. 4~ 11 _9 ' .

., Document of

- ThecWorld Ban,A

YOR OFFICIAL SE ONLY

Report No. 6679-GU

STAFP APPRAISAL lRT

GVUA

LTS I SERVICES DEVELOPIN PROJECT

Hay 29, 1987

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Population, Health and Nutrition Depatmtent

This doeal as a regukte diuributiou and may be wed by repits odly in the performance oftheir Ockia du i its teps may sot odmwis b diseleW withot WAd Bank abutoriation.

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Cmrrency Unit = Guiea, Franc (Gt)05$1.00 GUOt 410

a" 1 = 0US.00244off 1 Million U 0S 2,439

Metric Syste

January 1 - Decemer 31

AiD3 Africa Developmt BankMI Association Guindeo de Bie.tre Feailiel

(Guins" Asociation for Fmdly Velib1ng)CV? Centre de Fomtion Fdinine (W omeIs Training Center)co CaCitd de Geation (Health Nan_gnt'Coitt*e)C7V C.itd Technique de Coordination

(Technical Coordinating Comittee)DAT Division de l'Administration et ds Finas

(Division of Administrtion and F1in e)-P Division d'Etudew de Pleification et Fonation

(Division of iamins, Trainig and Studies)DS Direction de la SSatd (Directorate of _eltb)USC Helth Mhnagant ComitteeIDA rnternatioual Develquat Associationlee Imforation, Education ad CcanicationIMW tnternational Mobetary FundiWV International Planned Panthood FtedationIRAS Inspection Rdgionale de Ia SatE et des Atfairm Sociales

(Regional Inapectorate of Health and Social Affairs)MCI/VP Meternal and Child Health/tFinly PlanningHIS a n t Info mation Syates i ;fUAS Minist6re de la Santo et db Affaires Soci ales

(Ministry of Health and Social Affairs)NWO No4ovenmnuental OrganizationPPF Project Proparation facilitymR Rsdio-Tdldvision OuindenneSEaS Secretariat d'Etat aux Affairms Sociales

(Secretariat of State for Social Affairs)WlP U.itd de Gestion du Projet (Project M1mt Unit)UWPA United Nations Fund for Population ActiitiesUIIICEF United Nations Children's fundUFIIDO United Nations Industrial Developent OrganizationUSAID United States Agency for International DevelopmtWHO World Health Organizatioo

FOR OffiILAL UR ONLY -

C"Ts ADWU =

nrr : Republic of guinea

wLisi.s : tMinitry of Isalth nd Social Affairs (fB)

t :SR 15.1 ;,i1lion (US$19.7 million oquivalent)

- : 8Staudrd

fte11 t roThe project will suppattgovrznt's efforts to (i)JAi ,1Qdevelop planins and _mnagement capabilities within the

MM and introdce policy nd administrative reform toimprove the qulity and efficiency of basic bohlth /s_vicw, taludig tomitly plmtng; A(i) improve -helth care in the ragion of Middle Ogiiea; (iii)strengthn finacial and operational g t o tieregion of Mddle auinea; and (iv) develop and evaluatecost recovry activities.

ltitgtj : The project will help the Government to establiah apermanent capability for improved health sectorplaning, policy imlementation and coordintion ofexternal asistne. The project will als improve thequality and accessibility of helth and ocial -servicefor about 1.3 million people in Middle Guinea. TSeestablishment of regular program of in-srvice trainingad suprvision of medical and pd pernelwill upgrade their skills and imrove the overallquality of services. Strengtbhing of MCO, nutritionand helth education pgrm, including the prmotionand extension of family plaming sorvices, should reducemorbidity and mortality amg women and children.

This document has a estced distribution'and may be used by recipients only in the performanof their offlcia duties Its contents may not otherwis be diclosed without World Bank authoriaton.

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Nuim : lecaueo this will be the tfit k-ftianced operation iathe helth sector In Guine, there i the risk of dela.in ipl_tation. aoermet's comitment cod theca_petence of the umit set up to coordinateIwlinmntatiou have almbly been effectivelydmstrated by the suaceful and timely completion ofproject pnaratioa. Techical mistan and trainingwill help minimize the risk of delay ed unatisfactoryixplwnmtation. This risk will be further mitigated bythe direct participation of locl authorities andcomimittlie in projact mmngmt and implmntation.Anoher risk in that the cost recvry progr desito mbilise additioal r _sorcs for non-lriedVperatIng Costs ay not succeed. To minidmi this risk,cost revery is limited to curative services includingthe cost of drut, for which the populion bhdm-ntrated a willinss to pWy ad the _mtgemt ofesursm Is being decantrmlised to develop locl

cotrol ud improve manag_nt within each facility.annul evalustion of coat recovey activities sholdasble _nagmet comittee and halth authorities totak timely, corrective action.

Ia1t.aJLua JoL1 For ToaMalmet2d agAm ontat FWO~US* mLli TOW

A. ntiNttIal t t m

1. Strengtheig of mom Suppot fiti. 0.1 - 1.1 1.22. Str of MM techical ftntiams 0.3, 0.8 1.2

subtotal A. 0.5 1.9 2.4

B. Develo,amt of 1mith Sector erMtIm in Middlie

1. Strenenn of Ibnal kith 0.3 0.6 0.9

2. Strghing of Baic Neulth Services 4.8 6.6 10.43. Upgrading Shill. of Oegional Ilth 0.0 0.1 0.1

Personnel4. Improving finacial t d Cost 0.0 0.0 0.1

Rovery

subtotal 3. 8.2 6.3 11.5

C. Project _uasgenunt ed Administration 0.6 1.5 2.1

D. Project Prertion Advanc 0.2 0.7 0.9

Total BDmline Costs 6.4 10.5 16.9

phical Contingecie. 0.6 0.9 1.lPrice Contingenies. 3.7 0.4 4.1

TOTAL PJECT 005 10.8 11.8 22.5

Note: Total. my not add up due to roedint. kttimted project coot renet of taxes and duties frc, which the project would be expt.

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n ~ ~~~~~~~~~48 tOWi Te

DA 7.9 11.8 19.7Gov.tint- 2.0 - 2.0Imficiari.. 0.8 - o.a

Total 10.8 11.8 22.5

Notisted Didbur"_

ms m nso nml FM rm 94midll a

- Anual 2.2k' 3.1 5.0 4.3 2.9 1.8 0.4

- wGlattv 2.2 5.3 10.3 14.6 17.0 19.3 19.7

Ibt ofg Ibh: D. a.

ProJect -let io Date: Jm 30, 1993

~: MI=D 20128 and 201

1/ includes repaymet of I advanm o Of us0.9 milion.

Table gfCotet

Credit md Projeat Smrwy . . . .. *. .**... . . * IDefinitios . . . .....

X1 0* 90009909t 9 0 S 4 , 9 * * 1

II. TEPPUlN ELHAND UUU $207MR**.. 2

A. Populations Nslthad Nutrition Status . . . . . . 2

S. me thyst .......... 31. Orguiizatiom 9 4 9 9 9 0 0 9 0 9 * 9 9 n.. 9 S 32. Lavel .and Typ.f5ervicm o f. .S.. .. .' 3

3. .fwu 4

4. Drug Pfr cue't md Distribution ....'.. . 6

C. elthtihimaod t . ........... ... . . .a

1. cDrtr t .eaditures . . . . . . . . . . . .... 6

3. bxt.wul Assistance ..... .. 8

D. Halith Syatan PewOX *inuaoe- and Constraints . . . 91. P.rforumnc. 9 . 9 * 9 9 0 * 9 * * 0 32. Constraints . ... ....... . . . . .-. 9

This report is based on the findigs of an IDA ubiouaiohich visitedgauIDe in Decombr 1966. lbs aissin um composed of M. Anefor (Mission

a ) B. Sederlof (_in.o_al Analyst), D. Vaillancourt (Operatio_snalyst), D. Jolly (Constant, Public Nmith .asginut Specialist), C.sywr (Caosultant, Health Edation and Cmmications Specialist)* C.

Suftan (Conltsnt, Public Nalth Specialist) and J. Wechter (ConsultaArchitect).

i~~~-v 'I~ ~ ~ ~~~V

S. SectorPUc a 8trte ... .......... 102t * .trtio . . . . . . . . . . . . . . . . .. . ; 122. Nlutrition .23. Population .*. . . . *.99 @940. , . 13

F. DA's Role 13

Irl. P ID * 913

A. Project Objectives ..... . , - 13

Z. Sumwy Project Desoiptio ......... 14

C. Detailed ProjectDincription . 1

1. Institutionsl Delogmt of MM ...... 15a. Stregthening of Mm Suport mtio . . 16b. Strengthesing of 8M Techical mctic. . 17

2. Dee1oi.t of ealth Sector Oprattie icMiddle uia 20a. Strengthning of RIgioaol Health Ne_amt . 20b. Str thing of ami ilth Svice . . . 21C. Vprading Skills of Regional Helth

d. lmprovIg fiacial _ t andcoat Recovery . . . ..4

IV.P3JUOTCOT NDFinm .. ........... . 26

- .-. P... ... 29

VI. Pl m IT 1 34.

VII*P.J? IENEITOD ANO AND A0I*SI 36

I BasicData . . . . . . . . . . . . . . . . . ' 39

2-1 Orgnizational Chart of the Ministry of Hblthand Social Affairs 40

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2-2 Orsgizatiomal Cart of the Secetariat of statemm A In Chwr of 8ial Affairs ....... 41

2-3 Helth XnvestssIt Budget, is--7" 42

3-1 Vital staffing for central MBAs ubitsTo BID tr.t_me undr the Project 43

3-2 Tecdoaul Training Progrm for medical andPerutdic'L Pe1ersoupex in Middle Gue . . . . . 46

3-3 e f ees tor Helth Center Serviceso Be Tested Utr the Project . . .... . 47

3-4 lutited Nate of humuption by Ienficiwissof elth Ceter rug Costs and ComsequetPr_opo IDA Flnacig of Drugs ......... 48

4-1 ySr Account by Project Componet . . . . . . . . 494-2 Project C _oSn by Yer . ............ *504-3 B reekdo of umry hAounts .... . . . . 814-4 for lstiamtl Project costs . . . . . . . . 824-6 Dotils of Inar_metal Rncurret Costs

fw Yew Six of the Project . . . . . . . . . . 83

5-1 Projct Orgaixstion Scheme .W....878-2 Sumwyof Tecbiclh Aistanc . . . . . . 885-3 s7ry of FlO hips 898-4 ImpleatationSchedules .60

-6. Disburant. Plan . . . . . . . . . . . . . . 638-6 Esid th:timated ofDibarnits . . . . . .- . 64

Selected Documents aud D%ta Availuale to the Project file . . 66MAPS: IID 20128 and 20129

.

Adult Literacy-Rate :,,,The percentage of persons age 15 and over who.can read and write.

Chil,d Death Rate;, a Tenmber oif deaths among children 1-4 years'-of age per '1,000 Tchildren in the seams ggrouw in a given yearo

Crude Birth Rate : The 'numbr of live birth. per year per ljOOO-population in a given year.

Crude Death Rate : The numher of deiftbo per year per -1,000population' in a given year.-

Infant MortalitylBate : Tae number of death. of infants under I yewr- ~~of age in agiven yewrper 1,00O live births

during the saeasyear.

Life Expetotacy at Birth: N erof years a newborn child would live if-subject to the mortality risks prevailing forthe crass-section of population at time ofbirth.

Maternal Mortality Rate ume of deaths to wamenWm whode -due, topregnancy and cbiIltserS.ngcoqplicat ions in agiven year per 1,000 birth. in that year.

Morbidity : ~The frequency of diseaem and -i llness in -apopulation.

Rate of Natural Increase : Rate at which a population is increasing (ordeceasng)in a given year due to a surplus

(or a deficit) of births over deaths. rherate of natural increase equals, the crudebirth rate u$puu the crude death rate.

Total fertility Rate : The average number of children that would beborn alive to a wooma during her lifetius ifehe were to conform,, duEtiog ber reproductivelife, to age-specific fertility rates of a given year.

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* ~ s' ,. '- .

1.01 Althogb G.in. Is Well e sd With IWV+A=t grultural,mineral and enegrg resources, economic growth ilm ince indepneire has beemlimited. Poor ecoomic pwor c be In lo pert to

In-rpate onomic policies ad'to weak t of thw econay.Eonomic dl t'ha ao been cosmtraine by the rapid ate of'populatin wth which coutinue to outstrip the rate of wth o the,on__w ad of food production.

1102 As a copoooeof the abov factors, uinea ramaiwc one of thelea1t deelXod Wt African couotries. Social indicat#rs ae low eves byAfrican stendard: life expectanc at birth is under 40 year; the 6dultlitercy rate Is 20 percent; the priawy school eoroll_mt rate is 26percet; accs to sae ttr ts limited to les thl 20 peret of thepo lation; and (M per cwita in only US$230 (x 1).

1.03 With DW ad IDA _sistane, the nn t in'l iebxd en eneXtensve progrm to rebabilitate the eo6ny end to stimlate development.so pro ' a'tour 'an deloent poritie awe (i) monetary ,

includin improvemetst in the bankig otm and xchgs rt adtetmet;(ii) tatio f pvat setor el ent; (ii) strenghi qf theCapacity and Pe oe' f t or, water supply and social-ectors; end (iv) the increae ad divenafication of exports through_UpenteI dmetic production.' lie onoin economic atuastment. progr will.introduc policy r¢ef to increae tho-efficiecy of existing and fture

1.04 A concerted effort to duelop the contryl's human resouwces andslow population gowth is ads essetial for improvipg Guiea's Owthprospects. In or4er to improve the overall helth and wellbeing of thepopulation, the oot deloped a progr to Upove theefficiency, availability end qulity of key balth svices, includingfmily plmiw. That progrm which the Goverment -has asked IDA tofince-through the proposed prject, uld focus on mr efficient sectoralmeegeeaut, a model for the improved delivey of primwy health cae,inclug family plmang, nd the mobiliation of additionsl financialresourcesthrough ost recovery. It sould help over the medium and longterm to reduce mrbidity and mortality, promte fertility declines, andincreae the productivity and delopmt potential of the Guineanpopulation.

IL ¶ qU&IU L An3 aRinow SgOT

A. bemilkatid. a Mit tat,,

2.01 Bmw . Th population of Guina -s estimated at 6. millmin idd-19. Th atural rate of poulation growth ts estimated at 2.7PMrt Per _num. Coined with a not emiration lte .f 0.3 perent, th.anu1 rato flor t gw thisetated to be 2.4 pwret. With atotal fertility rate of 6.0 sd a crude irth rte of 47 pr thUm_d,fertility Is higb and c_srablh to the averg for SAa fria.Mortality is als hig; the crud -doeth rate is estimatod at 20 Pertb_umnd2 Averae populai diuty is 24 pwr q. ad- the -tely rurapopulation io vely distribte throughmt tbh country. Iternal m ionhas a odet influene on settl_mt patterns. ilq migration t tcapital city Con, acelated in recent yer, peondry tan hivsated as a ber he sloed growth In tecpital to 5 perc;vt pirsaoa. T?e ag structue of the population io youthful: 46 percet aeelow aso 16.

2.02 s ng a sldoq_ in gation, with lare cohorts enteringprodctiv ag,d with fertility rea_ining hig, pouatin growth will

upproech.3 prt averthe nXt tdecet, and tbe polatio will wo,ed10 'pllion by the twa of the ientury. This i tothe ostOf bm mt d acntrai the giowth of pe cpita DP.It will b eame Anceenintly difficult for Guine to t3sob the w=rIin eopopulation ito its bor fore,, d thls will aeratera migrationand _ualoymmt. fforts to address population rowth will hav to focuson improving msiaa and chld ealth and on reducing -fertility, sincesinficant fortility declin will not oocu til infant ed childhoodmotlity has decreese s ttiay.

2.03, "k.T health status of the popul*tiou in Guinea is asmonthe pooret In the world. Lifo eupetalcy at birth is a low 38 yeawn.Infant ad cild mortality rates we both hg at 176 d 44, repectively,aDd accomt tpr 60 percet of all death, in the country. 1tsrne mortalityis aelo high: naly 800 out of 100,000 prsmc result in the death ofthe mothe. While helth status has be r over the past two,decades, it apeer that tbh rate of i4 e;h slowed da si tbhsecond half of the 1970s, oe helth cae services beganto deteriorate.

2.04 Repiratory 4dseases3, tr_i and burns, malwia and diarrhasaccount for 514 percent of all dises" reported. Other preventable andesily treate6le dis-ea , such as measles, tubrculois, pertussis,polioyelitia, and tet aelso very prevalent. Morbidity- onachildren und" five is domiated by inlaria, qper respiratory disorder,sad easles, bhich togeter account fior thre quter of reported cses.IDaccessibility to potable water ad poor sitation cau a bigh prvalence

of parsitic and endemic disees, especially among children under theof 5.

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2.05 Nutriti. Malnutrition i d , with srious implicationsfor susceptibility to diseae ad death, labor force productivity andphYSical ad mtal grm*I. While rtes vary ever tim and acros rgion,theY are consistetly high mog the most vulable groups - children andnursing mther. Survey sug t that abot 50 pecent of the childrenunder five suffer frm sum deree of minutriti n. Per capita foodavailability has decreased over the pat 10 years; in 1994 it reached only93 percent of the 1974-76 level. A lack of u rstandling of basicautrition, traditional eating habits and food taboo that deprive pregnantwomen and young children of nutritious foods also contribute to poornutritional status.

