9. Medical Supplies 2 15 25 30 31 45 10. Administrative Material 9 30 35 39 41 47

TOTAL D1 71 D)292 D 397 D 443 D 473 D 550

/1 Comprising Government of Tunisia and US AID dinar budget. N7 Excludes new facilities amounting to D 5,397 for 1969 and D 2,512 for the first four months of 1970.

Source: Ministry of Health and IBRD Mission estimates. ANNEX 4-6 TUNISIA FAMILY PLANNING SERVICES

FAMILY PLANNING PROGRAM DINAR BUDGET FOR 19 70

(in 000's dinars) Med. Description N Admin. R&E Train. Comm. Serv. % of Tunisian Government Govt. Govt. and Total E Aid Totals 1. Salary 20 34 - 83 1 100 236 8B 2. Salary Suplement ------3. Contractual Services - - - - * * - 4. Travel - - - 5 - - 5 2 5. Research & Education - - . . - - * - 6. Printing & Production - - - * - - a 7. Seminars * ------8. FPA - - - - a - - - 9. Medical Supplies - - - - - 31 31 10 10. Administrative Material - 1 .. - 11 2 8 Subtotal D4 - D1 D144 D297 100

External Assistance Aid Total % I.saary 5 18 20 14 18 9 54 T2 2. Salary Supplement 2 6 - 1 1 5 15 6 3. Contractive Services - - - 16 8 23 47 18 4. Travel 6 - - 6 2 8 22 8 5. Research & rducation - - - - 9 - 9 4 6. Printing & Production - - 20 a - - 20 8 7. Seminars - - - 114 - 14 5 8.FPA - * * 8 - * 8 3 9. Medical Supplies - - - - - 16 14 5 10. Administrative material - 18 - - - 28 1. Subtotal D13 D2 D 69 D38 D59 D261 100 47 TOTAL D33 D86 D40 D157 D39 D203 D558 100

Source: Ministry of Health. TUNISIA FAMILY PLANNING PIiOJECT

FSTIMATE OF ANNUAL OPARATING CDSTS FbR PROJECT FACILITIES Di ¿а ³s

Additio ¿al Additional Total R²quired Tota1 Fcisting Tota1 Additional Required Existing Personnel Required Ex·sting Materials Peraonnel an ´ Personnel а¿´ Personnel а¿´ Personnel Personnel Required Mater als Materials Required Materials Mat ²rials Materials Required

