Documentof The World Bank

FOR OFFICIAL USE ONLY Public Disclosure Authorized ReportNo. 11788-COM

STAFF APPRAISAL REPORT

FEDERAL ISLAMIC REPUBLIC OF COMOROS Public Disclosure Authorized

POPULATION AND HUMAN RESOURCESPROJECT

NOVEMBER19, 1993 Public Disclosure Authorized

Population and Human Resources Division OperationsDepartment III Public Disclosure Authorized Africa Region

This document has a restricted distribution and may be used by recipients only in the perfornance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY EQUIVALENTS

Currency unit = Comorian Franc (CF) 1990 US$1 = CF 272 1991 US$1 = CF 282 1993 US$1 = CF 273

MEASUREMENTS

1 meter = 3.28 feet 1 kilometer = 0.62 mile 1 square kilometer = 0.39 square mile 1 hectare = 2.47 acres

FISCAL YEAR

January 1 - December 31

This report is basedon the findingsof an appraisal missionwhich visited Comorosin March 1993. The missionmembers were DanielViens (MissionLeader), AmoloNg'weno, MicheleLioy, Pierre Mersier, MalongaMiatudila, Cung Tran-Luu(AF3PH), and Paul Geli (consultant). The report was preparedby Lynne Sherbume-Benzand Amolo Ng'weno. The report was processedby Val6rie Vincent, RoselyneLeroy and Hilda Emeruwa. Willy De Geyndt is lead advisor and Messrs. Steen Jorgensenand AlexandreMarc were the peer reviewers. Francisco Aguirre-Sacasaand David Berk are the DepartmentDirector and ManagingDivision Chief respectivelyfor the operation. FOR OFFICIAL USE ONLY

ABBREVIATIONSAND ACRONYMS

AfDB African Development Bank AIDS Acquired Immuno Deficiency Syndrome ASI French NGO (Association Sante International) CARE International Development NGO CARITAS International NGO of the Catholic Church CCC Central Coordination Committee CDSF Community Development Support Fund CECI Canadian NGO (Centre Canadien d'Etudes et de Cooperation Internationale) CIR Country Implementation Review CPR Contraceptive prevalence rate CTARIAP Technical Commission on Adjustment and Strengthening of the Public Administration CYP Couple-years of protection DHE Directorate of Health Education DPI Directorate of Pharmaceutical Inspection ENS National Public Health School EPI Expanded Program of Immunization FAC Aid agency of the French Government (Fonds d'Aide a la Cooperation) FIRC Federal Islamic Republic of Comoros FP Family planning GDP Gross domestic product GNP Gross national product HIV Human Immunodeficiency Virus IDA International Development Association IEC Information, Education and Communication ILO International Labor Organization (of the UN) IMF International Monetary Fund MCH Maternal and Child Health MEN Ministry of Education MERCAP Macroeconomic Reform and Capacity Building Project MIS Management Information System MOH Ministry of Health NES National Executive Secretariat NGO Non-governmental organization PC Pilot Committees PHC Primary Health Care PEP Public Expenditure Program PNAC National Autonomous Pharmacy of Comoros RC Regional Committee RES Regional Executive Secretariat RHT Regional Health Team RMO Regional Medical Officer SSA Sub-Saharan Africa STD Sexually Transmitted Disease TB Tuberculosis UNDP United Nations Development Program UNFPA United Nations Fund for Population Activities UNICEF United Nations Children's Fund WHO World Health Organization

This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization.

TABLE OF CONTENTS

Basic Data ...... i Credit and Project Summary ...... ii

I. BACKGROUND ...... 1

A. Recent Economic Developments ...... 1 B. Conditions in the Social Sectors ...... 2 C. IDA's Assistance Strategy and Lessons Learned ...... 5

II. HUMAN RESOURCES SECTOR ISSUES ...... 6

A. Health Sector ...... 6 B. Education Sector ...... 9 C. Community Development ...... 10

III. THE PROJECT ...... 11

A. Project Objectives and Approach ...... 11 B. Project Description ...... 12

IV. PROJECT COSTS AND FINANCING ...... 23

V. PROJECT IMPLEMENTATION ...... 26

A. Project Preparation ...... 26 B. Project Management ...... 27 C. Implementation Schedule...... 31 D. Project Monitoring and Reporting ...... 33 E. Implementation Issues in Comoros ...... 34 F. Procurement ...... 36 G. Disbursement ...... 38

VI. BENEFITS AND RISKS ...... 39

VII. CONDITIONS AND RECOMMENDATION ...... 40 -2- (continued)

Tables in Main Text

Table 4.1 SummaryProject Costs by Component Table 4.2 SummaryProject Costs by Category of Expenditures Table 4.3 Allocationof IDA Credit by DisbursementCategory Table 5.1 ImplementationSchedule Table 5.2 : ProcurementArrangements Table 5.3 : DisbursementCategories

Annexes

Annex I : CommunityDevelopment Support Fund (list of sub-projects) Annex II Information,Education and Communication Annex III Technical Assistanceand Training Annex IV SummaryProject Costs and Financing Annex V : EstimatedSchedule of Disbursements Annex VI PerformanceIndicators Annex VII : SupervisionPlan Annex VIII SelectedDocuments in the Project File Annex IX The Pilot Experienceat MitsoudjdHealth Center Annex X : Health Component:Activity ImplementationSchedule Annex XI : ComorosDemography and Health Resources, 1991 - i -

BASICDATA (1990 or most recent estimate)

Comoros Sub-Saharan Africa

Total Area (kmi): 1,862 23,066,000 Grande Comore 1,147 Anjouan 424 Moheli 290

Total Population(millions) 0.48 495

Populationgrowth rate (annual %) 3.1 3.0

Populationper km: Grande Comore 243 Anjouan 429 Moheli 109

Crude birth rate (per thous. pop.) 44.7 45.9 Crude death rate (per thous. pop.) 13.6 15.6 Life expectancyat birth (years): Overall 54.5 50.6 Female 55.9 52.4 Male 53.0

Infant mortality rate (per thous. live births) 114.5 107.3 Under 5 mortalityrate (per thous. live births) 131.2 166.8 Total fertility rate (births per woman) 6.60 6.46

Primary school enrollment(% of school-age-group) 62.4 68.8

Populationper physician 8,816

Populationper nursing person 621

Populationper hospitalbed 363

Access to health care (% of pop.) 83%g

Percentageof pregnant women receivingprenatal care: 1982 24 1989 70

Per capita GNP (US$) 510 340

Daily calorie supply (calorieper person) 1,960 2,120 ContraceptivePrevalence Rate (1991) 4%

- 11 -

CREDIT AND PROJECT SUMMARY

Borrower: Federal Islamic Republicof the Comoros

ExecutingAgencies: Ministry of Health and CommunityDevelopment Support Fund (CDSF)

CreditAmount: SDR 9.2 million (US$13.0million equivalent)

Terms: StandardIDA terms, with 40 years maturity

ProjectObjectives:

The overall objectiveof the project is to strengthenthe developmentof human resources in the Comorosby: (i) increasingthe efficiencyand effectivenessof basic health services, through the establishmentof efficienthealth regions and other supportive services, which will be capable of providing comprehensivegood quality and cost effectivehealth care, includingfamily planning services and Acquired ImmunodeficiencySyndrome (AIDS) prevention,and will involve community participation, self-managementand cost recovery; and (ii) by promoting complementarycommunity development initiatives to develop social infrastructure and grassroots participationin small-scaleproductive activities, through a Community DevelopmentSupport Fund (CDSF).

Project Components:

The project has two components: populationand health, and communitydevelopment. The populationand health componentwill build upon existingsuccessful pilot programs for self-managementand cost recovery to establishservices capable of ensuring cost-effectiveand sustainableprovision of comprehensiveand good quality health care, includingFamily Planning (FP) and AIDS control services. To that end, the componentwill: (i) strengthenthe capacitiesof the three health regions to plan, implement,administer, and supervisehealth care services, in part through improving and expandingthe training of district health personnel; (ii) equip and rehabilitate two regionalhospitals and a number of health centers; and (iii) promote family planning and AIDS control services. In the second componentof the project, complementary communitydevelopment activities as well as activitiesto encouragesustainable economicdevelopment would be supportedthrough a CommunityDevelopment SupportFund (CDSF). While demand driven, the CDSF would focus primarily on: training of communitiesand groups in micro-projectdevelopment, management, and implementation;rehabilitation of social infrastructure(especially primary schools, water supply, and health posts); activitiesto promote the well-beingand development of women; and incomegenerating activities. - iii -

Benefits and Risks:

The project is expectedto enhancethe developmentof human resourcesby improving the health, education,and income status of the population. Through the health and populationcomponent, available primary health care is expectedto improve with the strengtheningof peripheral services and closer involvementof communitiesin their provision; Information,Education, and Communication(IEC) and better Family Planning (FP) services should increasethe contraceptiveprevalence rate, reducing fertility, as well as raising awarenessof the need for AIDS prevention. The CDSF would complementactivities in the health componentby buildingupon strong communityinvolvement and aiding communitiesand individualsto more effectively and efficientlychannel community resources and implementlocal developmentefforts, includingmuch needed rehabilitationof primary schools, water supplyand health posts. It would provide an opportunityto strengthen the capacity of local associations and NGOs, as well as encouragethe creation of new NGOs, in addition to enhancing the well-beingand economicrole of women in society.

The main risks to the implementationof the project are weak Governmentcapacity and potentialdelays due to politicaluncertainties. To address the first, the goal of the health and populationcomponent is to strengthen communityinvolvement, both financiallyand managerially,in the provision of basic health services as well as to build Governmentcapacity and improve the efficiencyof these services. More specifically,personnel would be trained, a unit within the Ministry of Health would be created under the Directorate General of Health Services for procurementand administrationof implementation,and technicalassistance would be provided in key areas for capacitybuilding. To insulate the CDSF from weak Governmentcapacity and political interference,an autonomousagency staffed by selected, contractual employeeswould managethe fund. In addition, communitytraining, strong CDSF supervision, a transparentmanagement information system, and semi-annualauditing of accountswould enhancethe overall efficiencyof the communitydevelopment componentof the project.

Project Cost Estimates: (in US$ thousands)

Estimated Costs Local Foreign Total Supportto the Health Sector 4,931 2,056 6,987 CommunityDevelopment Support Fund 5,979 911 6,890 PPF 500 300 800

Total BaseCosts 11,410 3,267 14,677

Price Contingencies 1,184 175 1,359

Total Project Costs 12,594 3,442 16,036 - iv -

Financing Plan: (US$ millions)

Local Foreign Total IDA 9,587 3,442 13,029 Government!' 3,007 - 3,007 Total 12,594 3,442 16,036

1/ Government contribution will include US$2 million in budgetary assurances to ensure adequate funding of health facilities to be rehabilitated; and US$1 million in community counterpart contribution to the CDSF.

Estimated IDA Disbursements (US$ millions)

IDA's Fiscal FY94 FY95 FY96 FY97 FY98 FY99

Annual 0.8 2.5 3.5 3.1 2.2 0.9 Cunulative 0.8 3.3 6.8 9.9 12.1 13.0

FEDERAL ISLAMIC REPUBLIC OF COMOROS

POPULATION AND HUMAN RESOURCES PROJECT

STAFF APPRAISAL REPORT

I. BACKGROUND

1.1 The Federal Islamic Republicof Comorosbecame independentin 1975. It had a GNP per capita of about US$510 and a populationof about 480,000 in 1992. Comoros, consistingof three islandsoff the east coast of Africa, is predominantlyrural and highly dependenton external assistance. About 40% of GDP derives from agriculture, 50% from trade and other services and the rest from manufacturingand construction. Agricultural practices are undevelopedand marketing systemsinadequate. Food production is insufficient to meet local requirementsand the country imports large quantitiesof rice and meat. The manufacturingsector comprisesprimarily processing of export crops and a few small factories supplyingthe domesticmarket. Tourism is still at an incipient stage. Major exports are vanilla, cloves and perfume essences.

1.2 At independencein 1975, the country found itself with little infrastructureand low educationand health standards. Politicalturmoil marked its first fourteen years of independence,culminating in the assassinationof the President in 1989 and subsequent departureof the foreign mercenarieswho had been controllingthe country. The elected Governmentswhich have followedhave seen frequent cabinet reshufflesand an uncertain politicallandscape. Since independence,with support from the internationalcommunity, economicand social infrastructurehas improved. The country now has a fairly well-developed road network, an internationalairport, and a deep-waterport in Anjouan. However, economic prospectsremain constrainedby the very small and segmenteddomestic market; the geographicalremoteness from major markets; and the limited natural resources.

A. Recent Economic Developments

1.3 Economicgrowth in the early 1980s was around 7% per year, but slowed to under 1% in the late 1980s due to a decline in the constructionand public works that had led the earlier spurt. Agriculturalgrowth has continuedat over 4% per year, but services have declineddue in large measure to the adverse impact of the political unrest on tourism. Export earningshave been eroded due to declining terms-of-tradefor vanilla and cloves, and exports presently cover less than half import costs. The major import is rice.

1.4 Inflation has been low and steady, averagingless than 4% during 1987-91, despite a large budget deficit. The Comorian franc is pegged to the French franc at FF1 = CF50. Due to the appreciationof the French franc vis a vis the US dollar, the Comorianfranc has appreciatedby about 60% in nominalterms (trade-weighted)and 25% in real terms in the late 1980s with serious consequenceson growth. Central Governmentdebt totalled US$170 million in 1990. Despite the concessionalnature of most lending, the debt service ratio is about 19% and likely to remain at this level for several years. Due to a steady increasein the wage bill in the late 1980sand the weaknessof the revenue base, the overall budget deficit 2

(excludinggrants) averagedover 20% of GDP in the late 1980s. Despite measures in 1990 and 1991 aimed at reducing the deficit, domesticarrears remain substantial.

1.5 Reform Program. Major structuralreforms are being undertakenwhich are oriented around better managementof public finances, improvementsin the climate for private investmentand employment,export diversification,better social sector planningand management,and environmentalprotection. Reformsinclude improvementsin the tax collectionsystem, reductions in civil service staffing and benefits, restructuring of the managementand financingof parastatal enterprises and the introductionof a new accounting system for public and private enterprises. IDA's Macro-EconomicReform and Capacity BuildingCredit (MERCAP),which became effective in December 1992,supports this reform process. In 1991the Governmentof Comorosreached an agreement with the IMF and cleared arrears to the African DevelopmentBank, opening the way for project lending to resume. A plan for civil service reform has also been undertaken. On trade, the Governmenthas acted to reduce export taxes on vanilla, and to remove taxes and other levies on all other export crops. Improvementsin domesticcompetition in these markets has also been encouraged. Export diversificationis to be emphasized,especially into tourism, tropical fruits and agro-processing. The resumptionof relationswith South Africa has improved prospectsfor tourism.

B. Conditions in the Social Sectors

1.6 Health, Population and Nutrition. The populationof Comorosis relatively young (46% under age 15) and growing at 3. 1% per year. Internal and external migration rates are high. More than 40,000 Comorianslive in France and a sizeable number in neighboringAfrican countries. The relativelyunderpopulated island of Moheli constitutesa strong pole of attractionfor migrantsmainly from Anjouan.

1.7 Life expectancyis low at 56 years for women and 53.0 for men. Infant mortality is estimatedat about 90 per 1,000live births and maternal mortalityat nearly 500 per 100,000pregnancies. Availabledata indicate a high incidenceof preventablediseases. In children, the leadingcauses of death are malaria, respiratory diseases, and diarrhea. Added to intestinalparasites, skin diseases, and trauma, these diseasesaccount for most health facility visits by childrenunder 5. Data from hospitals indicate high rates of obstetrical complications associatedwith pregnanciesthat are too early, too closely spaced, or too late. Only a quarter of births take place in health facilities. AIDS does not presently constitute a major public health problem. HIV seroprevalencerates are below 1 per 1000(0.07% in 1992). However, given the extremelyhigh prevalence of syphilis (19.2% among pregnant women in and around Moroni) and other conventionalsexually transmitteddiseases (STDs),this picture is likely to change with the anticipatedimprovement in internationalcommunications and expansionof tourism. As of December 1992, 16 HIV cases have been diagnosed, mainly among foreigners.

1.8 At the national level, current populationproblems are characterizedby a very high density of populationon arable land, high dependencyburden, and a high level of unemployment. Comorosis one of the most denselypopulated countries in Africa, with an average populationdensity of 205 persons per km2, or 398 persons per km2 of agricultural land. Anjouanis the most densely populated island, with 429 inhabitantsper km2, compared with 243 in Grande Comore and 109 in Moheli. The proportion of children under 15 years of age and adults age 60 and over (3%) suggests an age dependencyratio of 1.03 and a heavy 3 burden for the economicallyactive population. Governmentefforts to raise primary school enrollmentare frustrated by the growing number of children aged 6 to 15. Unemploymentis serious and growing and efforts to curb it are annihilatedby persistent unfavorable demographictrends. Comoros' demographyalso has a strong negative impact on the environment. Forest degradation, especiallyin Anjouan, and severe soil erosion are just some of its many adverse environmentaleffects.

1.9 Family Planning (FP) services are availablefrom most public sector facilities, includinghealth posts. Despite a doublingof the use of modern contraceptivemethods during the implementationof the Bank-financedHealth and Populationproject (completedin 1991), the contraceptiveprevalence rate (CPR) remains at a low 4%. Unmet demand for contraceptionis thought to be significantand there is now public consensusthat the country is fast becomingoverpopulated. A PopulationUnit exists in the Planning Ministry, but it has dealt primarily with the census.

1.10 The nutritionalstatus of the populationmay be poor. One regional study showedprotido-caloric malnutrition to affectover 40% of childrenunder 5 with severe malnutritionas high as 10% in children under 5. Deficienciesof specificnutrients are also common. Many pregnant women suffer from moderateto severe anemia, and iodine deficiency disorders are highly prevalent in Anjouan. A diet low in protein, and traditions in which certain foods are taboo, may contributeto high malnutritionrates in children.

1.11 Overall, coverageof the health system is dense by African standardswith 83% of the populationliving within one hour (walkingdistance) of a health facility. Health, populationand nutrition services are administeredthrough the Ministry of Health and Population. Service provision is currentlyorganized through 20 health districts (14 operational with six to become functionalin the future), each covering between 25,000 and 100,000 people. The districts are comprised of one health center and a constellationof health posts, dispensaries,and rural maternities. There are 15 health centers, and nearly 60 health posts and rural maternities. Tertiary care is provided in 2 hospitalswith a total bed strength of about 700. Outpatientcare at the tertiary hospitals is heavily utilized. Secondary care is provided in three surgical clinics with an average capacityof about 50 beds. A system of village pharmaciesprovide drugs at low cost and supplementsprivate sector pharmacies. 85% of children are fully immunized. Public expenditureson health care are about 9% of public expenditures,and about 2% of GDP, for a total of about US$7.50 per capita. The wage bill comprisesthree fourths of the health budget.

1.12 Governmentpolicy since independencehas stressed Primary Health Care (PHC) and has accordedpriority to the deliveryof basic services to the rural areas. Comoros has subscribedto the 1978Alma-Alta Declaration, which prescribed a primary health care approachwith the aim of ensuringhealth care for all by the year 2000. With external donor assistance, the actual orientation of the health serviceshas generally mirrored the stated plans, with recorded achievementsespecially in increasingvaccination rates.

1.13 Education. Althougheducation statistics are around the sub-SaharanAfrican average, they were decliningin the late 1980s and have only recently shown some improvement. Nonetheless,adult illiteracy is high (estimatedat 50%) and the absolute number of illiteratesmay be growing as growth in literacy is estimatedto be less than the population 4

growth rate. Gross primary school enrollmentratios were estimatedat close to 90% in 1991, after falling over the five precedingyears. Net enrollmentratios are about 62%. Rates of repetition are very high at about 35%. Pupil to teacher ratios in primary school are about 40:1. Double and triple shift classes are the norm, resulting in pupil-teachercontacts of 12-17 hours per week. Enrollmentfalls off in the secondary school years. The net participationrate in lower secondaryoverall was only 7% in 1991/92according to Governmentstatistics. In upper secondaryit was less than 3%. As with most sub-SaharanAfrican countries, salary costs consume most of the budget of the Ministry of Education, with suppliesand teaching materials makingup less than 3% of expendituresfor primary education in 1991.

1.14 The Ministryof Education(MEN) employsabout 1,800 teachers and 400 administrativestaff. About 40% of public educationexpenditures goes to primary education, and 11% to external scholarshipsfor universityeducation for 750 students. Education consumes22% of all public expendituresand about 4% of GDP.

1.15 Community Development. In Comoros, communitiesare traditionallyvery active in organizinglocal developmentinitiatives, in part due to weaknessesin the central Governmentand in part due to cultural traditions. Lineage associationsare very important in the social structure. The society is generally matrilineal (group membershipand status is transmittedthrough the mother) and matrilocal(a newly married couple resides with the wife's lineage). The exceptionis the island of Anjouanwhich is not matrilineal.

1.16 Village society is very cohesiveand village associationshave a long tradition of investmentin civic services, especiallyrelated to religion. Most villages have mosques, village squares, and markets which have been erected by the local communities. "Notables" play an important part in village society. Comoriansabroad maintaintheir close affiliation with their villages, and constitutean importantsource of investmentcapital for village projects. Tlhistightly-knit village structure is enhancedby the close physical proximityof houses -- villages are small urban units rather than dispersed farms; land is owned communallyby the village as well as by individuals.

1.17 Women in Comoros are in a relativelyprivileged position comparedto other countries. They are the owners of capital, especiallyreal estate, and most are economically active. Women's groups are active at the village level all over the country. However, women bear the brunt of the country's poverty, as they spend long hours in collectingwater and fuel, have very high fertility rates with negativehealth consequences,leave school earlier, and make up the majority of illiterates.

1.18 There also exist a number of other forms of association, includingrevolving credit societies("tontines") and mutualaid groups for particular tasks, as well as other sporting, musical, and cultural associations. In general separate associationsexist for men and women. Most associationshave little organizationalexperience and, in some cases, meager financial resources. Governmentprocedures require that associationsregister themselveswith the Government("declared" organizations). Some, in particular those for education(such as the parent-teacherassociations), also receive Governmentsupport. There are a number of federationsof associations,in particular the Federationof Women's Associationsof Comoros, which has drawn supportfrom UNDP; the NationalCoordination of Associationsfor Development,which coordinatesthe activitiesof NGOs with local associations;ULANGA, an 5

environmentalfederation; and professionalassociations. InternationalNGOs active in Comorosinclude CARE, which implementsa major environmentalproject for USAID on the island of Anjouanas well as interventionsin the health sector; CARITAS,which runs a dispensaryand school on Grande Comore and intendsto expand activitiesto the other islands; and CECI, which supports communitydevelopment and environmentalinitiatives. Other internationalNGOs active in Comorosinclude the InternationalCommittee of the Red Cross/Red Crescent, the Boy Scouts, the Lions and Kiwanis Clubs, HandicapInternational, Amici Raoul Follercao, Groupe de Service Volontaireand Amis du Pere Damien.

C. IDA's AssistanceStrategy and Lessons Learned

1.19 Health. The World Bank-financedHealth and Population Project (appraised in 1982and completedin 1991) was designed to help the Governmentdevelop a program to slow populationgrowth and strengthenthe managementand delivery of basic health services. While many elementsof the project had only minimalimpact, the project did register some progress towards its objectives. Amongits most importantachievements were: (i) contributionto the creation of a networkof family planningservices accessiblethroughout the country in almostall health facilities, helpingto change the initially very negative attitudesof political, religious, and traditionalleaders toward family planning, and increasingthe CPR to an estimated4% today; and (ii) establishingthe NationalAutonomous Pharmacy of Comoros (PNAC) which is now an autonomouslymanaged operation which successfullyoperates on a cost-recoverybasis and has greatly increasedthe population'saccess to essentialdrugs through its distributionsystems which includecost-recovering village pharmacies. The reasons for the adverse results of other componentsof the project are diverse. At the time of project design, the Governmentwas engaged in reorganizingits administrationand economicsystem and the Ministry of Health, which was only created in 1980,was still in the process of organizing itself. Amongthe important problemswere: (i) the MOH was not intimatelyinvolved in early stages of project preparationand there was a lack of ownership of the project; (ii) the project was a complexoperation of six separate and unintegratedhealth sector components,each of which was run by a separate national coordinator;(iii) the project was designed for a vertical rather than an integrated approachto its activities,resulting in poor integrationof these activitiesinto the mainstreamactivities of the MOH; and (iv) project preparationdid not provide the technicalprecision needed by a very new and weak MOH, (such as precision of which health posts were to be constructed)which resulted in considerabledelays and poor implementation. Project design was generallytoo complexwith excessivetechnical and coordination/managementexpectations of the MOH given the early stages of its organizational development.

1.20 The principal lessons to be drawn from the Health and Populationproject are the following: (i) project preparationneeds to directly involvethe principal implementation agency from the start and project design should be simple; (ii) activitiesshould be integrated in a horizontal rather than vertical manner within the operationsof the MOH; (iii) technical aspectsof the project should be specifiedin detail and agreed by credit negotiations; (iv) future projects should ensure that the implementingagencies have the capacity to develop these technical aspects and technicalassistance shouldbe secured to ensure good performance; (v) because of the Government'sfiscal situation, popular participationand cost-recoveryshould be explored to enhancesustainability prospects in future operations; and (vi) procurement procedures shouldbe specifiedand agreed during negotiations. The proposed project has 6

benefited from the above lessons by working closely with the Ministry of Health from the outset, ensuring the specificationof all technicaldetails before negotiations,promoting cost recovery and communityinvolvement in health facilities, and establishingthe CDSF as an operational institutionbefore negotiations.

1.21 Education. IDA has supportedreforms in the educationsector through two Education Projects. The objective of the ongoing secondproject is to assist institutional developmentin the Ministryof Educationthrough: (i) improvementsin education administrationand planning, mostly throughtechnical assistance, training, fellowshipsand study trips to other African countries; (ii) improvementsin the quality of educationat the primary and lower secondary level, which consist of training for underqualifiedteachers, training of advisers and principals and developmentof new teaching materials and guides; and (iii) upgradingof technical/vocationaltraining through provisionof training and equipment. This project has achievedsome of its training goals, althoughprogress has been slower than anticipateddue in part to the lack of a clear Governmentpolicy on the direction and form to be taken by the educationsector. This has been compoundedby the reluctanceof the Government to redefine its support of secondaryeducation and foreign scholarships,delaying progress on financial aspectsof the reform. The project has mainly encounteredproblems of management and financial discipline. Frequent changes in high level officials have led to lack of knowledge of the project and weak Governmentcommitment. However, recent progress has been achieved in the reorganizationof the educationsector staffing and administrationunder the frameworkof the ongoing public service reform which is supportedby MERCAP. Complementarycommunity-based efforts to increasecommunity involvement in primary schooling, includinginvolvement in rehabilitation,maintenance, and equippingof primary schools, would be highly beneficialto increasingthe sustainabilityof Governmentand donor efforts to improve the quality of primary schooling. The importantlessons learned from these two educationprojects include: (i) the importanceof the continuityof staff working on project implementation;(ii) the necessityof realistic expectationsof the Government's ability to provide financial contributions;and (iii) the importanceof and need to include communitiesin executionand planningof educationsector activities. These lessons have been particularly instructivefor the developmentof the CDSF, which directly supports communityactivities.