D. The salth Bsytes1. frgfanigton

2.06 The Ministry of Ebalth and Social Affairs (UBAS) is responsiblefor the formulation and implementation of national health policy and foroverall administration, coordination and management of the country's healthsystem. It was created by decree in December 19 tbrough a merger of theprevious Ministries of RHalth and of Social Affairs. That erger wasundrLtaken to eliminate duplication of taks betwee, the two ministries,which had seriously obotructed the eoffectiveness and efficiency of priorityhealtb ervices, most particularly those for internal and dcild bealth andfamily plaming, nutrition, bealth education and training. In accordancewith the new organizational structure of the MBAS, the Geverneant basrecently integrated budgetary end staff resources of units responsible forthese priority services (pars. 2.31). Within this now structure, threedivisions are responsible for coordinating key services: primary healthcare; administration and finance; and planning, training and studies. ASocretariat of State for Social ffairs (SlA) ha been retained within MMSto assume reoponsibility for social affairs, woman in deelopmet andservices for the handicapped. Regional gt of bhelth operations isdecentralized along the lines of Guinea's administrative structure. Fourregional inspectors of health end social affairs are responsible forInspection and coordination of health activities and for execution of in-service training of staff. In each of the 36 prefectures a director ofhealth and social affairs is responsible for allocation and utilization ofhuman, physical and financial resources; plaiming and programming ofactivities; supportive supervision; and monitoring and evaluation ofactivities. Organization charts for MAS and SLAS are presented in Annexes2-1 and 2-2, respectively.

2. Levels and Tines of Services

2.07 Public health services in Guinea are provided through a pyramid offacilities comprising 2 teaching hospitals in Conakry, 4 regional hospitals,29 prefectoral hospitals, 313 sub-prefectoral health centers and 205 villagehealth posts. The distribution of facilities throughout the country isreasonably equitable. Mobile health teems are supposed to serve comunitieswithout fixed facilities; however, they are unable to fill this roleeffectively due to a lack of adequate funding (pars. 2.18).

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2.08 gvn whe villag helth posts do exist, they he beenrelatively isolated from the forml belth sstm duo to the presetinability on the part of helth centers to provide adequate outreahincludin Support end upervision of village helth workers and refrralservice (pars. 2.25). Thus, the first forml entry point into the publichelth syst in the subprefectorel health cnter, which is dsigned toprovide a variety of curative ad preventive services, including maternityand maternal and child helth sevices, limited in-patieont srvices, healthand nutrition education and outreach services. ealth problem that cannotbe reolved at the elath enter level are referred to the prefeoctoralhospital, designed to provide g ral medical, urgical, maternity anddental services. The four regional and two teaching bospitals providetertiary care. A separate network of 15 public matemrl and child healthcar centors, located priwarily in urban aresw, completes the publip healthcare system.

2.09 Private sector health services are comprised of two hospitals runby bauxite companies in the secodarwy towns of lasar and Bokd, whoseservice are available to the entire population living within theirrespective catchment areas. There is also one private medical clinic inConakry with 17 bedb and four private medical offices for outpatientconsultations, of which three are in Conakry and one in lindia. Inaddition, some 6,000 traditional healors provide bealth services and severaltraditional birth attendants attend deliveries in each village. Finally,the Guineou Association for Family Wellbeing (AGREF), a recently establishedaffiliate of the International Planned Parenthood Federation (IPPF),provides information on family plaming services and distributes some non-medical contraceptives. At present, its activities are limited largely toConakry.

3. t r

2.10 Numbers and Distribution. A total of 7,089 medical andparamedical personnel presetly work in Guinea's public health system,including 636 physicians, 261 pharmacists, 34 laboratory technicians, 22dentists, 343 midwives, 2,113 nurses, 1,403 public health agents and 2,278support staff. Overall ratios of population to health personnel arefavorable in Guinea, relative to other West African countries, for allmedical and paramedical personnel except midwives. However, their hez vyconcentration in urban areas (92 percent of physicians, 96 percent ofmidwives and 78 percent of nurses) leaves rural areas, where 73 percent ofthe population resides, severely disadvantaged. The technical skills ofmedical and pearaedical personnel are iradequate, due to the poor quality ofbasic training (paras. 2.11 - 2.13) and to the complete absence of an in-service training program.

2.11 Basic training of physicians and pharmacists has been providedlocally at the University of Conakry since 1967. The quality of traininghas been poor due to the low level of secondary education in Guinea, lowentry require ents, inadequate teaching staff and facilities, inappropriatecurricule, a relatively short training program of 5 years and excessively

large mual enrollments. Growing disatisfbation with the quality ofgraduates led the Govenment in 196 to imp.. stricter entry requirements

* anad extend training to 7 yers. It has also begu to upgrade the quality ofteaching facilities and capabilities. Durig the period 1980-84 the mediclschool produced 564 doctor and 120 pharmacists. ecus the number of

* doctors and parmcists in guinea is suficiet, the Governmta"ropriately cut anmual intake begining in tCe sol yer 1984/65, from99 to 20 edical studets and frm 44 to 10 pharmacy studets. Reduedoutput of training program, accompaied by a reallocation of existing

edical personel to rectify existing Imalances in their distribution,would satisfy the liidtod incrmntal staffing needs murging fro, theGovernment's sector developuent strateg.

2.12 The quality of paramedical traini has also bee poor due'to lowentry requirements, an umuitable curriculus and inadequate teachi staffend facilities. The Government ha also taken masures to improve thequality of paradical training, icluding the revision of curricula ad theImposition of stricter entry rairments. Before 1975, basic training ofstate registered nurs, msidwiuve and laboratory technicians had beenprovided at the Univrsity of CGakry medicl scol, but training programfor thee staff, which, wvre of poor quality, wer dicontinued in 1975 for 8year. In 193, a ne Natioal ;chool of EOlth in india wcastablihedand it now provides forml trainiag for tbhe 3 categories of staff.Coined with the reallocation of some existing staff, the shool's amnalintake of 46 studets will satisfy the quantitative needs for thbecategories of staff in the medium term.

2.13 Loer level pamdical staff (asistant nurs_ and public healthagents) are trained in 3 geographicaly dispersed juior nuring schoolslocated in Lab6, RIankn and 6rdkorA, which wer establishd in 1982;before 1982, lower level ecstaff wer trained In hospitals. Theabsence of full tim teahing staffs the acute shortage of teaching -material, and the lack of course focus on sector needs compromie thequality of this training. The Government, with WEI aistance, ha begu toaddres these deficiencies. In keeping with Governamet policy to favor therehabilitation of existing facilities over the construction of nmw on, theG n has cut annual intake to the lower level health schools beginningin the school year 1986/86 from 76 to 20 students per school; this decreasedintake should satisfy projected needs for lowr level paramedical personnelin the near and medim term.

2.14 The NIAS has recently completed an inventory of health personneland is redefining ideal staffing of its health facility network. Based onthe results of this work, the MBAS Human Resources Service, to bestrengthened under the proposed project, will project the staffing needs ofthe MSAS, beginning in the project's first year. This will provide the

* b4ais for determining future intake of medical and paramedical schools (para3.06).

.~~~~~~~~~~~~~~~~~~~~~

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4. ru rorement and Digtribution

2.15 Until 18 two state _mpolies unde the m We active in thephamaceutical subsector. Pb de iported and distributed drugs freeof chare to health faciliti ad sold drus to the public throlp anetwork of drug stores ina conday tas. Its Imports were ostly bradnme and wwr procured on the basis of direct purchae, which in manyinstances elicited unnecessrily high prices. With UNIDO mistance, the-Governmt in 1979 edbrked on an abitious iroject to establish

nigphargui, a state compay wich produced aos drug locally and sold thmto Ph dn for distribution.

2.16 Poor mnagemt of Kniphargui and , themiappropriation of stocks ad funds'and the perennial shortage of foreignecchage led to a chronic shortage of drug in health facilities. It alsoencouged the mergen of a prallel mrket in drugp, hoe oupplies casefrom stocok mi priated frm the public sector and illicit imports. In1983, diversions of drugs fttmm public facilities were estimated at U$1.0million equivalent, or 53 percet of the Governmentts drug budget. Poorplanning and iefficient nmt in Inipbargui also led to higher pricesfor local than imported drugs.

2.17 To address these problem end mke drugs more readily available inthe sector, the Gonment io 1985 introduced reform to stop the localproduction of drug and to liit the functions and activities ofPamui"4"Lnde to the prcurmnt and distribution of ssJential drugs forpublic health facilltie. The Gvemoent, with the assistance of TheAfrican Developeent Bank (AtIJ), is reorganixing Pbsrmsguindesabdstrengthening its muigensut capabilities to enable it to- assume the morelimited role of only procuing ad distributing essetial drug for publicsector facilities within the next 2-3 years. The decision to open thepharmaceutical market to the private sector in 1985 has led to thestablishment of several private pharmacies and the creation of eightprivate pharmaceutical wholesalers to supply private sector services.Ieaures taken thus far by the Govermnt to addres the low availabilityand high cost of drugs ar appropriate; however, the GovOrnmeot still needsto refine its policies related to drug procuren t, distribution, qualitycontrol and pricing. The Goverament's strategy on drugs is discussed inpara 2.34.

C. Health Financinw1. Recurrent ituresi - -

2.18 Recurrent Ludfgeft for Wealth. Public financing of health sectorrecurrent costs cmes from the MMA budget, a budget allocation for trainingwithin the Ministry of Education, and local taxes at the prefectural level.The MSAS share of the national recurrent budget suffered a slow decline from5.9 percent in 1979 to 4.5 percent in 1983. However, it has since risen toGNF 2,161 million (US15.2 million equivalent) or 5.6 percent. This level,about average for countries with astandard of living comparable to that ofGuina, is not adequate to meet the recurrent financing needs of the health

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sector, especially where private health care service are limited. In 1986,the Social Affairs budget amounted to WNF 75.7 million (US$ 0.2 millionequivalent), or an additional 0.2 percent of the national recurrent budgetand, like the health budget, falls far short of meting recwurrt financingneeds. An additional GNF 60 million (US10.2 million equivalent) wasallocated to the technical Ministries responsible for training to financebasic training for doctors and paramedicals.

2.19 Of the combined health and social affairs budgets, 48 percent isallocated to salaries. This relatively low ratio of salaries to suppliesmay appear favorable compared with those of other West African healthbudgets, whose salary components range from 60 to over 80 percent. However,it is largely reflective of very low salaries. Government economic reformprograms will raise salary levels at a time when the recurrent budget forhealth is not likely to be increased. Thus, it in likely that increasedsalaries will consume a greater portion of the health budget in the mediumterm, leaving less for drugs, supplies and other operating costs. This willoccur at a time when funds for drugs and supplies are already inadequate tomeet the needs of the health services and their allocation has been heavilybiased towards hospitals and urban areas.

2.20 Local Government becurront fowenditures. Prefectures allocatepart of their own budgets, received from the central level, to the healthsector to finance salaries of unskilled staff and, in certain cases, todefray other operating costs. Annual expenditure of local budgets On healthamounts to about GNF 25 million (US$0.1 million equivalent). In addition,an estimated GW 200 million (US$ 0.5 million equivalent) of locallycollected tax revenues ("ristournes") are spent on health sector operations.

2.21 Private lxvenditagEs. The population is participating to a rathersignificant extent in the tinancing of the public health system. Costrecovery is already implemented in hospitals in Guinea. At present mostrevenues collected by hospitals through cost recovery activities areremitted to the Treasury. The two teaching hospitals, Ignace Deen andDonka, may retain collected funds over and above the amounts of GNF 6 and 8million, respectively, which must be remitted to the Treasury. Thesehospitals have in fact been unable to collect more than these amounts and sohave not benefitted directly from collected revenues. Two prefectoralhospitals have been authorized to retain all funds collected, in order tofacilitate financing of their operating costs. In addition to paymebt ofhospital fees, the population also purchases drugs sold through publicpharmacies. In 1983, private expenditure on services and drugs in publichealth facilities amounted to WNF 128 million (US$0.3 million equivalent) orabout GNF 22 (US$0.05 equivalent) per capita, about one fifth of per capitapublic expenditure on health for that same year. While information on thetotal amount of private expenditure on health is not available, it appearato be substantial. Data from a 1984 household budget survey in Conakryreveal an average annual expenditure per person of GNF 2,464 (US$6), ofwhich 85 percent was for modern medicine.

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2.

2.22 A thre r in m nt p hbs bo dram up for the 1967-6period ( 2.-3). The estimated cst of the progros is OR 19,94.5million (UU48.7 llion equivalent) or bout 7 prct of the oveallnational invetnt budget. about 90 peret of the propes would bae tobo financed by mternm assitane. The pIsn reflect GVWr A. s stratopto uprovWe coverage sa quality of bsic halth srvices, eospially inrurl ara, and to rebabilitate misting srvies. Ir, It cm only beconidered indicative ince it w_ not prepaed on the bsis of a carefulass__mant of priorities and of the reaurrt cot implicatios of proposdinetmets.*

3. MtervhahAlsUM2.23 Guie did not, imtil recetly, blenit 1fromternl aidd Inheath care . IOmver, in rent Yer ut$rnal finanin b beenincreaintg. DecOs of curret fianial difficlties which ae likely toPerist for sam tim* the bulk of Govemmt capital epeadit willb.eto be fianced by foreig dno and oew conterar funding in thoeinvet_ uta will be limited. finanming of helth seator recurret costs byexterli app_ws to be Astsntil, as well. incldin therviasi of drus id ines ad'tbe finwAntci of salaries ud othe

orating cost of health progrm.

2.24 Duri the period 18-W, extnal st to the healthsector amunted to 03*7.8 million (US31.3 Wr cpita). Among wltilatealdonors, the orld ealth Organiatio (MD) proides techical assistancead trainin, UNICIW proge focu on drug procurxment and im is;the Uted Nation Fund for Pouation Activitti (UVlPA) uppworts failyPlanning activitiesi AM supports INOrovements in eatioal plannitwithin UMt, iludin" the establin_it of a _mment normtio sytmad the provision or mamt training; ad the Iuropean DON ment Fundsupports the rehailitation of the Ignac Dea tehing hospital ed theestablishment of a children's nutrition institute in Coay. The smaibilateral donors are: Saui Arabia, which supports tbh extension of sub-prefectol health cters into the Upwr uineeo; the Republic of Germy, which is stregtheni m balth cae in theForest Region and rehabilitating the Do thoiwtal; and the UnitedStates Agency for Internatioa Deelopmet (USD), which is finacingtechnical asistance, medicines, vacines and other equipment to controlchildhood comuicable diseases In eritim Guinea. A n _r of otberdocra provide training, solarshIP, technial assistane and equipmt.Nongovernntal orgaiation (MO), including spital san Frontiire ndThe nternational Plannd Prthood Federation, hae recently been toswport basic helth sevice in the countryside.

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D. Iaith yte erfoc d Ctrait

2.25 The bhlth sytm is not rpin a tely to th needs ofthe population. While inufficient reswurce severely constrain theprovision of satisfactory health erviceo at all levels, urban fobilitiestend to be better staffed and equipped and hence provide better servicsthan their rural counterparts. The ystem is weakest at the priphery - atthe pretectoral and sub-prefectoral levels - wbre the neglect ot healthservices bas been most pronound. luildings and technical equ$p.not havedtriorated, drugs are scarce, facilities era isficiently staffed adpoorly equipped, and medial services are limited. VAny prefectoralhopitals, intended to serve as referral conters, are so smal Od ill-equipped that they are only able to fulfill uom of their rexpoQsibilities.Sub-prefectoralhealth cetersare functionally inadequate and frequentlylack electricity and adequto water supply. They are staffed by personlwhobo performanc is bnpered by poor definition of tasks and poorinttgration of key preventive progra, such as imounisation, educationalad outrch actvities, and a lack of training. Poor staff performanc isa xacebated by a almost total lack of in-service training and technicalsupervision of middle- and lower-level personnel. As a result of lowquality services, the population's confidence in the system has eroded and

se of public health servics is low, especially in rural areas, wherehealth center only average ame 850 visits per year. These issues are'ecemined below.

2. Coamtuinat

2.26 1b I -ment. Within the newly integrsted units of MEAS,capabilities in planning and *anagement of health ector resources andoperations are very limited due to the absence of: qualified staff,appropriate training, a management information system and a well definedmrk progrm. Investmnt plamning is not effectively carried out. Ratbhr,the investmet plan consists of a listing of various, uncoordinatedintervetiom of aid donors; and Insufficient regrd is given to urrentcost implication of investment or to their appropriateness visa--visbealth sector policy. Decision making responsibilities are too highlycentralixed, leaving local authorities with little autonomy for utilisinghealth resources and tailoring services in a *m8ner most appropriate tolocal realities.

2.27 Financial Resources. The chronic shortage of operating funds is amajor caome of acute shortages in medical equipment, supplies of essntialdrugs, fuel and of the state of disrepair of infrastructure and vehicles.The lock of fundb also limits needed in-ervice training and upervisionactivities and the effective delivery of services. Financial constraintsare acmpounded by the iadequate management of financial resources.Allocation of budgetary resources, for example, is not censurate withpriorities but rather is based on the previous year's budget. to addition,there is little accountability for the use of funds. Consequently, MM has

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little informtion with wch to proparo ad proeet to the Ministry ofconomy and Finance realistic and justifiable anual budget requests.

2.28 medical and Parmedical Staff. The low quality of staff skillsseverly comtrains the efficienc of MM. Bsic training for doctors andpamedical personel ha bee so inadequate In the past that the largemjority of existing helth personnl are not effectively qualified to carryout their respomibilities. The low level of technical skills of thesepoeoel deteriorates even further in the abse of ia-srvice traiingand supervision. rtroe the current distribution of existing medicaland paramedical personel has a heavy urban bias, leaving rural populatiomsevrely disadvantaged.

