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World Bank Document Report No. 651-TUN The Population Program of the Government of Tunisia A Sector Review Public Disclosure Authorized FILE COPY February 27, 1975 Population and Nutrition Projects Department Not for Public Use Public Disclosure Authorized Public Disclosure Authorized Document of the International Bank for Reconstruction and Development Public Disclosure Authorized International Development Association This report was prepared for official use only by the Bank Group. It may not be published, quoted or cited without Bank Group authorization. The Bank Group does not accept responsibility for the accuracy or completeness of the report. THE POPULATION PROGRAM OF THE GOVERNMENT OF TUNISIA A SECTOR REVIEW TABLE OF CONTENTS Page No. SUMMARY AND RECOMENDATIONS ................... i-vi PART I TUNISIA AND ITS POPULATION .............................. 1 A. Introduction .................................. 1 B. Brief Overview of Population Activities and the National Organization ......................... 6 C. Results of the National Family Planning Program 1964-1973 ..................................... 8 PART II I. THE NATIONAL OFFICE OF FAMILY PLANNING AND POPULATION 11 A. Organization .................................. 11 B. Future Plans .................................. 14 C. Recommendations ............................... 18 II. DELIVERY OF SERVICES ............................... 20 A. Health ........................................ 20 B. Family Planning ............................... 23 C. Recommendations ............................... 25 This sector review is based on the findings of two Bank missions to Tunisia. The first visited Tunisia in November/December, 1973 and was comprised of F.J.C.M. Rath (Chief), Dr. N.H. Fisek (Consultant), Joel Montague (Population Council) and A. Shaw (UNESCO), J.W. Kennedy (USAID) and H. Gaenger (UNFPA). Soon after the visit a new President Director General was appointed to the National Office of Family Planning and Population, and he made many changes in the organization, staff and program of the Office. Consequently, a second mission comprised of G. Zaidan (Chief), A. Shaw and Dr. C. Aguillaume (Consultant) was then sent to Tunisia in September, 1974 to review the draft report with the Government. This final version reflects the results of the reorganization which in many instances coincided with the earlier recommendations. Those comments and recommendations that are therefore no longer relevant have been omitted from this version. TABLE OF CONTENTS (Continued) Page No. III. MANPOWER AND TRAINING .............................. 30 A. Physicians .................................... 30 B. Paramedical Staff ............................. 33 C. Recommendations ............. ... ........... .. 35 IV. INFORMATION, EDUCATION AND COMMUNICATIONS .......... 37 A. Organization .................................. 37 B. Communication Activities ...................... 38 C. Media Research and Evaluation ................. 41 D. Rec ommendations ..................... ......... 42 V. EVALUATION AND RESEARCH ............................ 44 A. Production of Statistics ...................... 44 B. Research Activities ........................... 45 C. Recommendations ............................... 46 VI. PERSONNEL, SUPPLIES AND TRANSPORTATION ............. 48 ANNEXES 1. Tunisia: Enumerated Population in Censuses, 1891-1966 2. Tunisia: Percentage of Women Married as Reported in the 1956 and 1966 Tunisian Censuses, Classified by Age 3. Tunisia: Family Planning Program Activities and Percent Change, 1964-1973 4. Tunisia: Births Averted According to Method and Year, 1965-1971 5. Tunisia: Relative Contribution of Each Method to the Number of Births Averted, 1965-1971 6. Tunisia: Projection of Births to be Averted by Method and by Governorate for 1975 7. Tunisia: Family Planning Centers, 1972 8. Tunisia: Occupancy Rate and Duration of Stay in Hospitals, 1971 9. Tunisia: Distribution of Maternity Beds in Hospitals 10. Tunisia: Distribution of Hospital Beds and Utilization for Maternity and Gynecological Cases TABLE OF CONTENTS (Continued) 11. Tunisia: Activities of MCH Centers, 1971 12. Tunisia: New Family Planning Acceptors by Health Region, 1973 13. Tunisia: Objectives for the Year 1974 by Governorate and by Method 14. Tunisia: Family Planning Activities by Category of Center, 1972 15. Tunisia: Some Thoughts on Training and Employment of Health Workers 16. Tunisia: The Case for a Multipurpose Organization in the Provision of Family Planning Services 17. Tunisia: Geographical Distribution of Physicians, 1973 18. Tunisia: Tunisian and Foreign Physicians by Speciality, 1972 19. Tunisia: Students in Tunis Medical School by Class, 1964-74 20. Tunisia: Geographical Distribution of Midwives, Nurses and