Document of FILECoPY The World Bank

FOR OFFICIAL USE ONLY Public Disclosure Authorized

Report No. 3204-TUN

Public Disclosure Authorized TUNISIA

STAFF APPRAISAL OF A HEALTH AND POPULATION PROJECT Public Disclosure Authorized

May 6, 1981 Public Disclosure Authorized

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

US$1.00 = DO.4 D1.0O = US$2.50 D I million = $2,500,000

GOVERNMENT OF THE REPUBLIC OF TUNISIA FISCAL YEAR

January 1 to December 31

ABBREVIATIONS

BHC - Basic Health Care CARE - Cooperative for American Relief Everywhere CNI - National Computing Center CRFP - Center for Pedagogical Research and Training CRS - Catholic Relief Services DBHS - Director of Basic Health Services DGPH - Director General of Public Health EBU - Equipment and Building Unit (NOPH) GDP - Gross Domestic Product INE - National Institute of Child Health INNTA - National Institute of Nutrition and Food Technology MCH - Maternal and Child Health MIS - Management Information System MOE - Ministry of Equipment MOPH - Ministry of Public Health MWRA - Married Women of Reproductive Age NORAD - Norwegian Agency for International Development ONPFP - National Office of Family Planning and Population RDHs - Regional Directors of Health SIDA - Swedish International Development Authority SPD - Studies and Planning Directorate (MOPH) UTNFPA - United Nations Fund for Population Activities USAID - United States Agency for International Development WHO - World Health Organization FOR OFFICIAL USE ONLY TUNISIA

STAFF APPRAISAL REPORT

HEALTH AND POPULATION PROJECT

Table of Contents

Page No.

INTRODUCTION ...... 1

I. HEALTH, POPULATION AND NUTRITION IN TUNISIA ...... 2

A. Health, Population and Nutrition Conditions and Programs ...... 2 - Health ...... 2 - Population and Family Planning ...... 3 - Nutrition ...... 7 B. Financing of Health, Population and Nutrition Activities ...... 8 - External Assistance ...... 9 - IDA Population Project ...... 9

II. INTEGRATION OF HEALTH, POPULATION AND NUTRITION POLICIES AND SERVICES ...... 11

A. Development Planning and Objectives ...... 11 B. Integration of Services ...... 12 C. MOPH Service Delivery System, Organization and Management ...... 15 - Health Personnel ...... 16 - Education and Training Programs ...... 16 - Drugs and Medications ...... 18 - Need for the Project ...... 18

III. THE PROJECT .. 9...... 9

A. -Project Concept and Objectives ...... 19 B. Summary of Project ...... 21 C. Project Description ...... 22 - Management Improvement...... 23 - Strengthening of Basic Health Care Services 24 - Health, Population and Nutrition Communications ...... 26 - Training ...... 27 - Technical Assistance ...... 29

IV. PROJECT COSTS, FINANCING, PROCUREMENT, DISBURSE14ENT AND AUDITS .30

A. Costs and Financing ...... 30 B. Procurement .32 C. Disbursement .33 D. Audit .34 This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. - ii -

Page No.

V. PROJECT ORGANIZATION AND MANAGEMENT ...... 34

A. Coordination ...... 34 B. Implementation .....0...... 35 C. Programming and Budgeting ...... 37 D. Project Monitoring and Evaluation ...... 37

VI. JUSTIFICATION AND RISKS ...... 39

A. Justification ...... o...... 39 B. Risks ...... o.. 40

VII. RECOMMENDATIONS ...... 41

ANNEXES

1. Demographic Data

A. Demographic Profile: 1966-1978 44 B. Incidence of Notifiable Diseases 45 C. Infant Mortality in Hospitals by Major Cause, 1972 45 D. Age-Specific Fertility Rates, 1976 and 2000 46 E. Total Births to be Averted, 1980-1987 46 F. Family Planning Indicators 47 G. Impact of the Family Planning Program 48

2. Organization of the MOPH

A. Organigram: Ministry of Health - Tunis, May 1980 49 B. Organization of Regional Services 50

3. Medical Services

A. Estimates of Total and Communal Population in Areas Covered by the Project 51 B. Doctors and Hospital Beds in the Project Area (1980) 52 C. Regional Distribution of Health Facilities 1980 53 D. Effective Protection Prevalence (EPP) for Married Wonen of Reproductive Age (MWRA) Aged 15-49, in 1979 54 E. Regional and Skill Distribution of Paramedical Personnel 55 F. Estimated Number of Paramedicals Assigned Outside Hospitals in the Project Area (1980) 56 G. Graduates from Para-medical Schools 57

4. Health Financing

A. Distribution of Annual Allocation, by Type of Institutions 58 B. Distribution of Health Capital Expenditure 59 C. Evolution and Functional Distribution of Recurrent Public 60 Health Expenditure - iii -

ANNEXES (cont'd)

5. Health Objectives of the Project 61

6. Manpower Requirements

A. Staffing Patterns and Functions in the Integrated Health Delivery System 62 B. Classification of Services Provided Through the Integrated Health Delivery System 6 C. Additional Manpower Requirements Generated by the Project 64

7. Health, Population and Nutrition Indicators 65

8. The MIS

A. Proposed MIS for Tunisian Health System 66 B. Management and Information System for Peripheral Structures 67

9. Schedule of Implementation

A. Project Implementation Flow Chart 68 B. Quarterly Implementation Schedule of Project Activities 69 C. Schedule of Implementation for Civil-Works and Procurement 70 of Equipment and Vehicles

10. Schedule of Accomodation for Project Facilities 71

11. Location and Type of Health Facilities to be Constructed, Extended or Remodeled per Governorates and Districts 72

12. Cost Estimates

A. Cost Estimates per Category of Expenditure 83 B. Summary of Base Cost Estimates per Type of Activity and Expenditure 92 C. Summary of Base Cost Estimates per Category of Expenditure per Year 93 D. Estimates of Physical Contingencies and Price Escalations per Category of Expenditure 94 E. Estimated Schedule of Disbursements 95

13. Organization of Project Administration 96

TABLES

1. Estimated Project Cost by Component 2. Estimated Project Cost by Category

MAP IBRD 15368

This report is based on the findings of an appraisal mission which visited Tunisia in May 1980. The members of the mission were: Messrs. B. Hubert, A. Shaw, L. Vassiliou, IBRD, and Dr. P. Coudray, Dr. P. Cronin, Mr. F. Hachette, and Dr. J. Montague Consultants. This report was prepared by Mr. B. Hubert and Mr. L. Vassiliou with contributions from the other mission members.

TABLE 3A TUNISIA SOCIAL INDICATORSDATA SHEET

TUNISIA REFERENCEGROUPS (WEIGHTED AVER 4CZS LANDAREA (THOUSANDSQ - MOST RECENT ESTIMATE)- TOTAL 164.0 MIDDLEINCOME AGRICULTURAL 76.6 MOST RECENT NORTHAFRICA 4 MIDDLEINCOME 1960 lb 1970 /b ESTIMATE /b MIDDLEEAST LATIN AMERICA& CARIBBEAN

GNP PER CAPITA (US$) .. 360.0 1120.0 818.5 1562.9

ENERGYCONSUMPTION PER CAPITA (KILOGRAMSOF COAL EUIlVACANT) 190.0 261.0 543.0 545.0 1055.9

POPULATIONAND VITAL STATISTICS POPULATION,MID-YEAR (MILLIONS) 4.2 5.1 6.0 URBANPOPULATION (PERCENT OP TOTAL) 36.0 43.5 50.1 45.7 63.4

POPULALTIONPROJECTIONS POPULATIONIN YEAR 2000 (MILLIONS) 9.0 STATIONARYPOPULATION (MILLIONS) 14.0 YEAR STATIONARYPOPULATION IS REACHED 2075

POPULATIONDENSITY PER SQ. KM. 26.0 31.0 37.0 40.7 28.1 PER SQ. KM. AGRICULTURALLAND 55.0 67.0 78.0 598.6 81.7

POPULATIONAGE STRUCTURE(PERCENT) 0-14 YRS. 43.3 46.2 42.6 44.0 41.4 15-64 YRS. 52.5 50.0 53.8 52.5 54.7 65 YRS. AND ABOVE 4.2 3.8 3.6 3.5 3.9

POPULATIONGROWTH RATE (PERCENT) TOTAL 1.8 /c 1.9/c 2.0 2.6 2.7 URBAN .. 3.8 3.9 4.5 4.1

CRUDEBIRTH RATE (PER THOUSAND) 49.0 42.0 32.0 41.6 34.8 CRUDEDEATH RATE (PER THOUSAND) 21.0 15.0 12.0 13.7 8.9 GROSS REPRODUCTIONRATE 3.1 3.4 2.2 2.9 2.5 FAMILY PLANNING ACCEPTORS,ANNUAL (THOUSANDS) .. 29.2 73.5 PSERS (PERCENT OF MARRIEDWOMEN) .. 8.0 18.0 16.2

FOODAND NUTRITION INDEX OF FOOD PRODUCTION PER CAPITA (1969-71-100) 97.0 98.0 126.0 93.5 106.9

PER CAPITA SUPPLY OF CALORIES (PERCENT OF REQUIREMENTS) 80.0 88.0 112.0 103.6 107.4 PROTEINS (GRAMSPER DAY) 50.0 57.0 73.0 69.8 65.6 OF WHICHANIMAL AND PULSE 12.0 14.0 22.0 17.5 33.7

CHILD (AGES 1-4) MORTALITYRATE 29.0 20.0 15.0 17.5 8.4

HEALTH LIFE EXPECTANCYAT BIRTH (YEARS) 48.0 54.0 57.0 54.4 63.1 INFANT MORTALITYRATE (PER THOUSAND) 148.0/d 135.0 .. .. 66.5

ACCESS TO SAFE WATER (PERCENT OF POPULATION) TOTAL .. 49.0 70.0 62.5 65.9 URBAN ...... 82.9 80.4 RURAL ...... 45.1 44.0

ACCESS TO EXCRETADISPOSAL (PERCENT OF POPULATION) TOTAL ...... 62.3 URBAN .. .. 30.0 .. 79.4 RURAL ...... 29.6

POPULATIONPER PHYSICIAN 10000.0 5950.0 4800.0 4688.7 1849.2 POPULATIONPER NURSING PERSON .. 730.0 1070.0 1751.5 1227.5 POPULATIONPER HOSPITAL BED TOTAL 373.0/e 410.0 439.0 635.5 480.3 URBAN .. 280.0 RURAL .. 930.0

ADMISSIONS PER HOSPITAL BED .. 24.1

HOUSING AVERAGESIZE OP HOUSEHOLD TOTAL .. 5.1 /f 6.0 URBAN .. 5.1 7? 5.8 RURAL .. 5.1 7? 6.1

AVERAGENUMBER OF PERSONS PER ROOM TOTAL .. 3.2 /f URBAN .. 2.7 7 ** RURAL .. 3.6 7 ..

ACCESS TO ELECTRICITY (PERCENT OF DWELLINGS) TOTAL .. 24.0 /f URBAN .. RURAL .. Page 2 TABLE3A TUNISIA - SOCIAL INDICATORS DATA SHEET

TUNISIA REFERENCE GROUPS (WEIGHTED AVEAGES - HOST RECENT ESTIMATE)- MIDDLE INCOME MOST RECENT NDRTHAFRICA A HIDDLE INCOME 1960 /b 1970 /b ESTIMATE /b MIDDLE EAST LATIN AHERICA 6 CARIBBEAN

EDUCATION ADJUSTED ENROLLMENTRATIOS PRIMARY: TOTAL 66.0 100.0 100.0 76.4 99.7 MALE 88.0 120.0 118.0 92.2 101.0 FEMALE 43.0 79.0 81.0 59.9 99.4

SECONDARY: TOTAL 12.0 23.0 22.0 33.3 34.4 MALE 19.0 33.0 28.0 41.9 33.5 FEMALE 5.0 13.0 15.0 24.2 34.7

VOCATIONALENROL. (2 OF SECONDARY) 24.0 12.0 17.0 9.8 38.2

PUPIL-TEACHER RATIO PRIMARY 61.0 48.0 40.0 39.2 30.5 SECONDARY 16.0 28.0 23.0 25.1 14.5

ADULT LITERACY RATE (PERCENT) 15.5 24.0/f 55.0 39.7 76.3

CONSUMPTION PASSENGER CARS PER THOUSAND POPULATION 11.0 13.0 18.3 15.3 43.0 RADIO RECEIVERS PER THOUSAND POPULATION 40.0 74.0 138.0 139.6 245.3 TV RECEIVERS PER THOUSAND POPULATION 0.1 10.0 35.0 29.0 84.2 NEWSPAPER ("DAILY GENERAL INTEREST") CIRCULATION PER THOUSANDPOPULATION 19.0 16.0 33.0 22.2 63.3 CINEMA ANNUALATTENDANCE PER CAPITA 2.0 .. 2.3 2.8

LABOR FORCE TOTAL LABOR FORCE (THOUSANDS) 1137.9 1214.8 1533.5 FEMALE (PERCENT) 6.1 7.7 8.0 9.6 22.2 AGRICULTURE (PERCENT) 56.0 49.8 45.0 47.0 37.1 INDUSTRY (PERCENT) 17.6 21.0 24.0 23.8 23.5

PARTICIPATION RATE (PERCENT) TOTAL 27.0 23.7 23.7 26.1 31.5 MALE 50.2 44.2 44.0 47.4 48.9 FEMALE 3.3 3.6 4.0 4.7 14.0

ECONO1IC DEPENDENCYRATIO 1.4 1.8 1.8 1.9 1.4

INCOME DISTRIBUTION PERCENT OF PRIVATE INCOME RECEIVED BY HIGNEST 5 PERCENT OF HOUSEHOLDS .. .. 17.0 HIGHEST 20 PERCENT OF HOUSEHOLDS .. .. 42.0 LOWEST 20 PERCENT OF HOUSEHOLDS .. .. 6.0 LOWEST 40 PERCENT OF HOUSEHOLDS .. .. 15.0

POVERTY TARGET GROUPS ESTIMATED ABSOLUTE POVERTY INCOME LEVEL (US$ PER CAPITA) URBAN .. .. 204.0 262.5 RURAL .. .. 97.0 140.4 190.8

ESTIMATED RELATIVE POVERTY INCOME LEVEL (US$ PER CAPITA) URBAN .. .. 193.0 202.1 474.0 RURAL .. .. 193.0 122.2 332.5

ESTIMATED POPULATION BELOWABSOLUTE POVERTY INCOME LEVEL (PERCENT) URBAN .. .. 20.0 22.1 RURAL .. .. 15.0 33.1

Not available Not applicable. NOTES

/a The group averages for each indicator are population-weighted arithmetic means. Coverage of cunntriea among the indicators depends on availability of data and is not uniform.

/b Unless otherwise noted, data for 1960 refer to any year between 1959 and 1961; for 1970. between 1969 and 1971; and for Most Recent Estimate, between 1974 and 1978.

/c Due to emigration population growth rate is lower than rate of natural increase; /d 1960-65 average; /e 1962. /f 1966.

Most recent estimate of GNP per capita is for 1979, all other data are as of April, 1980.

October, 1980 Page 3 DEFINITIONS OF SOCIAL INDICATORS

Notes: Although the data are drawn from nuroes genre ally jodged the most athoritative and reliable, it should also be noted that they nay net be inter- natiooally compaehbl be.auue of the lock of sendardiznd defisitions and concepte used by different coontries in collecting the data. The data are, snoe- theless, useful to describe orders of nagnitude, indicote trends, and characterio certain major differences h .etween.coanties.

The reference groops ace (1) the aeCe .ca.nty group of the -ubject country and (2) a country group with so-enh-e high-er average Idc. e tha the canntry grnup of the subjecnt coutry (eacept foe "Copital Surplus Oil Eporters" group here "Middle Ico=e North Africa cad Middle East" is chases becau-e of ste.grg- soic-o-ultural affinities). Is the reference g-op data the averages are population weighted arith=etic means fee each indicator and shovn aply when et lease half of thbe o..tries In a group has data for that indicator. Sieee oh corerage of countries among the indicators depends on the evaieability of data end in nun upifera, ceution rust beexercised in relating averages of ne indicator so u-other. Theus averages are only useful in cunpar.ig the value of one indicator at a time anong the -otcry and -eference g..ups.

LANDAREA (th.o.a.d sqiku.) Fopulation pcr Physician - spupltien divided by runber ot practncing phy- Ttotl - Tftal surfaone area coprisiig land area and inland stees. siioans qualified frue a adital school at onivernity level. Agrdo-l2trol - Estipate of agricultural area aced teaporarily or pe-naently Popalatfon per Narsing Per-so - Population divided by neber of practiciag fc crops, pastures, market and kitchen gardens no to lie fallow; 1977 data, mle and female graduate nrses pruetital unens, and assistant nurse.- Papplatien fer H.spital fed - total. urbn. a-nd rural - Populatiop (trtel, GIP PER CAPITA (US$) - GNP pet capit.a estiates se coroent market prices, cl- urban, and rural) divided by their renpective umuber of hospital beds ouloted by nane converni.o methed an tenld Bank Atlas (1977-79 busts); 1960, available in public and private general and specialiaed hbepital -nd re- 1970, and 1979data. habilinaciont cenrsra Hospitols are eatablidhafteea pere ttly staffed by at least sue physician. Etablishnents providing principally osatedim1 ENfRGYCONSUMPTION PER CAPITA - Anual c onsumpsieucf cennercil energy (coal care are net included, Rfal henpitels, however, inclode heith and edical and lignite, petrole.., natural gas and hydra-, nuclear asd geothernal elec- centers sac pareaneotly staffed by a phynicias (but by a -edidal -asiata-t, reisity) in kilogeas of coal equivalent per capita; 1960, 1970, and 1978 nurse, midwife, etc.) which offer in-patioet roosedatini and penvide I data. liited range of medical facilities For statisticsl puepeses urban heapi- talm include WHO. prisnipsi ges-1a and spectalerd haspitais, and rura POPDLATIONAfD VIPTA STATISTICS hospitals IaCa1 or ruralh.pitels ted medical nd aternity teeters. Total Papulation, Mid-Ybea (nillisn- ) - An of July 1; 1960, 1973 and 1978 Admissions per foshaitL fed - Total noehr of edeisnis.n ta se dianbarse- data. from hospitals divided by the nunber of beds. Urban Populatios toerceneof tntal) - Ratio of urban to tot-l apoplation; different definitione of urban areus nay af fact conpPrshilty of data hOUSING among cosunries; 1960, 1970 and 917 data. Avrraae fine of fauneheld (pePsame er hss.ehold) - toal, urban, and newel- Popalotion Projections A househeld consists of a group of irdividuals sho share living quarters Peopultion in year l20i - Current pepalaidospr-jectiose aTe ba.ed on 1980 and their main -. ls. A boarder ot ledger nay at nay net be inaluded in teal popolation by age sod sea and their mortality and fernility rates, the household for utatinticl purposes. Projection pacanotens foe mortality rates neaprise of three levels annum- Average number of persons per rm - total, arbas, and rural - Averge nu- ing lir expectancy et birth increasing with coantry's per capita lacuna her of parsons pee roan In all urban, end rural occnpied cemventiseal level, snd fermle life expeocnscy stabilieing at 77.5 years. The pata- dwellings, respectively. DSellings enclude nn-pereanest etenetore- and sneers for fertility cato tlim have three levels assuing decline in nnccupied patns. fertility accrotdig to incane imeel and past fatily plea-isg perforuosce. ccess to Electricity (vercetC of dow-li,ss) - tntal. abean and rural - lath country is thes assigned sue of the ss nine cobinations of artality tanveutlanal dwellings with electricity in living quwtarter s P- .e.etge and fertiliuy trends for prjenetin psrposes. of tstal, ub=, and rural dwellings raspectivly. Statiosary prualati-n - In a stationary populattin there in ne growth sisce the birth rate is equal en the death nate, end alto the age trtuctort re- EDUCATION mains crsennt. This is auhieved only after fertility rntes decline ta Adjusted Etnoli=ent Ratiom the repla_esest level of unit ret nepnduntion rats, ghns each genre rties Pri=aty schnol - totalr, le wed fale - Grss. totl, male and femal of gores replaces itself eactly. The stationary popul..in. si_e wan ne.olleest of all ages at the primary level as percantages of reepantira entimated en the bain of the projected charatertics of the population primary schooi-age populatias; unenally igoludee children aged 6-11 in thc yearI f20, and the rate cf delise of fertility rate tn replace- ye-rs bht adjasted for differeet lengths of primary eduantien; feo met level. notei-s with univnr.nl education entailment may esteed 100 perent Year stationary population if reached - Th. ye-c when tsttienany ppoplation since sane pupils ace being at ub-ve the effiia1 schosl age. sian has hot reached. Si.cndary school -t toal, n1e and female - Cueputed an habve; .ecnddry Populatin Dety eduootinn orqoires at least four yeers of approved primary inetmsnirm; Pee us. bn - Mid-year pypulatina per squats kilceeter (1ff hectrare) of provides generaf,vccnnitnal, or teacher training festrtten f-r pspLb erotl ares stualyi of into 17 yearn of age; correspondencey cures are generally Pee s han agrioultural lard - Computed an abuve foe agniultural land excluded nly. V.oatinal enrollent n(pocent of ec.ndaryj - VPo..tinal iseftiteti.n Peulation Are ftructuCe (pec.ent) - Children (f-l4 years), waking-age (15- include technical, industrial, or other progr-es which apteate indepes- 64 yeace), end eticed (65 yearn end nver) as pecestages of rid-year popn- dently or an departments of secondary in-tit-tins. latint; 19f6, 197D, and 1918 data. Psul-ceocte- ratio - primary,sand seonedary - Intel studests eseolled in Puoulacion Grovth late (onroent) - total - Adoral grovth eaten of totas mid- primary and secowdary levels divided by maniacs of tneahers in the yee, populstions foe 195D-6D 19i0-70, end 1970-78. -creepondifg levels. Ppulatiun Grovth Raco (percent) - urb= - Annual grovth rateu of urhanb pop- Adult literacy rate (nerCent) - Literate t dults (rble te rend and grits) altions fo- 1950-60, 196f-7, and 1970-78. s a percentage nf total adult populatinn aged 15 years and o.ve Crude firth tate (oar thousand) - Annual live births per theusand of mid-year populacion; 19ff, 191f, and 1918 dana CON8UMPIOiN Crude Deathlate (net thousand) - A.n.al deaths per thousend of mid-year Passenger lets (per thnuuand Poulati-n) - Passesge ersen prite mater population; 19f6, 1917, and 1978 datac. os snaring lesn than eight persona; anclades nebalascas. heersam med icons Reproduccian Ratn -Averge sunier of danghtersas I an will bear in rilitaCy vehicles. hee tna. l reprndu-tive period if she esperiences present age-specific C en- Rldin teceivecs (per eth-and populatise) - All types af reneivere feor ed til i t y rates; usually fivn-yar aveages ending in 1960, 197D, and 19771. hbodasen no general public per thopeand of populaniun; esnlades unnl- Panily Planning - Acceptors, Adrsal (Idounueds) - A.nuol nI bber of acorptine cesed receivers in c-toiries ad in yearn vhan regietrati.a of radi- see f bircth-control devicss under auspices of _ational family planning program. ws in effe-t; date fae reaent yeses may not be .ospseable since mast Partly Planninn-gnatser (percent of married wanes) - Ptrcentage of macrind countries abolishrd licensing. waose of child-hearing age (15-i4 years) whi use birth-onstrol devices to TV Receivers (oo tinneand peoplation) - TV receivers for brndoaCst t all married vo=en in same age grnp. gener=l paublc per thousand populatino; ancluden anliceesed TV receivers fin osnCtrien nd in years when neglnttor at T7 nets was in effeot. F'OOD AND NUTRITION NCite~~~~~~oesapeirolao (rev thnusand upulaItlan) - Sbsw the -veag tieal-1 Iudma on Ford P-oduction per Capita (19h9-llt - 1ndex nf par capita na=nael off)of Cira ( t°tat ep.p-, defined * I peridial pb- production of all food co-noditie. Prudactian excludes seed and feed and liestin dalyot= p interey strcdnpe"g g,eferi ned It peindid pnsi-d is en celendar year basin. Cei uditien cover primary goods (e.g. sneane to be "daily" if it appears at least fonr tieesaeeki insertd of sugar) which arc edible and contain nunrinnt (.g. coafee=nd Cinema- Annual Attendance ore Inica mer Yeee- Bed an the nbee of tea ore mecludd). Aggr=g=tc production of each country in based 05 tichets sold during the year, including edmiseinna to drive-in nimemas n=tion=l avnruge producer price weights; 1961-615 9197, and 1918 data d bil i Per Cnpitn supply of calerien (p-retet of Cenuire=enns) - Colputed from energy equivalent of set fond eappli-s available in country pet topita LAbORPORCE per dy. Available supplien cunpriun dunentiC production, imputes Inns Totnl Labor Forct (thonsedn) - Eonnopically active presses, intludie exports, ad changes is it.ck Net sspplies anolade aimal feed, seeds, armed forces and unenploy=d but nxcluding bauswives. dnsteate, eta. qamaitirn used in food pCntessiig, ad lasses in disteibtin. Rlequire- Definitnons in vcioIs countries are netCot peeble.; 18970 nd _etn were estimated by PAt bined an phy=iologic=l needs foa no_nal anti- 1978 dat. viny and health couelderisgeneirunnntalreuperannet. body weights age FP==a= (P=rcest) - Peamle l=bor faor ns percentage of itel lame forne nd sex distribution of population, aAd allowing 10 percent fee waste atn(perc=t - Lbor f.ce Ln -ig, forestry, hting nd householdlevel; 1961-65, 1970D and 1977 date fishing as percentage of total labor force; 1960, 1970 and 1978 daa. Pee capita aspply of Protein (-rasp per dy) - Prori cntt of capine Indc (nrcent) - LaboC force isLniing, construction eanufeotnsing net -upply of food pr day. Net supply of food is d=fin=d n ubove. R=- and electricity, water cd gas as p=ent=atge of treal laber ferce; 1960, quireatns ton e11 countriesc .ablished by USDA provide for sini 1970 and 978d allovance of 60 drarn of totsP protein per dy ad 20ericieio l (percent) - total, male, and tangle - Participatles or pulse petscin, af which 1i grams should be animal protein These steed- activity rates tet computed as total, mai=, and female labor force as Otds see lower than thase of 75 green of tetai pret=in and 23 green ni pecoenn.gesof tot=l, malt and fe=ale populantion of silages oepeenively; animal pectnin an an average for the werld, prop-oed by YADin the Third 1960. 1910, and 1911 deta. These ace IL's partitipaties rates refle-ting fld Pond Survey; 1961-f5, 1970 and 1977 data. age-=e structure of the population, and long time tread. A fee neni- Per capita pCot=in suouly frun aimal end pulse - Protein nupply of fond de- mains ar from notionsi so rived tree aimai1 and pulses in gr-s pee dy; 1961-65, 1970 and 1977 daIs. EconoSo Depe-de-cy Ratin - Ratin of pupulatic u-der 15 ad 61 and aver Child (ages 1-i) Mort=lity fate (per thousand) - Anaa=l deaths per thousand in to the ntotl ision ferns age group 1-h years, en children in thiJ ge gtonp; for maet developing Cnum- tries data deriv-d fons life tables; 1961, 1970 end 1977 data. INCGii DISTRIBUTION