II. HUMAN RESOURCESSECTOR ISSUES

A. Health Sector

2.1 Many constraintshinder the improvementof health and demographic conditionsin Comoros. Chief among these obstacles are weak deliveryof health services at the periphery level and weaknessof populationactivities.

Weak deliveryof healthservices

2.2 The delivery of health services, especiallyat the periphery level, remains weak due to: (i) MOH inefficientorganization and management;(ii) inadequate infrastructure;and (iii) weaknessesof populationand AIDS activities. 7

2.3 MOH IneMcient Organization and Management. The effectivenessof MOH health activitiesis hindered by poor organization, lack of resources, and overcentralizationof the central administration. Medicalregions and districts where most health care activities should take place have only nominalpower and few resources,being ill equipped in terms of human, material, and financial resourcesand thus being unable to ensure the planningand implementationof good quality PHC services within their boundaries. The current level of centralizationof the MOH and the heavy reliance on vertical programspreclude the involvementof the health regions in the preparation, implementation,and evaluation of health activities. For instance,medical doctors in charge of health centers are involvedneither in the ExpandedProgram of Immunization(EPI) nor in the FP program, significantlylowering the potential impact of these programs. Additionally,efficiency is reduced by the lack of referral mechanismsand a lack of clarity as to the appropriatefunctions of each level of the health system. There is no organizedsystem to prevent patients from anarchicallymoving from one level to another level of the health care system. The tendencyfor patientsto bypass peripheral facilities results in underutilizationof an overly dense network of health posts and overcrowdingand inefficientuse of hospitals. Secondaryand tertiary health facilities are used as PHC centers.

2.4 The curricula used by the MOH for training health personnel does not conform to the skills needed for these workers to adequatelyperform their jobs. Both the level and mix of their current skills are inadequate. Existing health workers, includingthose trained at the NationalPublic Health School (ENS), have not been adequatelyexposed to PHC and communityhealth activities. About70% of MOH workers have no formal medical education. A sizable proportion of nursing staff is made of untrainedvolunteers, particularly in peripheral facilities, who often operate without adequatesupervision to assure satisfactoryquality. In additionto problems in the quality of health workers, another manpowerconstraint results from inadequatedistribution of health workers throughout the country. Becauseof the lack of proper managementor an incentivesystem to attract workers and retain them in poorer rural areas, there are wide disparitiesin the distributionof health personnel among individual facilities, as well as a relative surplus of qualifiednurses and midwivesin hospitals and a shortage of nurses in PHC facilitiesparticularly in remote areas. The main hospital in Moroni, El Maarouf, is disproportionatelywell staffed while rural health facilities are essentiallystaffed by often poorly trained volunteers.

2.5 Health InrrastructureInadequacies. Efforts to develop populationand health activities in Comoros are also frustrated by the dilapidationand underequipmentof health facilities. Health facilities are often decrepit and poorly maintained,medical equipmentis generallyminimal, and essentialcommodities are sometimesin desperatelyshort supply. Lack of maintenanceand other support from the central ministryand an inadequateflow of supplies and equipmentimpedes the operating efficiencyof health facilities, especially at the peripheral levels. There is also a tendencyto design and establishhealth structures without proper attentionbeing paid to the size of the populationto be served. The excessive number and size of facilities contributesto high unit costs of services provided by the MOH and lowers the efficiencyof the Ministry, which in fact fails to provide adequate, if any services, at many of these health facilities.

2.6 Weakness of Population and AIDS Activities. Althoughsignificantly improvedduring the implementationof the Health and PopulationProject, FP services still 8

have obvious shortcomingsand suffer from not being integratedinto other MCH services. While the Health and PopulationProject's approach was to train four well-motivatedand well-equipped mid-wivesto promote and superviseFP activities and to improve conditionsat the facilitieswhich provided these services, activitiesat which it was successful,much remains to be done. Because this approachlacked the inclusionof physicians in the provision of family planning services, the impact was less than it could have been. In addition,there is almost no follow-upto motivateusers to continueusing contraceptives. The monitoringof clients, supervision of services, and managementof contraceptivesstill remain weak and suppliesof contraceptives, which to date are solely financedby UNFPA, are unpredictableand subject to inventorybreakdowns. These and other factors make it difficultfor clients to get appropriate support and treatment for their complaintsand many get discouraged, failing to return to the center for further supplies.

2.7 IEC activitiesin the family planningarea, whichhave been financedby the UNFPA and which relied in part on traditional communicationnetworks such as mosquesand markets, were somewhatsuccessful in changingthe cultural and religiousclimate in Comoros. At present, there is little religiousopposition to the use of family planningfor health and socio-economic reasons. However, there is no clear understandingof the demographicneed to use family planning. In fact, current research indicatesthat many religious and traditional leaders are in favor of family planningfor health and socio-economicreasons but do not understand the demographicneed to limit populationgrowth. In the last several years, IEC activitieshave been diminishedfor familyplanning due to a lack of human, physical, and financial resources.

2.8 Becausethe AIDS virus has not been a serious problem in Comorosto date, most Governmentofficials and the populationhave not begun to address the potential impact this disease could have on Comoros. Comoroshas had a NationalAIDS Control Program since 1990and it has carried out some IEC activitiesaimed mostly to reach leaders and young people. However, althoughthe program allocates about half of its resources to IEC, it does not have enough resourcesto carry out the studies necessaryto the developmentof an effective IEC strategy. Trends experiencedby other countries, (e.g. Djibouti and Cote d'Ivoire), which previouslyhad low AIDS but high STD prevalence rates as Comoros currentlydoes and which showed dramatic increases in AIDS over short periods of time, show that it will be crucial for Comoros to intensifyits IEC campaignand to extend its condomdistribution program in order to prevent a rapid contaminationby HIV.

OngoingActivities to Addressthese Issues.

2.9 In order to create a more efficienthealth delivery system, Comoroshas implementeda pilot program of autonomousadministrative and financialmanagement at one health center, which has been highly successful. At the Mitsoudjehealth center, the communityparticipated in the constructionof the center and is involvedin its management, financingand maintenance. Support has also been provided by UNDP, with technicalsupport from ASI, a French NGO. The center was authorizedto charge fees, managemoney received, and was given greater autonomyover personnel. 2.10 At present, receipts cover not only the operatingcosts of the center, but also a system of bonuses for the staff (tied to performance)as well as major and minor maintenance 9 and purchase of equipment. UNDP continuesto defray the costs of the doctor, whose salary is higher than that of doctors in the public service. Utilizationof the center continues to rise steadily in spite of the proximityof El Maarouf Hospital and the existenceof fees for services. The utilization rate has reached a level of one curative visit per year per person living in the catchmentarea. A report issued in 1993 reviewing the pilot experiencefor the Government confirmsthat the system is efficient from the point of view of motivationof personnel as well as financial managementand quality of services. A survey taken one year after the institution of the fee for service system at Mitsoudjeshowed that averagehousehold spending on health care in the catchmentarea had fallen after the institutionof cost-recovery(and associated improvementsin quality and reliability). However, it notes the importanceof significant investmentsin training and modificationaccording to local conditions.

2.11 The Governmentplans to generalizethe principle of co-managementwith communitiesand of cost-recoveryof health facilities. It has issued a decree permitting autonomousmanagement of receipts in hospitals (December1992) and, under the ongoing public service reform will, in 1994, elaboratea new management,financial and administrative system for health centers based on the model of the one in operationat Mitsoudje.

2.12 The Governmentof Comoroshas recognizedthe need to expand the demand for, as well as the quality and the quantityof, fertility and AIDS control services. With substantialassistance from donors, the MOH continuesto make commendableefforts to ensure a steady supply of condoms,pills, injectablesand other FP commoditiesand to improve the country's capacityto prevent, diagnose, and treat STDs. However, the impact of these efforts is limited by the advancedstate of dilapidationof most MOH health facilities. To motivate Comoriansto change their behavior and to adopt practices which are conduciveto better health, programs addressingmajor public health problems each have an IEC component. However, this approachhas led to a fragmentationand unequal distributionof IEC resources, as well as a lack of coordinationand ineffectiveuse of existingresources. Presently, although family planning and AIDS preventionprograms have more resources allocatedto IEC than the other public health programs, they still do not have enoughresources individuallyto carry out the necessary activities. The UNFPA IEC Populationproject focused on three types of activities: (a) training of health personnel and communityworkers in family planning interpersonalcommunication; (b) research on obstaclesto the use of family planning; and (c) material production. However, because of limitedresources there were shortcomingsin the project, training was carried out only in project areas (ten villages), research samplingand methodologywere inadequate,and materials were not pretested. This lack of adequate resources is likely to becomeworse as the budget of the next UNFPA IEC project, which started in April 1993, is lower than that of the on-going project. In the AIDS area, IEC activitieshave been limitedand somewhathaphazard. They includedone poster, some radio spots and shows and some sensitizationseminars aimed at opinion leaders and young people.

B. EducationSector

2.13 As in the health sector, performancein the education sector has been compromisedby the weaknessof policy leadership and frequent personnel changesat senior levels. Althoughsome goals have been achieved in recent years, progress has been slower than expected due in part to significantpolitical pressures against certain aspects of the educationreform program. The Government'sgoals are: redistributionof expendituresin 10

favor of primary education; at the primary level, retrainingof teachers, provision of teaching materials and rehabilitationof school facilities; and at the lower secondary level, retraining of teachers. The plans for the Public ExpenditureProgram for FYs 1992-95 indicate a gradual fall in allocationsto secondarylevel education, a real decline of 3% between 1991and 1994. An even sharper decline is predicted for foreign scholarships,falling by two thirds as the number of new scholarshipsis reduced to zero by 1994. External aid is expectedto make up the differencewith 100 new scholarshipsper year. However, pressures to increaseadmissions into upper secondary and foreign scholarshipshave delayedthe full implementationof a system of financial controls. In addition, frequent strikes by primary teachers have underminedthe progress of reform at that level.

2.14 Becausesignificant resources remain in the SecondEducation Project and implementationhas been extendedto June 1994, the proposed Populationand Human ResourcesDevelopment Project would not directly address educationsector issues. Additionally,there is a follow-upproject planned in the educationsector once the Second EducationProject is completed. The proposed Populationand Human ResourcesDevelopment Project would affect education,however, by promotingcomplementary community involvementin the rehabilitation, maintenance,and equippingof primary schools, with technicaland financialsupport from the proposed CommunityDevelopment Support Fund.

C. Community Development

2.15 Local NGOs and communitygroups are responsiveto local felt needs, but they frequentlylack an interfaceto the formal sector. However, the environmentin which they work is improving. The intoleranceof former Governmentleaders for "modern" associations, in particular the Scouts and other youth movements,has been replaced in recent years with a more welcomingclimate. Associativelife has flourished and the Governmentnow welcomes the participationof communityorganizations in the elaborationand implementationof developmentplans.

2.16 The Governmentbelieves that the developmentand support of community organizationsshould play a vital role in socio-economicdevelopment. The contributionof communityorganizations in assessinglocal needs and capabilitiescan form an importantpart of social policy. Furthermore, communityorganizations may be best placed to implement certain activities. In particular, the contributionof communitygroups can be critical to the developmentof educationand health institutionsat a local level. After contributingtheir ideas and financialresources to the construction/rehabilitationof a school or clinic, community groups can play a crucial role in the sustainabilityof the institutionby organizingand maintaininga system of financial managementand maintenance. This could include cost sharing, contributionfor key salaries (eg. teacher or nurse), maintenanceresponsibilities or insurance/mutualaid.

2.17 The main outstandingissue remains the managerialand organizational weakness of communityorganizations. There are significant needs for training in financialand other forms of management;for technologytransfer for technology-intensiveprojects (eg. water supply or construction);and popularizationof availablefunding sources and assistance with project preparation. Communitiesin Comorosare generally in a position to provide 11

financial and in-kind contributionsto projects, with increasedownership, sustainabilityand impact resultingfrom this contribution.

III. THE PROJECT

A. Project Objectives and Approach

3.1 Project Objectives. The overall goal of the project is to strengthen regional and communityinvolvement in populationand human resource developmentthrough improving the delivery of basic health services and stimulatingcomplementary community activities. To achievethis goal, the main objectivesof the project are to: (i) support the establishmentof efficient health regions and other supportiveservices capable of providing comprehensiveand cost effectivehealth care, includingfamily planningservices and AIDS prevention, through communityparticipation, self-management and cost recovery, and (ii) support complementary communitydevelopment initiatives to develop social infrastructureand grassroots participation in small-scaleproductive activities.

3.2 ProjectApproach. To achievethe first objective, this project will selectively continuepast efforts initiatedby the Governmentin the health sector with assistancefrom the donor community. The populationand health componentof the project constitutesan integral and essentialpart of a packagewhich will be financedin parallel by the Comorian Government,French aid (FAC), UNDP, WHO, and UNICEF. The Bank's primary role is to rationalizeand improve the efficiencyof the MOH services, building upon successful experimentswith administrativeautonomy of health facilitiesand communityparticipation. To achievethe secondobjective, a demand-drivensocial fund approach will be used to support existingactive communityinvolvement in local developmentthrough a Community DevelopmentSupport Fund (CDSF). This approachwill require the following: that the request for support from the HumanResources Project to the community'ssub-project comes from the communitiesthemselves; that the beneficiariesare directly involvedin the planning, execution,and evaluationof the sub-project; that beneficiariescontribute either in-kind or financiallyto the sub-project's realizationto assure sustainability;and that when necessary and/or desired the communitybenefits from training to increase its capacity to develop sub- project proposals as well as to implementand sustain sub-projects.

3.3 Becausesub-projects which will be financedunder the social fund are to be demand-driven,precise and well-definedrules and criteria for sub-projectselection have been designed. To this end, a Manual of Proceduresto regulate and facilitate CDSF operationhas been prepared and was tested by meansof sub-projectsfinanced under the PPF. The Manual of Procedures is described in paragraphs 3.36-3.38, and is availablein the project files. The adoptionof a Manualof Proceduressatisfactory to IDA by the Central Coordinating Committee(CCC) of CDSF is a conditionof effectivenessof the proposed credit (para. 7.2(b)). The design of the CDSF is based upon lessons learned throughout the Bank and in the Africa region, in particular as spelled out in the regionalstudy, "Social Action Programs and SocialFunds: a Review of Experience in Design and Implementation,"and "Socio-economic DevelopmentFunds: A guidelinefor Design and Implementation." The project is also based on experiencegained from similar projects in Senegal, Mali, Zambia, Madagascar,and Burundi among others. Principal amongthese lessons are the importanceof promotion 12

activities; the need for a good systemof managementof financial data; the need for clear objectives and project selectioncriteria; and the importanceof training as a contributionto the effectivenessof the administrationof the fund as well as the success of sub-projects.

B. Project Description

3.4 The project will: (i) establishappropriate services capable of ensuring cost- effective and sustainableprovision of comprehensiveand good quality health care, including familyplanning services, AIDS prevention, and communityparticipation in both management and cost recovery, and (ii) support a social fund to finance communityactivities (including education sector related activitiesand communitylevel health activities).

Supportto Improve Health Services

3.5 To improve MOH efficiencyand ensure cost-effectiveand sustainable provision of essentialhealth services, this componentof the project will have three sub- components: (i) improvingMOH managementat the regional level; (ii) equippingand rehabilitatingregional hospitals and health centers; and (iii) promotingfamily planning and AIDS control activities.

3.6 ImprovingPlanning, Implementation, and Monitoring Capacityof Regions. To strengthen and develop program planning, implementingand monitoring capabilitiesat the regional level, the project will build and expandupon the experiencesgained from the above-mentionedMitsoudje pilot program (para. 2.9). Overall managementof the three health regions (one for each island) will be the responsibilityof RegionalHealth Teams (RHT). Each RHT will be headed by a Regional MedicalOfficer (RMO) and will be charged with supervisingthe implementationof health programs throughoutthe region, organizing on- the-job training for regional health workers, and stimulatingand streamliningcomrnunity participation. RHTs will have the responsibilityand authorityfor administrativeand technical matters in their area, includingthe supervisionof activitiesin hospitals and health centers against establishednorms and monitorableperformance indicators which are to be developed during preparationand the first year of project implementation. To ensure good quality and socially acceptablehealth and populationservices, special efforts will be made to stimulate communityparticipation in the planning, implementation,monitoring and evaluationof populationactivities. At the health center level, the populationwill be encouragedto participateby creatingdevelopment committees at the village level, participating in the rehabilitationof facilitiesand placing representativeson the managementcommittees. The health centers will be granted greater autonomyover the administrationof personneland the levying and managementof fees. This will be complementedby reforms in the regulatory environmentand in health personnelthrough the reform of the public service which is supportedby MERCAP,as well as by improvementsin the allocationand funding of the health sector budget which will be monitoredboth through the MERCAPcredit and this project. 3.7 The project will also increasethe productivityof regional personnel through a series of training activitiesfor various health workers. A list and descriptionof the basic training courses to be provided can be found in Annex 111. Special efforts will be made to endow regions and health facilities with qualifiedplanners and administratorscapable of properly carrying out the planningand the budgetingprocess required to efficientlyutilize 13 human, material and financial resources. Service providerswill receive appropriatetraining to raise their skills in the delivery of preventiveand curative care. The training will emphasize the role of multi-purposeworkers to dispenseintegrated basic health services (includingFP and STD management).1/ Under the Health Region scheme, RHTs are expectedto play a pivotal and dual role in the developmentof health programs in their jurisdiction. As physicians, they will have to spend part of their time working in health facilitiesto handle difficult cases, particularlythose identifiedby the auxiliarypersonnel at the health posts, dispensariesand rural maternities. As managers, they will be responsiblefor ensuringthe provision of good quality services throughouttheir district. RMOswill receive adequateand specifictraining to help them carry out the dual function. As has been done in the Mitsoudje pilot, an appropriate incentivesystem will be establishedto both attract and retain health workers, particularly into underservedareas, as well as to improve staff performance. This will include regular and adequatesupervision and may include incentivessuch as provisionof transportationand housing facilitiesparticularly for health cadres working in remote areas.

3.8 To ensure that FP services are integrated into the overall package of services provided by the health centers and are successful,the project will provide logisticalsupport for the incrementalsupervision visits which will focus on: integrationof FP into the MCH package,practical applicationof approvedservice norms, and the supply and procurementof contraceptives. Mechanismswill also be establishedto follow up on acceptors, motivateusers to continueusing contraceptivesand accuratelyrecord the number of acceptors, users and couple-yearsof protection (CYPs). To prevent shortagesof FP commodities,the project will financea contingencyfund to assumethe regular supply of contraceptives.

3.9 Complementary and Prerequisite Actions Required at the Central Level. In order for health regions to effectivelycarry out the above program, several actions need to be undertakenat the central MOH level to enablethem to provide adequatetechnical and operational support to the regional staff who implementthe vast majority of activities. To ensure proper administrationof the project, a Project Office will be establishedwithin the MOH Directorate General for health facilities. Additionally,MOH's central Directorates, particularlythe Directorate of Health Education(DHI) and the Directorate of Pharmaceutical Inspection (DPI) will be strengthened. The Project Office will be headed by a Unit Chief who will report to the Director General. The Project Office will be responsiblefor the administrativetask of overseeing the implementationof the component. This unit will provide assistanceto help the relevant MOH units and RHTs develop and/or improve the following: (i) appropriatesector norms, rules, regulationsand standards, includingPHC therapeutic protocols, a PharmaceuticalCode, and MOH administrativeand financial procedures; (ii) training modules for MOH staff based on agreed standardsand functionsto be performed by each category of personnel, as well as organizingtraining for RMOs in collaborationwith the ENS; and (iii) a monitoringand evaluationsystem for the health regions which would assess the results of efforts invested in the sector. Terms of reference for the technicalassistance (most of which will be local and regional)needed to aid the MOH in establishingsystems and

I/ With regard to FP, programs will be developed to train and explicitly and systematicaUy involve physicians (particularly Regional Medical Officers), nurses, auxiliary nurses, and pharmacists in the provision of FP services. Training modules will be developed and implemented in the management of FP services, communication, contraceptive technology, integration of FP and MCH services, and outreach programs. 14

proceduresfor improvingMOH efficiencyat central level are listed in Annex III. Funds will also be made availableto financetechnical assistance to aid the Governmentin improvingits health informationsystem (includingpublic expenditureprogramming and resource managementas well as disease trends) and improvingthe logistics systemfor the procurement and flow of supplies and equipmentto districts.

3.10 Equipment and Rehabilitation of Health Facilities. Given the fact that the dilapidatedphysical state of the publichealth care facilitiescontributes to their low performances,selected priority MOH facilitieswill be partially rehabilitatedand equipped so as to enablethem to effectivelycarry out their normativefunctions. The project will finance partial rehabilitation, includingwaste disposal and sanitary water supply, equipment,technical assistance and training of health personnel, for a total amountestimated at US$3.4 million. For health centers to qualify for rehabilitation,full communityinvolvement will be required. The CDSF will work with the MOH, mobilizingcommunities to participateand undertake part of the rehabilitation, as well as assure communitycommitment to maintenanceand management of these facilities. As a conditionof negotiations,preliminary architecturalplans, as well as time tables for rehabilitationof the designatedhealth facilities, and a preliminary list of medical equipment,grouped by lot for bids were finalized and submittedto IDA (para.7. 1(b)).

3.11 Expanding and Improving Family Planning and AIDS Control Activities. The project will support activitiesto improve the availabilityand quality of fertility and AIDS control services, as well as the demand for these services. During preparationand the first year of the project three studies will be conducted. One study using qualitativetechniques will assess the factors which influencedecisions on family size and the underlying causesbehind the low demand for FP services and low rate of continuityamong FP users. A second study will collect data on knowledge,attitudes and practices with regard to sexualityand AIDS in Comoros. A third study will investigatewhat are the credible sources of health and family planning informationfor Comoriansand what are the best channels to use for each target group. The three studies will help to provide first hand informationto assist in the improvementand design of multi-media,well-targeted IEC strategies and the formulationof other populationand AIDS activities. Based on the findings of these studies and on the results of the beneficiaryassessment study to be undertakenduring the first year of the project, appropriateIEC messageswill be produced and disseminatedaccording to the selected strategiesand any corrective operational and managerialmeasures will be adopted.

3.12 In the field of family planning, four priority groups will be targeted by information,education and communicationactivities, namely, religious and political leaders; women aged 15 to 49; men who are married to women of reproductiveage; and young people. Support will be given to both modern and traditionalmedia. In stimulatingthe demand for FP, person-to-personeducation will be combinedwith an enlarged mass communicationeffort (seminars, radio programs, theater, mobile video, etc.). A similar approach will be used for AIDS IEC activitieswhich will be targeted mostly to young people and to opinion leaders. Over the life of the project, group meetingswill be held to guarantee social acceptanceand support. As mobilizingreligious leaders is critical in addressingthese issues in Comoros, conferencesfor religious and other social leaders wouldbe held annuallyon each island. Representativesof women's and youth groups wouldbe invited. Leaders of community organizationswill be trained in interpersonalcommunication and communitymobilization with particular referenceto FP and AIDS and will be used as "relays" to disseminateFP and AIDS 15 messages. Other "relays" who will be trained will be journalists for whom four seminars will be held. The project would also financetwo study tours so that Comorians can learn from other countries' experience. Two monthsof technicalassistance will be provided for specific tasks as required (Terms of Referenceare in Annex III). Access to good quality family planning and AIDS control services will be expandedthrough the rehabilitationof health facilities and the adequatetraining and supervisionof health workers. Special attentionwill be given to ensure regular supplies of commoditiesrequired to perform fertility and AIDS control activities, includingcontraceptives, antibiotics and lab reagents in all health facilities. To improve the availabilityand quality of fertility and AIDS control services, the project will support the following: (a) equipping20 laboratoriesto improvetheir diagnosticcapacities; (b) training and supervisingservice providers and lab technicians;(c) ensuring regular supply of commoditiesrequired to carry out fertility and AIDS control activities; and (d) monitoring the impact of these control activities.

3.13 Policy Measures. In additionto technicalsupport for project implementation, the Governmenthas provided IDA with a health policy letter which includes the policy measures described below:

3.14 The letter outlines the programs and intentionsof the Governmentin the health sector. It recapitulatesthe NationalHealth DevelopmentPlan of 1991, which identifies the priority programs, which are (a) the promotion,through information,education and communications,of healthy lifestyles and behaviors; (b) the promotionof maternal and child health, includingpre- and peri-natal care, vaccinationsand familyplanning; (c) efforts against endemic diseases, includingmalaria, diarrheal diseasesand AIDS; and (d) the supply of essentialmedicines, notablythrough the developmentof village pharmacies. The letter stresses the importanceof populationpolicy and family planninggoals both in the health sector and in the national economicagenda.

3.15 The letter continuesby describingthe reforms of the system of administration and financingof health facilities, in line with the overall reform of the public service taking place under the mantle of the Structural AdjustmentProgram. Specifically,the reforms envisagethat the public system of health care will be simplifiedto focus on health centers and hospitals and these public health facilitieswill be endowedwith new powers of financialand administrativemanagement, including a universal principle of cost recovery. Improved central services of IEC, supervision/inspectionand training will support the public health activitiesof these more independentfacilities. The use of mobileteams for specificcampaigns will be reduced and replaced with facility-levelhealth teams with an integrated and diversifiedmandate and composition. The central functions of monitoring,training and program managementwill be decentralizedto the regional level (one region per island). The staffing will be reoriented in favor of more qualifiedworkers with a better geographicaldistribution.

3.16 This new arrangementwill be codified in a set of new regulationsand administrativeprocedures under developmentin 1993. These regulationsdefine the involvementof communitiesin the managementof health centers and their representationin the governingboards of hospitals. They define the parametersunder which cost-recoverycan take place, and the mechanismsby which the funds so generated are managed(all funds are retained at the facility level). They also define the relationshipsof facility managementto civil servants and to the public service, includingguidelines for performance-relatedincentives at the facility 16

level (incentivesat the regional and central levels will be addressedas the systemdevelops). Finally, they define the roles and responsibilitiesof the various levels (Central, Regionaland facility) for maintainingpublic health objectives, includingtraining, supervisionand IEC.

3.17 At the same time, with the Ministryof Finance, the MOH is putting together a budgetingprocess which will lead to more rational funding of the health sector. By December 31, 1994, the Ministry of Health will, with the Ministry of Finance, produce a public expenditureprogram to cover 1995-97and review it annually with IDA; this will be a rationalizedbudget responsiveto program needs. The involvementof the Ministry of Finance will ensure that the program is feasiblefrom a budgetary perspective. During negotiations assuranceswere given by the Governmentthat the budget for the MOH will be credited at a level which maintainsthe 1992 level of real expenditure, includingat least 20% of the total in non-salaryfunding, that the budget will be reviewed annuallywith IDA, and that the budget for the current and subsequentfiscal years will be reviewed annuallywith IDA (para. 7.1(c)), starting with the 1995budget.

