Document of The WorldBank
FOR OFFICIAL USE ONLY Public Disclosure Authorized Report No. 5440-MOR
Public Disclosure Authorized STAFF APPRAISAL REPORT
KINGDOMOF MOROCCO
HEALTHDEVELOPMENT PROJECT Public Disclosure Authorized
May 15, 1985 Public Disclosure Authorized
Population, Health and Nutrition Department
This document has a restricted distribution and may be used by recipients only in the performance of their oflicial duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCYEQUIVALENTS
US$1.00 = Dirham (DH) 9.47 DR 1.00 = US$0.106
FISCAL YEAR
January 1 - December 31 MOROCCO FORIOMFCIAL USE ONLY
HEALTH PROJECT
Table of Contents
Page No.
Table of Contents ...... i Loan and Project Summary *...... - iv Basic Data Sheet ...... vi Definitions ...... 0...... vii Abbreviations ...... *..* ** ix
I. THE SECTOR ...... 1 Background ...... 1
A. Population ...... 1 Population Profile ...... 1 Population Policy ...... 0.... 2 * Family Planning Program ...... 3
B. Nutrition ...... 4 Nutritional Status ...... 4 Causesof Malnutrition ...... 5 Government Nutrition Policies rnd Programs ...... 6
C. Health ...... 6 Health Status ...... 6 Environment...... 8 Bealth Services and Programs ...... 9 GovernmentHealth Policy ...... 10 Public Health Services ...... 11
D. Sectoral Resources ...... 12 PhysicalResources ...... 12 Human Resources ...... 13 FinancialResources ...... 14
E. Sectoral Issues ...... 15 HealthCare Delivery System ...... 15 Management...... 16 Supply of Basic Drugs ...... 16
F. Summarv Assessment of the Sector ...... 18
G. Government's Objectives and Bank Role ...... 19
This report is based on the findings of an appraisal mission vhich visited Morocco in September/October1984. The mission consisted of Messrs. Jean Pillet (Mission Leader), Louis G. Vassiliou, Richard Skolaik, Bernard Hubert, and Ms. Taraneh Tavana, World Bank staff, and Messrs. Hank Schut and Jean Lecoute, World Bank consultants.
This document has a restricted distribution and may be ued by recipients ooiy in the performance of their offcl duties Its contents may not otherwise be disdosed without World lank authorization. - ii -
II. THE PROJECT .. **...... 20
A. Proiect Concept and Obiectives ...... 20
B. Project Composition ...... 20
C. Proiect Description ...... 21 * Primary Health Services Component ...... 21 ManagementComponent ...... 23 * Training and IEC Component ...... 25 . Supply of Basic Drugs ...... 27
III. PROJECT COSTS AND FINANCING ...... 30 * Cost of the Project ...... 30 . Project Financing ...... 32
IV. PROJECT ORGANIZATION AND IMPLEMENTATION ...... 33 Organization ...... 33 . Procurement ...... 34 = Disbursement...... 35 * Accountsand Audits ...... 36 . Monitoring ...... 37 . Reporting and Evaluation ...... 38
V. PROJECT JUSTIFICATION AND RISKS ...... 39 Justification...... 39 . Risks ...... 40
VI. AGREEMENTS AND RECOMMENDATIONS ...... 41 = Condition of Board Presentation ...... 42 . Conditions of Disbursement ...... 42
ANNEXES
ANNEX A - Morocco Health Sector Basic Data Tables A.1 Contraceptive Prevalence ...... 44 A.2 Nutrition ...... 45 A.3 Causes of Mortality ...... 46 A.4 Profile of Demand for PHC ...... 47 A.5 Manpower Resources .a ...... 48 A.6 Manpower Education ...... 49 A.7 Health Care Facilities ...... 51 A.8 Capacity and Utilization of Hospitals ..... 52 A.9 MOPE Operating and Capital Budget ...... 53 A.10 Foreign Assistance in Population and Health Activities ...... 54 - iii-
ANNEX B - Proiect Area Description ...... 55 Tables B.1 Socio-demographic Characteristics ...... 58 B.2 Population Distribution ...... 59 B.3 Contraceptive Prevalence by Method ...... 60 B.4 Family Planning Acceptors ...... 61 B.5 MCH Consultations ...... 62 B.6 Existing Manpower ...... * *. * * * * * * * .. 63 B.7 Additional Manpower ...... 64
ANNEX C - PHC Core Proprams ...... 65
ANNEX D - PHC Strategies ...... 71
ANNEX E - Organization of the Health Delivery System ...... 74
ANNEX F - Plannina and Studies Structure and Rer.ponsibilities of the DICP ...... 75
ANNEX G - Druft Supply System Options for the supply of basic drugs ...... 79 Tables G.1 Requirements and Supply of Basic Drugs .... 82 G.2 Sequence of Operations of the Drug SupplySystem ...... 83
ANNEX H - Proiect Implementation Tables H.1 MOPH Organizational Chart ...... 84 H.2 Project Implementation Organizational Chart ...... 85 H.3 Project Implementation Timetable ...... 86 1.4 Technical Assistance ...... 87
ANNEX I - Disbursement & Cost Tables ...... 88-96
ANNEX J - IBRD Allocation ...... 97
ANNEX K - Selected Documents and Data Available in the Project File ...... 98-99
Maps IBRD 18651, 18652, 18653 ...... 100-102 - IV -
KINGDOM OF MOROCCO
HEALTH DEVELOPMENT PROJECT
Loan and Proiect Summary
Borrower The Kingdom uf Morocco
Beneficiary The Ministry of Public Health (MOPH)
Amount US$28.4 million equivalent
Terms Payable in 20 years, including five years of grace at the Bank's standard variable interest rate. The Borrower would bear the foreign exchange and interest rate risks. The loan would include the refinancing of the PPF of about US$.08 million equivalent.
Project Description The project would assist the Ministry of Public Health in strengthening and accelerating the ongoing shift from an urban-based hospital-oriented health system to a more cost-effective system of lrimary care including family planning. The project would include: (a) the strengtheningof primary care in three provinces by upgrading and expanding the physical infrastructure,provision of equipment, training of health staff and improving logistics; (b) the improvementof MOPE management; (c) the strengthening of training and IEC programs, and (d) the improvementof the supply of basic drugs. The main benefits of this first project in the health sector are to provide the Government with a cost-effectivemodel for primary care including family planning, while raising the capacity of the central MOPE to improve the logistics and yet control the costs of the health care delivery system. The main risk of the project relates to the stringency of MOPH recurrent budget. This risk is being addressed by minimizing incrementaloperating costs while reducing unit costs of the services. Project Costs Estimates: (US$ million) Local* Foreizn Total A. Development of Basic Health Services 12.5 10.7 23.2 B. Strengthening of NOPH Management 0.8 0.9 1.7 C. Strengthening of Trainiug and IEC Capacity 0.5 1.1 1.6 D. Improvement of Drug Supply System 2.4 4.4 6.8
Total Baseline Costs 16.2 17.1 33.3
Physical Contingencies 1.2 1.5 2.7 Price Contingencies 4.9 4.6 9.5 Provision for imple- mentation delays 1.0 1.1 2.1
Total Project Costs 23.3 24.3 47.6
(USS million)** Financing Plan: Local Foreian Total
IBRD 4.1 24.3 28.4 Government 19.2* - 19.2 Total 23.3 24.3 47.6
Estimated Disbursements: Bank Fiscal Year
1986 1987 19°8 1989 1990 1991 1992
Annual 1.3 3.7 5.4 6.0 6.0 4.5 1.5 Cumulative 1.3 5.0 10.4 16.4 22.4 26.9 28.4
* Includes US$7.1 million equivalent in taxes. ** This includes US$2.1 million provision for implementation delays. - vi -
MOROCCO
HEALTH DEVELOPMENTPROJECT
Basic Data Sheet
A. General Country Data:
1. Area (km2) 447,000 1983 2. Total Population (Million) 21.4 1983 3. Population Projections (Million) 31.0 2000 4. GNP per Capita (US$) 870 1983 5. Urban Population as Percentage of Total 42 1983
B. PoDulation Data:
1. Rate of Population Growth (Z) 2.6 1970-82 2. Rate of Natural Increase (Z) 2.9 1970-82 3. Total Fertility Rate 5.8 1983 4. Total Fertility Rate: - Among Women with No Schooling 6.4 1980 - With Seven Years of Schooling or More 4.1 1980 5. Crude Birth Rate (per 1,000) 46.0 1982 6. Crude Death Rate (per 1,000) 13.5 1982 7. Infant Mortality Rate .(per1,000) 120 1983 8. Percentage of Women of Childbearing Age Using Contraception 25.5 1983 9. Dependency Ratio {X) 96 1982
C. Health Data:
1. Life Expectancy at Birth (Years) 56 1982 2. Infant Mortality Rate 98 1981 3. Child Death Rate 22 1982 4. Physicians per 1,000 Population 0.89 1982 5. Health Expendituresper Capita (US$) 8.35 1982 6. Hospital Beds per 1,000 Population 1.2 1983
E. Education Data:
1. Adult Literacy Rate 57 1982 2. Percentage of Age 14-49 Ever Enrolled in Primary School: - Female 34 1980 - Male 71 1980 3. Number Enrolled in Secondary School as Percentage of Age Groups: - Female 20 1981 - Male 31 1981 4. Number Enrolled in Higher Education as Percentage of PopulationAged 20-24 Years 6 1981
Sources: World Development Report, 1984; MOPH; Sample Survey of 1983 Census Data. - vii -
POPULATION. MM=LTHAND NUTRIUTION
DEFINITIONS
Adult Literacy Rate . The percentage of persons aged 15 and over who can read and write.
Child Mortality Rate : Annual deaths of children 1-4 years per 1,000 children in the same age group.
ContraceptivePrevalence Rate The percentage of married women of reproductive age who are using a modern method of contraceptionat any time.
Crude Birth Rate : Number of live births per year per 1,000 people.
Crude Death Rate Number of deaths per year per 1,000 people.
Degree of Malnutrition The Gomez classificationscale distinguishes three degrees in malnutrition, namely: first (mild) - 75-90 of expected (or standard) weight for age second (moderate) - 65-75X of expected weight third (severe) - under 60% of expected weight or suffering from edema.
Dependency Ratio Population 14 years or under and 65 years or over as percentage of active population (aged 15 to 64 years).
Incidence Rate The number of persons contracting a disease as a proportion of the population at risk, per unit of time usually expressed per 1,000 persons per year.
Infant Mortality late Annual deaths of infants under 1 year per 1,000 live births during the same year. - viii -
Life Expectancy at Birth The number of years a newborn child would live if subject to the age-specific mortality rates prevailing at time of birth.
Low Birth Weight (LBW) Infant weight at birth less than 2,500 gr. LBW may be associated with either pre-term (less than 37 weeks gestation) or full-term but small-for-dates (38 weeks or more) of gestation.
Maternal Mortality Rate Number of maternal deaths per 1,000 births in a given year attributable to pregnancy, childbirth or post- partum.
Morbidity The frequency of disease and illness in a population.
Mortality The frequency of deaths in a population.
Neonatal Mortality Rate The number of deaths of infants under 28 days of age in a given year per 1,000 live births in that year.
Perinatal Mortality Rate The number of fetal deathJ after 28 weeks of pregnancy and of infant deaths under 7 days of age in a given year per 1,000 liv. b .ths.
Prevalence Rate The number of persons having a particular disease at a given point in time per population at risk; usually expressed per 1,000 persons per year.
Rate of Natural Increase Difference between crude birth and crude death rates; usually expressed as a percentage.
Total Fertility Rate The average number of children a woman will have if she experiences a given set of age-specific fertility rates throughout her lifetime. Serves as an estimate of average number of children per family- - ix -
AIPF - Association Narocaine de PlanificationFamiliale - Moroccan Family Planning Association
ASS - Agent de Sant& Nrivet&- Auxiliary Nurse
ASDE - Agent de Sante Dipla8ind'Ktat - Certified Nurse
ASDES - Adjoint de Sant& Dipl8m6 d'ltat Spfecialiste- Specialized Nurse
CIDA - Canadian International Development Association
CNSS - Caise Nationale de la S6curite Sociale - Social Security Fund
CP - Central Pharmacy
Du - Direction des Affaires Administrative* (MOPH) - Directorate of AdministrativeAffaizs
DAT - Direction des Affaires Techniques (MOPH) - Directorate of Technical Affairs
DICP ' Division de l'InfraatructureCharg&e de la Planification - Department of Infrastructure in charge of Planning
ENAP . Ecole Nationale d'AdministrationPublique - National College of Pub'licAdministration
FP - Family Planning
GDP - Gross Domestic Product
COM - Government of Morocco
IFC - Information,Education, Comunication
DIF - International Mo.aetary Fund
INI - Infant Mortality late
IPPF - International Planned Parenthood Federation
IPIIS - International Phar-maceutical Market Information System -x -
IUD 0 Intra-uterineDevice
JRPIEGO - Johns Hopkins Programs of InternationalEducation in Gynecology and Obstetrics
NCR - Maternal and Child Health
NoPE - Ministry of Public Health
MWRA * Married Women of Reproductive Age
ONEP - Office National de l'Eau Potable - National Office of Water Supply
PDC a Points de Contact - Meeting Points
PHC - Primary Health Care
FEV - Programe d'Etat de Vaccination - State Vaccination Program
PIU - Project Implementation Unit
PSME - Protection de la Sante Maternelleet de l'Enfant- Maternal and Child Health
SIAhP - Service de l'Infrastructured'Actions Ambulatoires Provinciales - Regional Office in charge of Ambulatory Services
TFR - Total Fertility Rate
fUl - Unite d'Approvisionneuenten Medicaments - Drug Supply Unit
UNSF - Mobile Family Health Units
UNFPA - United Nations Fund for Population Activities
UNICEF - United Nations Children's Fund
USAID - United States Agency fcr InternationalDevelopment
VAD - Visite i Domicile - House V-1it
VDMS - Visite a Domicile de Motivation Systimatique - House Visit for Systemtic Motivation)
WHO - World Health Organization I. THE SECTOR
Background
1.01 Moroccois situatedin the northwesterncorner of Africa. Forty-fivepercent of the populationis concentratedin the coastal plainsof the north and northwestwhich occupyonly 15% of the total countryarea. This region,with its fertilesoil, good rainfalland naturalresources, contains most of Morocco'smodern agriculture and industry,and consequentlyenjoys a higher standardof livingthan the rest of the country. 1.02 Moroccois going througha period of economicand financial difficulties.The growthof real GDP has remainedconstant since 1979 exceptfor a slightincrease in 1980. The budgetarydeficit has increased sharply,reaching 14% of GDP in 1983. The currentaccount deficit has increasedfrom US$124million in 1970 to US$1.9billion or 13% of GDP in 1983. The debt serviceratio increasedfrom 21% in 1979 and 27% in 1980 to 37% of the value of exports of goods and services in 1983. Efforts to improve the economic situation have been hampered by: a) the rise in oil prices from the mid-70s to 1980; b) the severe drought of 1980-81; c) the increase in the debt service burden due to the appreci- ation of the US dollarand the rise in internationalinterest rates; and d) a furtherdecline in 1982 in the world marketprice of phosphate, Morocco'schief export. 1.03 Hence,in the years to come, the Governmentvill face two major challenges:a) the need to accelerate economic growth; b) the need to improvethe effectivenessof its socialpolicies in reaching the disadvantagedgroups as well as the need to reduceunit costs of .publicservices provided to the population. The presentproject will help the Governmentachieve this secondobjective in the healthsector.
A. Population Population Profile 1.04 Moroccohad a populationof 21.4 millionin 1984. The crude birth rate remainshigh at 46 per 1,000,although the 1980 Fertility Surveyindicates a declineof the crude birth rate,at 41 per 1,000. The crude death rate has reached13 per 1,000 in 1980, and the return of migrantsoffsets the diminishing emigration. Preliminary results of the 1982 censusreported a total populationof 20.3 million,which indicatesa rate of naturalincrease of 2.9% over the last decade. The total fertilityrate (TmR)is still high at 5.8. Moroccohas a young populationas a resultof high fertilityand a reductio ='-infant and child mortality. The proportionbelow 15 years of age rose steadily to 42% in 1982, but is expectedto decreaseslightly in the next few years. The numberof vomen of reproductiveage rose from 4.4 million in 1980 to 5.3 millionin mid-1984. Since the numberof women of repro- ductiveage is bound to increase,even if fertilitydeclines, the crude birth rate is likely to remain high until the year 2000. - 2 -
1.05 Rapid population growth imposes a considerableburden on the economicallyactive population. The dependency ratio has stabilized at the very high figure of 96, as the slight decline in the lover age groups is offset by the increase in the age group 65 and over. In addition to creating a need for more schools and houses, and ezerting pressure on food supplies, population growth is responsible for the increasing drift of population from the countr3 to the towns, now running at the rate of 300,000 a year.
1.06 In Morocco, fertility is highest among illiterate rural women. In 1982 the fertilityrates for educated and illiterate women were 4.1 and 6.4 respectively. In the same year, the fertility rates for urban and rural women were 6.3 and 7.4 respectively. If present fertility continues, the total population could reach 34.4 million by the year 2000; a moderate decline in TFl - to 4.8 in the next five years - would still result in a population of 32 million. Only a rapid and sustained decline in TFR from present 5.8 to 2.6 could keep the popu- lation in the year 2000 below 30 million.
Ponulation Policy
1.07 As early as 1966, the GO showed its awareness of the implicationsof rapid population growth by including a family planning program in the 1968-72 Development Plan. However, only in 1979 did MNOPH launch a large-scalefamily planning program. Although King Hassan II has reaffirmed the high priority of the population problem, the Government has not adopted explicit demographic objectives. The 1981-85 Development Plan does not set population targets for any specific year; it does, however, call for a slower demographic growth and sets a target of 24% of contraceptive prevalence for 1985 - which would have resulted in a 23.5 million population in 1985 and eventually 36.9 million in the year 2000. Contraceptiveprevalence, however, increased rapidly and by mid-1983 it surpassed the target 'And reached 25.5% (Annex A.1). Encouraged by this progress the Government envisages setting a 33% contraceptive prevalence target for 1990 in the next plan. Assuming that subsequent five-year plans vould continue to raise contraceptive targets, the country"s population could be limited to 30 million by the year 2000. Within the Government,MOPH has full responsibility for expanding family planning activities, vhile the Ministry of Planning is responsible for the coordinationof policies. Some sectors have, so far, provided lukewarm support to population activities: population education in primary and secondary schools or in the Ministry of Youth and Sports programs has remained insufficient; low coverage of social security programs, particularlyhealth and retirement insurance, still acts as an incentive for large families; the legal status of women, especially the customary legislation on the age of marriage, polygamy and repudiation, remains a drawback for family planning. The 1986-88 Development Plan should strengthen other sectors' support to population and should introduce some of the desirable changes in social policies and legislation. -3-
Family Plannins Program
1.08 The Government has maintained a policy of integrating family planning and health programs. IOPH has placed its Population and NCI Divisions under a single Directorate of Technical Affairs (DAT). DAT executive.i have been the pioneers and are the most active promoters of family planning in the country; they have successfully mobilized resources and staff into an integrated MCR/FPprogram.
1.09 MOPE has clear family planning objectives: birth spacing through .reast-feeding and contraception by modern methods - especially condoms, pills, IUDs and tubal ligations. Priority target groups are multiparous w.,men, teenagers, and women over 35 years. MOPEdistributes contraceptives through all its 1,426 outpatient facilities. Family planning clinics are held in all dispensaries, health centers and outpatient departments of hospitals. In addition to external funding, government expenditures on family planning in 1983 reached US$6.9 million - US$1.5 per woman of reproductive age. In spite of these efforts, the national program does not reach the entire population, many of whom live in inaccessible areas. With a view to increasing coverage, in 1979 NOPE initiated, with support from USAIDand UNFPA,a pilot outreach project known as Visites a Domicile de Motivation Systemtique (VDNS). Under this program, paramedical personnel make five annual visits to every household with a woman of reproductive age to give family planning information or advice and to supply contraceptives, or direct women to Reference Centers or Mobile Units for I1ID insertion or tubal ligation. After a successful test in the Province of Marrakech, the VDNSsystem was extended to three more provinces and expanded to include health education, the distribution of oral rehydration salts, iron tablets and nutrition supplements and referral for immunization, which proved effective and well-accepted. A 1983 USAID evaluation of the program showed that contraceptive prevalence had risen from 24% to 41% in Meknes and 52Z in Marrakech, compared with the national average of 25.5%. According to the USAID report, the experience has demonstrated that: a) family planning, hone visits and contraceptive distribution by male and female health workers are well-accepted in Morocco; b) the provision of family services through the existing health services is the best vay of ensuring long-term-availability and coverage; and c) an efficient family planningprogram can be conducted in the absence of high visibility policy statements. MOPE will extend the program to the rest of the country. Over the next five years, the five largest urban areas and 16 provinces will be given priority, 13 provinces would be financed by USAID and three by the Health Development Project. 1.10 Family planning progra are supported by Information/Education/ Coimunication (IEC) activities. The Health Education Unit in MOPH's Population Division is responsible for the production of IEC materials for FP and PEC, but because it is also expected to meet the printing needs of the whole MOPH, it is overtaxed and finds it difficult to perform - I4-
its primary function adequately. As a result, manuals and handouts on family planning and NCR are insufficientand unattractive;IEC messages for family planning - posters, pamphlets, audiotapes, TV and radio spots - are often too theoretical. MOPH has 22 large IEC tractor-trailers, fully equipped for exhibits and projections of 16 and 32 films, but they are restricted to the main roads. They have proved useful for urban and suburban populations but bad only a limited impact in rural areas.
1.11 Other Ministries and government agencies, such as Education, Social Affairs, Agriculture,Youth and Sports, are increasinglysupporting the population program, and the Ministry of Planning is coordinating their activities. A private body, the Association Marocaine de Plani- fication Familiale (AMPF), supported by the InternationalPlanned Parenthood Federation (IPPF), operates family planning centers and programs for the distribution of contraceptives,trains private physicians in contraceptive methods, produces and disseminates IEC materials. USAID, the main foreign contributor to family planning, provides US$3.6 million per year on average. UNFPA has provided a total of US$8.7 million over the last ten years. These funds have been used to provide technical assistance, infrastructure,equipment and vehicles, training, demographic studies and a National Household Survey. In addition to UNFPA, UNDP, UNICEF, WHO and USAID-supported Johns Hopkins Programs of International Education in gynecology and obstetrics (JHPIEGO)have provided technical assistance and training, as well as support for MOPH's Center for Human Reproduction in Rabat, which conducts national and internationaltraining programs in tubal ligation for physicians.
B. Nutrition
Nutritional Status
1.12 The Moroccan rural population in general is poorly nourished. The last nutrition survey, conducted in 1971, revealed that 42% of children under four years of age suff'-!..dfrom moderate protein-caloriemalnutrition, 5% from severe malnutrition and 23% suffered from rickets. Forty-five percent of rural children under four years of age suffered from moderate and 6X from severe malnutrition. Although the average birth weight and height of Moroccan newborn children exceed normal standards, a serious deterioration takes place between 10 and 48 months. For example, at 24 months of age, the average height and weight of children are 7.3 cm and 2 kg respectivelybelow normal. This deterioration is due to abrupt weaning, undernutritionand unsanitary conditions. Among the adult population, pregnant and lactatingwomen on the average have a calorie intake 12% below the desirableminimum, and suffer from iron deficiency anemia, which is aggravated by successive pregnancies and short intervals between births. -5-
1.13 The nutritionalstatus markedly improved in the aid-seventies when food productionwas abundant. At the same time ricketswas virtually eradicatedthrougn a large-scaleNCR programand administrationof long-acting injectable Vitamin D. There is reason to believe that the nutritional statushas deterioratedsince 1980; the analysisof the 1983National Surveyon HouseboldExpenditure data and a surveyof the nutritionof childrenunder four years of age plannedto begin early in 1985 will provideup-to-date information on the nutritionalstatus of the population. Causesof Malnutrition 1.14 The most importantcauses of malnutritionare inadequatefood productionand consumption,bad infantfeeding practices and poor environ- mental hygiene:
(a) Food ProductionPatterns. The declinein agriculturalproduction since the 1970s causedby variationsin rainfalland the recent droughthas contributedto the poor nutritionalstatus of the population. Before 1970, Morocco produced enough cereals to meet its domestic needs. However, the rate of growth of agricultural outrut had fallen drastically from 4.7% in the 1960s to -0.3% by 1979. This failureof food productionto keep pace with populationhas createdfood shortagesand increased dependenceon imports. In the high Atlas mountainranges and semi-desertareas of the South,protein-calorie malnutrition as well as vitamindeficiencies are due to seasonalfood shortages.
(b) Food Consumption Patterns. The 1971 Nutrition Survey showed that the average calorie and protein intake of Moroccans is good. However, the typical diet is unbalanced and low in animalprotein and fats. The intakeof nutrientsvaries considerably from one income group and from one geographicalregion to another. In urban areas, the calorie intake of affluent groups averages 110% of requirements, compared with 75Z in shanty towns. In "he rural areas of the South, the average calorie intakeis 81% of requirements. Protein-calorie malnutrition is severe among low-income groups (DE 466 and below), farm workers, self-employed, artisans, and unemployed. The calorie intake of this group ranges from 61S to 66% of requirements.
(c) Infant Feeding Practices. The decline in breast-feeding in recent years may endanger the nutrition and health of young children. During weaning, breast milk or infant formulas are supplementedby vheat or barleyonly, causingprotein deficiencyaround 14 monthsWQen weaningis completed.-
(d) EnvironmentalSanitation. The nutritionalvalue of food is often reducedby improperpreparation. Contaminated food and water are prime causesof infantdiarrhea, in turn an importantcontributing factor to malnutrition. Government Nutrition Policies and Programs
1.15 In spite of the GOM's recognition of the critical need to improve nutrition, Morocco has no intersectoralfood and nutrition policy. MOPH is responsible for crinical services and nutrition education while an interministerialcommittee under the Ministry of Planning was expected to coordinate food and nutrition policies, but has remained inactive. To follow up on a food strategy study, carried out by the Government with CIDA assistance,an intersectoraltask force, under the Ministry of Agriculture, has completed by June 1984, a first phase of analysis and is presently developing alternatives for a food strategy.