ishpeccancySatALimbTdyeers) Peecestage of Privete Inco=e (both in cash and kind) - Received by rlioe-t 5 Life Epectany - Aveoage snhbe- of years of life remaining of percent,honusehnds. richest Zf percent, poorest 2D prerent, end psorest 40 percent at blrth; 19f6D 197D and 1978 data. Infet Mortality late (Per thosuand) - Adnual de-tis of itfets under .n= year POVEpTYTARGET GEOUPS of age pee thibu,d live births Etinated Absoluce Poverty IncursleLvel (1USSper rc a) - urb n sad real - Access to S.fa Water (percent of pyoplatin) - total. rb=n. nd rural - 71 Abseluen pov=rty income level in that intone level belan vhib a cinS al Nuarir of people (total, rbn, ad rural) with Cens bn.bleaccess to usife natrinionsly adequate diet plus essential sen-fend requir-aenie is set water supply (includes eateefd sarface eaters or n=trmated but uncnta=ipated affordabl. water such as than Prow protecend springs, nd seiniary wells) as Eorebles,intimated ROlative P.verty I..-me Level (US$ pee caapit) - utban saa runes - percentages of their respective populations Sn an urban rea I publin RuraI relative poverty Lmses level is one-third at average pee napita fountain or baneipst located eat nore tha 2DD meters fcow a inner may be perso tali-oow of the .- untry. Urban lvel is derived fmun the rural considered as heing witbin reasonable acces at that house. In rural areas level with adIjustmnt for higher coat cf lining Is urban aream ra na.ble.. access mould imply than the hou.owife or senheenof the hans-hold Intimated Poculein Selow dienlute Pover imenen Level (percent) - urban do nun hIve to spend a disproportionate part of the day in fetching the and natal - Percent of population (urban and meral) vhn are "ahsolute per". Atoese in ixccnta fienesal (nerceut ot vonuiatinn-ntotal. urban and rueni -_y=bec of people (trial, nt=, and rural) nerved bysuccena disposal as percentages of be respectetiv ons ereta die- Etonopic and Social DSan Divisien posal moY include the collectdon end disposal, gith or without treetnene,t-ennfio Adalysie and PDejentisna Separnet of h-.es encreta end wesne-t etet by nteer-berue nysn-a or the -ae of fOntber 1980 pit privies and similar inerelleninn

INTRODUCTION

(i.) Since Tunisia became independent in 1956, the Government has emphasized the development of the country's human resources and, in parti- cular, the health of the population. With health expenditures averaging close to 2.5% of GDP since independence, Tunisia's health system has registered impressive gains, as demonstrated by an increase in life expectancy at birth from 41 years in 1956 to 57 in 1978, a fall in the crude birth rate from 49 to 32 per thousand, and a decline in infant mortality from 202 to 123 per thousand. Nevertheless, the persistence of potentially controllable diseases, of high infant mortality and malnutrition, and a loss of momentum of the public family planning program, indicate that the system must be improved to better meet the needs of people in rural areas and in the poor parts of urban areas.

(ii.) Tunisia's health sector is in transition. Health services have hitherto been based on hospitals in urban areas, and had taken the form of curative, as opposed to preventive care, with disproportionate attention to the urban as opposed to the rural population. Apart from this disparity between urban and rural areas, there are still great differences between regions in the per capita supply of hospital beds, physicians and nurses and the effectiveness of the referral system. In rural areas, only about 50% of the population enjoys access to modern facilities. Yet, in urban areas, the system is quite sophisticated, and hospital beds, obstetricians, family planning counsellors, physicians and nurses are readily available. This imbalance is reflected in the higher fertility and infant mortality rates in rural areas. Both doctors and paramedicals are trained to provide specialized medicine and curative care of a kind only feasible in the better-off urban areas, whereas the health status of the urban poor and the vast majority of country dwellers can only be improved effectively by generalists trained in health education and prevention, backed up by an adequate referral system.

(iii.) In recent years the Government has focused attention on this problem and, encouraged by the results of pilot projects, has shifted the emphasis of the public health system from curative to preventive care, and is extending its reach into unserved or underserved areas, by a greatly increased reliance on appropriately trained paramedicals. The Government is strongly committed to this health policy which is also supported by local communities. The administration of health, nutrition and family planning services has been integrated and decentralized. The proposed project would help the Government of Tunisia to put these important changes of emphasis and structure into effect. - 2 -

I. HEALTH, POPULATIONAND NUTRITION IN TUNISIA

A. Health, Population and Nutrition Conditions and Programs

Health

1.01 Since 1969, the Government of Tunisia has made great progress in developing its public health services and in improving the health of the people. Vaccination and other preventivecampaigns have brought communicable diseases such as typhus, typhoid and malaria largely under control..Neverthe- less, a number of potentiallycontrollable diseases such as tuberculosis, gastrointestinaland respiratoryinfections, influenza, hepatitis,skin and eye diseases, are still prevalent, largely as a result of serious defi- ciencies in the health system as well as of insanitary enviromnentand ignorance of hygiene.

1.02 Although life expectancy at birth has increased from 41 years in 1956 to 57 years in 1978, infant mortality ranges from 70 in uTrbanto 170 per thousand in rural areas, giving an average of 123, which is high in comparison with similarmiddle-income countries. While some diseases of infancy and childhood (polio, diphtheria,whooping-cough and measles) are declining as a result of immunization,airborne, waterborne and nutrition-relateddiseases are still prevalent. Lack of pre-natal and post-natal care, especiallyin rural areas, where most births go unattended,and malnutritionof both mothers and children increase the susceptabilityof infants to disease. Polluted water is a principal cause of infectious diseases such as hepal'itisand typhoid. Intestinalparasites such as E.coli, trichinosis,and amoeba are especiallyprevalent among school-agechildren. About half of all deaths in Tunisia are of children under five, and about half of all child deaths occur during the first year of life. Premature births, which accouni:for 10 percent of infant deaths in hospitals and more in rural areas with no access to health services,are related to the poor health of the mothers. Poor health and malnutritionresult in high drop-out and repeater rates in primary schools and contribute to the low productivityof labour, especially in agiciculture.

1.03 In the early 1970s Tunisian public health policy was still empha- sizing hospital-basedcurative medicine and gave insufficientattention to prevention. The Governmentconstructed large urban hospitals, and trained highly specializedmedical staff. New hospital construction,planned without adequate considerationof financial and manpower implications,was at the expense of primary health care, where diagnosis, treatment and referral remain below standard. Because the rural population lies largely outside the referral system, the public health program needed reorientation.

1.04 A 1980 Bank report, entitled Tunisia: Social Aspects of Development, pointed out that the availabilityof health services appeared to be strongly correlatedwith the per capita income of the various regions. Great inter- regional differencesin the per capita supply of hospital beds, obstetricians, physiciansand nursing personnel exist. Also, since regional and general hospitals are located in the towns, there are great differencesbetween urban and rural areas in the availabilityof medical treatment. Moreover, because of the uneven distributionand poor functioningof dispensaries,a large proportion of the rural poor lacks ready access to basic health services (Annex 3C). The poor functioningof the referral system is indicated by the fact that, at the district level the average hospital occupancy rate is about 30%, at the regional level about 70%, while in largest cities hospital capacity is often overtaxed by patients who have bypassed the first two levels. Other factors contributingto these unequal occupancy rates are an insufficientawareness on the part of the rural populationof its health needs, inadequatepatient screening and processing by health workers, and the inadequate peripheral health infrastructure.

1.05 In Tunisia, public health services are provided virtually free in both urban and rural areas. Private physiciansand clinics are however found only in towns, although decreasing emigrationand slower growth of demand for medical services in urban areas have caused some self-employedphysicians and nurses to move closer to rural areas. At present there is about one physician for every 3,650 people in Tunisia (ranging from 1/1,465 in Tunis to 1/11,000 in the governorateof Zaghouan). Only 70% of the total population has access to safe water. Although most urban householdshave access to piped potable water, and are connected to a waste disposal system, the national water supply company rarely serves rural settlements,which rely mainly on public wells (76% of all localitiesin Tunis region, 40-50% in other regions) or individualwater tanks. In rural areas, 60-70% of public wells are inspected and chlorinatedsystematically, but in remote settlements the proportionis much lower (25% in Medenine, Jendouba and Gafsa; 14% in the isolated settlementof Beja).

1.06 In the mid-seventies,the Ministry of Public Health (MOPH), realizing that a different approach was needed, conducted a number of successful pilot projects designed to show how, by giving more emphasis to preventivemedicine and the use of paramedicals,better health services could be provided in rural areas (see para. 2.13). The MOPH has started to strengthenits infrastructure in peripheralrural areas and to combine the provision of public health, family planning and nutrition services,hitherto done by several agencies. In order to meet the requirementsof the reorganizedservice delivery system in terms of quantity and quality, the training of medical and paramedical personnel is being revised.

Population and Family Planning

1.07 Official estimates based on the 1975 census put the total population of Tunisia at 6.3 million in mid-1980, with a current rate of growth of 2.2% per annum, expected to fall to 2.1% by 1986. The rate of growth actually increased from 2.0% in 1961 to 2.8% in 1968, and then declined to 2.3% in 1978 partly as a consequenceof emigration. The general fertility rate declined substantially,from an average of 200 live births per thousand women of reproductiveage during the 1960s, to 155 per thousand in 1976. Con- sequently,the crude birth rate fell from 49 per thousand in 1960 to 32 in 1978, the lowest among Arab countries. -4-

1.08 Under-reporting in the civil registration system, especially in rural areas, makes it difficult, however, to assess actual trends in fertility and mortality. In recent years, both official and unofficial services have produced a wide range of estimates. The Ministry of Planning and Finance has recently begun a new analysis of current trends for the preparation of its sixth development plan. Preliminary results now suggest that population growth since 1975 has averaged 2.6% per annum, a rate much higher than expected, largely because of a reversal of the traditional migration pattern and a rapid decline of mortality, especially of infants. Recession in Europe and political events in Arab countries have virtually stopped traditional emigra- tion and caused significant returns of nationals (with their families) work- ing abroad. By the year 2001, the population is projected to grow to 10 mil- lion, assuming a regular decline in the net reproduction rate (number of daughters, per woman, who would survive to the mean age of child bearing) from an estimated 2.2 in 1980 to 1.15; if fertility remains unchanged, the population would exceed 12 million.

1.09 The remarkable reduction in the fertility rate was largely due to the success of the Tunisian Family Planning Program (TFPP), iritiated as the first in Africa in 1964. The success of the TFPP made Tunisia. a model and a training ground for Francophone Africa and Arab countries. In order to expand and improve the program, the National Office of Family Planning and Population (ONPFP), a semi-autonomous organization under the FOPH, was created in 1973. In spite of some opposition to abortion and sterilization, the TFPP has enjoyed broad political, religious and legislative support, and has been able to achieve a dramatic transformation in family planning knowledge, attitudes and practice in Tunisia. The ONPFP has formulated a family planning policy and introduced a wide range of programs, particularly in the areas of information, education, personnel training, research and evaluation. The ONPFP provided services not only through its own facilities, but also those of the MOPH, especially the latter's Maternal and Child Health (NCH) Centers. Although these services have for the most part served better-off groups, the TFPP deserves much credit for the decline in the crude birth rate. The 1978 National Fertility Survey showed that 92% of all married women of reproductive age (MWRA) knew of, and 43% had used, at least one method of family planning. In 1979, the annual number of family planning consultations in the ONPFP's facilities passed the 535,000 mark, corresponding to the ONPFP estimate of 137,000 protected MWRA and 50,000 averted births. Taking into account family planning services provided by private physicians, the estimated total number of protected MWRA was 180,000 which corresponds to about 63,000 averted births a year, equivalent to about 19% of actual births. The national prevalence rate in 1979 for MWRA between the ages of 15 to 49 was 21.3% (16.2% through the ONPFP program alone).

1.10 A wide range of contraceptive methods characterizes the Tunisian family planning program. Around 83% of acceptors rely on IUDs, pills, abortion and tubal ligations. IUDs, inserted free, are most widely used (34%), followed by oral contraceptives (31%) distributed free by the ONPFP and sold at a small nominal fee in pharmacies, and abortions (25%) which are legal and free of charge. Female sterilizations represent more than 10% of new acceptors. -5-

1.11 While great strides have been made in reducing fertility among women under 30 years of age (largely due to increasing age at marriage), there remains a large unmet demand by women in their 30s and 40s who are still at risk of pregnancy and are not receiving contraceptive services. The activities of the ONPFP are supported by a very active information and education campaign which included, in 1979, 80 articles in local publications, 208 radio programs, 4 television programs and a large number of conferences and seminars backed by audio-visual materials. However, ONPFP services are largely confined to the urban population. Rural women, who form about 50% of the target group of MWRA, account for less than a third of those served by ONPFP. Because of this urban bias, fertility is generally one-third higher in rural than in urban areas.

1.12 Since 1977, the official family planning program has been falling short of its targets of new acceptors. Recent evaluations by USAID and UNFPA revealed that the rate of increase of new acceptors served by the public sector program has slowed. However, this shortfall in the public sector was largely compensated for by the increasingly important role of the private sector as shown below:

TUNISIA FAMILY PLANNING: TARGETS AND ACHIEVEMENTS IN AVERTED BIRTHS

1975 1976 1977 1978 1979

Public Program

- target 26,250 34,350 45,000 52,000 63,100

- achievements 29,700 35,600 44,500 48,600 50,100

Private Sector

- target - - - 8,000 9,700

- achievements 3,000 3,200 8,200 9,500 13,500

Total

- target 26,250 34,350 45,000 60,000 72,800

- achievements 32,700 38,800 52,700 58,100 63,600

Source: ONPFP.

1.13 The shortfalls of the public sector program are largely due to the logistical problems which the ONPFP is facing in its efforts to extend services to rural areas, after having largely satisfied urban demand, rather than to a lack of potential demand. Tunisia now finds itself in an unusual situation: the well designed information and education program has had a successful impact on the entire population, but was not accompanied by a parallel expansion of family planning service delivery in rural areas. While the major urban centers are well served, three-fourths of all eligible couples largely in rural areas are still not able to take full advantage of family planning. Thus the unmet demand remains great, and has emerged each time family planning information and services were made more accessible. The recent evaluation of the Contraceptive Household Distribution Project carried out in the Sfax region from 1976 to 1979, with USAID support, clearly demon- strated that family planning practice could be dramatically increased among a dispersed and largely illiterate rural population. After only two years, the proportion of married women aged 15 to 44 practicing family planning rose drastically from 6.6% to 17.7%; the pregnancy rate for women of reproductive age fell from 20.3% to 17.0%; over one-half of all women practicing contracep- tion had received a tubal ligation. An encouraging finding for future program expansion is that family planning acceptance and use varied little according to the level of education of the woman, and not at all according to that of the husband, and there was also little association with the husband's occupation. Finally, the project demonstrated that contraceptive distribution in rural Tunisia is both socio-culturally acceptable as well as logistically and administratively feasible. These findings have been especially useful in the design of the integrated health delivery system.

1.14 The main deficiencies in family planning service delivery identi- fied by UNFPA and USAID are: a critical shortage of medical and paramedical services in rural areas; inadequate monitoring and supervision.by ONPFP of field activities, and logistical and financial constraints keeping the ONPFP from expanding into rural area. The USAID study also pointed to the need for an integrated program in which family planning services would be offered together with basic health care as a means of extending the outreach of the family planning program and thus reviving its flagging momentum. Furthermore, in order to ensure that family planning services are not diluted as a result of their integration into basic health services, a close monitor- ing of family planning efforts will be needed.

1.15 The Bank concurs with this assessment, and the propcsed project is designed to support MOPH's new integration policy. But for integration to be successful, it must result in a strengthening and expansion of both family planning and basic health services throughout rural Tunisia. If the crude birth rate is to fall to the Fifth Plan target rate of 30 per thousand in 1986, the proportion of protected MWRA (15-49) must be quickly increased to about 30%, from 21% in 1979. The Government has decided that all public health services, including family planning, will be provided by MOPH staff through MOPH channels, and that the ONPFP will therefore confine itself to its original functions of policy formulation, research, education and train- ing. The integration of health and family planning activities, already under- way in the medical regions of Sousse and Jendouba, is essential if the government is to extend its family planning program effective]y throughout rural Tunisia. -7-

Nutrition

1.16 Malnutrition, although diminishing, is still common. The fact that, in terms of percentages of minimum requirements, the average per capita supply of calories and protein is satisfactory conceals wide differences between groups and areas as well as specific dietary deficiencies. The results of the 1980 National Food Consumption and Nutrition Survey will only be available in late 1981, but a similar survey in 1975, showed that on the average, Tunisians consumed about 2,543 calories per capita per day (115% of the recommended requirement) and 72 g protein (180% of the recommended intake). Only at income levels below 100 dinars (US$240) per year did caloric intake fall below the recommended intakes, and only below 30-60 dinars did protein in- take become deficient, especially in urban areas. About 14% of the population in 1975 were unable to cover their minimum daily caloric intake requirement. This percentage corresponds closely with the 17% of the population below the absolute poverty threshold in 1975. Malnutrition was a more severe problem in urban Tunisia, where 18% of the population were unable to meet their caloric requirements, compared with only 9% in rural areas. According to the 1975 consumption survey, poor and malnourished people can be found in all occupations, self-employed and hired workers alike. They are in the mainstream of economic activity, but with low productivity and/or large families.

1.17 Vitamin and mineral deficiencies were more widespread than calorie or protein deciciencies, but it is not known how severe these deficiencies were. The 1975 survey suggests that well over half of Tunisia's population were consuming less than the recommended intakes of Vitamin B (riboflavin), calcium, Vitamin A, and iron. Clinically, about 20% of the cgildren surveyed in 1975 showed signs of riboflavin and iron deficiencies, and about 9% signs of rickets, which are indicative of Vitamin D deficiency. About 55% of the children surveyed nationwide showed evidence of stunted growth, but only 10% of them showed signs of severe malnutrition. In 1979 about 70% of children hospitalized suffered from various forms of malnutrition. Most of the severe cases were in very poor urban areas, where poor sanitation and unstable family situations predominate. Anemia caused by iron and folate deficiencies, and exacerbated by some parasitic infestations, was reported to affect nearly half of Tunisia's women of child-bearing age and nearly one quarter of the children, especially in the North West and in the Tunis area.

1.18 The Institute of Nutrition and Food Technology (INNTA), a semi- autonomous organization under MOPH, was created in 1969. With external assistance from USAID, FAO, WHO, UNICEF, SIDA and the Canadian Government, the INNTA's main activities are: nutrition research; assessment of the nutritional status of children below five years of age and of pregnant and lactating women; and assessment of regional food supplies in order to facilitate the setting of agricultural production targets. The INNTA has also organized applied nutrition programs, covering: nutrition education, primarily through the mass media; distribution of weaning food for severe cases of malnutrition; and distribution of vitamins, iron tablets and iodized salt. - 8 -

1.19 A staff of 140 INNTA nutritionists is attached to the MCH clinics to carry out the supplementary feeding and nutrition education. programs. The scope of this vertical program in rural areas is limited by lack of logistical support and trained field personnel. Tunisia's Office des Cereales produces a high protein, high calorie weaning food, Saha, for the supplementary feeding program and commercial distribution. Through CARE and CRS, USAID has also been funding a maternal/child feeding project. In 1979 this program reached about 180,000 children between two and five years and pregnant and lactating women, particularly in small towns and rural areas; it provided flour, blended foods and oil. The largest child feeding program is a primary school lunch program which reached about 260,000 needy children age 6-12 in. 1979, close to 26% of total enrollment. This program is also conducted in cooperation with CARE, CRS and the Tunisian Government. In addition a "food for work" program supported by the World Food Program improves the nutrition of about 55,000 workers a year and several times as many dependents. These various feeding programs are supported by a successful radio nutrition education campaign designed to modify people's habits, with particular emphasis on improved methods of child feeding.

1.20 As in the case of family planning services, the Government decided to make the applied nutrition program an integral part of the public health services and to use MOPH channels and staff for delivery. The training of MOPH personnel in nutrition is already taking place, following curricula prepared by the National Institute of Child Health (INE) and the INNTA. This reorganization of program delivery should expend its coverage, particularly in rural areas, and thereby address more effectively the problem of widespread nutritional anemia as well as moderate-to-severe malnutrition still affecting up to 20% of Tunisia's children below the age of six years.