3.18 Under the project, IDA will financethe rehabilitationand equippingof three regional offices, and two hospitals (Hombo and Fomboni). The project will also provide funds for the rehabilitationand equippingof health centers, the selection and scale of which to be decided on the basis of communitymobilization and participation. The project will financethe production of training modulesand in-servicetraining for health planners and administrators, regional medical officers, medical doctors, nurses and midwives,and technicians. The project will also provide for a limitednumber of study tours and analyticalstudies. Technical assistanceto the Project Office in the MOH will also be provided for by the project.

3.19 Sustainability of Regional Health Program. The proposed project will lay the groundworkfor the sustainabilityof the health system of the Governmnentof Comoros, which is weak due to the current large Governmentdeficit and weak institutionalcapacity. The project aims to enhancesustainability of health activitiesthrough improvementof health sector management,human resource development,health financing, improvedSTD/FP services, and health facility rehabilitation. This will build upon successfulpilot programs which increase beneficiaryparticipation in both managementand financingof health services. The operationalsustainability of the project will be achievedby relying on the involvementof experiencedprivate firms/NGOsand local communitiesto implementthe various project components.

3.20 Recurrentcost implications of the health component. The reforms to be undertakenunder the project are budget neutral. There will be no new facilitiesconstructed and staffingwill conform to the public sector rationalizationunder way for the Government overall. For the Ministryof Health, this reform impliesno net change in the number of people employed,but there will be a shift towards more qualified employees. The slight rise in the wage bill will be offset by a mild reductionin public spendingon non-salaryitems, which will be increasinglycovered by cost-recovery. In order to fully reflect the Government's commitmentsand obligations,the project cost tables indicatethe Government'scontribution of staff and supplies, without which the rehabilitatedfacilities cannot function. The only incrementalrecurrent cost implicationof the health componentis the operatingcost of the Project Office. As the Project Office's purpose is to supervise administrationof project 17

activities(procurement, disbursement, etc..), it is not expectedto continueafter the end of the project.

3.21 A new institutionalstructure for the health sector has been was signed and is expectedto be implementedin early 1994. This will have only a slight and progressiveeffect on the health sector wage bill, which is covered by reallocationsfrom other sectors, under the overall adjustmentprogram, and is not a consequenceof this project. Non-salarycosts at the health center level, while woefully inadequate,will be shifted in large measure to the communitiesthrough cost-recovery(fee for service) and communityresponsibilization. Some of these savings will be redeployedto the hospitallevel, and the hospitals will also mobilize resources through cost recovery. Cost recovery already fully pays for medications,and the operatingcosts of laboratories, radiology services and dentistry. It is conceivablethat these adjustmentswould result in a decrease in the recurrent budget of the Ministry of Health. However, this does not imply a decrease in expenditures,which have historically been well below the budget.

3.22 In 1994, the Ministry of Health will issue a Public ExpenditureProgram (PEP) to cover the years 1995-97,the executionof which will be reviewedjointly by the Governmentand IDA annuallyand at the mid-term review as agreed during negotiations(para. 7.1(i)). The PEP will cover investmentand recurrent expenditureat the facility level, and will conformto the Government's structural adjustmentplan as well as serving the aims of the reform of the health sector. It will take into accountrecurrent cost implicationsof investment projects.

3.23 The goal of the PEP is to provide a realistic budget that will be followed, and in which facilities, suppliers and contractorscan have faith. In the past, budget allocations have been reasonable, but actual paymentshave lagged far behind, with commitmentsbeing around two-thirdsof allocationsfor non-salariesexpenditures in 1989-92and actual payments lower still. The process has begun with the developmentof the Public InvestmentProgram in 1992. The PEP would analyzeactual payments, reducinghighly fungible categories(fuels, food) and aiming for full fundingof all allocations.

3.24 The criteria for budget allocation in the health sector have been simplified by the proposedreforms of the publichealth system. On the investmentside, no new facilities are to be built in the immediatefuture (before at least the year 2000). Investmentsare in rehabilitation, equipmentand human capital, and these are limitedlargely by the availability of donor funds. On the recurrent side, the proposed reforms would significantlyreduce non- salary expendituresat the lower levels (health centers and health posts) as these will become the responsibilityof the communityand the beneficiaries. At present the distributionof non- salary expenses is about 30% to central functionsand 70% to hospitals, both of which are very underfunded. The new structure of the health systemwill require increasedand improved performanceby the center. At the same time, the need for increases in fundingof recurrent costs for hospitals remains commanding. This distributionof allocationsbetween administrationand hospitals is therefore likely to remain much the same. The following agreementshave been reachedwith the Government:(i) the budget executedin each year of the project will be no less than the commitmentsfor 1992 in real terms (CF800 million);(ii) the budget executed in each year of the project will containno less than 20% will be allocatedto non-salaryexpenditures; (iii) medical evacuationcosts, which are currently disproportionately 18

high (CF36 million in 1992), will be reduced as agreed under the MERCAPprogram (CF20 million in 1993); and (iv) the budgets for health facilitieswill be allocatedon the basis of contracts between the MOH and the facilitiesstarting in 1995. These agreementsare reflected in the letter of health policy.

The CommunityDevelopment Support Fund

3.25 The CDSF is designed to encouragecommunity participation in sustainable economicdevelopment, support and develop the capacity of communitiesand non-Government organizations,and complementsectoral developmentstrategies, especiallyin the education and health sectors. It will bring additionalfinancing and technicalsupport to the realizationof communityprojects. Together the activitiesfunded by the project will have a synergistic effect on improvinghuman resources, promotingoverall economicdevelopment, and alleviating poverty. While the social fund will be demand-driven,i.e. sub-project ideas will come from the communitiesthemselves, and the criteria which have been developedto screen and evaluate the projects will determine which sub-projectsare to be funded by the CDSF (see para. 3.31), the primary focus is expectedto be on the followingtypes of activities: rehabilitationof basic infrastructure,especially primary schoolsand water supply; income generatingactivities; activitieswhich promote the well-beingand developmentof women; and training of communitiesand groups in appropriatetechnologies and in resource and project development and management. As mentionedabove, the selection of sub-projectswill be subject to a set of precise criteria in the Manualof Procedureswhich was drafted and discussed during project preparation, reviewed during appraisal, and was finalizedduring negotiations(para. 7.1(a)).

3.26 Rehabilitationof basic infrastructure. The vast majorityof sub-projectsto bp financedunder this categoryare expectedto be the rehabilitationof essentialservices (rimary schools, water supply, health posts), but could also includethe rehabilitationof feeder roads, bridges, markets, and food storage facilities. In the case of rehabilitationof essentialinfrastructure, project support will be possible if communitiesexpress these as their priority needs, contributeto the costs of project implementation,and develop a viable maintenancescheme. Already there have been over 20 requestsfor sub-projectsin the rehabilitationof primary schools, which are being refined, and about a dozen in water supply. (A list of sub-projectrequests which have been receivedto date and are expectedto be completedduring the first year of project implementationis listed in Annex I). The NGO CARITASis also working with communitiesin the area of primary health care and is respondingto several communitiesinterested in submittingproposals for the rehabilitationof health posts. Althoughsub-projects proposals have not been submittedto date for the rehabilitationof feeder roads and bridges, the project is open to financingthese infrastructures when they constitutemissing links for incomegenerating activities. Labor intensivework will be preferred wheneverproven as technicallyand economicallyefficient and insofar as it generates employmentopportunities. In coordinationwith the Ministry of Health, the CDSF will help to mobilizeand train communitiesfor their participationin the rehabilitationand managementof health facilities, funds for which are provided under the health componentof the project.

3.27 Income generatingactivities. The project will encouragethe poor to launch small-scale,viable, productiveactivities in sectors where a demand can be identifiedor expected and which have durable real income gains. The project will assist implementing 19

agenciesto organizegroups, particularlywomen's groups, to undertake sub-projects. The project will financespecific vocationaltraining and basic management,accounting, and marketing support. Becausethe creation and expansionof small businesses is critical to the growth of the Comorianeconomy, this is an importantelement of the project. However, the CDSF will enter this field very cautiouslyfor the first two years of its operation because experience with cooperativeenterprises is small. For this reason, for the first two years of CDSF operation, the project will work closely with a UNDP/ILO project which already has some experiencein lendingworking capital to micro-enterprises. During the first phase of two years, the CDSF will complementthe UNDP/ILO's activitiesby providing, where necessary, training and technicalassistance in work planning, supervision,and production. Support will also be given where needed to the expectedhundred small contractorswho will have contracts making furniture for the CDSF-fundedrehabilitation projects. The CDSF will not extend credit. After two years, an evaluation will be carried out by the CDSF to draw on the experience and make proposals to launch the second phase of the program.

3.28 Training. As the CDSF is aimed at promotingself-reliant, sustainablesocio- economicdevelopment of rural communities,by increasingthe local institutionalcapacity for developmentplanning and implementation,training would play a crucial role in helping communitiesattain the proposed targets. Training is expectedto be both supply and demand driven. It is foreseen that communitieswill need training in organizing, developingsub- projects, and managingthe implementationand maintenanceof them. The estimatedtraining plan (Annex III) is expectedto involveapproximately 1800 membersof the CommunityPilot Committeeswhich will be involvedin micro-projectexecution (see para. 5.15), 180 book- keepers, 600 masons, 180 carpenters,360 school furniture makers, 100 fitters and plumbers, 270 painters, and 2000 rural women in the three islands. Training activitieswill be coordinatedby the Informationand Training Unit. Staff and technicalassistants would actively participate in training. Seminars in communicationand training methods for technical skills in production will be organizedwith a view to strengtheningthe training corps. Training for managers at both central and local level will provided by consultantsfrom the NGO CECI, which supports managementdevelopment for the component. Training for the developmentof womenwill be carried out by CARITAS' professionalstaff. Basic skills training for workers will be provided on-the-jobby mobile teams composedof job site supervisors, foremen, and part-time teachers hired under the project. Training will also be provided by the private sector or other implementingagencies, especiallyfor sub-projectswhich request specifictraining.

3.29 Promotion of women. The womenof Comorosare in general economically active and interestedparticipants in the developmentprocess. This project seeks to support and further develop this participationof women. The CDSF approacheswomen's issues through two different means: specialprograms for women, and inclusionof women in all the regular activitiesof the CDSF. In the first instance, it offers a program of training for rural women in the areas of literacy, family planning, nutrition, mother and child health, and income generatingactivities. Throughthis program, womenwho are already active in their communitieswill also be given special coachingto assist them in project formulationand communityorganization, helping them to make proposals to the CDSF and other donors. The other means is through the general program of projects, where the CDSF will target activities that are mostly carried out by women(child care), provide disproportionatebenefits to women (education,nutrition, water supply etc.), or includewomen as equal partners (all village 20 residents must be membersof the communitycommittee). Projects will be monitored and care will be taken to maintaina high percentageof projects with significantbenefits to women.

3.30 InstitutionalStructure. The overall structure of the CDSF is a Central CoordinationCommittee (CCC), a NationalExecutive Secretariat(NES), Regional Committees (RC), RegionalExecutive Secretariats (RES), and Pilot Committees(PC). The CCC acts as the Board of Directors for the CDSF, setting overall policies at the central level, while the RegionalCommittees are the oversight and policy organizationsat the local level. The ExecutiveSecretariats are the administrative/executingorganizations which deal with the day- to-day operations of the CDSF. The PCs are the communitygroups which in most cases will be responsiblefor implementationof projects at the communitylevel. Detailed division of labor between the groups is presented in Chapter V under Project Management(para. 5.9).

3.31 Sub-ProjectSelection Criteria. Selectionof sub-projectswill take into account a series of criteria, including: (i) formationof a communitypilot committeel/ responsiblefor the overall managementof the CDSF financedsub-project; (ii) assuranceswere obtainedduring negotiationsthat the community'scontribution would be not less than 20% of the total cost of each sub-project(although in the case of communitiesannually identifiedas the poorest this could fall to 15%); (iii) an assessmentof cost effectivenessas reflected in the cost per beneficiary; (iv) for sub-projectsinvolving construction, strict observation of rules applied in environmentprotection (i.e. ban on the use of corals and beach sand); (v) adherenceto norms establishedby technical ministries,and consistencywith the sector strategies and programs; (vi) cost of sub-projectswhich are not beyond the capacity of community contributionor user charges; and (vii) provision for maintenanceof infrastructureand/or sustainabilityof sub-project operationbeyond the project period, includingrecovery of operating costs where appropriate;to this end, for many types of sub-projects,the CDSF would require that communitiesprovide evidenceof their ability and willingnessto ensure appropriatemaintenance of the sub-projectbeyond the period of CDSF assistanceas one of the criteria of sub-projectselection. In determiningthe costs of sub-projects,the CDSF would take into accountthe imputed value of the contribution(in kind and in cash) to be made by the beneficiarycommunity, as well as all financial costs.

Sub-ProjectCycle

3.32 Promotion and Identification. An intensiveIEC campaignhas taken place on all three islandsduring preparationof the project and more than 70 communitycommittees have been establishedwith the support of the RESs. These intensivecampaigns will continue periodically,although the RES on each island will continuouslyfulfill this promotionfunction, makingfrequent field visits to disseminateinformation about the opportunitiesoffered by the project, as well as to explain to potentialbeneficiaries the approach, objectives, and procedures of the project. For the periodic intensiveIEC campaignsinnovative techniques such as media coverageand competitionswill take place to encourageindividuals and organizedgroups to formulateprojects. To fulfill their function, the RESs will: (i) liaise with local constituencies and keep in contact with representativesof various organizationsworking at the local level in order to be ready to identifynew projects and to help their designersto put them into an

1/ Or availability of an implementing agency. 21

articulatedmanner, and (ii) collect sub-projectrequests. Promotion efforts will be intensified in areas where poverty is known to be widespreadand especiallysevere. Specialistsin social marketingand information, educationand communicationwill be called upon to help design and launch the more intensivecampaigns.

3.33 AppraisalProcedures. Each initial sub-projectrequest is to be logged in by the RES and classifiedaccording to the type of activities it belongsto. Then the following steps are taken: (i) the project is pre-sorted and declared eligibleon the basis of the category of activity, the project amount,the target population, and the sponsor agency; (ii) a field visit is organized; (iii) all criteria are reviewed and the budget analyzed. If the sub-project is judged appraisable,it is then transmittedto the relevant RegionalTechnical Department which has up to two weeks to object to or commentupon the proposal;I/ and (iv) depending on sub-project amount,final approval of grants is decided either by the Regionalsub-project committeeor the NES. At each step there is a possibilityto re-enter the cycle, with better, updated, or more complete information. The methodologyto be used in the appraisalof each type of sub-project is described in detail in a Manual of Procedurescontaining detailed selection criteria for each type of sub-project.

3.34 Sub-projectExecution. Once sub-projectsare approved, their implementation is the responsibilityof either a pilot committeeor an implementingagency. Pilot committees will implementmost infrastructuresub-projects and will plan and organizethe work, procure goods and contracts for works, and make sure that the beneficiariesparticipate and contribute as planned. Procurementprocedures must follow IDA guidelinesand are detailed in the Manual of Proceduresof the CDSF. All paymentsto suppliers, small contractorsand artisans, however, will be made directly by the CDSF within the amountsof the grants for the sub- projects. Where needed, RES staff will assistpilot comrnitteesmanaging the implementation of sub-projectsthrough strong supervision.

3.35 Income-generatingactivities and training activities, as well as some basic infrastructuresub-projects concerning several villages (for which there is no pilot committee) will be carried out by implementingagencies (NGOs, professionalassociations, or other non- profit organizationsand technicalassistance projects), will also follow the CDSF Manual of Proceduresfor procurementin particular. The proceeds of the grants will be made available by the CDSF to the implementingagencies in accordancewith a disbursementschedule includedin the financingagreement between the CDSF and the ImplementingAgency, which will be responsiblefor paying their own suppliers and contractorsand be subject to audit by the CDSF's auditors. No credit will be given under the project. The project will work with the on-goingUNDP/ILO credit project on a complementarybasis.

3.36 Manual of Procedures. A detailed Manual of Procedureshas been developed for the CDSF. The Manualof Proceduresis for daily use by the CDSF Administration. It guides all decisionsregarding the administrativeand financial managementof the CDSF itself as well as the selection, appraisal, supervisionand evaluationof sub-projects. It defines the

1/ This is to assure that sub-projects fit within the overall sectoral strategies. If it does not, the sub-project will either be redesigned or abandoned. 22

institutionand its mandates,and spells out the responsibilitiesand administrativearrangements for the CDSF, its three regional secretariats and its community-levelinteractions.

3.37 The Manual describesthe general types of subprojectseligible for financing, and the criteria for selection, as explainedin para 3.31. It details the administrativesteps by which the CDSF would receive, evaluate, approve, supervise and post-evaluatea project, includingguidelines for procurementconsistent with the World Bank's guidelines. It details the financialand auditing requirementsfor the CDSF Administrationas well as for sub- projects. It describes the recruitmentand managementof CDSF personnel in an appendix.

3.38 A dozen annexes are attachedto the Manualof Procedures. These annexes also form an integral part of the daily routine of the CDSF, as they give the legal structure for the organizationand a number of sample documentsencountered frequently by CDSF staff. The first two annexes give a copy of the laws creatingthe CDSF and defining its organization and operation. Sampledocuments includean applicationfor membershipin the CDSF for a Pilot Committee;a model statute of associationfor a CommunityDevelopment Association; modelmeeting minutes; a model request for official recognitionof a Pilot Committee;a sub- project applicationform; a model conventionbetween the CDSF and the Pilot Committee;a modelprotocol of agreementbetween the CDSF and an executing agency (such as an NGO); and a sub-project supervisionform. In additionannexes include proceduresfor procurementof works and equipment;and standard bidding documents.

3.39 Economic Rationale of CDSF. The economicrationale for the investment (non-income-generating)activities that it funds are principally: (i) it serves identifiedneeds which are perceivedby the communityrather than being centrally-planned;(ii) it raises additionallocal resourcesfor self-definedand targeted grass-roots developmentefforts; (iii) it assures the recurrent costs of the operations, which, relative to traditional investments, presents a saving both in the Government's recurrentbudget and in the cost of later rehabilitationof the dilapidatedinvestment; (iv) in some cases, it provides investmentsthat would be impossibleotherwise (due to the remotenessof the village, for instance); (v) usually there is a cost saving over centrally planned investments,especially for labor; and (vi) communitysupervision and managementreduces leakages, and in many cases will increase quality. Intangiblebenefits includethe empowermentand ownership of communities;their contact with the outside world and the Government;the empowermentof youth and especially young women; and tremendouscapacity building and training at the communitylevel which could then better harness local resources in the future.

3.40 Sustainability of CDSF. There are two levels of sustainabilityrelevant to the CDSF: sustainabilityof the sub-projectsfinanced, and sustainabilityof the institution itself. Concerningthe former, the Manual of Proceduresstipulates that before any sub-project can be financedby the CDSF, its sustainabilityafter CDSF interventionmust be assured. To achieve this, each sub-projectmust includea plan for communityparticipation in financing, implementing,and maintainingthe activity after sub-project support is completed. The assessmentof this plan is an integralpart of the appraisalof the sub-project. Without acceptableplans for the sub-project's sustainability,it will not be supportedby the CDSF. The question of whether the CDSF institutionitself should be sustainableis one to be answered during the mid-termreview of the project. If the CDSF is successfulat efficientlyhelping communitiesto implementsub-projects which have a proven track record at improvingthe 23 living standardsof the populationand generatingbottom-up development, then, as experience has shown, these types of funds have no problem in raising the money from external donors, organizations,and the Governmentto continuetheir work. If it is determined at mid-term review that needs still exist at the communitylevel and operations look successfulenough to merit continuationof the CDSF after the life of the project, a financingadvisor will be recruited to be in charge of fund-raisingfor the CDSF to assure its sustainabilityafter the end of project. If at the end of project executionit is decidedto dismantlethe CDSF, the benefits of the sub-projectsand training undertakenduring project executionwill continue.

3.41 EnvironmentalEffects of the Project. Althoughthis is illegal, sea-sandor ground coral is often used in constructionin Comoros. During project preparation, a specialist in tropical constructionworked with the Comoriansto develop several differentprototype constructiontechniques which use local materials other than sand and coral (crushedvolcanic rock for instance)which have been successfullyshown to minimizenegative environmental impact. These methods are being tested on sub-projectsduring preparation, for instance in the rehabilitationof school classrooms,to determine their quality, durability, cost-effectiveness, ease of use, and acceptabilityby local communities. If communitiesare found to be using any environmentallydamaging materials, CDSF financingwill stop immediatelyfor that sub- project. Close supervisionis facilitated by the regionaloffices of the CDSF. To minimize environmentalrisks in the health component,the project will also finance the developmentof appropriatewaste disposal and sanitary facilities.

IV. PROJECT COSTS AND FINANCING

4.1 The total cost of the project is US$16.0 million net of taxes and duties in August 1993prices. The Health componentaccounts for US$7.8 million, the Community DevelopmentSupport Fund for US$7.9 million and the PPF for US$0.4 million. Price contingencieshave been calculatedat 1.9, 2.7, 3.5, 3.5, 3.5% for foreign expendituresand at 4% for local expenditures,for the five years of project implementationstarting in 1994. There are no physical contingencies,because the scale and number of health centers to be rehabilitatedas well as the scale and number of sub-projectsof the CDSF will be a function of the amounts allocatedin the respective categoriesof expenditure. The project cost summary by componentand by categoryof expenditureare in Tables 4.1 and 4.2 below. These costs are based on estimatesprovided by MOH and CDSF with assistancefrom a consultingfirm. The appraisal missionreviewed these costs in collaborationwith the entitieswhich will be in charge of executingthe various components. The detailed costs of the project are shown in Annex IV.

4.2 The IDA contributionis US$13.0 million, of which US$6.0 million will be allocatedto the health componentand $7.0 million to the CSDF. The project will be financed by IDA, the Government,and local communities. During negotiations,it was agreed that the contributionof the communitiesto the CDSF has been set at a minimumof 20%, exceptfor the poorest communitiesin which case the contributionwould fall to 15% (para. 7.1 (k)). To allow for the CDSF to put priority on the poorest communities,the cost tables reflect an averagecontribution by communitiesof 16%. The costs shown for the health componentdo not reflect the Government'scontribution to the salaries of staff working part time on the 24

project, materials, office space and other incidentalcontributions. However, they do reflect the Government's commitmentto provide adequatestaffing and suppliesto rehabilitated facilities.

Table 4.1: Summary Project Costs by Component (US$ thousand)

USS thousand % Foreign Total Exchange Base

Costs Local | Foreign | Total A. Support to Health Sector 1. Support to Central Level 272 384 656 59 5 2. Support to Regional Level 165 275 440 63 3 3. Health Facilities Rehabilitation 3,829 996 4,825 21 33 4. Family Planning Program 106 151 257 59 2 5. STD/AIDS Program 107 182 289 63 2 6. Project Office 452 68 520 13 3 Sub-Total 4,931 2,056 6,987 29 48 B. Community Development Support Fund 1. Administration 1,075 0 1,075 0 7 2. Sub-Projects 4,904 911 5,815 16 40 Sub-Total 5,979 911 6,890 13 47 C. PPF 500 300 800 38 S TOTAL BASELINE COSTS 11,410 3,267 14,677 22 100 Price Contingencies 1,184 175 1,359 13 9 TOTAL PROJECT COSTS 12,594 3,442 16,036 21 109

4.3 The cost for rehabilitationof selected sites was estimatedfrom 40 to 60% of the cost of new construction;depending the status of the facility this results in costs of 2 US$220 to US$330 per m . Training abroad was estimated at US$5,000 per person/year and for local training US$600per person/month. Local salaries and operatingexpenses were estimated using UNDP standards.

4.4 Customs duties and taxes. All items importedfor the purpose of executing this project as well as the major imported itemspurchased locally will be exempt from direct customsduties and taxes, in line with the standardpractice of the Government. 25

Table 4.2: Summary Project Costs by Cateeory of Expenditures (US$ thousand)

US$ US$ % Total Foreign Base Exchange Costs Local Foreign r Total - 1. INVESTMENT COSTS A. Equipment, Vchicles, Mat. 493 1,237 1,730 72 12 B. Training 449 620 1,069 58 7 C. Civil Works 1,590 0 1,590 0 11 D. Technical Assistance 199 199 398 50 3 E. PPF 500 300 800 38 5 F. CDSF Sub-Projects 4,904 911 5,815 16 40 TOTAL INVESTMENT COSTS 8,135 3,267 11,402 28 78 It. RECURRENT COSTS A. Operating Costs 2,200 0 2,200 0 15 B. CDSF Administration 1,075 0 1,075 0 7 TOTAL RECURRENT COSTS 3,175 0 3,175 0 22 TOTAL BASELINE COSTS 11,410 3,267 14,677 22 100 Price Contingencies 1,184 175 1 359 13 9 TOTAL PROJECT COSTS 12,594 3 16,036 21 109

4.5 IDA is the sole source of foreign funding for the project. The Government will cover the salaries of the civil servants involvedin the project, includingthose on the Project Office staff, and the operating costs of the facilitieswhich are already in the budget of the MOH for a total estimatedat about US$2 million. The contributionof communitiesin CDSF sub-projectswould be a minimumof 20% exceptfor the poorest communities,and is calculatedat 16% of the sub-projectsfinancing for a total estimatedat about US$1 million. Recurrent costs for the health componentindicate the Government's commitmentto provide a full complementof staff and suppliesto the rehabilitatedfacilities; however, the reforms proposed for the health sector and supportedby this project are budget neutral. The only incrementalrecurrent cost associatedwith the health componentis the cost of the project office, which is a temporary cost. Maintenanceof facilitiesrehabilitated under either componentwill be assured by the local communitiesand does not therefore have budget implicationseither. Table 4.3 below shows the proposed allocationof the IDA credit by disbursementcategory. 26

Table 4.3: Allocationof IDA Creditby DisbursementCategory (in US$ thousand)

Foreign Local Total Exp. Exp. Amount % A. Goods Equipment,vehicles, 1,440 446 1,886 15 furniture, supplies

B. Civil Works 1,733 1,733 14

C. Consultancies 220 215 435 3

D. Training 614 551 1,165 9

E. Project OfriceOperating Costs 590 590 4

F. CDSF Operating Costs 1,172 1,172 9

G. CDSFSub-Projects 975 4,273 4,273 40

H. PPF 300 500 800 6 Total Disbursement 3,549 9Z480 13,029 100

V. PROJECT IMPLEMENTATION

A. ProjectPreparation

5.1 Health Program. A team of internationalconsultants worked out the health componentwith the MOH Directorate General. Very close contact has also been maintained with all donors involved--UNDP,WHO, UNICEF, UNFPA, the French Cooperation,etc.-- and most preparation missionshave been joint with these donors. Under the MERCAP,the MOH is engaged in major reformsof its personnel and administration,complementary to the project's goals. Regulationsredefining the roles and powers of health facilitiesand communitieswith regard to financial and administrativemanagement are under preparation and their applicationto the facilitiesto be rehabilitatedunder the project is a conditionof disbursementfor civil works (para. 7.3(b)), as is implementationof the new organisational chart in the facilitiesto be rehabilitated.