1.16 Within its limited responsibilitiesMOPH has addressed the problem of malnutrition in the following ways:
(a) Nutrition education and IEC tbrough mass media, mobile units, VDHS and clinics. The effect_venessof such interventions bas not been evaluated.
(b) Nutrition surveillancethrough clinical screening of infants, pregnant and lactatingvomen. However, in 1979 the program reached only IOZ of children in the 0 to 2 age group.
(c) Nutrition rehabilitationthrough distribution of Actamin, a protein-richweaning flour, in MCR clinics. Actamin is also-sold at a subsidized price in pharmacies. The production and distributionof Actamin have proved costly, and MOPE is seeking suitable alternatives.
1.17 MOPH programs for combating malnutrition are well-conceived but require better definition and targeting. Active rather than passive detection would increase coverage. Coordinationwith immunizations and oral rehydrationtechniques would increase the efficiency of the program.
1.18 The Ministry of Social Affairs also conducts nutrition education and food distributionprograms, the Ministry of Education provides nutrition education in schools, and the Ministry of Agriculture promotes food crop and home gardening. Hovever, there is little effective coordination of the efforts of these other ministries with those of MOPE.
C. Health
Health Status
1.19 In spite of its low per capita income, Morocco, like its neighbors, Algeria and Tunisia, exhibits a steady decline of infectious and parasitic diseases. The deatb rate, which fell from 17.5 per 1,000 in 1970 to 13.5 in 1980, is estimated at 12 per 1,000 in 1984. Life ezpectancy rose steadily from 50 years in 1970 to 56 in 1980. The high infant mortality, more than 100 per 1,000, and the prevalence of malnutrition and tuberculosis indicate, hovever, that these favorable trends may have slowed dow.
1.20 Moroccan health statistics are incomplete, and the basic health data necessary for planning are insufficient. Births are grossly underreported or reported late, and death certificates do not require recording the cause of death. To supplement the inadequate data base, MOPEhas relied on specific studies; however, the more comprebensive and therefore more useful indicators, such as age-specific mortality, infant, child and maternal mortality, and causes of morbidity, are not available. Statistics on mortality by causes and age groups are based on deaths in hospitals - only 13% of total deaths -- and satisfactory death certificates, which account for only 1.5% of total deaths, are thus not representative of the entire population. 1.21 Mortality. MOPEofficially reported the Infant Mortality Rate (IMR)at 91 per 1,000 live births in 1981. However, realistic estimates put it at 120 per 1,000. Deaths in the first year of life account for 43Z of total mortality. Studies on infant mortality reveal a disparity between income groups; in the modern urban sectors, infant mortality is estimated at 60 per 1,000, but it reaches 170 per 1,000 in the periurban shanty towns. Infant mortality in rural areas ranges from 110 in the plains to 150 in the mountains. Such distressingly high death rates compare poorly with countries with similar GDP and geographic settings, and raise questions about the coverage of MCH/FP services, and about the effectiveness and coverage of health services in general. The chief causes of infant mortality are diarrheal syndromes, acute respiratory infections, communicabLe diseases and tuberculosis, all of which account for 61% of all diagnosed motives of consultation for children under one-year and are the consequences of poverty, malnutrition and poor environment (Annex A.4). 1.22 Maternal mortality is high. Statistics for 1972 show an excess of deaths among women aged 15-49, compared with men in the same age group, attributable mainly to maternal mortality, which peaks between the ages of 35 and 40 years. This suggests that maternal mortality was of the order of 530 per 100,000 births in 1972, as in other countries at a similar stage of development (compared with 9.9 for the United States in 1978). Since 1972 better access to care has reduced maternal mortality drastically in urban areas. In rural areas, however, access to MCEand family planning services and health and nutrition education have not improved significantly. The number of obstetrical emergency admissions as well as the number of deaths associated with hospital deliveries indicates that maternal mortality is still high in rural areas. -8-
1.23 Morbidity. Morocco has been able to relieve itself from the burden of tropical diseases since most of them were controlled in the 1970s, and the climate and terrain do not favor their rapid spread. Malaria, once endemic in the coastal plains, has been virtually eradicated, although a costly surveillanceprogram is still necessary to prevent reinfestation from outside Morocco. Scattered small foci of urinary schistosomiasis,of which there were 7,400 cases in 1983, are under control. In 1983 a Bank-financedassessment of the risk of malaria and schistosomiasisin areas of irrigationdevelopment, indicated a moderate potential for increase in some areas.
1.24 Morocco is going through a period of epidemiologicaltransition in which, while infectious diseases are still prevalent, chronic and degenerative diseases are becoming increasingly important. Infectious diseases, favored by poor housing and sanitation and malnutrition, are diminishing but still prevalent among the poor and in rural areas. Chief among them are diarrhea, measles, acute respiratory infections, typhoid, hepatitis Type A, rheumatic fever, skin and eye infections, and tuberculosis. Morocco, however, has already reacbed the stage of "intermediatepathology", characteristicof urban populations: accidents, gastrointestinaldysfunctions, neuro-psychiatric disorders and addictions and the need for dental, surgical, gynecological and obstetrical treatment requiring considerable radiological and laboratory support. The increasing demand for secondary care is due partly to the rising expectations of some groups, but also partly to limited access to care on the part of others, which means that ailments easy to cure in their early stages are often not treated until complications arise. Finally, the incidence of chronic and degenerativediseases characteristicof industrial countries, such as cardiovascular diseases, diabetes, chronic lung conditions, cancer and occupational diseases, is rising as life expectancy increases. In Morocco, the overlapping in recent years of all three phases of this epidemiological transition has imposed heavy burdens on the staff and facilities of the health services and on national finances.
Environment
1.25 Limited access to potable water, particularly in periurban slums and rural areas, lack of sewerage and inadequatehousing contribute to the high incidence of infectious diseases in Morocco.
1.26 Water SuDDly. The Office National de l'Eau Potable (ONEP) under the Ministry of Equipment is responsible for supplying urban centers with potable water. Distribution within the larger towns is managed by municipal enterprises ("regies")and in the smaller towns, by ONEP itself. In 1981, 72% of the urban population vas served by public water systems - 35% by house connections and 37% by public standpipes. Only half of the latter vere within reasonable walking distance and served fever than 500 persons. In rural areas only 7% of the population have access to piped water, and the remaining 93% rely on unregulated vater sources - wells, cisterns, rainfall collectors, streams and ponds -- -9-
oftencontaminated by humn ezcreta. Waterborse diseases,in particular typhoidand dysentery,are still prime causesof desth and disease. NOPE, throughits Servicede l'Hygiinedu Milieu,is responsiblefor the controlof water qualityand the disinfectionof some 100,000water pointsin the country. The Serviceconducted 124,000 disinfections in 1982, which representslittle uore than 10Z of total needs, since the averagewater point shouldbe treatedten tims a year. It is unrealistic to expectNOPE to do all this work, and the solutionseems to be in delegatingsome of the responsibilities- particularlythe enforcement of regulations- to municipalities,and elicitingcomunity involvement. The Ministryof Agricultureand the Genie Rural made severalattempts to improverural water supplyby providinghandpumps, motor pumps,reservoirs and water towers,to be operatedand maintainedby local communities; one year later,most of the facilitiesprovided were underutilizedor abandoned. This experience showed clearly that such interventions should be tailoredto local culturesif they are to producehealth benefits. 1.27 Seweraoe. Urban seweragesystems have not been expandedto keep pace with population, particularly in periurban slums. Medium-size tonns often dischargeuntreated sewage into rivers. In rural areas, only 14Z of householdshave latrinesand there is no provisionfor solid waste disposal. A 1981 sanitationsurvey of 18,552rural households in the Province of Settat revealed the deplorablestate of the water supply and sewerage systems. 1.28 Housint. Overcrowded and crude housing helps to spread disease. Over the last decade,private and public housing construction has not kept pace witb urban population. It is estimatedthat 252 of the population live in squattersettlements and anotherlOZ in housingdilapidated beyondrepair. The 1982 Populationand lousingSurvey showed an average of 2 nuclearfamilies per householdin urban localities,and 2.6 in rural areas.
1.29 In 1984 under the preparationof the proposedproject, MOPH carriedout, with the supportof UNICEFand the collaborationof the InstitutAgronomique Hassan It, a study of the socio-culturaldeterminants of hygieneand sanitationin periurbanand rural areas. The study identified suitableinterventions based on comunity commitmentwhich would be implementedunder the proposedHealth Development Project.
Health Services and Proiraus
1.30 Health Providers- There are four health providers in Morocco: the HOPE, the Caisse Nationale de la Securite Sociale (CNSS), the Armed Forces, and the private sector. 1.31 NOPEis the largestprovider of healthcare; in 1982 it delivered 6.4 millionaedical consultations, 31.6 million units of nursing and preventivecare, and 5.8 millionhospital days. The numberof average bealthcontacts per person/year(1.8) and hospitaldays per 1,000population - 10 -
(276)would sufficeto ensureacceptable bealth and medicalcare if the qualityand efficiencycould be enhanced. Under the presentconditions and limitedresources, however, MOPE can meet only part of the demand. MOPE is too often the providerof last resortthat assumesexpensive care such am long-termtreatment for chronicand psychiatricdiseases, cancerand terminalillnesses. Other providersrely heavilyon the publicservice to provideunprofitable treatment and technology.MOPH is the only providerof preventivecare and publichealth programs. 1.32 The CaisseNationale de la SecuriteSociale (CNSS) was, until recently,a healthinsurance scheme that financedmedical care provided mainlyby the privatesector and, to a lesserextent, by MOPH. In 1982 the Caisseopened its own hospitalsand clinics,and becamea provider offeringmedical care on a fee-for-servicebasis. In 1982 the CNSS provided500,000 medical consultations and 250,000hospital days - about 71 of totalmedical care in the country. The CNSS offersthe kind of servicethat attractsmiddle-income members, and competesaggres- sivelywith privatephysicians, but poorer peoplefind it too expensive and continueto seek care in MOPH facilities. 1.33 The Realth Serviceof the Armed Forcesserves uniformed personnel and their families,who form 5Z of the population.
1.34 Privatephysicians and dentistsand privatehospitals primarily serve the higher-incomegroups. Becauseprivate physicians are often underequipped and poorly monitored,they do not in generaloffer significantly better care than MOPH. While the rapid expansionof privatepractice, which took place in the 1970s,was welcomedas relievingthe strain on the overburdenedpublic services,the competitionof the CNSS has almostbrought this expansionto a stop. 1.35 Urban and rural populationsoften resortto other providers for adviceor treatment. In 1981 pharmacistsand herbalist.provided 7.5Z of primarycare contacts. Althoughtraditional healers are not legallyrecognized and their activitiesare not recorded,they still play an importantpart in healthcare. Moderndental care is only available in urban areas;the rest of the populationresort to traditionalhealers for extraction.MOPH operatesa small preventiveprogram in dental health. GovernmentHealth Policy
1.36 Althoughthe GOM assignshigh priorityto health,its allocation of funds to the sectorremains very low, both in relativeterms at 1.2S of GDP, and absoluteterms at US$8.35per capitain 1982, comparedwith Algeriavith US$22.0,and Tunisiavith US$31.21. The Government'sdeclared priority on health should be viewedin the lightof this fundamental limitation. The Government is aware of the pressing needs in health, populationand nutrition;it is also aware of the modestbut nevertheless risingdemands of urban populationsfor care, and would like to come - 11 -
up with a cost-effectiveorganization of health services. The last two Plans reflecta changeof health servicepattern from the one based on privatepractice and large hospitals,to one more appropriateto Morocco'spresent needs and financialsituation.
1.37 The ambitiousprogram of investmentin largehospitals proposed in the 1977-80Development Plau - 78% to hospitalsand 16Z to basic care -- was curtailedin the courseof the ezecutionof the Plan in favor of healthcenters and dispensaries.Nevertheless, operating budgets for basic health servicesremained insufficient. As a result,the primary care systemhad a slow start.
1.38 The 1981-85Develo2ment Plan markeda sharp departurefrom the previouspolicy, giving priority to basic health servicesand allocating 55Z of the investmentbudget to basic healthcare and 45Z to hospitals over the five-yearperiod. This policy changewas reflectedin subsequent annual investmentbudgets: the 1983-84-85investment budgets allocated a total of DR 314 millionto basic health care and DE 199 million to hospitals. The Plan had set preciseMCR, familyplanning, iiuunizations, healtheducation and basic sanitationobjectives for basic health. It also gave priority to improving the management of basic health services by decentralized programming, improved rinagement information systems, and upgradedtraining of personnel. Most important,the Plan recommended the explorationof alternativesto the presenthealth care delivery system. To this effect,the Plan outlinedthe presentHealth Development Projectin the provincesof Agadir and Settat,it set up a separate allotmentof DR 60 million(US$6 million) in the investmentbudget, and requestedBank assistancefor this purpose. PublicRealth Services
1.39 Since 1981,budgetary limitations, particularly those imposed on the operatingbudget, have hamperedthe implementationof the Plan. MOPE servicesare presentlyill-prepared to meet the increasingdemand. 1.40 Overall,the healthdelivery system is still centeredon urban facilities.Hospitals, urban healthcenters and urban dispensaries still retainmost of the resourcesand prestigeand continueto attract rural populationsseeking care. As a consequence,the outpatientservices of the urban facilities are overburdened - in spiteof generous staffing - and the resultingquality of care is inadequate.In rural areas, rural healthcenters and dispensariesprovide primary care withoutadequate back-up by urban services - i.e. laboratoryand X-ray services- and withouteffective supervision and logisticalsupport. The shortage of drugs,which will be discussedin paras. 1.3 to 1.67,drastically limitsthe efficiencyof the services. Outreachactivities are coordinated by the "Service de l'Infrastructure d'Actions Ambulatoires Provinciales" (SIAhP): male itinerantnurses, based in each dispensary, are expected- to make monthly visits to every household in the cosmunity to provide first aid, health education,sanitation advice and to take blood samples - 12 - for malaria control. However,the monthlyvisit *cheduleproved unrealistic.As the itinerantnurse lackc the most basic drugs and only collectsblood samples,his credibilityis low - in sao areas he is openlyrejected by the population. 1.41 Becauseof these weaknesses,the actualcoverage of public healthprograms is low. MCR and PP reach only 301 of their targetpopu- lations;prenatal care coversonly 5.4Z of all pregnancies;only 112 of deliveries take place in maternities; less than 201 of infants from O to 2 years of age are monitored by child health clinics, nutrition programsreacb only a small percentageof the populationat risk; visits per person/yeardeclined from 2.45 in 1976 to 1.8 in 1982; and immunizationprograms bad reachedonly 451 of the targetgroup by 1983.
D. SectoralResources
PhvsicalResources
1.42 Morocco'shospital network is on a small scale for a middle- incomecountry, but is generallysufficient. It includes80 institutions: 2 universityhospitals for specializedcare, 44 generalhospitals and 34 bospitalsfor long-termcare. There are 24,913hospital beds, or 1.2 beds per 1,000 population,a minimumby internationalstandards. Makingbetter use of existingbeds is a higherpriority than providing additionalbeds. The network,as it is, could provideacceptable coverage if managment and performancewere improved;bed turnoveris slow, and averageoccupancy low at 63.51 (AnnexA.8). The radiological,diagnostic and laboratoryequipment is generallyappropriate, but lack of maintenance resultsin costlyrepairs and replacements.There is no technicalunit in charge of hospitals -- neither hospital technology nor hospital manage- ment -- in MOPH. The Ministry,however, sees an urgentneed for studies on hospitalorganization and managementwith a view to improvingefficiency, cost effectiveness,and uaintenance.The BealtbDevelopment Project will financesuch studies.
1.43 The outpatientservices consist of 840 dispensariesand 297 healthcenters. Most of the existingdispensaries are rudimentary, and poorlyequipped. Facilitiesare spreadtoo tbinlyand coverage is inadequate.According to MOPE's standards,there shouldbe one health centerfor every45,000 peopleand one dispensaryfor every 15,000people. The actual ratiosare one centerfor every 84,000people and one dispensary for every 25,000. To meet the standards countrywide, some 90 additional centers and 460 additional dispensaries would be needed. The detailed planning exercise carried out for the preparation of the project confirmed that a 55.T expansion of the physical facilities was necessary to reach 801 of the population.
1.44 Outpatient and outreach services rely beavily on transport, vhich accounts for 321 of their recurrent costs. The average itinerant - 13 - nurse travels 19.3 km per working day. The average four-wheel vehicle travels30.000 km per year, often in ruggedterrain, and lasts two and a half years. The choice of vehicles is still sn unresolvedproblem. HOPE plans to test alternstivesto the currentbicycles, mopeds and landrovers,such as 125-cc motorcycles sad light pick-ups. It is also exploringincentives for the properoperation and maintenanceof vehicles, such as bonuses,transfer of the vehicleto the user after three years, leasingand concessionaryloans for the acquisitionof vehicles. Hunan Resources
1.45 Medical Personnel. The training of physicians is the responsi- bility of the universities under the supervision of the Ministry of Educationand MOPE. There are at present4,000 physiciansin the country. evenlydistributed between public and privatepractice. The physician/ populationratio reached2 per 10,000by mid-1984,and is increasing rapidlyas 700 new physiciansgraduate annually. Even if this ratio is still low, comparedvith other middle-incomecountries, it is not possible to determine how many physicians will be required or what form their training should be until MOPHdefines the long-run structure of the bealtb sector through the presentproject. In 1978, the two medical schoolsagreed to reducetheir total output to 400 per annu and to strengthentraining in publichealth and preventivemedicine. Two small dental schoolsopened in 1981 and will progressivelyexpand their student intake. A schoolof Pharmacyis scheduledto open in 1985. In the meantime,the majorityof dentistsand pharmacistsare still trained abroad.
1.46 AdministrativePersonnel. Over 170 graduateswf the Ecole Nationaled'Administration Publique (ERAP) are now employedin MOPE, chieflyas managersof the big bospitalsand provincialservices. In 1983 the ENAP, in collaborationwith MOPH, createda s*pcializedsection in PublicReath Administration.The new curriculumcomprises public aduinistration,health administration and economicsand hospitalmanagement. This sectionvill provideMOPE with young and qualifiedmanagers who will be instrumentalin improvingthe managementof the services. 1.47 ParamedicalPersonnel. The trainingof paramedicalpersonnel, conductedat the Collegeof PublicHealth and 48 schoolsfor nurses and technicians,is the responsibilityof MOPH. Paramedicalpersonnel consistof three levelsof nursesand technicians:a) 16,000basic nurses,wbo providethe rank and file staffingof the services; b) 6,000 certifiednurses and technicians,who providethe intermediate staffiug;and c) 400 specializednurses or "cadristes",who fill key positionsin management,supervision, training and research. By and large,paramedical personnel are well-qualifiedand well-distributed. Detailsof categoriesof personnelare given in AnnexesA.5 and A.6.
1.48 MOPH has a total payrollof 29,000persons, including 1,100 physicians,18,000 paramedicals and 6,000 supportpersonnel. Unlike many developingcountries, the pyramidof personnelis well-balanced - 14 -
and there are no serious shortages. Liberal estimates of future manpover requirements, made in the prosperous oid-1970c encouraged a substantial ezpansionof trainingcapacity and of the staff of the publichealth service. In 1982 severebudgetary restrictions necessitated the curtailment of hiring. MOPH will reassessits manpowerrequirements in the light of the presentfinancial situation and of the cbangingpattern of the healtbservices. In particular,it will have to take accountof the Sollovingfactors: a) the basic health serviceswill requireauxiliary personnelfor ruralwork, with a shortertraining period and lowersalaries (one year of trainingafter two or three years of secondaryeducation is envisaged);b) in isolatedareas, utilization of comunity health workers,community uidwives, and traditionalbirth attendantsis bei'g explored;c) the need for fully qualifiednurses, technicians (ASDES) and cadristeswill increase;their trainingshould be intensified. 1.49 More generally,NOPE considersthe desirabilityof training technicianswith possibilitiesof self-employment,such as opticians, herbalists,dental hygienists, dental assistants, physiotherapists, and prostbetictechnicians, who could serve in the privatesector, and thus imposeno burdenon the nationalbudget.
1.30 NOPE, therefore,sees the need for a comprehensivereview of healtbmAnpower requirements covering the public,parastatal and privatesectors. However,NOPH does not envisageunilateral changes until the Governmentdefines the role of specifictraining progrms, such as those carried out by NOPH within the contextof its new Vocational TrainingStrategy, presently under preparationwith lank assistance. 1.51 The qualityof nursingeducation is generallyadequate. However, the trainingof certifiednurses has been impaired in recentyears because of inadequate facilities. The health component of the Bank'sThird EducationProject, appraised in 1976, provided for the construction and equipmentof a Collegeof Publichealth in Rabat,but it was only partiallyimplemented because of MOPE inexperienceof lank projects, and due to time-consumingadministrative procedures. Eventually,the Collegewas constructedunder the project,but not providedwith a library, textbooks,laboratory, demonstration equipment and vehicles. The Health DevelopmentProject will financethe completionof this component.
Financial Resources 1.52 Total publichealth expenditure amounts to about 1.22 of GDP, i.e. much less than in othermiddle-income countries, such as the Philippines and Syria (2.4S), Zambia (3.4Z) or Jordan (5.2S). They represent only 32 of total goverment outlays, a proportion which has declined from 7.8Z in 1965 to 3.01 in 1983 and a budgeted 3.51 for 1984, as shown in Annex A.9. As the COM fionaces90S of publichealth expenditure (81 are covered by the national social security system,and the remaining 2S by individual households), this decline has serious implications for national health. - 15 -
1.53 Annual cgaitalexpenditure on healthhas fluctuatedfrom DR 244 millionin 1983, comparedwith DR 300 million in 1982 and a projected figureof DH 139 million (US$15million) for 1984, and has fallensteadily as a proportionof total publicinvestment, from 3.2Z in 1965, to 1.3X in 1983 (see Annex A.9). Until the late 1970'sabout 70S of this capital expenditure was on hospitals, but under the 1981-85 Development Plan, the share of hospitals is expected to decrease to 60Z. 1.54 Oneratinf expenditures also have declinedas a proportion of total publicrecurrent expenditure, from 9.7Z between 1965 to 4.5Z in 1983;no changeis expectedin 1984 as theseare budgetedat DE 918 million,or 4.8% of Government'stotal operatingbudget. Salariesabsorb an increasingshare of the sector'scurrent resources and theirproportion increasedfrom 56.4% in 1965, to 70.52 in 1983 and 74.3Z in 1984. This trend has had a seriousnegative impact on the sector,especially at the outreach level, as less and less resourcesare left to cover other operating expenditure, such as drugs, maintenance and transport, resulting in the perceptibledeterioration of the qualityand coverage of services. 1.55 As a step towardsimproving the financesof the publichealth service,MOPE explorespossibilities of cost recovery. Recentsurveys have shown unexpectedlyhigh householdexpenditure on healthcare and drugs,thus demonstratingpeople's willingness to pay for healthcare. Hovever,it would be unrealisticto expectpeople to pay for services of the presentquality until the reputationof the systemhas been restored. To determinethe feasibilityand range of cost recoveryfor preventive and curativecare for ambulatoryand hospitalservicos, MOPE gives high priorityto the analysisof currentcosts and futuresector financing for vhich studies are includedin the HealthDevelopment Project.
E. SectoralIssues HealthCare DeliverySystem
1.56 Since the late 70s, MOPH has given priorityto continuedeploying the primarycare systemprogressively over the entirecountry. However, MOPE underestimatedthe technical,financial and managerialproblems of the task. As a result,the systemremains incomplete and has never been in full operation,with all necessaryinputs in any area. As MOPH lacked capacity to monitor the system, early signs that it vas not functioning according to expectationswere misinterpreted.In 1977 operating budgets declined in real terms. The scarce supplies were concentratedin hospitals. Implementationof the PHC systemslowed down considerably. -Outreach activities,in particular,were soon crippledby a varietyof shortages and came to a minimumwhen the drug supplydropped in 1980. As a result, Norocco is presently maintaining an ineffective PBC system at high cost. - 16 -
1.57 NOPE nov appreciatesthe technicaldifficulties and, with the help of field staff,bas improvedthe designof the PlC system.The technical difficulties relate to the targeting of activities,utilization of appropriate technology, supervision, delegation of responsibilities, referral and back-up by rural bospitals. MOPH has clearly identified these problemsin the 1981-85Development Plan and is ready to deploy the new PHC schemein three provincesunder the HealthDevelopment Project.