B. Financing of Health, Population and Nutrition Activities

1.21 Total health expenditure in the public sector amounted to 2.7% of GDP in 1979. At current prices, recurrent expenditure increased from D14.3M (US$27.2M) in 1971 to D58.9M (US$147.3M) in 1979, i.e., at an average rate of 19% per annum. Over the past five years, this corresponds to an annual average increase of 14% in real terms. However, the proportion of the recurrent budget devoted to health fell from 9.3% in 1971 to 7.8% in 1980. The distribu- tion of yearly allocations among the various health institutions has remained practically unchanged since 1973. General hospitals and institutes continue to receive the largest share - about 60% of total recurrent expenditure, whereas 28% is earmarked for regional hospitals and 9% for district hospitals. In contrast, only 0.5% was left to run the 600 urban and rural dispensaries, excluding salaries accounted for in hospital budgets (see Annex 4A). As a whole, the wages and salaries of health personnel represent more than 75% of total recurrent expenditure (Annex 4C).

1.22 An analysis of the recurrent expenditures of the MOPH in 1979 showed that low-income groups eligible for free medical care received 48% of total expenditure, while 40% was spent on workers and their families affiliated with the social security system. The analysis also showed that - 9 - about two-thirds was spent on hospital care, while outpatient services in hospitals absorbed 14% of the recurrent budget, dispensaries 16% and MCH centers 5%.

1.23 Capital expenditure in the health sector has increased consider- ably in recent years and amounted to D12.7M (US$31.&I) in 1978 and D16.9M (US$42.3M) in 1979 (See Annex 4B). This latter figure includes DO.6M (US$1.5M) for health campaigns and grants to the ONPFP (D2.3M or US$5.8M) and the Bal- neology Office (DO.5M or US$1.3 M). Direct investment in infrastructure rose from D9.1M (US$22.8M) in 1978 to D13.4M (US$33.5M) in 1979. Of this amount, ongoing projects absorbed D12.4M (US$31.OM), and new projects DO.9M (US$2.3M).

1.24 The ONPFP finances its own activities through separate "operating" and "investment" budgets. For 1979 the total operating resources of the ONPFP amounted to D2M (US$5M), while the investment budget was D2.3M (US$5.8M).

1.25 More than two-thirds of ONPFP's recurrent expenditure are financed by external donors; the larger contributor is USAID (32%), followed by UNFPA (25%); other bilateral or multilateral donors include WHO, the International Program for Voluntary Sterilization, and the International Statistics Insti- tute (World Fertility Survey). USAID and UNFPA provided in 1979 more than US$473,000 of contraceptives, US$40,000 of drugs and US$132,000 of equipment. The 1979 investment budget of US$5.8M was entirely financed by the Government and was earmarked for the IDA-assisted population project.

External Assistance

1.26 Besides the Bank Group, a number of bilateral and multilateral agencies have provided support for health, population and nutrition activities in Tunisia since the mid-1960s. Prominent among them have been USAID, UNFPA, WFP, SIDA and NORAD. WHO, French, Belgian, Canadian, Bulgarian, Dutch and Chinese agencies have provided technical assistance. USAID has taken the lead in providing external support for the development of Tunisia's rural health service network. Since 1965 USAID, with a total contribution of US$26 million, has been the principal external donor to Tunisia's family planning and nutrition programs. IDA and NORAD have each provided US$4.8 million.

IDA Population Project

1.27 The only previous Bank Group operation in the health sector in Tunisia was a population project for which an IDA credit of $4.8 million was approved in April 1971. The project was designed to strengthen the Tunisian family planning program by increasing the number of contraceptive acceptors, and to improve mother and child health care. It provided for: (i) the construction and equipment of four maternity hospitals (Tunis, Sousse, Sfax, Bizerte); 29 MCH centers, and an extension of the Avicenne Paramedical Training School in Tunis and its post-graduate training section; and (ii) the provision of management consultants and technical assistance for paramedical training and the assessment of the maternal and child health program and the - 10 -

TFPP. The project was at first administered by the MOPH, and later, from 1974, by the ONPFP, and was scheduled for completion by the end of 1975. Due to initial delays in selecting consultant architects and completing designs, construction did not begin until 1974, and progress was much slower than expected. This was partly due to administrative weaknesses in the ONPFP and to the fact that Tunisia's construction industry was overtaxed by the heavy construction programs called for by the Fourth and Fifth Five-Year Plans. The project is now expected to be completed by the end of 1981. As a result of the delays in implementation and of price escalation, the total estimated cost increased to about US$35 million, compared with the initial appraisal cost of US$7 million. Additional financing has been provided by NORAD (a US$4.8 million grant in August 1976) and the Government. So far, 76 percent of the combined IDA credit and NORAD grant has been disbursed.

1.28 The 1975 Bank sector review ("The Population Program of the Govern- ment of Tunisia", Report No. 651-TUN), IDA review missions, and other donors (mainly USAID and UNFPA) were instrumental in drawing attention to, and securing a reform of the ONPFP's administrative deficiencies. The Bank review noted that under the leadership of the ONPFP the delivery of family planning services had been increased and reorganized; more effective motivation and education campaigns had been conducted; research had been initiated; new contraceptive methods introduced; and the collection of family planning data and training of health workers in family planning methods had been intensi- fied. The review recommended that family planning services should be further increased, and that they should be provided by MOPH field staff under ONPFP supervision. However, the MOPH at that time lacked the continuity, commit- ment, infrastructure and management skills to take up additional operational responsibilities for family planning delivery. Consequently, the ONPFP filled the vacuum by expanding its own parallel delivery system despite the inefficiencies resulting from duplication of facilities, high unit costs and inability to cover rural areas adequately. Over the next three years, the Government moved toward the integration of health and family planning services and began to test a new delivery system through pilot project in Le Kef, Sfax, Jendouba and Medjez-el-Bab. Pending the outcome of those efforts, the Govern- ment permitted ONPFP to retain its established delivery system, as applicable to the Bank-aided project and elsewhere, as a practical way to maintain momentum in the family planning program.

1.29 The project's impact on infant mortality and child health cannot yet be determined, since the MCH centers have only recently come into operation. The urban centers show promising results, but those in rural areas are still understaffed, and have a low utilization rate; all centers will be integrated in the peripheral network of MOPH facilities. Three maternity hospitals have been constructed and the fourth is expected to be completed before the end of 1981. The extension of the Avicenne Paramedical Training School has enabled the Government to train specialized nurses and midwives. The IDA project reflected the general view prevalent ten years ago that vertical programs and hospital and clinic based post-partum programs were the most effective method of recruiting new acceptors. Experience in Tunisia as well as in other countries has shown that this approach is costly and reaches only a small proportion of the rural population. It has also shown that, to attract a larger proportion of the rural population and to generate demand for - 11 -

family planning, other health services have to be offered in conjunctionwith maternal and child care and family planning. On the other hand, experience has shown that more attention should be given during project preparationto: (a) the preparationof detailed and realistic project implementationschedules; (b) the type, size and design of facilities to be provided, and their finan- cial, manpower and training implications;and (c) the relationshipbetween project components and the existing health delivery system. This has been taken into account in the preparationof this proposed project, which is designed to provide health services as close as possible to where people live, using simple and economic health facilities and paying special attention to problems of management and training. The proposed project will benefit from other Bank projects in the same area. The Rural Roads Project (Loan No. 1601-TUN of 1978) and a similar project in course of preparationwill extend the rural roads network, while the Third Power (Rural Electrification)and the North West IntegratedRural Developmentprojects will meet pressing needs in the same underdevelopedarea.

II. INTEGRATIONOF HEALTH, POPULATION AND NUTRITIONPOLICIES AND SERVICES

A. DevelopmentPlanning and Objectives

2.01 The reduction of social inequalitieshas been a goal of the Tunisian Government since independence. During 1970-78 Tunisia spent about 16% of GDP on various social programs, of which public health took the second largest share. In the mid-1970's the Government became aware of the need for a radical shift in the emphasis of the public health system, and this awareness was reflected in the Fifth Development Plan (1977-81). In the health sector, the Plan gave priority to basic health care and preventive medicine, improved cost effectiveness,and better regional distributionof facilitiesand personnel. So far, progress in these directions has been confined to regions where pilot schemes have been carried out.

2.02 The Government'shealth policy, as expressed in preliminaryreports for the Sixth Five-Year Health Plan (1982-86),is to increase life expectancy and improve health by making basic health services available in all parts of the country. To this end, the Government is committed to a better balance between preventive and curative care and to an extension of health services to underservedand unserved rural and suburban areas. Among the particular targets is a reduction in infant mortality from 123/1000 to 50/1000.

2.03 The Government has establisheddemographic objectives designed to keep the population in line with the country s economic development(Annex 1.E). To attain these objectives,the Government will have to expand its family planning services,particularly in the rural areas, which are not effectivelyreached at present. The proposed program, which would be sup- ported by this project, would take services through the health system to underserved rural and urban areas, while continuing the specializedONPFP clinics in the major cities. - 12 -

2.04 The national family planning program aims at reducing the net reproduction rate from 2.2 in 1980 to 1.15 by the year 2001. Chus, the general fertility rate (15-49), which was estimated at 155/1000 in 1976, would need to fall to 135 in 1981, and to 120/1000 by 1986. This reduction would bring the crude birth rate down to 30/1000 in 1986 (from an est:imated 35.3/ 1000 in 1976).

2.05 It will not be easy to reduce the general fertility irate because: (a) the proportion of women in the 25-29 age group, the most fertile group, which contained 14% of the total number of women of childbearing age in 1976, will rise to 16.5% in 1981, and 17.6% in 1986; and (b) in 1977, rural women constituted 53% of all women in the country, but only 12% of a:l new acceptors. Improved motivational and service efforts are directed at these problems. To reach the goal of fertility reduction given in para 2.04 above,,about 410,000 births would have to be averted between 1980 and 1986. This would appear to be feasible considering that in 1979 the corresponding number was 63,000 (see Annexes 1E and 1G).

2.06 In order to reduce disparities in nutrition between regions and groups, the Government intends to: (a) improve the nutrition monitoring system; (b) intensify its nutritional education program; (c) itiprovenutrition in rural areas by providing nutrition services through the basi.c health care delivery system; and (d) step up programs to correct specific nutritional deficiencies of the lower-income groups. The Government is also carrying out a feasibility study for a food stamp program.

2.07 The proposed project would address major problems which the Sixth Plan seeks to correct: (a) strengthen MOPH's capacity for policy formulation, planning, management, and evaluation; (b) complete the decentralization of management to the operational level begun in 1977; (c) integrat:e the delivery of health, family planning and nutrition services, with emphasis on prevention rather than cure; (d) train new categories of public health workers to serve in teams at the basic health care level; (e) strengthen the public health component of medical school training and revise the curricula cf paramedical schools to meet the needs of the integrated system; and (f) expand infrastruc- ture in under and unserved areas.

2.08 In order to remedy the present deficiencies in the collection and analysis of health statistics, the MOPH is setting up a management information system (MIS) to: (a) provide information on inputs (finance, personnel and other resources); (b) evaluate the efficiency of the system by relating inputs to activities; (c) relate activities to changes in the health of the population; (d) evaluate the effectiveness of the system by measuring the proportion of the population reached; and (e) improve the cost-effective- ness of service delivery.

B. Integration of Services

2.09 The decentralization and integration of health services got underway in 1977 through a Presidential Decree and subsequent Circulars issued by the - 13 -

Minister of Health, which delegated increasing authority to the six medical regions (Tunis, Tunis-Sud, Sfax, Sousse, Gafsa, and Jendouba). The Decree and Circulars call for the integrated regional delivery of curative and preventive medicine, family planning and nutrition activities, and for the ONPFP and the INNTA to divest themselves of their field activities, and to concentrate on research, policy formulation, and the training of specialists in their own fields. The MOPH is now in the process of separating the management, administration, and the budget of hospital-based medicine from those of the peripheral basic health services. At the governorate level, Regional Directors of Health (RDHs), a new stratum of managers, will coordinate and control all health activities, including budgeting matters; specially appointed physicians (Chefs des Services de Sante de Base) will be reponsible for integrating all basic health services under the functional supervision of the Director of Basic Health Services (DBHS).

2.10 In order to attract recruits to the government health service, the Government is improving career prospects (in terms of salaries and promotion), living and working conditions. The Government is revising the training programs for physicians and paramedicals. Physicians will be offered courses in epidemiology and internships in the public health service, while courses in such subjects as health economics, management, planning and techniques of com- munication have already been introduced into medical schools. The training of paramedical workers will lay more emphasis on preventive medicine, health education, hygiene, nutrition, family planning, and techniques of communica- tion. More attention will be given to training in managerial skills.

2.11 The MOPH is already strengthening the peripheral health network in rural and suburban areas. Other aspects of health to which the MOPH also plans to give additional emphasis through integrated services are:

(a) the control of communicable diseases by means of wider immunization campaigns and earlier diagnosis;

(b) the control of endemic diseases such as tuberculosis by means of earlier diagnosis and treatment;

(c) the provision of family planning services;

(d) the early identification of malnutrition and the increased distribution of dietary supplements such as high protein flour, vitamins and iron; and

(e) the health of mothers and children, with particular emphasis on pre- and post-natal care, family planning and the systematic treatment of gastro-intestinal and respiratory ailments, and malnutrition, i.e., the chief causes of infant mortality;

(f) the strengthening of health education in the fields of sanita- tion, family planning and nutrition and its coordination among the agencies concerned; and

(g) the systematic control of water quality and treatment of wells with chlorine. - 14 -

2.12 The MOPH has prepared a detailed plan for the extens.Lonof this integratedapproach to medicine which is intended to bring health services closer to the populationby increasing the density of the healt:hnetwork at its lower levels and providing a more effective and uniform system of referral to higher levels. The system functions at four different levels:

(a) At the first level, basic services, such as vaccinati.on,the distri- bution of simple medicines and contraceptives,the detection oi infectious diseases and malnutritionand the treatment of minor ailments, are provided on one day every week or every two weeks in "meeting places" (which may be in public buildings such as chools, shops or private houses) selected by local inhabitants,by nurses who travel from one meeting place to another. The catchment area of each meeting place varies from 300-800 people. People whose needs cannot be met at these meeting places are referred to the dispensaries at the second level. In areas more than one hour's walking distance from dispensaries,a somewhat wider range of services, including in-jections,the distributionof contraceptives,and family planning advice, is provided by the same visiting nurses in health posts serving localitieswit:h 1,500-3,000 people.

(b) At the second level, a family-widerange of outpatient services is provided in dispensaries,each serving a population from 5,000--0,000people in rural areas or from 10,000 to 20,000 in urban areas, by teamisconsisting of two full-time nurses and visiting physicians,midwives and specialists. Each rural dispensarywill serve all people within a 6-km radius. The services include medical consultations,family planning advice, insertion of IUDs, the distributionof medicines, contraceptivesand food and vitamin supplements, and nutritionaleducation;

(c) The third level is based on district hospitals, each serving a population of about 30,000 people. At these hospitals larger t:eamsprovide, in addition to the services available at lower levels, hospitalization(includ- ing maternitywards), minor surgery (includingtubal ligation and medical abortion),Xray diagnosis and dental treatment. Hygiene techniciansare attached to district hospitals;they survey sanitation in public places, the quality of water supply and public waste disposal. They also treat rural wells with chlorine. Schools in the district are regularlyvisited by medical teams who provide systematicimmunization and control, and advise teachers on health education;

(d) The fourth level consists of the regional hospitals located in the larger towns, each serving a population of about 200,000 people, and offering a comprehensiverange of services. Patients whose needs cannol:be met at lower levels may be referred to these regional hospitals.

A summary of staffing and services envisaged at the first three of these levels is shown in Annex 6A. - 15 -

2.13 This approach is based on several pilot schemes 1/ carried out in the 70s which were designed to bring about significantimprovements in the coverage and quality of medical care. The most important of these projects-- sponsoredby USAID and implementedby WHO--was carried out in the Medjez-el- Bab district,covering a population of 76,000. The Medjez-el-Babproject, which was at first administeredby the ONPFP, working mainly with expatriate staff, was not successfuluntil the MOPH took over full responsibility for the project and replaced the expatriateswith Tunisian doctors better able to communicatewith the local people. The project has produced encouraging results since 1976: infant and maternal mortality have been reduced by about 50%; infant malnutritionhas fallen by 50%; the proportion of family planning acceptors is about 25% higher than in neighboring rural districts; access to safe water has been significantlyimproved, and the main communicablediseases have been brought under more effectivecontrol. The project extended the proportion of the population covered by health services from 50% to over 80%, and also resulted in a significantincrease in health facility utilization rates: from 30% to 70% in the district hospital and maternity clinics, and from about 40% to 100% in local dispensaries. With the encouragementof the Director for Preventive Medicine of the MOPH and a group of young physicians from the Tunis Medical School, and in response to popular demand, the MOPH early in 1980 started to extend the Medjez-el-Babproject to neighboring areas. The health team approach,upon which the system depends, was success- ful in attractingTunisian physiciansand paramedicalsto work in rural areas, served previouslymainly by expatriates.

C. MOPH Service Delivery System, Organizationand Management

2.14 Under the integrated approach,health, family planning and nutrition services are delivered principallyby the MOPH with support from the ONPFP and the INNTA.

2.15 For MOPH service delivery, the country is presently divided into six medical regions. A decree reorganizingthe MOPH and strengtheningdecentral- ized authorityhas been submitted for signature to the Prime Minister. It will establish a Regional Director of Health (RDH) in each governorate. The RDH, vested with full authorityon technicaladministrative and budget matters, will report to the Minister, through the Director of Basic Health Services (DBHS), a post also created within the General Directorateof Public Health (see Annex 12). Under each RDH, a physician ("Chef des Services de sante de base") will be directly responsible for integratingbasic health services.

1/ "Projet de sante familiale dans la region de Gafsa"; "Projet de sante familiale dans le gouvernoratde Le Kef"; "Renforcementet integration des services de sante du Cap Bon"; "Programmede medecine communautaire dans la region du Sahel"; "Experiencede planning familial a domicile dans le gouvernoratde Sfax"; "Experience-piloted'integration du planning familial a la sante familiale en milieu rural dans le gouvernoratde Jendouba." - 16 -

2.16 In 1979 Tunisia's public health system provided services through 824 basic health care facilities (126 health posts, 503 rural dispensaries, 85 urban dispensaries, 110 mother and child health care centers), and 49 district hospitals, 20 regional hospitals, and 18 specialized institutions and general hospitals (Annex 3C). In addition, the National Social Security Fund is building six poly clinics, including three in Tunis. The ONFFP provided family planning services in the 110 MOPH maternal and child care centers, 8 of which included maternity wards, and 316 MOPH dispensaries. The ONPFP also managed 15 regional education and family planning centers for counseling and other services, including sterilization. It also operated 45 mobile regional teams.

Health Personnel

2.17 The physician to population ratio has improved greatly in recent years from 1/4800 in 1978 to 1/3650 in 1980 (see Annex 3B). By mid-1980, Tunisia had about 1,730 doctors. Most are in the larger towns, including 760 in Tunis. The public health services employ about 1,330 doctors, including 450 expatriates serving mainly in rural areas. The number of doctors available for government service is expected to increase significantly in the next few years, for three reasons: (a) the very rapid increase in the number of medical graduates; (b) the leveling-off of emigration of Tunisian physicians to Arab oil producing countries; and (c) the limited growth of demand from middle- and higher-income groups in Tunisia for the relatively costly services of private physicians.

2.18 The number of paramedical personnel has increased regularly, from about 6,400 in 1972 to 10,400 at present. This figure includes 210 high-level technicians, 550 midwives, 1,230 specialized nurses and 4,080 nurses (see Annex 3E). Almost two-thirds of these personnel have been trained for, and serve in, hospitals.

Educational and Training Programs

2.19 The country has three Faculties of Medicine, in the Universities of Tunis, Sousse and Sfax, with a total enrollment of more than 3,000 students. Medical education takes seven years: five years of studies followed by two years of internship. The number of graduates has tripled in the last five years to about 340 in 1980. Some 500 graduates are expected in 1981, but the MOPH hopes to reduce future enrollments to reflect its forecast of manpower needs and avoid the costs associated with educating an excess number of physicians. This would also help to reduce pressures to expand costly, specialized, hospital-based services.

2.20 The training of paramedical personnel takes place in 14 regional schools as well as in facilities for high-level technicians in the Universities of Tunis and Sousse, opened in 1976. A large paramedical school (300 student capacity) is under construction in Monastir. The different types and levels of training provided are as follows:

(a) auxiliary health workers: one-year training after the fourth grade of secondary education; - 17 -

(b) nurses: two-year training after the fifth grade of secondary education;

(c) specializednurses: three-yeartraining after the seventh grade of secondaryeducation; specializations include surgery, intensive care, general care, pediatrics,psychiatry, public health, laboratoryassistance, pharmacy assistanceand medical secretarial (two-year training);and

(d) higher-leveltechnicians: three-year training after the bacca- laureate;specializations include nutrition, physiotherapy, radiology, radiotherapy,obstetrics, anesthesiology, biology, cytology,hygiene and environment,and dentistry.

2.21 Teachers in the paramedicalschools are either doctors, pharmacists or administratorsteaching part-time, or full-timetrainers. The latter are experienced specializednurses or high-level technicianswho have undergonea nine-month training course in the Center for PedagogicalResearch and Training (CRFP) attached to the Faculty of Medicine of Tunis. The CRFP is also respon- sible for the design and revision of paramedicalschool curricula. The teaching staff of the 14 paramedical schools consists of 139 full-time trainers and 404 part-time teachers.

2.22 The paramedicaltraining system has now more than 3,700 students: 2,300 in the regional schools and 1,400 in the two university sections. The output of the training system is shown in Annex 3G; in 1980 it comprised250 auxiliaryhealth workers, more than 500 nurses, 200 specializednurses and 450 high-level technicians,including 100 midwives.

2.23 The projectedoutput of the training system will be sufficientto cover manpower requirementsarising from current hospital constructionas well as the continuing expansionof the health system. However, a number of deficiencies,most of which have already been identifiedby MOPH, need to be addressed. They mainly stem from rapid, inadequatelyplanned expansionin response to the high attrition rate due to the migration of qualifiednurses to Europe and Arab countries,now slowing down, combinedwith increasing demand for education. Because employmentopportunities can hardly keep pace with the growth of the labor force, and the expansion of the educationsystem, candidates tend to have more education than the posts available to them require. As a result, health workers tend to be both over-educatedand over-trained,a situation that breeds frustrationand, in some cases, even affects the quality of services,since workers may consider the performanceof certain tasks as incompatiblewith their self-perceivedprofessional status. A good illustrationis furnished by midwives,who now receive a university training qualifying them as high-level techniciansin obstetricsand, in consequence,consider themselvesentitled to hospital appointmentsrather than work in villages.

2.24 A further difficulty is that responsibilitiesof most of these categories of personnel have not been clearly defined, and the corresponding job descriptionsare not always explicit. Curricula are strongly biased towards hospital and curative care, and do not give adequate attention - 18 - to hygiene, family health, family planning and nutrition. Moreover, the failure to distinguishclearly between job categories sometiriesleads to duplicationof training. The need for a reduction in the nuriberof special- izations, in favor of a more general, multipurposetype of training,and also for the harmonizationof overlappingcurricula has now been recognized,and will be reflectedin the revised curriculaprepared by the CaFP. The first year revision is already completed and the curriculafor the second and third years will be undertaken under the project.

2.25 Teaching methods do not call for enough active participationfrom trainees and put too much emphasis on theoreticalknowledge, at the expense of practicaltraining, teamwork and communicationtechniques. Trainers themselves often lack pedagogicalexperience and there is excessive reliance on part-time trainers (doctors,pharmacists, technicians, administrators), a situation which will be difficult to remedy in the short run. Finally, there is a general lack of adequate budgetary provision for equipment and teaching materials, especially in the smaller regional paramedicalschools. Moreover, some buildingsare inadequateand poorly maintained.

