- I Document of The World Bank FOR OFFICIAL USE ONLY Public Disclosure Authorized ReportNo. 9787-MAU STAFF APPRAISAL REPORT ISLAMIC REPUBLIC OF MAURITANIA Public Disclosure Authorized HEALTHAND POPULATIONPROJECT OCTOBER 28, 1991 Public Disclosure Authorized Populationand Human Resources Operations Division Sahelian Department Africa Region Public Disclosure Authorized This documenthas a restricteddistribution and may be used by recipientsonly in the performanceof their official duties. Its contents may not otherwise be disclosed without WorId Bank authorization. CURRENCY EOUIVALENTS Currency Unit = ouguiya (UM) / US$1.0 = 84 UM (August 1991) MEASURES metric system ABBREVIATIONS AND ACRONYMS AfDB African Development Bank BHU Village Basic Health Unit BMZ German Ministry for Economic Cooperation CEDS Centre d'Etudes Démographiques et Sociales (Center for Demographic and Social Studies) CHN Centre Hospital,er National (National Hospital Center) CPF Centre de Promotion Féminine (Center for the Promotion of Women) DAFA Directorate of Administrative and Financial Affairs DHE Directorate of Health Education DHR Directorate of Human Resources DHHP Directorate of Hygiene and Health Protection DPM Direction de la Pharmacie et de Médicaments (Directorate of Pharmacy and Drugs) DPC Directorate of Planning and Coordination DRASS Direction Régionale de l'Action Socio-Sanitaire (Regional Health Directorate) EC European Community ENSP Ecole Nationale de la Santé Publique (National School of Public Health) FPU Family Planning Unit HC Departmental Health Center HP Communal Health Post HEU Health Education Unit IDA International Development Association IEC Information, Education and Communication KAP Knowledge, Attitudes and Practice (study) LSMS Living Standards Measurement Survey MCH Maternal and Child Health M & E Monitoring and Evaluation MOHSA Ministry of Health and Social Affairs MOP Ministry of Plan NGO Nongovernmental Organization NU Nutrition Unit PREF Programme de Redressement Economique et Financier (Economic and Financial Reforrn Program) PCR Programme de Consolidation et de Relance (Economic Reform Program) PCU Project Coordination Unit PHC Prirnary Health Care PPF Project Preparation Fadiity RH Regional Hospital SEPF Secrétariat Exécutif pour la Promotion de la Femme (Executive Secretariat for the Promotion of Women' SOE Statement of Expenditures TSS Techniciens Supérieur de Santé (Senior Health Technicians) UNFPA United Nations Fund for Population Activities UNICEF United Nations Children's Fund VCT Vivres Contre Travail (Work for Food) WHO World Health Organization WID Women in Development FISCAL YEAR January 1 - December 31 FOR OFFICIALUSE ONLY ISLAMICREPUBLIC 0F MAURITANTA HEALTH AND POPULATIONPROJECT l'able of Contents PAUe CREDIT AND PROJECT SUMMARY ................................. i PART : INTRODUCTION ....................................... 1 PART Il: REVIEW OF THE HEALTH AND POPULATIONSECTORS .... ......I A. The Health Sector ....................... ............. 1 1. SectoralBackground ............................. I 2. Issues in Health Service Delivery ..................... 4 3. Government'sSectoral Strategy ...................... 6 B. The Population Sector ....... ................. 9 1. Sectoral Background ............................. 9 2. Population Policy .............................. 10 C. The Bank Group's Role ...... .............. 11l........... PART III: THE P&)J!QT ....................................... 12 A. Project Objectives ................. ................. 12 B. Project Description .............. .. .................. 13 1. Developingthe Regional Health Service System .... ....... 13 2. StrengtheningSupport Capacityat the Central Level ..... 17 3. Defining a PopulationPolicy and Action Program .... ...... 20 4. Promoting the Status of Women ..................... 20 C. Project Cost and Financing Plan .......... .. .............. 22 D. Lessons Learned ................. ................... 24 PART IV: PROJECT IMPLEMENTATION............................ 24 A. Status of Project Preparation and Readiness............. ..... 24 B. Project Coordinationand Management ...................... 25 C. Project Monitoringand Evaluation (M&E) .................... 25 D. SpecialistServices ................................... 26 E. Procurement ...................................... 27 F. Disbursements ..................................... 28 G. Accounting,Audits and Reporting ......................... 29 PART V: PROJECT BENEFITSAND RISKS .......................... 30 PART VI: AGREEMENTSREACHED ~.NRECOMMENDATIONS .... ....... 