Nanaaement 1.58 NOPE is responsiblefor the policymaking of the publicsector only. The parastataland privatesubsectors have developedwithout coordination,resulting in duplicationsand socialinequities. The capacityof MOPE to plan its own operationsand controlresource allocation and costs is limited. Decision-making in WMQOis still highly centralized in the office of the Minister and the Secretary General. The Directorate of Technical Affairs (DAT) is responsible for health programs and the Directorate of Administrative Affairs (DAA) is responsible for the day-to-day managementof the Ministry(Annex 1.1). 1.59 MOPE has had in the past a limitedplanning responsibility for coord4uatingall agencies- public and private - in the sector. The Ministryhas also demonstrateda limitedcapacity to programits internal operations. Since 1980, however, following a WHOrecoumendation supported by successive Bank miscions, the 'Division de l'lnfrastructure Charg&e de la Planification (DICP) has been strengthened. In 1983 and 1984, projectpreparation helped tu further improve the DICP by attracting additionalqualified staff and openingvider sectoralissues to discussion. 1.60 Since 1981, USAID-financedtechnical assistance, aimed at improving the management of MOPE, has achieved results in several areas, particularly in computerizing DICP's operations - inventories, record systems, processing of statistical, research and personnel data. Broader managerialor organizationalissues have been addressed. MOPH is presently conmittedto improving day-to-day management before any major structural reform could be envisaged. The Ministry has identified key areas in management to be strengthened under the project. Supply of Basic Drums
1.61 Moroccoconsumed DE 800 million (US$95 million) vorth of drugs in 1983, i.e. DE 40 (US$4.76)per capita. Of this total,MOPE distributed DR 47 million (US$5.6million) worth or less than 6Z, and of this amount only US$0.5million vorth, i.e. 0.5Z of nationalconsumption, went to primarycare, the rest going to hospitals. Primarycare servicesare presentlysupplied with an averageof US$0.15worth of drugs per person/year; MDPE estimates instead that a minimum of US$0.40 per capita is necessary to support primary care. - 17 -
1.62 Between1982 and 1984,MOPE, vith the assistanceof USAID, UNICEFand WHO,oade several studies which identified the technical and managerialdeficiencies of the present Drug Supply system: (i) Technicaldeficiencies: There is no standardlist of drugs, and the hea'thservices. and hospitalsbase theirrequisitions on individualpreference or on what they used in the previous year. A surveyof the demand for primarycare (AnnezA.4) coupleted in 1984, led to a standardizationof treatments and a standard list of basic drugs that vill be tested in 1985. The most common errors of prescription have been identified, - errorsof indication, dosage and duration of treatmentas vell as utilizationof antibioticsas placebos. Finally,most drugs are suppliedin bulk to dispensariesand healthcenters which, lackingsuitable packaging material, dispensethem in paper cones withoutlabels and instructions. Patients'compliance with treatmentinstructions is poor.
5ii) M_nexerialdeficiencies: Responsibilities for the supply of drugsare scatteredin differentservices of the Ministry: the allocationand controlof drug suppliesrest with the authorityof the Servicede l'Equipement;procurement of drugs is under the Servicedu Budget,both under the DAA; reception, storageand controlof stocksare the responsibilitiesof the CentralPharmacy (CP) under the DAT, while standardization rests with the DICP. Littlecoordination ezists between these services,clearances require moving papers back and forth. Procurementis not carriedout efficiently. There are usually delays through the several services involved in specifying items to be procured and in evaluatingtenders. In addition, manufacturersdo not submittenders for all itemsand frequently fail to deliveron schedule.and finally,pjyments to providers are made with considerabledelay. Druge are stored together with medicalequipments and furniture,as well as chemicals and flammables.The CP"s dilapidateedwareh,%use makes storage unsafeand the handlingof drugs and chemicalshazardous. Inventorycontrol procedures are obsolete.
1.63 Taking into accountall negativefactors - inefficient selectionand procurement,losses, thefts, misprescription and poor compliance-- less than one-thirdof the PHC drug allocationactually produces health benefits. A drastic improvement of the public sector drug supply systemis essential. 1.64 For its own use, MOPE preparessome forty basic drugs in the CP's formulationunit. The formulationlaboratory operates in unsuitable and dilapidated premises, processing does not comply with safety regulations, packaging is unsafe and unattractive. In order to simplify, reduce or even discontinue the formulation of basic drugs, NOPEhas explored several alternatives such as procurement of brand-name or generic drugs - 18 -
on the internationaland nationalmarkets, contracting with the local industryand, finally,'Toll Formulation"by which MOPE would buy inter- mediate ingredientson the open internationalmarket and contractvith localindustry for their final formulation.Local industryhas indicated interestin toll processingthe most complexand expensiveof the basic drugs,an alternativewhich will greatlysimplify NOPE formulation. The various alternatives considered by the Appraisal Mission are described in Annex G.
1.65 The 1981-85 Health Development Plan providedfor the reorganization of HOPH's drug system and improvement of the supply of basic drugs. To this effect, the Plan earmarked DR 12 million (US$2.3 million equivalent in 1981). This amount is allocated in the 1984-85 Loi des Finances as counterpart funds for a drug component of the Health Development Project.
F. Summary Assessment of the Sector
1.66 Since 1980 MOPEhas recognized the need to give priority to primary health care, but budgetary limitations have left the reorganization of HOPH incomplete and health programs -- family planning, i munizations, MCH, nutrition - unconsolidated. Over a period of economic stagnation and diminishing family incomes, high fertility, rapid demographic growth, unresolvedhealth problems, malnutrition and poor sanitationmay inflict irreparablebiological damage to tbe poprlationwith severelong-term consequencesfor the economicand socialdevelopment of the country. 1.67 The sectorfaces severalissues: the ineffectivesystem of healthcare delivery,presently biased towards urban care; the absence of policymakingin HOPE and consequentlythe lack of coordinationbetween differenthealth care providers;the weaknessof HOPH's internalplanning and management;inefficient use of resourcesby the hospitalsubsector; insufficientoverall financing of the sector;MOPE's disorganizedand complexpharmaceutical supply, resulting in a severeshortage of basic drugs which threatensthe credibilityof the entiresystem. 1.68 The sectorhas, however,valuable assets as comparedto many countriesat the same stageof development:first, its well-qualified and well-balancedhealth manpower, with neitheroverproduction of doctors nor shortagesof technicians.Second, its unsophisticatedhospital network which, once made more efficient,would not imposethe customary overwhelaingburden on the sectorfinances. Third, the realisticbut positiveattitude of key executivesin NOPH towardspriority interventions - familyplanning, primary care and managerialimprovement. NOPH is keenlyaware of its own limitations.It recognizesthat at present it is impossibleto expandits facilitiesor assumenew responsibilities, and that a periodof consolidationand reorganizationis necessarybefore - 19 -
expansioncan be resumed. The technicaland managerialaspects (f the new system have been carefully studied and tested on a small scale, and are now ready for the implementation of the changesoutlined in the Plan.
G. Government's Obiectives and Bank Role
1.69 The Bank's overallstrategy in Morocco pursues three major objectives: a) financing high yielding export-oriented or import- substitution activities as well as supportinginfrastruckure and services; b) increasingdomestic resource mobilization and budget savingsby, among otbers, improved productivity and efficiency; and c) improving income distribution by, amongothers, improving basic socialservices in rural areas. The Bank's objectives in the social sectorsinclude the shift from capitaland foreignexchange intensive bospitals to expanding basic bealth servicesto uaximizeaffordability and accessto low-income groups. 1.70 Government'slong-term objective in populationis definitely to controldemographic growth by steppingup populationactivities progress- ively,and raisingtargets for contraceptiveprevalence in order to reach a populationof 30 millionor less at the year 2000. In health and nutrition,Government's mid-term objectives are: to minimizethe biologicalimpact of the economiccrisis on the population;to improve M0PE'smanagement and hospitalperformance; and to identifycost-effective alternatives to the present health and nutrition programs. The long-term objectivesare to securea financingscheme for health care,and to eliminatepockets of malnutritionby raisingdomestic food production. 1.71 The presentHealth Development Project stems from Government's objectivesand discussionswith the Bank, since 1979, for the preparation of the 1980-85Realth Development Plan, which incorporates the development of cost-effective health care delivery systems with emphasis on primary care and family planning. The Plan relies cn a Bank-financed project to test an alternativeto the presenthealth system and set the basis for its countrywideimplementation. The Bank financingwill complement other donors'technical assistance and providethe financialstability to bring about the desired changes. - 20 -
II. THE PROJECT A. ProiectConcept and Obiectives
2.01 The projectwill assistNOPE in strengtheningand accelerating the shift avay from an urban-based hospital-oriented health system benefitting a limited segment of the population towards a more cost-effective system of primary care emphasizing outreach activities in the rural areas. 2.02 The project has two interrelated objectives which are stated in the 1981-85 DevelopmentPlan of MOPE: (a) Strengtheningprimary health care deliveryincluding family planning- in three provinces,totalling 1OZ of the country's population.Project implementation would be closelymonitored and accompaniedby operationalresearch, to allow for continuous adjustmentsresulting in a viable alternativeto the present healthcare deliverysystem.
(b) Strengtheningthe capacityof MOPH at centraland provincial levelsto make plans for the health sector,to train staff, to conductresearch and evaluation,and to administerthe public health service, as a necessary condition for a large- scale extension of the health care delivery system to the rest of the country.
B. Proiect Composition
2.03 The project will consist of four components, the first of which will meet the first of the above objectives,and the others the second.
(a) PrimaryHealth Services: The primaryhealth care systemenvisaged in the 1981-85Health Development Plan, but not fully implemented and revisedin the light of experience,will be fully deployed in three provinces - Agadir, Settat and Taroudant - with a view to futureextension of the projectto the rest of the country. The necessaryinvestment in additionalbuildings, equipment and vehicles will be made in the t.ree provinces.
(b) ement.-_na The project will provide technical assistance, training and equipment to strengthen the capacity of MOPE to manage the public health service, to formulate policy and plans, provide coordination for the healthsector as a whole, and to conduct research and evaluation.
(c) Trainin- and InformationlEducation and CommuDication (IEC). The project will strengthen capacity to train paramedical personnel - 21 -
and produceIEC X. '-rialsby providingequipment for a training centerconstructed inder the Third EducationProject. It will also provideequipment, vehicles, and technicalassistance for the productionand disseminationof IEC materials.
(d) SuDDly of Basic Drbus. The projectvill help establisha coordinatedsystem for the procurement,storage, formulation packaging,distribution and controlof drugs for the public health systemby providingconstruction, equipment, training and technicalassistance.
C. ProiectDescription
PrimaryHealth ServicesComponent
2.04 The first componentvill supportthe deploymentand operation, in a limitedgeographical area, of the primarycare and familyplanning schemeenvisaged for the entirecountry. Specialattention vill be given to the cost-effectivenessand replicabilityof six core programs - Immunization,Family Planning, Maternal and Child Health,Nutrition, Front-LineCare, and Basic Sanitation.The implementationof this component vill be carefullymonitored and evaluatedto obtainguidance for the futureexpansion of the primarycare system.
2.05 This componyntvill be carriedout in three provinces- Agadir, Settatand Taroudant -- with a total populationof 1.9 millionin 1984 (9.2Zof Morocco'stotal population).The three provinceswere selectedas representativeof the entirecountry in such re3pectsas geographicfeatures, ecological areas, socio-economic strata, ethnic and linguisticgroups, fertility rates and epidemiologicalprofiles, so that the experiencegained in the course of the projectvill serve as a guide for its replicationin other provinces. Descriptionof the three provincesand baselinedata are shovn in Annex 3.1 to B.6. 2.06 The primaryhealth care and familyplanning scheme will comprise six core programswhich vill be implementedas follovs:
(a) Imunizat-ion:The projectvill supportin the three provinces the nationvide imunization program designed with UNICEF assistanceagainst diphteria, tetanus, whooping cough, measles, polio and tuberculosis.The programvill be carried out through continuousvaccination by the healthfacilities and mobile teams.
1In 1983 the Provinceof Agadirwas split in two: Agadirand Taroudant. Consequently,in April 1984,MOPH establisheda new MedicalDirectorate for the Provinceof Taroudantvhich is includedin the proposedproject. - 22 -
(b) FamillPlannint: The projectwill implementthe VDMS approach (as describedin para. 1.09) in the projectarea in the same form as in the other provinces where it is in operation with USAID/UNFPAsupport. Contraceptiveprevalence in the project area is targetedto rise from present22% of NKRA to 33% in 1989. The programstrategy is three-foldand cowrpises: a) reachingrural NWRA, b) improvingcontinuation rates, and c) offeringa vider range of modern contraceptivemethods. (c) HCR Care: The projectwill deployMCH servicesfurther to the periphery. This will greatlyimprove the monitoringof pregnanciesand under five-year-oldchildren; it will also improvethe conditionsof home deliveriesand securehospital- izationof high-risk deliveries.
(d) Nutrition: The projectwill improve the nutritional status of infants,preschool children, pregnant and lactatingwomen throughpre- and post-nsatalcare and clinicsfor children under five years of age; throughactive detection of malnutrition by itinerantagents, mobile teams or familyhealth mobile units;and througheffective approaches to nutrition rehabilitation. (e) Front-LineCurative Care: The projectwill expandand improve curativecare by standardizingdiagnostic and treatmentprocedures, by providinglaboratory back-up, and improvingreferral and the supplyof basic drugs.
(f) Basic Sanitation: The project will iutensify the surveillance and continuousdisinfection of wells and cisterns,and improve solidwaste disposal. It will also enhancethe domesticuse of vater through locally-designed house improvements. The planned interventionswere carefullydesigned on the basis of experiencein Moroccoand other countries,witb technicalassistance from WHO, UNICEFand USAID. Technological innovations were reviewed at all staff levels. Detailedcontents and objectivesfor the six core programsare given in Annex C.
2.07 DeliverySystem. The six core programswill be delivered by multi-purposestaff sharingthe same facilities.The type of staff and facilitiesin any given area will be adaptedto local conditions - terrain,population density and socio-economiclevel. Projectpreparation includedextensive field surveysof the rural population,and systematic consultationswith field staff,civil authoritiesand local communities on the type of bealthservice delivery most suitableto the accessibility and degreeof dispersalof population.On this basis, it vas decided that six types of service,or "stratigies",each employingdifferent mixes of fixed facilitiesand outreachtechniques, vill meet the needs of all areas. For each locality,village or hamlet,a formalagreement was reachedvith civil authoritiesand coaunity leaderson the most suitablestrategy. Unlike theoreticalschenes proposed in the past, - 23 -
these strategiesare realisticand tailoredto the needs of the population. Detailson the strategiesare given in Annex D.
2.08 The projectwill providethe followingelements for the implemen- tation°f this component: the constructionof 10 BasicRural Dispensaries of 68 a each;38 RuralDispehsaries of 104.6a ; housingfacilities for 258 staff in distantrural areas; 102rural health centers of three differentsizes with an averageof 403 m ; 2 urban healthcenters and 2 smll rural hospitalsof 2,200m . It will also providefor substantial improvementor extensionof existingfacilities: 33 basic rural dispensaries, 41 rural dispensaries,32 ruralhealth centers, 8 urban healthcenters, 2 urbanmaternities, and 3 rural hospitals. Architectfees and supervision costswill be financedunder the project. At negotiations,MOPE has submittedthe final architecturaldesigns for dispensaries,and health centersType 1, 2, and 3; preliminarydravings for the hospitalsof Taliouineand Ouled Teima,and dravingsfor upgradingthe hospitals of Taroudant,Benahmed and Ait Baha, as well as the revisedcorresponding equipmentlists, for Bank approval. The locationof the new or upgraded facilitiesis shown in maps IBID 18651,18652, and 18653. 2.09 The projectwill provideequipment, and furnitureand vehicles for the additionaland upgradedfacilities as well as the following vehicles:21 ambulances,37 four-wheelarives, 27 light sedans,2 trucks, 49 uotorcyclesand 244 mopeds. It will also providefor the refresher trainingcarried out locallyfor medical,paramedical and supportpersonnel involvedin primaryhealth care, followedby continuingeducation of all personnel. The project will also provide for the incrementalrecurrent costs of expandinghealth programs in the three provinces- supervision and coordination,transportation and additionalsupply of basic drugs.
Management Component 2.10 The component will improve the managementcapabilities of MOPEand strengthen its role as policy-maker for the health sector. This will be achieved by strengthening its planning capacity, by estab- lishinga capacityto carry out evaluationstudies, and by improving administrstiveprocedures. 2.11 Planning. By the end of 1985,MOPE is expectedto have finalized a comprehensiveplan for the sector,to be includedin the 1986-88 DevelopmentPlan. This sectoralplan will be preparedin coordination with other publicand privateagencies in the sector. NOPE will then monitorthe implementationof the plan and preparean eztensionof baaic servicesto other provinces. During the final stages of project preparation the DICP has expandedits staff,and at negotiationsassurances were obtained that the Division de l'Infrastructure Chargee de la Planification (DICP) at all times will continue to carry its operations with full-time qualified and experienced staffin adequate numbers. The project vill further strengthen the DICP and develop its capacity in seven areas - long-term planning, short-term planning, manpowerplanning, health programming, physical planning, biomedical and hospital technology, research and evaluation. - 24 -
2.12 The project vill provide the DICP vith computer equipment, furniture,office supplies and vehicles. It vill also provide29 months of fellowshipfor post-graduatetraining in healthplanning and programming, healtheconomics, manpower planning, and managementinformation systems. Finally,the projectwill finance22 m/i of local consultantsto supplement the technicalassistance provided by the two advisersin healthplanning assignedby WHO to the DICP.
2.13 MOPH Management. The projectwill improveNOPH's overall administration.The projectwill followup on previousstudies and technicalassistance financed by USAID and WHO on managementinformati.on systems,and will in additionsupport the improvementof administrative proceduresin four priorityareas alreadyidentified by the Ministry. Under the coordinationof the SecretaryGeneral, NOPE staff assisted by localand foreignconsultants vill carry out a study on four managerial areas: a) programbudgeting and resourceallocation; b) procurement and biddingprocedures; c) civil works and maintenance;and d) management of personnel. On the basis of the study,an actionplan vill be developed, which will addressthe organizationof services,streamlining of procedures, retrainingof staff,and modernizationof officetechnology. At negotiations, assuranceswere obtainedthat the actionplan vill be preparedand submitted to the Bank by December31, 1986,and that the Borrower will carry out such actionplan as shallhave been agreedvith the Bank. 2.14 Studies. The projectvill includea programof studiesdesigned to supportthe planningand managementprocess. Agreementwas reached duringproject appraisal on generalterms of referencefor the three proposedstudies:
i) Healtb ServicesMonitorina. NOPE will implementa comprehensive monitoringand evaluatingsystem for the presentproject, includingfamily planning programs, as a firststep towards monitoringthe progressof the Plan as a whole. Data collected by healthfacilities will be processedand complementedby operationalresearch or evaluativeresearch. Conclusionson replicabilityof the projectare expectedby end of 1987, and will be includedin the mid-termevaluation (para. 4.14).
(ii) Study on the Financinsof the RealthSector. The study vill analyzethe availabilityand allocationof funds,and the efficiencyand equityof the presentand alternativefinancing schemes. The study is assignedhigh priorityby the GOC and MOPH. The GON will appointa SteeringCommittee with the participationof the Ministriesof Finance,Planning and EconomicAffairs for the coordinationof the studyvwich will be conductedin two phases. The firstphase, diagnosis, is alreadyunder way and will be completedby mid-1986;the second phase - exploring alternatives of financing - will be completed by end of 1988 to provideguidance for the implementation - 25 -
of the 1986-88Development Plan. At negotiations,assurances were obtainedthat the Borrowerwill appointby December31, 1985, an interoinisterialsteering comittee for the coordinationof the Study. Assuranceswere also obtainedthat finalresults avd recomendationsof the studyvill be furnishedand discussedwith the Bank by December31, 1988.
(iii) Study on HospitalManazeent. Since hospitalsabsorb 72Z of NOPH'soperating budget, the studywill focuson hospital performance,cost containmentand possiblemethods of cost recovery,in accordancevith the alternativesof the study on financing.The finalreport is expectedby the end of 1988. At negotiations,assurances were obtainedthat the Governmentwill furnishand discusswith the Bank by December31, 1988, the findingsand recommendationsof the study and will implement such recoomendations as shall have been agreed with the Bank. All three studieswill be managedby the DICP. The detaileddescription and timetableof the studiesare given in Annex F. 2.15 For the Studiessubcomponent, the pro3ectvill provide: a) technicalassistance consisting of 17 m/i of foreignexperts and 177 m/m of localexperts from consultingfirms and universities; b) trainingthrough 72 fellowship/monthsfor trainingoverseas as well as localseminars; c) computerand officeequipment. The projectwill also provide for local costs -- transportation, supplies, data processing-- as well as publicationof the resultsof the studies.
Training and IEC Component
2.16 The componentwill removetwo obstaclesstanding in the way of improvingthe healthsystem: a) the incompletetraining that has been given in recentyears to the mid-levelcadres - SpecializedNurses, Techniciansand Cadristesvho are presentlycrucial .for the operation of the system;and b) the insufficientIEC capacityto supportthe rising demandfor trainingof healthpersonnel as vell as priorityprograms such as familyplanning and PHC. This will be achievedby equipping the Collegeof PublicHealth and improvingthe productionand utilization of trainingand IEC materials. a) Equipmentof the Collegeof PublicHealth
2.17 The projectwill provideeducational materials and equipment for the trainingof paramedicalsin Rabat. This componentwas appraised in 1976 under the Third EducationProject, which vas only partially implemented,as describedin para. 1.51. The Collegeis nov operating at full capacity,and enrollsannually 720 paramedicaltrainees on two-year courses(120 nurses,80 psychiatricnurses, 40 physiotherapyassistants, 80 pharmaceuticalassistants, 40 radiologytechnicians, 80 laboratory - 26 -
technicians,40 anaesthetic.assistants, 80 sanitarians,40 statisticians and 120 cadristes).However, only theoreticalinstruction can be given at present,and trainingis severelyhandicapped by lack of textbooks and bilingual(French and Arabic)handouts, and equipmentfor demonstrations and laboratorywork.
2.18 The projectwill providecomputer and other educationaland technicalequipment in the form of textbooks,audiovisual and library equipment,materials for practicaltraining in laboratory,clinical and surgicalnursing, anaesthesiology, physical therapy and sanitation. The projectwill also providevehicles for the transportof students and instructorsfor hospital,community and fieldpractices. Printed materialsother than teztbookswill be providedby the trainingand IEC subcomponent described in the following paragraphs.
b) Production of Training and Information/Education/Comunication Materials
2.19 The project will strengthen MOPH's capacity to prepare, produce and distribute printed materials -- manuals, handouts, instructional materials, and audiovisuals. 2.20 The Health Education Unit of the Population Division already acts as MOPH's printing and IEC office, but lacks adequate capacity to meet its own needs as well as those of other branches of MOPH(see pars. 1.10). The Health Education Unit is presently underequipped to produce the quantity and quality of materials required.
(a) The College of Public Health and the 48 schools of nursing in the country are the chief users of educational materials in the sector, and require 70,000 copies of various manuals, handouts, and other educationalmaterials annually. The provincial health services require 40,000 copies annually of operating manuals and continuing education materials. (b) The supply of pamphlets, leaflets, posters, slides, TV video cassettes and audiotapes to be used in IEC support progrins for family planning and primary care (see para. 1.10). is deficient in quantity and quality. There is also a shortage of transport and equipment for the dissemination of IEC programs. 2.21 The project will improve the Population Division's capacity to produce training and IEC materials. It will provide printing, graphic and audio-video equipment, as well as supplies, to complement the equipment which has been sporadicallyprovided over the years by differentdonors - USAID, UNICEF, RHO, UNFPA. The project will improve the quality of training and IEC materials by providing 44 fellowship/months for the training of staff, and by providing for the diversification and pre-testing of materials. - 27 -
2.22 Finally,the componentvill addressthe deficientdissemination of IEC in rural areas - a lingeringproblem that affectsprincipally family planning, nutritionand sanitationprograms (see paras. 1.10 and 1.16). The projectvill improvethe deliveryof IEC by the healtb servicesin rural areasby using lighterand more versatilemobile units, shorterand simplervideo spots,mainly as supportfor presentati-ons in Arabic or Berber,followed by debateswith the coumunity. The project will provide32 lightmobile units - 17 four-wheeldrives and 15 light pick-upsvitb audiovisualequipment for use in rural areas. The project will includethe incrementaloperating costs of the IEC program. USAID, UNICEFand WHOvill continueto supplytechnical assistance for the design,pre-testing, production of IEC materialsadapted to rural area4. The programwill be closelymonitored for adjustmentsand evaluated periodically.At negotiations,assurances were obtainedthat the Borrower will prepareand submitto the lank for coaents, by December31 of eaeb year, the detailedannual program, including targets and timetables, for the productionand utilizationof IEC materials.
Suinly of Basic Druzs 2.23 In view of the paramountimportance of a dependablesupply of basic drugs for primarybealth care and the presentdisorganized state of drug manufactureand distributionin the publichealth service, this componentis designedto reorganizethe entired_ug supplysystem of the publicsector. 2.24 The privatesector will continueto distributeabout 952 of the drugs used in Morocco. In addition,it will continueto supply most of MOPH'sdrugs, either by cosmercialmanufacturing or by toll manufacturing.Over the projectduration, the Covernuentplans to maintain,as a minimumalternative, its total allocationfor drugs at present level, in real terms, with only a 3% annual increase to match demographicgrowth. Withinthis allocation,MOPB -- by judicious selectionof drugs,progressive utilization of genericdrugs, improved procurement,cost savingformulations, reduction of theftsand losses, and improveddispensing - will be able to increaseby 60% the avail- ability of basic drugs for PBC.
2.25 The project will reorganize MOPH's Drug Supply System under the authority of a newly created Drug Supply Unit (Unite d'Approvisionnement en MNdicaments - UAN) which will have full responsibilityfor the several stepsof the drug supplyprocess - budgeting,accounting, procurement, controlof stocks,contracting with the pharmaceuticalindustry, formulation and packagingof ba.iicdrugs and distributionto the provinces. The Central Pharmcy vill become a central supply unit dealing exclusively with furniture and medical equipment. Responsibility for the quality control of pharmaceuticals will remain under the National Control Laboratory. The sequence of operations to be performed, as well as controls and feed-back mechanisms, are shown in the diagram in Annex - 28 -
G.l. The UAM vill be establishedwithin MOPH vitb its ova individualized budgetand will have full authorityto carry all operationsrequired to ensurethe supplyof drugs which are mhown in Annex G.2. At negotia- tions,assurances were obtainedthat the Borrowerwill establishand maintainthe UAN with terms of referenceand staff acceptableto the Dank, to be responsiblefor all steps of the drug supplyprocess, and will ensure it is provided, through individualized annualbudgetary allocations, with sufficientfunds for its drug supplyoperation over the duration of the project. The establishment of the UAMwill be a condition of disbursement against the drug supply component. 2.26 The project will improve the UAN's management, storage, formu- lation and packaging capacity:
(a) Manatement. The managementsubcomponent will simplify the submission of orders by the provinces, and base local and international procurement on an International Pharuaceutical Market Information System (IPKIS). It will improvebudgeting, disbursement,contracting with the private sector for toll formulation,control of stocks -- including emergency stocks - and distribution.To this effect,the projectwill provide for constructionand equipmentof an administrativeoffice, and for equipmentand furniture,computer equipment and telex equipment,training of staff,contractual services with an internationalmarket informationsystem, and technicalassistance tbrough10 m=/ of trainingabroad and 20 m/i of foreignexperts.
