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World Bank Document 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
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