I. Maternit Hospitals 1. . onsei е s) 5b,3 .o0 - 54,301!.00 5±,ооо.00 - 5 ¬ , о00. о0 710,300. оо - 11 о,3 оо.00 ³. Sousse (140 ªе´s) 54, · .о0 33, ³±4. оо 21, о36.оо 56, ооо. оо 31,68 о.оо ³4,3 ³о.оо 11о,·оо.оо 64,944. оо 45,35 ¬.оо 3. S£ аÅ (140 beds) 54,300.00 26,334.00 ³7,9 ±6.00 56,000.00 25,08 о.00 30,920.00 11 о ,300.00 51,414.00 58,886.00 4. ²iZert ² (8 оь²аа) 31, ооо.оо - 31,ооо.оо 3³,ооо.оо - 32,ооо.оо 63, о.оо - 63, ооо.оо II. Sma11 ¼aternit Centers Rtro pediatricians о³ maternities 2-4 7, о0Í.00 - 7,000.00 - - - 7,000.00 - 7,000.00 1. xo,mlt sо¸º (n ²³ьа ³оь²´s) 11,600.00 5,8 оо.оо 5,8 оо.оо 8,3 оо. оо 4,15 о.оо 4,15 о. оо 19, Ã00. оо 9,95 о.оо 9,95 о. 2. Sedjehane (15 Êе´s) 11, ьоо. оо - 11,±оо.оо а, ·оо.00 - 8,3 оо,оо 19,9 оо.оо - 9,9 оо.оо 3. Sidi A1i В . Nasralah (15 beds) (with М¡Н center) 72,975 оо - 1³,9 ¢5оо 9,9 ³5.00 - 9,925.00 2³,9 о0.00 - 22,900.00 4. s ьlº¿а (5 ье´s) ( t ь¼Á½ center) 7,175. оо - 7,175.0 о 5,775.00 - 5,775.OO 12,950.00 - 12,95 о. оо III. М¡Н Centers ive pediatricians for М¡ Н xoa. ±-1t, 15-18, ³· а¿´ ³4 17,5 оо.оо - 17,5 оо.оо - - - 17,5 оо. оо - ³7,5 оо.оо 1. Teboursouk 2,75 о.оо 1,375. оо 1,375. оо 3,25 о.оо 1,625. оо а,6³5. оо ±,ооо. оо ·,ооо.оо З,ооо.оо 2. Zaouiet Madien 3,437.50 - 3,437 50 4, о62.5 о - 4, о6³.5 о 7,5 - 7,5 . ·. »,iе¿´оËьа 3,4 ·7.5 о 1,718.75 1,718.75 4, о62.50 ³,о·l. ³5 ³,о·l. ³5 7,5 . 3,75 о.оо 3,75 о. оо 4. ²е¿ salem 3,437.5 о 1,718.75 1,718.75 4, о6³.50 ³,о31.³5 ³, о·l. ³5 7,5 . 3,750. оо 3,750. оо 5. Sers 2,75 о.оо - ³,75о. оо ·, ³5о.оо - 3, ³5о. оо ¬, ооо.оо - ±,ооо.оо 6. Maknassy 3,437.5 о - 3,437.5 о 4, о6³.5о - 4, о±³.5 о 7,500.00 - 7,5 оо. оо 7. ½²gÆ²ь 2,75 о.оо - 2,75 о.оо 3,250. о0 - 3, ³5о. оо ±,ооо.оо - ±,ооо.оо 8. Е1 cuettar 2,75 о.оо - 2,750.00 3, ³5о.оо - 3, ³5о. оо ±, ооо.оо - ¬,о0о.0 о 9. Tataouine ·,437.5 о - 3,437.5 о 4, о6³.50 - 4, о62.5 о 7,5 оо.0о - 7,5 оо. оо 10. ²е¿ Áа³´а¿² ³,75 о.оо - ³,75 о.оо ·, ³5о.оо - ·,³50. оо ±,ооо.оо - ¬,ооо. оо 1. ОоÈ¿³ааае¿ 2,75 о.оо - ³,75 о. оо 3,25 о.оо - 3,25 о. оо ±, ооо.оо - ±,ооо. оо 12. ¼аt ¿аtа 2,75 о.оо - ³,75 о. оо ·,³5о. - 3, ³5о. оо ±, ооо.оо - ±, ооо. оо 13. xallat Lа¿аll ¸² 2,75 о. оо - ³,75 о. оо ·, ³5о.оо - ·,³5о. оо ¬,ооо.оо - 6, ооо.0 о 14. La Marsa 3,1137.5 о 1,718.75 1,718.75 4, О¬³.50 2,031. ³5 ³, о31.25 7,5 о0.00 3,750. оо ,750.00 1$. Ksour Essaf 2,75 о .00 1,375.00 1,375 00 3,250.06 1, ¬ ³5.00 1,625.00 6,000.00 3,000.00 3, о00.00 16. ¿²Â¿аl ³,750. оо 1,375. оо 1,375. оо 3, ³5о. оо 1, ¬³5.оо 1,±³5. оо ±,ооо. оо ·,ооо.оо ·,ооо. оо 17. xarrouz ³,75 о.оо - ³,75 о.оо ·,³50. оо - 3,³5о.оо ¬, ооо. оо - ±,ооо. оо 18. ½а´²ь ³,75 о.оо - 2,75 о. оо 3,25 о. оо - 3, ³5о.оо ±, ооо.оо - ±,ооо. оо 19. Kairouan 3,437.50 1,718.75 1,718.75 4,062.50 2,031.25 2,031.25 7,500.00 3,75 о. оо 3,75 о.0 о ³о. Е1 A1ia 2,750. оо - 2,75 о.оо 3, ³5о. - 3,³5о. оо ь, ооо.оо - ±, ооо. оо 2i. somaa ³,75 о.оо 1,375. Оо 1,375. 3, ³5о. оо 1,6 ³5. оо 1,6³5. оо ±, ооо.оо 3, ооо.оо ·, ооо. оо 22. xaouaria 2,75 о.оо - 2,75 о.0о 3,25 о. оо - 3,25 о.оо ±, ооо.оо - ¬, ооо.оо а 23. ³ a1i ²е=. ::r a1e 2;75 о, оо - ³,75 о. оо 3> ³5о. оо - 3, ³5о.0 о ±, ооо. оо - ±, ооо. оо 24. Merzel Chaker 2,75 о.оо - 2,75 о.оо 3,25 о.0 ¹ - 3,25 о. оо ±,ооо. оо - ±, ооо. оо Æ ³5. ¼еl аsа¿² 3,437.5 о 1,718.75 1,718.75 4, о±³.5 о 2, о31. ³5 ³,о31.25 7,5оо. оо 3,75 о.оо ·,750.00 I4. Avicenne Training Schools оо inc . fe o¸ ships ±, ооо.оо ±,ооо.оо 54, ооо.оо - 54, ооо.оо ±о,ооо. оо - ±о, ооо. ¢оÂАL 342,000. оо 79,497.75 262,5 о8.25 374, о5о. оо 77,566.25 29¬,483.75 716, о5о.оо t57,o58.00 558,99 ³.о0

MEX 5-1 Page 1 TUNISIA FAMILY PLANNINSgtIgj

DEMGRAPHIC DATA ON EXISTING AND PROPOSED MCH CENTERS

000vt) -Proposed Province / MOH Pop-p MOH

and County • POP.!- Centers Center Centers 1) 1. Mais66,724 14 47.6 4 (R) 2. SVoEuba 123 063 2 61.5 1 Total 7 97.3 2) 3. Bizerte 95,875 1 95.9 0 4. Sedjenane 48,240 1 48.2 0 5. Mateur 58,066 1 58.1 0 6. Tebourba, 42,827 1 42.8 0 7. Menzel Bourguiba 50,242 1 50.2 0 8. Ras Djebel 3 ,301 2 17.0 1 Total 329 551 7 7.1 1

3) 9. Beja 73.479 1 73.5 0 10. Asdoun 20;053 0 - 1 11. Djebel Labiadh 38,188 0 - 0 12. Tebourzouk 44,875 1 44.9 1 (R) 13. Gafour 18,662 1 18,7 0 14. Bou Arada 25,380 1 25.4 0 15. Fahe 42,430 1 42.4 0 16. Majez El Bah 34>429 1 34.4 0 17. Testour 23 169 1 23 2 0 Total 320,5 7 ~5.* 2