(b) Storageand Haodlitaof Drugs. The proj t will improvethe proceduresfor customsclearance, transportation, reception, samplingfor qualitycontrol, warehousing, internal handling, storageof finishedproducts, packing, dispatching and distribution to the provinces. The storageand handlingof some 280 pharm- ceuticalsand cbemicals,including flamma le gases and liquids as vell as toxicmaterial and insecticides, require appropriate facilitiesregulated by safetyand securi y codes. Thl project vill providefor constructionand equipmentof 5,500 m of storage, packing and shipmentspace, garage and workshop, handlingand packingequipment, and two five-tontrucks for distribution.The projectwill also providefor the local trainingof mid-leveltechnicians and 5 a/= of foreignexperts. (c) Foru lotion The formulationof 46 basic drugs will be split between industryand the UA. Formulationof all antibiotics, which involvesmore sophisticatedprocedures and represents the major investments,is expectedto be done by the private industryunder contractsfor toll manufacturingon the basis of costs plus an agreed-uponprofit. Contractingfor toll formulation,however, will not be consideredpart of the project. The rest of basic drugs such as tablets, syrups. ointments, - 29 -
solutions,and suppositories,will be formulatedby the upgradedformulation unit of the UAM. To this effect,the projeqt vill provide for construction and equipmentof a 800 m formulation laboratory, a small galenic control laboratory, a power plant and initial ingredients and supplies for the first year of operation of the formulation and packaging units. The project will provide for machinery, laboratory equipment, air conditioning and ventilation equipment. The projectwill also finance 18 fellowship/months for overseas trainingin formulation as well as 6 l/i of foreignexperts. (d) Packauin. MOPE uses small quantitiesof sophisticateddrugs which are importedand distributedto hospitalsalready packaged. It uses large quantitiesof some 120 genericdrugs purchased and distributedunder hospitalpackaging. Finally,the primary health care services use about 100 drugs which are dispensed to patients and therefore must be safely and efficiently packaged. The project will enableHOPE to purchasedrugs in bulk and packagethem locally;it will also explorenew forms of packaging -- color-coded courses of treatment, instructions understandable to illiterates, notices in French and Arabic, coupled with IEC materials. The project will provide for the construction of a 1,200 i packaging unit, and packagingand labelingmaterials and equipment. It will providefor 6 fellowship/ufor three key staff and 5 consultant/ months of foreign experts for the improvementand continuous adjustment of packaging. At negotiations, MOPHhas submitted the preliminary drawings and engineering studies for the UAN and the corresponding equipment list, which were approved by the Bank.
2.27 Summarvof TechnicalAssistance and Fellow- -s. The project will providefor architectfees as vell as a total of 340 man/months of technicalassistance and 248 man/monthsof fellovships:
(a) 222 consultanttmonthsby local expertsin the followingareas: health planning; preparation of the extension of basic health services; management of MOPH, health services monitoring; health economics; hospital management; pharmaceutical management and inventories.
(b) 65 consultant/months by foreign experts in management, operational research, health economics, hospital management, pharmaceutical management, control of stocks, industrial pharmacy and drug packaging. (c) 150 man/months of post-graduatecourses abroad in health planning, health economics,health administration, research management and methodology,business administration, formulation, industrial pharmacyand marketing. - 30 -
NOPE way use WHO's assistance in the implementationof technical assistance and the fellowship programs. The detail and timetable of the technical assistance and fellowships are shown in Annex 1.4. All technical assistance and fellowships financed by the project will be administeredby the PIU.
III. PROJECT COST AND FINANCING
Cost of the Proiect
3.01 The total project cost is estimated at US$47.6 million including taxes (US$7.1 million). The foreign exchange component of the project will amount to about US$24.3 million. The breakdown of costs by project component is shown below:
Tble i: Pfoject COstSM 01u31 low) S "0o0) z mel lowal Foreni Tota locl ram*. Total l_ba Costa
adie SmithUexvim 18,3.4 10.0873.0 219,259A 12,50.2 10,651.9 3,153.1 16 70 J. MlQ 7,435.8 8,58.7 16,08.5 785.2 906.S 1,691.5 54 5 C. MaiDa ad I :Capcit 4,317.5 10,36L8 14,686.3 455.9 1,09.9 1,550.8 n 5 D. DM awly 9tm 23,073.141,755.9 6X,82.0 2,436A 4,4093 6,845.7 64 21 TO N 153,212.8 161,51D3 314,7.1 16,178. 17,062.3 33,21.1 51 100 lyicl Ccitim 11,757.8 14,628.5 26,36.3 1,241.6 1,544J 2,786.3 55 8 Prim Ciatkamaw 46,061.7 43,7813 89,846.1 4,.0 4,623.5 9,487A 49. 29 TOaUlP3U 006o 21,03.3 219,93.2 41,02.5 22,34.3 ,230.5 45,514.8 51 137 m _- m Pzdo,r for lqieaim Bayus 10,O0.0 1,000.0 21,000.0 1,00.0 1,1.0 2,10.0 Tbtal PM 0065 witb Pivism Z1,2.3 230,93.2 452,05.5 2,34.3 24,30.5 4,4.8
3.02 The base cost estimates for the project are as of April 15, 1985. The estimates for zivil vorks are based on preliminary drawings of project-relatedconstructions and on the 1985 unit cost of construction for similar works using economical construction methods. The cost estimates for equipment, furniture, and drugs are based on agreed lists of items to be procured and on the cost of procuring similar items in 1984. The estimated cost of fellowships, including travel, averages about US$1,780 per man/month. Detailed cost tables are presented in Annex I. - 31 -
3.03 The total cost estimateincludes 102 physicalcontingencies for civil works, furniture,equipment, drugs and medicalsupplies. Price contingenciesare estimatedover the project implementationperiod, for all expenditurecategories, as follows: 1985/86 1986/87 1987/88 1988/89 1989/90 Local costs .10 .07 .06 .06 .06 Foreigncosts .07 .08 .08 .08 .08
In the absenceof a sectorprofile and becausethe averagedisbursement period for Moroccois 8 and a half years,as a hedge againstpossible delays in the proposedfive-year implementation, a contingencyfor implementationdelays for an amountof US$2.1million has been added to the projectcost. This contingencyis derivedfrom a direct estimate of two additionalyears for the completionof the project. 3.04 The estimatedforeign exchange component of the projectis estimatedat US$24.3million. The breakdownof foreignexchange by categoriesof expenditureis as follows: civilworks, 40z; furniture, 55z; equipment,802; vehicles,70S; drugs,60X; fuel. 802; foreignexpert services,902; fellowships,OOZ; and local training,302.
3.05 The loan will also finance on a declining basis the incremental operating costs of the health services (excluding hospitals)in the threeprovinces over a five-yearperiod in respectto: a) the basic drugs; b) transportcosts and statutorytravel allowances for staff (VDNS,itinerant nurses, mobile teams and supervisors);fuel and vehicle maintenance.
3.06 IncrementalRecurrent Costs. Incremental recurrent costs generatedby the projectare estimatedat US$9.9million includingcontin- gencies and US$1.6 million in taxes. This includes net of tax salaries (US$2.9million), an improvedsupply of drugs and medicalsupplies (US$3.1 million),as well as sanitationsupplies (US$0.2 million), office supplies (US$0.3million), fuel, travelcosts and subsistance(US$1.8 million) to improvethe mobilityof outreachpersonnel. Incrementaloperating costs of the projectwill increasefrom US$0.9million during the first year of the projectto US$2.8million in the fifth year and are expected to leveloff thereafter.The increasein incrementaloperating costs occursbecause in recentyears, MOPH's actual resources at the primary healthlevel declinedin real terms,resulting in a declinein coverage and deteriorationin the qualityof services. Consequently,outreach serviceshave to be fundedto a minimumlevel to restorethe credibility of the system,at the same time as the projecteztends coverage to larger segments of rural low-income populations. In the first year, incremental operating costs will represent0.9Z of MOPR's 1984 recurrentbudget; this ratio increasesto 2.9Z by the fifth year. Such low percentage of NOPE's operatingbudget underscores the replicabilityof the project. The feasibilityof futureexpansion of the proposedPBC systemis further enhancedby expectedsavings in the cost of drugs, improvedmanagement - 32 -
of hospitalsand cost recoveryuechanisms that vill be exploredby the studyon financingof the health sector. ProiectFinancing
3.07 The proposedIBRD loan of US$28.4million vill finance70X of total projectcosts net of taxes, includinga PPF of US$75,000that will be refinanced under the loan. The GONvill provide the equivalent of US$12.1 million to finance the local costs, equal to about 302 of the total projectcost net of taxes,plus US$7.1million in taxes and duties. The GON has includedin the 1984-85budget a total of DR 72 millionfor the initiationof the project. The financingplan, broken down by category of expenditures, is ohown below:
Table 2: Finwcing PIn
Bgediture~~~~::- . : * Tota*01 Category ::(US$wil) (Zfinmcuig): (E$ nil) (Ifinsnig): (U$ nil) 1.Civil Wlks :: 4.4 30: 10.2 70: 14.6
2-.3W#pwt, Maeialis1,:::: Frai±e GVehicls:: 2.4 20': 9.6 80: 12.0
3.Traing Seuinars :: 0 0: 0.3 100: 0.3 4.Tecbmical Assistance:: & Feldships :: 0 0: 2.8 100: 2.8 5.P0PA :: 0 0: 0.1 100: 0.1
6. lncrin±a: ReatwretnCosts :: 1.8 32: 3.9 68: 5.7
7. Salarias :: 2.9 100: 0 0: 2.9
8.Tmes :: 7.1 100: 0 0: 7.1
9. Provisi fi ::f lTZletatizmDelas:: 0.6 30 : 1.5 70 : 2.1
IUAL :: 19.2 : 28.4 : 47.6
* All amomtsfor It.X 1 thzu 7 arenet of tun. **0.1 is the roxded figue for the MF of S$5,OW. - 33 -
IV. PROJECTORGANIZATION AND IMPLEMENTATION
Ornanization 4.01 Overallresponsibility for the projectwill rest with NOPE through its Direction des AffairesTechniques (DAT). As shown in MOPH's organizational chart in Annex R.1, all units taking part in project implementation are under this Directorate. The DAT commands tb.I necessary lines of authorityfor projectimplementation. It will: a) supervise the implementation of the Health Services component, through its norual technicalauthority, over the Medical Directoratein each of the three provinces;b) implementthrough its DICP the Planningand Studiessub- components,and in coordinationwith the DAA, the MDPE Managementsub- component;c) implement,through its PopulationDivision, the Training and IEC component;d) and implement,through its UAf, the Drug Supply component. NOPE has designated the Directorof TechnicalAffairs as the "sous-ordonnateur" giving him full authority to comit all project resources and authorize payments accordingly. 4.02 Within the DAT and under the direct supervisionof the Director of TechnicalAffairs, a ProjectImplementation Unit (PIU)has been created by ministerialdecision No. 2669 DT/206 dated December4, 1984, establishing its terms of reference. The PIU has been given overallresponsibility to conductall project-relatedprocurement, disbursement and accounting operations.The decreeappointed the ProjectCoordinator, as vell as five professionals- an administrator,a medicaldoctor, an economist, and two bead supervisorsof healthservices. All PI-appointedprofessional staff are well-qualifiedand have activelyparticipated in the preparation of the project. An experiencedarchitect will be assignedto the PI. In addition,four secretarialand supportstaff have been assignedto the PIU. The Sinisterhas also designatedthe interimdirector of the UAE to be developedunder the project. All MOPE units will reportto the PIU on matters related to the project. At negotiations,assurances vere obtained that the Borrower will continue to maintain the PTU vith organization responsibilities, staff, and terms of reference satisfactory to the Bank over the duration of the project. 4.03 In the three provinces, the project vill be implemented by the provincial Medical Directorates of Agadir and Settat as implemen- tation in the recently created Province of Taroudant will be supervised through the experienced staff of Agadir Medical Directorate. Under the overallresponsibility of the PIU architect,civil works will be supervisedby MOPE's construction units in Rabat,Agadir and Settat; each one of these units will be reinforced with a civil engineer and a civil work supervisorwho vill work full-timeon the project. - 34 -
Prcu remeat
4.04 Laws and regulationsregarding local procureueutprocedures and practices in Morocco have been revieved in the Bank in order to reach a judgementas to whetherlocal proceduresare acceptablefor Bank-financedcontracts. The findingsof that reviewwere discussed with the Moroccanauthorities and agreementswere obtainedduring negotiations regarding any changesneeded to make the procedures acceptable to the Bank. Procureseut arrangements are sumarized in the table below.
Table 3: Pzruaun S-Mi:Y (in MSsumiica)
mmI NA. I Ct I I cbil un 1 - 26 2.0 - I 14.6 (8.8) (.) I O1) I I I5.3 0.6 1* - 1 7.2 (4.2) (03) (1.1) 1 (5.8)
-m;I 0.5 0. 0.* - I 1A . 0.4) (03) (0A) 1 (1.1) Ibtnia& I 2.1 - - - I Li :1jW I .7) I (1.7)
Vbic1m I 1.3 - - - I 1.3 I (1.0) ~~I (1.0)
Tzmi.i~ I _ _ - 0.3 1 0.3 S;IID 1 (03) 1 (0.3) -I I- T.imiclksiatm I - - - 28 1 2.8 _lWindds 1 (23) 1 (LS) 1inoa1 1 1.9 1.0 - 23 1 5.7 bin,nz= .t. 1 (1.3) (0.7) (1.9) 1 (3.9) = ~~~I I- sIari_ I - - - 2.9 1 L9 I (0) I (0) Il I ION I - - - 7.1 1 7.1 I (0) I (0)
?ruwiasi. f I 2.1 I 2. Tl_int*im ~1y1(.5) I (1.5) 1W I 0.11 0.1 I (0.1) I (0.1) I 1XL I 11.1 14.6 3.8 181 1 47.6 I (U6) (103) (2.9) (6.) I (254)
*1551.3 ilm Mt of tc in G*tiPm - Iuini- M t tobe i m.i Jkm . s1W;i n.500,00in .pi a am .ut to be I mI mh pzadm df-Um.:1f i,^.
Note: Figures in parenthesis are the approxiiate respective amounts financed by the Bank. - 35 -
4.05 Civil Wgrki. Most of the civil works will be locatedin remote areas and will be too samll to attractforeign contractors. Consequently, the amountof US$12.6million net of tazes will be avardedon the basis of competitivebidding advertised locally, in accordancewith procedures acceptableto the Bank. MOPE'scentral construction unit will prepare standardbidding documents acceptable to the Bank for each type of construction.Civil works,up to an aggregatecost of Vs$2.0million equivalent,for the remodeling works or the constructionof sall health facilities in remoteareas where no contractorscould be found,my be carriedout by force accountwith Bank'sprior approval.
4.06 Goods. The total cost of equipment,furniture, materials, supplies,vehicles and drugs, is estimatedat US$14.9million net of tazes,of which US$11.1million will be procuredthrough international competitive bidding in accordance with Bank guidelines.Qualifying domesticmanufacturers vill be given a margin of preferenceof 151 or the applicableimport duty, whicheveris lower. To the extentpracticable, contractswill be groupedin bid packagesof US$100,000equivalent or more, each. Equipment, furniture, materials and supplies for the health facilities,estimated to cost aboutUS$1.3 million net of taxes,may be procuredthrough UNICEF. Itemswhich cannotbe groupedin packages of more than US$100,000but not exceedingin aggregateUS$1.5 million equivalent may be procured through competitive bidding, advertised locally, in accordance with procedures acceptable to the Bank. Contracts for miscellaneous goods amounting to US$15,000 equivalentor less, but not exceeding US$500,000 equivalent in total, may be procured through prudent shopping after obtaining at least three price quotations. 4.07 Services. The selection and appointment of consultants and technical assistance specialists (including architects) will be in accordance with Bank guidelines.
4.08 Bank Review Requirements. Construction contracts in excess of US$200,000equivalent and contractsfor goods in excessof US$100,000 equivalent will be subject to tbe Bank's prior review. Such contracts will comprise about 80X of the total estimated value of civil works, furniture, material, equipment and vehicles. Other contracts will be subject to Bank review after award. Terms of reference and conditions of employment of consultantsand advisersas vell as their qual-'fication will be satisfactoryto the Bank. Assuranceswere obtainedthat a list of coursesand candidatesfor the fellowshipprogram will be submitted to the Bank for prior review.
Disbursement
4.09 The loan proceeds will be disbursed as follows (Annex J):
(a) civil works: 702; - 36 -
(b) equipment,furniture, materials, supplies and vehicles: OOZ of foreignexpenditures; 100% of local expenditures(ex-factory); and 60Z of total expendituresfor otber itemsprocured locally; (c) technicalassistance, fellowships and trainingseminars: 100x.
(d) incrementalrecurrent costs: 68%. Disbursementsvill cover payments from December4, 1984, throughthe first year after the signatureof the Loan Agreementup to a limitof US$0.3 million,US$0.8 million for the secondyear, US$0.7 for the thirdyear, US$0.6 for the fourthyeer, and US$0.2for the fifth year. Retroactivefinancing up to a limitof US$2.0million for all payments for expenditureseligible for Bank financing,made on or after December4, 1984, date of the establishmentof the ProjectImplementation Unit, will be accepted. Disbursementsfor packagingmaterials and ingredients under the drug supplycomponent vill be limitedto a total of US$1.5 millionequivalent. The GON will fully documentall disbursementsfrom the loan amountexcept for: (i) civil works on force account,and (ii) expendituresfor trainingwhich vill be made againstcertificates of expenditure.The documentationfor these expenditureswill be retained by the GO) for audit and inspectionby projectreview missions. The disbursementschedule is presentedin Annex I. The present loan is expectedto be fully disbursedby December31, 1991.
Accountsand Audits
4.10 Duringnegotiations, assurances were obtainedthat NOPH will keep separateaccounts for all project-relatedexpenditures, which will be auditedannually in accordancewith appropriateauditing principles by independentauditors satisfactory to the Bank. Copiesof the audited statementswill be providedto the Bank for reviewwithin six months of the end of the fiscalyear. These reportswill includean opinion (and commentsas necessary)on the methodsemployed in compiling the statementof expenditures,their accuracy,the relevanceof supporting documents,elegibility for Bank financing,and the standardof record- keepingand internalcontrols related to the foregoing. 4.11 It is estimatedthat the present five-yearproject will be completed by 1989, as shown in the implementation timetable in Annex 1.3. HOPE's central staff in charge of the preparation of the project will be incorporated in the PIU and DICP's units concerned with the project;implementation of many projectactivities will immediately followpreparation. In order to keep the momentum,during the first semester of 1985, MOPH will continue or initiate four key projectactivities: (a) first phasesof the studieson the Financingof the Sector and HospitalManagement; - 37 -
(b) trainingof key centraland provincialstaff;
(c) upgradingof existingfacilities in Agadir,Settat and Taroudant provinces;and
(d) preparationof the 1986-88Health Development Plan. To carry out these activities,MOPH will utilizefunds allocatedto the projectin the 1984-85budget: DR 60 millionfor the firstcomponent, and DH 12 millionfor the fourthcomponent. Monitorint
4.12 Continuousmonitoring and evaluationare essentialto the first componentof the project. The DICP will be responsiblefor monitoring implementationin the three provinces. Such measurementviII cover:
(a) inputs: civil works and procurement,timeliness of refresher training,increase of drug supply,improvement of ISC support, qualityof technicalsupport at centraland provinciallevels. Monitoringof inputsvill be carriedout by the PIU in collaborationwith the threeprovincial directorates.
(b) outp_utswill be monitoredthrough process indicators- activities performed,coverage, utilization of services,drug utilization, referrals,indicators of qualityand cost of services. Process indicatorswill be measuredthrough health services monitoring complemented by operational research as described in Annexes FKl and F.2.
(c) outcomesof the six core programs, detailed in Annex C, will be periodicallyassessed through population, health and nutrition indicatorsagainst set targets. Baselinedata will be collected in the projectby the end of 1985, mid-termevaluation will assessearly trendsby the end of 1988 but healthstatus indicators are expectedto show significantprogress at final evaluation, by mid-1992. Specificallythe projectwill focus on the following targets:
(1) Knowledge of modern contraceptive methods smong vomen will increase from the present 632 of MYRAto 90% in 1989.
(2) Contraceptiveprevalence will increaseto 362 in Agadir, 38.5Z in Settatand 232 in Taroudantby 1989. Intermediate targetsfor 1987 are shown in Annex C.
(3) Percentageof childrenreceiving standard isamunizations -- coverage is expectedto raise from present36% to - 38 -
60% in 1987 and 80% in 1989. The percentageof vomen receivingtetanus toxoid during pregnancy vill rise from the present5% of pregnanciesto 55% by 1989. (4) Coverageof prenatalclinics vill rise from present5.4% to 35% by 1989. The percentageof superviseddeliveries will increasefrom the present 11Z to 55% by 1989; 80Z of high-riskpregnancies vill be deliveredin uaternities by 1989. (5) Infantmortality among rural populationof the project area will decreasefrom 150 per 1,000 at to 80 per 11000 by 1989. Maternalmortality among rural populationof the projectarea will be reducedto under 250 per 100,000 live birthsby 1989.
(6) Five specificcauses of deaths,selected as tracersor indirectindicators of care - deathsunder 5 years of age due to diarrhealsyndromes and acute respiratory infections;death by eclaupsiaand ruptureof the uterus; and deathsof tuberculosisfor all ages and sexes -- will be measuredand monitoredfor progress.
(7) The supplyof 46 basic drugs vill increaseby 50X in 1987, and by 150% in 1989. The utilizationof basic drugs -- prescription, dispensing and patient's compliance- vill be monitoredthrough operational researchin nine provincesduring 1986, 1987 and 1988, as shown in the timetablein Annex F.2.
ReportinD and Evaluation
4.13 Overallmonitoring, reporting and evaluationof the project will come under the responsibilityof the PIU which will insuretimely collectionof informationneeded for the preparationof semi-annual progressreports and its submissionto the Bank.
4.14 As head of the PIU, the ProjectCoordinator vill conducta mid-termevaluation of the projectvhich will cover projectcomponents as vell as necessaryadjustments of the PHC systemsand conditionsof replicability.By December1987 the GOM expectsto receivethe mid-term evaluationreport to decideon the extensionof the PEC systemto other provinces,possibly with Bank assistance.Assurances were obtained duringnegotiations that the Borrowervill prepareand furnishto the Bank a mid-termevaluation report, including the findingsand recomen- dationsof the researchmentioned in para. 2.14 (i), by December31, 1987, and implementsuch tecommendationsas shallhave been agreedwith the Bank. - 39 -
V. PROJECTJUSTIFICATION MAD RISKS
Justif ication 5.01 In additionto br'ngingdirect benefits to 102 of Morocco's population,the projectwill help the Governmentto organizethe health sectorand introduceoverdue policy changes. It will improvethe health statusof a sizeableproportion of Morocco'spoorest population, test an alternativeto the presenthealth care deliverysystem, and assist institutionbuilding in MOPH. 5.02 The deploymentand operationof the reinforcedand reorganized bealthservices in three provinces(total population 2.1 million)will yield the followingtangible direct benefits:
(i) Pooulation: Improvedfaoily planning services and IEC will significantlyincrease contraceptive prevalence in three pre- domionatly rural provinces which include 10S of the Moroccan population. Contraceptive prevalence is expected to rise from present 242 of MMlA to 332 in 1989 and 372 in 1992. Hovever, the benefits expected in the project area, already significantby themselves,are only a step in the extension of the family planning program. The experience gained in the project area and other provinces covered by the VDHS program will facilitate the extension of the program to the rest of the country over the next ten years when the national contraceptiveprevalence will reach37Z in 1992, 40.52 in 1996 and 432 in the year 2000. These contraceptiveprevalence rates vould result in total fertilityrates of 4.8 in 1989, 4.6 in 1992, 4.4 in 1996 and about 4.3 in 2000. The crude birth rates would accordinglydecrease from 40 per 1,000in 1985 to 28 per 1,000 in 1996, and to approzimately27 per 1,000 in 2000. Assumingmortality and migrationremain constant,the total populationof the countryis projected at just over 30 millionby the year 2000.
(ii) Health: There will be a substantialimprovement in health conditionsin three provinces. Motherswill be protected by improvedMCB services;infants and childrenwill benefit from extendedimiunization and controlof diarrheaand acute respiratory infections.Restored confidence in the health services will open the possibilityof sustainedpreventive care in the future, and introduction of cost recovery mechanism (iii) Nutrition: Although only a limited improvement in nutrition could be expected from tbis project, especially if droughts persist, the most severeconsequences of childmalnutrition will be alleviated and irreversiblebiological damsge prevented. - 40 -
5.03 The testingof the new healthsystem in the three provinces vill pave the way for furtherexpansion of a more cost-effectiveapproach which will eventuallybenefit the vbole populationof Morocco.
