UNCLASSIFIED - - I UNITED STATES INTERNATIONAL DEVELOPMENT COOPERATION AGENCY AGENCY FOR INTERNATIONAL DEVELOPMENT WASHINGTON, D. C. 20523 PROJECT PAPER . AMENDMENT NO. 1 I TUNISIA : Rural Comuni ty Heal th 664-0296 JUNE 1981 I UNCLASSIFIED AGENCY FOR INTERNATIONAL OEVSLOPMENT UWtTRD aTATES A. I. 0 MlmmtOM TO TUNlWA FIRST AMENDMEXT PROJECT AUTHORIZATION Name of Country: Re ublic of Name of Project:Rural Community -kizir Health Number of Project: 664-0296 The Rural Community Health Project for the Republic of Tunisia was authorized by the Assistant Administrator for the Near East on September 22, 1977. That authorization. Pursuant to specific redelegation by the Acting Assistant ~dministrator, Bureau for the Near East, is hereby amended as follows: 1. Pursuant to Section 104 of the Foreign Assistance Act of 1961, as amended, I hereby authorize for the Project additional planned obligations of not to exceed Two Million Three Hundred Ninety Thousand U.S. Dollars ($2,390,000) in loan funds (the "Loan Amendment") and One Nillion Two Hundred Forty Thousand U. S. Dollars ($1,240,000) in grant funds (the "Grant Amendment") during FY 1981 subject to the availability of fmds in accordance with the A.I.D. OYBIallotment process, to help in financing foreign exchange and local crrrrency costs for the Project. 2. The second paragraph of the original project authorization is revised by: (a) deleting the first sentence thereof and substituting the following: "The Project is designed to enhance the quality and coverage of health services in four rural provinces of Tunisia, Gafsa, I<asserine, Siliana and Sidi Bouzid; " and (b) deleting from the third sentence thereof "forty (40)" and substituting therefor "sixty (60)." 3. The Project Agreement Amendment(s) which may be negotiated and executed by the Officer(s) to whom such authority is delegated in accordance with A.I.D. regulations and Delegations of Authority shall be subject to the following essential terms, covenants and major conditions, together with such other terms and conditions as A.I.D. may deem appropriate: Interest Rate and Terms of Repayment for the Loan Amendment Tunisia shall repay the Loan Amendment provided in this Amendment in United States Dollars within twenty-five (25) years from the date of first disbursement of the Loan Amendment, including a grace period of not to exceed ten (10) years. Tunisia shall pay to A.I.D. in United States Dollars interest from the date of first disbursement of the Loan Amendment at the rate of (a) two percent (2%) per annum during the first ten (10) years and (b) three percent (3%) per annum thereafter , on the outs tanding disbursed balance of the Loan Auendment and on any due and unpaid interest accrued thereon. 4. I hereby determine in accordance with Section 612(b) of the Act, that : (a) the expenditure of United States Dollars for the procurement of goods and services in Tunisia, as authorized above, is required to fulfill the purposes of this project; (b) the purpose of this project cannot be met effectively through the expenditure of United States owned local currencies for such procurement; and (c) the administrative official approving local cost vouchers may use this determination as the basis for his or her certification as required by Section 612(b) of the Act. 5. The Project Assistance Completion Date for the Project is hereby extended to June 30, 1985. 6. Except as amended hereby, the Authorization shall remain in full force and effect. 1 William F. G&bert . Director uSAID/Tunis, Clearances : CONT : HPP7 :DGibb : 0. I-- ' CGKNCY COA INTLRMATIONAL OeVLLOCMENT bANsAmoN CODE Docu'u~ < h = Add Amendment Number CODE . PROJECT DATA SHEET c - ~lulgc 1 ' 3 - D = Dclcte 2. COUNTRYIEKIITY 3. PROJECT h'UMBER -- -- TUNISIA p64-0296 2 4. BUREAU /OFFICE 5. PROJECT TnLE (mpximurr(,40ckocttm) -- --. - .-- :- NE Rural Community Health - I3l 7 6. PRI~JECTASSISTANCE COMPLETION DATE (PACD) 7. ESTLMATED ATE OF OBLI CATION (Unda 'B." bdow. ens& 1. 2, 3. or 4) -(4) 1 I I i I I I - TOTALS 1 1000 f 3000 1 1240 2390 1 2240 1 5390 10. SECONDARY TECIWICAL- CODES (moximw 6 coder of 3 poririou noch) I 11. SECONDARY PURPOSE CODE - 440 I 1 1 300 12. SL'ECLAL CONCERNS CODES (maximum 7 codu of 4 poririons mch) - A Codc B RW I DEL TECH I I 6. ArnwnC -- I I 13. PROJECT PURPOSE (-'mum 480 cktm) the quality and coverage of primary health care in four rural provinces of central Tunisia; through assistance aimed at restructuring the non-physician component of primary health care and impiementing' * a new system of primary health care delivery in an expanded network of health facilities. I 14. SCHEDULED EVALUATIONS 15. SOURCE/ORICIN OF GOODS AND SERVICES 1 MM YY - nd 10 13181 4 !3%1 d~,OOtb=(S~adh) 16. AMENDMENTS/NATURE OF CHANGE PROPOSED (Thu u pog. 1 of A poga PP Amrrrdmnrt) This amendment extends the project activities into two additional governorates in central Tunisia, and incorporates programmatic improvements recommended in the project evaluation of July 1980. - 4 1 1PDATE DOCUMENT RECEIVED w AJDIW. OR FOR .UDW DO':U- 1'7. APPROVED - MEHTS, DATE OF DISTFUBUI'ION BY William I?.