Drugs and Medication

2.26 Through a central pharmacy, the Government controls;the import, production,distribution and pricing of all medications,pharmaceutical products,medical equipment and supplies for both human and veterinary use. The central pharmacy produces about 55% of the value of all drugs prescribed in hospitals, and about 12% of the value of those distributed through retail pharmacies. Of about 270 retail pharmacies,about 80 are ope!ratedby the Central Pharmacy, and 190 by private enterprise. The Central.Pharmacy sells a wide variety of generic and name-brand drugs to retailersat prices much higher than cost; this serves to subsidize the cost of drugs made available through Government services.

2.27 While hospitals and urban dispensariesgenerally receive adequate supplies of drugs, rural dispensariesexperience periodic shortages, reflecting the hospital bias of the health system. This results from the existing budgeting system which does not disaggregatethe resource allocationsbetween hospitals and dispensaries. As of 1982, a revised budgeting system is being introducedin order to identify specific resources for basic health care, thus ensuring adequate provision of medical supplies at all levels.

Need for the Project

2.28 Despite substantialprogress, several important problems continue to affect the quality and coverage of Tunisian health, family planning and nutritionprograms. Growth of urban services has far outstrippedexpansion in rural areas. A large unmet demand for family planning services persists, in rural areas, partly because of 15 years of success in informationand education activities. Nutrition outreach is extremely limited, although nutrition education appears to have met with some success. At the same time, only about half the rural population has access to adequate health care. Health services retain a bias towards curative methods and expensive hospital care. Management,training and logistical deficiencies,acccimpanied by only slow progress towards integrationand decentralization,have perpetuated inappropriateand costly patterns of health, family planning and nutrition services. - 19 -

2.29 The Government'snew health policies and programs seek to remedy those deficiencies. The 1982-86 DevelopmentPlan is expected to propose major improvementsin the main areas of priority concern. First, it would strengthen MOPH central planning and management capabilitiesby training personnel and installinga management informationsystem for health surveillanceand to monitor and evaluate the performanceand financial aspects of the system.

2.30 Second, the new approach calls for further integration,redirection and decentralizationof health, family planning and nutrition services. Expansionand strengtheningof the rural health care network would correct rural-urbanimbalance; a shift toward broadening the delivery of preventive services would reduce curative bias. The plan also provides for the training and deploymentof para-professionalworkers and the developmentof an effective system to support and supervise them.

2.31 The Government seeks Bank assistance to carry out these improvements in eight governoratesas a step towards national coverage. The project was prepared over two years of close consultationwith both the Government and donor agencies, includingAID, which is already providing support for the new program in two governoratesand is expected to extend it to two more during the next year.

III. THE PROJECT

A. Project Concept and Objectives

3.01 The Government is strongly committed to its integratedhealth policy, which is clearly supportedby rural populationsand community leaders. The project would help the Government to extend basic health care to the whole population by 1990 by providingbetter and more cost-effectivehealth services for the lower income groups and increasing the efficiency of family planning and nutrition programs in eight selected governorates. Priority target groups would be infants, pre-schoolchildren and women of reproductive age. The project draws on the experience gained through the pilot projects carried out in the seventies, particularlyin the Medjez-el-Babarea (para. 2.13), which emphasized the health team approach and the need to: (a) gain better knowledge of the population'shealth needs by monitoring basic health indicators(see Annex 7); (b) strengthenpreventive care, with particular attention to mothers and pre-schoolchildren; (c) improve health education; and (d) encourageTunisian physicians to serve in rural areas.

3.02 The experience derived from the IDA population project is reflected in the special attention that has been given to: (a) strengtheningthe management capability of the MOPH and its equipmentand building unit; (b) simplifyingthe design of new health facilitiesand (c) planning how to meet the financial, staffing and training requirementsgenerated by the project. The project will also include a monitoring and evaluation system for the prompt identificationof implementationproblems to permit timely corrective intervention. - 20 -

3.03 In its first phase the national basic health care delivery system is being introduced in 12 governorates, of which eight will be included in the proposed project. For the Bank project, the Government has selected six thinly populated rural governorates with low per capita income (Jendouba, Le Kef, Beja, Zaghouan, Kairouan, and Mahdia) and two better developed and more densely populated governorates where trained personnel and training institutions are more readily available (Sousse and Monastir). A plan for the expansion of the new health delivery system to the rest of Tunisia would be prepared as part of the project.

3.04 Based on achievements in Medjez-el-Bab, the specific objectives of the project in the eight governorates are to reduce: (a) infant mortality to about 80/1000 from an estimated national average of 123 per thousand con- sidered as representative for the project area; (b) the birth rate from about 43/1000 to 36/1000; and (c) morbidity from tuberculosis and other respiratory diseases, parasitic and viral infections. These objectives are to be achieved over a five-year period, once the project has become fully operational. While ambitious, they are attainable where project services operate as planned. These objectives are to be attained by increasing the proportion of the population having access to basic health services from about 50% to about 90%, by extending health education and by providing the target population with services designed to:

(a) reduce infant mortality -- by providing systematic pre- and post-natal care; improving hygiene and nutrition for pregnant women and pre-school children; providing treatment of diarrhea by oral rehydration; identifying women at risk and increasing attended deliveries; ensuring vaccination against polio, diphtheria, and measles;

(b) reduce morbidity from common diseases -- by providing earlier diagnosis and treatment; improving sanitation, particularly as regards quality control and treatment of wells; extending health education; strengthening epidemic control programs, and making greater use of diagnostic equipment.

(c) reduce fertility -- by expanding family planning seruvices, population education, and counselling and making contraceptives widely accessible in rural areas; and

(d) ensure easy access to and adequate provision of the above services, where needed -- by providing the necessary outpatient facilities and equipment.

Annex 5 summarizes these services and their expected impact on the target population.

3.05 The Government's pattern of integrated basic health services delivery has been designed to provide 90% coverage in the following areas: family planning services; infant inoculations; preventive and curative services for children; general curative services and hygiene anad sanita- tion services. Staffing requirements and facility designs take full account of the daily workload represented by the above demand. - 21 -

3.06 The populationin the project area was estimated at 2.3 million in mid-1980, i.e. about one third of the country's population. It is expected to grow by 2% per annum, and is projected to reach 2.5 million or about 35% of the country'stotal population,by 1986. About 65% of the project area population can be considered rural, since only two governorates(Sousse and Monastir) are highly urbanized (Annex 3A). At 90% coverage,beneficiaries would include about 81,000 infants, 279,000 children between one and five years of age and 315,000 married women of reproductiveage, including 174,000 receiving family planning services.

B. Summary of Project

3.07 The project would: (a) improve the managementcapacity of the MOPH; (b) strengthenand extend the basic health care delivery system; (c) increase the scope and effectivenessof communicationprograms in health, population and nutrition; (d) upgrade the training system and infrastructure, and train and redeploy project personnel for the integrated delivery system; and (e) provide technical assistance to the MOPH in the fields of health planning, management informationsystems and curriculum development.

3.08 The projectwould provide for:

(a) Managementimprovement:

(i) Equipment and material for the MIS and project administra- tion, including4 sedans;

(ii) Computer services for new programs, data processing,moni- toring and evaluation;

(iii) Five man-years of technical assistancein health planning and MIS, and six scholarships(36 man-months) for training abroad in these fields;

(iv) Local consultantservices for the preparationof a plan to extend the integrated health system to the rest of the country, and the implementationof the applied research program;

(v) Internal travel expenditurefor project management staff.

(b) Strengtheningof Basic Health Care Services:

(i) The constructionand equipmentof 76 health-posts;82 rural dispensaries;11 urban dispensaries;88 staff houses; and 8 vehicle maintenanceworkshops; - 22 -

(ii) The remodelingor expansion of, and the provision of additionalequipment for 62 health posts, 201 rural dispensariesand 25 urban dispendaries;

(iii) Additional equipment for the 21 district hospitals in the project area;

(iv) Vehicles: 38 small sedans, 29 four-wheeldrive, 19 ambulancesand 100 mopeds;

(c) Health, Population and Nutrition Communications:

(i) The constructionand equipment of two regional health education centers, and the remodelingand additional equipment for the central health education center in Tunis;

(ii) Equipment, vehicles and material for the retraining programs and health education campaigns;

(d) Training:

(i) The remodelingof and provision of additionalequipment for six paramedical schools;

(ii) Vehicles: 4 small sedans and 6 mini-buses;

(iii) External technicalassistance in curriculumdevelopment (2 man-years), short-termscholarships for training abroad of 8 health educators, and local consultant services for the preparationof training programs and seminars;

(iv) Internal travel expenditurefor the implementationof training programs.

C. Detailed Project Description

3.09 The project would help the Government develop its integratedhealth delivery system (see para. 2.12) by strengtheningMOPH planning and manage- ment, and extending the decentralizationprocess begun in 1977. A program of constructionand remodelingwould expand peripheralhealth facilities. Health educationwould be extended. The integrationof preventive,curative, family planning, nutrition and sanitation services calls for appropriate retrainingof health workers, and a revision of the curriculumof paramedical schools. Both would be carried out under the project. Finally, a program of studies and applied research would be carried out with a view to improving the efficiencyof the integratedhealth delivery system and preparing for its gradual extension to the rest of the country. - 23 -

Management Improvement

3.10 Management System: Effective rationalizationand decentralization of the integrated health delivery system requires the Government to complete the process of setting-up suitable arrangementsfor management,administration and budgeting of basic health care. The MOPH is appointing a new category of managers (RegionalDirectors of Health, or RDH) to take charge at the governoratelevel, vested with adequate powers to exercise technical,adminis- trative and budget control over basic health care. The RDHs will report to the Minister through the Director of Basic Health Services (DBHS). To assist the DBHS in planning and programming,the project would provide the services of one health planner manager (three man-years). The project would also provide training for the RDHs and other middle-levelmanagers (see para. 3.31). Before negotiations,the Government designated the DBHS. The eight physicians in charge of BHC in the project governorateswere also appointed. The appointmentof the DBHS will be a condition of efectiveness.

3.11 The project would strengthen the MOPH's Management Information System (MIS) to permit better planning and control of resources. The basic features of the improved MIS will be: (a) standardizedcollection forms covering a limited number of basic health indicators (Annex 7); (b) systematic data collection by MOPH personnel; (c) the expansion of statisticaland supportingstaff and (d) computerizeddata handling (includingnew programs) using the central computer of the National Computer Center and decentralized regional terminals. The project would provide the services of one management informationexpert (two man-years) to assist in setting up the MIS. The project would also provide twelve computer terminals, calculatorsand other equipmentand material.

3.12 The MIS provides the tools for: (a) identifyingproblems promptly; (b) sound health planning; (c) better budgetingand more efficient cost- control of health services; (d) continuousmonitoring and evaluation of inputs, service delivery, and outputs; and (e) maintainingan updated health, nutrition and demographicprofile of the population.

3.13 Studies and Applied Research: The project would include research to identify through experience improved ways of meeting health needs in rural areas and the cost and relative impact of essential services. The project would finance about 100 man/months of consultantsservices, preferably local, to carry out applied research into these questions. The research program would be designed by the DBHS and the CRFP. During negotiations,the main topics to be included in the applied research program were reviewed and agreed and assurances obtained that the consultants qualifications,expe- rience and terms and conditionsof employmentwill be satisfactoryto the Bank.

3.14 Research topics already identified include:

(a) costs: the costs of preventive and curative services at the periphery; - 24 -

(b) behavioralpatterns: the results of the National Fertility Survey, which will be available shortly, will identify important new areas for family planning research,particularly into supply-demandrelationships; the attitude of rural popu- lations towards the health system; incentives and disincentives for health personnel to work in rural areas; and the relative effectivenessof various channels of health education, such as the mass media;

(c) management: communicationwithin the MOPH; inter-agency coordinationand cooperationat central and local levels; basic indicatorsfor local health planning and drug distribu- tion at the periphery;and

(d) impact: comparison between the impact of population,health and nutrition services in a project governorateand in one outside the project.

3.15 Project-financedlocal consultantswould also help the DBHS to prepare a detailed plan for the extension of the integrated health delivery system to the whole country. The plan will take into account the experience gained during the first three years of the proposed Bank and U5AID projects.

Strengtheningof Basic Health Care Services

3.16 This componentwould set up basic health care (BHC) services to reach 90% of the project populationwith integrated health, nuLrition and family planning services. These services would be provided by health teams operating through an expanded and upgraded network of posts and dispensaries as described in para 2.12, and would include MCH care, endemic disease control, nutrition and family planning. The teams would also provide health education as described in para. 3.24. Annex 6B provides a tabLe of these services.

3.17 The integrated delivery system will extend family planning services to under-servedrural areas where logistical problems and the absence of links with the health services have limited the effectivenessof the ONPFP. It will aim at increasing the prevalence rate among family plalning acceptors in the project area from an average of 17% to at least 25%, which represent an additional25,000 new continuing users by the last year of 1:heproject. It will not affect urban areas where MCH centers have proved successfuland will continue to operate. The new system will promote better nutrition education, micronutrientdistribution, and the supplementaryfeeding of malnourishedpre-school children and pregnant and nursing women. It will also improve sanitation through the systematic chlorinationand maintenance of wells, and the training of local populations in waste disposal, personal and environmentalhygiene.

3.18 Service Delivery: Health, family planning and nutrition services will be delivered by teams of public health nurses, general physicians and - 25 - midwives, who will be assisted by nutritionists, nurse-supervisors, health educators and sanitary technicians. In rural areas, each team will serve an average of ten dispensaries on a regular schedule (see Annex 6A). The teams will supervise resident nurses and monitor the performance of activities at each dispensary, including the systematic referral of patients. The project would include incremental operating costs. The system will also provide an adequate supply of drugs and contraceptives at the peripheral level.

3.19 Infrastructure: The project would reinforce the health infrastruc- ture in the eight governorates. Health posts and dispensaries would be improved or remodeled where appropriate, and provided with additional equip- ment. Modest staff housing would be attached to existing or new rural dispen- saries where necessary. Additional laboratory and medical equipment would be allocated to the district hospitals. The project would finance the construc- tion and equipment of additional health rooms (76), rural dispensaries (82), urban dispensaries (9) and staff houses (88). The MOPH building unit carried out a mapping exercise to determine their location on the basis of population densities and existing service facilities. Some of the new facilities would replace inadequate, rented or irreparable existing facilities.

3.20 The settlements at Jebel-Lahmar and Saida-Manoubia in the Tunis area are being upgraded under the Second Bank Urban Development Project which, however, provided only sites for health facilities. Jebel-Lahmar, with an area of over 80 hectares and a population of about 42,000, has only one dis- pensary; a clinic is under construction. Although Saida-Manoubia covers over 90 hectares with a population of about 32,000, it has no health facilities. The project would finance the construction and equipment of an urban dispen- sary in each settlement on sites prepared under the Second Urban Development Project (Loan 1705-TUN of 1979).

3.21 The Equipment and Building Unit of the MOPH (EBU) has prepared standard designs for each type of facility (Annex 10) and would supervise construction, which would be carried out by the Ministry of Equipment, or in the case of some rural health posts and dispensaries, by regional authorities acting on behalf of the MOPH. The selection and acquisition of the sites is not expected to present difficulties in rural areas, where Government owned land is readily available. The buildings would be small and simple to construct from mainly local mayerials.2 The nopms for health posts, rural and urban dispensaries are 50M , 100 M , 150 M respectively. Changes to be incorporated in the final architectural designs for health posts and dispensaries were agreed upon during negotiations, and assurances were obtained that the sites for the four new urban dispensaries will be acquired before December 31, 1981.

3.22 The project would provide ambulances and other vehicles to transport patients, staff and materials, as well as for the construction and equipment of a vehicle maintenance workshop in each of the eight governorates. Final architectural designs for vehicle maintenance workshops are being revised along the lines agreed upon during negotiations. Assurances were obtained during negotiations that the sites for the eight vehicle maintenance workshops will be acquired before December 31, 1981. - 26 -

Health, Populationand Nutrition Communications

3.23 The communicationscomponent is designed to strengthenand develop the population,health and nutrition activities of the ONPFP, the MOPH, the INNTA and the Ministry of Education. A working party set up by the MOPH for this purpose and, composed of two representativesof each, has already drawn up a communicationsdevelopment program.

3.24 The main purpose of the communicationsprogram would be to help field workers do a better job of motivating families to adopt improved health, family planning and nutrition practices. Mass media messages would reinforce individual and group contact between workers and the project population. The communicationseffort would be designed to meet two basic criteria: (a) the desired behavioral or attitudinalchange would be of major importance to family or individualwell-being and (b) it could be accomplishedwithout a major change in current economic or social conditions.

3.25 The members of the CommunicationsWorking Party wouLd organize in-service training courses for the field workers of all four agencies. The Regional Directors of the MOPH will coordinate these courses and will ensure that they are available to all extensionworkers, of agencies concerned in informingthe public.

3.26 During the first year of project implementation,a sample survey of peoples attitudes to health and their reactions to health educationwould be carried out in order to indentify the critical areas to be covered by the communicationsprogram. The survey would be included in the studies and applied research program.

3.27 The project would finance the production of educationalvisual aids, especially printed and illustratedmaterials for primary schools and mothers, all of which would be distributednationally. Motivationalf:Llms and slides for training purposes would be produced.

3.28 The project would provide for the constructionof two regional health education centers, one in Sousse and one in Jendouba, which would be used by the Working Party as training and retraining centers, for group meetings of community leaders, pregnant women and school teachers, for demon- strations to all field workers and other government personnel, as centers for the production of simple visual aids and for storage and distribution. The MOPH Center in Tunis would be expanded to.producemore, effective exhibition material and additional types of educational-visualaids. Assurances were also abtained that the two correspondingsites will be acquired before December 31, 1981.

3.29 Since communicationactivities-are now gravely hampered by lack of transport, the project would provide two vehicles to enable the Tunis Health Education Center to maintain liaison in the regional offices, two vans for the health education centers in Sousse and Jendouba and four vans for the eight project governorates. These vehicles would be maintained by t:heregional workshops. - 27 -

Training

3.30 This component would finance training for middle-levelhealth man- agers and statisticians,paramedical personnel and their teachers,health educators and physicians in the project area. It also would finance curricu- lum developmentfor training of physicians and paramedicalpersonnel and equipment,vehicles and the remodeling of six paramedicalschools.

3.31 Middle-levelManagers and Statisticians. The project would provide management training for 40 middle-levelmanagers and statisticians. At the regional and governoratelevels they will need, in addition to the skills they now possess, improved competence in such managerial functions as health assessment (data collection,MIS), programming (plan of work, scheduling, budgets), organizationand staffing, direction and supervision,evaluation and control. These programs would be organized by the MOPH in collaboration with the Faculties of Medicine and Economics of the University of Tunis. In addition, the projectwould provide 6 six months scholarshipsfor studies abroad.

3.32 Teachers. There are at present 139 full-time teachers (including 14 expatriates)and more than 400 part-time trainers (see para. 2.21). Start- ing in July 1981, with staff of paramedicalschools in the project area, the CRFP will undertake the systematicretraining of the 125 full-time Tunisian teachers,through short-term (four weeks) intensivecourses. By the end of October 1981, all 45 full-time teachers in the project area are expected to have been retrained.

3.33 Health Educators. The project would provide eight three-month scholarshipsin 1981 for the training abroad of members of the inter-agency working party set up by MOPH (see para. 3.23) in methods of health education and communicationtechniques. Upon their return, they will retrain health educatorsof all participatingagencies, who in turn will teach paramedical workers and other field staff how to impact health education.

3.34 Physicians and Paramedicals. The number of public service physi- cians serving outside hospitals in the project area will be increased from 60 to 80 (see Annex 60). They will all attend one-week seminars on the new integrated approach, in groups of six (para. 3.38).

3.35 About 1,020 paramedicalsare working outside hospitals in the project area (50 high-level techniciansand specializednurses, 410 nurses and 560 auxilliary health workers) (see Table 3F). They man 25 urban dis- pensaries, 36 MCH centers, 201 rural dispensariesand 61 health posts (see Table 3C). After completion of the project, the peripheral network will consist of 65 urban dispensariesand MCH centers, 252 rural dispensaries and 130 health posts. The application of the new staffing patterns described in Annex 6A to the extended network will entail the recruitmentof 500 more paramedicals(100 high-level techniciansand specializednurses and 400 nurses), i.e., an average of 100 per year over the project period (see Annex 6C). As mentioned above (see para. 2.23), the annual output of the training - 28 -

system is sufficient to meet the manpower requirements arising from the hospital construction program as well as from the extension of peripheral .services.

3.36 The program would thus provide training for about 1,060 para- medicals as follows:

(a) retraining of 700 persons -- 50 high-level technicimns and specialized nurses, 410 nurses, and 240 auxilla:ry health workers (it is etimated that some 40% of thor,e presently in service meet the required education and experience standards);

(b) additional training for 60 persons to meet replacement needs (20 per year assuming an attribution rate of 2%); and

(c) additional training for the 300 new paramedicals who will enter the system before the graduates trained under the revised curriculum.

3.37 The retraining program for physicians and paramedicals would focus on preventive care, outpatient treatment of common ailments, health education and communication techniques. MCH, nutrition and family planning would receive special emphasis. Two MOPH teams, already trained by the CRFP, would conduct the program. Each team would cover four governorates and would have five members: a physician experienced in primary health care, a family plan- ning educator, a nurse-teacher, a nursing supervisor, and a part-time nutri- tionist or public health educator. The retraining courses would be spread over a three-year period. For paramedicals they would consist;of two weeks of formal training, followed by 2-3 months of field work, and the!nby an addi- tional week of training. The CRFP has prepared a detailed timetable for the retraining program, which would be phased with the construction program and the opening of the new health facilities. By September 1985 all new para- medicals entering the public health system are expected to have been trained under the revised curriculum (see Annex 9B).

3.38 The same teams also would organize one-week seminars for physicians in charge of basic health services in the governorates. These seminars would pay particular attention to the special role of each member of the team, while emphasizing the physician's responsibility as team leader. The program includes training in communication techniques, administration and monitoring. The medical faculties, for their part, are organizing remedial training pro- grams to meet the special needs of individual physicians in gynecology, pediatrics, nutrition and public health.

3.39 Since paramedicals would be retrained in groups of 15 and physicians in groups of 6, the training teams would be required to organize, during the three-year period, a total of 70 three-week courses for paramedicals and 13 one-week seminars for physicians. - 29 -

3.40 CurriculumDevelopment. The CRFP already has prepared the revised curriculumfor the first year of paramedicalschools which will be introduced in October 1981. In addition to clinical training,the revised curriculum will include: practical epidemiology;communication techniques; nutrition; family planning and child rearing. At the end of the formal training period, paramedicalswill receive at least six months on-the-jobexperience in public health. The staff of the CRFP, which includes UNDP-financedexpatriates, has been reinforced by additionalTunisian personnel. The project would provide the services of a curriculumdevelopment specialist (two man-years of technicalassistance) to assit the CRFP in revising the curricula for the second and third year of paramedicaltraining, and the three-yearprogram for high-level technicians. The revised curriculumfor the first year of para- medical training was reviewed during negotiationsand assuranceswere obtained that the revision of curricula for the second and third year of paramedical schools, and the three-yearprogram for high-leveltechnicians, will be completedin time to be introducedat the beginningof each academic year, starting in October 1982.

3.41 The MOPH already has started strengtheningthe public health training of physicians. Courses in epidemiology,health economics,manage- ment, planning and techniquesof communicationhave been added to the curri- culum, while the number of internshipsin the public health services has been increased.

3.42 Infrastructure,Vehicles and Equipment. The project would provide funds for remodelingand equipping the regional paramedicalschools in Kairouan, Sousse, Le Kef and Menzel-Bourguiba. It would also provide for the conversionof hospitals in Mahdia and Jendouba into suitably equipped accommo- dation to replace two existing paramedicalschools, which at present have inadequatefacilities. Two new hospitals are to be opened in place of the ones which would become paramedicalschools. Each school would be provided with additionalteaching materials and a minibus to transport students to rural health centers for practical courses. The two training teams would be provided with four small sedans.