Nurse-Aides, 1972 21. Tunisia: Graduates of Nursing and Midwifery Schools, 1960-74 CHARTS 9490 Tunisia: Organigram of the National Office of Family Planning and Population 9491 Tunisia: Organigram of the Family Planning and Maternal and Child Health Services in a Governorate SUMMARY AND RECOMMENDATIONS Foreword: A sector review was undertaken at the request of the Tunisian Government, by two World Bank missions which visited Tunisia in November-December, 1973 and in September, 1974. The missions' main terms of reference were "to write a comprehensive report that will enable the Government to draft a detailed four-year plan of action." The first draft was designed to provide the basis for such a plan of action with the aim of improving family planning services and gaining a greater acceptance of the family planning idea by the general public. Before this draft was completed, the appointment of a new President Director General to the National Office of Family Planning and Population (ONPFP) led to a complete reorganization of the ONPFP. Many of the changes that this reorganization led to coincided with a number of the draft sector review's recommendations. The second Bank Mission visited Tunisia to up-date the review and this final version reflects the progress that has been made during 1974. The main findings and recommenda- tions are as follows: The Present Situation of the Family Planning Program 1. The official family planning program was started in 1963 with a two-year experimental program, followed by the national program which was launched in 1966. In 1973 a new law was enacted creating the National Office of Family Planning and Population (ONFPF). It functions under (or in rela- tionship with) the Ministry of Health. Apart from the ONPFP there are other bodies working in family planning, notably the Tunisian Family Planning Asso- ciation, the Tunisian National Railroad which has its own clinics, and private practitioners. From 1966 to 1973, family planning program performance was too modest to make an important impact on the fertility level but recent events suggest that the fertility rate is declining. However, it is now estimated that the national family planning program reaches about 7.33% of all eligible women. Organization 2. a. Relations between the Office, the Ministry of Health and the MCH Services: A major barrier to the full implementation of the family planning program in 1973 consisted of the Government's failure to precisely define the functions of the ONPFP. The decree establishing the Office gave it responsibility for the planning and execution of the program, but the Office saw its role as being mainly one of planning. The Ministry of Public Health was responsible for the delivery of services mainly through the maternal and child health (MCH) centers, and the Office was to a certain extent distinct from both of them. The appointment of the new President Director General (PDG) has changed this situation. - ii - The PDG has created excellent working relations with the Minister of Public Health and with the Regional Health Administrators. Through the latter he is in direct touch with the MCH centers; this link will be strengthened by the new infrastructure which the Office is creating by the appointment of a co-ordinating doctor and a regional secret- ary in each Regional Administrator's office. These personnel, who are responsible to the ONPFP, will provide a solid frame- work for family planning operations at the field level. At headquarters' level the system is mainly based on personal relations and this situation should be considered from a long- term point of view. It is recommended that the relations between the Office, the Ministry of Public Health and the MCH organization be put on a formal footing by the creation of a family planning opera- tion unit within the Ministry of Public Health in which all three organizations would be represented. This would enable the organizations concerned to work together to achieve com- plete coordination of effort, to have a creative interplay of ideas, to improve the program in all its aspects and provide a safeguard against difficulties which might arise because of changes in personnel. b. Relations with Other Ministries: For nationwide family plan- ning education and information the Office needs the cooperation of other ministries. The Office staff conduct courses for Government servants in ministries such as Agriculture, Labor and Social Affairs and Health, and they in turn pass the message on to their extension workers. The same approach is used with the large national organizations. In this manner a minimum number of people can influence very large numbers since the extension services of the ministries cover the whole country. Already the Office has set up
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