~elabirt .Dne signed W4 DD YY Direztor, USAID)YU~~S lo16 31~18111 - .. .A --% TABLE OF CONTENTS Paqe THE RURAL COMMUNITY HEALTH PROJECT ......................... 1 A . Goal and Purpose.................................... 1 B . Background ........................................ 2 C . Project Synopsis and Progress ....................... 3 PROJECT ELEMENTS UNDER THE RCH PP AMENDMENT ................. 7 A . Health Education ................................... 7 B . Staff Training ................................ 8 1 . Preventive Health Training/Retraining ....... 8 2 . Intern Training ............................. 9 3 . Involvement of Women ........................ 9 4. Continuing Education .. ...................... 10 C . Management Improvement .............................. 10 1 . Management Information System ............... 10 2 . Facility Planning ........................... 10 3 . Staff Lodging ............................... 11 4. Displacement Allowances ..................... 11 U.S. ASSISTANCE ............................................. 12 A . Technical Assistance ................................ 12 B . Training ............................................ 13 1 . Participant Training ........................ 13 2 . Support of In-Country Training .............. 13 C . Technical Assistance Budget (Illustrative).......... 14 D . Capital Assistance .................................. 15 TUNIS IAN PROGRAM CONTRIBUTION PROJECT SCHEDULE AND REVISED FINANZIAL PLAN ................. 19 A . Technical Implementation ............................ 19 B . Capital Implementation .............................. 21 C . Financial Plan ...................................... 21 1 . U.S ......................................... 21 2 . GOT ......................................... 22 VII . PRWECT ISSUES .............................................. 23 A . Social ...............................................23 B . Economic and Financial .............................. 25 C . Manpower ............................................25 VIII . EVALUATION ..................................................27 IX . COORDINATION WITH FOREIGN DONORS & AID-SPONSORED ACTIVITIES . 28 ANNEXES A. Revised Logframe B. Environmental Assessment C . Statutory Checklist D. 611 (e) Certification E. GOT Request for Assistance F. Current Project Obligations & Expenditures G. Assumptions Behind Illustrative Capital Costs RURAL COMMUNITY HEALTH PROJECT (664-0296) A'MENDMENT NO. 1 I. INTRODUCTION This paper describes an amendment in the Rural Community Health Project (664-0296 authorized 11/79) whichwill increase the geographic scope of the project to include Kasserine Governorate and the three northern most delegations of Gafsa Governorate. Currently, the project activity covers only Siliana and Sidi Bouzid Governorates. The focus and purpose of the project remains unchanged from that originally presented in the RCH project dated 8/15/77. The Amendment is consistent with AID'S health policy of supporting rural-based, primary health care programs in order to provide accessible health services of acceptable quality to rural populations that are presently unserved. Based on a Technical Report dated August 1980 prepared under the auspices of USAID (See Annex I), it is recommended that the RCH project be extended to cover Kasserine and Northern Gafsa, thus increasing life of project cost to $7630 million equivalent. THE RURAL COMMUNITY HEALTH PROJECT A. Goal and Purpose The project goal and purpose remain as stated in the approved RCH Project Paper: To improve the quality and coverage of primary care in the pre- dominately rural provinces of central Tunisia through assistance aimed at restructuring the non-physician component of primary health care and operationalizing a new system of primary health care delivery in an expanded network of health facilities. Backqround In 1976 and 1977 the U.S. Agency for International Development and the Government of Tunisia's Ministry of Public Health (MBBH) explored various health project options. This process is out- lined in technical documents entitled: 1. A review of Health Services Development in Tunisia*; 2. A Program Proposal for Integrated Rural Health Services in Siliana and Sidi Bouzid Governorate --Tunisia* ; 3. Design Study 11; Integrated Rural Health Services in Siliana and Sidi Bouzid Provinces --Tunisia*; 4. Architectural Design Study by Susan Christie Shaw; 5. Project Paper Rural