4) 18. Jendouba 66,920 1 66.9 1 (R) 19. B3u Salex 58,534 1 58.5 1 (R) 20. Tabarka 26,122 1 26.1 0 21. Ain Draham 50,394 1 50.4 0 22. Ghardimaou 52 866 1 52.9 0 Total , - ~3-m 7 5) 23. Le Kef 64,656 1 64.7 0 24. Sakiet Sidi Youseff 15,317 0 - 0 25. Tajeroulne 44,630 1 44.6 0 26. Kalaat Senan 16,366 0 - 0 27. Ebba Ksour et El Ksour 37,09 0 - - 0 28. Makthar 53,759 1 53.8 0 29. Sillana 48,191 1 48.2 0 30. Sers 31,131 0 - 1 Total 311,099 u -77 T 6) 31. Kasserine 39,310 1 39.3 0 32. Sbeitla 52,593 1 52.6 0 33. Sbiba 30,152 0 - 0 34. Tala 59,319 1 59.3 0 35. Feriana 30,361 1 30.L 0 Total 211,735 17 5 7) 36. Gafsa 50.604 1 50.6 0 37. Erredeyef 31,974 0 - 0 38. Nefta 12,156 1 12.2 0 39. Tazeur 12,193 1 16.2 0 40. Deguåche 13,54 0 - 0 41. El Mftlaoui 25,935 0 - 0 42. El Ghetar 19,457 0 - 1 43. Es-end 15,243 0- - - 0 4. El Maknassy 32,177 0 - - 1 45. ]å R1egab 23,728 0 - 1 46. Sidi Bouzid 49,051 1 49.0 0 47. Ben Aoune 28 098 0 - 0 Total 31,1 U - 7 8) 48. Medenine 39,526 1 39.5 0 49. Ben iheddache 15,908 0 - 0 50. CPumrassen 15,612 0 - 1 51. Remada 8,414 0 - 0 52. Tataouine 3h,115 0 - 1 53. Ben Gardane 24,957 0 - 1 54. Zarzis 35,567 1 35.6 0 55. Djerba 68,220 1 68.0 0 Total 24,319 3 -9.7 7 Page 2

(Oo) PModied Province MH Pop.per MCH and County Pop.- Centers Center Centers

9) 56. Gabes '75,218 3 25.0 0 57. EMHamma 32,251 1 32,3 0 58. Kebili 33,267 1 33.3 0 59. Douz 20 343 0 - 0 60. Matnata 25,924 1 25.9 1 61. Mareth 16 577 1 16.6 0 Total 203M 7 29.0 1

10) 62. Sfax 251584 2 125.8 0 63. Jebeniana 75,058 2 37.5 0 64. Mensel Hebichaker 18,970 0 - 1 65. Bir Ali Ben Khelif 19,814 0 - 1 66. Mezzouna 13,946 0 - 0 67. El Mahares 33 170 1 33.2 0 68. Kerkenah 12:567 1 12.6 0 Total 2,109 7

11) 69. El Kairouan 85,018 1 85.0 1 (R) 70. Sbikha 346191 0 - 1 71. Oaeslatia 23.130 C - 0 72. Haffouz 42,129 0 - 1 73. Hajeb el Aioun 17,782 C - 1 74. Sidi Ali Ben Nasrallah 29,162 0 - 1 75. Sidi Amor Bouhaila 46 912 0 - 0 Total. 2 i, 1 2 12) 76. Sousse 84,831 1 84.8 0 77. Kala Kebira 41,403 1 41.4 0 78. Enfida 30,554 1 30.6 0 79. Msaken 44,732 1 44.7 0 80. Djemmal 45?847 1 45.9 1 (R) 81. Souassi & Chorbane 52,944 0 - 0 82. El Djem 2?,927 1 27,9 0 83. Ksour Essaf 39,316 0 - 1 84. Mahdia 27,671 2 13.8 0 85. Poknine 49,81 1 49.8 0 86. Ksar Hellal 28,753 1 28.8 0 87. Monastir 47 272 1 47 3 0 Total fff, -56 TI- I7

13) 88. Nabeul 47 840 3 15.9 0 89. Korba 29,064 3 9.7 1 (R) 90. Mensel Temime 42,475 1 42.5 0 91. Kelibia 27,981 1 28.0 0 92. El Haouaria 19,523 0 - 1 93. Mensel Bouzelfa 27,881 2 13.9 0 94. Soliman 26,575 1 26,6 0 95. Grombalia 26,432 1 26,4 0 96. Bou Argoub 14,128 0 - 0 97. Zaghouan 36,752 1 36.8 0 98. El HammiamTet 25,438 1 25.4 0 Total 324,092 17 23,2 2

Total National 4,52,5009

/1 1966 Census

f2 On completion of the project there will be 111 MOH centers -- 89 existing centers, and 22 new MCH centers. (Seven existing MC0H centers will be replaced).

(R) , Replacement.