2.29 Dru. The current scarcity and high cost of drugp, whi6hseriowsly compromise the effective delivery of basic health care, are thereoult of the inefficient sanagement and mnopolistic status ofPharmauinde, the ambitious but unsucoessful attempt at local drugproduction undertaken by Snigphargui, and the shortage of budgetaryresaource for the purchas of drugs naeded in health facilities (paras. 2.15- 2.16). Current procr-n practices elicit unnecesar-ily high prices andload to significat misappropriation of stocks. Until recently, policiesprohibited the development of an efficient private sector that could improvedrug sWplies.

3. Sector Policy and Stratesv1. Ijlh

2.30 Pollv. The Government remain committed to a policy of primarybhlth care, incorporating curative and preventive services, and aimedlargely at rural areas. That policy would expand coverage and improve thequality of health services, particularly those oriented towards woome andchildren, who are the most vulnerable groups. The Government is aware ofthe constraints that obstruct implementation of its policy and of the needto correct them if the sector is to contribute to the country's developmenteffort in an efficient and effective mnr. Moreover, as budget resourcescan be expected to remain severely constrained for the foreseeable future,successful adjustmet in the sector will depend on the Government's abilityto control growth in expenditures and make more cost effective use ofexisting resources. In order to respood to the exigencies, the Governaenthas outlined the strateU noted below.

2.31 Sector management. The MSAS has recently integrated the budgetad _mawr resources for units in charge of priority health programs andservices within its newly organized structure. Administrative unitsresponsible for maternal and child health/family planning (MCH/FP),nutrition, training and health education are now under the full control ofthe Minister of Health and Social Affairs. The Government recognizes thatwhat rem ins crucial for sector development is the upgrading of skills ofMBk8 staff in planning and program development, and in mnitoring andevaluation. It is undertaking to improve these capabilities through thedevelopment of technical and mnaerial in-service training program and the

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establishent of a _nagmt informtion stm, all of which will beetended to regional and local staff to facilitate the ovenmt'sdecetralization policy in the halth sector. Under this policy, regionland prefectoral bealth authorities will be give more autonom to ableth_ to carry out their responibilities more effectively and efficiently(par. 2.06). Greater cunity participation in the financing andmaament of srvice will be sout through the creation of1 belthman_gemet comittees (Pra. 3.18) for each levl of service. ncreased--coordination of aid will be encouraged throug anna metinge with majordonor in the setor, based on comonly understood sector policies and oncoherent investment program.

2.32 Cgot Rryg. In recognition of the necesity of mobili;ingadditional financing for health sector operations, the Government inteds toelaborate a cohereat policy of cost recovery and to improve and extend costre overy activities to all levels of services. The MBMS has drum upseveral cost recovery schemes for initiating coast recovery activities at thnhealth center level end for strengthbning cost recovery activities at tvw,hospital level. These scheme will be tested and evaluated in the next fewyears in various part of the country, uwder a number of projects, includingthe proposed IDA project, with a view to their eventual extensionnationwide.

2.33 Staff Deve}loamet. The Governsent will establish regular Prograeof in-service training for all categories of health personel and develop a"stem of supervision to provide technical support and guidance to fieldstaft. To inprove the quality of basic training, the entry requirmnts formedical and ursing schools have been raised, the syllabus updated and theannual in-take curtailed. The Government will undertake an ongoing reviewof the adequacy of intake in these schools to ensure that future graduatescan be easily absorbed in the bealth system. The Governmnt also envselective specialized training abroad for medical doctors to Improve theqwality of referral services. It bas druen up program for technical in-service training of medical and paramdical personnel, which it also intendsto test and evaluate under the proposed project and eventually implinetcountrywide. The Goverment has just completed an inventory of its healthsector personnel and intende to elaborate and implement during the firstyear of the proposed project a program of staff redeployment to achieve amore equitable geographical distribution of staff (para. 3.06).

2.34 Essential Drug. In an effort to lower costs and increase theavailability of essential drugs, the Governaent has adopted an essentialdrugs policy and has drawn up a list of esential drugs and a nationalformulary to educate drug prescribers in the use of essential drugs. .It isalso plaming activities to inform the population at large about essentialdrugs and has scheduled the first of a series of training program forhealth personnel in September 1987. To enwure rational procure ent andefficient distribution of essential drug in the public health system, therole of Pharmaguin6e has been limited to the procurement and distribution ofessential drugs for the public health system. AfDB-financed studies on thefinancial and organizational restructuring of Phl nrmagun6e and the

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strengtbhning of its management t cabilties, incluitg the introduction ofappropr-ate procureMent, stock t and inventory cotrol practicehave been completed. In 1985 the GNM t itrodcd reforms to stop thelocal production of drus by biiphagul; and is currently revieing thepotential role of Enipborgui. The AtDD-financed studies Include proposalsto privatize the compay. Private pham} acts are being licensed to importand sell drug to the public (para. 2.36). which is expected to- improve thesupply and availability of drugs in Cosaky ad in secondary tUwns. Oncethe Governmt has improved its n t capabilities in the drug sector,it will addres more complicated issues uh the setting up of a drugquality control laboratory and the deelopmet of a aore refind pricingsystm for the private setor. During neotiations, the results of the AfDBstudie were discused and Gvernment agreed to submit to the Asociationfor its review and agr t by March 31, 1988 a national drug policy and aplan of action for its implementation. To asist the Goverumt in furthedelopig and implementing its national drug poli¢, the appropriatenes ofthe policy and Goverment progress in its mplemetion will be reviewedannally by the Asciation under the proposd project (par. 3.07).

2.35 Private health srvices. As part of its overall policy toliberalie all sectors of the economy, the Goverment is encouragn privateInitiatives in health care by gramting private physicians and Citlicess_ to set up clinics and pharmacies. It ha also athorized eightwholesale pharmaceutical companies to iwport drugs to be retailed by privatepharmacists licensd to operate drug stores.

2. Nhurition

2.36 While the Governmt acowledges thet mLantrition is a majorhelth problem in Guinea, data On the extent and prevale of nutritionaldeficiencies in the coutry have not bee collected syteatically, and theproblem of mlutrition and its deterniants is not well undetood. Thicontributes to the absn of any policy or coberent national program toimprove nutritional status. Some inforxtion will become available from ahousehold survey to be supported by France and a nutrition study to beundertaken with USAID assistance, both of which will be implemented withinthe next year. The proposed project will enable the Govermnent to Improvefurther its knowledge about the degree and extent of malnutrition throughthe undertaking of nutrition surveys and through the introduction of anutrition surveillance program to be carried out by urban and rural bealthcenters (pare. 3.26). It intends to improve nutritional status through itsprimary health care program by providing nutrition education to women andthe community at large at health facilities as well a through outreschprogran. The Government's progrm to encourage greater participation ofwoen In economic and social activities through its network of women'straining centers (par 3.25) will place emphsis an improving women'sknowledge of basic nutrition and will strengthen food production and otherincome genoerting activities that will give women the means to put acquirednutrition education into practice.

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3. muation

2.37 lntil 1984, Guinea had a pronstalist approach to population* - issue, baed an the view that Guina has bundat natural resources that

reuiro a lager populatioe to exploit thl. Hower, this peception baoundergonea gradual chang national economic and finacial difficultiesbve deepened. The Govrnmt to today concened at st the effects ofpopulation trowth on developmet and about the poristance of high rates ofinfant, childhood ad maternal mortality in the country. The Governmentemphsizes each citizen's right to detemin fmily size and to have accoeto family plaming srvices both for child spacing and for reducingchildhood and aternal mortality and morbidity. The Government isparticularly ccmitted to lowring currently high rates of childhood andmteaal mortality which it identifies a a major obstacle to its efforts toencourage WidespreAN ume of modern tchniques of birth reglation. TheGovernment also supports public, private and MMO program to raise theeconmic and social wellbeing of women, which would promote safe motherhoodand improved family wellbeing.

F. IPA Wole

2.38 As a part of its structural adstmet intervention, IDAemphaizes the elaboration of a viable public investmnt progrm whichplace priority on the rehabilitation and renovation of existinginfrastructure, and impRovmns in public sector managemet andperoce. oD strA y in the helth sector aim at iwproving thequality, availability and efficieny of basic health and family planningsevices through Improved management capabilities, upgrading of technicalskills and mobilization of additional resources for health. The proposedproject, which will be the first IDA-financed project in the health sectorin Guine, will support this strategy as follows. First, it will help theGoverint refine and implement a coherent sector strategy which emphasizesimprovements in the effectiveness and efficiency of health sector operationsand the upgrading of priority services and their eventual extensioncountrywide. Second$ it will maiet the Government in mobilizing additionalresources for health through improved cost recovery at the hospital leveland the introduction of cost recovery at the health center level. Third,project assistance aimed at the promotion and extension of family planningservices will initiate eassures to reduce population growth, which isessential for improving overall economic development. Fourth, it willencourage aid coordination and more rational investment planning in thesector.

CHRAPTR III. THE PROJECT

A. ProJect Ob3ectives

3.01 The project will support Government's efforts to (i) developplanning and management capabilities within the MBAS and introduce policyand administrative reform to improve the quality and efficiency of basic

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elths orviess; (ii) improve basic health oae in the region of Niddi"guinea; (iii) strengthen finacial and optiomal management in the ritgionof Middle Guinea; and (iv) delop ed ealuate coat recovey activities.

I. S,r ProJt Dscintion

3.02 TMe project will sumort the follown:

1. InstItutioMal Develomt of MA

a. Strenthemin of M uneort Futign

Stregthening the orgaixation of MU and MS planing andumna-amant capabilities through the provision of technical,asintance, trainisg, equipment, vebicles and aterials, andfinaning of incrnental operating costs.

b. Strengthening of MUS Teical b4 qZtio

Strengthening of central units in MM responsible for priorityhelth progr end sevices, including in-service training,MG/FP, nutrition and helth education,, through the provision oftechical mistance, training, equipumt, vebiclles sd materialand support of incruntal operating cost.

2. Develogment of Ibelth Sector O tli in Middle i

a. Stren tbenin of seionl NJam Mmnm t

Strengtheing of the financial and _magerial capabilities ofregial and prefectoral staff and the establishment of localhelth ca_ittee through the provision of fellowships, training,eupMeet, vehicles and funding of ntal opeting costs.

b. Stngthe=ni of Basic Ebith Services

Improving the quality and efficiec of esential basic healthservices through the rehabilitation and reequipuent of local levelfacilities, the provision of technical assistance, training,equipment, vehicles, drugs and material, and the financing ofincr ental operating costs.

c. UItradinf Skills of Hlealth Personnel

Implementation of technical and managerial training prograss forregional and field staff of all levels through the provision offellowships, training of trainers, technical assistance andvehicles and the funding of incremental operating costs.

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d. urovi Financial ManateMent and Cost Recove-

Implentation, evaluation and refinment of cost recovery schmsto be undertakenAin prefectoral hospitals, and in urban and ruralhealth centers and improving the planning and managemnt of looal

* ~ financial resources through the provision of equipment, trainingand technical amsistance, and through the fiacing of studios andincreental operating costs.

C. Detailed ProJect DescriDtion

1. Institutional Develoxent of Central MSAS

3.03 The proJect will strengthen, within the new organizational'structure of the fMAS, divisions whose operations are crucial to theeffective delivery of basic health care. Staffing for each of these newlyreorganized units was 4dentified during project preparation and is presentedin b 1=1. The MSAS has alreOady established and appointed the heads ofthese newly integrated units. Details of project assistance forinstitutional development of these units are described below. In order toensure timely start-up of project activities aimed at strengthening theseunit., vital staffing of all, of the newly reorganized units to bestrengthened under the project would be a conditiop-of projecteffectiveness. Moreover, the Government agreed during negotiations toconsult with the Association before making organizational changes in MSAS.

3.04 tn order to improve coordination aong MSAS units as they begin todevelop their work programs and improve the quolity and efficiency of theiroperations, the Government has set up a Technical Coordinating Comittee(CTC) On program coordination. The CTC is chaired by the Director ofCabinet and its members include the Inspector General for Health, the fourDirectors of Health, Social Affairs, Administration and Finance, andPlanning, Studies and Training, Regional Inspectors of Health and SocialAffairs, as well as the heads of priority services. The CTC meets quarterlyto review current progrms and coordinate the implementation of MBASprojects and develop strategies for future projects and programs.. Duringnegotiations the Government agreed that it would maintain the CTC at leastthroughout the life of the project.

a. Strenstthenint of MAS Sunport Functions (7% of total base costs)

Plannins -

3.05 Financial and Orsrational PlanninL The weak financial andoperational planning in MBAS (pares. 2.26 and 2.27) is due in large part tothe lack of appropriate training and to the lack of a satisfactoryt Management Information System (MIS). AfDB assistance, being provided in1987, is aimed at establishing an MIS and improving operational planning.The proposed project will assess the adequacy of improvements achieved

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with AiDB assistance end complemt thus by streWtheing capsbilities ininvestamt planning and aid coordination. The project will support,particularly in its firat yea, the establishment of a system for the

eratin of a rational, affordabJi and justifiable three-year rollinghelth investmnt plan for the health sector. This will reqire thatpotential investents in the health sector be oeluated oan the bais oftheir responsiveness to sctor priorities and on the basis of theiraffordability. This proces will be imtrumental in achieving improved aidcoordination. To these ends, the project will provide seven monthe Oftechnical assistance, two fellowships In bhelth plaming and mnagemt,office equipmt and materiala and recurrent costs such as office supplies.

3.06 Staff DevelogMt Plami. The project will strengthen the nulycreated Hvue Resources Service responible for the ongoing invetory andevaluation of peromel. It will support the analysi of the results of there tly completed personnel inventory, and, ubs tly, the elo6orationand impl emntation of a program of staff redeplo yet within MS in theproject's first year. Such a progrm will address staffing requirements ofthe newly reorgnized structure of MMA8; it will also call for incresemddeployment of staff to rural areas in an effort to rectify currentinequities in distribution of medical and paramedical personnel as well asto satisfy staffing require_ents for implementing deemntralizationobJectives within the health sector. During negotiations, agreement wasreached with the Government that it will evaluate its progrm of edical andparamedical staff deployment, including awonul staffing objectives andprogreas in achieving them, and prepare and submit to the Association forits review and approval no later then Septeber 30 of each year, a revisedprogra of staff deployment baod On the previous year's experience. Inaddition, the Human Resources Service in collaboration with the Planning,Studies and Training Division, will, as an ongoing activity, projectstaffing needs to determine future intake of medical and paramedicalschools. In support of the objectives, the project will provide 8 mntheof technical assistance, training of divisional staff in manpower planning,furniture, equipment and materials and will finance incremental operatingcosts.

3.07 To ensure that the improved quality of investment planning will bemaintained, agreement was reached with the Government during negotiationsthat it will review with the Association by Septseber 30 of each year (i)all investment expenditures ade in the health sector in the previous yearand those proposed for the coming three years, as part of the rolling publicinvestment program, with particular attention being given to recurrent costimplications; (ii) the allocation of the recurrent budget; and (iii) theappropriateness of drug policy and Government progress in itsimplaientation. During negotiations, agreement was also reached that theGovernment will organize by November 30 of each yer meetings of all aidagencies participating in the financing of health sector activities inGuinea to ensure that the Government, the Association and all other donorscoordinate their efforts around a comonly understood sectoral policy andthat the recurrent cost implications of health sector investments areaddressed.

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lanagemet ad Administration

3.08 The project will anoint the Division of Administration and Finance(DAY) to develop its capabilities in budgeting and in the anagement offinancial resources. It will support improvements in the system of budgetingand work program preparation. It will also assist in the establishment of afinancial accounting system that will permit the management and control offinancial resources going into the health sector and that will facilitatedecentralization of financial management responsibilities. The project willprovide 8 montho of technical assistance, two fellowships in financialmanagement and administration and tinance, and training in financialaccounting and management, including the use of micro-computers. It willalso finance office equipment and materials and incremental operating costsassociated with the impleoentation of improved financial manageent. Insupport of the Government's comitment to mobilize additional resoqrces forhealth through improved and expanded cost recovery (parm. 2.32), the projectwill provide 8 months of technical assistance to help the DAF to manage andevaluate cost recovery experiences and eventually elaborate a cost recoverypolicy to be applied nationwide. Under the project's regional component,cost recovery will be tested in the region of Middle Guinea (paras. 3.30 -3.34).

3.09 The project will also support improvement in the management andin the coverage of aiAtenance services and will amist the MSAS in thedesign and implementation of a preventive maintenance system. The projectwill finance 18 months of technical assistance three fellowships in themanagement of maintenance services and in the maintenance of specializedtechnical equipment and training. It will also finance minor renovation ofthe central maintenance workshop and needed equipment, tools, materials,vehicles and incremental operating costs. The project will strengthenmintenance activities at the local level under its regional component(para. 3.21).

b. Strengthening of MSAS Technical Functions (7% of total base costs)

Training and Research Service

3.10 Technical Trainin . The Government has established a draftprogram for regular inservice training which aims at improving servicedelivery skills, including MCH/FP, imiunization, oral rehydration therapy,detection and treatment of malnutrition, control of infectious and parasiticdisease, prescription of essential drugs and outreach activities. Theproject will assist the newly created training and research service toinstitutionalize these programs and to prepare for their eventual extensionnationwide. The project will also support the development of teachingmaterials, including training modules, reference manuals and evaluationtechniques. To these ends, the project will provide nine months oftechnical assistance, training, furniture, equipment, vehicles, resourcematerials, logistical support, incremental salaries and other incrementaloperating costs necessary to carry out and evaluate its programs. Thecontent and approach of the training and supervision program will berefined in light of implementation experience acquired in the region of

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Middle Guinea (para. 3.29) and in light of needs identified in otherregions.