5.04 Institutionbuilding in HOPR will lead to tangibleresults in terms of: a) betterallocation of scarceresources; b) cost-containment in hospitals;c) more efficientmanagement of drugs;d) bettertraining of paramedicals;and e) more cost-effectivebasic services. The project will equip NOPH to measure its own performanceand deviseoetter approaches to healtb problems. Policyvill be based on betterplanniing, research and evaluation,and changesof policyvill be more effectivelyimplemented. Institutionbuilding of HOPH will bring abouta coherenthealth plan, includingthe coordinateddevelopment of publicservices, Social Security and the privatesector; the gains obtainedwill greatlysurpass the immediatebenefits brought about by the improvedinternal management of MOPH. Risks
5.05 The projectis subjectto the risks attendanton a first project in the sector. The technicalrisks inberentto the deploymentand operation of a new health systemhave been reducedinsofar that the technical innovationshave been well-tested,and centraland provincialhealth teams have been reinforcedwith competentstaff. Riscs have been further reducedby early projectstart-up to be financedretroactively.
5.06 Duringproject preparation, the risk of delays in project implementationhas been reducedin the followingways: a) by strengthening HOPH coordination with the Ministries of Finance, Planning and Economic Affairs which led to a consensuson the proposedimplementation schedule and the correspondingannual budget allocations; b) by establishing a strong PIU and securing supportfrom other MOPP branches;and c) by seeking at negotiations assurances on deadlines for key operations, many of which are alreadybeing implemented.In addition,the strong political comituent and support for the project in the three provinces and the Government'sinterest for institution-buildingin MOPE from the outsetof the projectare likelyto keep implementationon schedule.
5.07 The projectvas designedto minimizeincremental operating costs,especially during 1985 and 1986, the first two years of operation. The project vill be included in the forthcoming Development Plans of 1986-88 and 1989-93, and the corresponding budgetary allocations will be individualized in the annual operating budget (Programe d'Emploi) of MOPE. - 41 -
VI. AGREEMENTS AND RECOMMENDATIONS
6.01 Before negotiations,MOPH has submitted the following documents vhich met Bank approval: (a) The revisedarchitectural designs for dispensaries,health centersTypes 1, 2, and 3; preliminary dravingsfor the bospitalsof Taliouineand Ouled Teima, and drawings for upgradingthe hospital.of Taroudant,Benabmed and Ait Baha, as well as the revisedcorresponding equipment lists (para.2.08); (b) the preliminarydrawings and engineeringstudies for the UAM and the correspondingequipment lists (para.2.26 (d)). 6.02 At negotiations,assurances were obtainedthat the Borrower Vill: (a) ensurethat DICP at all timescontinues to carry its operation with full-timequalified and experiencedstaff in adequate numbers(para. 2.11); (b) prepareand furnishto the Bank, by December31, 1986, the actionplan for the improvementof MOPH'smanagement, and will carry out such actionplan as shall have been agreed with the Bank (par. 2.13); Ic) appointby December31, 1985,an interministerialsteering comittee for the coordinationof the Study on the Financing of the Sector;final resultsand recomendationswill be furnishedto and discussedwith the Bank by December31, 1988. (para.2.14 (ii));
(d) furnishto and discusswith the Bank by Deceuber31, 1988, the findingsand recomendationsof the Study on Hospital Management,and will implementsuch recomendationsas shall have been agreedwith the Bank (para.2.14 (iii)); (e) prepareeach year, and submitto the Bank for coments befor- December31, the followingyear's detailed program for the productionand utilizationof IEC materials(para. 2.22);
(f) establishand uaintainthe UAN with terms of referenceand staff acceptableto the Bank to be responsiblefor all steps of the drug supplyprocess, and ensurethrougb individualized annualbudgetary allocations that the UAM is providedwitb sufficientfunds for its drug supplyoperation over the duration of the project(para. 2.25); - 42 -
(g) continueto maintainthe PIU with organizationresponsibilities. staff,and termsof referencesatisfactory to the Bank (para.4.02);
(h) submitfor Bank approvalthe termsof referenceof consultants and lists of coursesand candidatesfor the fellowshipprogram (para.4.08); (i) have the projectaccounts audited annually in accordancewith appropriateauditing principles by independentauditors acceptable to the Blak, and furnishto the Bank certifiedcopies oa: the projectaudit reportswithin six months of the end of each fiscalyear (para.4.10);
(j) furnishthe aid-termevaluation report, includingthe findings and recomendations of the study mentioned in pars. 2.14(i), to the Bank by December31, 1987, and implementsuch recommen- dationsas shall have been agreedwith the Bank (para.4.14).
Condition of Disbursement
6.03 No disbursements will be made against the drug supply component until the Government has establisbed the UAN.
6.04 The above assurances having been obtained,the projectis suitable for a Bank loan of US$28.4 million equivalent to the Kingdom of Morocco for a term of 20 years including five years of grace. - 43 -
ANNEXES -44 Annex A Table A.1
FAMI LY AN=I - CMInhCEPTIVEPREV&LI
:Cmtraceptive Distributioms Prevalence Rate CZ)
ByYears 1978 12 (1) 1979 _ 1980 19 (2) 1981 21 (3) 1982 - : 1983 25.5 (4)
ByUrban/ Urbn 42.5 Rural Rural 15.2
ByAge 19-24 yers 18.6 Group 25-34 " 30.1 _35-4 " 28.5 45-59 17.3
By Imber : 0 4.0 of Liig : 1 19.0 QCildrer.: 2 26.3 3 31.0 : 4 30.0 : 5 and over 30.9
By Metod : Pills 16.8 :IUD 2.0 Tubal Liation 1.7 Co:dm 0.7
Total Modern Methods 21.2
Traditional Mhtbods 4.3 Total All Nethods 25.5
Souces: (1) DS&I estinates based on statistical data. (2) Natia survey an fertility and family planirg. (3) 1SD appraisal mission estimtes. (4) National survey an contraceptive prevalence. Annex A Table A.2
IWAL7H1EVEUW PFJE
NMRMONL ffATUS- DEVTIWS FROMS AMARDS,Er AGE, EE IN 01 ANDMM IN KG (1970)
untry Urban Rural
Age in Height Weight Height Weight eigt Weight lith (CM) (kg) (an) (kg) (cm) (kg)
Birth 0.7 0.3 1.7 0.4 0.6 0.2 6 -1.6 -0.6 -0.3 -0.5 -2.3 -0.8 12 -3.2 -1.2 -2.2 -0.3 -3.8 -0,7 18 -1.8 -1.8 -1.9 -1.7 -3.6 -1.9 24 -7.3 -1.9 -6.5 -1.6 -7.7 -2.1 30 -8.1 -1.9 -6.9 -1.5 -8.7 -2.2 36 - -1.8 - -1.6 - -2.0 42 -7.8 -1.9 -7.7 -1.9 -7.9 -2.0 48 -6.9 -1.8 -6.6 -1.7 -7.5 -2.2
Source: Ministerede la SantePublique, 'Vliquete Ntionalesur l'Etat de Nutritiondes Enfants de Nbinsde 4 Ans, 1971", reportedin Bulletinde la Sante Publique, Rabat, 1973.
NUTIONAL MA= AS PHME2I OFDn XRSW1
Calories IProtein ICalciun I Irmn I Vit. A I Vit. Bi I Vit. B2 I Vit. C I Niacin Xir) 6)(g (Ng) IU*tirg) ( (Ng) 6E!1(mg ) I I I I l I URnaN 95.4 I 104.5 I 59.0 1 105.6 1 106.4 1 108.6 1 131.0 1 105.8 1 - HUamL 112.7 1 125.0 1 59.6 1 147.2 1 64.8 1 196.0 1 46.2 1 53.0 1 - nPAL 106.9 I 118.3 I 59.2 1 132.4 78.9 1 173.9 1 30.5 1 70.3 i 102.6 I I I I EI II
* International Unit
Sburce: Secretariatd'Etat au Plan et au Developpeneat Regional, La conscummtimnet les depenses des nrages au Maroc, 19 0-71,Vol. IV. [ S-N9Se@S iif¢ S. E
------N~~~~ ---- ii
0 0 0 0 - N~F W 0% 0 8 - w E
.~~~~~~~~~ uS 50 6 0sSSo Id~~~~~~~~~~~i"IN
------~ ~ ~ ~ ~ ~ ~ ~ ~ ~~:>
n | - 47 - Annex A Table A,4
D FM PRME ME SEV= MDrfVSOF t OI.NIt IT SYNI OR uP OFDISEASE - 1983
Nuber Mild & Treated Severe & Trested Syndrcuor Diseae of Cases % by Paruedicalby Medica1Staff Staff (Z) (Z)
A. 0 to 5 Yeas of Age
1. Diahea amd/orvaititg 4,523 39.2 81.6 18.4 2. Otherdisorders of digestivesystem 582 5.0 77.1 22.9 3. Acuterespiratory infertions 943 8.2 78.6 21.4 4. Skminfections 650 5.6 92.3 7.7 5. ?Im-infectiousskin disorders 1,061 9.2 n.o 29.0 6. Fervos system disorders 202 1.7 90.0 10.0 7. Fever,unmpecific origin 2,021 17.5 88.6 11.4 8. Urinary disonders 94 0.8 100.0 0.0 9. Trumsnsad burns 456 4.0 86.6 13.4 10. Eye disorders 192 1.6 89.0 11.0 11. Oral cavity disorders 111 1.0 100.0 0.0 12. Other syndruzes 710 6.2 75.5 24.5
70TAL 11,545 100.0 85.8 14.2
B. 5 Years and Over
1. Diarrhea and/orvcmitiig 2,674 14.4 59.4 40.6 2. Otbergastro-inteatinal disorders 2,179 11.7 59.7 40.3 3. Acute respiratory infections 1,306 7.0 61.2 38.8 4. Skin infectimns 368 1.9 84.2 15.8 5. Noo-infectiousdkin disorder 2,048 11.0 57.6 42.4 6. Nervoussysten disorders 1,080 5.8 86.1 13.9 7. Fever, unipecific origin 2,782 15.0 66.1 33.9 8. Uriamry disorders 907 4.9 44.1 55.9 9. Gynecologic disorders 743 4.0 50.0 50.0 10. Disorders related to prepnxy 65 0.3 15.4 84.6 11. Truans and burms 1,127 6.1 71.0 29.0 12. Eye disorders 340 1.8 78.8 21.2 13. Oral cavity and dental diworders 711 3.8 36.5 63.5 14. Other syKriw 2,233 12.0 69.0 31.0
IDTAL 18,563 100.0 59.9 40.1
Source: Adapted fran "SumpleSurvey of PathoDog", Project Prsparatimn, Prow. of Apadir, Ministry of Pbblic Health, 1984.
5IPWJPI/QB - 48 - Annex A Table A. 5
HFAEHDIEYEOUEN PFD=
Nk1RNOURESOURCES IN PTJKI HffiLTHSBCM1TR (1976 - 1983)
I TYOEF PES?B I 1976 1 1977 1 1978 1 1979 1 1980 1 1981 1982 1 1983 1
IMedical/Direetors I 441 461 461 46S 461 461 461 461
I hzmincist/Directors I 4 1 4 1 1 1 1 1 2 1 41 4 1 4 1 IDouctors 1 710! 780! 780! 780! 7801 7801 780! 1,0501
IPhazscist 1 8J7 87! 601 86 86! 871 87 1 wi
IDstists I 20 20! 201 20! 20! 20 21 301
IVeterinariAms 11 1 1 111 1 11 11 I I I I I I I I I I Architect/Engineers 1 17! 19! 191 19! 191 191 19! 31!
IMedical Faculty 1 81 8! 91 9 10! 9! 9 271
Certifid Nurses I 1,946 I 2,199 I 2,799 1 3,215 1 3,913 1 4,725 1 5,083 1 5,589!
I Atxiliary Nirses I 9,570 1 10,022 1 10,890 1 11,647 I 13,188 1 14,414 1 15,706 16,590
Aministrators 1 236 274! 2751 3191 318! 348! 350 438
I Skilled Workers I 1,581 I 1,785 I 2,462 1 3,100 1 2,929 1 3,346 1 3,432 1 4,016 I
I Intes 1 1,160 I 1,481 I 1,678 1 2,978 1 2,980 1 2,919 1 3,247 1 3,247 I
IResidents 1 417 636! 7651 931 931 1,235 1,475 1,475 I ~ ~~~I I 1 1 1 1 1 1 I Tpories 1 5,631 1 5,816 I 5,815 1 5,911 I 6,017 I 5,733 1 5,769 1 6,069 1
1Otber 1 310 345 1 474 1 557 1 539 1 655 ! 717 787! 1~~~~~ 1. 1 1 1 1 1 1I TAE;L 121,742 I 23,523 I 26,094 1 29,620D 31,779 34,341 1 36,745 I 39,487
Source: "Health Personnel Management", Revue Marocaine Med. Sante, 1983 - 49 - Annex A.6 Page 1 of 2
MOROCCO HEALTHDEVELOPMENT PROJECT HeolthManpower Educadon EducaibonScheme and Cokgode ofPeluonnel
J3 (Spud) (5) RadancV 2 _ ~~~~~~~~~~~~~DoeRmnh _ __ CMtF'~~~~~~~~~~~~Ocici swwico;------
ffE~~AE unwf 3 _ , D _ ffWNE--- S~rSDE(2) 2 M -
2rndCvdg 6 kO
1atcvei 3 ESic5Non 5.
1. AMents de Sant6 Bre'vetfis(ASB) or Basic Nurses
After four years of secondary education, applicants are recruited on the payroll of the civil service for two years of basic training in hospital nursing and public health nursing. Tventy-eight schools in as many provinces graduate a total of 2,000 basic nurses annually. Because of budgetary li-mitations,admissions were drastically reduced to 900 in 1983. The 16,000 basic nurses active in the country are evenly distributed between hospitals and peripheral health services; they provide the basic staffing of the services. Only 10% of the ASBs are female. While basic nurses are well suited for hospital work, they prove to be less cost-effectivein peripheral services. Because ASBs bave adopted urban values during their four years of secondary education, they have difficultiesin adapting to isolated rural areas, particularly to the low-prestigeitinerance. All paramedicalsmust serve in the MOPH for a number of years before they could go to the private sector. many ASBs, however, choose to complete secondary education by correspondence and apply to the School of Certified Nurses or quit the sector after their service obligations are fulfilled. - 50 - Annex A.6 Page 2 of 2
2. Agents de Sant6 Divl1m6s d'Etat (ASDE) or Certified Nurses
Recruited after the completion of secondary education and a qualifying examination, students undergo two years of training to become either Certified Nurses or Specialized Nurses (in clinicallsurgical, psychiatric,pediatric nursing, etc.) or Technicians (in laboratory, dentistry, X-ray, anaesthetisiology,rehabilitation, sanitation, etc.). The ASDE level offers different options. Eight schools of nursing and ten schools of techniciansgraduate an average of 400 certified nurses and 500 technicians each year. The 6,000 ASDEs are the backbone of the services, their qualificationsare well-appreciated in the public and private sector. Only 60% of the posts budgeted for ASDEs in the NOPH are presently filled with qualified incumbents, a situation that will be resolved by 1989. The percentage of female ASDEs, badly needed for MCH and family planning services, increases steadily and reached 33Z in 1983.
3. Adioints de Sante DiPl6m6s d'Etat SDecialistes (ASDES), better known as 'Cadristes"
After serving in the health services, the most capable ASDEs are proposed for two additional years of higher education in management, .trainingor research at the Ecole des Cadres in the Rabat College of Public Health. The cadristes form an elite corps whose quality and performance are well recognized and are in high demand for key positions in the services.
4. Medical doctors are trained according to European standards and following European curriculae in the two medical schools of Rabat and Casablanca. After five years of training, the medical student undergoes one year of internship in hospitals. All graduates in medicine, dentistry and pharmacy from Morocco or abroad must serve one year of civil services ("Civilistes")in the MOPH.
5. Specialists after internship and civil service about 35% of physicians undertake 2 to 5 years of residency to become specialists. All the major specialties are now taken in Morocco and only few sub-specialties require training abroad. P ------
* ------VP
------
to VI>_ g -V W
I- - gjm-I
------o _ ------r-- L-b ~ ~ - -6 __ _% w __s- f
w -% -% o 0 O~~~~~~0 Ui~~~~~J 1~~.1 1 U
V ___ - -W -52- *6un A tabn.SA.3
hALtS S3YSLOPUUUY 110480!T
Capacity and Utiltinatien Idicatera of Osupitale bv PrevL:a- - 1932
...... a...... __...... _._._.-...... _.,...... _ Total Average Average iTotel PataiAt Occpeancy Average Lengtb of Saily Province :z Bad* Aduiesiena De:' late Occupancy stay Aduiteiet * ----__.-- ...... fl.U.SSU.flSUS.fl.l...... __.....__ _
Agadir : 1 339 35.665 353.337 69.3 969.6 9.9 97.7
Al-ocacima s: 349 8.095 66.376 52.1 181.9 8.2 22.2
Asilal us 154 2.641 28.786 47.7 73.4 16.1 7.2 seni melles : 333 12.133 95.137 63.1 260.1 7.3 33.2
3am Ulinan a: 1? 417 3.467 50.0 9.5 8.3 1.1
Deulnane :: 40 3$6 5.172 35.4 14.-: 6 2.4
Cbsu :: 55 1.023 6.530 32.6 13.0 6.6 2.3
Kl-Jdida :: 520 9145 135.5384 71.4 371.5 14.8 25.1
11-Ide1a a: 187 4.521 50.662 74.5 139.3 11.3 12.4
Krrebidi-a : 415 9.814 113.736 75.1 311.6 11.5 27.1
-eeeo-ir-a : 367 5.249 64.747 46.3 177.4 12.3 14.4
o mra i:15 57 239 4.4 0.7 4.2 0.2
Fee :: 1.529 25.050 343.683 62.5 955.3 13.5 70.3
Fiig :: 49 643 6.925 27.5 13.5 7.7 1.3
Kenitra :: 97 19.637 184.824 56.5 506.4 9.4 53.9
Ihenimet : 269 7.409 47.331 48.2 129.7 6.3 20.5
Ibheifr a: 228 8.5B0 54.829 65.9 150.2 G.4 23.5
heuribtga 79 4.190 15,596 54.1 42.7 42.7 11.5
Laayse a: 114 3.111 17.155 41.2 47.0 5.5 3.5
Harraek-c a: 1.785 29.170 475.121 7:.4 1.301.7 16.3 79.9
Maek :: 1.565 21.987 352,811 61.3 966.6 16 60.2
Nader a: 317 10.340 U3.255 72.0 228.1 3.1 23.3
uareanate a: 437 6.912 75.474 42.5 206.3 10.9 13.9
Ojda :: 960 23,198 213.302 60.9 584.4 9.2 63.6
Owed adeb : 404 912 4.214 23.9 11.5 4.6 2.5
afti :: 616 14.363 163.983 72.8 449.3 11.4 39.4
3attat a: 2.664 3.970 455.980 50.0 1.331.0 54.1 24.6
Tanger :: 615 14.114 164.556 72.2 444.0 11.7 38.7
Tan-Tan : 92 2.315 15.184 45.2 41.6 5.4 7.7 taonnate :: 130 4.929 31.149 47.4 35.3 6.3 13.5
Tatt :: 25 602 4.527 49.6 12.4 7.5 1.6
ane a: 382 3.335 80.213 57.5 219.3 9 24.3
Tetouan : 1.293 17.673 299.743 63.5 321.2 17 48.4 tignit :: 413 1.315 71.252 43.7 195.2 9.7 20
Cecblhanca 3.5283 63,13 786.714 61.1 2.155.4 12.3 174.3 tRbot-Bale :: 2.837 36.305 370.984 32.7 2.336.3 10.1 236.5
tOtAL :: 24.913 481.539 5,774,334 63.5 15.320.2 12 .- _f..... ------, _ .__ , M.
* _ *-_ _ . __ ...... … - 53 - Annex A Table A.9
orsa o urms uionw CIlAMSu gm inAL g m 1970-19 Ou0Um Dkzb)
::o PM 3A1 ::eaL :: :: M::W : ~~~:1 3: UL: :UE :U: : : :~: :U ::,T SUA=: - : BM E : ; D : -L : - :.L: Z : 2 :: . (2) (2 :(Z
1970 :: 216: 55.2: 44.8 : 21: 37:: 2,719: 1,133 : 3,852:: 7.9: 1.9 : 6.2 1971 :: 217: 55.6: 44. : 14 : 231:: 2,97: 1395 : 4,34 :: 7.4 : 1.0 : 5.3 1972 :: 223: 55.8: 442 : 30 : 23:: 3,146: 1,609 : 4,754:: 7.1: 1.9: 5.3 1973:: 237: 57.8: 42.2 : 83 : 319:: 3,513: 2,2 : 5,751:: 6.7 : 3.7 : 5.5 1974:: 28: 63.1: 36.9: 41: 32B:: 6,123: 3337.: 9,450:: 4.7: 1.2: 3.5 1975:: 331: 63.1: 36.9 : 105 : 436:: 8,869: 68 : 15,137:: 3.7 : 1.7 : 2.9 1976:: 368: 60.5: 39.5 : 2 : 569:: 8,213: 9,4: 18,077:: 4.5 : LI : 3.1 1977:: 407 : 59.1: 40.9 : 195: 6:: 8,86: U,744 : 2,630:: 4.6 : 1.7 : L9 1978 :: 49 : 62.7 : 37.3 : 147 : 646:: 9,468: 8,1 : 17,597:: 5.2 : 1.6 : 3.7 1979 :: 540: 63.7 : 36.3 : U9 : 659:: 10.622: 8,736 : 19,358:: 5.1 : 1.4 : 3.4 196D :: 630 : 673 : 32.7 : 129 : 759 12,635: 8,42 : 21,062:: 5.0 : 1.5 : 3.6 196 :: 701 : 67J : 32.2 : 238 : 939:: 15,357: 9,997 : 25,:: 4.6 : 2A : 3.7 192 :: 8O : 69.8 : 30.2 : 300 : 1,10:: 18,105: 16,806 : 34,911:: 44 : 1.8 : 3.2 193 :: 95 : 70.5 : 29.5 : 244 : 1,149:: 20,140: 18,714 : 38,854:: 4.5 : 1.3 : 3.0 1964 :: 918: 74.3: 25.7: 139:1,057:: 19.26: 10,155:29,391:: 4.8: 1.4: 3.5
&m: Einistyof Public l1kb m 1unatry of Pmn ------:--- -. ------
:11 1 >z 1, z 1 1a
I~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~I _ I II I I I _-
j~~~~IiI II~~~~~IFI | ------W------
- ~~~~~1II---- 9 ------t __ - 9
_b _ b b _ L b b ; b " b
$1-gSi----y------, l i!I r ;lI,i !--- [!I I [[[l[ll| I.
t~h[S Ch I- 6b_^ &.|""t. I[
at v qu _ - 55 -
Annex 5 Page 1 of 3
MORwOCCO
HEALTH DRVCLOPSCWTPROJECT
DescriDtion and Baseline Datj Provincec of Azadir Taroudant and Settct
Suarv Descript ion
8gadir,Taroidant together with Ouarzazateare the southern most denselypopulated provinces; further south lay the deserticand sparselypopulated SaharaD provinces.
In 1983 the Governmentdivided the largeAgadir Provincewith 1.2 million populationin two smller provinces, Agadir and Taroudant. In addition, the new province of Taroudant now includes large areas previously belonging to Ouarzaate. Most statistical data available still lump the two provinces together, and the Government is in the process of separating the two data bases.
Province of Agadir
The province is now reduced to a coastal strip 200 km long and 50 km wide. The province is limited by the High Atlas range to the north and the Anti-Atlasto the south. In betweenthe coastal plain is crossedby the Oued ouse.,the Oued Chtouka,and other minor seasonal rivers. The provincehas a populationof 624,000- 3S of the country's total population- ef which 58S live in rural areas. Over the past eleven years, the population of Agadir city and its suburbs of Ineagane increased at a tremendous rate of 7.6Z. The presence of a modern city. totally reconstructed after the 1966 earthquake,oriented toward tourism and developing industries, sharplyconstrasta witb the semi-arid agricultural back country. Three socio-economic groups coexist without much inter- penetration: the Berber population of the Atlas and Anti-Atlas live a subsistence economy in dispersed villages high in the mountain valleys, the cosmopolitan urban population of professionals, governoent employees and industrial workers. *and finally the Arab-speaking farmers and migrant workers of the central agricultural plains.
There Pre threehospitals with a total of 1,200 beds (or a ratio of 1.9 beds per 1,000 population),9 health centers and 66 urban and ruraldispensaries. There are 76 physicians- or 1.2 per 10,000 population - evenly distributed between the public and privatesector. As such, the province appears relatively well served, but in fact the concentration of large hospitals in the city of Agadirmasks the shortage of facilities in rural areas. - 56 -
page 2 of 3
Provinceof Taroudiat
Taroudantis economicallyand sociallythe back countryof Agadir. It extendsover a vast territory,200 km from nortb to south and 250 km east to west. Higb mountainranges and arid plateausforecasting the Saharanrift, occupymost of the land. The Souse Valleynarrows rapidlyto the east and fadesout in deserticsparsely populated areas. The sain road links Ouarzazateto Agadirwith few transversaldirt roads. The provincehad a populationof 582,000in 1983 and the density is low - 11.6 per km2 Two semllcities, Taroudant (26.000 pop.) and Ouled Teima (25,000*pop.) make for most of urban populationwbile 9O0 live in rural areas. Arab-speakingpopulation. mostly settledin the west, representsonly 20S of the total while differentethnic groups of Berber origin occupy the sountsiveand Zasternplateaus. Most of the rural populationlives in subsistenceeconomy
Taroudanthas only one hospitalwith 280 beds operatingin precariousconditions, 7 health centersand 49 dispensaries.There are 23 physiciansin the public sector and 9 in private practice. As sucb, the province is grossly underequipped with 0.48 beds per 1,000 population and 0.5 pbysician per 10,000 population. The bealthstatus of the population is poorly documented. Malnutrition is highly prevalent: a survey of children between 0 to 4 years of age in the Aoulouz district showed in 1983, 31.91 of children as moderately malnourisbed and 10.81 as severelymalnourished.