TechnicalAssistance

3.43 The project would provide consultant services for the applied reserach program, the organizationof training and the supervisionof civil- works. The project would also provide three specialistsfor a total of seven man-years to train MOPH staff in the latest technologyin the fields of health MIS, health planning, and curriculumdevelopment. These consultants and specialistswould be engaged under terms of reference and conditions acceptableto the Bank. During negotiations,assurances were obtained that Tunisian counterpartswill be appointed before the arrival of the three technical assistancespecialists. - 30 -

IV. PROJECT COSTS, FINANCING, PROCUREMENT,DISBURSEMENT AND AUDITS

A. Costs and Financing

4.01 The total cost of the proposed five-yearproject is estimatedat US$41 million equivalent. Base costs are calculatedat US$29.6 million equivalentand contingenciesat US$11.4 million equivalent. Taxes and duties, estimatedat US$2.8 million are included. The foreign exchange component is estimatedat US$12.5 million, 30% of total project costs. Costs of construc- tion, equipmentand vehicles account for US$13.8 million, or 46% of base costs. Computer services costs are US$1.1 million, 4% of base costs. Technical assistance,consultant services, scholarshipsabroad, training and project management account for US$1.4 million, or 5% of base costs. Incre- mental salaries arising from project implementationare estimatedat US$10.7 million, or 36% of base costs. Finally, drugs, contraceptivesand other supplies amount to US$2.6 million, or 9% of base costs. Tables 1 and 2 below summarize cost estimates by component and by expenditure category.

4.02 Basis of cost estimates. The costs of civil works have been esti- mated on the basis of current contracts for the constructionof comparable facilities. Equipment costs are based on current CIF unit prices duties and taxes, plus local transportationand installationcosts. Vehicle costs are based on unit prices in Tunisia about half of which consists of duties when the vehicles are not assembled locally. The costs of computer and consultant services are based on current contracts for similar services. In line with local experience,cost estimates of technicalassistance are based on an average of US$6,600 per man month for experts and about US$2,000 per month for scholarships,including travel costs. Estimates of incrementalsalaries are based on current MOPH scales. Incremental training costs are based on current monthly stipends paid to trainees in paramedicalschools. Estimates of other incrementalexpenditures (drugs, supplies,maintenance, etc.) are based on actual MOPH budget allocations.

4.03 Contingencyallowance. The project costs include a contingency allowance of US$11.4 million for (a) physical contingenciesestimated at 10% for civil works and equipment and 5% for computer services, technical assist- ance and consultant services and other incrementalexpenditures; and (b) price contingencies,estimated at 29% of the base cost plus physical contingencies. Total contingenciesrepresent 38% of-base cost. Price contingenciesfor both foreign and local costs were computed on the basis of increases of (a) 9% in 1981, 8% in 1982 and 7% per annum thereafter for construction;(b) 10% in 1981, 9% in 1982, 8% in 1983 and 7% per annum thereafter for equipment and vehicles;and (c) 8% in 1981 and 1982 and 7% per annum thereafter for other types of expenditure (Annex 12 D).

4.04 Foreign exchange component. The estimated foreign exchange componentis US$12.5 milion, equivalent to 30% of total project cost. The calculationof the foreign exchange component is based on the expectation that (a) all civil works contractswill be awarded to local firms; (b) all - 31 -

Table 1: ESTIMATED PROJECT COST BY COMPONENT (million units)

TDs US$s % of base- Category Local Foreign Total Local Foreign Total line cost

Management 0.78 0.47 1.25 1.95 1.17 3.12 11 Strengthening of BHC - infrastructure 2.74 2.00 4.74 6.84 5.00 11.84 40 - service delivery 3.76 0.57 4.33 9.40 1.43 10.83 36 Communications 0.13 0.32 0.45 0.33 0.80 1.13 4 Training 0.69 0.15 0.84 1.73 0.39 2.12 7 Project administration 0.14 0.09 0.23 0.35 0.22 0.57 2 Total Base Cost 8.24 3.60 11.84 20.60 9.01 29.61 100

Physical contingencies 0.51 0.28 0.79 1.28 0.68 1.96 (7) Price contingencies 2.65 1.11 3.76 6.62 2.79 9.41 (32) Total Contingencies 3.16 1.39 4.55 7.90 3.47 11.37 (38)

Grand Total 11.40 4.99 16.39 28.50 12.48 40.98

Table 2: ESTIMATED PROJECT COST BY CATEGORY (million units)

TDs US$s % of base- Category Local Foreign Total Local Foreign Total line cost

Construction 2.31 0.79 3.10 5.78 1.98 7.76 26 Equipment 0.21 1.35 1.56 0.52 3.38 3.90 13 Vehicles 0.50 0.37 0.87 1.25 0.91 2.16 7 Computer services 0.31 0.13 0.44 0.77 0.33 1.10 4 Technical assistance, consultant services, scholarships, train- ing and project mangement 0.17 0.39 0.56 0.43 0.98 1.41 5 Incremental salaries 4.28 -- 4.28 10.70 -- 10.70 36 Drugs, contracep. and supplies 0.46 0.57 1.03 1.15 1.43 2.58 9 Total Base Cost 8.24 3.60 11.84 20.60 9.01 29.61 100

Physical contingencies 0.51 0.28 0.79 1.28 0.68 1.96 ( 7) Price contingencies 2.65 0.11 3.76 6.62 2.79 9.41 (32) Total Contingencies 3.16 1.39 4.55 7.90 3.47 11.37 (38)

Grand Total 11.40 4.99 16.39 28.50 12.48 40.98 - 32 - equipment will be of foreign origin and about 90% will be directly imported; (c) all vehicle contracts will be awarded to local suppliers; (d) about 70% of the consultant contracts will be awarded to local firms; and (e) all tech- nical assistance will be provided fr-om foreign sources. The resulting foreign exchange components for the various categories of expenditure are as follows: (i) civil works 26%; (ii) equipment 87%; (iii) vehicles 42%; (iv) computer services 30%; (v) technical assistance, consultant services and scholarships 80%; (vi) training, project management and incremental salaries 0%; and (vii) drugs, contraceptives and supplies 55%.

4.05 Financial feasibility. Recurrent public health expenditures outside hospitals in the project area (estimated at US$6.5 million in 1980, or 4.4% of the total operating budget of MOPH) represent an average of US$2.81 per capita. After completion of the project, recurrent health expenditures outside hospitals in the project area would reach US$4.19 per capita (a total of US$10.5 million). During the past five years, current health expenditure increased, in real terms, by an average of 14% per annum, and amounted to more than 8% of the total recurrent budget (see Annex 4C). Bank projec- tions for 1980-1985 show GDP and total public expenditure, both growing at 6.5% in real terms per annum. Because of the Government's social objectives and its commitment to the expansion of integrated health services in rural areas, recurrent health expenditure can also be expected to grow at the same rate. By 1985, recurrent health expenditure outside hospitals in the project area would then represent 5.2% of the operating budget of the MOPH (compared with 4.4% in 1980). Incremental expenditures generated by the project during its last year would represent less than 2% of MOPH's recurrent budget for that year. This is considered an attainable objective, in view of the Government's stated policy of redressing the balance of expenditure between hospital and peripheral services.

4.06 Financing. The total cost of the project (US$41 million) is to be financed by an IBRD loan of US$12.5 million equivalent which is equal to the estimated foreign exchange cost, and a Government contribution of US$28.5 million equivalent. The loan will be at an annual rate of interest of 9.6% for a period of 17 years, including a grace period of 4 years. The Govern- ment's contribution will finance the local costs (Annex 12).

B. Procurement

4.07 Contracts for civil works amounting to US$9.2 million including physical and price contingencies will, for the most part, be awarded on the basis of competitive bidding following domestic advertising and local proce- dures which are satisfactory to the Bank. These procedures will permit the grouping of contracts and the participation of foreign contractors (the prequalification of contractors would be required by the EBU). It is very unlikely, however, that foreign or even local firms will be attracted by very small contracts for health facilities scattered over isolated rural regions of the country; therefore some of the remodelling work and small isolated - 33 - buildingswill be executed by regional authorities,through force account, not to exceed an aggregate total of US$3.9 million including contingencies. The Bank's prior approval would be required for individual civil works contractsexceeding US$100,000 equivalent.

4.08 To the extent practicable,contracts for furniture, equipmentand vehicles with an estimated total cost of US$7.4 million, including contin- gencies,will be grouped in packages of not less than US$50,000 equivalent. Contracts in excess of US$50,000 will be awarded on the basis of international competitivebidding in accordancewith Bank Guidelines for Procurement. Contracts of less than US$50,000 equivalent,expected to total about US$0.5 million, will be awarded on the basis of competitivebidding advertised locally in accordancewith local procedures satisfactoryto the Bank. The likely size of bid packages for equipmentand vehicles is projected to be about US$300,000. For bid evaluationpurposes, a 15 percent margin of preference,or the actual customs duties, whichever is lower, would be allowed for equipment, furniture,vehicles and materials manufacturedin Tunisia.

4.09 The coordinatingunit (see para. 5.01) will be responsiblefor schedulingall project procurement. Under the supervisionof the Secretary General of the MOPH, the Equipment and Building Unit (EBU) will conduct the procurementof the construction,equipment and vehicles. The EBU has the appropriateexpertise and will coordinatethe procurementwith the Ministry of Equipment and regional authoritiesas required.

C. Disbursement

4.10 The loan would be disbursed to meet:

(a) 40% of the cost of civil works;

(b) 100% of the foreign cost of directly imported equipment, furniture,vehicles and materials or 50% if purchased locally ("off-the-shelf"),and 100% of the ex-factory price of locally manufacturedequipment and vehicles;

(c) 100% of the cost of technicalassistance and scholarships, training and incrementalcosts of internal travel of project management staff; and

(d) 60% of computer services.

4.11 Disbursementswill be made on the basis of full documentation, except for: (i) civil works on force account, and (ii) expenditurefor local training and project management,which would be made against certificatesof expenditure,the documentationfor which would not be submitted to the Bank, but retained by the Government for audit and for inspection by project review missions. No disbursementswould be made against drugs, contraceptivesand other supplies. A schedule of disbursementof the Bank loan is presentedin Annex 12 E. - 34 -

D. Audit

4.12 The accounting department of the MOPH, whose procedures are adequate, will keep separete accounts for the purposes of the project. Project accounts (includingcertificates of expenditure)will be regularlyaudited by the Directoratefor Financial Control of the Ministry Planning and Finance whose procedures are satisfactoryto the Bank. During negotiations,assurances were obtained that project accounts will be audited annually and that certified copies of these accounts, together with audit reports will be forwarded to the Bank not later than six months after the end of the Government fiscal year. Assuranceswere also obtained that certificatesof expenditurewould be audited internallyat least once every six months, and that the relevant certificatesand audit reports will be retained by the MOPH Ior examinationby Bank review missions. These reports would show, inter alia, that the funds withdrawn were used for the purposes intended, the goods had been received, work performedand that payments had been made.

V. PROJECT ORGANIZATIONAND MANAGEMENT

A. Coordination

5.01 The MOPH will set up a special unit attached to the Ministerial Cabinet to coordinate the project. The unit will report directly to a senior staff of the Cabinet of the MOPH, who will be appointed project coordinator. It will be staffed by a full-time project administrator,recruited from senior MOPH staff, an accountant and support staff. The Project CoordinationUnit will: (a) coordinate all project activities; (b) identify and take steps to ensure prompt anndefficient implementation;(c) monitor project progress and expendituresand arrange for the audit of project accounts;cnd (d) maintain contact with the Bank. Before negotiations,the Government establishedthe project coordiationunit and appointed the project coordinatorand the project administrator. During negotiations,assurances were obtained that the coordi- nating unit properly staffed and vested with adequate powers will operate through the closing date of the project, and agreementwas reached regarding the terms of reference of the administrator.

5.02 An Advisory Committee led by the Minister.ofPublic Health will be set up to help to ensure that health, family planning and nutrition services are properly integrated. In addition to senior MOPElstaff, the commitee will include the heads of ONPFP, INNTA, INE, CRFP, t:hetwo Medical Schools and representativesof the ministries of Social Affairs, Education and Equipment. Annex 13 shows how the project would be organized. Assurances were obtained during negotiationsthat the Health Advisory Committee will be set up before March 31, 1982. - 35 -

B. Implementation

5.03 Project activities will be carried out by various MOPH Directorates and other Government Agencies, as indicated below:

Directorate/Agency Activity

- Health Advisory Committee - Health, Population and Nutrition Policy

- Project Coordinating Unit - Project coordination and imple- (Project coordinator) mentation -with DBHS - Mid-term evaluation

- Director Basic Health Services - Strengthening peripheral services - Project monitoring and evaluation - Preparation of plan to extend new system to the rest of the country

-with ONPFP, INNTA, INE - Integration of field personnel and activities - Communicationsprograms -with CRFP - Studies and applied research program

- Studies and Planning Directorate - MIS data interpretation and analysis -with CNI - MIS programming and data processing

- Center for Pedagogical Research - Training and Training -with Health Training Unit (MOPH) - Curricula design -with ONPFP, INNTA, INE - Retraining and upgrading programs

- Equipment and Building Unit - Construction and remodelling program - with Ministry of Equipment - Procurement and regional authorities

- Regional Directors (BHS) - Peripheral services delivery - Activity, performance and impact data

Flow and bar charts of project implementation schedules appear in Annexes 9A, 9B and 9C. - 36 -

5.04 Under the supervision of the Secretary General of t:heMOPH, the Studies and Planning Directorate (SPD) would be responsible for implementing the Management Information System (MIS) and making the necessary arrange- ments for computer services with the National Computer Center (CNI). The SPD will be assisted by an MIS specialist and the statisticians assigned to each of the eight governorates; it would ensure the prompt. processing of data for project monitoring and evaluation. During negotiations, assurances were obtained that the contract with the CNI will be concluded by March 31, 1982 under terms satisfactory to the Bank.

5.05 The CRFP, in conjunction with the Health Training Unit of the MOPH, will be responsible for adapting the curricula of paramedical. schools to the Government's new health policy, and for retraining the teachErs. The Director of the CRFP would organize and supervise the retraining of MCIPH personnel in the eight governorates (see Annex 9 B.) The ONPFP, the INNTA and the INE would take part in the retraining program. The Administration and Finance Directorate of the MOPH would be responsible for the training of the middle- level managers and for the selection of scholarship candidates. The timetable for the training programs was reviewed and agreed upon during negotiations.

5.06 Under the supervision of the DBHS, the Health Training Unit of the MOPH will be responsible for coordinating the health educaticn programs of the country's principal health agencies, and for improving the quality and effectivenes of the programs.

5.07 The DBHS will have the overall responsibility for the strengthening of primary health care under the project. To this end the ONPFP, the INNTA and the INE would ensure that their field staffs and activities in the project area are integrated with those of the MOPH. To attract Tunisian doctors to serve in rural areas the MOPH has agreed to set up a commission to determine what incentives should be offered. The commission has been instructed to submit its recommendations before December 1981.

5.08 The MOPH and regional authorities have started to select and acquire sites for the new health facilities in locations chosen on the basis of dis- tribution of population, accessibility, and the availability of safe water and electricity.

5.09 The Equipment and Building Unit (EBU) of the MOPH will be respon- sible for the supervision of the construction and remodeling program and for the maintenance of MOPH facilities. The EBU, which has been recently rein- forced and now has three architects and eight draftsmen, has actively partici- pated in selection of locations for new health facilities. The EBU will prepare the working drawings, equipment lists and bidding documents for the project facilities. The project would provide further reinforcement for the EBU in the form of consultant architectural services (4 man-years) and two construction supervisors (6 man-years). The timetable for the construction program and the supply of project-financed equipment and vehicles was reviewed and agreed upon during negotiations. - 37 -

5.10 The Project Coordinator will be responsible for monitoring and evaluating the progress of the project and conducting a mid-term project review. The SPD and the eight RDHs will be responsible for the prompt proces- sing of the data necessary for the monitoring and evaluation of the project. The project will provide for incremental cost of internal travel by project management staff; this is considered necessary because of Government's low ceiling on travel allocations which might adversely affect project management and field supervision.

5.11 Based upon the mid-term evaluation of the project and the applied research program, the MOPH will prepare a plan to extend the integrated health delivery system to the whole country. The plan preparation will be undertaken under the provision of the DBHS. The Director of the CRFP will select the consultants for the implementation of the research program and prepare their terms of reference in consultation with the Bank; he will also oversee the studies and applied research program.

C. Programming and Budgeting

5.12 In each governorate, the RDHs will prepare: (a) quarterly work programs; and (b) annual budget proposals for review and consolidation by the Project Coordinator and the DBHS. After the program has been approved by the Health Advisory Committee, the Project Coordinating Unit would notify regional authorities and excuting agencies accordingly, and forward the approved pro- gram to the Administration and Finance Directorate of the MOPH for incorpora- tion in the annual budget. Within 30 days of budget approval, the Project Coordinator would notify the departments and agencies concerned of the approved work programs and budgets. The flow of funds would follow established Govern- ment procedures.

D. Project Monitoring and Evaluation

5.13 Regular monitoring and evaluation would be based on comparisons with the first (baseline) year of operations. The Government considered the possibility of undertaking a pre-project baseline survey, or monitoring a control population outside the project area. With Bank concurrence, it decided against both possibilities because of prohibitive costs (a baseline survey would have cost at least US$0.5 million), technical difficulties and, most serious, manpower implications.

5.14 Physical and financial progress will be monitored by the Project Coordination Unit by comparing the established quarterly targets with quarterly status reports from EBU and the RDH in each project governorate.

5.15 By providing systematic and timely data about project activity in the eight governorates, the MIS would promote the speedy identification and correction of problems. The MIS would rely on activity, performance and impact indicators compiled monthly by health supervisors at dispensaries and consoli- - 38 - dated quarterly by the governorate statistician,who would then forward the informationto Tunis for analysis (See Annex 8 A). The specific indicators would include:

(a) activity levels

(1) number of patients, total and new;

(2) number of women whose pregnancy becomes known before the fifth month;.

(3) number of pregnant women benefittingfrom prenatal care;

(4) number of women undergoing prenatal antitetanus inoculation;

(5) number of hospital deliveries;

(6) new family planning acceptors;

(7) number of attended births; and

(8) proportion of infants followed during postnatal period

(b) Outreach and performance

(1) prevalence rate of family planning acceptors/numberof eligible couples;

(2) number of cases of acute child diarrhoeawith dehydration/ total number of child diarrhoea cases reported;

(3) number of preschool children gaining weight normally/ total number of preschool children weighed;

(4) number and type of child inoculationsbegun/total number of eligible children;

(5) number of children completingimmunization series/total number of children registeredfor immunizationseries;

(6). number of persons receiving TB therapy/totalnumber of, TB cases reported;

(7) total number and type of communicablediseases reported.

(c) Impact

(1) number of stillbirths;

(2) number of post-partummaternal deaths; - 39 -

(3) number of deaths of children under five years of age by age category;

(4) number and types of new cases of diseases preventableby immunization;

(5) age specific fertility rates.

5.16 The MIS would also collect and analyze data on recurrentcosts of the dispensary and outreach parts of the health system in project areas in order to disaggregatethe MOPH budget to permit specific provision for financing the services placed under the authority of the DBHS. These data would also make it possible to assess alternativeunit costs for various services provided at the peripheral level.

5.17 Data would be collected both in dispensariesand by visiting nurses whose registerswould record births, deaths and pregnancies in the estimated 200 households in each assigned community. Supervisory staff would check these registers periodicallyfor completenessand at random for accuracy.

5.18 The project coordinatorand the DBHS will conduct a mid-term evaluation of the project, focusing on the impact of the health policy, with particularemphasis on the reduction of morbidity, mortality and fertility and cost-effectivenessat the periphery. The evaluationwill also include the functioningof the new institutionalset-up at the governorate level, budget allocationsfor basic health services, logistics,maintenance and data collection for the MIS. The mid-term review would provide an opportunity to adjust project targets in the light of the experience gained during the first two and a half years of project implementation. During negotiations, assuranceswere obtained that: (a) the mid-term review will be conducted before January 31, 1984, under terms of reference satisfactoryto the Bank, and (b) remedial action, satisfactoryto the Government and the Bank, will be taken accordingly.

VI. JUSTIFICATIONAND RISKS

A. Justification

6.01 The project would assist the government in achievingits objectives of improvinghealth and nutrition standardswhile slowing the rate of popula- tion growth. When fully operational,at 90% coverage,project services would reach about 2.25 million beneficiariesper year, includingmore than 700,000 persons now unserved,mainly in rural areas, by adequate health and family planning measures. In the beneficiariesare included about 315,000 married women of reproductiveage and about 360,000 preschool children. The bulk of project activity would take place in the Northwest and Central regions, where income distributionis relatively uneven and significantproportions of the population live in absolute or relative poverty. By increasing services in these areas, the project thus would assist the government to attain its objective of more equitable income distribution,while meeting basic human needs. - 40 -

6.02 Attempts to quantify the economic impact of improved health con- ditions are limited by methodological difficulties and inadequate data. The project would reduce the number of sick days and thereby contribute to increased productivity. Although the exact amount cannot be calculated, the increase would not have to be great to offset the incremental recurrent costs of the health system supported by the proposed project. The incidence of disease in Tunisia, as in several other countries, correlates with times of peak demand for agricultural labor. Illustrative calculations indicate that if, as a result of better health, each of the projected 600,0C0 full-time workers in the project area would be able to work two extra days each year, they would enjoy annual income gains of about US$4.5 million at minimum daily agricultural wage rates, which would more than cover the $4 million incre- mental operating costs in 1986 of the integrated health system in the project governorates.

6.03 While the planned reduction of the birth-rate from 43 to 36 per thousand in the project governorates is ambitious, it is attainable. Its achievement would be an important contribution to the Government's objective of reducing the crude birth rate for Tunisia from 35/1000 in 1976 to 30/1000 in 1986. Substantial unquantifiable benefits would also accrue from improved child health and lower infant mortality. First, the survival of more children promotes acceptance of family planning, since the parents attain the desired family size earlier. Second, improved child health makes education more effective. Third, the project should help to raise the quality, vigor and productive capacity of the future work force.

B. Risks

6.04 The Government has clearly demonstrated its strong commitment to the integrated health policy, which is also supported by local population, community leaders and young public health physicians actively involved in field operations. For its part, the MOPH has taken important steps during project preparation to improve its administrative and planning capability. Yet the project still faces three main risks. First, as in any large and decentralized venture, effective coordination and implementation may prove difficult to achieve. For that reason, the MOPH is establishing a separate Directorate of Basic Health services whose capabilities will be further reinforced by Project financed technical assistance. The establishment of the Health Advisory Committee chaired by the Health Minister, and the appointment of a project coordinator would promote smooth coordination among the participating agencies and within the Ministry. Further, the lessons learned from the IDA Population project have been taken into account in preparing the present project. The country has a well-developed construction industry, which can manage the civil works proposed under the project. Moreover, adequate supervision of the construction program would be assured through project-financed consultant services. Finally, the technical and managerial feasibility of the proposed project activities has already been proven in Medjez-el-Bab. Nevertheless, sustained Government efforts will be - 41 - required to ensure full cooperation by agencies like the ONPFP and the INNTA, accustomed to a high degree of autonomy, in the integrated delivery of services which they formerly provided separately.

6.05 A second risk is the possibility of lingering resistance to the shift of emphasis to rural areas and preventive medecine. The frequent changes of Health Minister--there have been five since 1975--have hampered continuity of MOPH leadership and enabled part of the medical establishment to resist such changes as decentralization of administration. However that attitude is changing as a result of more than four years of implementation of the integrated policy, particularly in view of the tangible results achieved so far, and the positive reactions from populations concerned.