3.11 M_naemt Trainig. The ormet, with the assistance of theAfDD, is undertaking the elaboration and implemntation of a am aa nttraining progrm which will include overeas, local and on-the-job trainingin financial and operational managemento plming, accounting, statisticsand computer science for central-lel staff. Swaer, once ISMA staff havebeen fully redeployed to accindate the newly reorganized structure,additional needs in management training are likely to emerge at all levelsof service. An aunt of US$300,000 equivalent ha beeo set aside under theproJect to finance anagement training needs which will be identified duringthe course of project impleometation and tv not covered by AiDS assistance(parm. 3.06). During negotiations, agreement WaS reached that theGovernment will evaluate annual technical and anagment in-service trainingactivities undertaken during the previous year and furnish to theAgsociation, by September 30 of each year, for its review and approval,revised plans based on the evaluation for that training.

Maternal ad Chld Heath and Family ElMigg ices (M_ /VP)

3.12 The MNC/FP service is responsible for ensuring proper execution ofMCI/FP policy, for planning and management of operations and for trainingand supervision of MCI/VP staff, including village-level traditional birthattendants. The proJect will strengthen the MC/VFP service to enable it to

anage and carry out its responsibilities more efficiently, particularlythose for family planning, which arm relatively new. The project willimprove management and evaluation capabilities within the MCI/FP service. Inparticular, it will assist the MC/VFP service in supervising and evaluatingMCI/FP activities to be implemented under the project's regional component(paras. 3.22-3.25) with a view to their refinement and eventual extensionnationwide. The project will provide equipment, vehicles, materials andlogistical support end finance other incremental operating costs which wrenecessary for it to manage and implement its work program. Five physiciansand five midwives are being trained overseas in family planning techniqueswith external assistance. The project will complement those fellowships byfinancing the short-ter training of 12 health center midwives in familyplanning techniques. They will, in turn, train under the project otherMC/VFP staff, including hospital and health center nurses and traditionalbirth attendants.

3.13 The Guinean Association for Family Wellbeing (AGDIF) undertakesthe promotion of family health, with particular emphasis on family planning(para. 2.09). The project will, as a complement to USAID assistance,support AGBEF's efforts to sensitize the population about the availabilityand benefits of family planning services and to create a distributionnetwork for non-medical contraceptives. That network will be based on anetwork of women's training centers (para. 3.25). The project will renovateand equip an air-conditioned warehouse for AGVEF for stocking contraceptivesand other medical supplies. The assistance will be a Government grant toAGDEF. Disbursement of funds for AGBEF activities are conditional upon theAssociation's approval of an agreement between MBAS and AGB8F on the terms

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ad conditions of the grant, which inter alia would ensure that AGF wouldcontinue to use the goods acquired under the project exclsively for itsfamily health and wellbeing activities, including fmily planing, duringand after the project and which would reqire the anul adit of AGBIFaccounts (para. 5.14).

3.14 To support MCH/FP aime, the project will strengthen the newlyestablished division for women in development within 8BM to develop andimplement its program of activities. That division coordinates women'sdevelopment activities such s literacy program and support of women'scooperatives. The project will provide two months of technical assistance,training equipment and material and will finance incremental qperating coststo assure the proper planning, manageeant, implementation and supervision ofactivities in support of women's development. It will finance short term (3aonths) training for one person each in social work and in financial.management to strengthen capabilities in the development of women'scooperatives.

Nutrition

3.15 The project will assist MSAS in carrying out its proposednutrition activities (para. 2.36) by strengthening the new nutrition serviceand assisting it in the establishment of a nutrition surveillance system andin improving the reporting and analysis of nutrition statistics. It willfinance office equipment, a vehicle, resource xaterials and the cost of twosurveys on food tecbnology and nutritional statu to help strengthen thecapacity to collect, process and analyze data as well as to supervise andevaluate ongoing activities. The project will also finance two study tripsto Senegal and to Rwanda/Burundi, whose successful nutrition surveillanceand recuperation activities could be adapted to the Guinean context.Nutrition will constitute an important element of the health educationprogram to be developed with project agsistance (para. 3.16).

Health Education

3.16 The project will strengthen the health education service to enableit to implement a well structured health education program, which was elab-orated during project preparation. With project assistance, importantprimary health care thems as well as mssages On AIDS prevention, will becommnicated to target groups through the radio, television and pressnetworks in Guinea, as well as through other comunity communicationschannels within the health, education, agriculture, women's and ruraldevelopment sectors. Film, radio and television progra s and slide showswill be produced, and posters and literature on health will be prepared anddisseminated widely. Field research, testing of mesosages, and systematicfeedback from field staff will help improve the focus of the healtheducation messages. The project will provide 19 months of technicalassistance, three fellowships, and inhouse training in management,curriculum development, training, production and comunity health. It willalso sup- port the development of outreach activities through the trainingof health workers, teachers and other social workers at the peripheral levelin inter-personal coumnmication skills. The services of Radio-T616vision

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Guindene (RN) will be sougt to mist In the production of radio andadio-visual program for the health education orwvice. The heltheducation srvice within MBAS will be provided with equipmt and mterialsto give it a limited cacity to produce origial mtorial end to analyzesocial scienc data. The project will also finae incrmntal recurrentcosts for supplies and logistical support.

2. Develoment of Heltb Sctor ODeratios In Middle ia

3.17 In pport of the Govern mt's policy for developing prilryhealth care and preventive medicine in rural areas, the project will improvethe efficiency, effectivenos and coverage of priority program andservices, in five prefecture. in the region of Middle Guinea. Projectamistance will focus on (i) strengthening of regional health management inupport of decentralization; (ii) strengthening of basic bealth services,

particularly bErnFP, nutrition and the development of outreach program,including health education and commuity activities; (iii) upgrading of theskills of regional bealth personnel; and (iv) mobilization and management offinancial resources for health. This component will focus on five of tenprefectures in the region of Middle Guinea, including the regional capitalof Lsb6 and the four contiguous prefecture of Dalaba, LJlot.a, Pita andTougud. Within each of these prefectures, 2-3 subprefectures will alsobenefit fho proJect assistance. Thes prefectures were chosen for projectassistance because they have an important concentration of population ofabout 1 million people. Furthermore. their contiguity and relatively easyaccesoibility to Conakry will facilitate implemotation of a firstoperation, the rationale being to extend the experience gained under asuccessful first project to more difficult areas under subsequent projects.

a. Strenbthening of Readonel Health Maaement (5 iercent of total

3.18 The MBAS will initiate and test health sector decentralization inthe Region of Middle Guinea. The project will support institutionaldevelopment of the Regional Inspectorate of Health and Social Affairs(IR88s) to enable it to assue newly acquired management responsibilitieseffectively. The regional inspector of health will be responsible forinspection and control of health operations. The prefectoral directors ofhealth will assume greater responsibility for management of human, physicaland financial resources (although payment of salaries will remain theresponsibility of the Ministry of Economy and Finance); planning andpragramaing; supervision; and monitoring and evaluation. Health ManagementComittees (CGs) made up of comunity representatives will be set up tomanage resources and participate in progrem development within eachfacility. The CG will have primary responsibility for financial control andmonitoring and controlling financial resources collected through costrecovery. In collaboration with the prefectoral director of health andhealth center chief, it will review monthly financial reports, monitorexpenditures and define financing needs. Incremental staff needs for thenewly decentralized magement responsibilities have been filled.

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The project will provide training to the regional.inspector of helth, theprefectoral directors of bhlth and hospital directors in the fiveprefecturs to be assisted under the project and the cbiefs of the 17 helthcenters to be renovated under the project. Training will focus on thedevlopmnt of skills in angem ent, planning, accoutintg, stock inventory,drug supply managemet, training and upervision of steff, monitoring andevaluation. Training in the mt of finanial resources will beextended as wall to the heads of OG0. Four felloships in bhalth servicesuansgemDt will be provided to regional smnagers. CI. for the 17 healthcenters to be rehabilitated under the project will be established in August1987 when national staff will meet in Lobe with regional authorities toelaborate organizational arra ngemets for implementation of the regionalcc ponent. The project wIll also finane the renovation and extension of[IBAS offices in Labe and provide office, technical equipment, a vehicle andfuel to enable it to carry out its awly assigned functions.

b. StnreMatin of Baic telto Srvices (64 REM&agt of al

3.19 The focus of this compoent is on local level health facilities,prefectoral hospitals and health center which sbould provide bastc bealthcare services including outreach activities. These facilities represent thsmost cost effective vehicle for providing e ssetial services to the gratestnuober of boneficiaries in urban and rural area. The project willreovate these facilities, as docribed imediately below, and willstrengthen priority services to be delivered by these facilities, includingMOIVVP, nutrition, health education and outreach (pare. 3.22 - 3.28).

3.20 The project will upgrade 6 prefectoral bospitals, 6 urban healthcentero and 12 rural bealth centers. Buildings for each of these facilitieswill be renovated or rwonstructed; in the case of the-rural health centwer,the population will contribute about 30 percent to the cost of civil worksin money, labor and in local materials. , drugs, materials andfinancing of incremntal operating costs for supplies, fuel and otherlogistical support will be provided. To strengthen outreach and supervisionactivities, the project will provide vehicles for hospitals, otorcycles forhealth centers and 2-way radio equipment to facilitate coomunication betweenthe hospital and health centers.

3.21 In an effort to maintain the upgraded quality of renovatedfacilities and to complement proposed 1w rovement to the central mainte-nance service (para. 3.09), the project win support the strendgthoWng ofthe M maintenance service in the regional capital city of Lobel Inconjunction with efforts at the central level, it will finance 24 month oftechnical assistance and training in the setting up and anagement of apreventive mintenance syste" at the local level and on the maintenmance oftechnical equipment. It will also provide equipment, vehicles, materials,'and incremental operating costs in support of iuplentation and a tof an outreach program of preventive and curative maintenance.

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3.22 Materl -nd ¢bild §Helth -R(MCO Seic. Materal ad childhealth care In guina Includes the following services: suveillanc ofpregnant and lactating wom (prticularly high risk pregnacies),deliveries, pre- and post-natal cre, well baby clinics, vaccinations andoral rehydratio. In adtion to masures being taken at the central leel,the project will support the ttheg of tbhse servies through theprovision to prefeoctoral hospitals and health coters of necessary equipontand materials, including gyneological and other technical equipment, growthcharts and baby scales. The project will also support outreach activitiest the provision of motor scooters for helth center midwives who willundertake training and suprvision of village birth attendants, who,themselves, will be provided with simple midwifory kits. The project willfinance incremental recurrent costs, including equipment maintenancp,replenishenet of supplies, vehicle operation and maintenance and otherlogistical support.

3.23 Fbmily Plsminst (VP). The project will support the introductionand integration of VP services beyond Consky to hompital and bealth

enters, in the project area. Thse services iaclude family bealth education,the promotion of birth spacing practices and the prevention of high riskpregn aies. Under the proJect, ten bealth staff (2 per prefecture) will betrained in family plannig techniques in Tunisia, wbose national program bhaenjoyed Nch success. Bach bealth facility to be refurbished under theproject will be prowided with gynecological equipment and materials; andhealth staff will be given inmervice training in family planing servicedelivery. Family planing education will be provided for under theproject$s health education component.

3.24 The project will also support the extenion of AMF's activitiesto the regio of Middle Gunea (pra. 3.13). They will be undertaken inws!sn's training centers located in prefectoral capitals and run by theDivision for Women in Development within SAS. The project will provide theAGUF regional office in Labe with furniture and equipment needed to executeits responsibilities (promotion and provision of FP services) and willfinance a vehicle and operating costs for the supervision of regionalactivities. The project will provide training end materials to permit theuse of health and family planning documents in literacy program and willfinance activities to sensitize target groups about the benefits of familyplanning services. Ncmedical contraceptives will also be provided to theprefectoral level women's training centers to satisfy the demand for familyplanning, which is expected to be stimulated by promotional activities. Asnoted earlier, disbursaement of funds for AGIEI activities will beconditional upon the Association's approval of an agreemnt between MBAS andAGIEF On the terms and conditions of the grant (parm. 3.13).

3.25 The project will also finance minor refurbishment and equipment ofthe 6 prefectural women's training centers (para. 3.24) in the projectregion which are responsible for carrying out women's developmentactivities, including functional literacy training and other activitieswhich would promote the social and economic wellbeing of women. These

23 -

training eters will be instrumental in protX gmternal an childhealth. Inervice training will be provided to one social worker perwomen a center who will be resposible for managing women's activities atthe prefectoral level; tbey will alo be provided with motor scooters adopeating costs in upport of outreach activities.

3.26 IhVtrition. Project support will focus on developing local andregionl capabilities to car out nutrition surveillace, recupertion andeducation, with particular emphasis on maternal and child nutrition. Itwill support the incorporation of nutrition training into refresher coursededigned for hospital and healtb center personnel and will provide then withthe mean to carry out nutrition activities including equipment, materialsand logistical support. These activities will be reinforced by the, bealtheducation program to be imple'ented under the project.

3.27 ealth Education end Coumitv Deve10ent. Information,education and comunication (1C) program developed by the Health ducationService in MSAS would be tested under the regional component of the projectfor eventual we countrywide. Thse mss wmould covr M IP, theprevention of AIDS ad sexully transmtted diseases, nutrition,Iimmunization, family hygieeo, community bhelth and other preventive heathseanure and would be introduced through hospitals, health centers andvillag outreach programs wall as through youth, woman's and otherco munity groups. To enable the staff to carry out these activities, INCsubjects will be introduced in refresher and inmervice training prograes;particular epbais will be given to developing interpesoanal communicationskills of health and social personel.- The project will provide materials,equipment and transport and fuel costs to eanure the successfulimplementation of this progrm.

3.28 In order to give cou wities the opportunity to put Into practiceacquired hehlth and nutrition information. US$100,000 equivalent bh beenallocated under the project to financ small, health-related projects in anarea of about 70 comunities. Such projects wil support activities whichwould improve the health and wellbeint of coaUnities. As part of outreachwork, health center staff would asist comunities in identifying andpreparing project proposals. These would be forwarded by health centerstaff through the Regional Inspector of Health and Social Affairs to theProject Munagemeut Unit (tUP) for approval. Another US$100,000 equivalentof project fundb would be used to finane implementation of ocial andeconomic activities to be undertaken by existing womens cooperatives in theproject region. This am will allow women the opportunity to put acquiredtraining into practice, raise their incoese and improve the health andwllbeing of themelves and ot their children. Bringing women together insueb grous will also provide a effective venn for creating increasedurareness of health, bygien and ntrition practice and of the benefits offmily plaming. Proposals for "projects In support of these activitieswill be forwarded through the Regional Ispector of Health and SocialAffairs to the central Division for Women in Development for its appraisal,and, submsquetly, to the VW0? for approval. Disbursement of funds for

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for me's ad community activities will be conditiol upo theAociation's approval of - anul plam of action for such activities,which wuld be submitted to the Association by 8ept_eb 30 of each year.

1acb propoal would include investment and recurrent cot etimte and aProposed laplemetation scoeduloe d would be approved by the PU oan thebasis of its technicl, economic and financial tfaibility, itssustainability, its replicability, and its expected socieconomic benefitsto the cimuity. Once a subproject Is included in the above-mntioedannual pla of action and approved by IDA, the PCU will finnceo 96 percetof needed equipment, materials and training with funds from the localproject aunt. The villages and oman's cooprative will fionan 8percet of nvestmets and will be financially responsible for intand otbhr oporating cots own Initiatives are i operation.

c. Upgdading Skills of Raion Halth Psnnel (I Dercent of tota

3.29 The Training and Research Srvice of 16* will train stafftraines. These will cary out a progr of refreshr training for existingstaf in the five prectur which would focu on the dolivery of priorityserice to be stregthe unde the project (ai 32). Training will

massa all paramedical d social servios staff in prefectoralhospital, health center ad womoe's training cnter to be renovated umdrthe project ad will be extended a well to traditioal birth attendats in72 villoges. Training will focu en 8wro glw helth and ocial sevicodelivery, tocusint particularly on co,uity helth, pre- ad post-natalcear, deliveries, family planiw techiques, health edcation, cmityoutrech ad social deelpmat. Th project will finance 4 onths oftechical assistance to orgaize trainin activities and equipmet,mterial, trasportation ad operating costa of Implementing the trainingproVI..

d. ovim al Mnaemnt and Cost Recver (7 percent oftotal base costs)

3.30 During proJect preparation. a study of the financial managemnt ofthe soctor ws undertake within whch ccot recovery scebes wer dvelopedfrw the health centers and existing schme revied for the prifectoralhospitals. The project will support in the project region the introductionof cost recovery activities at the health center level and the strengtheningof cost reovry activities at the hospital leel. Under the proposedschee, a flat fee will be charged for each treatment which will cover thecomultation ad required drugs. Tbhes fee vary with the type of diseand are set on the bais of the cost of the treatment (includin the cost ofdrug) and its affordability to the population. A schedle of fee to bechrged at the health center, which bhA been agreed with the Qovement, isprsnted n Aex 3-3. Fe will be charged for curative ervies only;preventive swviceo, such as iuniztion, fmily plaming and nutritioneducation, will cotinue to be provided free of cbhge. The target for costrecovy activities, when fully impleented, will be to covwer about 80

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percent of all non-salary operating costs of health centers, including 100percent of-the cost of drugs and about 50 percent of the balance of non-

* salary operating costs (including operation and maintenance, logisticalsupport, supplies, vaccines and amortization of investments). This targetis reasonable and will be monitored annually and extended to other areas.