Province-ofSettac
The province of Settat is located in the Central region with a population of 717,500 in 1983. 791 of which live in rural areas. Settatprovince is typically agricultural and is known as the granary of the country. Flat or gently rolling terrains in the westerntwo-thirds of the territorychange to less fertile plateaus in the easternthird. The climateis influencedby the Atlanticwinds and precipitationallows for extensivedry-farming of wbeat. During the period1971-1982, its general population growth rate has been below the national averageat a rate of 1.8 (as compared to 3.1), urbanisation has been at a rate of 3.8 (as compared to 4.4 nationally) and rural population growth rate is 1.3 (as compared to 1.4 nationally). The rural ezodus in Settat has affected other neighboring provinces ratbhr than its own urban centers which, in turn, contributed to its low population and urban growth rates. Settat's population is economically and socially boogeneous. The vast majority is of Arab origin. About 301 of the agricultural population are small farmers farmingtheir own plots wbile 701 are tenantsor agricultural workers farming largeproperties. Insufficient rainfall in the past few years has adversely affected family income, and in a cereal-ricb provincemalnutrition is still prevalent. A nutrition surveyof Settat provincein 1982 sbow that, of 2,692 infants in the urban areas, 161 are moderatelymalnourisbed, 7.51 are severely malnourisbed. - 57 -
Annex B Page 3 of 3
There are three hospitals in the province: a 1,900-bed psychiatric national hospital in Berrechid which serves the entire country, a 309-bed tuberculosishospital in Benabmed also serving several provinces, a 200-bed general hospital in Settat, and finally 56 beds in two Rural Health Centers. In spite of the apparent infrastructure,the province is underequipped with only 256 beds to serve a population of 717,500 for a very low ratio of 0.35 bed per 1,000 population. There are 10 health centers and 36 dispensaries with a ratio of one health center for 71,750 inhabitants and one dispensary per 19,930. The province of Settat had 53 physicians in 1983, or a ratio of 0.74 per 10,000 population, of which 36Z practice in the private sector and 642 in the public sector. - 58 - Annex B Table. B.
s0c0-aoAc ~aIhcsf CO AM PF AEA
CEaIACIfISII(; NH0 : PAGDM SEr:TO TANWM: kear (2)* :- 712,550: 23,480: 9,750:
Popalatim density : (persamper km2) :: 29: 48: 71:
1umtainacsares (% * :: - : 60: 30:
Tota population: :: 21,000,0D : 624,600: 717,500 582,200 - vral paim (Z) :: 57: 58: 79; 90 - urbm pouation(Z) : 43: 42: 21: 10 - w iinreproductive age (Z) :: 17 : 27 : 16.9: - Fbpdatiax grCh gax.tb~~~~~~~~ : rate(197182) :: 2.9: 3.8: 1.8: 2. - ubm areas :: 4.4: 7.9: 3.8: 6.2 - rural arms 1.4: 1.5: 1.3: 1.7
* ta for Andir include Taroudantprovince as well.
Soure: Miziatryof PublicBealth, 1984, andhAt & CambesReport, 1983. -59 - Annex B Table B.2
#IIUAT:I DISRIBUS N ABGE COMIM AM PD ARN
: Project Area 2/
Age Gr 1/rocco: 4Agsi Settat (Z) :&Taroudmnt : (Z) aZ)
<1 15.2 2.7 16.0 1-4 14.9 5-9 14.3 15.4 16.9 10-14 12.6 11.5 14.5 15-19 : 10.9 8.0 9.4 2D-24 9.8 6.5 6.5 25-29 7.6 : 6.4 5.6 30-34 5.6 5.8 5.5 35-39 : 4.1 5.1 5.0 4044 : 4.3 : 4.5 5.0 45-49 3.5 : 3.3 3.2 50-54 3.5 : 3.6 3.4 55-59 2.2 2.1 1.5 >60 6.4 3.1 2.5
Sowce: Ministry of Public Health
1/ Baset m 1982 cenmis. 2/ Base on 1971 census. - 60 - Annex B Table B. 3
EON
EMRVEOR PDJB ar Ac 'ICETWPREWA1W IN )IM M AM RJB AREA- 1983
I l!etbod :N: occo Agadir Settat I ' :'' PPill 16.8 16.9 18.6 I
11Wm2 C.t 0.4
ubal Ligation 1.7 0.6 0.4 1
ICmdan 0.7 1.8 21
I Traditionml ethods 4.3 4.3 4.3 I
luTL' 25.5 24.2 25.7 I
Sourre: Natiotl Survey m Cotraceptive Prevalexe, 1983-84, Apdir and Settat - 61- Annex B Table B,4
FAMMYPLAN= ACCPMS 1977-1983
I : :: I :: AGADIR(1) :: SEI
I DI.OF NW ND. F I I ::AR :: :i.0AOPR I lI: :: l PPills : D :: Pills : D I
19771 :: 3,024: 87:: 4,594: 21 I~~~~~ I 1 1978 :: 4,260: 188:: 5,386: 1581 I ~ :: : :: :I 11979 :: 5,968: 197:: 8,597: 421 I ~ :: : :::I 1 1980 :: 7,370: 319:: 8,153: 831
I 1981 :: 10,363: 276:: 9,096: 411 * :: : :: :I 1 1982 :: 15,484: 404:: 11,215: 1511 I :: : :: : I 1 1983 :: 12,980: 456:: 10,192: 3481 l :: : :: :I
(1) Includes Taroudant province
Source: Statistiques Snitaires, MER - 62 - Annex B Table B.5
BMAUR DEVmEPIffl WFJC
mm IN MM :Fr ZONE (1981)
I D. I . I I I EsxMz I %P~A I Z t'I&A I I I Si I1r w SiR I S I I~~~AI I ~ I E I
~~~~I I AGI R I SErI * I I *IsI
URBA 17,8851 3,121 50 128 58 1581
X ~ ~~I I I I I I I * RUAL 146,751 129,8681 10 I 61 23 1181 I I 1 1 I I I I TOAL 54,636 132,9891 16 17.7 .28 1221
* IncludesTarodmunt province
Source:hmt amd Ca bes Rqport, 1983 - 63 Annex B Table B.6
IN TZ (XM11 ANDPODJEC ARA
Certified Auziliary Doctors Nires Nurses Other Total
MODBOCO : 1,101 6,013 16,OZ 5,993 29,131
- Ambulatory 591 2,268 7,981 1,248 12,088 - Hospital 510 3,745 8,046 4,745 17,046
AGADIR 44 197 463 411 1,115 X= = -
-Ambulatory 11 70 223 42 346 -Hospital 33 127 240 369 769
SETTAT :: 27 98 388 262 775
- Amulatory :: 8 11 166 32 217 - Hospital 19 87 222 230 558
TABotOANr : : 13 32 174 122 341 ::= _-
- Abulatory :: 7 16 117 57 197 - HoVpital 6 16 57 65 144
PYT= AREA 84 327 1,025 795 2,231 :: -___
- mbulatory 26 97 506 131 760 - ospital 58 230 519 664 1,471
Source: Ninistry of Public Health, 1984. - 64 - Annex B Table B.7
MCM UEALUH EUNM PDWT
AIDILNA P3SOIU UE DJ FOR7HE P1WBCT
: Certified Nurse: Axliay Nurses :Doctors: : Total : Total % Fale: Total 2 Femle: AGADIR
- Additiaml persomel :: 6: 35 77 50 42 : 91
- Increase* :: 14: 18 - : 11 - 8
- Additiml permel :: 3: 22 82 : 32 9 : 57 -Z lncrm * :: 11: 22 - : 0.2 7
- ditiol persomel :: 2: 8 0 : 37 49 47 - ncrese* :: 15: 25 - 21 - : 14
PF:: :A: :
- ditiml perooml :: 11: 65 69: 119 35 195 - Z Icree* :: 13: 20 -: 12 - : 9
* Additil perscxmelgenerated by the project as percentage of total perscmel in the praoince.
Somme: Miistry of Pulic Hlth, 1964 - 65 -
Annex C Page 1 of 6
MOROCCO 'EALTH PROJECT
CONTENTOF PROPOSEDPRIMARY CAUE PRIMARYHEALTH CARE CORE PROGRAMS
The uodel of Ambulatory Care to be implemented in Agadir and Settat will consistof six core programsin priorityareas:
1. Immunizations (PEV) 2. Family Planning 3. Maternal and Child Care (PSME) 4. Nutrition 5. Front-lineCurative Care 6. Basic Sanitation
For each program,the major operationalor technicalchanges are summarized belov.
I. UUZMIN
The iumunization program (PEV) presently reaches 45Z of national coveragein 1982. Urban areas are coveredat 631 vhile rural coverage stalls at 26Z. The project will support the nationwide immunization strategy by shifting from vaccination through periodic campaigns by mobile units to continuing vaccination by fixed posts - Health Centers and Dispensaries -- supplemented by mobile units in rural areas. The smaller rural dispensaries(DRB) vill not be includedas imunization outlets, for reasonsof cost-effectivenessof vaccineutilization and technicalcontrol. Detailedprogramming of vaccinationagainst six diseases-- Diphtheria,Tetanus, Whooping Cough, Measles, Poliomyelitis, and Tuberculosis- under the nev approachwill increasethe immunization coveragein Agadir and Settat from the present 361 to 601 in 1987 and 801 in 1990. In addition,the strategywill allow for the coordination of immunizationactivities with prenatalclinics and clinicsfor children under five years of age, sore convenientfor consumersand providers. The shift in strstegy requires: a) expansion of the cold chain to 47 nev facilities, b) provision of equipment, c) retraining of personnel, d) improved IEC support, e) vertical monitoring of operations at provincial level, and f) operational and evaluative research. The cold chain, logistics and equipment specific to imsunization will be provided by UNICEFwhile general equipment, training,I8C, monitoring and research vill be provided by the project. - 66 -
Annex C Page 2 of 6
II. FAKIIT PLANIUIh
In the three projectprovinces, the familyplanning program mill mobilizethe followingcombination of resources:
(a) All 48 smallerBasic RuralDispensaries vill deliverfamily planningadvice, and contraceptives.All 65 largerRural Dispensaries,which will be staffedvith a femalenurse as as vell as all 43 Health Centers,vill carry daily family planning clinics with capacity for IUD insertions.
(b) At the peripheral level, family planning clinics held in dispensaries and health centersvill be complemented by the outreach activities as described in para. 1.09. In the case of concentratedpopulations or populationslocated within 10 kas of a facility,the outreachvill proceedthrough bome visits. In the case of distantpopulations family planning programsvill be deliveredthrough biweekly clinics at meeting points,mobile teams or, in the uost remoteareas, by comunity workersand traditionalbirth attendants.
(c) All Health Centers and Hospitals out-patient services vill serve as back-up level and will operate FP and gynecology clinics manned by specialized female nurses and physicians.
Cd) The specializedfa._ily planning centers in Agadir,Settat and Taroudantprovincial hompitals will providetubal ligations and specializedback-up to familyplanning.
(e) IEC services will provide support to all family planning services and promotion activities in the comunity.
The objectivesof the programare: (i) to provideinformation on familyplanning and contraceptives to jL women in reproductiveage. To improveknowledge of modern contraceptivemethods including IUD and tubal ligation, from present63Z to 90% of women in reproductiveage in 1989; (ii) to increasetotal contraceptiveprevalence in the project area from the present 24.7 to 33 in 1989. Contraceptive prevalencetargets by provincewill be as follows: 1983 1987 1989
Agadir 24.2 30 36.3 Settat 25.7 31.8 38.5 Taroudant 15.2 18.8 23 - 67 -
Amnex C Page 3 of 6
Increaseof total contraceptiveprevalence will be obtained through an improvedfollow-up of recentacceptors (drop-out rates are high in all three provinces)and tbrough wider utilization of IUD - presently les. than 21 of KWRA-- to 62 by 1989, and tubal ligations - presently 1.7Z of HURL - to 41 in 1989. (iii)to avoid teenagepregnancies, lengthen birth intervaland drasticallyreduce high paritypregnancies as well as pregnancies in the 35-44 age group.
(iv) to increaseand improveIEC supportfor familyplanning, by audiovisualmethods and mass media channelsin urban areas, and by IEC mobile units in the distantrural areas.
(v) to carryout operationalresearch on acceptabilityof ZUD and implants,continuity rates by methodsand impactof IEC.
III NIERALr AMB CZ=LD CARE
Expansion and improvement of NCR -- particularly maternal care and family planning - depend to a large extent on the staffing of peripheral facilities vith a female nurse in charge. Maternal and child care will be deliveredin close coordinationwith im-unizations, family planning and nutrition through two activities: (a) Prenataland ObstetricalCare. The activitieswill be reoriented according to three operational objectives: (i) to expand the coverage of prenatal clinics to 35Z of all pregnancies - as compared to the present 5.4Z - focusingon high-riskpregnancies;
(ii) to improvethe conditionsof deliveriesin healthfacilities;
(iii) to improve the conditions of home deliveries through health education and supervision of traditional birth attendants by the health services; (iv) to secure hospitalization for high-risk deliveries.
The project will implement standardized clinical and laboratory proceduresfor prenatalaid obstetricalcare, based on risk assessment;retrain and re-assign60 femalenurses already in service,to carry out prenataland FP activitiesin ambulatory facilities; train and supervise traditional birtb attendants; upgrade existing maternity beds in rural health centers and provide for two additional rural maternities. - 68 -
Annex C Page 4 of 6
(b) Postnataland Clinicsfor ChildrenUnder-Five Yeagr of Ate. Periodic clinics for postnatal -- including PP care - and growthmonitoring of cbildrenunder five will be expanded to 77 facilitiesin the projectarea. Presentcoverage of motherand infantunder one year of age will increasefrom current 202 to 30S in 1987 and 551 in 1990. Special attention will be given to imunizations(I above)and controlof diarrheal diseases,for wbich detailedprocedures have been prepared. Controlof acute respiratoryinfections will be introduced in 1987under WH0' LachaiC&l a8SicStancC.
IV. *NDITICE
In coordination with other government agencies and assistance from UNICEF, USAID, World Food Program and UNFPA, NOPEhas initiated interventions at the nationallevel such as: reactivationof the production and marketing of Actamine; research of alternative supplementation formulas (such as ANDY), introduction if nutrition activities in the program of the Mobile Family Health bnits (UMSF), and reactivation of the InterministerialCommission on Food and Nutrition(CIAN).
Under the project, a limited number of well-definedinterventions, integrated in the PSMEprogram, will be implementedin Agadir,Settat and Taroudant:
(a) The major operational innovation will be the detection and referral of malnourished children and pregnant women by itinerant nurses or uobile teams, either by home visits (Strategies1, 2 and 3), or at Contact Points (Strategies 4 and 5). Similarly, villages, hamlets and pockets of poverty at high riak of malnutrition will be identified and screened (active detection). This approach will permit the detection of malnourished ehildren below 5 years of age whose wast'ig or stuntingseldom motivates consultation.
(b) Introductionof PSME units, staffed with female nurses, in the peripheralfacilities, particularly the Rural Dispensaries, will facilitate th.e fclol-up of referred cases and the long-term rehabilitation of malnourished children and pregnant vomen. In addition, pwsetnatal clinics will contribute to the detectiou of malnourished infants and toddlers of 0 to 2 years of age by systematic growtb monitoring (passive detection).
(G) Generalization of nutritional rehabilitation by the mother at home - rather than at the hospital, by improving the fauily's diet and cooking methods instead of providing supplements especially intended for the patient which are expensive and seldom reach the child. This approach reduces hospitalization - 69 -
Annex C page 5 of 6
costs but requiresincreased supervision by itinerantnurses or mobileunits accordingto the differentoutreacb strategies. It also requiresa dependablesupply of supplementationnutrients. The interventionhas undeniableeducational value but needs to be preciselytargeted if it is to remainwithin the present limitedbudget.
T. yaU LIM cURTvE CAN MOPH acknowledgesthe necessityto improveaccess to the healtb services. Duringproject preparation, consultations with representatives of the coumunityhave underlinedthe need for effectivebasic curative care as a prerequisitefor any furtherintervention in preventivecare. Objectiveswere set in threeareas:
(a) Hospitality:Improved reception and orientationof patients, improvedorgenization of clinicsand changesin workinghours for consumers'convenience, decrease of waitingtine, easier accessto nurse or physician,facilitation of referraland transportation. (b) Ouslityof Core: More efficientresponse to the felt needs, improvedlaboratory and X-ray services,assistance in trans- portationof emergencies,facilitation of admissionsto hospitals, continuityof care and medical records,standardization of 5 treatments,provision of basic emergencydental care. (c) DisnensinEof Basic Druns: Improvedsupply of appropriate drugs, correct prescription, efficient dispensing. Civil authorities,traditional and religiousleaders have made clear that continuedparticipation of the cou.m.ityin healthmatters is likelyto be conditionalto progressmade in those three areas. To assess presentand potentialdeuatd for care, a study of consultation was carriedout in Agadirand Settatduring project preparation. Causes of consultationwere surveyedand the effectivenessof the medicaland social answers provided by the health services was analyzed. NOPR now has a precise profile of current demand and a good insight of major flaws; a timetable for improvement has been set according to each one of the six proposed strategies. In view of the importance of qualitative improvements.progress will be closelymouitored and severalprotocoles for operationalresearch were designedfor the verificationo' effec- tivenessand assessmentof costs.
VI. "SIC IATIO
NOP's approach to sanitation is realisticand interventions are well-designed.Priority is given to drinkingwater for wbich there is a felt need, and collective interventions are well-accepted and - 70 -
Annex C Page 6 of 6 financiallyfeasible. Some of the denselypopulated areas require, however,inutallation of latrineswhich, conversely, are not traditionally accepted,derive from individualinitiatives and are relativelyexpensive.
Caution has boen exercised against introducing in ruralor periurbanareas costly uodern solutions wbich may be culturally and ecologicallyunadapted. Priorityhas beeD givan to supportand improvement of local initiatives.
The followingobjectives, allowing for variationsaccording to the terrainand settlement,are set for Agadir,Settat, Taroudant:
(a) In urban areas servedby house convectionsor public standpipes and sewagesystems, bacteriological control and chlorination will be improved. (b) In rural areas,wells, cisterns anI other groundwaterpoints alreadysurveyed in 1983 will be placed under bacteriological surveillanceby healthpersonnel according to Strategies1 to 5. Wells and cisterns, within 5 koe of a bealth facility, will be limed periodicallyor treatedby continuouscblorination with locallymade chlorediffusers. Casesof typhoid will be systematicallyfollowed up in the coemunity. In specific areas,particularly in Settat,ground waters will be tested for fluor, nitratesand ferroussulphate. (c) Improvementof 200 wells, cisternsand greundwaterpoints will be made cs demonstrationprojects, in collaborationwith the Ministryof Agriculture,in scbools,mosques, souks or villages. Financialparticipation of the comunity will be soughtfor the civil works in exchangefor information,training for localworkers and technicaladvice by NOPE.
(d) Demonstrationactivities will also be carriedout for household water conservation-- local constructionof filters,utilization of storagetanks, and improvedbandling of water. Kxperizental construction of latrines will be carried out in selected villages and periurban low-income settlements.
(e) Coordination will be establishedbetween several water supply interventions - handpumpsand plasticwater tanks installed witb UNICEFassistance, emergency relief by publicwater trucks and Bank-financed water supply developments in liougra,Taroudant and Ouled Teima in Agadirprovince and El Gara in Settat. Responsibilities of the Health Services will be coordinated with those of ONMPand the Ministryof Agriculture. Iuplentatian of this progrin will require upgrading of public health laboratory facilities, laboratory fixed and portable equipment and umterials as well as a dependable supply of chlorine and line. - 71 -
Annex D Page I of 3
MOROCCO HEALTHPROJECT
ProposedStrategies for the Delivery of PrimarlCare
Based on precisemapping of populationsettlements and field studiescarried out for projectpreparation, MOPE identifieddifferent combinationsof resourcesfor deliveringprimary care in a cost-effective manner. Severalcombinations of resources- known as "strategies" - use fixed facilities and outreach in different ways according to populationdensity and dispersal,terrain and socio-economic organization. In rural areas of Agadir,Settat and Taroudant,the strategyto be utilized for each settlement,village or commune was discussed with health staff, civil administrators,religious and communityleaders. In most cases, a formalagreement was reacbedbetween MOPH, civil authoritiesand the comunity leaderson the contributionexpected from each party. Six strategies will be implemented:
SIDATEY I1
ConcentratedPonulation (small towns,periurban developments, villages). A fixed facility- urban or rural healthcenter, urban or rural dispensary,according to the population- will deliverthe six core programsthrough general clinics, open to all patients,and specialized clinics - prenatal, family planning, tuberculosis, NCR, pediatrics -- held on specific days each week. Emergency care will be available at all times by staff on call. Health centers will be staffed with physicians, dispensaries will be staffed by nurses, with at leastone female nurse. Residents live within walking distance and will be expectedto aeek preventiveas well as curativecare at the facility. Rome visitswill be limitedto the VDMS and specialpurposes such as epidemiologicalinquiries and controlof bedriddeninvalids.
3SRAPF 2
Populations located between 1 and 5 kms of a health facility will still be expected to seek curativecare and followpreventive clinics at the facility. Preventive care vill be complemented by home vi8s.ts by an itinerant nurse equipped with a bicycle or moped - five visits per year for the VDMS,special visits as in Strategy 1, and visits for the control of wells and basic sanitation. An interplay will develop between the facility and the outreacha'tivities. - 72 -
Annex D Page 2 of 3
STEATKG!3
Population located between 5 and 10 kUs vill be expected to seek emergency and curative care at the facility. It is however unlikely that the populationwill follovpreventive clinics. Outreachactivities become the main element of the system. Itinerant nurses equipped with mopeds or motorcyclesvill make home visitsand vill be trainedto provide both curativeand preventivecare.
SAQI 4
Dispersedpopulations located beyond 10 km8 of a facility are unlikelyto seek curativeor preventive care on a continuing basis but only emergencycare. Multipurposeclinics for curative and preventive care vill be held once or twice a week at convenientlylocated Meetint Points. These clinicsvill requirea paramedicalstaff of two to three personswith a lightvehicle and portableequipment.
5 Dispersed,distant, nomadic populations, or settlementsthat are isolatedduring part of the year by rainfallsor snow,vill be served by mobileteams. on a periodicbasic - five times a year. At each visit,curative and preventivecare shouldbe deliveredas a one-time operation.This modalitywill requirea staff of threeto four, larger vehiclesand heaviermedical and dentalportable equipment.
SlU*FGr 6
In the case of isolatedclusters of population,where social organizationof the communityis propitious,utilization of co unitv healthvorkers may lend better resultsat a lovercost than the mobile teams. Voluntaryhealth vorkers and traditionalbirth attendants,under the controlof the communityleaders and periodicsupervision by nurse supervisorsvill serve as outpostsof the health services. This approach vill require well-trainedsupervisors and vehiclesadapted to the terrain.
By constructingadditional facilities in the rural areas - 48 basic rural dispensariesand 37 ruraldispensaries - the project will improvethe percentdistribution of ruralpopulation by distance to the nearestfacility: - 73 -
Annex D Page 3 of 3
Current Proposed
-3kus 3-5kus 6-9kus +l0kms -3kms 3-5k=s 6-9kms +l0kus
Agadir 23 14 24 39 40 20 19 22 Settat 24 12 41 23 42 19 33 6 Taroudant 14 10 18 59 27 19 28 26
Besidesdistance, a varietyof criteriawas utilizedto decideon the strategyto be used for each settlement. Strategiesare thereforedistributed to fit local needs realistically.The distribution of populationby strategyvill be as follows:
WDEA3EaF RLNALPOPATMU (ByProjert Stmteies)
I I A'ADJRA SE=IAT TAmN
I S _ _ _ _ _ - -______I I I PIATIIUE % I LouAItaMA X IPOFUIAL N % I I I aaI EDI aaI I1and 2 (fixedpos) 22D3,072 57 1 357,820 58 1 227,799 43 1 13 ad 4 (itinurnt) 1 95,152 27 1 125,192 20 I 2D9,185 40 1 15 and6 (bile tenmor 1 58,955 16 1 136,468 22 1 87,457 17 1 cuzmmityagent) IIII I I 1 1 1 ¶TOML I 357,179 100 1 619,480 100 1 524,441 100 1
SOURE:Mini"ty of Public Hbalth,1984. - 74 - M Annex E WLTH rEHM PR=
oWIZATINOF TIE WAm CAKE IFLIERY SYSTEM
LEYL ETDiL TE OR FIXED AW &IOP. 1311(M IN SERVICS LOATION FWILITT mmEVE STRAMT CwE WFEED
Pclatim inaccessible - - S6 - ommity LocalVillager kith First aid part of theyer Driers MUlerad Traditiuaal Distributioof Basic BirthAtteSt Mum ad tntracetives Liaiseuthilth Services
Distat ard dsesed - - $ lmile I fl.D.,3 paeicals Owewnmive or clinics, or nomadicpepilatim Clinics in NfbileClinics ere vwgas Orative care IStal care
Disersedpwulation - - St - Weting 2 pardcals in 1eky half-wayclinics for k mO Ib of a PoinW ligt vehicle 6 coreproW fixedfaility
fil Villages BasicRural 5,00D S2& $ - Hme 2 ale paruedicals 5 core powas, plus VMU Disea Visits VIE) alte ting after ard imizatiors
Largevillas or Dispensary 15,000 S2& S - H1 2 ale paredicals, 6 care pro fIURs Subrb areas Visits (WI) I feule nwse ad iniLatirns f nrme
mieftm of klth 45,00 S1,S21 3- l or 2 lI.D.s, 6 to 12 6 corepr, Districts Center HOnWVisits paraudicals specializedclinics, bck-w (VI) tlaboraturyad x-ra. Sad m weratim for S4,53 ad aprvisiunof S6
KajarTIS ral 200,00D - 6 to 10 L.D.s,24 to Dnter ald nil Hospital 40 pnedicals srgery, Pediatrics, oU-GN f0l0beds
CIpitalof Prince Ptrdncial 60,OOD - 25 to N.D.s,10 to AllUior clinicalad ospital 20 peruedicals sagicalspecialties. *-300beds
catlm a t 2 thiversity 21,00,00 - Alls-p aities hopitabls Total1100 bd - 75 -
Annes F Page 1 of 4
MOROCCO HEALTHDEVELOPMENT PROJECT
Structure and Resuonuibilitiesof the Division de l'InfrastructureChargfe de la Planification (DICP)
A. PLANNING
The planning section of the DICP has developed through project preparation and is presently staffed by three physicians, an economist, four instructors in nursing (cadristes),one administrator,statisticians, computer programuers and support staff. Part of this staff - one physician, one cadriste and one administrator -- will be assigned to the Project ImplementationUnit (PIU), and will only be available to the DICP part-time. Before negotiations begin, two economists and a social scientistwill have been recruited. The DICP has successfullymade good use of foreign technical assistance and at present employs three full-time advisers financed by USAID and two full-time WHO advisers.