Source: MCH and Family Planning Directorate. ANNEX 5-2

TUNISIA - HEALTH MINISTRY NUMBER OF MEDICAL AND PARAMEDICAL POSITIONS FAMILY PLANNING PROGRAM, MARCH 1970

Description P 0 V

1. 06n6ral 1. General 2IDI-t.Sante Publique .F1=T Health Admin. 21 21 0 Anesth6aistes __-_kneathesiologiste 135 64 71 Infirmiers Nurses 205k 1731 323 Aides-Soigneure Nurse Assistants 3470 3054 416 2. Maternit6 2. Maternity Hospitals djncooogues Gynecologists NA 55 NA Internes Interns NA 9 NA Sage-Femme Midwives 89 81 8 3. Centre PMF et Groups 3. MCH & Small Maternity Centers Med. Gener. Generalists NA 113 NA Pediatres Pediatricians NA 36 NA Sage-Fne PMI Midwives MCH Care 60 22 38 SF Mixte PHI-MAT. Midwives MCH-Maternity 37 24 SF - 13 Total Midwives - Total 186 127 59 4. Planification Familiale 4. Family Planning Programs Inspecteurs Inspectors 16 0 16 Secr.-R6gionals Regional Secretaries 16 14 2 Moniteurs Teachers - 4 0 4 Educ. Postpartum Postpartum Educators 60 51 9 Educ. Rgionals Regional Educators 16 7 9 Chauf. Anim. EM Educator Chauffeurs 16 7 9 07n6cologues Gyneoologists MT 23 21 2 8F Equipe Mobile Midwives XT 18 15 Aides-Soigneurs EM 3 Nurse Assistants MT 18 12 6 Chauffeurs EM Chauffeurs MT 18 14 SF PT Formation 4 Midwives PT Training 30 2 28 5. Ecole Para-Med 5. Paramedical School Mnitrice - ntitre teachers - Trained 79 * - Enfonction 36 43 Teachers - Working NA 23 NA * - Total Teachers - Total 79 59 20

EN a Equipe Mobile. RT * Mobile Team. PT * Part-time. P - Positions. o - Occupied. V - Vacant. SF * Sae-Femme NA * No Available

ANNEX 5-3

PROJECTION OF GRADUATES FROM HEALTH MINISTRY PARAMEDICAL TRAINING SCHOOLS, 1970-1973

Nurse Assistants Nurses Midwives Anesthesiologists Teachers Lab Technicians

1. Tunis 1970 50 30 20 16 8 16 1971 90 70 22 8 10 8 1972 70 70 26 10 10 15 1973 70 70 30 10 - 15

2. Sousse 1970 66 13 - - - 1971 60 70 - - - - 1972 60 70 - - - - 1973 60 70 1.0 - - -

3. Nabeul 1970 63 0 -- - 1971 30 0 - - - 1972 30 30 - - - - 1973 30 30 - - - -

4. Sfax 1970 53 33 - 1971 100 70 - - - 1972 100 70 - - - - 1973 100 70 10 - - - 5. Menzel- Bourguiba 1970 21 - - - - - 1971 35 - - - - - 1972 35 - - - - - 1973 35 - - - - -

6. Le Kef 1970 32 - - - - - 1971 35 - - - - - 1972 35 - - - - - 1973 35 - - - - -

7. Kairouan 1970 0 - - - - - 1971 35 - - - - - 1972 35 - - - - - 1973 35 - - - - -

8. Gabes 1970 28 - - - - - 1971 35 - - - - - 1972 35 - - - - 1973 35 - - - - -

Total 1970 313 76 20 16 8 16 1971 420 210 22 8 10 8 1972 400 240 ?6 10 10 15 1973 400 240 >0 10 - 15 TOTAL 1 533 766 118 44 28 54 ANNEx 5-4

TUNISIA HEALTH SERVICES

PARAMEDICAL PERSONNEL NEEDS

EALTH MINISTRY GERAL (1570) z Anesthesiologists 135 64 71 71 Nurses 2,054 1,731 323 323 Nurse Assistants 3,470 3,054 416 416 Maternity Hospitals Midwives 126 105 21 21 Midwives Canbined MCH-Mat included above 37 24 13

MCH Centers & Small Maternity Centers.. Midwives MCH Paid F? Budget 60 22 38 38 Midwives Total 186 127 59 Family Planning Program Postpartum Educatois. 60 51 9 9 Midwives Mobile Teams 18 15 3 3 Nurse Assistant Mobile Teams 18 12 6 6 Midwife FP Training Part-time 30 2 28 28 3ubtotal §0 PROJECT (1971-1975) 94 1 Kfatenity Hospitals Midwives 25 25 25 Anesthesiologists 10 10 10 Nurses 48 48 48 Nurse Assistants 80 80 8 Postpartum Educators 15 15

HCH Center Midwives 58 58 58 Nurses 18 18 18 18 Nurse Assistants 68 68 68 Small Maternity Centers Midwives 4 4 4 Nurses 10 10 10 Nurse Assistanta 33 33 33 .Postpartum Educators 4 4 4 Paramedical School Teachers 20 20 Subtotal 1 92 TOTAL. 101 218 TO 8-2 495 649

(P) Positions (M) Iidwives S(0) occupiad - (N) Nurses . . AV) - -acant. - ... I(NO Nuram.Assistanta Sourcet Ministry of Health. TUNISIA

UTILIZATION OF OBSTETRICAL BEDS BY PROVINCE. 1969

Annual Ranking of Hospital Deliveries Yearly Births Hospital Provinces by Estimated Total Yearly Obstetrical per Obstet- Delivery Obstetrical Bed Average Le th Population Deliveries Number % Beds rical Bed per Bed Utilization of Stay -

1. Tunis 859,600 32,358 20,750 64 280 115 7h 3 5 days

2. Bizerte 358,700 14,210 4,241 30 68 208 62 4 6

3. Beja 349,000 12,121 2,275 19 7h 163 31 12 12

[. Jendouba 377,300 9,425 2,544 27 Sh 174 47 9 8

5. Le Kef 338,600 13,340 1,59 12 38 351 h2 10 8.5 6. Kasserine 230,hoo 9,493 461 5 8 1,186 58 6 6

7. Gafsa 349,500 14,839 2,609 18 h 337 59 5 6

8. Medenine 263,700 11,318 1,153 10 38 297 30 13 12

9. Gabes 221,500 9,881 1,511 15 20 494 75 2 5

10. Sfax 462,700 17,266 '5,371 31 67 257 80 1 4.5

11. Kairouan 303,000 13,6h 1,059 8 33 414 32 11 12

12. Sousse 567,200 23,890 8,061 34 151 158 53 7 7

13. Nabeul 352,700 15,178 4,966 33 96 158 51 8 7

TOTAL 5,033,900 196,963 56,595 29 971 202 58 6

/1 Uncorrected for occupancy rate.