3.31 Before this target is attained, the project will ensure anadequate supply of drugs for health-fatt$ties, allowing them sufficienttime to assume gradually over the life of the project, the financialresponsibility for replenishing drug stocks and covering a portion of otheroperating costs, through a financing scheme for drugs developed under theproposed project. Under this scheme, IDA would finance, in FY87, the firstyear of the project, 100 percent of an initial stock of drugs for each ofthe health facilities to be renovated under the project, and, subsequently,the cost of replenishing these drugs on a declining basis: 80 percent inthe second year, 50 percent in the third year, 30 percent in the fourthyear, 20 percent in the fifth year and zero thereafter. The financingscheme for the gradual assumption of drug costs by the beneficiaries and theconsequent declining financing of rDA is presented in Annex 3-4. Theproject will provide 2 months of technical assistance to assist in theinitial implementation of cost recovery activities and will also financeequipment, materials and other necessary operating costs.

3.32 Drugs will be procured centrally once a year, initially by the PCUand eventually by Pharmaguinee once it has been sufficiently strengthenedwith AfDI msistance (para. 2.34). Drugs will be stored at the IRSASfacilities in Lab6. Bach health facility will receive an initial 3-monthstock of drugs which they will be responsible for replenishing quarterly,based on the preparation of a report documenting the actual consumption ofdrugs for the prious three months and the projected needs for the comingthree months. During negotiations, the Government undertook to open andmaintain an account in a co ercial bank for deposit of cost recoveryproceeds which shall be used for the purchase of drugs to replenish thestocks of facilities practicing cost recovery in Middle Guinea.Disbursement of funds for drugs will be conditional upon the opening of thisaccount. During negotiations, the Government also undertook to beginimplementation of the agreed schedule of fees in the 5 hospitals and 17health centers to be rehabilitated under the project immediately uponreception by those facilities of their respective initial stocks of drugs(expected during the first quarter of 19B8). It provided assurances that(i) it will submit to IDA for its review by June 30, 1988 an action plan forthe extension of cost recovery to other facilities in the region of MiddleGuinea, and will agree with IDA on a timetable for its implementation; and(ii) it will prepare and submit to the Association no later than September30 of each year an evaluation of cost recovery activities being implementedin the Region of Middle Guinea and proposals for their refinement in lightof experience gained. Annual evaluation of cost recovery activities andproposals for their extension will be undertaken by the Regional Inspectorand the Prefectoral Directors of Health and Social Affairs with theassistance of the DAF (para. 3.08).

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3.33 Financial manaemnt and cotrol of collected resourcs will becrried out as follow: hospital and health cnter staff will be trained tomaintain acounts and to operto iple finacial nagment and cntrol *

sytm; IECs will udertake monthly reviews of financial stateents andmoitor the collection and documentation of financial resources and theirue and will be responible for asssing the ability of beeficiaries topay for services; ed prefectoral directors of halth and social ffairswill supervise the _manamt and implmetation of all aspects of costrecovery activities. The project will finaee the costs of training inaccnting and finanial mnget for helth center staff and for helthcomittee mabor to enable thm to Iplem t, moitor and manage cotrecovery activitie. As a condition of effectivenes, the Goverment willdevelop and put into place simple f*inial maemet and control systmfor the hopitals end bealth center to be renovated under the project topomit the prpr maagent of finacial resuces. During ngotiatieonthe Govern_mt and the Aociation agreed on the genea principles for thedevelopmt of the system, which will be developed with PlY asistance.Accouts for the revenues collected through cost recvry in the heglthfacilities to be renovated under the project will be establised inconjunction with the developmet of simple finacial maagment and coutrolsyst. Becas_e of the somll sise of individual accounts (ranging from3*2, 000 to US$1B,000 equivalent), they will be selectively audited

according to terms of referenco satisfactory to the Asociation (para.5.14).

3.34 While, at present, most hospitals are required to remit collectedfees to the Treoaury (pwra. 2.21), health center which do practice costrecovery retain revenues. In order to ensure the retention and propermanagemnt of tnoancial resources, the Government will submit to the'Association as a condition of project effectiveness a Ministerial arr*tdsigned by the Minister of- altb and Social Affairs and the Minister ofEconowy and Finance autborizing the retention and management by hbelthfacilities included in the project of revenue collected through costrecovery activities.

IV. P9OJECT COST AND FINUNCING PUN

4.01 The total cost of the project is estimated at US*22.5 millionequivalent, net of taxes and duties, with a foreign exchange comPonent ofUS$11.8 million equivalent, or 52 percent of total project cost. Details ofthe project costa are given i Annexes 4-I through 4-3 and are summarized inTable 1 below. The bases for estimating costs are given in Annex 4-4.

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Table I

CU1P M1LL1on) (USS Mi llion) I Tota

>-- 1 FOrt Tof uLcal Fov.in Tot Exbo Cost

A. 1101112ONU L EUELWt

"AMB As1Jl_ 56*8 45.2 586.0 0.1 1.1 1.2 8 72.

F P30M3 amlS 14.2 331.8 M.o 0.3 0.6 1.2 70 7

hb4tot4 IWWII~ mawumnlUFU 17.0 763. m.o 4.5 1.9 2.4 0 14

Sao= IN No" NM

to I DUN= o0:T CWALUTIB IN

NW1F IECl tIZIIO 118*5 262.4 310.9 0.3 0.6 0.9 6 52. S _RISHEN W

NImCWIN s6M. = IIS.9 227h67 4,255.4 4.8 5.4 10.4 53 613, UOIWD SML

f NEALTN I U t 13.9 39.4 564 0.0 0.1 0.1 6 14. TEIN

COST RC -11 ;:IMIMIFMEIIIWNEIIRT 17.2 14.7 31.8 0*0 060 01 46 0

M-rotl DEELnPNEIT V NINM SECTORnPEATIN IDL one 29133,4 2493.2 4726.6 5.2 6.3 11.5 55 68

C. PRIJECT _MEITAI An IiSlaTI 246.3 077 654.0 0.46 1. 2.1 71 12

go WATISUFFF 65m1 305.0 370.1 0.2 0.7 0.9 82 5- -z- - -- n-

Total seLIE COSTS 26421.8 4203.9 69930.*7 64 10.5 16.9 62 100Phuical Ciutdmflhi- 239.3 372.5 U116 0.6 09 1.5 61 9Price Continiancios 1.528,4 153.4 1,*666. 3.7 0*4 4.1 9 24

Total PROJECT COsts 4.409.h 4,619.8 9,229*4 10.8 11.8 22.5 52 133umi n. m ma- .

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4.02 An IDA Credit of Us$19.7 milion equiva.ent would fInanc 87percnt of the total project cost, net of tae. Tbe credit would finance100 percent of the foreign costs and 73 percent of local cost. The balsanof project costs would be financed by the Governent (US$2.0 millionequivalent or 9 percent of total project cost) end the benficiaries (US$0.8million equivalent or 4 percent of total project cost). A financing planfor the project is give in Table 2 below.

Table 2 - Ficing Plan(US$ million equivalent)

Cattorv r t of a lmeficiaries DA Iot

Civil Works 0.2 9.5 9.7Furniture,- - 1.8 1.8Equipment,vehicles,Material

Drugs - 0.6 0.7 1.3Technical Assistance, - - 3.4 3.4

Contractual Servicesand Fellowships

Studies and Technical - - 0.7 0.7Training

_anagement Training - 0.3 0.3Funds for Implementing, - -s 0.2 0.2Women's and CounityDevelopment Sub-Projectat the Village Level

Funds for Strengthening AGBEF - - 0.1 0.1ProJect Preparation Advance - - 0.9 0.9Incremental Salaries 0.2 - - 0.2Operating Costs 1.8 - 0.5 2.3Unallocated - - 1.6 1.6

Total 2.0 0.8 19.7 22.5

* US$4,000.

4.03 The project will finance incrmental recurrent oswts on a declin-ning basis (para. 5.11). When fully developed, the project will generateannual incremental recurrent costs On the order of GNF 208 million (US$0.5million equivalent) in constant 1987 prices, of which Off 73 million forincreental drug costs and GNF 135 million for otber incremental operatingcost. of health service delivery and administration. A detailed breakdownof these incremental recurrent costs is presented in Annex 4-. Revenuesgenerated through cost recovery should effectively cover by the end of theproject all drugs needs in the 5 prefectoral hospitals, and in the 5 urban

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and 12 rural center and about 50 percent of oter health facility opeatingcosts, which had not bees effectively covred by the health budget. Thetovernbent will so the tiacing of the balane of amual ineremntaloperating cost amounting to GKW 135 million (US$0.3 million) or 6 perentof the total health and social affairs budget for 1986. It sould be notedthat the helth and social affairs budget is vey low - lese than one halfof that for Niger, with a population a large as that of guinea.

V. PUOJBCT DAISNPION

5.01 Project Prearation. Under a first Project Preparation Facility(PP?) advance of US$300,000 equivalent, approved in Februar 1986, the MASsot up a natioal project prepartion tem, which undetook preparationactivities with the technical assistance of specialists in civil works,planning, coordintion, public health, INC. management and organizatisn,health financing and cost recovery. With the active participation of thehelth authorities and of the beneficiaries of the region of Middle Guinea,the preparation team undertook the design and preparation of the regionalcomponent. It developed an integrated primary health care program forMiddle Guinea emphasizing MIVIFP, preventive services and basic curativecare and identified essential requirements for its implementation, includinga training program, supervision, outreach, supplies, maintenance, logisticalsupport and other incremental operating support. It also prepared a rehab-ilitation program for health facilities to be asolted under the project,including an implementation schedule. For the national component, itstudied and elaborated reco endations for improving management of MMASwithin its Mne oregaizational structure, developed an appropriate andcomprehensive health education program and elaborated a cost recovery feesystem, including proposals for its management and iapleentation. TheGovernment proJect preparation docunent was submitted to the Association inOctober 1986. During proJect preparation the tBAS undertook an inventory ofall its health personnel. The recruitment of local staff needed to fillvital positions within tEAS is underway. With AfDB assistance, theelaboration of a management training program is currently underway andshould be completed by September 1987. An essential drugs list and a drugformulary have been prepared by the Government.

5.02 A second tranche PPF was approved by the Bank in April 1987 in theamount of US$660,000 equivalent to ensure sufficient advancement of projectstart-up activities by the time of credit effectiveness. The four maJoractivities to be supported under this second advance are: start-upactivities for the civil works component, including design, survey work andsite development; overseas mnagement training of staff appointed to keypositions in priority units within MBAS and in the project management unit;the setting up of simple financial management and accounting system forcost recovery, and a project lar1ch workshop to be held in Lab6.

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5.03 Project _aEgMt. The MU will be responsible for mnagemntand implemetation of project activities, wich will be integrated into itsexisting sevices. Particular attention wns pd during the course ofproject development to minimize the ned for incremental staff. Centralministry units in chagse of progrm to be streftheand dr the projectwill have primry responsibility for proJect Implementation. A projectmanagement unit (UGP), reporting to the NS8 staff director (Directeur duCabinet), is in place. It will be resposiblo for overall coordination ofproject activities, preparation of annual work progra and budgets,monitoring and evaluation of activities, procumo nt of goods, processing ofcredit withdrawal applications and consolidation of project progressreports. The VOP persennel, drawn froa existing MMa staff, consists of anational coordinator, an architect, a procurement officer, a forwardingagent, an accountant and support staff; it will be assisted by about fourstaff-years of technical assistance in procur- A t, auditing, plamning andprograMing of activities and project evaluation. Asurances were obtainedfrom the Government during negotiations that the DOP will remain fullystaffed during the life of the project. The project organization scheme ispresented in ADBmL-1.

5.04 To ensure frequent coordination and full involvement of concernedstaff and units within the M[AS in project implementation, the CTC in [SAS(Par. 3.04) will during its quarterly meetings carry out a thorough reviewof progress in project implementation. The Rbgional Inwpector of Health inLab6 and the five Prefectoral Directors of Health will be responsible foroverall managemt and coordination of project activities at the regionallevel.

5.05 Technical Assittance and Fellowdhia. The project will provide atotal of 181 months of technical assistance at an average cost of US$12,000equivalent per month. These experts will be recruited by the UGP in accord-ance with IDA guidelines. Logistical support for technical assistance willbe the responsibility of the technical units receiving assistance. Technicalassistance is sumarized in Arr 5-2. A total of 174 montha of fellowships,itemized in Amex 5-3, will be financed under the project at an averagemonthly cost of US$1,000, for Africa, US$1,380 for Burope and US$1,740 forNorth America. Following a procedure that is already working satisfactorilywithin MSAS, the PCU will manage the fellowship program in consultation withthe Training and Research Service and with the appropriate technicaldivisions. During negotiations, the Government agreed that for allfellowships to be financed under the project it will (a) submit to theAssociation for its approval (i) the functions and qualifications of thecandidates and (ii) the curriculum or program for the propose training; and(b) take all necessary measures to ensure that all individuals receivingsuch training rmain assignsed to posts for which they were trained for aperiod of at least three years after completion of training.

5.06 Civil works. Under a first PPF tranche, requirements for renov-ation and for reconstruction, as well as preliminary cost estimates, wereprepared for 5 hospitals, 17 health centers and the Regional Inspectorato ofhealth in Lab4. These were reviewed and considered appropriate by theappraisal mission. All project construction sites are owned by MMAS and are

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available for construction. The UP ha locally recrited an achtoct an afull-tim basis to overse the contruction progm a noted below.

6.07 ospitabl. The UGP will hire architectual/egiseringconsltants under the second trn of the WI' to prepar detailedconstruction plan and draft bid docmentation and, subsequently, to

upevise cosmtruction. Did doc_ents will be reviewed by the Ur and theAssociation to ensure that the agreed standwds have been adhed to. Bidswill be publicly opened and _evauated by the Tnde Comittee of MSAS,which ha a its _mbw re presntatives of the Minstries of Plan, Finoaneand Public Works. lid Ineam atiom will be revied by the Associationprior to ward. It Is expected that draft bidding docm_ent will beavalable by the end of October 1987. Th WP director and architect, theRegioal Inspector of Helth and Social Affairs, the hospital directors andthe Regional Public Works Office will verity conotructio prore.s.

5.08 !1th cmtem. Architectural conmultants will be selected andrecruited by the IQP under the second tranche of the PPF to prepareconstruction plo, draft bid docmetatio and provide technicalsupervis ion duriog construction. The W P architect will prepare draft biddocuments prior to review by the Dnk. As discused with reprsentatives ofthe tEAS and Public Works, the OIP will advertis locally for bids for: (a)supplies of construction materiale; (b) labor for conotruction in accordancewith local procedwres acceptable to the lBak. As local coomunities will becontributing towards the cbst of renovation of the 12 rural health centersin labor., fund and/or material., the UIP will prepare local protocol 'agreemn ts with counity representatives which will elaborate the contentand costs of the local contribution, the implementation schedule andarrangements for the supervision and monitoring of works. Contracts for thernovation of each center will be drawn up so as to exclude localcontribution and construction materials. IDA would finance 100 percent ofsuch contract costs. Day-to-day supervision of renovation works for healthconters will be unkdrtaken by a works supervisor, who will be recruitedlocally by the UoP and who will report regularly to the UIP architect and tothe Regional Inspector of Health and Social Affairs in Lab6.

5.09 Procm e-nt. All goods and ervtces financed under the projectwould be procured in accordance with the Asociation's guidelines. Contractsfor renovation of $ hospitals, whose individual costs range from US$1.4million to US$2.1 million equivalent, will be awarded o. the basis ofinternational competitive bidding (ICD) in accordance with the Association'sguidelines for procurement. A preference of 15 percent will be granted tolocal firm participating in ICB for civil works. Civil works contracts forrenovation of health centers estimated, not to exceed US$0.4 millionequivalent per contract, will be awarded following local compotitive bidding(LCB) acceptable to IDA. Contracts for furniture, equipment, vehicles,materials and drugs will be awarded according to tCB procedures acceptableto the Association. Exceptions to ICB would be for (i) contracts with avalue of less than US$78,000 equivalent, each of which would bo awardedafter LWB according to procedures acceptable to the Asociation; and (ii)small value items costing loss than US$10,000 equivalent per contract thatwould follow prudent local shopping procedures acceptable to the

- 32 -

Assoiation. The agpggate mountx of tbhe two eoceptiom is not expectedto exceed the equivalent of USO.4 million and UB*0.l million, respectively.Working arrangements for the prodction of radio and television heltheduction pro_ will be made with on a cas by cae bais. Wherfeaible, purchaes of dru and mdical equipmt would be ade throughUNICBF, which use International pr t p that are acceptableto the Association. Procurement arr t are auwrized below.

(us$ million equivalent)

Proaurent MethodTotal

Project Elemnt IC8 LC Other N/Aa' Cost

- Civil Works 8.8 2.0 (-) 10.5(8.5) (1.8) (-) (10.3)

- furniture and Materials 0.7 0.2 0.1 1.0(0.7) (0.2) (0.1) (1.0)

-Medical/Technical 2.1 (-) 2.1Equip_mt and Drug (1.6) (-) (1.6)

- Vehicles 0.4 0.2 0.6(0.4) (0.2) (0.6)

- Techical Assistance, 3.0b/ 3.0Fellowships and Studies (3.0) (3.0)

- contractual services 0.4 0.4(0.4) (0.4)

- Technical Training 0.8 0.8(0.8) (0.8)

- Mmnageet Training 0.3 0.3(0.3) (0.3)

- Project Preparation 0.9 0.9Facility (0.9) (0.9)

- Funds for Implnting 0.2 0.2Sub-Projects at the (0.2) (0.2)Village level

- Operating Costs 2.7 2.7(0.7) (0.7)

TOTAL 11.7 2.4 4.6 3.8 22.5(11.1) (2.2) (4.6) (1.8) (19.7)

a/ Not applicable.b/ Imploymet of technical assistance would be in accordance with IDA

guidelines.