To meet its responsibilitiesin the preparation, advocacy and isplementationof the 1986-88 three-year plan, the DICP will develop seven functiunal units or task groups, some of them permanent, others temporary. Task groups will also utilize professionals from otber MOPE departments to help on particular problems. The units will be as follows:
1. Lont-tersPlanning vill examine the long-term options for the sector, thus providing a framework for short-term planning and research.
2. Short-termPlannin& will prepare the three-yearPlan and coordinate the consultativeprocess within and outside MOPE.
!. Manpower Planning will reviev the performance and costs of the main categories of personnel in collaborationwith the Training Division and the Division of Personnel, as a basis for estimating future requirements and needs for training.
4. Health Programs vill set standards and annual targets for the health services, and monitor tae implementationof health programs in the provinces, in particular in the three project provinces, in collaborationwith the PIU. - 76 -
Annex F Page 2 of 4
5. Physical Planning presently regulates the creation of new outpatient facilities. The scope of the unit will be extended to include hospitals, and the unit will work in cooperation with the construction unit of the DAA.
6. Biomedical and Hospital Technology. This unit will control the acquisition and utilization of biomedical technology - laboratory, radiology and radiotherapy, electro-medical diagnosis, -- where major investment and recurrent expenditures are entailed.
7. Research and Evaluation vill coordinate the research and evaluation program described in B below.
B. STUDIES
The Health Development Plan for 1981-85 sets the following researcn objectives for possible Bank financing:a) to carry a detailed analysis of the health problems and problems posed by health care delivery; and on that basis, b) to establish and implementappropriate programs in the Basic Health Services (Agadir, Settat and Taroudant); c) to assess the costs and benefits of programs; and d) to prepare their extension to the rest of the country. Emphasis was placed on establishinga permanent research capacity in MOPE for management and planning purposes.
three main research areas are proposed: a) health services monitoring; b) financing of the health sector; c) hospital management and performance.
Health Services Monitoring
Health services monitoring will cover three main areas:
(i) Evaluative research on performance will be based on standard information collected monthly or weekly by all health facilities in the three provinces, and focusing particularly on:
* Accessibility and effectivenessof family planning programs, number of acceptors and contraceptiveprevalence. * Accessibility and performance of MCB programs. Catchment areas and gradients of care. * Outreacb activities. Performanve dnd output of itinerant nurses and mobile teams. . Referrals. * Sanitation/Drinking vater. Number and type of activities performed. - 77 -
Annex F Page 3 of 4
(ii) Operational research on alternativemethod of delivering care vill be based on informationcollected by selected health facilities. This research vill call for experimentationon techniques and/or organizationand management, carried out in rural areas of the provinces of Agadir, Settat and Taroudant, plus six other provinces. Priority areas vill be:
HMethods of contraception. * Utilization of IEC materials. * Techniques for monitoring pregnancy, growth and nutrition rehabilitation. * Distribution of health teams. * Quality of reception and orientation of patients. * Domestic use of vater.
(iii) Monitoring of bealth indicators- a statutory joint reponsibility of the DICP and the Division of Epidemiology. Three priority areas have been identified:
* Follow-up on the study of contraceptiveprevalence. * Follow-up on the study of infant mortality. Application of the findings of the National Household Survey of Expenditures on Nutrition for nutrition program.
Most of the evaluative research will be carried out directly by the staff of the DICP with the participation of other Divisions of MOPH assisted by Moroccan or foreign consultants, MHO and USAID advisers as necessary.
Most of the field research vill be carried out by provincial staff under the supervisionand technical guidance of the DICP, with the assistance of consultantsas necessary. Research that requires specialized capacity vill be carried out under contracts for the DICP by faculty and graduate students of the Departments of Social and Preventive Medecine of Rabat and Casablanca Universities.
Study on the Financin2 of the Health Sector
The GOM gives high priority to a comprehensive study on the financing of the sector as a follov-up to the 8ealth Sector Financial Analysis prepared by the Bank in 1983. The study will cover the public, parastatal and private subsectors. The first phase of the study vill analyze the financial flows in the sector. It vill reviev the sources, channelling and allocation of resources for health activities - including the Rabat and Casablanca University E,spitals but excluding social welfare - and will assess the equity and efficiency of the system. The second phase of the study vill explore alternative methods of financing: modalities of cost-recovery, the expansion of social security or insurance - 78 -
Annex F Page 4 of 4
schemes,and indirectrevenues. The Bank vill have an opportuniL7to expressits views before any policy based on the study vas put into effect. The resultsof the first phase are expectedby mid-1986.
The study vill be directed by a Steering Comittee vith the participation of the Ministries of Health, Finance, Planning and Economic Affairs, and carriedout by a Task Force under the directionof the Secretary General of NOPR. Technicalcoordination will be provided by the DICP with technical assistance from local and foreign consultants or uultilateral agencies. The projectwill financecontracts for servicesand technical assistancefor the preparation,discussion and publicationof the study.
Studyon HospitalPerformauce and Management Increasing demands for hospitalcare lead to delays in the admissionof patieutsreferred by the outpatientservices. In addition, the escalatingenats of hospitalsthreaten the financingof outpatient services. Rerearchon hospitalperformance and management is urgently needed to increase prodactivity and reducecosts. The study will cover a sample of selected hospitals inside and outside the Project Area: six provincialhospitals (Agadir, Settat, Narrakech, Fez, Neknesand Kenitra)and four districthospitals to be selected.
Basic data on costs of provincialand districthospitals were collectedin 1983 and 1984, so that the study will focus on organization (clinical and supportservices), performance (quantity and quality), and management issues in 1985 and 1986. The studywill be carriedout by a consultingfirm assisted by MOPE vith the technicalassistance of local and foreignconsultants.
The projectwill financematerials and local expenditures related to the study,data processing,contracts for servicesand technical assistance,seminars to discussthe findingsand their applicationand publLcationof the results. - 79 -
Annex C Page 1 of 3
MOROCCO
HEALTHDEVELOPMENT PROJECT
SuDDly of Basic Druis
Since 1979 MOPE has been concernedwith the progressiveshortage of basic drugs and the CentralTharmacy's aging facilities,and has explored alternative supply systess. In search for solutions,the Direction des AffairesTechniques has coordinatedthe work of WHO and UNICEFconsultants and technicctlassistance by ManagementSciences for Health (MSH) financedby USAID,as well as assistanceoffered as courtesy of the local pharmaceuticalindustry. MOPE and/orconsultants prepared eight technicalreports on publichealth, pharmacological, engineering, architecturaland economicaspects of the drug supplysystem vhich are availablein projectfiles.
On the basis of these technicalreports, discussions with BOPH officialsand representativesof the pharmaceuticalindustry, the AppraisalMission agreed that the reorganizationof the drug supply systemis an urgentnecessity. For NOPE's operations,efficiency requires that the severalmanagerial, administrative and technicalfunctions - selectionof drugs,standardization, budgeting, ordering, procurement, reception payments, storage, packaging, distribution and supervision of utilization -- be regrouped under a single agency. This opinion is strongly supported by the health services, wholesalers and manufacturers who will then deal with one agency ratherthan severaladministrative units in differentdepartments of MOP8 and Ministryof Finance. The real issueunder discussionhas been the opportunityfor MOPE to buy basic drugs, eitherlocally or abroad,or to formulateits own basic drugs. The AppraisalMission revieved with MOPEofficials, WHO,UNICEF and USAID consultants,three major alternatives.
1. Formulation I by NOPH
NOPH's Central Pharmacy will continue to formulate some 46 basic drugs for primarycare, and will improveand increaseits output to make up for the presentshortage and meet futureneeds. This alternative, originallyproposed by MOPE, was includedin the 1981-85Health Divelopment
lote: "Formulation"is the final stage of drug production,from inter- mediateingredients to final or finishedform. It consistsof simple mechanical operations such as mixing, solving or dispersing, and fragmen- tation into dosage forms (tablets, capsules, tubes, etc.). By comparison, "productione covers the entire transformation process from raw materials or basic chemicals to intermediate ingredients and final formulation - it consists of complex physical/ehemical operations such as extraction, fermentation and synthesis. - 80 -
Annex C Page 2 of 3
Plan. It vill require,however, a US$10 million investment to construct and equip a nev plant accordingto regulationsand prevailingstandards; acquisitionof advancedtechnology (i.e. in the formulationof antibiotics and toxics),and a substantialincrease of staff-- from the present 32 to 115 workers. Accordingto MOPH's atudies,expected savings, as comparedto procurement,could offsetthe amortizationof investments and the additionaloperating costs, although significant risks - technical as well as financial -- will be involved.
2. Procurement of Finished Basic Drugs in Bulk
HOPHwill procure all the 46 basic drugs neededfor basic health care, either in the local market or in the international market. This alternative will spare NOPE a major investment and greatly simplify its operations.Only a small formulationlaboratory, such as all major hospitalshave, vill sufficeto prepareabout ten basic solutionsand ointments. A packagingunit will still be requiredto convertthe drugs in bulk into single-dosagepackages. The localpharmaceutical industry, however,has consistentlyshown littleinterest in tenderingfor the formulationof low-costgeneric drugs, which will requireimmobilization of capitaland productioncapacity, for minimalbenefits. KOPH'sbasic drugs will only represent2Z of total drug expendituresin the country. For similarreasons, joint ventureshave not been attractivefor the industry. Procurementof basic drugs under finishedforms in the internationalmarket proved expensive in foreigncurrency, and the finishedforms did not alwaysfit the needs of primarycare. MOPE has evidence of many failures with procurement of finished drugs over the last years in spite of the declaredgood will of the industry. 3. Toll Formulation
This alternative has developed recently in many middle-income countr es. Documented experience existc for India, Tunisia, Brazil and Cost* Rica among others. Toll formulationconsists of Government procuringintermediate ingredients on the internationalopen market and contracting vith local industry for the formulation, on the basis of costs plus an agreed-upon benefit. The finished product is deliver-d in bulk under the Government's label. Toll formulation allows for considerable savings by purchasing ingredients in the open market and will spare NOPEmajor inveatments.It is attractiveto the local industry which will use its idle capacity witbout imobilizing capital. The industry will be ready to toll-formulate the more sophisticated drugs, such as antibiotics, for vhich idle technology and installations cannot be utilized for other purposes. Eowever, for the simplest drugs which require virtua!.ly no technology and only standard equipment, the industry's idle capacitycan be utilized for otber products,such as cosmetics, for much larger profits. This alternative still requires from the Central Pharmacy an accurate planning, an excellent procurement capacity based - 81 -
Annex G Page 3 of 3
on up-to-date information on internationalmarket prices, and flexible and rcpid procedures for contracting and payment.
Having reviewed these alternatives with the assistance of two consultants from the pharmaceutical industry, the Appraisal Mission agreed to the final MOPE proposal, vhicb, in turn, meets the local industry's approval:
MOPH will procure ingredients in the open internationalmarket and vill:
(a) Contract with local industry for the toll formulationof anti- biotics and some six products requiring sophisticated technology. The industry will utilize its available capacity of non-versatile equipment and deal witb the most expensive and therefore profitable drugs. HOPH will be spared an investmeat of about US$8 million in sophisticatedand rapidly changing technologyand equipment.
(b) Formulate in its own facilities the simplest high-volume, low-cost,minimal technology products wbich yet represent the most comon drugs in every day use in the health services - pills, powders, ointments, solutions, syrups and suppositories. The industry will rather avoid these cumber- some operations. For the formulation of this group of drugs, NOPS will only need an additional investment of US$1.3 million (as some of the present equipment could be utilized), and minimum additional staff and acquisition of simple technology.
The proposed project reflects these conclusions. ------
|-~~~~~~~ I f j |.U B
'4 r
il;Siiii $ Iji
j t~~~ 0 J z5 u I 0 k J
-~~~~~~~~~~~~~~~~~~~~-
. . . ___ . . . . .
______"_e____-_@_h___^S
i' V3%§ i a! git E3" 3i g j - 83 Annex C Table C. 2
MOROCCO HEALTHDEVELOPMENT PROJECT The Dmg Supply System - Sequence of Operalbns Control and Feedback Mechanisms
jStofau(VIW~ 1 1
-- ^6I I Du Cltrv--
N _ ~~~ono *
I, I < Fnno D cm mt Accamntmg J Itocuman
ACcoucb I
l_tw_wd_t_ Sk-ooI
J, -- % -1 Qvoft Cc- I * Conbo t owt |
C CP I 'wvn rus I .+~~~~~Cn~o~ I
D~._ t'.__._o
-~~~~~ ._._._._.i- I
S"wvoCx w0
r---- Pib5OtO_w I---
- C-smaft'wocv OW'SMrt4 SWOS5 .' - 84 - TAble .1
MOROCCO HEALTHDEVELOPMENT PROJECT OtgonizottonChart of the MinWtiyof PubikcHoIm
F LWJ Mrms,wOf L~~~~~~~2J7~~~~~~~~
SWCfWArArefttVM~ Gltnuw&cwtkGn -Dr Conft A Do of ho D d -k TWnAM _o Ad"WlffhwwAf
l ~ ~ mrn~Eckicoc C at -Acuig"3tI
t0OsurOfed_ P'o - i I Ihs POWc._C_ON - &ai PSCnr, _FW% -- DwgaeSum4 - llua@t4o Ltwaclh
So~~~~iOffyOf .n HeOfi iift* Gng% Vvta L hlllollion
SW"rofRaft wm , -85- Annex H Table H.2
MOROCCO HEALTHDEVELOPMENT PROJECT Project Implementation
Public Hech
| I lleDeot e o | Tednlical Affirs Directate of | - ~~~~~~~~~~~~~~~~~~~Admin.Alicrs
,Dug SuPP Unit
Divisionde n College of Divisionof Irln0rostructurieDisonOBug& Publc Heatth Population chorgee de la EqIpnaont Picanilication proe
- - ~~~~~~~~~~~~~~~~~. FtincenofI iPronceof | Sett ll Agodir T[oucnt |
Legend:
Pmject Implementation Auijht Line - MOPlsGenewo Authoity Line World Baor-26967 - 86 -
MOROCCO HEALTHDEVELOPMENT PROJECT Annex H Implmentatlon Schedu Table B. 3
19 1905 1510 19l7 *O 1909 1990
14 2. 3 a2J1 I2 3 4 1 2 3 . 1 l2 3 4 .11 ______~~~~~~~~~~~~d~,l2 13 ., I If I 2 3 I4 COMPREIOJ/ACIIVUECI 3AR I WAR2 W| R 3 T R4 VEAR5
of~P13 staff
-s. w= az ci1 -1 I Li .
-wL - u - b-iU .=NOW
am~i ci haicth .rL
hpu.m i KU staf -.
?lig U1siuS t i ffad
UP- he .ofamU4 bad& hPi P. uwf .It]T TWu-im Cm at-f - !.£tsimcitiimpi a p 13. sts
- lpaii ofsct pinp - qumylcin o W-m P
-Finift of do smctw lot jift-- r
- i~~~Iinpwtatim
Mx. 7aMB 6 DC00nm W~~~miCaUDs of'c pm ofmuff_t co apdpJ veichss ||W| f <7 I: Pho._ft of prfint*actlirMona & h-VFM=' spip. Is fg p. ofdml pvq Pzoi. a iqmtiinm Of yvcsm Dimm&tim in 3 projwet psasmm W inrt ofcomny
Hamiatci IEp.
ftW. ofima sUs & bidiixin Pip.mn of onI comm&*ts P wsti. ci "*mmin P-
1nmft ce ni tUumti
activity Vj ak2% * plAnned output I-T ------T -l----I
I P
Phh
$~~~~~~~~~~11S> '* i* 1 q Jill "~~~~~~~~',,,, , SS''SS U. i ,t
.A CP;V U tA e Nh, 0
5.~, 1¢ 1.I *1. ,_,1.P .,l@1
8 ~ if ~~~~~111111I, I, I"I W I ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~___ I40 " 4.W.~~~______*I~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ " cs . " n19 I I I I I -1 ______1 I 17 - 1^N ""~~~~~- W " as 1--, ta t, 8 I ,, "M- 1 , ,W.I 1 "F WtoR
- g~~~~~~6------I - It- - I""- I- - t: - I- - I- - - - - 0- - - I - - I I- - _"- I - I- - I b_U- I.- - I I- I I I I I I I I" | -88- Annex I Table I.1
m - w p4trr8SCMElM clErTe
ohin-im US$)
I :: : k : teU ndhli I Fiscal Year/ :: Dislxlts : Isbswsuiet : blance I Sester : I I ::4!Dalts: Z :Mnmts: S :~IZt: I I I .I
IFY161:8 I :: : : : :I IDecember31, 1985:: 0.3 : 1.0 : 0.3 : 1.0 : 28.1 : 99.01 IJume30, 1986 :: 1.0 : 4.0 : 1.3 : 5.0 : 27.1 : 95.0 1171987 ~:: : : : : : I I ~~~~:: : : : : : I Deember 31, 1986:: 1.4 : 5.0 : 2.7 : 10.0 : 25.7 : 90.0 1 June30 1987 :: 2.3 : 8.0 : 5.0 : 18.0 : 23.4 : 82.0
IFY 1988:: : : : : : I I :: : : : : I Deceiber 31 1987:: 2.6 : 9.0 : 7.6 : 27.0: 2D.8: 73.01 June30, 1988 :: 2.8 : 10.0 : 10.4 : 37.0 : 18.0 : 63.0 1 I ~~~~:: : : : :: I I F1989 :: : : : : : I I :: : : : :: l IDecember 31, 1988:: 2.6 : 9.0 : 13.0 : 46.0 : 15.4 : 54.0 IJune 30, 1989 :: 3.4 : 12.0 : 16.4 : 58.0 : 12.0 : 42.01 I :: : : : : : I F1990 :: : : : I ~~~~:: : : : :: IDecember 31, 1989:: 2.6 : 9.0 : 19.0 : 67.0 : 9.4 : 33.01 IJune 30, 1990 :: 3.4 : 12.0 : 22.4 : 79.0 : 6.0 : 21.0 I :: : : : : : IFT 1991 : I - :: : : : : 1 IDecember 31, 1990:: 2.8: 10.0 : 25.2 : 89.0 : 3.2 : 11.01 IJune 30, 1991 :: 1.7 6.0 : 26.9 : 95.0 : 1.5 : 5.0 I ~~~~:: : : : :: FY 1992 :: : : : : : DecmbrI- , 9911-:: : . : : : Ieceier 31,1991 :: 1.5 : 5.0 : 28.4 : 100.0 : 0.0 : 0.01 I ~~~~:: : : : : 1 -89 - Annex I Table I.2
MOROCCO HEALThDEVELOPMfET PROJECT ProJect Comanentsby Year (DIRHANI'000)
Base Costs Total
198511986198611987 1917/1188 198811989 1989!1M DIPHAI CUSS000)
A. DLPMENT OFBASIC HEALTH SERVICES 179079.6 4B,618.1 58,333.4 55,595.7 39,632.6 219i259.4 23,153.1 B. STREN6TIEIN5NOPH W6E 49547.4 39965.9 3%577.5 2,917.5 1,010.3 16,0o8.5 1,691.5 C. STRENGTHEN1N6TRAINING AND IEC CAPACITY 59309.0 5,211.9 1,948.5 1,187.5 1,029.4 14,686.3 1,550.8 D. DEVELOPMENTOFDRU6 SUPPLY SYSTEM 5,269.7 15,586.9 29,411.4 14,560. - 64,829.0 6,845.7