5.2 CommunityDevelopment Support Fund. Considerablework has been undertakenon the preparationof the CDSF. ExtensiveIEC campaignshave been undertaken by the National PreparationCommittee on each of the three islandsto sensitize communities about the CDSF. Regionalpreparation committees were chosenon each island to form the RegionalExecutive Secretariats during the preparationperiod. Preparationwork has progressedquite well, due in large part to the Government'sdetermination to strengthen its 27

policy of support to grassroots activities, and equally to the enthusiasticadherence of communitiesto the project's objectives.The PresidentialAct setting up CDSF was signed on January 6, 1993, and the PresidentialDecree defining its functions signed on April 13, 1993. The NationalExecutive Director, who was selectedthrough broad consultation,was appointed by the Chairmanof the PreparationCommittee. The RegionalExecutive Directors have also been appointed.

5.3 More than 45 sub-projectsestimated at US$1,200,000equivalent have been identified by communitiesand regional committees;ten totalling about US$200,000 are being implementedand nine sub-projectsrelated to the sectors of school rehabilitationand water supply have been completedsuccessfully with the community'scontribution exceeding in some cases 20% of the total cost of the sub-project(see Annex I for a list of sub-projectsto be implementedin the first year of the project).

B. ProjectManagement

5.4 To facilitate executionof the two componentsof the project, separate implementationstructures will be used for each component. For the health componentstrong support will be given to the Ministryof Health to improve its capacity to implementthe health program. Becauseof the cross-sectoralnature of the social fund, it will not be directly tied to a particular ministry but will be independentand autonomouslyrun.

Health Program

5.5 Within the Ministry of Health a small Project Office will be establishedunder the Directorate General to aid the MOH in the administrationof the IDA credit. The Project Officewill be responsiblefor overseeingthe implementationof the component. In particular, this unit will perform the followingadministrative tasks: (i) prepare annual work programs and correspondingbudgets; (ii) coordinatethe activitiesof the various components;(iii) maintain an accountingsystem for each project sub-componentsatisfactory to IDA and prepare quarterly and annual financial reports; (iv) prepare all bidding documentsin a manner acceptableto IDA; (v) prepare quarterly and annual progress reports; (vi) ensure that audits are performed annually in a timely fashion; (vii) manageall technicalassistance contracts for the project; and (viii)perform a mid-termreview of the health componentduring the third year of project implementation. The Project Office high level staff will includea project director, an accountant, and a procurementspecialist, with necessary support staff. Terms of reference for the Project Office and its staff members are includedin Annex III. Assuranceswere given during negotiationsthat Project Officehigher level staff at all times have qualificationsand experienceacceptable to IDA (para. 7. l(d)). In addition, the person responsiblefor procurementwithin the Project Office will attend a training course on Bank procurement during the first year of project implementation.

5.6 Architecturaldesign, preparationof bidding documents, bids, and supervision of civil works financedthrough the project will be executedby a private firm or NGO recruited with procedures acceptableto IDA. The Project Office will be responsiblefor coordinatingthese activitiesas well as visiting the sites regularly. In the same way the procurementof goods, technicalassistance and training will be executedby private firms or NGOs recruited with procedures acceptableto IDA. The Project Office's Director will be 28 responsiblefor coordinationof all these activities accordingto the Work Plan. The recruitmentof private firms and/or NGOs for the first year, the procurementof goods, the preparation of architecturaldesign and bidding documentswill be a conditionof effectiveness (para. 7.2(e)).

5.7 At the regional level, project implementationwill be executed by the Regional Health Teams with the assistanceof the Project Office. The RHTs which are headed by the RMO will be charged with supervisingthe implementationof health programs throughoutthe region, organizing, with the assistance of the contractedprivate firm or NGO, on-the-job training for district health workers, and stimulatingand streamliningcommunity participation. RHTs will have the responsibilityand authority for administrativeand technicalmatters in their region, includingthe supervisionof activitiesin hospitals, health centers, rural maternities, pharmacies,and health posts against establishednorms and monitorable performanceindicators.

5.8 For IEC activities,the project will strengthen managementcapacities of the unit which will have the responsibilityto plan, coordinateand superviseIEC activities. A consultantwill assist MOH in reorganizingits IEC activities, in defining the mandateof the unit which will have the responsibilityto coordinateand plan IEC health and population activities, and in establishingthe coordinatingmechanisms between the IEC coordinatingunit and the various projects/programs,in preparing the job descriptionsfor the IEC central and regional staff, and establishingprocedures to ensure that resources are shared between programs. This strengtheningwill take place before the credit becomeseffective and will be done in collaborationwith other concerneddonors, in particular with UNDP which is preparing a developmentcommunication project.

Social Fund

5.9 Because of the nature of the social fund, its managementhas been given to an organization, the CommunityDevelopment Support Fund, which has administrativeand financial autonomyfrom the Government. The CDSF will enter into an agreementwith the Governmentregulating the channelingof the proceeds of the IDA credit. The signing of that agreementwill be a conditionof effectivenessof the proposed credit (para. 7.2(a)). During negotiations,the Governmentand CDSF gave assurancesthat this agreement and any amendmentthereto will be acceptableto IDA (para. 7.1(e)). While the headquartersof the CDSF is on the island of Grande Comore, because of geographicallocation, difficultyof communications,and specific characteristicsof each island, each of the three islandswill have a regional bureau. A bank accountwill be openedfor each regional bureau and the deposit of US$5,000 equivalent in each accountwill be a conditionof effectiveness(para. 7.2(f)). During negotiations,the Governmentand the CDSF gave assurancesthat the positions of National Executive Director, RegionalExecutive Deputy Directors, and other higher level personnel will be filled at all times with personnelwhose qualificationsand experience are satisfactoryto IDA (para. 7.1(f)).

5.10 CentralCoordination Committee. The primary task of the CCC, which meets twice a year, is to act as a Board of Directors setting the overall policiesof the CDSF. As such, its responsibilitiesare: 29

Define and orient the general policiesof the CDSF;

Approve the annual budget and financial managementprocedures which are submittedby the NationalExecutive Director of the CDSF;

Analyze the audit reports on the managementof the CDSF;

Examine and adopt appropriateprocedures which will enable the CDSF to support projects in the poorest areas;

Approve the global objectivesof each RegionalCommittee's annual plan;

Adopt the Internal Rules and the PersonnelStatute of the CDSF which are submittedby the National ExecutiveSecretariat;

- Adopt the Manual of Procedures (para. 3.36); and

- Appoint the NationalExecutive Director and the RegionalExecutive Deputy Directors through open competition.

5.11 The CCC will be composedof 15 members who are to be named by decree - 7 representativesof the public administration(from the Ministriesof Finance, Plan, Equipment, Education, Health, and Production, and a representativefrom the Prime Minister's office), 8 representativesfrom the provinces (2 from each island) and 2 from national associations. The president of the CCC will be nominatedby his peers.

5.12 National Executive Secretariat. The NES is a permanentbody composedof the NationalExecutive Director, an accountant,an administrativeassistant, a procurement specialist and a secretary. Their main tasks are the following:

- Assure the financial and administrativemanagement of the CDSF, including preparing the budget of the CDSF;

- Establishthe financial accounts and prepare all other financial management statements;

- Assure the managementof the IDA special accountfor the CDSF under the responsibilityof the NationalExecutive Director;

- Assure that all procurementfollows the procurementrules stipulated in the Manual of Procedures;

- Study and propose to the CCC the elementsof a national policy and a financing strategy for communitydevelopment;

- Write and submit to CCC semi-annualevaluation reports on the activitiesof the CDSF and propose necessary adjustments; 30

- Define and create a data base of unit costs which are to be applicableduring sub-projectevaluation; and

- Approve sub-projectrequests which are FC5 million (about US$17,000)and above, forwardingthose above equivalentof FF350,000 (FC17.5 million or about US$60,000)for non-objectionfrom IDA;

5.13 Regional Committees. For each of the three islands, there will be a RC which is composedof 8 members. The presidents are elected by their peers. The members include: a representativeof the RegionalFinance Directorate, a representativeof the Regional Directorate of Plan (CommunityDevelopment), and 6 other non-Governmentmembers chosen on the basis of their qualificationsand their knowledgeof communitiesand their problems. The primary responsibilitiesof the RegionalCommittees are the following:

- Develop and propose to the NES a regional communitydevelopment policy and strategy; - Review and endorse or modify the annual programs developedby the Deputy Regional Director; - Evaluate the impactof the CDSF on the developmentand welfare of the island and propose modificationsand adjustments; - Appoint a Regionalsub-projects committee which will be responsible for selecting sub-projects,approving grants of less than CF5 million (about US$17,000)and submittingto the NES for decision all sub-projectsabove FC5 million; and - Collaboratewith the RES to assure close liaison between local communities and the CDSF to help define projects which respond to the needs of the poorest groups.

5.14 Regional Executive Secretariats. The RES is headed by the Deputy Regional Director who is the regional representativeof the CDSF and has an accountantl/, a specialist in communication,and a secretary as support. The RES is responsiblefor:

- Animatingthe IEC campaignof promotionof the CDSF in the communitiesof the island; - Preparing the annual action program for communitydevelopment on the island; - Furnishingtechnical and financialsupport to communitiesin the preparation and executionof projects; - Appraisingsub-project requests accordingto the criteria and proceduresin the Manual of Procedures; - Assuringtimely disbursementsaccording to advancementof work; and - Submittingquarterly reports to the RC on the state of advancementof sub- project implementation.

I/ This individualwill also receive training in contractsand procurementto assure they fulfillthis functionat the regional level. 31

5.15 Pilot Committees. The PCs are communitygroups which work with the RESs of the CDSF to:

- Identify sub-projectsaccording to needs of the community; - Prepare with the RESs a proposed budget for the sub-project, includingthe contributionsof the communitytowards the sub-project realization; - Obtain firm commitmentfrom the communityor communitieson their participationin the executionand monitoringof work during project implementation; - Sign the financial contract with the CDSF; - Mobilize local human, material, and financial resources necessaryfor execution of the sub-project;and - Report periodicallyto the RES on the state of advancementof sub-project implementation.

5.16 IDA review of sub-projects. The CDSF would have the authority to approve sub-projectscosting the equivalentof FF350,000 (about US$60,000)or less. Sub-projectsthat have a total cost of more than FF350,000 equivalentwould be submittedto IDA for prior review. All sub-projectswould, however, be subject to random ex-postreview by IDA during project supervision.

C. ImplementationSchedule

5.17 ImplementationSchedule. The project ImplementationSchedule by category is shown in Table 5.1 below. The project is expectedto be completedby December 31, 1998, and the Credit closed by June 30, 1999. 32

Table 5.1: Implementation Schedule (US$ million)

Project Elkment Project Year Total 1 2 3 4 5 Payments Remarks Credit Inning Sign/Effectiveness/Close xx x Civi Works A.3 Facilities Rehabilitation 0.04 0.20 0.80 0.60 0.10 1.74 LCB A.6 Project Office 0.02 0.02 LCB xxx xx xxxx xxxx xx Goods A.l Central Level 0.05 0.10 0.15 0.10 ICB xx xxxx xxxx 0.05 Lah A.2 Regional Level 0.02 0 03 0.05 0.03 ICB xx xxxx 0.02 Lah A.3 Facilities Rehabilitation 0.90 0.43 1.33 0.92 ICB xxx xx 0.41 Lah A.4 FamnilyPlanning 0.03 0.03 0.06 ICB xxx xx A.5 STD/AIDS 0.07 0.05 0.04 0.16 ICB xx xxxx xxx A.6 Project Office 0.08 0.08 Lah xxx Consultancie A.1 Central Level 0.03 0.08 0.10 0.21 xx x xx A.3 Facilities Rehabilitation 0.08 0.08 (UNV) xxxx A.4 Family Planning 0.03 0.03 0.06 xxx xx A.5 STD/AIDS 0.01 0.02 0.02 0.01 0.01 0.07 x xx xx x x Tr g A.l Central Level 0.05 0.10 0.11 0.09 0.35 x x x x A.2 Regional Level 0.06 0.10 0.10 0.09 0.05 0.40 xx xx xxx x x A.3 Facilities Rehabilitation 0.04 0.04 0.04 0.02 0.14 xx xx xx x A.4 Family Planning 0.02 0.05 0.08 0.03 0.18 x xxx xxx xx A.5 STD/AIDS 0.01 0.02 0.05 0.08 x x xxx

CDSF Administration B.l Administration 0.23 0.24 0.24 0.24 0 24 1.17 xxxx xxxx xxxx xxxx xxxx CDSF Sub-Projects 0.53 1.20 1.30 1.20 1.20 5.43 0.50 Lah B.2 Sub-projects xxxx xxxx xxxx xxxx xxxx 4.93 LCB Miscellaneous A.6 MOH Project Ofrice 0.09 0.09 0.09 0.09 0.09 0.45 PPF Refinancing 0.80 0.80

TOTAL (Bank Financed) 2.10 3.29 3.50 2.43 1.71 13,03 xx refer to quarters 33

D. ProjectMonitoring and Reporting

5.18 Health ComponentMonitoring. The Project Office will monitor and evaluate project implementationaccording to the agreed performanceindicators (Annex VI). The Project Office will have an overall view of problems and issues in project implementationand be in position to recommendany corrective actions that maybe required. It was agreed that a project performancereview, includingmanagement, will be carried out annuallyunder terms of reference acceptableto IDA and that the review findingsand recommendationswill be discussed with IDA no later than October 31 of each year of project implementation. Because communityinvolvement is so importantto the success of this component,this annual review will also include an beneficiaryassessment which looks into how beneficiariesfeel health services to be improvingas well as further changesand modificationswhich could continueto improve services. During negotiations,the Governmentgave assurancesthat, no later than July 31 of each year of project implementation,the Project Office will make availableto IDA the necessarydocuments and evidencefor a review of (i) project implementation;and (ii) the status of maintenanceand operations of buildings rehabilitatedwith IDA credits (para. 7.1(b)).

5.19 CDSFSub-Project Monitoring. Strong monitoringof sub-project implementationand impact will be conductedby the RES and reviewed by the NES. The monitoringwill be physical and financial, and will take into accountthe impact of the sub- project on beneficiaries. The physical and financialmonitoring will be includedin the Managementand InformationSystem (MIS). The signatureof a contract with a consulting firm to put in place the MIS will be a conditionof effectiveness(para. 7.2(d)). During RES supervisionmissions a detailed supervisionreport will be prepared indicatingthe physical advancementof the project and flagging any implementationissues. The views of the beneficiariesand the implementingagencies will also be recorded during these missions. Every disbursementby the RES will be monitoredthrough the MIS. A summary of the findingsof the supervisionmissions will be presented in the quarterly reports with recommendationsto improve the implementationand design of sub-projects.

5.20 During project implementationimprovements would be made to strengthen the MIS's capacityfor the establishmentand maintenanceof "communityprofiles" - a set of social indicatorson communitieswhere CDSF financedprojects have been, or will be carried out. Performancesindicators would also be used to reflect the number and type of beneficiariesof each type of project, such as the number of classroomsrehabilitated, beneficiariesof water supply sub-projects,health care visits, vaccinations,trainees, in order to monitor real benefits provided under CDSF sub-projects.Based on the results for the period of project preparation, outcomes expectedfor the lifetimeof the project could be quantifiedas final targets. The number of beneficiariesare expectedto be approximately:(i) 50,000 for the water supply sector, involving40 villages; (ii) 35,000 for the seweragesector; (iii) 2,000 rural women; (iv) 15,000students in primary schools; (v) 1,500 trainees in basic skills at the communitylevel; and (vi) 40,000 health care visits per year (additionalto 75,000 existingat present). The implementationof sub-projectswill be monitoredagainst a set of quantifiedperformance indicatorswhich will be adjustedevery year. The indicators are summarizedin Annex VI. 34

5.21 To help monitorthe quality and effectivenessof project implementation,each RES will carry-out annual BeneficiaryAssessments (BA) for a selected numberof sub-projects representativeof the portfolio under implementation. Local consultantswill be used for this purpose. The informationcollected will focus in particular on the level of participationof the beneficiariesin the sub-project, their view of the usefulnessof the sub-project, the immediate benefit of the sub-projectsfor the community,the relation with implementingagencies, the sustainabilityof the activitiesundertaken, and any other issue relevant to the local population. The findings of the BA will be presented in the annual report and will be discussed with the CCC. Agreementwas reachedduring negotiationson performanceindicators for both componentsof the project (para. 7.1(g)).

5.22 Accounts. Separateaccounts will be maintainedfor each component. Such accounts will be maintainedin accordancewith internationallyrecognized accounting principles and practices which are satisfactoryto IDA.

5.23 Audits. The accounts, statementsof expendituresand documentationrelative to procurementwill be auditedannually by an externalauditor for each componentacceptable to IDA. Auditswill be undertakenon a semi-annualbasis for the CDSF. Audits will be undertakenannually for the health component. Audit reports will be submittedto IDA three months after the end of the period. The audits will include managerial,technical and financial aspects of the project, will follow the InternationalStandard for audits and accounting, and will include a statementon the adequacyof the accountingsystem and internal controls, the reliability of the statementsof expendituresas a basis for loan disbursements,compliance with financial covenantsand for the CDSF compliancewith the Manualof Procedures. The audit reports will include a managementletter. Agreementwas reached during negotiationson the content and timing of the audits (para. 7. l(h)). As a conditionof effectiveness,the Governmentwill sign a contract or contractswith independentauditors, for each component, satisfactoryto IDA (para. 7.2(c)).

5.24 Mid-term Review. It was agreed during negotiationsthat a mid-termreview will take place not later than October 31st 1996 (para. 7.1(f)). In additionto the topics covered in the annual and quarterly reviews, the mid-termreview will examinein particular the sustainabilityof the CDSF as an institution. If the institutionis deemedsustainable, alternative sources of funding will be sought to ensure its existencebeyond the end of the project.

E. Implementation Issues in Comoros

5.25 Comoroshas a poor implementationrecord mainly due to high turnover of personnel working on the projects, slow disbursements,and lack of Governmentcounterpart funds. During the FY92 ARIS review process, three out of four projects were consideredproblem projects. However, since then there has been considerableprogress. A Country ImplementationReview (CIR) was undertakenin early 1993which has focused the country's attentionon project implementation,and significantimprovements have been seen in disbursementsfor all ongoing projects, which were US$4.5 million in FY93 as opposed to US$2.1 million in FY92.

5.26 The administrativereform coordinatedby the CTARIAPwill rationalizethe personnel budget for all the ministries; significantprogress has been made and the process is 35

expectedto be completedin early 1994. A reductionof at least 100 unqualifiedtechnical staff of the MOH is a conditionof disbursementsfor civil works for the rehabilitationof health facilities (para. 7.3(a)).

5.27 Lessons drawn from the implementationexperience in Comorosinclude: (i) institutionaland political commitmentis key to project success, includingcontinuity of project staff; (ii) recurrent funding and Governmentfinancial planning have presented a problem; (iii) projects should be as simple as possible and avoid excessiveneed for multi-agency coordination; and (iv) maintenanceof physical investmentsis poor and linked to poor motivationof public servants.

5.28 This project will address these shortcomingsin several ways: (i) the relevant institutionshave been thoroughly involvedin the project preparation (Ministryof Health and staff of the CDSF); (ii) essentiallegal texts for both componentshave been enactedbefore Board presentation; (iii) project design and administrativearrangements have been kept as simple as possible, with two components;and (iv) maintenanceof physical investmentis more likely due to communityparticipation in financingof investmentsand managementof their operation.

5.29 In addition, for the health sector: (i) technicaldetails for the civil works for the health componenthave been completedbefore negotiations;(ii) the project works within the frameworkof the structural adjustmentprogram, and in particular is based on a reform of the entire publichealth system; and (iii) the project leveragesadditional resources through cost- recovery and communityresponsibilization. The Governmentis reforming the budget process and has assured that financingof the health sector will be at a level commensuratewith its efficient functioning(see para 3.17). For the CDSF: (i) successfulpilot operationshave been undertakenduring project preparationunder the PPF; and (ii) the CDSF has been created with staff independentfrom the public administration.

5.30 In order to ensure that the project objectivesand the World Bank's procedures are well understoodwithin the implementinginstitutions, there will be a project launch workshopat which administrativearrangements will be reviewed. A mid-term review will take place after somewhatmore than 2 years (presently scheduledfor October 1996), which will allow the Governmentof Comorosand IDA to review progress and make changes as necessary. Particular focus of this review will be on the budget executed in the health sector, the maintenanceof investmentsmade under the CDSF, the future of the CDSF and the level of communitycontribution in CDSF activities(para. 5.25). 36

F. Procurement

5.31 Procurementarrangements are summarizedin Table 5.2 below:

Table 5,2: Procurement Arrangements (US$ million)

Project Element ICB LCB Other Total Costs 1. Goods 1.27 0.56 1.83 (1.27) (0.56) (1.83) 2. Civil works 1.76 1.76 (1.76) (1.76) 3. Consultancies 0.42 0.42 (0.42) (0.42) 4. Training 1.15 1.15 (1.15) (1.15) 5. MOH Oper. Costs 2.44 2.44 (0.45) (0.45) 6. CDSF Inc. Op. Cost 1.19 1.19 (I. 19) (I. 19) 7. CDSF Sub-Projects 4.93 1.52 6.45 (4.93) (0.50) (5.43) 8. RefinancingPPF 0.80 0.80 (0.80) (0.80) Total 1.27 6.69 8.08 16.04 _ (1.27) (6.69) (5.07) (13.03)

Figures in parenthesis represent IDA financing.

5.32 Civil works. For the health componentcivil works contractswill be awarded followingcompetitive bidding procedures acceptableto IDA in accordancewith IDA guidelines for procurement. Refurbishmentof existingbuildings will be awarded followingLocal CompetitiveBidding (LCB), up to an aggregate amountof US$1.9 million. Tenders will be advertisedlocally, bidders will be given minimum45 days for submissionof bids. Evaluation criteria will be specified. All bids will be opened in the presence of bidder's representatives. Eligible foreign contractors will be allowedto participate in the bidding, and standard bidding documentswill be reviewedand approved by IDA prior to advertising. For the implementationof this sub-component,a selectedprivate firm/NGO will be contractedto help the Project Office prepare bidding documents,launch bids, select contractors,prepare contracts and superviseworks.

5.33 Goods. Goods financedunder the project will include vehicles, furniture, medical equipment,and other equipmentand materials. Except as provided below, goods will be procured through InternationalCompetitive Bidding (ICB) in accordancewith IDA's Guidelinesfor Procurementunder IBRD Loans and IDA Credits (May 1992). Contracts for 37

goods procured through ICB would amountto about US$1.4 million. Other goods, which cannot be grouped into bids packages of at least US$25,000equivalent, up to an aggregate amountof US$1.4 million, would be procured through prudent shoppingon the basis of price quotationsfrom at least three suppliers. This consistsof supplies and operatingcosts of the project office of the MOH and for the CDSF (US$0.2 million and US$0.6 million) as well as other goods to be procured under the health component,mainly supplies (US$0.15 million), vehicles(US$0.10 million) and communicationand computerequipment (US$0.35 million).

5.34 Technical Assistance. For the technicalassistance (US$420,000)and training (US$1.15 million), consultantswill be selected in accordancewith the "Guidelinesfor the Use of Consultantsby World Bank Borrowers and by the World Bank as Executive Agency." The work program and financinghave been described in such a manner as to encouragethe use of consultantsfrom Comoros, and, where expertisedoes not exist in the country, consultants from the region. Details on consultanciesare given in Annex III.

5.35 CDSF. For the CDSF, civil works will be carried out by local communities accordingto the Manual of Proceduresagreed by IDA. For sub-projectsfinanced under the CDSF (US$5.4 million), the executingagency responsiblefor sub-project implementationwill be responsiblefor procurementand will follow IDA's guidelinesfor procurement(paras 3.34 and 3.35). Becausemost of the executingagencies and local communitieslack experiencein procurement,the CDSF will assist them for the preparationof bidding documents,bid evaluation,contract award, and contractmanagement. Prior to signing the sub-project contract, the CDSF will assure that procurementprocedures to be followedare in compliance with agreed guidelinesdetailed in the Manualof Procedures. Contracts for goods and civil works for sub-projectswill be awarded as follows: (a) contractsranging in size from US$20,000to US$100,000,up to an aggregateamount of US$4.0 million, will be awarded on the basis of LCB; (b) for contractsvalued at less than US$20,000equivalent, up to an aggregateamount of US$1.5 million, local bidding wouldtake place through notices posted in the villages and in the offices of the CDSF as well as by radio. Resultsof such bidding would be publishedofficially; and (c) for contractsvalued at less than US$20,000equivalent, up to an aggregate amountof US$0.5 million, the beneficiaryagencies will carry out local shopping and would provide CDSF with all relevant documentationfor review, indicatingits choice among the offers presented. Aggregateamounts for procurementmethods for sub-projectsadd up to more than the total amountof the IDA credit allocatedto sub-projectexecution ($5.4 million), in order to allow the CDSF the flexibilityto make greater use of LCB wherever possible. Suppliesprovided under CDSF's financingwill be deliveredto the executingagencies as the need for them arises accordingto the sub-project implementationschedule and under the supervisionof the NGO CECI (refer to CECI's terms of referencein Annex III chapter II).

5.36 Bank Review Requirements. Prior review by IDA would be required for all consultancycontracts for individualsor for contractsof over US$10,000equivalent. Working drawings, draft tender documents, master lists of furniture, equipment, suppliesand vehicles will be reviewed by IDA. For the health component,IDA review of tender documentsprior to award will be required for contractsabove US$50,000equivalent for civil works, and US$25,000for goods. For the CDSF, any sub-project of a total investmentof FF350,000 equivalent(about US$60,000)or more will be subject to prior review by IDA. All other contractswill be subject to selectivepost award review by IDA. The use of IDA's standard bidding documentsfor goods and works and IDA's letter of invitationfor consultantswill be 38 made mandatoryby the Project Office and contractedprivate firms/NGOs. Assuranceswere obtained during negotiationsthat the Manualof Proceduresof the CDSF, includingits annexes on procurementand standardbidding documents,will be at all times acceptableto IDA. IDA will organize a project launch workshopwhen the Credit is effective and will prepare an implementationmanual including IDA's standard bidding documentsfor goods and works and IDA's standard letter of invitationfor consultants,for the use of the Project Office and contracted private firms/NGOs. Agreementon the use of IDA's standard bidding documents was obtainedduring negotiations(para. 7.1(j)).

G. Disbursement

5.37 The proposed IDA Credit of SDR 9.2 (US$13.0 million) will be disbursed in accordancewith table 5.3 below:

Table 5.3: DisbursementCategories

US$ ______thousand % Goods Equipment, vehicles, 1,700 100 furniture, supplies Civil Works 1,600 100 Consultancies 400 100 Training 1,100 100 MOH Oper. Costs 400 100 CDSF Inc. Operating Costs 1,100 100 CDSF Sub-Projects 4,900 100 PPF 800 100 Non-AllocatedTj 13,00 TOTAL - 300

Note: Health component: Government contribution of staff and supplies for which IDA does not disburse are not shown. CDSF component: contribution of the beneficiaries in kind and in manpower are not shown.