Source: Ministry of Health. Annex 5-6

GRADUATES IN MIDWIFERY AND PERSONNEL NEEDS FOR THE HEALTH MINISTRY AND IDA PROJECT

N EEDS Health 1/ Vacancies in Services Project- Replacement Graduates Health Services

1970 20 - 20 90 2/

1971 11 5 6 22 79

1972 7 11 8 26 72

1973 22 19 9 50 50

1974 25 14 11 50 25

1975 24 43 13 80 1 1976 65 - 15 80 - 1977 63 - 17 80 -

1978 61 - 19 80 -

1979 58 - 22 80 -

1980 55 - 25 80 -

1/ Project requirements are estimated as follows: - maternity hospitals 25 - rural maternity centers 4 - MCH centers 58 - extension of paramedical school 5 2/ Present requirements in health services based on vacancies ANNEX 5-7

TUNISIA FAMILY PLANNING PROJECT IDCATION OF FACIJTIES

Location Approximate Bed Capacity Maternity Hospitals

1. Tunis 140 2. Sousse 140 3. Sfax 1h0 h. Bizerte 80

Rural Maternity Centers

1. Houmt Souk (Djerba) 10 2. Sedjenane (Bizerte) 15

Maternal and Child Health Centers

1 . Teboursouk (Beja) 2. Zaouiet Madien (Beja) 3. Djendouba 4. Bou Salem (Djendouba) 5. Sers (Le Kef) 6. El Maknassy (Gafsa) 7. El Regab (Gafsa) 8. El Ghetar (Gafsa) 9. Tataouine (Medenine) 10. Ben Gardane (Medenine) 11. Goumrassen (Medenine) 12. Matmata (Gabes) 13. El Hafsia (Tunis) 14. Ezzouhour (Tunis) 15. Kallat Landllus (Tunis) 16. La Marsa (Tunis) 17. Melassine (Tunis) 18. Ksour Essaf (Sousse) 19. Djemal (Sousse) 20. Haffouz (Kairouan) 21. Hadjeb (Kairouan) 22. Sbikha (Kairouan) 23. Sidi Ali Ben Nasrallah (Kairouan) 24. Kairouan 25. El Alia (Bizerte) 26. Somaa (Nabeul) 27. Haouaria (Nabeul) 28. Merzel Chaker (Sfax) 29. Bir Ali Ben Khalif (Sfax)

Avicenne Paramedical Training School in Tunis Including its Postgraduate Training Section TUNISIA FAMILY PLANNING PROJECT CAPITAL COST ESTIMATES (7n thousands of Dinars)

CONSTRUCTION TECHNICAL EQUIPMENT PROFESSIONAL FEES FURNITURE AND EQUIPMENT GRAND Local Foreign Total Local Foreign Total Local Foreign Total Local Foreign -Total TOTAL

8 (1) Maternity Hospital (140 beds) 4,420 125,580 210,000 60,300 89,700 150,000 5,789 8,611 14,400 Tunis

(2) Maternity Hospitals (140 beds 252,000 202,000 454,000 125,210 356,390 481,600 15,088 22,336 37,42I each) Sousse & Sfax

(i) Maternity Hospital (80 beds) 83,800 67,200 151,000 41,070 118,790 159,860 7,40 12,434 Bizerte 4,996

TOTAL - Large Maternity Hospitals 420,220 394,780 815,000 226,580 564,880 791,460 25,871 38,387 64,258 50,165 104,967 155,132 1,825,850

(1) Maternity Center (10 beds) 0,820 7,176 12,000 Houmt Souk

(1) Maternity Center (15 beds) 7,276 10,823 18,099 Sedjenane

TOTAL - Small Maternity Centers 12,100 17,999 30,099 760 1,131 1,891 11,266 35,034 46,300 78,290

(29) Integrated MCH Centers 353,760 526,240 880,000 13,874 20,639 34,513 34,011 178,023 212,034 1,126,547

( ) Expansion Avicenne Paramedical Training School including Post- 54,803 81,507 136,310 17,005 25,296 42,301 2,872 4,272 7,144 17,994 2,614 20,608 206,363 Graduate Training Section I

TOTAL (Dinars) 840,883 1,020,526 1,861,409 203,585 590,176 833,761 43,377 60,029 107,806 113,036 320,638 034,070 3,237,050

TOTAL (US$ million) 1.60 1.96 3.54 0.06 1.12 1.58 0.08 0.12 0.20 0.22 0.61 0.83 6.15 TUNISIA FAMILY PLANNING PROJECT

CONTINGENCY ALLOWANCE (in thousands of dinars)

Technical Assistance Technical Furniture & Professional in ConstrUction Building Equipment Equipment Fees and Other T.A. Grand Local Foreign Local Foreign Local Foreign Local Foreign Local Foreign Total

Allowance for Unfore- seen Factors 10% 10% 5% 5% 10% 10% 10% 10% 5% 5% Allowance for Price Increases 8% 8% 8% 8% 8% 8% 8% 8% - -