6.06 A third risk is the historical difficulty of recruiting Tunisian physicians to serve in rural areas. This risk is being offset by the rapidly increasing output of domestic medical graduates, the reversal of the outflow of physicians to other countries, and a leveling off of competing opportuni- ties in the private sector. In addition, the Government has appointed a Commission to report by December 1981 on the incentives necessary to attract physicians to public health posts in rural areas.

VII. Recommendations

7.01 Before negotiations, the Government:

(a) Appointed the project coordinator and the project administrator (para. 5.01);

(b) Designated the Director of Basic Health Services (para. 3.10), and appointed the eight physicians in charge of basic health services in the eight project governorates (para. 3.10).

7.02 During negotiations, the following were reviewed and found satisfactory:

(a) Main topics to be included in the applied research program (para. 3.13);

(b) Revisions to be made to Final architectural designs for health posts, dispensaries and vehicle maintenance workshops (paras. 3.21 and 3.22);

(c) Revised curriculum for the first year of paramedical training (para. 3.40);

(d) Terms of reference of the project administrator (para. 5.01);

(e) Timetable for the training programs (para. 5.05); and

(f) Timetable for the construction program and the supply of project financed equipment and vehicles (para. 5.09). - 42 -

7.03 Assurances were obtained during negotiationsthat:

(a) The terms of reference for consultantsand specialistswill be satisfactoryto the Bank (para. 3.43);

(b) The sites for the four new urban dispensaries(para 3.21), the eight vehicle maintenanceworkshops (para 3.22), and the two regional health education centers (para 3.28) will be acquired before December 31, 1981;

(c) The revision of curricula for the second and third year of paramedicalschools, and the three-year program for high- level technicians,will be completed in time to be introduced at the begining of each academic year, starting in October 1982 (para. 3.40);

(d) Tunisian counterpartswill be appointed before the arrival of the three technical assistance specialists (para. 3.43);

(e) Project accounts for each fiscal year will be audited by the Ministry of Planning and Finance, and that the results of all audits will be forwardedto the Bank not later than six months after the end of the Government fiscal year. Certi ficates of expenditurewill be audited internally at least once every six months, and that the relevant certificatesand audit reports retained by the MOPH for examinationby Bank review missions; these reports will show, inter alia, that the funds withdrawn were used for the purposes intended, the goods had been received,work performed, and that payment had been made (para. 4.12);

(f) The coordinatingunit properly staffed and vested with adequate powers will operate through the closing date of the project (para. 5.01);

(g) The Health Advisory Committee will be set up before March 31, 1982 (para. 5.02); and

(h) The contract with the CNI will be concluded by March131, 1982 under terms satisfactoryto the Bank (para. 5.04);

(i) The mid-term project review will be conducted beforleJanuary 31, 1984 under terms of reference satisfactoryto the Bank and remedial action, satisfactoryto the Government and the Bank will be taken accordingly (para. 5.18).

Condition of Effectiveness

7.04 The appointmentof the Director of Basic Health Services will be a conditionof effectiveness(para. 3.10). - 43 -

A N N E X E S TUNISIA

IA. DEMOGRAPHIC PROFILE: 1966 - 1978 (thousands)

Out (-) Mid-Year Natural Rate Net Rate Estimated Estimated Estimated Estimated Estimated or In (+) Estimated of Increase of Increase Crude Crude Infant Births Deaths Migration Population (%) (%) Birth Rate Death Rate Mortality Rate

1966 206.7 70.1 -19.0 4,583.2 2.98 2.57 45.1 15.3 n.a.

7 197.2 71.1 -21.8 4,694.1 2.68 2.22 42.0 15.1 n.a.

8 198.1 66.6 -21.4 4,801.3 2.76 2.29 41.3 13.9 n.a.

9 205.2 74.8 -36.3 4,903.4 2.66 1.92 41.8 15.3 n.a.

1970 194.1 63.9 -19.6 5,005.8 2.60 2.21 38.8 12.8 124.6

1 188.0 67.6 -33.2 5,104.7 2.36 1.71 36.8 13.2 132.0

2 203.1 54.5 -23.8 5,210.7 2.85 2.39 39.0 10.5 103.0

3 196.7 60.8 -15.3 5,333.4 2.55 2.26 36.9 11.4 110.3

4 194.6 54.7 - 5,463.6 2.56 2.56 35.6 10.0 92.0

5 205.4 55.5 + 6.0 5,611.5 2.67 2.78 36.6 10.0 96.1

6 208.1 50.2 +11.9 5,774.4 2.73 2.94 36.0 8.7 n.a.

7 213.5 47.7 -27.7 5,928.3 2.80 2.33 36.0 8.0 n.a.

8 207.1 48.6 - 2.6 6,075.3 2.61 2.57 34.1 8.0 n.a.

Source: Statistiques Sociales Retrospectives - Ministere Du Plan - Mars 1980

H- .. -45- ANNEX 1 B,C 1B.- INCIDENCE OF NOTIFIABLE DISEASES

1969 - 1970 - 1971 Rate Per Diseases Number of Cases 100,000 Inhabitants 1969 1970 1971 1969 1970 1971

Tuberculosis ---- 1,786 1,979 ---- 34.8 37.7

Typhoid and Paratyphoid 1,511 1,171 978 30.1 22.8 18.7

Hepatitis 1,033 1,290 1,149 21.0 25.1 21.9

Syphilis 251 1,124 1,034 5.0 21.9 19.7

Meningitis 167 162 403 3.4 3.2 7.7

Dysentery 117 231 219 2.3 4.5 4.2

Hydatic cysts 80 98 92 1.6 1.9 1.7

Poliomyclitis 77 8 101 1.5 0.2 1.9

Diptheria 57 54 48 1.3 1.1 0.9

Typhus 51 30 47 1.0 0.6 0.9

Tetanus 26 23 48 0.5 0.5 0.9

Leprosy 22 22 32 0.4 0.6 0.6

Rabies 48 14 5 1.0 0.3 0.1

Malaria 467 93 100 9.3 1.8 1.9

Cholera 0 27 0 0.0 0.5 0.0 Source: Ministry of Public Health

1C. INFANT MORTALITY IN HOSPITALS BY MAJOR CAUSE, 1972

Gastro- Respiratory- intestinal pulmonary Age (in months) diseases diseases Measles

0-1 117 197 160 1-6 1,230 586 n.a. 6-12 750 628 n.a. 12-24 200 515 123 Mortality rate (in % of hospital admission) 25.9 19.7 18.4

Source: Based on a study by the National Childrens Institute in 1972, quoted from Institut national de nutrition et de technologie alimentaire, Premier Rapport Annuel 1978, p. 125. ANNEX 1 D, E

-46-

TUNISIA

11 AGE-SPECIFIC FERTILITY RATES, 1976 AND 20Co

Age Groups 1976 Rate Expected Rate-2000

15-19 38.5 22 20-24 200.8 104 25-29 294.5 156 30-34 282.3 108 35-39 190.2 58 40-44 95.2 28 45-49 25.4 2

Total Fertility Rate 155.1 86.5

Source: Republique Tunisienne, Ministere de La Sante Publique, Projet Demographique, 1980-1986

TUNIS IA

IE TOTAL BIRTHS TO BE AVERTED, 1980-1987

Year 1980 1981 1982 1983 1984 1985 1986 1987

Contraceptive Methods 50,950 51,901 51,413 50,257 47,995 45,348 44,796 44,076

Abortions 12,375 11,250 10,687 9,862 8,250 6,825 8,250 8,100

Total 63,325 63,151 62,100 60,119 56,245 52,173 53,046 52,176

Source: Republique Tunisienne, Ministere de La Sante Publique, Prcjet Demographique, 1980-1986 1F. Family Planning Indicators

1966 1972 1973 1974 1975 1976 1977 1978

No. of Consultations 41,517 - 273,156 302,015 351,322 429,891 500,957 527,501

No. Practicing F.P. 41,517 246,675 241,335 256,984 289,351 346,351 397,834 397,682

New Acceptors, of which: 16,176 43,665 43,840 50,901 58,052 75,323 86,021 81,149

IUD 12,077 13,250 16,790 19,084 17,307 20,830 23,879 26,273 Pill 350 12,026 11,194 10,795 16,310 25,987 27,567 27,017 Tubal Ligation 766 2,453 4,964 10,757 9,896 8,269 7,987 8,832 Social Abortion 1,326 4,621 6,547 14.427 16,000 20,341 21,162 20,999

Source: ONPFP IG - Impact of the Family PlanningProgram

1975 1976 1977 1978 1979 NFPP (2) Total (3) NFPP (2) Total (3) NFPP (2) Total (3) NFPP (2) Total (3) NFPP (2) Total (3)

No. ProtectedWomen 77,959 88,328 94,294 107,163 117,006 140,976 131,165 159,980 137,427 180,878

PrevalenceRate (1) 10.06% 11.5% 11.75% 13.5% 14.54% 17.5% 16.07. 19.4% 16.2% 21.3%

Births to be Averted 26,250 - 34,350 - 45,000 - 52,000 60,000 63,084 72,800

Averted Births 29,720 37,720 35,578 38,800 44,508 52,750 48,639 58,092 50,106 63,643

Crude Birth Rate 36.2% 36.4% 34.8% 33.9% n.a. oo

FertilityRate (15-44) 176% 176% 1667 161% n.a.

FertilityRate (15-49) 1607 160% 152% 146% n.a.

FertilityRate (15-54) 150% 149% 141% 136% n.a.

(1) For 100 marriedwomen of reproductiveage (15-49) (2) NationalFamily PlanningProgram (ONPFP) (3) Includingprivate sector

Source: ONPFP -49-

TUNISIA 2A. - MINISTRY OF HEALTH ORGANIZATIONAL CHART ANNEX 2 A (May 1980)

HdeothH tt

I | g g gl I I I

Healthren

Roth ~ R

|ondooba Snosno Sfao Gafta IMedical Regions)

World h ak - 22549 -50- ANNEX 2 B 2B. ORGANIZATIONOF REGIONAL SERVICES

Gouvernorat1980 Health Regions 1980 Medical Regions

(18) (24) (6)

Tunis Tunis Tunis

Zaghouan Zaghouan Tunis Sud.

Bizerte Bizerte Menzel Bourgiba

Nabeul Nabeul Menzil Temine

Jendouba Jendouba Jendouba

Beja Beja Medjez el Bab

Le Kef Le Kef

Siliana Siliana

Kasserine Kasserine Gafsa

Sidi Bouzid Sidi Bouzid

Gafsa Gafsa Tozeur Metlaoui

Sousse Sousse Sousse

Mahdia Mahdia

Monastir Monastir

Kairouan Kairouan

Sfax Sfax Sfax

Gabes Gabes

Medenine Medenine Djerba ANNEX 3 A -51-

TONISIA

3A. EstimLtcs of Total and Communal Population in Areas covered by the Project (in 1980 - per thousand inhabitants)

TOTAL COMMUNAL NON-COIMUNAL (urban) No % of Total

Region Sousse 1,185.0 572.3 612.7 51.7

G. Sousse 293.2 207.6 85.6 29.2 G. Monastir 256.4 197.4 59.0 23.0 G. Mahdia 249.1 83.9 165.1 66.3 G. Kairouan 386.3 83.4 302.9 78.4

Region Jendouba 840.4 175.7 664.7 79.1

G. Jendouba 323.0 47.8 275.2 85.2 G. Le Kef 249.7 59.4 190.3 76.2 G. Beja 267.7 68.5 199.2 74.4

G. Zaghouan 231.0 50.8 180.2 78.0

TOTAL 2,256.4 798.8 1,457.6 64.6

Tunisia 6,318.0 3,001.0 3,317.0 52.5

Source: Based on "Projections de la population tunisienne par delegation, sexe, age et annee: 1975-1986" (ONPFP - Janvier 1979), and ratios from the 1975 Census. TUNISIA

3B Doctors and Hospital Beds in the Project Area (1980)

------DOCTORS------…-- Private ------Public------Total Population ----- Hospital Beds----- of which per population per No. expatriates doctor No. hospital bed

Region Sousse 50 237 92 287 4A,29 1,865 635

G. Sousse 32 110 33 142 2,065 803 365 G. Monastir 10 53 24 63 4,070 346 741 G. Mahdia 4 29 17 33 7,548 216 1,153 G. Kairouan 4 45 18 49 7,884 500 773

Region Jendouba 23 98 65 121 6,945 1,514 555

G. Jendouba 5 28 27 33 9,788 432 748 G. Le Kef 7 39 21 46 5,428 606 412 G. Beja 11 31 17 42 6,374 476 562

G. Zaghouan 5 16 6 21 11,000 90 2.567

TOTAL 78 351 163 429 5,260 3,469 650 ..~ ~ ~ ~ ~ - in m.m mmm.__mm *- -- *- n

Tunis 218 545 ... 763 1,463 5,506-/ 203

Tunisia 401 1,331 454 1,732 3,648 13,3581/ 473

1/ 1979

Source: MOPH-SPD 'IltU IJ1

3C Rego1nal llutributIon or llealth Facitlities 1980

1/ iReglon Region Couv. Project Tunisia- Souuse 1to,iastlr Mahdtlla KtIrotigati Somiuve JerIdoub)a Le Kef Ba#J Jendouba Zaghouan Area

Institutes, specialized and general hioiiptaJIs 18 1 - I - - - - - 1

Regional lIospitals 20 - 1 I 1 3 1 1 1 3 1 L

Local hospitals 49 1 3 2 4 10 4 3 2 9 2 21

HCHcenters 110 4 6 5 I 1f6 5 5 6 16 4 36

No. of hosp. beds 13,358 803 346 216 500 1,865 432 606 476 1,514 90 3,469

Urban dtspen8aries 85 6 3 4 5 18 1 1 5 7 - 25

Rural dispenaaries 503 36 28 31 23 118 26 14 21 61 22 201

Health roons 126 1 fi 15 5 27 2 20 7 29 5 61_

No. of rural persons per rural disp. 6.594 23,781 2,107 5,329 13,170 51192 10,585 13,593 9,486 10.897 8,191 7,252

1/ 1979

Source: I.p ANNEX 3 D

-54-

3D -TUNISIA: Effective Protection Prevalence(EP]?) for Married Women of Reproductive Age ('MWRA) Aged 15-49, in 1979. National FamiLy Planning Program.

MWRA EPP Prevalence rate

- Sousse 39952 7427 18.59 _ Monastir 32393 5873 18.13 - Mahdia 34410 4762 13.84 - Kairouan 53398 3802 7.12 - Jendouba 48980 8944 18.26 - Le Kef 34183 8556 25.03 - Beja 36061 8698 24.12 - Zaghouan 30928 4095 13.24

- Total Project area 310305 52157 16.81

- TUNISIA 878795 141925 16.15

Source: ONPFP. ANNEX 3 E

TUNISIA 3E REGIONAL AND SKILL DISTRIBUTIONOF PARAMEDICAL PERSONNEL (June 1979'

Specialized Auxiliary Technicians Midwives nurses Nurses health workers Total

Tunisia 209 553 1.1234 4072 4,365 10,433

Region Sousse 28 122 200 791 856 1,997

Sousse 13 53 114 348 246 774 Monastir 5 28 43 153 220 449 Mahdia 3 18 17 124 120 282 Kairouan 7 23 26 166 270 492

Region Jendouba 7 46 49 302 509 913

Jendouba 1 14 9 72 188 284 Le Kef -1 15 13 89 173 291 Beia 5 17 27 141 148 338

Gouv. Zaghouan - 10 3 51 71 135

Prolect Area 35 178 252 1,144 1,436 3,045

Source: MOPH-SPD -56- ANNEX 3 F

3F. ESTIMATED NUMBER OF PARAMEDICALSASSIGNED OUTSIDE HOSPITALS IN THE PROJECT AREA (1980)

Sousse Jendouba Zaghouan Total

- High level technicians and specialized nurses 20 30 - 50

- Nurses 240 120 50 410

- Auxiliary health workers 310 190 60 560

- Unskilled workers 70 150 20 240

Total 640 490 130 1.260

Source: MOPH-SPD -57- ANNEX 3 G

TUNISIA

3G Graduates from Para-medicalSchools

1975/76 1976/77 1977/78 1978/79 1979/801-

Auxiliary health workers 102 727 568 367 248

Nurses 493 437 635 594 507

Laboratory assistants 84 64 - 72 98

Pharmacy assistants 30 15 - 48 45

Specializednurses 155 222 13 130 202

Medical secretaries 16 20 17 13 15

High level technicians - - 281 345 450 (of which obstetrics) (97) (96) (98)

1/ estimates

Source: MOPH TUNISIA

4A. DISTRIBUTIONOF ANNUAL ALLOCATION, BY TYPE OF INSTITUTIONS (ALLOCATED BUDGETS "A" AND COLTEC'TED FEES "F") (in thousand Tunisian dinars)

1973 1974 1975 1976 1977 1978 1979

Institutesand universityhospitals T 9.617 11,324 13.140 14.518 16,49'3 A .. .. 12,117 14,079 16,065 F .. .. 1,023 439 434 ) Non-universityhospitals ) 21,515 . T . 652 719 816 940 1,009 ) 20,919 25,707 A .. .. 769 906 965 596 F .. 47 34 44

Regional hospitals T 4.2S0 5,220 6.244 7,301 7 994 10,740 A ., ., 5,711 7,044 7,720 10,413 12,341 F .. 533 257 274 327 Paramedical schools fT i 476 528 608 713 798 1il6116 A .. .. 604 710 795 1,110 1,368 ao F .. .. 4 3 3 6 .. Local hospitals T 1.748 2.017 ..2.415 ,75 27574 3.095 A .. .. 2,216 2,658 2,484 2,992 3,740 F . .. .. 199 93 90 103 Dispensaries T 85 96 114 144 133 148 A .. ., 109 141 131 146 214 F .. ., 5 3 2 2.

Total T 16,858 QL23 ' 22,7 , .. A 16,385 17,733 21,f26 25,538 28,1G0 370 43,370 Y .-473 2,173 -1.,8U -829> -84-7 1,034

Source: HOPH-DEP. ANNEX 4 B -59 -

TUNISIA

4B. DISTRIBUTION OF HEALTH CAPITAL EXPENDITURE

(in thousand Tunisian dinars)

1978 1979

Direct investments 9,700 14,093

Health campaigns 465 560

Infrastructures 9,129 13,383

Ongoing projects (8,049) (12,443)

New projects (1,080) ( 940)

Other settlements 106 150

Financial operations 2,950 2,804

Grant to F.P. Office 2,600 2,300

Grant to Balneology Office 350 504

Total capital expenditures 12.650 16.897

National investment budget 368,000 423,000

Source: MOPH-DEP TUNISIA

4C. Evolution and Functional Distribution of Recurrent Public Health Expenditure (allocated Budgets) (in thousand Tunisian dinars)

1971 1972 1973 1974 1975 1976 1977 1978 1979 198nR' X

Salaries & wages 688 838 1,299 1,616 2,204 4,331 5,690 6,879 7,050 44,2031/ 75.1

Travel, missions 52 60 70 96 106 165 173 166 191 211 0.3

Material & administr. 294 268 358 423 450 580 584 510 592 626 1.1

Allocations to hospitals 2/ 3/ / 21.5 and schools 13,175 14,236 16,385 17,733 21,525 25,538 28,158 35,580- 43,370- 12,628

Allocations to economic, cultural & intl. institutions 81 52 53 319 397 644 795 995 1,104 1,195 2.0

Total current health expenditures 14,290 15,454 18,165 20,187 24,682 31,258 35,400 44,130 52,309 58,863 100.0

Total current national budget 154,000 175,000 208,100 247,200 344,600 385,500 '441,500 541,200 625,100 751,600 -

Health (current exp. X) Total 9.3 8.8 8.7 8.2 7.2 8.1 8.0 8.2 8.4 7.8 -

1/ As of 1980, salaries and wages in hospitals and schools are included in the first item. 2/ of which 21,348 for salaries and wages. ! f bh4ih 92 n,Q for salav4^a anA wges.

Source: MOPH-DEP. TUNISIA

HEALTH OBJECTIVES OF THE PROJECT,

Problem Elements of Problem Actions to be Undertaken Expected Benefits

A. General Poor coverage of the health Expansion of primary health care 80-90% coverage and family planning needs services

B. High Rate of Causes of Infant Mortality to 80 per thousand Infant Mortality! 1. gastro-enteritis (about 30%) - intensify health education reduction in infant mortality - improve sanitation of the - from 30% of deaths to 5% enivironment * - nutrition education j earlier diagnosis oral rehydration

2. respiratory diseases/TB - extend BCG - from 457. to 80% of children (about 20%)

3. measles (about 18%) - increase immunization coverage eradication

4. Neonatal tetanus (about 2%) - systematic innoculation of eradication pregnant women

5. malnutrition i - education, distribution of weaning flour, vitamins and iron 6. diptheria, polio and - increase immunization coverage other communicable * to 90% disease (18%)

7. unattended births and - increase number of attended births - reduction of neonatal mortality too frequent pregnancies from 12% to 36%; increase the number: of family planning acceptors; earlie4 - reduction of maternal mortality diagnosis and standardized treatment

C. High Crude 1. Insufficient awareness - intensive family planning education - increased demand Birth Rate 2. insufficient medical support - integration of services , - reduction of CBR from 43 to 36 to family planning programs , per thousand and insufficient coverage of: rural areas - increase prevalence rate from 16 to 25% of MWRA (15-44)

3. high drop-out rate among - improved follow-up and distribution acceptors * of contraceptives in rural areas

D. MorBidity insufficinnt coverage of the - health education - reduction in morbidity associated with Associated with population by the health care most common deseases Most Common delivery system - increase the scope and coverage from about Diseajes , , of immunization campaigns - average coverage increased 50% to about 90%

- epidemic control

- earlier diagnosis and treatment

- improve access to referral system TUNISIA 6A STAFFING PATTERNSAND FUNCTIONS IN THE INTEGRATEDHEALTH DELIVERY SYSTEM

Fili ~~~~~~~~~~~~~~~Time Neo Faciliiy Population Hours of No. Category Commitment Functions Type of Unit Area in M Served Opening

Meeting Place Existing 300-800 3h/day 1 Visitingnurse 3h/week --systematicimmunization of children and F ld/week pregnantwomen, therapeuticfollow-up' i --nutritionaland medical advice. r --inspectionand disinfectionof water sources s --small dressings and simple prescriptions t --councilingon family planning and nutrition L --matters,distributionof contraceptives e --demographicand epidemiologialsurveys. v --periodichousehold visiting. e I Health Posts 30 1500-3000 2h/day 1 Visiting nurse lOh/week Same as above 5d/week + --referral to dispensaryor district hospital a'

Rural Dispensary 100 5000-10000 8h/day 1-3 Visitingnurse 8h/day Same as above 5d/week 2 Dispensarynurse Full time + 1 Maintenance Full time --supervisionof 1st Level S worker --referral to appropriatehospital e 1 Midwife 4h/week --treatmentof infections c 1 General physician 8h/week --treatmentof tuberculosisand other chronic o illnesses n 1 Intern 8h/week -- pre- and postnatal consultations d 1 Nutritionist 4h/week --health, hygiene and nutrition education seminars Le Urban Dispensary 130 5000-20000 8h/day 2-4 Visiting nurse 8h/week ::re errnaltoappropriate hospital v 5d/week 2-3 Dispensarynurse Full time e 1 Maintenance Full time 1 wrker 1 Midwife Bh/week 1 General physician 16h/week 1 Intern 16h/week 1 Nutritionist 8h/week

. District Hospital Existing 30000-60000 9-20 llosnfeal -Sa s ml ab^v 3-6 General 24h/week +- h physician --overall supervisionof 1st and 2nd levels r 3-6 Intern 24h/week --hospitalizationof children and adults d 4-6 Midwives 24h/week --laboratorydiagnosis 1 Public health Full time --x-rays L technician --emergencycare e --sterlizationsand abortions v 1 Nurse super- Full time --dental care e visor --personnel training 1 1 Nutritionist 8h/week --data collectionand processing --reffral to governorate,regional or specialized hospital 63

ANNEX6 B

TUNISIA

6B CLASSIFICATIONOF SERVICES PROVIDEDTHROUGH THE INTEGRATED HEALTHDELIVERY SYSTEM

Preventive Care Control of communicablediseases; health education and medical advice: personal hygiene, prevention of common ailments and diseases; systematic immunization of children and pregnant women; prenatal care; household visiting; collectionof demographicand epidemiological data (incidenceand prevalence of diseases, causes of morbidity and mortality);monitoring and evaluation.