5.38 All disbursementswill be fully documentedexcept for: (i) paymentsunder contracts and subprojectsof less than US$10,000; (ii) training; and (iii) incrementaloperating costs which will be submittedunder statementsof expenditure(SOE). The Project Office within the MOH and the CDSF will be responsiblefor monitoringdisbursements. The SOEs and all records such as contracts, orders, invoices, and payroll vouchers will be retained by these units for inspectionby supervisionmissions and reviewed by the annual audit. The Project Office director and the CDSF ExecutiveDirector will be the primary liaison persons between IDA and the borrower for all disbursementissues pertaining to the project. The closing date of the credit will be June 30, 1999. 39

5.39 Special Account. To ensure that funds for this project are readily available and to facilitate disbursementMOH and CDSF will each open a SpecialAccount in French Francs in a commercialbank on terms and conditionssatisfactory to IDA. Initial deposits each of US$200,000will be advancedto those accountsfrom the IDA credit. The funds in these special accounts will be managedby the Project Office and the CDSF and all documentation pertinent to these accounts will be maintainedin a manner acceptableto IDA for inspection during regular supervisionmissions. The Project Office director and the CDSF Executive Director will be responsiblefor their respectivedisbursements during project implementation, will provide monthly statementsto IDA and will be responsiblefor submittingapplications for the replenishmentof these accounts. All paymentsof less than US$10,000will be made through the SpecialAccounts. Paymentrequests above this threshold may be submittedunder the direct payment, reimbursementor Special Commitmentprocedure. The SpecialAccounts will be replenishedmonthly, or when one-third of the Special Accounthas been disbursed, whichever is sooner.

5.40 The standard disbursementprofile for health projects in sub-SaharanAfrica is nine and a half years. However, there is a pipeline of sub-projectsthat have been developed which will be appraised by credit effectiveness. In addition, standard bidding documentsand procedures will be developedby effectivenessfor the health component. Therefore, disbursementswill pick up rapidly after the first year of project implementation. The estimated scheduleof disbursementsis at Annex V.

VI. BENEFITS AND RISKS

6.1 Benefits. The project is expectedto enhancethe developmentof human resourcesby improvingthe health, education, and incomestatus of the population. Through the health and populationcomponent, available primary health care is expectedto improve with the strengtheningof peripheralservices and closer involvementof communitiesin their provision; information,education, and communicationand better family planningservices should increasethe contraceptiveprevalence rate, reducing fertility, as well as raising awarenessof the need for AIDS prevention. The CDSF would complementactivities in the health componentby buildingupon strong communityinvolvement and aiding communitiesand individualsto more effectivelyand efficientlychannel community resources and implement local developmentefforts, includingmuch needed rehabilitationof primary schools, water supply and health posts. It would provide an opportunityto strengthenthe capacity of local associationsand NGOs, as well as encouragethe creationof new NGOs, in addition to enhancingthe well-beingand economicrole of womenin society.

6.2 Risks. The main risks to the implementationof the project are weak Governmentcapacity and potentialdelays due to politicaluncertainties. To address the first, the goal of the health and populationcomponent is to strengthencommunity involvement, both financiallyand managerially,in the provision of basic health services as well as to build Governmentcapacity and improve the efficiencyof these services. More specifically, personnel wouldbe trained, a unit within the Ministryof Health wouldbe created under the Directorate General of Health Services for procurementand administrationof implementation, 40 and technical assistancewould be provided in key areas for capacity building. To insulate the CDSF from weak Governmentcapacity and political interference,an autonomousagency staffed by selected, contractualemployees would managethe fund. In addition, community training, strong CDSF supervision,a transparentmanagement information system, and semi- annual auditingof accounts would enhancethe overall efficiencyof the community developmentcomponent of the project.

VII. CONDITIONS AND RECOMMENDATIONS

7.1 During negotiations,agreement was reached with the Governmentas follows:

(a) agreementon the Manualof Proceduresof the CDSF, which is to rule selection and executionof all sub-projects;and that any change will be submittedto IDA for approval (para. 3.25);

(b) in collaborationwith the Government,IDA will, not later than October 3 1st, 1994 and, thereafter, not later than October 31 of each subsequentyear, undertakea joint annual review of the project during which they will exchange views generally on all matters relating to the progress of the project, and in particular financial and procurementperformance of the CDSF and MOH (containingthe findingsof the independentaudit), CDSF sub-project performance,and progress made by the MOH in light of the agreed performanceindicators. Three months prior to the annual review, a report will be submittedto IDA reviewingthe situation and describing problems encounteredand solutionsto be applied. These reports will contain a draft budget and work program, and will review maintenanceand operation of physical investments. Quarterly reports will also be submitted. (para. 5.18);

(c) the budget for MOH will maintainthe 1992 real level of expenditurewith at least 20% in non-salaryexpenditures, and the budget for the current and subsequentfiscal years will be reviewed annuallywith IDA (para. 3.17);

(d) the CDSF and the Project Office are to be staffed at all times with competent higher-levelpersonnel with terms of reference, experience, and qualifications acceptableto IDA (para. 5.5 and 5.9);

(e) the agreementbetween the Governmentand the CDSF for the channelingof the proceeds of the IDA credit and any amendmentthereto will be acceptableto IDA (para. 5.9);

(f) not later than October 31, 1996, a joint mid-term review will take place. In additionto the topics covered in the annual and quarterlyreviews, the mid- term review will examine in particular the sustainabilityof the CDSF as an institution. (para. 5.24); 41

(g) agreementon performanceindicators for each componentwhich can be found at Annex VI. (para. 5.21);

(h) for the CDSF component,audits twice a year. The health componentwill have annual audits. Independentaudit reports will be submittedto IDA (para. 5.23);

(i) that MOH will issue a public expenditureprogram for the health sector for 1995-97by December31, 1994, which will be reviewed annuallywith IDA. (para. 3.22);

(j) agreementon standard bidding documentsfor civil works, purchase of goods, and the recruitmentof consultants(para. 5.36);

(k) the contributionof communitiesin CDSF sub-projectsand involvementin local health initiativesis a minimumof 20% except for the poorest communities (para. 4.2); and

(l) that no sub-projectwould exceed the equivalentof FF450,000 (about US$80,000),and that prior review by IDA will be required for all sub-projects exceedingFF350,000 equivalent (about US$60,000)(para. 5.16).

7.2 Credit Effectiveness will be conditionalon the followingmeasures:

(a) the Financing Agreementbetween the Governmentand CDSF has been duly executed; (para. 5.9);

(b) the Manualof Procedureshas been adopted by CDSF (para. 3.3);

(c) the Governmentwill sign a contractor contractswith independentauditors, for each component,satisfactory to IDA (para. 5.23);

(d) a contract, acceptableto IDA, for the installationof a managementinformation system for CDSF has been signed (para. 5.19);

(e) the Governmenthas recruited the private firms or non-governmental organizationsfor the procurementof goods, for the preparationof architectural designs and bidding documents, for the supervisionof civil works, and for the preparation and supervisionof training programs, during the 12 monthsperiod immediatelyfollowing effectiveness (para. 5.6); and

(f) the Governmenthas opened, on behalf of the CDSF, a bank account in local currency, to be operated and maintainedby CDSF, in each of the three sub- regions, and has made an initial deposit of US$5,000 equivalent into each such account (para. 5.9). 42

7.3 As a condition of disbursementof the civil works for rehabilitationof MOH facilities:

(a) the unqualifiedtechnical health personnel of the MOH, as determinedas of June 1, 1993, has been reduced in number by not less than 100 agents; (para. 5.26); and

(b) the facilitiesto be rehabilitatedhave been (i) vested with financial and managerialautonomy in accordancewith the administrativereform program detailed in the letter of health policy; and (ii) reorganizedand the staff redeployed,as needed, to meet the requirementsof the revised organizational structure prepared in 1993 (para. 5.1).

Recommendation

7.4 Subject to the above assurancesand conditions,this project constitutesa suitable basis for an IDA credit of SDR 9.2 million (US$13.0 million equivalent)to the Federal Islamic Republicof Comoroson standard IDA terms with 40 years maturity. 43

ANNEXES 44

ANNEX I Page 1 of 3

COMMUNITY DEVELOPMENT SUPPORT FUND

LIST OF SUB-PROJECTS (FIRST YEAR)

VILLAGE TYPEfWORK (COS BENEFICIARIES (FC 1,000) NGAZIDZA School Reh/Cons Students Oussivo ...... 3,000 160 Simamboini ...... 3,660 160 Ouroveni ...... 2,750 120 Didjoni ...... 2,400 120 Kopveni ...... 7,000 160 Moemboidjou ...... 1,200 120 Sidjou ...... 7,000 160 Djongue ...... 7,000 160 Diboini ...... 2,400 120 Nyambeni ...... 1,500 120 Mal ...... 7,700 240 Kandzile ...... 3,640 160 Ntsinimoichong ...... 2,300 120 Dimadjou ...... 9,500 240 Itsandzeni ...... 7,000 160 Chouani ...... 2,400 120 Iconi II ...... 10,000 320

Water Supplv Inhabitants Kandzile ...... 1,020 1,100 M iali ...... 800 780 M vouni ...... 1,200 3,800 Sada ...... 1,500 210 Health Post Simboussa ...... 2,400 600 Sidjou ...... 1,600 500 Koimbani ...... 4,100 800 Bahani ...... 1,600 1,100 M bibodjou ...... 1,100 1,740 Diboini ...... 1,600 600 Nyambeni ...... 1,000 ...... Bambani ...... 4,500 ...... Chindini ...... 2,000 ......

Rural Road Djongue ...... 10,000 ...... N 'Droue ...... 13,000 ...... 45

ANNEX I Page 2 of 3

NGAZIDZA School Reh/Cons Students Oussivo ...... 3,000 160 Simamboini ...... 3,660 160 Ouroveni ...... 2,750 120 Didjoni ...... 2,400 120 Kopveni ...... 7,000 160 Moemboidjou ...... 1,200 120 Sidjou ...... 7,000 160 Djongue ...... 7,000 160 Diboini ...... 2,400 120 Nyambeni ...... 1,500 120 Male ...... 7,700 240 Kandzile ...... 3,640 160 Ntsinimoichong ...... 2,300 120 Dimadjou ...... 9,500 240 Itsandzeni ...... 7,000 160 Chouani ...... 2,400 120 Iconi II ...... 10,000 320

Water Suyvlv Inhabitants Kandzil6 ...... 1,020 1,100 Miali ...... 800 780 Mvouni ...... 1,200 3,800 Sada ...... 1,500 210

Health Post Simboussa ...... 2,400 600 Sidjou ...... 1,600 500 Koimbani ...... 4,100 800 Bahani ...... 1,600 1,100 Mbibodjou ...... 1,100 1,740 Diboini ...... 1,600 600 Nyambeni ...... 1,000 ...... Bambani ...... 4,500 ...... Chindini ...... 2,000 ......

Rural Road Djongue ...... 10,000 ...... N'Droue ...... 13,000 ......

TOTAL COST: 127.870.000 FC 46

ANNEX I Page 3 of 3

COMMUNITY DEVELOPMENT SUPPORT FUND

LIST OF SUB-PROJECTS

(FIRST YEAR)

VILLAGE TYPE/WORK Co BENEFICIARIES (FC1 ,000) MWALI SchoolReh/Con Students

Oualla ...... 3,100 Ndrondroni 160 ...... 7,800 240 Nioumachoi ...... 7,600 320 Mbatse ...... 3,930 Miringoni 160 ...... 4,200 160 Bangoma ...... 13,800 400 Barakani ...... 5,800 80 Kanalene ...... 9,900 160 Njimbia ...... 9,900 160 Siry Ziroudany ...... 9,900 160 Hoani ...... 4,200 160 Bandaresalam ...... 4,500 120 Health Post Kangani ...... 10,220 ...... Ndrondro ...... 10,220 ...... Infrastructure Oualla2 Rural road 3,600 ...... Hoani Rural road 2,300 ...... Fomboni Sewerage 18,000 ...... Domoni Sewerage 6,900 ...... Water Supplv Nioumachoi ...... 2,000 ...... Hamba ...... 5,000 ......

TOTAL COST: 142.870.OQOFC 47 ANNEX II Page 1 of 5

INFORMATION.EDUCATION AND COMMUNICATION

Background

1. The Governmentof the Comoroshas recognizedthe need to use Information, Educationand Communication(IEC) to motivateits populationto adopt health practices which are more conduciveto good health. For this reason, it has includedin all its major public health program an IEC component. However, this program approach has, as in many countries, lead to a fragmentationof IEC activities. Becauseeach project or program has an IEC component,the resources allocatedto IEC activitiesare not allocatedon the basis of nationalhealth priorities but on a program basis, and in some cases, on a project basis, which lead to coordinationproblems within programs. The resources allocatedto IEC are often limited and linked to the importance the project designer had given to IEC rather than to real needs. Consequently,some programs have more IEC resources than others and some do not have any. Presently, the IEC Population Program and the NationalAIDS Control Program (NACP), discussedbelow, have more human and financial resources than the other public health programs.

2. PopulationIEC activitieshave been carried out in the Comorosby the First IEC PopulationProject since the launchingof the national family planningprogram in 1986. This project as well as that which is presently on-goingwas financedby UNFPA and executedby FAO. The objectivesof the Second PopulationIEC project are to increaseawareness of family planning and to eliminatethe obstaclesto the use of contraceptives. This project, which spent an average of US$185,000a year on familyplanning IEC, concentratedits activitiesin three main areas:

a. Training of health personnel and of communityworkers in familyplanning interpersonalcommunication and counselling. However, these training activities have been limitedto project areas (about ten villages) and only 160health personnel and about 60 communityworkers were trained;

b. Research studiesthe objectivesof which were to identifypsycho-socio-cultural obstacles to family planningand minimizethe risk that formal and informal opinion leaders speak out against the use of contraception. These research activities were to provide a data base on social organization,cultural models and ideal family size which could be used to develop an IEC strategy and appropriate messagesfor differenttarget groups. However, the studies althoughuseful must be interpreted with cautionbecause the sampleswere very small and the methodologywas not alwaysas rigorous as it should have been; and

c. IEC materialproduction which was carried out in the audio-visualcenter of the project. Here too, because of limited resources, some short cuts were taken and materials were not alwayspre-tested before they were produced, but only evaluated after they had been produced and distributed. This practice has led to the productionof materials which were not understoodby the target groups.

3. The purpose of these activitieswas to inform opinion leaders and target population about familyplanning. To this end, the IEC Populationproject organized seminars, conferences and study tours for officials. For example, in December 1987, a colloquiumbrought together in 48 ANNEX II Page 2 of 5 Moroni many religiousleaders includingthe Grand Mufti to discuss the acceptabilityof family planning in an Islamic context. The Grand Mufti then went to Morocco in March 1988to observe how a muslimcountry dealt with family planning. In addition, several seminars were organized for village religiousleaders. These activitiessucceeded in makingfamily planning more acceptablein the Comoros. The Grand Mufti and some other religious leaders endorsed openly the use of contraceptionfor health and socio-economicreasons in 1988. However, neither leaders or the public seem to understandthat populationgrowth is a problem and that slowingthe rate of this growth is necessaryfor the country.

4. The second PopulationIEC project will end in April 1993and is to be renewed at the request of the Government,however, accordingto the UNFPA, the level of financial support is to be reduced (only US$110,000is budgeted for 1993). Consequently,the existing need for additionalsupport will become even greater.

5. The Governmentof the comoroslaunched its NationalAIDS Control Program (NACP) in June 1990 with a resource mobilizationconference. Its first Medium-TermPlan was prepared at that time. Since then, the NACP has been supportedby several donors. In 1992, the program received about US$246,300from four donors: WHO/GPAprovided about US$160,000, the European EconomicCommunity (EEC) US$36,000, the Republicof South Africa US$12,500 and the UNDP US$37,500. About half of these funds were used for IEC activities while the other half was used for laboratoryactivities and epidemiologicalsurveillance. For 1993, WHO committedUS$160,000 which will be added to the US$40,000left over from 1992-93EEC contributionand US$37,000provided by the UNDP. WHO has indicated that they intend to maintainthe present level of support until 1995, but no other financial aid is assured. Therefore, if the NACP is to continue its IEC activitiesas well as to detect STDs and to develop the capacity to do blood screening to prevent the spread of HIV, it will need additionalresources. AIDS IEC activitieshave includedthe productionof one poster, several awarenessand informationseminars for opinion leaders and youth, radio shows, radio spots and songs. Althoughthe program spend about half of its resources on IEC activities, it does not have enough resources to do the research necessaryto develop messagesand produce IEC materials appropriatefor the various target groups. In addition, the program personnelneed to be trained in these areas.

6. The other public health programs have even fewer resources than the family planningand the NACP. The ExtendedProgram of Inoculation(EPI), financedby UNICEF and WHO, has limitedfinancial and human resources (it does not have an IEC specialist on staft) but it disseminatemessages during soccer matches and in theater plays. It cannot however, use the radio for lack of resources. The NationalMalaria Control Program, also financed by UNICEF and WHO, has very few resourcesfor IEC. The other public health programs--nutrition,water and sanitation and mother and child health--haveno or very few IEC activities.

7. IEC activitiesat the level of the ministryare to be coordinatedby the National Health Education Service (NHES) that was created in May 1991. For the period 1992-93,WHO has programmedUS$34,000 to supportthis service, some local training and the productionof IEC materials. However, this service is very weak: It is in fact constitutedby only one person who is involvedin EPI and malaria IEC activitiesbut who spend most of its time on AIDS IEC activitiesand who has moved to the NACP office. The PopulationIEC project carry out its activitiesindependently not only of the NHES but also of the MCH/FP program. 49 ANNEX II Page 3 of 5

8. In conclusion, some IEC activitiesare carried out in the Comoros,but they are concentratedin two programs. In addition, because each program/projecthas its own IEC componentand there is no coordinationbetween programs/projects,IEC resources are fragmented, no program has the capacityto produce quality IEC and some program cannot have any IEC activities. Projects generallydo not have resourcesto conduct studies that are necessary to better understandtarget groups, to know what are the best communicationchannels for each group and thereby develop more appropriateand better targeted messages. To remedy this situation, the Health componentof the IDA project proposes, on the one hand, to reinforce the planningand coordinationcapacities of the NHES, and, on the other, to provide resources to support IEC activitiesfor priority public health programs. ProposedProject Activities

9. The objectivesof the Health componentof the project are to: (i) increase the efficiencyof the Ministryof Public Health and Population(MOH) at the central and regional levels (institutionalreinforcement) so that it can provide better quality services to the Comorian population;and (ii) to supportpriority programs such as the family planningand the NACP. BecauseIEC has an importantrole to play to increasecontraceptive prevalence rates and prevent the spread of HIV contamination,the project proposes to: (i) assist the MOH to reinforce its IEC capacitiesboth at the national and the regional levels; and (ii) support the IEC componentsof the familyplanning program and the NACP. These IEC activities,although program specific, will need to be carried out in the context of the nationalIEC strategy for health and populationwhich will be developedby the Directorate for Health Education which will be created to replace the NHES in collaborationwith the various publichealth and populationprograms. A. InstitutionalStrengtheing

10. Rationale. Program/projectmanagers who need to use IEC to reach their objectivesand internationaldonors who support these programs/projectsrecognize that, in order to improve qualityand cost-efficiencyof IEC activities,it is necessary to reinforce the NHES and to replace it by a NationalHealth EducationDirectorate (NHED), as was suggestedin the preparationdocument written by the Governmentand the AssociationSante-Internationale. This institutionalstrengthening will assist the MOH to carry out its IEC activitiesfor all its programs, but in particular for its priority programs. The mandate of this directorateshould be to: (i) plan and coordinateIEC activitiesof the differenthealth and populationprograms; (ii) control the qualityof the IEC materials producedby the programs/projects;(iii) provide technicalassistance to IEC staff at the central and the regional levels; (iv) identifystudies which need to be carried out to develop appropriate messages,prepare terms of reference for these studies and supervise them; and (v) produce or supervisethe production of IEC audio-visualand printed materials. In the case of the last two activities,the NHED would be encouragedto sub-contractto outside experts from both the public and the private sectors.

11. Activities. This will be done by strengthening: (i) IEC and management capacitiesof the existingIEC staff of the variousprograms/projects, both at the central and the regional level; and (ii) productioncapacities for audio-visualand print materials of the IEC Populationproject so that this production unit can produce higher quality materials, not only for the IEC Populationproject but for all the ministry programs (the project does not intendto give the center the capacitiesto produce more materialsnor to provide the center with capacitiesto produce other than audio and video tapes and to do simple printing as it does at present. It is 50 ANNEX II Page 4 of 5 expectedthat much of the material production will be sub-contracted). Internationaltechnical assistance will be necessary to assist the MOH to: (i) organize its new directorateand to define its mandate and that of the provincialteam; (ii) identifythe coordinationmechanisms between the various programs/projectsand the NEHD and to specify how the resources will be shared; and (iii) establishsupervision mechanisms for the various levels. This technical assistancewill also assist the MOH to prepare job descriptionsfor all the personnel who will be carrying out IEC activities at the central, regional and communitylevels.

12. In order to strengthenthe capacitiesof the central level IEC personnel, the project will financeone long-termtraining for the NHED Director and a two-monthIEC training in Africa for three IEC staff. For the regional personnel, the project will finance one-monthforeign training for three regionalIEC officers. In addition, a session for the training of trainers in interpersonalcommunication and communitymobilization will be organized in Moroni. This training will be carried out with the assistanceof an internationalconsultant who will assist the NHED personnel in adaptinga curriculumdeveloped and pre-tested in Zaire and in carrying out the workshop.

13. The equipmentto be provided by the project will increasethe capacitiesof the central material productionunit to produce higher quality materials, it will not increase it ability to produce more materials nor will it provide new capacitiessuch as the capacity to do photographyor serigraphy. In addition, the four mobile videos will make it possible for the IEC personnel at the central level and in the three regions to make audio-visualpresentations at seminars or in villages.

B. Supportto IEC Activitiesfor Priority Programs

14. Rationale. Resourcesavailable for IEC activitiesare too limitedeven for priority programs. The strengtheningof the NHED and of the regional teams will contributeto a higher quality and a better cost efficiency, but additionalsupport will be necessary to ensure that these programs can reach their objectives.

15. Activities. The objectivesof the IEC activitiesfor the family planningand the AIDS control programs are the following:(i) motivatetarget populationsto use contraceptivesor, in the case of the AIDS program, to adopt low risk behaviors; (ii) develop messagesbased on an in-depth knowledgeof the target audience; and (iii) disseminatemessages using a multimedia strategyl/ tailored to the media habits of the target audience. In order to reach these objectives, the project propose to finance the followingactivities:

a. Two study tours: One for family planningand the other for AIDS. The family planningtour could be to one of the Muslimcountries that has been successfulin setting up training, monitoring,supervision and evaluationmechanisms in an integrated context (FP and MCH) such as Tunisia. It is also a country where a mobile strategy has been tested and from which the Comoriancould learn. The AIDS study tour shouldbe to a country which has one of the most successful AIDS preventionIEC Program in Africa;

1/ The media that can be uaed are radio (national and local), theater, video, traditional media and interpersonal communication. 51 ANNEX II Page 5 of 5 b. Several studies: (i) a knowledge, attitude and practice (KAP) study on AIDS and sexuality; (ii) a target audiencesurvey to determined what are the privileged means of communicationfor the various target audiences,their media habits, etc.; (iii) a study on obstaclesto family planning and causes of discontinued contraceptiveuse; and (iv) some qualitativestudies as needed (for example, focus group discussions,in depth interview, points of service intercept studies); c. Training: (i) ten workshopsto train "relays", i.e. persons who will assist in disseminatingmessages, such as leaders of communityassociations. These "relays" will be trained in interpersonalcommunication and community mobilization,with particular reference to FP and AIDS; and (ii) four seminars for radio and print journalists; d. IEC Materials: Design, pre-test and production (by NHED or by a sub-contractor under the supervisionof NHED and of the concernedprogram) of IEC materials which could include audio-visualmaterials (video or audio tapes), theater plays, songs, sketches, flip charts, in agreementwith identifiedneeds; and e. Technical assistance: Two months of technical assistanceto assist with specific tasks which will be identified as the project progresses. It could be to assist with the design and the executionof studies or to design printed material such as a flip chart. 52 ANNEX III Page 1 of 18

TECHNICALASSISTANCE AND TRAINING

I. HEALTH COMPONENT

A. Descriptionof Project Office

1. A smallProject Office will be put in place and attached to the General Director of Health within the Ministryof Health. The office will be located in a buildingbelonging to the Ministry of Health, and its rehabilitationwill be financedthrough the PPF.

2. The Project Office will be responsiblefor ensuring that project componentsare being executed in a timely fashion. More specifically,the Project Office will: (a) prepare annual work programs and correspondingbudgets; (b) coordinatethe activitiesof the various components;(c) maintainan accountingsystem for each project sub-componentsatisfactory to IDA and prepare quarterly and annual financial reports; (d) prepare all bidding documentsin a manner acceptableto IDA; (e) prepare quarterly and annual progress reports; (f) ensure that audits are performed annuallyin a timely fashion; (g) manageall technical assistance contractsfor the project; and (h) perform a mid-term review of the project during the third year of project implementation.

3. The Project Office will be comprisedof nationals, includinga project director, a financial director, an engineer/procurementspecialist and the necessary support staff.

4. Studies and supervisionof civil works financedthrough the project will be executedby a private firm or NGO recruited with procedures acceptableto IDA. The Project Office engineerwill be responsiblefor coordinatingthese activitiesas well as visiting the sites regularly. In the same way procurementof goods, technical assistanceand training will be executedby private firms or NGOs recruited with procedures acceptableto IDA. The Project Office's Director will be responsiblefor coordinationof all these activities accordinglyto the Work Plan.

5. Regarding procurement,standard bidding documentsfor civil works and equipments(as well as equipmentlists) were prepared during the appraisal mission. However, short-term internationaltechnical assistancehas been budgeted to assist in the finalizationof these lists and the preparationof technicalspecifications for civil works. In addition, the person within the Project Office that will be responsiblefor procurementwill attend a training course on Bank procurementduring the first year of project implementation. 53 ANNEX III Page 2 of 18 B. Terms of Referencefor Staff of the Project Office

Coordinator

6. The Project Office Coordinatorwill be responsiblefor the overall managementof the activitiesand resourcesof the health component.More specifically,the Coordinator's responsibilitieswill include:

- plan yearly work plan for the Project's health component;

- implementthe Project's rules and regulations;

- review and submit annual budgets for the Project's health component;

- ensure applicationof rules and standards regarding administrativeand financial operations of the Project;

- negotiate, collect and distributefinancial and material resources for the benefit of the health componentof the Project;

- managethe Project Office staff and consultantsfor the benefit of the Project;

- review, commenton and promptlydistribute the quarterly and annual reports of the Project's health component;

- commenton the Project's audit reports

- review and commenton conventions,contracts or agreementsfor the implementationof project activitiesto be signed by the Minister of Health and Population;

- ensure relationshipswith partners of the Project on behalf of the Minister or the MOH Director General;

- follow and supervise a strategy of hiring NGOs and private firms to execute civil works and purchase equipment;and

- assist the Minister in the selection of implementingagencies and consultants;

7. Duration will be for five years (renewableevery year).

8. Profile. The Project Office Coordinatormust have a universitydegree in Social Sciences. Previous experiencewith donor-financedproject would be a strong advantage. Must be fluent in spoken and written French. 54 ANNEX 11I Page 3 of 18 Accountant

9. Under the supervisionof the Project Coordinator, the Accountant'sresponsibilities will be as follows:

assist in establishingthe Project's yearly budget based on work program to be submittedto IDA;

monitor and insist on the applicationof rules and standards regarding administrativeand financialoperations of the Project;

prepare quarterly, annual and other reports on the various aspects of the administrativeand financialmanagement of the Project in accordance with the rules of IDA as containedin the document "FinancialReporting and Auditingof Projects Financedby the World Bank" (March 1982);

- maintainall accountingrecords;

- monitor closely expenditurespertinent to the Project;

- monitor carefullythe implementationof financialoperations on a cash basis;

- establishlogistics for the benefit of the Project;

- provide input on IDA requirementsfor the automationof the accountingsystem;

10. Duration would be for five years (renewableevery year).

ProcurementSpecialist

11. Profile. The Procurment specialistmust have at least 3 years of work experience as an accountant,preferably having worked on a donor-financedproject. A universitydegree, with a major in accounting,would be preferred. Familiaritywith computers will be required. The Accountantwill have to become familiar with IDA disbursementand other procedures. Fluency in French necessary. Proficiencyin English would be desirable.