Total 18% 18% 13% 13% 18% 18% 18% 18% 5% 5%

Total Cost before Contingencies 840.9 1,020.5 243.6 590.2 113.4 320.6 43.4 64.4 58.o 204.0 3,499.0 Contingencies: Unforeseen Factors 84.1 102.1 12.2 29.5 11.3 32.1 4.3 6.4 2.9 10.2 295.1 Price Increases 67.3 81.6 19.5 47.2 9.1 25.6 3.5 5.2 - - 259.0

Total 151.4 183.7 31.7 76.7 20.4 57.7 7.8 11.6 2.9 10.2 554.1

Total Project Cost Including Contingencies 992.3 1,204.2 275.3 666.9 133.8 378.3 51.2 76.0 60.9 214.2 4,053.1

Ln TONISIA - FAMILY PLANNIG PROJECT IMPLEMENTATION SCHEDULE

(000 Dinars) (US$000) YEAR 1971 1972 1973 1974 1975

1 Paramedical Training School 213.7 407.1 vvy *,, ya XXX XXX XXX +

1 Rural Maternity Center 31.4 59.8 ,,; ; XXX XXX XXX +

9 Maternal and Child Health 361.3 688.3 ain - ()3

1 Maternity Hospital - Sfax 549.3 1,06.6 xx xxx IM xxx + (+ 12 Maternal and Child Health74 Centers 48_.7 _____ x 1 Maternity Hospital - Souse 549.3 1,066.6 ,, ;;; XXX XXX XXX IXX X XXX + (a)

1 Rural Maternity Center 67.2 89.9 ,,,;;; aXXI XXX xx XXX

8 Maternal and Child Health 321.1 611.7 ,,,iii I XX x( 1 Maternity Hospital - Tunis 633.2 825.2 ,,, 3; xinxxx xM M( 1 Maternity Hospital-Bizerte 360.8 687.6 ,,,,;; XX Lxu xxx III x +(

TOTAL 3,369.0 6,379.8

loreign '000 DIIARS Excha=ge

Civil Works (1) 1,861.L 3,966.0 55 _ __ 210.9 46.2 273.7 279.0 322.0 130.5 96.9 68.1 36.1

Professional Services (2) 107.8 205.1 60' 66.7 32.3 10.8

Technical Equipment (3) 833.8 1,688.6 729 91.6 69.0 102.6 118.5 119.7 150.5 56.3 117.1 30.9

Equipment 9, Furniture (3) 636.0 826.8 72% 85.5 66.8 3 -8 79.2 56.9 63.8 17.7 27.5 6_8

Hospital Advisor (a) 112.0 213.6 756 75.0 37.0 Technical Assistance (5) 150.0 285.9 808 66.8 52.5 44.7 8.0

Contingencies (6) 556.1 1,055.6 19.0 75.9 101.6 66.9 87.9 78.6 55.9 26.7 32.2 5.7

TO)TAL 6,053.1 7,721.2 138.8 555.6 661.6 575.2 1608.7 195.6 235.7 141.8 41.6

'008 DIARS

Local Financing 1,533.[ 35.9 209.1 298.3 189.2 261.2 227.6 166.6 75.3 80.3 18.7 134-1 IDA Financing 2,519.7 102.9 3660 663 6 285.6 60o.4 367.6 266.3 120.3 19.6 3.1

000 DOLLARS

tocal Financing [2,921.1 68.6 398.9 568.3 360.6 1 59.5 433.5 275.1 143.6 193.0 3 .6 - IDA Financing 6,800.0 196.0 659.1 865.1 566.1 1_762.7 662.2 503.5 229.2 296.0 144.o 56,

[1) On the assumption that 50% of the costs will be incurred in the first third of the time allowed for LEGEND- construction, 43X in the next two thirds, and 10% 6 months after completion of facilities (end of defects liability period) 'rn-Selection and appointmnt of -Tender architects al nsultants sn - Cal s nction (2) 60% before the start of onstruction, 30% two years after the start of construction, 10% at the com- pleti.n~~ oftefclteSurreyof sites, timetables, M- In3tallation + - End defets liability peziod jar (3) 25 efore the start of construction, 359% one year after the start of construction, _ ) at the time master plans of completion of facilities, and 10% one year after completion of facilities (end of iefects liabili- -epi n- Ensfctros ty period) of hid-packages f defeitsrPreparation liability-q-ud period (6) consulting services for the schematic and final designs (5) assumption that technical assistance will be entirely provided during the first threc years of the project except for a review mission taking place in the Fall of 197 (6) assumption that contingency payments will be proportional to the scheduled disbursements for all cost categories ANNEX 6 Page 1

THE DEMOGRAPHIC EFFECT OF THE PROJECT

Introduction

The purpose of this annex is to outline the demographic effect of the proposed project in terms of the number of averted births. This dis- cussion is preceded by an analysis of the probable effect of the present program on the number of averted births.