Curative Services Therapeutic follow-upand drug distribution;small dressings and simple prescriptions;treatment of infectious diseases; minor surgical interventions; at the upper echelon, laboratorydiagnosis, X-rays, dental care, emergency care, hospitalization,major surgery; monitoring and evaluation.

Family Planning : Informationand motivation;counseling; distribution of conventionalcontraceptives; under medical super- vision: IUD insertions,sterilization, abortions; monitoring and evaluation;program evaluation.

Nutrition : Nutritional advice and counseling;nutrition education; food preparation demonstrations;weight and height control; diagnosis; distributionof vitamins and food supplements;follow-up of vulnerable groups; monitoring and evaluation.

Hygieneand sanitation: Environmentaleducation; inspection and desinfection of water quality in public and private wells (samples, laboratory tests, chlorinization);controls of cons- truction and maintenance of public latrines; control of waste disposal;monitoring and evaluation. 64

ANNEX 6 C

6C - Additional Manpower Requirements Generated by the Project

Base Year Target Year Increase 1. Health Personnel

- MD Public Health 60 80 20

- High level technicians and specializednurses 50 150 100

- Nurses 410 ) ) 1370 400 - Auxiliary health workers 560 )

- Unskilled workers 240 320 80

Total 1320 1840 600

2. Other Categories

- Directors BHS - 8 8

- Statisticians - 10 10

- Project Administrator - 1 1

- Project Accountant - 1 1

- Full-time Educators - 2 2 .65

ANNEX 7 Health, Population and Nutrition Indicators

Data Presently Collected By: Recommended At Indicator MOPH INS Dispensary Level x No. of pregnant women identified before 5th month No. of pregnant women receiving x any prenatal care No. of women delivered who have x received tet. toxoid No. of deliveries in hospital x x Maternal mortality x x No. of live births x x Percentage of stillbirths x x Post-neonatal infant mortality x x Mortality in age group 1-5 x x years Percentage of live births x followed post-natally Weight gains of infants x Vaccination coverage - x x percentage of live births Prevalence of diseases x preventable by innoculation Incidence of diarrhea with x dehydration (by severity) Incidence of tuberculosis in x childhood Incidence of measles x complication Abnormalities of growth rate x (0-15 weeks) Number of women accepting x contraception by type Number of new patients seen in x health units Percentage of TB patients x completing therapy Percentage bed occupancy - x aux. hospital Mortality - by age x Hospital mortality - by age and x sex Communicable diseases x Incidence of Parasites x Causes of hospital admissions x 66

ANNEX 8 A

8A. ProposedMIS For Tunisian Health System

Peripheral Governorate Regional Regional C.N.I. Central Level Level Hospital Directorate Central Administration - dispensaries (DBHS) Computer - studies and - meeting places + Terminals Terminal planning - health posts statistician - basic health services

Data rigi

Data Control ta/Dta \ Data & 7(ProcessineProcessing) Processing Transfer \ Regional j'\ National Level'. Lev p.1

ResResults

Da/ ' ta j |Data Result Z Results Result s

''VProcessr) Diffusion

Result R Result R esul r Isuction

i' = Terminals

Central Computer - 67 ANNEX8 B

TUNISIA

8B. A MANAGEMENTAND INFORMATIONSYSTEM FOR PERIPHERAL STRUCTURES

Policymaking I

Sources of Information

Service Statistics Special Studies Demographic Regularly Collected and Reports Data

Input Data - Mortality studies - Census figures Program resources - Morbidity studies - Target Populations, etc. i.e. - Family planning - Data from other - Financial services and prevalence ministries - Equipment - Costs - Visiting nurses registers - Manpower - Behavioralpatterns - Supplies - Management - Activity indicators - Impact - Performanceindicators - Impactindicators. E ,S-!'-9 ------1-- - -, L . .~~~~~~~~~~~~~~--

zcc

o ~ ~ w ;hoI _ t

9~~~~~~i i S

°~~ XL TUNISIA 9B - QUARTERLY IMPLEMENTATION SCHEDULE OF PROJECT ACTIVITIES

Project Activities com- 1981 1982 1983 1984 1985 1986 2 pleted 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1

1. Administration Approval of loan Loan effectiveness a Designation of Project Coordinator 0 Appointment Project Administrator 0 Appointment Project Accountant a Appointment 1 architect, 2 supervisors s Appointments CRFP a Recruitment 3 technical advisors Soo 6

2. Management & Evaluation Designation DGBHS e Designation 8 DBHsand statisticians e Contract with CNI of Preparation of new data forms *-e s Programs for primary health care 00 0 Programs for hospital management *e 066 0 0 0 a *0 Project monitoring a 0 * * a 0 Mid-term Project Evaluation fee

3. Training Curricula (TC) Revision TC for 1st year paramedical schools - Completion revision TC paramedical schools 6-- *es 6a *a 6- *a6 TC for paramedical teachers TC for mid-level managers *e- TC for existing health personnel * Health Education curriculum

4. (RE)Training 40 mid-level managers & It, statisticians *-s * 6 60* -6 short-term scholarship *e 06e 45 paramedical teachers in project area *e *a- 80 other paramedical teachers *-- *e- foe 8 health educators *00 health education seminars 00* off *a0 2 retraining teams - 80 physicians *e0 *00 *ao 00* 606 *0e 700 in-service paramedics 0*a *ee 060 6ee 066 *-a 600 060 6*00 360 new paramedics 6 *-o *00e *- Introduction new curriculum e of *06e

5. Studies & Research Design of research program *oa Terms of reference a so 006 Carrying out of studies *....foe off ea *ee *--oe *e000 0*e 066 oe- 00*ee 0 f *s * Extension plan for integrated system _O_ 06_

o - 1 month TUNISIA 9C- SCHEDULE OF IMPLEMENTATION FOR CIVIL-WORKS AND PROCUREMENTOF EQUIPMENT AND VEHICLES

1981 1982 1983 1984 1985 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Construction 1. Paramedical School Remodeling (a) Kairouan, Sousse, Le Kef and Menzel-Bourguiba 000 vvv I +++ 4+4 +4 +44+ (b) Jendouba, Mahdia 000 vvv +++ 2. Health education centers (and remodeling) Jendouba, Sousse (and Tunis) =4= 000 vvv 4-H H-.. 4-H 3. Reinforcement of PMC Infrastructure

Phase 1 --- 000 VVV +4+ 4-H-. +4.- H- Phase 2 ... oo0vvv -H4 -H4 ... 4---4++++4-- I Phase 3 ' ======ooo a vvv 4-H4-H+ I+ a 4H +-F +-- -++ Remodeling and extension of existing dispensaries- 2 urban dispensaries in Tunis 000 vvv ++.. I 4H -4-H

Equipment I i 1. Management and evaluation computer and telecommunications equipment 000 vvv I xxx xxx xxx Office equipment and materials ooo vvv I xxx xxx xxx 2. Strengthening of PMC infrastructure Phase 1 000 VVV I xxx l(x I Phase 2 .= ... ooo vvv xxx xxx Phase 3 ...... 000 V I xxx xxx xxxxxx 3. Training I Equipment for paramedical schools o000 vvv xxx xxx Didactic equipment for retraining courses 000oo VVV xxx xxx 4. Health education I Health education centers --- ooo vvv ! xxx Audio visual equipment -= 000 vvv xxx xxx I Audio visual materials .. ooo vvv a xxx xxx xxx 5. Project administration 000 vvv xx x

Vehicles -" 000 VVV I xxx xxx xxx I ~ I I I II I j K

Legend - design period and preparation of lists o preparation of bidding documents v bidding operations + construction period (includes handing over) x delivery period 71 ANNEX 10

TUNISIA SCHEDULE OF ACCOMODATIONFOR PROJECT FACILITIES

1. Health Post: (1500-2000 persons) Each health post will comprise an office, a waiting room, a small storage area: its net area will not exceed 50 sq/meter.

2. Rural Dispensary: (5000 to 10000 persons) Each rural dispensary will comprise: one waiting room (35 sq/m), one treatmentroom (15 sq/m), two consulting rooms (2 x 15 sq/m), an office (10 sq/m), a storage room and toilet (10 sq/m). The total net area should not exceed 100 sq/m including circulation and partitionwalls.

3. Urban Dispensary: (10000 to 20000 persons) Each urban dispensary will have, in addition to the elements included in the rural dispensary,a third consultationroom, a larger waiting room and a small pharmacy. The total net area should not exceed 155 sq/m.

4. Vehicle Mainte- nance Work Shops: (one in each governorate) Each vehicle mainte- nance shop will comprise a storage room, a small office, a toilet, three covered parking spaces (one with an inspectionpit) and an outside car-washingarea. The total area should not exceed 100 sq/m.

5. Health Education Centers: (one in Jendouba and one in Sousse) Each health education center will comprise: a multipurpose assembly room with audio-visualequipment (60 sq/m), an audio-visualworkshop (15 sq/m), a small printshop (15 sq/m), four offices, one being larger for staff meetings (50 sq/m) and a toilet. The total net area should not exceed 150 sq/m including circular and partitionwalls. TUNISIA

LOCATION AND TYPE OF HEALTH FACILITIES TO BE CONSTRUCTED, EXTENDED OR REMODELED PER GOVERNORATES AND DISTRICTS

… __----____Type Facility…------New Construction--- Health Rural Urban Staff New Room Dispensary Dispensary House Location Replacement Extension Remodeling Location HR RD UD SH

JENDOUBA GOVERNORATE Ghardimaon District Es Sraia 0 0 + Ain Soltane o o + Lahmed o o + Hakim o o + Halima o o + Fej Hassine o o + Zraibia o + Ettaref o + El Fzouei o + Ed Doura o + El Gamara o + Oved Maaden O + Dhailia o o (SH) + + Jendouba District Ettataover o + Satfoura o + Bella Regia o + Ovled Mehaa o + Elkhadra 00 + Ain Krima 0 a + Ain Metouia O a + Oved Ghrid o o + S. aiLra o o T Essaada 0 + El Azima 0 + Jendouba o + Souk Essebet a + Bousalem District Mine Bouaouane 0 + Laanad a + Dzira o + Abderazak 0 --- \->.eTn acili.y- Health Ru Fa c lity - - -. 1f- --- iw Construction--- Room Dispensary Dispensary iouse Location Replacement Extension Remodeling Location lIR RD UD STI

Bousalem District (Continued) Bir Bou Jniba o o + Baldia o o + Hadj Hacime o o + Bolaaba o o + Koudiat o + + Balta ° + Badrouna o + Riabna a + Ain Draham District Homrane 0 0 + Tabarka District Ain Charohara o o + Ain Saida o o + L Ouled Helal o 0 + Bou Hertma o o + Oued Garib o 0 + Rbiaa o 0 + Sidi Said 0 0 + Sidi Rouine a 0 + Hdhil 0 + Dar Fatma o + Majen Essef o + Souk Essebet a + El Magroune o + Malloula o + Ain Draham 0 + Ain Draham 0 + + Houamdia a + + Benimtir + H. Bourguiba o + Khedaina a + Tebainia o + Fernana a + --'Iype Faculity --- New Construction--- Health R1u-al UrL)aa Staff New R-.or. Lispensary Dispensary Hiouse Location Replacement Extension Remodeling Location HR R\D UD SH

LE KEF GOVERNORATE Le Kef District Barnoussa o o + Oved Rmal o + Oved Sweni o + Sers District Sers o + Maria o + Baualia o + Lor Beus o + Elles o + Sers o + Sakiet District Sidi Rabeh o o + + Sidi Youssef 0 + Ain Mazer o + Ain Karma o + Jeradou o + Mabeur District _____ Mabeur o 0 + Sidi Khiar o + Tel el Ghozem 0 + Mellala o + Bahra 0 + Borj el Ifa + Dar-aai Distrct___ IJdLIUI4IL-I-~~ .JL .i .LL .L Danmani 0 + Sidi Baraket (Ghoozi) 0 0 + Meskiat 0 + + Zouarine 0 + 0 x Mdaina o + H Ksour District ___ Ksour 0 + Banou o 0 + …------Type Flcility-…------New Construction--- Ile.a Ith Rural Urbaiin -~, a'w Rc,~~n iopensary Dispcn~ar', House Location R~eplacement Extension Remodeling L~~c~~tix E~FR RD) S'ii

BEJA GOVERNORATE Beja District Bir Houffa a o + Maagoula o o + Mas tout a 0 o + Ain Zbir o + Charchara o + Mkachbia o + Beja (Larbi Zarouk) o + Hamman Sayala o o + + Sidi Smail o + Aim Hnech o + Munchar o + Km 16 o + El Ghira o o + +

Nefta District ______Djebel Dis o o + Jmila o o + Zaga a + Rmnila a + Tebaba o o + + Ouled Salem o o + Ouled Gacem o + Ouchtata a + Amdoune District Rmadhnia ~~~~~~~0 + Beni Malek a + Zahret Mediane 0 0 + t Tarhoumi a a + Zouza ~ 0~~~~~~~~~~~~~~~~~~~~~~~~~~~~FH Zouza a~~~~~~~ o + + Amn Sallem a a + -- Type Facility New Construction--- lHealthi Rural Jrbai' Stsff New Room Li:pensary Dispensary Hiouse Location Replacement Extension Remodeling LOca ln HR RD UD SH

Ksour District (continued) Ouslatia 0 + Louta 0 + Banou o + Ain Ksiba o + Ain Fdhil o + Koudiat Cnair o o + Ksour 0 Malaat Senan _ K. Senan o + Ajerda o + Felta o + Tadserouine Djerissa o + C' Tadjerouine 0 + Menzel Salem o + Djezza 0 + Sidi Mtir O + Garn Halfaya o + ZAGHOUAN GOVERNORATE ZaghouanDistrict Smindja o 0 + Mograne 0 0 + Zriba Hamman o o + O0ed Remal o o + Ain Batria 0 + Ain Lamsarime o + Bov Achir o + Djeradou 0 + Birnchergua Disjrict Ain Askar o 0 + >x Birmcherg Agare o + Boucha 0 + Djebel Ovst 0 + Ain Saf Saf o + Ehnfaid o Birmcnergua o + …-Type Facility- New Construction--- .Health Rural Urban Staff New Room Dispensary Dispensary liouse Location Replacement Extension Remodeling Location HR RD UD SH

Mhamdia District Mhamdia a + Djebel Ressas o + Fouchana o + Sidi Frej o + Mghira Centre o + Mornag District Zaouitmornag 0 0 + Ovrzat 0 + Gret Ville a + Bakhbahka 0 + Ain Ragaoa 0 + Sidi Saad o + Fahs District Sidi Aouidet 0 a + Oum Labouab a + Tlil Salhi o + Draa Jouder a + El Griffet o + Oued el Kebir o + Ben Saidane + Ennadhour District *Saouaf o 0 + Bir Chaouch 0 + Souar o + Himra 0 + Mornaguia District ______-_._-- _____._.____ Sidiali Hattab a a + Hmein o o + Bordj French o 0 + Bir Touil 0 + El Fejja 0 + 0 El Mengoub 0 + Fourna 0 + I' Borj el Amri 0 + Habibia + Bordj French 0 + -Type Facility … ------New Construction--- Health Rural Urban SI:af f New Room Dispensary Dispensary House Location Replacement Extension Remodeling location IIR RD UD SH

Tebourba District Battane + Bir Zitoune 0 + Chaouat + Laroussia 0 + Ain el Karma 0 + El Mansoura 0 + Chouigui + SJUSSE GOVERNORATE Sousse-Nord District Jawhara 0 + Sousse + Kalaa Sghira 0 + Sousse-Sud District- Hedi Chaker 0 + M'Hamed Ali 0 + Ksibet Sousse 0 + Zaouet Sousse 0 + Hammam Sousse District Hammam Sousse 0 + Kalaa Kebira Districtc Essed Chieb 0 + Akouda District Akouda 0 + + + Msaken District Sidi el Heni + Beni Rebiaa o o + Farada o + - Messadine o + - Kroussia 0 + I Mouriddine o + ------Type Facility ------New Construction--- Health Rural Urban Staff New Room liLpensary Dispensary House Location Replacement Extension Remodeling Location HR RD UD SH

Sidi Bou Ali District Sidi Bou Ali 0 + Essid Nord o + Essid Sud 0 + Mhadba o + Enfidna District Takrouna o + Komdar 0 + Chegarnia 0 + Ouled Abdallah 0 + Bechachma o + Ouled el Abed 0 + Menzel Feth 0 + Hicher o + Ouled Ammar + Bir Gedid + + Bouficha District Bouficha 0 + Sidi Khalifa 0 Ain Ranma o + Safha o + Sidi Said + MONASTIR GOVERNORATE Monastir District Stah Jebeur + R6 0 + Skanes a + Jammal District_ Mazdour o + Menzel Kamel 0 + 0D Jammal o + Zeramdine District Zeramdinem e Behi Hassen 0 + Hatem 0 + ------Type Facility ------New Construction--- Health Rural Urban Staff Ne-w Room Dispensary Dispensary llouse Location Replacement Extension Remodeling Location HR RD UD SH

Moknine District Moknine o o + Sidi Bannour o + Amira Fhoul 0 + Ovardanine District ,_ Ovardanine o + Moatmer O + Ksar Helal District Rsar Helal o + Bennane o + Ksibet el Mediouni Boder + Zeramdine District co__ Menzel Hayet o + 0 Mlichet + , Guenada o + Mzaougha o + MAHDIA GOVERNORATE Mahdia District Essed 0 + Mahdia o + Rejiche o + Borj Erras 0 + Jaouaouda o + Hekayma o + Ksour Essaf District Recharcha o + Ghedhabna o + P Si-diAiouane District Oued Beja o o + >x Sidi Alouane o + MONASTIR GOVERNORATE Sidi Alouane District. Zorda o + Saket Khadam o + Essaada 0 + Zelba Ouesti o + …------…Type Facility------New Construction--- Heal.h Rural Urban Staff New .Room Dispensary Dispensary House Location Replacement Extension Remodeling Location UR RD UD SH

El Djem District El Djem o + Sidi Bou Helal 0 + Achachba o + El Djem 0 + Tlalsa a + Ababsa + Boumerdes District Bouhlal Ali a + Boumerdes a + Souassi District Chechimet Sud a + Ouled Chamekh District _ Oued Chamekh a Oued Chamekh o Kharza a + Somar o + Chorbane District - Chorbane a + + Cradha a + Merkez Hached a + Ouled Hanachi a + Chaaba District Saafet + Ouled Abdallah O + Ouled Jaballah 0 + Sidi Abdelaziz a + KAIROUAN GOVERNORATE I Kairouan District 0 Kairouan a + 0 El Khadhra o + El Baten a + t Zaafrana o o + Kairouan (MCH) O + El Ouamria o + … ------…Type Facility------New Construction--- Health Rural Urban Staff New Room Dispensary Dispensary Ilouse Location Replacement Extension Remodeling Location HIR RD UD SH

Sbikha District Sidi Messaoud o ; El Ayem o + Sisseb o + Nasrallah District .--...... Sidi Saad o 0 + Haffouz District Trozza o o + El Ala District __ El Ala o + M'Said a + Ovaslatia District Ain Jloula o a +

a oH- FH TUNISIA HEALTH, FAMILY PLANNING AND NUTRITION PROJECT

12A. COST ESTIMATES PER CATEGORY OF EXPENDITURE * (TD and US$ 000)

Year 1 Year 2 Year 3 Year 4 Year 5 ______TOTAL------Type of Expenditure/Activity Basis of Estimate TD TD TD TD TD TD US$

1. Construction

A. Paramedical schools remodeling Kairouan - additional teaching area to be remodeled facilities or added to 4.0 8.0 12.0 30.0 Sousse - remodeling of offices into teaching facilities " 3.0 7.0 10.0 25.0 Le Kef - remodeling of teaching facilities " 3.0 7.0 10.0 25.0 Menzel-Bourguiba - remodeling of teaching facilities " 2.0 6.0 8.0 20.0 Mahdia - remodeling of existing hospital " 15.0 15.0 30.0 75.0 Jendouba - remodeling of existing hospital " 20.0 20.0 40.0 100.0 OD

Subtotal 12.0 63.0 35.0 110.0 275.0

Local 192.5 Foreign 82.5

B. Health Education Centers Jendouba 180 sq/m X D 100 18.0 18.0 45.0 Sousse " 18.0 18.0 45.0 Tunis (extension and remodeling) area to be remodeled 4.0 _ 4.0 10.0 or added to Subtotal 4.0AQ 36.0 40.0 1..00

Local 70.0 Foreign 30.0 C. Strengthening of BHC infrastructure Jendouba 18 health rooms (HR) unit cost 4.0 72.0 180.0 25 rural dispensaries (RD) " 12.0 300.0 750.0 1 urban dispensary (UD) " 16.0 16.0 40.0 X 26 staff houses (SH) " 6.0 156.0 390.0 1 maintenance shed (MS) " 10.0 10.0 25.0 X remodeling and extension total 62.0 62.0 155.0 0 Subtotal 76.00 180.0 180.0 180.0 616.0 1,540.0 @

* Excluding taxes and duties, estimated at US$2.8 million Year 1 Year 2 Year 3 Year 4 Year 5 --- TOTAL------Type of Expenditure/Activity Basis of Estimate TD TD TD TD TD TD US$

Beja 6 HR Unit cost 4.0 24.0 60.0 7 RD 12.0 84.0 210.0 17 SH 6.0 102.0 255.0 1 MS 10.0 10.0 25.0 remodeling extension total 10.0 10.0 25.0

Subtotal 30.0 70.0 70.0 60.0 230.0 575.0

Le Kef 2 HR Unit cost 4.0 8.0 20.0 4 RD 12.0 48.0 120.0 3 UD 16.0 48.0 120.0 10 SH 6.0 60.0 150.0 1 MS 10.0 10.0 25.0 remodeling and extension total 81.0 81.0 202.5

Subtotal 45.0 70.0 70.0 70.0 255.0 637.5

Zaghouan 31 RR Unit cost 4.0 124.0 310.0 17 RD " 12.0 204.0 510.0 1 UD " 16.0 16.0 40.0 17 SH 6.0 102.0 255.0 1 MS 10.0 10.0 25.0 remodeling and extension total 14.0 14.0 35.0

Subtotal 70.0 130.0 140.0 130.0 470.0 1,175.0

Sousse 8 HR Unit cost 4.0 32.0 80.0 9 RD " 12.0 108.0 270.0 1 UD of 16.0 16.0 40.0 10 SH it 6.0 60.0 150.0 1 MS 10.0 10.0 25.0 remodeling and extension total 60.0 60.0 150.0

Subtotal 46.0 80.0 80R(0 8n 928. 0 715.0

Monastir 2 HR Unit cost 4.0 8.0 20.0 9 RD 12.0 108.0 270.0 y 1 UD " 16.0 16.0 40.0 1 SH 6.0 6.0 15.0 1 MS 10.0 10.0 25.0 remodeling and extension total 37.0 37.0 92.5

Subtotal 35.0 50.0 50.0 50.0 185.0 462.5 Year 1 Year 2 Year 3 Year 4 Year 5 ----- TOTAL----- Type of Expenditure/Activity Basis of Estimate TD TD TD TD TD TD US$

Mahdia 4 HR Unit cost 4.0 16.0 40.0 6 RD " 12.0 72.0 180.0 1 UD t 16.0 16.0 40.0 1 SH " 6.0 6.0 15.0 1 MS * 10.0 10.0 25.0 remodeling and extension Total 56.0 56.0 140.0