12. Under the supervisionof the Project Coordinator, the ProcurementSpecialist's responsibilitieswill be as follows:

prepare and finalize documentsfor the selection of implementingagencies;

prepare conventions,contracts or agreementsfor the implementationof project activitiesto be signed by the Minister of Health and Population;

supervisethe work of private firms and NGOs responsible for the elaborationof bidding documentsfor civil works, equipment,vehicles and the selectionof companiesto perform civil works required under the project, following the standard bidding documentsprovided by IDA, and in accordance with IDA's rules 55 ANNEX III Page 4 of 18

as containedin the document "Guidelinesfor Procurementunder IBRD Loans and IDA Credits" (May 1992)

- prepare documentsfor hiring consultants,in accordancewith IDA's rules as containedin the document "Use of Consultantsby World Bank Borrowers and by The World Bank as Executing Agency" (August 1981); draft terms of reference, and participatein consultationsfor the selection of consultants;and

- coordinatethe work of contractorsperforming civil works undertakenunder the project, includingregular visits to the buildingsites.

13. Duration wouldbe for five years (renewableevery year).

14. Profile. The procurementspecialist wouldhave training and/or extensive experiencein procurementfor civil works and equipment,preferably for a large institution. Experience with a World Bank project wouldbe highly desirable. Training as an engineer or architectwill be a plus. The procurementspecialist would have to become quickly familiar with IDA procurementguidelines. Fluency in French is necessary. Proficiencyin English will be desirable.

C. Terms of Referencefor Technical Assistance

Supervisionof PharmaceuticalSector

15. The Consultantin the NationalDirectorate of PharmaceuticalInspection (Direction Nationaled'Inspection Pharmaceutique) will assist MOH in strengtheningof the capacitiesof the Directorate to monitor and enforce the applicationof regulationsand standardsregarding Comoros' pharmaceuticalsector. The Consultantwill assist in the preparationof a comprehensive NationalPharmaceutical Code and in the design of therapeuticprotocols for Primary Health Care Workers. He/she will also develop task and performancestandards for MOH Pharmaceutical Inspectors.He/she will conduct inspectionof the PNAC, private and communitypharmacies, and other units involvedin the distributionof pharmaceuticalproducts.

16. Durationwould be for three years (renewableevery year).

17. Profile. The Consultantmust have a universitydegree in Pharmacy and at least 5 years of experiencein drug management,preferably having worked in a successfulhealth project as a team leader. Familiaritywith Sub-SaharanAfrica will be a strong advantage.Proficiency in French will be required.

Health Administration

18. The Consultantsin Health Administrationwill assist MOH in preparing rules, proceduresand administrativestandards required for improvingthe performancesof health facilities.Based on these documents, the consultantswill design working tools and curricula to be used for the training of cadres in charge with the managementand supervisionof health facilities. They will also conduct training for MOH administrativestaff, includingmanagers of health facilities, secretariesand accountants. 56 ANNEX III Page 5 of 18 19. Duration wouldbe:

5 persons-monthsin the first year;

2 persons-monthsin the second year.

20. Profile. The Consultantsmust have at least 5 years of experienceas Health Administrators.They will have a universitydegree with major in Health Administration. Training in Health

21. The Consultantsin Training in Health will assist MOH in preparing health service policy and standardsdocuments. Based on these documents, they will help design therapeutic protocolsfor Primary Health Care Workers and curricula for FP and STDs-AIDS.They will also develop task and performancestandards for supervisors. In addition, they will conduct clinical skills workshops for physiciansand refresher training courses in comprehensiveprimary health care for nurses and midwives.

22. Duration would be:

4 persons-monthsin the first year

3 persons-monthsin the second year

3 persons-monthsin the third year

23. Profile. The Consultantsmust have a good experiencein training in health, preferablyworking for an institutionspecialized in human resources developmentin Sub-Saharan Africa. Familiaritywith FP and AIDS will be a strong advantage.Proficiency in French will be required.

Social Studies

24. Consultantsin SocialStudies will assist the MOH in the administrationand organizationof survey activitiesparticularly in the field of AIDS and Family Planning and in formattingthe protocols of result analysis. The Consultantswill also be responsiblefor the training of the staff who will participatein survey activities.

25. Duration would be:

4 persons-monthsin the first year;

3 persons-monthsin the second year;

3 persons-monthsin the third year 57 ANNEX III Page 6 of 18

26. Profile. The Consultantswill have good experiencein designing and leading surveys in social sector, particularlyregarding the data processing, statisticaland social areas.

Information.Education and Communications

27. The objective of this consultationwould be to: (a) operationalizethe National Health EducationDirectorate (NHED)of the Ministry of Public Health and Population(MOH); and (b) define the coordinationmechanisms between the various programs and the NHED.

28. In order to achieve these objectivesthe consultantwill work in close collaboration with the NHED personnel and with the personnelof the various health and populationprograms and with the concerneddonors. In particular, the consultantwill coordinatewith the United Nations DevelopmentProgram (UNDP) which is presently developinga Development Communicationproject.

29. The consultantwill assist the NHED personnel to organize a three-day seminar that will have the followingobjectives:

* Identify issues facing the MOH in the areas of IEC;

* Review the mandate of the NHED;

* Identify mechanismsfor coordinatinghealth and populationIEC activitiesand develop an organizationchart specifyinghow the various programs will relate to the NHED;

* Make an inventory of human (number of persons and skills), financial and material resources which should be put at the disposal of the NHED;

* Identify the personnelwho would have the responsibilityto carry out IEC activitiesat the periphery;

* Specifyhow IEC activitieswill be manageboth at the central and peripheral levels.

Participantsin this seminar would includethe managementpersonnel of the various health and populationprograms, representativeof the concerneddonors and the regionalmedical officers.

30. The consultantwill assist the NHED personnel to:

* Prepare a one year activityplan correspondingto the health and population priorities of the Ministry;

* Prepare job descriptionfor the personnel of the NHED and for the regional IEC personnel;

* Review, in close collaborationwith program personnel, the job descriptionof the person(s) responsiblefor IEC activitiesin each of the various health and 58 ANNEX III Page 7 of 18

populationprograms and specify the procedure by which this/these person(s) will collaboratewith NHED personnel;

* Assess the training needs of the IEC personnel (in the NHED, in the programs and in the regionalteam) and prepare a training plan; and

* Identify the task for which short term technical assistancewill be needed and prepare terms of referencefor each of the needed consultations.

31. Duration would be eight weeks.

32. Profile. The consultantshould have experience in developingsocial communicationprograms in the field of health and populationin less developedcountries and a minimumof five years of professionalexperience in Sub-SaharanAfrica. The consultantwho will be fluent in spoken and written French should at least have a Master's degree in social sciences or in social communication.

D. Trainin2Activities in the Health Sector

Training in Managementfor 15 higher-levelstaff of the MOH

33. Objectives. To provide a team of 15 higher level MOH staff with the capability to set up and operate an efficientsystem for personnel management;health center supervision; budget management;and staff training. These training programs will be provided by WHO's Public Health Training Centers.

34. Location: Africa

35. Schedule:

First year (5 people) Second year (5 people) Fourth year (5 people)

36. Duration would be 3 months.

Managementtraining for 3 RegionalMedical Officers

37. Objectives. To provide each of the country's health regions with a senior physician able to efficientlyensure the smoothdevelopment of priority health programs throughoutan island. This training will be provided by instituteswith experience in training District MedicalOfficers.

38. Location: Africa

39. Schedule:

First year (for the 3 physicians) ANNEX III Page 8 of 18 40. Duration wouldbe 3 months.

Training in public health for 3 nurses from the RegionalHealth Teams

41. Objectives. To provide each of the 3 regional health teams in the country with one nurse specializedin Public Health and having the capacity to assist the Regional Medical Officer in organizingPublic Health activities. This training would be provided by a French- speaking Public Health School.

42. Location: Africa, Europe or Canada

43. Schedule:

Fourth year (for the 3 nurses)

44. Duration wouldbe 18 months.

Training in public health for 6 nurses from the RegionalHealth Teams

45. Obiective. Provide each of the three regional health teams with 2 nurses qualified in public health and capableof planning, administration,and evaluationpublic health activitiesat the island level. This training will be providedby the WHO's Public Health Institutesor other national instituteswhich train districthealth staff.

46. Location: Africa, Europe or Canada

47. Schedule:

First year (for 3 nurses) Second year (for 3 nurses)

48. Duration wouldbe for 3 months.

Training in managementfor 5 hospital directors

49. Objectives: To provide each of the country's 5 hospitalswith the capacity to set up and operate an efficient system of managementof human, physical and financial resources. This training will be provided by specialistsin hospital administration.

50. Location: This training will take place partly in Moroni and partly in well- managedhospitals in France.

51. Schedule:

First year (for Hombo and Fombonihospitals directors) Third year (for directors of the three other hospitals)

52. Duration wouldbe 6 months, of which 3 months in Moroni and the remaining in France. 60 ANNEX III Page 9 of 18 Training in managementfor 15 managers from health centers

53. Objective: To provide each of the 15 country's health centers with a high level staff able to set up and operate efficientlya system of managementfor human, physical and financial resources. The candidatesfor this training will be recruited from among BEPC graduates from Comoros' schoolof managementscience. This training will be provided by specialistsin hospitaladministration.

54. Location: Moroni.

55. Schedule:

First year (for 5 managers) Second year (for 10 managers)

56. Duration would be for 3 months.

Training in administrationfor 5 MOH secretaries

57. Objectives. To provide 2 central Directoratesand 3 regionalHealth Teams with an agent able to take responsibilitiesusually delegatedto a director's assistant, regarding mainly the efficientuse of office equipment,mail preparation, filing and office organization. Candidates to this training will be recruited from among the Government's administrativestaff. This training will be provided by specialistsin Administration.

58. Location: Moroni.

59. Schedule:

First year (for the 5 secretaries)

60. Durationwould be for 3 months.

Training in managementfor 27 high level staff of the MOH

61. Objectives. To integratethe techniquesof good managementof resources into the functioningof the programsof the ministry. Consultantsspecialized in health administrationwill provide the training.

62. Location: Moroni.

63. Schedule:

Second year (for the 27 staff)

64. Duration would be for 3 days. 61 ANNEX 111 Page 10 of 18 Training in FP for 9 high level staff of the MOH

65. Objectives. Increase the number of MOH staff able to adequatelyprovide a wide range of FP services, includingIUD and NORPLANT. Training will be provided by institutions specializedin FP training.

66. Location: African or Asian Islamic countries.

67. Schedule:

First year (for 1 physician and 2 nurses) Secondyear (for 2 physicians and 2 nurses) Third year (for 2 nurses).

68. Duration: 8 weeks.

Training in FP for 150 MOH staff

69. Objectives: To increasethe number of MOH agents able to adequatelyprovide essentialFP services (counseling,contraceptive methods, pill, injectablecontraceptives). The upgrading of FP agents will be providedjointly by consultantsand by high level MOH staff trained in FP.

70. Location: main administrativetowns of Comoros. 71. Schedule:

First year (for 25 agents in one session) Second year (for 50 agents in 3 sessions) Third year (for 75 agents in 3 sessions).

72. Duration wouldbe for 2 weeks.

Training for Director of NationalHealth EducationDirectorate

73. Objectives: To have one IEC professionalwho can provide leadershipand technicalexpertise in communicationplanning, strategy development,and material design and production.

74. Location: Universityoffering advancedcommunication training in French.

75. Schedule: Startingacademic year of the first year of the project 76. Duration: 18 months 62 ANNEX III Page 11 of 18 Training for 3 regionalTEC Coordinators

77. Objectives: To have, in each region, one agent trained in IEC and who will be able to provide technical leadership, coordinateregional IEC activities, supervisecommunity level IEC activitiesand liaise with the central level.

78. Location: To be determined.

79. Schedule: First year of project implementation.

80. Duration: 3 - 4 weeks.

Training for 3 IEC agents at the central level

81. Objectives: To increase the number of agents who have expertise in IEC and provide assistanceto the various health and populationprograms and to the regions. 82. Location: Africa

83. Schedule: To be determined

84. Duration: 5 - 8 weeks

Training of trainers in interpersonalcommunications and social mobilization

85. Objectives: To have IEC trainers who will be able to trained community workers and health personnel in interpersonalcommunication and social mobilizationto motivate the public to adopt new health practices.

86. Location: Moroni

87. Schedule: During the first year of the project.

88. Duration: Three weeks.

Technicaltraining of 3 laboratory assistants

89. Objectives. To provide each health unit in the country with a lab assistant able to adequatelycarry out examinationsto identify STD (sexually-transmitteddiseases) agents, includingAIDS, having the capabilityto keep laboratoryrecords up-to-date, ensure adequate suppliesof reagents, ensure the maintenanceof lab equipment,train other lab assistants, and provide supervisionand quality control of the lab activitiesconducted throughout the island. The training of these lab assistantswill be provided in a laboratory with experience in MST and AIDS training.

90. Location: Yaounde. 63

ANNEX III Page 12 of 18 91. Schedule:

First year (for 1 lab assistant) Second year (for 2 lab assistants)

92. Duration would be for 3 months.

TRAINING PLAN: HEALTH COMPONENT

Person-months of training provided:

Subject Year I Year 2 Year 3 Year 4 Year 5

Management: Local 36 43 Foreign 30 24 15 Public health:

Foreign 9 9 36 18 Family planning:

Local 15 25 40 Foreign 6 8 4 IEC: Foreign 9 18 3 Laboratory techniques Foreign 3 6 64 ANNEX III Page 13 of 18

II. COMMUNITYDEVELOPMENT SOCIAL FUND COMPONENT

A. Terms of Reference: Assistanceof NGO

93. General context. PresidentialDecree No 92-054/PRof March 14 1992provides for an NGO to assist the PreparationCommittee in the preparationof communitydevelopment activities. The CanadianNGO CECI was identifiedand its support has proved efficient. To ensure the continuityof this intervention,CECI has been called upon to continue to help the CDSF with the followingtasks: (a) organizationand animationof the public awarenessand informationcampaign; (b) identificationand preparationof micro-projectssolicited by village communities;(c) managementof work sites and/or installationof sub-projects;and (d) administrativeand financial managementof the CDSF.

94. Compositionof CECI team. The CECI team consistsof a coordinator(36 months), an accountingexpert (3 months) and 4 volunteers (1 accountantsand 3 specialistsin project managementfor communitydevelopment: 36 months for each). This compositionas well as the duration of the interventioncould be revised in the light of new needs and of the evolution of the CDSF, particularlyfor interventionspromoting the status of women (nutrition, child care, health, literacy, home economicsetc).

Coordinator

95. Working under the authority of the ExecutiveDirector of the CDSF, the coordinatorhas, amongothers, the followingtasks:

Administrativeand financial management: assure the managementof the funds of the CDSF, which come in large part from the IDA credit; in that regard, observe the specific procedures in the Credit Agreementand in the manual of procedures of the CDSF; plan and control quarterly and annual reports submittedby the regionaloffices; prepare the financial statementsin conjunctionwith the accountingspecialists; assure the financial control and supervisionof the projects financedby the CDSF, and analyzeany irregularities;participate in the editingof periodic reports on activities;help to put in place the accountingunit; and train the responsiblenational personnel in financialmanagement.

Technicalassistance: help to coordinatethe activitiesof the cooperants;put in place a supply system for work sites, and provide efficient supportfor the realizationof micro-projects;establish to this end a system of information managementwhich will allow the periodic supervisionof the situationat the work sites and of works completedin the differentregions; help, as much as possible, with the preparationof sub-projects;and organize and participate in seminarsfor the central and regionalstaff of the CDSF on the followingsubjects: (a) identification,preparation and appraisalof micro-projects,and (b) organization and managementof work sites and/or sub-projectsfinanced by the CDSF. 65 ANNEX III Page 14 of 18

96. Profile. Preferably engineerin rural civil works; proven experience in the organizationand managementof projects and work sites; previous experience in rural developmentprojects; knowledgeof computersrequired; team spirit and communicationsaptitude; perfect spoken and written French.

Volunteers

97. Working under the authorityof the RegionalSub-Directors, the volunteers would have, amongst others, the followingtasks:

- Public awarenessand information: participatein the training of the members of the Pilot Committees;in that regard, initiate simpletechniques adapted to the Comorian situation;participate, with the cooperationof the nationalsresponsible, in the organizationand animationof the public awarenessand information campaignpromoting the CDSF; in this campaign, pay particular attention to the principal themes relating to the introductionof a new culture of community organizationand management,keeping in mind: the objectivesof the CDSF, the assemblageand/or the coordinationof different village associations,the classificationof developmentactivities based on the resources available, the identificationand preparationof sub-projects,the preparation of an annual budget, the programmingof activitiesaccording to the financial capacity of the villages, and the introductionof a budget for upkeep and maintenance.

- UTechnicalAssistance: participate in the identificationof communitydevelopment sub-projects;help with the preparation of sub-projectssolicited by the village communities;animate the public awarenesscampaign aimed at mobilizinghuman, financial and material resourcestoward the realizationof the sub-projects; participatein the organization,programming and supervisionof activitiesat the work sites; supervise, in close cooperationwith national specialistsand the CECI coordinator,the supply system for the work sites; establish periodic reports on progress at the work sites for the central and regional authorities, signallingany anomaliesobserved.

98. Profile. Volunteersmanifesting a strong interest in the problems of community developmentat the village level; training in communicationsrequired; sense of public relations; knowledgeof work site management;capability to endure the conditionsof living and transport as well as frequent visits to remotevillages; fluent in spoken and written French.

AccountingSpecialist

99. Working under the ExecutiveDirector, under the technicalsupervision of the CECI Coordinator, the specialist would have, among others, the followingtasks:

help to establishthe accountingand financial system of the CDSF; putting in place, in that regard, a computerizedsystem of financial information;

propose the procedures of budget preparationand cash flow plan; 66 ANNEX III Page 15 of 18

define the proceduresfor engaging expenditures,and the instructionsfor use of bank accounts, conformingto the Manual of Proceduresfor the CDSF;

supervisethe institutionof financial and accountingarrangements;

plan and control the quarterly and annual reports;

prepare the financial statements;

assure the control and financial supervisionof projects financedby the CDSF, as well as analyze any irregularitiesnoted;

assure the training of national responsiblefor accountingand financial managementat the central and regional levels; and

- participatein the editingof periodic activityreports.

100. Profile. Proven experiencein computerizedfinancial management. Experience desirable in internationalprojects especiallythose financedby the World Bank; sense of public relations; knowledgeof communicationsdesired; ability to maintainactivities accordingto the hours of work in the main office or on visits to regionaloffices and work sites. Results ExDected

101. Financial and administrativemanagement. A structured and organizedExecutive Secretariatwould be functional,endowed with appropriatemeans and procedures of work, and staffed with qualified professionals. More precisely, a reliable and proven system of supply and financial managementwould have been establishedwithin six monthsof the interventionby CECI (target date: December 1993). The financial managementcell wouldbe endowedwith capable local personnel. Organizationally,the Manualof Procedureswould be put in place; the functional relationsbetween the different posts and levels of decision would have been established;the informationsystem wouldbe in position and working: financial and technical documentswould be produced accordingto the calendar forecast and wouldbe of sufficientquality accordingto an external audit (monthlyaccounts, financial reports, logbooks, annual reports).

102. TechnicalAssistance. At least 50% of the villagesof Comoroswould have benefittedfrom the technicaland financial support of the CDSF for the realizationof their program of communitydevelopment; the same number of pilot committeeswould be installedand trained by the CDSF; the rate of activitywould be 20 sub-projectsper year in Grande Comore and Anjouan, and 10 in Moheli; at least 50% of villages which have completeda project with financingfrom the CDSF will be maintainingtheir investmentsusing a budget for upkeep and maintenance. 67 ANNEX In Page 16 of 18 B. Training Activities 1991-95

103. Introduction.As the CDSF componentis aimed at promotingself-reliant, sustainable,socio-economic development of rural communities,by increasingthe local institutionalcapacity for developmentplanning and implementation,training would play a crucial role to help communitiesattain the proposed targets.

104. Objective. The general objectiveof the training plan is: (a) to help implementa new conceptof communitydevelopment based on an effectiveuse of available resourcesthrough a better organizationand management,and a larger concern for maintenanceof existingpublic property; (b) train managers for communitiesin basic techniquesof management,project and budget preparation, and communication.The training plan has also its own specific objectives, which are: (i) at the intermediateand lower level to train manpowerthat is needed to implement sub-projectsin various sectors (school rehabilitation,water supply system, post health construction,etc.); (ii) to provide support to small contractorswho have contracts with communitiesthrough the CDSF's financing; (iii) to help promote women's developmentby providing training in primary health care, nutrition, child care and by improvingliteracy rates.

105. Training Plan. The training plan would involve: (a) 1800members of the CommunityPilot Committeesfrom about 180 villages (GrandeComore: 800 agents, Anjouan: 800 agents, Moheli: 200 agents); (b) 100 book-keepers-one for each community-;(c) 100 warehouse-keepers;(d) 600 masons, 180 carpenters, 360 school furniture makers, 100 fitters and plumbers, and 270 painters; (c) 90 job site supervisors; (d) 2500 rural women in the three islands.

106. Organizationof Training. Training activitieswill be coordinatedby the Informationand Training Unit (ITU). In view of the special nature of the CDSF, both activities must be coordinatedvery closely if they are to be successful:

a. Information.In the area of information,ITU's main responsibilitiesare: (i) to coordinatemain activitiesof the informationcampaign on the the CDSF; (ii) to identify main issues in implementingthe CDSF's program, in particular introducinga new concept of organizationand managementat the communitylevel, and the communityadopting a maintenancebudget as a conditionalityfor the financingof any micro-projectby the CDSF; (iii) to organize seminars and colloquyson communitydevelopment, by special attentionto the social behavior of communities;and (iv) to propose a strategy of informationfor the CDSF, and an appropriateaction plan.

b. Training. ITU's responsibilitiesare: (i) to propose a training strategy, in accordancewith the needs of each communityand in response to the main issues identified, (ii) to draw up the training programs with the participationof professionalstaff and consultantsboth national and expatriate, (iii) to propose suitablemeasures to associate supervisorystaff closely with training activities; (iv) to provide for monitoringand control of training; and (v) to evaluate training actions and propose adequateactions to improve the quality of training provided.

107. Strategy of Training. The function of training should be understoodby all as crucial to the CDSF's success. Staff and technicalassistance would activelyparticipate in training. To this end, terms of reference for their assignmentwould includespecific clauses on training, 68

ANNEX III Page 17 of 18 and their participationwill be clearly defined in close coordinationwith ITU to ensure a coherence in methodologyand evaluationof training; the performanceof consultantswill be finally evaluatedto a large extent on their ability and efforts in providing training to local staff; in addition, seminars in communicationand training methodsfor techniciansskilled in production will be organizedwith a view to strengtheningthe training corps and ensuring effective monitoringof trainees in their place of work.