PresentFamlPanninProgr

It is estimated that the present family planning program delivered services to 21,300 acceptors in 1969 (Annex 3-6). These acceptors were distributed as follows, with respect to contraceptive methods: IUD (43% or 9,200 acceptors); pill (37% or 7,800 acceptors); tubal ligations (11% or 2,400 acceptors); social abortions (8% or 1,700 acceptors) and other methods 1%. While the total, number of abortions in 1969 was 2,800 (Annex 3-6) many of these patients requested tubal ligations. The mission estimates that this proportion is about 40% or 1,100, leaving 1,700 women who had only social abortions. The number of births averted by the present program is calculated as follows. For the 17,000 acceptors using pills and IUD's, it is estimated that 40% of women remain in the program at the end of one year. Furthermore, the expectation is that women who are practicing contraception are subject to the average fertility levels prevalent in the population - i.e. in the absence of the necessary statistics, acceptors are assumed to be representative of the general population with respect to age distribution, parity, and other factors that are related to fertility. Since the general fertility rate is 200 (i.e. 200 children are born for every 1,000 women in the reproductive ages every year), the assumption is that for every 5 women practicing contraception for a year, one birth is prevented. On the basis of this estimate and of the continuation rate of 40%, the number of pill and IUD acceptors in 1969 was estimated to avert about 2,380 births in the following year and over 1,400 births in all subsequent years. The following table shows these approximate calculations.

Mid-year Number of Number of Number of Year Acceptors Acceptors Births Averted

1969 17,000 11,900

1970 6,800 4,760 2,380

1971 2,720 1,904 952

1972 1,088 544 Annex 6 Page 2

For the 2,400 acceptors having had tubal ligations, the number of births averted is estimated at 480. This is based on the fertility levels prevailing in the general population. Finally, on the assumption that 4 abortions will prevent one live birth, the 2,800 acceptors having had social abortions averted an estimated 700 births. Consequently, the total number of births averted between 1970 and 1972 from all contraceptive methods amounts to approximately 6,000 out of this cohort of 21,300 new acceptors in 1969.

Proposed Project

A. Maternal and Child Health Centers

In 1969, there were 89 MCH centers in Tunisia (Annex 3-1). The total number of hours devoted to family planning in all these centers amounted to 240 hours per week. The staff consisted of a visiting doctor and a midwife and most of the work (consisting mainly of IUD insertions) was performed by the doctor. There were 98,951 consultations held in these facilities in 1969. The average number of hours of family planning services scheduled per week at each center was 2.7 or 135 hours of services and 1,100 consultations per year. On the basis of the available data, an average number of eight consultations per hour takes place in the MCH center when family planning services are provided.

The proposed project is estimated to reach 48,000 additional acceptors in the MCH clinics. This is based on the following estimates:

(a) two family planning midwives are assigned to each MCH center, and each midwife devotes at least 20 hours per week to family planning. This amounts to 40 man-hours of family planning per week per MCH center;

(b) there would be only 5 consultations per hour. This is equivalent to 200 consultations per center per week and 10,000 consultations per MCH center per year. Since the project consists of 29 MCH centers, the total number of consultations in all proposed MCH centers amounts to 290,000; and

(c) the consultation-acceptor ratio goes down from the present ratio of 7.3:1 to a ratio of 6:1 due to better facilities and services. With 290,000 family planning consultations expected to be delivered in all the MCH centers, this ratio yields a total of 48,000 acceptors.

B. Maternity Hospitals

There are 525 beds in the proposed urban and rural maternity hospitals. On the basis of: ANNEX 6 Page 3

(a) an average utilization of beds of 5 days per delivery, or 70 patients per bed per year, and

(b) three-quarters of the additional beds (or 394 beds) being effectively utilized in the postpartum program, an additional 27,600 potential acceptors could be motivated, and of these, at least 25% or about 7,000 persons can be expected to accept family planning services. This ratio of 25% is a conservative estimate, based on average international experience in postpartum programs. The more successful postpartum programs, such as the one in Singapore, have enlisted close to 60% of the women.

The total number of annual acceptors consequently amounts to 55,000 acceptors, 48,000 from the MCH centers and 7,000 from the maternity hospitals and rural maternity centers.

In order to estimate the number of births averted as a result of having 55,000 acceptors per year, the following assumptions are made:

(a) the present mix of contraceptive techniques will be adopted in the same proportion in the future. Con- sequently, of the 55,000 acceptors, 80% or 44,000 will use the pill or have IUD insertions; 11% or 6,050 acceptors will have tubal ligations, and 9% or 4,950 acceptors will have social abortions or use other methods; and

(b) the same general fertility rate of 200 will prevail and the age distribution, parity and other charac- teristics of acceptors will be such that their fertility will be the same as that of the general population. Con- sequently, 5 women practicing contraception for a year will prevent one birth.

The proposed project provides services for 55,000 acceptors per year. Since the number of acceptors was 21,300 in 1969, the entire program will result in a total of at least 76,300 acceptors. To determine the number of averted births from this cohort of 76,300 new acceptors, the same assumptions are made as those described on page 1 of this annex. On this basis, a cohort of 76,300 new acceptors in a given year will have averted 13,000 births after one year, 18,100 after two years, and 21,300 after three years. However, the project, through its technical assistance and other components, can be expected to improve the effectiveness of the program as a whole. This effect could be substantial, but it is difficult to estimate. All the preceding figures are, then, a conservative estimate of the effect of the project. The present program and the project can be put in perspective by comparing their probable effect on the size of the population in year 2000. Going from the present level of 21,300 new ANNEX 6 Page 4 acceptors per year between 1970 and 1975, to a level of 76,300 new acceptors per year between 1976 and 2000, the total number of averted births will reach 551,000 by the year 2000. The impact of the total family planning program would be to make the population in year 2000 4.6% smaller than it otherwise would be, and the labor force 2.3% smaller (based on Annex 2-1, Series C). The project alone would make the population and the labor force 3.2% and 1.6% smaller respectively by the year 2000. It is likely that the family planning program will have a greater impact than the figures above indicate because the assumptions made in the calculation of the number of averted births were consistently on the conservative side and because we did not allow for the effect of the technical assistance component on the efficiency of the present program; the magnitude of this effect is difficult to estimate. ANNEX 7 Page 1

DESCRIPTION OF PROJECT FACILITIES

1. Maternity Hospitals

The maternity hospital in Sfax will consist of a total of about 140 beds; 79 allocated to maternity, 55 to gynecology and 6 for consultation.