Total BASELINECOSTS 32'205.8 73P382.7 939270.8 74,261.6 41,672.3 3147793.1 33P241.1 Physical Contingencies 29581.0 6,358.0 8P111.9 6,250.7 3,084.6 26,3B6.3 2,786.3 Price Contingencies 24817.1 139582.8 250735.0 27,844.8 199866.2 899846.1 9,487.4
TotalPROJECT COSTS 37,604.0 93,323.6 127,117.7 108,357.1 64,623.1 431,025.5 45,514.8 __== ------= -======- ___ __= Taxes 6r287.4 14905.2 20,789.7 14,836.4 109571.4 67,390.0 7v116.2 ForeianExchange 19,158.8 44t940.4 67y468.4 589771.2 29i654.4 219,993.2 23r230.5
Aipril 19,1985 15:49 - 90 - Anue I Tabl- 1.2 (cmlt'd)
H6HLTHIBIBQIEIT PROJECT ProjEt Caunnts bs Yar Totals IwcludiniCwiowncius Tots IncludingCotinocius (Dblow OO (UH U00 n19951196 1991/137 1997/lYB11l99w1m 199W19 latal 1985/19619191897 /1871"o1 1931/19 l 9/1 Totw
A. I nT OFILI iC WLTH ISERYIES 199M.7 6PY5M.279694.5 8,137.3 61,597.2304,173.9 2,110.B 6,542.3 9,395.4 89,567. 6,503.432,119.7 3. SIUEN6UENIWHP H1917 5.107.5 4499.4 49739.1 4,137.0 1,504.0 20,396.1 539.3 517.4 5W.3 43U.9 159.3 21532.7 C. SIREIIITNEIUTUAIhINI I IECCAPACITY 6h230.06,500.9 2599.6 Is663.7 1,531.9 19,515.0 *7.9 686.5 273.4 175.7 161.3 1,95.1 D. IIERlU'IEITOF 5 UPlY SYSTE1 6,276.8 19I,68.340r216.4 21t419.0 - 97.950.5 662.B 2I109.6 4,254.1 2,261.3 - 9,297.3 Totl PROJECTMSIS 37,604.0 934323.6127,117.7 109,357.1 U44623.1 431,25.5 3.970.9 9,954.7 23,423.211,442.1 6,34.0 45,514.8 _===== := _ _ = 29 _ 1 93
April 19, 1Y95 15:N - 91 - Minex I Tabla 1.3
_ce aLTNFRESIFT PIRC Samw Avamt by ProjKt Com_ent
Phnical UEVLCPUETF TUHEHSlBIE DEEL'PEHYWF Cant nyAin MNAICHEATHI STR IEIIIMI TUAINIEAIAD IEC MU SUPPLY - - SERVICES ONHllAMT CACITY s1s Total I _Ant -- UU aa_ ___. _. .sa-us- n=ua . inaa su. ussa...as,
1. INVESTIIETCGSTS
A. CIVILgm3125
1. PRIDMTIALTH FACILIES
NEWCONSTRUCTION 50h751.2 - - - 5O0751.2 10.0 5,075.1 UPGRADINGAN REPAIRS 14319.5 - - 14,319.5 10.0 1I432.0
Sub-TotalPRIMARY HEALTH FACILITIES 65,070.7 - - - 65,070.7 10.0 6,507.1 2. WITSP.TLFACILITIES
MENCDTRUCTIOK l5v93.2 - - - 15.9.2 10.0 1i599.8 UPWIIINGAND REPAIRS 15,340.1 - - - 159340.1 10.0 1534.0
Su-Total NHSPITALFACILITIES 31.338.3 - - - 32,338.3 10.0 3,133.1 3. DRLI SUPPLYSTSTEN - - - 20*672.0 20*672.0 10.0 2,067.2 4. SUPERVISIEIAM ARCHITECTFEES 4v820.5 - 79229.3 12.D49.9 10.0 1.205.0
Sub-Total CIVILHlIRS 101,229.5 - - 27,901.3 129,130.9 10.0 12P913.1 1. EWUIP10T
PRILUTHEALTH FACILITIES 10,410.0 - - - 10,410.0 10.0 1,041.0 HOSPITALFACILITIES 20P815.9 - - - 20,115.8 10.0 2,031.6 DRUGSUPPLY SSTEIM - - - 20,440.7 20O440.710.0 2,044.1 PRINTINGAn AIDIO- VISUAL - - 2*105.5 - 2.105.5 10.0 210.5 PUBLICHALTH CMLLEGE OF RANT - - 5,025.0 - 5,025.0 10.0 502.5 RESEARCHACTIUITIES - 3.135.6 - - 3,135.6 10.0 313.6 RDJECTADINISTRATIO - 502.5 - - 502.5 10.0 50.3
b-T-lotal EMUINENT 31,225.8 34639.1 7130.5 209440.7 629435.0 10.0 6,243.5 C. FURLITIRE
n114RITEALTN FCILITIES 3,304.8 - - - 8,304.8 10.0 B30.5 HOSPITALFACILITIES 2.362.6 - - 2.362.6 10.0 236.3 PROJECTAIIISTRaTION - 153.7 - - 153.7 10.0 15.4
Sb-Total FUiITUK 10,667.4 153.7 - - 10,921.1 10.0 1.062.1 D. MATERIALANDSUPLIES - - 1.561.8 11,912.3 139494.1 10.0 1,349.4 E. VEHICLES
PR11Y HEALTHAM HWITSLFCILITIES 3,564.2 - - 9,564.2 10.0 856.4 MUGSuPLY SYSTEM - - - 502.5 502.5 10.0 50.3 AUDIO- uISuL - - :.s - 2,577.3 10.0 257.3 PU8LICHETH COLLEGE OF RABNT - - 502.5 - 502.5 10.0 50.3 RESERCHACTIVITIES - 542.7 - - 542.7 20.0 54.3 PROJECTNIIINISTRATION - 241.2 - - 241.2 10.0 24.1
Sub-otalUEHICLES ,564.2 703.9 3,0a0.3 502.5 129130.9 10.0 I,292.1 F. TEONICALASSISTICE
LAL EXPERTS - 4,699.2 - - 4,699.2 5.0 235.0 FOREIGNEXPERTS - 2,M.1 - 3,445.0 6.220.1 5.0 321.0
Sib-Total TEDlEICALASSISTMIE - 7,474.3 - 3,445.0 10,919.3 5.0 54.0 G. ERSES 7RAIIIG - 1,219.7 745.4 576.0 2,541.1 0.0 0.0 H. TRAININGSE1111RS
IIS. TtElRAININGSERIMS - 402.3 201.7 31.1 62.6 0,0 0.0 REGIEtLTRAININ SEHINARS 1,566.4 - - - 1,560.4 0.0 0.0
Sib-ot TRAIGalU SEMINARS 1,561.4 402.8 2e.7 51.1 2.2l1.0 0.0 0.0 1. PU PREPATIMFACILITY - 710.3 - - 710.3 0.0 0.0
Total IINE5T1EN8cUs 153t25.2 4302.-8 122746.6 64,129.0 245,213.5 9.6 23,427.2 - 92 - Annex I NmROCCO Table 1.3 WALTmKMWMmc ioaC' (cont'd) Summ Acart bi PnJut Comment (KMi 1001
IEUIPIET F STE)REN1IE EIIAT OF Continencies MC EALTH STENETIOX TRAININGMmS EC N5 SAPPLY RlUICES MAPFIMAN CAPACITY SYSTE Total z burt
II. RECLRRENTCOSTS
1. TIREEPRVINCES
SLMxIESOE INCRErmAL STAFF 21.0M3.1 - - - 21,093.1 0.0 0.0 DRUGSiPEDICAL GAFIES 29,591.6 - - - 29591.6 10.0 29959.2 FUELAND VEHICLE OP ANDMINTEIWE 6998.4 - - - 6,986.4 0.0 0.0 TRAVESUISISTANCE 5t456.8 - - - 5,456.8 0.0 0.0 OFFICESPPLIES 1W349.6 - - - 1,349.6 0.0 0.0 SANITATIONSUPPLIES 1.626.8 - - - 1,626.8 0.0 0.0
Sub-Total THREEPROVINCES 66.004.2 - - - 66.004.2 4.5 29959.2 2. PIMSTAFF IN RAT
FUELAND VEHiCLE OP. ANDHAINTWNCE 211.1 - - 211.1 0.0 0.0 TRAWLSA3SISTANCE - 265.0 - - 265.0 0.0 0.0 TRAWELCOST (AIR) 95.4 - 95.4 0.0 0.0
Sub-Totl PIDSTAFF IN RANT - 571.5 - - 571.5 0.0 0.0 3. RESEARCHACTIVITIES
FUELAD VEHICLEOP. NDNAINTECE - 422.1 - - 422.1 0.0 0.0 TRAWLSUISISTANCE - 212.0 - - 212.0 0.0 0.0 TRAWLCOSTS (AIR) - 265.0 - - 265.0 0.0 0.0 OFFICESUPPLIES - 165.2 - - 165.2 0.0 0.0
Sit-Total RESEARCHACTIVITIES - 1,064.3 - - 1,064.3 0.0 0.0 4. TRAININGAND IEC
FUEL C EIICLEOP. AMNMINT. - 1,939.7 - 1.939.7 0.0 0.0
Sut-Total TRAININGAND IEC - 1.939.7 1939.7 0.0 0.0
Total RECIRRENTCOSTS 66i004.2 1.635.8 1P939.7 - 6957.6 4.3 29959.2 Total BASELINECOSTS 21S9259.4 l16018.5 14686.3 64829.0 314,793.1 8.4 26'386.3 Pihsical Cantiniencies 18.127.8 B31.3 19179.3 6P247.9 26,386.3 0.0 0.0 Price Contingencies 66876.7 3P536.3 2,649.5 169873.6 99,846.1 7.6 6h843.6
Total PROJECTCOSTS 3049173.9 20,386.1 15.515.0 979950.5 431,025.5 7.7 33v279.9 s . ~~~~~~~~-~=Z= S t=wS=S== ZX= t== 3=-:-:===:_= Tas 509627.8 29090.7 3377.8 1192M3.7 67.390.0 9.7 5,835.1 Foreign Exchan 1399601.7 109771.9 12i877.2 -:9742.4 219,93.2 9.3 18.272.0
April 19, 199M5155: -93- Anab I Table .4 IEILTHIIE!NT PROME mmCM uTST WAYv
(DD m0) 1 '(lU) I Total S Foeign Bu Local Fomi Tota Local Foritih Total Eads Costs
I. IESTNR COSTS
A. CIVILIMES 1. MN41WALTNFACILITIES IEn NUCTION 319022.3 19,728.9 50,751.2 3,275.9 2,013.3 5,359.2 39 16 IFUDIE AN REAIRS 1,753.0 5,566.5 14.319.5 924.3 537.1 151.1 39 5
Sub-TLotlM11W ELT FACLIkES 399775.3 25,295.4 45,070.7 4200.1 t2671.169371.2 39 21 2. WI3T5L FAILITIES
EUICUST3ICTION 9,779.1 6,219.1 15,9".2 1.032.6 6il. 1,09.4 39 5 19345 AnDREMISS ,376.8 5,963.3 15,340.1 90.2 629.7 16191.9 39 5
Sub-TotalHOSPITAL FACILITIES 19,155.9 12,182.4 31,30.3 74022.81,26.4 3,309.2 39 10 3. IRIESIUPL SISTER 12.636.0 9.036.0 20O.62.0 1u334.3 948.6 2182.9 39 7 4. SUPERVISIONAD ACITECT FEES 7.277.6 4,M.2 12,049.3 761.5 503. 1,M.4 40 4
Sb-Total CIVILEkS 78,344.9 50.25.9 129,130.8 1,325.3 5,310.013,635.8 39 41 3. EUIIIENIT
PRINSTWEL.TN FACILITIES 2,0Q.0 9,32B.0 10,410.0 219.9 979.4 1,079.3 Be 3 IWSITALFACILITIES 4,163.2 16,652.6 20,15.8 439.6 ,5.S 2,193.1 so 7 RU SUPPLYSISTEN 4,0U8.1 l6.352.6 20,440.7 431.7 1726.3 2151.5 go 6 PRIN111AD AMUI0- VISIUL 421.1 1,64.4 2105.5 44.5 In., m.3 90 1 PIILICINALTY COILLEE CFIWAT 1,005.0 4.020.0 502e.O 106.1 424.5 530.6 B0 2 RESEECHACTIVITIES 627.1 2.5O.5 3.M35.6 66.2 264.? 331.1 90 I PROJECTADHINISTTIOh 100.5 402.0 502.5 10.6 42.4 53.1 9o 0
Sub-TotlE0NUPENT 12,487.0 49,948.0 62,435.0 19318.6 ,74.3 6,592.9 so 20 C. FMIITUIE
PMW HEAILHNFACILITIES 3,323.7 4,481.1 9,304.3 403.8 473.2 n77.0 54 3 NOSPITALFACILIMES 1,087.9 l2748. 2362.6 114.9 134.6 249.5 54 1 PROJECIADIINISTRATION 70.7 12.9 153.7 7.5 8.8 16.2 54 0
Sub-TotalFIIITUE 4,n.3 5t313.8 10,321.1 526.1 616.6 2,142.7 54 3 D. MTERIALS sULIEs 2.346.1 10,643.0 13,494.1 300.5 1,124.4 1,424.9 79 4 E. VEHICLES PRIHAR"IENTH AND HOSPITAL FACILITES 2,569.2 5,974.9 3.564.2 271.3 633.0 904.3 70 3 uaSUPL SISTER 150.3 351.9 502.5 15.9 37.1 53.1 70 0 A1310- VISUAL 773.3 1,304.5 2tW.7. 31.7 190.5 27.2 70 1 FSIC HALTHCLIE IF AAT 150.8 351.8 502.5 15.9 37.1 53.1 70 0 IESE4INACTIITIES 162.8 379.9 542.7 17.2 40.1 7.3 70 0 PROJECTAIHIaISTRnAnoN 72.4 168.8 241.2 7.6 17.8 25.5 70 0
Sub-TotalVEHIES 3.39.3 9051.6 12,930.9 409.6 99.8 1,365.5 70 4 F. TEC0IC4LASSISTIMCE
LIAL EXPETS 4.475.3 223.4 4,699.2 472.6 23.6 46.2 5 1 FIIIEI EXERTS 652.5 5.57.6 69220.1 68.9 587.9 6568 90 2
Sat-Totl TlV ASISTMEE 5-12.2 sM.1 10,9%9.3 541.5 611.5 1,153.0 53 3 S. IIAS T1I1U0 - 2.541.1 2,541.1 - 268.3 2633 100 1 HN.1111 SlIMS
3TIUE. 1I"= 5EI_S 471.2 191.5 642.6 49.8 20.2 70.0 29 0 REUSETJEINS 93MS55 1.115.2 453.2 15Y84 117.8 47.9 165.6 29 0
Su-Total TR1I35NSOIMS 1.536.4 644.6 2,231.0 17.5 U.1 235.6 29 1 I. PUS TIUII FELMU 234.1 426.2 710.3 30.0 45.0 75.0 60 0
Totl IEIIIT WTrs Il1.31.3 135175.32413.35 11.6619.7:4.74.1 MOW93. 55 73 - 94 - Annex I Table 1.4 - (cont' d) su c camsue (BW11'000) (USI'000) ZTotal ------I Foreinm 3w Local Formi Total Local Forein Total Exchmu Costs aun i __auZnu= 9 a i a aa u II. RECUIRENTCOSTS
I. THREEPROVINCES
SALARIESF INCREENTAL STAFF 21,093.1 - 21,093.1 2t227.4 - 2.227.4 - 7 [tUGAND MEICAL SUPPLIES 11,974.4 17,617.2 29t591.6 19264.5 1,960.33,124.8 60 9 FUELAND VEHICLE P ANDMAINTENANCE 1:377*3 M50M.1 698U6.4 145.4 581.7 727.2 so 2 TRAVELSUBSISTANCE 59456.9 - 59456.8 576.2 - 576.2 - 2 OFFICESIPPLIES 824.1 525.5 19349.6 87.0 55.5 142.5 39 0 SANITATIONSUPPLIES 996.1 630.7 1,626.8 105.2 66.6 171.8 39 1
Sub-TotalTHREE PROVINCES 41.721.724P282.5 669004.2 4t405.7 2,564.2 6,969.8 37 21 2.PIU STAFF [N RABAT
FUELAND VEHICLE OP. AND MAINTENANCE 42.2 168.8 211.1 4.5 17.8 22.3 80 0 TRAELSUDSISTANCE 265.0 - 265.0 28.0 - 28.0 - 0 TRAVELCOST (AIR) 95.4 - 95.4 10.1 - 10.1 - 0
Stub-TotalPIUSTAFF IN RABAT 402.6 168.8 571.5 42.5 17.8 60.3 30 0 3. RESEARCHACTIVITIES
FUELAND VEHICLE OP. AND MAINTENANCE 84.4 337.7 422.1 8.9 35.7 44.6 80 0 TRAVELSUOSISTANCE 212.0 - 212.0 22.4 - 22.4 - 0 TRAVELCOSTS (AIR) 265.0 - 265.0 28.0 - 29.0 - 0 OFFICESUPPLIES 100.9 64.3 165.2 10.7 6.8 17.4 39 0
Sub-TotalRESEARCH ACTIVITIES 662.3 402.0 19064.3 69.9 42.4 112.4 38 0 4. TRAININGAND IEC
FLELAND VEHICLE UP. ANDMbINT. 387.9 1,551.71.939.7 41.0 163.9 204.6 sO 1
Sub-TotalTRAINING ND IEC 387.9 19551.71,939.7 41.0 163.9 204.8 80 1
TotalRECURRENT COSTS 43,174.526.405.1 699579.6 4,559.1 29788.3 7.347.4 38 22 TotalBASELINE COSTS 1539212.8161,580.3 314,793.1 16t178.8 17,062.3 33,241.1 51 100 PhsicalContinsencies 11,757.814,628.5 26,386.3 1,241.6 1,544.7 20786.3 55 8 Price Continuencies 46,061.743,784.3 89,846.1 49864.0 4:623.5 9,487.4 49 29
TotalPROJECT COSTS 211,032.3219.993.2 431,025.522,284.3 23.230.5 45.514.8 51 137
Anil--======------=== ---- 19--1-85---:-- April19 198 5l:51 Table 1.5
ammnpm PROJEC Suqanv Accuts bk Year IDllllA 0002
am Costs Forrin Exchaws
I995/I9B 193W997 1997/1M9 19911969 1999/IWO Total : mo.j.t S8USu3us 33353333m SUSEUSUUUEWSSSWUE ManUaUss. SBnS.asma flUU SsUaf
1. IN1ESTIEI MsTS
A. CIVIL MS
1. PRIlRY HEALTHFACILITIES
NEUCOeSTRUCTION 2P490.9 12u454.613,387.4 149945.5 7,472.3 50752.2 38.9 19729B.9 GRING AD REPAIRS 4.:55.9 5474.4 44389.1 - - 14.319.! 3N.Y 5566.5
Sub-TotalPRIERY HEALTH FACILITIES 69646.9 29,229.017,776.5 14945.5 79472.5 65,070.7 38.9 25,295.4 . HOSPITALFACILITIES
NEMCONSTRUCTION - 2,759.7 2.759.7 7,079.27 3.39.6 15999m.2 38.9 6,219.1 UPGRADINGAND EAIRS - 4,660.8 5,206.9 2,680.4 2,792.2 15 340.1 39.9 59963.3
Sub-Total HOSPITALFACILITIES - 7,420.5 7,966.5 9,759.6 6,291.7 31.338.3 3S.9 12.182.4 3. IIO SIUPLYSYSTEM 2.0467.2 8268.8 109336.0 - - 20U.72.0 U3.v S.036.0 4. SUPERVISIONAD ARCHITECT FEES 29954.7 4v649.1 2.527.5 1.235.3 683.2 12P049.B 39.6 4,772.2
Sub-TotalCIVIL VORKS 1l1668.8 39s567.4 38t60f.5 25,940.4 14.347.7129i130.8 38.9 50295.9 D. EOUIPNENT
PRIANKYHEALTH FACILITIES 520.1 3. 122.1 3.197.6 2,556.2 1.012.0 10,410.0 90.0 8.328.0 HOSPITALFACILITIE - 2u518.5 B.420.7 5,196.4 4t480.2 20.Bis.8 50.0 16,652.6 BRU6SUFPtY SISTER - 29044.1 16.352.6 29044.1 - 20.440.7 80.0 16,352.6 PRINTINGDOADIO - VISUAL 589.6 926.7 589.1 - - 29105.5 80.0 1,684.4 PIUBLICHEALTH COLLEGE OFRABAT 31015.0 2010.0 - - - 5.025.0 80.0 4,020.0 RESEARCHACTIVITES 778.9 773.9 C29.l 748.7 - 3v135.6 80.0 2*50B.5 PROECTAIINISTRATION 251.3 251.3 - - - 502.5 90.0 402.0
5t-Total EQUIPMENT 5.154.8 11,651.5 29.589.1 10.547.4 5.492.2 62435.0 50.0 49.949.0 C. FURNITLRE
PRIAR HEALTHFACILITIES 622.0 2v771.6 2.5375.7 IB,68.1 507.4 8t304.8 54.0 4,481.2 HOSPITALFACILITIES - 179.1 702.7 456.2 1.024.6 2u362.6 54.0 1.274.8 PRDJECTADHINISTRATION 30.7 30.7 30.7 30.7 30.7 153.7 54.0 02.9
Sub-TotalFIINITURE 652.7 2.991.4 3v269.2 2,355.1 19i562.7I0.821.1 54.0 5,83B8. D. MATERIALAND SUPPLIES 158.2 158.2 474.5 124386.9 316.4 139494.1 75.9 10.648.0 E. VEHICLES
PRINRYHEALTH MD HOPITALFACILITIES 1.678.4 1.455.5 1.678.4 2,517.6 839.2 B.564.2 70.0 5.94.9 DRUCSUPY SYSTEH - 201.0 201.0 100.5 - 102.5 70.0 351.9 ADID- VISUAL I203.0 1.203.0 171.9 - - 2.577.8 70.0 1a804.5 ULIC HEALTHCOLLEGE OFRANT 301.5 201.1 - - - 502.5 70.0 351.8 RESEARCHACTIVITIES 168.8 217.1 156.8 - - 542.7 70.0 379.9 ECT ADrINISTRATION 160.8 - 80.4 - - 241.2 70.0 168.8
Sub-Toal MEHICLES [email protected]!412.5 2.2B8.5 29618.1 839.2 12t930.9 70.0 99051.6 F. TECDICALASSISTANCE
LOCALEXPEIRTS 1.032.0 1:.22.3 :.06.7 IOO.2 298.1 4.69.2 4.9 223.4 FOEIGNEPERTS 1.210.! 2.167.5 1,706.1 866.0 267.9 6.220. 89.5 5,567.6
Sub-Total TECICAILASSISTANCE 2.242.5 3v3B9.7 2.774.B 1946.2 566.0 10.91. 53.0 5-791.1 5. OVESEASTRAINING 355.9 745.4 677.6 474.3 298.0 2.541.l 100.0 2.41.: H. TRAININGSEIINS
NATIONLTRAININ6 SENINS 132.9 150.1 200.2 137.6 41.7 662.6 29.9 191.5 REGINL TRAININGSEINARS 470.5 313.7 313.7 235.3 235.3 1 568.4 29.9 453.2
Sub-TotalTRAINING SEIERS 603.5 463.7 513.9 372.9 277.0 2.31.0 B2.9 644.6 I. PRJECTPlPOTIDN FACILITY 710.3 - - - - 710.3 60.0 4-6.2
Tot INVESTINITCOSTS 25,059.0 61s629.8 7B.194.1 56,641.3 23.489.2245.213.3 55.1 135,175.3 -96 - Annse I Table 1.5 (cant 'd)
NEALTNUEVELWENT PROJECT Sumrv a 1 ts bi Year (low '000)
mu Cots Foreign Exchane
1 15N 19161l"7 1"7/19 1998/99 199/19M Total z Amount wn..u u a . u .a mongoosesuu...... sound..... a ..a..a... II. RECURRENTCOSTS
1. THREEPROVINCES
SMRIESOF INCREMENTALSTAFF 1,123.3 3,156.4 59335.9 59738.7 5.73B.7 21093.1 0.0 0. MMU6AD IEDICALSULIES 3,S42.1 4,854.5 5,504.0 7M.6 8 852005.29,591.6 59.5 17,617.2 FUELAN VEHICLEOP AND MAINTENANCE 694.1 1W158.2 1,678.0 1.679.0 14678.0 6,986.4 80.0 S,509.1 TRAVELSUISISTANCE 903.5 1,178.4 1,138.0 19096.7 1,140.1 5.456.B 0.0 0.0 OFFICESUPPLIES 221.1 257.9 273.1 299.8 298.9 19349.6 38.9 5.25.5 SANITATIONSUPPLIES 325.4 325.4 325.4 325.4 325.4 1,626.6 3E.6 630.7
Sub-Total THREEPROVINCES 6,909.4 10930.7 14,254.4 16#823.4 17,106.3 66.004.2 36.9 24,928:. 2. PIUSTAFF IN RABAT
FUELAND VEHICLE UP, AND MAINTENANCE 50.3 50.3 50.3 30.2 30.2 211.1 a0.0 1o8.8 IRANtLSUISISTANCE Ss.o 53.0 S3.0 >2.0 53.0 265.0 0.0 0.0 TRAVELCOST (AIR) 21.2 2!.2 21.2 15.9 15.0 9!.4 0.0 C.0
Sub-TotalPIU STAFF IN RANT 124.5 124.5 124.5 9vs, 9.1 S71.5 :9.5 169.8 3. RESEARCHACTIVITIES
FUELAND VEHICLE OP. AND MAINTEANCE 84.4 84.4 84.4 04.4 94.4 4 :.1 90.0 337.' TRAVELSU3SISTANCE 42.4 42.4 42.4 42.4 42.4 21. 0.0 0.0 TRAVELCSTS (AIR) 53.0 53.0 53.0 ;3.0 Z3 0 :265.0 0.0 3.0 OFFICESUPPLIES 33.0 33.0 33.0 33.0 33.0 165.2 38.9 o;.3
Sub-totalRESEARCH ACTIVITIES 212.9 212.9 212.9 11 21:.Q lo4.3 37.8 40:.G 4. TRAININGAND IEC
FUELAND VEHICE OP. AND IAINT. - 484.9 484.9 484.9 494.9 1.439.7 60.0 1291.'
Sub-TotalTRAINING AND IEC - 484.9 404.9 484.9 494.9 1,939.7 80.0 1SS1.
TotalRECURRENT COSTS 7,146.711,752.9 15,076.6 17,620.3 1,.983.1 6M7'9.6 37.9 :6,405.1 Total BASELINECOSTS 32,205.8 73,382.7 939270.8 74,261.641,672.3 3144793.1 !I.3 1w19C.3 PhysicalContm csias 2.81.0 6W358.0 3111.9 60250.7 3.084.6 26.86.3 5S.4 14625.5 Price Contrmncits 2417.1 13.582.8 25735.0 27,044.6 1898. 99846.1 48.7 43,794.3
Totl PROJECTCOSTS 37.604.0 939323.61279117.7 1089357.1 o6213.1431,025.5 51.0:19M9'3.: - ...... |ssa.s -t-aan ...... -wssralt.. "s-m .- t....asa .s-as-...... - ...... TAcus 6,.27.4 14905.2 20,79.7 14,336.4 1C9571.4 679390.0 0.0 0.0 Fotuian Exchag 19.158.8 449940.4 67,468.4 589M,1.2 29.654.4 219,93.: 0.0 0.0 bril 19,IM 15:41 * ------@------
¢51~~~~~~~ S S 0 6 °S 0[X 0 glt pI ______j-F1
_ _ _ _ _S______I
~~~~~------
~~~~~~IH ii:!~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~L - 98 - AnmezK Page 1 of 2
MOROCCO
RIALTH DZVEOPMWT PROJECT
8electedDocumets and Data Available in the ProiectFile
Sectiou& Generalreports on Moroccoand population.Health and nutrition sectors. A-I Ministryof PublicHealth, "Eaquite d'opinion our la planification familiale",1971. A-2 USAID,"Morocco: Food Aid and NutritionEducation", August 1980.
A-3 "D&finition des *edicaw.atsde base pour la circonscription", Rabat,1981.
A-4 Alaoui,Mechbal, "La sant& au Maroc en l'an 2000",Rabat, 1982.
A-5 Alaoui, Mecbbal,"La santepublique". A-6 Ministryof PublicHealtb, Directorate of TechnicalAffairs, "Kenseignewents &pidlmiologiques", 1981-82. A-7 APHA, "INC for Family Planning in Morocco", 1980.
A-8 APH&, "FamilyPlanning Manpower Development", 1980.
SectiQon: Generalreports and studiesrelating to the project.
1-1 Ministry of Public Health, "Projet de d&veloppeoentdes services de aant& dans lea provincesd'Agadir at Settat: Plan d'op&ration, rapportcompl&mentaire 1981; Budgetprograme (1982-83)".
5-2 VRIOIUMM,Premier r auort d ivjluatiou, 1983.
3-3 Casparetto, laDuort PXAR3I, 1983.
3-4 Ministry of Public Health, 'Donnies d4&ographiques de Settat", 1983.
3-5 T. Amt. M. Combes, RaDort de mistion a *UaouruDi oroiet de *oins de *t& de base,CLEAR, July 1983. _ 99 _ Annex K Page 2 of 2
B-6 Ministry of Public Health and CINAN, "Rapport int&rimaire de preparation", June 1983.
3-7 Ministry of Public Health, "Project Preparation Documents", 1984. B-8 Ministry of Public Health, "VDMS, Resuu e succinct, Marrakech", December 1978. B-9 USAID, "Final Evaluation of VDMS", December 1983.
B-10 Ministry of Public Realth,"Health Development Project - Proposal documents No 1 to 14", Rabat, 1984.
Section C: Selected working papers prepared by Bank staff and consultants. C-1 C. Pierce, "Morocco: The Demographic Situation',1978.
C-2 S. Basta, "The Nutrition Situation in Morocco". 1981. C-3 C. Pierce, "The Health Situation", 1978. C-4 SCET-AGRIfor the World Bank, "Morocco: Health Risks Evaluation", March 1984. C-5 J. Andreu, "Morocco Health Sector Financial Analysis", 1983.
C-6 "Training of Paramedical Manpover for Family Health and Family Planning", March 1979.
C-7 J. Pillet,"Morocco Drug Supplyand Utilization", 1984.
C-8 Hank Schut, "Morocco Drug Supply", 1984.
C-9 Hank Schut, 'Drug SupplyFollow-Up Report", 1984
C-10 J. Lecomte, 'Le planning familial au Maroc", 1984.
C-ll WHO/EURO,"Education pour la sante",1984. 9aO' % fi,,N>+ ; MOROCCO ~~~ ~HEALTH DEVELOPMENT
ESSAOUIRA . PROJECTI E -~~~~~~~~~~~~~~ ~~~~~~AGADIR PROVINCE :.h II. EMlCiOMWSU H, t '~~'~~ e * BasooDi"sodnili
~LAS 2_ 0 6
'r.q.v Mw - - *- .4 A.*&11I
200
Riven OUSS~ ~ ~ ~ ~ ~ ~ ~ - UrtmAai - MainRacls
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