Note: Figures in parentheses are the respective amounts financed by IDA.

33

5.10 Itm would be grouped to the extent practicable to encouragecompetitive bidding and to permit bulk procurement. Review of tnder

* _ dicmnts by the Asociation prior to ard will be required for civil workscontracts for renovation of hospitals; it will also be required for helthcenter renovation contracts valued at or above WS60,000 equivalent. Thisis expcted to cover about 60 percet of contracts. Reiew of tenderdocuments by the Asociation will alo be required for contracts forfturiture, equipmnt, vehicles, materials and drugs costing more thenU*60,000 equivalent each. This Is expected to result in covemrge of about70 percent of goods contracts.

6.11 D i ln n *a. The project is expected to be implemented over aperiod of 5 years as laid out in the implemetation schedules presnted innes 5. The credit of M$19.7 million equivalent will be disbursed over

six and one half years agpaint the following items, net of taxes:

(a) civil works (3S*9,500,000)* 100 percent of the total cost ofrenovation works for Lab6, Dalaba, Pita, Llomms end Tougudhospitals and for urban health centers and 100 percent of approvedontracts for rural health centers;

(b) furniture, equipment, vehicles, materials (US 1,800,000): 100percet of foreign costs; 85 percent of local costs;

(c) drugp (U3*0,000): 100 perent in FY87 and 88; 80 perCent inFm; 60 percent in FY90; 30 percent in MF; 20 percent in FY92end 0 thereafter;

(d) technical assistance, contractual services, fellowhps, studiesend training (13$4,400,000): 100 percent of total cost;

(e) funds for implementing women'. and comunity developmentsubprojects at the village level (USS200,000): 95 percent of totalcost;

(f) funds for strengthening AGDUF (U3$100,000): 100 percent of totalcost;

(g) in2remnetal operating costs (U*600,000): 60 percent in FY87 and88; 40 percent in FY89; 20 percent in FY90; 10 percent in M 1;and 0 thereafter;

(h) refunding of the project preparation advance (US$960,000); and

(i) unallocated (USS1,5C0,000).

A disbursement plan and an estimated schedule of disbursements, the latterbased on a Guinea disbursement profile of 16 projects, dated September 1985,are at Annexes 5-5 and 5-6, respectively.

- 34 -

5.12 Deiburseet aPplications to IDA will be grotped into packas ofat lent US60,000 equvalent and will be fully documted, except forexpene related to project edministratio ed imiscellan oporatingcosts, inovative activities of ¢amnities and w=mn' groups traiing andcontracts of les thl U$10,000 equivalent. These expens would berebburs agaist certified statemets of pena turs, for whichdocUntation would be retained for revie by MA supervision missions andthe project auditors.

5.13 Scial Aemt., To facilitate the finaning of foreign exchangeexpenditure by the Government, an amot of U0.4 million will be advancedfrom the IDA credit and deposited ip a Special Account held in a localce_mrcial bank under the control of the Project Director. The SpecialAccount would cover foreig expnitures estimated to be incurred locallyover a six xmth period and would be replenishod by IDA in accordance withthe disbursment pla In nAJIX 5- an receipt and approval of applicationsfor roisburement. In order to ensure that financing of projectexpenditures in local currency is promptly available, the Governmeent willestablish a sqparate replenishable Project Accout in local currecy, andwill deposit, in local currency, an initial amount of ODF 86 million(US$210,aoo equivalent), representing the approximate amount of operatingexpenditures for the first 4 months of proJect activities. The accountwould be replenished by the Government and IDA am it is dram douw, and atthe beginning of each quarter the Goenmnnont would deposit sufficientadditional funds to met estimated xpenss in the up-coming three months.IDA would replenish the account in acconce with the disbursement schedulein §& on receipt and approw vl of applications for reisbursemtcovering paymets ae from the account for eligible works, goods andservice required for the project. Opening of this accout and depositingthe initial am t of 0KV 86 million is a condition of credit effectiveness.

6.14 coutins. Auditinst ad eorti . The PCU and the IRSAS in Labewill establish and maintain accounto in accordance with accepted accountingpractices for all project expenditures. During negotiations assurances wereobtained from the Government that it will furnish to IDA annally, within 6months of the close of the fiscal year, separate audits of: the IDA SpecialAccount, the Local Project Account, selected accounts in the 17 healthfacilities for revenues collected tbrough cost recovery, AGB8F accounts,statements of expesses, including those for eomunity and women'sdevelopment subprojects, and other project accounts, which will be conductedby independent auditors to be appointed on term and conditions acceptableto the Association. Certified copies of the accounts and the auditorsreport will be forwarded to the Association for review within six monthsafter the end of each fiscal year. Quaterly reports on the progress ofimplementation will be submitted to IDA by the UGP. A project coWpletionreport will be submitted within six month of the closing date.

-36 -

VI. MM 337f mm RUN

A.

6.01 Tho project is expected to Improve the efficiny ndeffctivenes ot health sector opeation md to iWroe the qulity andcoverae of basic health sevice la the Region of Nlddle Guinea.Stregthaning M Ustitutionl capabilities will led to better planinand g t for the health sector and a more efficient utilization ofbhm, physical ad financial resoures in acieving helth sectorobjectives. n addition, mt ad decision mki responsibilitieswill be sufficiently dcetralixed to allow loal officials ad helthcittes the automy to plan ad progrm resorce ad activitie in a

aner mor responsive to local relities.

6.02 Strenathing ceotral units Ia corge of priority hoalthl pwill also incre the effectivene with which MM addree health andsocial problems. The establishmet of regular progrems of techiclinserice training and supevision of medicl ad peicl personnel willupgrade their skills, particudarly with regard to rority programs andervices, an, consquetly, iprove the ovall oulity of sevice.

6.03 The impl tation of the reidoal cosoent will improve theqality and accessibility of health weandA social welfare, eceavilable to aut 1.3 sillton peole by, 1993." he prmotia d eCsioUSof fmily planning to tos and rural ars wll also improve thehealth of otha and- chidre. The ined utilization of improvedservices will lead to a reduction in il1nee and preastur. deth freepreveale and eaily treatable diseses.

6.04 Th project will also allow th ove t to test and evluatehealth and social policy initiatives such as the decetralization ofmommag,met responsibilities within the sector, the mobilization ofadditionl resources for helth through indrensd cost recvery and theextenion of family planning sevices beyond Cnakry to secondary tns andrural areas. Experiece gained in the Reion of Middle Guinea will provideuseful guidnce for the eventual exeiaon of such activitiaes nationwide.

Risks

6.05 The project will be the first IDA-finaed opweration in the halthsector in Guinea end the NSAS has no experiae in implementing a project ofthis size and scope. Thee is, therefore a risk of delays inimplemntation. However, the Governmt's comitomt and the copete ofMAS staff to implement this project ha already beei offectivelydmntrated by the successful and timely copletion of project prepration.Loal staff responsible for project managemt and administration is of highquality; and the 16AS will complete the aswignmt of qualified staff to keypositions within NM8 by the time of effectivenes. They will also besupported by appropriate technical mistanoC and training. Moreover, mAchha already been done with PPF assistance to ensure expeditious projectstart-up. To leand further support, a project implemntation workshop is

- 36 -

planned prior to effectiveness. Th. risk of unsatisfactory luplemetationwill be further mitigated by the decentralization of sector managementreponmibilities in the Rksion of Middle ouinea which will elicit the directinvolvement of local authorities and beneficiaries in project management andimplemntation.

6.06 Another risk is that the cost recovery progm, desied togenerate additional resources for non salaried opating costs, will notsucceed. To minimize this risk, reasonable trgets for cost recovery havebee set and these would be mitored anually. The magment of resourcesis being dectralized to develop local cmotrol and improve mnagemnt ateach facility. These meaures should provide ealy warning system toenable gent comittees and health authorities to take timly andapropriate s_aures to vorrect any elem ts of cost recovery that are notworking effectively.

VII. AmR_II AMAD QMNA

7.01 During negotiations, The Government of the Bepublic of guineaprovided assurances that:

(a) it will submit to the Association for its review and agreement byMurch 31, 1988 a national drug policy and a plan of action for itsimplemeotation (para. 2.34);

(b) organizational changes in NBAS will be carried out in consultationwith IDA (pam. 3.03);

(c) it will evaluate its program of medical and paramedical staffdeployment, including annual staffing objectives and progress inachieving them, and prepare and submit to the Association for itsreview and approval no later then September 30 of each year arevised program of staff deployment based on the previous year'sexperience (pare. 3.06);

(d) it will review with the Association by September 30 of each year(i) all investment expenditures made in the health sector in theprevious year and those proposd for the coming three years, aspert of the rolling public investment program, with particularattention being given to recurrent cost implications; (ii) theallocation of the recurrent budget across existing programs andservices; and (iii) the appropriateness of drug policy andGovernment progess in its implementation; and that it willorganize by November 30 of each year meetings of all aid agenciesparticipating in the financing of health sector activities inGuinea (parm. 3.07);

(e) it will evaluate annual technical in-service and managementtraining activities undertaken during the previous year and

-37 -

furnish to the Ascmiation for its review sd approval bySeptoer 30 of each yew revised plum, based on that evaluation,for in-service technical and _magerial training (para. 3.11);

(f) it will open and maintain an accomut in a com_ercial bank fordeposit of cost recovery proceeds which shall be used for thepurchase of drugs to replenish the stocks of facilities practicingcost recovery in Middle Guinea (parm. 3.32);

(g) it will begin implementation of the agreed schedule of fees in the5 hospitals and 17 health centers to be rehabilitated under theproject irnediately upon reception by those facilities of theirrespective initial stocks of drugs (para. 3.32);

(h) it will submit to IDA for its review by June 30, 1988 an actionplan for the extension of cost recovery to other facilities in theregion of Middle Guinea, not being renovated under the project,and will agree with IDA on a timetable for Its implementation(para. 3.32);

(i) it will prepare and submit to the Ausociation no later thanSeptember 30 of each year an evaluation of cost recoveryactivities being imple mented in the region of Middle Guinea and

.proposals for their refinrmt in light of experience gained(para. 3.32);

(j) the lISP will remain fully staffed during the life of the project(para. 5.03);

(k) for all fellowships to be financed under the project, it will (i)submit to the Association for its appraisal the functions andqualifications of the candidates and the curriculum or program forthe proposed training and (ii) take all necessary measures toensure that all individuals receiving such training remainassigned to posts for which they were trained for a period of atleast three years after completion of training (para. 5.05); and

(1) it will have the IDA Special Account, Local Project Account, theaccounts for the revenues collected through cost recovery in the17 health facilities, statement of expenses and all projectaccounts, and AGREF's accounts, for each fiscal year audited byindependent auditors, and that it will furnish to the Associationaudit reports within six months after the end of each fiscal year(para. 5.14).

Conditions of Effectiveness

7.02 As conditions of effectiveness, the Government would:

(a) submit to IDA satisfactory evidence that all newly reorganized

- 38 -

units within bMB to be tnwed under the project hbe thekey staff idetified in Am_31=1 (per1 3.03);

(b) deelop and put Into plaeo siple finmce1 l _mnagaet and controlsystems for the hopitals and helth cente to be renovated underthe project to pedit the proper tof financial resoure._d *umit to the Association the wr$td signed by the Minister ofeonomy end flumes and the Minister of elth end Social Affaiauthorising the retentin end a_et by ealth facilities tobe renoted uder the project in Middle Guina of rourcescollected through cost recovry actties (pas. 3.33 end 3.34);

(c) set up an apropriat, project accoutin motes (par. 5.03); ed

(d) ope the Project Account and depoit en initial bunt of (IWF 86million (paru. 5.13).

Coitionm of Disbumnt

7.03 The conditions of disburment are follow:

(a) disburs_ et of fumd for inovative activities will beconitional upon the Assoclation's approval of en anl plan ofwtion for such activities which would be sumitted to theAsociation by S.ptoer 30 of each yea (pare. 3.28);

(b) diebsant of fands for AO activities will be conditionalthe Asociation's approval of e sgrem t betwn HEM and

£01 o the twr end conditions of the grt (pare. 3.13); and

(c) ds t of funds for drugs will be oanditional upon thepening of e account in a co myeial bak for depoit of cost

recovery proceed which hll be used for the purchas of drug toreplenish stocks of facilities practicing cost recovery in MiddleGuinea (pa. 3.32).

7.04 On these conition, the project would be suitable for an IDAcredit of W*19.7 million equivalent.

- 39-

IWLT SICBS BLVM Elmo

BABIC DATA

Total Area 246,000 kmhTotal Population (1985) 6.1 millionDenity per kin 24Rate of Nitural Incre in population (1986),Total Fertility Rate (average live births per van

at end of reproductive lif. (1980) 6.1Crude Birth Rate (1985) (live birtbh per 1000 population] 47Crude Death Rate (198) [deaths pr 1000 populationl 20Child Death att (deaths 14 per 100 children

in age group) [1984. 44 'Urban population as X of total poplation (1984) 27Adult Literacy rate (198- estimate) , 30.2 -Prijary School enrollmet (1984 estimate) 23.8Age Structure (1985)

0 - 14 44X15 - 64 53X65 and over 3*

Population per physician (1986) 9,893% of physicians in urban areas (1986) 923Population per nurse (1986) 3000Daily per capita calorie supply (as pecentage of

requiremet 1983) 84Per capita Gross National Product (1986) US$ 330

Sources: - 1986 World Development Report- Ministry of Health and Social Affairs, Plan d'Action Sanitaire

de la Guino. pour Ia period. 1987-1989. Conakry, November 1986- PI Sector Report No. 6229-GUI, May 16, 1986.

r-

l -

Organiastiomel Q1gkt of tbg Minstry of HeIlth ad Soid Atffars

o°f mm se F--

. for lth o Dlduf Insc _ Servies

aegltlnd S4ut f

Labomt*W meacim SCabin Ttv&c@tt a Suwlia.s&MVIces: ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ I imaea Amr.inalstrial N"ImCentral natl fr

-9041th B&CatiDir ndTorateGnerl elt blic altb |ie tlw . Boni cionl oB l c ?a st e i

Iaoratoq M edice Care 1 Mdicine -Service - Cuter & Meinaumm

Se Jrvices . .eJlitite 1){diyna for . _at

trial Helth PIeig, Stce .intb Bducati adTan

cable iea_e Se*-e:

Prcessing'

-41-.- . e.

*13 2-2

Org.tstts Om2. at d. S.astadat of ftate

______b_ v___ _

M~in No inau _ud SwAS* ft £

~- tSW og'st

- ..

EE1 mfvS ubta8" l8n ~ t

KV"d"I fo.uimpdVSt

9 ~ ~ ~ ~ ~ ~ ~ . .

alvim mo* amo foetml

tott;im Ca*,

s ma

Health r t_e t umtt I977CGNF million)

......... .......................... ... ...... ...... .. ... ..... ... ... .............. ........................ .. . _._ ..... .. . .. ._ . .......... .......... ... ................ .. . _. .. ... ... _._. ..... .. .......... .. ... __. ...... .. .. ........ .

ISI I I Smm d11I 1 910 I 130 It, ltstemul foe"

_--- - .- _ ..-. _.--….. _._. I----..-..-- ... ... -.--------...- I-....- _. t-_--.-_-.__tre,t at. _m_l talm bbl NMt. _wtmt alami low t1. _wlmt Odmnl law. Me. 1au u stlmi Nate I

taw k t foe" I SA few I 1t rSow-,,---------,---,---,---._ ....................................................................------------------- I----------------------------I----------I --. -.------

lntitt bdicim Iradiltril o.* - .0 1 n2. 12.0 I - 12.8 2. I 0.0 14.0 £. IS _ tSlU btal ttmisg Fuilid 4.0 4.) S.O. - S.01 3.0 - 3.0 I 1. - 2.6 1Dpi M, AU-Ulmiug fSiliut 14.3 51.0 44.31 1S.3 t. 23.3 1 S.3 0.0 23.31 .1 4.0 3.91 ItbailiWim Iwid lwac 5.4 .S 3. I - - - s - - - 5.4 s0.6 36.01 F Saobe 1u: 9issi kS 6.0 12 32.2 - - -I - -- 6.0 3.* 1.- if (MI Luttl cmtleI'mchwcu 45.0 310.0 35.0 I 20.0 310.0 302.01 11.0 31.6 3W. I 1.0 W.0 in. I MP1tictieMCm ,l e1II 12.0 - 12.0s - - -t - -l n. - n.0 ) Ittem tbie "I. tram. (at10) n.s 23.1 9.2 1 3.s - u3.5 - - - £ Ie.0 2. i1.1 s i_wattire d'wim ladise1 13.2 - U3. 1 - - S - - -I U.2 U.2 1ute t swsychiatric h 13. - 1.0.0 I - - - I - - - 1. - 1.0j

liai,ut w Switain to"t UI. 1.0 1-.08 15.4 - U.41 - - 1 33.4 - A.4 1Cuutiti 1o cUe l Sute Pt". is 64.0 64. 1.6 1 91.6 I .) 1201.9 1 - - - J 154 £13.3 86.1 I Fhit dwu _" 5 uw 4.S 210.1 5 I.2 Its0.0 2m. V4. 2I.0 22S4 23 I 0.5 n8.2 3110.1£ DAhueti. mwiprn ote e fall U/pe*f. all - 3. I 5.U sI.0 435.01 3.0 1M.0 130. 1 53.0 13.6 113.01 J M "IIew tl Iuibtiiuim. tlS S11at 3.0 I".0 10.01 - - - C - - - I 3.0 184.0 )iO I Wletilate bitim fast 23 43.5 422.S) - - -I - - - 2.3 4.5 423.1 5(m9l)9 temzbie, bus* h 18.4 52.0 .41 0.0 - .0 I--I.4 5 13.4n1 Sw. Eqtpisml Liweleir dn SU1 5.4 24.0 3.28 S. 25.5 3s.5 - - - I £6.4 3.3 0.71 NWuels di Sdi-auls 17.5 - 17.58 - - - I - - -U It.S - t.S I

t uim is ca ela de Sute *tabi 4.3 27M. 325. I 6.3 1.0 11 .3.4. I 4.3 30.0 42.31 SUS.0 .. 81.01 inOIitilatim 6pitl tws L.S 243.0 24.31 1.5 146.2 41. -I- I Lo 3.0 3. I El am

pau Statrs dei ccietisUm, 51 14.0 11.3 4.0.3 1 183.0 616.6 M. I 11.0 W. S.0 311.0 1.3 2336.3 t5. ON ,tLut Cme uleie d $wil - -t - 120.3 £3.01 - 121 21.01 - 241.1 201.01 J N _ ICults timi Grkl osif 1£.6 - 0.010 13.8 43.5 5. 1 7. 3t.0 51.0 30.0 03.5 1.3 I am ytluslute 3lhuIo ie - - - I - 25.0 251.0 1 - - I - W.W 251. I: m ytL a.t)iu lte flw - 54.0 54.01 - - -- I - 54.0 54.61 km "t

1lola 10.1 4211.4 6L. 50.4 GIA.4 3. I 55. 51.6 511.2 I 8311.1 1M-.4 0.5

.................................... . ... . ........ ............. .. ........ .................. . .. .... - -----.. .................. . ...... - - - ----- - ------ - - - .............