31 This report is basaedon the findingsof an appraisalrnission which visited Mauritansfrom April-May 1991, comprisingMessrs./Mmes. T.J. Ho (Economist/MissionLeader); A. Sales (Public Health Specialist/Consultant);J. Hermlt-Delanoo(IEC Specialist/Consultant);1. Lecomte(Fanily Planning Specialist/Consultant);and E. Huybens (Health Pinancing and W'IDSpecialist). Mr. R. Hecht and Mr. R Castadot wen the peer reviewe-rsfo. the operation.Aftor negoti.hions, Ma. Eva Jarawanwas responsiblefor p.upaxingthe doeumerts iorboard presentation. Mr. BirgorFredriksen and Ms. KatherineMarsha1l am the manxagingDivision Chief and DepainmentDirector, rspectivoly. This document has a restricteddistribution and may be used by recipientsonly in the performance of their officiaiduties. Its contents may not otherwise be disclosedwithout WorldBank authorization. Annexes: Page 1 Basic Data Sheet and Comparative Indicators ...................... 35 2-1 Organization Charts of MOHSA and of Regional Directorates .... ....... 37 2-2 Tke Health Service System ................................. 40 2-3 Personnel Redeployment and Recruitment, 1992-96 .................. 44 2-4 Financing Health Services, 1992-96 ............................ 52 3-1 Training Programs for Regional Health Personnel ................... 77 3-2 The Maintenance System .................................. 91 3-3 Regional Services in Brakna, Hodh el Gharbi an' Nouakchott .... ....... 94 3-4 Family Planning Delivery through Public and Private Sector Channels ... ... 118 3-5 Strengthening Health Education ............................. 129 3-6 Improving Targetted Nutrition Interventions ....................... 136 3-7 Promoting the Status of Women .............................. 141 3-8 Project Costs and Financing ................................. 146 3-9 Key Documents in the Project File ............................ 152 4-1 Supervision Plan ........................................ 154 4-2 Key Indicators ......................................... 157 4-3 Specialist Services ....................................... 160 4-4 Drug Procurement Procedures ............................... 161 4-5 Disbursement Profile ...................................... 164 MAP: IBRD 23274 b:toc (tj-mta-m) ISLAMICREPUBLIC OF MAURITANIA HEALTH AND POPULATIONPROJECT CREDIT AND PROJECT SUMMARY B2rrofLer: Islamic Republicof Mauritania Beneficiaries: Ministries of Health and Social Affairs; and of Plan; Executive Secretariatfor the Promotionof Women Credit Amount: SDR 11.8 million (US$15.7 million) Tenrs: Standard, with 40 years maturity Project Description: The objectives of the proposed project are to: (a) improve the quality and accessibilityof basic health and family planning services followinga strategy of decentralizationof service delivery; (b) assist the Government to articulate a national populationpolicy and define a correspondingprogram of actions; and (c) enhance women's ability to participate in and contribute to the country's social and economicdevelopment. A heavy emphasisis placed on policy reforms related to the proposed investments which are secured by specific project conditions. To achievethese objectivesthe project would finance investmnentsto: (a) develop the regionalhealth service systemthrough (i) developmentof training programs for regional personnel; (ii) developmentof a maintenancesystem for vehicles, equipment and inftastructure; (iii) strengthening of financial managementat the regional level; and (iv) assistance for health services in the regions of Brakna, Hodh el Gharbi, and Nouakchott;(b) strengehencapacity at the central level to support regionalhealth services through (i) strengtheningof technicalcapacity in three programsof specialemphasis - familyplanning, health education, and nutrition; and (ii) improvement of management systems for personnel, financeand health information;(c) define a national populationpolicy and its action plan and assist in its implementation;and (d) promotethe status of women through (i) institutionalsupport for the Executive Secretariat for the Promotionof Women, includingthe developmentof a nationalWID strategy and action plan; (ii) micro-projectsfor women's cooperatives; and (iii) fuinctional literacy training for women's cooperatives. Benefitsand Risks: The healthcomponent would directlybenefit over 750,000 people, mostlywomen and childrenin three regions, who wouldgain improvedaccess to basic services. In addition, the qualityof health services throughoutthe country will improveas a result of intensive retraining of regional-level personnel. Sector-wide restructuringmeasures wUl stabilize financing and help reduce unit costs of basic health care, improvingthe prospects for a large and sustainableimprovement in service quality and accessibility. The exact value of cost savings is difficult to quantify. They will include savings on the cost of drugs (around 50-75% decrease in cost per episode) resulting from the essential drugs program,