These services will be supported by Reception and Administration, Admissions and Labor and Operating suites. In addition, a section for family planning and an out patient prenatal clinic are programmed.

It is intended that the planning and design of this maternity hospital should allow for flexibility in its spaces and services, and a form of repetitive or modular construction be evolved which may then be applied to the three other maternity hospitals at Tunis, Sousse and Bizerte. This last will be provided with only 80 beds and its supporting services will be reduced in proportion.

At Sousse and Sfax the proposed new buildings will be located within the site of the existing maternity hospitals. Means of access to the existing main building from the new maternity hospitals will be maintained in order to utilize the existing operating rooms for serious cases.

The total area of each of the 140-bed maternity hospitals will be approximately 5.5 thousand m2. They will be installed with air conditioning in the delivery sites, and central heating generally in the buildings.

All the buildings will be sited to take full advantage of the climate and topography and, by prudent landscaping, improve the ambiance and micro-climate of the site.

The various units or departments in each of the projected buildings shall be planned, wherever possible, to share common facilities, to allow for growth and adaptation and to resolve circulation and communication in the most efficient and economic manner.

2. Rural Maternity Centers

The project includes the construction of two small rural maternity centers (RMC) which will contain a total of 25 maternity beds. These RMC are justified by population needs and the pilot role they would play for this kind of facility in rural areas. On the island of Djerba in the province of Medenine,10 beds will be added to 10 existing beds when the center is re- modeled. At Sedjenane in the province of Bizerte, a small maternity hospital of three rooms (five beds in each room) will be constructed to complement the existing MCH Care Center and small dispensary. ANNEX 7 Page 2

3. Maternal and Child Health Care Centers

The project includes the construction of 29 MCH centers. Each MCH center is comprised of three parts. The first part follows the standard design for MCH pediatrics activities and covers 300 m2, including a waiting room, first-aid room, two medical examination rooms, a dressing room, a demonstration room, a laboratory for basic analysis as well as another small room suitable for the introduction of a mobile x-ray unit. The second part of the MCH center covering 220 m2 is devoted to family planning activities and includes a waiting and projection room, offices for the social worker and postpartum educator, for the regional secretary and/or regional educator, two examination rooms, and two small offices for the doctor and the midwife. The third part of the MCH center, covering 100 m2 includes a residence for the family planning midwife.

4. Extension of Paramedical Training School

The project includes an extension of the existing Avicenne School as well as a number of improvements in the existing structures. The school extension includes six classrooms, six demonstration rooms, an amphitheatre with a capacity for 250 students including a projection room, a demonstration room and an office for a professor, a dormitory with a capacity for 120 students including sanitary block and elevators, equipment for a library and a gymnasium, two lodgings for the director of the school and the assistant director, construction of an access road to the school, construction and installation of electric equipment in the existing facilities, fences and terracing of the ground to prevent erosion, installation of hot water equipment and heating for the classes and administrative offices and equipment for the laundry, improvement of classroom acoustics, and division of the existing large dormitories into small compartments of four to six beds each. MAP.1

TUNISIA PROPORTIONAL DISTRIBUTION editerr ean Sea OF THE POPULATION BY PROVINCE

~U~rban popalotion B R E Dnsely papultedreas Sparsely populoted Greas

POPULATION DENSTY, 1966 CENSUS

rU -L - RA -Provincial boundaries li KE F - International houndaries

-- n AF R C A -1~ 1

ALGERIA

- 1

J 0 0 20 3 4o 5o

ril <0 2,0 ,40 6p 6 KILOWETERS j - --- 0

0--

CHOTT EL OJER1D

. .... MEDE NIN E LWBYA

OCTOBER 1970 1IBRD-31

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'`.. ~ L 16 YA > ² ° ¢°1°ouine е° '\ а ' 1BRD-31530.t FEBRUARY 1971

MAP 3.

8. TUNISIA sAd M.C.H. NETWORK

93% (30) (30) FPConsullations in RCH., [66] 93% -ntouad FP Consultations in MC.H. 325,000 [295] 93% as percentage of total Province 146,000 76 0 6.6 FP Consultations. -2) I4600 764, (1 Pediatrics Consultations in 95% B/ZER TE T 663,000 0% K[295] , in tousands [ -_40.2] [97.] Population of Provinces, 1966 25,00~ 0 UN / 317,000 63-c7 Urban popu'ation af Provinces, 1966 20,000\16,000 Provincial capitals DJENDOUBA 7 3 NABEL --- -Provincial boundaries Djendoubo 87% - International boundaries - [33.8]

(23)~~ 37,000 ) ~ 70% -'~ I LeKef Tunisia [36.3]

--36' 41,000 3e- E KEF A F R I C A Z Sousse 6\ (10.6) - 27]Koimucn 84% fl <2.9~

Kasserine t j KASSERINEJ~ {( 41% /' [61.4] Sfox

(x ' 100% 1217000 [32] 3 600 S FA X Gof sa 95,000 0 o 20 30 40 50 G A F S A MILES

0 o 40 80 80 < A S20LOMETERS

é ('5.0)-

[35] 203,000 48,000

Gj_*M "A B E S ---

236,0001 33,000 MEDEN/NE LIBYA

OCTOBER 1970 IBRO 3152