43 -

Pae of 2

TIAIR SUVICBS DRYTWAIMI PFART

StlIAL for Central MAN Unit to 1b Str edUder the Project (Xinimu r.ouirentu

(Key Staff Necesary for Btfectiveess Mmrked with Asterisk)

A. Division of Prevention and Pr*m Health Care.

1. Maternal nd C!dld _1ath ad Fmily Piami Serice.

I Chief - ND*1 Administrative Officer2 Nts with spcialization in NOR and m*1 Finance Clork*I Sscretry/typist*

2. - lth Education -vice

1 Chief - ND or Social Scientist with trainig in MassCMnications*

1 Assistant Chief, Social Scientist with IBC training1 IBC Applied BAN cher*1 Speialist in IBC trinin and curricul developmnt*1 tmsag (I3C) Conceptualizer1 Radio Technician1 Video Technician1 Photogaher1 Designer/artist1 Doc,mtalist

3. Nutrition Service

1 Chief - ND with training in Nutrition*1 Nutrition Specialist*1 Administrative Assistant1 Clerk/typist

5. Division for Women in Develoiemnt

1 Director of Division - Social Scientist with training in women'aprogram*

1. Women's Develotmet Servica

1 Chief - Social Scientist/Social Worker*1 Administrative Assistant*1 Clerk/typist*

- 44 -

Pae 2 of 2

2. Coonera Outt * Proram Service

1 Chief - Social Worker with trainig skills*I Administrative Assistant1 Specialist in Nume's Cooperatives*1 Clerk/typist*

C. Division f-rIBfr Xtn:trl lid q

I Director - Architect or Helth Raginer*

1. Medical R@uiumnt Mainteance Svice

1 Chief - Medical equipmnt umintesm techniciam*1 Techuician*

D. Division of Adaintration amd Fi_a

1 Director - dministrator/Accountent*1 Accountant/Finance Officer*1 Administrative Assistant*1 Administrative Clerk*1 Secretary*

1. ma Reso Service

1 Director - M with Personnel Mmnmg.nt training orSecialist in amnesoure Mlt*

I Health PeWrsonne Officer*1 Social Affairs Personmel Officer*i Administrative Personnel Officer*1 Secretary/Typist*

I. Divisoa of PlanDins. Training end Studie

1 Director*1 Senior Health Planner*1 Health Rconomist*1 Medical Statistician*1 Doameatalist*1 Progracmr*1 Secretary/typist*

1. raning ad Rsarch Servie

1 Director - Kpidemiologist*1 Training Specialist*1 Research Officer1 Clerk/typist*

- 45 -

2-Page 1 of 2

Tmhaicml 'p'~minMik Pa sd P.rica Pr.c l Middlg

Traiin Curse title a loction Pticition tilo and Dratioo Funn

I I I1. Traning cose Public Oealt, techncal 1 40I S NApril l87 - tw Wbsi U

and Namt, Coa". I I

2. egonal traininginn eltb Sevice I SONedsof la,lw 19J- a Oebs I a10Hanage_nt, Lae. I facilities I

3. Regional MMNCFPItrtitin course Lab. I 40 IJ=n 1907 - - w.k I UNPAI I 1

4. Projet Lawd Workshop, Lab. 1 0 Halth facility He. ISepter 10w I PmFatiol Project TM Cosultat + I Nationa ad egiol 5 ds I

ha Staff. I ProJect tas sod mmt IIcomitte rwretatives. I I

I ~~~~I IS. AlgotW trainin, alab. I 0 oital ad Hu lth ISepter 1W I Project

Staff: atioml project TM I Costar wrs el 1 4 das IIs

6. Hetritla Suvey training, Said. i 25 SNIl, NC perso l ISepteber lw IStaff: Natioal Projet TM , ays I

I J

7. Training for ld valn ses Iln ulth 1 12 pers el respoible for lktoWr 1 1 ProjectCaters, Lab. (Teo). I Ip wrvices in helth 1 5 daysStaff: J midlves froo project ae. I caters in project oe. I

8. Progra () to be followd by practical 1 12 traies lOctoW 1987- 1 Projectcourse in groups of 4 for o th I IJaay 1088 ceutively. Stff: 2 ositl dsivs. 1 1 3 mths

I I |

9. Ann refrsar training for 1 20 physicians INove_r 18W, 88, 89,1 Projectphysicians : Conar. (Pedlatrics, Surgery, P.N. 1 190, 91; 5 das lterl Nedicie, Obstetrics end g ology) I ItStaff: I Ezternl Consltat * local consuiot an(To e undertaken aully throughout *ratio I Iof project). I

10. training for Traditionl Birth Attednts at 1 6 persos flecear 1087 1 Projecteh of 12 rural heath ceoter in project Ione.: 12 centers 1 2 daysStaff: 2 midivIs.

11. ept training l0, evy six mths. 1 6 rsons 'Froa Deteber 1907 Project12 centers 1 2 days