108. Several modes of training will be used to help implementthe training plan:

a. training in managementfor managers at both central and local level will provided by CECI's consultants,whose experience and skills have proved to be satisfactoryduring the project preparation.Trainees wouldbe selectedthrough the formation of the Pilot Village Committeesamong the best educatedhabitants and/or those recognizedfor their strong leadership.Training would consist of 2 to 3 one-week seminars organizedyearly for groups of about 12 trainees. The majorityof training would, however, be delivered on-the-jobduring the period of project identification,preparation and implementation. Topics of discussionwould include: (a) the CDSF's objectives, organization, and financingprocedures; (b) project preparation, proposals, and implementation,(c) communitydevelopment and organization, (d) budget preparationand monitoring, (e) work planningand organization,(f) communicationand reporting, and (g) specificissues either politicaland social or economicrelevant to the new concept of community developmentand organization;

b. training for women's developmentwould be carried out by CARITAS's professionalstaff whose performanceis well-knownin this area; training would be conductedfor one half-day a week for 10 months, includingreading, arithmetic, home economics,family book-keeping,child care, basic health care, nutrition and tailoring; each trainee wouldhave to pay an annual tuition fee of 1,200 FC. The impact of this program is likely to be importantbut not sufficientin relation to nationalneeds. During the project implementationsupport would be provided by the CDSF to build up the training capacity of local NGOs, particularlyWomen Associations,in improvingthe literacy rate and deliveringtraining at the most remote and poorest villages.

c. training for workers in basic skills will be provided on-the-jobby mobile teams composedof job site supervisors, foremen and part-time trainers hired under the project. Trainees for each job site would be selected and dividedinto professionaland qualification groups. Training programs wouldstart with a two-dayorientation session including presentationof the main features of work, organizationof the job site, preparationof materials, testing of equipmentand inventoryof individualtools, discussionof individual assignment.Most training would be deliveredon the job. Each group of trainees would be placed under the responsibilityof a foreman whose professionalqualification and communicationability are confirmedafter test. Foremen are responsiblefor ensuringthe quality control, providing technicaladvice, and organizingtheoretical training as necessary. 69 ANNEX III Page 18 of 18

TRAININGPLAN: CDSF

(1991-95)

SPECIALTY GDE COMORE ANJOUAN MOHELI TOTAL (trainees! (trainees) (trainees) (trainees) Management 800 800 230 1.830

Job site 80 80 23 183 Supervision Accounting 80 80 23 183

Basic Skills Masons 280 280 70 630 Carpenters 80 80 20 180 Fitters 40 40 15 95 Painters 120 120 30 270 Furniture makers 160 160 40 360 Women 1.000 500 500 2.000 development TOTAL 2.640 2.140 951 5.731 COMOROS POPULATION AND HUMAN RESOURCES DEVELOPMENT Project Cost Estimates Projects Components by Year

Totals Including Contingencies Totals Including Contingencies FC SUS

01 02 03 04 0S Totat 01 02 03 04 05 Totat

A. Support to Heatth Sector 1. Support to Centrat Levet 36125 77507 54065 19373 0 187070 134 287 200 72 0 693 2. Support to Regionat Levet 15057 33222 36644 29059 14127 128108 56 123 136 108 52 474 3. Heatth Facitities Rehabit 130695 381596 497306 273914 140024 1423535 484 1413 1842 1014 519 5272 4. FamiLy Ptanning Program 4106 33251 27455 9081 0 73893 15 123 102 34 0 274 5. STD/AIDS Program 6300 30675 29146 14179 3151 83450 23 114 108 53 12 309 6. Project Ilptementation Un 52149 25734 23830 24783 25774 152270 193 95 88 92 95 564

Sub-Total 244432 581983 668446 370389 183077 2048327 905 2155 2476 1372 678 7586

B. CommiunityDev. Soc. Fund 1. Adninistration 59211 61579 64043 66604 69268 320706 219 228 237 247 257 1188 2. Sub-Projects 169107 370792 385113 400223 415928 1741163 626 1373 1426 1482 1540 6449

Sub-Total 228318 432371 449155 466828 485196 2061869 846 1601 1664 1729 1797 7637

C. PPF 219469 0 0 0 0 219469 813 0 0 0 0 813

Total PROJECTS COSTS 692219 1014355 1117601 837216 668273 4329665 2564 3757 4139 3101 2475 16036 0

Vatues Scated by 1000.0 11/3/1993 11:52

(D

0 < Fh COMOROS POPULATIONAND HUMANRESOURCES DEVELOPHENT Project Cost Estimates FC

Project Components by Year

Base Costs Totat

01 02 03 04 05 FC SUS A. Support to Health Sector 1. Support to Central Level 35640 74250 49950 17280 0 177120 656 2. Support to Regional Level 14850 31860 34020 25920 12150 118800 440 3. Health Facilities Rehabit 128250 363150 454950 238950 117450 1302750 4825 4. Family Planning Program 4050 31860 25380 8100 0 69390 257 5. STD/AIDS Program 6210 29430 27000 12690 2700 78030 289 6. Project Implementation Un 51300 24300 21600 21600 21600 140400 520 Sub-total 240300 554850 612900 324540 153900 1886490 6987 B. Community Dev. Soc. Fund 1. Administration 58050 58050 58050 58050 58050 290250 2. Sub-Projects 1075 166050 351000 351000 351000 351000 1570050 5815 Sub-total 224100 409050 409050 409050 409050 1860300 C. PPF 6890 216000 0 0 0 0 216000 800 Total BASELINE COSTS 680400 963900 1021950 733590 562950 3962790 14677 Physical Contingencies 0 0 0 0 0 Price Contingencies 0 0 11819 50455 95651 103626 105323 366875 1359 Total PROJECT COSTS 692219 1014355 1117601 837216 668273 4329665 16036 Taxes 0 0 0 0 0 Foreign Exchange 0 0 171957 300162 273013 108986 75270 929389 3442 Values ScaLed by 1000.0 11/3/1993 11:52

tD

O COMOROS POPULATIONAND HULAN RESOURCESDEVELOPMENT Project Cost Estimates Sufary Accounts by Year

Totals Including Contingencies Totats Including Contingencies FC SUS

01 02 03 04 05 Total 01 02 03 04 05 Total

1. INVESTMENT COSTS

A. Equipment, Vehicles, Mat. 36088 250387 194572 11142 0 492189 134 927 721 41 0 1823 S. Training 36136 86864 100399 68107 18837 310342 134 322 372 252 70 1149 C. Civil Works 13770 85925 205532 151796 19331 476354 51 318 761 562 72 1764 D. Technical Assistance 37262 32785 36879 3037 3151 113113 138 121 137 11 12 419 E. ppf 219469 0 0 0 0 219469 813 0 0 0 0 813 F. CDSF sub-projects 169107 370792 385113 400223 415928 1741163 626 1373 1426 1482 1540 6449

Total INVESTMENT COSTS 511832 826752 922495 634306 457246 3352631 1896 3062 3417 2349 1694 12417

II. RECURRENT COSTS

A. Operating Costs 121176 126023 131064 136307 141759 656328 449 467 485 505 525 2431 B. CDSF Acdninistration 59211 61579 64043 66604 69268 320706 219 228 237 247 257 1188

Total RECURRENT COSTS 180387 187602 195107 202911 211027 977034 668 695 723 752 782 3619

Total PROJECT COSTS 692219 1014355 1117601 837216 668273 4329665 2564 3757 4139 3101 2475 16036

Values Scaled by 1000.0 11/3/1993 11:52

C- Fhs COMOROS POPULATION AND HUMAN RESOUJRCESDEVELOPMENT Project Cost Estimates Table 10. Support to Central Level Detailed Cost TabLe FC

Totals lncluding Contingencies Quantity Unit Cost Base Costs In SUS SUS

01-05 Total 1-05 01 02 03 04 05 Total 01 02 03 04 05 Total 1. INVESTMENT COSTS

A. Equipment repinfolec - - - 52000 100000 0 0 0 152000 52654 104097 0 0 0 156751 B. Technicat Assistance Foreign - - - 30000 52000 62000 0 0 144000 30442 54432 67210 0 0 152085 IEC foreign - - - 0 12000 12000 0 0 24000 0 12561 13008 0 0 25570 IEC local - - - 6000 12000 12000 0 0 30000 6088 12561 13008 0 0 31658

Sub-Total 36000 76000 86000 0 0 198000 36531 79555 93227 0 0 209313 C. Training Foreign - - 20000 70000 70000 50000 0 210000 20278 73117 75667 56055 0 225118 Local - - - 6000 14000 14000 14000 0 48000 6083 14623 15133 15696 0 51536 IEC foreign - - - 18000 15000 15000 0 0 48000 18250 15668 16214 0 0 50133

Sub-Total 44000 99000 99000 64000 0 306000 44612 103409 107015 71751 0 326787

Total INVESTMENT COSTS 132000 275000 185000 64000 0 656000 133797 287061 200241 71751 0 692851

Total 132000 275000 185000 64000 0 656000 133797 287061 200241 71751 0 692851 11/3/1993 11:51

-10

0_

0) COMOROS POPULATIONAND HUMANRESOURCES DEVELOPMENT Project Cost Estimates Table 20. Support to Regional Level Detailed Cost Table FC

Quantity Unit Cost Base Costs in SUS

01-05 Total 1-05 01 02 03 04 05 Total

1. INVESTMENT COSTS

A. Equipment, Vehicles, Hat repinfo - - - 0 18000 30000 0 0 48000 S. Training Foreign - - - 45000 90000 90000 90000 45000 360000 Local - - 4000 0 0 0 0 4000 IEC foreign - - - 6000 6000 6000 6000 0 24000 IEC local - - 0 4000 0 0 0 4000

Sub-Total 55000 100000 96000 96000 45000 392000

Total INVESTMENT COSTS 55000 118000 126000 96000 45000 440000

Total 55000 118000 126000 96000 45000 440000

11/3/1993 11:51

c-I 0< COMOROS POPULATIONAND HUMANRESOURCES DEVELOPMENT Project Cost Estimates Table 20. Support to Regional Level Detailed Cost Table FC

Totals Including Contingencies sus

01 02 03 04 05 Total

1. INVESTMENT COSTS

A. Equipment, Vehicles, Hat repinfo 0 18590 31945 0 0 50534 B. Training Foreign 45626 94008 97286 100900 52324 390144 Local 4056 0 0 0 0 4056 IEC foreign 6083 6267 6486 6727 0 25563 IEC local 0 4178 0 0 0 4178

Sub-Total 55765 104453 103772 107626 52324 423941

TotaL INVESTMENT COSTS 55765 123043 135717 107626 52324 474475

Total 55765 123043 135717 107626 52324 474475

11/3/1993 11:51

iiOC. COMOROS POPULATIONAND HUMANRESOURCES DEVELOPMENT ProjectCost Estimates Table 30. Health FacilitiesRehabilitation DetailedCost Table FC

Quantity Unit Cost Base Costs in SUS

01-05 Total 1-05 01 02 03 04 05 Total 1. INVESTMENTCOSTS A. Civil Works Hombo Hospital - - - 10000 200000 340000 0 0 550000 Fomboni Hospitat - - - 10000 0 150000 190000 0 350000 CS/Cm - - 10000 100000 200000 300000 60000 670000 Sub-Total 30000 300000 690000 490000 60000 1570000 B. Equipment Hombo Hospital - - - 0 650000 0 0 0 650000 FamboniHospital - - - 0 0 200000 0 0 200000 CS/Cm 0 0 400000 0 0 400000

Sub-Total 0 650000 600000 0 0 1250000 C. Training Foreign - - - 0 20000 20000 20000 15000 75000 Local - - - 0 15000 15000 15000 0 45000 Sub-Total 0 35000 35000 35000 15000 120000 D. TechnicalAssistance VNU - - - 85000 0 0 0 0 85000 Total INVESTMENTCOSTS 115000 985000 1325000 525000 75000 3025000 11. RECURRENTCOSTS ...... A. Goverrnentcontribution - - - 360000 360000 360000 360000 360000 1800000

Total RECURRENTCOSTS 360000 360000 360000 360000 360000 1800000

Total 475000 1345000 1685000 885000 435000 4825000 11/3/1993 11:51

01

0<1 COMOROS POPULATION AND HUMAN RESOURCES DEVELOPMENT Project Cost Estimates TabLe 30. Health Facilities Rehabilitation Detailed Cost Table FC

Totals Including Contingencies Sus

01 02 03 04 05 TotaL

I. INVESTMENT COSTS

A. CiviL Uorks Hombo Hospital 10200 212160 375099 0 0 597459 Fomboni Hospital 10200 0 165485 217999 0 393683 CS/Cm 10200 106080 220646 344208 71595 752730

Sub-Total 30600 318240 761230 562207 71595 1743872 S. Equipment Hombo Hospital 0 676633 0 0 0 676633 Fomboni Hospital 0 0 215216 0 0 215216 CS/CM 0 0 430432 0 0 430432

Sub-Total 0 676633 645648 0 0 1322280 C. Training Foreign 0 20891 21619 22422 17441 82373 Local 0 15668 16214 16817 0 48699

Sub-Total 0 36559 37833 39239 17441 131072 D. Technical Assistance VNU 86254 0 0 0 0 86254

Total INVESTMENT COSTS 116854 1031431 1444711 601446 89037 3283479

II. RECURRENT COSTS

A. Goverranentcontribution 367200 381888 397164 413050 429572 1988874

Total RECURRENT COSTS 367200 381888 397164 413050 429572 1988874

Total 484054 1413319 1841875 1014496 518609 5272353

11/3/1993 11:51

El 0) COIiOROS POPUULATIONAND HUl4ANRESOURCES DEVELOPMENT Project Cost Estimates Table 40. Family Plaming Program Detailed Cost Table FC

Totals Including Contingencies Quantity Unit Cost Base Costs in SUS SOS

01-05 Total 1-05 01 02 03 04 05 Total 01 02 03 04 05 Total

1. INVESTMENT COSTS

A. Equipment 0 0 0 15615 IEC - - - 0 15000 0 0 0 15000 0 15615 0 0 0 31229 Contraceptives - - - 0 30000 0 0 0 30000 0 31229 0 0 46844 Sub-Total 0 45000 0 0 0 45000 0 46844 0 B. Training 0 19457 0 0 19457 IEC foreign - - - 0 0 18000 0 0 18000 0 6486 0 0 9619 IEC local - - 0 3000 6000 0 0 9000 0 3134 32429 33633 0 97398 Foreign - - - 0 30000 30000 30000 0 90000 0 31336 16214 0 0 47091 Local - - - 15000 15000 15000 0 0 45000 15209 15668 33633 0 173566 Sub-Total 15000 48000 69000 30000 0 162000 15209 50138 74586 C. Technical Assistance 0 0 0 10468 IEC study - - - 0 10000 0 0 0 10000 0 10468 10840 0 0 26542 IEC surveys - - - 0 15000 10000 0 0 25000 0 15702 16260 0 0 16260 IEC other - 0 0 15000 0 0 15000 0 0 0 0 53270 Sub-Total 0 25000 25000 0 0 50000 0 26169 27101 101687 33633 0 273680 Total INVESTMENT COSTS 15000 118000 94000 30000 0 257000 15209 123151 101687 33633 0 273680 Total 15000 118000 94000 30000 0 257000 15209 123151

11/3/1993 11:52

00

0< COMOROS POPULATIONAND HUMANRESOWRCES DEVELOPMENT Project Cost Estimates Table 50. STD/AIDS Programs Detailed Cost Table FC

Totals Including Contingencies Ouantity Unit Cost Base Costs in SUS Sus

01-05 Total 1-05 01 02 03 04 05 Total 01 02 03 04 05 Total

I. INVESTMENT COSTS

A. Equipment IEC - - - 0 15000 0 0 0 15000 0 15615 0 0 0 15615 Diagnostic - - - 0 23000 0 0 0 23000 0 23942 0 0 0 23942 Suppties & reagents - - - 0 40000 40000 37000 0 117000 0 41639 43043 41268 0 125950

Sub-Total 0 78000 40000 37000 0 155000 0 81196 43043 41268 0 165507 B. Technical Assistance IEC surveys - - 0 10000 10000 10000 10000 40000 0 10468 10840 11247 11670 44225 IEC research - 0 5000 5000 0 0 10000 0 5234 5420 0 0 10654 IEC other - - 15000 0 0 0 0 15000 15221 0 0 0 0 15221

Sub-Total 15000 15000 15000 10000 10000 65000 15221 15702 16260 11247 11670 70100 C. Training IEC foreign - - - 8000 0 0 0 0 8000 8111 0 0 0 0 5111 IEC local - - - 0 6000 0 0 0 6000 0 6267 0 0 0 6267 Foreign - - - 0 10000 45000 0 0 55000 0 10445 48643 0 0 59088

Sub-Total 8000 16000 45000 0 0 69000 8111 16713 48643 0 0 73467

Total INVESTMENT COSTS 23000 109000 100000 47000 10000 289000 23333 113610 107947 52516 11670 309075

Total 23000 109000 100000 47000 10000 289000 23333 113610 107947 52516 11670 309075

11/3/1993 11:52

(D

0

0) COMOROS POPULATIONAND HUMAN RESOURCESDEVELOPMENT Project Cost Estimates Table 60. Project Implementation Unit Detailed Cost Table FC

Totals IncltudingContingencies Quantity Unit Cost Base Costs in SUS SUS 01-05 Total 1-05 01 02 03 04 05 Total 01 02 03 04 05 Total 1. INVESTMENT COSTS

A. Civil Works - - 20000 0 0 0 0 20000 20400 B. Training 0 0 0 0 20400 Foreign - - - 10000 10000 0 0 0 20000 10139 C. Equipment 10445 0 0 0 20584 Repinfovehfurn - - - 80000 0 0 0 0 80000 81006 0 0 0 0 81006 Total INVESTMENT COSTS 110000 10000 0 0 0 120000 111545 10445 0 0 0 121991 II. RECURRENT COSTS

A. Operatin costs - - - 80000 80000 80000 80000 80000 400000 81600 84864 88259 91789 95460 441972 Total RECURRENT COSTS 80000 80000 80000 80000 80000 400000 81600 84864 88259 91789 95460 441972 Total 190000 90000 80000 80000 80000 520000 193145 95309 88259 91789 95460 563962 11/3/1993 11:52

0C

0 COMOROS POPULATIONAND HUMANRESOURCES DEVELOPMENT Project Cost Estimates TabLe 70. CDSF Adninistration Detailed Cost Table FC

Quantity Unit Cost Base Costs in SUS

01-05 Total 1-05 01 02 03 04 05 Total

11. RECURRENT COSTS A. Adninistration CDSF administration - - - 215000 215000 215000 215000 215000 1075000 TaRUE.S5 215000 215000 215000 215000 10--000 Total RECURRENT COSTS 215000 215000 215000 215000 215000 1075000

Total 215000 215000 215000 215000 215000 1075000 11/3/1993 11:52

00

0< Shc: COMOROS POPULATION AND HUKAN RESOURCES DEVELOPMENT Project Cost Estimates Table 70. CDSF Achninistration Detailed Cost Table FC

Totals Including Contingencies SUS

01 02 03 04 05 Totat

11. RECURRENT COSTS

A. Acdninistratlon CDSF administration 219300 228072 237195 246683 256550 1187800 Totl2130 ECURET CST 228072--- 237195--- 246683-- 256- 1 Total RECURRENT COSTS 219300 228072 237195 246683 256550 1187800

Totat 219300 228072 237195 246683 256550 1187800

11/3/1993 11:52

a)

O C COMOROS POPULATION AND HUMAN RESOURCES DEVELOPMENT Project Cost Estimates Table 80. CDSF Sub-Projects Detailed Cost TabLe FC

Quantity Unit Cost Base Costs in SUS

01-05 Total 1-05 01 02 03 04 05 Total 1. INVESTMENTCOSTS

A. Sub-projects CDSF sub-projects - - - 500000 1100000 1100000 1100000 1100000 4900000 Govt & Cmmnty Participatn - - - 115000 200000 200000 200000 200000 915000

Sub-Total 615000 1300000 1300000 1300000 1300000 5815000 Total INVESTHENTCOSTS 615000 1300000 1300000 1300000 1300000 5815000

Total 615000 1300000 1300000 1300000 1300000 5815000

11/3/1993 11:52

00 CO,

0< FH COYOROS POPULATION AND HUMAN RESOURCES DEVELOPMENT Project Cost Estimates Tabte 80. CDSF Sub-Projects Detailed Cost Table FC

Totals Including Contingencies SUs

01 02 03 04 05 Total

1. INVESTMENTCOSTS

A. Sub-projects CDSF sub-projects 509023 1161142 1205698 1252836 1301822 5430522 Govt & Cmmnty Participatn 117300 212160 220646 229472 238651 1018230

Sub-Total 626323 1373302 1426344 1482308 1540473 6448751

Total INVESTMENTCOSTS 626323 1373302 1426344 1482308 1540473 6448751

Total 626323 1373302 1426344 1482308 1540473 6448751

11/3/1993 11:52

03

0OCl COMOROS POPULATIONAND HUMANRESOURCES DEVELOPMENT Project Cost Estimates Table 90. Project Preparation Facility Detailed Cost Table FC

Totals Including Contingencies Quantity Unit Cost Base Costs in SWS SUs

01-05 Total 1-05 01 02 03 04 05 Total 01 02 03 04 05 Total -- - , - - - ...... ------1. INVESTMENT COSTS

A. PPF PPF - - - 800000 0 0 0 0 800000 812850 0 0 0 0 812850

TotaL INVESTMENT COSTS 800000 0 0 0 0 800000 812850 0 0 0 0 812850 ======Z ======Z======wt w=====rs Total 800000 0 0 0 0 800000 812850 0 0 0 0 812850

11/3/1993 11:52

OD cn

00

'-1 H O q 86 ANNEX V Page 1 of 1

ESTIMATED SCHEDULE OF DISBURSEMENTS

QUARTER DISBURSEMENTS | ACCUMULATED DISBURSED l______I_ DISBURSEMENTS |_ % FY94 March 31, 1994 0.4 0.4 3 June 30, 1994 0.4 0.8 3 FY95 September 30, 1994 0.5 1.3 4 December 31, 1994 0.6 1.9 5 March 31, 1995 0.7 2.6 5 June 30, 1995 0.7 3.3 5 FY96 September 30, 1995 0.7 4.0 5 December 31, 1995 0.8 4.8 6 March 31, 1996 1.0 5.8 8 June 30, 1996 1.0 6.8 8 FY97

September 30, 1996 1.0 7.8 7 December 31, 1996 0.8 8.6 6 March 31, 1997 0.7 9.3 5 June 30, 1997 0.6 9.9 5 FY98

September 30, 1997 0.6 10.5 5 December 31, 1997 0.6 11.1 5 March 31, 1998 0.5 11.6 4 June 30, 1998 0.5 12.1 4 FY99

September 30, 1998 0.5 12.6 4 December 31, 1998 0.4 13.0 3 87

ANNEX VI Page 1 of 4

PERFORMANCE INDICATORS: HEALTH COMPONENT

I. Indicators of Activity Value at start Value at Value at (1991) mid-point end (1999) l______(1996) 1. Total number of outpatient visits per year 850000 2. Medication distributed annually by public 70,20 145,75 establishments (value in FC millions)

3. Contraceptives other than condoms 7131 17490 distributed annually by the FP program (couple- years of protection)

4. Condoms distributed per year (thousands of 287,897 600 1200 units)

5. Doses of vaccine administered annually by 126 the EPI program (thousands of doses)

6. Pre-natal consultations per year 20442 68000 7. Births correctly assisted per year 5780 20000 8. Consultations/visits for family planning per 18253 30000 50000 year

10. Number of HIV tests performed per year 25000 11. Number of human treponema palladium 25000 type A tests performed per year

12. Cumulative number of health facilities made 0 3 5 functional under the project (minimum) 13. Cumulative number of higher level staff of the 0 50 80 MSPP trained under the project l 14. Cumulative number of health workers of the 0 75 150 MSPP trained locally under the project

15. Cumulative number of participant-days 0 500 750 provided in seminars financed by the project l 16. Cumulative number of health facilities 0 3 5 rehabilitated by the project (minimum) 17. Cumulative number of functioning regional 0 3 3 health teams 88

ANNEX VI Page 2 of 4

I. Indicators of Achievement Value at Value at Value at start mid-point end 1. Percentageof required reports actually received 90 95 and correctly drawn up . - 2. Percentageof supervisionvisits performed 75 90 relative to norms and provisions of MSPP 3. Numberof new consultationsper resident 0,5 1 2 per year 4. Percentageof pregnanciescorrectly 46,6 60 90 monitored 5. Percentageof births correctly attended 27.2 40 60 6. Percentageof childrencorrectly vaccinated 84,96 95 7. Percentageof people over age 14 who have 90 heard of AIDS 8. Percentageof people over age 14 who have 90 heard of family planning 9. Percentageof adults (over 15 years) who know 90 the 3 means of transmissionof AIDS 10. Percentage of adults (over 14 years) who know 90 how to effectively protect themselves against AIDS 11. Number of active users 3384 20000 12. Annual consumptionof contraceptives(number 7,42 12 18 of couple-yearsof protectionper 100 women aged 15to 49 years). 89

ANNEX VI Page 3 of 4

III. Indicators of Impact Value at Value at Value at start mid-point end 1. Gross mortalityrate (per 1000 population) 13,6 10 2. Maternalmortality (per 10000 pregnancies) 460 100 3. Infant mortalityrate (per 1000 live births) 91.9 60 4. Under-fivemortality rate (per 1000) 131.2 75 5. Mean birth interval (months) 36 6. Global fertility rate 216,2 110 7. Numberof high risk pregnanciesper 1000 25 women age 15 to 45 (per year) l 8. Numberof cases of neo-nataltetanus 10 9. Number of deaths from malaria among children 2200 700 aged less than 5 years l 10. Numberof deaths from diarrheal diseases 1800 600 among children aged less than 5 years l 11. Annualgrowth rate of HIV seropositivityamong 0 pregnant women 12. Seropositivityrate for human treponema 22,1 2 palladium type A among pregnant women If 13. Contraceptiveprevalence rate (accordingto 3,2 7 10 survey) 90

ANNEX VI Page 4 of 4

Indicators of Performanceof the FADC

The performanceof the FADC will be evaluatedevery three months, in particular at the end of each fiscal year, based on the indicatorsof performanceestablished in the light of the results obtainedduring the preparation of the project. These indicatorstranslate, dependingon the sector of intervention, into numbers of classroomsrehabilitated or constructed(education); the number of beneficiariesof water supply and rural roads projects (social infrastructure);the number of medical visits at the level of remote villages (primary health care); the number of women benefitting from literacy programs and other training for the promotionof women (women in development). Furthermore, indicatorswere also agreed for the evaluationof the FADC in other ways, such as (i) the effect of capacity buildingefforts at the village level, in particular in terms of the number of village steering committeestrained in administrativeand financial project management;(ii) the improvementof the techniquesof local labor, through the introductionof improvedtechniques in the sub-projectsof the FADC.

Results expected at the end of each year are the following:(a) education: 3,000 students benefitingfrom 35 to 40 rehabilitatedclassrooms; (b) water supply: 10,000 beneficiaries;(c) health care: 40,000 health care visits; (d) women in development:4,000 womentrained in literacy, childcare, nutrition, and artisanry; (e) roads and bridges: 2,000 people; (f) management strengthening:40 steering committeestrained in project management;(g) human resources: 800 people trained in differentprofessions.

The managementcapacity of the FADC will also be evaluated, based on the followingannual indicators: (a) ability to assist the preparation and implementationof sub-projects: 50 sub- projects approved and 40 sub-projectscompleted; (b) popularisationcampaigns: training of 30 steering comrnittees;(c) sustainabilityof the interventionsof the FADC: 20 steering committees still in operationafter the completionof sub-projects,as measured by the creation of a maintainancefund, and by the constitutionof units responsiblefor the maintainanceof the works completed;(d) participationof other donors in sub-projects;(e) training of local NGOs working in the fields of literacy and women in development(3 NGOs per year). 91 ANNEX VII Page 1 of 1

SUPERVISION PLAN

Approximate Date Activity Staff 05/94 Project Launch and Project Supervision E, IS, SFS, PHS, CDS, FA, JECS 09/94 Supervision mission E, IS, CDS, PHS 03/95 Supervision rmission E, CDS, HFS 07/95 Supervision rmission (annual review) E, IS, CDS, PHS, SFS 01/96 Supervision mission E, CDS, PHS 06/96 Joint Bank/Governnent Mid-Term review E, IS, CDS, PHS, HFS, SFS, FA, JECS 10/96 Supervision mission E, CDS, PHS 02/97 Supervision mission E 06/97 Supervision mission (annual review) E, IS, CDS, PHS 10/97 Supervision mission E, CDS, PHS 02/98 Supervision rnission E 09/98 Final supervision mission E, IS, CDS, PHS

E = Economist (task manager), IS = implementation specialist, PHS = public health specialist, FA = financial analyst, SFS = social fund specialist, IECS = specialist in information, education and communications, CDS = community development specialist, HFS = health financing specialist.

Expected staff inputs represent 75 sw broken down as follows: 20 in 1994, 15 in 1995, 20 in 1996 and 10 in 1997 and 1998. This does not include the TM's desk work. Due to the implementation record in Comoros and the fact that there is no resident mission in Comoros which can maintain contact with the project, supervision missions are correspondingly heavy. 92 ANNEX VIII Page 1 of 1

SELECTEDDOCUMENTS IN THE PROJECT FILE

1. Preparation report of the Governmentfor the health component,prepared by the consultantsAssociation Sante-International (ASI). Five volumes: - General presentationand executivesummary - The health system - Financial and administrativemanagement - Equipment needs - Civil works needs

2. InterministerialOrder of December21 1992concerning an autonomousregime of managementof receipts and expensesin hospitals.

3. Tripartite review of MitsoudjePilot Project between the Governmentof Comoros, UNDP and ASI, January 1993.

4. Nationalplan for developmentin health: perspectivesfor the year 2000, MOH, March 1991, Moroni.

5. OperationalManual of the CDSF (AF3PH divisionfiles)

6. Said Islam MoinaechaMroudjae and Sophie Blanchy:The status and situation of women in the Comoros, UNDP, March 1988, Moroni.