Subtotal 26.0 50.0 50.0 50.0 176.0 440.0

Kairouan 5 HR Unit cost 4.0 20.0 50.0 S RD " 12.0 60.0 150.0 40.0 1 UD " 16.0 16.0 6 SH " 6.0 36.0 90.0 1 MS " 10.0 10.0 25.0 remodeling and extension Total 10.0 10.0 25.0 OD

Subtotal 32.0 40.0 40.0 40.0 152.0 380.0 Tunis Construction of two urban dispensaries in Tunis suburbs Unit cost 16.0 16.0 16.0 32.0 80.0

D.Installation of additional D4 per hospital 40.0 44.0 84.0 210.0 equipment in 21 district hospitals

TOTAL CONSTRUCTION 376.0 825.0 775.0 660.0 2,636.0 6,590.0

Local 263.2 577.5 542.5 462.0 1,845.2 4,613.0 Foreign 112.8 247.5 232.5 198.0 790.8 1,977.0

2. Equipment

A. Management and Evaluation 12 computer terminals Unit cost 4.80 28.8 28.8 57.6 144.0 2 calculators " 6.00 6.0 6.0 12.0 30.0 2 wide band data channel telecommunications links " 6.00 6.0 6.0 12.' 30.0 10 calculating machines " 0.16 1.6 1.6 4.0 Office equipment and material Current prices 16.80 8.0 4.0 4.8 16.8 42.0

Subtotal 50.4 44.8 4.8 100.0 250.0 LaD

Local 10.0 25.0 Foreign 90.0 225.0 Year 1 Year 2 Year 3 Year 4 Year 5 ----- TOTAL------Type of Expenditure/Activity Basis of Estimate TD TD TD TD TD TD US$

B. Training Equipment for paramedical schools Current prices Mahdia (itemized list 16.0 16.0 40.0 Jendouba prepared by MOPH) 18.0 18.0 45.0 Kairouan 6.0 6.0 15.0 Sousse 4.0 4.0 10.0 Le Kef 4.0 4.0 10.0 Menzel-Bourguiba 4.0 4.0 10.0

Subtotal 18.0 34.0 52.0 130.0

Local 5.2 13.0 Foreign : 46.8 117.0

Teaching materials for the Current prices 8.0 2.0 2.0 12.0 30.0 retraining of paramedics (lump sum) in the eight governorates

Local 4.2 3.0 X Foreign 10.8 27.0

Subtotal 8.0 20.0 36.0 64.0 160.0

Local 6.4 16.0 57.6 144.0 Foreign

C. HPN Communication health Current prices Education Centers (itemized list) Jendouba 4.0 4.0 10.0 Sousse 4.0 4.0 10.0 Tunis 10.8 10.8 27.0 Production material and Current prices equipment production of 8 films (plus copies) 27.0 60.0 87.0 217.5 purchase of foreign training film 20 units 2.0 3.0 5.0 12.5 production sound slide sets 25 units 2.2 1.0 3.2 8.0 A.,h-'bitit' n materi-al (display boards, cut-outs etc.) 2.0 2.0 2.0 2.0 2.0 10.0 25.0 film teaching brochures 3.8 4.0 7.8 19.5 ' health teaching manuals 8.0 8.0 8.0 8.0 8.0 40.0 100.0 printed material (brochures, posters handbooks, etc.) 20.0 20.0 20.0 20.0 20.0 100.0 250.0 >

Subtotal 65.0 108.8 38.0 30.0 30.0 271.8 679.5

Local 27.2 68.0 Foreign 244.6 611.5 Year 1 Year 2 Year 3 Year 4 Year 5 Total------Type of Expenditure/Activity Basis of Estimate TD TD TD TD TD TD US$

D. Strengthening of basic health care equipment of new facilities (standard list) 76 HR per unit 1.0 76.0 190.0 82 RD " 4.0 328.0 820.0 11 UD 5.0 55.0 137.5 88 SH " 0.5 44.0 110.0 8 MS " 2.0 16.0 40.0 additional medical and professional itemized list 546.0 1,365.0 equipment for existing district worked out with hospitals and dispensaries in the MOPH eight governorates

Subtotal 555.0 260.0 250.0 1,065.0 2X662.5

Local 106.5 266.25 Foreign 958.5 2,396.25

E. Project administration - office equipment lump sum 4.0 4.0 10.0 60

Local .4 1.0 Foreign 3.6 9.0

TOTAL EQUIPMENT 127.4 728.6 338.8 2800 30:0 1,504.8 3,762-0

Local 150.5 376.2 Foreign 1,354.3 3,385.8

3. Vehicles

A. Training 1 minibus for each paramedical school (6) Unit cost 5.0 30.0 30.0 75.0 retraining team 4 small sedans (SS) Unit cost 3.5 14.0 14.0 35.0

Subtotal 44.0 44.0 110.0

Local 22.0 55.0 Foreign 22.0 55.0

B. HPN Communications 2 station wagons Unit cost 8.0 8.0 8.0 16.0 40.0 u, 2 vans with audio visual equipment 13.0 13.0 13.0 26.0 65.0 o 4 small vans with audio visual h equipment 10.0 20.0 20.0 40.0 100.0 Subtotal 41.0 41.0 82.0 205.0 Local 41.0 102.5 Foreign 41.0 102.5 Year 1 Year 2 Year 3 Year 4 Year 5 Total------Type of Expenditure/Activity Basis of Estimate TD TD TD TD TD TD US$

C. Strengthening of basic health care Jendouba 12 WD (4 wheel drive vehicles) Unit cost 9.0 108.0 8 SS (small sedans) " 3.5 28.0 20 MP (mopeds) o 0.35 7.0 Bela 6 WD 9.0 54.0 2 SS " 3.5 7.0 30 MP " 0.35 10.5 Le Kef 8 WD 9.0 72.0 3 AMB (ambulances) " 7.0 21.0 50 MP " 0.35 17.5 Zaghouan 3 WD " 9.0 27.0 4 SS 3.5 14.0 Sousse 8 SS 3.5 28.0 4 AMB 7.0 28.0 OD Monastir 8 SS 3.5 28.0 4 AMB 7.0 28.0 Mahdia 8 SS 3.5 28.0 4 AMB 7.0 28.0 Kairouan 8 SS 3.5 28.0 4 AMB 7.0 28.0

Subtotal 290.0 300.0 590.0 1,475.0

Local 295.0 737.5 Foreign 295.0 737.5

D. Project administration 3 sedans Ur4n-tcost 4 0 19fl 12.0 30.0

Local 6.0 15.0 Foreign 6.0 15.0

TOTAL VEHICLES 387.0 341.0 728.0 1,820.0

Local 364.0 910.0 Foreign 364.0 910.0 Year 1 Year 2 Year 3 Year 4 Year 5 - Total------Type of Expenditure/Activity Basis of Estimate TD TD TD TD TD TD US$

4. Computer services Development of new data forms and programs for use with CNI computer, equipment and services 84.0 88.0 88.0 88.0 88.0 436.0 1,090.0

Local 305.2 763.0 Foreign 130.8 327.0

5. Technical assistance, scholarships abroad and consultant services

A. Management 1 MIS specialist 2 m/y at US$80,000 16.0 32.0 16.0 64.0 160.0 1 health administrator, planner 3 m/y at US$80,000 16.0 32.0 32.0 16.0 96.0 240.0 scholarships ( 6 X 6 m) US$2,000 m/m + travel 10.4 20.8 31.2 78.0 preparation of training module (m/m) 8.0 8.0 20.0 local courses - management (m/m) 6.8 6.8 17.0 local courses - MIS (m/m) 4.0 4.0 10.0 studies and applied research 20.0 40.0 40.0 100.0 250.0 co Subtotal 50.4 115.6 88.0 56.0 310.0 775.0

Local 62.0 155.0 Foreign 248.0 620.0

B. Training curricula 1 health trainer/curriculum 2 m/y at US$70,000 14.0 28.0 14.0 56.0 140.0 designer

Local 11.2 28.0 Foreign 44.8 112.0

C. HPN Communications scholarship (8 X 3 m) US$2,000 m/m + travel 24.0 24.0 60.0 program preparation lump sum 1.8 1.8 4.5

Subtotal 25.8 25.8 64.5

Local 5.16 12.9 Foreign 20.64 51.6 O a

D. Supervision of construction 1 architect (4 m/y) m/y = TD 12,000 12.0 12.0 12.0 12.0 48.0 120.0 >

2 site supervisors ( 2 X 3 m/y) m/y - TD 8,000 16.0 16.0 16.0 48.0 120.0 '0

Subtotal 12.0 28.0 28.0 28.0 96.0 240.0

Local 19.2 48.0 Foreign 76.8 192.0 Year 1 Year 2 Year 3 Year 4 Year 5 - Total----- Type of Expenditure/Activity Basis of Estimate TD TD TD TD TD TD US$

E. Training and project management travel allowances for paramedical school teachers during retraining period D 120 X 45 3.6 1.8 5.4 travel allowances for CRFP personnel 180 days at D 10 0.6 0.6 0.6 1.8 travel allowances for retraining teams 120 weeks at D 40 X 9 14.4 14.4 14.4 43.2 travel allowances for health educators 25 weeks at D 40 X 8 4.0 4.0 8.0 travel allowances for project management D 10 per day/200 per year 2.0 2.0 2.0 2.0 2.0 10.0

Subtotal 20.6 22.8 21.0 2.0 2.0 68.4 171.0

Local 60.4 171.0 Foreign

TOTALTECHNICAL ASSISTANCE, SCHOLARSHIP, CONSULTANTSAND TRAINING AND PROJECT MANAGEMENT 122.8 194.4 151.0 86.0 2.0 556.2 1,390.5

Local 166.0 415.0 Foreign 390.2 975.5

6. Incremental salaries

A. Management and evaluation 8 DBHS M/Y -. OOOD 7.24 57.9 57.9 57.9 57.9 57.9 289.5 10 statisticians M/Y - .OOOD 2.11 21.1 21.1 21.1 21.1 21.1 105.5

Subtotal 79.0 79.0 79.0 79.0 79.0 395.0 987.5

Local 79.0 79.0 79.0 79.0 79.0 395.0 987.5 Foreign - - - _ _ _ _

B. Project administration 1 administrator M/Y = .OOOD 7.2 7.2 7.2 7.2 7.2 7.2 36.0 ; aceur.tant M/Y -. OOOD 2.1 9 1 1 211 2.1 2.1 10.5

Subtotal 9.3 9.3 9.3 9.3 9.3 46.5 116.25

Local 9.3 9.3 9.3 9.3 9.3 46.5 116.25 m Foreign - _ - _ _ _ co o Year 1 Year 2 Year 3 Year 4 Year 5 Total----- Type of Expenditure/Activity TD TD TD TD TD TD US$

C. Training 2 health educators for the CRFP M/Y = .OOOD 7.25 14.5 14.5 14.5 14.5 14.5 72.5 181.25 2 retraining teams 34.4 34.4 34.4 - - 103.2 258.0 stipends to paramedical students D25-10 months per year 72.6 72.6 72.6 72.6 72.6 363.0 907.5 during training period

Subtotal 121.5 121.5 121.5 87.1 87.1 538.7 1,346.75

Local 121.5 121.5 121.5 87.1 87.1 538.7 1,346.75 Foreign ------

D. Strengthening BHC services in the eight governorates salaries of additional health personnel (see working paper) current rates 189.6 399.8 633.6 894.3 1,185.8 3,303.1 8,257.75

Local 189.6 399.8 633.6 894.3 1,185.8 3,303.1 8,257.75 Foreign - - - - -

TOTAL INCREMENTAL SALARIES 399.4 609.6 843.4 1,069.7 1,361.20 4,283.30 10,708.25

Local 399.4 609.6 843.4 1,069.7 1,361.20 4,283.30 10,708.25 Foreign ------

7. Other incremental expenditures 25% of pers. expend. 73.1 125.7 184.2 249.3 322.2 954.5 2,386.25 (drugs, supplies,

Local 40% 29.2 50.3 73.7 99.7 128.9 381.8 954.50 Foreign 60% 43.9 75.4 110.5 149.6 193.3 572.7 1,431.75

0S

10 I-. O I" TUNIS IA 12B- SUMMARYOF BASE COST ESTIMATES PER TYPE OF ACTIVITY AND EXPENDITURE * (TD and US$ thousand)

T.A., Schol. Computer and Consult. Incremental Other Current-- Total------Construction Equipment Vehicle Services Services Salaries Expenditures TD US$

Management 100.0 436.0 310.0 395.0 1,241.0 3,102.5

Local 10.0 305.2 62.0 395.0 772.2 1,930.5 Foreign 90.0 130.8 248.0 468.8 1,172.0

BHC infrastructure 2,486.0 1,065.0 590.0 4,141.0 10,352.5

Local 1,740.2 106.5 295.0 2,141.7 10,352.5 Foreign 745.8 958.5 295.0 1,999.3 4,998.25

BHC service deliver 3,303.1 954.5 4.257.6 10,644.0

Local 3,303.1 381.8 3,684.9 9,212.25 Foreign 572.7 572.7 1,431.75

HPN communications 40.0 271.8 82.0 25.8 419.6 1,049.0

Local 28.0 27.2 41.0 5.2 101.4 253.5 Foreign 12.0 244.6 41.0 20.6 318.2 795.5

Training 110.0 64.0 44.0 56.0 538.7 812.7 2.031.75

Local 77.0 6.4 22.0 11.2 538.7 655.3 1,638.25 Foreign 33.0 57.6 22.0 44.8 157.4 393.50

Prnipnt administration 4.0 12.0 164.4 46.5 226.9 567.25

Local 0.4 6.0 87.6 46.5 140.5 351.25 > Foreign 3.6 6.0 76.8 86.4 216.00

Total TD 2,636.0 1.504.8 728.0 436.0 556.2 4,283.3 954.5 11,098.8 27,747.0

Local 1,845.0 150.5 364.0 305.2 166.0 4,283.3 381.8 7,496.0 11,740.0 Foreign 790.8 1,354.3 364.0 130.8 390.2 572.7 3,602.8 9,007.0

* Excluding taxes and duties estimated at US$2.8 million .93 ANNEX 12 C

TUNISIA 12C. SUMMARYOF BASE COST ESTIMATES PER CATEGORYOF EXPENDITUREPER YEAR* (TD and US$ thousands)

------Total------Year 1 Year 2 Year 3 Year 4 Year 5 TD US$

1. Construction 376.0 825.0 775.0 660.0 -- - 2,636.0 6,590.0

Local 263.2 577.5 542.5 462.0 -- - 1,845.2 4,613.0 Foreign 112.8 247.5 232.5 198.0 -- - 790.8 1,977.0

2. Equipment 127.4 728.6 338.8 280.0 30.0 1,504.8 3,762.0

Local 12.7 72.9 33.9 28.0 3.0 150.5 376.2 Foreign 114.7 655.7 304.9 252.0 27.0 1,354.3 3,385.8

3. Vehicles 387.0 341.0 728.0 1,820.0

Local 193.5 170.5 364.0 910.0 Foreign 193.5 170.5 364.0 910.0

4. Computer services 84.0 88.0 88.0 88.0 88.0 436.0 1,090.0

Local 58.8 61.6 61.6 61.6 61.6 305.2 763.0 Foreign 25.2 26.4 26.4 26.4 26.4 130.8 327.0

5. Technical assistance, scholarship, consultant services and training and pro;jectmanagement 122.8 194.4 151.0 86.0 2.0 556.2 1,390.5

Local 41.1 57.1 47.0 18.8 2.0 166.0 415.0 Foreign 81.7 137.3 104.0 67.2 -- - 390.2 975.5

6. Incremental salaries 399.4 609.6 843.4 1,069.7 1,361.2 4,283.30 10,708.25

Local 399.4 609.6 843.4 1,069.7 1,361.2 4,283.30 10,708.25 Foreign ------

6. Other incremental expenditures (drug, supplies, etc.) 73.1 125.7 184.2 249.3 322.2 954.5 2,386.25

Local 29.2 50.3 73.7 99.7 128.9 381.8 954.5 Foreign 43.9 75.4 110.5 149.6 193.3 572.7 1,431.75

TOTAL 1,569.7 2,912.3 2,380.4 2,433.0 1,803.4 11,098.8 27,747.0

Local 997.9 1,599.5 1,602.1 1,739.8 1,556.7 7,496.0 18,740.0 Foreign 571.8 1,312.8 778.3 693.2 246.7 3,602.8 9,007.0

* Excluding taxes and duties estimated at US$2.8 million - 94 ANNER 12 D

TUNISIA 12D. ESTIMATES OF PHYSICAL CONTINGENCIES AND PRICE ESCALATIONS PER CATEGORYOF EXPENDITURE * (TD and US$ thousand)

-- Total…------Year 1 Year 2 Year 3 Year 4 Year 5 TD *S$

Construction 376.0 825.0 775.0 660.0 2,636.0 6,'90.0

Physical contingencies 10% 37.6 82.5 77.5 66.0 263.6 659.0 ST 413.6 907.5 852.5 726.0 2,899.6 7,,49.0

Pri-e escalation 49.6 195.1 260.9 288.2 793.8 1,'184.5

463.2 1,102.6 1,113.4 1,014.2 3,693.4 9,233.5 324.2 771.8 779.4 710.0 2,585.4 6,463.5

Equipmest 127.4 728.6 338.8 280.0 30.0 1,504.8 3,762.0

Physical contingencies 10% 12.7 72.9 33.9 26.0 3.0 150.5 176.2 ST 140.1 801.5 372.7 306.0 33.0 1,655.3 4,38.2

Price escalation 17.5 185.9 110.1 134.6 17.7 465.8 1,L64.5

157.6 987.4 482.8 442.6 50.7 2,121.1 5,j02.7 15.8 90.7 48.3 44.3 5.0 212.1 ;30.3

Vehicles 387.0 341.0 728.0 1,320.0

Physical contingencies ST 387.0 341.0 728.0 1,320.0

Price escalation 48.4 79.0 127.4 i18.5

435.4 420.0 855.4 2,L38.5 217.7 210.0 427.7 1,269.25

Cenputer cornices 84.0 88.0 88.0 80.0 88.0 436.0 1,390.0

Physical c-ntiegencies 5% 4.2 4,4 4.4 4.4 4.4 21.8 54.5 ST 88.2 92.4 92.4 92.4 92.4 457.8 1,L44.5 Price escalation 8.8 17.4 25.3 33.5 42.3 127.3 318.25

97.0 109.8 117.7 125.9 134.7 585.1 1,362.75 57.0 7A.5 2.74 RA,1 Q4.3 099.6 1,523.9 TechnicaL assistance, cossultant services, scholarship and training and proeict canagement 122.8 194.4 151.0 86.0 2.0 556.2 1,190.5 Physical contingencies 5% 6.1 9.7 7.6 4.3 0.1 27.8 69.5 ST 128.0 204.1 158.6 90.3 2.1 584.0 1,L44.5

Price escalation 12.9 38.4 43.5 32.8 0.9 128.5 321.25

141.8 242.5 202.1 123.1 3.0 712.5 11781.25 28.4 48.5 40.4 24.6 0.6 142.5 136.25

Increoental nalaries 399.4 609.6 843.4 1,069.7 1,361.2 4,283.3 10,708.25

Physical cestingencies 5% 20.0 30.5 42.2 53.5 68.0 214.2 535.50 ST 419.4 640.1 885.6 1,123.2 1,429.2 4,497.5 11,243.75

Price escalation 41.9 120.3 242.6 407.7 654.6 1,467.1 3,667.75

461.3 760.4 1,128.2 1,530.9 2,083.8 5,964.6 14,711.50 461.3 760.4 1,128.2 1,530.9 2,083.8 5,964.6 14,111.50

Other incrne=ntal expenditures 73.1 125.7 184.2 249.3 322.2 954.5 2,386.25

Physical contingencies 5% 3.6 6.3 9.2 12.5 16.1 47.7 119.3 ST 76.7 132.0 193.4 261.8 338.3 1,002.2 2,505.5

Price escalation 7.7 24.8 53.0 95.0 154.9 335.4 838.5

84.4 156.8 246.4 356.8 493.2 1,337.6 3,344.0 33.8 62.7 98.5 142.7 197.3 535.0 1,337.6

Grand Total TD 1,840.7 3,779.5 3,290.6 3,593.5 2,765.4 15,269.70 38,174.2

Local 1,149.1 2,029.0 2,177.2 2,540.6 2,381.0 10.276.90 25,692.3 Fo-eign 691.6 1,750.5 1,113.4 1,052.9 384.4 4,992.8 12,481.9

Total physical contingencies 725.6 1,814.0

Toia price escalations,4. 8632 * EIcluding tasen and dnties estinated at U0$2.8 aillian 3,443.3 8,613.23

Price escalation is compsted an the basis of: (a) annual incrnase rates for each category of enpendit,re, thn esstinted raten for lecal and foreigs casts ar equal; (1) prejent -onpletion by June 30, 1986; (c) estinared prngress nf vork per year; (d) baseline cost pltts physical c-nting-ncies.

1901 1982 1983 1954 1' 05 1936 Loeal Fureign j Local FPreign !Leeal Foreign Local Foreign Local PFeeign Local FPreign

Construction 9% 9% 8% 8% 7X 7X 7% 7% 7Z 71 7% 7% Equipment and vehicles 10% 10% 9% 9% 8% 8% 7% 7% 7% 7% 7% 7% Conputer services 8% 8% 8% 8X 7% 7% 7% 7% 7% 7% 7% 7% Technical assist. 8% 8% 8% 8% 7% 7% 7% 7% 7% 7% 7% 7% Incre-ental expenditures 8% 8% 8% 8Z 7% 7% 7% 7% 7% 7% 7% 7% .95 ANNEX 12 E

TUNISIA

12E. ESTIMATED SCHEDULE OF DISBURSEMENTS

(US$ million)

Disbursements Accumulated Disbursements Undisbursed Ll Year/Quarters per Querter Amount % Balance

82 'tember 30, 1981 0.0 ember 31, 1981 0.0 - 0% 12.50 ch 31, 1982 0.40 0.40 12.10 Le 30, 1982 0.53 0.93 7% 11.57

183 'tember 30, 1982 0.45 1.38 11.12 Lember 31, 1982 0.48 1.86 15% 10.64 ch 31, 1983 0.90 2.76 9.74 Le 30, 1983 1.01 3.77 30% 8.73

'84 'tember 30, 1983 1.10 4.87 7.63 :ember 31, 1983 1.21 6.08 49% 6.42 *ch 31, 1984 0.92 7.00 5.50 Le 30, 1984 0.92 7.92 63% 4.58

185 ,tember 30, 1984 0.72 8.64 3.86 ember 31, 1984 0.72 9.36 75% 3.14 ch 31, 1985 0.62 9.98 2.52 .e 30, 1985 0.63 10.61 85% 1.89

86 tember 30, 1985 0.63 11.24 1.26 ember 31, 1985 0.62 11.86 95% 0.64 ch 31, 1986 0.32 12.18 0.32 .e 30, 1986 0.32 12.50 100% 0.00 96

ANNEX 13

TUNISIA 13. - ORGANIZATION OF PROJECTADMINISTRATION

ONPFP-| |Ministerr~ q |-

I I -| INNTA

I I NE | Health J Cabinet Advisory Committee - Coordinating Unit F-~~~~~~l

Director General - - - of Health Secretary General l l ~~~~~~~I I l~~~~~~~~~~

DBH-S PDU HTU I. SPD EBU AFD

|BEJA LE KE | Jendouba Souse 1KAIROUANMONASTIR MAHDIA

MEDICAL REGIONS

LEGEND: AFO - Administration and Finance Directorate HTU - Health Training Unit CRFP - Center for PedagogicalResearch and Training INE - National Institute for Child Health Care DBHS - Directorate of Basic Health Services INNTA -- National Institute of Nutrition and Food Technology ESU - Equipment and Building Unit ONPFP- National Office of Population and Family Planning PDU - Pharmacy and Drugs Unit SPD - Studies and Planning Unit Directorate

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