I~~~~~ S

WI - '* pm 4 dw

V.,, ~~~~~~~~~~~.a

~~~~4 ~ ~~I- --- 4----

liii III '4 jI~~~~q~!II QI '40

- - -P - -i - - - - --

8q r' I a a ii* __ __5' _ __ _ _ _ _

V I

U, U{ S . 1 t t Z({ {,,,,{ i

Ic W

47- AM 3-3

* 3~~~,d 1. or m o slam gt dint.' Uw ignto Imtad gif the ProJoint

T miMrN 1Prix rev. i4uent1t# I tx do I Trx d** I do ce Ids 1'UnttdIakesatrs rovient I vents

eeti6 lawcamont pr trat-ldu traito-I propos4___ ___ __ ____* I Glll I temn t sent

Pslu : siple 1 30 1 2,25 1 4 9 1 4-~~~Pl u: gmv. 30 1 25 1 3 - I5 240

Proahrlaxt* orftatalol 750 1 4.25 1 90 202 1GoaMldio do votes

-resptratotres I I Cml 1 I 200 I a1 J .18 0 1 4 1.700

I I I~~~~adugtos III I I .6 weI 18 s 600

Ca 2 .00 5 6,75 20 ocoam. 135 I 400I | | ~~~10/onf. 67 200

AndMis _F" S .nceine 250 I 0,35 1.60 |22. 100

-wants 3001 0.35 1 20 a 34 I 100

-Grave' 30oo 0." 11 camp. 27 9 5

-maodsre o I 1.800 I 17 12 sachets | 34 1 100-Grave _ 180 F 143 1 2 1 287 1 820

-Ankylostome 3.7W01 7 10 70 208ilharuioos I I I r

I , I I .

I I | ~ ~ ~ ~ I Ilooe*-IntostunA1o 1 100 j 2, - 40 I1.050 1 =000 oaf.

I I ~~~12.000 adul

Soo 215 so ~~~15030axO". ~ ~I I I I I

11.500 1 20 I1 l20 I 50-Graves 150 I I I 100

Infections de la Paul 2.000 I 10 I 1 10 l 20L&ro T 75 f 0,6 1300 comp. 150 1.000Myose 1.510 10 I 1 1 5-Accouchmont I I I I-44orml 1 70 I15 l - I 150 I 400

-Compliqu6 I ?5 | 1 175 2.000tnfection ceilAr1 1 I I-Conjonctivtto I 750 I 31 tubes I 1 31 100-Tracw m 300 1 31 _ 3 93 . 300

Couleurs divorses 5.000 0,66 9 I 6 1 20infections voles I I I I Iurinaire ' I 1 1 1

'enceintos 1 75 1 6,3 1 20 1 126 1 400-Autres 300 1 6,3 1 20 1 126 I 400

Gonococcie f 300 1 6.3 20 f 126 I 400Otice I I

-L6giroe 4.000 I I I I 20-S4v6re J 400 j 6,3 1 10 1 63 j 200

IstimAted Ba.o" Aimsmotion by~ e~Imiu of ona~th Center ruCotAnd Conaeuumt PrssdIDA, -.adz~ of Drugs

a P~~~~roject Years I Post-Project Total I

,,~~~ 1T 1 E Gl 2m 1 3 1 4 1 S 1 6 1 7 1 Tas-

… ---- - - ------- -t 1 | 2 1 3 5 ~~4 5 6 1 7 Vowens 1-S

Population Broeth Assumtion 3.1 1 3.01 1 3.01 1 3.01 1 3.11 1 3.0A 1 3.01 1 1 u1 1 , I I , I

Target Coverage of ealtb Centers 1 251 1 402 1 501 . 0 1 751 : 75S 751 1 -| g 1~~~~ ~ ~~., S : I

Total lase Cost of Drugs for emlth I I a t I I |Centers (assuuing 15 Cf per 14746.3 1 24160.7 1 31106.J 1 384.6 145 3. 1 47002.7 1 8412.9 1 15496.0 tpopulation covered) I I I I I I 5 1

Rate of Cost Recovered 1 30 .60t I o51I lOO 1101 I12 130t :.

Participation of Beneficiaries 1 80 1 1474.31 2416#.7 t 31106.71 38448.6 1 45633.71 47602.7 1 l

1 1 t 301JO 1t1 6 1 51 t0 111011: ta1 a I

A:ouat I 1 4423.9 '144%.4 5 2640.7 1 348.6 I 50197.1 1 56403.2 1 309.6 (541) 1as percent of total base cost I I t 182 1 4t 1 691 1 8U I l0n l1 117 . 1

I I " I 1 1 1 1 1Proposed IDA Financins Scheme

8~~~~~~~~~~~~~~~~~~~ ~ ~~~~~~~~ a a g S I I : I I I I I a,J I'.:as percent of total base cost 100I 80 11 5021 301 1211 1 0 1 0 1: Asount 114746.3 1 19328.6 115553.3 :111534.6 9126.7 t : 70209.S (41 I

I -- . . t ' , l.:.* O _ __ _ * *1 1 .1 . .____ _.~~~~~~~~~~~~~~~~ 1 1 *

*~~~~~~~~~~~~~~~~~~ 4, -

"UmN 4-1

L cm ~ ~ ~ ~ ~ ~ m

main m - m"

C. ralim - a n~~~im m aurs

a -w -\

"0 _mm w a _ U at mi__ u- as _mai __- ur D_ _

am_m 100041m isumo now" no _As memat u -w bb i

loom am dit"?m m umm ai ms mmmi iumu ISMIAe *1 5si

- - wr --" - mh.in

omu ranu" 114 imam I" *A 111i a.swz.a wo136. I" 414141433.43

C. m . __ _. _

HIMS fLm me a* 2UN NO

m. .m1_smisu.g ~ ua. 31.13 43.35 3.06 5. 014 -. 5 - 13.43, LU 14474

imamP4343 t I43 too" 4t34 240.1 * SOMA.t * 3t44 LU

INKI t*WVdM U41t, g t stA *b-tA 7o

Faun"13. O5.46. )bU3. 3.934M I-* a 4k112.9 214 .4 LU 214WMIS 63. 32. - 133.443 11*40 * X 631 t54w47 I" 3 .w3i. 14W - -

. M isM 24 7 U a - * - 45.4141 144 41. 2 1141to 11. . 3 .S .5 .^tA

_W M -I4 - 13 * * 04"W .- -.31.2

n~~ - -4 -W -4 - - - - Uh-At

w. w au mute t u.m.t * - - - - - 13.t.4 0 04

&ummim gumHAM 4 9.5 . * * 11.5bwa04 .4 *4.

. at oinswiv L

9131?_Z 15 * -4t * t - . * 319.4634 31.434Ut

t, s - _- - - 313.364 37134 - Ueemu vote rant _ -s o ".144 13. a 114 U U#°~~~~- - - - - e

"Wtu ham teE UPlA MONZA maw _ .9113. 11.43 Solna 15. 3-13 - S.7 _.6IA3

FSU 5015d 5 4.. *4 031124 201331204A 2A57.2 - - 1441.4 - 40.3114 2 4 21.

F at M Ulm 4 _t13.3 - *.32A * 4 3 - U O b7ma_ U US I?> 13. 4.14 - .31 12.5 8. - 143. - 92.43)L 1M4t4313115 2.463 7.334 3.4 243. 243J.4 - 3.5. - 4943. LUe 4.969413t11 ^ te633 3. 25.4t? -3.74 t. A1 . - - 3.U4 * 3.7414 u3 e. 4.

bt. tim 3 14 13.314 t145 8347. #e95 * 141413 -*w 71 4 Pt4714

OK. ~IthIn3 3 4 1191. 334 1.1.69 145 5314 U1.27 - Id 314. Uh54.1.1

btaut mu i 11.t. 4541. 35. 5.54 1445. 43.5. 1.6.91. 13.46 9.39.13.34 1 5.32

~~ - m . ,,e . m - m

*z 2WU U

*50 -

�!~~~~~~~~~~~~~~~~~~~h

(UP1 2 3 4 5 SF Ntlip~)

- ~ ~ ~ ~ ~ u m u uu. ua

A. DNSTITUTONA IYE'JEIPEOF NW

1. STRENIHEII UFRAMUIIS NO6 IWIAUCI 225.0832.,7 02.1 43.6 d8. 506.0 1.2

2. SIUESIININ U

OF, MPRMT WITS 130.5 143.9 65.5 59.6 73.4 472.0 1.2

t- -i - -

wTota INRl DTfUT__ I I (UWUNsA 36*4 225.7 147.4 100.2 142.2 S 3S0 2,4

D.oEUELWN U 1 16A _ W W3SC TIOPERTIWS IN NIBBLE OmIE

1. OFINAMIS CWABIITIS IaSIifOR OF ECJMtRAUIATION 032 158.3 684 33.5 32.7 38009 0.9

2. U2. SIIEIfIIM W

BSIC H S 1-,03 1. 3 2.3 827. Z5 * 2 .4 24 .0 1.225.4 10,43. SB KI;LS

U NEALI PERSIII 13. 25.2 16.6 4.3 3.8 53.4 0.14. IESTN UF

COST - -- - 3. 0 IJUVII FDINANCIAL WREIS 31.8 -1s

Si- Totul IE~DI U -XN MTOPERTIONS Di NIBBLE WuE 1,160.9 1,710.3 1,312.3 264.1 270.4 4,726.6 11'5

C. PRO NANSEIITAND SIIIAM 394.2 160.7 150.9 70.4 61.6 854.0 2.1

B. RA,TIENT 1 11F ,01 - - - 370.1 0.9

TOWa BSELIN cOST 2,281.5 2,105.2 1,410.8 450.9 482.3 6,9307 16.9Piwical CmotiMswigs 102.4 197.3 143.6 41.2 42.3 611.0 1.5MMic CmntirdWcif 229.7 520.9 593.0 154.0 197.3 1#686*B 4,1

Total PROJECT COSTS 2,404. 2,0234 2WS3. 646.1 7219 9P229.4 22.5

Fomig O E IlEClf 1O643.4 1,414.3 1.056,2 336.2 34.53 4,819.8 11.8

Fgbrwrv 26. 1997 11:55

.. I 1cU .1.1 ..! lar.1 .. I 1 ,, ,

hI1r;.t flI.I.. ..2 i~t.t 22 1212C I! 11i

dO

.. ~~~01 .I.12 ... Iit .. I ,,,IfF| .

I21e£tET F1 .I .. U 11212! I 1tf. i OR

!XIE4x; .X !~1 . I.. IE.} ... I t! |F I

. .~! 1 .1.1 ... 1!.. 1 . . Ii 222 1

- 52 -

A7X F44

for unforese pbysical contingecies 10% has been added to thebase cost of civil works, furniture, equipamet, vehicles, materials, drup,technical mistance, training and operting costs. Allowane. for annualprice esaltiom frm the bas cost date (Decmber 1986) are based on thefollowing estimated inflation rates:

17 1998 1989 m0 1991-8

- Foreign 3.0* 1.0* 1.0* 1.0* 3.58- Local 25.0* 25.0* 15.0* 16.0* 15.0*

The foreig annual rates of inflation are In accordae withept"ar 1986 GUN guidelines on expectod price incr_ea. Tre local annual

rate have bean revied by ank staff and have beun found satisfactory.

Cost estimte for rehabilitation works are basd on recentquotatios by local uliers. Cost estimtes for other expenditures arebed on recant experieces in neighboring Vst Africa coutries and anquotation fm supplier. e avergee cast per onth of iternatiallyrecrued pcialist services is estimted at US$12,000 oquivalent, which isin line with prices for comprable sevices in Vet Africa. Rational staffsalary etimates are basd on public service pay scales in Guinea.

Se foreign ohase cow_mp t h been calculated an follow:(a) civil works - 48*; (b) furniture, material and studies - 60*; (c)techical equipmet and drug - 90*; (d) vehicles - 70*; (e) technicalmistance and followhips - 100*; (f) inservice training - 10*; and (g)operating costs - 35*.

.

- 53 -

Page 1 of 4

GUINEA

HEALTH SERVICES DEVELOPMENT PROJECT

Details of IncreMental Recurrent Costs for Year Six of the ProJect

A. Central Level

1. Central MCWH/FP ServiceField Visits (? trips x 7 days x 2P) 112.0Vehicle Operation and Maintenance 1,428.6Maintenance of Equipment (4X/yr) 104.0Office Supplies 333.3Printing of Documents 555.6Subscriptions 277.8

2,811.2 US$6,857

2. Central Health Bducation ServiceSalaries 3,360.0Ideunities & Per Diems for Field Work 574.0Vehicle Operation and Maintenance 6,986.6Maintenance of Zquipment (4%/yr) 444.4Office Supplies 555.6Printing of Documents 4,666.7Subscriptions 194.4

15,781.6 US$38,492

3. Central Nutrition ServicePer Diem. for Field Work 90.0Subscriptions 388.9Maintenance of Equipment (4%/yr) 318.9Vehicle Operation and Maintenance 1.428.6

2,226.3 US$6,430

4. Central Maintenance ServicePer Diems 408.0Vehicle Operation and Maintenance 3,673.5Maintenance of Equipment (4%/yr) 23.1Building Maintenance (0.1%/yr) 13.5Supplies 400.0

4,518.1 US$11,019

* 5. Central Division for Women's DevelopmentPer Diems 224.0Vehicle Operation and Maintenance 1,768.7Maintenance of Equipment (4w/yr) 45.1

2,037.9 US$4,970

-54-

ANNEX 4-5Pap 2 of 4

6. Central In-Service Training and RwearchDivision

Per Diem 330.0Vehicle Operation and Maintenance 2,108.9Maintenanc of Equipmt (a%/yr) 111.9Subscriptions M.

2,828.6 US$6,899

7. Central Plming DivisionMainttenan of Equipmnt (4%/yr) 424.5Other Operating Costs 1I6

6m0.1 US$1,342

8. Ihw Rbuoures DivisionMaintenance of Equipmet (4%/yr) 424.5other Operatin Costs Z1.1

675.6 US$1,649

9. tinace and Administration Division (DAF)Maintenance of Equipmet (U/yr) 424.5Other Operating Costs I1.1

675.6 US$1,648

B. AZNhQ3Lievel

1. In-Service TrainingVehicle Operation and Mintane 714.3Maintenance of Equipt (4*/yr) 145.9Office Supplies 666.7Training of Medical and Paremdical

Personel 8.2_00.09,726.9 US$23,724

2. HospitalsDrug x 2/3 42,450.5Vehicle Operation and Maintena 4,591.9generator Operation and Maintenance 1,310.2Maintenance of gquipmet (4k/yr) 419.8Per Diem 378.0Office Supplies 651.0Building Maintenance 25.269.0

75,070.4 US$183,099

- 55 -

AM 4-6Page 3-of 4

3. Urban Health CentersDrugs x 2/3 10,654.6Vehicle Operation and Maintenance 3,781.3Refrigerator Operation and MainteDance 97.3Hbalth Information Form 333.3Maintenance of Equipment (4%/yr) 172.3Office Supplies 19000.0Building Maintenance 19753.4Per Dim s -_ _

17,792.1 US$43,394

4. Rural Health CentersDrugs x 2/3 19,767.9Vehicle Operation and Maintenance 9S075.0Refrigerator Operation and Maintence 1,156.3Health Information Forms 664.5Mainteanace of Equipment (4%/yr) 410.8Office Supplies 2,400.0Building Maintenance 2,337.0Per Diem 1.140.0

36,951.5 US$90,126

5. Health Education ActivitiesPer Diems 988.0Maintenance of Equipment (4%/yr) 154.2

1,142.2 US$2,786

6. Women's Development ActivitiesPer Diems 1,056.0Vehicle Operation and Maintenance 7,607.8Maintenance of Equipment (4%/yr) 13.5Supplies 800.0Rent 133.3Building Maintenance 280.6

9,891.2 US$24,125

7. Maintenance ActivitiesSalaries 2,400.0Per Diems 470.0Vehicle Operation and Maintenance 2,619.1Generator Operation and Maintenance 270.0Supplies 133.0Maintenance of Equipment (4S/yr) 117.9Building Maintenance 404.1

6,414.1 US$15,644

-56 .

AMUPage 4 of 4

8. gegional and Prefectoral MangemtVehicle Operation and Maintenance 11,275.8Geuerator Opertion and Maintema 873.3Maintenance of Rquipuet (4%/yr) 708.3Subscriptions 66Utilities and Other Miacellanoo Costs 1,216.7Per Diem 1,397.0Building Maintenace 3.M.2

19, 116.9 US$46,682

T0tM8 - 208^210^3 iO7-830~~~~~~~~~~~~~~~~~~~~~~~~

lI~~~~ ji j iCl0i

JI;I I ,t i

*X I ii3II S &i

AM= 5-2AI.h Serces k mt_ Project

Snry of lekia *usl

1. Strrgtbemite of P a aid lubemuit kerpntluo mIa ps .t of UrIc 12 6'._wstu flomiw 3 1 1 1 1 7

__Umkuuneshw"grt 4 I I t I .a 6bptl g af le _ t 4 I I I I 0

Eva"ltil ofobst e:tl yttl 6 * 4 0 4 S

2. Stromgliegieg of riorilty ISIS kiti keith o 1cgvaf t

_tlz ~~~~~~~.2 * 6,.biricoiro _r t d tulu d tratnr 4 4fnaualo 2 1 3

Ira3iogbde i u_ _ nt 3 3 h,lout of edoc l Medal for Irle 2 .2

Ewebtim f Treeg 1 I3 4 0_l t of Litea Pre dit ith i 1b u t2 12 a

I.euosmeot of kei1th Sector fpeatIONS (UNiX. b e

1. strngthmi of d tme Cuulltiuls kofIopbt o .im m e 6 U 4din Suwort of 1Semtrutiot )

2. Strntulbr of aul sith Sbrvie bdm_ 1 _u's t_u al SutiIt . 2 2, , , , ~~~~~~~~~~~~~~~~~~~~~~~~~, {~~~~~~~~2)

3. igra SUills of adtd hresl oretiu of ledilwl t rlrdde Aktlvtu 2 2 ' -

4. testle of lost kewry Sehmes ad hfs tisg iAetiS eUPlo t of nost 2 2lo di., !l.w jl Rhaaguunt reorI ad W ud accoumta .,

C. Project oagemt aid 4t istratigj IHii of Project bc ts 2. 2 2 2 2 10Prewemnt SeeliJst K 2 12 24PlnesgdPrgrbig 6 6 .6 26Project Evatetls t 1 2

(66)

TOTAL16* sA" '0 dW il W"A

o Sutotls ar she is ptereies .................

,u': g .~~~~~~~'9,\.

- 59 -

man 8eCA none - T n¢T

O Project Tars

Description 0 1 2 3 4 5 TOTAL

Helth Planning 12 12Health WOament 12 12 24Finn Ig"ut 9 9Ad.ihistration ad Finace 9 911_gmt and Orguizatlo of 9 9

aint_ce SeicesaIntanace of aiologIcl 9-Eqwipemt

fltiemnce of Electronic Eqgipsmt 9 9Health Service Nhbam t for 12 12 24 48

four Regioul NbnCurriculuom Delopment for Health 12 12

Education4nageuent of Hnith Eduation 12 9 21

Mao ad teleision for Health 6 6Edutation

Social Cumnication for Health 6 6Education --.

174

U~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

ANN 5-4 ()

nm LilmraiXMInlMtdattioa Udamuha gmr Glyn Works

ACTIVITIES tears 1W 19S 199 1990 1991Owms 1,213,4 1/2/3/4 1/213/4 1/2/314 1/23

1. leoatio and Iestructioa lerk for 5 Prefectoral Hospitals

Appointant of Architect 1xSketch-plans for each Ibsplbital, Oak by exMarking Drawines XI lid Awrd *xx:8Costuctim snalxttlaspectios ad Receptumo ox

2. ImOvatio ad hcustrucat Mart for 17 eialth Canters

Aoisbet of Architect NmSktch-pls for h Center, ank eview maDot fiiti of aildisg ftteril bets XXXXMaorkiog Dranns sxlid Awads txriIhlinn of kilding aterials at Ea Pefecture sxilCotructis XXlXtXx

3. Ranoatios ad eutestioo of Raimal Directorate of Health sdSocial Affairs in Labe.

AppOiitmt of Archit-ctSktc-plan, ank bview - Xoking Draigss

id Awrd xconstructio x

S~ ~~~~~~~~~~~~~~~~~~~~~~~~ 0

61-

ANNEX 5-4 (b)Page I of 2

4~ -

.e rs 198 lw 193 1969 19 1I1 1992hwts 3/4 1/2314 1/2/3/4 1/23/4 1/213/4 1/2/3/4 1/2/3/4

IWService traisin for ketors nd krs

- Mblc HNalth Tockuical mm Nnsgot cu.(Counr), 40 dotors.

--giol treinia in UNItI Senice N t.Ube; Se ld of facilities

- isoal eorse oN/F and Itritim in Labe.4 rticats s

- Algorthe traing is kldab, for 40 prticipats. 7

- Hetritio Sm training, Peloba.25 prticipats. -

- C/F rainin (or N lu/re Ter)in L*. 12 prtidpat. . x

- N/F? trainig for Nihivu irs (Practicl),Lbe; 3 grous of 46e b. - - - -

-. Al refrresb traioki for 20 doctors in mkry. a a I

- Tratini for tradtiol birth attedatsItl2r nwl Halth Citers inproJect on. a t X X * a X X I* wps Ptr center.

- Training in oral rOydration theray in Dalba.35 doctors andurses. m m .

- Food snd Sgtriti training for 3S prticiptsinabl. a a I

- Faily Plnnin traini in Pita for 35 elith* canter staff. x a r- -

- Faily Planing training for traditionl birthattkendnts; 10 participats pwr cater. * a a a

- Ana refresher training for aidoies andnurses, Lb. a a a x

- 62 -

2 ()Page 2 of 2

Years lI8M 1987 19"8 1989 1990 199 imOnarters 314 1/2/314 1/2/3/4 1/2/3/4 1/2/3/4 1/2/3/4 1/2/3/4

Refresher training for Social Affairs Staff

- Annual refresher trainilog for 20. Social Affairsaides (witrices), Conakry. I K I I

- Annual refresher training for 10 social affairsaides (monitrices), Labe I I K K

Refresber training for Laboraonry technicians

- nnual refresher curse for 25 laboratorytechnicians, Dalaba. J 1 - K

Nanaement Training

- Project launch uorkshop in Labe, for 60 participants -

- Refresher training in Hospital Admistrationfor 5 Hospital Administrators. I I I

- Financial Wanagement training for 25 participants,Labe. K I I

- Financial and prograe nagemnt training for25 ageent comittee meebers. I x I

- 63 -ANNEX S-5

6 UINEA

HEKATH SERVICES DEVELOPNENT PROJECT

Disburneaent Plan

* .. .. .. ..................................... ............................ * ............................................. ............................. ...

Category Amount of Credit t of ExponditureAllocated to be Financed

(US$ '000 quivalent)........ .... ........ .................. ........................ ...................................................... .. 7.. .........

1. Civil aorksa) 5 hospitals and 5 urban 9,000 100%

health centersb) 12 rural health centers 500 100%

2. furniture, Equipment, Vehicles, Naterials 1,800 100l of foreign expendituresand 85% of local expenditures

S. Drugs 700 100% in FY87 ad FY88;80% in FY89;50% in FY90;30t in FYMI;20% in FY92;and 0 thereafter

4. Technical Assistance, Contractual Services, 4,400 100%Fellouships, Studies and Techndcal Training

S. Funds for loplementing Sub-projects at theVillap Levela) Homen's Development 100 95%b) Comnity Oevelopment 100 95%

6. Funds for Strengthening AOBEF 100 100I

7. Operating Costs 500 60% in FY87 and FY88;40% in FY89;20% i FY90;10% in FY91;and 0 thereafter

8. Reftunding of Project Preparation Advance 950 Amount due as specified inV Section 2.02(c) of the Credit

Agreement.

9. Unallocated 1,5SO

19,700

...............................................................................................................

*S61 'II i.ldns pIn6p'spaoi 91 j§J *i ojd vnqS uo psq ot,;°ojd htmfs P;o

*1 '1f je.0 :lt BU;soJ l6x30661 '@0 .ur :uo:u"I laJd 10 ltO13 PrP*3L861 'Of Mt :90;sOd :swua1a:osf3 silo pvawx3

1861 'lot Mt :mto pno p6)d3 :SON

M aP d 304; "mSJq P IR13" /I^1 110J; 14N6 lot mtt

A~~~~~~~~~~~~~~~~~~~~~~~~~~A- 6 9661 '0f wnrt

00 001 LOOt l661 'If JO19390

f6 AJ

10 806 f'61 9'0 0661 '0 IttO't S6 8t1 't Z661 '10 Js

a.....

06 1

Z68 S'Lt Z't 1661 '0 9WI

I'L LB rIT II 1661 "it A6)W33

16A4t6 I '91 to 0661 'lot M

PL9 #9 9o1 f o6~1 IfJSqua

16 1U

3.6 it OKO It t66t 'I0n Uso1 A 9 Zt 9Z 6861 'It J0BP

.....rti LI 01 11 6.-061t '0£ 030

|tT ~OrAm 6- 9im Z 687 't 4

4.. ............

*t1 ~ IO IN 13I £'SV . 86 0

9 'LI tt 0' 361 'Of N531I Jt 9 Z'1 Z't N6t 't£ _IUSO

. .

ismv imau 311~ umu1

-an.

.39.~~~~~~

- 65-

§dgtd I btut ad Data Availeble in tMe Proect ile

A. Reports and Studis related to the sector.

1. Pus, Guine, iLX ltl ad IhiRD 8 rIiWorld Bak, Yellow Cover Report No. 02 It, Mhy 15, 198B.

2. UIVA, Guna Deot of Mision on Ned haet forEIAt1iou .minteam. Deport No. 30.

3. lyme Laur1n, Health Situation In the 1e,lic ofWAID, 1984.

4. Patrick Kelly, M.D., 1uie Sector Miion Inlrt, March 1985.

5. D. Fiahault, M.D., Report on the Devlopmet of Helth Personel.

6. M. Asofor, The Dampohic Situation in Gueaand Muturernand Policies. Conultsnt reort for PIll, October 1S4.

T. J.M. Fleury, Diosactic du System Phazuaetiaue ea Remublicande M, SOUL=, 1984.

S. S. BDetoud, P. Brudo-Jakbic d Don, Pr r tioal deFiin1.Jg mtilI, 01, Juillet 1986.

9. Minister. de la Coopeation Iaternationale, Politises atfrofr Alnentaires et Nutritioe11. en lulio Podulaire.1 m.iutioneire do

10. 158, Pl d'Action Sanitaire de la Guinea M a Pfriod.197-1, Conakry, Novbre 1986.

11. Dr. 3.8. Adjou3 _umouni, Seine do Sante Primaire. Formation desA.T.S. dn Las .1.8.., bRpport Mission ONS, MASS,1982.

12. MGMO, Ragubiqe do Quin-.. Peruoectivee et Contraint- duDeelgent de l'Education. 3lV132 Rapport No. 42, 1985.

13. Dr. Moeri Pat, Rmuide Bilen NItritio_mel at Alimentaire do lajauigg, WHD, IP/CRU/02-84, 1984.

- 66_

S. -d e Project.

1. Jacque Aim r. Prrati d'ua nroed 1. Sct>r.RaPp Arhitscturbs JUia 196 S_M6e 196

2. Jacque Aim abtor, vaulatoN du Proet dam 1 S8Emit. aport Misio IDA 1-15 D car 1e66.

3. Toula Mm*, Resort of Pro3Jct Ittificastiol i O is u,Conltant Reort, PoN, Septi_ 1964.',

4. F. Orivel d J. Parrot, tW& 4Aa hmitnA Jg Dlo_tMI duSrlc dO SAte en Denubliou de MM: RIWO de taboJul31, 1966.

5. Dm . Dr_ IMu* Codo# ed Guy pietet Se.8ice d 1ePrin&=r et Serica do Pevntion 1ntMr. Coamday. Julia 196.

6. fatbi Zad Dotros, Jet do ago Rugl OnMe. atiJa.hmaku Juillet--l -- 7)

7. MM, P2 do P Ia du Prof t apt an Milianu R1l,rappor dii prnior o.lier do coortation, Lab, du 30 Avril eu3 MM 16.

8. Glues Ddlom, PrAlet 8agt 1 M Rura X l VAlet: C _amosauNat toal. Reogeniat tent Iseantnal"LMsin 68CEL aaa18 Octobre 1916.

9. Nh/MUC3, Plan Natil pM re ProIr lr 8 do VaiaiJintewe w- Soim do Sante PridMre. e vis d'&tt iAdreVacination Univrselle dg. emfan, 1966-1j1, Ibv. 1, CmonkryLvril 1966.

10. Dotalled Cost Estimt.

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