7. Women in Comoros,CECI

8. Notes on poverty in Comoros(AF3PH division files)

9. Decree of January 6, 1993concerning the creation of the CDSF and its administrative structures; and that of April 23, 1993concerning its organizationand operations. 93 ANNEX IX Page 1 of 4 THE PILOT EXPERIENCEAT MITSOUDJEHEALTH CENTER

1. The project consistsof the constructionand equipmentof a health center, the installation of a system of managementto ensure the operatingcosts of the center, and the elaboration of a model of health services that could be reproduced in other areas. Money was raised in the communityfor the constructionof the facility, and UNDP has provided major assistance. The French NGO ASI has been engaged for technical assistance. The project is to run three years of which 2 are completed. A review was conductedin January 1993, the report of which is in the project files.

2. The center, located on the island of Grand Comore in the relativelywealthy village of Mitsoudje, includes services of external consultation,MCH/FP, EPI, laboratory, dentistry as well as hospitalizationfor observation. As the center is about 40 minutesaway from Moroniby car, serious cases are evacuatedto the hospitalthere, as are radiology requests.

3. All services are paying, except for vaccinations. Surveys were conductedin the local area to determine what the rates should be. For instance,the rate of FC200 to see a nurse (triage) was fixed to equal the cost of the taxi fare to Moroni where treatmentwould be free at a regular clinic. The tariff is shown below:

Consultation triage 200 physician (direct) 1,000 emergency 500

Care emergency 1,000 injections 100 dressing 1,000 incision 1,500 circumcision 3,000

Laboratory (dependingon 500 exam) 1,000 1,500

Dental care 1st cons. 1,000 2nd cons. 500

Hospitalization 1,000

Childbirth 1,500

Prenatal cons. 500

Evacuations 1,500 94 ANNEX IX Page 2 of 4

There is no formal system of fees for the indigent. This will depend on the discretionof the staff, and rebates are rare. All receipts are retained at the facility level.

4. Drugs are supplied through a village pharmacy installedwithin the center. Patients must pay for their drugs, as with all other pharmacies in Comoros. Review of the system shows that patients spend on averageFC 900 per prescription and that virtually no patients were unable to fulfill this prescription (eitherthrough lack of money or due to lack of stock in the pharmacy). However, a problem noted in the report is that the margin allowed by the PNAC (20%) does not cover all the center's costs in running the pharmacy, and discussionsare under way regarding the possibilityof increasingthis margin.

5. When setting up the center, the project also conductedsurveys in the area on what the populationexpected from their health center. One importantcomplaint about public health services is that the patients are treated impolitely. Therefore at Mitsoudje, care was taken to train all the staff in patient relations. Receptionstaff in particular are evaluatedon their courtesy. When the center was first in operation, a "greeter" was posted at the receptionto explain to newcomersthe philosophyof service and cost recovery.

6. Managementof the center is shared by a committeeof local residents, and by the doctor. Other than requiring conformitywith standardsfor a health center, the Ministry of Health has very little involvementin the operationof the facility.

7. Staff in the center consist of 18 civil servants and 3 unskilledstaff hired contractuallyby the center. The doctor is on detachmentfrom the governmentservice, and is paid by the project at a rate about twice that of doctors in the Ministry of Health. In additionto their regular salaries, staff receive a "prime" based on their individualperformance and on the receipts on the center. This prime averagedabout 25% of their salaries in January 1993. The center also has the right to return to the public service any employeeswho do not meet the standardsof their work. This has already occurred twice.

8. The results: The center became operationalin April 1992. Consequently,definite conclusionsare premature. However, important initialreactions were reflected in the evaluation report and confirmedby the officialsof the Ministry of Health.

9. Financially,the center is doing very well. Receiptshave been rising about 10% per month and have reached over FC1 million for the month of January 1993. About 30% of receipts come from direct consultationswith the doctor (bypassingthe triage stage). This amount will enable the center not only to cover all recurrent costs but also to establisha reserve for minor and major maintenanceand equipmentpurchase. The budget of the health center (proposed 1993) is attached. Althoughthe salary of the doctor is at present paid by UNDP, the center expects to be able to fully make up the differencefrom the receipts once the doctor reverts to the public service at the end of the project in 1994.

10. Satisfactionwith the services provided is indicatedby the steady and continuingrise in utilizationand by the fact that at present (early 1993) about half of all patients come from outside the catchmentarea of the center. This demonstratesthe willingnessand ability of the population of Grande Comore to pay for services that are perceivedto be of high quality and reliable. Note: if all health centers were similarly improved, Mitsoudjewould lose some of these clients, reducing the efficiency of its services and receipts, especially in dentistry. 95 ANNEX IX Page 3 of 4

11. Although the center now sees significantlymore patients than most health centers in Comoros, and this number continues to increase, the total utilizationhas not yet achieved more than a relativelylow level of utilizationrelative to population(about one visit per year per person in the catchmentarea), and only about a quarter of childbirthstake place in the center. There is no system of house calls by center staff. The bed occupancyrate is very low (about 10%). The center appears, like many in Comoros, to be oversized and possiblyoverstaffed.

12. The report commentsthat Mitsoudjeremains, like most health centers, isolated from the levels above and below it. It does not have technicalsupervision from above, nor does it supervisethe 2 health posts in its area. Feedback on referrals is poor between the health center and the hospital.

13. Some lessons: (1) Local surveys and extensivetraining were important in providingthe center with policies and skills that are suited to their local environment. (2) Real results are achievable,but the time taken may be longer than expected.

14. Some caveats: (1) Not all communitiesare as financiallyable as that of Mitsoudje, and tariffs must be set at the facility level to adjust for this. Consequently,the governmentmust keep an eye on where subsidiesare needed, especiallyfor major maintenanceand investment. (2) Not all communitiesare as cohesive as those of the Grande Comore. More time and effort may be required on the other islands to bring the communityinto the managementof the centers. (3) The presence of a doctor has been very importantfor the credibilityof the services. Not all health centers at present have a doctor. (4) The centers must have real responsibilityover personnel, as is the case at Mitsoudje. (5) A good quality facility manager is very important, and most in place would need significantretraining to fulfill this task. At Mitsoudje the manager is a qualifiedaccountant, but this is not considerednecessary. 96 ANNEX IX Page 4 of 4

BUDGET PROVISIONS FOR 1993 MITSOUDJE HEALTH CENTER

(FC)

Budget items State Total including Fees Pharmacy WFP project

Staff expenses -Staff of the Ministry of Health 9,820,000 9,820,000 (doctor included) -Transportation 4 680,000 4.680,000 -Local salaries 420,000 420,000 -ASCSM staff 960,000 960,000 -Receptions 420,000 420,000

Supplies -Medical supplies 1,500,000 1,500,000 -Other supplies 480,000 166,000 312,000 (fuel, maintenance) -Support to management 600,000 150,000 450,000 -Outside services 60,000 60,000 -Electricity 1,300,000 1,300,000 -Food supply 200,000 200,000

Maintenance/working equipment -Automobiles 300,000 300,000 -Fixed assets 300,000 300,000 -Rehabilitation 250,000 250,000 -Technical material 200,000 100,000 100,000 Sub-total Administrative expenses 21,490,000 11,786,000 8,542,000 960,000 200,000 Capital expenditures New fixed assets 720,000 144,000 576,000 Provision for major repairs 4,875,000 3,875,000 1,000,000 Automobile 2,400,000 2,400,000 Sub-total Capital expenditures 7,995,000 4,019,000 3,976,000 Grand total Administrative expenses + capital expenditures 29,485,000 15,805,000 12,518,000 960,000 200,000 97

ANNEX X Page 1 of 3

HEALTH COMPONENT: ACTIVITY IMPLEMENTATION SCHEDULE

ACTIVITY YR -1 YR 1 YR 2 YR 3 YR 4 STRENGTHENING OF MOH EFFICIENCY Appointment of Project Office Staff X members by MOH Minister in agreement with IDA Appointment of DHE Staff members by X MOH Minister Definition of DHE coordinating X mechanisms by MOH with support from Technical Assistance Appointment of Regional Health Team X Staff members by MOH for a 5 year contract Training of a DHE Staff member as IEC trainer Training of 3 MOH Staff in IEC X Training of 15 MOH cadres in the X X X management of Public Health programs Training of 5 MOH cadres as X Executives Secretariats, 2 for MOH central directions and 3 for Regional Health Teams Training of 27 MOH cadres in the X management of health programs. Elaboration of documents on MOH X norms and procedures and on Pharmaceutical Legislation with support from Technical Assistance Elaboration of MOH therapeutical X protocols, with support from Technical Assistance Organization of 5 workshops on MOH X objectives and strategies for a total of 210 participants-days 98

ANNEX X Page 2 of 3

ACTIVITY YR -1 YR I YR 2 YR 3 YR 4 Training of 3 Regional Medical X Officers in Health District Management Training of 2 nurses per each of the 3 X X Health regions in the management of Health District Training of 3 accountants for the 3 X Regional Health Teams (RHT) Provision of equipments to 3 RHTs and X MOH Central Directions

Promulgation of texts on autonomy of X health facilities by the Head of State. Physical rehabilitation of Hombo X hospital Physical rehabilitation of Fomboni X Hospital Physical rehabilitation Sima Health X Center Physical rehabilitation of Moroni X Health Center Physical rehabilitation of Foumboni X Health Center Provision of equipments and seed X money to the 5 health facilities rehabilitated under the Project Training of 5 cadres in Hospital X X Administration Training in Comoros of 15 managers of X X Health Centers Supervision of RHTs by the Staff from X------MOH central directions ----X Supervision of health facilities by RHT X- ---- Staff ------X 99

ANNEX X Page 3 of 3

ACTIVITY YR -1 YR 1 YR 2 YR 3 YR 4 PROMOTING FP ACTIVITIES Organization of workshops on FP for X X X X leader and the general public to a total of 1800 participants-days Realization of 3 studies/surveys in the X X field of FP Training of 3 physicians and 6 nurses X X X in FP technic Training in Comoros of 150 health X X X workers in FP technic Delivery of equipments to MOH X Direction of Maternal and Child Health Provision to DMCH of an amount of X X X X money equivalent to US$3,000 as a contribution to the direction's recurrent costs SUPPORT TO THE NATIONAL AIDS CONTROL PROGRAM Organization of workshops on AIDS X X X X for the general public to a total of 2000 participants-days Realization of 5 transversal surveys in X X X X the field of AIDS Training of a Staff member of the X National AIDS Control Committee Elaboration of STD therapeutical X protocols Delivery of standard equipment X required for laboratory work to 20 MOH laboratories Provision of reagents and other X X X X commodities required for laboratory work on STDs to 20 laboratories Training of 3 lab technicians in STDs X X and AIDS 100 ANNEX XI Page 1 of I

COMOROS DEMOGRAPHY AND HEALTH RESOURCES. 1991

FIRC Grande Anjouan Moheli Comore POPULATION Total population 476.059 259.425 193.157 23.477 Under 5 population 84.262 45.918 34.189 4.155 Women aged 15 - 49 106.637 58.111 43.267 5.259 HEALTH FACILITIES

Health Posts 55 29 18 8 Health and Medical Centers 15 4 7 2 Rural Maternities 4 2 1 1 Hospitals/Surgical clinics 5 2 2 1 PERSONNEL

Comorian Physicians 22 14 7 1 Expatriate Physicians 31 16 11 4 Midwives (total) 75 52 16 7 Midwives (who have undergone a 46 23 16 7 specific training in Family Planning either in or outside Comoros)

Nurses 131 86 57 4 Technicians 48 20 22 6 Health Auxiliaries 560 262 220 78

Sources: MSSP, Memento des Statistiques Sanitaires et Demographiques, 1991. ANNEXXWI 101 Page 1 of 6

REPUBLIQUE FEDERALE ISLAMIQUE . - DES COMORES ------Moroni, le .

MINISTERE DE LA SANTE PUBLIQUE A l'attention de Monsieur Fransisco Aguirre-Sacasa Directeur du Departement IlIl R6gion Afrique, Banque Mondiale Washington D.C.

Objet: Politique de d6veloppement Sanitaire aux Comores

Monsieur le Directeur,

1. J'ai l'honneur de porter a votre connaissance par la pr6sente, les politiques et les strat6gies que le Gouvernement de la Republique F6d6rale Islamique des Comores entend poursuivre afin d'accro?tre l'efficacit6 des actions men6es dans les domaines de la Sante et de la population.

2. Depuis son accession a la souverainete internationale en 1975, le pays s'est fixe comme objectif d'assurer un niveau acceptable de soins de sante pour tous ses habitants. La politique sanitaire des dix dernieres ann6es a et6 ax6e sur les soins de sante primaires, mettant I'accent sur la disponibilit6 A 1'6chelon le plus periph6rique, d'un ensemble de services de sant6 prioritaires. Ainsi, conform6ment A 1'esprit de la declaration d'Alma-Ata, nos efforts ont-ils privilegie (a) I'immunisation de tous les enfants contre les six maladies cibles du Programme Elargi de Vaccinations, (b) La disponibilit6 et I'accessibilite universelle aux medicaments essentiels sur tout le territoire, (c) la surveillanc6 correcte des grossesses et des accouchements, (d) I'accbs aux m6thodes modernes d'espacement et de controle des naissances et (e) La prevention, la surveillance et le controle des principales endemies, et epid6mies, notamment le paludisme a Plasmodium Falciparum, la filariose et les maladies sexuellement transmissibles y compris le SIDA.

3. Malgre des succes signicatifs et I'appui important d'organismes d'assistance et de bailleurs de fonds de la communaut6 internationale (PNUD, OMS, UNICEF, FNUAP, CEE, COOPERATION FRANCAISE, APEFE, CARE, LIGUE ISLAMIQUE, BANQUE MONDIALE, BANQUE AFRICAINE DE DEVELOPPEMENT, etc.. .la Republique Fed6rale Islamique des Comores doit deployer des efforts additionnels afin d'atteindre l'objectif de la sante pour tous, mentionne plus haut. Les taux de mortalite se trouvent encore a des niveaux inacceptables. La situation qui prevaut a l'heure actuelle est caracteris6e par la precarit6 de 1'etat de sante des populations, notamment des femmes en age de procreer et des enfants. La pathologie demeure dominee par le paludisme, les infections respiratoires aigues, les maladies diarrheiques, les maladies sexuellement transmissibles, ainsi que par d'autres maladies infectieuses et parasitaires. Les difficult6s socio-6conomiques du pays aussi bien que l'organisation et le fonctionnement du systeme de sante limitent l'acces des groupes A risque aux soins primaires de bonne qualit6. 102 ANNEXXII Page 2 of 6 - Plan National de Developpement Sanitaire.

4. Depuis mai 1991, le pays s'est dote d'un Plan Sanitaire qui definit les grandes orientations et les axes prioritaires de la politique Sanitaire dans la perspective de l'an 2000. Les activites et les programmes prioritaires poursuivront les memes objectifs que par le pass6, a savoir: la promotion par l'information,l1'ducation et la communication, des comportements favorables a la sante, la prestation des services de sant6 maternelle et infantile, y compris les vaccinations, la surveillance pr6- et peri-natale et la planification familiale, la lutte contre les eridemies et les 6pidemies, en particulier le paludisme, les infections respiratoires aigues, les maladies diarrh6iques, les maladies sexuellement transmissibles et le SIDA; et enfin l'approvisionnement et la fabrication locale de medicaments essentiels, notamment par le d6veloppement du reseau des pharmacies mises en place selon la strategie de l'lnitiative de BAMAKO.

5. Toutefois, la forte croissance demographique des Comores et la structure de la population (le rapport d'age est tr6s d6plac6 au ben6fice des classes d'fge les plus jeunes) requierent une attention toute particuliere car ils soulevent des problemes sp6cifiques dans l'organisation des services et en matiere d'education pour la sant6: on pensera en particulier aux complications sanitaires dont souffrent beaucoup de femmes en age de procreer ( trop d'enfants, trop rapproches, meres trop jeunes ou au contraire trop agees.) Nous d6velopperons donc des efforts particuliers dans le secteur de la planification familiale et de la population, appuyes dans notre action. Notre strategie en la matiere s'organisera selon deux axes: I'IEC, cibi6e sur des groupes sensibles ( femmes de 15 a 49 ans et leurs maris, jeunes, leaders d'opinions) sera renforcee et 61argie; I'accbs aux m6thodes modernes d'espacement de controle des naissances et aux fournitures correspondantes sera g6neralise. Notre objectif est d'ameliorer le taux actuel d'utilisation des moyens modernes de regulation et de parvenir a un taux de 20% d'utilisatrices/ utilisateurs en I'an 2000.

- R&organisation du systeme de sant6

6. Au terme d'une periode de plus de quinze ann6es, les responsables politiques du pays ont duj prendre acte d'une evolution irreversible de la demande de soins , de pr6vention des maladies et de protection de la sante. L'augmentation continue des depenses de sante, la volont6 et la capacite de participation de la population a la resolution des problemes de sante impose une profonde et rapide reorganisation du systeme comorien.Pour des raisons qui tiennent a la fois des choix de societ6 effectues en R6publique Federale Islamique des Comores et des capacit6s 6conomiques et sociales du pays, il est devenu evident qu'au cours des prochaines annees, la politique nationale de la sante devra s'appuyer sur le developpement concerte du secteur public, du secteur prive, et communautaire meme si le secteur public a pour mission de constituer toute l'armature du systeme.

7. Afin de faciliter la mise en oeuvre de ce developpement, le Gouvernement a decid6 d'initier un ensemble de reformes institutionnelles qui concernent tous les niveaux de notre systeme sanitaire. Son objectif est d'offrir a 1'ensemble de la population l'acces a des soins de qualite et a une protection toujours efficace, associant les possibilit6s combin6es d'une accessibilite g6neralis6e independamment des ressources et du statut social d'une part, et d'un libre choix 6ventuel a l'initiative de l'utilisateur, d'autre part. 103 ANNEXXII Page 3 of 6 Une ioi-cadre permettra de d6finir les conditions dans lesquelles les secteurs publics, priv6 et communautaire pourront s'organiser et se d6velopper en foncion des besoins et des moyens du pays.

8. Pour assurer un developpementcoh6rent du secteur priv6, et communautaire I'ETAT mettra en place les organismes professionnels charg6s d'organiser et de contr6ler la pratique priv6e des professions m6dicales ( medecins, sages- femmes, infirmieres, pharmaciens, para-medicaux)et 6tablira les regles regissants les autorisations des installations, des constructions et des equipements.

9. Pour ce qui concerne le secteur public, la strat6gie d6veloppee mettra un accent particulier sur l'amelioration de la qualit6 des services fournis a la population. Elle impliquera: (a) la rehabilitation des structures sanitaires, (b) la fourniture d'equipements et de materiels essentiels pour garantir la coherence et la continuit6 des services prioritaires, (c) ia formation pertinente et la r6partition adequate des personnels de sant6 et (d) la mise en place de proc6dures de suivi et d'6valuation des activit6s sur le terrain. La mise en oeuvre de cette strat6gie n6cessitera un recours plus important au financement exterieur mais elle permettra d'assurer une meilleure protection de la population et de maintenir, voire de restaurer sa confiance dans un systeme qui joue un r6le essentiel dans le d6veloppement du bien-etre economique et social du pays. (e) -Le maintien de la carte sanitaire actuelle et l'interdiction de toute construction de nouvelle formation Sanitaire avant l'an 2000.

- Reforme institutionnelle et statutaire du secteur oublic

10. Pour parer aux graves difficuites de fonctionnement qui se sont manifest6es ces dernieres annees dans le secteur public,et pour lui donner toute la souplesse de fonctionnement et d'adaptation n6cessaire a une evolution rapide de la demande et des techniques, le Gouvernement a entrepris une profonde r6forme institutionnelle et statutaire de ce secteur.D'une maniere gen6rale, un accent particulier est mis sur la rationalisation du systeme sant6 et sur l'adaptation du secteur public aux realit6s demographiqueset socio-economiquesregionales. A cet effet, les services et les structures de soins et de prevention relevant du Ministere de la Sant6 Publique seront replaces dans un dispositif pyramidal hi6rarchise ou les services de sant6 periph6riques seront etablis a partir du Centre de Sant6 de district, veritable f6derateur des activit6s sanitaires effectuees par lui et par les postes de Sante qui lui seront r6f6r6s, y compris la distribution des m6dicaments reconnus essentiels. Chacun des centres de sant6 de district sera lui-meme r6f6re pour ses activit6s m6dicales et soignantes au centre hospitalier Regional (CHR) situe dans le chef-lieu de sa region, et son action sanitaire sera coordonnee avec celles des autres centres de sant6 de la region par l'interm6diaire des structures relevant de la direction Regionale de la Sant6 et des Affaires Sociales. ANNEXXII Page 4 of 6

11. Dans le souci d'accro^tre la rentabilite des moyens mis en oeuvre et conformement a l'esprit de la Declaration d'Alma-Ata, le Gouvernement organisera l'offre des services sur le principe de l'integration des activites des programmes verticaux nationaux, en remplacant progressivement les equipes mobiles par des elements polyvalents et integres au sein des 6quipes chargees du fonctionnement des services de sante peripheriques.

12. La distribution des soins de sante par le secteur public s'appuiera sur une responsabilisation accrue des cadres de la sante et des communaut6s et sur une participation directe a la gestion des structures, ainsi que sur un dispositif de financement combinant des ressources locales, nationales et eventuellement exterieures a des financements assures sur le budget de l'Etat. Les 6l6ments critiques essentiels de cette participation communautaire seront la decentralisation, I'intensification des activites d'information, d'education et de communication a tous les niveaux, la generalisation du principe du recouvrement des couts, la dotation de toutes les formations sanitaires d'une autonomie de gestion financiere et administrative avec integration des representants des communautes dans les instances de d6liberation et de d6cision.

13. Les formations sanitaires seront dotees d'un statut et d'un ensemble d'instruments juridiques conformes a leurs missions et a l'exercice de cette autonomie. La volonte d'etablir et de garantir l'efficacite de la gestion des centres hospitaliers regionaux se materialisera notamment par leur transformation en EtablissementsPublics Hospitaliers dotes de la personnalite morale, conformes aux dispositions des textes legislatifs en vigueur.

Ces etablissements seront dotes d'un Conseil d'Administration qui assurera le contr6le direct du fonctionnement et de l'usage des ressources allouees et de recettes apportees par la tarification officielle des actes effectues. Ces conseils seront composes de trois categories de membres, a savoir: des representants des collectivites territoriales, des representantsdes personnels de I'etablissement et des personnalites exterieures reconnues pour leur competence et leur interet dans l'un des domaines touchant au fonctionnement et aux activit6s du centre hospitalier Regional. Les representants regionaux du ministere criarge de la sant6 assisteront aux r6unions du Conseil d'Administration et y feront entendre la voix et les observations du ministere, en particulier en ce qui concernera le budget de fonctionnement, les equipements et la politique de developpement.

L'Etat pourra allouer des subventions en particulier pour I'acquisition d'equipements lourds et pour la realisation de travaux d'am6nagement ou d'extension. II participera directement au financement des activites de chaque etablissement hospitalier en mettant a sa disposition, un effectif de personnels agents de l'Etat, de toutes disciplines, places sous I'autorite hierarchique des responsablesde la direction du centre hospitalier Regional. Des conventions pourront soutenir la realisation d'activites specifiques a l'etablissement au regard des besoins regionaux ou nationaux. 105 ANNEXXII Page 5 of 6

14. Les Centres de Sante, (CS) les centres medico-urbains (CMU)et les centres medico-chirurgicaux (CMC) se verront dotes dans le meme temps du statut d'Etablissements prives sans but lucratif avec des missions de service public. Confies a des associations sans but lucratif cr6es a cet effet et agr6es par le ministere charg6 de la sante, ces centres disposeront des moyens n6cessaires a leur fonctionnement par le biais de dotation en personnels et en credits provenant du budget de l'Etat et affectes par convention et par le droit a percevoir le montant d'actes tarifes. La gestion des Postes de Sante sera confiee a des associations villageoises de soutien, qui se verront par convention, autoris6es a percevoir le montant d'actes tarif6s pour en couvrir les frais de fonctionnement. La participation de I'Etat, outre la prise en charge eventuelle de travaux de construction ou de rehabilitation, s'exprimera par des moyens affectes au poste au sein du budget du centre de sante de reference.

15. Les depenses engag6es par le Gouvernement pour participer au financement de ce dispositif devront se maintenir au niveau r6el des engagements reconnus pour 1992, soit au moins 800 millions de francs Comoriens.

20% au moins de ces engagements devront etre consacres aux depenses non salariales.

a partir de 1995 les budgets des formations Sanitaires seront alloues sur la base des contrats existants entre le Ministere de la Sante Publique et les formations sanitaires, et ce en relation avec le programme des d6penses Publiques que le Ministere de la Sant6 Publique 6tablira.

16. La mise en place de toutes les reformes mentionn6es ci-dessus n6cessitera la formation en gestion des responsablesdes etablissements sanitaires et de ceux des niveaux central et regional du Ministere de la Sante Publique. Des m6canismes seront mis en place pour assurer une repartition adequate des cadres form6s et garantir leur motivation et leur stabilit6.

17. Pour r6aliser un tel programme, I'echelon national du Ministere sera restructur6 de facon a lui permettre de: i) renforcer ses capacit6s d'appui aux r6gions sanitaires, ii) developper un systeme d'information sanitaire susceptible d'am6liorer la gestion de programme de sante,

ii) mobiliser et coordonner I'aide exterieure pour une meilleure utilisation de ressources sectorielles. 106 ANNEXXII Page 6 of 6

18. A l'echelon regional, la reforme consistera A la mise en place d'une equipe de sante dans chacune des 7ies. Chaque 6quipe sera dirigee par un medecin, directeur regional de la sante, et aura pour taches specifiques de:

a) programmer et mettre en oeuvre 1'ensemble des actions de sante au niveau de la region, y compris les activites d'information, d'education et de communication a destination de la population,

b) programmer et coordonner les activites A realiser dans les structures de sante peripheriques pour satisfaire aux programmes verticaux nationaux,

c) promouvoir et suivre la mise en place des nouvelles dispositions concernant la gestion et le fonctionnement des structures publiques de soins et de prevention,

d) veiller au bon fonctionnement de ces structures et y faire connaltre les points de vue, les recommandationset les decisions du Ministere,

e) favoriser la concertation locale, regionale et des partenaires sur le fonctionnement et les orientations A donner au developpement du systeme de sant6, en particulier par le biais de Comites locaux et regionaux de Developpementsanitaire.

4{*4*444

19. Nous sommes tout a fait conscients de l'ampleur de la tache entreprise, mais nous y avons ete vivement encourages par les appuis que nous avons recus tant de la part des organismes internationaux qu'auprAs de la population desireuse de voir s'am6liorer et se consolider un systeme de sante pour lequel elle temoigne un attachement constant. Nous ne doutons pas que notre action conduira A une sensible am6lioration de la sante de tous et aux developpements des comportements responsablesen matiArede demographie,de protection de la sante, d'hygiAne de vie et de solidarite nationale.

20. Nous vous prions de bien vouloir agreer, Monsieur le Directeur 1'expression de notre tres haute consideration;

Pour le Gouvernement,

LE PREMIERMINI STJ - LE MINISTRE,DE;A.SANTE PUBLIQUE CHEF DU GOUVE

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